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A guide to nurse prescribing in diabetes

Molly Courtenay
PhD MSc BSc Cert Ed RN
Professor of Clinical Practice (Prescribing and Medicines Management)
University of Surrey

Nearly 20,000 nurses across the UK are qualified as independent and supplementary prescribers and around a third of these prescribe for people with diabetes. Nurse prescribing in primary care has been shown to significantly improve service delivery, as Molly Courtenay explains

There are now more than 30,000 nurses across the UK who are able to prescribe from a limited list of medicines described in the Nurse Prescribers' Formulary (NPF) for Community Practitioners. These medicines comprise mainly over-the-counter medicines and include wound dressings, laxatives and emollients.

A further 19,000 nurses are qualified as both independent and supplementary prescribers.1 If using independent prescribing, these nurses are able to assess, diagnose and prescribe any licensed or unlicensed medicine within their area of competence.2 Although nurse independent prescribers can prescribe controlled drugs (CDs), these medicines and the conditions for which they can be prescribed are restricted. Legislation lifting these restrictions is currently awaited.3

By contrast, supplementary prescribing takes place following an assessment and diagnosis of a patient's condition by a doctor and a clinical management plan has been drawn up for the patient. Within this plan, there is a list of medicines from which the supplementary prescriber is able to prescribe.4 Supplementary prescribers are able to prescribe any medicine (including CDs), and this mode of prescribing is best suited to patients with long-term chronic conditions.

Appropriately qualified pharmacists are also able to prescribe using both independent and supplementary prescribing, whereas allied health professionals (AHPs) (radiographers, physiotherapists and chiropodists/podiatrists) may only use supplementary prescribing. Optometrists can train to prescribe and can use both independent and supplementary prescribing for conditions that affect the eye, and the tissues that surround the eye.

The extension of prescribing rights are under consideration for other groups of non-medical healthcare professionals, including dieticians and paramedics.5,6 Several countries, for example, Canada, New Zealand, Sweden and the US, have implemented prescribing for nurses; however, unlike the UK, these nurses can only prescribe using  limited lists and formularies.7  

The prescribing programme and necessary prerequisites
The prescribing programme, validated by the NMC, is offered by a number of higher education institutions throughout the UK and provides students with generic knowledge and skills that underpin prescribing. Learning on the prescribing programme is shared between nurses, pharmacists and AHPs. Those who successfully complete the course are awarded the dual qualification of independent and/or supplementary prescriber and this qualification is recorded for nurses on the Nursing and Midwifery Council (NMC) Register.

The programme involves 27 days in the classroom (although some courses have a distant learning component) and 12 days in practice. Prerequisites for prescribing training include:

  • A minimum of three years' experience as a qualified nurse, the year immediately preceding application being in the clinical field in which the applicant intends to prescribe.
  • The ability to study at degree level.
  • Employer support and a need within the applicant's role to prescribe.
  • A designated medical practitioner (such as a doctor prepared to mentor and supervise the applicant through the 12 days learning in practice component of the prescribing course).
  • Assessed as competent to undertake a history, clinical assessment and diagnosis.
  • Appropriate numeracy skills.8
  • Topics covered on the NMP programme include:
  • Consultation skills.
  • Prescribing within a team context.
  • Influences on the psychology of prescribing.
  • Clinical pharmacology.
  • Evidence-based prescribing.
  • Legal, policy and ethical issues.
  • Prescribing accountability and responsibility.
  • Prescribing within a public health context.8

The assessment of students learning is rigorous and involves several strategies (including a portfolio of learning, Objective Structured Clinical Examination, and multiple choice questions).

Nurse prescribing in diabetes service delivery - the evidence base
It is evident that nearly 90% of independent supplementary prescibers do prescribe. These nurses mostly use independent prescribing. The majority have had more than 10 years' experience as a qualified nurse before accessing the prescribing course, five of which have been in their specialist area.9 Over 50% have a specialist qualification at master's level.10

Approximately 30% of nurse prescribers prescribe medicines for people with diabetes and most work in general practice. These nurses prescribe between one and five items a week and monitoring equipment, oral anti-diabetic drugs, and insulin are the products most often prescribed.11 Few barriers to the implementation of nurse prescribing have been reported in diabetes service delivery.

It has been suggested that this is because nurses already have well established roles in this specialty; that good working relationships exist between nurses and doctors, which provides sound organisational and interpersonal support; and that there is no need for any major alterations to service provision when implementing this relatively new role for nurses.12

Where nurse prescribing has been implemented, diabetes service delivery has been enhanced. Nurses are able to make better use of their skills which, in turn, leads to increased service efficiency. More flexible team working and improved communication between members of multidisciplinary teams has also been reported. Furthermore, new ways of working, arising from the introduction of a single review process for patients (where in addition to diabetes, nurses are able to consider the management of other co-morbidities), has resulted in a more cohesive and simplified approach to patient care.13 This is in line with policy guidance where a single comprehensive and patient-centred review is recommended.14

Work exploring the practices of nurse prescribers who care for patients with diabetes has identified that nurses demonstrate very good communication skills and work in partnership with their patients. When these skills are integrated with the ability to prescribe, the importance of treatment regimens are said to be reinforced and medicines adherence increased. An additional benefit is increased safety, where nurses take responsibility for their prescribing decisions and doctors are no longer asked to issue prescriptions for patients they had not assessed; this is also thought to reduce the potential for error.15 

The findings from research specifically examining the views of patients with diabetes report patients to be confident in the nurse's ability to prescribe. This confidence is inspired by nurses' specialist knowledge and experience, a mutual trusting relationship, a thorough consultation, and experience of the benefits of nurse prescribing. Patients also report that nurse prescribing improves service efficiency, reduces the number of appointments they need to have with a doctor, reduces waiting time as a result of the nurse no longer requiring a prescription to be signed by a doctor, and provides easier access to non-review appointments, supported by telephone advice. In order that prescribing is safe, patients believe that there must be good communication between nurses and doctors about their care. They also believe that nurses must be aware of their area of competence, be appropriately trained, have specialist diabetes knowledge and be able to access training updates.

Conclusion
Where nurses have adopted the prescribing role, services run more efficiently and patients are able to access their medicines more quickly. Additional benefits include increased medicines adherence and increased safety. Patients are supportive of nurse prescribing and confident in the ability of the nurse to prescribe medicines.  Given the new white paper reforms and the benefits that NMP can offer in diabetes service delivery, it is important that commissioners of services include nurse prescribing in service redesign.15

References

  1. Culley F. Professional considerations for nurse prescribers. Nurs Stand 2010;24(43):55-60.
  2. Department of Health. Written Ministerial Statement on the expansion of independent nurse rescribing and introduction of pharmacists independent prescribing. London: DH; 2005.
  3. Royal College of Physicians of Edinburgh. Public Consultation - Independent Prescribing of Controlled Drugs by Nurse and Pharmacist Independent Prescribers. Edinburgh: RCPE: 2007.
  4. Department of Health. Supplementary Prescribing for Nurses and Pharmacists within the NHS in England. London: DH; 2002.
  5. Department of Health. Allied health professions prescribing and medicines supply mechanisms scoping project report. London: DH; 2009.
  6. Department of Health. Proposals to introduce prescribing responsibilities for paramedics: stakeholder engagement. London: DH; 2010.
  7. Ball J. Implementing Nurse Prescribing. Geneva: International Council of Nurses; 2009.
  8. Nursing and Midwifery Council. Standards of proficiency for nurse and midwife prescribers. London: NMC; 2006.
  9. Courtenay M, Carey N. Nurse Independent Prescribing and Nurse Supplementary Prescribing: Findings from a national questionnaire survey. J Adv Nurs 2008;61(4):403-2.
  10. Drennan J, Naughton C, Allen D et al. National Independent Evaluation of the Nurse and Midwife Prescribing Initiative. Dublin: University College Dublin; 2009.
  11. Courtenay M, Carey N. The prescribing practices of nurse independent prescribers caring for patients with diabetes. Practical Diabetes International 2008;25(4):1-6.
  12. Stenner K, Carey N, Courtenay. Implementing nurse prescribing: a case study in diabetes. J Adv Nurs 2010;66(3):522-31.
  13. Courtenay M, Stenner K, Carey N. The views of patients with diabetes about nurse prescribing. Diabet Med 2010;27:1049-54.
  14. Department of Health. Medicines Matters: A Guide to the Mechanism for the Prescribing, Supply and Administration of Medicines. London: DH; 2005.
  15. Department of Health. Equity and Excellence: Liberating the National Health Service. DH: London; 2010. 

Your comments (terms and conditions apply):

"As a Supplementary Prescriber I am extremely frustrated that new over the counter products are not available to prescribe ie Nicotine Replacement products leading to reduced efficiency and a poorer service" - Jill Denton, Scotland