A comparison in the clinical application, patient experience and costs between independent nurse prescribing and patient group directions in sexual health services

• Main Author: Black, Adam Wilson
• Other Authors: Norton, Christine Susan
• Published: King's College London (University of London) 2018
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.754961

Introduction: Nurses legally deliver medication through independent nurse prescribing (INP) or patient group directions (PGDs). There is limited sexual health evidence of clinical application and patient experience. Methods: Multiple mixed methods design was used in this study involving: staff interviews and questionnaires, clinical diary, clinical notes review, consultation observations, patient questionnaires and a costs review in five UK sexual health services, between September 2015 and August 2016. Results: Staff interviews reported governance and service delivery preferences for INP over PGDs, but they valued both methods. Staff questionnaire response rate: 64% (61/95; INP=26/28, 93%; PGD=35/67, 52%). INP were mainly Band 7 (n=13/26, 50%), educated to Masters (n=16/26, 62%); PGD users were mostly Band 6 (n=24/35, 68.6%), educated to Diploma (n=13/35, 37%). Both groups reported that medication access made their roles easier (n=60/61, 98%). Clinical diary: There was no difference in medication delivery frequency between both groups (INP=460/737 care episodes, 62%; PGD=348/593, 59%; p=0.168); however, PGD users required more professional support for medication delivery compared to INPs (INP=419/460 care episodes, 91%; PGD=245/348, 70%; p < 0.001). Notes review: INPs delivered medication more frequently (INP=385/711 care episodes, 54%; PGD=548/1,140, 48%; p=0.011) and worked more autonomously than PGD users (INP=310/399 medication delivery care episodes, 78%; PGD=308/480, 64%, p < 0.001). Overall, 91% (n=798/879) of medication delivery episodes were assessed against guidelines as ‘safe and appropriate’ (INP=372/399, 93%; PGD=426/480, 89%). The main reason for not being ‘safe and appropriate’ was lack of documentation (n=56/104, 54%). PGDs were used outside their restrictions in 8% (n=39/480) of consultations. Patient questionnaires: 92% response rate (n=360/393). Patients reported a high degree of satisfaction with information about medication (Satisfaction with Information about Medicines Scores: 13.4/16: the higher the score the greater the satisfaction). Observational study: nurses medication delivery consultations scored very highly against the prescribing framework (INP=44.7/46; PGD=45.4/46, p=0.407). Costs: INP training and governance required more initial investment, compared to PGDs, but facilitated INPs to autonomously manage more clinically complex patient presentations. Discussion: INPs and PGDs support safe autonomous practice. INP offered a highly flexible method of medication delivery that facilitated management of complex patient presentations but requires extensive resources from the NHS, and individual nurses, which were not always readily available. PGDs offer a suitable alternative, but were sometimes used outside of their restrictions. Improved clinical documentation is recommended throughout. CONCLUSION: Independent access to medication using INP and PGDs has facilitated a paradigm shift for nurses, progressing them from doctors’ handmaidens to autonomous advanced clinical practitioners. Access to medication is now a fundamental component of the advanced sexual health nursing role.