Prescribing medication is a significant addition to a registered nurse’s scope of practice. As a professional skill it builds on the qualifications and competencies traditionally recognised at the point of general nurse registration.
An interview with Theresa Lowry Lehnen, RGN, RNP, PhD, Clinical Nurse Specialist and Associate Lecturer with South East Technological University
We recently spoke to Theresa Lowry Lehnen, RGN, RNP, PhD, Clinical Nurse Specialist and Associate Lecturer with South East Technological University to discuss how systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks inform prescribing decisions and help maximise safe and effective practice as a Registered Nurse Prescriber (RNP).
A nurse prescribing candidate attains the competencies of prescriptive authority by completing an accredited nurse prescribing educational programme. When considered competent to prescribe as per the HEI’s standards for the theoretical and clinical components of the programme, the prescribing candidate gains formal recognition by entry to the Registered Nurse Prescriber division of the register maintained by the NMBI.
“Minimising risk and maximising effectiveness are two key underlying principles of nurse prescribing practice,” Theresa told us.
“Safe and effective practice is founded on a thorough understanding of the theory, concepts, legislation, frameworks, policies, procedures and guidelines pertaining to nurse prescribing. Patient safety is paramount. Therefore, professional and ethical nurse prescribing practice must be based on systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks. Such processes inform prescribing decisions and help maximise safe and effective practice as a registered nurse prescriber (RNP).
“Prescribing medication is a complex and multi-faceted process which can be associated with adverse risks and inadvertent consequences. Prescriptive authority is therefore governed by a dual framework of professional regulation and legislation pertaining to medication and its associated regulations.
“Practice standards, decisionmaking frameworks, clinical governance structures and NMBI guidelines outline the criteria for safe and effective nurse prescribing practice. They provide a regulatory framework and professional guidance for prescriptive authority which should be subject to continuous quality assurance and regular audits. The laws and regulations, the standards, frameworks and criteria are designed to assure the public of the RNP’s accountability and professional competence. They ensure that appropriate measures of clinical- and self-governance are in place.”
The NMBI Practice Standards and Requirements for Education Programmes for Nurses and Midwives with Prescriptive Authority sets out the educational standards and requirements for nurse and midwife prescriptive authority. The domains of competence represent the levels of knowledge, skills and competence the prescribing candidate must achieve in order to prescribe safely and effectively.
Theresa notes that good prescribing practice should support patient care and encourage treatment concordance and adherence while considering clinical response, tolerability, and lifestyle factors.
“Patients should be included in clinical decision-making processes which affect them, providing them with choices, while ensuring that prescriptive practice is also safe and appropriate,” she says. “Unsafe practices are a leading cause of medication errors worldwide. The World Health Organisation’s Global Patient Safety Challenge: Medication.
Without Harm outlines key local, national and global actions required to reduce the level of medication-related harm, among them patient engagement, education and training, communication and teamwork, professional competence and incident reporting and learning.
“Continuous professional development, education, audit, and evaluation of nurse prescribing practice maximise safe and effective prescribing. Audit, monitoring and evaluation of prescribing practice is a continuous process. It promotes best practice and measures the clinical outcomes and effectiveness of care.”
Prescribing medication is a complex process often associated with side-effects, risks, and unintended consequences.
It is paramount. Teresa says, and in the patient’s best interest to minimise risk and maximise the effectiveness of prescribed medications. “While most medication errors are avoidable, risk cannot always be eliminated. However, as a registered nurse prescriber every step must be taken to ensure that safety is maximised, and risk is minimised within professional practice,” she told us.
“Nurse prescribers must have a thorough understanding of the medication they prescribe, including side effects and possible interactions. They must be proficient in practice and demonstrate the understanding, skills and knowledge required to carry out a competent history, assessment and examination specific to the patient’s presenting condition.
“This includes understanding the relevance of any diagnostic tests and results in relation to specific conditions and medications. In practice, the RNP must be satisfied that the patient’s presenting condition is within their scope of clinical and prescriptive practice. An understanding of pharmacology, the patient’s needs and the condition being treated help determine the most appropriate medication including dose, form, frequency and route of administration based on the individual patient’s characteristics. “Prescribed medication must be safe, evidence-based and in the patient’s best interest. Underlying principles of good prescribing practice involve selecting appropriate, safe and cost-effective medicines, individualised for the patient’s needs. While pharmaceutical reference books such as the BNF and Irish Medicines Formulary inform prescribing decisions and guide safe practice, each individual consultation must also closely examine the patient’s past medical history, current medications (including OTC, herbal remedies, vitamins and food supplements, homeopathic medications, and any possible interactions), known allergies, sensitivities, and previous drug reactions.
“Other relevant factors that may need to be addressed include pregnancy, breastfeeding, co-morbidities, polypharmacy, cognitive impairment, or difficulties adhering to medication regimen. In addition, social, occupational, and family history must be taken into consideration, and lifestyle factors such as smoking, alcohol and illicit drug use explored to assess potential risks or interaction with the medication prescribed.”
Theresa goes on to highlight that good prescribing practice involves patient education and a management plan for follow-up, monitoring and evaluation of care.
“Reviewing medications and monitoring the effectiveness of treatment at each visit enhances patient safety. This is particularly important when polypharmacy exists and in patients with comorbidities. Patients should be provided with clear explanations and a rationale for the medication prescribed, including name, description, purpose, dose, frequency, duration, route, and any additional instructions required.
“Any potential side effects or interactions with other medicines or food products should be discussed, and patients advised what to do if they have any concerns. Prescriptions issued must comply with legislation and NMBI practice standards. They should state the precise medication, generic name, regimen, dose, strength, route and frequency, the patient’s name, address, date of birth, date of initiation of the medication and maximum duration. Abbreviations are avoided, and only internationally and nationally recognised units are used.
“All prescriptions issued are dated and signed and include the nurse prescriber’s NMBI personal identification number (PIN). Should an error occur, the script should be reissued rather than altered or crossed out.
“In my personal practice, I do not prescribe MDA and off-label medication. However, it is important to be aware that particular requirements are necessary for Schedule 4 and 5 MDA drugs and a named schedule 2 or 3 MDA drug to be prescribed and issued by an RNP.”
Nurse prescribers have no legal authority to prescribe for any condition or change the route of administration for any Schedule 2 or 3 MDA medication not listed in Schedule 8, she adds.
“Issuing prescriptions for off-label use and EMPs must be within the RNP’s scope of practice. Nurse prescribers must be aware of PPPGs and governance regarding off-label prescribing and the use of medical products outside of the terms of marketing authorisation in Ireland by the HPRA or EMA. Issuing a prescription verbally, by telephone, email or fax, is not permitted under normal circumstances.
“However, provision under Regulation 8 of the Medicinal Products Prescription and Control of Supply Regulations (2003, amended 2007) allows certain prescription-only medicines to be supplied in emergency situations where a written prescription cannot be issued immediately. Legislation changes were issued to facilitate the safe supply of medicines during the COVID-19 pandemic.
“Under the new provision, the National electronic prescription transfer system allows for the transfer of a prescription between the prescriber and dispensing pharmacy by electronic means. However, any prescription sent outside of the National electronic prescription transfer system by fax or personal or commercial email accounts is not recognised in the legislation as a legally valid prescription.”
Theresa says that important considerations apply within nurse prescriptive practice.
“In the case of repeat prescriptions, an established therapeutic relationship must exist with the patient, and an assessment of the need for continued treatment carried out and documented. The actions of prescribing and administering medication are separated as part of an episode of care, except in agreed circumstances. In keeping with professional practice, prescribing for oneself, family or friends should not be undertaken.
All nurse prescribing decisions and actions undertaken must be documented. Documentation provides information and continuity of care and promotes quality and evidence-based practice. Comprehensive documentation is a legal requirement and an integral part of the prescribing consultation to ensure accountability and patient safety, thus minimising risk in practice.
“To comply with standards and ensure safe and effective nurse prescribing, risk assessment tools and guidelines must be in place, including PPPGs for medication safety, managing adverse events and incident reporting.
“If a medication error or adverse incident occurs, nursing and medical interventions must be implemented immediately, focusing first on the patient’s physical needs to ensure safety and limit potential adverse effects. Medication adverse risk management guidelines and protocols must be strictly followed and adhered to. Line management and relevant staff must be informed of the incident as soon as possible and the National Medicines Information Centre (NMIC) and/or the National Poisons Information Centre (NPIC) contacted where appropriate. The patient, their family or carer must be made aware and informed of the incident as per the National HSE Open Disclosure Policy. The incident and all actions taken must be documented and incident management forms completed and returned.
“Medication errors resulting in adverse reactions must be reported to HPRA in accordance with their criteria. The National Incident Report Form (NIRF) should be completed and returned as soon as possible after the incident occurs, usually within one working day.”
The main objective of incident reporting and management is to learn from the incident to reduce the risk of its reoccurrence and ensure the safety of future patients.
Theresa concludes, “Registered nurse prescribers’ decisions are based on pharmaceutical knowledge, professional judgement and practical skills, and underpinned by an in-depth understanding of the relevant professional, legal and ethical frameworks and guidelines. Safe and effective practice in the best interest of patients is of the highest importance and must take precedence in nurse prescribing practice.
“A commitment to continuous education and professional development, including regular audit, monitoring and evaluation of care ensures safe and effective prescribing practice within the clinical setting. While risk cannot always be fully eliminated, it can be minimised, and effectiveness maximised, through collaborative working, clear communication, systematic clinical decision-making and rigorous risk management processes within relevant clinical governance frameworks.”
