The case for more nurse prescribing

Extending the scope of nurses and midwives to prescribe medicines would lead to more efficient and cost-effective ways of delivering patient care, say experts.

The only nurses who can currently prescribe medicines in Australia are nursing practitioners and midwives with an endorsement for scheduled medicines.

Chief Nursing and Midwifery Officer Debra Thoms believes it’s time we opened up the debate about nurse and midwife prescribing more broadly.

Adjunct Professor Thoms described the issue in terms of giving patients safe and timely access to medicines in a background paper released by the Department of Health (DoH) earlier this year for a symposium on the issue.

“In order to ensure that the Australian community continues to receive high quality care, it is necessary to consider the contribution that nurses and midwives can make to the strategies and models of health service delivery across all sectors.

“Internationally there has been a steady increase in models of nurse prescribers within health systems and… within Australia we have seen specific roles incorporate prescribing.”

Professor Lisa Nissen, head of the clinical sciences school at QUT, told The Lamp that increasing nurse prescribing roles “can assist nursing professionals to work at the full scope of their practice, facilitating better access to care for patients, easier navigation of healthcare, and collaboration between health professionals”.

Professor Nissen has been an expert adviser for the National Prescribing Service on prescribing competency standards, and she’s been closely involved in the training and development of nurse practitioners who have been able to prescribe for more than 15 years.

In Professor Nissen’s view, nurse prescribing is about “putting patients across the whole sector with health professionals who can assist with the management of their medications.”

Changing Australia’s framework of prescribing medicine should mean giving patients access to “the right person with the appropriate skill set available in the right setting at the right time.”

Efficiency and cost-effectiveness a factor

As the DoH background paper notes: “Health systems worldwide are looking for ways to develop more efficient and effective models of service delivery designed to manage workforce shortages, improve access to medicines and increase patient choice”.

Nurse and midwife prescribing is already in place in the US, Sweden, UK, Canada, Ireland, and NZ. While prescribing medications has traditionally been the domain of the medical profession in Australia (with the exception of some midwives and nurse practitioners – see box) discussions are building about whether this is sustainable.

In 2015, the Nursing and Midwifery Board of Australia commissioned a literature review to better understand the evidence around registered nurse and midwife prescribing. The benefits of nurse prescribing identified by the review included:

  • Enhancement of RN’s ‘skills’ and facilitating continuity of patient care
  • Improved access to timely treatment including medications
  • Improved cost effectiveness
  • Potential for improved relationships among RNs, medical practitioners and pharmacists
  • Opportunities for nurses to have increased professional recognition and respect, enhanced career development and increased nursing autonomy.

The review also found that patients generally appeared satisfied with RN prescribing in terms of accessibility, timeliness and convenience and quality of relationships with the RN. Several studies reported that a high proportion of patients who experienced RN prescribing had no preference in terms of who they see in future; an RN or medical practitioner.

Professor Nissen sees opportunities for nurses to develop and expand their skill base by offering prescribing services in a range of health areas “from paediatrics to aged care or mental health to oncology”.

With the right “systems to support people to operate in their scope of practice” the ability of nurses to care for patients through prescribing can be expanded, Professor Nissen says.

“Nurses and midwives already play a major role in the health sector around the management of medicines across a range of areas,” says Professor Nissen. “It is important that this opportunity is based on appropriate competency and training”.

 

Current nurse and midwife prescribing in Australia

Nurse prescribing was first introduced in Australia in 2000 with the creation of nurse practitioner (NP) roles. Now prescribing is established practice for midwives with an endorsement for scheduled medicines; other health professions in areas such as dentistry, podiatry, pharmacy, and optometry now hold varying authorisations to prescribe. Nurses and midwives who prescribe and manage medications are subject to Nursing and Midwifery Board of Australia (NMBA) regulatory requirements, and they must complete an approved post-graduate education program.

Since 1 November 2010, NPs and midwives with a scheduled medicines endorsement have been able to prescribe medicines subsidised by the Pharmaceutical Benefits Scheme (PBS). Medicines that NPs and midwives may prescribe independently within the PBS are listed and others are identified as medicines NPs may prescribe for ‘continuing therapy only’ after a medical officer makes the first prescription.