O`Rourke, Tammy (e.100) Otros : advanced nurse practitioners,chronic pain,evidence-based practice,factor analysis,nurse practitioners Aims and objectives: In Canada, nurse practitioners (NP) were legally authorised to prescribe controlled drugs and substances (CDS) in 2012. The objective of this study was to understand current NP-CDS prescribing in Alberta, Manitoba and Saskatchewan, Canada. This study is a component of a larger three-phase survey of NP practice patterns in these same provinces. Background: Nurse practitioners are nurses with a graduate degree who have the legal authority to perform expanded functions in health systems, including prescribing CDS. Given the novelty of CDS prescribing for NPs in Canada, little is known about this component of their role. Design: A secondary analysis of survey data collected between March 2016 and May 2017 was used to examine NP-CDS-prescribing patterns and identify potential associated factors. Methods: Nurse practitioners in Alberta, Manitoba and Saskatchewan were invited to complete a professional practice pattern survey. The survey was administered through a secure electronic data collection software application (redcap). In the practice pattern survey, 42 variables from 15 distinct conceptual questions were analysed in this study as potential predictors of NP-CDS prescribing within a purposeful selection ordinal logistic regression model. This scientific submission has been assessed for accuracy and completeness using the Equator STROBE guideline criteria (see Appendix S1). Results/Findings: Five variables were found to be associated with an increased odds of more frequent NP-CDS prescribing in addition to three confounders/clinically relevant variables. Factors commonly associated with an increased frequency of NP-CDS prescribing relate to location of practice, area of practice, previous nursing experience, team environments and common diagnoses. Conclusion: Little is known about NP-CDS prescribing. Understanding this important component of the NPs emerging legal scope of professional practice can contribute to the continued refinement of this role as well as support ongoing enquiry into the causes of, and potential interventions to prevent, the present opioid overdose deaths occurring while under an active prescription. Relevance to clinical practice: Understanding factors that influence NP-CDS prescribing has relevance to the current drug-related prescription fatalities crisis in all countries.
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García Vera, César (e.100) Otros : Anti-Bacterial Agents / therapeutic use*,Antimicrobial Stewardship,Child,C||`esar Garc||`ia Vera,Drug Prescriptions / statistics & numerical data*,Editorial,Humans,MEDLINE,Mar||`ia Rosa Alba||~nil Ballesteros,NCBI,NIH,NLM,National Center for Biotechnology Information,National Institutes of Health,National Library of Medicine,Primary Health Care,PubMed Abstract,Spain,doi:10.1016/j.anpedi.2018.06.014,pmid:30054224
Noblet, Timothy (e.100) Otros : Barriers,Facilitators,Independent prescribing,Non-medical prescribing Question What are the factors that affect the implementation or utilisation of independent non-medical prescribing (iNMP)? Design Mixed-methods systematic review. Two reviewers independently completed searches, eligibility and quality assessments. Data sources Pre-defined search terms were utilised to search electronic databases. Reference lists, key journals and grey literature were searched alongside consultation with authors/experts. Eligibility criteria for included studies Qualitative and quantitative studies investigating independent prescribing by any non-medical professional group. Study participants included any stakeholders involved in actual or proposed iNMP. Measurements reported on data describing stakeholders` perceptions and experiences of the barriers to/facilitators of iNMP. Results A total of 43 qualitative and seven quantitative studies from three countries (n = 12, 117 participants) were included. Quality scores varied from 9 to 35 (Quality Assessment Tool for Studies with Diverse Designs, 0 to 48). Qualitative data were synthesised into four themes (and subthemes): systems (government and political, organisational, formulary); education and support (non-medical prescribing (NMP) courses/continuous professional development (CPD); personal and professional (medical profession, NMP professions, service users); and financial factors. Quantitative data corroborated the qualitative themes. Integration of the qualitative themes and quantitative data enabled the development of a NMP implementation framework. Conclusion Barriers to and facilitators of the implementation and utilisation of iNMP are evident, demonstrating multifactorial and context-specific variables within four explicit themes. Professional bodies, politicians, policy and healthcare managers and clinicians could use the resulting NMP implementation framework to ensure the safe and successful implementation and utilisation of NMP. Clinical physiotherapists and other clinicians should consider whether these variables have been adequately addressed prior to adopting NMP into their clinical practice. Registration PROSPERO CRD42015017212. [Noblet T, Marriott J, Graham-Clarke E, Rushton A (2017) Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of Physiotherapy 63: 221–234]
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Jiménez, León (e.100) Otros : 0913,Control del dolor,Dolor,Enfermeras prescriptoras,Nurse prescription,Nurse prescriptors,Pain,Pain control,Prescripci||`on enfermera,Revisi||`on exploratoria,Scoping review
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Andrade, Heuler S. (e.100) Otros : BACKGROUND: Nonmedical prescription is recognized in several countries as an excellent strategy in facing emerging demands that put a strain on the health system. It is a practice carried out by professionals who are not doctors and who, after obtaining specific qualifications and legal authorization, can prescribe medication and curatives. In Brazil, although there is already a legal subsidy for prescription in some professions, it is still an underdeveloped activity with few studies. OBJECTIVE: This study aimed to describe the conceptual aspects and state of the art of this type of prescription in Brazil. METHODS: It is a narrative review of the literature that included national and international regulations related to the subject, as well as available articles, published in electronic journals in different databases. Key terms used were nonmedical prescription, nursing prescription, and pharmaceutical prescription. RESULTS: It was evidenced that nonmedical prescription has ample potential for improving the quality of care and the health conditions of patients. One can highlight as positive results the improvement of work satisfaction and self-confidence of those who have developed this practice; improvement of teamwork reported by other professionals due to the reduction of work overload; greater patient satisfaction in relation to access; and care provided by prescribers. CONCLUSIONS: It is understood that there are many challenges for the consolidation of this activity in Brazil and that its success depends on a joint effort of health and educational institutions, health professionals, and patients.
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Ruiz Sánchez, Juan José (e.100) Otros : MeSH: Efficiency,Nursing prescription Objectives: To analyse the efficiency of nurse prescription of the health products inherent to their care work, in Andalusia, Spain, between the years 2009-2015. To also analyse the discussions by the Medical Colleges Organisation and the Ministry of Health, Social Services and Equality, before the draft bill on nurse prescription and their outcome. Design: Scoping review. Data source: Main bibliographic databases of Latin-American, Spanish, and foreign languages were reviewed, including, Fundaci||`on Index, Doyma, and Medline Library. Google Scholar was also used with the same search terms, adding to limit the search the term “Andalusiaâ€: “prescription nurse†AND “efficiency†OR “Andalusiaâ€. Another search was conducted in the grey literature using the same criteria in the Andalusian Health Service (SAS) web site. It was complemented with an interview with the care director of the SAS. Data extraction: A total of 617 articles were found, of which 20 were selected. In the grey literature, 52 documents were found, of which 4 were used. Results: Few studies were found on the efficiency in nurse prescription in Andalusia, although they are as strong as the data provided by the Andalusian Health Care Directorate on the health products inherent in their profession. After modification of Royal Decree 954/2015, and under pressure from the Medical Colleges Organisation, it leaves the competence of prescription nurse exclusively to the medical indication, who diagnoses and prescribes and eliminates it without argument scientifically endorsed. Conclusions: We corroborate the incorporation of efficiency in the Health System through the nurse prescription, and the rupture with the Royal Decree 954/2015. The allegations of the Medical Colleges Organisation are without argument.
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Graham-Clarke, Emma (e.100) Otros : Alison Rushton,Clinical Competence,Drug Prescriptions / standards*,Emma Graham-Clarke,Humans,John Marriott,MEDLINE,Models,NCBI,NIH,NLM,National Center for Biotechnology Information,National Institutes of Health,National Library of Medicine,Nurses`,Nurses*,Organizational,PMC5927440,Pharmacists*,Pharmacy / methods*,Practice Patterns,Prescriptions,Primary Health Care,Professional Autonomy,PubMed Abstract,Review,Secondary Care,Systematic Review,United Kingdom,doi:10.1371/journal.pone.0196471,pmid:29709006 Introduction Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom. Methods The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786). Results Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals`, ‘area of competence`, ‘impact on time` and ‘service`. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances. Discussion Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists.
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Chater, Angel (e.100) Otros : Angel Chater,Hannah Family,MEDLINE,Molly Courtenay,NCBI,NIH,NLM,National Center for Biotechnology Information,National Institutes of Health,National Library of Medicine,PubMed Abstract,doi:10.1093/jac/dkaa335,pmid:32766694 Background: The need to conserve antibiotic efficacy, through the management of respiratory tract infections (RTIs) without recourse to antibiotics, is a global priority. A key target for interventions is the antibiotic prescribing behaviour of healthcare professionals including non-medical prescribers (NMPs: nurses, pharmacists, paramedics, physiotherapists) who manage these infections. Objectives: To identify what evidence exists regarding the influences on NMPs` antimicrobial prescribing behaviour and analyse the operationalization of the identified drivers of behaviour using the Theoretical Domains Framework (TDF). Methods: The search strategy was applied across six electronic bibliographic databases (eligibility criteria included: Original studies; written in English and published before July 2019; non-medical prescribers as participants; and looked at influences on prescribing patterns of antibiotics for RTIs). Study characteristics, influences on appropriate antibiotic prescribing and intervention content to enhance appropriate antibiotic prescribing were independently extracted and mapped to the TDF. Results: The search retrieved 490 original articles. Eight papers met the review criteria. Key issues centred around strategies for managing challenges experienced during consultations, managing patient concerns, peer support and wider public awareness of antimicrobial resistance. The two most common TDF domains highlighted as influences on prescribing behaviour, represented in all studies, were social influences and beliefs about consequences. Conclusions: The core domains highlighted as influential to appropriate antibiotic prescribing should be considered when developing future interventions. Focus should be given to overcoming social influences (patients, other clinicians) and reassurance in relation to beliefs about negative consequences (missing something that could lead to a negative outcome).
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Ness, Valerie (e.100) Otros : Antibiotic,Antimicrobial resistance,Behaviour,Influences on behaviour,Nurse prescribing Aims and objectives: To present the findings of a systematic review which explored the influences on the antimicrobial prescribing behaviour of independent nurse prescribers. Background: Antimicrobial resistance is an urgent public health concern and inappropriate antibiotic prescribing is linked to an increase in this resistance. With a growing number of nursing staff potentially prescribing. Design: A systematic review. Methods: A comprehensive search strategy was employed to identify appropriate research papers. Results were screened for relevance using eligibility criteria, and the assessment of the methodological quality of the papers was conducted using a critical appraisal tool. Results: Seven studies were found which explored influences on nurse prescribers` antimicrobial prescribing behaviour. Three of these expected that an antimicrobial would be given and therefore influences discussed were on the choice of the antimicrobial given. Guidelines/protocols, safety, tolerability and efficacy of the antimicrobial itself, patient/parent pressure and training/experience were mentioned as influencing factors within the reported studies. The other four studies explored influences on whether to prescribe an antimicrobial or not and also found that guidelines/protocols were an influencing factor, however, the influence occurring most frequently was diagnostic uncertainty. Conclusions: The studies were limited by methodological issues and therefore further research is recommended to explore all influencing factors on prescriber behaviour. Relevance to clinical practice: It has been recommended that interventions to change healthcare professionals` behaviour must be based on theory-based research. Future research should therefore focus on the use of sound theoretical frameworks in the planning of the studies if we are to be able to understand and, if required, change nurses` behaviours.
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McIntosh, Trudi (e.100) Otros : Consultation,Doctor-patient relationship,Family health,Multidisciplinary care,Nurse practitioners,Pharmacology/ drug reactions Background. Suitably qualified non-medical healthcare professionals may now prescribe medicines. Prescribing decision-making can be complex and challenging; a number of influences have been identified among medical prescribers but little appears to be known about influences among non-medical prescribers (NMPs). Objective. To critically appraise, synthesize and present evidence on the influences on prescribing decision-making among supplementary and independent NMPs in the UK. Methods. The systematic review included all studies between 2003 and June 2013. Included studies researched the prescribing decision-making of supplementary and independent NMPs practising in the UK; all primary and secondary study designs were considered. Studies were assessed for quality and data extracted independently by two researchers, and findings synthesized using a narrative approach. Results. Following duplicates exclusion, 886 titles, 349 abstracts and 40 full studies were screened. Thirty-seven were excluded leaving three for quality assessment and data extraction. While all studies reported aspects of prescribing decision-making, this was not the primary research aim for any. Studies were carried out in primary care almost exclusively among nurse prescribers (n = 67). Complex influences were evident such as experience in the role, the use of evidencebased guidelines and peer support and encouragement from doctors; these helped participants to feel more knowledgeable and confident about their prescribing decisions. Opposing influences included prioritization of experience and concern about complications over evidence base, and peer conflict. Conclusion. While there is a limited evidence base on NMPs` prescribing decision-making, it appears that this is complex with NMPs influenced by many and often opposing factors.
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Do Nascimento, Wezila Gonçalves (e.100) Otros : Advanced Practice Nursing,Descriptors: Nurse,Prescription of Medications,Primary Health Care,Request for Examination,Transformation of Care Objective: To carry out a documentary study on the rules, guidelines, policies and institutional support for the nurse to prescribe medicines and request tests with a view to the advanced practice in the scope of Primary Health Care. Methods: Documentary research using open-access institutional documents-Federal Nursing Council (COFEN), its regional representations in the respective Brazilian states (COREN) and the Brazilian Nursing Association (ABEN). Results: Most of the news/notices were issued by the Regional Nursing Councils in the different Federative Units. The argumentation regarding the prescription of medicines and request for tests by nurses is based on three categories: Autonomy and competencies for the prescription of medicines and/or request of tests; Corporate policies that undermine the full exercise of nursing; and Transformation of health and nursing care in Primary Health Care. Conclusion: The prescriptive practice by nurses integrates health care and has been defended by the institutions that represent the category. It emerges as an important element of advanced practice and in the transformation of care in the context of health teams.
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Graham-Clarke, Emma (e.100) Otros : CRD,Centre for Reviews and Dissemination,Cochrane Library,DARE,Dissemination,EBM,Economic Evaluation Database,Effective care bulletins,HTA database,Information,NHS EED,NHSCRD,Systematic,clinical effectiveness,cost-effectiveness,evidence-based medicine,health technology assessment,matters,medical,promotion Introduction Non-medical prescribing was introduced into the United Kingdom (UK) to improve patient care, through extending healthcare professionals` roles. More recent government health service policy focuses on the increased demand and the need for efficiency. This systematic policy review aimed to describe any changes in government policy position and the role that non-medical prescribing plays in healthcare provision. Method The systematic policy review included policy and consultation documents that describe independent non-medical prescribing. A pre-defined protocol was registered with PROSPERO (CRD42015019786). Professional body websites, other relevant websites and the following databases were searched to identify relevant documents: HMIC, Lexis Nexis, UK Government Web Archive, UKOP, UK Parliamentary Papers and Web of Science. Documents published between 2006 and February 2018 were included. Results and discussion Following exclusions, 45 documents were selected for review; 23 relating to policy or strategy and 22 to consultations. Of the former, 13/23 were published 2006-2010 and the remainder since 2013. Two main themes were identified: chronological aspects and healthcare provision. In the former, a publication gap for policy documents resulted from a change in government and associated major healthcare service reorganisation. In the later, the role of non-medical prescribing was found to have evolved to support efficient service delivery, and cost reduction. For many professions, prescribing appears embedded into practice; however, the pharmacy profession continues to produce policy documents, suggesting that prescribing is not yet perceived as normal practice. Conclusion Prescribing appears to be more easily adopted into practice where it can form part of the overall care of the patient. Where new roles are required to be established, then prescribing takes longer to be universally adopted. While this review concerns policy and practice in the UK, the aspect of role adoption has wider potential implications.
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Weeks, Greg (e.100) Otros : Acute Disease / therapy*,Blood Pressure,Chronic Disease / drug therapy*,Derek Stewart,Developed Countries,Developing Countries,Diabetes Mellitus / drug therapy,Drug Prescriptions / standards*,Glycated Hemoglobin A / analysis,Greg Weeks,Humans,Interrupted Time Series Analysis,Johnson George,LDL / blood,Lipoproteins,MEDLINE,Medication Adherence,Meta-Analysis,NCBI,NIH,NLM,National Center for Biotechnology Information,National Institutes of Health,National Library of Medicine,Non-U.S. Gov`t,Nurses`*,PMC6464275,Patient Satisfaction,Pharmacists*,Practice Patterns,Professional Autonomy,PubMed Abstract,Quality of Life,Randomized Controlled Trials as Topic,Research Support,Review,Systematic Review,doi:10.1002/14651858.CD011227.pub2,pmid:27873322 Background: A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. Objectives: To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). Search methods: We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. Selection criteria: Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. Data collection and analysis: We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. Main results: We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location. A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies. Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers. The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. Authors` conclusions: The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Wilson, Donna M. (e.100) Otros : Ireland,legislation,midwife,nurse prescribing,post-graduate education,scope of practice For 10 years, select Irish nurses and midwives who pass a rigorous 6 month theory and practical program can prescribe medications and other medicinal products. Given the need for timely, accessible, and affordable health-care services in all countries, this nursing/midwifery education and practice development is worthy of examination. Irish nurse/midwife prescribing occurred following long-term deliberative nursing profession advocacy, nursing education planning, nursing administration and practice planning, interdisciplinary health-care team support and complementary efforts, and government action. A review of documents, research, and other articles was undertaken to examine this development process and report evaluative information for consideration by other countries seeking to improve their health-care systems. Nurse/midwife prescribing was accomplished successfully in Ireland, with the steps taken there to initiate and establish nurse/midwife prescribing of value internationally.
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Fernández Molero, Sonia (e.100) Otros : ,Concept analysis,Nurse,Prescription Objective: To critically analyse the concept of nursing prescription through the study of its background and a review of the scientific literature, in order to develop an accurate conception of this nursing activity and to identify the essential elements surrounding this concept. Method: Application of the concept analysis method described by Wilson, and adapted by Avant. Results: The concept of nurse prescription implies prescribing, by the nurse, the best therapeutic regimen for a health problem. This prescription will be guided by the assessment of the health problem, by the criterion of the good clinical practice of the nurse, and will be focused to satisfy the health needs of the patient and the population. Conclusions: The results clarify the meaning of the study`s concept to help professionals understand and address this nursing activity in all its dimensions, and promote social recognition of the nursing profession.
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Laurant, Miranda (e.100) Otros : Anneke Jah van Vught,Family Practice / economics,Family Practice / organization & administration*,Health Services Needs and Demand / economics,Health Services Needs and Demand / organization & administration*,Humans,MEDLINE,Meta-Analysis,Mieke van der Biezen,Miranda Laurant,NCBI,NIH,NLM,National Center for Biotechnology Information,National Institutes of Health,National Library of Medicine,Non-U.S. Gov`t,Nurse Practitioners / organization & administration,Nurses`*,Nursing Staff / organization & administration*,PMC6367893,Personnel Delegation / organization & administration*,Practice Patterns,Primary Health Care / economics,Primary Health Care / organization & administration*,PubMed Abstract,Quality of Health Care,Randomized Controlled Trials as Topic,Research Support,Review,Systematic Review,doi:10.1002/14651858.CD001271.pub3,pmid:30011347 Background: Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. Objectives: Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on: patient outcomes; processes of care; and utilisation, including volume and cost. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to `Studies awaiting classification`. Selection criteria: Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. Data collection and analysis: Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. Main results: For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied. Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence): Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence). Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence). Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence). We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low. The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence). We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low. Authors` conclusions: This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.
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Badnapurkar, Ashish (e.100) Otros : developing country,mental health nurse,nurse prescribing,survey Nurse prescribing has the potential to improve patients` access to, and experiences of, treatment. The aim of the present study was to examine nurse and psychiatrist attitudes about this extended role in a developing country. We conducted a cross-sectional survey using a previously-used, 65-item, seven subscale measure of attitudes to nurse prescribing in mental health. We achieved a 79% response rate. The majority of participants had trained in developing countries where nurse prescribing has yet to be implemented. Across five subscales (general beliefs, impact, uses, training, and supervision), both groups reported positive attitudes about nurse prescribing. Both groups scored the training subscale particularly highly. Compared with psychiatrists, nurses were more confident about the range of clinical settings where nurse prescribing could be applied (e.g. acute inpatient and substance use). Although both groups had less favourable attitudes on the two subscales relating to clinical and legal responsibility, compared to nurses, psychiatrists were more undesirable. Although, overall, clinician attitudes do not seem to represent a barrier towards the potential implementation of nurse prescribing in the study setting, clarity about clinical and legal responsibility needs to be addressed.
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Mills, Timothy (e.100) Otros : Background: Uptake of non-medical prescribing by pharmacists working in primary care has been slow. This is despite benefits such as quicker and more efficient access to medicines for patients, a reduction in doctor workload, and enhanced professional satisfaction. This systematic review explores the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Methods: Medline, ScienceDirect, Embase, and the University of Reading Summon Service were searched to identify qualitative and mixed methods papers that examined the views, opinions, and attitudes of pharmacists and graduates towards non-medical prescribing. Papers published between January 2003 and September 2017 were included. Studies were quality assessed using the CASP checklist and then analysed using thematic synthesis. Results: After 85 full-text articles were assessed, a final 14 studies were eligible for inclusion. The included studies assessed pharmacists who currently prescribe, and other pharmacists and graduates with familiarity of non-medical prescribing. Thematic synthesis identified two themes: (1) practice environment, and (2) pharmacist`s role. Non-medical prescribing was considered a natural extension to the role of a pharmacist despite difficulties in completing the required training. The ability to then prescribe was dependent on funding and access to medical records, time, and support staff. Pharmacists experienced professional rivalry with both support and resistance from members of the primary care team. The provision of training was frequently referred to as unsatisfactory. Pharmacists were motivated to prescribe, deriving increased job satisfaction and a sense of professionalism; however, they often felt underprepared for the reality of unsupervised practice. Furthermore, pharmacists reported a cautious approach with a fear of making errors frequently discussed. Conclusions: This review has identified themes and subsequent barriers and facilitators to non-medical prescribing. Many of the barriers are more perceived than real and are diminishing. Consideration of these will assist and advance pharmacist prescribing in primary care, leading to positive outcomes for both patient care and the pharmacy profession.
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Abuzour, Aseel S. (e.100) Otros : Competence,Expertise,Non-medical prescribing,Nurse,Pharmacist,Prescribing Background Prescribing is a complex and error-prone task that demands expertise. McLellan et al.`s theory of expertise development model (“the modelâ€), developed to assess medical literature on prescribing by medical students, proposes that in order to develop, individuals should deliberately engage their knowledge, skills and attitudes within a social context. Its applicability to independent prescribers (IP) is unknown. Aim A systematic review was conducted to explore whether the model is applicable to non-medical independent prescribing and to assess the factors underpinning expertise development reported in the literature. Method Six electronic databases (EMBASE, Medline, AMED, CINAHL, IPA and PsychInfo) were searched for articles published between 2006 and 2016, reporting empirical data on pharmacist and nurse IPs education or practice. Data were extracted using themes from the model and analysed using framework analysis. Results Thirty-four studies met the inclusion criteria. Knowledge, pre-registration education, experience, support and confidence were some of the intrinsic and extrinsic factors influencing IPs. Difficulty in transferring theory to practice was attributed to lack of basic pharmacology and bioscience content in pre-registration nursing rather than the prescribing programme. Students saw interventions using virtual learning or learning in practice as more useful with long-term benefits e.g. students were able to use their skills in history taking following the virtual learning intervention 6-months after the programme. All studies demonstrated how engaging knowledge and skills affected individuals` attitude by, for example, increasing professional dignity. IPs were able to develop their expertise when integrating their competencies in a workplace context with support from colleagues and adherence to guidelines. Conclusion This is the first study to synthesize data systematically on expertise development from studies on IPs using the model. The model showed the need for stronger foundations in scientific knowledge amongst some IPs, where continuous workplace practice can improve skills and strengthen attitudes. This could facilitate a smoother transfer of learnt theory to practice, in order for IPs to be experts within their fields and not merely adequately competent.
