Is advanced nursing practice possible without a nurse prescribing?

Dear Editor:

Over the last 20 years there have been significant advances worldwide regarding the adoption of the prescribing role by nurses. Nurses in several countries including the United Kingdom (UK), the United States (US), New Zealand, Netherlands, Ireland, Australia, Canada and Sweden can prescribe.¹ Factors that have driven this development include the need for faster and more efficient access to medicines, improved use of nurses’ knowledge and skills, a need to reduce the workload of doctors and address doctor shortages, and the development of advanced practitioner roles.¹

In 1994 in the UK, community nurses were the first group of nurses to be able to prescribe from a restricted list of medicines. This list includes: laxatives; antifungal preparations; emollients; some analgesics, nicotine replacement products; anthelmintics and insecticides; catheter management preparations; stoma appliances; and wound dressings. Independent prescribing in the UK was later extended to include other groups of 1st level registered nurses in 2001, pharmacists in 2006, optometrists in 2007, and allied health professionals (including physiotherapists and podiatrists) in 2013.

Nurse independent prescribers in the UK have the most extended independent prescribing rights worldwide. These nurses can prescribe any medicine independently within their area of competence, and are responsible for the assessment, diagnosis, and decisions about the clinical management required in patients with diagnosed or undiagnosed conditions. In order to fulfil the needs of the workforce, the numbers of these nurses has steadily increased over the last 5 years.² Furthermore, given the recent accepted proposals (NMC 2017) to include prescribing knowledge and skills in undergraduate nurse education, enabling less experienced healthcare professionals to access shortened post registration prescribing courses, this increase will be further supported.

In order to access education to prescribe, 1st level registered nurses must have at least three years’ qualified experience (of which one year must be in the area in which they intend to prescribe), and the ability to study at degree level. Education programmes are typically six months in duration, and include a number of days in the classroom and supervised learning in practice. This contrasts with some countries, for example the US, Canada and Australia, where education to prescribe is at master's level and is a component of the advanced nurse practitioner programme, which is usually two years in length.¹

There are around 37,000 nurse independent prescribers in the UK representing about 5% of the nursing workforce. These nurses work in a variety of advanced practice roles, across a range of healthcare settings (including primary, secondary and tertiary care) and prescribe medicines across a range of therapeutic areas for example infections, respiratory conditions, diabetes, and minor ailments.³ Although these nurses are only required to be at degree level and have 3 years qualified experience,⁴ over 50% have an academic qualification at master's level, and most have more than five years’ qualified experience before undertaking the prescribing programme.

Patients are satisfied with nurses adopting the prescribing role, and are able to access healthcare services faster. Nurse prescribers themselves describe increased autonomy and satisfaction, and the ability to provide patients with a complete episode of care. It is evident that nurses prescribers are safe and prescribe therapeutically appropriate medicines.⁵ There is little difference between nurses and doctors with regards to the type and dose of medication prescribed.⁶ Furthermore, clinical and patient-reported outcomes, such as systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction and health-related quality of life, are comparable to those of medical prescribers,⁷ and increased cost savings have also been demonstrated.⁸

Extending the role of the UK nurse to include prescribing has improved the use of nurses’ knowledge and skills, and enabled the development of advanced practitioner roles. These roles are central to meeting workforce needs and have led to more efficient services, with patients able to access their medicines faster and increased cost savings. Learning to prescribe has been reported to be one of the most personally challenging areas of development for nurses, prescribing decisions perceived to be complex (McIntosh et al., 2016)⁹. Proposals to include prescribing knowledge and skills in UK undergraduate nurse education programmes will result in new challenges, and these changes will need to be carefully monitored.