VOL: 102, ISSUE: 09, PAGE NO: 60
Although over 6,100 nurses are qualified to prescribe from the extended formulary (DoH, 2005), there are many more …
Although over 6,100 nurses are qualified to prescribe from the extended formulary (DoH, 2005), there are many more for whom the ability to prescribe would be beneficial. For example, the Royal College of General Practitioners (2005) estimates that the UK has 10,465 GP practices, so even if all nurse prescribers worked as the sole nurse prescriber in a practice, over 4,000 would have no nurse prescriber.
Nurse prescribers work in a range of settings, which include the community, walk-in centres nurse-led clinics for people with chronic conditions and in secondary care. This means there is enormous potential for nurses who wish to become prescribers.
One factor that may have deterred some nurses from becoming prescribers is the limitations of the extended nurse formulary. However, legislation to open up the entire British National Formulary to nurses - with the exception of most controlled drugs - is expected in the spring.
No announcements have been made about whether the coming change will lead to more stringent educational requirements, although Matt Griffiths, joint prescribing adviser at the RCN, believes these would be most likely to come from updated guidance from the NMC, due later this year.
‘It may recommend some changes to distance learning courses, such as more contact time, and it may standardise certain aspects of all courses, such as the assessments used, and the pass mark,’ he says. ‘Some courses currently have a 40 per cent pass mark, while for others it’s higher, so the council may want that to be standardised.’
Cheryl McKay, non-medical prescribing facilitator, Kent and Medway Strategic Health Authority, believes clinical governance and continuing professional development will play key roles in ensuring that standards of practice are maintained.
Once the formulary limitations are removed, more nurses with advanced clinical skills may think about becoming prescribers. So what are the factors they should consider in making their decision?
‘The first question they should ask is: ‘Will it benefit my patients?’,’ says Mr Griffiths. ‘A prescribing qualification isn’t just something to go on your CV to help you get a better job. It should help you to do your current job more effectively.’
In theory this could apply to any nurse, but in practice it is most applicable to those who regularly deal with particular conditions, such as those running clinics, and those dealing with minor injuries and ailments. In addition, they should also be working at an advanced level, and have the ability to diagnose and consult.
A good rule of thumb here is that nurses who refer patients to a doctor simply to have medicines supplied - often on the nurse’s recommendation - are competent to undertake any assessment and monitoring required by their patients, and those who know when patients need to be referred to a doctor or other professional, may be good candidates for nurse prescribing.
Some nurses may find the opening up of the BNF a daunting prospect, but it does not mean they will be expected to prescribe anything and everything.
‘While, in theory, nurses could prescribe across the whole BNF, in reality this simply won’t happen because they have to prescribe within their competence and they will be held accountable if they prescribe outside this,’ says Ms McKay. ‘Doctors have always had access to the whole formulary but you would not find a diabetologist prescribing cancer drugs, and the same applies to nurses.
‘Specialist nurses will still prescribe within their patient groups, but the new system may make it easier to provide comprehensive care for some patients. For example, some diabetes specialist nurses may well be prescribing to manage patients’ blood pressure or cholesterol levels through supplementary prescribing at the moment. ‘Opening up the formulary will give them the tools to prescribe right across their competence rather than from a limited range of drugs.’
Although the opening up of the BNF may initially appear likely to render supplementary prescribing obsolete, Molly Courtenay, reader in prescribing and medicines management, University of Reading, and RCN joint prescribing adviser, believes it may actually come into its own.
‘There will still be a place for supplementary prescribing, since nurse prescribers may not feel competent and confident in prescribing for certain patients,’ she explains. ‘Supplementary prescribing provides a good framework for them in working with these patients, and can also be used as a ‘stepping stone’ - you might start off with supplementary prescribing and move to independent prescribing once the nurse feels ready to do so for that particular patient.’
But deciding to become a prescriber is only the first step. The next is to gain employer approval. Employers will look at which nurse or nurses will be most appropriate to undertake a prescribing qualification. For example, in a GP practice with a number of nurses, one of whom runs clinics for people with chronic conditions, it would make most sense for that nurse to become a prescriber.
Another key requirement is a mentor - a designated medical practitioner who is willing and able to direct at least 12 days’ learning in practice for the nurse. This is to provide support and to assess whether the nurse has met the course learning outcomes and achieved the required competencies to prescribe.
Mr Griffiths believes selecting the right mentor is crucial. ‘They will be working closely together for 12 or 13 days, so it has to be someone with whom they have a good professional relationship - although it should not be a relative - and someone who has some knowledge of education and training,’ he says.
Finally, it is important to choose the right course. While employers are likely to have agreements with specific education providers, they may still offer some choice. Nurses may also have the option of studying at degree or master’s level and either a classroom-based course or one taught through distance or web-based learning. Deciding which type of course involves assessing their own needs (Box 1).
‘Some people like the flexibility of being able to study at their own pace and at times to suit them and may prefer distance learning, while others find it hard to motivate themselves or like the contact time and peer support of classroom-based learning,’ explains Ms McKay. ‘Other commitments may come into play, too, such as getting released from work at particular times - this is particularly pertinent for pharmacists, who cannot simply close their shops to go to college.’
However, Ms McKay stresses that employers must acknowledge the requirements of distance learning. ‘If someone chooses the distance learning option it is important that employing organisations acknowledge that they will still need the study time and 12 contact days,’ she says. ‘This is not a soft option for employers, although it may make some things easier, such as rostering, if they have that bit more flexibility.’
Becoming an independent prescriber may be a major undertaking, but for nurses with advanced clinical skills it can mean being able to offer complete episodes of care and to make the best use of their skills. It also enables both nurses and doctors to use their time more effectively.
However, Ms Courtenay points out that employers have a role in making the system work: ‘This involves not only picking the right person to go on the course, but also making sure other professionals in the practice are aware of the possibilities and benefits of nurse prescribing,’ she says. ‘It is also important to put the mechanics in place, such as organising the prescription pads in time and ensuring the nurse will have ongoing support and supervision.’
It is only with this practical and moral support that independent nurse prescribers can use their skills effectively for their patients and allay the concerns of other professionals about their competence for this role.
Guide for repeat prescriptions
The National Prescribing centre has produced a Repeat Prescribing Service Improvement Guide which includes advise on assessing repeat prescribing policies and ordering of repeat prescriptions. www.npc.co.uk