Chapter 5 Nurse prescribing

INTRODUCTION

The prescribing of medicines by nurses is a significant development of their professional role. First recommended by the Royal College of Nursing in 1980 (Blatt 1997) and addressed in more detail in the Cumberlege Report (Department of Health and Social Security 1986), nurse prescribing evolved with the growing realisation that much of patients’ and community nurses’ time was being wasted in waiting to get prescriptions signed by a doctor when in many cases it was the nurse who had recommended the dressing or appliance in the first place. It was also apparent that community nurses were becoming increasingly skilled in managing pain relief for terminally ill patients (Humphries and Green 1999). Clarification of professional responsibilities was long overdue. The Crown Report (Department of Health 1989) took the matter further with the recommendation that suitably qualified nurses working in the community should be authorised to prescribe in defined circumstances from a limited list, i.e. a nurse prescribers’ formulary. A further recommendation was that nurses should be able to supply medicines within group protocols. The legislation permitting nurse prescribing within the NHS received the royal assent in March 1992. This primary legislation was introduced to permit appropriately qualified nurses working in community practice who had had the recognised additional training to prescribe (within the NHS) medicines and appliances (surgical dressings, etc.) needed for the nursing care of their patients.

In 2000, further proposals to extend the range of prescription-only medicines that may be prescribed by independent nurse prescribers were issued for consideration. These wider prescribing powers were granted in 2001.

A joint Medicine and Healthcare Products Regulatory Agency and the Department of Health consultation was undertaken in 2005 to examine options for the future of independent nurse prescribing. This was in response to claims that the Nurse Prescribers’ Extended Formulary (NPEF) was too complex, and that supplementary prescribing could not be used in all settings in which patients would benefit, such as emergency care, as the clinical management plan (CMP) must be prepared in advance. Experience had also shown that updating the formulary was difficult and resource-intensive. A working group of the Committee on Safety of Medicines first considered the responses to the consultations in September–October 2005, and decided to recommend that suitably trained and qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition, within their own competence.

LEVELS OF AUTHORISATION

For many years, nurses had access to a range of medicinal and nursing care products that were used without medical prescription. With the interests of patient need and the effectiveness and safety profile of the products in mind, written protocols were subsequently developed. Such protocols took the form of, for example, a formulary of nursing care products. Guidance included in the protocols was determined jointly by clinical staff.

The development of policies such as those for symptomatic relief provided a framework to allow the nurse to use a limited number of simple medications used in the treatment of minor ailments (e.g. simple analgesia, aperients and demulcents). Doctors initiated symptomatic relief for the individual patient by entering the words SYMPTOMATIC RELIEF on the prescription, along with their signature and the date. Nurses use their professional judgement in selecting the appropriate preparation and dose from the agreed limited list and then administer and record it. Provided the guidelines that accompany the symptomatic relief policy are adhered to by the nurse administering the medicine(s), it is the doctor who is accountable for the effects of the medicine(s). The policy provides benefit to patients, doctors and nurses by speeding up the process of relieving the patient’s symptoms, reducing the number of times doctors are interrupted, and allowing nurses to exercise their professional role in order to meet the needs of patients. With the reduction in junior doctor working hours and the requirement for greater professional accountability, it is likely that the increasing use of patient group directions (PGDs) and of independent and sup-plementary prescribing will supersede patient-specific policies.

A number of levels of authorisation are currently in place that, depending on the training and accreditation the individual has received, allow nurses to utilise their knowledge of patients and make informed judgements of a patient’s requirements. These include the use of PGDs, independent formulary prescribing and supplementary prescribing. With the extension of independent prescribing rights to include almost the full range of medicines in the British National Formulary (BNF), the role of the nurse in prescribing is becoming ever more important.

PATIENT GROUP DIRECTIONS

Following concerns about the legality of group protocols highlighted in the Crown Report 2 (Department of Health 1999), changes were made to the Medicines Act 1968 that allow the legal supply and administration of medicines under PGDs, replacing the term group protocol. PGDs are written instructions for groups of patients in specific situations who have not been individually identified before presentation for treatment (Department of Health 1999). They allow prescription-only medicines to be administered or supplied without the need for a patient-specific ‘direction’ of a doctor.

Patient group directions have been introduced in both hospital and community practice to reduce the time that patients have to wait for treatment. Increased use of the nurse’s professional skills has resulted in more effective utilisation of resources. Those authorised to supply or administer medicines under PGDs include individually named registered nurses, midwives, health visitors, pharmacists, and a range of professionals allied to medicine who have undergone training and accreditation relevant to the clinical condition(s) to be treated and medicine(s) to be used. Each PGD is formally established by local professional advisory groups in wide consultation with senior representatives of the appropriate professional group. The legislation specifies that each PGD must contain the following information:

• the name of the business to which the direction applies

• the date the direction comes into force and the date it expires

• a description of the medicine(s) to which the direction applies

• the class of health professional who may supply or administer the medicine

• the signature of a doctor or dentist, as appropriate, and a pharmacist

• the signature by an appropriate health organisation

• the clinical condition or situation to which the direction applies

• a description of those patients excluded from treatment under the direction

• a description of the circumstances in which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral

• details of appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum and maximum period over which the medicine should be administered

• relevant warnings, including potential adverse reactions