The recognition of prescribing by nurses, a battle that is about to be won

International studies show that prescribing by nurses (PN) is associated with better care for individuals who require medical care, together with more effective use of time and resources and better relationships between healthcare professionals.^1,2 In Spain the only professionals who are now able to prescribe are doctors, odontologists and podologists.

At an international level there is a long history of PN, and it was proposed for the first time in Sweden in 1978. In the United Kingdom in 1986 the need was identified for certain nurses to be able to use professional criteria to modify medical prescriptions, in aspects such as analgesic doses for terminal patients. This led to changes in the law, authorising this practice and then broadening and deepening their field of action.

PN is legal and possible for nurses in the U.S.A., the United Kingdom, Sweden, South Africa, Australia, Canada, New Zealand, Brazil, France, Ireland, Lesotho, Botswana and Argentina. Specialised training is required in almost all of these countries so that professionals are able to acquire the necessary skills.

With the aim of standardising the training requisites for PN, in 2002 the International Council of Nurses (ICN) defined the criteria for advanced practice nurses³: “An advanced practice nurse is a registered nurse who has acquired a foundation of expert knowledge, decision-making skills and clinical expertise in broad practice, in the field in which the nurse is qualified to work, recommending a Master's Degree for access level. One of the core aspects in the field of competence in this practice is the authority to prescribe, supporting professional autonomy and independent practice” (p. 12). We have to underline here that advanced practice nurses do not exist in our country except for the specialities recognised in Royal Decree 450/2005, so that it is another challenge in the development of the profession as a whole.

In September 2002 the World Health Organisation (WHO)⁴ passed a resolution requesting, among other measures regulating the rational use of medicines, “the development of the competence of nurses and other healthcare professionals so that they are able diagnose, prescribe and dispense medicines” (p. 6). The WHO emphasises the strengthening of primary care, as well as the development and furtherance of nursing responsibilities to achieve strong healthcare systems.⁵ Starting from this basis, it is not only Spanish nurses who demand the authority to prescribe for the professional development and efficiency of the healthcare system. Rather than this, the managers and healthcare systems themselves are interested in authorising and broadening the said responsibility, taking into account the benefits deriving from this for the safety of patients and the good of the system itself.

In our country the debate on the law governing nurses’ participation in pharmacological prescribing commenced with Law 29/2006 on the guarantee and rational use of medicines and healthcare products⁶ or the Medicine Law. It was not until December 2009 when Law 28/2009 modified Law 29/2006 and finally recognised this participation.⁷

Law 28/2009 opened the door to PN. While it was necessary that it be applied throughout national territory, the different governments of the autonomous regions had to legislate for this, while the professionals involved had to work on modernising and gaining specific training.

Andalusia was the pioneer, publishing Decree 307/2009 in the BOJA on 21 July. This defined the working of nurses in the field of pharmaceutical prescribing in the Public Health Service of Andalusia.⁸

This decree allowed nurses in the Public Health Service of Andalusia to use and prescribe medicines not subject to prescription by a doctor and to indicate or prescribe medical products financed by the pharmaceutical assistance fund of the Public Health Service of Andalusia. It also allows them to collaborate with doctors and odontologists in the protocolised monitoring of patients with specific pharmacological treatments if they require medical prescription. It establishes which medicines and medical products may be prescribed by nurses, as well as the nursing order.

Based on studies undertaken in Andalucía^9,10 it is possible to deduce that the reduction in spending on absorbent materials and capillary glycaemia self-monitoring strips has arisen thanks to suitable prescribing by nurses. It is also due to the inclusion of clinical practice guides on urinary incontinence and the integrated care programme for diabetes. All of this shows that the inclusion of PN for medical products intrinsic to their work in care has led to an important reduction in health system spending on the said products.

All of these advances in PN suffered a major setback with the publication on 23 December 2015 of RD 954/2015. This regulated the prescription, use and authorisation of nurses to dispense medicines and medical products for human use.

Regarding nurses’ authority to prescribe, use and authorise the dispensing of medicines subject to medical prescription in their work, article 3.2 of the said Royal Decree states that all nurses who wish to develop this professional competence, must previously hold accreditation from the Ministry of Health, and that once they are accredited it will be necessary for a professional prescriber (i.e., a doctor) to have prescribed the product in question and determined the patient follow-up protocol; this means that it is necessary for nurse to possess accreditation by the ministry and also to have the corresponding medical prescription before they can indicate that a product be dispensed.

This is highly prejudicial for the nursing profession, for the care dynamic and for patient safety at all levels of care. It means that currently in critical patient units, if an ICU nurse needs to cure a pressure sore, she first has to ask a doctor to establish the debriding product to be used in the treatment of the patient, and also to prescribe the dressing that the nurse will use to treat the patient. All of this hinders care work, showing that the current regulations ignore the reality of health care work. In the same way, if a patient needs a urinary catheter the doctor must be asked to establish the type of catheter (medical product) to be used in the treatment as well as its calibre. If the doctor does not prescribe this then the nurse is acting outside the law and her third party insurance will not protect her. Another common example arises when a patient needs a perfusion of vasoactive drugs. The nurse is unable to modify a prescription based on the protocols agreed in the unit, but rather must call the doctor who prescribes the change in dosage depending on the haemodynamic of the patient, leading to dysfunctions and delays in care that would easily be avoided if it were possible to work using clinical protocols. These everyday examples prove that the current regulations are inoperative and dysfunctional, and that they reduce the independence of Spanish nurses. These regulations are a long way away from clinical reality and cause an unreasonable delay in the treatment of patients sent to visit doctors by nurses for unnecessary purposes. All in all it amounts to a return to the nursing of the 1970s.

Ruiz Sánchez¹¹ analyses the main statements of the Organización Médica Colegial (OMC) on PN that influenced the Ministry of Health, Social Services and Equality and led to the modification of the draft law. He demonstrates the lack of knowledge of the OMC regarding the scientific evidence at an international level in the field of PN, that nursing is a specialised field of health care that uses a series of specific medical products that are intrinsic to its professional field and which doctors themselves do not usually use.

Current scientific evidence, at a national and international level, shows that PN¹² is an efficient medical action and that Spanish nurses are extremely well-trained in medication. They also have wide knowledge of the medical products used in chronic patients. Their skills also include health promotion and education. The results of the study by Ruiz Sánchez corroborate the fact that the inclusion of PN in the healthcare system improved its efficiency, while the decisions expressed in RD 954/2015 amount to a step backwards from this achievement. On the other hand, although the statements of the OMC criticise this medical action, its arguments have no scientific basis.

We are about to achieve the modification of Royal Decree 954/2015 to ensure the legal security of nurses who prescribe, as they have done so fully competently while maintaining the quality of patient care and attention. An agreement was reached on 24 October between the nursing profession committee, the medical profession committee and the Ministry of Health, proposing the following types of PN:

• 1.

  Medical products and medicines that do not require prescription: in these cases PN will be autonomous and free, with the logical professional responsibility.

• 2.

  Prescription medicines that do NOT require medical diagnosis as they are nursing interventions: vaccines, insulin, wound dressings, oxytocin and analgesics, etc. In these cases nurses will act according to protocols established previously between the professions and the authorities, without the need for a doctor to intervene.

• 3.

  The prescription of medicines that are subject to prescription by a doctor in cases when diagnosis and prescription by a doctor beforehand are always necessary, when the nurses carry out the subsequent care and follow-up of the patient. In these cases, and once the said diagnosis and prescription have been undertaken, the nurses will act according to protocols established previously between the professions and the authorities.

All of this will be possible without the need for accreditation of the nurses, as the title of Diploma in Nursing is recognised as equivalent to Graduate in Nursing, as a requisite to be able to carry out PN according to the modification of the Royal Decree.

We are awaiting the publication of the new legal regulations that have been adopted, and that at last the day to day work of nurses associated with prescribing and managing drugs and medical products will be recognised, making Spanish nurses the only ones in the world who are all able to prescribe.

There is no doubt that all of this will be a first step towards new future scenarios for nurses, when for the first time European regulations recognise the competence of general nurses to independently diagnose the care that is needed. This norm contained in Directive 2013/55/EU was transposed by RD 581/2017¹³ in June 2017, and it will no doubt create a key precedent. It is therefore now necessary to continue advancing at a professional level, with the need to incorporate this key responsibility of diagnosis by nurses, as well as the authority to prescribe, in the Law on the Regulation of Medical Professions, which has to be updated immediately, The professional advances in nursing must be recognised, as they will surely lead to advanced practice nursing and the acquisition of new, increasingly complex and pioneering caring roles for all nurses in Spain.