Nurse prescribing: Time for change?

One of the most fundamental opportunities for nursing in recent times has come with the advent of nurse prescribing. As diabetes specialist nurses we welcomed the opportunity to at last be able to move along from advising both patients and medical colleagues regarding diabetes treatments to issuing prescriptions in our own right. However, nurse prescribing has evolved into a process fraught with difficulties as nurses and medical staff in primary and secondary care work through the idiosyncrasies of both the limited formulary for the independent prescriber and guidelines for supplementary prescribing.

Since the development of extended nurse prescribing training in 2002, there have been several Department of Health (DoH) consultation exercises regarding extending the nurses’ formulary, however, the DoH recognise that adding to the formulary in this way is resource intensive. As a result, they have now put forward a definitive joint consultation document with the Medicines and Healthcare Products Regulatory Agency (MHRA) regarding the way forward for nurse prescribing (DoH and MHRA, 2005). This consultation exercise, while maintaining key principles of nurse prescribing, such as patient safety and nurses working within their own code of professional conduct, highlights five options for nurse prescribing.

Options for change
Option A: Do nothing. This means that nurses will continue to prescribe independently from a specific formulary of medications from a specified range of medical conditions, which does not include diabetes. For the majority of diabetes medications, the specialist nurse will need to continue to prescribe using supplementary prescribing. This process has been frustrating for nursing and medical staff. The use of clinical management plans has been fraught with problems, with some nurses experiencing difficulty accessing an independent prescriber (doctor) to approve the plan, and some Trusts insisting clinical management plans be approved by medicines management committees. Clinical management plans are becoming lengthier and more unwieldy as medications for hyperlipidaemia and anti-hypertensive treatments are added.

Option B enables prescribing for any medical condition from a limited formulary. This option would still be restrictive for diabetes management.

Option C allows prescribing for specified medical conditions from the whole British National Formulary (BNF). This option demands further comment from health professionals on which medical conditions should be added to the current list. It is probably unlikely that diabetes would be added to the list of specified conditions and, if it were, would treatments for hypertension and hyperlipidaemia also be included?

Options A, B and C still demand the use of clinical management plans and so still provide limited access to nurse prescribing for appropriately trained nurses.

Option D allows prescribing independently for any medical condition and opens up the whole BNF formulary for the nurse prescriber. This option will remove the need for the clinical management plan. It must be emphasised that the nurse prescriber would still only be expected to prescribe within their own scope of practice and most diabetes specialist nurses would therefore only be expected to use a range a medications, including those for glycaemic control and cardiovascular protection.

Option E recommends that only nurses considered as working at advanced practitioner level would be allowed to prescribe from the whole of the BNF. Those without this recognition would still need to prescribe from a limited range of medical conditions and medicines. Consultation regarding recognition of advanced level practice is underway but it is expected that it will require the attainment of a Masters level degree and the process of registration approval by the Nursing and Midwifery Council may take up to five years.

Discussion
The present limits set on nurse prescribing are both frustrating for health professionals and cause unacceptable delays for people with diabetes needing medication. This consultation opens up a window of opportunity to advance nurse prescribing.

In my opinion, Option D will simplify the whole process and at last allow suitably qualified diabetes specialist nurses working within their scope of practice to do what they do best – care for people with diabetes without undue restriction.

Please encourage all the members of your diabetes teams to respond to this document. While nurses are in the forefront of this document, pharmacists are also accessing training, and podiatrists, ophthalmologists and radiographers will soon be joining the ranks of the non-medical prescriber. The closing date for comment is 23 May 2005.

I would also be pleased to hear from any nurse prescribing for diabetes as I think it would be useful to create a database of nurses working in this area so that support can be given or queries and problem areas highlighted. I can be contacted through the journal.