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Nurse prescribing a reality at last: it's been a long time coming but nurse prescribing has finally arrived. From November 1, nurse practitioners will be able to prescribe within their defined areas of clinical practice. What will this mean for these new prescribers and for the profession?

Nurse prescribing is finally a reality. After well over a decade of advocating for nurse prescribing, nurse practitioners (NP) will now be able to prescribe a range of medicines. In almost her last act as Minister of Health, Annette King, successfully steered the regulations needed for nurse prescribing through Cabinet Last month. The regulations needed to implement NP prescribing come into effect on November 1.

Announcing Cabinet approval of the regulations, the Minister said NPs were an invaluable resource and to be able to extend their role even further would be a huge benefit to all New Zealanders. The decision comes after a second round of consultation on nurse prescribing, which attracted 84 submissions and closed on August 26. The summary of the submissions had not been made public when Kai Tiaki Nursing New Zealand went to press.

The New Prescribers Advisory Committee (NPAC) in its recommendations to the Minister of Health following the further round of consultation, recommended the Minister proceed with the proposal for NP prescribing with NPs having access to the medicines listed in the medicines list derived by Nursing Council. The committee recommended that anaesthetic drugs falling within the classes of neuro-blockers, anaesthetic inhalants and anaesthetic induction medicines be excluded.

NZNO has welcomed the extension of prescribing rights to NPs. Professional nursing adviser Susanne Trim said the move would improve access to services, improve health outcomes and tap into the "enormous potential" of nurses to improve the delivery of health services.

In many sectors, eg the rural sector, nurses were the primary health care providers. "Shortages of GPs and the extension of nursing practice over the last two decades have resulted in nurses successfully treating and managing illnesses and health issues that in the past were the domain of doctors, Trim said.

Nurse practitioners would continue to work collaboratively with their medical colleagues in the interests of patients. "Nurse prescribing is one tool to assist in comprehensive health care provision," she said.

NZNO's professional services manager Joy Bickley Asher says nurse prescribing will mean greater autonomy for nurses, more responsibility and authority. "It will give NPs greater freedom and autonomy to make a nursing judgement. It will enable a NP to make a better and more comprehensive response to another human being."

She does not believe it will change the profession in any fundamental way. "This is an incremental change, not a dramatic one. A small number of nurses want to prescribe and that will make a difference to a large number of people," Bickley Asher said.

The Nursing Council had developed stringent requirements for nurse prescribing to ensure public safety. Prescribing will be limited to NPs' defined clinical areas of practice and by authorisation to prescribe included on their annual practising certificates (APCs). These set conditions limiting presribing to the NP's approved clinical area of practice, rather than a specific schedule of medications. Nursing Council will monitor the implementation of prescribing closely to ensure public safety, including re-certification and auditing all nurse prescribers when their APCs are renewed.

The ability to prescribe will make a huge difference to NP Adrianne Murray's practice, to health outcomes for her clients and to her own sense of professional satisfaction. Murray is an NP in the Far North, endorsed in the whanau ora scope of practice.

She believes the ability to prescribe will enable a more effective primary health care service for her clients, many of whom find it very difficult to access health care. It will also mean improved patient outcomes. "To be able to prescribe a full course of antibiotics immediately will reduce the incidence of ineffective treatment. The ability to treat chlamydia without referring young clients on to GP care will have a significant impact on chlamydia and other sexually transmitted infections in our region."

Murray will prescribe those medicines she has been using under standing orders. These include topical and oral preparations for treatment of fungal or bacterial skin conditions; drugs for respiratory conditions, including chronic pulmonary respiratory disease, asthma and bronchiolitis; sexual health drugs for oral contraception and emergency contraceptions; and drugs for women's health, including urinary infections. In consultation with the relevant GP team, Murray will also prescribe drugs for the management of chronic diabetes and cardiovascular disease.

She believes being able to prescribe will also mean culturally appropriate care. "I am aware of many cultural barriers that may impede effective care and this can be discussed with the client and worked into their care plan. Local knowledge in isolated rural communities is also essential. An effective primary health care clinician must be informed of their community's strengths and weaknesses as these can be potential barriers to effective care. Visiting locums don't have that community or cultural knowledge needed for effective treatment regimes," Murray said.

Collaborative practice

She stressed that NPs in primary care did not work in isolation and prescribing could not be seen in isolation from other nursing skills. "We promote and advocate collaborative practice with our GP teams and all other care providers. In this way, Local community resources are used to fully benefit clients' well-being. This is particularly necessary in rural communities that typically tack public transport, specialist services, after-hours care and regular GP cover, and have Limited home support services."

Palmerston North-based NP, Helen Snell, a specialist in diabetes, believes prescribing rights will mean NPs can practise to their full potential She will be prescribing drugs related to diabetes and it co-morbidities. This will include insulin, oral diabetes agents, Lipid Lowering agents and anti hypertensives. She will also be able to prescribe blood glucose testing strips and other supplies.

Prescribing rights will mean immediate care and treatment for clients and reduce duplication of visits to other health care providers. "Communication will be important, both with the client and their primary care provider," Snell said. Many people with diabetes understood and recognised her expertise with the specialty of diabetes and would feet safe with her prescribing decisions, she said.

She believed there was the potential for prescribing rights to change the NP/client relationship. "But as a nurse, I will continue to approach a person's health needs with a person-centred, well health focus. Prescribing will be just another mechanism to assist me to meet their needs, it will not be the primary focus." New Zealand's first NP, Deborah Harris and chair of the Nurse Practitioner Advisory Committee (NPAC-NZ), was "absolutely delighted" when she heard the news. "But I am very cognisant of the significant change this represents for nursing and the new responsibilities within this."

Her application to prescribe is with the Nursing Council and she will be able to prescribe medicines for neonates. "The academic preparation for prescribing has changed my practice already. Prescribing rights will open new doors for my practice."

Harris paid tribute to former Minister of Health Annette King's role in promoting nurse prescribing. "She has always had great vision for the impact nursing can have on health care delivery. In my role as chair of NPAC-NZ, I have always considered she has done her utmost to assist with the development of the NP role."

In its submission on the Ministry's consultation document, the New Zealand Medical Association (NZMA) wants each NP to have an "individualised formulary of an appropriate range for their field of expertise, numbering perhaps 20 medicines and certainly no more than 50".

This, according to the NZMA, would set clear and well-defined parameters of independent practice within niche fields of practice.

The association also questions the "primary care" scope of practice which, it says, depicts the full breadth of care given in a community-based setting. But the association believes there is scope for NPs with prescribing rights to be delivering aspects of primary health care but stresses this "must operate in conjunction with a full team of medical professionals".

NZMA supports nurses providing a point of first contact service or routine management of chronic conditions or "other easily identified areas of care within the health system".

The NZMA also has concerns about the training, evaluation and quality control of NPs as put forward by the Nursing Council. "We feel that, as proposed, the accreditation panel for NP prescribing will Lack the competencies required to prescribe safely and effectively, and therefore question its capacity to safely assess someone else in terms of an identical set of competencies."

It is also concerned at the scope of nursing practice and ongoing professional development, which it believes is inadequate.

Referring to the exclusion of anaesthetic agents, the immediate past president of the New Zealand Society of Anaesthetists, Mark Bukofzer, claimed "common sense has finally won the day" The decision was a win-win for all concerned, he said.

In its recommendation to exclude anaesthetic agents, the committee stated: "While the NPAC is confident the Health Practitioners Competence Assurance Act provides the Nursing Council with sufficient mechanisms to ensure NPs with an endorsed clinical area of practice of anaesthetics would be competent to prescribe and administer anaesthetic agents, there is currently no training programme to prepare nurses to prescribe anaesthetics."

It also said that, because these drugs were prescribed and administered at the same time, there was not the same ability for a pharmacist to monitor the appropriateness of the prescribing, as there was with other prescribed drugs. The exclusion decision allowed the anaesthesia community to work in conjunction with the Nursing Council and individual NPs to develop advanced scopes of practice in fields such as acute and chronic pain and recovery room care, Bukofzer said. "This decision will ultimately benefit our patients and is warmly welcomed by the anaesthesia community."
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Title Annotation:NEWS FOCUS
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Date:Oct 1, 2005
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