Should registered nurses prescribe drugs?
The Ontario provincial government has said it will expand the scope of practice of registered nurses (RNs) in Ontario to allow them to prescribe medications. Currently, only doctors and nurse practitioners have the ability to prescribe medications. This is a move that could radically change health care – some say for the better, but others are concerned.
The main impetus for the increased scope of practice is that allowing RNs to prescribe medications could dramatically improve access to care for some – like people in rural and remote areas who have limited access to nurse practitioners (NPs) and physicians. It can also enable NPs and physicians in busy clinics and hospitals to focus on patients with the most complex conditions, while RNs diagnose and prescribe medications to treat some of the more straightforward reasons people seek health care, like routine vaccinations for healthy babies.
“If RNs could write scripts for patients with simple issues – a urinary tract infection, for example – many patients wouldn’t even have to see a doctor,” argues Doris Grinspun, chief executive officer of the Registered Nurses Association of Ontario (RNAO). “NPs and doctors would have more time to deal with the less run-of-the-mill cases. It would unlock the system,” she says.
But not everyone is convinced that RN prescribing is necessary in the first place, and some worry if RNs are allowed to prescribe without supervision, it will jeopardize patient safety.
In order to learn more about the benefits and challenges of RN prescribing, Ontario’s Minister of Health and Long-Term Care has asked the Health Professions Regulatory Advisory Council (HPRAC) to investigate and make recommendations to the Province about RN prescribing. The Council has been tasked with figuring out which of the three different models for RN prescribing is best for Ontario. They are to evaluate the models on various criteria, including whether the form of RN prescribing would fill a public need and how easily the risks of each model could be mitigated.
Models for RN prescribing
The model of RN prescribing that is the most different to the status quo is independent prescribing, where RNs would be able to diagnose certain conditions and prescribe the most appropriate medications to treat those conditions – either from a pre-defined list of medications or based on a specific area of medicine.
In this model, RNs who work in a travel clinic, for example, would be enabled to prescribe some vaccinations. RNs who work in long-term care, meanwhile, might be allowed to diagnose and treat a urinary tract infection in elderly clients.
Independent prescribing by RNs is not a completely new concept. In British Columbia, RNs who meet requirements including the completion of an online course can independently prescribe drugs including medications to treat sexually transmitted infections, vaccines for travelers as well as a limited number of other special-case scenarios. Newfoundland and Labrador and many other provinces are considering or currently implementing RN independent prescribing for specific medications and situations. Internationally, various forms of independent prescribing are in place in Ireland, New Zeland, the UK and some US states.
The second model is protocol-based prescribing, in which RNs could prescribe, but only following a protocol developed by a team of medical professionals. The protocol might instruct the RN on what tests to order, what questions to ask and what dose to provide under what circumstances. As Grinspun points out, this model is, practically speaking, the same as what is already in Ontario and in most provinces in the country. Currently in Ontario, RNs can prescribe under protocols, which are known as standing orders or medical directives and have been developed by a doctor or medical team within their organization.
The third model is supplementary prescribing. In this model, a NP or physician comes up with a plan for a specific patient, and the RN may prescribe according to that patient’s plan.
The evidence behind any of the models is limited. A preliminary review conducted by HPRAC looked at RN prescribing in other countries and found that, overall, there were no major differences in the appropriateness or safety or prescriptions made by nurses versus doctors – whether nurses were prescribing in an independent, protocol-based or supplementary way. But the studies were few and the methods open to bias. (As RN prescribing is new in British Columbia, HPRAC wasn’t able to find evidence of RN prescribing effectiveness here.) Plus, it’s hard to compare RN prescribing in one country to another, given each jurisdiction has different processes and education requirements for RN prescribing.
Arguments for independent versus protocol-based RN prescribing
Because the debate among stakeholders centres around independent versus protocol-based prescribing, we will focus on these models.
Adriana Tetley, chief executive officer of the Association of Ontario Health Centres, says that independent RN prescribing would save patients time as well as be cost saving, because patients would see one professional instead of two. “Right now, patients will see the nurse, the nurse can do the assessment, and they know they have a common infection, but they have to now be seen by another provider – either a nurse practitioner or a physician to get that prescription,” says Tetley, who represents community-governed primary health centres.
The move would be a huge help to marginalized populations as well, argues Kim Cook, a RN and vice president of community health and chief of professional practice at Scarborough Centre for Healthy Communities. For RNs who do outreach work in sexual health clinics or homeless shelters, they may meet a patient who clearly has a treatable infection, but they miss the opportunity to treat it because they have to refer the patient to see a doctor. “They’re on the street and you may never see them again,” says Cook.
Nancy Lefebre, chief clinical executive at Saint Elizabeth, which provides home care services across Canada, also sees RN prescribing as being a win for patients who are visited by nurses at home. “Home care is a 24-7 kind of service and people live in remote and rural locations so it’s not always easy to access someone who can prescribe,” she says.
Tetley and Cook explain that protocol-based prescribing won’t suffice because many organizations don’t go to the trouble of developing protocols – they take professionals’ time and therefore money to produce and need to be frequently updated, explains Grinspun. For this reason, as Cook says, “There are a very limited number of protocols.”
On the other side of the argument are groups like the Ontario Medical Association and the Nurse Practitioners Association of Ontario.
Theresa Agnew, president of the Nurse Practitioners Association of Ontario, thinks that protocol-based prescribing is the way to go, and that protocols should be increased. “If RNs want to [independently] prescribe, they should become nurse practitioners,” she says. “We already have the evidence to show that nurse practitioner prescribing is safe. And we have the education models and quality control in place. Why reinvent the wheel?”
RNs can take a NP course after three years of working as an RN (on average, however, most wait 16 years, according to Agnew). To become a NP, a RN must take a 24-month course that includes 750 hours of training in a clinical setting. The 300-hour course that the RNAO is proposing for RNs who wish to prescribe isn’t adequate enough,” says Agnew.
Michael Toth, president of the Ontario Medical Association also seems to suggest that only doctors and NPs should independently prescribe. “Currently, [NPs] have specialized training that allows them to independently prescribe medications. They can do this because they possess graduate level training that includes advanced health assessment…caution should be exercised in deciding whether or not a group of practitioners should be able to independently prescribe,” wrote Toth in a statement to Healthy Debate.
But Lefebre says there are not enough NP training centres. “We don’t graduate enough NPs to meet the need,” says Lefebre. “And while intensive training makes sense for NPs, who can diagnose and treat a wide range of conditions, RNs would prescribe in limited circumstances, for some of the most common conditions they see.”
Agnew isn’t comforted by the idea that if independent prescribing was pursued, RNs would only prescribe within their scope – for conditions in which they feel they have the training and experience to prescribe. “You don’t know what you don’t know,” she argues. What looks like a simple urinary tract infection could in rare cases be something more serious – and RNs don’t have the training to always know when to consider the rare, other possible causes, says Agnew.
Allan Malek, senior vice president of professional Affairs at the Ontario Pharmacist Association is also concerned that the idea RN can independently prescribe to treat ‘simple’ conditions is too simplistic. “When it comes to prescribing, it’s not really a simple algorithm, saying this is the condition, this is the drug for that condition and away we go,” he says. “Do they know how to appropriately assess the individual, do they know what the various medical conditions are that may be underlying their symptoms, do they know about the other the medications they take and the interactions?” (While Malek isn’t completely against the idea of RNs prescribing, he says that prescribing skills should be taught and examined to ensure that all of the issues that “wrap around” a prescription are well understood.)
To Lefebre, the fear that RNs might not safely prescribe without protocols in place doesn’t hold water. She points out that in northern communities, RNs are already making decisions on which patients may need to be flown to another location for emergency care, for example. “They’re assessing, they’re making critical diagnoses,” she says. “It doesn’t make sense that nurses can make major decisions in one area, but they can’t do it in another area.”
And the suggestion that nurses could unwittingly prescribe outside of their knowledge base is also unfounded, RN prescribing proponents argue. Grinspun points out that “any health provider, including doctors can do more than what they know.” Just like doctors, adds Cook, RNs are regulated by a College, which requires them to “do self-reflection” in regards to their knowledge and skills and ensure they meet the skills they require are up to date via continuing education. And it’s not just the individual – supervisors at workplaces would also decide which conditions a RN would be able to treat, based on the persons’ skills and training, Cook explains.
Are RN prescribers really needed?
Barbara Mildon, chief nursing executive at Ontario Shores Centre for Mental Health Sciences, takes a third position: RN independent prescribing makes sense for a limited range of settings and sectors but shouldn’t happen everywhere.
Mildon doesn’t think for example, that there is benefit to RNs prescribing in in-patient settings where physicians and nurse practitioners are available. Mildon also worries about patient safety if there are multiple people prescribing for the same patient: “if providers don’t know all of the medications a patient is already taking there is a potential for duplication of medication or for adverse reactions if new medications are added,” explains Mildon. (That said, even if independent RN prescribing was made legal by the Ontario government, hospital managers would be able to decide if RNs could take on prescribing roles at their institution, and whether RN prescribing is done in a protocol-based or independent way.)
Agnew added that RN prescribing could add to a problem health care is facing – that of too many prescriptions. “I sit on five different committees that are looking at the negative effects of polypharmacy,” says Agnew, referring to the fact that currently, too many Ontarians are taking multiple different medications, some of which are unnecessary.
But unlike Agnew, Mildon thinks that independent RN prescribing, if circumscribed, will be beneficial. In BC, she explains, nurses in sexual health clinics have a list of medications they can prescribe, including contraception and antibiotics for sexually transmitted infections. “They learn, ‘This is what these medications do, these are the indications to prescribe them, this is how you’re going to teach the patient about how to take them, this is what to watch for in terms of good outcomes,” she explains. (RNs would also need to know what kind of co-existing medical conditions to ask about before a certain drug is given, if the drug could exacerbate other conditions). Likewise, in remote or rural health centres, RNs could prescribe from a limited list of drugs. “If a patient has all the signs of a urinary tract or wound infection, RNs being able to prescribe antibiotics makes perfect sense,” says Mildon. When a case is more complicated, and an RN is not sure whether a patient should take a certain antibiotic or contraceptive drug, he or she would be expected to refer to a nurse practitioner or doctor.
Allowing some, but not all, nurses to prescribe also makes sense from a cost perspective. It doesn’t make sense to pay for extra training of RNs if they’ll work in a setting where they won’t need to prescribe, says Agnew. “Imagine the cost of training 100,000 more prescribers, it boggles the mind,” she says.
In all three potential models, the College of Nurses of Ontario will determine what education RNs will be required to have before they are able to prescribe, and how RNs and their employers will decide when a RN has the skill and knowledge to prescribe in particular circumstances. They will also have to put in place regulations and policies to monitor the safety and appropriateness of RN prescribers – just as they currently do for NPs.
Whatever solutions are chosen, Malek is happy to see that the Ministry is asking the question about how to revamp health care roles to better meet patient needs. “It’s exciting times for health care to see interest in expanding access to patient care,” he says.