A study into the trends in nurse prescribing in primary care published recently found that while the number of nurses registered to prescribe has increased the number of nurses actively prescribing is declining. The study was published in the BMC Health Services Research journal in mid February.
The researchers from Kingston University analysed data from a database that records all of the prescriptions issued by the NHS on the NHS Business Service Authority called ePACT (electronic Prescribing Analysis and Cost). The database identifies the prescriber by a unique identifying code and also links the prescription to the GP with whom the patient is registered.
The study found that between 2006 and 2010 the number of nurses registered by their employers to prescribe with ePACT rose by 18 per cent from 30,753 to 36,281. The greatest increase was those with the independent nurse prescribing qualification, which rise from 5014 to 12,975 while the Community Nurse Prescribers (CPNPs) who use a limited formulary, decreased by 2347.
The research also found that nurses tend to prescribe certain items within specific clinical areas such as gel and colloid dressings, medicated stockings, and incontinence appliances.
Vari Drennan, the lead researcher and professor of healthcare policy and research at Kingston University, says that the motivation behind carrying out this study was her own background as a nurse and health visitor. 'I have always been a part of the development of nurses and one aspect was the boundary of nurse prescribing. The UK has the widest prescribing authority compared to most other countries in the world.'
'I was interested in the development of the nursing role and they have evolved and are used in different settings. I have done previous studies looking at nurse prescribers and was keen to look the prescription data for all prescribing in primary care through the central prescribing database.'
This study raises the questions of why nurses aren't prescribing as widely as they should be and what restrictions they may face in practice.
History of the qualification
The role of the nurse prescriber has developed steadily over the past two decades. In 1992, legislation was put in place for specialist qualified community nurses (district nurses and health visitors) with extra prescribing qualifications to prescribe from a limited nurse formulary. In 1996, a limited Nurse Prescribers Formulary for district nurses and health visitors was introduced, which included dressings, medicines for skin conditions and catheter management. Two years later, The NHS Executive authorised the national introduction of nurse prescribing by district nurses and health visitors, with additional prescribing qualifications, using the Nurse Prescribers' Formulary for District Nurses and Health Visitors.
In 2001, legislation was passed for the extension of prescribing authority to nurses, midwives and health visitors, with additional qualifications as independent prescribers and supplementary prescribers (i.e nurses with additional qualifications given authority to prescribe from a patient specific medicines prescribed by a medical or other independent prescriber).
A year later the NHS introduced the Nurse Prescribers extended formulary (NPEF) list, including 140 prescription only medicines (POMs) all general sales list pharmacy medicines, for independent nurse prescribers undertaking an extended prescriber qualification.
Finally in 2006, legislation for nurse independent prescribers to prescribe any licensed medicines including some controlled drugs, for any medical condition within their clinical competence. 1
There are now two categories of nurse prescribers. The first is an independent prescribing qualification for nurses (INP) to prescribe, within their scope of practice, any licensed medication including some controlled drugs. The registered nurses, with more then three years clinical practice, can with their employers support undertake a Nursing and Midwifery Council (NMC) approved course.
Current picture of prescribers
A document outlining the state of nurse prescribing in 2012, issued by the RCN breaks down the number of nurse prescribers in the UK.
According to figures from the Nursing and Midwifery Council (NMC) there are 34,442 community practitioner nurse prescribers, 1405 nurse independent prescribers and 29062 nurse independent/ supplementary prescribers.
Ms Drennan, said that although the number of nurses taking up the prescribing course has been steady, the number of nurses actively prescribing has declined by around 10 per cent since 2006. There are many reasons behind this. Ms Drennan says that this could be because there are other ways around issuing prescriptions such as through patient group directions (PGDs), nurses may not feel confident about prescribing, or their particular practice may not require them to use their qualification. 'This is an area that needs further research,' concludes Ms Drennan.
What restrictions do nurses face?
Louise Brady, a practice nurse from Hyde, Greater Manchester, has just completed her independent/supplementary prescribing qualification and is awaiting the results. She was supported by her employers and the GPs in the practice.
'I approached my GP employers to see if they felt this would be beneficial to the patients at our practice. My employers at Donneybrook Medical Centre were very keen.
'I have found the course very challenging in terms of learning about pharmacology/pharmacodynamics and how this applies/ translates into clinical practice. Many practice nurses have built up a unique relationship with their patients over many years, and this extends to prescribing partnerships.'
However it is not always the case that managers are so supportive of nurses undertaking the prescribing qualification. Independent Nurse found that around a third of nurses that answered said that they were not supported by their managers to take up the qualification. One response said that the GP laughed when the issue was raised. Other reasons why some of the nurses have not taken up the course was because there was a lack of funding for them to take it up, and they didn't want to take on the extra responsibility with no promise of a pay rise at the end of it.
Ms Stuttle, says that even though some of the respondents have said that they are facing resistance from the GPs and managers that they work with, this has improved in recent years.
The respondents also highlighted that time pressures were a huge restrictor when it came to doing the course.
'The pressure on healthcare professionals is phenomenal. This may be one of the reasons why nurses are not necessarily encouraged to take the qualification because many practices are unable to allow nurses the time off to take study for the qualification.
| NICE consultation on the BNF |
Most nurses will prescribe directly from the British National Formulary (BNF) and the Nurse Prescriber's Formulary (NPF). NICE provides these texts to the NHS. The way that the BNF and NPF are being used are changing and NICE have announced that they are consulting on the ways that they can enhance the BNF in line with the way that the healthcare professionals use it.
The print version of the BNF has been reduced to being printed once a year and instead the phone apps and digital versions will be updated monthly. This is because more and more healthcare professionals access the BNF digitally.
All healthcare professionals involved in prescribing or handling medicines are encouraged to submit views to the consultation. The feedback will be used to inform future developments to the BNF and the BNFC. NICE will also run three interactive workshops to gather in-depth feedback. More information can be found at https://www.nice.org.uk
Overwhelmingly, over 90 per cent of respondents to our survey said that allowing more nurses to prescribe in a primary care setting would improve the efficiency of practice.
'These are very challenging times for the NHS so it is important that we get more nurses to prescribe so that doctors and nurses can work together.
'More than anything if nurses are able to prescribe it provides better care for patients. If nurses are able to prescribe then it completes the episode of care for patients. It means that they won't have to refer to other healthcare professionals, so that patients only have to see one healthcare professional.'
However, Molly Courtenay, professor of clinical practice: prescribing and medicines management at the University of Surrey does not think that increasing the numbers of nurse prescribers would not increase the efficiency. 'The role is not meant for all nurses as they may not all want to become prescribers. However, if nurses have the necessary pre-requisites. I do believe there are many benefits for the NHS, patients and nurses, to be gained.'
Professor Courteney has also conducted a study about nurse prescribing featured on page 16, which found that nurse prescribing can improve the access of treatment for people with complex respiratory disease.
Judging by the number of responses Independent Nurse received for our reader survey proves that prescribing is an issue that nurses in primary care are keen to engage in. Although it appears that managers are becoming more supportive of nurses to take up this qualification, our survey results indicate that some nurses do still face challenges. This article just scratches the surface of the trends in nurse prescribing in primary care, but it seems that more research is required to continue this multi-layered aspect of one part of a nurses role.
1. 1. Drennan et al BMC Heath Services Research 2014.
Why don't nurses presribe widely?
Independent Nurse's survey found a much more varied selection of clinical areas that nurses prescribe in such as diabetes, COPD, hypertension and dermatology as indicated in the infographic.
Barbara Stuttle, the chairman of the Association for Nurse Prescribers (ANP), says that nurses tend to prescribe within their competencies. 'Nurse practitioners and practice nurses tend to work in certain areas so they are more likely to prescribe within their competencies. We need more nurses doing more specific areas, so that they work within their competencies.'