Prescribing: decision-making framework
This framework is designed to assist nurses and midwives and their employers in their decision making about nurse and midwife prescribing. Footnotes 1-6 which are shown in the framework are explained below. This framework should be reviewed in conjunction with the Practice Standards and Guidelines for Nurses and Midwives with Prescriptive Authority.
1. Policy identifies the structures that authorise and provide a framework for the practice of nurse/midwife prescribing in the organisation. This may include reference to the involvement of Drugs and Therapeutics, Risk Management and Clinical Governance Committees.
2. The Collaborative Practice Agreement (CPA) is drawn up with the agreement of the nurse/midwife, the registered medical collaborating practitioner/s, and the employer outlining the parameters of the nurse/midwife’s prescribing authority (their scope of practice). Refer to the the most current edition of the NMBI Collaborative Practice Agreement Guidanace for Nurses and Midwives with Prescriptive Authority.
3. Scope of practice and competency – Does the nurse/midwife meet the requirements and standards set by NMBI through completion of the education programme for nurse/midwife prescribing? Are they on the Division of the Register of Nurse Prescriber as maintained by NMBI? Is the registered nurse prescriber undergoing continuing professional development in prescribing practice to enable competency assessment?
4. Assessment includes:
- Physical examination
- History taking (including medications)
- Clinical diagnostic decision*(diagnosis, hypothesis)
5. Orders and interprets laboratory and other diagnostic tests – e.g. bloods and spirometry.
6. If the patient/service-user assessed needs exceed the nurse/midwife’s scope of practice, the patient/service-user is referred to the appropriate registered collaborating medical practitioner.
7. Documentation and record keeping for registered nurse prescribers should be outlined in local policy e.g. prescription writing including prescription pad responsibilities, medication administration record and patient/service-user’s individual case notes; supporting material for clinical audit of the registered nurse prescriber’s prescribing practice.
8. Continuing care/Discharge plan – Monitoring of therapeutic effect of the prescribed treatment by the registered collaborating medical practitioner/s, registered nurse prescriber and other team members
*An example: a nurse with prescriptive authority is working in the diabetic day care centre. Her patient population includes individuals with known diagnoses of insulin dependent diabetes. A patient presents with a pattern of hyperglycemia. The nurse through her assessment skills checks for ketones in the urine and for any source of infection. She also enquires about any recent changes in the patient’s diet. Based on this information the nurse makes a clinical diagnostic decision regarding the elevated blood sugars and the insulin dose is adjusted appropriately.