A keynote paper on nurse prescribing was delivered at the Society of
Occupational Health Nursing conference, and OHNs were then asked whether they
felt this practice should be adopted as part of their role, by Jan Maw
Despite the long gestation period, many occupational health nurses (OHNs)
struggle to understand the scope, clinical and academic requirements that are
needed to undertake nurse prescribing.
OHNs, under Schedule 5 of the Medicines Act (1968) (Exemptions) 58 (2) have
exemption from the restrictions on supply of prescription-only medications that
are supplied in the course of an OH scheme, provided that the registered nurse
is acting in accordance with the written instructions of a doctor.1
In essence, this allows OHNs to administer certain prescription-only
medication (POM) under protocols and Group Patient Directions. It does not give
OHNs prescribing rights.
The recommendations for nurse prescribing were originally in the Report of
the Community Nursing Review, frequently referred to as the Cumberlege Report.2
The potential benefits of nurse prescribing were investigated and published in
the Crown report.3
Legislation permitting nurse prescribing finally received the Royal Assent
on 16 March 1992 and was enacted in England in October 1994, and the Medicinal
Products: Prescription by Nurses etc Act 1992 amends the Medicine Act 1968 and
the NHS Act 1977.
The above legislation heralded nurse prescribing pilots in England, and the
subsequent rolling out of nurse prescribing across the country.
An announcement at the Royal College of Nursing Congress, in April 2002, by
the then health minister, Alan Milburn, said it was: "the intention to
ensure that every nurse who wants to, and is trained to, is able to prescribe
appropriate drugs/medicines to patients".
Categories of nurse prescribing
There are three distinct categories of nurse prescribers:
Limited prescribing for health visitors and district nurses
This was the first type of nurse prescribing to be introduced and was
piloted in 1994 in eight general practices.
Training was only open to qualified health visitors and district nurses,
who, on successful completion of training, could prescribe from a very limited
nursing formulary, which included appliances, dressings, some medications and
about 12 prescription-only medicines. It was expanded to all regions by 1997.
Initially, a short, stand-alone module of preparation, it is now
incorporated in the Specialist Practitioner Programme of Health Visiting and
District Nursing.
Independent (or extended) prescribing
An announcement by the Department of Health (May 2001) extended the previous
arrangements for health visitors and district nursing, to 10,000 more
first-level nurses and registered midwives, who, following preparation, would
be known as independent prescribers.
Responsibilities of an independent prescriber include the clinical
assessment of patients; establishing a diagnosis and the clinical management
required; and prescribing where necessary the appropriate prescription.
Guidance on training was issued by the English National Board for Nursing,
Midwifery and Health Visiting (ENB) in September 2001.4
The prescribing formulary for independent prescribers included all the items
covered in the limited formulary for health visitors and district nurses, plus
all licensed pharmacy medicines and general sales list medications, and around
140 prescription-only medicines.
Prescribing was restricted to the four therapeutic areas of minor illness;
minor injury; health promotion and palliative care.
The programme of study, which cannot be incorporated into any other,
consists of a minimum 25 days theory and 12 days practice. The level of study
is first degree (level 3). Candidates for this type of preparation must have
the support of their employing organisation and have the support and
supervision of a designated medical practitioner while training.
On completion of training, students are tested by written and practical
examination. Successful students have a mark annotated against their name on
the professional register.
Supplementary prescribing
Following further consultation (May to July 2002), it was announced that
further extension to prescribing rights would be given to nurses, who,
following preparation, would be known as supplementary prescribers.
These prescribers would be able to prescribe from an even wider range of
medicines and for a broader range of conditions outside the four categories
stipulated for independent prescribers.
The programme of study mirrors the preparation of independent prescribers,
with an additional module on supplementary prescribing. Successful students
have a mark annotated against their name on the professional register.
Selection for training is a local decision, with central funding to support
training coming from the Workforce Development Confederations for NHS nurses.
The independent sector (which includes many OHNs) can voluntarily adopt
supplementary prescribing, but they are not able to access central funding.
Method
To capture the views of OHNs as to whether nurse prescribing would enhance
their role and services, data was collected from delegates attending the Royal
College of Nursing Society of Occupational Health Nursing (SOHN) Conference in
November 2002.
The scope and preparation of the three types of nurse prescriber was
outlined in a keynote paper, followed by a nurse prescribing workshop.
The following question was posed to delegates attending the workshop:
‘Currently, the vast majority of OHNs administer drugs/vaccines under
"protocols". Do you feel there would be a benefit to your
clients/service by becoming independent nurse prescribers – if yes, why? If no,
why?’
Data was collected from the SOHN workshops by a simple questionnaire posing
the stated question and leaving room for respondents to justify their ‘no’ or
‘yes’ or ‘other’ answer.
Results
Thirty two delegates took part in the workshop. Of these, 80 per cent
supported the premise that OHNs should not adopt nurse prescribing. Some 12.5
per cent supported the need for nurse prescribing, with 7.5 per cent unsure.
The first theme to emerge from the no respondents was the fear that nurse
prescribing would impact upon the vision and function of OH. A significant
proportion of respondents (37.5 per cent) felt OH should not be seen as a
treatment service. The struggle to move towards a more proactive service and
away from treatments was highlighted by 12.5 per cent, and 6 per cent said they
were concerned about the pressures that would be put upon them to return to a
treatment service. This theme continued in the concern that expansion of a
treatment/prescribing base would potentially detract from, and diminish the
advisory and preventative aspects of the OHN role (12.5 per cent).
The second theme to emerge was consideration of the current administration
of prescription-only medications, and the perceived lack of benefits that nurse
prescribing would give. Protocols currently used to administer POMs by many
OHNs were seen to serve the client population well (35 per cent), and
respondents felt that nurse prescribing would not be an added benefit for their
client needs.
Others felt that patient group directions (Health Service Circular 2000/26)
provided sufficient flexibility for the administration of POMs (25 per cent),
but additional comments concluded that there was a need to ensure that
administration of POMs under such instructions required adequate training to
ensure competence, and proper written instructions to ensure compliance.
The theme of competence continued, with concern about the lack of support
and supervision, and the current lack of a nurse prescribing infrastructure
within OH practice (12.5 per cent). Some commented upon being lone
practitioners out with the NHS system (12.5 per cent) which made them feel more
vulnerable, and a further (6.25 per cent) said they did not want the additional
responsibility that nurse prescribing would bring.
The fourth theme to emerge was consideration of who should be responsible
for the prescribing and administering of medications in general, as who had
prime responsibility and expertise to provide treatment. It was felt by some
(18.75 per cent) that clients requiring general medications are better served
by their GP.
They felt that the GP would have knowledge of the clients full medical
history, and that similarly, clients requiring anything other than immediate
first aid treatment, were better served by the accident and emergency services
in the NHS. Six per cent commented upon the potential duplication of services,
and concern that nurse prescribing was ‘off loading’ part of the GP role to
free up their time, at the expense of the more pro-active preventative aspects
of the OHN role.
The fifth theme centred on training needs, with concerns about the costs in
terms of fees and time required to undertake training (18.75 per cent).
Respondents highlighted the on-going difficulties that face many OHNs in
acquiring funding, release and support to attend post registration education
for OHNs, and felt that employers would not support additional costs for nurse
prescribing without a sound cost-benefit analysis.
Finally, one respondent said the discipline of an OHN needed more of an
evidence base to support its overall core functions before taking on
prescribing.
The first theme to emerge from the ‘yes’ respondents was the belief that OH
nursing has been left behind in the nursing agenda, and that OHNs needed to
make sure they were at the front of developments (9.5 per cent).
It was also said that while nurse prescribing would not make any obvious
difference in care at this moment in time, that it was important for OHNs to
engage with nurse prescribing so that they could shape policy which might
impact upon client care in the future.
The second theme to emerge was that of professional equivalence. Comments
captured a desire to be professionally equivalent with others who were nurse
prescribers (6.25 per cent), with an underlying belief that prescribing would
enhance OH nursing practice and increase flexibility of care. This theme
captured the belief that by becoming prescribers, OHNs would take greater care
and thought when administering prescribed medicines.
One respondent (3 per cent) reported that training was high on their
personal agenda, and as they had been administering vaccines and
non-prescription medication for 20 years, they felt further training would
benefit practice.
Disappointingly, one respondent said "OHNs are already prescribing
vaccines and immunisations", and confused administering under protocols
with prescribing, leading to the conclusion that if OHNs were not prescribers,
they would not be able to administer vaccines. The same person said that OHNs
were already competent and independent prescribers.
Statements given by ‘Other’ respondents
Three per cent said that in their current role resources would not allow
their take on prescribing and they had no time to offer a treatment service,
but was not sure if nurse prescribing was a good or a bad idea. It was also
felt that more could be done to link prescribing to ‘consultant status’ for
OHNs.
Another respondent found it impossible to say whether nurse prescribing
should be adopted for OH nursing generally (3 per cent), because they felt OHNs
worked in different work contexts, with different client and group needs,
therefore it should be up to the individual OHN to decide.
Conclusion
The data shows that most OHNs in the sample were not supportive of adopting
prescribing, the deficits greatly outweighing the perceived benefits. While the
sample size was small, it was representative of the discipline as a whole,
including delegates from across the country.
If OHNs are to embrace nurse prescribing alongside their nursing colleagues,
greater evidence is required to support the benefits. To strengthen the
reliability of these findings, a larger survey of OHNs is required. In
addition, funding to support a pilot of nurse prescribing in OH nursing
settings would greatly assist the body of knowledge in either supporting or
refuting the value of nurse prescribing in a workplace setting.
Jan Maw is an independent practitioner and part-time lecturer in
occupational health at the University of Sheffield
References
1. Health Service Circular (2000/26) Patient Group Directions (England
Only).
Medicines Act 1968
2. DOH (1986) Cumberlege Report (Report of the Community Nursing Review).
3. DOH (1989) Crown Report (Report of the Advisory Group on Nurse
Prescribing).
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4. ENB (2001) Outline Curriculum for training and preparation of Extended
Formulary nurse prescribing. September 2001
www.nmc-uk.org/advice
www.hmso.gov.uk/legislation
www.doh.gov.uk/nurseprescribing
www.groupprotocols.org.uk
