How clinically appropriate is, and what are the influences on, antibiotic prescribing by Nurse independent prescribers, working in general practice settings?

Abstract

Antimicrobial resistance is a global public health concern. Inappropriate antibiotic prescribing is one of the factors related to this growing resistance. In the UK many nurse independent prescribers (NIPs) are employed in general practice settings and are prescribing antibiotics on a regular basis, potentially more than GPs. They are increasingly managing patients with minor illnesses, in on the day access clinics, when antibiotics are more likely to be prescribed. It is acknowledged, that there is an unexplained wide variation and a level of inappropriate antibiotic prescribing by GPs, but little is known about NIPs. GPs directly employ the NIPs who work in their practice and frequently act as medical supervisors and advisors to them. In the NHS this relationship is unique to general practice, elsewhere NIPs are employed by larger organisations such as hospital and community trusts.

Case study methodology was undertaken to explore the appropriateness of and influences on NIPs antibiotic prescribing in general practice, and whether the setting and relationship with the GP impacts on their prescribing, Quantitative and qualitative methods were employed, to mitigate the limitations of each method, and through triangulation of data to increase confidence in the validity and interpretation of the findings. A validated tool, the medicines appropriateness index (MAI) was used to evaluate the appropriateness of the NIPs antibiotic prescribing, by evaluating patient records where antibiotics were prescribed, 10 from each NIP in the month prior to consenting to take part in the study. 60 patient records in total were reviewed. Semi-structured interviews were undertaken with three NIPs in two Cases, and one GP in each Case. Nonparticipant observation, drawing on ethnographic methods, of the NIPs antibiotic prescribing practice was observed in 200 consultations until data saturation.

The NIPs demonstrated competence and confidence in treating minor illness presentations and prescribed antibiotics appropriately according to local and national guidelines. This may have contributed to the overall reduction in inappropriate antibiotic prescribing rates reported in the latest ESPAUR report (2019). The NIPs were influenced by a range of factors, mostly related to clinical issues, such as; co-morbidities and severity of illness, however there were other influencing factors, time, patient pressure and a desire to help the patient as best they could. Time and lack of it, was the influence that the NIPs found most difficult to manage. The NIPs valued the GPs knowledge, experience and support, however they asked for their advice infrequently about minor illness conditions and antibiotic prescribing, due to their own experience in treating common minor illnesses. The GPs did influence the NIPs as novice prescribers however this influence declined as the NIP gained experience, they then sought advice from experts such as microbiologists and pharmacists, when there was uncertainty related to antibiotic prescribing. They are valuable and highly skilled members of the workforce with the potential to reduce GP workload further with increased support.

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Identifiers

ORCID for Susan Latter: orcid.org/0000-0003-0973-0512

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