Nurse Prescribing, 2nd edition


Dr Nigel Baber, Medicines Control Agency, Post-Licensing Division, Market Towers, 1 Nine Elms Lane, London SW8 5NQ, UK. E-mail:

eds J.L. Humphries & J. Green
Published by Palgrave, foreword by Baroness Cumberlege
ISBN 0-333-93092-4. Price: £16.99. 186 pages including index

The earlier edition of this book appeared in 1999, but nurse prescribing was first recommended by the Royal College of Nursing (RCN) in 1980 and became part of the Government's policy agenda in 1986, with the Cumberlege report. At the time of the first publication, prescribing by nurses was restricted to district nurses and health visitors who had undergone specialist training following the recommendation of the 1989 Crown report.

The list of drugs which could be prescribed in defined circumstances at this time was published in the Nurse Prescriber's Formulary (NPF). The drugs and products in this list are limited and relatively innocuous, including laxatives, and mild analgesics. The Crown report also recommended that nurses could supply medicines within group protocols (later called patient group directions) in which nurses (or other healthcare professionals) could supply medicinal products to anonymized patients according to a strict protocol signed by a registered doctor or dentist.

The second Crown report of 1999 covers a much wider remit than community nurses, and outlines in some detail the importance of appropriate professional training to prescribe not just for nurses, but also pharmacists, optometrists, podiatrists and others. This will lead to a sea-change in prescribing practice which is enshrined within the National Health Service Plan of July 2000 and published in Reform for NHS Staff – Taking Forward the NHS Plan. In this regard, prescribing by nurses is only part of new ways of team-working which is spelled out in this report.

By April 2001, 23 000 nurses were prescribers, predominantly District Nurses (DN) and Health Visitors (HV). In the intervening years there has been considerable pressure by the nursing profession to lay the basis for all nurses with training to be able to prescribe from an expanded formulary. In May 2001, this was recognized when the Health Minister responsible announced both initiatives. Between 2002 and 2004, 10 000 nurses will be trained to be able to prescribe from this expanded formulary. Nurses will be able to prescribe all general sales list (GSL) and pharmacy medicines which are prescribable by doctors under the NHS, together with a list of prescription-only medicines (POM) listed for specific medical conditions. This list is published as an appendix in Nurse Prescribing. The proposal is that suitably trained nurses will be ‘independent prescribers’, i.e. able to initiate treatment without reference to a physician.

Teachers of medical students will be jealous to learn that these nurses will undergo 35 h of pharmacology and therapeutics training, though how their competence to prescribe within a disease management setting is to be tested, is not clear. Oddly, ‘Independent Nurse Prescribing’ is to be followed rapidly by the provision for ‘Supplementary Prescribing’, in which nurse practitioners in specialist roles, for example those working in teams caring for patients with cancer, coronary heart disease, diabetes or asthma, would be responsible for the care of the patient after the initial assessment and diagnosis has been made by the clinician.

Nurse Prescribing traces the history from 1986 right up to the present day. It has 10 contributors, nurses, ­pharmacists, educationalists and a solicitor and its stated aim is to ‘provide access to a range of perspectives on nurse prescribing and to promote discourse on these issues’.

It takes a critical look at the development and implications of nurse prescribing in the context of the nurse professional role and reflects on the implications from both local and national perspectives. It has 11 chapters, 2 appendices (the old and the new NPFs) and a comprehensive index.

Chapter 1 gives an historic overview within the legislative framework outlining the development of training.

Chapter 2 discusses ethics and accountability.

Chapter 3 is particularly good, probably the best, on the legal issues of nurse prescribing.

Chapters 4, 5 and 6 deal with the practical aspects of assessment, evaluation, communication, prescription writing and sources of information and touch on drug interactions and adverse events reporting.

Chapter 7 is rather out of place on the noncompliant patient.

Chapter 8 discusses the reality of how nurse prescribing was set up in eight private studies around the country with DNs and HVs and gives some personal insight into how nurse prescribing enhanced the role using 4 case studies.

Chapter 9, entitled ‘Will you walk a little faster…?’ is the hardest hitting chapter, exploring the frustration that nurses who could not prescribe (e.g. mental health nurses) felt, and exploring the professional sensitivities and confusion that Government sources have caused between 1986 and now. It also debates whether a two tier nursing scheme could develop, i.e. an elite group who prescribe independently and the rest, but recommends that all qualified nurses should be allowed to prescribe and could function effectively as supplementary prescribers. It is somewhat confused over the final position of independent prescribers, but does venture onto the grounds where doctors may feel most vulnerable, i.e. taking over some of their role in the name of ‘freeing up doctor's time’. The authors also make the interesting but opaque point about the education and training of nurses ‘the professional bodies have been complacent about the form of assessment for nurse prescribing; the classroom-based examination. The educationalists involved in the pilot scheme wanted a practical aspect to the examination, but were over-ruled. Hardly a practical venture’. This chapter (and the final one) come closest to expressing the apprehensions that a number of healthcare professional bodies have expressed; namely, that whilst the concept of nurse prescribing is welcomed, it is being rushed through without time to evaluate the outcomes or define success criteria.

Chapter 10 is devoted to 13 case histories of management scenarios when a nurse would be called upon to prescribe (or withhold prescription). Although it is based on the old limited Formulary, it does highlight one or two examples of where an independent nurse prescriber might be in a dilemma as to whether to refer to a doctor for further advice or not.

The final chapter looks to the future and brings the reader up to date. It is optimistically cautious, recognizing that prescribing in practice is different from theory and calls for the regular evaluation and reporting of both positive and not so positive issues as they arise; it asks that reliance should not just be placed on anecdote but there should be properly structured and organized research.

A rapid expansion of nurse prescribing, as part of the nurse's new role in primary hospital care is a certainty. This book summarizes the history and key elements of its development. It is not a book on clinical pharmacology and therapeutics for nurses and it also shies away from a detailed study of how a nurse prescriber would be trained to diagnose and manage patients with more complex diseases. It could also be shortened with an amalgamation of several chapters. The next edition will be most interesting and hopefully will include more case histories based on the expanded formulary and on the results of prospectively planned research.

Nurses and other healthcare professionals who need to bring themselves up to date in this aspect of the future role of nurses, should buy this book.