Advanced Practice: The History of Nurse Prescribing in the UK

[XB9S, BSN, MSN, EdD, RN, APN]

What is prescribing?

Churchill’s Illustrated Medical Dictionary defines prescribing as:

“To order for use in treatment or prevention of a disease or injury, a drug, diet or regimen”

There are now 3 types of nurse prescriber's:

• District Nurse, Health Visitor Independent nurse prescriber's (limited) who continue to prescribe from the nurse prescriber's formulary
  
• Supplementary Prescriber's who can prescribe for any medical condition provided it is supported by an agreed clinical management plan, this included non-licensed and controlled drugs
  
• Independent Nurse Prescriber's who may prescribe for any medical condition within their area of competence defined as: ‘prescribing by a practitioner (e.g. doctor, dentist, nurse, and pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing’.
  

(Welsh Assembly Government (July 2007)

Within the UK, in 1990 community based nurses were given the ability to prescribe independently from a limited formulary, this was following recommendations made in the Cumberledge report (Department of Health 1986) Then in 1989 the crown report (Department of Health 1989) supported the legislative changes recommending that prescribing rights be made available to district nurses and health visitors. (Avery and James 2007, Whitaker 2006.).

These prescribing powers were limited to community nurses and did not include hospital nurses as it was felt that hospital nurses had greater access to doctors for prescribing needs. Nurses who were employed as District Nurses or Health Visitors within a health authority were offered a special training program and on completion were able to prescribe from a limited formulary (McHale 2003)

In Wales these prescribing powers were made available to this group of nursing professionals in 2000 after they had completed the appropriate training by the Welsh National Board.

Then in 1999 the Department of Health produced another Crown report, this reviewed the prescribing, supply and administration of medicines, it also recommended that other health professional should prescribe as dependent prescribers (supplementary prescribing), this was not adopted by the Welsh Assembly Government until 2003.

The developments in nurse prescribing are largely due to broadening the scope of nurse’s professional practice and boundaries, driven and support by the government reform of healthcare. In 2000, The NHS plan: a plan for investment, A plan for reform (Department of Health 2000) emphasised that there was a necessity to organise and deliver our services around the needs of the patients. It recognised that in order to achieve this some of the traditional boundaries between clinical roles would need to be broken down to allow the clinical professionals within the NHS to work more flexibly for the benefit of the patients, prescribing was one of these areas.

In 2001 the government announced that nurse prescribing would be extended to cover four areas, these were

1. Minor Ailments

2. Minor Injuries

3. Health Promotion

4. Palliative care

Nurse prescriber's would be able to prescribe all General Sales List and Pharmacy medications that general practitioners could prescribe with the exclusion of some controlled medications. They would also be able to prescribe some prescription only medications from a defined list. This prescribing was also extended from District Nurses and Health visitor to include any first level registered nurse and registered midwife, listed on the nursing and midwifery council’s central register as completed an approved program of preparation and training. The guide for implementation (Department of Health 2002a) suggested that likely candidates would include nurse consultants, practitioners and specialist practitioners. (McHale 2003)

In Wales in 2003 the NHS regulations were amended allowing supplementary prescribers to prescribe within the NHS at NHS expense. The Welsh Assembly Government sponsored nurses and pharmacists to undertake training to qualify to become the first supplementary prescriber's in Wales (Welsh Assembly Government 2004).

Training was offered to nurses to allow them to prescribe from an extended formulary (Courtenay and Griffiths 2005) and the proposals from the Medicines and Products Regularity Agency (2003) were accepted allowing inclusion of a number of additional conditions and medications to the Nurse Prescriber's Formulary (Nurse Prescriber's Formulary 2003)

The next progression within the UK for nurse prescribing happened in 2005 when the Department of Health announced that from the spring of 2006 the whole of the British National Formulary would be exception of a some controlled and unlicensed drugs would be made available to nurse and pharmacy prescriber's.

Additionally in 2005 the Nursing and Midwifery Council made recommendations that;

training be extended to all nurses taking Community Specialist Practice qualifications and be further extended in 2007 so that any nurse, who meets the entry criteria, may be trained to independently prescribe from this limited formulary.

In Wales the introduction of independent nurse prescribers has been a little slower than in England, with the Welsh Assembly Government , in 2005 changes were made to the Medicines and Human Use order of May 2006 to enable nurses to train and qualify as “Independent Nurse Prescribers” these changes took effect from February 2007. It was believed that the introduction of Independent Nurse Prescribers within Wales would support the implementation of the “Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century” (Welsh Assembly Government 2005) and it was felt that this development would support patient choice, improve access to services, facilitate the appropriate use of the skilled healthcare workforce, introduce more flexible team working across the NHS, and these would in turn increase capacity meeting demand by working in new ways and improve patient care without compromising safety.

Nurse Prescribing – Educational and Professional Requirements

In order to gain access to the Independent prescribing course and following this course has that qualification registered with the Nursing and Midwifery Council there are specific requirements that a nurse has to evidence. These being:

Current Registration as a first level nurse pr midwife

Demonstrated ability to study at level 3

Have at least 3 years experience as a qualified nurse

Have a medical prescriber who is willing to contribute to learning in practice and assessment and supervise prescribing practice after qualification

Employer’s agreement to undertake the prescribing course

Be in a post that you would be expect to prescribe (Nursing and Midwifery Council 2006)

The educational program requirements are subjects that are essential to safe prescribing, these being:

• Consultation, decision making and therapy including referrals
  
• Influences on the psychology of prescribing
  
• Prescribing within a team context
  
• Clinical pharmacology including the ethics of co-morbidity
  
• Evidence based practice and clinical governance
  
• Legal, policy and ethnical aspects of prescribing
  
• Professional accountability and responsibility
  
• Prescribing in the public health context
  

Assessment is carried out in both the clinical setting and educational institution and will consist of:

• A portfolio of learning or a log that demonstrates the supplication of theory to practice and provides rationale for prescribing decisions and reflection
  
• Objective structured clinical examination (OSCE) which will examine practice
  
• Examination of practice
  
• Written final examinations with test pharmacology and application to practice
  
• Numerical assessment in which a 100% pass rate must be achieved.
  

(Nursing and Midwifery Council 2006)

[bigie1978]

Wow. Very informative article. Thanks for the education.

[uniquenurse, BSN, RN]

Hi Sharrie, could you please give me some input about "Advanced Nurse Practitioners"... how did this role start, advantages, disadvantages, patient's benefits and their contribution in relation to government targets. How do you see these roles progressing in the future. I would greatly appreciate if you could give me some ideas. Thanks in advance.

[XB9S, BSN, MSN, EdD, RN, APN]

Hi there give me a day or two your question warrents quite a detailed answer and I've got a busy couple of days so to give it the proper attention I'll need to sit down and dig through some of my older literature. Will have something for you by Thursday

[uniquenurse, BSN, RN]

thank you.

[lovelylovely86]

Currently I am about to enter my last year in nursing school and I am considering working in the UK. My partner has British citizenship, so it seems like a good plan. I found this article very helpful in understanding the role of the advanced practice in the UK. Do you know what I would need to do to work as a an advanced practice nurse in the UK if I am trained here. I've looked at the RCN website, but I am interested in other resource. Thanks

[XB9S, BSN, MSN, EdD, RN, APN]

Hi there, sorry for the delay in replying.

Becoming a ANP in the UK is very different to the US. At the moment there is no requirement for an ANP degree to be able to do this type of role and they are usually advertised on the NHS jobs website. Requirements for the role vary depending on where you work.

I would expect at least 5 years post reg experience within that speciality and a nursing degree, with clinical assessment in that. (UK nurses are not taught formal clinical examination skills such as heart and lung sounds as part of their training which is why an additional course would be desirable)

Once in post then I would encourage the ANP masters degree as part of the development of that practitioner

[lovelylovely86]

Its fine. I know how life can sweep you away. To be specific than I was in my last post, I am currently getting a masters in Pediatric Nurse Practitioner. Would this improve my position since most nurse prescribers don't have this master's degree? Thank you.

[XB9S, BSN, MSN, EdD, RN, APN]

Definately, there will come a time hopefully soon where it will be a requirement to have a nurse practitioners degree to hold the title but we are still some way off that. For someone who already having that qualification I would say you will be viewed much more favourably than someone without.

[vinie]

Wow Thanks for the information. I would like to share also some information i have found about nursing schools in UK. I saw this article from facebook.

[NoleNurse2000]

Thank you XB9S for the great info!

I am stressing as I read the last section as to what I "think" I would be required to do before being able to practice as a Nurse Practitioner there in the UK.

We have just found out that we will be moving to the UK in a few months for my husband's job. Debating to work or not to work...depending on how difficult it will be to complete everything. We plan to stay at least 2 years....could be longer depending on how he/we like it.

I just posted further info/questions on the international board.

Any advice!?!

TY!

[XB9S, BSN, MSN, EdD, RN, APN]

Thank you XB9S for the great info!

I am stressing as I read the last section as to what I "think" I would be required to do before being able to practice as a Nurse Practitioner there in the UK.

We have just found out that we will be moving to the UK in a few months for my husband's job. Debating to work or not to work...depending on how difficult it will be to complete everything. We plan to stay at least 2 years....could be longer depending on how he/we like it.

I just posted further info/questions on the international board.

Any advice!?!

TY!

I've answered your post there

There is no formal requirements for advanced practice in the UK, but many trust do have specific requirements in the jobs spec on advert. Take a look there

NHS Jobs - Search Results

The minimum requirements for the team I manage is degree level study, clinical assessment skills is desirable and 5 years post grad experience.