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Why has the Nurse Practitioner been granted
Prescribing Privileges?
Journal of Pharmacy Practice and Research Volume 40, No. 4, 2010.
First November 2010 saw the enactment of legislation pertaining to nurse practitioners and midwives and their access to the Medical Benefits Schedule and the Pharmaceutical Benefits Scheme. The Federal Health Minister, the Honorary Nicola Roxon announced: ‘For the first time, Nurse Practitioners are able to access relevant new items under the Medicare Benefits Schedule and to prescribe certain medicines under the Pharmaceutical Benefits Scheme'.
Background
The role of the nurse practitioner is not new in the international world of health professionals. In the UK, Canada and USA, the nurse practitioner role for advanced practice clinicians has been in place for over 50 years. The roles and scope of practices provide health services for under-served populations and enhance timely and efficient care in over-utilised services, with nurse practitioners as integral members of healthcare teams.
The introduction of nurse practitioners into the Australian professional health workforce was first mooted in 1990 but it was not until 2001 that the first nurse practitioner was appointed (in a remote area without a practising doctor). The intervening 11 years were challenging with a somewhat misinformed media campaign being waged by medical groups against the role.
Following the first few appointments of nurse practitioners in New South Wales, a momentum built up across the country as more nurses with advanced skills and a passion for what they did were able to gain the qualifications necessary to be authorised in the role. At the same time, doctors who worked alongside nurse practitioners began to speak out in support, negating the adverse effects of the negative press. Thus, while the movement began slowly in 1990, in 2010 there are over 400 nurses in various roles and they are represented by the Australian College of Nurse Practitioners.
The relatively recent (10 years) recognition in Australia of the nurse practitioner as an authentic healthcare provider has been chiefly driven by the needs of the health system. Most pertinent drivers have been the fragmentation in continuum of care for patients, diminishing funding sources and the threat of workforce shortages. Federal and state healthcare reform and productivity papers over the past 20 years that have reviewed the status of the Australian health system and workforce, confirm these facts and concerns. Meanwhile, international evidence confirms that nurse practitioners deliver safe and effective care to patients, families and communities with many working in rural and remote communities as the only health professional.
Why the nurse practitioner?
The Australian Nursing and Midwifery Council defines a nurse practitioner as: a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. This role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health professionals, prescribing medications and ordering diagnostic investigations.
Nurses holding the legally protected nurse practitioner title must be authorised by the Australian Health Professional Regulatory Agency. The nurse practitioner title is fundamental to making the distinction and constitution for the nurse practitioner scope and role. The authorisation to use this title requires a registered nurse to complete rigorous academic and clinical training, such as Masters in Nurse Practitioner (up to 4 additional years of postgraduate education) and the development of an advanced practice specialty with 3 years experience. The core units for a Masters in Nurse Practitioner include: advanced health and physical assessment, advanced pharmacology, diagnostics and management and evidence-based practice.
Up until 1 November 2010, the full capacity of the nurse practitioner to practice at the advanced and extended clinical scope had been inhibited by lack of access to the Medical Benefits Schedule and the Pharmaceutical Benefits Scheme. Leading up to 1 November many nurse practitioners hoped for a tsunami of change and opportunity for non-medical health disciplines hoping to gain prescribing rights. However, things are not quite what they seem, and change seems to be more of a ‘ripple' effect.
What does this mean for pharmacists?
The Medical Benefits Schedule provider numbers will only be made available to nurse practitioners employed in the private sector or in private practice. Nurse practitioners employed in the public sector remain ineligible. This means that the majority of the 400 nurse practitioners will not have access to the ordering of pathology and diagnostic services, nor the ability to provide referrals to specialists and consultant physicians. Nurse practitioners employed in the private sector or private practice will have not only pathology/diagnostic ordering and referral rights, but the opportunity to use four different Medical Benefits Schedule items for consultations ranging from a few minutes to over 40 minutes duration.
In terms of attaining a Pharmaceutical Benefits Scheme prescriber number, processes are a little more complicated. Authorised nurse practitioners working in all areas of health (public and private) can formally apply for a Pharmaceutical Benefits Scheme prescriber number.
However, the clinical use of a prescriber number is valid only in those health services and states that are formally part of the Pharmaceutical Reform Agreement. This excludes three states and territories who have not formally signed this agreement.
There are additional layers to having authorisation to prescribe medications available on the Pharmaceutical Benefits Scheme determined by the Pharmaceutical Benefits Advisory Committee. Under the General Schedule - Section 85, there are four sections applicable to nurse practitioners:
1. unrestricted;
2. continued therapy only model;
3. shared care model; and
4. no access at this time.
Prior to reviewing patients, nurse practitioners must first enter into formalised collaborative arrangements with one or more specified doctors. Several examples of such arrangements are described in the National Health (collaborative arrangements for nurse practitioners) Determination 2010.
For a prescription to be eligible for subsidy, nurse practitioners must ensure that they prescribe medications available on the Pharmaceutical Benefits Scheme and in accordance with the restrictions listed for their prescriber type. Listing details for a medication product may differ between sections and different Pharmaceutical Benefits Scheme item codes apply for each prescriber type.
Nurse practitioner Pharmaceutical Benefits Scheme prescriptions are identifiable by colour, and include the indicator ‘NP'. In addition, ‘NP' medicines are identified by the codes ‘CTO' for continuation therapy only, or ‘SCM' for prescribing within a shared care model. ‘Continuation therapy only' is when the treatment and prescribing of a medicine has been initiated by a doctor but prescribing is continued by a nurse practitioner, if within their scope of practice. (Similar to existing arrangements between specialists and doctors for prescribing certain medicines.)
The journey towards non-medical prescribing continues. The changes that started on 1 November 2010 should be viewed as an important step, but one part of a much larger process for logical and streamlined healthcare delivery. Challenges and barriers remain and it is time to acknowledge what has been achieved so far and what remains to be addressed in the future.
Professor Judy Lumby, AM, RN, PhD, NP
Emeritus Professor, University of Technology Sydney
Adjunct Professor, The University of Adelaide
Adjunct Professor, The University of Sydney
Director, Joanna Briggs Foundation Inc
The University of Adelaide
Adelaide SA 5001
Michelle Robins, RN, NP, CDE, MRCNA
Credentialled Diabetes Educator
Community Diabetes Education Manager
Michelle Woods, BS, RN, GradCert (Emerg Nurs),
GradDip (Health Prom & Ed), MS (Nurs Pract), ND
(Nurs Doctorate)
Journal of Pharmacy Practice and Research Volume 40, No. 4, 2010. 261
Coordinator and Lecturer in Community and Rural
Nursing
School of Nursing and Midwifery
University of Tasmania
Hobart Tas. 7000
E-mail:
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