HNB3141 Nursing And Complex Care

Introduction

A nurse practitioner is a healthcare provider with advanced education, training and expert knowledge in diagnosing, managing and treating complex acute and chronic conditions. Depending on their state or country’s legislation, they can order for diagnostic tests, prescribe medication, admit patients in hospitals, request for patient referrals and perform minor, non-surgical procedures on patients (International Council of Nurses, 2018). Nurse practitioners began coming to the foreground during the 1960s and their role was formally brought about by Loretta Ford, a nurse educator, and Henry Silver, a medical doctor, in 1965 (Stewart & DeNisco, 2018, p.4).  

The program Ford and Silver created was meant to cater to the underserved and remote populations who had nursing shortages The first program was meant to be based on pediatrics but it ended up advancing clinical practice by enabling students to diagnose patients and provide primary care (2018, p.4). In the 1970s, the nurse practitioner programs grew from funding by the federal government to deal with doctor shortages especially in the remote parts of the country. In 1971, the state of Idaho became the first to allow nurse practitioners to prescribe medication in the United States (2018, p.4). In Australia and New Zealand, nurse practitioners obtained their prescriptive authority in 2001 while in the UK and Canada, nurse practitioners began prescribing medication in1998 and the early1990s respectively (Fong, Buckley & Cashin, 2015).

Literature Review: Barriers to Nurse Practitioner Role

There are barriers/issues that continue to affect the scope of practice within which nurse practitioners work one of which is resistance from physicians (Buchsel & Yarbro, p. 66). Nurse practitioners face resistance especially from doctors because of their expanding role which now allows them to prescribe medication, diagnose patients and refer them for further treatment. Many physicians see this as an encroachment on their profession because the difference in roles between doctors and nurses is diminishing (Elder, Evans & Nizette, 2009, p.72).

There are issues with regulation resulting from rapid population growth which necessitates changes in health policy to meet the increasing healthcare demands. The most prominent issues that nurse practitioners face are prescribing medication and being able to practice independently (Cowen & Moorhead, 2011, p.35). Most of the regulations that govern this profession are not backed by evidence or research but they instead create a barrier to the effective practice and provision of care by these nurses (2011, p. 35). Another issue that affects nurse practitioners is that they have to know and observe both the state and federal legislation of where they practice.

This affects their job performance because a new bill introduced in government might be done with the best intention but it can impact on their ability to do their job (2011, p.36). An example of harmful legislation is the Medical Home Bill of the United States. The original purpose of this bill was to provide a centralized healthcare delivery system for children with special needs but this goal was later expanded to cover the needs of adults in a patient-centered medical home. The legislation that mandated these homes was written to include only physicians and excluded nurse practitioners despite the fact they played an integral part in these homes (2011, p.36). The issue that will be analyzed in this essay is prescribing authority and how it affects nurse practitioners.

Identification of Potential Issue that Affects the Role of Nurse Practitioners

The prescription of medication over the years has mostly been the preserve of medical doctors. During the twentieth century, this began to change as nurse practitioners had their scope of practice expanded to include prescribing medicine (Bellaguarda, Nelson, Padilha & Caravaca-Morera, 2015). Nurses have had a major impact on how doctors prescribe medication because they know more about their patients’ preferences and needs. Because they also work as nurses, they have a base knowledge of their patients which gives them an advantage when prescribing medication (Elder, Evans & Nizette, 2009).

Prescribing authority is the ability of a healthcare provider to independently provide patients with prescriptions without having to consult a doctor. The extent of nurse prescribing varies in the country or state in which they practice (Stokowski, 2018).  The types of medications that nurse practitioners prescribe based on research from the US, New Zealand, the UK and Canada are pain medication, hypertension drugs and antimicrobials. In Australia, pain medication and anti-infective drugs are the most commonly prescribed medication by nurse practitioners (Fong, Buckley & Cashin, 2015).

Prescribing authority can be independent or supplementary. Independent prescribers have the responsibility to perform an assessment of the patient and prescribe the necessary medication that will treat the diagnosed condition (Kroezen, Dijk, Groenewegen & Francke, 2011). Supplementary prescribing is where an independent prescriber (doctor or dentist) voluntarily partners with a supplementary prescriber (nurse or pharmacist) to prescribe medication. This is after the supplementary prescriber has assessed and diagnosed the patient. This form of prescribing is a collaborative or consultative approach with the doctor because direct supervision is not required (Kroezen et al., 2011).

Issues Affecting Nurse Practitioners Prescribing

In a lot of countries, nurse practitioners face limitations when it comes to prescribing controlled drugs which are medications that have a high potential for being abused and lead to severe dependence. These drugs fall under Schedule II, III and IV controlled medication. Examples include oxycodone, fentanyl, Adderall, morphine, Dilaudid, methadone, Demerol, steroids, ketamine, xanax, Ativan, Tylenol with Codeine and Valium (DEA, 2018). In Canada, there is an effort to have nurse practitioners give prescriptions for controlled drugs especially in primary healthcare to improve access to healthcare and the quality of services being provided in health facilities (Ambrose & Tarlier, 2013).

Many people in the country visit health facilities to get prescriptions for pain medication many of which fall under the controlled substances category (Ambrose & Tarlier, 2013). Canadian medical doctors and dentists are the only professionals allowed under federal law to prescribe pain medication. This has led to frustration with the nurse practitioners because they are unable to write prescriptions for patients suffering from chronic pain. This barrier also limits the number of patients they can treat and it increases patient wait times when they have to consult with physicians, who also have their patients, to get a prescription (Ambrose & Tarlier, 2013, p.60).

In the United States, a report by the Institute of Medicine (IOM) identified that nurse practitioners faced stringent legislation on prescribing authority (Iglehart, 2013). According to a study done by Gadbois, Miller, Tyler and Intrator (2015) between 2001 and 2010, states such as Montana, New Hampshire, Washington and Alaska had the least amount of restrictions for nurse prescribing. The study found that in Florida and Alabama, nurse practitioners were not allowed to prescribe controlled substances while in most of the other states a physician was required to provide a prescription or oversee the nurse’s prescribing authority (Gadbois et al., 2015).

The IOM found variations in practice regulations for nurses because in some states they were allowed to examine patients and provide prescription services without having any physician supervision or collaboration (Iglehart, 2013). Sixteen states together with the District of Columbia allowed nurse practitioners to perform assessments, diagnosis and prescription services for their patients without collaborating with physicians or having their supervision (Iglehart, 2013). Nine states in the US required these nurses to have physician involvement when they prescribed medication but not when they diagnosed or treated patients.

Twenty four states required physician involvement when nurse practitioners were diagnosing, treating and prescribing medication. There has been very slow progress in recent years to have these restrictions removed even with their expanding scope of practice (Iglehart, 2013). The figure in the appendix demonstrates physician involvement in the various states.

There has been an expansion on nurse prescribing in the United Kingdom as a result of changing government policies. Community based nurses in the 1990s were able to prescribe medication independently from a limited list of drugs especially for wound management and bowel care. Changes in legislation in 2006 saw nurse practitioners being able to prescribe medication that was listed under their scope of practice to treat conditions (Avery & James, 2007). In recent years, nurse practitioners in the United Kingdom work as independent prescribers and have a responsibility to diagnose, treat and prescribe medication to their patients in primary and secondary healthcare (McIntosh, Stewart, Forbes-McKay, McCaig & Cunningham, 2016).  

They are referred to as non-medical healthcare professionals (NMP) because they have education, training and skills to prescribe medication. This category also includes pharmacists, physiotherapists and paramedics (Graham-Clarke, Rushton, Noblet & Marriott, 2018). The United Kingdom and Ireland are the only two countries with fair restrictions on prescribing where doctors and nurse practitioners have equal jurisdiction. Many countries such as Canada, the United States, Australia, New Zealand and Sweden impose very restrictive conditions on the independent prescribing authority of nurse practitioners while physicians continue to maintain an exclusive jurisdiction in prescribing (McIntosh et al., 2016).

This has led to subordinate jurisdictions in the mentioned countries because nurses are giving prescriptions to harmless medication which are seen as routine while the more complex prescriptions are handled by medical doctors. Countries such as Sweden place a restriction not only on the type of medicine nurse practitioners can prescribe but also on the type of patients they are allowed to examine and treat (McIntosh et al., 2016). The table in the appendix provides an overall prescriptive authority for nurses in Western European and Anglo-Saxon countries.

The concept of nurse prescribing is fairly new in Australia because it was established recently. Two thirds of nurse practitioners in Australia are allowed to prescribe medication as part of their scope of practice (Dunn, Cashin, Buckley & Newman, 2010, p.155). Legislation that allows nurse practitioners to prescribe has been passed in all the states and territories of Australia apart from the Northern Territory where it is still being reviewed. The scope of practice is usually spread across the national and state jurisdictions (Dunn et al., 2010).

A study conducted by Dunn et al., (2010, p.154) revealed that Australian nurse practitioners faced a lot of barriers when it came to prescribing because of restrictive legislation that was inconsistent and complex. The nurses had full legislative authority in all the states but the types of medication they could prescribe and the ability of the pharmacist to dispense this medication according to the prescription proved to be inconsistent. The Australian Medical Association has also voiced its objections to nurse prescribing which has led to constraints in expanding their scope of practice in the healthcare system (Dunn et al., 2010).

There are nurse practitioner practice protocols in some organizations that are meant to restrict the practice of these nurses. Dunn et al. (2010, p.154) argue that the use of these protocols is dangerous because it leads to the loss of independence and critical thinking skills resulting in misdiagnosis of patients and poor decisions. They also limit and restrict the capabilities of nurse practitioners to work independently and utilize their advanced training to treat patients at the primary level of healthcare. This reduces their overall contribution in providing efficient, effective and quality care in the Australian health system (2010, p.154).

How to Manage Issues of Prescribing within Legal and Professional Boundaries

In the US, the (IOM) developed a report in 2010 with recommendations that nurses should be allowed to practice without any restrictions or policy barriers and be able to partner with doctors fully (Altman, Butler & Shern, 2016). The IOM report has influenced the Federal Trade Commission (FTC) to put pressure on legislators in Missouri and Tennessee to allow nurse anesthetists to provide pain management without doctor supervision to patients suffering from chronic pain. Before this, the FTC targeted health markets that were not competitive and it mostly focused on promoting policies that were more politically based than consumer oriented (Iglehart, 2013).

Nurse practitioners need to know the limitations imposed on their profession to continue prescribing in a safe way. They also need to update their training to reflect current practice standards which in turn increases stakeholder confidence (Blanchflower, 2013). Physicians and other providers also need to play a supportive role when working with nurse practitioners to reduce waiting times (Carr, Layzell & Christensen, 2010, p.177). To expand the role of nurse prescribing, legislation needs to be created that supports the role of nurse practitioners in this field. Until this is done, nurse practitioners have to continue observing the law that governs their practice of prescribing medication.

From my observations during my work placement, nurse practitioners lacked support in prescribing medication from the doctors who worked in the unit. The doctors believed they had the sole jurisdiction and authority to write orders for their patients. This created some delays in getting medications for patients who needed new orders urgently because the nurse had to request for a prescription from the doctor. At times, the doctors did not stay for long in the unit because they had a lot of patient rounds. This created difficulties for the nurse practitioner especially if a patient developed complications and needed new medicine. The nurse would have to go looking for the doctor as he did his rounds in-order to get a prescription.

In my view, allowing nurse practitioners to have independent authority is very beneficial in provide efficient healthcare. Doctors are overwhelmed already with huge patient loads and it creates difficulties when urgent medication orders are needed to address a patient’s changing medical condition. Allowing nurse practitioners to prescribe without having requesting prescriptions from doctors or having their supervision will decrease waiting times and prevent safety issues during the care process. For nurse prescribing to be a success, doctors need to be supportive and create an environment that fosters partnership.

Conclusion

The barriers that were highlighted in the paper were restrictive legislation on the practice of nurse practitioners, lack of support especially from medical doctors and restrictive prescribing authority. The issue that was selected for this topic was prescribing authority and it was examined based on existing legislation in Canada, the United Kingdom, the US and Australia. While these countries have legislation that governs the scope of nurse prescribing, it was only the United Kingdom that had the least restrictive legislation.

Countries such as the US, Canada and Australia had stringent laws which made it hard for nurse practitioners to have a full prescribing authority. The study found that in the United States, nurse practitioners can prescribe independently in some states while in others they need physician supervision for prescriptions only. In other states, nurses required doctor supervision during patient diagnosis, treatment and prescription while in states such as Florida and Alabama nurse practitioners had no prescribing authority especially for controlled medications.

In Canada, it was only doctors and dentists that were allowed to prescribe pain medication. In Australia nurses faced protocols in health institutions which limited their independence to practice and restricted their ability to prescribe. For nurse practitioners, overcoming restrictions placed on their practice will remain difficult as long as the current laws exist. Until changes are made to existing legislation, they must continue to provide safe, effective and quality care when diagnosing, treating and prescribing.

References

Altman, S.H., Butler, A.S., & Shern, L. (2016). Assessing progress on the Institute of Medicine report ‘the future of nursing’. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK350168/#sec_000030

Ambrose, M.A., & Tarlier, D.S. (2013). Nurse practitioners and controlled substances prescriptive authority: improving access to care. Nursing Leadership, 26(1), 58-69. Retrieved from https://pdfs.semanticscholar.org/4314/f404a745e361fef70e729d50386ffdf5578f.pdf

Avery, A.J., & James, V. (2007). Developing nurse prescribing in the UK. BMJ, 335(7615), 316. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1949441/

Bellaguarda, M.L., Nelson, S., Padilha, M.I., & Caravaca-Morera (2015). Prescriptive authority and nursing. a comparative analysis of Brazil and Canada. Revista Latino-Americana De Enfermagem, 23(6), 1065-1073. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664006/

Blanchflower, J. (2013). Breaking through barriers to nurse prescribing. Nursing times, 31(32), 12-13. Retrieved from https://www.nursingtimes.net/clinical-archive/medicine-management/breaking-through-barriers-to-nurse-prescribing/5061983.article

Buchsel, P.C., & Yarbro, C.H. (2005). Oncology nursing in the ambulatory setting: issues and models of care. Massachusetts, United States: Jones and Bartlett Publishers.

Carr, E., Layzell, M., & Christensen, M. (2010). Advancing nursing practice in pain management. West Sussex, United Kingdom: Blackwell Publishing.

Cowen, P.S., & Moorhead, S. (2011). Current issues in nursing. Missouri, United States: Mosby Elsevier

DEA (2018). Drug scheduling: drug schedules. Retrieved from https://www.dea.gov/drug-scheduling

Dunn, S.V., Cashin, A., Buckley, T., & Newman, C. (2010). Nurse practitioner prescribing practice in Australia. Journal of the American Academy of Nurse Practitioners, 22, 150-155. Retrieved from https://www.cdu.edu.au/sites/default/files/nurseprac.pdf

Elder, R., Evans, K., & Nizette, D. (2009). Psychiatric and mental health nursing. New South Wales, Australia: Elsevier Australia.

Fong, J., Buckley, T., & Cashin, A. (2015). Nurse practitioner prescribing: an international perspective. Nursing: Research and Reviews, 5, 99-108. Retrieved from https://www.dovepress.com/nurse-practitioner-prescribing-an-international-perspective-peer-reviewed-fulltext-article-NRR

Gadbois, E.A., Miller, E.A., Tyler, D., & Intrator, O. (2015). Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010. Medical Care Research Review, 72(2), 200-219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730953/

Graham-Clarke, E., Rushton, A., Noblet, T., & Marriott, J. (2018). Facilitators and barriers to non-medical prescribing: a systematic review and thematic synthesis. PloS One, 13(4). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5927440/

Iglehart, J.K. (2013). Expanding the role of advanced nurse practitioners: risks and rewards. The New England Journal of Medicine, 368, 1935-1941. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMhpr1301084

International Council of Nurses (2018). Definition and characteristics of the role. Retrieved from https://international.aanp.org/Practice/APNRoles

Kroezen, M., Dijk, L., Groenewegen, P.P., & Francke, A.L. (2011). Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature. BMC Health Services Research, 11, 127. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141384/

McIntosh, T., Stewart, D., Forbes-McKay, K., McCaig, D., & Cunningham, S. (2016). Influences on prescribing decision-making among non-medical prescribers in the United Kingdom: systematic review. Family Practice, 33(6), 572-579. https://doi.org/10.1093/fampra/cmw085

Stewart, J.G., & DeNisco, S.M. (2018). Role development for the nurse practitioner. Burlington, United States: Jones and Bartlett Learning.

Stokowski, L.A. (2018). APRN prescribing law: a state-by-state summary. Retrieved from https://www.medscape.com/viewarticle/440315