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Independent nurse prescribing

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Independent nurse prescribers will be able to prescribe from almost the entire BNF, offering huge potential in all settings and specialties. Seonaid Strachan-Bennett explains

When the government announced at the end of 2005 that independent nurse prescribers would soon be able to prescribe from almost the entire BNF, it was hailed as a victory for the profession.

The decision followed years of campaigning by nurse organisations that had criticised the nurse prescribing formulary for unnecessarily restricting the ability of nurses to respond to patient needs. In theory nurse prescribers will now have a ‘free rein? to extend the services they offer in terms of prescribing.

‘I’ve been campaigning for six or seven years for nurse prescribing to be opened up,? says Matt Griffiths, joint prescribing and medication management adviser at the RCN and senior charge nurse at a walk-in centre in Peterborough. ‘I could see it was going to make a great difference. In practice we will be able to complete episodes of care and people can go home with a definitive answer.?

The idea of nurse prescribing was mooted in 1986 in the report Neighbourhood Nursing: A Focus for Care by Baroness Julia Cumberlege (who later became vice president at the RCN). It was not until 1992, following a further report from a governmental advisory committee, that legislation was passed allowing nurses with a district nursing or health visitor qualification to prescribe from a limited formulary after a short training course.

Despite this it was nearly a decade later, in 2001, that the government introduced legislation allowing more nurses to become prescribers and extending the formulary to allow the prescribing of extra drugs for specific conditions.

Since then, the government has gradually extended this formulary until last year when a review held by the Committee on Safety of Medicines recommended to the government that the entire formulary be opened up.

Although welcomed by nurses, the British Medical Association reacted angrily, claiming nurses are not as highly trained as doctors and that the move was a dangerous one.

However, nurse campaigners also argue that nurses are the natural choice to prescribe - many already make recommendations to doctors on suitable medications or write prescriptions for doctors to sign. In addition, nurses work more closely with patients than other health professionals and are therefore more able to monitor their requirements.

‘Having the full formulary enables us to get on with the job,? argues Barbara Stuttle, chairperson of the Association for Nurse Prescribing. ‘It enables patients to be treated by the most appropriate clinician.?

At Macmillan Cancer Relief the opportunities for nurses as prescribers are currently under review following the decision to open up the formulary. Dame Gill Oliver, adviser for allied and nursing professionals at Macmillan Cancer Relief, says: ‘If patients have increasing pain and the painkillers they are prescribed aren?t working and nurses are able to prescribe it means that patients don?t have to wait so long. It makes sense because nurses spend more time with patients than anyone else. It would be providing a better service for the patients.?

One nurse who is acutely aware of this potential is Heather Williams, clinical nurse specialist in chronic pain management at Newcastle Upon Tyne Hospitals NHS Trust. Although she has been a qualified nurse prescriber since 2004, she has rarely been able to put her new skills into practice because the drugs she needs to prescribe are not on the limited formulary.

‘I work with patients who have [pain relief] implants. Sometimes they become infected and need to be prescribed antibiotics. At the moment we have to say to them ‘go and see your GP?. I was looking at prescribing with a management plan but, to be honest, to put that into practice was so time consuming it wasn’t something that made patient care more efficient,? she explains.

‘When the BNF is opened up I will be able to do that. It will be easier to give them a prescription there and then, plus I will know the patient has actually got it,? she adds.

Ms Williams is hoping to use the open formulary to set up a community clinic where she can see patients and prescribe pain-relieving medication. At the moment she has to fax the GP of each patient to tell them what to prescribe.

Discharge planning is another area set to benefit from the opening up of the formulary. Simon Bowles, junior charge nurse and cardiac inpatient discharge coordinator at Norfolk and Norwich University Hospitals NHS Trust, is one of five nurses trained to prescribe discharge medications or TTOs(to take out) to speed up the discharge process. But the variety of TTOs required means this has not yet been implemented.

‘If you?ve got a ward round, the consultant may say ‘I don?t think this pain is from your heart, you can go home?. The junior doctor will finish the ward round first and then come back and do the paperwork. At the moment we write out the TTOs but we still need to get them signed,? he says.

He also hopes to use the opened-up formulary to enable more patients to self- medicate and keep their medication in locked cupboards by their beds. This requires drug charts written in ‘layman?s terms?, which can be time-consuming for doctors to complete.

However, opening up the formulary will not magically change the misgivings of certain health professionals and employers. Mr Bowles and his colleagues are having to contend with concerns arising from the fact that nurse prescribing in acute settings is still relatively unusual. In order to allay these fears the team has written management plans for common conditions that they encounter, such as congestive cardiac failure and acute coronary syndrome, which doctors will need to approve before nurses start prescribing.

In addition the opened-up formulary is not a ticket to being able to meet all the prescribing needs of these patients. Controlled drugs, covered by law under separate legislation, will still have to be prescribed by doctors and this may feel like a barrier to nurses.

Nurses will also face a much more stringent training programme and eligibility criteria developed by the NMC (see box). This includes a 100% pass rate required on a maths test - double the grade demanded of doctors and pharmacists - which current nurse prescribers fear will put many colleagues off training. They believe it may be up to 20 years before nurse prescribing becomes an integral part of the nursing role (NT Analysis, 21 March, p12).

There are also concerns that nurse prescribing is taking a step too far towards the medical model. Ms Stuttle disagrees. ‘Nurses are trained differently [from doctors],? she says. ‘It?s about using our nursing skills in the best way possible. I certainly encourage nurses to [become prescribers], this will enable them to utilise all their skills but also it gives them huge opportunities to do things differently.?

Mr Griffiths adds that nurses cannot underestimate the importance of the recent decision to open up the formulary to nurses. ‘We’ve got people from across the world looking to see what?s happening. This really is groundbreaking stuff, not only for nurses in the UK but for nurses worldwide.?

Nurse prescribing - the story so far

Government plans

- In April 2002 the DH set a target for 10,000 extended formulary nurse prescribers by 2004, pledging £10m to pay for their training. Only 6,800 are currently registered. The target has now been extended to the end of 2006.

‘At the end of 2005 the DH announced that from May 2006 independent nurse prescribers will be able to prescribe from the entire BNF, with the exception of controlled drugs.

- Overall funding for training and CPD has not yet been secured for the coming year and there are doubts over whether any of it will be
ringfenced, although Christine Beasley, chief nursing officer for England, has requested this.

NMC eligibility criteria and training

‘Last month the NMC announced new criteria for trainees including three years? experience and an appraisal that includes a Criminal Records Bureau check.

‘Nurses will have to prove they can study at degree level and have written support from their employer, programme leader and designated medical supervisor.

‘The training programme will include 26 days? classroom learning, 12 days? shadowing their medical supervisor, a portfolio and detailed scrutiny of practice.

‘Written papers on pharmacology and maths will require pass rates of 80% and 100% respectively.

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