New proposals to allow nurses to prescribe drugs are restricted to those with highly specialised training. Elaine Edwards reports
Proposals by Health Minister Mary Harney to allow nurses and midwives to prescribe certain medication, albeit in tightly defined circumstances, have been widely welcomed by the nursing profession.
Contrary to some impressions, however, it is unlikely that powers to prescribe medication to patients will be widely extended to general nurses, but will be restricted to those with extremely specialist qualifications, experience and training.
Harney told a nurses' conference in Mullingar last week that the Bill to outline the circumstances in which nurses can prescribe for patients will be enacted by the end of the year. Regulations will then be put in place to allow "nurse prescribing" in certain circumstances.
Specialist nurses and midwives (mainly with the advanced nurse practitioner (ANP) qualification) are currently "prescribing" medication for their patients under stringently defined protocols at nine sites throughout the State.
This follows a pilot project undertaken at the end of last year as part of a wider study, Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products, by An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery.
The report of that review group was favourably disposed towards extending protocols that will allow certain nurses to prescribe drugs. However, those involved in the review, including the nurses who took part in the pilot project, stress that appropriate support structures and education must be put in place to empower nurses to achieve the right outcomes.
Any adult can, at present, walk into one or more supermarkets or pharmacies in a single day and buy multiple packs of products containing potentially dangerous substances such as codeine or paracetamol.
Yet, ironically, highly trained and experienced nurses cannot give a patient under their care a paracetamol tablet without a prescription written by a doctor. This, according to some nurses, is an absurd situation that can also cause unnecessary delays and contribute to a lack of continuity of care for patients.
At a presentation of the medication management report in Dublin recently, delegates were given information on a number of studies in Britain and the US. Some of those studies found that nurse practitioners who were prescribing drugs did so in an appropriate and safe way, that they asked more questions of the patient, were less likely to use a drug-based approach to treatment and that patient satisfaction was high.
One study in a dermatology environment showed that the prescription decision of a nurse practitioner differed from that of a consultant in just 20 out of 100 cases, compared with 39 for senior house officers.
Christine McDermott of the Rotunda Hospital in Dublin is one of just two ANPs currently working in neonatology here, although others are training.
She and her colleague Edna Woolhead each have, essentially, two nursing degrees, a master's degree, a specialist course qualifying them as ANPs from the University of Southampton and further training from the Royal College of Surgeons in Ireland which they had to undertake before the pilot study started.
McDermott has more than 1,500 hours training in pharmacology, in addition to the experience gleaned in more than 20 years of work in neonatology.
As one senior person in another hospital remarks, quite often such specialist nurses have more formal education and training behind them than some doctors.
Under the strict protocols established for the pilot study, McDermott and Woolhead can administer a single dose of crucial medication to newborn infants and sick babies without having to wait for a doctor to write a prescription.
"By administering surfactant to babies of less than 26 weeks' gestation at birth, you actually improve their lung condition and make it easier to ventilate them and it also reduces the amount of time they are on the ventilator. Prior to the prescribing project, we would have had to have that prescribed in advance for us by a doctor," says McDermott.
"Another instance would be the case of a baby who comes up from the neonatal ward with very low blood sugar. There is some information that suggests if that is left untreated, it can have long-term neurological problems. Now we can give those babies a single dose of dextrose which treats them immediately for their low blood sugar under the protocols we have developed.
"When you are dealing with intensive care patients and a situation where parents have a very sick newborn baby or a premature infant, who treats their baby at that time doesn't really enter into the equation. They know that you're a professional and that you have the education and the training and that you're going to do the best for their baby. The parents know that we're not doctors but they're not exactly sure what we are because the role is still so new."
McDermott says any sensitivity remaining in relation to nurse prescribing is about change, the pace of that change and "the blurring of professional boundaries". "It's understandable that some people may feel a little bit hesitant about the changes and, I don't know, maybe in some cases they feel a little threatened. I can understand that. I don't claim to be a pharmacist, I don't claim to be a doctor, I know what I am and I know what I am capable of and what I'm trained to do," she says.
"There's also a little bit of competition. The pharmacists are looking for prescription rights and they were just a little bit slower off the mark than we were and there are those little tensions that happen. But at the end of the day, either way, the patient is going to benefit."
She acknowledges the "leap of faith" by consultants, including Dr Tom Clarke at the Rotunda to support herself and her colleague in this scheme and in their advanced training.
Sandra Delamere, ANP in sexual health at the genito-urinary infections (GUI) clinic at St James's Hospital, Dublin, is also very positive about her experience of the pilot programme. Protocols put in place with her mentor, Dr Grainne Courtney, allow her to prescribe 29 different drugs for patients with infections such as chlamydia, gonorrhea and syphilis.
Delamere sees 15-20 patients a day (the clinic has some 26,000 total patient visits a year) and the protocols, she believes, prevent delays for her patients and also allow greater continuity of care and a more holistic method of treatment.
She says the clinic's work is very protocol based anyway and, as such, was an ideal location for the pilot programme.
By following the protocols, she can see a patient, make a clinical diagnosis and treat him or her on the same day without having to refer to a doctor. Substances she can prescribe include various antibiotics and anti-fungal medications, such as metronidazole, fluconazole, ceftriaxtone and clotrimazole.
Delamere says some people are under the impression that rights to prescribe drugs will be "extended to everyone" but that is not the case. "We need to be very careful how it rolls out. I think nurses need to be empowered and supported to ensure it's successful. It will not only benefit them professionally, but it will also benefit the patient and the health service as a whole."
Consultation will take place with the various "stakeholders" over the coming months before regulations are drawn up by the Department of Health. The Irish Medicines Board Bill is due to be at Committee Stage in the Seanad shortly.
However, other drug-related legislation, including, but not exclusively, the Misuse of Drugs Acts and the Poisons Act may also need to be examined to allow an expansion of the circumstances in which nurses can prescribe for their patients.
Advanced Nursing
• Education: Advanced Nursing Practitioners (ANPs) are educated to master's degree level or higher. Their postgraduate qualification must be in nursing/midwifery or in an area which is "highly relevant" to their specialist field.
• Duties: They are responsible for advanced decision-making and for clinical diagnoses. ANPs are, according to the National Council for the Professional Development of Nursing and Midwifery, pioneers and clinical leaders in that they may initiate and implement changes in healthcare service in response to patient need and service demand.
"They must have a vision of areas of nursing/midwifery practice that can be developed beyond the current scope of nursing/midwifery practice and a commitment to the development of these areas."
Weblinks:
• National Council for the Professional Development of Nursing and Midwifery: www.ncnm.ie/
• Irish Nurses' Organisation: www.ino.ie
• An Bord Altranais: www.nursingboard.ie
• Rotunda: www.rotunda.ie
• St James's Hospital: www.stjames.ie/
• Genito-Urinary Infection clinic, St James's: Tel: 01-4162312/01-4162314