Here comes the fear again

November 12, 2005 -- Two recent press pieces highlight the reaction from organized medicine to the seemingly inexorable increase in nurses' authority to prescribe medications. In a good November 10 piece in the Guardian, John Carvel reported that U.K. health secretary Patricia Hewitt would outline plans to give experienced nurses--not just nurse practitioners (NPs)--the "right to prescribe almost every medicine in the national formulary," a "historic move that smashes the demarcation barrier between doctors and nurses." The piece described the British Medical Association (BMA) reaction as one of "outrage," with a representative citing the usual training and "patient safety issues." Today, New Zealand's Stuff site ran a generally fair piece from The Press (Christchurch) about the aggressive reaction by local physicians to plans to expand prescription rights for NPs. The report, by Mike Houlahan and Amanda Warren, gives somewhat more play than the Guardian item did to the "scathing" physician attacks. Articles in the New Zealand Medical Journal have argued that nurse prescription would be unsafe because NPs have less formal training than physicians. Both the U.K. and New Zealand pieces seem to reflect a growing realization by policy makers that many people are not getting adequate care under current health systems, and perhaps a sense that the "sky-is-falling" warnings about nurse prescription have no scientific basis.

Carvel's Guardian piece, "Nurses to get far-reaching prescribing powers," reports that Hewitt's move to give patients quicker and more effective access to medicines will also "give a huge boost to the clinical status of nurses." It says the proposed legislation permits nurses to "treat every aspect of a patient's illness, including diagnosis, prescription and monitoring, without supervision by a doctor," with the exception of prescribing "a few controlled drugs such as diamorphine." The piece notes that pharmacists are set to gain similar prescription rights.

Much of the piece explores the "fierce argument" the proposals have provoked between physicians and their health care colleagues. A representative of the BMA, which had fought the proposals, said the group thought it was all right for nurses and pharmacists to prescribe from a "limited range" of medications, but that "only doctors" had the "diagnostic and prescribing training" to handle the full range. He cited undefined "patient safety issues" and pronounced the BMA "extremely concerned that the training provided is not remotely equivalent to the five or six years every doctor has undertaken." (This comment is interesting because some U.S. physicians suggest that U.S. nurse practitioners' six years of university is insufficient compared to their eight.)

The U.K. proposal reportedly allows nurses with three years experience and pharmacists to gain the new rights after undergoing an additional training course. Hewitt's prepared statement noted that nurses running clinics that manage chronic conditions like diabetes or heart disease would be able to prescribe independently, allowing general practitioners to "focus on more complex cases" and improving the availability of care. English nurses can already prescribe about 240 medicines, but that is "only a small fraction of the formulary." The Royal College of Nursing (RCN) was reportedly "jubilant." The RCN's "joint prescribing advisor" is quoted as saying that the move is "about being a maxi-nurse, not a mini-doctor, and providing the best care for the patient." He also predicted that "tens of thousands" of nurses would likely qualify in the next few years.

Carvel's description of the importance of Hewitt's proposal does not seem like hyperbole. If bedside nurses gain the power to prescribe virtually all medications, the changes in access to care and the respective roles of nurses and physicians could be immense. Some might see it as a step toward a world that recognizes nurses' central role on the health care team and sees most physicians generally as important, highly trained technical specialists. That, of course, could explain the BMA's reaction.

The Stuff piece puts somewhat more emphasis on the warnings of some New Zealand physicians about the expansion of NP prescribing due to begin on December 5. "Mistakes predicted if nurses prescribe" leads with the idea that "[p]atient safety is under threat" because of the specter of NP prescription, "senior Christchurch doctors claim in an attack described as a public warning." Clinical pharmacologist "Professor Evan Begg" co-authored the "scathing" article in the New Zealand Medical Journal saying that the changes would damage "medical teamwork" and threaten patient safety. The piece quotes Begg as saying that even physicians make mistakes, and that "people who are trained less will make more mistakes." But just to show that he does recognize the many years of rigorous university science training it takes to become an NP, Professor Begg offers this flattering analogy: "Would you like to go to Australia in an aeroplane piloted by one of the flight crew who had some extra training?" Begg's article reportedly questioned NP training directly, suggesting that, although the NPs will be limited to administering drugs in their areas of expertise, only physicians have the comprehensive knowledge base to assess the potentially complex medication interactions involved. The piece also notes that the chairman of the New Zealand Medical Association, Dr. Ross Boswell, previously described the planned expansion of NP prescription authority as "loony." We're not quite sure, but we think that's an advanced medical term meaning "inadvisable."

Not surprisingly, New Zealand nurses have a different view. The Nursing Council reportedly cited a lack of "evidence to support the doctors' claims." Spokeswoman Annette Huntington also pointed to the "large body of international evidence" indicating that NPs are safe. To prescribe, the NPs would be required to have four years of experience in their specialties (even beyond their general nursing experience), to have "a clinically focused master's degree," and to complete a "registration process which would probably include doctors on the panel." The article does not say so, but we note that physicians are permitted to prescribe medications with far less relevant experience than this. The piece reports that Nursing Organisation chief executive Geoff Annals argued that the risk of error from NPs was no greater than with physicians, and noted that the move would increase access to care among those currently in great need of it.

Health Minister Pete Hodgson echoed that point, stressing that the prescribing NPs would provide increased "flexibility" and access to care in needy rural areas. Hodgson also noted that, if anything, New Zealand was (as the article put it) "behind the times" in making the change, in view of the 3,000 NPs in Britain and "more" than that in the U.S.

We thank these journalists, especially John Carvel, and their respective publications for covering these important developments in the ongoing expansion of nurses' scope of care.

See a Press Zoom article on the story.

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