The existing primary health and specialty team RN prescribing requires nurses to complete a postgraduate diploma (including a prescribing practicum) and allows nurses to collaboratively prescribe from a broad range of prescriptions medicines including not only common ailments but also to support long-term conditions management and prescribing in some specialty areas.

The new level of community health RN prescribing requires experienced nurses to undergo a period of supervised practice and a Nursing Council-approved recertification programme to allow them to collaboratively prescribe from a much more limited list of medicines targeted at treating common ailments like sore throats and common sexually transmitted infections. The first and most longstanding form of nurse prescribing, independent prescribing by a nurse practitioner, has been carried out by nurse practitioners since 2003.*

A trial and evaluation of the new RN prescribing level started in April with 33 primary health nurses at Counties Manukau Health and 24 nurses from Family Planning beginning a recertification programme to meet the Nursing Council competency requirements in readiness for the new community health RN prescribing level coming into force in July.

Nursing Council chief executive Carolyn Reed said both organisations serve populations that would benefit from easier access to medicines required by “normally healthy people” and were supportive of the proposal to extend RN prescribing in the place of standing orders. A decision of when in 2018 to further rollout the new prescribing level will follow a full evaluation of the six month trial that is looking at both the recertification programmes and the trial nurses’ prescribing practice.

Reed said this new prescribing level would improve access to health care for people in vulnerable communities – including children at risk of skin and throat infections that could lead to more serious complications and hospitalisation.

Emphasis on antimicrobial stewardship

Karyn Sangster, chief nurse advisor for primary and integrated care at Counties Manukau Health, said antimicrobial stewardship, through responsible use of antibiotics, is an important focus for the recertification education programme developed by the district health board.  “We have been challenged (over whether) we going to have nurses accessing antibiotics inappropriately.”

But she said analysis of nurses treatment of skin infections under the region’s existing Mana Kidz programme found that only four per cent of the nurses had used standing orders for antibiotics.  “What the research is indicating is that nurses are very judicious in their use of antibiotics and most of the treatments for skin infections have been around cleaning wounds and applying dressings.”

The nurses on the Counties Manukau trial are all currently using standing orders and includes 16 primary health care nurses working in general practice, 11 public health nurses and six secondary school nurses.  Sangster said it had received very good support from GPs ready to provide clinical supervision of the nurses at their practices. Clinical supervision of the public health and school nurses in the trial, would be provided by nurse practitioners and clinical nurse specialists.

To date the trial nurses have had two face-to-face teaching days from clinical experts including a clinical microbiologist and a nurse practitioner.  The recertification programme also includes the nurses completing six online education modules covering areas including pharmacology and clinical assessment.  Sangster said the modules have been developed with the aim of rolling them out nationwide if the trial and evaluation is successful. The education programme is also linked to the HealthPathways support system (developed by Canterbury Health and used by Counties Manukau) which provide a ‘care map’ for consistent patient care of a range of conditions including, for example, a child with scabies.

The Counties Manukau recertification programme is focused on educating nurses to be able to treat common skin conditions, ear infections, low-level pain, sore throats and provide preventative and ongoing treatment for rheumatic fever. Sangster said on completion of the Counties Manukau programme it had arranged with Family Planning for ten of the trial nurses to also complete further training on contraception and treating common sexually transmitted diseases.

Sangster said standing orders has been a great enabler but believed RN prescribing would be much safer, particularly as training of nurses to use standing orders was left up to the discretion of the prescriber.

“They are getting much more training around medicines and antimicrobial stewardship doing this programme.”

She said a focus of the community health prescribing trial was ensuring there  enough rigour in the training process to ensure nurses were safe as it was all about patient safety.  As prescribers the trial nurses accountable for any prescribing decisions they made. But she said the key outcome hoped for was that having community nurse prescribers would enable easier and more convenient access to medicines for common complaints which would free up doctors time and improve access to health care.

Family planning trial also underway

Rose Stewart, National Nurse Advisor for Family Planning, said 24 of its about 70 nurses were involved in the prescribing trial.

She said its recertification programme differed from Counties Manukau’s as when first recruited all Family Planning nurses underwent an extensive training programme on the treatment protocols and specialised range of medications currently supplied by Family Planning nurses under standing orders.

All the nurses who volunteered for the trial were already working at a level where their standing orders were audited monthly, rather than requiring countersigning, but under the recertification programme they had been assigned prescribing mentors to supervise and support them meet the recertification competency requirements which included a series of workbooks. The trial nurses were spread from Invercargill to Whangarei with all of the nine South Island nurses involved being supervised by nurse practitioners.

Stewart said becoming community health prescribers would allow the nurses to take full responsibility and accountability for the care they offered and also changed the relationship between the nurse and the authorising prescriber.

Stewart, who has completed a clinical masters and works clinically two days a week and, said late last year she was approved by the Nursing Council to prescribe at the registered nurse prescribing in primary health and specialty teams (postgraduate diploma) level and was currently the only nurse working at that prescribing level in Family Planning and one of still very few in the country

*Nurse practitioners (who require a clinical masters degree) can work autonomously and can assess, diagnose and treat patients using the same authorised prescriber status as doctors and dentists.