This paper was presented as oral communication at the Northern European Conference on Travel Medicine, Dublin, Ireland (June 6–8, 2012).
Corresponding Author: Femke W. Overbosch, MD, National Coordination Centre for Traveler's Health Advice (LCR), Nieuwe Achtergracht 100, 1018 WT Amsterdam, The Netherlands. E-mail: firstname.lastname@example.org
In travel medicine, as in other specialties, independent prescribing of medication has traditionally been the domain of practitioners like physicians, dentists, and midwives. However, a 2011 ruling in the Netherlands expands independent prescribing and introduces supplementary prescribing by nurses, with expected implementation over the next few years. As specialist nurses will not be eligible for independent prescribing, this study addresses supplementary prescribing, specifically by travel health nurses. Such nurses will work in partnership with an independent prescriber, usually a physician. After the physician evaluates a patient's condition and needs, the nurse may prescribe from an open or limited formulary. This supplementary approach seems appropriate in travel medicine, which is highly protocolized. A questionnaire survey was conducted to assess whether travel health nurses themselves aspire and feel competent to prescribe, and what training they might need.
All travel health nurses in the Netherlands received a questionnaire seeking their anonymous response.
The response rate was 58%. Self-reported compliance with protocols and quality criteria was high; 82% of respondents aspire to prescribe and 77% feel competent to prescribe. Of the latter, 22% indicated that ongoing access to a doctor would remain important, and 14% preferred to prescribe under certain conditions like a restricted number of medicines. The reason most frequently given for not feeling competent was the need for additional education before obtaining prescribing rights (40%). Aspiration to prescribe was the only significant predictor for feeling competent to prescribe (odds ratios: 6.8; 95% confidence intervals: 3.5–13). Of all the responding nurses, 95% reported one or more educational needs related to prescribing, particularly in pharmacology.
Most Dutch travel health nurses aspire to prescribe and feel competent for the supplementary approach, but require further education before the approach is implemented in travel medicine.
In all clinical specialties, prescribing medication has traditionally been limited to practitioners like physicians, dentists, and midwives. In travel medicine, however, the growing number of travelers has led nurses to play an increasingly important and autonomous role in that field.
In 1996, the Dutch National Coordination Center for Travelers Health Advice [Landelijk Coördinatiecentrum Reizigersadvisering (LCR)] began periodic publication of national guidelines and criteria for the quality of travel health care provided at travel clinics and doctors' offices. In addition, a special LCR group developed the criteria for a training curriculum for travel health professionals. Travel health nurses who meet these criteria can enter the LCR register, which opened in September 2006. The Ministry of Health considers the LCR guidelines and quality criteria as the national standards for travel medicine.
Since 1996, travel health nurses have been permitted to expand travel health consultation with prescribing medication including vaccinations to healthy individuals under certain conditions. Mainly, they can prescribe and administer vaccinations and also provide prescriptions for malaria chemoprophylaxis and antibiotics in case of diarrhea, along with pertinent advice. The medication is dispensed using preprinted prescriptions that are pre-signed by a physician; on the same day, another health care professional checks such prescriptions so that any mistakes can be swiftly corrected. Thus, while travel health nurses have gained responsibility and perform the majority of travel health consultations nowadays, the final responsibility has remained reserved for physicians.
In 2011, a change in the Dutch Medicine Act (Geneesmiddelenwet) and Individual Health Care Professions Act (wet BIG) was approved by the House of Representatives (Tweede Kamer) and Senate (Eerste Kamer), expanding independent prescribing and introducing supplementary prescribing by nurses.[3-5] As before, independent prescribers are responsible for the clinical assessment of a patient, the establishment of a diagnosis, and decisions about appropriate treatment, including the writing of a prescription. “Nurse specialists”, for example, will be considered for independent prescribing. Supplementary prescribing is defined as a partnership between a nurse and an independent prescriber, usually a physician. After initial evaluation of the patient by the independent prescriber, a nurse may prescribe from an open or limited formulary, depending on the specialty. He or she will consult with the independent prescriber before issuing the prescription, although direct supervision is no longer required. Supplementary prescribing is reserved for “specialist nurses” such as travel health nurses. As travel medicine is highly protocolized, with clear quality criteria, supplementary prescribing by nurses seems appropriate.
The nation's foremost travel health nursing organization favors implementation of the 2011 ruling. However, the opinion of the individual travel health nurse has not been investigated. We conducted a questionnaire survey among all Dutch travel health nurses to assess whether they aspire and feel competent to prescribe, and whether they have related educational needs.
In October 2011, we attempted to reach all Dutch travel health nurses with a questionnaire, to be completed anonymously. Designed using NetQ® (NetQuestionnaires Nederland BV, Utrecht, The Netherlands), the questionnaire was directed to 382 LCR-registered travel health nurses and also to 93 travel health nurses who are not registered but subscribed to LCR services. These 475 nurses were invited to participate through an email including a link to the questionnaire. In addition, to optimize overall response and to reach nurses without LCR registration or subscription, invitations including a link to the questionnaire were sent by post to all Dutch travel clinics. Reminders were sent twice, only by email. The deadline for participation was December 1, 2011.
The questionnaire consisted of three different sections with a maximum of 31 questions, depending on the answers provided. The first section addressed the demographics of individual participants, eg, length of experience as travel health nurses, LCR registered or not, and type of employer organization. This section also questioned their current practice of travel care, eg, number of patients who were given travel health advice (which includes vaccinations, malaria chemoprophylaxis, and pertinent advice). Tick boxes were included to indicate responses.
The second section focused on adherence to LCR quality criteria and examined current practice within an employer organization and the daily routines concerning prescribing medication, eg, method of checking accuracy of prescriptions and advice, availability of consulting physician, and average monthly number of patients given malaria chemoprophylaxis. To limit the size of the questionnaire, the questions concerning prescribing medication focused on prescriptions for malaria chemoprophylaxis rather than vaccinations, as vaccines are usually administered without a prescription and therefore seldom cause prescribing difficulties. In this section also, tick boxes were supplied to indicate response. If a response deviated from current LCR quality criteria, an open field and/or another question followed to motivate the response.
The final section asked whether and why nurses aspire to prescribe, feel competent to prescribe, and whether they perceive educational needs. Open fields were used for the aspiration and competence question. A list with seven fixed and three open-ended answers was used to indicate educational needs. Respondents were asked to tick all that applied.
Microsoft Excel and SPSS for Windows version 19.0 were used for data entry and analysis. Descriptive statistics were used to describe the demographic nature of the sample. Univariable odds ratios (OR) and 95% confidence intervals (CI) were obtained by means of logistic regression modeling.
The questionnaire was sent to 475 travel health nurses, of whom 317 responded; 274 finished the questionnaire completely. The 43 uncompleted questionnaires were excluded from analysis. The overall response rate was 57.9% (274/475). The response rate of the 382 registered travel health nurses was 62.3% (238/382).
Demographic Details and Adherence to LCR Quality Criteria
The characteristics of the participants are presented in Table 1. The majority (84%) has more than 10 years of nursing experience, and 60% have more than 5 years experience as travel health nurse. Of all respondents, 238 (87%) are registered in the LCR register; and 60% work at a Public Health Service facility. A substantial number of travel health nurses provide travel health advice frequently: 90% provide at least several per week. A total of 104 respondents (38%) give advice to 100–250 patients per month, and 57% prescribe malaria chemoprophylaxis to 10–50 patients per month.
Table 1. Characteristics of Dutch travel health nurses participating in a survey to assess whether they aspire and feel competent to prescribe (October and November 2011)
Number of subjects
Length of time as nurse
Length of time as travel health nurse
Registered as travel health nurse
Length of time as registered travel health nurse (n = 238)
Character of organization in which employed
Public Health Service (GGD)
Safety, Health and Welfare Service
Commercial vaccination center
Practice of general practitioner
Frequency of provided travel health advice (includes immunization,malaria chemoprophylaxis, and pertinent advice)
Several per day
Several per week
Several per month
Few per year
Average number of patients given travel health advice per month
Average number of malaria chemoprophylaxis prescriptions givenper month
Possibility of consulting a doctor when giving advice
Person by whom advice is checked (multiple answers allowed)
Do not know
By a doctor
By a colleague travel health nurse
Aspiration to prescribe
Feeling competent to prescribe
Self-reported adherence to mandatory procedures of LCR quality criteria was good: of all respondents, 99% used LCR guidelines, and 93% always had access to a consulting physician. When they gave advice, it was checked later 93% of the time by another health care professional.
Aspiration and Competence to Prescribe
Of all participants, 226 (82%) aspired to have prescriptive authority. Of these, 26% believed it would improve consultations by making them more efficient, easier, and more customer friendly. Other reasons for the aspiration were feeling competent and/or having enough experience (18%), being already engaged in prescribing according to current national protocols (16%), feeling supported by clear national guidelines (16%), and wishing to be fully responsible and/or independent (8%). The 48 participants not aspiring to have prescriptive authority said that they felt insufficiently educated and/or capable (33%), were comfortable with current ways of providing travel care (31%), and had a preference for final responsibility at physician level (23%).
The respondents were also asked whether they felt competent to prescribe, and 211 (77%) gave a positive response. Their most cited reasons included sufficient experience (26%), sufficient education or qualification (20%), support from clear national guidelines (14%), and being already engaged in prescribing according to current national protocols (10%). Of those who felt competent, 22% indicated that ongoing access to a doctor would remain important, and 14% preferred to prescribe under certain conditions like a restricted number of medicines (eg, only malaria chemoprophylaxis) or only after additional education.
Among the respondents who did not feel competent (23%), the most frequently mentioned reason was a need for extra education before obtaining prescribing rights (40%). Some felt that nurses might not be capable of prescribing even with extra education (32%), and 10% felt more strongly, saying “nurses aren't doctors.”
Logistic regression was used to analyze how feeling competent relates to experience as a travel health nurse, registry as travel health nurse, amount of advice/malaria chemoprophylaxis given per month, and aspiration for prescribing rights. Only aspiration for prescribing rights appeared to be a significant predictor for the travel health nurses who feel competent for prescriptive authority (OR: 6.8; 95% CI: 3.5–13.3).
Educational Needs for Prescribing
Figure 1 shows that 95% of travel health nurses have one or more educational needs to fill before prescribing. More than half expressed the need for further education in the areas of pharmacology, medication in general, and immunology; more knowledge about malaria chemoprophylaxis was desired by 33% and about diseases in general by 25%. Entries in the open-text fields expressed interest in knowing more about diseases/medication related to immune suppression, altitude disease and acetazolamide, antibiotics, contra-indications and interactions (especially in combination with malaria chemoprophylaxis), and the special needs of pregnant travelers as well as children.
Following the United States, the first country to introduce nurse prescribing in 1969, and seven Western European/Anglo-Saxon countries (UK, Canada, New Zealand, Australia, Sweden, Ireland, and Finland), the Netherlands has recently introduced prescribing by nurses. The results of our questionnaire survey indicate that most Dutch travel health nurses are prepared to prescribe. Advice and prescription by these nurses is already provided according to highly protocolized criteria; 82% of the travel health nurses aspire to the expanded responsibility and 77% feel competent to undertake it.
An interesting finding was that many positive respondents indicated that ongoing access to a doctor would remain important. This implies that they are not yet completely aware that access to a doctor is a requirement for the designation of supplementary nurse prescribing in travel medicine. There is thus a need to raise awareness among travel health nurses concerning the responsibilities and restrictions associated with their future privileges.
Further education is likewise needed before nurse prescribing is implemented in travel medicine. We found that 95% of the travel health nurses have one or more educational needs; they most often mentioned pharmacology. This result is in line with other studies, although comparison among countries is difficult. Differences among their legislative procedures and their regulation of nursing practice have led to different models of prescribing worldwide. A questionnaire survey was performed among UK nurses who prescribe medicine for diabetic patients, in which participants were asked if they had needs for the current 12 months, the following 12 months, or not at all. The pharmacology of diabetes was most frequently mentioned, with 42.7% expressing need for education in the current 12 months.
Remarkably, these UK nurse prescribers also expressed the need for an update on prescribing policy (42.5% within 12 months). In our study among travel health nurses, no such need was mentioned, perhaps because Dutch travel medicine is highly protocolized and the LCR provides updated guidelines twice each year.
The content of training programs for nurse prescribing seems to be fairly similar across the Western European/Anglo-Saxon countries, and pharmacology is generally an important component.[6, 8] In the Netherlands, an educational program including special attention to pharmacology is one of the requirements for the designation of supplementary nurse prescribing. For travel medicine, the nation's foremost travel health nursing organization will collaborate with the Dutch Nurses' Association to create such a program. In addition, the LCR will formulate quality criteria specific to nurse prescribing. Travel health nurses will obtain prescriptive privileges only if they meet both criteria.
For a successful implementation of nurse prescribing more is needed, eg, patient acceptance of the nurse as prescriber, organization of a well-equipped working environment, and the opportunity for travel health nurses to become and remain experienced in prescribing. The questionnaire did not incorporate questions toward these topics: currently, most travel health advice in the Netherlands is already performed by travel health nurses. Therefore patient acceptance will be an unlikely barrier. This is also supported by a UK-based review which found two studies that investigated patients' perception of nurse prescribing. Both studies reported that the majority of the patients were in favor of nurse prescribing. Insufficient organizational readiness toward nurse prescribing, for example, lack of prescription pads or inadequate formulary as found in another UK study, is also not likely to cause any implementation problems, as Dutch travel health nurses are already permitted to provide pre-signed prescriptions. Lastly, current LCR quality criteria demand that travel health nurses perform at least 200 travel health consults under supervision per year for registration and at least 250 travel health consults per year for re-registration. Unsafe prescribing due to poor experience will therefore not arise.
Our study has some other limitations, such as possible selection bias. Respondents to our questionnaire may feel more strongly about prescribing rights than non-respondents, resulting in overestimation of their aspiration and competence to prescribe. Finally, we attempted to reach all Dutch travel health nurses, but a few LCR-registered travel health nurses may lack an email account. Moreover, the number of unregistered travel health nurses without a subscription to LCR services is unknown. The few nurses missed by our survey could have influenced the denominator, but probably not to a large extent.
Most Dutch travel health nurses aspire to prescribe and feel competent to prescribe. Further education is required before implementing nurse prescribing in travel medicine.
As this is the first study to focus on nurse prescribing in travel medicine, evaluation of travel nurse prescribing is strongly recommended and should start directly after the new responsibilities are implemented.
Declaration of Interests
The authors declare that they have no competing interests.