Nurse prescribing education and formulary must change

Experts set out the conditions community nurses should be able to prescribe for

Experts set out the conditions community nurses should be able to prescribe medicines for

Picture: Science Photo Library

Prescribing is a pivotal role for community nurses (Health Education England 2015, 2016). Although community nurses view prescribing as an important element of their role (Downer and Shepherd 2010, NHS England 2014), decreasing numbers of these nurses are prescribing medicines (Young 2009). It has been reported that items included in the Nurse Prescribers’ Formulary for Community Practitioners (NPF) used by community practitioner nurse prescribers (CPNPs) do not meet the needs of the patients these nurses manage (While et al 2004, Hall and Biggs 2006, Drennan et al 2014, World Health Organization 2017). 

There is huge diversity in community and public health nursing roles globally, but typical activities of these nurses include health promotion, disease prevention and disease management (Kemp et al 2005). The available evidence suggests that there has been a shift in focus of the care provided by community nurses. For example, researchers in Australia (Kelehera and Parker 2013, Roden et al 2016), Finland (Maijala et al 2016) and Israel (Nissanholtz-Gannot et al  2017), have reported community nurses to be increasingly working in roles that involve the provision of a more 'acutely' focused episodic care with increasing involvement in health promotion activities.

The NPF has remained unchanged since its inception in 1998 and it is highly likely, given the changing population profiles and changing patterns of client and service delivery, that items in this formulary no longer reflect the prescribing needs of these nurses.  However, there is no evidence available that has explored the conditions these nurses manage. 

Consensus on formulary 

Courtenay et al (2018) adopted a modified Delphi method to reach consensus across an expert panel of 89 CPNPs (including district nurses, health visitors, school nurses and community staff nurses) on the conditions for which CPNPs should be able to prescribe. The panel identified 19 such conditions (see box, below). Consensus was achieved by district nurses and community staff nurses on several chronic conditions, whereas agreement was reached on several more acutely focused conditions across all CPNP groups. 

This work provides national guidance on the items CPNPs need to prescribe, plus international guidance for countries where prescribing by community and public health nurses is established, as well as for those countries wishing to establish prescribing by these nurses. 

The findings can also be used to direct national education and training for the preparation of community and public health nurses. Given community nurses can now access training to prescribe immediately on qualifying as a registered nurse (Nursing and Midwifery Council 2018), it would seem important to include this preparation in undergraduate nurse education programmes.

Conditions CPNPs should be able to prescribe for

District nurses

Wounds; varicose veins, varicose eczema, and leg ulcers; catheter care; constipation; dry skin; skin infections; fungal infections (skin and oral); stoma care; lymphedema 

Health visitors

Fungal infections (skin and oral); dry skin; nappy rash; mastitis; infant colic; infestations (threadworm, lice, scabies); post-immunisation fever

School nurses

Contraception and sexual health; smoking cessation; dry skin; infestations (threadworm, lice, scabies); constipation; nocturnal enuresis; skin infections; fungal infections (skin and oral); pain; post-immunisation fever; conjunctivitis 

Community staff nurses

Wounds; skin infections; constipation; pain; fungal infections (skin and oral); dry skin 



Courtenay M, Franklin P, Griffiths M et al (2018) Establishing priorities on the range of conditions managed by UK community practitioner nurse prescribers: A modified Delphi consensus study. Journal of Advanced Nursing. 74, 8. 

Downer F, Shepherd C (2010) District nurses prescribing as nurse independent prescribers. British Journal of Community Nursing. 15, 7, 348-52.

Drennan V, Grant R, Harris R (2014) Trends over time in prescribing by English primary care nurses: a secondary analysis of a national prescription database. BMC Health Services Research. 14, 54.

Hall J, Cantrill J, Noyce P (2006) Why don't trained community nurse prescribers prescribe? Journal of Clinical Nursing. 15, 4, 403-12.

Health Education England (2015) Shape of Caring Review. HEE, London.

Health Education England (2016) Primary Care Workforce Commission. HEE, London.

Kelehera H, Parker R (2013) Health promotion by primary care nurses in Australian general practice. Collegian. 20, 4, 215-21.

Kemp L, Harris E, Comino E (2005) Changes in community nursing in Australia: 1995–2000. Journal of Advanced Nursing. 49, 307-314.

Maijala V, Tossavainen K, Turunen H (2016) Primary health care registered nurses types in implementation of health promotion practices. 2016, Primary Health Care Research and Development. 17, 5, 453-6.

NHS England (2010) Five year forward view. NHS England, London.

Nissanholtz-Gannot R, Rosen B, Hirschfeld M (2017) Community Nursing Study Group. Isr J Health Policy Res. 6, 1, 69.

Nursing and Midwifery Council (2018) Standards for prescribing programmes. NMC, London.

Roden J, Jarvis L, Campbell-Crofts S et al (2016) Australian rural, remote and urban community nurse’s health promotion role and function. Health Promotion. 31, 3, 704-14.

While A, Biggs K (2004) Benefits and challenges of nurse prescribing. Journal of Advanced Nursing. 45, 6, 559-67.

World Health Organization (2017) Enhancing the role of community health nursing for universal health coverage. Human Resources for Health Observer Series No. 18. WHO, Switzerland.

Young D (2009) Nurse prescribing: an interpretative phenomenological analysis. Primary Health Care. 19, 7, 32-6.

Molly Courtenay, professor of health sciences, School of Healthcare Sciences, Cardiff University
Twitter:  @CUHealthSci

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