“A lot of people aren’t aware that their general practice nurse (GPN) can prescribe. They feel they have to attend the GP first where in actual fact there are other options,” says Sonja Corrigan, public relations officer of the Irish General Practice Nurses Educational Association (IGPNEA).
“There is a lot of shared work within general practice and a lot of time saved for GP consultations in coming to the nurse first.
“As nurses, we have an ever-expanding role. Being able to prescribe is good for us, good for the patient and good for the GPs.”
Sonja, who is also a midwife, has been a qualified nurse prescriber since 2016. Qualification for this role comes after gaining a professional diploma in prescribing medicinal products. The study involves pharmacology, health assessment and prescribing practice.
This prepares the nurse or midwife for registration with the Nursing and Midwifery Board of Ireland (NMBI) as a registered nurse prescriber (RNP) or a registered midwife prescriber (RMP).
Between the HSE and private health service providers, there are 1,904 nurses and midwives registered* as nurse/midwife prescribers with the NMBI.
“Nurse prescribing enhances the role of the nurse and improves the quality and standard of patient care. This is well documented. It is framed by practice protocols and guidelines ensuring safe prescribing,” Sonja says.
* As of 31 December 2021.
Conditions they can prescribe for
As generalists, there are many conditions for which the GPN can prescribe. These include immunisations, chronic disease (a rapidly expanding part of the GPN role) such as asthma and diabetes, hypertension, soft tissue infections and minor injuries as well as women’s health needs eg family planning.
Sonja advises finding out what services your practice provides.
“Many practices have excellent websites where services can be booked online. Find out if there is a practice nurse. If you require a repeat pill prescription or have a women’s health issue, there may be no need for you to see a doctor first. It’s about being aware that whether the GPN prescribes or not, she/he provides a range of services including immunisation, cervical screening, wound care, ear syringing, health promotion and general advice where needed. A phone consultation with the nurse may suffice so if in doubt, ask.”
Norma Caples is an advanced nurse practitioner in heart failure and is employed by University Hospital Waterford (UHW). Norma runs a diagnostic and titration heart failure clinic in Dungarvan Primary Care Centre, assessing patients with heart failure early on and adjusting their medication as required.
Heart failure means that the heart has become weak or stiff and is unable to pump blood around the body properly. Medication is prescribed to relax blood vessels to lower blood pressure, improve blood flow and decrease the strain on the heart.
Norma has been nurse prescribing for over nine years after recognising the need for it when she was working as a clinical nurse manager in the coronary care unit in University Hospital Waterford (UHW).
“Another nurse and myself felt that if we were nurse prescribers, we could prescribe medication for patients being discharged from hospital rather than having to ring the doctor and take him or her away from whatever job they were at, to write the prescription.
“We told management that we felt that it would be a huge saver of doctors’ time and that we could make an impact in our area so we went on to do the training from there.”
More efficient system
Norma has since moved into working in the community, where she also recognises the value of nurse prescribing.
“Having a heart failure clinic in the community – in this case, Dungarvan – has made the whole system way more effective and efficient for patients,” she says.
“Before, in the hospital, I’d have to go get a prescription from the doctor but, with the time I’m saving, I can see extra patients and now they’re getting treatment quicker as well.
“Instead of them being on a waiting list of two years to see a consultant, GPs can refer them straight to me at the new clinic (because I can prescribe) and patients coming in via the hospital’s central referral system can also be referred to me if they meet certain criteria. Staff there look out for keywords in referrals and know when to refer a person to me.”
Referral usually kicks in if the person’s NT-Pro BNP blood test shows a reading over 2,000pg/ml (picograms per millilitre) she says.
“This specific blood test is a marker of stress on the heart wall and if the reading is greater than this, the GP or person in central referrals refers them directly to me. I will then see the patient, with same day ECHO (echocardiogram – an ultra sound of the heart), within two weeks. If diagnosed they are started on baseline heart failure medication. Here in Dungarvan, 104 patients have availed of this service at this clinic already and their NT-Pro BNP figure reduced by over 50% in four weeks so it just shows the impact of early treatment being available.”
Nurse prescribers being able to initiate early treatment means that people avoid hospital stays too.
“Every time a person with heart failure is admitted to hospital with a build-up of fluid caused by heart failure,” Norma explains, “the efficiency of their heart is deteriorating so that’s avoided by being treated early. For someone aged 55, for example, getting an early diagnosis and treatment adds on eight and a half years survival to them so it has a huge impact.”
All this means cost savings for the health service too, of course.
“The quicker we can get a diagnosis and treatment for a patient the better the outcome and the less resources are used by the hospital. The money saved can then be used to treat other people on waiting lists.”
Another major advantage of nurses being able to prescribe medication is that it improves medication compliance among patients, she states.
“Compliance is generally poor and the more medication people go on, the more likely they are not to comply properly but it’s usually down to misunderstanding and miscommunication. When they get educated about it, they understand why they have to take it so the compliance rate goes up. Education is a huge part of prescribing,” she says.
It was only when Norma trained as a nurse prescriber that she realised patients needed more explanation around how and when to take medication.
“When I became a nurse prescriber, I realised that patients may not be taking medication the way they were supposed to, for example, they were maybe taking blood pressure medication twice a day, yes, but they were taking it in the morning and again at lunchtime rather than with a 12-hour time frame between.
“In that situation their blood pressure might go down because they took the medication too early. Then they would go to the GP and might be taken off that tablet because it’s deemed ‘not tolerated’ even though it actually could be lifesaving for them and they only had problems because they were taking it at the wrong time.”
As nurse prescribers, nurses like Norma can explain how to take it and patients can ring them at the clinic if they have an issue.
Because nurses meet patients on a regular basis, they build up a rapport with them and people are then more likely to ask questions, she believes. “Some older people might be a bit in awe of consultants and unlikely to ask enough questions, so the rapport with nurses helps with compliance.”
Feedback from patients shows the importance of explaining things well.
“‘Nobody ever explained why I’m taking the tablets’ and ‘you’ve explained it in easy language’ – we get that feedback a lot. It’s the understanding. If it’s a cardiac issue, people might go from never having been on medication to suddenly ending up on eight tablets and not understanding why or the importance of taking them.”