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Are nurses benefiting from their new prescribing rights?

Ailsa Colquhoun
BSc(Hons)
Freelance journalist specialising in pharmacy

First of May 2006 was a big day for nurses in England and Scotland. It was the day legislation started to roll out across the UK enabling qualified nurse independent prescribers (NIPs) to prescribe any licensed medicine for any medical condition - including some controlled drugs.* 
The legislation aims to offer patients better access to healthcare services, a choice of prescriber and to make better use of nonmedical prescribers' skills. Within nursing, it also aims to fix some of the problems identified by the Nurse Prescribers' Extended Formulary (NPEF). NPEF said prescribing was too complex and supplementary prescribing could not be used in all settings where patients could benefit, such as emergency care.(1)
Currently, 1,653 nurses are registered in the UK as NIPs, and in Scotland alone, NIPs are qualifying at a rate of around 250 a year. However, many more are not strangers to prescribing, having enjoyed increasingly extended prescribing rights since the introduction of the NPEF in April 2002.

NPEF experiences
The NPEF shows that most nurses are prescribing relatively frequently, with 42% prescribing between 11 and 30 items per week.(2) It also provides documented evidence of how well independent nurse prescribing may work in practice.
In the NPEF evaluation nurses reported that they feel confident in their prescribing powers - although less so in their ability to diagnose.(2) Most feel that extended independent prescribing can positively impact on professional satisfaction and, importantly, quality of patient care. Patients also feel it can improve relations, as they consider improved access to appropriate prescribed medicines a major advantage.  
Doctors are also positive. A similar evaluation of extended formulary prescribing in Scotland identified specific advantages, namely:(3)

  • Improved medication management: improved drug compliance, less need for repeat prescriptions, improved detection of adverse drug reactions.
  • Improved teamwork: improved discharge planning or continuity of care, improved nurse-doctor relationships, less return consultations/referrals.

However, the report also highlights certain negatives associated with extended formulary nurse prescribing. Doctors report that prescribing legislation has not unequivocally reduced their workloads, nor has it reduced their role as a nurse mentor. They also highlight that nurses now tend to be slower and more protocol driven in their consultations than before.
Nurses themselves also acknowledge that a lack of peer support, and poor access to resources such as PACT data, the current British National Formulary (BNF), the internet, and computer-generated scripts has hindered their practice.
An evaluation of the first year of full nurse independent prescribing is currently under way, and the results are to be presented to the country's various health departments later this year. According to Ian Murray, policy officer for Scotland and Ireland for the Council of Deans for Nursing and Health, the research is likely to reflect a slow start to nurse independent prescribing, because support is needed from local clinical governance. However, he adds that support is now being put in place and the demand for nurse prescribers, particularly in new nurse-led or out-of-hours services, continues to grow. The National Prescribing Centre, for one, estimates that there could be as many as 12,000 nonmedical, independent prescribers (including nurses) by the end of 2008.
Certainly, nurses' representatives see nurse prescribing as becoming increasingly important in general practice, with nurses taking complete and even first contact care of patients. Professor Matt Griffiths, joint prescribing and medicines manager at the Royal College of Nursing (RCN), points out that a number of job advertisements now ask for an independent prescribing qualification and demand for training is high.
But whether or not nurses benefit financially from their new qualification remains an unanswered question. The RCN, for one, does not believe that advertised salaries are universally rising accordingly. As Professor Griffiths says: "There is potential for practices to benefit in terms of Quality and Outcomes Framework target gains. We don't see this as just an extra small role but rather, a qualification that requires proper training and proper assessment. Extra salary is something we would really want to see."
 
How to become a NIP
The Department of Health's working definition of independent prescribing is that carried out by a practitioner (eg, doctor, dentist, nurse or pharmacist) who is responsible and accountable for assessing patients and for making decisions about their clinical management, including prescribing. It notes that, normally, prescribing in practice would be carried out within a multidisciplinary healthcare team, either in a hospital or in a community setting, and within a single, accessible healthcare record.
Such is the Department of Health's commitment to establishing nonmedical prescribing that it has allocated funding to meet the cost of training nurses. But, recognising that there is likely to be both a strong demand and supply of would-be nonmedical independent prescribers, the Department of Health has also set out a number of criteria to help stakeholders prioritise the applicant flow.(4) It advises that priority should be given to applications for independent prescribing training that may:

  • Improve patient safety.
  • Speed up patients' access to medicine.
  • Make better use of professional's skills.

The legislation leaves employers to decide which, if any, nurses should train as independent prescribers, after assessing their local service and patient needs. Implementation guidance stresses, however, that all individuals selected for prescribing training must have the opportunity to prescribe in the post that they will occupy once they finish training, and that the therapeutic area(s) in which they prescribe should also have been identified before training begins. This will almost certainly be in the field in which they already hold considerable expertise.
In addition, implementation guidance stipulates that nurses should be able to:

  • Study at level 3 (degree level).
  • Gain at least three years' postregistration clinical nursing experience, of which at least one year immediately preceding their application to the training programme should be in the clinical area in which they intend to prescribe.
  • Competently take a history, undertake a clinical assessment and make a diagnosis. 
  • Gain support from a medical prescriber willing and able to supervise their 12-day "learning in practice".
  • Find a local need for them to prescribe - NHS trusts and PCTs will decide whether there is a local NHS need for staff to access prescribing training, and nurses should not be able to undertake NHS-funded training unless there has been prior agreement about the therapeutic area in which they will prescribe. 
  • Act as an independent prescriber immediately upon qualifying with a budget to meet the costs of their prescriptions.
  • Have employers' clinical governance framework support and be accountable to both their employers and their regulatory bodies for their actions.

Training: what's involved?
The Nursing and Midwifery Council (NMC) has set out standards that nurse prescribing training should follow, and also validates new training courses (see www.nmc-uk.org). Only successful completion of NMC-approved programmes can lead to registration as a NIP.
Courses currently enable nurses to qualify as both a nurse independent and a nurse supplementary prescriber. The programme comprises:

  • A minimum of 26 days at a higher education institution.
  • Twelve days "learning in practice", during which a supervising designated medical practitioner (DMP) will supervise and support the student while developing their competence in prescribing practice.

It is worth noting that the DMP is not paid, so support for the would-be nurse prescriber may vary. Training and preparation programmes may last between three and six months. There is also an element of self-directed learning. NHS or private organisations may pay to train nurses and pharmacists using other sources of funding.

*The joint DH/Home office consultation, Independent prescribing of controlled drugs by nurse and pharmacist independent prescribers, closed on June 15, 2007

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References

  1. Medicines and Healthcare products Regulatory Agency. Consultation on options for the future of independent prescribing by extended formulary nurse prescribers. MLX 320. London: MHRA; 2005.
  2. Department of Health Policy Research Programme. An evaluation of extended formulary independent nurse prescribing. London: DH; 2005.
  3. Pollock L, Dudgeon N; Scottish Executive Health Department. The Scottish Nurse Prescribing Audit. Edinburgh: Scottish Executive; 2006.
  4. Department of Health. Improving patients' access to medicines: a guide to implementing nurse and pharmacist independent prescribing within the NHS in England. London: DH; 2006