A cautionary approach to the introduction of nurse and midwife prescribing is safest for patients, writes Dr Michael Barry.
Earlier this month, the Department of Health and Children announced plans for the introduction of nurse/midwife prescribing, a move that will allow all nurses and midwives to prescribe drugs in all healthcare settings.
The aims of nurse prescribing include improvement in patient care, making it easier for patients to get the medications they need, increasing patient choice in accessing medicines, making better use of the skills of health professionals and contributing to the introduction of more flexible teams working across the health service.
But the concept of nurse prescribing is not new. The Department of Health in Britain introduced nurse prescribing nationally for district nurses and health visitors from December 1998. In April 2003, the British government enabled all nurses to train to become supplementary prescribers.
Further developments last year saw the introduction of independent nurse prescribing. Nurses there are now able to prescribe any licensed medicine for any medical condition within their confidence, including some controlled drugs.
In Britain, there are two types of nurse prescriber: supplementary prescribers and independent prescribers. These two types of nurse prescriber differ significantly.
Supplementary prescribers can prescribe in partnership with a medical doctor (or dentist), once a diagnosis has been made.
Such prescribing may take place only after assessment and diagnosis by an independent practitioner who should be the clinician responsible for the individual's care. A clinical management plan is the foundation stone of supplementary prescribing and must include details of the illness or conditions which may be treated by the nurse, the range of medical products used, as well as limitations as to the strength of any medicine.
While it seems reasonable to assume that supplementary nurse prescribing will indeed improve patient care and facilitate services such as palliative care and the care of the elderly, the evidence to support this assumption is weak.
Independent nurse prescribing, however, does raise important safety issues. An independent nurse prescriber will be required to make the initial patient assessment, interpret that assessment, make a decision on safe and appropriate therapy and be responsible for ongoing monitoring.
Before undertaking supplementary or independent prescribing, nurses will be required to complete specified training and preparation successfully. The duration of such a training programme varies but it is typically 37 days (25 taught days at a higher education institution plus 12 days' learning in practice). This is the area that is likely to cause most concern to Irish medical practitioners and, indeed, patients.
Will just 12 days of "learning in practice" be sufficient for the nurse prescriber to develop the expertise required to assess, diagnose and then prescribe for a range of clinical conditions? Will such a short training period (as compared with years in medical school) be sufficient to enable satisfactory clinical examination, and the correct interpretation investigations, to support a diagnosis prior to choosing a drug?
Draft regulations would appear to facilitate full, independent nurse prescribing from a wide range of medicines including intravenous opiates such as fentanyl and morphine
There is clearly an issue of patient safety here, prompting the British Medical Association to respond with dismay to
recent UK developments; its main concern is that it is not safe to prescribe without adequate
training in diagnosis.
For medical practitioners in Ireland, the issue of liability arises, as it appears that the nurse prescriber can prescribe only for patients who "must be within the care of a doctor". The UK guidelines on supplementary prescribers remind us that practitioners may be held "vicariously liable" for the action of such prescribers. Will medical practitioners here accept liability for nurse prescribers?
From the patients' perspective, it is important that they are informed that they are being treated by a non-medical practitioner and they should be aware of the scope and limitations of the supplementary or independent nurse prescriber.
In this era of evidence-based medicine, it is worth noting that although nurse prescribing has been in operation in Britain for some years, there is very little peer-reviewed data demonstrating the benefits of this strategy in terms of health outcomes or value for money.
Prescribing is one of the most important interventions available to health professionals in combating disease. But nurse prescribing enthusiasts need to be aware that it is also an important cause of patient harm (approximately 6 per cent of acute medical admissions to our hospitals are medication related). Prescribing safely and effectively requires high levels of knowl
edge and skill. Balancing benefits against risks can be a difficult challenge, despite many years of training.
The Irish Nurses Organisation has resiliently argued that there should be no restriction in regulations and that the choice of drugs be determined for the nursing and midwifery profession in the same manner as for other health professionals. In the absence of good health outcome data, such a view could be considered somewhat naive.
But patient safety is paramount, and many will feel that nurse/midwife prescribing should begin with supplementary prescribing in the majority of clinical settings. Only after careful assessment of benefits and risks should we proceed to widespread, full independent nurse prescribing.
Dr Michael Barry is a consultant clinical pharmacologist and director of the national centre for pharmaeconomics at St James's Hospital in Dublin.