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					Nurse prescribing: The next steps
14 July 2009 | By Clare Lomas Nurse prescribing powers have grown from small beginnings to cover the entire formulary today. But area is still not without its concerns and difficulties. Clare Lomas reports on barriers facing nurse prescribers When the Department of Health published the NHS Plan in July 2000, it promised to create new roles and responsibilities for nurses, and provide them with greater opportunities to extend their current nursing roles. One of the key elements to the ten-year radical reform was to radically extend the role of nurse prescribers with the then health secretary, Alan Milburn, pledging an extra £10m to train 10,000 more nurse prescribers over the following three years. Although there were some initial objections to the extension of the nurse prescribing role – some doctors called the practice „dangerous‟ because nurses were not as highly trained as doctors – nurse prescribing has grown significantly over the past ten years. According to the RCN, there are now over 48,000 nurse prescribers in the UK. Of these, 33,000 are health visitors and district nurses, who can prescribe from the Nurse Prescribers‟ Formulary for community Practitioners. The remainder are qualified as nurse independent prescribers or nurse supplementary prescribers. These nurses are now able to prescribe any licensed medicine – including some controlled drugs – as long as they work within their area of competence. Gaining access to the full British National Formulary (BNF), in May 2006, gave appropriately qualified nurses virtually the same independent prescribing powers as doctors. It was thought that opening up the formulary – thus further extending nurses‟ independent prescribing skills – might have reduced the need for supplementary prescribing. However, a study of 1,400 independent nurse prescribers – conducted at the end of 2006 – found that more than 40% were still using supplementary prescribing. This compares to a similar survey in 2005, which found that 35% of 868 nurses qualified to prescribe independently were still supplementary prescribing.

„Nurses who look after patients with complex conditions may not feel happy to prescribe alone, but they‟re happy to do it using a clinical management plan‟ Professor Molly Courtenay

Molly Courtenay, professor of prescribing and medicines management in the school of health sciences at Reading University, who conducted both pieces of research, said this figure now stands at around 20%. „There has been a definite shift towards independent prescribing, but some nurses still prefer to use supplementary prescribing to help develop their skills and confidence,‟ she said. „Nurses who look after patients with complex conditions may not feel happy to prescribe alone, but they‟re happy to do it using a clinical management plan,‟ she added. „However, supplementary prescribing can be too “clunky” for some nurse prescribers, such as those working in A&E, and using a clinical management plan does not fit with their prescribing needs,‟ Ms Courtenay told Nursing Times. Since 2004, nurse prescribing is a joint qualification, and all nurses who complete the NMC V300 prescribing course are qualified to prescribe independently, as well as in a supplementary role. However, Nursing Times has learnt that some NHS trusts have local policies in place that are restricting the extent to which nurses can prescribe medications to patients. Despite being qualified to prescribe independently straight away, nurses at King‟s College Hospital in London are required to practice as supplementary prescribers for six months before they can prescribe independently. A spokesperson for the hospital told Nursing Times: „Prescribing medicines is a new responsibility for nurses. We adopted this policy after listening to the views of nursing staff who had worked as supplementary prescribers, many of whom felt it helped them “feel their way” into the role of prescribing medicines. „We do accept, however, that in areas like the emergency department, supplementary prescribing is not always feasible; as a result, staff may be permitted on a case by case basis to practice independently within an initially restricted scope of practice,‟ he added. Manchester Mental Health and Social Care Trust has adopted a similar policy, requiring nurses to complete mental health-related learning and „prove their ability‟ by supplementary prescribing for the first six months after qualifying. The trust is also yet to approve the use of nurses as non-medical, independent prescribers. „The prescribing course is excellent at teaching basic prescribing skills, but the extra learning ensures that nurses have the necessary skills to prescribe competently for mental health patients. This is the same for all mental health trusts across the Manchester area,‟ said Petra Brown, chief pharmacist at the trust.

„We have many high-risk patients with a huge range of symptoms and co-existing conditions, and there are excellent ways of using nurse prescribing. We are currently in the process of identifying areas where nurse independent prescribing will fit very well,‟ she added. However, at many other trusts across the country, nurse prescribers are able to work independently as soon as they are registered with the NMC, and limiting qualified nurses to a supplementary prescribing role has caused some concern among nurse prescribers. „Supplementary prescribing is incredibly time consuming for prescribers, particularly those who work in walk in centres and specialist roles across multiple practices,‟ said Judith Williams a nurse prescriber at Peterborough PCT. „I can see no benefit from [supplementary prescribing for six months], newlyqualified prescribers are already highly experienced practitioners who have been requesting medications for their patients for years,‟ she added. Alison Williams, emergency nurse practitioner in the emergency care centre at Maidstone and Tunbridge Wells NHS Trust in Kent, said supplementary prescribing would be of no benefit to her role. „If you have your own caseload of patients, supplementary prescribing may work. But I don‟t know who is going to walk through the door, so drawing up a clinical management plan is not feasible,‟ she said. Ms Williams also told Nursing Times that delays in putting policies in place at the trust also hindered her role as a nurse prescriber. „Now that policies are in place, the trust has been very supportive,‟ she said. But when I qualified in 2004, nothing was set up and it was very frustrating that it took almost a year before I could use my prescribing skills,‟ she said.

„It is also an insult to nurses because the prescribing course is not easy, and those who complete it have earned the right to make their own prescribing decisions‟ Barbara Stuttle, chair of the Association of Nurse Prescribers

Barbara Stuttle, director of quality and nursing at South West Essex PCT, and chair of the Association of Nurse Prescribers, said that some nurse prescribers were being further restricted by having to work within the trust‟s local formulary. „Anecdotal evidence suggests that individual trust polices are hindering nurses in prescribing roles,‟ Ms Stuttle told Nursing Times. „This is a real shame because it is not maximising the advantages of prescribing in terms of patient care, and is it not making the best use of nurses‟ clinical skills.

„It is also an insult to nurses because the prescribing course is not easy, and those who complete it have earned the right to make their own prescribing decisions,‟ she added. Local barriers to the right to use their prescribing powers is not the only issue facing nurse prescribers. Further support and training once they have finished their initial prescribing course appears to be lacking in many parts of the country. Continued professional development (CPD) is essential for nurses to keep their knowledge and skills up-to-date. Yet according to a study by Molly Courtenay and colleagues at Reading University, nurse prescribers training needs are currently going unmet, as reported by Nursing Times last week. Between February and April 2009, they surveyed 546 nurses from the Association for Nurse Prescribing database. The researchers found that three-quarters of the nurses surveyed felt they needed more education and training in the pharmacology of medicines, and more than half felt their CPD needs were not being met in the areas of assessment and diagnosis. The study also revealed that e-learning was the preferred method for undertaking CPD, with almost 60% of respondents supporting this method. „It can be very difficult for nurse prescribers to access the appropriate CPD,‟ said Ms Courtenay. „In the current climate, attending conferences and study days is becoming increasingly difficult. „Everybody learns differently, and trusts need to ensure that nurses are given the flexibility to be able to study,‟ she added. Steve Jamieson, head of the RCN‟s nursing department, added that nurses often had to pay for training themselves. „If trusts want nurses to continue with their development in this area, they need to give more thought to funding training for nurse prescribers, and provide more support for nurse prescribers once they have qualified,‟ he said. Although nurse prescribers have encountered some problems in this relatively new role, evidence shoes that it has been welcomed by patients other nurses, and even doctors are now supportive of nurse prescribers. A study of more than 20 doctors, non-prescribing nurses and administration staff – who worked with nurses who prescribe for patients with diabetes – found nurse prescribing to a „positive and welcome addition‟ to the nursing role.

„Nurse prescribing is absolutely invaluable‟ Bill Beeby, chair of the BMA‟s prescribing committee

Those studied said nurse prescribing improved service efficiency by reducing interruptions, enhanced nurses‟ relationships with patients, and facilitated the shift of diabetes care into community settings. Sharon Kitcatt, consultant nurse in the acute pain service at Ashford & St Peter‟s Hospitals NHS Trust in Surrey, said: „Being a nurse prescriber makes you look at things in a different way. It has really helped me to develop therapeutic relationships with patients, and has also facilitated continuity of care. „I have a mentor who is very supportive, and the role has also been welcomed by junior doctors,‟ she added. Bill Beeby, chair of the British Medical Association‟s prescribing committee, told Nursing Times that despite some initial concerns, nurses have proved to be very effective prescribers. „Nurses know what is normal practice, and will confer with a doctor if they feel it is necessary,‟ he said. „The perceived potential dangers have not materialised and nurse prescribing is absolutely invaluable,‟ he added.

The history of nurse prescribing 1998 – First limited national formulary published for district nurses and health visitors – now called the Nurse Prescribers‟ Formulary for Community Practitioners 2002 – Nurse Prescribers Extended Formulary (NPEF) introduced for four therapeutic areas – minor injuries, minor ailments, health promotion and palliative care.The NMC introduces the first independent nurse prescriber course 2003 – Supplementary prescribing introduced. This is a voluntary partnership between a doctor and a nurse who draw up a clinical management plan (CMP) for a patient‟s condition. Once the plan is agreed with the doctor, the nurse can then prescribe anything from the plan. 2004 – NMC changes nurse prescriber course to a dual independent/supplementary prescriber course 2005 – NPEF extended to cover a range of medicines and conditions, mainly for emergency contact and first care 2006 – Almost all of the BNF opened up to independent and supplementary nurse prescribers, replacing the need for the NPEF.


				
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