NCNM Open Day 27th November 2007 Nurse Prescribing Implications for the ANP

1. NCNM Open Day27th November 2007Nurse Prescribing Implications for the ANP Karen Brennan ANP STGH Emily Lockwood ANP WRH

2. Brennan & Lockwood 2007 Role of ANP Current Practice Legislation Processes required for Prescribing Impact on Patient Care

3. Brennan & Lockwood 2007 Advanced Nurse Practitioner Advanced Nursing Practice refers to a level of practice that maximises the use of experienced nursing skill and knowledge in meeting the requirements of the health service user The ANP role is concerned with the provision of holistic autonomous timely clinical care

4. Brennan & Lockwood 2007 Current Practice �The basis of our health service should be that patients receive the right care from the right person in the right setting�. (Harney, 2007) Scope of Practice � notion being role expansion, with the emphasis on accountability & autonomy in practice. Ethical considerations

5. Brennan & Lockwood 2007 Supply & Administration Guidelines �To provide, give, offer or sell a medicinal product to a patient or client under the directions of a registered medical practitioner as noted in an individual prescription or written instructions� (DOHC, 1998) ABA & NCNM 2003 sought clarification � Attorney General advised that other than controlled drugs the responsibility for procedures & controls applicable to medications rests within the hospitals & their management.

6. Brennan & Lockwood 2007

7. Brennan & Lockwood 2007 Gentamicin DRUG: Gentamicin CLASSIFICATION: Aminoglycoside antibiotic. CLINICAL INDICATIONS: For the purpose of this guideline, Gentamicin is used as part of the antibiotic treatment of open fractures (local policy) RECOMMENDED DOSE: 80mgs as a slow I/V bolus over minimum of 3 minutes, or infusion, once off dose if > 60kgs body weight, 60mgs once off dose if < 60kgs. EXCLUSION CRITERIA: Pregnancy, renal impairment, > 65years of age, auditory problems, hepatic impairment, myasthenia gravis, hypersensitivity to gentamicin or any other Aminoglycosides, parkinsonism. INCLUSION CRITERIA: Patients > 16 years of age , < 65 years of age. Patients agree to the administration of the medication under the protocol. INTERACTIONS: Should not be used concurrently with other potentially nephrotoxic or ototoxic drugs: agalsidase beta, indometacin, Ciclosporin, Platinum chemotherapy agents, neuro-muscular blocking agents, Neostigmine, digoxin,Tacrolimus, and loop diuretics (eg Frusemide). RARELY OCCURRING SIDE EFFECTS:Hypomagnesaemia on prolonged therapy, exacerbation of myasthenia gravis, pseudomembranous colitis, stomatisis, Otoxicity, nephrotoxicity, vestibular and auditory damage (at high doses or in the presence of renal impairment), transient elevation of LFTs, nausea, vomiting. ADVERSE EFFECTS: All adverse effects must be reported to the Dr. on duty, to the Pharmacist, and to the Irish Medicines Board. An Incident/ Near miss form must be completed. ADMINISTRATION DETAILS: May only be supplied by Advanced Nurse Practitioners (Emergency) or Advanced Nurse Practitioner Candidates, who have participated in a recognised nurse prescribing Programme and competed IV cannulation and administration study days. Drug name, dose, route of administration, date and time must be entered on the relevant section of the patients record. A record of each patient must be kept, to facilitate audit of the efficacy of the administration.

8. Brennan & Lockwood 2007

9. Brennan & Lockwood 2007 Review of Nurses and Midwivesin the Prescribing & Administration of Medicinal Products 2005 Joint�Project:�NCNM & An�Bord Altranias Identify�benefits�including: Appropriate�&�safe� Patient�satisfaction Convenience�&�greater�accessibility Improved�compliance�with�medication Appropriate�clinical�decisions Cost�effective

10. Brennan & Lockwood 2007 NCNM & ABA Following on from the review Initiatives such as the provision of professional guidance in relation to agreed medication protocol & the development of an interactive e learning programme, (www.hseland.ie) Development of Independent Nurse Prescribing

11. Brennan & Lockwood 2007 Legislative Changes Irish Medicines Board (Miscellaneous Provisions) Misuse�of�Drugs� (Amendment) � Regulations�2007 Medicinal�Products� (Prescription�and�Control� of�Supply)� Amendment) � Regulations�2007 Nurses�Rules�2007 Commitment to review in two years

12. Brennan & Lockwood 2007 Legal Authority This legislative change gives nurses the legal authority to prescribe medication following a programme of education. Independently prescribe from a open formulary Professional regulations dictate that prescribing be specific to area of practiceControlled Drugs Schedule 8 restricted misuse of drugs (Amendment) Regulations 2007 & restrictions for prescribing schedule 4 & 5 Employer can set criteria 2007 first accredited module on nurse prescribing in Ireland facilitated RCSI & UCC.

13. Brennan & Lockwood 2007 Schedule 8 drugs Drugs for pain relief in Hospital Morphine Sulphate, Codeine Phosphate Drugs for palliative Care morphine sulphate, hydromorphine, oxycodone, buprenorphine, fentanyl, methylphediate, codeine phosphate Drugs for Midwifery Pethidine Drugs for neonatal care in hospital Morphine sulphate, Fentanyl.

14. Brennan & Lockwood 2007 Site Development for NP Identification of Key Stakeholders Site declaration form Prescribing policy document Collaborative Practice Agreements

15. Brennan & Lockwood 2007 Site Declaration Form Identified essential criteria for site selection Safe Management: policy for prescribing, risk management, quality assurance Practice & Education Development: collaborative practice agreements, named medical practitioner to develop CPA, mentoring arrangements, Organisation: drugs & thereupetics, firm commitment from management to support prescribing initiative, Audit & Evaluation

16. Brennan & Lockwood 2007 Key Stakeholders The Nurse Prescriber Mentor Practice Development Hospital Management Pharmacy Drugs and Therapeutics Committee Site Liaison Co-ordinator Education Providers Risk Management Resourse & Implementation Group

17. Brennan & Lockwood 2007 Prescribing Policy Document Practice Standards Prescription writing Prescribing for self, family & others, Repeat prescribing, Prescribing of unlicensed medications, Prescribing by means of verbal, telephone, e-mail or fax, Seperation of responsibilities in the Medication management process, Influence of outside interests, Communication & documentation, Continuing professional development & continued competencies

18. Brennan & Lockwood 2007 Collaborative Practice Agreement (CPA) Provides�guidelines�to�the�nurse/midwife, medical�practitioner�and�health service�provider� for�development�of�the�individual�CPA Details�the�RNP�s scope�of�practice�including medication�approval� Requires�the�review�and�approval�of�the� employer�and�medical� practitioner�working�with� nurse�prescriber For annual�review

19. Brennan & Lockwood 2007 CPA Form An Bord Altranais Personal Identification Number This is an initial collaborative agreement practice agreement (CPA) (only) when first applying for registration in the Nurse Prescriber Division) ? Surname:- Forename: Please tick the box to indicate your appropriate Division(s) on the Register:- ? Provide brief details of academic and clinical practice experience. Date of completion of education programme for prescriptive authority Name of Third Level Institution:- Employment Contact Details:- Place of Employment and Address:-

20. Brennan & Lockwood 2007 Collaborating Medical practitioner Information Surname:- Forename:- Area of Medical Speciality:- Medical Council Registration Number:- CPA Commencement Date:- Please specify date for review: I declare that the above information, to the best knowledge, is true and accurate. I declare that I have reviewed:- 1. The Hospital Policy and Procedure for Nurses/Midwives with Prescribing Authority. 2.The following An Bord Altranais documents:- Practice Standards for Nurses and Midwives with Prescriptive Authority (An Bord Altranais 2007). Competencies for Nurses and Midwives with Prescriptive Authority (An Bord Altranais 2007). Requirements for Continued Competence (currently being developed). As a Registered Nurse/Midwife prescriber, I agree to meet the requirements for continued competence as determined by An Bord Altranais and the health service employer. Signature of Registered Nurse/Midwife Prescriber _ Signatures of Collaborating Medical Practitioner _Signature of Authorised Representative of Health Service Employer This document must be annually reviewed

21. Brennan & Lockwood 2007 Category of Medications Considered for Prescribing Current BHF Analgesics/NSAIDS Anaphylaxis Anaesthesia (Local) Antibiotics Anti-emetics Antifungal Antihistamines Corticosteroids I/V Fluids MDA Schedule 8 Muscle Relaxant Narcotic Antagonist Proton Pump Inhibitors/antacid Vaccinations Wound care

22. Brennan & Lockwood 2007 Nurse Prescribing Changes to Clinical Practice Facilitates the provision of a complete episode of care, Facilitates the delivery of holistic nursing care, Legal and professional accountability, Strengthens professional development.

23. Brennan & Lockwood 2007 Monitoring Registration with ABA Annual review of CPA Audit - Database

24. Brennan & Lockwood 2007 Conclusion With the introduction of prescriptive rights for Nurses and Midwives in Ireland it is evident that; There is a requirement for legislative structures, There is a requirement for support from policy makers and services managers, A base of knowledge is essential, The needs of the patient and the provision of quality nursing care must always determine the way in which nurses expand their professional role.

25. Brennan & Lockwood 2007 Education Programmes UCC February 14th 2008 ( Rena Creedon) RCSI 21st April 2008 (Chanel Watson) Closing date for Applications January 11th 2008

26. Brennan & Lockwood 2007 Eligibility Employment Voluntary�and�statutory�services�of�the�HSE Site�Requirements Support�from�employer�to�undertake�the�programme Nomination�&�confirmation�of�a�designated�medical�practitioner�mentor Experience 3�years�recent�post�registration�clinical�experience�(within�the past�5� years) With�equivalent�of�1�year�fulltime�experience�in�specific�area�of�practice Competencies Competencies�recognized�at�Level�8�(NQAI�framework) Evidence�of�further�education Possess�a�competent�level�of�information�technology�literacy.

27. Brennan & Lockwood 2007 Recommended Reading Review of Nurses & Midwives in the Prescribing & Administration of Medicinal Products� - Summary (An Bord Altranais & National Council for the Professional Development of Nursing & Midwifery, 2005) The Introduction of Nurse and Midwifery Prescribing in Ireland : An Overview ( DOHC, HSE, ABA, NCNM, 2007) www.nursingboard.ie www.ncnm.ie