The Pharmaceutical Journal
Vol 270 No 7230 p24
4 January 2003

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Pharmacist prescribing summary

Lessons learnt from the nurse prescribing experience

Trudy Granby, Nurse Prescribing Support Manager, National Prescribing Centre, reflects on nurses’ experiences of prescribing and suggests ways for pharmacists to avoid the pitfalls

Although supplementary prescribing (first referred to in the Review of Supply, Administration and Prescription of Medicines as "dependent" prescribing3) is new to everyone, the prescribing role is now well established in nursing practice. Since its introduction in 1994, appropriately trained district nurses and health visitors have been able independently to prescribe items listed in the Nurse Prescribers' Formulary (NPF). Also, since January 2002, other groups of nurses, following extended training, can independently prescribe a wider range of items to treat specific conditions.

The success of nurse prescribing has undoubtedly laid a firm foundation for current developments. However, all developments bring some challenges. As pharmacists prepare to adopt this new and important role, it would seem timely to reflect on some of the hurdles which faced the nursing profession as pioneers of non-medical prescribing. This will allow pharmacists can take a proactive stance to integrating prescribing into their existing role.

21,700 nurses can prescribe

In England there are currently around 21,700 nurses able to prescribe from the NPF and around 400 qualified to prescribe from the Nurse Prescribers' Extended Formulary (NPEF). Figures for October 2002, provided by the Prescribing Support Unit, show that only 11,100 were actively prescribing in England. The obvious next step would be to consider why this should have happened.

Although there is no national study to identify the reasons, there is a plethora of anecdotal evidence to indicate this is due to a number of inter-related factors. Some issues concerned with education and training are briefly discussed below.

During the initial roll-out of nurse prescribing in England, around 22,000 nurses were trained to prescribe from the NPF. Although the Department of Health guide for implementation clearly stated that training in prescribing should be optional, the accompanying Health Service Circular (HSC 1998/232) called for regional offices to draw up implementation plans "with the aim of ensuring that all suitably qualified nurses receive training". It would seem this latter point was interpreted literally by some health authorities and NHS trusts, with little consideration given to local service needs, workforce planning or the desire of individuals to take on the prescribing role. As a result a number of nurses were trained who, because of their clinical role and the limitations of the NPF, had little or no opportunity to prescribe, which undoubtedly contributed to loss of competence and confidence.

This potential barrier has since been recognised and addressed. The selection criteria for nurses to train as extended independent nurse prescribers in England includes the identification of service need and benefit to the patient.

The initial training programmes consisted of 20 hours of open learning with three days face-to face taught component, assessed by formal written examination.

One evaluation by Keele University of the initial training programme was generally favourable in terms of meeting the broad learning outcomes for the course set by the English National Board for Nursing, Midwifery and Health Visiting (ENB). However, anecdotal evidence strongly indicated that the content of actual sessions within individual courses varied considerably. Consequently, newly qualified nurse prescribers were equipped with varying levels of competency and confidence. This issue may have been further complicated because, at this time, the specific competencies for prescribing nurses had not been defined. This meant that the initial learning outcomes for individual courses, as well as being difficult to identify and measure, could not be truly competency based.

Although the merits of students engaging with a "mentor" during their training were generally acknowledged, the curriculum did not include any formal training or assessment in practice. With hindsight this may have added to the initial lack of confidence because some nurses had difficulty in relating theory to practice and questioned their existing level of competency in some areas, such as diagnostics.

Things have moved on considerably since then. The outline curriculum for the preparation of extended independent nurse prescribers, is much more detailed and directional than the initial curriculum, which should reduce variation in course content. As the curriculum also includes 12 days of learning and assessment in practice, supported by an identified medical practitioner, student prescribers now have the opportunity to link theory to practice and develop practical skills.

In November 2001 the National Prescribing Centre (NPC) published a framework of competencies for nurse prescribers which has since been used by a number of higher education institutions to develop detailed assessment strategies. This means that student nurse prescribers can now be assessed against achieving competencies specifically related to being an effective prescriber. This work has been further developed and the NPC plans to publish and distribute a framework of competencies for supplementary prescribing pharmacists in the near future.

The need to reflect continually on practice and identify and address ongoing training and development is well established within the nursing profession. This ethos is underpinned by the mandatory requirement for every registered nurse to meet the post-registration education and practice (PREP) standards, set by the Nursing and Midwifery Council. Although the responsibility for meeting these standards is placed on the individual registrant, the principles of clinical governance require employers to support and encourage appropriate learning activity and many local organisations have developed infrastructures to support the practice development of all staff.

In the early days of nurse prescribing, the approach to addressing the continuing professional development needs of nurse prescribers at a local level was often ad hoc and based on what local organisations could provide, rather than what the prescribers actually needed to develop and maintain confidence and competency in their prescribing role. Again, it is likely this situation is linked to the previous absence of a definitive framework of competencies for nurse prescribers because, without such a tool, it was difficult to carry out a meaningful training needs analysis.

So, in conclusion, reflecting on the nurse prescribing experience, in order for future pharmacist prescribers to maximise their potential they must have the opportunity to prescribe on a regular basis. This will help ensure they develop and maintain the competency and confidence needed to continue to prescribe safely and effectively. In addition, local organisations have a clear responsibility to support the CPD of all staff and should ensure that infrastructures are robust enough to support the additional needs of prescribers.