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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 25-November-2005, Vol 118 No 1226

Nurse practitioner (NP) prescribing in New Zealand: a NP’s response to the editorial by Drs Moller and Begg
On 8 December 2005, NPs—New Zealand’s most experienced, expert, educated, and accomplished clinical nurses—will incorporate ‘independent’ prescribing into their practice following an extensive and lengthy government consultation process to which NZMA contributed, supported by New Zealand’s New Prescribers Committee and the subsequent change in legislation. There are 17 endorsed NPs in NZ to date (2001–2005). Of those 17 NPs, one has had prescribing rights for 2 years, one will be endorsed in December 2005, and perhaps 8 more will become prescribers in the coming year (2006).
Collaborative practice is integral to the safety and ongoing monitoring of NP prescribing in NZ. Ongoing competency assessment is obligatory, and includes ‘evidence of ongoing multidisciplinary peer review of their prescribing practice’.1

Are we well trained enough to engage in prescribing—“the most dangerous activity a medical degree confers on doctors”?

NPs receive an extensive postgraduate clinical education within the Master’s degree, including:
  • Pharmacology and pharmacotherapeutics (developed in conjunction with NZ’s pharmacy schools and medical specialists, and at least equivalent to medical school training at the University of Auckland);
  • Diagnostic reasoning and specialty practice courses (taught in part by Medicine); and
  • Evidence-based practice, research, and practicums culminating in a prescribing practicum being signed off/passed by a medical colleague.
No prospective NP will get past this final training step without demonstrating a solid knowledge of all the skills required, and especially a knowledge of one’s limits and excellent consultation-seeking. To date, doctors (who have played this role and who have worked in close conjunction with an academic mentor within the School of Nursing) have been supportive and impressed with the training of the candidates. Where this is not the case, there is no hesitation in failing or recommending further hours/training before endorsement OR a period of supervised prescribing once endorsed.
The NP candidate then undergoes a process of Nursing Council endorsement through portfolio, site visits, and interview by a panel which includes a physician/doctor in the applicant’s scope of practice (if prescribing is to be included). Only then can NPs finally incorporate ‘independent’ prescribing into the range of care they offer to their patients. This takes a minimum of 8 and probably at least 10 years of combined university education and years of practice to achieve—more than the (dismissive in the context of the argument) “nursing training about appropriate caring”.
Whether midwives should engage in equivalent postgraduate experience and education in order to practice ‘independently’ is another question—and, in this day and age, perhaps they should be an integral part of a seamless continuum of primary healthcare for that mother /infant dyad.

Prescribing practice: ‘independent’ and ‘dependent’

Drs Begg and Moller2 seem to be concerned that ‘independent’ prescribing equates to non-collaborative practice, an inherent “threat to the standard of healthcare in New Zealand”—as we NPs “place the interests of patients second to a major experiment on behalf of a sectional interest” .
This is astonishingly at variance with reality. Our objective is to improve care, improve timely access, and improve(not destroy) healthcare teamwork, leading by example. Indeed, most NPs will be integrally linked into some sort of collaborative practice setting with peer review and ready consultation and referral systems, whether in primary care or tertiary. However ‘dependent’ prescribing means working under ‘standing orders’ or getting every script co-signed and neither of these is necessary or practical to an NP on a day-to-day basis.
In short, we prescribe ‘independently’ and practice ‘collaboratively’. And yes, some NPs in tight-knit medically-specialised tertiary settings may be able to work perfectly well with standing orders, while others do need prescribing rights and will improve adherence to treatment regimes, combining their advanced pharmacology knowledge with the ‘nursing’ expertise in teasing out ‘determinants of compliance’ and helping the difficult patient take ownership of a treatment plan in a true partnership of care!
If NPs establish an ‘independent’ practice, it will be because they have special skills and are acknowledged consultants or expert clinicians in a defined area; for example, wound care. And if an independent ‘whanau ora’ or equivalent NP is also a prescriber, they will prescribe in close collaboration with a medical consultant (hopefully linked with the primary care providers for their populations).
In conclusion, if NZ doctors do not want to see the possible adverse effects of ‘independent’ prescribing, then:
  • Identify the top clinical nurses in your field;
  • Encourage them to undertake postgraduate study;
  • Help them find the best place to undertake coursework you see as key to the practice and well-mentored prescribing practicums (in NZ or internationally); and
  • Keep the best clinical nurses in NZ to build and boost your service to our population!
Why didn’t we do medicine in the first place if we want to prescribe? Because we were busy doing other degrees; we may have been more brilliant in arts than in science at school; and we felt called to make a difference in caring for individuals and communities more than being driven to ‘find the cure’ and know every single-most-complex and unusual differential diagnosis.
We keep people well, have a solid knowledge of normal practice, and focus more on what makes people tick. Does this mean we couldn’t get ‘A’s in the complex sciences of pharmacology, pharmacotherapeutics, and diagnostic decision-making when we saw we could provide more comprehensive care by prescribing too?
We come from a different paradigm, but NPs can prescribe just as well as doctors can ‘care’.
Paula Renouf (RN, MS [UCSF]
Nurse Practitioner (Child and Youth)/Prescriber
Raukura Hauora o Tainui:Trust Health Manurewa
Lecturer: School of Nursing, University of Auckland
Auckland
(p.renouf@auckland.ac.nz)
References:
  1. Medicines (Designated Prescriber: Nurse Practitioners) Notice 2005, NZ Gazette, 188, p4750. Available online. URL: http://www.nursingcouncil.org.nz/Issue188_7428.pdf Accessed November 2005.
  2. Moller P, Begg E. Independent nurse prescribing in New Zealand. N Z Med J. 2005;118(1225). URL: http://www.nzma.org.nz/journal/118-1225/1724

Response by Moller and Begg

We thank Ms Renouf for reading our article and responding. This topic needs wider debate, even though it seems it is ‘fait accompli’.
We are disappointed that Ms Renouf finds dismissive our comment that nursing training has been more about appropriate caring than accurate diagnosis. There is nothing more important than caring, and it has been this attribute of nursing that has kept nurses in the first place of trust amongst occupational groups.
Independent nurse prescribing has several problems, which we have outlined. We believe it is self-evident that the level of training cannot match that of a doctor until it duplicates it. The past 50 years has seen a dramatic rise in powerful medical treatments that can provide great benefit, but can equally cause great harm. While tighter controls and credentialling are increasingly applied to doctors, the educational requirements for prescribing are being relaxed. The risks of this need to be recognised. The point at issue is whether or not the two-tier structure of health practice that now arises is acceptable to the people of New Zealand.
The term ‘dependent prescribing’ refers to prescribing within a group where the standards are overseen and audited by the senior doctors in the group. Junior medical officers perform in this framework, and all doctors undertake continuing education directed to diagnosis and therapeutics. Although we do not like the term, we believe that dependent prescribing will be valuable in a number of areas.
Ms Renouf says: “we (nurses) felt called to make a difference in caring for individuals and communities more than driven to ‘find the cure’ and know every single most complex and unusual diagnosis. We keep people well, have solid knowledge of normal, and focus more on what makes people tick”. We agree.
What nurses do is important and valued, but it does not prepare an individual to take on the additional responsibilities of diagnosis and independent prescribing. We believe that the medical team, which has evolved over centuries, remains the best model. Making nurses independent prescribers does not improve health service collaboration. Since midwives became independent there has been a reduction in collaboration in maternity services.
We are now moving into a new paradigm that we believe is not in the best interests of the people of New Zealand.
Peter W Moller
Rheumatologist
Evan J Begg
Professor, Department of Clinical Pharmacology
Christchurch School of Medicine, University of Otago
Christchurch
(evan.begg@chmeds.ac.nz)
     
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