Nurse and midwife medicinal product prescribing in general practice

Nurses and midwives all over Ireland are becoming registered prescribers, which appears to be positively influencing patients, services, and practitioners themselves. Patients generally have confidence in and a therapeutic rapport with their general practice nurse (GPN), and prescribing contributes to this confidence and rapport, as well as to safer, evidence-based patient care and effective workload management within the service. The Office of Nursing and Midwifery Services Director (ONMSD)1 agrees that medicinal product prescribing has been of substantial benefit in assessing, monitoring, and treating patients, while prescribers consistently report enhancement of professional development among other associated benefits. If you are considering expanding your knowledge and skills, your Professional Development Coordinator for GPNs (PDCGPN) can help you navigate the process and reach the right decisions for you.

History of nurse and midwife prescribing in Ireland

Prescribing is described by the Nursing and Midwifery Board of Ireland (NMBI) as “an expansion of a nurse’s/midwife’s scope of practice, beyond the skills, competence, and knowledge an individual practitioner possesses at the point of registration.”² The prescribing of medicines by nurses and midwives in Ireland was established in 2007. The first nurse and midwife prescribers registered with the NMBI in 2008 and the first GPN registered as a nurse prescriber in 2009. Since then, GPNs and many other nurses and midwives have become qualified and proficient prescribers across an array of disciplines and specialties.

Why prescribe as a GPN?

Appropriate and safe prescribing improves a GPN’s skills, knowledge, and competencies. It also increases professional development, autonomy, and overall job satisfaction.³ Prescribers frequently describe improved use of their skills and enhancement of the quality of patient care through increased convenience and greater accessibility to medications. They also report improved patient compliance due to appropriate clinical decision-making and time taken to give explanations and education to patients in relation to prescriptions offered. De-prescribing and non medicinal prescribing are also beneficial tools in addressing polypharmacy,reducing non-essential pharmacological interventions, and improving cost effectiveness. The GPN is ideally placed to achieve clinical excellence in the field of prescribing due to the holistic approach, longevity of therapeutic relationships with patients, and the accessibility and perceived approachability that accompanies general practice nursing, all of which allow the development of prescribing practices in a safe and appropriate environment.

Clinical governance

The clinical governance for the prescribing of medicinal products is determined by the local health service provider. The relevant medicines legislation, associated regulations, national and health service provider’s policies, protocols, and guidelines will inform and regulate most aspects of prescribing practices. The NMBI is mandated to establish the professional regulatory framework for the nurse or midwife prescribing. For further information please refer to the Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority document at www.nmbi.ie/NMBI/media/NMBI/NMBI_PracticeStandardsGuidelines_07102019.pdf?ext=.pdf.

Overall, however, responsibility ultimately lies with the individual practitioner toensure they work within that framework, within their scope of practice, and in compliance with standards and guidance set out in legislation and regulation nationally. Each registered nurse prescriber (RNP) or registered midwife prescriber (RMP) is also individually accountable for keeping up-to-date with advances in medicinal product prescribing and best practice recommendations. A sound knowledge-base to support clinical decision-making and judgement is also an essential component of safe prescribing. The decision-making framework for prescribing clearly sets out the requirements for prescribing within scope of practice and the standards for prescribing practice. The RNP or RMP must always be able to provide an evidence-based rationale for taking a particular course of action when prescribing any medicinal product.⁴ They must also acknowledge any limitations in their levels of knowledge, competency, and proficiency. 

What would I prescribe? 

Authority to prescribe is not a blanket ‘have pen, will prescribe’ certification. The medicines prescribed will depend on the scope of practice of the individual RNP/ RMP and must adhere to requirements of education, clinical governance, and professional guidance. For example, a nurse who is providing care to asthmatic patients will have undertaken an asthma qualification, will have knowledge of appropriate inhalers and medications, and will base their care provision and decisions on national and international best practice guidance. All prescriptions would be in accordance with these recommendations, would be clearly documented, and recorded in the patients’ notes. The RNP/RMP would also take responsibility and accountability for signing the prescription and any subsequent outcomes, responses, or allergies.

Steps to becoming a registered prescriber

• Access all relevant information from the NMBI, ONMSD, and the relevant educational institutions. At this point, we would recommend contacting your nearest PDCGPN to support you through the process.  
• Initiate local discussions with the GP (or GPs) to identify service needs and potential prescribing role within the individual service. 
• Identify and manage expectations of the prescribing role. Discuss funding, timeline to registration, prescribing rights, and inappropriate areas, such as repeat prescriptions and transcriptions. Include all practice staff, including admin and practice manager, in discussions.
• Identify roles within practice: Medical Mentor and Prescribing Site Co-ordinator (PDCGPN will fulfil this role upon request if the GP agrees).  
• Discuss the development of local structure to ensure governance of prescribing activity. Your PDCGPN will be happy to advise you and support this process.  
• Steps to becoming a registered prescriber
• Access all relevant information from the NMBI, ONMSD, and the relevant educational institutions. At this point, we would recommend contacting your nearest PDCGPN to support you through the process.  
• Initiate local discussions with the GP (or GPs) to identify service needs and potential prescribing role within the individual service. 
• Identify and manage expectations of the prescribing role. Discuss funding, timeline to registration, prescribing rights, and inappropriate areas, such as repeat prescriptions and transcriptions. Include all practice staff, including admin and practice manager, in discussions.
• Identify roles within practice: Medical Mentor and Prescribing Site Co-ordinator (PDCGPN will fulfil this role upon request if the GP agrees).  
• Discuss the development of local structure to ensure governance of prescribing activity. Your PDCGPN will be happy to advise you and support this process.  
• Application process for education programmes (see next section).
  
  

Education programmes 

Education programmes for medicinal products prescribing are available in several of the higher education institutes (HEIs) across the country. The duration, delivery, and schedule of the courses differ, and the prospective prescriber should explore all the courses on offer to identify the most suitable. The most up-to-date prospectus is available from your PDCGPN and contains links to each of the available courses, costs, and application procedures. 

Requirements 

Prior to application for the education programme, the prospective prescriber must identify the roles of medical mentor and prescribing site coordinator for their area. A prescribing site evaluation should be completed in advance of the application and the steps in the section ‘Becoming a registered prescriber’ followed. General requirements will include:  

• Level 8 qualification or recognition of prior learning to an equivalent degree;  
• Registration as a nurse or midwife on the Active Register of NMBI;  
• Currently be employed as a nurse or midwife;  
• Have a minimum of three years postregistration clinical experience (within the past five years), with at least one year in the area in which prescribing is proposed. 

How to register 

On completion of the education programme and when transcript is available, NMBI online registration process for candidate nurse and midwife prescribers is as follows: 

Please see My NMBI Registrant User Guide, Section 6, pages 22-25. This section is relevant to those who are registered in the Register of Nurses and Midwives and would like to add a new division to their registration record (such as RNP/RMP). 

When completing registration with NMBI as a nurse/midwife prescriber, it will be necessary to upload the following two documents: 

• 1. Official results transcript from relevant HEI; 
• 2. Nurse or Midwife Prescriber Employment Validation Form; 
• 3. A once off registration fee will apply (currently €80). 

Post registration  

• Local policy document is developed.  
• RNP/RMPs in general practice are advised to create a formulary or agreement outlining what medicines they will prescribe (in the manner of the collaborative practice agreement, although this is no longer a legislative requirement). This should be appended to the local policy document.  
• Quality in practice policy should be agreed and include schedule of review, audit plans, and any other local arrangements, such as GP review of prescribing practice at intervals if required. Initial audit is recommended three months after first prescription and six-monthly thereafter unless a requirement for a shorter interval is identified.  
• Communications to patients, local pharmacies, and any other stakeholders identified, informing of new prescriber and any change in practice as a result of same.  
• Software may require adjustment to user profile to allow prescriptions to be created on electronic files and sent to pharmacies via same. The prescriber should also familiarise themselves with use of the software for data collection and audit purposes. 

Important resources

Nurse/midwife medicinal product prescribing websites: 

The National Nurse and Midwife Medicinal Product Prescribing Guideline 2020 (hse.ie) is a valuable resource. The ONMSD also provide a range of useful links about:  

• Sample Audit Tools;  
• Guidance for Clinical Audit;  
• Quality Improvement Plan;  
• Sample Excel Audit Tool (which can be adapted for local use);  
• Information sheet on Authorised, Offlabel and Exempt Medicinal Products. 

These links and documents can be accessed at https://healthservice.hse. ie/en/about-us/onmsd/onmsd/specificprogrammes/nurse-midwife-medicinalProduct-prescribing.html

NMBI resources: 

• www.nmbi.ie/NMBI/media/NMBI/ NMBI-Medication-Administration-2020. pdf?ext=.pdf. 
• www.nmbi.ie/Standards-Guidance/ Prescribing-Standards.  
• www.nmbi.ie/NMBI/media/ NMBI/decision-making-frameworkprescribing.jpg. 
• www.nmbi.ie/NMBI/media/NMBI/NMBI-Practice-StandardsGuidelines-02-03-2020_2.pdf?ext=.pdf. 

Scope of practice document:  

• www.nmbi.ie/nmbi/media/NMBI/ Publications/Scope-of-NursingMidwifery-Practice-Framework. pdf?ext=.pdf.

Registration with the NMBI and RNP/RMP  

• https://healthservice.hse.ie/about-us/ onmsd/onmsd/specific-programmes/ registration-with-the-nursing-andmidwifery-board-of-ireland-nmbi-as-aregistered-nurse-or-registered-midwifeprescriber-rn-mp-.pdf

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