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Prescribing should be integrated into education for advanced nursing practice
The United Kingdom has seen a recent major expansion in the scope of nurse prescribing, reflecting government policy1 and the international trend towards advanced nursing practice.2 In the 1990s it became possible for community based nurses to prescribe independently from a limited formulary, thereby facilitating their traditional roles such as wound management and bowel care. From 2000, further changes in legislation radically altered the professional restrictions on prescribing, and since May 2006 independent nurse prescribers in England have been able to “prescribe any licensed medicine for any medical condition within their competence.”3 Each stage of the development of nurse prescribing in the UK has had its advocates and detractors, but this recent initiative has proved the most controversial, fuelling debate about the adequacy of training of nurse prescribers and risks to patient safety.4
The training for independent nurse prescribers consists of a standalone course of 26 days of theory, 12 days of mentored practice, and five assignments. More than 8000 nurses in the UK have now been trained as independent or supplementary prescribers and thus have access to the full formulary that doctors use,5 and many more district nurses and health visitors prescribe from a restricted formulary. Nevertheless, in England in 2005 just 0.6% of prescription items came from nurses working in the community6; this proportion increased to almost 0.9% in April to September 2006.7 Figures for this later period show that those nurses with access to the full formulary were prescribing drugs previously restricted to doctors, including antimicrobial agents, asthma drugs, nicotine replacement products, and statins.7 Comparative figures for secondary care are not available.
Early international analyses of nurse prescribing indicate that nurses prescribe within their areas of competence and according to guidelines.8 These findings were echoed by a study of independent nurse prescribing in the UK in which an expert panel judged the appropriateness of prescribing decisions made during consultations.9 Nevertheless, detractors are ready to pounce on any contrary findings, and an example is a recent study that raised concerns about the pharmacological knowledge and decision making ability of nurse prescribers. In this study, 25 nurse prescribers were presented with a number of prescribing scenarios.10 Only a minority were able to identify more than half of the pharmacological problems relevant to each case and to suggest an appropriate course of action. This led Pulse (a weekly newspaper for general practitioners) to state that “nurses are ‘floundering' in their new prescribing role.”11 In contrast, the authors suggest that the participants would have referred patients to the general practitioner for matters that were outside their area of competence.
This type of problem is at the heart of the current debate about independent nurse prescribing in the UK. On the one hand, the training and competence of nurse prescribers continues to be called into question. On the other, it is argued that nurses can diagnose and treat conditions safely and effectively within their areas of competence. While it is possible to dismiss some of the criticisms as due to doctors' concerns about nurses encroaching on their traditional territory,12 we believe that for nurse prescribing to contribute more to patient wellbeing in the future, certain educational and practice problems need to be dealt with.
A further expansion of nurse prescribing in the UK is likely in coming years, but the extent to which it develops will depend partly on National Health Service trusts and general practices having confidence in the safety and effectiveness of nurse prescribers and their value in meeting patient needs. Some issues will be clarified by current research studies and local experiences, but concerns are likely to remain about the adequacy of the standalone training module.1
To deal with these concerns and bring about a further step change in nurses' contribution to health care we believe that the “task” of prescribing should be incorporated within the broader framework of the internationally recognised clinical role of nurse practitioners. The current short training course for independent nurse prescribers was designed to allow rapid expansion of a prescribing workforce among experienced practitioners. It is now time to build prescribing into the development of advanced nursing practice2 so that it becomes a complementary part of training in assessment, diagnosis, clinical decision making, audit, evaluation, and referral. This would provide a firmer foundation for nurse prescribers and help to strengthen the case for nurses having a greater role in prescribing.
Competing interests: AJA and VJ are co-investigators on a study of nurse and pharmacist prescribing funded by the Department of Health.
Peer review and provenance: Commissioned; not externally peer reviewed.