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Nurse prescribing: current status and future developments.

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Health secretary John Reid said in his speech to nursing managers at the chief nursing officer’s conference on 14 November 2003 that ‘by opening up the prescription pad to nurses we have given them a powerful and symbolic tool. One that makes choice a reality for patients’.


VOL: 100, ISSUE: 17, PAGE NO: 29

Marian Lanyon, MA, BA, CertEd, RCN Registered Clinical Teacher, RN, is new prescribers’ coordinator (Suffolk-wide), The Ipswich Hospital NHS Trust.

Health secretary John Reid said in his speech to nursing managers at the chief nursing officer’s conference on 14 November 2003 that ‘by opening up the prescription pad to nurses we have given them a powerful and symbolic tool. One that makes choice a reality for patients’. Last week there was an increase in the possibilities of this choice with a new government proposal under which nurse prescribers could have another 60 drugs for emergency use added to their formulary (Norris and Strachan-Bennett, 2004). Prescribing legislation
In 1986 the Cumberlege report recommended that there should be a limited list of items that could be prescribed by nurses (Department of Health and Social Security, 1986). These recommendations were reviewed by the Department of Health in the first Crown report (DoH, 1989). Changes in legislation between 1992 and 1994 then allowed district nurses and health visitors prescribing rights from their own limited nurse prescribers’ formulary. In 1999 an extensive review of prescribing, supply, and administration of medication was conducted by the DoH, again under the leadership of Dr June Crown (DoH, 1999). This report spearheaded the expansion of independent prescribing by other nurses. Nurses were able to prescribe from the original nurse prescribers’ formulary plus all licensed pharmacy and general sales list medicines and selected prescription-only medicines. Prescribing to improve patient access
The DoH saw four areas where patient access to treatment could be enhanced through nurses being able to prescribe medication. These areas were: - Minor illness; - Minor injury; - Health promotion; - Palliative care. In 2000 the first extended independent nurse prescribers were trained and began to prescribe within walk-in centres, A&E departments, and GP practices. In November 2002 it was recommended that nurses and pharmacists should become trained as ‘supplementary prescribers’. Supplementary prescribers do not undertake the initial assessment, diagnosis, and prescribing for patients but operate within the framework of a clinical management plan (CMP) to manage chronic conditions such as diabetes or asthma within such settings as outpatient departments and clinics. This is a partnership between an independent prescriber (medic) who makes the initial diagnosis and initiates treatment, and the supplementary prescriber (nurse/pharmacist) who can then adjust medication as required (within the parameters of the CMP). Both the independent and supplementary prescriber must have access to a common medical record, and timely medication reviews must be undertaken. The role of supplementary prescriber will eventually be extended to other allied health professionals such as optometrists, physiotherapists, and radiographers. This will enhance the ability of patients to access services quickly and efficiently, thereby improving patient flow through the health care system. This is at the core of The NHS Plan (DoH, 2000) - for services to be available when people need them, tailored to their individual needs. Prescribing training
Suffolk has over 30 nurses working in primary and secondary care who are currently qualified as independent and extended prescribers and as supplementary prescribers. They have completed a degree-level training programme that has given them a solid theoretical and practical base. The programme, provided by the local higher education institute at Suffolk College, is run over a six-month period. There are 26 days of tuition within the college, and 12 days of supervised practice in the nurses’ clinical areas. In order to achieve supplementary prescribing status students have to attend one extra taught day and produce a further portfolio of evidence. Each student has a supervisor who must be a senior medical practitioner with at least two years’ experience within the student’s field of practice. Course lectures are delivered by multiprofessional staff including nurses, pharmacists, and medics, and cover a range of topics including clinical governance, prescription writing, and the legal and ethical implications of prescribing. Formal assessment of the course is undertaken via an objective structured clinical examination (OSCE), a portfolio of evidence related to practice, and a written examination. The programme costs are currently met by the workforce development confederation (WDC), and so the course is free for all nurses who care for NHS patients. Potential applicants must be able to study at degree level, have at least three years’ post-registration clinical experience, and the support of their line manager as well as an identified medical practitioner who is willing to supervise the student’s 12 days’ learning in practice. Managers should be planning to extend nurses’ prescribing powers since NHS modernisation plans demand a radical shift away from traditional roles. A selection process to find suitable candidates for the course in Suffolk has been developed by a Suffolk-wide steering group that was originally set up to oversee the implementation of the national directives with regards to the extension of prescribing roles. The Suffolk New Prescribers Steering Group comprises nurse and pharmacy representatives from the three acute hospital trusts and five primary care trusts within Suffolk, the local WDC, and Suffolk College. It hopes to welcome a representative from the local trust that provides mental health services for Suffolk. By taking on the responsibility of selection, it is able to ensure that service needs are met in this initiative in an equitable way across the local health economy (Box 1). Prescribing in practice
Nurse prescribing status is formally recorded on the NMC register and nurse prescribers are expected to fulfil the continuing professional development requirements of the role. At The Ipswich Hospital NHS Trust nurse prescribers practise within a medicines management governance framework and a policy has been developed for non-medical prescribing within the trust. A non-medical prescribing group with multidisciplinary membership maintains an overview of new prescribers’ activity in relation to clinical governance (Box 2). Through funding from the local WDC, the Suffolk Steering Group was able to appoint a coordinator whose role was to raise awareness of the course, support students undertaking the course and to arrange opportunities for continuing professional development. Nurse prescribers have requested CPD topics and these have been supplied via workshops across the county. The workshops have been well attended and very positively evaluated by the participants, and more are planned for the future. New developments
In the DoH’s recently commissioned evaluation of extended formulary nurse prescribing by the University of Southampton, the preliminary findings demonstrate that 90 per cent of independent prescribers claim to feel frustrated by the limitations of the nurse prescribers’ extended formulary and that 87 per cent of them would feel happier prescribing a greater range of antibiotics. The announcement by the health secretary of proposals to expand the extended nursing prescribers’ formulary even further with an extra 60 prescription-only medicines for the treatment of 30 or more conditions could improve first contact and emergency care for patients. Current discussions between the DoH and the Home Office’s Advisory Council on the Misuse of Drugs will probably add 13 controlled drugs to the formulary - a valuable development for nurses working in both emergency settings and palliative care. Recent changes in the rules surrounding the provision of nurse prescribing training have resulted in more flexibility in the structure and assessment of courses. Flexible methods of delivery such as e-learning and open learning are now possible. This should help to increase the number of nurses who are able to access the training. The importance of nurse prescribers
As a result of the recent introduction of the new General Medical Services contract, where core services are provided by GPs, out-of-hours services could become nurse led (Chatterjee, 2004). Nurses could, therefore, become the major providers of additional and enhanced services in primary care. The government has recognised the wealth of knowledge and expertise that nurses have acquired through the expansion of their scope of professional practice. Nursing remains a dominant feature of NHS modernisation reforms. Prescribing is just one of the avenues down which the nursing profession is venturing. This article has been double-blind peer-reviewed.

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