Intended for healthcare professionals


A prescription for better prescribing

BMJ 2006; 333 doi: (Published 31 August 2006) Cite this as: BMJ 2006;333:459

Independent nurse prescribing


In the editorial by Aronson et al (BMJ 2006;333:459-60) attention has
been focused on poor prescribing amongst doctors and the pressing need to
make medical school teaching more comprehensive. It would be hard to argue
against this; indeed an audit of recorded adverse drug reactions (ADRs) by
junior doctors showed startling omissions (Barnard, Mackle, Bamrah, 2006;
postgraduate presentation). Over 42% of prescription charts had no entry
of ADRs, 33.5% of those with known ADRs were incorrect entries, and only
25% were correctly recorded. The curriculum for medical students might be
very congested but given that most of them will go on to prescribing for
most of their working lives, and for many this will be their core job,
training should start at an early stage and continue even when they become
senior doctors.

How then does independent nurse prescribing compare in terms of education
and training? Just prior to this editorial being published, Professor
Rawlins (one of the co-authors) stated on BBC Radio 4 that nurses were
better trained in drug prescribing than doctors. We beg to differ.

To become an independent prescriber, the DH guidelines
( are that the nurse must complete 26
days of organised learning (of which a substantial proportion is web-based), and 12 days practice with a doctor (usually as an observer). The
course is less than comprehensive; it purports to teach nurses (and
pharmacists) to undertake physical examinations, and in a short space of
time it expects nurses to understand pharmacology, pharmacokinetics and
importantly, drug interactions. It also allows them to critically analyse
the roles of others involved in prescribing drugs (e.g. doctors), and
extends their prescribing ability to any medical condition, including some
controlled drugs and off-label drugs. Apart from in-depth training in
pharmacology, training in basic and clinical sciences, comprehensive
assessments to derive a diagnosis are all essential ingredients of safe
prescribing which are lacking in any such compressed course on independent

In mental health, where there is no requirement for nurses to do ‘general
medicine’ throughout their training as was the case prior to the 2000
training programme, the pitfalls of such prescribing are many.

Supplementary prescribing, which we would fully support, is not an option.

If it is the government's intention to broaden the prescribing base then
surely training should be to the same level for nurses as it is for
medical students and junior doctors. The safety of patients requires that
nurses should be trained to the same standards as doctors if they are
undertaking the same tasks. But surely, if all our jobs are likely to be
similar in the new NHS what is the point of doctors undergoing rigorous
technical training over a prolonged period before they can become
established in their field of practice?

Competing interests:
None declared

Competing interests: No competing interests

03 October 2006
J.S. Bamrah
Chairman, BMA's Psychiatric subcommittee
S Datta, I Cormac, J Wise, J Crichton, M Harris, R Arnold, K McKenzie, N Chaudhry, P Miller (members, Psychiatric subcommittee),J Dunmur (Patient Liaison Group)
North Manchester General Hospital, Crumpsall M8 5RB