Nonphysician Prescribing in the
UK Benefits Patients With Diabetes

Through the increased use of flexible skills, nurse prescribing can optimize patients’ care.

The national service framework for diabetes within the UK’s Department of Health1 focuses on structured, proactive care to support people with diabetes in managing their condition. This framework emphasizes the role of the nurse in service delivery for patients with diabetes. It is evident that nurse specialists in diabetes care have a role to play with regard to the management of medicines. For a number of years, nurses have been adjusting insulin dosages or oral hypoglycemic medication, and so have in effect been making prescribing decisions.2-4

This role developed in recognition of the fact that to reduce long-term complications and improve hospital bed states, access to health professionals who are skilled in insulin therapy is vital.5 Through the increased use of flexible skills, nurse prescribing should optimize the role of these nurses and ensure that care is better and more convenient for patients.

Recommendations were first made in 1986 for nurses to take on the role of prescribing by the UK Department of Health and Social Security. There are now approximately 29,000 district nurses and health visitors in the United Kingdom qualified to prescribe from a list of appliances, dressings, pharmacy, general sales list items and 13 prescription-only medicines included in the Nurse Prescribers’ Formulary for Community Practitioners.

The introduction of independent extended prescribing in 20026 and supplementary prescribing in 20037 has expanded the prescribing powers of nurses even further. Any appropriately qualified registered nurse is now able to prescribe medicines. Nurses qualified as nurse-independent prescribers are able to assess, diagnose and independently prescribe any licensed medicine (and some controlled drugs) described in the British National Formulary — provided that it is within their area of competence.8 By contrast, supplementary prescribing takes place following an initial assessment and diagnosis of a patient’s condition by a doctor. A clinical management plan is then drawn up for the patient. This plan, agreed to by the patient, nurse and doctor, includes a list of medicines (within the supplementary nurse prescribers area of competence) from which the supplementary prescriber is able to prescribe. Supplementary prescribers are able to prescribe any medicine, but this mode of prescribing is best suited to patients with chronic or long-term health care needs.

Training and education for nurse-independent and nurse-supplementary prescribing is combined. Those who successfully complete the program are awarded the dual qualification of nurse-independent/nurse-supplementary prescriber. Nurses registering to undertake this training must be able to study at degree level and have ≥3 years experience as a qualified nurse.9 The prescribing course is made up of a 27-day classroom component (although other ways of learning such as open and distance learning formats are available at some universities) and 12 days learning in practice with a designated medical practitioner. Courses run over a period of 3 to 6 months.

Topics covered during the classroom component include:
• clinical pharmacology including the effects of co-morbidity;
• professional accountability and responsibility;
• prescribing in the public health context;
• consultation, decision-making and therapy including referral;
• legal, policy and ethical aspects;
• influences on, and psychology of, prescribing;
• prescribing in a team context; and
• evidenced-based practice and clinical governance in relation to nurse prescribing.9

There are now more than 8,000 nurses qualified to prescribe both as independent and supplementary prescribers.10

The impact and effectiveness of nurse prescribing has largely been a positive development.11 Benefits include a belief by nurses and patients that patients receive better information from nurses about their medicines, in addition to an increased sense of satisfaction, status and autonomy. Other benefits include time savings and convenience for patients, improved communication among health care professionals, the ability to deliver complete episodes of care and better use of nursing skills.12-16

Several disadvantages have been reported by nurses adopting the role of prescriber. These include the abuse of the prescribing role by colleagues through misunderstanding, a lack of support once qualified, increased workload and effects on the role of the nurse (ie, a move toward a medical model of care to the detriment of other aspects of nursing care such as health promotion).17,18

A number of benefits of nurse prescribing have been reported by doctors.12,19 These benefits include improved professional relationships, a means of refreshing doctors’ own knowledge, fewer interruptions to sign prescriptions and reduced workload. A disadvantage reported, however, is the level of commitment required of doctors in order to supervise nurses adopting the prescribing role.

For nurses caring for patients with diabetes, the introduction of nurse prescribing represents an important landmark. It should ensure that these nurses are better able to utilize their skills and are not reliant upon the doctor for the signing of a prescription. Patients will receive a complete episode of care from the nurse, therefore they can access their medicines faster and more conveniently. Prescribing knowledge gained through the prescribing program will also enable nurses to provide patients with better information about their medicines.

Many patients with diabetes have multiple pathologies. Nurses may well feel unhappy prescribing independently for these other conditions and the associated polypharmacy issues. A supplementary prescribing arrangement, in which the doctor is responsible for the assessment and diagnosis of a patient’s condition, will work extremely well when caring for these patients.

Nurse specialists in diabetes care have been making decisions related to prescribing for several years. There are a number of benefits to be gained by appropriately qualified nurses adopting the role of nurse prescribing. These benefits include faster access to medicines by patients and more effective use of nursing skills. An additional benefit provided by supplementary prescribing is that a framework is provided within which to prescribe medicines for patients with multiple pathologies.

Molly Courtenay, PhD, MS, BS, RN, is from Reading University, Reading, UK. She may be reached at m.courtenay@reading.ac.uk.

1. Department of Health National Service Framework Diabetes. 2003a. Department of Health, London.
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5. National Institute of Health Diabetes Control and Complications Trial (DCCT). Available at: http://diabetes.niddk.nih.gov/dm/pubs/control/#what%20is. Accessed on Dec. 7, 2006.
6. Department of Health. Extending Independent Nurse Prescribing within the NHS in England: A guide for Implementation, Department of Health, London. 2002.
7. Department of Health. Supplementary Prescribing for Nurses and Pharmacists within the NHS in England, Department of Health, London. 2003.
8. Department of Health. Written Ministerial Statement on the expansion of independent nurse prescribing and introduction of pharmacists independent prescribing, Department of Health, London. 2005.
9. Nursing and Midwifery Council. Nurse Prescribing-ENB Policy. 2001. Available at: www.nmc.org-uk. Accessed on Dec. 7, 2006.
10. Nursing and Midwifery Council. Number of Independent Extended Nurse Prescribers, Personal Communication with NMC April 2006.
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18. Bradley E, Nolan P. The progress of nurse prescribing: a commentary. Nurse Prescribing. 2004;2:148-151.
19. Avery A, Savelyich B,Wright L. Doctors’ views on supervising nurse prescribers. Prescriber. 2004;5:56-61.
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