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No conflict with NPs in pharmacies

A study has shown private nurse practitioner clinics do not conflict with or duplicate the traditional roles of the pharmacist. By Linda Belardi.

Nurse practitioners in community pharmacies provide a timely, accessible, primary healthcare service and do not necessarily encroach on the role of pharmacists, according to the first independent evaluation of the model.

The exploratory study of all nine operational Revive Clinics in Western Australia, said the roles of the nurse practitioner and pharmacist were complementary, not competitive.

The independently funded study was conducted by Associate Professor Lynne Emmerton from Curtin University’s school of pharmacy and Sara McMillan, pharmacy lecturer at Griffith University.

The research centred on the Revive Clinic franchise in WA – which was first established in 2008 and remains the only Australian company to supply nurse practitioners to local pharmacies. By next April, the Revive chain plans to have a total of 160 clinics operating in every state and territory.

The authors examined the operational aspects of the model and interviewed staff about the interaction between the pharmacy and the nurse practitioner. McMillan told Nursing Review the role of the pharmacist remained virtually unchanged following the introduction of a nurse practitioner service.

“The scope of practice of the nurse practitioner complements the role of the pharmacist, with pharmacists continuing their professional role in advising clients about the quality use of medicines,” said the report.

The report, released to Nursing Review, also noted the advantages of a collaborative primary healthcare services for patients.

The co-location of the services meant the nurse practitioner was able to assist the pharmacist in the patient care process by performing tests and observations within their scope of practice. Conversely, the pharmacist was able to provide medicine-related information or to check a person’s prescription record in the dispensary computer to reduce errors and optimise prescribing.

Contrary to initial reservations from the Pharmacy Guild of Australia about overlapping or competing roles, the preliminary findings described a clear separation of services. However, McMillan said there are opportunities for nurse practitioners and pharmacists to work better as a team to offer co-ordinated services, such as in the provision of the emergency contraceptive pill and sexual health services.

“The presence of a nurse practitioner did not impact on the pharmacists’ provision of this medicine. [However] there is potential for nurse practitioners to become involved, by co-ordinating care for sexual health services such as STI screenings,” said the report.

There is also the potential for nurse practitioners, pharmacists and pharmacy assistants to collectively manage certain conditions, such as a child’s ear infection. “The acute nature of these conditions means that complete pharmacy-based management would be timely and ultimately cost effective for clients,” said the report.

The research is the first to examine the role of the nurse practitioner within a private community setting. Interviews with six nurse practitioners, 10 pharmacists and 11 pharmacy assistants were conducted between August and September in metropolitan and regional WA.

When the report asked why the pharmacy had introduced a Revive Clinic, the main reasons were to meet client need in areas of medical shortage and to address the transient population of patients from overseas or interstate. The study found clients were not being referred to nurse practitioners unnecessarily if the pharmacist could provide the information for free.

Training needs

Despite the potential for nurse practitioners to offer timely access to primary care services, the authors found that the nurse practitioners did not feel prepared to work in community health settings.

Emmerton said there was a gap in the knowledge of the surveyed nurse practitioners in the area of writing prescriptions and their training in non-prescription medicines, although this is now being addressed in the revised master’s degree curriculum in WA.

Founder and CEO of Revive, Louise Stewart said this finding confirmed her own experience of recruiting nurse practitioners to work in Revive Clinics and reflected the young history of community NPs in Australia. “There is a massive gap at the moment in the curriculum and training for nurse practitioners. The focus has been very much on government-employed nurse practitioners working in hospitals and emergency departments.

“There are very few nurse practitioners who have experience working in general practice. We are finding there is a varying degree of scope of practice and autonomy between nurse practitioners to be able to treat a wide range of minor illnesses and injuries,” she told NR.

Stewart has notified the WA Department of Health of this skills gap identified in the study. She said that nurse practitioners with ‘‘generalist’’ skill sets were best placed to deliver primary health services.

The report called for the master’s curriculum to be monitored in relation to prescribing and the recommendation of non-prescription medicines, specifically the technicalities of prescription writing and dose calculations, and particularly if the community practice career option continues to expand. Stewart said universities in WA have started to act on this recommendation but a national review of the educational preparation for nurse practitioners was necessary.

“Even though there is evidence demonstrating that privately practising nurse practitioners are the most cost-effective option for governments the extent of community-focused training and preparation presents a barrier to their employment in community settings,” said Stewart.

This year, Revive Clinics in collaboration with Curtin University, has introduced clinical placements for NPs-in-training. An online forum and video-conferencing opportunities have also been established for nurse practitioners to collaborate across clinics.

Emmerton said the availability of clinical placements and curriculum electives at university level would strengthen the choice of career pathways for NPs and expose them to a community practice model.

Ongoing research

Curtin University is planning further research to analyse the prescribing patterns of nurse practitioners within community pharmacies to better identify the impact of their role. The potential of community NPs within a rural setting is another research priority.

Emmerton said there is a need for further research to identify the client patterns of NPs, their reason for using the service and what service they might have used instead.

Stewart is currently lobbying the WA Department of Health to help fund the accommodation costs of nurse practitioners to work in rural areas as the model is rolled out to areas of significant medical shortage. She said there is “high level” interest in the funding proposal from the department and she anticipates a program will be established within the next two years.

Client feedback

Client feedback obtained in the study indicated that the majority of clients found the service offered by the NPs was professional and convenient. The clients who used the service were predominantly female and between the ages of 46 and 60.

“The nurse practitioner service was viewed by clients as a valid alternative to consultation with a general practitioner, suggesting that they were choosing freely between available health professionals.”

However, more than half of the surveyed patients who had a regular general practitioner said that their doctor was unaware of their visit to the nurse practitioner.

The authors said a better relationship with GPs and the roll-out of electronic health records would improve communication between health professionals to facilitate collaborative care. Revive’s online health records allow patients to share their records with GPs and other professionals.

While the potential for “drug or doctor shopping” was raised as an issue by one nurse practitioner, the authors concluded the risk would be minor due to the NP’s limited prescribing formulary. The risk was considered to be no greater for a GP.

Pharmacy Guild’s position unchanged

The Pharmacy Guild of Australia said it remained the position of the guild that private nurse practitioner clinics were based on a US model and were unnecessary in Australia. “Such clinics create a new tier in Australia’s healthcare model and place an additional cost burden on our health system,” the guild said.

Unlike in the US, Australia’s medicine scheduling system includes pharmacy medicines and pharmacist-only medicines, which allow pharmacists to deal with minor ailments via appropriate therapies, said a guild spokesperson.

In many cases patients attending a NP clinic are either paying or creating a Medicare charge for a service they could already get for free. As such, these clinics are inefficient and create an unnecessary drain on already scarce health funding, the guild said.

In the US, more medicines are available only on prescription, creating a space where another prescribing tier – utilising the skills of nurse practitioners – helps to address community need and adds efficiency to the health system.

Associate Professor Lynne Emmerton from Curtin University’s school of pharmacy disputed the Guild’s claims. She said Revive Clinic data demonstrates that the majority of consultations with a pharmacy-based nurse practitioner relate to prescriptions, which would have otherwise incurred the same Medicare costs for the patient but with delay from having to wait for a GP appointment.

“There was minimal or no impact of the nurse practitioner on pharmacy roles or services, which continue to be provided by the pharmacist in Revive Clinic sites, and remain free,” she said.

Emmerton said nurse practitioners are positioned in pharmacies to provide an option for consumers who would otherwise have visited their GP.

“Nurse practitioners do not impact on the pharmacist’s roles and services. Indeed, they can enhance the pharmacy services by being available to perform diagnostic services and write prescriptions. This demonstrates collaboration rather than competition,” she said.

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