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Nurse prescribing FAQ

  • Last modified date:
    22 March 2010

Frequently asked questions about nurse prescribers, which medicines they can prescribe for which conditions, and what training is involved.

Types of prescriber and scope of nurse independent prescribing

Q: What is independent prescribing?

A: Independent prescribing is prescribing by a practitioner eg. doctor, dentist, nurse, pharmacist or optometrist responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management, including prescribing.

Q: What can Nurse Independent Prescribers prescribe?

A: Any medicine for any medical condition within their competence, including some controlled drugs for specified medical conditions.

Q: What can Community Practitioner Nurse Prescribers prescribe?

A. Community Practitioner Nurse Prescribers may only prescribe the dressings, appliances and licensed medicines listed in the Nurse Prescribers' Formulary for Community Practitioners.

Prescribing unlicensed medicines and ‘off-label’ / ‘off license’ prescribing

Q: Can Nurse Independent Prescribers prescribe unlicensed medicines?

A. Yes, following changes in December 2009, Nurse Independent Prescribers can prescribe unlicensed medicines for their patients, on the same basis as doctors, provided that they are competent and take responsibility for doing so.

Q: Can Nurse Independent Prescribers and Community Practitioners prescribe medicines ‘off-label’ or ‘off-license’ ?

A: Qualified Nurse Independent Prescribers are able to prescribe medicines ‘off-label’ or ‘off-license’.
However, Nurse Independent Prescribers must take full clinical and professional responsibility for their prescribing and should only prescribe ‘off-label’ where it is best practice to do so.

Community Practitioner Nurse Prescribers do not undertake the same depth of prescribing training as Nurse Independent Prescribers and should not prescribe medicines ‘off-label’ / ‘off-license’, apart from the exception below.

Nystatin – Prescribing off-label

Community Practitioner Nurse Prescribers may exceptionally prescribe nystatin off-label for neonates. Where Community Practitioner Nurse Prescribers are absolutely clear that the diagnosis is one of oral thrush, they may prescribe nystatin at the dose recommended in the British National Formulary (BNF) for Children. An exception for nystatin is allowed on the basis that there is no systemic absorption of the product and the use of the product in treatment of oral thrush is long-established.

This decision is without precedent and there are no other exceptions for off-label prescribing by Community Practitioner Nurse Prescribers.

Community Practitioner Nurse Prescribers who prescribe nystatin off-label must be clear that they accept clinical and medico-legal responsibility for prescribing that medicine. Community Practitioner Nurse Prescribers should only prescribe nystatin 'off-label' within their own competence and where they are clear that the diagnosis is one of oral thrush.

Mixing of medicines

Q: Can Nurse Independent Prescribers mix medicines prior to administration?

A: Yes. Changes to medicines regulations came into effect from December 2009 that enable Nurse Independent Prescribers to mix medicines prior to administration, and direct others to mix.

Borderline substances

Q: Can Nurse Independent Prescribers prescribe borderline substances independently?

A: Yes, but DH guidance recommends that Nurse Independent Prescribers restrict their prescribing to the substances on the Advisory Committee on Borderline Substances approved list, in Part XV of the Drug Tariff

Use of Botox® and Vistabel® in cosmetic procedures

Q: Can Nurse Independent Prescribers independently prescribe and administer Botox® for use in cosmetic procedures?

A: Yes. A Nurse Independent Prescriber can legally prescribe and administer licensed parenteral medicines such as Botox® in cosmetic procedures on his or her own initiative.

However, the use of Botox for cosmetic treatment is outside the product’s licensed indications.  Nurse Independent Prescribers may prescribe medicines independently for uses outside their licensed indications, so called ‘off-licence’ or ‘off-label’ prescribing. They must however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe ‘off-label’ where it is accepted clinical practice.

Q: Can Nurse Independent Prescribers independently prescribe and administer Vistabel® for use in cosmetic procedures?

A: Yes. A Nurse Independent Prescriber can legally prescribe and administer licensed parenteral medicines such as Vistabel® in cosmetic procedures on his or her own initiative.

Q: Can Nurse Independent Prescribers order and receive supplies of Botox® and/or Vistabel®?

A: No. The law as it currently stands prohibits this activity and there is no intention to change this in the foreseeable future. The changes to legislation to introduce nurse independent prescribing were based on the long standing principle that a prescriber prescribes and that his or her prescription is then dispensed by a pharmacist.

Nurse Independent Prescribers can administer medicines themselves and authorise others to do so under their patient specific direction. The Department of Health and the MHRA do not consider that there are compelling grounds for reviewing the position.

Q: Are nurses able to issue private prescriptions?

A:  Nurse Independent Prescribers can issue private prescriptions for any medicine within their competence, including some controlled drugs for specified medical conditions.

Q:  Are Nurse Independent Prescribers able to give directions to a non-prescriber for the administration of a medicine?

A:  Yes. A qualified Nurse Independent Prescriber may give directions for the administration of any product he or she is legally allowed to prescribe ie a medicine for a condition within his/her competence. The prescribing nurse  needs to be satisfied that the person to whom he or she gives the instructions is competent to administer the medicine concerned.

Q:  Are nurses able to prescribe or supply blood or blood products on the NHS?

A:  Blood, including the cellular elements that are packaged for use as ‘packed cells’ and platelets, is not considered to be a medicinal product and is therefore outside the ambit of the Medicines Act and its subsequent amending Regulations. The ‘prescribing’ of blood for a patient is not therefore appropriate for nurse independent prescribing or for supply under the terms of a Patient Group Direction (PGD). Nurses should discuss the current local policy regarding ordering of these products with their Trust's haematology department. Consideration could be given to developing local guidelines for the ordering and supply of blood, based on the format of a PGD.

However, products derived from the plasma component of blood such as blood clotting factors, antibodies and albumin are considered to be medicinal products and are required to have marketing authorisations. These products may be prescribed by Nurse Independent Prescribers or as part of a supplementary prescribing arrangement. It may also be sensible to discuss any proposed prescribing with the Trust’s Haematology Department, in advance.

Prescription forms

Q: What prescription forms should Nurse Independent Prescribers use?

A: Further information on prescription forms, including the types of form and how to order supplies of these, is available in the Department of Health’s prescribing implementation guidance and via the NHS Business Services Authority website.

Training

Q:  Who will decide which nurses are eligible to be trained as prescribers?

A:  Nurses must first meet the eligibility criteria as determined by the Nursing and Midwifery Council. Once these are met, it is a matter for local decision, in the light of local NHS need, benefit and circumstances. No nurses will be required to undertake training for prescribing unless they wish to do so. There should also be a local need for them to prescribe and for the service.

Q: Can nurses employed by prisons or charitable and private organisations outside the NHS undertake prescribing training?

A: Yes – nurses employed outside the NHS may also apply to undertake prescribing training.  Nurses employed by charitable organisations and who provide the majority of their services to NHS patients can also be considered for SHA funded prescribing training from the Multi-Professional Education and Training (MPET) levy. Other non-NHS nurses will need to identify an alternative source of funding.

The Nursing and Midwifery Council’s ‘Standards of proficiency for nurse and midwife prescribers’ are available on the NMC website. They include standards for training and an outline curriculum.

Accountability

Q:  Who bears legal and professional responsibility for the actions of nurse prescribers?

A:  Nurse Independent Prescribers are professionally responsible for their own actions. Where a nurse is appropriately trained and qualified as an independent prescriber, and prescribes as part of his or her nursing duties with the consent of the employer, the employer may also be held vicariously responsible for the nurse's actions. The Department's guide to implementation of nurse independent prescribing,  advises all nurse prescribers to ensure that they have professional indemnity or insurance - for example through membership of a professional organisation or trade union.

Funding

Q: What funding will be provided to support prescribing training in the future?

A: DH provides funding to SHAs through the Multi-Professional Education and Training levy.

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