Non-medical prescribers: prescribing within practice

While medical prescribing by registered nurses has been operational in the USA since the 1960s, the Republic of Ireland only introduced it relatively recently with the first registered nurse/midwife prescriber (RNP/RMP), prescribing medicines in 2007 (Government of Ireland 2006, 2007; Nursing and Midwifery Board of Ireland (NMBI), 2019). Independent prescriptive authority, from a limited formulary, is open to all registered nurses and midwives with relevant clinical experience, who have completed the accredited generic nurse and midwife prescribing education programme, delivered in five Higher Education Institutions (NMBI, 2019; Office of the Nursing and Midwifery Services Director, 2018).

In part fulfilment of the requirements of the prescribing programme, assessment of competence to prescribe is demonstrated through clinical assessments based on the candidate’s area of practice by their assigned clinical mentor. The candidates are guided in prescribing practice by the Decision-Making Framework for Nursing and Midwifery Prescribing, set down by the NMBI (Bord, 2017). The parameters for each prescribing decision by an RNP/RMP are that the practitioner works within their scope of practice, a patient history and a thorough physical examination are undertaken, prescribing practice is supported in the employing organisation, and the patient or family is included in, and understands the treatment (Bord, 2017). All requirements must be met prior to the writing of a new or continuing prescription, or cessation of a medication. In addition, a National Nurse and Midwife Prescribing Minimum Dataset to record and monitor prescribing activity across the country has been developed and implemented (Creedon et al, 2014). RNPs work in adult or childrens’ services in a variety of settings including disability support, mental healthcare, primary care and acute hospital-based services, with RMPs working in midwifery. There are RNP/RMPs practicing at the professional grades of Staff Nurse/Midwife, Clinical Nurse/Midwife Specialist, and Advanced Nurse/Midwife Practitioner.

Irish studies to date have found that nurse prescribing has benefits for patients by reducing waiting times, decreasing the fragmentation of care, increasing access to medications, and facilitating more efficient and effective use of resources (Creedon et al, 2014; Drennan et al, 2019; Naughton et al, 2012). Evidence also suggests that nurse and midwife prescribing has led to an increase in patient satisfaction and medication adherence, with nurses and midwives often seen as more approachable by patients than medical doctors (Creedon et al, 2015).

Although funding and governance structures are provided for nurses and midwives to undertake the prescribing education programme, applications and subsequent entrants to the prescribing register declined in the first half of this decade (NMBI and Health Service Executive (HSE); 2015). In 2015, a national review was undertaken to identify and address the reasons for this decline and promote the uptake of the programme, which highlighted the need for quality assurance within clinical practice, in terms of competency and efficiency in the regulatory validation processes for registering RNPs/RMPs and further research (NMBI and HSE, 2015). One of the processes involved in nurse and midwife prescribing is completion of National Nurse and Midwife Prescribing Minimum Dataset, where it was mandatory to input the details of each prescription. However, in the national review undertaken in 2015, it was identified that this mandatory inputting of the prescriptions was onerous on the individual nurse/midwife prescribers and a barrier to more nurses and midwives undertaking prescribing and it was recommended in the review that this mandatory activity become optional (NMBI and HSE, 2015). This study (Casey et al, 2020) conducted in 2018, explored the prescribing practice behaviours and confidence of RNPs and RMPs in the Republic of Ireland, and was undertaken three years after the NMBI and HSE review. Currently there are approximately 1300 nurse or midwife prescribers in Ireland (Office of the Nursing and Midwifery Services Director, 2018).

Methods

This paper reports on the qualitative findings of a larger mixed method study that explores the prescribing practice behaviours and confidence of RNPs/RMPs in Ireland. The quantitative findings are reported elsewhere (Casey et al, 2020). The objectives of this arm of the study were to explore practitioners’ perspective on prescribing within practice, and their experiences in this area. Recruitment to participate in the study was done through social media, as well as escalating through professional networks. Participants indicated their willingness to be interviewed via an online survey, which was part of the larger study, and consent was confirmed verbally at the start of each interview. Semi-structured phone interviews were conducted with participants (n=6) on agreed dates and times, using an interview guide. The interview guide was informed by the Theoretical Domains Framework (TDF) (Michie et al, 2005) and used in a fluid manner to prompt discussion, as opposed to a rigid sequence of questions (Table 1). The TDF has been defined as a useful tool to investigate how interventions, such as expanding scope of practice in prescribing, change practitioner behaviour and the subsequent effect on patients’ behaviours (Atkins et al, 2017). However, during the interviews the participants found it challenging to stay on the relevant topic as they were focused on telling the narrative in a sequence and flow that matched their priorities as opposed to the researcher and the framework’s priorities.

All six participants were female, with a mean age of 49 years. Participants were all registered as prescribers with the NMBI for a mean period of five years. They were working in nursing (n=5) and midwifery (n=1) in a variety of specialist areas in hospital (n=5) and community sectors (n=1). Further demographic details are presented in Table 2.

Data analysis

Due to the small number of participants, the TDF was not used to guide the data analysis process. Instead interview data were transcribed and subjected to an inductive thematic analysis (Graneheim and Lundman, 2004). The interview data were coded into meaningful units, compared and merged into higher order themes through an iterative process of reading of transcripts, coding and team discussion to build consensus. At each stage, the transcripts were searched to identify any contrasting or refuting evidence to the identified themes. The process continued until consensus around the themes and the supporting data was reached. To enhance robustness two people analysed the data. Ethical approval was obtained from the University Ethics Committee.

Findings

The five themes that emerged from the analysis were supports and challenges to prescribing practice, patient-centred care, prioritising safety, behaving professionally and confident decision makers.

Supports and challenges to prescribing practice

All participants found prescribing a positive experience for patients, themselves, colleagues and their service. Several factors were identified that facilitated their practice, including the relationship with the interdisciplinary team, having access to formal education and practice updates, and peer support. Some of the challenges to prescribing practice included the lack of support by colleagues, the perceived complexity of the academic prescribing programme, the distractions of noise in environment when engaging in the prescribing process, and the operational challenges of the Drugs and Therapeutic Committee (DTC) such as infrequent meetings. Support for nurse prescribing from the interdisciplinary team was a key enabling factor reported by all participants.

‘The four consultants that I work with which have actually approved this process [nurse prescribing], without them… You would be getting nowhere… Our pharmacy department was hugely supportive as well’

Having access to formal, educational practice updates and resources, in addition to the availability of peer support, was highlighted as being important in maintaining competency in prescribing.

‘We would meet as a group of prescribers within our service and definitely there would be one other prescriber that we would certainly run stuff by or if a new drug came out or we were wondering about a drug interaction… It’s ongoing. We go to the prescribing day [as well as the networks organised by the Office of the Nursing and Midwifery Services Director’

Participants also highlighted several challenges to prescribing, including difficulties with the DTC, attitudes of some health professionals, and the demands of the academic programme and the physical environment.

The DTC was frequently commented on as a barrier to change, in terms of facilitating non-medical prescribing as part of the nursing role. Variation between and within workplace settings further compounded this issue, and for some resulted in their inability to prescribe despite being a registered prescriber.

‘‘I did the D&T [application to the committee for approval to prescribe named medications] three or four times a year and you are very much at the mercy of who is on the D&T on the day…’

While most participants spoke about the positive support they received from colleagues, some of the participants stated that not all members of the multidisciplinary team embraced the introduction of non-medical prescribing. This participant was supported by their medical mentor, but the mentor’s medical colleagues initially did not support her to prescribe for their patients.

Awareness of the process of prescribing and the support required was sometimes absent or lacking in some organisations, leading to frustration. One participant spoke about the lack of awareness among nursing management, as well as being frustrated by the level of documentation required, which she perceived as a barrier due to the additional workload.

‘Management they don’t always understand because everything is about statistics, filling in your numbers and stuff like that and prescribing isn’t really about that’

The academic prescribing programme was perceived to be a barrier to considering the non-medical prescribing role by many of the participants. The complexity of the programme and workload involved was considered arduous, and a deterrent for many in taking on the non-medical prescribing role as part of their practice.

‘I feel there is a lot of work involved in that particular course. And then it’s just a certificate level I feel it should be more than that’

Another challenge discussed by the participants was being distracted by noise within the environment. While some had access to privacy when undertaking prescribing decisions, others were not as fortunate.

Patient-centred care

The participants all discussed how the patient was always at the centre of their clinical practice. Providing individualised, holistic care was considered an essential part of their prescribing role.

Prescribing was not viewed as a task-based activity, rather it was one aspect of their role that enabled them to deliver a high level of patient-centred care and maximise health outcomes in the shortest possible time.

‘Early intervention is very, very important and it has a huge benefit to patients if they can come in and you find maybe that they are hypertensive or that they are bradycardic, and they need a medication adjustment or if they are fluid overloaded and they need a diuretics adjustment. If you can intervene at an early stage, you really have a very positive impact on the outcome’

Patient-centred prescribing was central to their role, as it ensured a therapeutic relationship where trust and partnership was evident. This was developed over time, as the participants reviewed the success of their prescribing interventions on patients’ quality of life, and the impact that had on their family and community functioning. Patient buy-in and understanding the nuance in individual circumstances was viewed as pivotal to achieving successful outcomes. Engaging with patients on a continuous basis enabled the participants to tailor their care and ensure individual patients’ needs were met, while practicing within their scope of practice.

‘I think you can prescribe medications till the cows come home, but if you don’t have psych[ological] and social piece going on especially with mental health patients you are at nothing. If people can’t manage their environment and their stress and their triggers and know their early warning signs [for relapse] …they will just keep arriving at the door in crisis. So, I think one is nearly as important as the other and there would be as much if not more focus on the psychosocial intervention side of things for us as medication’

Part of that engagement also involved continuous follow-up to monitor the impact of their prescribing interventions on patients’ progress and quality of life. The close relationship that the participants developed with patients over time also ensured that any deterioration in the patient’s condition was quickly noticed.

‘It does require constant regular follow up through phone calls or visits in the clinic, but we would have a very close relationship with our patients, and they would ring us up if they notice a deterioration in their symptoms’

Patient-centred care also involved engaging and communicating with family members, as they were frequently the ones supporting the patient to take the medication and, in some cases, ensuring that the medication was taken correctly.

‘Because there are multiple children in families and there are family dynamics, there are different people giving children medication as well, you know, there are mammies, daddies, step mammies, step daddies, child minders, grannies, you know, and that all comes into play’

The economic cost to patients or the health service for the medications they prescribed was also considered. Participants were aware that sometimes noncompliance was nothing to do with the patient’s ability to take the medication, but their ability to pay for it.

‘The thing is that if some of the medications from a [names chronic condition] point of view are very expensive, so patients will say will I be on this for life. And the other thing I come up with, it is very upsetting to see patients who can’t afford medication and they are working full time and they have got a nasty disease and they are trying to make a decision based on their finances to decide on the medicine which is the wrong way for patients to have to make that decision. That really frustrates me as well’

In circumstances where there was a question of affordability, participants explored cheaper possibilities with the patient.

‘So yes, absolutely finance sometimes has to dictate my prescribing. I don’t feel I am prescribing the patient’s best therapeutic option, but it is all the patient can do and something is better than nothing in some circumstances for the patient. Because otherwise their disease will just spiral out of control’

Prioritising Safety

It was evident throughout every interview, that participants prioritised safety. The desire to be safe and the commitment to do no harm was expressed frequently and underpinned prescribing behaviours. To ensure that prescribing activity was safe, all participants reported auditing the various components of the prescribing process. Audits of generic prescribing, completion of prescriptions details, and documentation became part of the feedback to improve practices.

‘With audit… you see that gives you confidence, you think oh right well I ticked all the boxes there and I did that. Or I forgot date of births because I thought it was on the addressograph, or the weight or whatever. The audit is not a bad thing [to know how you are performing]… Have something that you can check, you are just reassured I suppose, it gives you back-up’

In addition to viewing audit as a mechanism to reassure them of the appropriateness of their prescribing practice, it was also viewed as beneficial in encouraging other colleagues to improve their accuracy in prescription writing.

‘It might be that they have initiated it [drug] and they spelled it wrong or they got the wrong dose, or they haven’t got the route, so there are incomplete prescriptions. So, from that point of view I think that, and I keep trying to get more of my midwife colleagues to do it’

The online minimum data collection system used by prescribers was seen as a positive tool in the auditing process. This is a system where non-medical prescribers input details of their prescription and/or when they alter a prescription.

‘I didn’t have a big issue with the database because I didn’t mind entering the data because it gave me a second chance to look at it [the prescription]’

In addition to auditing, participants spoke of constantly updating their knowledge to inform their practice. They outlined the importance of searching for new evidence as well as linking with medical colleagues and organisations such as the Health Products Regulatory Authority (HPRA) for updates on new medicinal products. Indeed, signing up for the HPRA email alerts to keep abreast of information on unusual adverse side effects or difficulties with medications was considered an essential aspect of safe practice.

‘Trying to stay up to date and then if I come across something, I am not certain about, like that, reading around it or linking in with the [medical]consultant. As a nurse prescriber it is very important that you’re in contact with things like HPRA, medication changes emails, you are signed up for things like that’

Collaboration within the healthcare team based on individual patient needs was central to safe and effective decision-making. Case conferences and case reviews occurred regularly, and decisions were made based on a team assessment of patient outcomes.

‘We do have case conference reviews every week where we discuss drug choices and so that does reinforce my decision and the team decision to use certain drugs. Because it’s a collaborative thing really because they initiate while they initiate the drug and I optimise it I think we all have to have a buy in that is the right drug for the patient and that it is suiting them’

Having confidence in the appropriateness of their intuitive assessment and reflection was also part of the decision-making process.

‘For want of a better word we know the subtleties of someone’s house and their home and their relationships and if something isn’t going to work, just from being there…it might not have anything to do with knowledge it might be just your feelings about something… Your intuition. You think that it’s not going to work like it’s not going to be a runner’

Many of the participants spoke about the safety issues around ensuring adherence with medication, and how patients may simply not understand why they need to take the medications prescribed or take medication correctly to prevent the exacerbation of their illness. Participants discussed the benefits of using evidence to encourage patients to take medication correctly.

‘Using the outcome measures [changes in blood profiles] to show the patient that the medication is working, these outcome measures, the blood results can get them on board’

As part of educating the patients, understanding their perspective was also viewed as essential to safe prescribing practice. Exploring patients views’ on medication, including why they might not take the medication was considered a key part of their role.

‘As a nurse prescriber you have that relationship with the person and you say to them, ‘are you going to take that medicine?’ ‘No.’ Right, you are not going to take that so what else can we do? Because you know a lot of the time, they might sit in the clinic to get a prescription, ‘oh yes doctor I will take that,’ go off and don’t take it. So, you link in with them and you can tease that [perspective] out’

Recognising and acknowledging the expertise of the patient in the prescribing relationship was also seen as key in managing and optimizing engagement with treatment.

‘I do say to people they are looking after t hemselves. The patient should be the first person you ask if you don’t know anything because they will know more from a [chronic disease identified] perspective than a lot of the doctors or nurses who are looking after them’

Behaving professionally

All participants described their perception of professional practice in their current role, and spoke assuredly regarding their scope of practice. While there was variation in the number of items the participants could prescribe, they all confirmed that they knew exactly what they were permitted to prescribe and any medicine that was outside of their list immediately generated a referral back to the medical practitioner.

‘I know my limitations, that is the biggest thing, …and I know what I am confident doing, and then if there is any blurring at the edges, I am not even touching that… Because at the end of the day I am very conscious I have got a registration, there is a very set scope of practice and extended scope that has been defined within the area and I am not going to step over that boundary’

Thr individual nature of the scope of practice was identified, which is pertinent among RNPs/RMPs as even within their own department there could be variation in roles of prescribers based on overall level of expertise, registration and qualification and, consequently, the scope of practice. Advanced practitioners’ roles were identified and acknowledged as being different to those of RNPs/RMPs working as Clinical Nurse Specialists, or the scope of practice of registered nurses/midwives working in the clinical area. The level of expertise and prescribing parameters were based on these variances in roles.

‘It should be driven by you as the health professional as what you feel is in your scope, within your job and what you feel you want to do with your prescribing’

While the prescribers themselves were sure of their role and subsequently their scope of practice, sometimes their colleagues were not as certain. Prescriber confidence in their role and scope ensured they did not succumb to pressure to prescribe for patients that were not part of the clinical caseload, or in situations where deemed there was no clinical need.

‘I get frustrated when they [other nurses] come to me once or twice and they have asked me to prescribe something and I am very firm, I say, ‘no it is not my patient, not under my care, you will have to go back to the consultant’

Participants reported also having to resist pressure and act professionally when family members or the patient wanted them to prescribe a medication they did not agree with. Patients or families often cited internet searches, or recommendations from friends as a way of putting pressure on the prescriber.

‘Well you are often put in a situation where parents want medication, they have seen something on the internet, or a friend of a friend has something, and they might put a little bit of pressure on you. I would have to be very circumspect to say that there is predisposing factors to all these different cases and you can’t just prescribe because the parent wants you to’

While the prescribers were confident in their role, they were also very willing to accept alternative views that challenged their thinking. Although this was sometimes difficult, personal feelings were put to one side as the patient and the potential outcome of treatment was the primary focus.

‘Sometimes we agree to disagree and that is fine and they [medical consultants] are the team leader. But a lot of the time there is discussion about it… At the end of the day it’s about the outcomes for patients first’

Confident decision makers

One of the most notable characteristics of the participants was their level of professional preparation and clinical expertise. Five of the six participants were educated to master’s degree level, with a mean of 26 years’ working in nursing. Participants spoke of developing their expertise over time, which resulted in them expanding the number of medications they prescribed, as their competence and confidence developed.

‘We decided that we keep it [number of medications] small until we found our feet because we were the first ones through [the prescribing programme] …and we didn’t know how this was going to work out. We really were in uncharted territories so we decided it would be easier to roll back from a small list than roll back from a big one…so it was a slow lift off which was no harm. I think it would probably be very overwhelming to have the list of drugs I now have. I think there is probably forty different drugs on the list of things I can prescribe’

This gradual, staged progression in conjunction with the education and mentoring gave participants the confidence to believe they had the skills to undertake a holistic assessment of the patient and prescribe appropriately for them.

‘You can say with confidence to someone, ‘actually you have just got a cough, you don’t actually have a chest infection, like you don’t need an antibiotic or whatever’

It also gave them confidence to advise medical colleagues when they looked to them for advice on prescribing. Being asked for advice by medical colleagues was viewed as a strong acknowledgement and endorsement of their expertise and clinical credibility, which further enhanced their confidence.

‘We get calls from the doctors all the time sometimes even externally from some GPs looking for advice on what they should put somebody on… Because they are not prescribing as much now, I have taken over the role [ prescribing medicine]… That does it mean that they get deskilled [ the doctor]. But sometimes I would advise them, and they still do their prescribing on the wards under advice’

Having their specialist knowledge and expertise recognised by nursing/midwifery and non-nursing/midwifery colleagues was also evident. This in turn resulted in a great sense of pride in themselves and in their role. This acknowledgment was earned over-time and was felt to be protected by their commitment to maintaining high standards of practice. It was also viewed as a consequence of good working relationships and partnership over time and was highly valued by the participants.

“I am [a] very long [time] on the staff here, so I suppose with that comes a bit of respect you know…and [with] that my position, that I have earned my stripes. They [medical colleagues] are giving you the patients. I can’t go out and take a patient off the street, so they share their caseload and workload with you because obviously they value your input’

Despite the difficulties experienced in the process of becoming a registered prescriber, as discussed earlier, participants spoke of experiencing a huge degree of job satisfaction with the addition of prescribing to their clinical role.

‘It has been the making of me as a professional …I have greater autonomy, I have greater confidence, I have better relationships with my patients and I really do feel that it has great deal to my practice’

Prescribing was seen to enhance professional autonomy, which was primarily of benefit to the patient. Decisions could be made in a timely manner, which impacted positively on the patient experience.

‘Straight away you can go and make an autonomous decision… Since 2014 I have done 1860 prescriptions, so with every outpatient and in-patient I see I can make a quick decision on what we are going you know what is going to be carried out. And you are not waiting for a consultant to come around, which you may only see once a week, and do you know it makes you more autonomous as well’

Discussion

The aim of the study was to explore the prescribing practice behaviours and confidence of RNPs/RMPs in Ireland, and develop a deeper understanding of practitioners’ perspectives on, and experiences of prescribing within practice. One of the key positives of prescribing practice, reported by the participants was support and respect from their colleagues and particularly their medical colleagues. Kroezen et al (2014) also reported that success or failure of nurse and midwife prescribing essentially relied upon this cooperative respectful relationship. Wells et al (2009) expressed concern that nurse prescribing might negatively impact on professional relationships between nurses and doctors, but that was not evident in this study. One of the implications of this study is the need to continue to familiarise doctors with non-medical prescribing so that they can continue to support and encourage nurses and midwives to prescribe. Interprofessional prescribing education programmes could promote this interprofessional cooperation.

Lack of understanding by other colleagues of how nurses and midwives engage in prescribing was identified as a challenge, consistent with those of previous studies (Drennan et al, 2019; Connor and McHugh, 2019). In Drennan et al (2019) all non-medical prescribers in Ireland at that time were included in their study. While non-medical prescribing was a relatively new initiative, understanding of the process that the nurse/midwife had to go through was absent, for example undertaking the physical assessment. Connor and McHugh (2019) undertook their study in Ireland, 11 years after non-medical prescribing was introduced, with over 1200 active non-medical prescribers and still this lack of awareness of how the non-medical prescriber undertakes prescribing persisted. This may suggest a need to educate all health professionals together as part of their undergraduate education. or consider interprofessional education in the area of medication management and prescribing, or have national prescribing competencies in a similar way to the UK (Royal Pharmaceutical Society, 2016).

The findings highlighted that the patient is at t he center of current nurse/midwife prescribers’ practice. Being responsive to the patients’ needs in relation to understanding their condition and giving them information about medicine in a timely manner was central to the provision of care. The findings support that argument that the RNPs/RMPs deliver care that is holistic, and patient-centered (Harris et al, 2004; Latter et al, 2005; Lewis-Evans and Jester, 2004; While and Biggs 2004; Scrafton et al, 2012; Kroezen et al, 2014).

Descriptions of safe prescribing practice was in-keeping with what is described in the literature as safe practice, through auditing, ensuring patients were educated about their medication and adherence and the consequences of taking medication (Luker et al, 1997; Drennan et al, 2019; Hojaili et al, 2013; Bolt et al, 2014). This reinforces the assertion that RNPs/RMPs are safety conscious and anxious to do no harm to their patients.

A perceived certainty in role and scope of practice was articulated throughout the study, suggesting that the participants were confident about what they prescribe and knew their limitations. Even when pressured by colleagues and patients or the patient’s family, the findings suggest that certainty of the prescriber’s role and scope of practice coupled with confidence guided them to not prescribe when they were at their professional limit, or when the clinical indications did not recommend a prescription. This certainty of role and confidence is important to keep patients safe (Cashin et al, 2014). Acknowledgement and confidence in their own expertise in keeping patients safe was evident in the findings. This supports the findings in the larger study, where increased autonomy and role certainty was reported as an integral part of RNPs/RMPs practice (Casey et al, 2020).

This study was undertaken three years after the review of the processes and implementation for non-medical prescribing was published (NMBI and HSE, 2015). It was disappointing to see that some of the barriers referred to by the participants such as the difficulties with DTC seem to persist. Some of the participants who were non-medical prescribers for at least five years, reported on difficulties with the DTC for colleagues who were recently qualified as non-medical prescribers. However, some of the participants were positive about the online data collection system for their prescriptions, and were using it as part of their audit process. This is encouraging as it was seen as a barrier to prescribing before, as it was viewed as an onerous task when it was mandatory.

Limitations

While the findings are novel in the Irish context and provide deep insights into the experience of the six participants, the findings are not generalisable. Due to the small sample size, the convenience nature of the sample, and the fact that the sample were educated to masters level with many years of clinical experience disproportionate to RNPs and RMPs in general, the generalisability of the findings beyond the sample is limited. The limit to generalisability is further compounded by the differing clinical roles and clinical expertise of the participants; three of the participants were registered advanced practitioners and one other was a candidate advanced practitioner, less than 20% of the non-medical prescribers in Ireland are advanced nurse practitioners (Office of the Nursing and Midwifery Services Director, 2018). Finally, the TDF was not used in the data analysis due to the small number of participants. Therefore, its usefulness as an analytical framework cannot be commented on.

Conclusion

Several implications emerge from this study; the need for interprofessional educational to harness earlier the cooperation between health professionals in making prescribing decisions. Adoption of national competencies for all prescribers, medical and non-medical, similar to the UK and Australia, would benefit the patient at the center of prescribing in that every prescriber would have the same competencies, be confident and trust each other’s prescribing decisions. The need to increase awareness of the role and process of prescribing for all nurses and midwives and aiding their understanding of what it means to have prescriptive authority. The certainty of their role and scope of practice of the participants in this study, would support continuing the requirement for several years of experience as a RNP/RMP before embarking on the process to become a prescriber.

Key Points

• RNP/RMPs are effective and efficient when operating in supportive teams and organisations
• Safety is of paramount importance to RNPs/RMPs in their extended roles
• Individualised, holistic and patient-centred care is central to clinical practice for RNPs/RMPs
• Professional expertise and clinical judgement of RNPs/RMPs in completing episodes of prescribing can positively effect engagement with treatment by patients

CPD reflective questions

• What are the organsational factors that can enable or inhibit extended practice roles such, as prescribing of medicinal products. by registered practitioners?
• How does scope of practice influence the prescribing behaviours of nurse/midwife practitioners?
• How can quality assurance measures influence the safety of medical and non-medical prescribing of medications in clinical practice?
• Has the implementation of the review of the prescribing processes and implementation of nurse and midwife prescribing in Ireland (NMBI and HSE, 2015) improved the day-to-day experience of nurse and midwife prescribers?