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Implementing Nurse Practitioner Prescribing
on behalf of the College of Nurses Aotearoa (NZ)
Introduction
The College of Nurses considers prescribing to be a vital function of
the Nurse Practitioner role and essential to consumer access to effective
care. We consider implementation of nurse prescribing to be long overdue
and sincerely hope that this will be the last submission we make on the
issue. This submission represents the core College position but various
sections within the College may make additional submission on points of
relevance to their specialty practice concerns or population group of
interest. We have previously submitted at length on this issue so confine
ourselves mainly to the specific questions asked.
Question 1: Do you think that the proposed monitoring of the
Nurse Practitioner prescribers is adequate?
The consultation document outlines how the Nursing Council of New Zealand
and the Ministry of Health will monitor Nurse Practitioner prescribing.
Ongoing assessment and evaluation of all prescribers is an essential public
safety mechanism, however it is the view of the College that the proposed
monitoring (annual audit) is excessive and far more than is expected of
other disciplines. The College understands these monitoring requirements
are in accordance with the requirements under the Heath Practitioners
Competency Assurance Act. This explanation is unclear and does not explain
the discrepancy with other prescribers. In addition we are concerned at
the volume of work this will generate for the Nursing Council of New Zealand
as more and more nurse prescribers require monitoring in the proposed
manner.
Question 2: Are the criteria that were used to derive the exclusions
lists appropriate?
The process for deriving exclusion lists seems appropriate.
Question 3: Are the proposed exclusion lists appropriate?
In general, the proposed exclusion lists seem appropriate however, as
Nurse Practitioners are frequently the lead health professional caring
for individual patients, the College suggests that potential access to
the full range of medications relevant to their specialty area of practice
is essential. It is therefore suggested that a process is required to
enable application for an exemption for the use of a medication from the
exclusion list on a case by case basis.
Supplementary comments
Collaborative practice
While NPs are autonomous in their clinical practice and will have independent
prescribing responsibility, frequently the context within which we practise
is multidisciplinary in nature, promoting a collaborative approach to
care for our population groups. Furthermore, the expert clinical judgement
that NPs possess ensures that referrals are made as appropriate to medical
or allied health colleagues as the need arises. A common perceived threat
of initiation of nurse prescribing is that increasing nursing independence
will destroy the natural teamwork (i.e. be divisive) based on supposedly
previously existing, good collaborative relationships. However, the evidence
suggests a completely opposite view that collaboration is enhanced when
it is between team members who have equivalent access to power, status,
and information and who share mutual goals (Jones, 2002; Soothill, McKay
& Webb, 1995).
Nurse practitioner prescribing safety
International research has consistently demonstrated the safety of independent
nurse prescribing. The role of the nurse practitioner as an independent
prescriber in New Zealand is too new to provide comprehensive patient
safety data, therefore we turn to international data regarding the safety
of advanced nursing practice. This data tells us that in the over-35 year
history of nurse practitioners there is no evidence that nurse practitioner
services are detrimental to patient safety (Ministry of Health, 2002).
For example, a large randomised controlled trial (n = 1316) published
in the American Journal of Medicine found that there was no difference
in patient safety when the outcome of nurse practitioner care was randomly
compared to medical doctors care (Mundinger, 2002). A meta-analysis (Horrocks,
Anderson, and Salisbury, 2002) of primary health nurses that independently
diagnosed and treated from Europe, North America, Australasia, South Africa
and Japan were found to provide safe and effective care for patients in
a number of quality indicators including accurate diagnosis, patient education,
and appropriate medication use. These nurses were also found be as accurate
as medical colleagues in interpreting X-ray and laboratory data. Although
there is no comparable New Zealand data, it is clear from the international
investigations that nurse practitioners provide safe and effective care
(which includes prescribing) for the patients they serve.
We hope that all future assertions of nurse practitioner prescribing
as unsafe are vigorously challenged and not just by nurses.
Summary
Thank you for the opportunity to respond to the consultation document.
We look forward to Nurse Practitioner prescribing progressing positively
in the near future.
Professor Jenny Carryer
References
Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review
of whether nurse practitioners working in  primary
care can provide equivalent care to doctors. British Medical Journal.
324(7341), 819-23.
Jones, E. M. (2002). Interprofessional practice – the meaning for
nursing in New Zealand, In E. Papps (Ed.), Nursing
in New Zealand: Critical issues, different perspectives (pp. 138-149).
Auckland: Pearson Education
Ministry of Health, (2002). Nurse Practitioners in New Zealand,
Wellington, New Zealand.
Mundinger, M., Kane, R. L., Lenz, E., Totten, A. M., Tsai, W. Y., Cleary,
P. D., Friedewald, W. T., Siu, A. L., & Shelanski,
M. L. (2000). Primary care outcomes in patients treated by nurse practitioners
or physicians: A randomized trial. Journal of the American Medical
Association, 238(1), 59-68.
Soothill, K., Mackay, L., & Webb, C. (1995). Interprofessional
relations in health care. London, England: Edward Arnold.
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