Nurse prescribing: the process, preparation and its impact on diabetes care
Nurse prescribing, although primarily carried out in the community setting, is growing in secondary and specialist care – for example, in diabetes centres. The advent of the Extended and Supplementary Prescribing Course has provided an opportunity for nurses working within the specialty of diabetes not only to prescribe medicines such as insulin and oral hypoglycaemic agents but, for the first time, to be able to adjust therapy legally.
The Royal College of Nursing first recommended nurse prescribing for district nurses in 1980, but it was not until the final Crown Report1 that there was support for an extension of the groups of professionals who could prescribe and in turn improve multidisciplinary team-work. It was at this time that there was a key recommendation to recognise two types of prescriber: the Independent Prescriber who would be responsible for the assessment of patients with undiagnosed conditions and for decisions about the clinical management required, including prescribing; and the Dependent Prescriber who would be responsible for the continuing care of patients who have been clinically assessed by an Independent Prescriber. This care would be informed by clinical guidelines and be consistent with individual treatment plans. Regular clinical reviews would also be carried out by the assessing clinician. The need to ‘extend the role of nurses, to make better use of their knowledge and skills, including making it easier for them to prescribe’ was reinforced by the document ‘Making a Difference’,2 produced at this time.
An Independent Nurse Prescriber can only prescribe from a specified nurses' extended formulary. This includes a list of around 240 prescription-only medicines, general sales list and prescription medicines (including controlled drugs) for a range of around 110 medical conditions. However, the Department of Health has deemed independent nurse prescribing appropriate for certain circumstances only. These circumstances include: common conditions as listed in the Nurse Prescribers' Extended Formulary (NPEF), if the nurse is working remotely from a doctor, seeing patients independently for those conditions listed in the NPEF, and if the nurse is competent to assess, diagnose and make treatment decisions for the patient. Independent nurse prescribing is not suitable for complex medical conditions or for patients with several co-morbidities3 – for example, diabetes.
Supplementary prescribing is more appropriate for nurses working in diabetes care. Supplementary prescribing is designed to assist continuing care rather than ‘one-off’ episodes of care – for example, patients with long-term needs such as chronic disease including diabetes. It is defined as: ‘A voluntary partnership between an independent prescriber (doctor) and a supplementary prescriber (nurse), to implement an agreed patient-specific Clinical Management Plan (CMP) with the patient's agreement.’4
There are no legal restrictions on the clinical conditions that a Supplementary Prescriber may treat. Supplementary prescribing requires a prescribing partnership and a CMP for the patient before it can begin, so it is deemed to be more useful when dealing with long-term medical conditions such as diabetes. However, the Independent Prescriber will decide with the Supplementary Prescriber, in drawing up the CMP, when supplementary prescribing is appropriate.
There is no specific formulary or list of medicines for supplementary prescribing, so as long as the medicines are referred to in the patient's CMP, the Supplementary Prescriber is able to prescribe all drugs as discussed above. The Supplementary Prescriber should not, however, prescribe any drug that they do not feel competent to prescribe.5, 6
Clinical management plan
A CMP is a legal requirement, and supplementary prescribing cannot happen without it. It is a patient-specific document which relates to an individual patient. Once it is drawn up in conjunction with and agreed by the Independent and Supplementary Prescribers, and the arrangement is endorsed by the patient, the CMP enables the Supplementary Prescriber to manage the treatment of individual patients (including prescribing), within the identified parameters.
The CMP should contain enough detail to ensure patient safety and must:
Specify range and circumstances within which the Supplementary Prescriber can vary the dosage, frequency, and formulation of the medicines identified (medicines may be identified by reference to protocols or guidelines for a specific condition, e.g. diabetes).
Specify when to refer to the Independent Prescriber.
Contain relevant warnings about known sensitivities of the patient to particular medicines, and include arrangements for the notification of adverse drug reactions.
Contain date of commencement and date for review.
The CMP should be simple and quick to complete and not duplicate information that is in the shared medical record.7 A concern among nurses is that these plans will be very time consuming and therefore not worth the bother. However, if written concisely and carefully they can allow nurses to provide holistic care to the person with diabetes. The ability to prescribe during the consultation can actually save the time that trying to find a doctor to sign a prescription may take.
Preparing for extended and supplementary nurse prescribing
The Nurse Prescribing Course is very demanding but comprehensive, providing at the end a great sense of achievement. The aims of the course are to prepare nurses, midwives and health visitors to prescribe from both the Nurse Prescribers' Extended Formulary as Independent Prescribers, and the British National Formulary as Supplementary Prescribers. It also aims to facilitate opportunities to apply the principles of prescribing to meet patient/client need in relevant clinical settings.
The course requirements are 27 taught days in a university which include taught sessions, workshops, group work, seminars and tutorials. In addition, students need 12 days' protected time with their supervisor to develop the knowledge and skills required for prescribing.
The Department of Health and the Nursing Midwifery Council (NMC) jointly outlined the competencies to be achieved and the assessments required for this course. The assessments include a Practice Portfolio, a written examination and an Objective Structured Clinical Examination (OSCE). Students are supported throughout the course by a medical supervisor and an academic personal tutor.
The entry requirements for the course include registration with the NMC, at least three years' post-registration experience, and the ability to study at degree level. The nurse must have the opportunity to prescribe after training and be willing to undertake the course. Confirmation that the nurse is in a position where there is a need and opportunity to act as a Supplementary Prescriber is required from his/her employer. Primary care nurses need confirmation from their employer that they have access to a prescribing budget. All nurses undertaking this course must have access to Continuing Professional Development (CPD) on completion.
In practice, however, although all of the issues described above are agreed, a number of nurses have experienced difficulties in actually getting started with prescribing once qualified. The main difficulties seem to be verification from the local trust with regard to legal issues, development of individual CMPs and obtaining a prescription pad. Some nurses have reported the passing of a year or more, after their course, before they are in a position to prescribe!
Recent research has shown benefits of nurse prescribing for both patients and doctors.8 The benefits for patients included time saving, more convenient, improved continuity of care with increased information for them about medicines. The benefits for nurses, in addition to the above, included increased satisfaction, status and autonomy in their role. Research also revealed some concerns from nurses, including anxieties about making a diagnosis, writing a prescription and the feeling of a lack of knowledge of pharmacology. Doctors perceived benefits such as the improvement of professional relationships, refreshment of doctors' own knowledge, reduced workload and fewer interruptions to sign prescriptions.9
As a relatively new Nurse Prescriber, I have found myself approaching the care of the person with diabetes quite differently. The responsibility of being able to prescribe a medication makes one concentrate on the diagnosis, clinical assessment, and biomedical aspects of care, in addition to the educational input. The influences on prescribing – for example, the amount of support received in practice and the information gleaned from the pharmaceutical companies – become very important. The availability of clinical supervision and the opportunity for CPD are also crucial. I was unsure at first of the appropriateness of nurse prescribing in diabetes, but following the course, accessing a prescription pad and actually prescribing a medication, I am convinced this is an important development in overall diabetes care.