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Nurse prescribing in primary care: where are we now?

In this article, Molly Courtenay provides a general overview of nurse prescribing and the education and training required for this role. She focuses specifically on primary care nurses and how the acquisition of greater prescribing power has affected them in everyday practice

Molly Courtenay
PhD MSc BSc Cert Ed RGN RNT
Professor in Prescribing and Medicines Management
Reading University
Prescribing Adviser
Association for Nurse Prescribing

The Cumberledge Report provided the initial impetus for the adoption of the role of prescribing by nurses.1 This report identified that some very complicated procedures had arisen around prescribing in the community, and that nurses were wasting their time requesting prescriptions from GPs. Recommendations that nurses should be able to prescribe were then made by the Crown Report.2

Educational preparation enabling qualified district nurses and health visitors to prescribe from a small formulary (now known as the Nurse Prescribers' Formulary for Community Practitioners) was rolled out in 1997 and integrated into the specialist practitioner programme in 2000. Later extensions from the Nursing and Midwifery Council (NMC) enabled any community nurse (including those without a specialist practitioner qualification) to prescribe from this formulary.3,4

In 2001, support was given by the government for the extension of prescribing to other groups of professionals.5 Since 2003, nurses have been able to undertake educational preparation enabling them to prescribe both as independent and supplementary prescribers, the aims of which are to:

  • Improve patient care.
  • Make it easier for patients to access their medicines.
  • Increase patient choice in accessing their medicines.
  • Make better use of nurses' skills.
  • Contribute to more flexible team-working.6

Nurse independent prescribers (NIPs) can independently prescribe any licensed medicines for any condition and some controlled drugs (CDs) including:

  • Diamorphine, morphine or oxycodone for use in palliative care.
  • Buprenorphone or fentanyl for transdermal use in palliative care.
  • Diamorphine or morphine for pain relief in respect of suspected myocardial infarction or for relief of acute or severe pain after trauma, including in either case postoperative pain relief.
  • Chlordiazepoxide hydrochloride or diazepam for treatment of initial or acute withdrawal symptoms caused by withdrawal of alcohol from people who are habituated to it.

In contrast, nurse supplementary prescribers (NSPs) can prescribe any medicine for any condition, in partnership with a doctor and provided that the medicine is listed on the patient's clinical management plan (CMP).7

Education and training
A number of prerequisites are required by nurses who wish to undertake independent and supplementary prescribing training. These include:

  • Registration with the NMC as a first-level nurse or midwife.
  • The ability to study at Level 3 (degree level).
  • Have at least three years' experience as a qualified nurse (the year immediately preceding application to the programme must be in the clinical field in which the candidate wishes to prescribe).
  • Have agreement from a doctor that they will contribute to the 12–13 days learning in practice and postqualifying experience.
  • Have their employer's agreement to undertake the course and also that they will support continuing professional development (CPD).8

Nurses must also be assessed by their employer as competent to take a history, and make a clinical assessment and diagnosis, and demonstrate appropriate numeracy skills.8

The independent and supplementary prescribing training programme involves at least 26 days in the classroom (for distance learning programmes, eight taught days must be included in the programme) and 12 days in practice with a designated medical practitioner. Generally, courses run over three to six months, but must be completed within a year. Topics taught include the following:

  • Consultation skills.
  • Influences on the psychology of prescribing.
  • Prescribing in a team context.
  • Clinical pharmacology.
  • Evidence-based practice.
  • Legal, policy and ethical aspects.
  • Professional accountability and responsibility.
  • Prescribing in the public health context.8

A range of assessments are used to assess students' knowledge and skills, including a numeracy assessment in which they must achieve a 100% pass rate. Only nurses with the relevant knowledge, competence, skills and experience should prescribe medicines for children, and students are also required to demonstrate that they are aware of the anatomical and physiological difference between children and adults; are able to take an appropriate history and clinical assessment; and can make an appropriate decision to diagnose or refer.9 

Nurse prescribers are not required to undertake any additional hours of practice to meet CPD needs. However, appraisal of these needs should be undertaken on a yearly basis as part of performance review and support must be provided by the nurse prescriber's employer.10

Effects on practice
There are approximately 14,000 qualified independent supplementary prescribers across the UK. The majority of these nurses (over 65%) work in primary care, and most (36.8%) are in general practice. Independent prescribing is used by most of these nurses who typically prescribe 17.5 items a week for a broad range of conditions, many of them chronic.11 Supplementary prescribing is used to a much lesser extent.12

Barriers to prescribing have been cited, including access to prescription pads and prescribing budgets, inability to access computer-generated prescriptions and objections by medical staff and pharmacists. Peer support and CPD have been identified as important factors that facilitate prescribing and although it is evident that CPD is available for these nurses, they do have concerns about their pharmacological knowledge.11

A number of benefits have been reported as arising from prescribing, including improved use of healthcare professionals' skills, improved access to medicines and increased choice in accessing medicines.13 Care has been reported to be enhanced through a more holistic approach, and increased patient involvement, and improved prescribing decisions.14,15 Services are also said to have been improved through increased efficiency; an increase in the number of appointments enabling patients to access their medicines more conveniently and, in some instances, services have become dependent upon the capacity of the nurse to prescribe.15,16

Conclusions
The large number of practice nurses adopting the role of prescribing suggests that healthcare reforms are shifting care closer to patients' homes, as these nurses are now frequently the first point of contact for patients to access their medicines.17 The numbers of these nurses prescribing for chronic conditions such as those described in the Quality and Outcomes Framework of the new General Medical Services Contract suggests that these nurses are supporting GP services.6 The reported benefits of nurse prescribing are in line with those predicted by the government. However, it is important for employers to ensure that these nurses have access to appropriate CPD to support them in this new role.

References
1. Cumberledge J. Neighbourhood Nursing - A Focus for Care: Report of the Community Nursing Review. London: HMSO; 1986.
2. Department of Health (DH). Report of the Advisory Group on Nurse Prescribing (Crown Report). London: DH, 1989.
3. Nursing and Midwifery Council (NMC). Circular: V100 Nurse Prescribers. London: NMC; 2005.
4. NMC. Circular: Standards of educational preparation for prescribing from the community NPF for nurses without a Specialist Practice qualification – V150. London: NMC; 2007.
5. DH. Patients to get quicker access to medicines. London: DH; 2001.
6. DH. Standard General Medical Services Contract. London: DH; 2004.
7. DH. Supplementary prescribing. London: DH; 2002.
8. NMC. Standards of proficiency for nurse and midwife prescribers. London: NMC; 2006.
9. NMC. Circular: Prescribing for children and young people. London: NMC; 2007.
10. NMC. Guidance for Continuing Professional Development for Nurse and Midwife Prescribers. London: NMC; 2008.
11. Courtenay M, Carey N. The prescribing practices if nurse independent prescribers caring for patients with diabetes. Practical Diabetes International
2008;25(4): 1–6.
12. Courtenay M, Carey N. Nurse Independent Prescribing and Nurse Supplementary Prescribing practice: national survey. J Adv Nurs 2008;61(3):291–9.
13. Latter S, Maben J, Myall M, Courtenay M, Young A, Dunn N. An evaluation of extended formulary independent nurse prescribing. Final Report. Department of Health/University of Southampton; 2005.
14. Bradley E, Nolan P. Impact of nurse prescribing: a qualitative study. J Adv Nurs 2007;59(2):120–8.
15. Courtenay M, Carey N, Stenner K. Nurse prescriber-patient consultations: a case study in dermatology. J Adv Nurs 2009 (in press).
16. Carey NJ, Stenner KL, Courtenay M. The Impact of Nurse Prescribing on the configuration of dermatology services. J Clin Nurs 2009 (in press).
17. DH. Shifting Care Closer to Home. London: DH; 2007.