As registered nurse prescribing inches closer, MARK JONES and JILL WILKINSON argue that prescribing innovations could be better and faster in the future if the Queen wasn't involved. They are calling for the proposed new Medicines Act to see a handover in power for deciding nursing's prescriptive authority from the Queen (i.e. the Crown) to the Nursing Council.
As far as extending prescriptive authority to nurses is concerned, we have around 40 years’ experience between us in influencing national health policies around the world.
Although we are both Kiwis now (Jill always and Mark recently so), in both our respective home countries the answer to ‘who decides about nurse prescribing?’ is ‘the Queen’.
This may seem a little odd for a country seriously considering eradication of all reference to ‘the motherland’ from its flag, but yes, the agent of Her Majesty (the Governor General), and the Ministers of the Crown determined back in 1998 that nurses could prescribe here in New Zealand.
As for the United Kingdom, the original legislation in 1992 allowing nurses to prescribe was ‘enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons’.
Of course, everyone knows the Queen doesn’t really sit down and spend a great deal of time thinking about who prescribes (although she may a little), rather she has been advised that the legislation she, or her representatives, sign-off on is a good thing for the people.
The ability of nurses to prescribe here in New Zealand is founded in the Medicines Act 1981. Even though nurses (as nurse practitioners) had been prescribing in the US for more than 20 years, nobody seriously thought they would here.
So now New Zealand has a raft of regulatory amendments stuck over that original Act to permit such outrageous ideas. Essentially this is a ‘sticking plaster’ approach and it means the original medicines legislation is simply out of touch. New Zealand is now at the point where there are more plasters than original text and some are starting to peel, revealing a bit of a mess underneath.
Fortunately, New Zealand’s legislators have acknowledged the Medicines Act 1981 is out of date. We have been working on a consultation submission from the College of Nurses, putting our case forward as to how prescriptive authority for nurses should be determined once the current Medicines Act (and associated plasters or regulatory amendments) has been repealed and replaced by a new one. Our submission didn’t say so much about the Queen.
Clunky, out-of-date legislation
Right now, New Zealand’s medicines legislation tries to encompass a range of things not considered when it was drafted 35 years ago. Consider also, when innovations to improve patient care – such as the right of nurses to prescribe – were being mooted some people didn’t really like that idea and lobbied long and hard against regulatory change.
Sometimes these people also told government officials, Ministers (maybe even the Queen) and the nation in general that, at best, nurse prescribers could harm people and fragment care, and at worse there would be deaths. This happened in the United Kingdom and other countries too. Perhaps not surprising then that New Zealand’s medicines legislation wrestles with protecting the public from errant prescribers, while facilitating prescribing by new groups such as nurses. It ties everybody up in knots and tries to determine what safe practice should look like.
There should be warning bells ringing about now for everyone who understands our professional regulatory system. Is it not our Nursing Council that determines safe practice, not some clunky out-of-date medicines legislation? Well, this is exactly the point. Sure enough, the Health Practitioners Competence Assurance (HPCA) Act we all know and love has the official approval of the Queen via the Governor General too, but it recognises the best place for professional regulation is with the professional regulator.
With this in mind, we have proposed something that might be a radical shift for some people, including nurses. Rather than have an Act that permits people to prescribe also telling us how, where and what they should prescribe, why not just have our new medicines legislation facilitate prescribing by nurses and leave the nitty gritty to the Nursing Council?
In this model, the Ministry of Health and whoever is in government doesn’t have to try and understand and legislate for an expanding area of nursing practice; rather the Council is charged to do this. The replacement Medicines Act should simply reiterate the legality of nurses as prescribers.
What this means is that our primary medicines legislation should allow registered nurses to legally prescribe medicines and therapeutic products that are deemed safe for use in New Zealand, full stop.
The Nursing Council will then use its current processes to determine the nature of education and expression of competency required for nurses to prescribe within their various scopes of practice. In this model we’d no longer see categories such as ‘authorised’, ‘designated’ or ‘delegated’ prescriber complicating things; rather, which nurse prescribes what and how becomes the responsibility of the Council.
Of course, the Council may wish to describe prescribing practice as a tiered activity of sorts underpinned by a range of educational options associated with practice scopes; but this time around it will be nursing deciding who, what, where and when, not some dislocated, patched-up legislation.
The Queen might not get to know much about this, but if she did she would see it makes sense!
Authors: Dr Mark Jones is a former chief nurse of New Zealand, a director of the College of Nurses Aotearoa and now the associate head of school for Massey University's School of Nursing
Dr Jill Wilkinson is a senior lecturer at Massey University's School of Nursing and a College of Nurses Aotearoa spokesperson on prescribing.
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