How To Prescribe Medicinal Products

Transcription

1 Volume 3 Number 1 June 2010 Nurse practitioners in western australia The Nurse Practitioner Series A series produced by the Nursing and Midwifery Office Department of Health, Western Australia HP10462 NOV 10

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3 Volume 3 Number 1 June 2010 Nurse practitioners in western australia The Nurse Practitioner Series A series produced by the Nursing and Midwifery Office Department of Health, Western Australia 1

4 Nurse practitioners in Western Australia The Nurse Practitioner Series The Nurse Practitioner Series. ISBN The Nursing and Midwifery Office publishes and distributes The Nurse Practitioners Series. The primary purpose of the series is to promote the development of the nurse practitioner role in Western Australia. Copies of The Nurse Practitioners Series are available from: Nursing and Midwifery Office Department of Health 189 Royal Street East Perth Western Australia Australia Volume 3 Number 1 June 2010 Department of Health Western Australia 2010 This work is copyright. It may be produced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above requires the written permission of the Department of Health Western Australia, 189 Royal Street, East Perth, Western Australia Disclaimer The opinions expressed within are the authors and not those of the Nursing and Midwifery Office, Department of Health Western Australia, the Co-Editors, or the Editorial Board. Design and Layout: Nursing and Midwifery Office, Chief Nurse and Midwifery Officer, Adjunct Associate Professor Catherine Stoddart. Aim The primary aim of The Nurse Practitioner Series is to promote and disseminate information on approaches, activities, theory and research relating to the role and the implementation of nurse practitioners in Western Australia. 2

5 Table of Contents Aim 2 Co-Editors 4 Editorial Board 5 Editorial 6 A Snapshot of Australian Nurse Practitioners Extended Practice Activities 8 Glenn Gardner, Anne Gardner, Sandy Middleton, Phillip Della and Anna Doubrovasky Nurse and Midwife Medicinal Product Prescribing: A New Initiative for Ireland 16 Elizabeth Adams, Annette Cuddy, Maureen Flynn, Rose Lorenz and Clare MacGabhann Nurse practitioner Programs: The Need for Giving Good Advice 30 Joyce M. Hendricks and Vicki Cope Nurse Practitioners Emergency Services: A Western Australian Perspective 35 Bronwyn Nicholson Power, policy and politics their interaction in evaluating nurse practitioner implementation 42 Phillip Della and Huaqiong Zhou Nurse Practitioner David Charlton Discusses His Journey of Becoming a Nurse Practitioner 49 Nurse Practitioner Fran Lee Discusses Her Journey of Becoming a Nurse Practitioner 51 Nurse Practitioner Leah Hansen Discusses Her Journey of Becoming a Nurse Practitioner 55 Nurse Practitioner Mary Dodds Discusses Her Journey of Becoming a Nurse Practitioner 58 Guidelines for Contributors 62 3

6 Nurse practitioners in Western Australia The Nurse Practitioner Series Co-Editors Adjunct Associate Professor Catherine Stoddart BSc (Nursing), MHSc, MBA, Winston Churchill Fellow Chief Nurse and Midwifery Officer Department of Health, Western Australia Adjunct Associate Professor Catherine Stoddart is the Chief Nurse and Midwifery Officer of Western Australia. In this role, she sets the strategic direction for the nursing and midwifery professions of Western Australia. She completed her Hospital Based Diploma of Nursing at Royal Perth Hospital. Since graduation has held executive management roles and senior clinical nursing positions at Sir Charles Gairdner Hospital. Catherine has held positions in both the State and Commonwealth Governments and more recently as the Executive Director of Nursing across WA Country Health Service and the Regional Director for the Kimberley. In 2009, Catherine was appointed to the position of Adjunct Associate Professor at Curtin University in recognition of her leadership in the Nursing profession in Western Australia. Catherine is a Winston Churchill Fellow and reviewed models for isolated nursing practice in Alaska and Canada looking particularly into indigenous communities. This experience has fuelled her passion for improving indigenous health and contributing to the global health agenda. 4

7 Professor Phillip Della RN RM BAppSc MBus PhD Head of School School of Nursing and Midwifery Curtin University Western Australia Professor Phillip Della has had extensive experience in policy development, analysis and evaluation. This includes the areas of public policy; the political process and the policy legislative intersect. In his previous role as the Chief Nursing Officer of Western Australia he led the Western Australian Nursing and Midwifery legislative-policy reforms including the introduction of the Nurses and Midwives Act 2006, the Nurses and Midwives Regulations 2007 and the Nurses Amendment Act 2003 that introduced nurse practitioners into Western Australia. Professor Della has also extensive experience in policy and evaluation research within the healthcare area and has recently conducted policy reviews for New South Wales Health and was a member of the Irish Commission into Nursing. Professor Della was appointed as Head of School of Curtin University of Technology s School of Nursing and Midwifery in February His research interests are healthcare reforms, organisational culture and patient outcomes. His current research activities include evaluation of the nurse practitioner role in Australia and clinical handover which together amount to over $5 million of competitive external funding. 5

8 Nurse practitioners in Western Australia The Nurse Practitioner Series Editorial Board Professor Dianne Wynaden RN RMHN MHN B.AppSc (Nursing) PGDip(HSc) MHSc(HSc) PhD MACMHN Professor (Mental Health)/Minimal Risk Ethics Coordinator School of Nursing and Midwifery, Member of the Curtin Health Innovation Research Institute, Curtin University of Technology Research Consultant, Fremantle Mental Health Services Fremantle Hospital and Health Service Research Consultant, State Forensic Mental Health Services and Adjunct Senior Research consultant, Fremantle Hospital Ms Annette Fraser RN, BSc (Nursing), RM A/Principal Nursing Officer, Department of Health, Western Australia Dr Vicky Brown RN., M.Sc., PG Dip Hlth.Prom., BAppSc., PhD Clinical Nurse Manager, Orthopaedic Ward, Fremantle Hospital Health Service Dr Beverly Scott RN NP BAppSc(Nurs), PGDipClinSpec(Nurse Practitioner), MAppSc(D)(ScEd), PhD, FRCNA Nurse Practitioner, Brightwater At Home and Clinical Nurse Consultant, Brightwater Group Technical Editor Ms Huaqiong Zhou RN, MCN, BSc (Nursing) Research Officer, School of Nursing and Midwifery, Curtin University of Technology, Western Australia and Clinical Nurse, Surgical Ward, Princess Margaret Hospital for Children, Western Australia 6

9 Editorial Welcome to this edition of the Nurse Practitioner Series which presents discussion on the progress of nurse practitioners and the development of advanced practice. This edition commences with a snapshot of Australian Nurse Practitioners and their scope of practice. This article is timely as it presents findings drawn from the AusPrac Study. The article presents the range of diagnostics and referrals that nurse practitioners are making. As we move to the new era of restrictive access to Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) for nurse practitioners it highlights valuable information on what is actually happening in clinical practice. The second article in this edition has international favour and has been written with Irish favour. Nurse and midwife prescribing has been introduced to the Irish Health Service as a whole systems approach. The introduction has required legislative, regulative and clinical practice change. This article overviews the introduction of this new initiative into Ireland. The third article returns to Western Australia and provides an overview of advice registered nurses should consider before commencing a nurse practitioners education program. The Western Australian favour continues in the remaining articles which presents information of the development of nurse practitioners in Western Australia. Included in these articles is an overview of the interplay between power, policy and politics of the implementation of nurse practitioners it should be remembered that major achievements have been made since the commencement only seven years ago. The work of nurse practitioners in emergency service is presented and highlights the barriers and obstacles that prevent full utilisation of these practitioners in health services delivery. Interviews with four nurse practitioners present their journey on becoming a nurse practitioner. The interviews are real live experiences which includes the defining time when they choose to take a path to become a nurse practitioner, why they choose their speciality areas and the goals they want to achieve. Nurse practitioners in Western Australia are making a real difference to patient care across a wide range of settings. Their work is acknowledged by health services and by the patients they care for assess, diagnosis and treat every day. It is now in the realm of the policy makers and funders to remove artificial barriers that are prevent the full utilisation of their services to provide the full of scope of care that nurse practitioners have been educated to delivery. Unless these barriers are removed nurse practitioners will continue to practice with limitations. Professor Phillip Della Head of School School of Nursing and Midwifery Curtin University of Technology Western Australia 7

10 Nurse practitioners in Western Australia The Nurse Practitioner Series A Snapshot of Australian Nurse Practitioners Extended Practice Activities Professor Glenn Gardner RN PhD Director of the Centre for Clinical Nursing Royal Brisbane and Women s Hospital and Queensland University of Technology Brisbane, Australia Professor Anne Gardner RN BA MPH PhD Professor of Nursing Tropical Health James Cook University and Townsville Health Service District Townsville, Australia Professor Sandy Middleton RN BAppSc (Nursing) MN PhD Professor of Nursing Research St Vincents and Mater Health, Sydney Director, National Centre for Clinical Outcomes Research (NaCCOR) Nursing and Midwifery, Australia Australian Catholic University Sydney, Australia Professor Phillip Della RN RM BAppSc MBus PhD Professor of Nursing Head of School of Nursing & Midwifery Curtin University of Technology Perth, Australia Anna Doubrovsky BSc(Hons) MPH Project Coordinator Australian Nurse Practitioner Project Queensland University of Technology Brisbane, Australia Keywords: Nurse practitioner, clinical audit, prescribing, extended practice 8

11 Introduction The Australian Nurse Practitioner Project (AUSPRAC) was initiated to examine the introduction of nurse practitioners into the Australian health service environment. The nurse practitioner concept was introduced to Australia over two decades ago and has been evolving since. Today, however, the scope of practice, role and educational preparation of nurse practitioners is well defined (Gardner et al, 2006). Amendments to specific pre-existing legislation at a State level have permitted nurse practitioners to perform additional activities including some once in the domain of the medical profession. In the Australian Capital Territory, for example 13 diverse Acts and Regulations required amendments and three new Acts were established (ACT Health, 2006). Nurse practitioners are now legally authorized to diagnose, treat, refer and prescribe medications in all Australian states and territories. These extended practices differentiate nurse practitioners from other advanced practice roles in nursing (Gardner, Chang & Duffield, 2007). There are, however, obstacles for nurse practitioners wishing to use these extended practices. Restrictive access to Medicare funding via the Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) limit the scope of nurse practitioner service in the private health sector and community settings. A recent survey of Australian nurse practitioners (n=202) found that two-thirds of respondents (66%) stated that lack of legislative support limited their practice. Specifically, 78% stated that lack of a Medicare provider number was extremely limiting to their practice and 71% stated that no access to the PBS was extremely limiting to their practice (Gardner et al, in press). Changes to Commonwealth legislation is needed to enable nurse practitioners to prescribe medication so that patients have access to PBS subsidies where they exist; currently patients with scripts which originated from nurse practitioners must pay in full for these prescriptions filled outside public hospitals. This report presents findings from a sub-study of Phase Two of AUSPRAC. Phase Two was designed to enable investigation of the process and activities of nurse practitioner service. Process measurements of nurse practitioner services are valuable to healthcare organisations and service providers (Middleton, 2007). Processes of practice can be evaluated through clinical audit, however as Middleton cautions, no direct relationship between these processes and patient outcomes can be assumed. Methodology Study population In Phase One of AUSPRAC, nurse practitioners who completed a national survey were invited to submit an expression of interest to participate in Phase Two. The majority (n=144) of nurse practitioners in Australia at that time registered to participate. From this pool a process of stratified random sampling by state and geographical location (metropolitan or non-metropolitan) selected 37 nurse practitioners who were invited to participate in this phase of the Project. Phase Two involved two separate but related studies, firstly, work sampling research that collected activity data from 30 of the invited 37 nurse practitioners around Australia and, secondly, case study research that involved collection of a range of data on the organisational and service impact of the nurse practitioner role. The case study component of Phase two recruited 11 nurse practitioners from the 9

12 Nurse practitioners in Western Australia The Nurse Practitioner Series 37 who were invited to participate in Phase two studies. Data was collected between September 2008 and August The case study included collection of data from the nurse practitioners, other health care professionals in their team and patients. The sub-study reported here is drawn from data collected from consenting patients health care records relating to nurse practitioner service. Consecutive patients of the nurse practitioners were invited to enrol in the study and the first ten patients to consent were included. In some cases, it was not possible to secure the enrolment of ten patients within the data collection period and thus the total number of patients was 96. Instrument and Data Analysis The instrument used in this study was adapted from a generic tool used for chart abstractions from a sample of patients in the ACT Nurse Practitioner Trial (ACT Health and the Nurses Board of the ACT, 2003 p138). Data from patient charts were collected retrospectively for a 30 day period. The sample included 96 data sheets. Information collected included presenting issues, number of visits, diagnostic investigations, therapeutic interventions, prescribed medications, and referrals recommended by the nurse practitioner. A descriptive analysis of the data was performed using Microsoft Excel 2007 (Microsoft, Redman, WA, USA). Ethics This study was approved by the Human Research Ethics Committees of all participating Universities and hospitals where this research was undertaken. Results and Discussion Assessment of extended practice in nurse practitioners was performed on data abstracted from clinical notes of 96 patients of 11 nurse practitioners. These nurse practitioners were recruited nationwide, two each from Victoria, Western Australia and New South Wales; and one from Queensland, South Australia and the Australian Capital Territory. Nine of the nurse practitioners worked in a hospital setting and two worked in the community. Nurse practitioner service models included Emergency (2), Rural and Remote (2), Mental Health, Orthopaedics, Sexual Health, Women s Health, Chronic Disease (2) and Neonatal. Diagnostic Investigations Over half the patients (52%) in the study received at least one diagnostic investigation during the study period. There were on average 2.2 diagnostic investigations per patient. The number of investigations requested was relevant to the model of nurse practitioner service with a range of 0 to 5.9 investigations per patient. Two nurse practitioners did not request any diagnostic investigation for their patients enrolled in the study within the study timeframe. The common types of diagnostic investigations requested are shown in Figure 1. Most requests from nurse practitioners were for haematology and biochemistry. Histology was not requested and only one request for cytology was made. The use of serology, microbiology and radiology diagnostic investigations were highly dependent on the type of nurse practitioner model. Serology investigations were limited to two of the nurse practitioners in the study and only four nurse practitioners requested radiology. 10

13 Nurse practitioners made extensive use of pathology requests, however it is not possible to determine the reason why they were used for example assessment for diagnosis, monitoring of chronic conditions or screening of vulnerable populations. Figure 1: Diagnostic investigations requested by nurse practitioners (n=211 investigations) Referrals Nurse practitioners made referrals for 63.6% of patients in the study (see Figure 2) and all nurse practitioners in the study referred patients to other professionals and agencies. Rates of referral varied amongst the nurse practitioner models, from 1.6 referrals per patient down to less than 0.2 referrals per patient. Figure 2 lists the types of referrals made. One fifth of the nurse practitioner referrals were to a general practitioner and all these referrals were made by nine of the 11 participating nurse practitioners. Most of the referrals (85%) to medical specialists were made by three nurse practitioners, who referred 20% of the patients in the study. Another three nurse practitioners made only one referral to a medical specialist during the study period. All nurse practitioners who referred patients to medical specialists were based in a hospital setting. Forty percent of patients were referred to allied or other health professionals. These included social workers, occupational therapists, physiotherapists, dentists, sexual health counsellors, pharmacists and wound care nurses. Over 10% of patients were referred to other agencies such as interpreter services, osteoporosis metabolic clinic, diabetes unit, community nursing service, hospital emergency. 11

14 Nurse practitioners in Western Australia The Nurse Practitioner Series Figure 2: Referrals recommended by nurse practitioners (n=81 referrals) Therapeutic Interventions Overall 93.8% of patients received a therapeutic intervention from a nurse practitioner, averaging 3.7 interventions per patient in the 30 day period. The maximum number of interventions for one patient was 33, and eight patients received at least 10 interventions in the study period. Therapeutic interventions were classified as procedural, counselling and education, monitoring, social assistance, provisions with aids, hospital administration and others (Figure 3). Most common were counselling and education interventions. All nurse practitioners provided counselling and education, with 86.5% of patients receiving this type of therapeutic intervention (with a range of 4.3 to 0.5 interventions per patient). Procedural interventions were also frequent and were performed on 43.7% of the patients; however three nurse practitioners did not perform any procedural interventions (range from 0.0 up to 3.1 procedures per patient). Only 5 nurse practitioners provided social assistance interventions and only seven nurse practitioners documented that they had monitored patients. Provision of aids and hospital admission of patients was rare. 12

15 Figure 3: Therapeutic interventions performed by nurse practitioners (n=358 interventions) Prescription of Medication Just under 45% of patients received medication from a nurse practitioner, averaging 0.62 prescriptions per patient. During the study period, 59 prescriptions for medication were produced by the participating nurse practitioners. All but one nurse practitioner prescribed medications, with a range of prescriptions per patient. Table 1 list all medications recommended by the nurse practitioners during the study. They are classified according to their drug group. Most prescriptions were for antibiotics, narcotic analgesics and antifungals. Nine of the participating nurse practitioners were hospital based and thus were not restricted by the lack of access to PBS provider numbers in prescribing medication for their patients. 13

16 Nurse practitioners in Western Australia The Nurse Practitioner Series Table 1: Medications prescribed by nurse practitioners (n=59 prescriptions) Drug Group Number of Prescriptions Antibiotics 11 Narcotic analgesia 9 Antifungals 5 Respiratory stimulant 4 Anti-anxiety agents 2 Antidepressants SSRI 2 Antiemetics, antinauseants 2 Immunoglobulin tetanus 2 Non-steroidal anti-inflammatory agents 2 Topical corticosteroids 2 Vaccine Gardicil 2 Vitamin folate 2 Anaesthetic 2 Anti-diarrhoeal 1 Antihypertensive 1 Antipsychotic agents 1 Antiviral 1 Beta-adrenergic blocking agents 1 Dextrose 1 Hormone contraceptive 1 Hypoglycaemic agents 1 Mineral iron 1 Sedatives, hypnotics 1 Topical hormone 1 Topical ocular anti-infective preparation 1 Limitations Drawing conclusions and generalisability from the findings of this study is subject to the limits of retrospective chart audits. It is not possible to comment on whether the use of these extended practice services was appropriate in terms of safety and effectiveness, other than that they occurred. Also, as most of the nurse practitioners (82%) in this study worked within the financially benign context of a hospital setting, the lack of their access to PBS and MBS appeared to have no financial consequence for their patients. Consequently this study, with its major focus on nurse 14

17 practitioner service conducted within the financially protective confines of the public hospital setting masks the real significance of restrictions to practice for this reformative model of health service. Conclusions This study has provided a snapshot of the documented actions of a sample of nurse practitioner service. The findings from this study are useful in demonstrating the extended practice activities of a sample of Australian nurse practitioners. However these findings need to be read in the context of the holistic practice of nurse practitioners and the variability of service across difference specialist models. The nurse practitioners in this sample readily referred patients to other clinicians and agencies; primarily used counselling and education as treatment modalities and whilst almost all nurse practitioners in the study prescribed medication these prescriptions were for less than 50% of their patients. These findings are tentative but provide a good basis to inform further research into nurse practitioner service and resource usage. References ACT Health 2006, Nurse Practitioners in the Australian Capital Territory: The Framework, Canberra ACT Health and the Nurses Board of the ACT. (2002). The Act Nurse Practitioner Project Final Report of the Steering Committee, Melbourne. Gardner, A., Gardner, G., Middleton, S., Della, P. (2009). The status of Australian Nurse Practitioners: Findings from the first national census. Australian Health Review, 33(4), Gardner, G., Carryer, J., Gardner, A., & Dunn, S. (2006). Nurse practitioner competency standards: findings from collaborative Australian and New Zealand research. International Journal of Nursing Studies, 43(5), Gardner, G., Chang, A., & Duffield, C. (2007). Making nursing work: breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), Middleton, S. (2007). Audit or research? Should nurse practitioners participate in these types of evaluation and what is the difference between them? The Nurse Practitioner Series, 2(1),

18 Nurse practitioners in Western Australia The Nurse Practitioner Series Nurse and Midwife Medicinal Product Prescribing: A New Initiative for Ireland Adjunct Associate Professor Elizabeth Adams RGN, Cert (ODN), BNS (Hons), Dip (Mgt) Dip (Counselling), Dip (Phy and Chem), PGDip (Stats), MSc Director of Nursing and Midwifery and Deputy Nursing Services Director Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Annette Cuddy RGN, RM, PG Cert (Facilitation), BSc, MSn Assistant Director of Nursing and Midwifery Office of the Nursing Services Director Clinical Care and Quality Directorate, Health Service Executive Ms. Maureen Flynn RGN, RNT, PGDip (Stats), Dip (Hospital and Community Infection), Dip (Research Methods), Dip (Hospital and Health Service Administration), Dip (Teaching Methods), MEd, MSc Assistant Director of Nursing Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Rose Lorenz RGN, RM, PGDip (Clinical Practice), PGDip (Human Resource Mgt) Assistant Director of Nursing and Midwifery Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Ms. Clare MacGabhann RGN, RM, HDip (Mgt), MComm (Government and Public Policy) Assistant Director of Nursing and Midwifery Office of the Nursing Services Director, Clinical Care and Quality Directorate, Health Service Executive Abstract The introduction of nurse and midwife prescribing in Ireland is an important and significant new initiative in the Irish Health Service which has implications not just for nurses and midwives, but for the healthcare system as a whole, in particular for patients and service users. In 2007 the Act and associated Regulations were signed into law. Nurse and midwife prescribing is underpinned by a twin-track approach encompassing amending Irish legislation and the introduction of new professional regulations. This dual framework enables a registered nurse or midwife, who has completed an approved six month post-registration education programme, has the appropriate clinical experience, is registered with the Irish Nursing Board (An Bord Altranais) as a Registered Nurse Prescriber, and has authority from the health service provider that employs them, to prescribe a range of medicinal products within their scope of practice. 16

19 This article sets out the national processes used in the introduction of nurse and midwife medicinal product prescribing in Ireland from inception, to legislative changes, educational preparation, governance arrangements, registration requirements and clinical practice outcomes. The critical success factor was the introduction of a standardised approach applied in a systematic manner in each health service provider with the ongoing support of the Office of the Nursing Service Director within the Irish Health Service Executive. The change management process was finalised with the commissioning and completion of an independent external evaluation of the first two years experience of nurse and midwife prescribing in Ireland. Overall, the evaluation found that the extension of prescriptive authority to nurses and midwives has been a positive development, particularly for the impact that it has had on patient care and also on the professional development of nurses and midwives. Key Words: Change Management, Collaboration, Legislation, Medicinal Products, Registered Nurse Prescriber, Role Expansion Introduction Nurse and midwife medicinal product prescribing is one of the key initiatives of the Irish Minister of Health and Children, Mary Harney, Teachta Dála (TD) (Member of Parliament). There are now over 160 nurses and midwives with prescriptive authority employed in the health services. This has real potential to enhance the efficiency and responsiveness of the health services for patients and service users. The initiative endorses the Government s policy for the expansion of nursing and midwifery roles. This article provides the background on how this was achieved. Background In October 2005, the Irish Minister for Health and Children identified the introduction of nurse and midwife prescribing as a high priority. A number of national and international trends were identified as supporting the extension of prescriptive authority to nurses and midwives in Ireland: Social and demographic change (e.g. ageing population) Changing services configuration for patients with increased specialisation of services (e.g. diabetes, asthma, oncology) Value for money Implementation of the European Working Time Directive A greater focus on community services. The nursing and midwifery professions were well prepared to respond to the Ministers direction in that a national pilot study (conducted over a three and a half year period) which rigorously evaluated the potential for the introduction of nurse prescribing had just been completed by the statutory bodies with responsibility for nursing and midwifery (An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery, 2005). 17

20 Nurse practitioners in Western Australia The Nurse Practitioner Series Legislation Primary legislation, the Irish Medicines Board (Miscellaneous Provisions) Act allowing for the introduction of independent nurse and midwife prescribing in Ireland, was introduced in May In November that year, the Department of Health and Children established a national steering group the Resource and Implementation Group on Nurse and Midwife Prescribing to advise on the regulations to be drafted and to oversee the rollout of nurse and midwife prescribing on a national basis (Office of the Nursing Services Director, Department of Health and Children, An Bord Altranais, National Council for the Professional Development of Nursing and Midwifery, 2007).. The subsequent regulations The Medicinal Products (Prescription and Control of Supply (Amendment) Regulations 2007 and the Misuse of Drugs (Amendment) Regulations 2007 were signed into law in May 2007 specifying the requirements/conditions for prescribing of medicinal products by nurses and midwives. These, together with the Irish Nursing Boards Nurses Rules 2007 form the basis on which nurse and midwife prescribing became a reality in 2007 (An Bord Altranais, 2007a). A number of conditions must be satisfied for prescribing authority. They are summarised as follows: The nurse/midwife must be employed by a health service provider in a hospital, nursing home, clinic or other health service setting (including any case where the health service is provided in a private home) The medicinal product is one that would be given in the usual course of service provided in the health service setting in which the nurse/midwife is employed The prescription is issued in the usual course of the provision of that health service The An Bord Altranais registration number (also known as the Personal Identification Number (PIN)) must be stated on the prescription. In addition, the 2007 regulations allow a health service provider to determine further conditions for the prescriptive authority of the nurse or midwife. A new schedule setting out restrictions and conditions for RNPs to prescribing certain controlled drugs was established for Ireland. This new schedule referred to as Schedule 8 names the specific controlled drugs that certain nurses and midwives, who are RNPs, may prescribe relevant to their scope of practice and area of work. The stipulations and particular conditions for prescribing are detailed in the Misuse of Drugs (Amendment) Regulations Dual Framework for Nurse and Midwife Prescribing Independent nurse and midwife prescribing in Ireland is underpinned by a twin-track approach encompassing amending Irish legislation and the introduction of new professional regulations. This dual framework enables a registered nurse or midwife, who has completed an approved six month post-registration education programme, has the appropriate clinical experience, is registered with An Bord Altranais as a RNP, and has authority from the health service provider that employs them, to independently prescribe a range of medicinal products within their scope of practice. 18