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Setting standards for nurse prescribing

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Since the publication of the first limited nursing formulary in 1998, prescribing has been a serious undertaking for nurses and midwives. Those who qualify to prescribe take on a significant additional responsibility - with attendant risks.

VOL: 102, ISSUE: 22, PAGE NO: 46

Ann Shuttleworth


The opening up of virtually the whole British National Formulary in May to what are now known as nurse independent and supplementary prescribers has taken prescribing to a whole new level. This has made it even more important that nurses are adequately prepared for prescribing responsibilities and for practising to the highest standards within their individual competencies.

The NMC had acknowledged the need to ensure standards of education and practice well before health secretary Patricia Hewitt announced this major extension of nurse prescribing in January. The council was nearing the end of an eight-month process of developing standards in response to the Shipman Inquiry (Smith, 2006), which recommended that prescribing professions have standards and a code of practice.

The standards were published in April (NMC, 2006), and set out in detail what is expected of prescribing courses and nurse prescribers.

The education standards cover a range of issues, including admission to courses, eligibility for qualification, academic standards, and the balance between theory and practice. They also contain detailed learning outcomes and requirements in terms of programme content (Box 1) and assessment. The NMC will assess educational institutions running prescriber programmes against these standards to ensure all courses meet the requirements.

Once nurses qualify as prescribers they must adhere to a rigorous set of 21 practice standards (Box 2). The council has also determined the competencies required of nurse independent and supplementary prescribers. They must be able to:

- Assess the clinical condition of patients;

- Undertake a thorough history;

- Decide on the management of the presenting condition and whether or not to prescribe;

- Identify appropriate products if medication is required;

- Advise patients on effects and risks;

- Prescribe if patients agree;

- Monitor patients’ response to the medication and offer lifestyle advice.

The practice standards and competencies will be used as a benchmark for nurse independent and supplementary prescribers’ fitness to practise. This means that any nurse brought before an NMC fitness- to-practise hearing on a prescribing-related issue will be judged against those standards.

While the standards are certainly rigorous, Liz Plastow, professional adviser, specialist community, public health nursing, standards and registration directorate at the NMC, points out that this is not only necessary, but also beneficial for nurses: ‘The standards are there to protect the nurses as well as the public,’ she says. ‘Provided nurses prescribe within the standards we set, the NMC would support them should they be referred to us for fitness to practise.’

The rigour of the standards has also significantly reduced opposition from within the medical profession - particularly since consultation on the standards involved the General Medical Council and the Royal College of Paediatrics and Child Health, along with other stakeholders such as the RCN and nurse and patient groups. In fact, it could be argued that nurses will now be better prepared for prescribing than their medical colleagues, as Matt Griffiths, RCN joint prescribing adviser, points out:

‘I’m proud of the fact that nurses receive prescribing training,’ he says. ‘The medical profession doesn’t, and it covers so many facets in addition to pharmacology, including informed choice and concordance. In fact the first thing you’re often taught is how to avoid prescribing by looking for alternatives to drugs. I’d like to think the medical profession will follow our lead and give doctors specific training on prescribing.’

While current medical education requirements do mention prescribing, this is in general terms and there is no mandatory requirement for prescribing-specific units or modules before doctors are allowed to prescribe.

One element of the standards that did cause some controversy when they were published was the requirement for nurses to gain a 100% pass mark in numeracy within the context of prescribing. However, Molly Courtenay, professor of prescribing and medicines management, University of Reading, and RCN joint prescribing adviser, believes this is entirely appropriate, given the importance of accuracy in calculating dosage. ‘There have been general concerns about nurses’ maths skills, and Welsh prescribing courses have had a maths element for some time. I think this addresses the problem for prescribing - particularly since not all nurses will have a maths qualification.’

Mr Griffiths agrees: ‘I think it’s perfectly acceptable to expect nurse prescribers to achieve a 100% mark in numeracy - I wouldn’t want a prescription from someone who had achieved any less,’ he says, adding that maths is an area he would like to see given more emphasis in preregistration education.

‘People used to have to pass calculation tests to get into nursing. We’ve lost that, along with life sciences and biology, in the preregistration curriculum. Around 70% of nursing time is spent dealing with medications - shouldn’t we be reflecting that in their education?’

He believes that nurses should see the stringent numeracy requirement as another example of the profession taking a lead that medicine could follow.

Although there have been concerns that the education standards may deter nurses from becoming prescribers, Ms Courtenay does not agree:

‘I don’t think the standards will put people off becoming nurse prescribers,’ she says. ‘They aren’t that different to the current situation - they simply set down the requirements for educational institutions to ensure all courses prepare nurses to the same standards, because there have been significant differences in courses around the country.’

Mr Griffiths believes the standards are entirely appropriate, and have come at exactly the right time as nurse prescribing takes its giant leap. ‘Nurse prescribing has just become much more interesting with the opening up of the formulary. It’s a truly historic development that will have huge benefits for patients and the profession. We are leading the way in changing nursing practice worldwide.’

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