ORIGINAL RESEARCH
Sources of information used to support quality use of medicines: Findings from a national survey of nurse practitioners in Australia Thomas Buckley, RN, BSc(hons), MN, PhD1 , Helen Stasa, BA (Hons), PhD1 , Andrew Cashin, RN, MHN, NP2 , Meg Stuart, B. App. Sc (Physiotherapy), MSc, PhD, Grad Cert HS (Education)3 , & Sandra V. Dunn, RN, PhD, FRCNA4 1
Sydney Nursing School, University of Sydney, Sydney, Australia School of Health and Human Sciences, Southern Cross University, Lismore, Australia 3 School of Physiotherapy, Australian Catholic University, Sydney, Australia 4 School of Health, Charles Darwin University, Darwin, Australia 2
Keywords Nurse practitioners; prescribing; medications; marketing. Correspondence Thomas Buckley, RN, BSc(hons), MN, PhD, Sydney Nursing School, A4.28 Building MO2, University of Sydney, NSW 2006, Australia. Tel: +61 2 9114 4043; Fax: +61 2 9351 0615; E-mail: [email protected] Received: 29 August 2012; accepted: 25 February 2013 doi: 10.1002/2327-6924.12138
Abstract Purpose: The purpose of this study was to investigate the sources, both print and electronic formats, which Australian nurse practitioners (NPs) currently use to obtain information regarding quality use of medicines (QUM). An additional aim was to document NPs’ preferences for continuing education in relation to QUM. Data sources: A national electronic survey of Australian NPs was conducted in 2007 and again in 2010. Conclusions: Eighty percent of respondents accessed information on QUM from professional literature, which may include scholarly journal articles, reports, and independent publications. There was a decrease in the percentage of respondents who obtained information from drug industry representatives. NPs prefer to receive medicines information in an electronic form, rather than a paper-based version, and over the time period more NPs are utilizing electronic sources rather than paper. Implications for practice: These findings provide important insights into medical information products for the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines in electronic format, but also highly value conference proceedings, may help to inform future planning of NP education needs in relation to QUM.
Introduction and background Internationally, the term “nurse practitioner” (NP) is used to refer to registered nurses (RNs) who have “acquired the expert knowledge base, complex decisionmaking skills and clinical competencies for expanded practice” (Australian Nursing and Midwifery Council, 2006; International Council of Nurses Nurse Practitioner/Advanced Practice Nurses Network, 2012; Nursing and Midwifery Board of Australia, 2011a). NPs were first introduced in the United States in the 1960s, and since then, similar roles have been created in Australia and many other countries, such as Canada, the United Kingdom, and New Zealand (Canadian Nurses Associa-
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tion, 2002; Cashin, Buckley, Newman, & Dunn, 2009; IBM SPSS Statistics Version 20, 2011). Nonetheless, there is significant variability across these countries in regards to the use of the NP title and educational requirements. For instance, in the United States, the NP title is regulated, and prospective NPs are required to have completed a postgraduate qualification in their area of intended practice. However, the NP scope of practice (e.g., prescribing or referral rights) varies between states (American Nurses Credentialing Center, 2008). In contrast, in the United Kingdom, there is no title protection or minimum educational requirements for NPs, and scope of practice is often based on employers’ requirements (Barton & Mashlan, 2011). In Australia, the
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NP title is protected by legislation, and is used to refer RNs who, through specialist Master’s level education and at least 3-year specialty clinical experience, are “authorised to function autonomously and collaboratively in an advanced and extended clinical role” (Australian Nursing and Midwifery Council, 2006). Additionally, it should be noted that the prescribing practices of NPs vary markedly across these countries. In the United States, NPs have the authority to prescribe in all 50 states, and can prescribe independently in 27 states (Byrne, 2010). In the United Kingdom, independent nurse prescribers have unlimited prescribing rights within their areas of competence, with the exception of certain controlled and unlicensed medications (Department of Health (UK), 2010a, 2010b). Following appropriate training with a medical prescriber, the U.K. nurse prescribers are able to initiate prescriptions, as well as continuing them (Department of Health, 2006). In Australia, endorsed NPs are authorized to prescribe medications relevant to their scope of practice (Cashin et al., 2009; IBM SPSS Statistics Version 20, 2011; Nursing and Midwifery Board of Australia, 2011b). The issue of prescribing is important to ensure that healthcare practitioners can provide comprehensive health care to their clients (e.g., to monitor and revise pharmacological treatment regimens) and to ensure that health service professionals with the authority to prescribe possess a good understanding of the medications available to treat conditions in their area of specialization. Research has shown that patients rely heavily on health service professionals to provide them with information about their medication, and they often wish to know more information than the prescriber is able to provide (Dickinson & Raynor, 2003; Ekman, Schaufelberger, Kjellgren, Swedberg, & Granger, 2007; Lokk, 2011; Ndosi & Newell, 2010). In recent years, more patients are using the Internet to access information about their conditions (Fortinsky, Fournier, & Benchimol, 2012). For instance, a recent study in the United States found that 63% of clients who were eligible to use an online health web service had taken advantage of this opportunity. Interestingly, the researchers found that the digital service was particularly well utilized by older individuals, with 60% of those in the 60–69 age group taking advantage of this (McDonald, 2012). Despite the increasing popularity of online information, studies have suggested that patients tend to view such resources as an adjunct to the information provided by health professionals, rather than as the primary source of advice (Pohjanoksa-Mantyla et al., 2011; Tio, LaCaze, & Cottrell, 2007). Similarly, in a U.K. study, Lorimer, Cox, and Langford (2012) surveyed patients who had been admitted to hospital following an
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adverse drug reaction, and found that respondents tend to feel that the health professionals should have been more communicative and provided more information regarding the prescribed medications. Given the diversity of medications available, and the fact that new medications are continually being developed, it is vital that prescribers are able to access accurate, current, relevant, and evidence-based medication information to assist them in their prescribing practice. Ensuring that prescribers are adequately informed about medications is one of the key tenets of the Australian Government’s quality use of medicines (QUMs) strategy (Australian Government Department of Health and Ageing, 2002). As with the World Health Organization’s (WHO) “rational use of medicines” (2012), QUM involves a number of distinct but related aspects, including
r r r r
selecting management options wisely; critically evaluating whether medication is needed in a particular case; choosing a suitable medication if one is considered necessary, while taking into account factors such as the individual’s preferences, clinical condition, risks and benefits, dosage, and coexisting conditions; and using medicines safely and wisely
(Australian Government Department of Health and Ageing, 2002). A number of international studies have examined the sources of medications information used by medical practitioners. In a British study, McGettigan, Golden, Fryer, Chan, and Feely (2001) examined the sources of medication information used by both general practitioners (GPs) and hospital medical practitioners. The researchers found that the GPs tend to rate the Drugs and Therapeutics Bulletin and medical journal articles as important source of information on old and new drugs, while pharmaceutical representatives and colleagues were rated as most important source of information on new drugs. In contrast, hospital medical practitioners tend to rely on the British National Formulary and senior colleagues for theoretical information, and colleagues and pharmaceutical representatives in practice (McGettigan et al., 2001). In Australia, the National Prescribing Service (NPS), an independent, not-for-profit organization that seeks to foster QUM, conducted a study of the sources of information that GPs use when prescribing (National Prescribing Service Limited, 2008). The researchers found that Monthly Index of Medical Specialties, more commonly known as MIMS (contains Australian Therapeutic Goods Administration approved product information that originates from the manufacturer/distributor), the Prescribing Benefits Schedule (the Australian Government schedule of prescribing
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benefits), and therapeutic guidelines (TG; a peer-reviewed independent publication related to use of medicines) were the most commonly used sources of drug information. Less is known about the sources of information used by nurse prescribers. One exception is an early study by Hall, Cantrill, and Noyce (2003), which is a small U.K.based study that analyzed the sources of medication information used by community nurse prescribers. The investigators found that the nurse prescribers tend to seek information from professional journals and the British National Formulary, although they also relied on pharmaceutical company representatives, community pharmacists, nurse specialists, colleagues, and GPs (Hall et al., 2003). However, to date, no research has been published regarding NPs’ sources of medication information in the Australian context. This gap in the literature is problematic, because understanding which sources of information NPs use when making medication decisions can help educators in the designing curricula and continuing education courses to meet the information needs of NPs, and thereby promoting improvements inpatient services. The primary aim of the present study was to investigate the sources, both print and electronic formats, which Australian NPs currently use to obtain information regarding QUM, and to document NPs’ perceptions of the usefulness of such resources in supporting prescribing practice. An additional aim was to document NPs’ preferences for continuing education in relation to QUM.
Methods Study design In years 2007 and 2010, a descriptive online survey exploring medication-prescribing behaviors was conducted with members of the Australian College of Nurse Practitioners (ACNP) to examine the sources of information used by NP members to inform their use of medicines in practice. On both the occasions, the electronic survey was available for a 6-week period, accessible via the college website. Frequent reminders (every 2 weeks) were e-mailed throughout the survey periods to encourage participation.
Study participants All authorized NPs, who were members of the ACNP, were eligible to participate in this study. In 2007, 68 authorized NPs participated in the survey (27% of Australian authorized NPs at the time) and in 2010, 209 NPs participated in the survey, which gave a response rate
of 83% of ACNP eligible members and represented approximately 50% of all Australian NPs.
Ethics and consent Ethical approval was received from the Human Research Ethics Committee of the Northern Territory Department of Health and Community Services, and Menzies School of Health Research. While accessing the online survey, potential participants were first provided with an introduction outlining the aims of the study. Implied consent was assumed if potential participants proceeded past this screen. Participants were free to discontinue their participation at any time. All data collected were deidentified prior to analysis.
Questionnaire The survey was designed to document various aspects of prescribing practices using a questionnaire reported previously (Cashin, Buckley, Newman, & Dunn, 2009; Dunn, Cashin, Buckley, & Newman, 2010; Newman, Buckley, Dunn, & Cashin, 2009). Content validity of the questionnaire was established by a review conducted by three doctoral-prepared researchers and NP educators including one endorsed NP. In addition to demographic data, participants completed questionnaires specifically evaluating the most common sources of information used related to medications and the format of information used (paper or electronic). Participants were asked “How do you currently obtain information on medicines and Quality Use of Medicines” with potential responses, including drug industry marketing or representatives, professional colleagues, professional literature, national prescribing service resources, professional organizations; conferences or workshop presentations, or clients or families. Participants were able to report whether these resources were used in print (paper) and/or electronic format, allowing trends to be calculated over the time period from 2007 to 2010. Participants who used these resources were asked to rate their perceived importance of each of the sources of medicine information in informing their use of medicines on the Likert scale ranging from very important (scored as 3) to not important (scored as 0). To determine preferences for continuing education related to QUM, participants were asked to indicate their preferred means of receiving such information from the following response options: e-mail, for example, newsletters, fliers, etc.; online discussion groups; interactive online case studies or tutorials; face-to-face lectures or educational evenings (multidisciplinary or NPs only); conference workshops; online video presentations; 89
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downloadable print learning packages; downloadable audio files (e.g., for MP3 players); downloadable case studies/quizzes for personal digital assistant (PDA); or interactive modules on CDs. Participants were able to choose more than one option while responding to this question.
Data analysis Data were collected online using Survey Monkey (2007) and Lime Survey (2010; an Open Source PHP web application; LimeSurvey Project Team/Carsten Schmitz, 2012). After the survey period ended, data were transferred to an Excel data sheet, before being imported to SPSS for statistical analysis (IBM SPSS Statistics Version 20, 2012). Frequency and descriptive data were presented for each variable. Statistical comparative analysis was not performed between responses from the 2007 and 2010 participants as the samples were not considered totally independent, and it is very likely that some participants would have participated in both surveys.
Results Participant demographic information is presented in Table 1. Both survey respondents (2007 and 2010) were very similar in age, sex, years practicing as an RN, and location of practice, although there were slightly more NPs practicing in the private sector in 2010 compared to 2007 (6% vs. 10%). The proportions of respondents who reported using each source of medication information are shown in Figure 1. The majority of respondents reported that they obtained their information regarding QUM from professional literature, followed by professional colleagues and NPS resources. Less than 50% of participants reported using the Australian MIMS (MIMS, 2012), followed by the Australian Medicines Handbook (AMH Pty Ltd, 2012), TG (Therapeutic Guidelines Limited, 2012), and professional organizations. As shown in Figure 1, in 2010, a greater proportion of NPs reported using MIMS and TG for information regarding QUM, while less NPs reported relying on drug industry representatives for information compared to the 2007 survey. Overall, professional literature was the most reported information source in years 2007 and 2010. Participants were asked to rate the importance of each of the sources of information on medicines and QUM. These results are shown in Figure 2. Perhaps reflective of participants’ choice of use, professional literature, NPS resources, and professional colleagues rated highest, whereas conversely drug industry marketing was rated least important. 90
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Table 1 Characteristics of study participants
Mean age in years (range) Female Male Years practicing as an RN 25 years Did not state Location of practice Metro Rural Remote Practicing in public sector Practicing in private sector Jurisdiction of authorization • New South Wales • Western Australia • Queensland • Victoria • South Australia • Australian Capital Territory • Tasmania • Northern Territory • Did not state
2007 (n = 68) 47.1 (31–64) N 53 78% 15 22%
2010 (n = 209) 48.5 (31–65) N 168 80% 41 20%
0 3 7 10 14 34 0
0 4% 10% 15% 21% 50%
0 7 24 26 39 78 35
0 3% 11% 13% 19% 37% 17%
52 12 4 64 4
76% 18% 6% 94% 6%
151 49 9 189 20
72% 23% 5% 90% 10%
36 5 7 8 5 6 0 1 0
53% 7.5% 10% 12% 7% 9% 0 1.5% 0
56 40 37 26 19 10 4 3 14
27% 19% 18% 12% 9% 5% 2% 1% 7%
Participants were asked to nominate which information sources they had used in the 4 weeks immediately preceding the survey, and if the information had been accessed in an electronic or paper-based format. These results are presented in Table 2. Overall, in 2010, a higher proportion of participants reported utilization of electronic resources for the most commonly used resources. For example, 36% more were accessing electronic versions of the MIMS Australia resource and 14% more were accessing TG Australia electronic version, compared to 2007 (Table 2). Participants’ preferences for continuing education related to QUM are presented in Figure 3.
Discussion The study found that over 80% of NP respondents reported gaining their information on QUM from the professional literature, which may include scholarly journal articles, reports, and independent publications. Professional colleagues and NPS resources were the second and third most commonly cited sources of information, respectively. This order of sources did not differ between 2007 and 2010. The high percentage of NPs using the professional literature for information on medicines
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Figure 1 Sources of information used by participants to support prescribing practice. Note. Participants could choose more than one response. NPS, National prescribing services; AMH, Australian Medicines Handbook.
Figure 2 Respondents’ ratings of their perceived importance of each of the sources of medicine information (2010 participants). Note. Higher scores indicate greater perceived importance (possible range 0–3).
is extremely positive, as such sources tend to be peerreviewed and provide an objective evaluation of available medications. Of particular interest is the decrease in the percentage of respondents who obtained information from drug industry representatives, and the observed increase in the percentage of respondents using MIMS and TG for information. This decreased reliance on drug industry representatives would seem to be an encouraging sign because prescriber–industry relations often influence subsequent prescribing behavior (Campbell, 2007). While such interactions and information exchange may be helpful in providing prescribers with a greater knowledge and understanding of available medications, such re-
lationships can have negative effects as well. For example, an NP who formed a good relationship with a representative of a particular drug brand may be more inclined to prescribe that brand to a client, despite the fact that cheaper, and possibly more effective, alternatives may exist (Campbell, 2007; Skoglund, Bjorkelund, Mehlig, Gunnarsson, & Moller, 2011; Yoon et al., 2010). The finding that NPs reported using and placing greatest value on the professional literature to support their medication practices is similar to that reported of GPs, who also reported considering professional literature of high importance (Hall et al., 2003; McGettigan et al., 2001). However, in evaluating the actual sources of information 91
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Figure 3 Preferences for continuing education related to QUMs. Note. Higher values indicate greater percent of NPs preference. Table 2 Proportion of respondents who used either paper- or electronic-based resources to support their QUMs in the prior 4 weeks 2007 participants
Australian Medicines Handbook (AMH) MIMS Australia Therapeutic guidelines (Australia) Cochrane database Australian prescriber Pharmaceutical benefits scheme (PBS) schedule British Medical Journal (BMJ) clinical evidence National Prescribing Service (NPS) RADAR Other national prescribing service products
2010 participants
Change in use of resources over time
Paper-based resource (%)
Electronic resource (%)
Paper-based resource (%)
Electronic resource (%)
Paper-based resource (%)
Electronic resource (%)
54 44 41 10 18 22 7 6 4
47 34 39 34 22 17 18 15 10
60 41 26 3 23 10 7 6 4
47 70 53 35 24 26 22 16 13
+6 −3 −15 −7 +5 −12 0 0 0
0 +36 +14 +1 +2 +9 +4 +1 +3
Note. Participants could choose more than one format for each resource.
NPs had accessed in the 4 weeks prior to the survey; the AMH, MIMS, and TG were the three most frequently accessed. This finding is similar to previous reports where Australian hospital based doctors reported accessing these same sources of medicines information to support prescribing practices (National Prescribing Service Limited, 2008). This similarity may be reflective of the place of practice for NPs in Australia, where 90% NPs worked in the public health service, a significant proportion of which are assumed to be hospital-based positions. At this point, it is important to make two main comments about the differing sources of information available to prescribers. When evaluating the utility of different medication information sources, it is vital for the 92
prescriber to critically assess the independence of these sources. For example, information that is gained from a pharmaceutical company representative may be less independent than information gained from a publication that is not aligned to any particular industry group, such as TG or the Cochrane database (The Cochrane Collaboration, 2012). A second important factor that needs to be considered is how the prescribing information may be accessed. This involves a number of aspects, including the format of the information, and whether the user needs to pay a fee. For instance, some information sources, such as MIMS and the Cochrane Library, are accessible in various formats (such as print, PDA, or online), while others may not be available in as many different ways (MIMS Australia Pty Ltd, 2012).
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Whether a particular information source is available in the users’ preferred format is likely to have a large influence on its usage. Similarly, as many medication information sources require a user to pay an access fee, the cost of these licensing agreements may also impact a user’s choice. For example, recent figures show that the annual print version of MIMS costs AU$220, while the electronic eMIMS costs $360 (MIMS Australia Pty Ltd, 2012); the AMH costs $160 for any format (AMH Pty Ltd, 2012); and eTG costs $325 for a single online user (Therapeutic Guidelines Limited, 2012). While it is often possible for hospitals and healthcare groups to gain institutional access to such information sources, some NPs, especially those working off hospital sites, may elect to purchase their own licenses to different information sources. Nonetheless, it should also be borne in mind that the information provided by MIMS is Australian Therapeutic Goods Administration approved product information that originates from the manufacturer/distributor, although the creators of MIMS emphasize that the information provided by the drug is subject to strict editorial review (MIMS Australia Pty Ltd, 2012). The results also suggest that NPs prefer to receive their medicines information in an electronic form, rather than a paper-based version and over the period of time more NPs are utilizing electronic sources rather than paper. There are a number of advantages associated with electronic prescribing information. First, electronic versions of medicines information are often more cost-effective than print versions, and may be able to be utilized by multiple users (MIMS Australia Pty Ltd, 2012). Second, electronic medicines information may be more easily updated than print information. For example, the electronic versions of TG are updated three times per year (Therapeutic Guidelines Limited, 2012), whereas most print publications are only updated once per year (MIMS Australia Pty Ltd, 2012). As such, opting for an electronic version of medicines information may enable NPs to stay better informed about current developments and new products. Third, electronic information may be more portable than printed material, and more easily accessed via laptop or PDA, providing greater options for both transportation of information and access when required. This is particularly important for those NPs who may undertake substantial hours of their work off-site, or who see patients in different locations, and require continuous access to medicines information.
Limitations There are a number of limitations associated with the present study. The first of these is that participants required computer access to participate in the online sur-
vey. As such, participants who were not able to access a computer (and the Internet) either at work or home were not able to participate. This limitation may have skewed the reported preference of many of the respondents to access medicine information in electronic format. It is possible that some of those NPs who would prefer to use a paper-based medications information format may not have completed the survey because they were either unwilling or unable to access the Internet. Second, while the survey asked respondents which resources they had used for medicines information and QUM, it did not ask them why they chose the resources that they did. While we can speculate that factors, such as cost, accessibility, and format, may have played a part, further investigations are clearly needed in order to better understand precisely what influences NPs’ choices of medicines information.
Conclusion The results of this study provide important information about the method Australian NPs use to receive information on medications, and their preferences in regards to QUM. Additionally, they suggest that the sources of information and the preferred format for such information have changed over the past 3 years with lesser reliance on drug industry representatives and paper-based sources, and more reliance on electronic information sources, such as MIMS and TG. These findings provide important insights into medical information products to the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines by electronic format, and additionally value conferences, informs future planning for NP education needs in relation to QUM.
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Sources of information used to support quality use of medicines: Findings from a national survey of nurse practitioners in Australia Thomas Buckley, RN, BSc(hons), MN, PhD1 , Helen Stasa, BA (Hons), PhD1 , Andrew Cashin, RN, MHN, NP2 , Meg Stuart, B. App. Sc (Physiotherapy), MSc, PhD, Grad Cert HS (Education)3 , & Sandra V. Dunn, RN, PhD, FRCNA4 1
Sydney Nursing School, University of Sydney, Sydney, Australia School of Health and Human Sciences, Southern Cross University, Lismore, Australia 3 School of Physiotherapy, Australian Catholic University, Sydney, Australia 4 School of Health, Charles Darwin University, Darwin, Australia 2
Keywords Nurse practitioners; prescribing; medications; marketing. Correspondence Thomas Buckley, RN, BSc(hons), MN, PhD, Sydney Nursing School, A4.28 Building MO2, University of Sydney, NSW 2006, Australia. Tel: +61 2 9114 4043; Fax: +61 2 9351 0615; E-mail: [email protected] Received: 29 August 2012; accepted: 25 February 2013 doi: 10.1002/2327-6924.12138
Abstract Purpose: The purpose of this study was to investigate the sources, both print and electronic formats, which Australian nurse practitioners (NPs) currently use to obtain information regarding quality use of medicines (QUM). An additional aim was to document NPs’ preferences for continuing education in relation to QUM. Data sources: A national electronic survey of Australian NPs was conducted in 2007 and again in 2010. Conclusions: Eighty percent of respondents accessed information on QUM from professional literature, which may include scholarly journal articles, reports, and independent publications. There was a decrease in the percentage of respondents who obtained information from drug industry representatives. NPs prefer to receive medicines information in an electronic form, rather than a paper-based version, and over the time period more NPs are utilizing electronic sources rather than paper. Implications for practice: These findings provide important insights into medical information products for the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines in electronic format, but also highly value conference proceedings, may help to inform future planning of NP education needs in relation to QUM.
Introduction and background Internationally, the term “nurse practitioner” (NP) is used to refer to registered nurses (RNs) who have “acquired the expert knowledge base, complex decisionmaking skills and clinical competencies for expanded practice” (Australian Nursing and Midwifery Council, 2006; International Council of Nurses Nurse Practitioner/Advanced Practice Nurses Network, 2012; Nursing and Midwifery Board of Australia, 2011a). NPs were first introduced in the United States in the 1960s, and since then, similar roles have been created in Australia and many other countries, such as Canada, the United Kingdom, and New Zealand (Canadian Nurses Associa-
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tion, 2002; Cashin, Buckley, Newman, & Dunn, 2009; IBM SPSS Statistics Version 20, 2011). Nonetheless, there is significant variability across these countries in regards to the use of the NP title and educational requirements. For instance, in the United States, the NP title is regulated, and prospective NPs are required to have completed a postgraduate qualification in their area of intended practice. However, the NP scope of practice (e.g., prescribing or referral rights) varies between states (American Nurses Credentialing Center, 2008). In contrast, in the United Kingdom, there is no title protection or minimum educational requirements for NPs, and scope of practice is often based on employers’ requirements (Barton & Mashlan, 2011). In Australia, the
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NP title is protected by legislation, and is used to refer RNs who, through specialist Master’s level education and at least 3-year specialty clinical experience, are “authorised to function autonomously and collaboratively in an advanced and extended clinical role” (Australian Nursing and Midwifery Council, 2006). Additionally, it should be noted that the prescribing practices of NPs vary markedly across these countries. In the United States, NPs have the authority to prescribe in all 50 states, and can prescribe independently in 27 states (Byrne, 2010). In the United Kingdom, independent nurse prescribers have unlimited prescribing rights within their areas of competence, with the exception of certain controlled and unlicensed medications (Department of Health (UK), 2010a, 2010b). Following appropriate training with a medical prescriber, the U.K. nurse prescribers are able to initiate prescriptions, as well as continuing them (Department of Health, 2006). In Australia, endorsed NPs are authorized to prescribe medications relevant to their scope of practice (Cashin et al., 2009; IBM SPSS Statistics Version 20, 2011; Nursing and Midwifery Board of Australia, 2011b). The issue of prescribing is important to ensure that healthcare practitioners can provide comprehensive health care to their clients (e.g., to monitor and revise pharmacological treatment regimens) and to ensure that health service professionals with the authority to prescribe possess a good understanding of the medications available to treat conditions in their area of specialization. Research has shown that patients rely heavily on health service professionals to provide them with information about their medication, and they often wish to know more information than the prescriber is able to provide (Dickinson & Raynor, 2003; Ekman, Schaufelberger, Kjellgren, Swedberg, & Granger, 2007; Lokk, 2011; Ndosi & Newell, 2010). In recent years, more patients are using the Internet to access information about their conditions (Fortinsky, Fournier, & Benchimol, 2012). For instance, a recent study in the United States found that 63% of clients who were eligible to use an online health web service had taken advantage of this opportunity. Interestingly, the researchers found that the digital service was particularly well utilized by older individuals, with 60% of those in the 60–69 age group taking advantage of this (McDonald, 2012). Despite the increasing popularity of online information, studies have suggested that patients tend to view such resources as an adjunct to the information provided by health professionals, rather than as the primary source of advice (Pohjanoksa-Mantyla et al., 2011; Tio, LaCaze, & Cottrell, 2007). Similarly, in a U.K. study, Lorimer, Cox, and Langford (2012) surveyed patients who had been admitted to hospital following an
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adverse drug reaction, and found that respondents tend to feel that the health professionals should have been more communicative and provided more information regarding the prescribed medications. Given the diversity of medications available, and the fact that new medications are continually being developed, it is vital that prescribers are able to access accurate, current, relevant, and evidence-based medication information to assist them in their prescribing practice. Ensuring that prescribers are adequately informed about medications is one of the key tenets of the Australian Government’s quality use of medicines (QUMs) strategy (Australian Government Department of Health and Ageing, 2002). As with the World Health Organization’s (WHO) “rational use of medicines” (2012), QUM involves a number of distinct but related aspects, including
r r r r
selecting management options wisely; critically evaluating whether medication is needed in a particular case; choosing a suitable medication if one is considered necessary, while taking into account factors such as the individual’s preferences, clinical condition, risks and benefits, dosage, and coexisting conditions; and using medicines safely and wisely
(Australian Government Department of Health and Ageing, 2002). A number of international studies have examined the sources of medications information used by medical practitioners. In a British study, McGettigan, Golden, Fryer, Chan, and Feely (2001) examined the sources of medication information used by both general practitioners (GPs) and hospital medical practitioners. The researchers found that the GPs tend to rate the Drugs and Therapeutics Bulletin and medical journal articles as important source of information on old and new drugs, while pharmaceutical representatives and colleagues were rated as most important source of information on new drugs. In contrast, hospital medical practitioners tend to rely on the British National Formulary and senior colleagues for theoretical information, and colleagues and pharmaceutical representatives in practice (McGettigan et al., 2001). In Australia, the National Prescribing Service (NPS), an independent, not-for-profit organization that seeks to foster QUM, conducted a study of the sources of information that GPs use when prescribing (National Prescribing Service Limited, 2008). The researchers found that Monthly Index of Medical Specialties, more commonly known as MIMS (contains Australian Therapeutic Goods Administration approved product information that originates from the manufacturer/distributor), the Prescribing Benefits Schedule (the Australian Government schedule of prescribing
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benefits), and therapeutic guidelines (TG; a peer-reviewed independent publication related to use of medicines) were the most commonly used sources of drug information. Less is known about the sources of information used by nurse prescribers. One exception is an early study by Hall, Cantrill, and Noyce (2003), which is a small U.K.based study that analyzed the sources of medication information used by community nurse prescribers. The investigators found that the nurse prescribers tend to seek information from professional journals and the British National Formulary, although they also relied on pharmaceutical company representatives, community pharmacists, nurse specialists, colleagues, and GPs (Hall et al., 2003). However, to date, no research has been published regarding NPs’ sources of medication information in the Australian context. This gap in the literature is problematic, because understanding which sources of information NPs use when making medication decisions can help educators in the designing curricula and continuing education courses to meet the information needs of NPs, and thereby promoting improvements inpatient services. The primary aim of the present study was to investigate the sources, both print and electronic formats, which Australian NPs currently use to obtain information regarding QUM, and to document NPs’ perceptions of the usefulness of such resources in supporting prescribing practice. An additional aim was to document NPs’ preferences for continuing education in relation to QUM.
Methods Study design In years 2007 and 2010, a descriptive online survey exploring medication-prescribing behaviors was conducted with members of the Australian College of Nurse Practitioners (ACNP) to examine the sources of information used by NP members to inform their use of medicines in practice. On both the occasions, the electronic survey was available for a 6-week period, accessible via the college website. Frequent reminders (every 2 weeks) were e-mailed throughout the survey periods to encourage participation.
Study participants All authorized NPs, who were members of the ACNP, were eligible to participate in this study. In 2007, 68 authorized NPs participated in the survey (27% of Australian authorized NPs at the time) and in 2010, 209 NPs participated in the survey, which gave a response rate
of 83% of ACNP eligible members and represented approximately 50% of all Australian NPs.
Ethics and consent Ethical approval was received from the Human Research Ethics Committee of the Northern Territory Department of Health and Community Services, and Menzies School of Health Research. While accessing the online survey, potential participants were first provided with an introduction outlining the aims of the study. Implied consent was assumed if potential participants proceeded past this screen. Participants were free to discontinue their participation at any time. All data collected were deidentified prior to analysis.
Questionnaire The survey was designed to document various aspects of prescribing practices using a questionnaire reported previously (Cashin, Buckley, Newman, & Dunn, 2009; Dunn, Cashin, Buckley, & Newman, 2010; Newman, Buckley, Dunn, & Cashin, 2009). Content validity of the questionnaire was established by a review conducted by three doctoral-prepared researchers and NP educators including one endorsed NP. In addition to demographic data, participants completed questionnaires specifically evaluating the most common sources of information used related to medications and the format of information used (paper or electronic). Participants were asked “How do you currently obtain information on medicines and Quality Use of Medicines” with potential responses, including drug industry marketing or representatives, professional colleagues, professional literature, national prescribing service resources, professional organizations; conferences or workshop presentations, or clients or families. Participants were able to report whether these resources were used in print (paper) and/or electronic format, allowing trends to be calculated over the time period from 2007 to 2010. Participants who used these resources were asked to rate their perceived importance of each of the sources of medicine information in informing their use of medicines on the Likert scale ranging from very important (scored as 3) to not important (scored as 0). To determine preferences for continuing education related to QUM, participants were asked to indicate their preferred means of receiving such information from the following response options: e-mail, for example, newsletters, fliers, etc.; online discussion groups; interactive online case studies or tutorials; face-to-face lectures or educational evenings (multidisciplinary or NPs only); conference workshops; online video presentations; 89
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downloadable print learning packages; downloadable audio files (e.g., for MP3 players); downloadable case studies/quizzes for personal digital assistant (PDA); or interactive modules on CDs. Participants were able to choose more than one option while responding to this question.
Data analysis Data were collected online using Survey Monkey (2007) and Lime Survey (2010; an Open Source PHP web application; LimeSurvey Project Team/Carsten Schmitz, 2012). After the survey period ended, data were transferred to an Excel data sheet, before being imported to SPSS for statistical analysis (IBM SPSS Statistics Version 20, 2012). Frequency and descriptive data were presented for each variable. Statistical comparative analysis was not performed between responses from the 2007 and 2010 participants as the samples were not considered totally independent, and it is very likely that some participants would have participated in both surveys.
Results Participant demographic information is presented in Table 1. Both survey respondents (2007 and 2010) were very similar in age, sex, years practicing as an RN, and location of practice, although there were slightly more NPs practicing in the private sector in 2010 compared to 2007 (6% vs. 10%). The proportions of respondents who reported using each source of medication information are shown in Figure 1. The majority of respondents reported that they obtained their information regarding QUM from professional literature, followed by professional colleagues and NPS resources. Less than 50% of participants reported using the Australian MIMS (MIMS, 2012), followed by the Australian Medicines Handbook (AMH Pty Ltd, 2012), TG (Therapeutic Guidelines Limited, 2012), and professional organizations. As shown in Figure 1, in 2010, a greater proportion of NPs reported using MIMS and TG for information regarding QUM, while less NPs reported relying on drug industry representatives for information compared to the 2007 survey. Overall, professional literature was the most reported information source in years 2007 and 2010. Participants were asked to rate the importance of each of the sources of information on medicines and QUM. These results are shown in Figure 2. Perhaps reflective of participants’ choice of use, professional literature, NPS resources, and professional colleagues rated highest, whereas conversely drug industry marketing was rated least important. 90
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Table 1 Characteristics of study participants
Mean age in years (range) Female Male Years practicing as an RN 25 years Did not state Location of practice Metro Rural Remote Practicing in public sector Practicing in private sector Jurisdiction of authorization • New South Wales • Western Australia • Queensland • Victoria • South Australia • Australian Capital Territory • Tasmania • Northern Territory • Did not state
2007 (n = 68) 47.1 (31–64) N 53 78% 15 22%
2010 (n = 209) 48.5 (31–65) N 168 80% 41 20%
0 3 7 10 14 34 0
0 4% 10% 15% 21% 50%
0 7 24 26 39 78 35
0 3% 11% 13% 19% 37% 17%
52 12 4 64 4
76% 18% 6% 94% 6%
151 49 9 189 20
72% 23% 5% 90% 10%
36 5 7 8 5 6 0 1 0
53% 7.5% 10% 12% 7% 9% 0 1.5% 0
56 40 37 26 19 10 4 3 14
27% 19% 18% 12% 9% 5% 2% 1% 7%
Participants were asked to nominate which information sources they had used in the 4 weeks immediately preceding the survey, and if the information had been accessed in an electronic or paper-based format. These results are presented in Table 2. Overall, in 2010, a higher proportion of participants reported utilization of electronic resources for the most commonly used resources. For example, 36% more were accessing electronic versions of the MIMS Australia resource and 14% more were accessing TG Australia electronic version, compared to 2007 (Table 2). Participants’ preferences for continuing education related to QUM are presented in Figure 3.
Discussion The study found that over 80% of NP respondents reported gaining their information on QUM from the professional literature, which may include scholarly journal articles, reports, and independent publications. Professional colleagues and NPS resources were the second and third most commonly cited sources of information, respectively. This order of sources did not differ between 2007 and 2010. The high percentage of NPs using the professional literature for information on medicines
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Figure 1 Sources of information used by participants to support prescribing practice. Note. Participants could choose more than one response. NPS, National prescribing services; AMH, Australian Medicines Handbook.
Figure 2 Respondents’ ratings of their perceived importance of each of the sources of medicine information (2010 participants). Note. Higher scores indicate greater perceived importance (possible range 0–3).
is extremely positive, as such sources tend to be peerreviewed and provide an objective evaluation of available medications. Of particular interest is the decrease in the percentage of respondents who obtained information from drug industry representatives, and the observed increase in the percentage of respondents using MIMS and TG for information. This decreased reliance on drug industry representatives would seem to be an encouraging sign because prescriber–industry relations often influence subsequent prescribing behavior (Campbell, 2007). While such interactions and information exchange may be helpful in providing prescribers with a greater knowledge and understanding of available medications, such re-
lationships can have negative effects as well. For example, an NP who formed a good relationship with a representative of a particular drug brand may be more inclined to prescribe that brand to a client, despite the fact that cheaper, and possibly more effective, alternatives may exist (Campbell, 2007; Skoglund, Bjorkelund, Mehlig, Gunnarsson, & Moller, 2011; Yoon et al., 2010). The finding that NPs reported using and placing greatest value on the professional literature to support their medication practices is similar to that reported of GPs, who also reported considering professional literature of high importance (Hall et al., 2003; McGettigan et al., 2001). However, in evaluating the actual sources of information 91
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Figure 3 Preferences for continuing education related to QUMs. Note. Higher values indicate greater percent of NPs preference. Table 2 Proportion of respondents who used either paper- or electronic-based resources to support their QUMs in the prior 4 weeks 2007 participants
Australian Medicines Handbook (AMH) MIMS Australia Therapeutic guidelines (Australia) Cochrane database Australian prescriber Pharmaceutical benefits scheme (PBS) schedule British Medical Journal (BMJ) clinical evidence National Prescribing Service (NPS) RADAR Other national prescribing service products
2010 participants
Change in use of resources over time
Paper-based resource (%)
Electronic resource (%)
Paper-based resource (%)
Electronic resource (%)
Paper-based resource (%)
Electronic resource (%)
54 44 41 10 18 22 7 6 4
47 34 39 34 22 17 18 15 10
60 41 26 3 23 10 7 6 4
47 70 53 35 24 26 22 16 13
+6 −3 −15 −7 +5 −12 0 0 0
0 +36 +14 +1 +2 +9 +4 +1 +3
Note. Participants could choose more than one format for each resource.
NPs had accessed in the 4 weeks prior to the survey; the AMH, MIMS, and TG were the three most frequently accessed. This finding is similar to previous reports where Australian hospital based doctors reported accessing these same sources of medicines information to support prescribing practices (National Prescribing Service Limited, 2008). This similarity may be reflective of the place of practice for NPs in Australia, where 90% NPs worked in the public health service, a significant proportion of which are assumed to be hospital-based positions. At this point, it is important to make two main comments about the differing sources of information available to prescribers. When evaluating the utility of different medication information sources, it is vital for the 92
prescriber to critically assess the independence of these sources. For example, information that is gained from a pharmaceutical company representative may be less independent than information gained from a publication that is not aligned to any particular industry group, such as TG or the Cochrane database (The Cochrane Collaboration, 2012). A second important factor that needs to be considered is how the prescribing information may be accessed. This involves a number of aspects, including the format of the information, and whether the user needs to pay a fee. For instance, some information sources, such as MIMS and the Cochrane Library, are accessible in various formats (such as print, PDA, or online), while others may not be available in as many different ways (MIMS Australia Pty Ltd, 2012).
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Whether a particular information source is available in the users’ preferred format is likely to have a large influence on its usage. Similarly, as many medication information sources require a user to pay an access fee, the cost of these licensing agreements may also impact a user’s choice. For example, recent figures show that the annual print version of MIMS costs AU$220, while the electronic eMIMS costs $360 (MIMS Australia Pty Ltd, 2012); the AMH costs $160 for any format (AMH Pty Ltd, 2012); and eTG costs $325 for a single online user (Therapeutic Guidelines Limited, 2012). While it is often possible for hospitals and healthcare groups to gain institutional access to such information sources, some NPs, especially those working off hospital sites, may elect to purchase their own licenses to different information sources. Nonetheless, it should also be borne in mind that the information provided by MIMS is Australian Therapeutic Goods Administration approved product information that originates from the manufacturer/distributor, although the creators of MIMS emphasize that the information provided by the drug is subject to strict editorial review (MIMS Australia Pty Ltd, 2012). The results also suggest that NPs prefer to receive their medicines information in an electronic form, rather than a paper-based version and over the period of time more NPs are utilizing electronic sources rather than paper. There are a number of advantages associated with electronic prescribing information. First, electronic versions of medicines information are often more cost-effective than print versions, and may be able to be utilized by multiple users (MIMS Australia Pty Ltd, 2012). Second, electronic medicines information may be more easily updated than print information. For example, the electronic versions of TG are updated three times per year (Therapeutic Guidelines Limited, 2012), whereas most print publications are only updated once per year (MIMS Australia Pty Ltd, 2012). As such, opting for an electronic version of medicines information may enable NPs to stay better informed about current developments and new products. Third, electronic information may be more portable than printed material, and more easily accessed via laptop or PDA, providing greater options for both transportation of information and access when required. This is particularly important for those NPs who may undertake substantial hours of their work off-site, or who see patients in different locations, and require continuous access to medicines information.
Limitations There are a number of limitations associated with the present study. The first of these is that participants required computer access to participate in the online sur-
vey. As such, participants who were not able to access a computer (and the Internet) either at work or home were not able to participate. This limitation may have skewed the reported preference of many of the respondents to access medicine information in electronic format. It is possible that some of those NPs who would prefer to use a paper-based medications information format may not have completed the survey because they were either unwilling or unable to access the Internet. Second, while the survey asked respondents which resources they had used for medicines information and QUM, it did not ask them why they chose the resources that they did. While we can speculate that factors, such as cost, accessibility, and format, may have played a part, further investigations are clearly needed in order to better understand precisely what influences NPs’ choices of medicines information.
Conclusion The results of this study provide important information about the method Australian NPs use to receive information on medications, and their preferences in regards to QUM. Additionally, they suggest that the sources of information and the preferred format for such information have changed over the past 3 years with lesser reliance on drug industry representatives and paper-based sources, and more reliance on electronic information sources, such as MIMS and TG. These findings provide important insights into medical information products to the developers who may be able to use these results to ensure that their products meet the needs of NP clinicians. Additionally, the finding that NPs prefer to receive their continuing information related to medicines by electronic format, and additionally value conferences, informs future planning for NP education needs in relation to QUM.
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