Nurse prescribing has become well established in the UK. It has developed over the years since the Cumberledge report in 1986 recommended non-medical prescribing from a limited list for community-based nurses (Department of Health and Social Security, 1986; Cope et al, 2016). Nurse prescribing is now an integral part of advanced level practice.
There are two main types of nurse prescriber (Royal College of Nursing (RCN), 2021). These are:
- Community practitioner nurse prescribers (CPNPs)
- Independent prescribers (IPs).
CPNPs are nurses who have successfully completed a Nursing and Midwifery Council (NMC) Community Practitioner Nurse Prescribing course (V100 or V150) and are registered as a CPNP with the NMC (RCN, 2021). Most of these nurses work in primary care and are only qualified to prescribe from the Nurse Prescribers Formulary for Community Practitioners (Nurse Prescribers Advisory Group, 2021). This is a limited formulary that contains dressings, pharmacy (P), general sales list (GSL) and 13 prescription-only medicines (PoM).
Nurse independent prescribers (NIPs) can assess, diagnose, and prescribe independently any licensed medicine and products listed in the British National Formulary (BNF) (Joint Formulary Committee, 2021), unlicensed medicines and all controlled drugs in schedules two to five, provided this is within the area of their competence (RCN, 2021). These nurses have completed an NMC Independent Nurse Prescribing course (V200 or V300). Registered nurses who have successfully completed the supplementary part of the prescribing course, known as nurse supplementary prescribers (NSPs), can prescribe after assessment and diagnosis of a patient's condition has been carried out by a doctor, and a clinical management plan has been drawn up for the patient. This mode of prescribing is best suited to patients with long-term medical conditions or healthcare needs.
The benefits of nurse prescribing have become increasingly evident and the potential to expand continues. For example, the NMC Standards for pre-registration nursing programmes (NMC, 2018a) and Standards for prescribing programmes (NMC, 2018b) identify the need for newly qualified nurses to be ‘prescribing ready’ and for greater access to prescribing programmes earlier in nurses' careers.
Prescribing practice is underpinned by several frameworks and the potential for medicines to cause harm has been acknowledged by patient safety agencies across the UK. One of the major drivers behind the ongoing development of nurse prescribing has been the significant changes in clinical practice. These changes have been in direct response to the NHS Outcomes Framework (NHS Digital, 2021) and Public Health England's (2019)Public Health Outcomes Framework 2019-2020, which identified the priorities in health reflecting the increase in the number of people living with long-term conditions and to address the demands on services, to reduce hospital admissions and long hospital stays. Health professionals' expertise has been recognised as a valuable resource that could be used more effectively to transform healthcare services (Health Education England, 2021). This has resulted in the development of new and advanced roles such as: advanced practitioners, community matrons and specialist midwife roles. Many roles have been redefined and non-medical prescribing has proved useful in these developments and in some cases is a central component of these roles, enabling practitioners to complete every episode of care (Nuttall and Rutt-Howard, 2019).
Professional, legal and ethical issues
UK prescribing law is ever changing, so it is important that prescribers consistently update their knowledge of legislation. There are several legal, professional, and regulatory frameworks to support prescribing practice (Table 1). For prescribers, the virtues of openness, transparency and duty of candour are imperative and should be embedded into clinical practice (Nuttall and Rutt-Howard, 2019).
Table 1. Legal, professional, and regulatory frameworks
| Legislation | Professional | Regulatory |
|---|---|---|
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Source: Adapted from Nuttall and Rutt-Howard, 2019
All prescribers are required to work within their own professional boundaries and standards of conduct to provide high-quality health care. Nurse prescribers' practice is grounded in the professional code of practice that guides prescribing practice. The introduction in 2016 of a set of competencies by the Royal Pharmaceutical Society (RPS), which is regularly updated (RPS, 2021), has ensured that high standards are maintained, and capabilities are synonymous between disciplines.
Nurse prescribers practice autonomously within the code of the ethical principles of non-maleficence, deontology, and paternalism (Courtenay and Griffiths, 2010). Prescribing demands a higher degree of professional responsibility and accountability (Nuttall and Rutt-Howard, 2019), so that in taking on the responsibility of prescribing medicines, the nurse prescriber must also be willing to take the consequences of actions or inaction.
Prescribing governance
The competency framework (RPS, 2021) is structured in two key domains of prescribing governance and consultation with the patient at the centre. Prescribing governance refers to prescribing safely and focuses on the need to reduce risk and maintain patient safety by prescribing within the boundaries of the individuals' competence, an awareness of potential risks and appropriate strategies to ensure monitoring and reporting.
As part of the role, nurse prescribers are expected to demonstrate competence in professional prescribing with evidence of accountability for clinical decisions within legal, professional, and professional boundaries. Prescribers are expected to work at an advanced clinical level, reflecting on current practice to improve patient care and outcomes while challenging the practice of others that may compromise patient safety (RPS, 2021). Legal and professional accountability requires prescribers to provide a rationale for:
- What is prescribed
- When over-the-counter products are recommended
- When decisions are made not to prescribe or recommend a product.
In addition, prescribers are expected to have knowledge and competence in patient assessment within the context of prescribing (Table 2).
Table 2. Patient assessment and prescribing governance
| The patient | Prescribing practice |
|---|---|
| Circumstances and current medication | A thorough knowledge of the medicine to be prescribed, its therapeutic action, side-effects, and interaction. Current patient medication and any potential interactions with new medications |
| Past medical history | A thorough knowledge of alternatives to prescribing. Previous drugs the patient has taken and full medical history |
| Current and anticipated health status | Frequency of the use of drug and dosage, adherence to current medications and patient's perception of health |
Source: Nuttall and Rutt-Howard, 2019
To appropriately prescribe it is essential that prescribers have a good knowledge and understanding of pharmacology in relation to the drugs prescribed this includes pharmacokinetics and pharmacodynamics (Table 3).
Table 3. Pharmacokinetics and pharmacodynamics
| Pharmacokinetics | Pharmacodynamics |
|---|---|
| Involves the changes in the serum concentration of a drug in the body over a period of time. Absorption, distribution, metabolism, and excretion of the drug bring this about. The last two processes also account for the elimination of the drug from the body | This is the term to describe what a drug does to the body including therapeutic and adverse effects |
Safety and efficacy remain the key objectives for prescribing. All prescribers are required to work within the boundaries of their own standards of conduct and scope of practice. In gaining a prescribing qualification, the practitioner must be fully conversant with their codes of practice (Table 4).
Table 4. Prescribing proficiencies for safe practice
| Prescribes within own scope of practice | Recognises limits of own knowledge and skill |
| Understands about common types of medication errors | Recognises how to prevent, avoid and detect medication errors |
| Identifies potential risks associated with prescribing via remote media (telephone, email, third party) | Takes steps to mitigate and minimise risks |
| Develops process to support safe prescribing practice (eg, transfer of information about medicines, prescribing of repeat medicine) | Minimises risks to patients |
| Keeps up-to-date with prescribing practice | Awareness of emerging safety concerns related to prescribing |
| Reports prescribing errors, near misses and critical incidences | Reviews practice to prevent recurrence |
Source: Adapted from Royal Pharmaceutical Society, 2021
In order to ensure safe prescribing and the effective use of medicines all practice should be underpinned by the principles in Table 5. The prescriber must inform the patient (Nuttall and Rutt-Howard, 2020):
- What to expect when taking the medicine
- How to take/administer the medicine
- The duration of the time taken for effect/improvement
- Medication efficacy
- Precautions and likelihood of side effects.
Table 5. Ten principles of good prescribing
| Be clear about reasons for prescribing | Prescribers should establish an accurate diagnosis whenever possible and be clear what the patient is likely to gain from the prescribed medicines |
| Take into account the patient's medication history before prescribing | Obtain a list of current and recent medications. Ask the patient/carer about any over-the-counter medications, adverse drug reactions and drug allergies |
| Consider factors that might alter the benefits and risks of treatment | Consider individual factors for example physiological changes with age, pregnancy or impaired kidney, liver or heart function |
| Take into account the patient's ideas, concerns and expectations | See section on values-based prescribing |
| Select effective, safe and cost-effective medicines | Consider if the effect of medicines outweighs the extent of potential harms. Review published evidenceChoose the best formulation, dose, frequency, route of administration and duration of treatment |
| Adhere to national guidelines and local formularies where appropriate | Select medicines with regard to cost and needs of other patients (healthcare resources are finite)Access and use reliable and validated sources of information eg British National Formulary |
| Ensure prescriptions are written on the correct documentation | Be aware of common factors that cause medication errors and how to mitigate risk factors |
| Monitor the beneficial and adverse effects | Identify how beneficial and adverse effects can be assessed. Understand how to alter prescriptions as a result of information. Know how to report adverse drug reactions (Yellow Card Scheme) |
| Communicate and document prescribing decisions and rationale | Communicate effectively with patients, carers and colleaguesUse the health record to document prescribing decisions accurately |
| Prescribe within the limitations of your knowledge, skills and experience | Be prepared to seek advice and supportMake sure appropriate prescriptions are checked |
Source: Adapted from British Pharmacological Society, 2021
Values–based prescribing
A patient-centred approach to prescribing is important for patients' needs and beliefs to be explored. Health education and preventive health behavior are synonymous in prescribing practice and can explore successful outcomes of therapeutic intervention. The Health Belief Model (Becker, 1974) is widely accepted in clinical practice to assist with understanding patient's health behaviours. The model is used to help understand how patients perceive their susceptibility to disease or illness and the relevance of the suggested therapy to their perception of the degree of severity of the illness and the consequences to daily life (Davis et al, 2013). An understanding of the patient's beliefs and cultural impact on their behaviours will influence the choice of treatment and increase the chances of concordance.
Clinical skills
Physical examination
Clinical skills are fundamental to safe prescribing practice and the nurse prescriber needs to be able to perform the required physical examinations to inform differential diagnosis and drug choice. It is crucial that the prescriber can assess vital signs to make safe clinical decisions (Nuttall and Rutt-Howard, 2020). Vital signs are also fundamental to ongoing monitoring responsibilities that prescribers have for the written prescriptions.
When completing systematic physical examination it is important to practise and master an inspection, palpation, percussion, auscultation (IPPA) approach (Willis, 2016; Bickley, 2020) to explore the appropriate body systems (Table 6).
Table 6. IPPA approach to physical examination
| Inspection | Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Assess for colour, size, location, movement, texture, symmetry, odours, and sounds as you assess each body system |
| Palpation | Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. Because your hands are your tools, keep your fingernails short and your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. Light palpation is used for finding surface abnormalities and deep palpation for internal organs |
| Percussion | Percussion involves tapping your fingers or hands quickly and sharply against parts of the patient's body to help you locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas |
| Auscultation | Auscultation involves listening for various lung, heart, and bowel sounds with a stethoscope |
Source: Adapted from Willis, 2016
History taking
History taking is essential for a full holistic assessment before prescribing. Table 7 highlights key areas to cover in relation to physical health when taking a history that can aid with choice of physical assessment and triangulation of assessment data (Douglas et al, 2013; Rawles et al, 2015).
Table 7. History taking—relevant information and symptoms to note
| Presenting symptoms |
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| Past medical history |
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| Family history |
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| Drug history |
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| Social and personal history |
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| Cardiovascular system |
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| Respiratory system |
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| Gastrointestinal system |
|
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| Haemopoietic system |
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| Central nervous system |
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| Genitourinary system |
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| Endocrine system |
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| Locomotor system and joints |
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| Skin |
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Source: Adapted from Rawles et al, 2015
Consultation
The ability of the nurse prescriber to effectively interact and illicit the information they need from the patients to inform a prescribing decision is paramount (Nuttall and Howard, 2020). Key areas in effective consultation are therapeutic communication skills, and maintaining a structure.
Setting the scene and building a trusting rapport with the patient can promote their engagement and a far more accurate assessment of their needs (Walker, 2014). A high level of self-awareness and reflective abilities on the part of the prescriber are helpful in fostering therapeutic engagement. This includes consideration given to tone and volume of voice, rate of speech, conversational rather than a checklist approach to exploring the patient's needs (Rawles et al, 2015). Active listening skills including good eye contact, an engaged but non-threatening body posture, warm facial expressions, consideration of appropriate body space for the situation and use of reflective summary to clarify the patient's account of their issue all demonstrate genuine interest in the patient's needs (Walker, 2014).
When consulting with a patient and engaging with them in the desired conversational manner it can be easy to lose track, miss information and run out of time. Therefore, having a structure in mind to follow can really help (Nuttall and Howard, 2020). Although there are several different consultation models, the Calgary–Cambridge model is a universally accepted framework often used by prescribers (Kurtz and Silverman, 1996).
Prescribing for specific groups
As a prescriber it important to be cognisant of people from specific groups, for example, women who are pregnant and breastfeeding, older adults, children, and those with hepatic and renal impairment. These specific groups may need special attention when prescribing due to altered physiological processes and associated risks (Woodfield et al, 2017). When making a prescribing decision for any of these groups it is important to consider the holistic impact of the condition, the psychological, social, spiritual in context with the physiological as one (Baker et al, 2014). Furthermore, there are other groups and subgroups of people who have specific needs that the nurse prescriber needs to be culturally aware of to prescribe safely and therefore a good level of professional curiosity is required in assessment (Nuttal and Rutt-Howard, 2020). An understanding of a patient's culture, integrated with the healthcare provider's culturally appropriate interventions, can promote improved adherence and improve patient outcomes.
For up-to-date prescribing information prescribers should refer to the British National Formulary (https://bnf.nice.org.uk/). The BNF aims to provide health professionals with sound, up-to-date information about the use of medicines. It includes key information on the selection, prescribing, dispensing and administration of medicines. Medicines generally prescribed in the UK are covered and those considered less suitable for prescribing are clearly identified.
Clinical knowledge summaries produced by the National Institute for Health and Care Excellence (NICE) are available online (https://cks.nice.org.uk/) and these provide practitioners with a readily accessible summary of the current evidence-base, practical guidance on best practice and prescribing information.
Considerations for breastfeeding
Mothers are likely to be concerned about whether drugs they are prescribed might be passed on and affect the infant, which is complicated by an overall lack of evidence available to share with mothers. However, neonates and infants are at greater risk when exposed to medications that might be present in breast milk as they have less ability to excrete them, resulting in prolonged half-life and heightened levels of the medication in the blood and adverse effects. Prescribers should first of all consider whether the medication is required by the mother. It is important she is given all the information required to make an informed decision. In some cases, it may be better for the mother to minimise exposure by timing breast feeds to align with low blood concentration just before taking the dose or stop breast feeding temporarily. Psychological and social factors need to weigh up in this decision making—the risk of deteriorating mental health on mother and baby. Ongoing review and monitoring are vital (Nuttall and Rutt-Howard, 2020).
Considerations for children and young people
Non-medical prescribers need to consider the use of the BNF for Children (https://bnfc.nice.org.uk/) to aid their prescribing decisions. This is because the body organs, systems and enzymes all develop at different rates. Children can be more sensitive to the formulation, taste, and appearance of the medicine and so these are important considerations. The child's preference for administration, an easy-to-understand regimen that suits the child's routine and keeping use of medication to a minimum are all important considerations. A simple regimen should be prescribed with as few medicines as possible, tailored to the child's routine with doses scheduled to waking hours where possible (Baker et al, 2014).
Considerations in older adults
Older adults are more likely to be taking multiple drugs for various disease processes. This means that there is a higher chance of unwanted drug interactions and adverse effects, which can impact on concordance. When prescribing for older adults it can be useful to consider lower doses, typically 50% of the usual adult dose and focusing on the minimal effective dose (Woodfield et al, 2017). Nurse prescribers should check for polypharmacy and effectiveness of medication through regular monitoring and review. It is important to remove any unnecessary medications, review doses and try to ensure that dosing regimens are as simple as possible to avoid confusion. Prescribers should check the patient's understanding of the medication and how to take it to promote concordance. There are some drugs that are well known to cause adverse reactions in older adults and should avoided or used with caution when necessary if there is no alternative. For example, non-steroidal anti-inflammatory drugs (NSAIDs), which can have side effects increasing risk of bleeding, heart failure and renal impairment. Diuretics should not be used for long-term treatment of oedema, instead long-term management focuses on treating the underlying cause. Hypnotics can increase confusion, drowsiness, and risk of falls (Courtney and Griffiths, 2010).
The STOPP/START cr iter ia are evidence-based criteria used to review medication regimens in elderly people is now integrated in the BNF to help with decision making. STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) aims to reduce the incidence of medicines-related adverse events from potentially inappropriate prescribing and polypharmacy, while START (Screening Tool to Alert Doctors to Right indicated Treatments—ie appropriate treatment) is for people over 65 years for specific conditions where no contraindication to prescription exists (Gallagher et al, 2008). Information on using this tool kit can be found in the NHS England Toolkit for general practice in supporting older people living with frailty (Moody et al, 2017).
Considerations for prescribing in liver disease
Liver function needs to be considered in all prescribing decisions due to increased risk of drug interactions and adverse effects. Most drugs will pass through the liver and liver disease can cause changes in pharmacokinetic and pharmacodynamics. Nuttall and Rutt-Howard (2020) suggested that when assessing for liver impairment the nurse prescriber should consider the presence of these chemicals in liver function tests: damaged liver cells can release transaminase enzymes and alanine aminotransferase (ALT) and aspartate aminotransferase (AST). However, these can be released from other body organs as well and on their own may not indicate liver damage.
If it is suspected that a patient may have abnormal liver function, consider prescribing guidance highlighted in the BNF.
Considerations for prescribing in renal disease
The kidney is responsible for excreting most drugs. It is therefore vital that the nurse prescriber understands their patients' renal function before making a prescribing decision. A creatinine clearance (CrCl) result helps to provide information about how well the kidneys are working. The test compares creatinine level in urine with the creatinine level in blood. The current method available to assess renal function and staging of chronic kidney disease is estimated glomerular filtration rate (eGFR), which is is a mathematically derived entity based on a patient's serum creatinine level, age, sex and race. This is usually calculated by the laboratory analysing the blood sample and reported along with the serum creatinine result. Several recognised and well-validated formulae have been used for this purpose including CKD-EPI equations. ‘Normal’ GFR is usually >90 ml/minute/1.73m2. (Note the correction for body surface area ‘per 1.73m2’, which is important for certain patient groups, such as those who have had an amputation, or extremes of body habitus.) It is best to follow the locally calculated eGFR if possible, although one can be calculated using an eGFR calculator (NICE, 2021). Nurses can refer to the NICE (2021) guidance for the classification of stages of chronic kidney disease.
When choosing a drug for someone who has an impaired renal function it important that the drug has minimal or no nephrotoxicity and that recommended dosages are used as outlined in the BNF with regular review and monitoring, (Woodfield et al, 2017).
Conclusion
Nurse prescribing is an essential part of advanced clinical practice and managing the increasing complexity of patient's health conditions within primary and secondary care. Prescribing practice is governed by ethical and legal principles to ensure a holistic patient-centred approach.
KEY POINTS
- Nurse prescribing is an essential part of the ACP role
- Values-based prescribing is a patient-centered approach whereby patients' needs, and beliefs must be explored
- Clinical skills and good physical assessment are fundamental to safe prescribing practice
CPD reflective questions
- What are the benefits of nurse prescribing?
- How do you ensure values-based prescribing in your prescribing practice?
- How confident do you feel as a nurse prescriber and what additional CPD training would you consider to enhance this further?