New Zealand has been late in implementing nurse prescribing. Towards the end of the 20th century non-medical prescribing was introduced into many westernised countries, notably in the UK, where nurses have been prescribing for decades.^1,2 The situation regarding the late introduction of nurse prescribing in New Zealand, is a curious one. In 2006, there were only five nurse practitioners prescribing in New Zealand (the only group who were eligible to prescribe at the time), which was in part due to objections raised regarding the safety to the public of these professionals and future nurse prescribers.³ One commentator at that time highlighted that there were more registered nurse prescribers in the UK than there were doctors registered with New Zealand’s General Medical Council.⁴ Since then, the numbers and levels of nurses prescribing in New Zealand have substantially increased along with other groups of non-medical prescribers such as pharmacists and optometrists.² This article explains the evolution and nomenclature of the different levels of nurse prescribing in New Zealand and the legislation under-pinning each of the three levels (see Tables 1 and 3). Additionally, the prerequisites, education, competencies and registration of the three levels are defined along with the intent of each prescriber’s role and the clinical contexts. The discussion will be drawn from current New Zealand legislation as well as professional guidelines published by the Nursing Council of New Zealand (NCNZ), who are the responsible agency for setting educational and professional standards for nurses in New Zealand.

Authorised versus designated prescribers

In order to discuss nurse prescribing it is first necessary to clarify two pertinent terms used in the New Zealand legislation; authorised and designated prescribers. Authorised prescribers may independently prescribe, supply, sell, administer or arrange for the administration of any medicine that relates to their area of practice.¹ Current authorised prescribers include nurse practitioners, optometrists, practitioners (dentist or medical practitioner), registered midwives or veterinarians.¹ Designated prescribers, on the other hand, may only prescribe from a list of medicines published in the New Zealand Gazette by the Director-General of Health under section 105(5A) of the Medicines Act.¹ Designated prescribers are also expected to prescribe collaboratively alongside an authorised prescriber and have limited permission to diagnose (only minor ailments and illnesses, eg, those that can be confirmed with a simple diagnostic test such as a UTI).² Current designated prescribers include pharmacist prescribers, dietitian prescribers and RN prescribers.1 Table 1 lists all New Zealand legislation that pertains to nurse prescribing in New Zealand.

Table 1: Legislation pertaining to prescribing.

Table 2: Examples of contexts suitable for nurse prescribers (not an exhaustive list).

The following section will discuss each of the three types of nurse prescribers registered in New Zealand [nurse practitioners, registered nurse prescribers (rnp) in primary health and specialty teams and registered nurse prescribers (RNPCH) in community health] and Table 3 summarises the legal and prescribing status of the three types of nurse prescriber in New Zealand.

Nurse practitioners—highest level

In 2001, the first nurse practitioners (NPs) were registered with the Nursing Council of New Zealand (NCNZ), some of whom had limited (designated) prescribing rights.¹⁴ The numbers of NPs were slow to increase over the following decade, due in part to the onerous process to register with NCNZ and the lack of job opportunities following registration.^15,16 However, in the last few years streamlining the registration process along with increased employment opportunities has led to an increase in the numbers of NP registrations. In 2013, the Medicine Amendment Act listed NPs as authorised prescribers, with near identical prescribing rights to doctors and dentists (See Table 1).⁷ Currently there are 465 registered NPs (current on 10 June 2020, figures from NCNZ register).

Nurse practitioners are registered nurses who have been conferred with an additional registration by the NCNZ, following completion of an approved clinical Master’s degree. The clinical Master’s programme must include bioscience, pharmacology, advanced assessment/diagnostic reasoning and a prescribing practicum (300–500 hours of supervised practice).¹⁷ Under the Health Practitioners Competence Assurance Act, NCNZ is responsible for ensuring that only those who are competent to practice independently are registered as NPs.^1,3 NPs are permitted to diagnose and prescribe independently and autonomously; they can procure, supply and administer medications and prescribe any medicines relevant to their population group.^1,4 NPs work as a sole provider or within a team/service and do not require supervision by a medical practitioner, although supervision by a NP or medical practitioner is recommended in their first year of practice. There are no limitations to the type of presentation or disease that NPs can manage. They are required to undergo regular continuing professional development and participate in self and peer review.¹⁸ Responsibility for ensuring competence and patient safety lies with the individual NP and NCNZ.

The intent of the NP role is to provide high-level expert nursing care combined with diagnostic and treatment skills commonly associated with medical practitioners. As clinical leaders, they influence policy, address inequity by improving access to healthcare for all New Zealanders and role model best practice in patient care.¹⁸

Registered nurse prescribers (RNP) in primary health and specialty teams—middle level

During 2011, registered nurses (RN) specialising in diabetes care were piloted in four sites around New Zealand following a legislation change that gave them limited authority to prescribe.⁸ Evaluation of the project described these nurses as providing safe, high-quality prescribing decisions.¹⁹ A further legislation change in 2016 allowed NCNZ to register RN prescribers working in primary care and other specialty areas who had completed a Post-Graduate Diploma, which included a prescribing practicum (150 hours of supervised prescribing practice by an authorised prescriber). Subsequent to the enaction of this new act in 2016, newly registered RNPs working in diabetes care came under the umbrella term of RNPs in primary health and specialty teams. RNPs are described as designated prescribers and the limitations on their prescribing are summarised in Table 3. RNPs work collaboratively with an authorised prescriber and may only prescribe within that collaborative relationship.^1,2,9 RNPs prescribe for a discreet list of conditions and adhere to a specific list of medicines published by the NCNZ.²⁰ Some of the medicines on this list have been deemed suitable for continuation prescribing (which differs from a repeat prescription as the patient must be assessed face to face and allows for dose adjustments as required).²⁰

Table 3: Comparison of nurse prescribers.

The intent of the RNP role, is to prescribe within an existing or pre-determined diagnosis, although NCNZ does allow for RNPs to make simple diagnoses such as urinary tract and skin infections.² However, RNPs are not expected to demonstrate the same diagnostic skills as medical and nurse practitioners and are required to have oversight from an authorised prescriber who is readily accessible to examine the patient if required.²¹ While there is an associated workload for authorised prescribers to supervise RNPs, it is arguably more satisfying than overseeing standing orders. There are clear expectations in terms of governance, audit, ongoing education requirements and peer review for workplaces who employ RNPs.² Other restrictions to RNP prescribing are described in Table 3.² As of 31 March 2020, there were 59 diabetes nurse prescribers and 213 primary health and speciality teams nurse prescribers registered with NCNZ.

Registered nurse prescribing in community health (RNPCH)—lowest level

In 2019, a third group of nurse prescribers were created; RN prescribers in community health (RNPC). They are also classed as designated prescribers and registered by NCNZ following successful completion of a workplace toolkit.^9,22 The list of medicines they can prescribe from is very limited and the duration of the prescription is for a single dose or course.²⁴ Like RNPs, RNPCs must work and prescribe collaboratively with and be supervised by authorised prescribers.

The intent of this role is to address inequity in primary care provision and to promote population health by providing access to care and expediting treatment of conditions such as group A streptococcal pharyngitis or impetigo.²² As with RNPs, these prescribers are not expected to diagnose anything other than simple ailments. As of 31 March 2020, there were 60 community nurse prescribers registered with nursing council.

To allow further comparisons and clarification, Table 2 summarises some appropriate contexts for each type of prescriber and Table 3 summarises the main differences between the three groups.

Discussion

NPs have the same autonomous diagnosing and prescribing rights as medical practitioners, which allows them to work flexibly and independently in any number of contexts. They can diagnose and treat all first presentations of patients within their knowledge and skillset and do not require medical oversight. In addition, they are expert nurses with the associated knowledge and skills. Despite these attributes NPs still face barriers to employment and restrictions in some practice settings. Arguably the numbers registered are not commensurate with the needs of the New Zealand population, particularly in primary healthcare.¹⁵ RNPs are well placed to run nurse-led clinics for chronic conditions and some specialty services where the diagnosis is already established and the medicines list they prescribe from is pertinent. Utilising them to see purely first presentations is not impossible but requires RNPs to discuss all but the simplest of cases with an authorised prescriber. RNPCs can prescribe limited medications for simple conditions in uncomplicated patients. Both RNPs and RNCPs require an authorised prescriber to be freely available or to work in tandem with them. The added supervisory burden to the authorised prescriber must be factored into the service delivery model and resourcing. It should also be noted that this model places the accountability for the diagnosis of all discussed patients with the supervising authorised prescriber, whereas the prescribing accountability remains with the RN prescriber.