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Nurse prescribing: The next steps

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Nurse prescribing powers have grown from small beginnings to cover the entire formulary today. But area is still not without its concerns and difficulties. Clare Lomas reports on barriers facing nurse prescribers

When the Department of Health published the NHS Plan in July 2000, it promised to create new roles and responsibilities for nurses, and provide them with greater opportunities to extend their current nursing roles.

One of the key elements to the ten-year radical reform was to radically extend the role of nurse prescribers with the then health secretary, Alan Milburn, pledging an extra £10m to train 10,000 more nurse prescribers over the following three years.

Although there were some initial objections to the extension of the nurse prescribing role – some doctors called the practice ‘dangerous’ because nurses were not as highly trained as doctors – nurse prescribing has grown significantly over the past ten years.

According to the RCN, there are now over 48,000 nurse prescribers in the UK. Of these, 33,000 are health visitors and district nurses, who can prescribe from the Nurse Prescribers’ Formulary for community Practitioners.

The remainder are qualified as nurse independent prescribers or nurse supplementary prescribers. These nurses are now able to prescribe any licensed medicine – including some controlled drugs – as long as they work within their area of competence.

Gaining access to the full British National Formulary (BNF), in May 2006, gave appropriately qualified nurses virtually the same independent prescribing powers as doctors.

It was thought that opening up the formulary – thus further extending nurses’ independent prescribing skills – might have reduced the need for supplementary prescribing.

However, a study of 1,400 independent nurse prescribers – conducted at the end of 2006 – found that more than 40% were still using supplementary prescribing.

This compares to a similar survey in 2005, which found that 35% of 868 nurses qualified to prescribe independently were still supplementary prescribing.

 

‘Nurses who look after patients with complex conditions may not feel happy to prescribe alone, but they’re happy to do it using a clinical management plan’

Professor Molly Courtenay

 

Molly Courtenay, professor of prescribing and medicines management in the school of health sciences at Reading University, who conducted both pieces of research, said this figure now stands at around 20%.

‘There has been a definite shift towards independent prescribing, but some nurses still prefer to use supplementary prescribing to help develop their skills and confidence,’ she said.

‘Nurses who look after patients with complex conditions may not feel happy to prescribe alone, but they’re happy to do it using a clinical management plan,’ she added.

‘However, supplementary prescribing can be too “clunky” for some nurse prescribers, such as those working in A&E, and using a clinical management plan does not fit with their prescribing needs,’ Ms Courtenay told Nursing Times.

Since 2004, nurse prescribing is a joint qualification, and all nurses who complete the NMC V300 prescribing course are qualified to prescribe independently, as well as in a supplementary role.

However, Nursing Times has learnt that some NHS trusts have local policies in place that are restricting the extent to which nurses can prescribe medications to patients.

Despite being qualified to prescribe independently straight away, nurses at King’s College Hospital in London are required to practice as supplementary prescribers for six months before they can prescribe independently.

A spokesperson for the hospital told Nursing Times: ‘Prescribing medicines is a new responsibility for nurses. We adopted this policy after listening to the views of nursing staff who had worked as supplementary prescribers, many of whom felt it helped them “feel their way” into the role of prescribing medicines.

‘We do accept, however, that in areas like the emergency department, supplementary prescribing is not always feasible; as a result, staff may be permitted on a case by case basis to practice independently within an initially restricted scope of practice,’ he added.

Manchester Mental Health and Social Care Trust has adopted a similar policy, requiring nurses to complete mental health-related learning and ‘prove their ability’ by supplementary prescribing for the first six months after qualifying. The trust is also yet to approve the use of nurses as non-medical, independent prescribers. 

‘The prescribing course is excellent at teaching basic prescribing skills, but the extra learning ensures that nurses have the necessary skills to prescribe competently for mental health patients. This is the same for all mental health trusts across the Manchester area,’ said Petra Brown, chief pharmacist at the trust.

‘We have many high-risk patients with a huge range of symptoms and co-existing conditions, and there are excellent ways of using nurse prescribing. We are currently in the process of identifying areas where nurse independent prescribing will fit very well,’ she added.

However, at many other trusts across the country, nurse prescribers are able to work independently as soon as they are registered with the NMC, and limiting qualified nurses to a supplementary prescribing role has caused some concern among nurse prescribers. 

‘Supplementary prescribing is incredibly time consuming for prescribers, particularly those who work in walk in centres and specialist roles across multiple practices,’ said Judith Williams a nurse prescriber at Peterborough PCT.

‘I can see no benefit from [supplementary prescribing for six months], newly-qualified prescribers are already highly experienced practitioners who have been requesting medications for their patients for years,’ she added.

Alison Williams, emergency nurse practitioner in the emergency care centre at Maidstone and Tunbridge Wells NHS Trust in Kent, said supplementary prescribing would be of no benefit to her role.

‘If you have your own caseload of patients, supplementary prescribing may work. But I don’t know who is going to walk through the door, so drawing up a clinical management plan is not feasible,’ she said.

Ms Williams also told Nursing Times that delays in putting policies in place at the trust also hindered her role as a nurse prescriber.

‘Now that policies are in place, the trust has been very supportive,’ she said. But when I qualified in 2004, nothing was set up and it was very frustrating that it took almost a year before I could use my prescribing skills,’ she said.

 

‘It is also an insult to nurses because the prescribing course is not easy, and those who complete it have earned the right to make their own prescribing decisions’

Barbara Stuttle, chair of the Association of Nurse Prescribers

 

Barbara Stuttle, director of quality and nursing at South West Essex PCT, and chair of the Association of Nurse Prescribers, said that some nurse prescribers were being further restricted by having to work within the trust’s local formulary.

‘Anecdotal evidence suggests that individual trust polices are hindering nurses in prescribing roles,’ Ms Stuttle told Nursing Times. ‘This is a real shame because it is not maximising the advantages of prescribing in terms of patient care, and is it not making the best use of nurses’ clinical skills.

‘It is also an insult to nurses because the prescribing course is not easy, and those who complete it have earned the right to make their own prescribing decisions,’ she added.

Local barriers to the right to use their prescribing powers is not the only issue facing nurse prescribers. Further support and training once they have finished their initial prescribing course appears to be lacking in many parts of the country.

Continued professional development (CPD) is essential for nurses to keep their knowledge and skills up-to-date. Yet according to a study by Molly Courtenay and colleagues at Reading University, nurse prescribers training needs are currently going unmet, as reported by Nursing Times last week.

Between February and April 2009, they surveyed 546 nurses from the Association for Nurse Prescribing database. The researchers found that three-quarters of the nurses surveyed felt they needed more education and training in the pharmacology of medicines, and more than half felt their CPD needs were not being met in the areas of assessment and diagnosis.

The study also revealed that e-learning was the preferred method for undertaking CPD, with almost 60% of respondents supporting this method.

‘It can be very difficult for nurse prescribers to access the appropriate CPD,’ said Ms Courtenay. ‘In the current climate, attending conferences and study days is becoming increasingly difficult.

‘Everybody learns differently, and trusts need to ensure that nurses are given the flexibility to be able to study,’ she added. 

Steve Jamieson, head of the RCN’s nursing department, added that nurses often had to pay for training themselves.

‘If trusts want nurses to continue with their development in this area, they need to give more thought to funding training for nurse prescribers, and provide more support for nurse prescribers once they have qualified,’ he said.

Although nurse prescribers have encountered some problems in this relatively new role, evidence shoes that it has been welcomed by patients other nurses, and even doctors are now supportive of nurse prescribers.

A study of more than 20 doctors, non-prescribing nurses and administration staff – who worked with nurses who prescribe for patients with diabetes – found nurse prescribing to a ‘positive and welcome addition’ to the nursing role.

 

‘Nurse prescribing is absolutely invaluable’

Bill Beeby, chair of the BMA’s prescribing committee

 

Those studied said nurse prescribing improved service efficiency by reducing interruptions, enhanced nurses’ relationships with patients, and facilitated the shift of diabetes care into community settings.

Sharon Kitcatt, consultant nurse in the acute pain service at Ashford & St Peter’s Hospitals NHS Trust in Surrey, said: ‘Being a nurse prescriber makes you look at things in a different way. It has really helped me to develop therapeutic relationships with patients, and has also facilitated continuity of care.

‘I have a mentor who is very supportive, and the role has also been welcomed by junior doctors,’ she added. 

Bill Beeby, chair of the British Medical Association’s prescribing committee, told Nursing Times that despite some initial concerns, nurses have proved to be very effective prescribers. ‘Nurses know what is normal practice, and will confer with a doctor if they feel it is necessary,’ he said.

‘The perceived potential dangers have not materialised and nurse prescribing is absolutely invaluable,’ he added.

 

 

The history of nurse prescribing
1998 – First limited national formulary published for district nurses and health visitors – now called the Nurse Prescribers’ Formulary for Community Practitioners
2002 – Nurse Prescribers Extended Formulary (NPEF) introduced for four therapeutic areas – minor injuries, minor ailments, health promotion and palliative care.The NMC introduces the first independent nurse prescriber course
2003 – Supplementary prescribing introduced. This is a voluntary partnership between a doctor and a nurse who draw up a clinical management plan (CMP) for a patient’s condition. Once the plan is agreed with the doctor, the nurse can then prescribe anything from the plan.
2004 – NMC changes nurse prescriber course to a dual independent/supplementary prescriber course
2005 – NPEF extended to cover a range of medicines and conditions, mainly for emergency contact and first care
2006 – Almost all of the BNF opened up to independent and supplementary nurse prescribers, replacing the need for the NPEF.

 

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  • 7 Comments

Readers' comments (7)

  • I am a Community Matron and find independent prescribing an absolute bonus for my practice. I have no doubts that my patients will agree. I can, if required, write a prescription in my patient's home, and if necessary get one of my local chemists to deliver- this enhances patient satisfaction and treatment. Medication can start on the same day without waiting for a GP to return to the surgery, print and sign a 'script and family collect. I have written more prescriptions than I had anticipated, and extended my area of competence to meet the individual needs of my caseload. I am very mindful that, at times, I need consultation before prescribing, and I take my extended role seriously. The majority of my GP practices are very supportive of my skills and I have never encountered a problem with my choice of drug - using the PCT formulary as my firstline; and being aware of cost/side effect/OTC implications. Nurses are good prescribers as they understand the patient as a "person", and appreciate concordance issues alongside family dynamics. I have been at the RCN today for a seminar about generic prescribing - networking with my peers and understanding the barriers they meet and the solutions found/ outcomes has been professionally rewarding.

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  • I cannot see what all the fuss is about! I have been an Independent Prescriber since 2004 working in WIC's, UCC's and GP OOHours services, and I would say as a non-medical prescriber, we are probably more safer and competent as prescribers than some of our Medical Colleagues due to the rigourous training we undertook whilst training to be a prescriber.
    I think we take our Code of Conduct more seriously and do not prescribe anthing just for the sake of it to keep the patient happy. Prescribing medication was drummed into us during training was a last resort and patients must take ownership of their own self-care and management through health promotion and education, unless it is deemed clinically appropriate at time of consultation.
    Barbara Nugent who trained us at Birmingham UCE in 2004 was an inspiration and was an excellent Lead Educator and it is down to her, that our cohort manages our practice in this manner.
    Each patient is seen on an autonomous basis and educated appropriately. We do not give out Amoxicillin for the sake of it just to get patients back out through the door with no clinical need for the Abx - unlike some of our Medical Colleagues!
    Paul.

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  • The suggestion by Barbara Stuttle that formularies are constraining the development of nurse prescribing should not go unchallenged . The use of Formularies to restrict choice and encourage clinically and cost effective prescribing has been a mainstay of medicines management in acute Trusts for many years, and the principles have more recently been
    widely adopted in primary care by both GP practices and PCTs. Their use is widely advocated by the DH , Audit Commission and National Prescribing Centre among others, and there is extensive UK and International evidence of their value in promoting safe, effective and
    economic prescribing practice. To suggest that nurse prescribers should in some way be exempted from the use of Formularies is contrary to one of the underpinning principles of good prescribing practice.

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  • All I can say is now that Nurses have taken over a lot of the roles of Doctors, and continue to take more and more roles and responsibilities, when will our pay and status increase to a Doctors level as a result?

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  • I am a practice nurse and in independent aesthetic nurse, I want to do my nurse prescribing but the gps I work for won't support me and I cannot find a mentor to help. It is a night mare if you can't get a mentor. I am extremelt disapointed as I feel this is the way forward and I think both my patients would really benefit if I could do it

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  • I am a staff nurse and an independent nurse prescriber.I really enjoy my prescribing but the only thing I do not like is about not being paid for this new responsibilities I have taken on.I was on Band 5 before I did my nurse prescribing course and after completing the course ,I am still on band 5 with all other staff nurses on the ward who had not done this hard and difficult course.I am so disappointed and sometimes does not feel like using this skill.

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  • I have been qualified as a nurse prescriber since 2006 and I have gained more experience within the private sector that the NHS, I thing there are some concerns within the NHS to allow nurses to prescribe independently therefore the FT I work for is only allowing supplementary prescribing, which have proven counter productive as there were some occasions I could not prescribe as there was no CMP in place. Thus it went against the one of the main drivers of NMP "quicker access to medication". The NMC is clear on its code as far as accountability is concern, that nurses including prescribers are accountability for their actions and omissions, some of the nurses who have qualified have left the trust as from qualifing since 2006 they are not allowed to prescribe independentaly till today, it is fustrating as I have proven to be capable to prescribe independently within the private sector

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