Maureen Nolan Director of Nursing National Lead for the Implementation and Audit of Nurse Prescribing of Ionising Radiation and Medicinal Prescribing Dublin Mid Leinster
Prescribing Team Clare MacGabhann, National Lead & HSE South Annette Cuddy, HSE West Maureen Nolan, HSE DML Rose Lorenz, HSE DNE Website: http://www.hse.ie/go/nurseprescribing
2006 Irish Medicines Board (Miscellaneous Provision) Act 2006 July 2006 DoHC consultation process 2006 Drafting of Regulations May 2007 Misuse of Drugs (Amendment) Regulations 2007 Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2007 Irish Medicines Board (Miscellaneous Provision) Act 2006 (Commencement Order 2007) New Nurses Rules 2007 (An Bord Altranais) Accessible at http://www.oireachtas.ie and http://www.nursingborad.ie
Dual Framework Legislation Irish Medicines Board (Miscellaneous Provisions) Act 2006 Misuse of Drugs (Amendment) Regulations 2007 Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2007 Professional Regulation -- Nurses Rules 2007 Misuse of Drugs Regulations 2017 All nurses and midwives employed by a Health Service Provider All prescription drugs Schedule 4 & 5 unrestricted Schedule 2 & 3 (Controlled Drugs) restricted (Schedule 8) Drugs must normally be used in the setting Employer can set criteria RNP must write PIN on every prescription
Drugs for Pain Relief in Hospital Morphine Sulphate - Oral, Intramuscular, Intravenous Subcutaneous Morphine Tartrate -Intramuscular, Intravenous, Subcutaneous Buprenorphine - Transdermal Codeine Phosphate - Oral Dihydrocodeine - Oral Fentanyl - Intranasal, Intravenous, Transdermal, Transmucosal, Subcutaneous, Sublingual/Buccal Oxycodone - Oral, Subcutaneous, Intravenous Pethidine - Intramuscular, Intravenous, Subcutaneous Drugs for Palliative Care Morphine Sulphate - Intramuscular, Oral, Subcutaneous Morphine Tartrate - Intramuscular, Subcutaneous Fentanyl - Intranasal, Intravenous, Transdermal, Transmucosal, Subcutaneous, Sublingual/Buccal Hydromorphone - Oral, Subcutaneous Methylphedidiate - Oral Buprenorphine - Transdermal Codeine Phosphate - Oral Oxycodone - Oral, Subcutaneous Drugs for Purposes of Midwifery Pethidine - Intramuscular Drugs for Neonatal Care Fentanyl - Intravenous, Transdermal, Transmucosal Morphine Sulphate - Intramuscular, Intranasal, Intravenous, Oral, Subcutaneous Morphine Tartrate - Intramuscular, Intravenous, Subcutaneous Drugs for use in Mental Health or Intellectual Disability Methylphenidate - Oral Currently under review by Department of Health
Nursing and Midwifery Board of Ireland: Education Clinical Competence Clinical Governance Registration Documents: Requirements and Standards for Education Programmes for Nurses and Midwives with Prescriptive Authority (2007) Decision Making Framework for Nurse and Midwife Prescribing Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority (2018) Collaborative Practice Agreement (CPA) for Nurses and Midwives with Prescriptive Authority 4th Edn (2016) Website: https://www.nursingboard.ie
Requirements to register as RNP Division of the Register for Nurse Prescribers First opened January 2008 Candidate Registration is required Registration linked to other factors Completion of education programme Collaborative Practice Agreement completed Application Form for Registration with NMBI Notification of Collaborative Practice Agreement Registration fee (once off) Accessible at: http://www.nursingboard.ie
1 Clinical Decision-making 2 Communication and History Taking 3 Documentation 4 Prescription Writing 5 Prescribing for Self, Family and Significant Others 6 Repeat Prescribing 7 Prescribing of Off-label and Exempt Medicinal Products 8 Prescribing by Means of Other than an Original Prescription 9 Separation of Responsibilities in the Medication Management Cycle 10 Influence of Outside Interests 11 Continuing Professional Development and Continued Competency Accessible at: www.nursingboard.ie
Revised in 2016 Principles of: professional accountability, responsibility, competence and clinical governance underpin the CPA The Collaborative Practice Agreement (CPA): details the lines of communication established between RNP and the Medical Practitioner regarding the care of their patients and agreed by the employer defines the parameters of the RNPs scope of practice outlines the parameters of the RNPs prescribing authority Accessible at: www.nursingboard.ie
Employment Voluntary and statutory services of the HSE Name on Division of the Register General, Psychiatric, Children s, Intellectual Disability, Midwife or Public Health Nurse Site Requirements Support from employer to undertake the programme Nomination and confirmation of a designated medical practitioner mentor Experience 3 years recent post-registration clinical experience (within the past 5) With equivalent of 1 year full-time experience in specific area of practice Technical Requirements Competencies recognised at Level 8 (NQAI framework) Evidence of further education Possess a competent level of information technology literacy. Website: www.hse
Delivered over a Six month period Theoretical instruction no less than 28 days -includes self directed learning) Clinical instruction no less than 12 days (96 hours) Three core modules 1. Professional Accountability in Nurse/Midwife Prescribing 2. Pharmacology and Prescribing 3. Systematic Assessment and Evaluation in Patient care 250 hours in each module Contact time >30 hrs lectures Each module 10 ECTS Level 8 National Qualifications Authority of Ireland
Firm commitment (employer/organisation) National Policy Access to a Drugs & Therapeutics Committee/Review Group Prescribing Site Coordinator to oversee the introduction (named individual) A named medical mentor for each candidate Collaborative Practice Arrangement Commitment to continuing education and National Nurse and Midwife Prescribing Minimum Data Set Commitment to submit Attachment B of CPA to D&T committee within 3 months of successful completion of education programme Once CPA approved, commitment to submit documents for registration to NMBI within two weeks Website: www.hse.ie
Contact between education provider, NMBI and HSE Central point of contact for candidate, RNP, medical mentor, collaborating medical practitioners Approval and implementation of national policy Oversee safe management & quality assurance Liaise with D&T Coordinate CPA process Ensure compliance with audit and monitoring (per policy)
Explore with student learning needs and agree a programme/contract for learning Provide support, teaching and learning opportunities equivalent of 12 days history taking and assessment Supplement pharmacology teaching specific to clinical area Meet formally at 3 and 6 months for review Clinical assessment ensure achievement of competence in practice (ABA competency framework) Review and signs off the Competency Booklet
Requirement for services introducing nurse/midwife prescribing Multidisciplinary Group Review and advise on the proposed list of drugs of CPA Authorised product (or off-label use) Normally used in setting Appropriate to clinical setting and scope of practice of RNP In keeping with the organisations formulary /guidelines and legislative requirements Generic form of medicinal product
Toolkit for the Implementation of Nurse and Midwife Prescribing Other publications Audit, Monitoring, Application Guidelines etc Prescribing Site Coordinators Groups Course Fees funded directly by HSE National Policy Toolkit for Drugs and Therapeutics Committees Clinical Indemnity State Claims Agency Access to GMS and other schemes On going communication Irish RNP enetwork Irish PSC enetwork Newsletters (Health Matters Features), Professional Journals Patient Information Leaflet Website: www.hse.ie/go/nurseprescrbing Nurse and Midwife Prescribing Data Collection System
Policy purpose/scope/aims Roles and responsibilities Eligibility to prescribe CPA ensure health service provider is part of the process, final approval issuing commencement date Good prescribing practice Prescription forms/writing/security/loss/theft Role Drugs & Therapeutics Reporting near misses Record keeping Monitoring and audit Verification of status
National Nurse and Midwife Prescribing Minimum Data Set Purpose: To develop a system for each individual nurse/midwife prescriber to monitor and report on the number of prescriptions written by them, for what conditions
Finding: model chosen for Ireland appropriate and safely implemented Conclusion: national roll out be continued and further strengthened Recommendations: legislation, education, RNP registration, CPA, practice standards, CPD, further developments Recommendations outstanding: Schedule 8; Prescribing of unauthorised (unlicensed) medicines
Currently there are 1104 Nurses and Midwives registered to Prescribe
Health Service Provider = 198 Candidates funded = 1462 Registered Nurse Prescriber = 1104 (including 63 private) Health Service Provider by HSE Area Dublin MidLeinster 50 57 52 39 Dublin North East South West Variety of Clinical Areas Acute hospitals Older Persons Services Intellectual Disability Mental Health Services Public Health Nursing Services Prison Nursing Specialist Services Private Organisations
Number of applicants for education programmes decreased since 2011 Factors contributing to decrease: Public service moratorium in place since 2008 Regulatory requirements relating to Collaborative Practice Agreement arrangements including A) Requirement for annual/biannual review B) Access to Drugs and Therapeutics Committee Requirements for inputting prescriptions to Nurse Midwife Prescribing Data Collection System (HSE)
A collaborative approach was established between NMBI and ONMSD (HSE) to review regulatory and implementation systems and processes. Work commenced March 2015 and concluded with Final Report and Recommendations - October 2015
1. The Collaborative Practice Agreement is retained as a governance tool which must be completed at the point of application for registration with NMBI as a Registered Nurse Prescriber (RNP). 2. The governance for the ongoing review of RNP prescribing practices should be managed through local health service provider policy as directed by the NMBI and HSE. NMBI will continue to require the RNP to attest to having a valid CPA in the short term through the Annual Retention Notification, and subsequently through the NMBI continued competency scheme for nurses and midwives. The NMBI requirement and notification for annual and biannual review will cease.
3. The CPA form should be maintained. However, the NMBI should provide more clarity and guidance for the development of Attachments A, B and C.
4. The D&T committee is to review and advise on the list of Medications on the CPA and provide support to the DON/M who authorises the CPA on behalf of the health service provider. This reflects its advisory and supportive role with regard to nurse midwife prescribing. The framework in place for use of authorised medicines prescribed for unauthorised indications (off label) as currently established should be retained.
5. The D&T committee or the relevant review group is provided with clear directions regarding its role and function specific to nurse and midwife prescribing. This will provide for a national consistent standard involving a tripartheid approach from the DoH, healthcare regulation and HSE.
6. The NMBI should revise its professional guidance documents on prescriptive authority. The ONMSD should revise its National Policy for Nurse and Midwife Medicinal Product Prescribing (2012) and accompanying guidelines.
7. Each health service provider should have an agreed schedule for routine audit of nurse/midwife prescribing as part of its overall organisational audit programme for prescribing and medication management. The NMPDCS should continue to be available for local use as a support for monitoring and clinical audit of RNP prescribing practice. The HSE national mandatory requirement for RNPs to input their prescriptions into this system should be removed. 8. The HSE ONMSD to engage with HSE ICT regarding the potential to further develop the NMPDCS to generate electronic prescriptions. This would be in collaboration with relevant stakeholders involved in ehealth strategy, eg DoH/HSE.
9. The Department of Health to amend the legislative authority for RNPs to prescribe exempt (unauthorised) medicines and draft regulations to enable this. The health service provider should utilise the existing HSE and NMBI guidance frameworks for the use of medicines for unauthorised indication for managing the implementation of exempt medicine prescribing by RNPs.
10. Based upon findings of consultation activities regarding exempt and off label products, communication from Advisory Group should be circulated to stakeholders regarding: a. The provision of information updates about exempt (unauthorised) medicines and unauthorised indication medicine usage (off label). b. RNP use of Irish medicine references such as HPRA and the Irish Medicines Formulary vs reliance on UK sources (British National Formulary BNF).
11. a) NMBI to examine a process for competency assurance for addressing the current issue of long term candidate nurse prescribers (i.e. candidates who have successfully completed the education programmes but not yet registered as RNP). 11. b) NMBI to examine a process for competency assurance for addressing the current issue of RNPs who have not utilised their prescriptive authority, i.e. those returning from long term leave /maternity leave/career break etc.
12. The Director of Nursing/Midwifery/Public Health Nursing/Services must have overall responsibility and authority for the governance of nurse and midwife prescribing to ensure due diligence in their health service provider. This should be in collaboration with Chief Executive Officers (group hospitals), Chief Officer (Community Health Organisations), Superintendent Pharmacist and Clinical Directors as appropriate.
Review of CPA guidance document and forms Communication from NMBI regarding CPA annual/biannual review Information provision regarding off label and exempt medicines - reflecting Review findings Development of guidance for D&T committees Communication regarding Nurse Midwife Prescribing Data Collection System Revision of existing guidance for audit practices
National Medicinal Product Prescribing Policy revision Ongoing communication with HSE ICT Liaising with DoH regarding exempt (unauthorised) medicines Competency assurance for RNPs Linking with developments of NMBI CC schemes Explore supports for inactive RNPs who are not prescribing Long term candidates not yet registered Guidance to Directors of N/M/PHN services for ongoing and future governance for nurse midwife prescribing. RNP Capacity Building
Clare MacGabhann Director of Nursing and Midwifery (Prescribing) Office of the Nursing and Midwifery Services Director HSE South E-mail: clare.macgabhann@hse.ie Office: 021-4921210 Phone: 087 9317025 Maureen Nolan Director of Nursing and National Lead (Prescribing of Ionising Radiation) Office of the Nursing and Midwifery Services Director HSE Dublin MidLeinster E-mail: Maureen.nolan1@hse.ie Phone: 086 6012195 Rose Lorenz Assistant Director of Nursing and Midwifery (Prescribing and Continuing Education) Office of the Nursing and Midwifery Services Director HSE Dublin North East E-mail: rose.lorenz@hse.ie Office: 041-6850658 Phone: 087 2864075 Annette Cuddy Assistant Director of Nursing and Midwifery (Prescribing) Office of the Nursing and Midwifery Services Director HSE West E-mail: annette.cuddy@hse.ie Office: 094 9049013 Phone: 087 9317039
Maureen Nolan Director of Nursing National Lead for the Implementation and Audit of Nurse Prescribing of Ionising Radiation
The European Directive 97/43 EURATOM was transposed into Irish Law by SI 478. SI 478(2002) was amended in 2007 by SI 303. Section 2 provides for a person whose name is entered on the register of nurses as maintained by An Bord Altranais established by the Nurses Act 1985 and who meets the standards and requirements set down by An Bord Altranais from time to time to allow them to refer individuals for medical exposures to a practitioner
Up to Date there are over 320 nurses registered on "The National Nurse Prescribing Ionising Radiation Data Collection System" authorised to prescribe ionising radiation in the voluntary and statutory services of the HSE.
As per the HSE and Government priority, the ONMSD are supporting the education programmes to increase the number of nurses who may prescribe Ionising Radiation. Maximising the number of Nurse Prescribers of ionising radiation (X-Ray) will lead to increased levels of patient/service user satisfaction Providing a more responsive, accessible, effective, timely and efficient service that improves and expedites the patient/service user journey.
Target is to increase the number of nurses registered on "The National Nurse Prescribing Ionising Radiation Data Collection System" authorised to prescribe ionising radiation in the voluntary and statutory services of the HSE The Centres of Nurse and Midwifery Education in Tullamore and Connolly and University College Dublin provide the eduaction programme and TCD as part of other programmes. This is currently being expanded.
This evaluation has found that overall nurse prescribing of ionising radiation is safe and that the prescriptions for ionising radiation were appropriate.
The Evaluation of the Programme (2014) found that the impact of nurses prescribing was to be of huge benefit to the patients and improved efficiencies in the services. Overall there were good levels of support for the initiative with the majority of stakeholders reporting that the introduction of nurse prescribing of ionising radiation had had a positive impact on patient care as well as meeting the clinical the needs of patients.
The education programmes ensured that nurses were effectively and competently prepared to practice as nurse prescribers of ionising radiation. The radiological investigations requested by nurse prescribers of ionising radiation were appropriate based on the patient s history and/or physical examination.
Patients who came into contact with a nurse prescriber of ionising radiation were highly satisfied with the care they received which was found to be comprehensive including education and advice and that receiving a request for a radiographic examination from a nurse had reduced the time they spent waiting for treatment. The initiative has had a positive impact on the professional role of nurse prescribers of ionising radiation. The greatest benefit of the initiative has been the impact it has had on facilitating patients
The greatest benefit of the initiative has been the impact it has had on facilitating patients access treatment and care in an equitable and timely manner. The nurse s ability to prescribe ionising radiation had reduced delays in initiating treatment for patients as well as enabling patients to access care quicker.
1. The National Advisory Group will expand the governance and education programme(s) to include the prescribing of ionising radiation for children guided by service need and by the Requirements and Standards for Nurse Education Programmes for Authority to Prescribe Ionising Radiation (X-Ray) (An Bord Altranais 2008).
2. The National Advisory Group will consider amalgamating the governance and administration of all nurse and midwife prescribing initiatives i.e. Medicinal products and X-Ray prescribing. And specifically: a. Review the continued use of the database considering the national rollout of NIMIS. b. Engage with key stakeholders to ensure that Radiology Information Systems (RIS) support the identification of nurse prescribers of ionising radiation.
3. The National Advisory Group will review the Guiding Framework for the Implementation of Nurse Prescribing of Medical Ionising Radiation (X-Ray) in Ireland (HSE 2009) to reflect the implications of findings and the recommendations of this evaluation report.
4. The National Advisory Group will arrange for the national dissemination and communication of this report to relevant stakeholders.
5.Local Implementation Groups will identify and support the expansion of the scope of nurse prescribing of ionising radiation to include: a. Prescribing of ionising radiation for children guided by service need. b. An expanded list of additional imaging views guided by service need that may be requested by nurses already prescribing within their services. c. The implementation of audit of prescribing practice at agreed intervals as a means of quality and safety assurance and improvement. d. Put into place processes to ensure the timely introduction of nurse prescribers of ionising radiation into their healthcare organisation.
6. All nurses prescribing ionising radiation will incorporate the implications of the findings of this national evaluation into their practice. And specifically: a) Regularly engage in audit of their practice of prescribing ionising radiation. b) Develop the evidence base to expand their scope of prescribing ionising radiation practice where there is a service need.
7. All providers of preparatory educational programmes for prescribing practice will incorporate the implications of the findings of this national evaluation into their programmes to ensure continued best practice by those undertaking the programme. This includes: a. Design and development of preparatory educational programme(s) that: i. Incorporate education on the prescribing of ionising radiation for children. ii. Facilitate additional preparation for nurse prescribing of ionising radiation for children for those nurses already prescribing for adults where it is required within their service. b. Enhancing the content and experiential learning related to physical assessment in educational programmes with due recognition of prior learning and level of clinical experience of nurses on the programme.
8. Nurse prescribers of ionising radiation will identify their continuing professional development needs and access relevant education/development activities (local or national) that will maintain and enhance their competence as prescribers. Services will facilitate the provision of, and access to, relevant education and development activities. 9.The National Advisory Group will arrange for nurse prescribers to identify continuing professional development needs and facilitate the provision of relevant education where it is not available locally. 10. Nurse prescribers of ionising radiation will maintain records of continuing professional development relevant to their role in prescribing ionising radiation as they do for other areas of practice.
11. It is recommended that there should be public/patient involvement with the National Advisory Group. This will allow the public and patients to bring their experience of healthcare to inform decision on services that will directly affect them and the care they receive from nurse prescribers of ionising radiation.
A new Database has been developed which is aligned to the NIMIS system, including a revised Minimum Data Set. This will eliminate the need for the nurse to enter data on 2 systems. There are 37 sites with NIMIS of which there are currently 26 sites where Nurse Prescribing of Medical Ionising Radiation is implemented. Currently validating the current list of Nurse Prescribers
Those without NIMIS currently 9 sites will continue to manually upload their prescribing practice onto the new database until each site develops a reporting system from their current Radiology system. The data collection changed in 2016 and rather than the number of view s being captured we will capture the number of X Rays ordered.
Accession Number Facility Code( as in CUH) User ID (Name) NMBI PIN NIMIS Exam Code Order Date and Time Cancelled Date and Time (if cancelled)
The project to provide a One day Programmes was for Emergency Medicine ANPs to enable them to prescribe for children is complete. Two days were held in December 2015 and February 2016 with 65 attendances.
The development of an online learning package commenced which will enable Nurse Prescribers of Ionising Radiation to enhance their education. It will be available for all nurse prescribing Ionising Radiation
The development of a Toolkit to support the new developments to accompany the current guidelines.
To continue to support the implementation of this initiative including the provision and funding of the educational programme. To hold a Masterclass for Nurse Prescribers of Ionising Radiation To meet Non NIMIS Sites to support them in forwarding reports of Nurse Prescribing Activity to the National Database
To continue to implement the recommendations of the Evaluation of the HSE (2009) Guiding Framework for the Implementation of Nurse Prescribing of Medical Ionising Radiation (X-Ray) in Ireland (2014).
QQI Accredited Level 8 Special Purpose Award (20 ECTS Credits) & Nursing & Midwifery Board of Ireland Approved Special Purpose Award
The purpose of the education programme is to ensure that upon successful completion the nurse is equipped with the knowledge, skills and competence to prescribe ionising radiation (X-Ray) safely and appropriately within his / her scope of practice (Nursing & Midwifery Board of Ireland, 2015).
The programme of education consists of two modules. Module 1 comprises five theoretical days delivered over six weeks. Module 2 consists of 100 hours of supervised practice in prescribing ionising radiation (X-Ray), under the supervision of an agreed registered medical practitioner, in a designated clinical setting, over a sixteen week period. Learners are required to complete both academic and clinical competency assessments during the programme, details of which will be included in the Programme Handbook.
Programme applicants must: Be actively registered with the Nursing & Midwifery Board of Ireland in the General Nurse Division of the Register (prescribing for adults) OR in the Children s Nurse Division of the Register (prescribing for children within their Scope of Practice) Have a minimum of three years post registration experience in the designated area of clinical practice Be currently practicing in the designated area for a minimum of one year Be nominated by their Director/s of Nursing to undertake the programme based on a clearly identified service need Complete a Programme Application Form (available from Director of Nursing) and submit to the Director of Nursing Clinical governance arrangements must be in place through a Local Implementation Group for applicants to be considered for this programme.
RCNME Blanchardstown UCD RCNME Tullamore Applicants must be available to attend on all identified dates.
Governance including Audit Risk Management Evaluation Director of Nursing Clinical Supervisor Head of Radiology
Clinical governance arrangements must be in place through a Local Implementation Group. Registered nurses accessing this programme: Must be nominated by their Director/s of Nursing based on identified service need; Must be practicing in a designated clinical area for a minimum of one year where nurse prescribing of ionising radiation (X-Ray) is established, or in the process of being established; Must have a minimum of three years post registration experience in the designated area of clinical practice; Must have a designated clinical supervisor, who is a Registered Medical Practitioner, agreed through the Local Implementation Group.
The registered nurse must complete a Programme Application Form (available from Director of Nursing) and submit it to the Director of Nursing for approval. The Director of Nursing must forward the following documentation for each individual programme applicant, to the Programme Coordinator, by the advertised closing date. Completed Programme Application Form. Fully completed and signed Declaration Form.
Review completed programme application forms against the stated programme access criteria. Hold a follow-up meeting, or teleconference, with programme applicants to review application documentation, as necessary. Inform applicants, in writing, of acceptance onto the programme and provide them with the Programme Handbook and other relevant documentation in advance of programme commencement
Must have 100% attendance on the five theoretical days of the programme in addition to 100 hours of supervised practice in prescribing ionising radiation (X-Ray), over sixteen weeks, in the designated clinical setting. Must commit to undertake self directed learning. Must successfully complete all programme requirements including theoretical assessments and clinical competency assessment.
On successful completion of the programme the registered nurse is responsible for submitting a copy of his/her award certificate to the Line Manager and Director of Nursing. On receipt of this documentary evidence, the Director of Nursing is responsible for ensuring entry of the registered nurse s name on the National Database of Registered Nurses with Authority to Prescribe Ionising Radiation (X-Ray). The National Programme Coordinator will advise on this process, as required. A registered nurse whose name is entered on the National Database of Registered Nurses with Authority to Prescribe Ionising Radiation (X-Ray) has the authority to prescribe ionising radiation (X-Ray) within his/her scope of practice and in compliance with approved employing institution s policy.
Maureen Nolan Director of Nursing National Lead for the Implementation and Audit of Nurse Prescribing of Ionising Radiation and Medicinal Prescribing Dublin Mid Leinster HSE, First Floor Vista Primarycare Centre Ballymore Eustace Road Naas Co Kildare Email: maureen.nolan1@hse.ie Mobile 086 6012195