We started the week with a new proposal by the Grattan Institute to shake up the hospital workforce and allow nurses to take on more roles traditionally performed by doctors. But should registered nurses’ roles extend even further, to prescribing medication?
As the population ages and has a higher rate of chronic conditions such as diabetes, heart disease and arthritis, primary care needs will continue to grow. And as a previous Grattan report noted, more than one in four Australians already feel they have to wait too long for an appointment with a general practitioner.
But extending registered nurses’ roles to prescribing, as the Nursing and Midwifery Board of Australia has proposed, isn’t the answer. Australia already has a category of nurse specialists who can prescribe some medicines – nurse practitioners.
International prescription
In the United Kingdom, suitably trained nurses have been able to act as independent prescribers since 2006, and some nurses had limited prescribing rights before that date. The UK government implemented the change in a bid to improve patient choice, provide better access to care and enhance multidisciplinary team care.
Evidence from the UK suggests that overall, nurse prescribing is currently of a high quality: it’s safe, clinically appropriate and educational programs adequately prepare nurses for this role. Patients are also accepting of nurse prescribing.
Nevertheless, a recent UK study found that patients generally preferred to see their own doctor for minor illnesses; however, those who had previously seen a nurse were happy to consult a nurse.
The cost of drugs prescribed and assessment and diagnostic skills are seen as areas where nurse prescribers need to improve. International evidence suggests that nurse practitioners in primary care tend to order more investigations than doctors. They also spend more time with patients and achieve better patient compliance to medication regimes.
Nurse practitioners
To become a nurse practitioner, Australian nurses must undergo extended education at masters level, then complete a long and rigorous process of endorsement to prove their clinical competency in a specified area such as emergency care, wound management, palliative care, and so on.
Most nurse practitioners in Australia work within hospitals, but some work in areas of need such as aged care, palliative care and primary care (in collaboration with a doctor, though in some isolated communities, doctors only visit periodically).
Once endorsed, nurse practitioners can diagnose and treat conditions within their scope of practice. And, since November 2010, nurse practitioners have had limited prescribing rights.
A nurse practitioner working in an aged care facility, for example, is able to diagnose conditions such as urinary tract infections and prescribe antibiotics in a timely manner. This means that the patient doesn’t have to wait for a doctor to visit and risk becoming more unwell or be transferred to hospital.
Studies show that nurse practitioners can address the needs of an ageing population with chronic and complex conditions. And they may be able to provide the most cost-effective care, if they can reduce the time they spend with patients and reduce their return consultation rate (which increase the cost of care).
There is obviously scope for nurse practitioners to provide more care in areas of geographic isolation, where it is hard to recruit doctors and in areas such as aged care, where patients have complex and high needs.
They are also able to provide effective care to patients with chronic and complex conditions. Such activities could include broadening the range of medications these nurses can prescribe and enabling them to review a patient’s medication.
Proposal for nurse prescribing
The Nursing and Midwifery Board of Australia, the body responsible for registering nurses and developing professional standards, released a draft proposal in October to allow registered nurses and midwives to “supply and administer” scheduled medicines.
This applies to registered nurses and registered midwifes but not to nurse practitioners whose rights rest in legislation.
The proposal would see nurses administer a range of medicines:
schedule 2 and 3 medicines which are available from the pharmacy without prescription such as aspirin, paracetamol, ibuprofen, and cold and flu tablets
schedule 4 medicines that are available by prescription only, such as contraceptives and antibiotics
schedule 8 drugs, which doctors need a special permit to prescribe such as fentanyl, morphine, oxycodone, which are highly addictive.
To be eligible for endorsement, the registered nurse or midwife would need to have “completed a program of study in medicines management, clinical assessment and differential diagnosis”.
The draft standards state that the endorsement of registered nurses and midwives to supply and administer medication is “intended to provide safe and timely health care when a medical practitioner or nurse practitioner is not immediately available”. But it’s not clear from the draft standards how “immediately available” is defined.
Nurses working in rural and isolated areas currently have certain rights to supply and administer scheduled medicines. These are recognised areas of medical workforce shortages.
Unanswered questions
Nurse practitioners are a relatively new professional group in Australia and, in particular, in primary care. The public and even other health professionals often have little knowledge of their skills and scope of practice. Adding another level of prescriber may bring opposition from medical groups and confusion among the public.
While the proposals make it clear that nurses should be properly trained to administer medication, there is also a need for them to have skills in diagnostics, history taking and recognising adverse drug reactions. As we learnt from the UK experience, this is required for best practice.
There is also a concern that broader nurse prescribing rights would lead to fragmentation of care and an increase in the number of people seeking out different health professionals for the supply of medication. Unlike the UK, Australians aren’t registered with a particular GP practice and can seek primary care anywhere.
There is also the question of insurance. Nurses endorsed to supply medication would likely face higher insurance premiums. Nurses working in health services would be covered by their employer. But those working for private business, such as a general practice, would need to get their own insurance or the practice would need to agree to provide insurance cover under its policy.
Although nurse prescribing has been extended in the UK, the Australian health system is different enough for us to think carefully before following this lead.