Ready to take the medicine

1 April 2013

Some call it the biggest revolution for New Zealand nursing since training left hospitals. A decade since the first Kiwi nurse practitioner was authorised to prescribe, the Nursing Council is proposing the long-awaited widening of prescribing to registered nurses. Prescribing is the buzz. Along with cries of “at last” and “fantastic”, there is a desire to get it right from the outset if the country wants more RNs to leave the protection of standing orders and become prescribers in their own right. FIONA CASSIE reports.

Any mum can dish out paracetamol to a child grizzly and miserable with a runny nose and mild fever caused by a simple head cold.

But there has been frustration and confusion that experienced nurses cannot use their clinical judgment to provide such simple pain or fever relief without a doctor countersigning their decision. 

In fact a registered nurse can provide advice about over-the-counter (OTC) medications like paracetamol (but must be knowledgeable and accountable for their advice including making and documenting a comprehensive nursing assessment*). They just can’t prescribe it...but this may soon change.

Nurse practitioners were the first to step over the prescribing threshold in 2003, and after many legal hiccups and detours (see timeline p.8), there are now about 100 prescribing NPs.

Those same legal hiccups also stalled the momentum to extend prescribing to RNs until in 2011 came the successful demonstration of prescribing by diabetes nurse specialists that’s now being rolled out to more nurses across the country.

The demonstration went ahead as part of a new zeitgeist – sanctioned and backed by Health Minister Tony Ryall and Health Workforce New Zealand – for all health practitioners from pharmacists to dietitians to work at the top of their scope. The aim is to provide better access for patients to timely and affordable health care – particularly the growing number with chronic conditions.

Now the Nursing Council, at the invitation of Tony Ryall, has put out a comprehensive consultation document as the first step to formally seeking Government approval for two levels of RN prescribing.

The near universal buzz from nursing is positive, with the proposal being called “a giant stride forward” to “pragmatic” by nursing leaders and practitioners keen to see nursing take what is seen by many as an inevitable and logical step. The only “buts” come when it gets down to the detail: Is two levels of RN prescribing a good thing? How qualified should RN prescribers be? Who is going to fund that training and mentoring? What should RNs be able to prescribe? Will RN prescribers feel safe?

Double trouble or the right thing?

At present only 0.25 per cent of New Zealand’s practicing nurses are authorised to prescribe compared to 7.5 per cent in the United Kingdom, where research has found nurses safe and conservative prescribers.

Community nurse prescriber and specialist nurse prescriber are the two RN prescribing options being proposed by Nursing Council to join the existing NP role (see prescribing model summary box).

That would see New Zealand end up with three prescribing levels – similar to the UK, where limited community RN prescribing began in the 1990s and where there are now more than 50,000 RN prescribers (see overseas box).

There is a mixed reaction to whether New Zealand should have a two-tier prescribing model for RNs – the limited community nurse prescriber model, for minor illnesses and ailments, and a higher level specialist nurse prescriber, like the diabetes nurse specialists.
The College of Nurses spokeswoman on prescribing, Dr Jill Wilkinson, says the two-level proposal is a pragmatic solution to getting nurse prescribing quickly where it is needed most.

Rosemary Minto, the chair of NZNO’s College of Primary Health Care Nurses, says her personal opinion is that it’s safest and simplest to just introduce specialist nurse prescribers. A prescribing NP herself, she believes primary health care is too complex to easily draw a line cutting off what is minor and what is not.

Hilary Graham-Smith, associate professional services manager for the New Zealand Nurses Organisation, thinks the community nurse prescribing role is a good idea but the model proposed is “perhaps a step too far just at this point in time” and more work needs to be done shaping it into a workable model.

Dr Helen Snell, the diabetes NP who has led the diabetes nurse specialist prescribing demonstration, backs the two tier model, believing it delineates well between lower level prescribing for the “everyday, straightforward and minor”, and prescribing at a specialist condition-focused level.

Pam Doole, the Nursing Council’s strategic policy director, says at the beginning the Council was considering only one level of RN prescribing, with the likely qualification set at postgraduate diploma level or similar.

But when it looked at the qualifications held by primary health care nurses – the area it believes RN prescribing could make the most difference to patients – it found the number of primary health care nurses with a postgraduate diploma or papers was low.

“We were also hearing a lot of feedback about the frustration nurses were feeling about not being able to prescribe some quite simple, sometimes over-the-counter (OTC) medicines,” says Doole. “Like school nurses who couldn’t prescribe paracetamol.”

“So the idea of having another level that could have a much shorter qualification but enable nurses to prescribe for normally healthy people for minor ailments and things that would promote health like contraceptives and vaccines etc. seemed like it could be a good idea.”

Yes! But…

The model being given a big positive tick by many in nursing is specialist nurse prescribing.

With the diabetes nurse specialist (DNS) prescribing pilot a success – and already many clinical nurse specialists and rural nurse specialist having a postgraduate diploma or masters degree under their belt – the specialist nurse prescriber model is seen as a comfortable fit.

It is the pioneer territory of community nurse prescribing where the feedback is mixed and includes a series of “buts”. Some think the Nursing Council has got it basically right first time, others that it is a good idea “but” the framework needs clarifying and tightening to ensure nurses feel adequately prepared and safe, and Rosemary Minto for one believes it shouldn’t be there at all.

“If we’re going to close the gap with the high needs people – which ultimately should be our aim – and provide health care to them, I don’t think having a community nurse prescriber with limited prescribing skills is going to help that,” says Minto. “All we are doing is plugging a current gap rather than looking to the future and being more effective about the use of our nurses and doctors.”

Helen Snell believes it is probably the title “community” that makes the lower level prescribing tier appear problematic, and the focus should be on the targeted level of prescribing practice rather than the setting.

Jill Wilkinson, the Massey University lecturer who was one of the authors of the DNS prescribing evaluation report, says the lower level community prescribing option is a pragmatic solution to getting nurse prescribing more quickly into the area that increased access to medicine was needed most – primary health care.

“Because nurses who work in PHC have traditionally had pretty poor access to postgraduate education, there aren’t that many nurses who would be eligible to prescribe in the specialist category.”
With many of the drugs listed already used under standing orders, she believes the community nurse prescriber option, with its nationally consistent training qualification, could be “in many respects safer” than what currently occurs under standing orders with ad hoc training standards.

Graham-Smith says while she is hearing feedback that the community prescriber role has the potential to improve health care access, she is also hearing quite a few “buts” around assumptions in the model.

“I think there’s some assumptions that we have a skilled nursing workforce who are already doing this under standing orders – and to some extent, that’s true – but I don’t think every nurse working in the community has the skill set to function in that way.

“I think the other assumption is that nurses won’t prescribe if they don’t feel comfortable about it, and I think that’s true as well, as they are well aware of the risk, but is there going to be some pressure to step up?” asks Graham-Smith. “We’ve certainly seen that occurring in cases where practices already have extensive standing orders and nurses feel intimidated by those and also feel some pressure to use them when it’s actually outside their comfort zone.”

153 medicines from antibiotics to zinc

Some of the “buts” also centre around the proposed community nursing formulary – which at 153 prescription medicines and 110 non-prescription medicines looks intimidatingly large.

“There are drugs on there that I don’t pretend to want to prescribe as an NP,” says Minto.

Doole says the extensive list has been drawn up with the UK evidence in mind that “nurses will prescribe medicines they know, for patients they know, for conditions they know”. “So we don’t expect there to be many nurses who will prescribe everything on the list.”

The council also did not want to go down the failed pathway that nursing had been down before, of having individual lists for individual specialty areas. Instead the community prescribing list aimed to cover all medicines that all potential community prescribers – from family planning to public health nurses and practice to prison nurses – might need to prescribe for minor illnesses and ailments.

And yes, the assumption is that nurses will only prescribe what they are qualified and competent to prescribe. “I think it makes more sense for us to have a broad list and for us to educate nurses to understand their own level of competence when using those lists,” says Doole, but the list would be refined and shaped by consultation feedback.

As would the proposed community nurse prescribing qualification. A number of nurses, including Graham-Smith, expressed concern that a six day theory course and three days supervised prescribing was not enough to support nurses in taking the ‘leap of faith’ into prescribing. Minto says nothing less than a postgraduate diploma would do and Graham-Smith believes something more like a postgraduate certificate was needed to ensure nurses were adequately prepared.

Doole said it would definitely listen to feedback, particularly from the PHC sector, as it wanted a qualification and formulary list that was “first and foremost safe but also practical and enabling”.

Mentoring and employer support essential

The Nursing Council also wants would-be fledgling nurse prescribers to have the backing of their employer and a prescribing mentor before signing up to a training course.

This new criteria is partly in response to UK research showing that if newly authorised nurse prescribers have little or no employer support, their prescribing competence and confidence drops away. The criteria also aims to avoid a repeat of the situation back here in New Zealand where so many nurses with clinical master’s qualifications have not made the transition to being registered nurse practitioners or finding an NP job.

“I guess what we’re trying to do is set it up for success by putting those criteria in. So individual nurses have that support around them before they start and there is already an identified role for them as a prescriber,” says Doole. “It will grow naturally as people see the success of it.”

With the high numbers of nurses already having completed prescribing practicums, there may be several hundred nurses ready in the wings to apply for specialised prescribing status, if they can get employer backing.

Which brings us back to a “but”, with Graham-Smith pointing out that another assumption is that there are sufficient resources in the community to provide mentoring and support for nurse prescribers, but she’s not sure that’s the case.

She is not alone in that concern. Wilkinson, who co-ordinates prescribing practicums for Massey University, says she has students struggling to get funding for practicums, with some even resorting to paying their clinical supervisor out of their own pockets. With the Health Workforce New Zealand (HWNZ) postgraduate funding pool for nurses already stretched, she says a separate funding pot will be needed if would-be nurse prescribers weren’t going to have “refight all the battles” that NPs have had to fight over the years.

Minto says extra HWNZ funding and support would be needed as it was already a struggle for GPs to find the time to supervise nurse practitioner candidates without adding the volume of nurses who might want to go down this new track.

“To be honest HWNZ has not done much for NPs in that area it will be interesting to see what they provide for nurse prescribers.”

Of course another unknown is how many employers and GPs at this point are keen to support having nurse prescribers on the team and whether the new roles will face less or similar barriers to nurse practitioners. Snell – who did much of the behind the scene’s work to make DNS prescribing a reality – says she may be “naively optimistic” but having encountered little resistance from any quarter, she believes rolling out wider nurse prescribing will be relatively straightforward.

Graham-Smith adds that for the benefit of any doctors anxious about liability, the nursing profession has to “simply keep reinforcing the message that nurses are accountable for their own practice”.

Doole says along with working with HWNZ and the Chief Nurse’s Office, the council has met regularly with the Medical Council, College of Physicians and College of General Practitioners during the drawing up of the consultation paper and says responses have been “reasonably positive to date” from the medical fraternity with the fine detail once again being the area where differences of view emerge. (see Other Comment sidebar for NZMA opposition)

Meanwhile the jury is still out on whether opening up the option of specialist nurse prescribing will become a natural stepping stone on the way to independent NP status or a stepping-off point for nurses content to practice and prescribe at that level (and who may be dissuaded from going further by the demanding NP registration standards and/or an employer unwilling to offer them an NP position).

Snell, for one, believes many specialist nurse prescribers will go on to seek NP status as they (and employers) will become frustrated at not being able to deliver the full range of care of an independent NP.

“I think we also need to dispel the myth that prescribing is the key difference between the RN and the NP scope – people put too much emphasis on the NP prescribing role – an NP is much more than that.”

Prescribing by RNs may, in time, be the ‘new normal’. Submissions on the Nursing Council’s consultation document closed on April 19. Doole says after analysing the submissions and refining the models, it hopes by the end of year to put an application to the Health Workforce New Zealand board who will in turn advise the Minister of Health whether RN prescribing regulations are good to go.

And the judicious and timely prescribing of paracetamol by suitably skilled and qualified nurses is possible at last.

*The original article was altered on May 9 2013 to clarify issues around OTC medicines.  Some of the latest advice for nurses on recommending OTC medicines can be read online see: Advising on OTC medicines

Proposed and existing nurse prescribing models

Community nurse prescriber
Able to diagnose and treat minor ailments and infections (e.g. common skin infections, sore throats and hay fever) in normally healthy people and promote health and prevent disease by prescribing contraceptives, vaccines and other medicines.

Minimum of three years experience and a community prescribing course (of up to six theory days and three days supervised practice with authorised prescriber mentor e.g. GP or NP).

Must have support of employer and identified mentor to undertake course and employer organisation has to support nurse prescribing through policy, audit, peer review and access to ongoing education.

Specialist nurse prescriber
Able to diagnose and treat common conditions in their specialty area (e.g. asthma, diabetes or hypertension) within a collaborative interdisciplinary team. Must seek doctor assistance when making complex clinical decisions.

Aimed at nurses with advanced skills and knowledge working in specialty services (like diabetes nurse specialists) or in general practice (including rural nurse specialists).

Requires minimum of three years experience and postgraduate diploma in prescribing (including pathophysiology, pharmacology and 150 hours supervised prescribing experience with medical mentor).

RN must have employer backing to prescribe in their role once qualified. Also need support of identified medical mentor and to work in an organisation that supports nurse prescribing through policy, audit, peer review and access to continuing education.

Nurse practitioner
Able to independently diagnose, treat and prescribe for a range of acute and chronic conditions in their area of practice. Consults and refers to a doctor as required. Minimum of four years of practice in specialty area and a master’s degree (that could include the postgraduate diploma in prescribing) plus advanced practice and education to be an authorised prescriber.

Currently NPs are designated prescribers but after Medicines Amendment bill is passed (had had second reading at time of going to press) they will become authorised prescribers). The two other nurse prescribing roles are proposed to be designated prescriber roles.

 

Other comments

New Zealand Medical Association opposition
“The NZMA opposes the proposals by the Nursing Council to extend designated independent prescribing rights to community and specialist nurses. This stems primarily from our concerns that prescribing is inextricably linked to diagnosis.

Medicines are a critical component in effective, quality and safe healthcare delivery. Prescribing of medicines, however, cannot be considered in isolation from diagnosis, which requires knowledge and skills built on years of study of anatomy, pathology and physiology, followed by years of training in clinical methods.

The NZMA would however support delegated prescribing rights* for nurses as this model would mitigate the risks involved in non medical prescribing and would best facilitate the collaborative team based care that is the shared objective of our respective professions.”

Statement by Dr Paul Ockelford, NZMA Chair

*Delegated prescribing is to be introduced under the Medicines Amendment Bill, which has passed its second reading. A delegated prescribing order is issued by an authorised prescriber like a GP or (soon) NP.

Health Workforce New Zealand
Brenda Wraight, director of Health Workforce New Zealand, says the agency is in continuing dialogue with the Nursing Council and is supportive “in principle” of prescribing by suitably qualified registered nurses in order to “provide patients with better access to healthcare and enable full use of registered nurses’ professional knowledge and skills”.

When asked about funding the training of future RN prescribers Wraight says nurse practitioner training funding includes prescribing practicums and “we would expect any authorised or designated nurse prescriber to undertake full training and assessment”. “However, it is too early to speculate on the funding of training for additional groups.” 

She says HWNZ will continue to prioritise its training funding according to those areas that are critical to delivering better health care services. The proposal for a dedicated nurse practitioner ‘registrar’ or ‘candidate’ programme has also been received by HWNZ but it is “awaiting further advice” from the Council following the current consultation process.

Health Minister Tony Ryall
“We support more health practitioners working to the full extent of their scopes of practice – and taking on new roles where it is appropriate. It’s good for patients, especially those with high needs. And nurses and other health professionals also benefit from further opportunities for developing their careers. For example, diabetes nurse specialists can now be designated prescribers – and they are operating very successfully for patients.”

 

Specialist prescribing a “fantastic fit"

Opening up the option of specialist prescribing is a ‘fantastic’ fit for respiratory nurse specialist Nicola Corna. A major motivation for her starting off down the nurse practitioner pathway was the belief that prescribing could add to her practice and becoming an NP was the only path.

But now with her master’s degree under her belt, she has put NP and prescribing practicum plans on hold as she believes being a clinical nurse specialist with prescribing rights could be a really good fit for her employer’s and patients’ needs as well as for herself and her family.

“Right now I think it is exciting to be a CNS because there are opportunities to extend your practice and provide better for the patients you care for. I think it’s fantastic.”

She says the service she works for, at Counties Manukau District Health Board, already has a respiratory nurse practitioner “doing some amazing work” and in the future she may sit down and re-evaluate whether she too wants to start down the NP pathway once again. “But it’s a pretty good fit for where I want to be at the moment.”

Nurse prescribing overseas

Nurse prescribing first began in the UNITED KINGDOM in the 1990s for community nurses with a limited formulary, independent nurse prescribing with an extended formulary followed in 2002, and supplementary prescribing in 2003. Since 2006 independent nurse prescribers (have to be suitably qualified and have employer support) are able to prescribe any medicine from the British National Formulary but recent research indicates they are “cautious” prescribers who self-restrict their prescribing. There are now more than 30,000 community prescribers (4.5% of all registered nurses) and in addition about 20,000 independent and supplementary prescribers (3%).

Since 2008 IRELAND has had nurse prescribing with similar entry requirements to the UK and has 545 registered prescribers. Ireland requires the nurse prescriber to have a collaborative practice agreement with a medical practitioner, which stipulates the medicines the nurse may prescribe and in what setting.

In AUSTRALIA there are 788 prescribing NPs and 804 RNs in rural and isolated practice authorised to supply medicines. Health Workforce Australia is in the process of developing a consistent prescribing pathway for all health professionals

Prescribing in the UNITED STATES is largely restricted to NPs, nurse anaethetists, nurse midwives and clinical nurse specialists with the level of prescribing differing state to state.

 

NURSE PRESCRIBING TIMELINE

1998 

 

  • Ministerial Taskforce on Nursing launched by Health Minister Bill English who backs nurse prescribing. 

1999 

  • Amendments to Medicines Act 1981 allows nurse prescribing.

2001 

  • NP scope of practice launched and first NP authorised.
  • Medicines (Designated Prescriber: Nurses Practising in Aged Care and Child Family Health) Regulations gazetted.

2003 

  • Paula Renouf approved as first prescribing NP (child health).

2004

  • Attempt to “streamline” NP prescribing regulations hits legal brick wall.

2005

  • New NP prescribing regulations go out to consultation twice after medical opposition to proposed process before Medicines (Designated Prescriber: Nurse Practitioners) Regulations 2005 gazetted in December
  • Adrianne Murray becomes second NP prescriber.

2006

  • Therapeutic Products and Medicines Bill introduced that proposes new prescribing regulations for NPs and nurses.

2007 

  • Therapeutic Products and Medicines Bill shelved because of controversy over trans-Tasman therapeutic products authority.

2010 

  • Health Minister Tony Ryall signals Medicine Amendment bill on way including prescribing reforms for nursing.

2011  

  • Medicines Amendment Bill enters parliament proposing authorised prescribing status for NPs. Also proposes third prescribing category of delegated prescribing.

2012  

  • Health Select Committee reports back on submissions to Medicines Amendment Bill.

2013  

  • Nursing Council releases RN prescribing consultation document.
  • Medicines Amendment Bill has second reading.
     

See extra online-only story Pioneer prescriber looks back on New Zealand’s first NP prescriber Paula Renouf at www.nursingreview.co.nz