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BACKGROUND PAPERRegistered Nurse / Midwife Prescribing SymposiumMarch 2017

Registered Nurse & Midwife Prescribing Symposium Outcomes Report

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MESSAGE FROM DEBRA THOMS, CHIEF NURSING AND MIDWIFERY OFFICER

Thank you for accepting the invitation to attend this symposium to consider registered nurse and midwife prescribing in Australia. Health systems across the world are facing a range of challenges in the coming years. As we know these include ensuring safe and timely access to medicines as we face the ever increasing burden of disease. Within Australia there is a significant agenda for health reform.

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. The focus of this symposium is on the potential for nursing and midwifery to contribute by supporting timely access to medicines.

The symposium will draw on previous work done on the Health Professionals Prescribing Pathway and also work done by the National Prescribing Service on prescribing competencies.

Internationally there has been a steady increase in models of nurse prescribers within health systems and while within Australia we have seen specific roles incorporate prescribing it is now timely to consider the future direction for nurse and midwife prescribing (protocol and non-protocol) more broadly.

This represents a significant opportunity for both the nursing and midwifery professions to identify a clear direction for future work.

This day is being undertaken with the support of the Nursing and Midwifery Board of Australia (NMBA). The outcomes of the day will provide an important base for future work by the NMBA.

I look forward to meeting with you and hearing your thoughtful, considered and robust discussions on the day.


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TABLE OF CONTENTS

Message from Debra Thoms, Chief Nursing and Midwifery Officer.....................2

Table of Contents................................................................................................5

Purpose of this Paper..........................................................................................7

About the Symposium.........................................................................................9

Context..............................................................................................................10

Nurse and Midwife Prescribing – an International Perspective.........................12

United States.............................................................................................................13

Sweden.....................................................................................................................13

United Kingdom.........................................................................................................13

Canada......................................................................................................................14

Ireland.......................................................................................................................14

New Zealand.............................................................................................................15

Australia....................................................................................................................16

Findings from the International Peer Reviewed Literature................................18

Health Professionals Prescribing in Australia....................................................23

Background.......................................................................................................................23

Health Professionals Prescribing Pathway.......................................................................26

The Consumer Perspective..............................................................................................30

Health Professionals Prescribing Competencies..............................................................31

Legislation and Regulation................................................................................34

Implementation of nurse / Midwife Prescribing models in New Zealand and the United Kingdom.................................................................................................36

New Zealand.....................................................................................................................36

United Kingdom.................................................................................................................39

Evidence in the UK........................................................................................................44

Practice requirements...................................................................................................44

Education, training and regulation.................................................................................45

Bibliography......................................................................................................................46

Tables

Table 1 Summary of nurse and midwifery prescribing in countries................................12


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Table 2 nurses and midwives endorsed to prescribe/supply medicines in Australia.....17Table 3 most frequent medications prescribed by RN prescribers in the UK.................20Table 4 Analysis of the key elements of identified prescribing models..........................25Table 5 Comparable models of prescribing to HPPP Models of prescribing.................26Table 6 Prescribing privileges according to category.....................................................43


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PURPOSE OF THIS PAPER

This paper provides background information for participants attending the Registered Nurse / Midwife Prescribing Symposium in March 2017. The paper provides an overview of relevant research and work conducted to date on non-medical prescribing in the Australian context together with a summary of the implementation of relevant nurse prescribing models internationally with a particular focus on United Kingdom (UK) and in New Zealand (NZ).

The paper also presents key issues for the reader to consider that will help inform discussions throughout the Symposium.

List of Acronyms

APRN Advanced practice registered nurseBNF British National FormularyCMP Clinical Management PlanCNMO Chief Nursing and Midwifery OfficerCPA Collaborative practice agreementHPPP Health Professionals Prescribing PathwayHWA Health Workforce AustraliaHWPC Health Workforce Principal CommitteeNCNZ Nursing Council New ZealandNHWP&RC National Health Workforce Planning and Research CollaborationNMBA Nursing and Midwifery Board of AustraliaNMC Nursing and Midwifery Council UKNPEF Nurse Prescribers Extended FormularyNPF Nurse Prescribers Formulary for Community PractitionersNRAS National Registration and Accreditation SchemeNCNZ New Zealand Nursing CouncilPCT Primary Care TrustPGD Patient Group DirectivePOM Prescription only medicineRIPEN Registration standard for endorsement of registered nurses (rural

and isolated practice)


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Definitions

Administer The act of giving a medicine to a person which may include some activity to prepare the medicine to be administered.

Dispense To prepare and distribute for administration medicines to those who are to use them. Dispensing includes:

The assessment of the medicine prescribed in the context of the person’s other medicines, medical history, and the results of relevant clinical investigations available to the pharmacist

The selection and supply of the correct medicine Appropriate labeling and recording Counselling the person on the medicine and its use

Formulary A circumscribed list of the medicines that are normally available at a particular health care location such as a hospital or pharmacy, and that are approved for use in that setting or by a specific prescriber.

Medicines Therapeutic goods that are represented to achieve, or are likely to achieve, their principal intended action by pharmacological, chemical, immunological, or metabolic means in or on the body of a human.

Non-medical prescribingPrescriber A health professional authorised to undertake prescribing within

the scope of their practice.Prescribing An iterative process involving the steps of information gathering,

clinical decision-making, communication and evaluation that results in the initiation, continuation or cessation of a medicine.

Protocol Written instructions developed by a multidisciplinary team for the initiation or administration of a specific medicine in particular circumstances in a defined environment and approved by the relevant institutions with whom ultimate responsibility lies; an agreed protocol may not require retrospective signature by an authorised prescriber.

Supply The act of providing medicines to a person or third party for the use by the person only.


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ABOUT THE SYMPOSIUM

The Symposium is the initial step in work being progressed by the Chief Nursing and Midwifery Officer (Australian Government Department of Health), together with the Australian and New Zealand Council of Chief Nurses and Midwives (ANZCCNM) and in collaboration with the Nursing and Midwifery Board of Australia (NMBA) to explore the potential for nurse / midwife prescribing in the Australian context.

Aim

The Symposium aims to engage a cross section of the nursing and midwifery professions in dialogue on registered nurse / midwife prescribing in Australia. More specifically, discussion will focus on three key themes:

the contexts or situations in which extending the ability to prescribe would improve access to health care for Australian communities,

the key elements the professions consider would be important features in future prescribing models; and

the essential frameworks to support the delivery of safe and high quality prescribing practice including education, governance, evaluation strategies and regulatory requirements.

Who will be attending?

The Symposium will be attended by an invited audience representing consumer groups, nurses and midwives from practice contexts including clinical, management and education from both the public and private sectors, together with nurses and midwives from professional, research and third sector organisation backgrounds. In addition, invitations have been extended to colleagues from pharmacy, and from health policy and health workforce portfolios.

What will we do?

The symposium will include presentations on key topics, however, the primary objective is to generate focused discussion. It is anticipated that the audience will share a wealth of expertise and also valuable opinion, advice and ideas on key issues that will guide and inform the future of nurse / midwife prescribing in Australia. The outcomes of the Symposium will also be shared with the Health Workforce Principal Committee to ensure the Committee remains informed as work progresses.

To maintain the focus of the Symposium, the following topics will be out of scope: issues of eligibility under the Pharmaceutical Benefits Scheme (PBS) discussion regarding impact on workload or industrial agreements legislation changes required to support non-medical prescribing jurisdictional health policy supporting non-medical prescribing.


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CONTEXT

This section provides a brief overview of the current status of non-medical prescribing in Australia and outlines the main drivers that have created the opportunity for the nursing and midwifery professions to explore the possibility of extending nurse / midwife prescribing models.

Traditionally, the prescribing of medications has been the domain of the medical profession. This traditional view has been challenged in recent times as health systems around the world search for innovative ways to develop more efficient and effective models of service delivery designed to manage workforce shortages, improve access to medicines and increase patient choice. Non-medical prescribing has been progressed across health policy platforms for decades as a way of addressing these issues. This includes Australian communities experiencing challenges in receiving equitable and timely access to health care.

Nurse prescribing was introduced in Australia with the role of the nurse practitioner (NP) in 2000. Since then the ability to prescribe has become established practice for midwives with a scheduled medicines endorsement and for other health professions including dentistry, podiatry, pharmacy and optometry who now hold varying authorisations to prescribe.(1) The ability for nurses and midwives to prescribe and manage medications in these circumstances is subject to NMBA regulatory requirements including the requirement to complete an approved post graduate education program, to comply with established practice standards and formularies, where applicable, together with meeting relevant state and territory legislation.

Additionally, registered nurses (RN) may apply to the NMBA for an endorsement under the registration standard for endorsement for scheduled medicines registered nurses (rural and isolated practice), also known as the RIPEN standard, to obtain, supply, and administer (but not prescribe) scheduled 2,3,4 & 8 medicines in accordance with established protocols in rural and isolated practice.

The need to progress work on nurse / midwife prescribing models has been highlighted by issues raised in recent consultation by the NMBA on the future of the RIPEN standard. The standard was established in 2010 to replace existing jurisdictional arrangements enabling nurses to obtain, supply and or administer scheduled medicines that were enshrined in state and territory law that would be abolished with the accession of the Health Practitioner Regulation National Law (the National Law). The standard was therefore established as an interim measure, with a review date of three years, to support the transition to alternative arrangements as deemed necessary by jurisdictions.


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In 2015, the NMBA reviewed the RIPEN standard and consulted with stakeholders on a proposal to expand the standard beyond nursing practice in rural and isolated areas. General feedback on the proposal was mixed and highlighted that, in fact, there remained little need for the standard as in the majority of jurisdictions relevant legislation and or policy to enable registered nurses to obtain, supply and administer scheduled medicines in accordance with protocols has been established.(2)

Therefore, the option of discontinuing the RIPEN endorsement standard was posed by the NMBA with the majority of jurisdictions not opposing this option. However a small number of jurisdictions continued to rely on the RIPEN standard and withdrawal did not receive unanimous support.

HWPC did recommend to the NMBA that the RIPEN standard continue for a two year period prior to its discontinuation, whilst pursuing a workable solution in collaboration with jurisdictions. It was also noted that the Chief Nursing and Midwifery Officer (Australian Government Department of Health) in collaboration with the ANZCCNM and the NMBA will progress necessary work exploring a potential model for non-medical prescribing. This work aims to promote workforce flexibility and support initiatives to improve access to medicines for communities on the eventual withdrawal of the RIPEN standard. While international experience will undoubtedly provide valuable guidance, the proposal to extend nurse / midwife prescribing is not simply a chance to implement observed practice, but an important opportunity to support current health reform objectives to improve equity of, and access to, high quality health care for Australian communities.

Notes:


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NURSE AND MIDWIFE PRESCRIBING – AN INTERNATIONAL PERSPECTIVE

The past two decades have seen an increase in the number of countries in which nurses or midwives may legally prescribe medicines.(3) Nurse and midwife prescribing is legislated in the US, Sweden, UK, Canada, Ireland, NZ and Australia (Table 1).

TABLE 1 SUMMARY OF NURSE AND MIDWIFERY PRESCRIBING IN COUNTRIES

Country NP prescribing Registered nurse prescribing Midwife prescribingUnited States

Yes. Independence in prescribing practice varies by state from independent to supervised

No. Prescribing restricted to legislated advanced practice roles only

Yes. Nurse Midwives permitted to prescribe

Sweden No. Although the role is developing there is no specific NP legislation or regulation

Yes. Specialist nurses working in community care or home nursing

No

United Kingdom

Yes. However NP role not regulated / legislated therefore NP prescribing is in context of RN prescribing

Yes. May be independent, supplementary or by patient group directive and within scope of practice

Yes. Collaborative and patient group directive prescribing

Canada Yes. Governed by territory regulation which varies among territories

No. Current proposal to expand prescribing to RNs.The title of RN Prescriber is proposed

Yes. Independently prescribe as indicated in designated legislative regulations

Ireland Yes. Advanced NP role regulated

Yes.Prescribers regulated as Registered Nurse Prescribers

Yes. Midwifery prescribers regulated as Registered Nurse Prescribers.May also prescribe as registered Advanced Midwife

New Zealand

Yes. NPs are authorised prescribers (independent prescribing)

Yes. Legislation provides prescribing under sanction of authorised prescriber known as designated prescribing. Also provision for delegated/protocol prescribing

Yes. May prescribe for antenatal, intrapartum and postnatal care.

Australia Yes. Independent prescribing

No. However legislation provides for endorsement for scheduled medicines registered nurses (rural and isolated practice) which allows for supply and or administration of medicines under protocols / restricted formularies.State legislation or health policy enables supply and or administration in a number of jurisdictions.

Yes. Endorsed midwives may independently prescribe as per approved drug list.Some examples of protocol or restricted formulary prescribing at state level


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United StatesIn the US, prescribing by nurses and midwives has been in place since the 1960s, is regulated at state level, and is limited to legislated advanced practice registered nurses (APRNs) that include NPs, nurse anaesthetists and nurse midwives.(4)

There is currently a national wide move to align practice authority across the US for APRNs. Currently 21 states in the US deemed to have full practice authority for these nurse prescribers including prescriptive authority without mandated collaborative arrangements with physicians, with other states having some form of mandated physician collaboration or restriction on prescribing practice in place.(5)

SwedenRN prescribing was introduced in Sweden in 1994 when aged care and district nurses gained the authority to prescribe over-the-counter medications.

In 2000 the right to prescribe was extended to other specialist nurses working in community care or home nursing who have completed education at the post graduate diploma level.(6)

United KingdomIn the UK, various forms of prescribing have been in place since 1994, when a health visitor formulary was introduced. An expanded prescribing formulary was introduced in 2002 facilitating forms of nurse prescribing in other health settings. In 2006 this formulary was superseded by legislation that enabled nurse independent prescribers, who have completed specific prescribing training (also required for dentists, independent prescribing pharmacists and optometrists), to prescribe from the entire British National Formulary (BNF) within their scope of practice.(7)

These 2006 legislative changes also allowed for a collaborative model of prescribing (i.e. prescribing in collaboration or consultation with an independent prescriber who formulates the initial patient diagnosis). Collaborative prescribers include nurses, midwives, pharmacists, podiatrists, physiotherapists, diagnostic and therapeutic radiographer specialists (8, 9) and are known as supplementary prescribers.

Additionally, in the UK, nurses (and many other health care professionals) may supply medicines using a patient group directive (PGD), or protocol that consists of a formal written instruction, drawn up locally by a doctor and pharmacist, for the supply or administration of named medicines in identified clinical situations. For example, a patient that presented with a dog bite would be treated according to a documented protocol and would receive an antibiotic as stipulated by the PGD. In the PGD, patients do not need to be identified individually, or in advance of treatment, but clear lines of accountability and precise clinical criteria are detailed.(10) These practices are similar to


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arrangements including standing orders or RIPEN models in the Australian context, however governance arrangements are developed and implemented locally by health services. The use of PGDs is not regulated by authorities such as the NMC.

CanadaAlthough the NP role first commenced informally in Canada in the 1960s the trajectory of development was not linear and it was not until the 2000s that Canadian NPs and midwives gained prescribing privileges.(4)

In 2012 the Canadian federal government made changes to regulations under the Controlled Drugs and Substances Act that enabled NPs in Canada to prescribe controlled drugs and substances. Similar to Australia, as a Federated nation aspects of health care are regulated by the provinces and territories in Canada, and thus NPs in some provinces may not be legislatively able do so.(11)

In Canada, midwives may prescribe drugs designated in legislative regulations (i.e. from a formulary). Some medicines may be prescribed independently and other drugs require a physician order for initiation. The regulations also provide for midwives to prescribe any drug that can be lawfully prescribed without a legal prescription.(12)

Currently, a proposal to expand prescribing to RNs in Canada is under consideration, the Framework for Registered Nurse Prescribing in Canada proposes a protected title of Registered Nurse Prescriber to differentiate RNs from NP prescribers, with the main differentiation in practice being that RN prescribing is a form of collaborative prescribing conducted in consultation with a NP or medical physician, who forms the initial patient diagnosis.(13)

IrelandIn Ireland, nurse and midwifery prescribing was introduced in 2007 with prescribers gaining the regulated title “Registered Nurse Prescriber” (note: the same title applies to both nurses and midwife prescribers).

Nurse and midwifery prescribing in the Irish health care context is conditional upon:

1) the prescriber being employed by a health service provider, 2) the medicine is a product that would be given in the usual course of health care

provision in the health service and 3) the prescription is issued in the usual course of the provision of that health

service.(14)

As such, RN and midwifery prescribing is conducted within employment models (hospital, nursing home, clinic or other health service setting and a collaborative


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practice agreement (CPA) is required between a medical practitioner, the health service and the Registered Nurse Prescriber.

Additionally, nurses and midwives may apply for registration as an advance practice clinician (Advanced Nurse Practitioner or Advanced Midwife Practitioner), which also requires registration as a Registered Nurse Prescriber and is dependent on development of a clinical position in this advanced practice role.(15)

New ZealandIn NZ, nurse prescribing coincided with the development of the NP role in 1999, although initially NP prescribing was limited to a set formulary of drugs.(4) Since legislative changes made in 2014 and enacted in 2016, NPs are now authorised prescribers and can prescribe all medicines within their scope of practice.(16)

In 2011 legislation enabled diabetes specialist RNs to prescribe 26 medicines related to diabetic patient care.(17) In 2013, further amendments extended prescriptive authority to other health practitioners under either designated or delegated authority. In 2016, regulations for other registered nurse prescribers came into force enabling RNs practising in primary health and specialty teams who meet educational requirements of the New Zealand Nursing Council (NCNZ) to prescribe under the designated authority criteria. The prescriptive authority of Designated Prescriber: Registered nurse practising in primary health and specialty teams now also incorporates RNs prescribing in diabetes health. These RN prescribers predominately work with people with common, chronic and long term conditions in order to improve access to care. The model enables appropriately qualified and experienced nurses to prescribe independently within their scope of practice for patients under their care

from a list of medicines specified in designated prescribing regulations in collaboration with an authorised prescriber and within requirements set by the NCNZ, including peer review.(18)

In 2017, NCNZ is trialling a community nurse prescriber model in two different settings. This model, if evaluation demonstrates its safety and efficiency will enable RNs who have completed an appropriate course of study to prescribe from a limited list of medicines for minor ailments and illnesses under the designated prescriber regulations.

Additionally, changes to the Medicines Amendment Act 2013 and Misuse of Drugs Amendment Regulations 2014 have provided for a new delegated prescriber category in NZ, defined as prescribing under the authorisation of an authorised prescriber who will issue a delegated prescriber order that specifies the medicines, circumstances and to whom they may prescribe.(17) This model is similar to a protocol prescribing model. The NCNZ has chosen to not utilise this model of prescribing for nurses and midwives as it was not supported by the profession during consultation.

In NZ, midwives may prescribe within their scope of practice, since the 1990 amendment to Medicines Act allows prescribing for antenatal, intrapartum and


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postnatal care. Midwives may not prescribe for underlying medical conditions. Since July 2014, the Regulations allow for midwives to prescribe morphine, fentanyl and pethidine. Prior to 2014, under the existing legislation the only controlled drug midwives could prescribe was pethidine.(17)

AustraliaIn Australia, NPs and midwives with a scheduled medicines endorsement are able to prescribe. The NP role was first introduced into the health care context in 1998, with prescriptive authority commencing in some jurisdictions in 2001.(19) Similar to the US and Canada, the title NP is protected by legislation and endorsed NPs in Australia are authorised to prescribe medications relevant to their scope of practice.(20, 21)

As of 1 November 2010, NPs and midwives with a scheduled medicines endorsement have been able to prescribe medicines subsidised by the Pharmaceutical Benefits Scheme (PBS), Australia’s universal subsidisation scheme for specified prescription medicines.(22) 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 the first prescription is made by a medical officer.(20) A number of medicines are also only subsidised if prescribed by a NP within a model of care ‘shared’ with a medical officer, these are known as ‘shared care model’ within the Pharmaceutical Benefits Scheme.

In Australia, midwives may attain endorsement to prescribe scheduled 2, 3, 4 and 8 medicines required for midwifery practice across pregnancy, labour, birth and post-natal care.(23) These prescribing privileges are similar to those afforded to NPs however, midwives may independently prescribe only from a Board approved list of scheduled 4 and 8 medicines as well as some intravenous fluids.(24)

In addition to NP and midwife prescribing, there have been several examples that may be considered RN prescribing in the Australian context. These examples are not commonly referred to as “prescribing” and are more often referred to as “supply”, “possess and administer” or “initiation” of particular medicines in well-defined circumstances and usually in accordance with formularies or protocols that govern such practices.(25)

The majority of these models are enabled by mechanisms developed at a jurisdictional level. Examples of how these models have been incorporated into practice are provided at Appendix A.

The number of NPs, endorsed midwives and nurses endorsed under the RIPEN standard across each state and territory as of June 2016 are summarised in Table 2. Overall, from statistics available from nurse and midwife registrant data, there were 2765 nurses and midwives endorsed by the Board to prescribe or supply medicines


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either independently or from restricted formulary, representing approximately 0.9% of all nurses and midwives collectively.(26)

TABLE 2 NURSES AND MIDWIVES ENDORSED TO PRESCRIBE/SUPPLY MEDICINES IN AUSTRALIA

QLD VIC NSW WA SA ACT TAS NTNO PPP Total

Nurse practitioner 367 274 317 238 119 38 28 21 16 1415

Scheduled medicines (Midwife)

88 47 40 39 24 2 8 2 250

Midwife practitioner*

- - 1 - - - - - - 1

Scheduled

medicines (rural

and isolated) **

829 164 39 21 7 5 5 18 7 1096

Total 1284 485 397 298 150 45 41 42 23 2765* 1 midwife from NSW classified as a midwifery practitioner (endorsed prior to 2010 National Scheme)

** endorsement by NMBA only required in QLD and Vic.


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FINDINGS FROM THE INTERNATIONAL PEER REVIEWED LITERATURE

It is both important and necessary that any development of a registered nurse prescribing framework is informed by current evidence. In 2015 the NMBA commissioned a literature review on registered nurse and midwife prescribing to develop greater understanding of and wisdom around existing challenges and benefits. A summary of the main findings is provided below.

Review findings

From the literature nine key themes were identified as follows:

1. Perceived benefits of prescribing,

2. Acceptability of prescribing,

3. Barriers to prescribing,

4. Confidence in prescribing,

5. Medication prescribed,

6. Patient outcomes,

7. Health service/ policy considerations,

8. Educational considerations and

9. Models of prescribing.

Perceived benefits of prescribing

The perceived benefits of prescribing reported in the literature include: Enhancement of RN’s ‘skills’ & facilitating continuity of patient care (27-30) Improving access to timely treatment including medications (28, 31-34)

Improved cost effectiveness, Potential for improved relationships among RNs, medical practitioners and

pharmacists (7, 27, 28, 30, 35-37) Benefiting the nursing profession: opportunities for increased professional

recognition and respect, enhanced career development (27, 28, 30, 34, 38) and increased nursing autonomy (30, 33, 38, 39)


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Acceptability of prescribing

In relation to the acceptability of prescribing:

Overall, studies suggest that patients generally appeared satisfied with RN prescribing on a range of different aspects, including accessibility (40), timeliness and convenience(32, 41-44) and quality of relationships with the RN(41, 42, 45, 46)

Several studies reported that a high proportion of patients who have experienced RN prescribing have no preference in relation to who they see in the future, i.e. either a RN or medical practitioner (47-50)

Consumer awareness and education on registered nurse prescribing is an important component of the implementation of RN prescribing (51) and is likely to facilitate consumer acceptance.

Barriers to prescribing

Potential barriers and enablers to RN prescribing identified included: Formularies, protocols and guidelines as barriers to prescribing (35, 37, 38, 52-54)

Lack of knowledge to prescribe has been identified as a potential barrier to RN prescribing, often related in the literature to educational preparation and experience and level of support and mentorship (38, 55-57)

Lack of confidence in their ability to prescribe. (58)

Confidence in prescribing

The ability to prescribe is dependent on the prescriber’s confidence to do so:The majority of studies reported that RNs felt confident in their prescribing practice (27, 28,

48, 52, 59) and the public who have experienced RN prescribing generally felt confident in RN prescribing. (47, 60, 61)

Medication prescribed

Studies of RN prescribers in the UK suggest that they do so within their practice on average between 1-5 items a week with the majority prescribing 6-10 items per week.(36, 62, 63) Table 3 summarises the medications most commonly prescribed by RNs.


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TABLE 3 MOST FREQUENT MEDICATIONS PRESCRIBED BY RN PRESCRIBERS IN THE UK

Specialty Medications most commonly prescribed by RNs

Mental health (Nolan et al., 2001)

Anti-psychotic medications, anti-depressants, anti-cholinergic medications, mood stabilisers, benzodiazepines, anti-dementia medications

Diabetes (Carey & Courtenay, 2008)

Oral anti-diabetic medications, hypertension medications, lipid lowering medications, Insulin

Pain management (Stenner et al., 2011)

Opiate and non-opiate medications

Emergency and Acute Care Setting, (Naughton et al., 2013)

Non-steroidal medications, opiate and non-opiate analgesia, antibiotics, antiplatelet medications, antihypertensive medications, topical agents, oral glycaemic medications, insulin, anti-emetic medications, IV Fluids, vitamins/minerals, local anaesthesia medications

HIV nursing (Ormiston, 2013)

Anti-retroviral medications, dietary supplements, topical agents, anti-emetics and anti-diarrheal medications, analgesia, antibiotics

Ophthalmology (Johnson et al., 2003)

Antiglaucoma agents, Opthalmics used to treat ocular hypertension

Dermatology (Carey et al., 2013)

Emollients, oral antibiotics, topical antifungals/corticosteroids/anti-bacterial, topical preparations for warts/acne/coal tar

General Practice (Davis & Drennan, 2007)

Bulking forming agent laxatives, stimulant laxatives

Patient outcomes

Studies that explored outcomes related to RN prescribing, (all conducted in the UK): Suitably trained RNs appeared well able to diagnose and prescribe within their

scope of practice. (50, 64) Data collected over two 6 month periods in 1998-99 that compared RN prescribers (both practice nurses (PNs) and health visitors (HVs) to comparable GP practice in management of patients with acute minor illness, identified that there was no significant difference between these groups in the number of prescriptions issued (PNs =60%, HVs =54% and GPs 59% of consultations). (50)

A more recent evaluation of RN prescribing reported that RNs’ prescribing decisions were generally clinically appropriate across a range of different dimensions. (9) In this study of 118 consultations in which RNs or midwives prescribed, generally the expert reviewers of the prescriptions audited considered that there was an indication for the medicine prescribed, that it was effective for the condition with the correct dosage and there was no unnecessary duplication with other medicines.


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In a study of 532 GP, RN and pharmacist prescribing consultations, where 273 patients managed by this cohort were surveyed, patients reported higher satisfaction levels after RNs prescribed compared to other prescribers. (65) Additionally, patients also reported experiencing greater empathy from RN prescribers when surveyed compared to other prescriber consultations. (65) Another study comparing RN prescribing (via protocol) to that of GPs for patients presenting with sore throats, patients prescribed medications by the RN reported significantly higher recollection of advice from the RN (76% vs 54%, p<0.001). (49)

In this study there was no difference in time taken for symptoms to resolve between the RN prescriber and the GP patients. (49)

Two studies suggested reduced length of hospital stay related to RN prescribing. (52, 62)

Health service / policy considerations

Organisational issues have the potential to restrict the success of RN prescribing. (66) Peer support and supervision in practice were highlighted as absolutely essential

as well as the need for adequate project management and support of practice. Participants highlighted the need for employers to allocate set time for professional development in relation to prescribing in order to remain up to date.(67)

The potential cost related to implementing RN prescribing (Cooper et al., 2008). The legislative implications and fear of legal consequences need to be

considered prior to implementation of RN prescribing. RNs expressed fear of legal consequences of prescribing as a potential barrier to implementation in practice. (57, 68, 69) In a survey of 283 Irish clinical RN specialists regarding future role expansion to include prescribing, fear of legal litigation was a primary concern with participants also suggesting RN prescribing be restricted to clinical CNS designation in specialist areas. (57)

Educational considerations

Evaluations of generic (not profession specific) post registration prescribing education programs in the UK reported that overall these programs appeared to meet student learning needs. (9) (70)

A study of 976 RN prescribers in the UK reported that most participants reported the prescriber course met their learning needs to prescribe, although community RNs reported less support to undertake the education program. (9) It was reported by 90% that it was easy to identify a medical practitioner to supervise and mentor their prescribing education & training, including the required 12 days’ clinical practice. (9)

Selection of appropriate candidates to undertake prescribing education, including the need for specialist training in the RN’s specialist area of practice prior to undertaking RN prescribing. (56)

Content of prescribing courses: The importance of adequate pharmacological knowledge, advanced clinical skills and physical assessment skills were highlighted as essential prerequisites. (71)


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An evaluation of RN, physiotherapist and pharmacists who had completed prescribing education, reported high anxiety about prescribing from participants, as well as negative views regarding online education as a mode of prescribing education with preference for a blended approach (i.e. face to face complimented by eLearning strategies and additional clinical mentorship/ supervision). (72)

Models of prescribing

Models of prescribing identified within current literature: Independent prescribing is prescribing by a practitioner (e.g. medical practitioner,

NP, dentist, and in the UK setting RN 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.

Supplementary prescribing is within a voluntary partnership between an independent prescriber and a supplementary prescriber to implement an agreed patient-specific clinical management plan and with the patient’s agreement. Supplementary prescribing occurs under the supervision of a specific independent prescriber.

Protocol prescribing relates to the practitioner’s ability to autonomously administer medication in specific circumstances and to defined populations as clinically indicated from a pre-defined formulary or guideline.

Notes:


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HEALTH PROFESSIONALS PRESCRIBING IN AUSTRALIA

As part of workforce redesign and reform strategies looking to create greater system efficiencies, in 2011 Health Workforce Australia (HWA) progressed work to establish a nationally consistent approach to non-medical prescribing. (73) This work culminated in the publication of the Health Professionals Prescribing Pathway (HPPP) approved by the Standing Council of Health in 2013 which may be considered by the nursing and midwifery professions as a useful foundation on which to develop future prescribing models.

BackgroundWhile work has been undertaken to extend prescribing rights to a number of health professions in Australia, these efforts have not occurred concurrently nor have they resulted in a consistent approach to education, competence and practice standards taken by health professions.

Subsequently there are a variety of approaches through which health professionals are educationally prepared and supported to prescribe, creating confusion, inconsistency and potential for the confidence of both consumers and the health care system in the safety and effectiveness of non-medical prescribing models to be undermined.(74)

Therefore, work to explore a nationally consistent framework to support the implementation of non-medical prescribing was commenced in 2010 with the National Health Workforce Planning and Research Collaboration (NHWP&RC) commissioning an exploratory review of non-medical prescribing to inform the development of a nationally consistent approach to prescribing by non-medical health professionals in Australia. (75)

The following four models were identified throughout the international literature:


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TABLE 4 ANALYSIS OF THE KEY ELEMENTS OF IDENTIFIED PRESCRIBING MODELS.Symptom recognition / diagnose

Select therapy Supply and administer therapy

Initiate therapy Monitor and modify therapy

Stat therapy Continue therapy Discontinue therapy

Supervision

Independent Full Full No Full Full Full Full Full IndependentCollaborative prescribing

Medical practitioner diagnosis, initial treatment decision

Yes No Yes Yes Yes Yes Yes Collaborative nominated individual independent prescriber

Supplementary prescribing


Agreed patient specific management plan

No Agreed patient specific management plan





Nominated individual independent prescriber

Patient referral Medical practitioner diagnosis, initial treatment decision


No Medical practitioner diagnosis, initial treatment decision

Management of specific therapy or specific therapeutic outcome




Delegated by nominated individual independent prescriber

Formulary List of approved treatable symptoms

Pre-approved formulary according to symptoms

No Indirect – pre-approved formulary

Criteria for referral Length as per pre-approved formulary

Length as per pre-approved formulary

Length as per pre-approved formulary

Indirect according to preapproved therapy

Protocol List of approved treatable symptoms


Yes Protocol driven symptoms

According to pre-approved protocol




Prescribing delegated by independent prescriber

Patient group direction

List of approved treatable symptoms

Written direction under pre-approved protocols

Supply and administration written under pre-approved protocols

No No Yes No No Nil – delegated under pre-approved conditions and protocols

Repeat prescribing (continuance)



Supply (only) sufficient until next appointment

No No No Yes – previously prescribed medication only – no modification

No Nil – delegated under pre-approved conditions

Administration List of approved treatable symptoms


Administer for immediate treatment only

No No According to pre-approved protocol

No No Nil- delegated under pre-approved conditions and protocols


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Health Professionals Prescribing PathwayThe work of the NHWP&RC was incorporated into the HPPP Project undertaken by Health Workforce Australia (HWA). The four models identified by Nissen et al, (2010) were consolidated into three models, with the defining feature of each model being a graded level of autonomy to prescribe medicines. The three HPPP models of prescribing are described as follows:

Autonomous prescribing Prescribing under supervision Prescribing via a structured prescribing arrangement

All three prescribing models proposed in the HPPP of prescribing were identified in the international literature related to nursing and midwifery, although the terminology differs among countries (Table 4).

TABLE 5 COMPARABLE MODELS OF PRESCRIBING TO HPPP MODELS OF PRESCRIBING

HPPP model Comparable prescribing models

Autonomous Independent (UK RN, Ireland RN/ Midwife, Canada NP, Australia NP and Midwife)

Authorised (NZ NP)

Under supervision Supplementary (UK RN and Midwife)

Designated (NZ RN and Midwife)

Structured prescribing arrangement

Delegated (NZ RN)

Patient Group Directive (UK RN)

Supply of Medicines (Australia RN and Midwife)*

*Supply of medicines does not require writing a legal prescription

Autonomous prescribing

The prescriber undertakes prescribing within their scope of practice without the approval or supervision of another health professional.

The prescriber has been educated and authorised to autonomously prescribe in a specific area of clinical practice.

Despite the ability to prescribe autonomously, the prescriber recognises the role of all members of the health care team and ensures appropriate communication occurs between team members and the person taking medicine.


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The autonomous prescriber takes responsibility and is accountable for the assessment of undifferentiated health problems and for decisions about the clinical management required, including prescribing.(10)

The HPPP model of Autonomous prescribing describes the prescribing practice of NPs and midwives with a scheduled medicine endorsement in Australia and has many similarities to the independent nurse prescriber in the United Kingdom (UK) and authorised nurse prescriber in New Zealand (NZ).

UK and NZ autonomous nurse prescribing models are not subject to mandated collaborative arrangements with medical practitioners or employing institutions in order to prescribe or enable access to subsidised medicines as are models in Australia, Ireland and some states in the United States (US)

Prescribing under supervision

The prescriber undertakes prescribing within their scope of practice under the supervision of another authorised health professional.

The supervised prescriber has been educated to prescribe and has a limited authorisation to prescribe medicines that is determined by legislation, requirements of the National Board and policies of the jurisdiction, employer or health service.

The prescriber and supervisor recognise their role in their health care team and ensure appropriate communication occurs between team members and the person taking medicine.

Independent nurse prescribers in the UK may prescribe within their scope of practice and are not restricted by formularies or drug lists.

The HPPP model 2 has many similarities to supplementary prescribing in the UK and designated prescribing in NZ.

In the UK, supplementary prescribing is within a voluntary partnership between a medical practitioner and a supplementary prescriber. Prescribing practice occurs within the limits of a patient specific clinical management plan developed by the medical practitioner with a patient’s consent once a diagnosis has been made.

In NZ, designated nurse prescribers may prescribe independently within their scope of practice for patients under their care from a list of medicines specified in designated prescribing regulations under the supervision of an authorised prescriber and within regulatory requirements set by the NZ Nursing Council.

It does not appear that designated prescribing in NZ needs sanctioning for every patient, as is the case with supplementary prescribing in the UK. This is an important differentiation as it means NZ designated prescribers can prescribe more autonomously within their scope for patients under their care.

In practice, this NZ designated model has many similarities to the HPPP autonomous prescribing model, except prescribing requires supervision by an authorised prescriber and therefore has been classified in this review as a form of supervised prescribing.


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Prescribing via a structured prescribing arrangement

Prescribing occurs where a prescriber with a limited authorisation to prescribe medicines by legislation, requirements of the National Board and policies of the jurisdiction or health service prescribes medicines under a guideline, protocol or standing order.

A structured prescribing arrangement should be documented sufficiently to describe the responsibilities of the prescriber(s) involved and the communication that occurs between team members and the person taking medicine.

The HPPP model 3 appears similar to the UK model of supplying and or administering medicines using Patient Group Directions (PGD), which is a form of protocol prescribing that requires a formal written instruction (similar to drug protocols or standing orders).

Formal written instructions are drawn up locally by an independent prescriber that authorise the supply or administration of named medicines in identified clinical situations and outline clear lines of accountability. Examples include the provision of pain relief in emergency departments of the supply of antibiotics for bite wounds.

Patients are not identified individually within a structured prescribing arrangement, rather as a clinical group presenting with precise clinical criteria in advance of treatment.

Further information of the HPPP is available in the Final Report: Health Professionals Prescribing Pathway Project (HWA).

While the HPPP was approved by Ministers in 2013, with the dissolution of HWA it was not formally implemented. However, in the current context, it provides an overarching framework that may be useful in guiding the implementation of nurse / midwife prescribing and would ensure consistency should the pathway be implemented as a nationally consistent approach to non-medical prescribing in the future.

Point to consider: As provisions for protocol prescribing exists within the relevant legislation or policy of the majority of Australian jurisdictions, is inclusion of model 3 (protocol prescribing) relevant for inclusion in future nurse / midwife prescribing models in the Australian context?

Notes:


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Fig. 1 Health Professionals Prescribing Pathway

The Consumer PerspectiveConsumers are central to initiatives that change the way health care is delivered. As part of work undertaken to support the development of the HPPP, a consumer narrative survey was commissioned on prescribing by non-medical prescribers.(76) Preliminary focus groups and in depth interviews were undertaken across metropolitan, rural and remote areas in four States and Territories, the outcomes of which informed a national on-line survey conducted with 1033 participants. In summary, the research found that participants had an expectation that regardless of a prescriber’s professional background that they will be:

Appropriately qualified and legally able to prescribe Knowledgeable about their health complaint and medicines Prepared to spend time with patients and consider alternatives to the prescription

of medicines Willing and able to fully explain how and why a medicine should be taken, how to

assess response and what to do if the patient experiences any difficulties Respectful of a patient knowledge, their treatment preferences and interested in

their perspectives and experiences.

The report also found that 37% of people were very supportive and 44% somewhat supportive of non-medical prescribing as long as there were clear guidelines and safety mechanisms in place. These safeguards included:

Robust professional standards together with sound legal and regulatory processes Sound supplementary education on pharmacology that includes patient

counselling skills that culminates in a nationally recognised qualification Ongoing professional development Non-medical prescribing models are framed by formularies and guidelines that

guide practice and consider the risk profile of different medicines Prescribing occurs in a model that requires clear communication with the ‘usual’

GP and non-medical prescriber Requirements are in place to ensure periodic review by a doctor

periodically and where patient needs fall outside of the non-medical prescriber’s scope of practice, where there is uncertainty about a patient’s condition or response to treatment or when a patient requests medical review

Prescribing is guided by and recorded within the patient’s main or usual medical record

Consumers have the right to choose to see a medical practitioner or other health professional and that choice is always respected

Mechanisms are in place to monitor the prescribing practices of non-medical professionals to ensure quality and detection of system abuse.

Notes:


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Health Professionals Prescribing CompetenciesIn addition to the HPPP, in 2012 the National Prescribing Service (NPS) published national Competencies required to prescribe medicines (fig. 2) designed to support the prescribing practice of all autonomous prescribers across Australia.(77)

The NPS prescribing competencies describe the knowledge, skills, and behaviours of professionals who prescribe autonomously to an acceptable standard in the contexts in which they are reasonably expected to practise.

The Framework was developed across health professions and sought to identify the core competencies necessary for the safe and effective prescription of medicines across the Australian healthcare system. The tool has been designed to provide a nationally consistent standard for the education, training, credentialing and professional development of prescribers and to promote the quality use of medicines in prescribing practice by outlining the expected standards for making safe and effective, judicious and appropriate prescribing decisions.(77) They have been incorporated into the HPPP and also inform the ANMAC standards related to prescribing.

The Framework consists of seven competencies, five of which are specific to the role of prescribing and two more general professional competencies deemed crucial to the prescribing role.

The complete Framework document is available at: NPS: Competencies required to prescribe medicines: putting quality use of medicines.

Point to consider: While not mandated for use nationally, the framework has been adopted to underpin the Accreditation Standards for Programs Leading to Endorsement for Scheduled Medicines for Midwives and nurse practitioners and may provide a useful tool in the development of further standards developed to regulate nurse / midwife prescribing in the Australian context.

Notes:


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https://www.nps.org.au/__data/assets/pdf_file/0004/149719/Prescribing_Competencies_Framework.pdf

https://www.nps.org.au/__data/assets/pdf_file/0004/149719/Prescribing_Competencies_Framework.pdf


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Fig 2. NPS Prescribing Competencies for Health Professionals

LEGISLATION AND REGULATION

Detailed discussion regarding legislative change to support the expansion of nurse / midwife prescribing has been deemed out of scope for the Symposium, however an overview of existing legislation pertinent to non-medical prescribing has been included in this paper for information.

The introduction of the National Registration and Accreditation Scheme (NRAS) across Australia in 2010 created the possibility of consistency across future initiatives designed to create a more flexible health workforce, including the implementation of non-medical prescribing.

The Health Practitioner Regulation National Law as in force in each state and territory (the National Law), provides for National Boards to endorse registered health practitioners, subject to the successful completion of Board approved qualifications and compliance with any relevant registration standard, to obtain, possess, administer, prescribe, sell, supply or use a scheduled medicine or class of scheduled medicines (Section 94).

However, when endorsed by a particular Board, the authorisation to prescribe medicines varies across Australia due to significant legislative and regulatory differences that currently exist for health professionals among states and territories.

Across Australian States and Territories, legislation provides for health professionals to obtain, prescribe, possess, supply and or administer medicines however legislation is not uniform across jurisdictions and therefore in some States and Territories legislative change may be required to enable nurse / midwife prescribing.

Appendix A summarises the current legislation for health professionals to prescribe medicines in each State or Territory.

State and territory legislation related specifically to nursing and midwifery prescribing is summarised and the relevant legislation presented in Appendix B. In relation to the three models of prescribing identified in the HPPP, NPs (but not necessarily RNs not endorsed as NPs) and endorsed midwives have authority to prescribe autonomously (HPPP model 1) in all States and territories within midwifery scope of practice and from the approved Board schedule of 2, 3, 4, and 8 medicines.

Additionally, a number of states and territories have legislation or policy that allows some form of prescribing via a structured prescribing arrangement (HPPP model 3) for RNs, usually in specified circumstances and likewise for midwives in Vic, Tasmania, QLD, and the NT. The review of legislation did not reveal provision of prescribing by RNs or midwives under supervision (HPPP model 2). Legislation referring to RN or non-endorsed midwives supply of medicines aligns more closely with the HPPP model 3 (prescribing via a structured prescribing arrangement).A summary of findings in relation to HPPP models is presented in Appendix C.


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The review of state and territory legislation related to prescribing of medicines reveals that while NP and Endorsed Midwife prescribing is autonomous (independent prescribing), different mechanisms are in place to facilitate and govern such prescribing. For example, in Victoria, approved formularies are enshrined in legislation for specified practice areas and NPs are required to have notation on their endorsement to prescribe within these specified areas where most other States or territories permit prescribing within scope of practice, but often within defined parameters, such as the QLD Drug Therapy Protocol (that relates to all prescribers), the Tasmanian Medicines Formulary or the NSW state-wide formulary for NPs employed in NSW Health facilities. In NSW NPs practising outside of the public health sector are required to apply for approval of their formulary. The Chief Nursing and Midwifery Officer (CNMO) acts as the delegate of the Secretary of Health to approve formularies in this instance. Other States such as WA and ACT require approval of scope of practice at state level and in SA approval of formulary is required at health service level. In relation to endorsed midwife prescribing, most states or territories permit prescribing within scope of midwifery practice and in accordance with NMBA approved medicines specified on endorsement that relate to midwifery practice across pregnancy, labour, birth and post-natal care.(24) A summary of approval and regulation of prescribing for NPs and endorsed midwives is presented at Appendix D.

Notes:


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IMPLEMENTATION OF NURSE / MIDWIFE PRESCRIBING MODELS IN NEW ZEALAND AND THE UNITED KINGDOM

New Zealand

Diabetes nurse prescriber

Diabetes nurse prescribers are a discreet group of designated prescribers in NZ. The designated prescriber model was implemented in NZ in 2011 and enabled appropriately trained specialist nurses to prescribe streamline access to common routine medicines for people with diabetes. Prescribing by diabetes nurse prescribers is undertaken in collaboration with medical specialists and is specific to the condition of diabetes.

The role has been evaluated and found that the role is effective, safe and efficient with a high level of acceptability and satisfaction for both those using the service and the nurse prescribers themselves. (78) Appendix E outlines the evaluation of a diabetes nurse specialist prescribing project undertaken in NZ in 2011. The evaluation provides important data on the quality of nurse prescribing and its impacts on patient access to care, cost effectiveness and service delivery.

Designated registered nurse prescribers

Building on the success of diabetes nurse prescribers, the designated registered nurse prescriber model was introduced in 2016. The model was implemented to improve access to medicines for populations with long-term conditions and for groups who experience difficulty accessing health care services including Maori and Pacific people, those with lower socioeconomic resources, younger people and rural and remote communities.

Consultation process

Consultation on two models of registered nurse prescribing, in addition to the diabetes nurse prescriber, was commenced in 2013 by the NCNZ. The models proposed were developed in collaboration with professional and stakeholders from across the health sector with Ministerial support following the success of the diabetes nurse prescriber demonstration projects.(79)

Submissions to the consultation were positive. A high level of support was seen for a model of specialist nurse prescribing to be implemented within multi-disciplinary teams in specialist in outpatient settings and general practice to supplement prescribing for common health conditions including hypertension and asthma.(79) Submissions also recognised the potential difficulties in implementing designated nurse prescribers’ roles in the community as opposed to health services.


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Submissions supported the proposed qualification to be post graduate diploma level and felt that regulation should include the inclusion of a condition or authorisation on existing registration rather than require nurse prescribers to be registered in a new scope of practice.

The model of designated nurse prescribing in primary health and specialist teams was preferred over a model for community outpatient allowing nurses to prescribe for minor injury and illness. While submissions recognised the potential of such a model, concerns were raised regarding the education and training of nurses in these areas, the availability of necessary clinical support frameworks and potential for the fragmentation of care.

The issue of title was also raised during the consultation process. Suggestions included using a level to differentiate the prescribing role or including the area of ‘primary health’ in the title. The use of the term ‘specialist’ in the title was not supported as it might incorrectly imply the nurse was practicing in a particular specialty. The medicines able to be prescribed was also, predictably, a topic of debate. (79)

The NCNZ made the decision to progress prescribing rights for registered nurses practising in primary health and specialty teams in an application to the Ministry of Health in 2014 proposing that suitably qualified and experienced registered nurses be allowed to prescribe for patients with some long term and common conditions within a collaborative team. In 2015, the proposal was agreed by the NZ Government. Designated registered nurse prescribers have been able to prescribe in NZ from 20 September 2016.

The NCNZ has future plans to progress the alternative model of Community Nurse Prescribing.

Practice areas

Designated nurse prescribers may prescribe for specific conditions including diabetes and related conditions, hypertension, respiratory disease including asthma and COPD, anxiety, depression, heart failure, gout, palliative care, contraception, vaccines, common skin conditions infections and pain management.

Nurses who prescribe will be working in collaborative teams within primary health care and specialist services including general practice, specialist outpatient clinics, sexual health, public health, district and home care, family planning and in rural and remote areas.

Practice and collaboration requirements

Registered nurses prescribing in primary health and specialty teams require a minimum of 3 years of full-time equivalent practice in which they are intending to prescribe.

Designated nurse prescribers are able to prescribe for conditions including respiratory disease including asthma and COPD, depression, cardiac failure, anxiety, hypertension, gout, diabetes and related conditions, palliative care, contraception, common skin conditions, infections and vaccinations.


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They are required to undergo a period of 12 months supervised practice following authorisation to prescribe and are required to comply with the Nursing Council’s Competencies for Nurse Prescribing which are based on the Australian NPS Competencies for Prescribers.

Education

Registered nurses seeking authorisation to prescriber as designated prescribers are required to successfully complete a Post Graduate Diploma in registered nurse prescribing for long term and common conditions which includes high level scientific knowledge in pharmacology, pathophysiology, assessment and diagnostic reasoning related to clinical management and prescribing for long term and common conditions.

Education programs include a minimum of 150 hours of prescribing practice in a collaborative clinical setting supervised by an authorised prescriber who is a medical or nurse practitioner.

Prescribing authority

Designated registered nurse prescribers practising in primary health and specialty teams are authorised to prescribe specified prescription medicines, controlled medicines including restricted and pharmacy only medicines and therapeutic medical devices or related products within their scope and area of practice.

Continuation prescribing

The Council has included ‘continuation prescribing’ for a small number of high risk medicines prescribed as ongoing therapy that may require monitoring and dose adjustment.

The initial prescription of a medication prescribed under a ‘continuation’ arrangement must be issued by an authorised prescriber (medical or nurse prescriber), however, as part of an established pharmacotherapy care plan, a designated nurse prescriber may assume responsibility and authority for prescribing continuation of the medicine.

In these circumstances, the designated nurse prescriber also assumes responsibility and accountability for initiating and maintaining appropriate assessment, monitoring, re-prescription, dose adjustments and referral within the collaborative team environment.

The term ‘continuation prescribing’ is used clearly articulate the requirement for ongoing monitoring and to avoid confusion with the concept of ‘repeat prescribing’ where an ongoing prescription is issued for a medication based on established clinical data without the need for repeat consultation.

Formulary


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http://www.nursingcouncil.org.nz/Nurses/Registered-Nurse-Prescribing

Medicines able to be prescribed by designated nurse prescribers are restricted to a list specified by the Director-General of Health in accordance with the Medicines Act. The Medicines list for registered nurse prescribing in primary health and specialty teams has been developed from the New Zealand Formulary and the Community Pharmaceutical Schedule.

The list contains commonly used medicines for common conditions and is focused on prescribing for long-term and common conditions within primary healthcare and outpatient settings. Restrictions on the specific form, route and the context in which these medicines can be prescribed is also included in the list.

Unapproved medicines and unapproved uses of medicines

In NZ, legislative requirements require unapproved medicines to be prescribed by a medical practitioner or dentist in order to be dispensed by a pharmacist, however, a small number of medicines that are commonly prescribed for unapproved use under section 25 of the Medicines Act (1981) have been included in the list.

Regulation

Nurse prescribing is regulated by government and the Nursing Council of New Zealand (NCNZ).

Delegated prescriber model

As previously discussed a delegated model of prescribing has been legislated in NZ in addition to the existing categories of authorised and designated prescriber. This model enables registered health professionals to prescribe within limited parameters (as set out in a delegated prescribing order) under the sanction of an authorised prescriber. The delegated prescribing order would set specific conditions and restrictions on prescribing (such as only certain medicines for certain patients) for an individual delegated prescriber. This model is similar to a protocol prescribing model. It does not appear that the NCNZ has adopted this model of prescribing for nurses and midwives.

United Kingdom

Non-medical prescribing has been a significant feature on the UK health policy agenda for the past twenty years. Extending the ability to prescribe to other health professionals has required significant legislative and policy reform driven primarily by key stakeholders including the Department of Health, professional regulators and nursing professional bodies. Currently in the UK, Dentists, pharmacists, physiotherapists, nurses, midwives, optometrists, podiatrists and diagnostic and therapeutic radiographers all have varying levels of authority to prescribe, creating new opportunities to improve access to care by maximising the skills of health professionals and increasing flexibility in the delivery of services across the National Health Service (NHS).(80)

Evidence suggests that the standard of care provided by nurse prescribers is at least equal to that of traditional prescribers and that patients are satisfied with the care they


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http://www.nursingcouncil.org.nz/Nurses/Registered-Nurse-Prescribing

provide, confident in their level of knowledge, experience and ability to recognise the limitations to their prescribing practice. (81)

A 2015 report commissioned by NHS Health Education North West also highlighted that non-medical prescribing to be saving the NHS approximately £777 million annually which could be increased by at least an additional £270 million a year if the GP practices most pressured in meeting service demand who did not employ nurse prescribers were to employ them.(82)

Background and Statistics

Registered nurses and midwives in the UK have the most developed prescribing powers afforded to nurse prescribers anywhere in the world. While the journey has been detailed and complex, it offers other countries considerable opportunity to share the lessons learned and perhaps benefit from the significant knowledge it has generated. Since the 1980s when the Cumberlege Report (1986) recommended that nurses be enabled to prescribe from a limited list of medical appliances and medicines registered nurses have been afforded increasing powers to prescribe scheduled medicines. In 1992, legislation was put in place for appropriately qualified community nurses (district nurses and health visitors) to prescribe from a limited nurse formulary, a practice which was commenced in 1996 with the introduction of a limited Nurse Prescribers Formulary for District Nurses and Health Visitors which included wound dressings, medicines for skin conditions and catheter management. In 2001, legislation was passed to extend the prescribing authority to other nurses and health visitors and also to midwives implementing additional qualifications as ‘independent prescribers’ and ‘supplementary prescribers’. One year later the Nurse Prescribers Extended Formulary (NPEF) which included 140 prescription only medicines (POMs) all general sales list pharmacy medicines was implemented for independent nurse prescribers undertaking an extended prescriber qualification. An evaluation in 2004 found nurse prescribing to be appropriate with minimal evidence of unsafe practice.

Consultation was undertaken to review options for the future development of nurse prescribing. This was in response to suggestions that the current models were restrictive, in particular the supplementary prescribing model which was very difficult to implement in more unpredictable settings, such as emergency, as it required individualised clinical management plans to be prepared by a doctor prior to treatment. Ensuring the Formulary available to independent prescribers remained current was also challenging, with reviews taking more than a year to complete.

As a result, the Committee on Safety of Medicines (CSM) in September 2005 recommended that suitably trained and qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition, within their own competence. Changes to medicines and NHS regulations were made in 2006, nurse and pharmacist prescribers gained access to the entire British National Formulary (BNF) a move to increase flexibility and increase the number of nurse independent prescribers to further improve access to care. (83) Subsequent changes in 2009 and 2012 lifted


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restrictions on the prescription of unlicensed (primarily mixed medicines) and the ability to prescribe controlled drugs.

Of note, nurse prescribers in the UK are unable to dispense nor obtain and keep stores of medicines they may prescribe.

In April 2016, there were approximately 73 804 qualified nurse and midwife prescribers on the Nursing and Midwifery Council (NMC) register, representing 10.7 per cent of the total nursing and midwifery workforce (84) who are practicing across a vast array of health care specialties (Figure 3).

Figure 3. Specialties in which nonmedical prescribers prescribe. Note: Figure includes all nonmedical prescribers.

Reproduced from Courtenay M, et al. An overview of non medical prescribing across one strategic health authority: a questionnaire survey. BMC Health Services Res 2012;12:13.

Independent Prescribing

The UK Department of Health definition of independent prescribing is prescribing undertaken by a health practitioner (e.g. doctor, nurse, pharmacist dentist) who is responsible and accountable for the assessment of patients with diagnosed or undiagnosed conditions and for the decisions regarding their clinical management, including the prescription of medicines.(80)Independent prescribers may prescribe, within their scope of practice, almost any medicine from the BNF which is similar in concept to the Pharmaceutical Benefits Scheme (PBS) in


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Australia, however, independent nurse and pharmacist prescribers are precluded from prescribing a limited number of controlled substances including cocaine, diamorphine and dipipanone for the treatment of addiction).

A Nurse Independent Prescriber must be a 1st level Registered Nurse, Registered Midwife or Registered Specialist Community Public Health Nurse whose name in each case is held on the NMC professional register, with an annotation signifying that the nurse has successfully completed an approved program of preparation and training for nurse independent prescribing. Nurse Independent Prescribers (formerly Extended Formulary Nurse Prescribers) are able to prescribe any licensed medicine in the UK listed in the BNF for any medical condition, including some controlled drugs. Nurse Independent Prescribers must only ever prescribe within their own level of experience and competence, acting in accordance with Clause 6 of the NMC’s ‘code of professional conduct: standards for conduct, performance and ethics’.

Supplementary Prescribing

This model involves a voluntary prescribing partnership between a doctor or dentist (not independent nurse prescriber), the patient and a nurse as a supplementary prescriber. Supplementary prescribers may also prescribe any medicine from the BNF, including controlled medicines, for any condition within their scope of practice. However, the prescription of medicines by supplementary prescribers must occur only after a definite diagnosis has been made by the doctor and in accordance with a patient specific clinical management plan (CMP). The CMP should identify the parameters within which the supplementary prescriber is able to prescribe for any condition that is specified on the plan.

There are no restrictions on the conditions for which a supplementary prescriber may prescribe as long as they fall within the prescribers competence. This model has been found to be most beneficial for nurses caring for patients with long-term conditions like diabetes and asthma.

Community practitioner nurse prescribers

Community nurse prescribers are a discreet group of independent nurse prescribers. This group includes health visitors, district and school nurses who may prescribe from a limited formulary (Nursing Prescribers Formulary (NPF) for Community Practitioners) on their own initiative. The formulary includes over the counter preparations, wound dressings, appliances, 13 prescription only medicines and topical applications for skin conditions.


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TABLE 6 PRESCRIBING PRIVILEGES ACCORDING TO CATEGORY

Type of nurse prescriber

Can prescribe any licenced / unlicenced medicine

Can prescribe appliances

Notes

Nurse Independent Prescriber

YES within their level of competence. May also prescribe Schedule 2,3,4 or 5 controlled drugs (except diamorphine, dipipanone or cocaine for the treatment of addiction.

YES Pharmacists, optometrists, podiatrists, physiotherapists and radiographers may also qualify as independent prescribers but may be subject to different rules

Supplementary Prescriber

YES but only as agreed by patient and doctor as part of a patient’s clinical management plan.May also prescribe Schedule 2,3,4 or 5 controlled drugs (except diamorphine, dipipanone or cocaine for the treatment of addiction.

YES The allied health professions above may also qualify as supplementary prescribers along with diagnostic radiographers and dieticians These health professionals may be subject to different rules.

Community Practitioner Nurse Prescribers

NO may only prescribe items included in the Nurse prescribers Formulary for Community Practitioners

YES Community prescribers are also subject to additional restrictions. For example may only prescribe paracetamol tablets 500mg in quantities up to 100 tablets.

Adapted from Dowden, A 2016 ‘The Expanding role of nurse prescribing’ Prescriber June 2016.

Patient Group Directions

A long standing framework to support the supply and or administration of medicines using Patient Group Directions (PGD) is also used in the UK, however the use of PGDs is not considered prescribing. PGDs are developed by multidisciplinary teams across organisations to facilitate timely access to medicines including pain relief and antibiotics for specific patient populations in identified circumstances. The RIPEN model may be considered as a similar example in the Australian context.

There are two ways in which nurses can prescribe in the UK known as supplementary prescribing and independent prescribing.


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Evidence in the UK

The benefits of nurse prescribing in the UK are frequently reported in the literature. More than a decade after implementation, research highlighted the successful uptake of nurse prescribing in primary care trusts (PCT), GP practices and in hospitals. Findings suggest that approximately one third of primary care practices and a quarter of hospitals and outpatient services use non-medical prescribing and that non-medical prescribing practices in these settings were safe and clinically appropriate.(85-87) In March 2010, the NHS Prescription Service (NPS) in England reported receiving 12.8 million items prescribed by nurses for processing over the year.(88)

Nurse prescribing has also been shown to enhance primary and secondary care for patients by ensuring timely access to treatment and by increasing flexibility for patients who would otherwise need to travel or experience longer waiting times to see a doctor. (14, 89, 90) The ability to prescribe is known to increase autonomy and job satisfaction for nurses which is especially important for nurses who are geographically isolated in areas with reduced access to medical services.(91)

Nurse prescribing also increases service efficiency by managing less complex and routine conditions requiring medication management, allowing doctors to focus on more complex health care needs.(92) Research also reports that nurse prescribing helps to avoid unnecessary presentations to tertiary services and improves access to treatment, particularly for patients with long-term conditions like chronic respiratory disease and diabetes.(91, 93) The ability to prescribe also enhances nurse-led services by enabling more streamlined care particularly the management of chronic and complex disease where nurses caring for patients can utilise their skills to deliver coordinated, patient-centred care by routinely monitoring and initiating required changes to treatment often delivering such care outside of the hospital environment.(83, 94)

Patients have reported a high level of satisfaction and confidence in nurse prescribing. Nurse prescribers are known to provide clear information, education and advice on medications, their side effects, dosages and on the correct use of medications and adherence.(60, 95)

However, there remains little empirical evidence that supports the clinical and economic outcomes for nurse prescribing.(91)

Practice requirements

To become an Independent or Supplementary prescriber in the UK, nurses / midwives are required to have three years post registration experience with the year immediately prior to commencing education as a prescriber having been within the specialty in which the nurse is intending to prescribe, for example primary or mental health. The nurse must also be deemed competent to undertake the necessary education and training by their current employer.

Some NHS organisations impose practice conditions on newly qualified nurse prescribers that limit their prescribing practice to supplementary prescribing conditions for a period of time before they take on independent prescribing responsibilities. Furthermore, nurse


44

prescribing may be further restricted by local health policy related to setting (e.g emergency department), or locally prescribed formularies.(96)

Education, training and regulation

To qualify as a nurse prescriber, nurses must undertake a recognised NMC accredited prescribing course through a UK university. Upon successful completion, the qualification must be registered with the NMC. Since 2004, all nurses who complete the NMC qualification can prescribe independently as well as in a supplementary capacity.(97-99)

Recent changes to the way prescribers are educated in the UK now mean a nurse is prepared to prescribe as both an Independent and Supplementary Prescriber by undertaking one course, known as the V300. The V300 must be accredited by the NMC and usually involves the equivalent of 26 face to face teaching days and 12 days in clinical practice supervised by an authorised independent prescriber.

The ability for a nurse to undertake one course in order to qualify as both an Independent and Supplementary Prescriber creates flexibility within the workforce by ensuring all nurse prescribers are prepared to practice across settings which may utilise either of the two different prescribing models and are not required to undertake additional education and training should health service delivery requirements or employment conditions change.


45

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43. Snowden A. Quantitative analysis of mental health nurse prescribers in Scotland. Journal of Psychiatric and Mental Health Nursing. 2008;15(6):471-8.

44. Wilhelmsson S, Ek, A. C., & Akerlind, I. Opinions about district nurses prescribing. Scandinavian. Journal of Caring Sciences. 2001;15(4):326-30.

45. Daughtry J, & Hayter, M. Practice Nursing. 21. A qualitative study of practice nurses' prescribing experiences.;6(310-314).

46. Dhalivaal J. Patients' perspectives on prescribing by nurses in general practice. Practice Nursing,. 2011;22(1):41-6.

47. Banicek J. Attitudes of postoperative patients towards hospital nurse prescribing. Nurse Prescribing. 2012;10(12):612-8.

48. Courtenay M, Carey, N., & Burke, J. Independent extended nurse prescribing for patients with skin conditions: A national questionnaire survey. Journal of Clinical Nursing,. 2007b;16(7):1247-55.

49. Cox C, & Jones, M. An evaluation of the management of patients with sore throats by practice nurses and GPs. British Journal of General Practice. 2000;50(460):872-6.

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51. McCann TV, & Clark, E. Attitudes of patients towards mental health nurse prescribing of antipsychotic agents. International Journal of Nursing Practice. 2008;14(2):115-21.

52. Courtenay M, & Berry, D. Comparing nurses' and doctors' views of nurse prescribing: a questionnaire survey [corrected]. Nurse Prescribing. 2007;5(5):205-10.

53. Hall J, Cantrill, J., & Noyce, P. Managing independent prescribing: The influence of primary care trusts on community nurse prescribing. International Journal of Pharmacy Practice. 2004;12(3):133-9.


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54. Kroezen M, Veer, A., Francke, A., Groenewegen, P., & Dijk, L. Changes in nurses' views and practices concerning nurse prescribing between 2006 and 2012: results from two national surveys. Journal of Advanced Nursing. 2014;70(11):2550-12.

55. Cabilan CJ, Eley, R., Hughes, J. A., & Sinnott, M. Medication knowledge and willingness to nurse-initiate medications in an emergency department: a mixed-methods study. Journal of Advanced Nursing. 2016;72(2):396-408.

56. Hemingway S. The mental health nurse's perspective on implementing nurse prescribing. Nurse Prescribing. 2004;2(1):37-44.

57. Lockwood EB, & Fealy, G. M. Nurse prescribing as an aspect of future role expansion: the views of Irish clinical nurse specialists. Journal of Nursing management. 2008;16(7):813-20.

58. Small K, Sidebotham, M., Gamble, J., & Fenwick, J. Exploring midwifery prescribing in Australia. Women and Birth. 2016.

59. Sodha M, McLaughlin, M., Williams, G., & Dhillon, S. Nurses' confidence and pharmacological knowledge: a study. British Journal of Community Nursing. 2002;7(6):309-15.

60. Berry PA, Gillespie GL, Gates D, Schafer J. Novice nurse productivity following workplace bullying. Journal of Nursing Scholarship. 2012;44(1):80-7.

61. Wilkinson J, Carryer, J., & Adams, J. Evaluation of a diabetes nurse specialist prescribing project. Journal of Clinical Nursing. 2014;23(15-16):2355-65.

62. Carey N, Courtenay, M., James, J., Hills, M., & Roland, J. An evaluation of a Diabetes Specialist Nurse prescriber on the system of delivering medicines to patients with diabetes. Journal of Clinical Nursing,. 2008;17(12):1635-44.

63. Carey N, Courtenay, M., & Stenner, K. The prescribing practices of nurses who care for patients with skin conditions: A questionnaire survey. Journal of Clinical Nursing. 2013;22.

64. Hart M. Investigating the progress of community matron prescribing. Primary Health Care,. 2013;23(2):26-31.

65. Weiss MC, Platt, J., Riley, R., Chewning, B., Taylor, G., Horrocks, S., & Taylor, A. Medication decision making and patient outcomes in GP, nurse and pharmacist prescriber consultations. Primary Health Care Research & Development. 2015;16(5):513-27.

66. Carey N, Stenner, K., & Courtenay, M. Stakeholder views on the impact of nurse prescribing on dermatology services. Journal of Clinical Nursing. 2010;19(3-4):498-506.

67. Humphries JL, & Green, E. Nurse prescribers: infrastructures required to support their role. Nursing standard (Royal College of Nursing (Great Britain). 2000;14(48):35-9.

68. Nolan P, Haque, M. S., Badger, F., Dyke, R., & Khan, I. Mental health nurses' perceptions of nurse prescribing. Journal of Advanced Nursing. 2001;36(4):527-34.

69. Ziegler L, Bennett, M., Blenkinsopp, A., & Coppock, S. Non-medical prescribing in palliative care: A regional survey. Palliative Medicine. 2015;29(2):177-81.

70. Latter S, Maben, J., Myall, M., & Young, A Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: Findings from a national survey in England. Nurse Education Today. 2007a;27(7):685-96.


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71. Bewley T. Preparation for non medical prescribing: a review. Paediatric Nursing. 2007;19(5):23-6.

72. Weglicki RS, Reynolds, J., & Rivers, P. H. Continuing professional development needs of nursing and allied health professionals with responsibility for prescribing. Nurse Education Today. 2015;35(1):227-31.

73. Mason J. Review of Australian Government Health Workforce Programs. 2013.

74. HWA. Health Professionals Prescribing Pathway (HPPP) Project – Final Report. Health Workforce Australia; 2013.

75. Nissen L, Kyle, G., Stowasser, D., Lum, E., Jones, A., Mclean, C., & Gear, C. Non-Medical Prescribing. An exploration of likely nature of, and contingencies for, developing a nationally consistent approach to prescribing by non-medical health professionals.; 2010.

76. Consulting I. Consumer Narrative Survey of Prescribing Experiences. Research Report.: Inca Consulting; 2012.

77. NPS. Competencies required to prescribe medicines: putting quality use of medicines into practice. Sydney: National Prescribing Service Limited; 2012.

78. University M. Evaluation of Diabetes Specialist Nurse Prescribing Project,. New Zealand Society for the Study of Diabetes.; 2011.

79. NCNZ. Consultation on two proposals for registered nurse prescribing: Community Nurse Prescribing & Specialist Nurse Prescribing.: Nursing Council New Zealand; 2013.

80. DoH. Improving Patient’s Access to Medicines: A Guide to Implementing Nurse and Pharmacist Prescibing within the NHS in England. Department of Health; 2006.

81. V D. Trends over time in prescribing by English primary care nurses: a secondary analysis of a national prescription database. BMC Health Services Res. 2014;14(54).

82. NHS. Non-medical prescribing (NMP). An economic evaluation.: NHS Health Education North West.; 2015.

83. DoH. Extending independent nurse prescribing within the NHS in England: a guide for implementation.: Department of Health; 2006.

84. Dowden A. The Expanding role of nurse prescribing 2016 [Available from: http://www.prescriber.co.uk/article/expanding-role-nurse-prescribers/

85. D W. Major study acclaims nurse prescribing success. 2011 [Available from: http://www.nursingtimes.net/nursing-practice/clinical-specialisms/prescribing/major-study-acclaims-nurse-prescribing-success/5029754.article

86. Southampton Uo. Wide-reaching report finds strong support for nurse and pharmacist prescribing. 2011 [Available from: http://www.soton.ac.uk/mediacentre/news/2011/may/11_45.shtml.

87. Latter S. Evaluation of nurse and pharmacist independent prescribing. Department of Health Policy Research Programme Project. England.: Department of Health.; 2011.

88. NHS. Report- Update on growth in prescription volume and cost in the year to March 2010. Prescription Services; 2010.

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http://www.soton.ac.uk/mediacentre/news/2011/may/11_45.shtml

http://www.nursingtimes.net/nursing-practice/clinical-specialisms/prescribing/major-study-acclaims-nurse-prescribing-success/5029754.article

http://www.nursingtimes.net/nursing-practice/clinical-specialisms/prescribing/major-study-acclaims-nurse-prescribing-success/5029754.article

http://www.prescriber.co.uk/article/expanding-role-nurse-prescribers/

90. NPC. Non-medical prescribing by nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers. A quick guide for commissioners.: National Prescribing Centre; 2010.

91. Bradley EN, P. Impact of nurse prescribing: a qualitative study. Journal of Advanced Nursing. 2007;59:120-8.

92. Kewntoh ML RJ. Non-medical prescribing: the story so far. The Psychiatrist. 2009;33:4-7.

93. M C. The views of patients with diabetes about nurse prescribing. Diabetic Medicine. 2010;27:1049-54.

94. N CMC. Preparing nurses to prescribe medicines for patients with diabetes: findings from a national questionnaire survey. Journal of Advanced Nursing. 2008;61:403-12.

95. K S. Consultation between nurse prescribers and patients with diabetes in primary care: a qualitative study of patient views. International journal of Nursing Studies. 2011;48(1):37-46.

96. C L. Nurse prescribing: the next steps. Nursing Times online. 2009.

97. DoH. Nurse prescribing training and preparation: extended formulary nurse prescribing and supplementary prescribing.: Department of Health; 2010.

98. DoH. Non-Medical Prescribing Program: Department of Health; 2012 [Available from: http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Prescriptions/TheNonMedicalPrescribingProgramme/Nurseprescribing/DH_4123001

99. NMC. Standards of proficiency for nurse and midwifery prescribers. England: Nursing and Midwifery Council; 2006.


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http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Prescriptions/TheNonMedicalPrescribingProgramme/Nurseprescribing/DH_4123001

http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Prescriptions/TheNonMedicalPrescribingProgramme/Nurseprescribing/DH_4123001

Appendices

Appendix A

Current legislation for health professionals to prescribe medicines in each State or Territory

Note: health professionals are referred to in Appendix A using the descriptors appearing in the relevant legislation.

State Professionals LegislationVictoria Nurse practitioner (prescribe)

Authorised registered midwives (prescribe)Authorised podiatrist (prescribe)Authorised optometrist (prescribe)Medical practitioner (prescribe)Dentist practitioner (prescribe)Veterinary practitioner (prescribe)Registered nurse (possess and supply)

The Drugs, Poisons and Controlled Substances Act 1981The Drugs, Poisons and Controlled Substances Regulations 2006https://www2.health.vic.gov.au/public-health/drugs-and-poisons

New South Wales

Medical practitioner (prescribe)Dentist (prescribe)Veterinary practitioner (prescribe)Pharmacist (prescribe schedule 2 & 3)Nurse practitioner (prescribe)Optometrist (prescribe)Midwife (prescribe)Podiatrist (prescribe)Dental therapist / oral health therapist / dental hygienist (possess and supply)Ambulance officer (possess and supply)Medical superintendent of hospital (possess medicines only unless is an authorised prescriber)Registered nurse involved in vaccination program (possess and supply)

Poisons Act 1966http://www.legislation.nsw.gov.au/viewtop/inforce/act+31+1966+FIRST+0+N/

Poisons and Therapeutic Goods and Regulation 2008http://www.legislation.nsw.gov.au/viewtop/inforce/subordleg+392+2008+FIRST+0+N/


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State Professionals LegislationWestern Australia

Endorsed optometrists (prescribe)Endorsed midwife (prescribe)Endorsed podiatrist (prescribe)Medical practitioner (prescribe)Nurse practitioner (prescribe)Veterinary surgeon (prescribe)Dentist (prescribe)Pharmacist (prescribe schedule 2 & 3)Registered nurse (possess and supply)

Medicines and Poisons Act 2014http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_1920_homepage.html

South Australia

NPs can lawfully, possess, use supply or prescribe Schedule 2, 3, 4, or 8 medicines within their scope of practice. Public sector employed NPs must be credentialed as an approved prescriber by their Local Health Network (LHN).Registered Midwives, with an NMBA Endorsement for Scheduled Medicines, can lawfully possess, use supply or prescribe Schedule 2,3,4, or 8 within their scope of practice. Privately Practising Midwives, seeking access to public maternity services for the provision of private midwifery care, and public sector employed Registered Midwives with an endorsement for Scheduled Medicines must be credentialed as an approved provider by their LHN.Registered Nurses and Registered Midwives can administer but not legally prescribe medications under nurse/midwife initiated medications in accordance with a treatment protocol or standing orders as endorsed by the Drugs and Therapeutic Committee and approved by their LHN.Veterinary surgeon (prescribe)Medical practitioner (prescribe)Dentist (prescribe)Pharmacist (prescribe schedule 2 & 3)

Controlled Substances (Poisons) Regulations 2011http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/legislation/controlled+substances+legislation?contentIDR=e3181

Tasmania Medical practitioner (prescribe)Dentist (prescribe)Veterinary surgeon(prescribe)Pharmacist (prescribe schedule 2 & 3)Nurse practitioner (prescribe)Registered nurse (possess and supply)

Poisons Act 1971 consolidated 2015Tasmanian poisons regulations 2008http://www.thelaw.tas.gov.au/print/index.w3p;cond=;doc_id=%2B162%2B2008%2BAT@EN%2B20150507000000;histon=;rec=-1;term=


54

State Professionals LegislationEndorsed midwife (prescribe)Midwife (possess and supply)

Queensland Doctors (prescribe)Nurse practitioner (prescribe)Indigenous health worker (possess and supply)Endorsed midwife (prescribe)Midwife (possess and supply)Physician assistant (under supervision of medical officer - prescribe or supply)Registered nurse (possess and supply)Surgical podiatrist (prescribe)Pharmacist (prescribe schedule 2 & 3)Dental hygienist (administer only)Oral therapist (possess and supply)

Health Act 1937http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HealA37.pdf

Health (Drug and Poisons Regulation 1996)http://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HealDrAPoR96.pdfhttp://www.legislation.qld.gov.au/LEGISLTN/CURRENT/H/HealR96.pdf

Australian Capital Territory

Doctors (prescribe)Intern doctor (prescribe)Health practitioners employed at institution (possess and supply)Nurse practitioner (prescribe)Nurses (possess and supply)Midwife (possess and supply)Endorsed midwife (prescribe)Dentists (prescribe)Trainee dentists (possess and supply, under supervision of dentist)Dental hygienist (obtain, possess and administer)Dental therapist (obtain, possess and administer)Oral health therapist (obtain, possess and administer)Optometrist (obtain, possess and administer)Podiatrist (obtain, possess and administer)Pharmacist (prescribe schedule 2 & 3)Veterinary surgeon (prescribe)

Medicines, Poisons and Therapeutic Goods Act 2008http://www.legislation.act.gov.au/a/2008-26/current/pdf/2008-26.pdf

Medicines, Poisons and Therapeutic Goods Regulation 2008http://www.legislation.act.gov.au/sl/2008-42/current/pdf/2008-42.pdf

Drugs of Dependence Act 1989 http://www.legislation.act.gov.au/a/alt_a1989-11co/current/pdf/alt_a1989-11co.pdf

Drugs of Dependence Regulation 2009http://www.legislation.act.gov.au/sl/2009-5/current/pdf/2009-5.pdf

Northern Territory

Dentist (prescribe)Dental therapists, dental hygienists and oral health therapists (possess and administer)Doctor (prescribe)Endorsed midwife (prescribe)Nurse practitioner (prescribe)Nurse and midwife (possess and supply)

Medicines, Poisons and Therapeutic Goods Acthttp://notes.nt.gov.au/dcm/legislat/legislat.nsf/linkreference/medicines%2C%20poisons%20and%20therapeutic%20goods%20act?opendocument

Medicines, Poisons and Therapeutic Goods Regulationhttp://notes.nt.gov.au/dcm/legislat/legislat.nsf/linkreference/


55

State Professionals LegislationAboriginal and Torres strait island health practitioner (possess and supply)Optometrist (prescribe)Podiatrist (prescribe)Podiatrist surgeons (prescribe)Veterinarian (prescribe)Pharmacist (prescribe schedule 2 & 3)Approved ambulance officers (possess and supply)

medicines%2C%20poisons%20and%20therapeutic%20goods%20regulations?opendocument

Notes:


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Appendix B

Summary of legislation review in relation to nursing and midwifery prescribing

Jurisdiction Summary of findingsVictoria Allows NPs to lawfully, possess, use, supply or prescribe Schedules

2, 3, 4 or 8 medicines from an approved list. An authorised registered midwife is authorised to obtain,

possess, use, supply or prescribe medicines in Schedules 2, 3, 4 or 8 that are ‘approved by the Minister’ (for Health) in the lawful practice of his or her profession as an authorised registered midwife.

A RN or midwife is lawfully authorised to administer or use scheduled poison when administering under the conditions of a Health Services Permit (e.g. the Standing Orders permit condition) or under an approval issued by the Secretary of the Department of Health (e.g. nurse immunisers, midwives). Authorisation to supply or prescribe scheduled poisons is dependent on his/her registration been endorsed to do so (e.g. RIPEN). The nurse is acting under clinical circumstances approved by the Minister for Health, incorporating relevant health management protocols that set out the conditions and restrictions related to the use and supply of medicines.

NSW A nurse or midwife may be authorised in writing by the Secretary to possess, use, supply or prescribe medicines if endorsed under s94 of the National Law

RNs who are not endorsed to do so, do not have legal authority to prescribe medications but are able to administer scheduled medicines under a standing order in accordance with state health policy.

WA NPs can lawfully, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines from an approved formulary.

Endorsed midwives are able to prescribe medicine, from a specified prescribing formulary and within the scope of practice of the endorsed midwife.

Psychiatric emergency packs, supply of medicines by certain RNs under the instruction of a psychiatrist or medical practitioner.

SA NPs can lawfully, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines from an approved formulary.

Registered midwives with scheduled medicines endorsement are able to prescribe within a collaborative arrangement and using a prescribing formulary.

RNs can administer but not legally prescribe medications under nurse initiated medications and standing orders governed by the LHD and drug and therapeutic committee.

TAS NPs can lawfully, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines from an approved formulary and within their scope


57

Jurisdiction Summary of findingsof practice.

Endorsed midwifes may administer, obtain, possess, sell, supply or prescribe substances if the midwife is acting in the lawful practice of the profession of midwifery in Tasmania

RNs are able to possess and administer certain narcotic drugs following training and endorsement in certain circumstances (e.g. emergency in remote area and absence of a medical practitioner).

RNs and midwives may possess and supply medicines under certain conditions (e.g. palliative care, approved community health centre or after hours in approved medical institutions).

QLD NPs are lawfully able to, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines from an approved formulary.

An endorsed midwife may prescribe restricted medications relevant to their scope of practice.

Drug therapy protocols are in effect in QLD to enable RNs and midwives to administer or supply medicines from a specified list. (e.g. immunisation nurses, RIPEN endorsed nurses or midwives)

ACT NPs and endorsed midwives can lawfully, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines from an approved formulary and scope of practice.

RNs and midwives may possess medicines, administer medicines in accordance with prescription or standing order, supply medicines in accordance with a standing order issued by chief health officer or a requisition or supply medicines dispensed for patient to another health practitioner on patient’s transfer within institution.

NT NPs and endorsed midwives can lawfully, possess, use, supply or prescribe Schedules 2, 3, 4 or 8 medicines appropriate to scope of practice.

Scheduled substance treatment protocols are in use in the NT which approves nurses, midwives and Aboriginal and Torres Strait Islander Health Practitioners (ATSIHPs) to administer schedule 4 or 8 substances. This protocol allows the nurses, midwives and ATSIHPs to possess, administer and supply medicines specified in the protocol following prescription by a medical practitioner either written or verbal.

Notes:


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Appendix C

Summary of analysis of state and territory legislation in relation to HPPP models of prescribing

State or Territory HPPP Model 1

Autonomous prescribing

HPPP Model 2 Prescribing under supervision

HPPP Model 3

Prescribing via a structured prescribing arrangement

Vic NPEndorsed Midwife

- RNMidwife

NSW NPEndorsed Midwife

- RNMidwife

WA NPEndorsed Midwife

- RN (Psychiatry)

SA NPEndorsed Midwife

- RN

Tasmania NPEndorsed Midwife

- RNMidwife

QLD NPEndorsed Midwife

- RNMidwife

ACT NPEndorsed Midwife

- RNMidwife

NT NPEndorsed Midwife

- RNMidwife

Notes:


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Appendix D

Mechanisms of approval and regulation of prescribing for nurse practitioners and endorsed midwives as legislated across states and territories

State Approval mechanism for prescribing

Victoria Nurse practitioner: Approved formulary for specified practice areas. All endorsed NPs wishing to prescribe in Victoria must have a notation of one or more practice categories. There is an approved formulary (list of drugs) approved for each category.

Midwife: Prescribing by eligible midwives in Victoria with Scheduled Medicines Endorsement is limited to the list of medicines approved by the Victorian Minister for Health. The list includes Schedule 2, 3, 4 and 8 medicines required for midwifery practice across pregnancy, labour, birth and post-natal care.

SA Nurse practitioner: A formulary approved by a NP Prescribing Formulary Approval Sub Committee at the NP’s health service is required prior to submission and approval by the Medicines and Technology Policy and Programs, Nursing and Midwifery Office, South Australia Health.

Midwife: A midwife acting in the ordinary course of his or her profession whose registration is endorsed with a scheduled medicines endorsement is authorised to prescribe scheduled medicines in accordance with that endorsement. Midwives must be in a collaborative arrangement with a medical practitioner.

QLD Nurse practitioner: Within scope of practice in accordance with the QLD Drug Therapy Protocol. Drug therapy protocol does not apply unless the scope of practice has been defined in writing and approved by either: • The Chief Executive of the Health Service District or State-wide Health Service OR• The Chief Executive of a licensed private health facility OR • A health practitioner who is the employer, or a delegate of the employer, and holds current registration under the Health Practitioner Regulation National Law Act 2009 with no conditions or undertakings OR • In all other cases, an interdisciplinary team comprising, as a minimum, a RN, a medical practitioner and a pharmacist, who each hold current registration.

Midwife: An endorsed midwife may prescribe restricted medicines, relevant to their scope of practice, under section 167A in the Health (Drugs and Poisons) Regulation 1996.

Tasmania Nurse practitioner: NPs are able to possess, prescribe and supply scheduled substances from the approved Tasmanian Medicines Formulary in accordance with their approved scope of practice and their DHHS Prescribing Authorisation issued by the Chief Pharmacist. May prescribe in public or private sector.

Midwife: An endorsed midwife may prescribe and/or supply NMBA approved Schedule 2, 3, 4 and 8 substances, to the extent authorised under the state legislation, for the management of women and their infants in the pre-natal, intrapartum, and post-natal stages of pregnancy and birth.

ACT Nurse practitioner: Prescribing is dependent on the ministerial approved NP scope of practice.


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State Approval mechanism for prescribing

Midwife: Qualified eligible midwives to prescribe and/or supply Board approved schedule 2, 3, 4 and 8 medicines for the management of women and their infants in the prenatal, intrapartum and post-natal stages of pregnancy and birth.

NSW Nurse practitioner: Scope of practice, may prescribe from defined state-wide formulary for public health nurses (which includes PBS agreed medicines for NPs) if employed in the public health system. The NSW NP formulary does not apply to NPs’ in private practice or those employed by non-government organisations (NGOs). Under s21 of the Health Administration Act, the responsibility for authorising a NP to prescribe, possess, use and supply a poison, restricted substance or drug of addiction is delegated by the Health Secretary to the Chief Nursing and Midwifery Officer (CNMO) NSW. Therefore, in private practice, NPs are required to submit a separate formulary appropriate to their scope of practice to the NSW CNMO for approval.

Midwife: Qualified eligible midwives may prescribe and/or supply Board approved schedule 2, 3, 4 and 8 medicines for the management of women and their infants in the prenatal, intrapartum and post-natal stages of pregnancy and birth.

WA Nurse practitioner: Clinical practice guidelines (which define scope of practice in relation to medicines and are personal to the clinician) approved by the CNMO.

Midwife: Qualified eligible midwives to prescribe and/or supply Board approved schedule 2, 3, 4 and 8 medicines for the management of women and their infants in the prenatal, intrapartum and post-natal stages of pregnancy and birth.

NT Nurse practitioner: Particular arrangements not identified.

Midwife: Qualified eligible midwives may prescribe and/or supply Board approved schedule 2, 3, 4 and 8 medicines for the management of women and their infants in the prenatal, intrapartum and post-natal stages of pregnancy and birth.

Notes:


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Appendix E

Evaluation of the Diabetes Nurse Specialist Prescribing project (NZ)

In 2011, an evaluation to determine whether prescribing by diabetes nurse specialist was

conducted by a team at Massey University, NZ. The aim of the evaluation was to

determine whether diabetic nurse specialist prescribing was safe, effective, and cost

effective using a ‘designated prescriber’ model, to inform potential implementation and

extension of the model elsewhere (Wilkinson, Carryer, Adams, & Chaning-pearce, 2011).

The evaluation involved an audit of 11 RNs’ prescribing practices during a 6-month trial

period with data collected from prescriber’s logs by a cohort of RN prescribers, surveys of

stakeholders and patients as well as a review of adverse events. The model of prescribing

by RNs in this project fits under the Australian HPPP model 2 description, prescribing

under supervision.

Findings reported demonstrated diabetes specialist RN prescribing as safe, of good

quality and clinically appropriate. No adverse events of hospitalisations were reported.

Patient outcomes, in relation to management of HbA1c remained stable thought the

period audited and 96% of prescriptions were deemed to have complied with legal

requirements. Patient satisfaction was reported to be very high and patient acceptance

and confidence in the RN prescribing also reported to be very high. The service of

diabetes RN prescribing was considered to be cost effective with most patients reporting

preference to see the RN for diabetes-related prescriptions as there were fewer costs

associated (Wilkinson et al., 2011). Similar to reports in the international literature, the

wider team members were supportive of diabetes RN prescribing, although there were

reservations about providing supervision and how well RNs were prepared to begin

prescribing, voiced by both prescribers themselves and members of the healthcare team

(not specifically identified by profession). Diabetic RN prescribers had undertaken a

postgraduate certificate or equivalent to be authorised and also completed a 12 –week

supervised practicum (Wilkinson et al., 2011). The standards of educational preparation

were considered by many stakeholders as a minimal standard required and further

continual education was required to maintain and enhance prescribing capability

(Wilkinson et al., 2011), a theme also evident in international evaluations of RN

prescribers.


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Appendix F

Examples of RN / Midwife supply of medicines

Nurse Initiation Medicines (S2 or 3 medicines from a limited formulary or protocol),

Rural and Remote Emergency Access “authority to supply” (RN can supply S2, 3

or 4 medicines from a formulary on telephone order of medical practitioner),

Emergency Rural Access (restricted to rural or remote setting under authorisation

by regulatory authority or government and medicine initiated by protocol with

limited doses allowable)

Standing Orders (institution based authorisation using protocols and includes S4

and S8 medicines in some cases) (National Nursing & Nursing Education

Taskforce, 2006).

Special Prescribing Program: Emergency (Tasmania)

Sexual and Reproductive Health Program (QLD)

Standing Order Public Health Emergency (NSW) (National Nursing & Nursing

Education Taskforce, 2006)

Community midwife programs (NT) and midwifery initiated medicines (Tasmania)

(National Nursing & Nursing Education Taskforce, 2006).


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