VOL: 101, ISSUE: 48, PAGE NO: 56Nurse prescribing was introduced in 1998 to support the expanding role of nurses, particularly in primary care. It acknowledged that many nurses were taking increasing responsibility for managing patients with a range of conditions yet, despite their specialised knowledge, they were unable to prescribe the relevant medications and products.
Nurse prescribing was introduced in 1998 to support the expanding role of nurses, particularly in primary care. It acknowledged that many nurses were taking increasing responsibility for managing patients with a range of conditions yet, despite their specialised knowledge, they were unable to prescribe the relevant medications and products.
Independent nurse prescribing was initially allowed from an extremely limited formulary. It was extended a number of times over the following years for nurses who had undertaken extended prescriber training, although nurse organisations complained that the extensions responded to policy initiatives rather than the needs of nurse prescribers. But 2005 has seen major changes that many nurse prescribers had doubted would ever happen.
A recent amendment to the Misuse of Drugs regulation 2001 will allow independent nurse prescribers working in critical care, palliative care and substance misuse to prescribe from a more extensive list of controlled drugs, while in early November health secretary Patricia Hewitt announced that appropriately qualified nurses will be allowed to prescribe from the whole of the British National Formulary - with the exception of some controlled drugs - after changes to the Medicines Act enable this development. Nurse prescribers welcomed the move, having found the previous piecemeal extensions problematic.
'While the extensions were helpful, because they were done in stages nurses were often confused about what they could and could not prescribe,' says Molly Courtenay, reader in prescribing and medicines management, University of Reading and RCN joint prescribing adviser.
However, nurses have no doubt that nurse prescribing has improved patient care - even with the current restrictions: 'It gives patients the continuity, and quicker access to treatment - that's especially important for patients who are in pain, when they may have to hang around for two hours for a doctor to come and prescribe analgesia. No one should have to wait around in pain unnecessarily,' says Linda Nazarko, consultant nurse - older people, Richmond and Twickenham PCT, and visiting senior lecturer, London South Bank University.
The system has also had professional benefits for nurses: 'For me, the most important thing is that you can take responsibility for your own decisions, rather than having someone else OK them,' says Anne Baird, nurse practitioner at Porter Brook Medical Centre, Sheffield.
Over 28,000 nurses are now able to prescribe from the limited formulary, and there are currently over 4,000 extended prescribers (Medicines and Healthcare products Regulatory Agency, 2005). However, this is far from the Department of Health's target of 10,000 independent nurse prescribers by the end of 2005.
A number of reasons have been suggested for the numbers being lower than hoped. A key factor is availability of training for such large numbers in a relatively short time, and there are now concerns that the numbers being trained will soon drop off for financial reasons. The Department of Health's ring-fenced funding for training is due to end in April 2006. The Department is issuing guidance to strategic health authorities about funding for non-medical prescribing training, but no details are currently available.
Other forms of supplying medicines have been developed to enable nurses to supply medications. Supplementary prescribing, for example, involves a partnership between an independent prescriber (a doctor or dentist) and a nurse, midwife or pharmacist to implement a patient-specific clinical management plan.
Following assessment and diagnosis by the independent prescriber, the supplementary prescriber can choose dosage, frequency and products within the specifications of the plan. Patient group directions is a method of enabling nurses to supply and administer medicines to groups of patients with particular conditions, although the method does not constitute prescribing.
There has been some reluctance, however, to adopt supplementary prescribing within primary care. There are certainly benefits, but it also has its limitations.
Molly Courtenay believes that some practices are put off by the clinical management plan because they think it will be time-consuming to develop, but adds: 'It should not take any longer to develop than usual patient notes - it is simply documenting their care, which is done whether or not the nurse is a supplementary prescriber.'
For independent nurse prescribers, one of the main frustrations has been the limitations of the extended formulary, which does not always meet their patients' needs. It has also led to anomalies in nurses' prescribing powers. For example, while they can prescribe antibiotics for women with urinary tract infections, they cannot currently do so for men.
Linda Nazarko believes these restrictions have put some nurses off becoming prescribers. 'Nurse prescribing developed from a disease and acute care perspective, which is ironic since it is overwhelmingly used in primary care,' she says. 'While extended prescribing and additions to the formulary have opened things up it still doesn't work well for people with more than one condition because it focuses on the condition rather than the patient.'
While some - notably the British Medical Association - may have concerns about enabling nurses to prescribe from the whole BNF, Molly Courtenay believes it is a positive development. She points out that the vast majority of nurse prescribers have over 10 years' experience as well as specialist clinical knowledge, and are well able to take on the responsibility. 'Giving independent nurse prescribers access to the full formulary will not mean they will be prescribing right across it - not even doctors do that,' she says. 'It will iron out any anomalies by enabling nurses to prescribe within their own area of expertise and competencies. I think this will have real benefits for patients, nurses and doctors.'
Anne Baird agrees that competencies are a major issue: 'The whole business of working within your competencies will have to be stressed within training. People will have to be very clear about their own competencies - but I think that's the same for any prescriber, not just nurses.'
Although the system is not perfect, independent evaluation of nurse prescribing has been positive. Latter et al (2005) undertook a national survey of 246 nurse prescribers and 10 in-depth case studies of practices in which nurse prescribers worked. They concluded that nurse prescribing is largely successful in both practice and policy terms (Box 1), and that nurses prescribe appropriately.
Dispensing with the extended formulary and allowing nurses to prescribe as truly autonomous practitioners will enable them to increase the benefits they can offer to their patients and make full use of their knowledge and expertise.