ORIGINAL ARTICLE
Evaluation of a diabetes nurse specialist prescribing project Jill Wilkinson, Jenny Carryer and Jeffery Adams
Aims and objectives. To evaluate the diabetes nurse specialist prescribing project with the aim of determining whether diabetes nurse specialist prescribing is safe and effective and to inform the implementation and extension of registered nurse prescribing. Background. Registered nurses in many countries are able to prescribe medicines, but in New Zealand, prior to the diabetes nurse specialist project, nurse practitioners were the only nurses who could prescribe medicines. New regulations allowed the nurses to prescribe a limited number of prescription medicines. Design. The study was a process and outcome clinical programme evaluation. Methods. The project took place between April–September 2011 and involved 12 diabetes nurse specialist in four localities. Quantitative data were collected from clinical records maintained by the diabetes nurse specialist for the project (1274 patients and 3402 prescribing events), from surveys with stakeholders (general practitioners, n = 30; team members, n = 19; and patients, n = 89) and audits from patient notes (n = 117) and prescriptions (n = 227), and qualitative data from interviews with project participants (n = 18) and patients (n = 19). All data were analysed descriptively. Results. Diabetes nurse specialist prescribing was determined to be safe, of high quality and appropriate. It brought important benefits to the effectiveness of specialist diabetes services, was acceptable to patients and was supported by the wider healthcare team. Conclusions. These findings are consistent with the findings reported in the international literature about nurse prescribing in a range of different practice areas. Clarification of the education and competence requirements and resourcing for the ongoing supervision of nurses is recommended if the prescribing model is to be extended. Relevance to clinical practice. Diabetes nurse specialist prescribing improved access to medicines by providing a more timely service. Nurses felt more satisfied with their work because they could independently provide a complete episode of care. As novice prescribers, nurses need to be well prepared educationally and have access to supportive clinical supervision.
What does this paper contribute to the wider global clinical community?
• Registered nurses who are spe-
•
•
cialists in diabetes can provide safe and appropriate prescribing decisions. There are important benefits when registered nurses prescribe such as a more effective specialist diabetes service, improved access to medicines and a more timely and acceptable service for patients. Novice prescribers need to be well prepared educationally and have access to supportive clinical supervision.
Key words: clinical programme evaluation, diabetes, diabetes nurse specialist, prescribing, registered nurse, regulation Accepted for publication: 19 October 2013 Authors: Jill Wilkinson, PhD, RN, Senior Lecturer, School of Nursing, Massey University, Wellington; Jenny Carryer, PhD, RN, Professor of Nursing, School of Nursing, Massey University, Palmerston North; Jeffery Adams, PhD, Researcher, SHORE and Whariki Research Centre, Auckland, New Zealand
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366, doi: 10.1111/jocn.12517
Correspondence: Jill Wilkinson, Senior Lecturer, School of Nursing, Massey University, Private Bag 756, Wellington, New Zealand. Telephone: +64 4 801 5799 ext. 63350. E-mail: [email protected]
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J Wilkinson et al.
Introduction Although prescriptive authority has been available to registered nurses (RNs) for some time in many countries (Watterson et al. 2009, Latter et al. 2011), nurse practitioners have been the only nurses who could prescribe medicines in New Zealand. The desire to extend the prescribing framework to RNs in New Zealand has been under discussion for some time (Wilkinson 2011). Diabetes services have been identified as a high priority area for workforce development and a suitable location to trial nurse prescribing where nurses already operate with a high degree of autonomy (Health Workforce New Zealand & Ministry of Health 2010, July). Without prescriptive authority, there are delays for patients and interruptions for doctors or nurse practitioners who must provide the prescriptions. There is evidence from the UK that nurse prescribing in diabetes health is well established (Carey & Courtenay 2008), has positive effects on patient outcomes (Carey et al. 2008), is easily assimilated into established nursing roles (Stenner et al. 2011) and has high acceptability amongst patients (Courtenay et al. 2010).
Background The New Zealand Society for the Study of Diabetes (NZSSD) was commissioned by Health Workforce New Zealand (HWNZ) to test the safety and effectiveness of diabetes nurse specialist (DNS) prescribing. The aim of the project was to make better use of DNS skills and experience and streamline the prescription procedure. Following an expression of interest process, demonstration sites were chosen in specialist outpatient clinics based in four major hospitals around the country (Auckland, Hawkes Bay, Palmerston North and Hutt Valley). Twelve DNS participated in the project which took place between April– September 2011. Each nurse had been accredited by the New Zealand Nurses Organisation as a DNS, and they also met or exceeded the postgraduate education requirements of the Nursing Council of New Zealand to prescribe diabetes medicines (Nursing Council of New Zealand 2011, March 31). Six doctors who were diabetes specialist physicians and endocrinologists provided supervision and mentorship to the nurses. The ethnicities of doctor and nurse participants were New Zealand European, European, Maori or Pacific. New regulations were enacted to allow nurses working in diabetes health to prescribe a limited number of prescription medicines under the supervision of an authorised prescriber [Medicines (Designated Prescriber—Registered Nurses Practising in Diabetes Health) Regulations 2011].
2356
The nurses who participated in this project provide mostly hospital-based clinics for people with complex diabetes problems who have been referred by their primary care provider. Before the project started, prescriptions for patients were arranged by the DNS through the patient’s general practitioner (GP) or directly from the diabetes physician on site. Changes to the dose or frequency of insulin or oral hypoglycaemic medications had been managed under standing orders (Medicines (Standing orders) Regulations 2002), which were later signed off or audited by a medical colleague. Recommendations for changes to or initiation of antihypertensive or lipid-lowering medications were previously communicated by letter to the patient’s GP. The project was independently evaluated with the aim of determining whether DNS prescribing is safe and effective, and to inform the implementation and extension of RN prescribing.1 Specific evaluative questions were derived from the Latter et al.’s (2011) evaluation of nurse and pharmacist independent prescribing in England and guided this evaluation: 1 What is the quality of, how safe and how clinically appropriate is DNS prescribing? 2 What is the contribution of DNS prescribing to an effective specialist diabetes service? 3 Is DNS prescribing acceptable to patients, and what are patients’ experiences of DNS prescribing? 4 What are the views of healthcare professionals?
Method The approach to this evaluation made use of the theoretical notion of valuing (Christie & Alkin 2013). This is based on Scriven’s (1991) general logic of evaluation which involves determining the merit or worth of an evaluand (i.e. the project, programme or policy to be evaluated). Four steps comprise this general logic: (1) establish criteria of merit (aspects of an evaluation that define whether it is good or bad and whether it is valuable or not valuable), (2) construct standards for the criteria, (3) measure performance and compare with standards, and (4) synthesise and integrate data on performance into a judgement of merit or worth (Fournier 1995). In this evaluation, the criteria and standards of performance for each criterion were developed jointly by the evaluators and the NZSSD project reference group. These criteria and standards were written as rubrics 1
A full report of the evaluation of the project has been published on
the Ministry of Health website: http://www.health.govt.nz/publication/ evaluation-diabetes-nurse-specialist-prescribing-project. This project is based on the full report.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366
Original article
which were understood as statements of what is ‘valued’ in respect of achieving the project objectives (Davidson 2005, 2007). Relevant data were then collected, and these descriptive facts were compared with the standards established. These were interpreted and woven together which enabled evaluative conclusions to be drawn about the project performance, which in turn provided direct answers to the evaluation questions (Davidson 2007). This approach ensured the evaluation moved beyond simply providing descriptive facts about the project’s implementation results. Ethical approval for the evaluation was provided by the Multi-region Health and Disability Ethics Committee. Participation was voluntary for all staff and patients, and confidentiality has been protected.
Data sources The study design and data sources were chosen in conjunction with the NZSSD and HWNZ to answer the evaluation questions and involved the collection of both qualitative and quantitative data. Clinical record and prescribing log data from each demonstration site were required by the NZSSD as part of the project monitoring requirements. These data were included as evidence to support the evaluation claims. Clinical data and prescribing logs Two record sheets were developed and data recorded throughout the project by the nurses: the clinical data record and the nurse prescribing log. The clinical data record was used to collect basic demographics such as age, sex, ethnicity, type of diabetes, comorbidities, medications and most recent blood chemistry [HbA1C, Albumin:Creatinine Ratio (ACR), creatinine, eGFR, lipids]. The prescribing log recorded every prescribing decision, noting the drug, new or repeat prescription, dose adjustment, diagnostic tests ordered and type of contact (telephone, email, home visit or clinic visit). Service usage data Service usage data were collected to count the total number of patients seen by doctors, DNS and nonprescribing nurses for two weeks prior to the project start and for each month during the project. Surveys Satisfaction surveys for patients, relevant GPs and team members of the prescribing DNS (i.e. nonprescribing DNS, team leaders and endocrinologists) were developed and were informed by other studies that have evaluated nurse prescribing (Watterson et al. 2009). Surveys were offered in paper copy or online. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366
Evaluation of a DNS prescribing project
Patient interviews and interviews with project staff Patients who completed the satisfaction survey were invited to talk by phone to a member of the evaluation team about their views and experiences of DNS prescribing. Semistructured interviews with all participating DNSs and diabetes physicians were conducted in the first and final month of the project. Clinical audit A random selection of clinical records of patients was audited by the diabetes physicians at each site during August. The audit criteria were developed using a modification of the Medication Appropriateness Index (MAI) (Latter et al. 2007). The audit tool required a judgement concerning the appropriateness of the prescribing decision and identified whether untoward events occurred for patients as a result of DNS prescribing. Quality audit of prescriptions In addition to the clinical audit, the quality of up to 20 randomly selected prescriptions written by each DNS was audited during August by the diabetes physicians against the ‘form of prescription’ instructions for prescriptions listed in the regulations (Part 7 s41) (Medicines Regulations 1984).
Analysis Numerical data from the logs, surveys, audits and service usage were entered into Statistical Package for the Social Sciences (SPSS), version 19 (IBM SPSS Inc., Armonk, NY, USA) and analysed using basic descriptive statistics. All interviews were audio-recorded and transcribed, then analysed for common themes with the aid of the qualitative data analysis software package NVIVO, version 9 (Qualitative Solutions and Research Pty Ltd, Melbourne, Australia).
Results Description of the patient group Clinical record data were collected for 1274 patients who were seen by DNS during the project. These data describe a complex patient group who not only have diabetes, but a high level of comorbidity for which they are prescribed multiple medications. These patients are referred to the diabetes centres by GPs usually because of complicated diabetes needs which have responded poorly to management in primary care. Seventy-three per cent of patients had type 2 diabetes (n = 928), 20% had type 1 (n = 250), 6% (n = 79) had
2357
J Wilkinson et al.
gestational diabetes and 1% (n = 13) ‘other’. Fifty-five per cent were female (n = 695). Fifty-four per cent (n = 677) were of New Zealand European/European ethnicity; 17% (n = 216) Maori; 17% (n = 220) Pacific; 10% (n = 123) Asian; 3% (n = 38) other or unknown. Further detail is shown in Table 1. The evaluation results are reported in the following sections as answers to each of the evaluation questions.
What is the quality of, how safe and how clinically appropriate is DNS prescribing? The data used to determine the safety and clinical appropriateness of DNS prescribing were collected from audits of patient notes, interviews with the DNS and physicians and patient outcomes recorded in the clinical data and prescribing logs. Excerpts from interviews are italicised and the speaker is indicated. Audits A total of 117 sets of patient notes and prescriptions were audited during August and September by the participating physicians. Prescribing decisions were assessed as clinically appropriate with the exception of five minor instances related to ambiguous documentation. There were no adverse events or hospitalisations related to DNS prescribing. Nine administrative errors (39%) such as a missed signature, registration number, date or amount to dispense were noted in the quality audit of 227 prescriptions. Clinical review meetings Prescribing decisions made by DNS during the week were discussed at weekly or fortnightly clinical review meetings with the DNS and physicians. When interviewed, the DNS talked about the importance of these meetings because of the:
Informal supervision also took place on a one-to-one basis, and this was extra work for doctors who typically have limited hours allocated to working for the diabetes service. Considerable goodwill and collegiality in relation to these exchanges was evident, with doctors making themselves available outside their designated ‘diabetes’ hours to provide support. The prescribing logs (3402 entries) indicate that most prescribing decisions took place independently 942% (n = 3206), 26% (n = 89) were dual consultations, and 31% (n = 107) occurred following consultation with an authorised prescriber. These data indicate that collaboration took place when it was needed and this is corroborated by the interview data. Patient outcomes The baseline mean blood chemistry, weight and blood pressure measurements for all patients with data available at project entry are presented in Table 2. Given that there were no study baseline or exit tests, the best option to determine clinical outcomes was to examine the longitudinal data available. For those patients with repeat measures recorded, the earliest measures available have been compared with the last measures available. Over an average of 100 days (range: 8 to 250 days), most of the 10 measures remained stable or improved. Notable was the improvement in mean glycaemic levels.
Determination of merit Using these data above and the criteria and standards established in the rubric (Table 3), the rating for quality, safety and clinical appropriateness for DNS prescribing was determined to be excellent. This rating was given as all six criteria were met at the described standard.
giant step between having the theoretical knowledge and putting things into practice by actually writing the prescription and giving it to the person. (DNS)
Physicians and DNS expressed appreciation for the mutual exchange of knowledge at the clinical review meetings and the tangible support formal review offered. Table 1 Patient group characteristics
Age Number of years with diabetes Number of comorbidities Number of prescribed medications
2358
Mean
Range
56 125 3 6
16–95 years
Evaluation of a diabetes nurse specialist prescribing project Jill Wilkinson, Jenny Carryer and Jeffery Adams
Aims and objectives. To evaluate the diabetes nurse specialist prescribing project with the aim of determining whether diabetes nurse specialist prescribing is safe and effective and to inform the implementation and extension of registered nurse prescribing. Background. Registered nurses in many countries are able to prescribe medicines, but in New Zealand, prior to the diabetes nurse specialist project, nurse practitioners were the only nurses who could prescribe medicines. New regulations allowed the nurses to prescribe a limited number of prescription medicines. Design. The study was a process and outcome clinical programme evaluation. Methods. The project took place between April–September 2011 and involved 12 diabetes nurse specialist in four localities. Quantitative data were collected from clinical records maintained by the diabetes nurse specialist for the project (1274 patients and 3402 prescribing events), from surveys with stakeholders (general practitioners, n = 30; team members, n = 19; and patients, n = 89) and audits from patient notes (n = 117) and prescriptions (n = 227), and qualitative data from interviews with project participants (n = 18) and patients (n = 19). All data were analysed descriptively. Results. Diabetes nurse specialist prescribing was determined to be safe, of high quality and appropriate. It brought important benefits to the effectiveness of specialist diabetes services, was acceptable to patients and was supported by the wider healthcare team. Conclusions. These findings are consistent with the findings reported in the international literature about nurse prescribing in a range of different practice areas. Clarification of the education and competence requirements and resourcing for the ongoing supervision of nurses is recommended if the prescribing model is to be extended. Relevance to clinical practice. Diabetes nurse specialist prescribing improved access to medicines by providing a more timely service. Nurses felt more satisfied with their work because they could independently provide a complete episode of care. As novice prescribers, nurses need to be well prepared educationally and have access to supportive clinical supervision.
What does this paper contribute to the wider global clinical community?
• Registered nurses who are spe-
•
•
cialists in diabetes can provide safe and appropriate prescribing decisions. There are important benefits when registered nurses prescribe such as a more effective specialist diabetes service, improved access to medicines and a more timely and acceptable service for patients. Novice prescribers need to be well prepared educationally and have access to supportive clinical supervision.
Key words: clinical programme evaluation, diabetes, diabetes nurse specialist, prescribing, registered nurse, regulation Accepted for publication: 19 October 2013 Authors: Jill Wilkinson, PhD, RN, Senior Lecturer, School of Nursing, Massey University, Wellington; Jenny Carryer, PhD, RN, Professor of Nursing, School of Nursing, Massey University, Palmerston North; Jeffery Adams, PhD, Researcher, SHORE and Whariki Research Centre, Auckland, New Zealand
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366, doi: 10.1111/jocn.12517
Correspondence: Jill Wilkinson, Senior Lecturer, School of Nursing, Massey University, Private Bag 756, Wellington, New Zealand. Telephone: +64 4 801 5799 ext. 63350. E-mail: [email protected]
2355
J Wilkinson et al.
Introduction Although prescriptive authority has been available to registered nurses (RNs) for some time in many countries (Watterson et al. 2009, Latter et al. 2011), nurse practitioners have been the only nurses who could prescribe medicines in New Zealand. The desire to extend the prescribing framework to RNs in New Zealand has been under discussion for some time (Wilkinson 2011). Diabetes services have been identified as a high priority area for workforce development and a suitable location to trial nurse prescribing where nurses already operate with a high degree of autonomy (Health Workforce New Zealand & Ministry of Health 2010, July). Without prescriptive authority, there are delays for patients and interruptions for doctors or nurse practitioners who must provide the prescriptions. There is evidence from the UK that nurse prescribing in diabetes health is well established (Carey & Courtenay 2008), has positive effects on patient outcomes (Carey et al. 2008), is easily assimilated into established nursing roles (Stenner et al. 2011) and has high acceptability amongst patients (Courtenay et al. 2010).
Background The New Zealand Society for the Study of Diabetes (NZSSD) was commissioned by Health Workforce New Zealand (HWNZ) to test the safety and effectiveness of diabetes nurse specialist (DNS) prescribing. The aim of the project was to make better use of DNS skills and experience and streamline the prescription procedure. Following an expression of interest process, demonstration sites were chosen in specialist outpatient clinics based in four major hospitals around the country (Auckland, Hawkes Bay, Palmerston North and Hutt Valley). Twelve DNS participated in the project which took place between April– September 2011. Each nurse had been accredited by the New Zealand Nurses Organisation as a DNS, and they also met or exceeded the postgraduate education requirements of the Nursing Council of New Zealand to prescribe diabetes medicines (Nursing Council of New Zealand 2011, March 31). Six doctors who were diabetes specialist physicians and endocrinologists provided supervision and mentorship to the nurses. The ethnicities of doctor and nurse participants were New Zealand European, European, Maori or Pacific. New regulations were enacted to allow nurses working in diabetes health to prescribe a limited number of prescription medicines under the supervision of an authorised prescriber [Medicines (Designated Prescriber—Registered Nurses Practising in Diabetes Health) Regulations 2011].
2356
The nurses who participated in this project provide mostly hospital-based clinics for people with complex diabetes problems who have been referred by their primary care provider. Before the project started, prescriptions for patients were arranged by the DNS through the patient’s general practitioner (GP) or directly from the diabetes physician on site. Changes to the dose or frequency of insulin or oral hypoglycaemic medications had been managed under standing orders (Medicines (Standing orders) Regulations 2002), which were later signed off or audited by a medical colleague. Recommendations for changes to or initiation of antihypertensive or lipid-lowering medications were previously communicated by letter to the patient’s GP. The project was independently evaluated with the aim of determining whether DNS prescribing is safe and effective, and to inform the implementation and extension of RN prescribing.1 Specific evaluative questions were derived from the Latter et al.’s (2011) evaluation of nurse and pharmacist independent prescribing in England and guided this evaluation: 1 What is the quality of, how safe and how clinically appropriate is DNS prescribing? 2 What is the contribution of DNS prescribing to an effective specialist diabetes service? 3 Is DNS prescribing acceptable to patients, and what are patients’ experiences of DNS prescribing? 4 What are the views of healthcare professionals?
Method The approach to this evaluation made use of the theoretical notion of valuing (Christie & Alkin 2013). This is based on Scriven’s (1991) general logic of evaluation which involves determining the merit or worth of an evaluand (i.e. the project, programme or policy to be evaluated). Four steps comprise this general logic: (1) establish criteria of merit (aspects of an evaluation that define whether it is good or bad and whether it is valuable or not valuable), (2) construct standards for the criteria, (3) measure performance and compare with standards, and (4) synthesise and integrate data on performance into a judgement of merit or worth (Fournier 1995). In this evaluation, the criteria and standards of performance for each criterion were developed jointly by the evaluators and the NZSSD project reference group. These criteria and standards were written as rubrics 1
A full report of the evaluation of the project has been published on
the Ministry of Health website: http://www.health.govt.nz/publication/ evaluation-diabetes-nurse-specialist-prescribing-project. This project is based on the full report.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366
Original article
which were understood as statements of what is ‘valued’ in respect of achieving the project objectives (Davidson 2005, 2007). Relevant data were then collected, and these descriptive facts were compared with the standards established. These were interpreted and woven together which enabled evaluative conclusions to be drawn about the project performance, which in turn provided direct answers to the evaluation questions (Davidson 2007). This approach ensured the evaluation moved beyond simply providing descriptive facts about the project’s implementation results. Ethical approval for the evaluation was provided by the Multi-region Health and Disability Ethics Committee. Participation was voluntary for all staff and patients, and confidentiality has been protected.
Data sources The study design and data sources were chosen in conjunction with the NZSSD and HWNZ to answer the evaluation questions and involved the collection of both qualitative and quantitative data. Clinical record and prescribing log data from each demonstration site were required by the NZSSD as part of the project monitoring requirements. These data were included as evidence to support the evaluation claims. Clinical data and prescribing logs Two record sheets were developed and data recorded throughout the project by the nurses: the clinical data record and the nurse prescribing log. The clinical data record was used to collect basic demographics such as age, sex, ethnicity, type of diabetes, comorbidities, medications and most recent blood chemistry [HbA1C, Albumin:Creatinine Ratio (ACR), creatinine, eGFR, lipids]. The prescribing log recorded every prescribing decision, noting the drug, new or repeat prescription, dose adjustment, diagnostic tests ordered and type of contact (telephone, email, home visit or clinic visit). Service usage data Service usage data were collected to count the total number of patients seen by doctors, DNS and nonprescribing nurses for two weeks prior to the project start and for each month during the project. Surveys Satisfaction surveys for patients, relevant GPs and team members of the prescribing DNS (i.e. nonprescribing DNS, team leaders and endocrinologists) were developed and were informed by other studies that have evaluated nurse prescribing (Watterson et al. 2009). Surveys were offered in paper copy or online. © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 2355–2366
Evaluation of a DNS prescribing project
Patient interviews and interviews with project staff Patients who completed the satisfaction survey were invited to talk by phone to a member of the evaluation team about their views and experiences of DNS prescribing. Semistructured interviews with all participating DNSs and diabetes physicians were conducted in the first and final month of the project. Clinical audit A random selection of clinical records of patients was audited by the diabetes physicians at each site during August. The audit criteria were developed using a modification of the Medication Appropriateness Index (MAI) (Latter et al. 2007). The audit tool required a judgement concerning the appropriateness of the prescribing decision and identified whether untoward events occurred for patients as a result of DNS prescribing. Quality audit of prescriptions In addition to the clinical audit, the quality of up to 20 randomly selected prescriptions written by each DNS was audited during August by the diabetes physicians against the ‘form of prescription’ instructions for prescriptions listed in the regulations (Part 7 s41) (Medicines Regulations 1984).
Analysis Numerical data from the logs, surveys, audits and service usage were entered into Statistical Package for the Social Sciences (SPSS), version 19 (IBM SPSS Inc., Armonk, NY, USA) and analysed using basic descriptive statistics. All interviews were audio-recorded and transcribed, then analysed for common themes with the aid of the qualitative data analysis software package NVIVO, version 9 (Qualitative Solutions and Research Pty Ltd, Melbourne, Australia).
Results Description of the patient group Clinical record data were collected for 1274 patients who were seen by DNS during the project. These data describe a complex patient group who not only have diabetes, but a high level of comorbidity for which they are prescribed multiple medications. These patients are referred to the diabetes centres by GPs usually because of complicated diabetes needs which have responded poorly to management in primary care. Seventy-three per cent of patients had type 2 diabetes (n = 928), 20% had type 1 (n = 250), 6% (n = 79) had
2357
J Wilkinson et al.
gestational diabetes and 1% (n = 13) ‘other’. Fifty-five per cent were female (n = 695). Fifty-four per cent (n = 677) were of New Zealand European/European ethnicity; 17% (n = 216) Maori; 17% (n = 220) Pacific; 10% (n = 123) Asian; 3% (n = 38) other or unknown. Further detail is shown in Table 1. The evaluation results are reported in the following sections as answers to each of the evaluation questions.
What is the quality of, how safe and how clinically appropriate is DNS prescribing? The data used to determine the safety and clinical appropriateness of DNS prescribing were collected from audits of patient notes, interviews with the DNS and physicians and patient outcomes recorded in the clinical data and prescribing logs. Excerpts from interviews are italicised and the speaker is indicated. Audits A total of 117 sets of patient notes and prescriptions were audited during August and September by the participating physicians. Prescribing decisions were assessed as clinically appropriate with the exception of five minor instances related to ambiguous documentation. There were no adverse events or hospitalisations related to DNS prescribing. Nine administrative errors (39%) such as a missed signature, registration number, date or amount to dispense were noted in the quality audit of 227 prescriptions. Clinical review meetings Prescribing decisions made by DNS during the week were discussed at weekly or fortnightly clinical review meetings with the DNS and physicians. When interviewed, the DNS talked about the importance of these meetings because of the:
Informal supervision also took place on a one-to-one basis, and this was extra work for doctors who typically have limited hours allocated to working for the diabetes service. Considerable goodwill and collegiality in relation to these exchanges was evident, with doctors making themselves available outside their designated ‘diabetes’ hours to provide support. The prescribing logs (3402 entries) indicate that most prescribing decisions took place independently 942% (n = 3206), 26% (n = 89) were dual consultations, and 31% (n = 107) occurred following consultation with an authorised prescriber. These data indicate that collaboration took place when it was needed and this is corroborated by the interview data. Patient outcomes The baseline mean blood chemistry, weight and blood pressure measurements for all patients with data available at project entry are presented in Table 2. Given that there were no study baseline or exit tests, the best option to determine clinical outcomes was to examine the longitudinal data available. For those patients with repeat measures recorded, the earliest measures available have been compared with the last measures available. Over an average of 100 days (range: 8 to 250 days), most of the 10 measures remained stable or improved. Notable was the improvement in mean glycaemic levels.
Determination of merit Using these data above and the criteria and standards established in the rubric (Table 3), the rating for quality, safety and clinical appropriateness for DNS prescribing was determined to be excellent. This rating was given as all six criteria were met at the described standard.
giant step between having the theoretical knowledge and putting things into practice by actually writing the prescription and giving it to the person. (DNS)
Physicians and DNS expressed appreciation for the mutual exchange of knowledge at the clinical review meetings and the tangible support formal review offered. Table 1 Patient group characteristics
Age Number of years with diabetes Number of comorbidities Number of prescribed medications
2358
Mean
Range
56 125 3 6
16–95 years
