Prescribing practicums--getting the balance right: with the advent of nurse prescribing, it is essential that the way in which nurses gain prescribing rights--through prescribing practicums--is balanced, safe and consistent.

I AM presently completing a prescribing practicum to gain prescribing rights through the Nursing Council. This article is concerned with how reliable guidelines can be established to ensure prescribing practicums meet the academic requirements of the university, are clinically credible and result in nurses gaining the necessary practical prescribing skills--in other words that nurses have a balance of clinical and academic expectations.

The Nursing Council has identified a number of competencies for nurse practitioners (NPs), with the sixth covering prescribing. The sixth competency identifies the following as essential skills: uses professional judgment to prescribe; collaborates and consults with the client, family, and other health professionals over prescribing; prescribes within legislative framework; understands use, implications, contra-indications and interactions of prescription medication; understands age related implications of medications; evaluates the effectiveness of the client's response; demonstrates an ability to limit and manage adverse reactions; recognises situations of drug misuse; and understands the regulatory framework of prescribing. Any NP wanting to gain prescribing rights will need to demonstrate competencies in all these areas.

The prescribing practicums are the means by which students gain the practical skills to prescribe through an academic course. Currently prescribing practicums are part of clinical masters' programmes. Students who haven't yet applied for NP registration can complete prescribing practicums after completing courses in pharmacology, pharmacokinetics and pharmacodynamics. The prescribing practicums are one semester courses in all our universities at present.

Students must be supervised by a current prescriber. This effectively means by a doctor. While doctors are extremely well trained, highly skilled professionals, there is still the implicit difficulty of one professional group overseeing the work of another. Doctors will require clear guidelines or protocols to assess the work and standard of students on prescribing practicums. There might, for example, be different expectations of NPs and registered nurses completing a practicum. The clinical supervision needs to ensure that not only are students safe but that they are exposed to new and evolving information. To ensure there is an incentive for doctors to volunteer their expertise, it could be argued some financial payment should be made for their time and supervision.

The prescribing practicums are academic courses and hence there is need to use academic criteria to assess them. Writing and presenting case studies are useful ways of achieving this objective. However, there is a need to ensure clinical criteria are also part of the assessment, through clinical supervisors having input into the evaluation process. Additionally, students must be able to expect uniform standards across the country for prescribing practicums.

Students doing the prescribing practicums need to be very clear about their scope of practice and particularly their scope as it relates to prescribing. This might mean indicating an age range, a range of diagnostic problems, types of comorbidities and the limits to prescribing competence and when suitable referrals to specialists will occur. One of the more controversial areas is whether students should select a small formulary of medications within their scope, or whether they should be able to prescribe any medications within their identified scope or subscope.

Students need to be safe and yet they need to gain real experience in prescribing. Clearly supervisors need to be aware that students cannot actually prescribe.

Once NPs complete the prescribing practicum, they can apply for prescribing rights and the Nursing Council will decide what exactly they will be endorsed to do. This is particularly problematic, as only two scopes currently have a legal right to prescribe in nursing: elderly care and family/child health. How those other scopes will gain approval is still being decided by the Ministry of Health and the Nursing Council.

Once NPs gain prescribing rights, they are essentially at the start of their prescribing lives, hence there is a need for ongoing supervision and mentorship. There would seem to be two approaches to this. The prescribing practicum itself could be extended in time to cover much of this supervisory need, or a form of internship programme could be introduced to ensure ongoing education and professional development after endorsement as a prescriber.

Nurse prescribing is upon us. The prescribing practicums are the vehicle for nurses to gain practical skills in prescribing. We need to ensure there is some uniformity in the way these courses are administered and taught nationally. We need to ensure a blend and balance between academic and clinical needs. And we need to ensure ongoing professional development and safety, once NPs gain prescribing rights.

REFERENCES

(1) Nursing Council of New Zealand (2002) The Nurse Practitioner; Nursing Council of New Zealand: Wellington.

--Mark Smith, NP, RPN, MSc, is a nurse practitioner in Health Waikato's Mental Health Service and a senior lecturer at Auckland University.