Why I became an Independent Nurse Prescriber

Laura recently embarked on a journey to becoming a Nurse Prescriber - she shares why she chose this pathway in this blog!

Having worked in mental health services for 17 years and been a qualified RMN for 12 years I decided to train as an Independent Nurse Prescriber.

In this article I will talk about my journey to prescribing, what the course was like, why I wanted to be able to prescribe and how it has contributed to my current role.

History of Nurse Prescribing

Prescribing any medication is a significant responsibility and up until 1992 the role was reserved for the medical profession.

In 1992 changes in legislation meant that community nurses could legally prescribe from the then Extended Formulary for Nurse Prescribers.

Further national reviews and reports between 1997 and 2000 concluded that Nurse prescribers could expand the list of medications they could prescribe under a supervisory framework (a partnership between a Doctor and Nurse) called supplementary prescribing.

As the landscape of the NHS changed and access to healthcare changed, so too did prescribing policies.

In 2006 the Department of Health announced that Independent Nurse Prescribers would be able to prescribe any licensed medicine for any medical condition.

Nurse Independent Prescribers are also able to prescribe, administer, and give directions for the administration of Schedule 2, 3, 4, and 5 Controlled Drugs.

This extends to diamorphine hydrochloride, dipipanone, or cocaine for treating organic disease or injury, but not for treating addiction.

What drove me to consider prescribing?

Currently, to qualify as an Independent Nurse Prescriber you have to have at least 3 years post registration experience and have extensive clinical experience in your field of practice.

Ideally, you will be “sponsored” by your organisation to undertake the prescribing module.

Independent prescribing is taught either at Level 6 (degree) or Level 7 (Masters).

Before commencing the module you will need to have a Designated Medical Practitioner (DMP) identified who will be your clinical supervisor throughout the course and sign you off as competent to prescribe.

I had always taken a particular interest in the pharmacological interventions used within Mental Health Services and how they had benefited the patients I worked with.

"I knew my patients, I knew how they felt, what caused distressed, what time of day was more difficult and what worked when things became too much."

I worked on a Psychiatric Intensive Care Unit (PICU) for 9 years and saw how medications could ease acute symptoms of mental illness and support a persons recovery.

As a Senior Nurse I remained reliant on the presence of a Doctor to prescribe any medications and this was sometimes the cause of delaying treatment or changes to medications, ultimately causing distress or an increase in risk.

PICUs can be a fast paced environment with admissions throughout the 24 hour period.

I became aware over the years I was there that access to Doctors was changing.

Read more from Laura

• What to expect from your job as a prison nurse

• What does a Mental Health Nurse do?

• What is forensic mental health, and how did I end up working in it?

• A guide to Community Mental Health Nursing

Out of hours it was incredibly challenging to have junior Doctors present to undertake admission assessments or review patients after incidents.

There were many times I wished I could of prescribed emergency medications rather than wait for long periods for a Doctor to arrive.

Another motivation to train as a prescriber was the nature of the Nurse-Patient relationship.

As Nurses, we spend considerable time with our patients, building therapeutic relationships and really getting to know people on a meaningful basis.

I knew my patients, I knew how they felt, what caused distressed, what time of day was more difficult and what worked when things became too much. Nurses are there, on the wards 24 hours a day.

This level of engagement can only contribute to prescribing decisions and I knew when I worked on the ward that I was best placed to make prescribing decisions in collaboration with my patients.

Since the emergence of more independent Nurse Prescribers there has been significant evidence to support the role.

Wide scale studies suggest higher patient satisfaction, better adherence to prescribed medications and a reduction in over prescribing of medications.

As a Nurse working in PICU, Prisons and Forensic Mental Health I developed specific knowledge and skills in the management of acute disturbance.

As I moved through my career I studied medications which are used in emergency situations, called “Rapid Tranquilisation” or “RT”.

How to become an Independent Nurse Prescriber

For any Independent Nurse Prescriber it is important to develop a “scope of practice” and as a Mental Health Nurse my scope of practice included drugs prescribed for psychosis, mania, depression, agitation and acute behavioural disturbance.

Whilst in my current role as Matron in Forensic Mental Health I approached my manager and requested support in applying for the V300 Module.

V300 is the recognised stand-alone module for Nurses, Pharmacists and Allied Health Care Professionals who wish to qualify as Prescribers.

Many NHS Trusts will have a local agreement with the nearby universities and within your Trust there will likely be an Independent Prescribing lead for Nurses.

I contacted the lead within my NHS Trust and was asked to submit a training request form which outlined my rationale for wanting to train.

Once submitted I had a brief interview with the Trust Lead.

It is important to identify if there is a need for nurse prescribing in your service and how you will prescribe once qualified.

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Many Nurses are anxious about drug calculations, especially if significant time has passed since they last studied.

I dug out my old nurse calculations book and practiced a lot before starting the course. In order to get onto the course I attended an induction day and passed a mock calculations exam.

V300 courses are run by a number of universities across the country and will vary slightly in their structure.

It is likely that the course will run over 6 months with taught lectures and study time.

What was my Prescribing course like?

V300 Prescribing courses are generic courses; the content of the course is relevant to any area of practice.

On my course there were Mental Health Nurses, Adult Nurses, Community Nurses, Cardiac Nurses, Children’s Nurses and A&E Nurses.

The most intensive part of the course was the pharmacology lectures which covered in detail the way drugs work on the body (pharmacodynamics) and how the body responds to drugs (pharmacokinetics).

I found it important to make thorough notes and revise each session as all students have an exam at the end of the course.

As with any Nurse education, supervised clinical practice time provides the experiential learning to develop competency and confidence.

You will be required to spend at least 90 hours prescribing with 45 of these with your DMP.

The others hours can be spent with any other prescribing professional and I was fortunate to have another Nurse Prescriber and Pharmacist Prescriber in my hospital.

I ensured my allocated DMP was working closely in my service and that we put time in our diaries to practice and reflect.

Getting the time to study alongside a full time clinical job was the most challenging part of this course.

"The course is labour intensive!"

Alongside the taught lectures, exams and supervised prescribing hours you will have to complete a portfolio of work.

As with previous nurse education, the Nursing and Midwifery Council (NMC) have identified specific competencies and domains which you need to demonstrate you have met in order to pass and register with the NMC as an Independent Nurse Prescriber.

My portfolio consisted of two 3000 word essays based on case studies, seven reflective accounts covering areas of prescribing practice, such as prescribing for specialist groups, prescribing as a team, anti-microbial resistance and antibiotics and two examples of writing prescriptions.

I also had to pass a numeracy exam and undertake an OSCE (an observed assessment) which included a prescribing decision.

Each piece of work had to be signed by my DMP and then cross referenced with the NMC competencies.

"I will remember writing my first prescription for the rest of my career."

To say I needed to be organised is an understatement!

I underwent a significant professional transition during my training, and I utilised reflective accounts to acknowledge the change.

What I learned about myself

As a nurse I would often advocate certain medications and request that Doctors write certain prescriptions.

During my training I noticed how much more anxious I was when deciding which medications to prescribe and wanted to ensure all physical health checks had been completed before prescribing.

In mental health services, some of the commonly used anti-psychotics can increase the risk of cardiac disease.

Prior to prescribing I would advocate them in the management of agitation.

As I transitioned to a nurse prescriber, I became aware of the increased accountability and responsibility of writing prescriptions and wanted to ensure all the possible risks were reduced.

At the end of the course I took an exam covering the pharmacology theory and also using the British National Formulary (BNF).

I was very pleased to pass both my exam and the portfolio and be assessed as competent to register my qualification with the NMC.

Next steps - following qualification

You have to pay £20.00 to register your prescribing qualification but once the NMC have received your payment the qualification was present the next day.

At this point I was legally able to prescribe; however, it is important both as best practice and to be covered by indemnity insurance to ensure you are signed off within your trust or place of work.

The NHS Trust I work for requires an “intent to prescribe” form to be submitted yearly.

This form outlines your scope of prescribing practice, which medications you will prescribe and who will be your own going DMP.

Independent Nurse Prescribers are required to have regular supervision with their DMP throughout their career and I have been able to continue working with the Consultant Psychiatrist who supervised me in my training.

Career Progression

Any nurse with the required 3 years post registration experience can become a prescriber. You will usually be working as a Band 6 nurse and becoming a prescriber can support the progression to a Band 7 post.

Historically, Independent Nurse Prescribers only worked as Band 7s and above, however the role is now often carried out by Band 6 Nurses and a pay rise and career progression is not automatic.

An excellent career pathway for nurses is to gain an Advanced Nurse Practitioner (ANP) qualification.

The Masters level qualification will include the prescribing module and advanced assessments which support the diagnosing of conditions.

As an ANP you can apply for 8a and 8b posts and expect to earn 45-55k a year.

What is it like in practice?

Once I had been signed off by my Trust, I was able to prescribe.

As a Matron in an inpatient setting it quickly became apparent that I needed to provide some reassurances to the Doctors who I worked with.

There were concerns regarding me changing medication plans or prescribing without discussing with the wider team.

To rectify this, I arranged a local Independent Prescribing committee and wrote a local protocol outlining the role and responsibilities.

I will remember writing my first prescription for the rest of my career.

I was nervous, methodical, used my best pen and felt immensely proud. Medications form just part of the work I do with patients but qualifying as an Independent Prescriber has added a further dimension to my nursing practice. The NHS is changing.

Nurses remain the largest group of professionals in the NHS workforce.

Any skill which supports the professionalism, expertise and autonomy of nurses is to be advocated.