Nurse practitioner prescribing: an international perspective

Abstract

s, including 145 duplicates removed. Full texts of the remaining 110 articles were obtained. A further 70 articles were excluded as they did not meet the criteria pertaining to NP prescribing practices in the specific countries reviewed. Non-English and systematic reviews and other integrative review papers were also not selected, leaving 40 articles selected for the review (Figure 1). Surveys or questionnaires were the most commonly used method (n=20), followed by focus groups/interviews/expert panel review (n=10), retrospective designs (n=5), audits (n=4), and one randomized control trial (n=1). USA Nurse prescribing has been in place in the USA since the 1960s, with the purpose of reducing the workload of physicians and addressing the needs of patients in remote areas. Nurse and midwife prescribing has evolved in the USA out of the establishment of the advanced practice roles such as NP, physician assistants (PAs), and nurse–midwife. NPs were granted prescriptive privileges in 1969, when initially legislation was introduced to allow NPs to prescribe medications under the rules and regulations of the regulatory Boards of Medicine and Nursing and was limited to a dependant/ collaborative arrangement. By 2005, 13 states and the District of Columbia authorized NPs to independently prescribe, including controlled drugs. This involved state-mandated requirements for collaborative practice arrangements, between the NP and medical practitioner. There are now 21 states in America deemed to have full practice authority. This authority includes prescriptive authority without mandated collaborative arrangements. To obtain licensure in the USA as an NP, candidates must hold a master’s degree, a post-master’s certificate, or a doctoral degree in nursing from an accredited program. There is a move toward a full requirement for a doctorate as the entry level qualification. Generally, NPs are licensed by the Board of Nursing for the state in which they will practice; laws differ depending on the state. Depending on each state’s regulations, licenses must be periodically renewed, with some states requiring continuing education in order to renew licenses. Although NPs have had prescriptive authority for some time, surprisingly, there is limited research published regarding patient outcomes of NP prescribing practice in the USA. Hooker and Cipher studied the prescriptive practices of NPs, PAs, and medical practitioners by analyzing data from The National Ambulatory Medical Care Survey and found that NPs wrote significantly more prescriptions in rural areas when compared to PAs and medical practitioners. It was proposed that this may relate to more primary care NPs being located in nonmetropolitan areas compared to the number of physicians in these areas. There is no significant difference found in antibiotic prescribing by NPs compared to medical practitioners in a retrospective study of data from the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey between 1997 and 2001, which investigated NPs (n=506) and medical practitioners (n=13,692) prescribing for upper respiratory infections. It appears that in the elderly, the most commonly prescribed drugs by NPs in the USA include antihypertensive drugs, analgesics, cardiovascular drugs, and diabetic medications. In the 2004 AANP National Nurse Practitioner Sample Survey, a survey of 16,543 NPs identified that the most commonly prescribed medications were nonsteroidal anti-inflammatory drugs (NSAIDs) and antibiotics followed by antihypertensive medications, diabetic medications, contraceptives, and bronchodilators. This study reported that NPs routinely prescribe in all 50 states and in the District of Columbia, as well as in all practice settings, regardless of specialty. The types of medications prescribed in the USA support the notion that NPs employ pharmacotherapy in the management of acute and complex chronic conditions as well as health maintenance and diseases prevention. Studies that compared NP’s prescribing practices with other clinicians demonstrated the principal finding that there is no difference between NP and medical practitioners prescribing practices. Europe In mainland European countries, some nurses have prescriptive authority, although this varies among specific European countries. Sweden has had prescriptive authority for nurses since 1994, whereas the Netherlands and Spain have explored legislative and procedural amendments to allow prescriptive authority. The Finnish Government has also proposed that nurses working in national public health centers are given a limited right to prescribe medication to patients in their care. Nurse prescriptive authority was primarily implemented in Europe for similar reasons to the USA to improve the patient’s access to medicines, in particular for those in remote areas to both supplement the shortage of physicians and reduce the work load of medical practitioners. In many European countries, NPs have been practicing in the health care system for years, although the level of education can vary between countries and even within the states