Nurse prescribing of medicines in 13 European countries

The right to prescribe medications has for long been reserved to the medical profession only. This situation has changed, with an increasing number of countries worldwide having introduced reforms to authorise nurses to prescribe certain medications [1‐6]. The United States of America (US) and Canada have a long tradition with nurses working in advanced practice roles, which includes the right to prescribe medicines [7‐9]. Common drivers that led to nurse prescribing reforms include physician shortages (e.g. in rural areas), the rise in chronic conditions, more interprofessional team work and an increase in nursing education at higher educational institutions [1, 3, 10]. Introducing new roles for nurses has been referred to as a disruptive innovation in healthcare [11]. Advanced nursing roles have shown to have implications not only for the nurses and the teams in which they practice and are influenced by policies and regulatory mechanisms [12, 13]. For instance, changes to scope-of-practice laws and policies on advanced educational programmes have shown to facilitate the uptake of nurse prescribing and other advanced practice nursing roles [12‐14].

Nurse prescribing refers to the official right granted to nurses to prescribe certain medications [4, 15]. The extent of nurse prescribing depends on several factors: first, the groups of nurses authorised to prescribe, which can range from small, highly specialised groups of nurses to all professional nurses; second, the type of medications that nurses are allowed to prescribe, which can range from all medicines to a restricted set; and third, the overall legal responsibility, ranging from independent prescribing to a delegated model under the supervision of a physician [15‐17]. Nurse prescribing has been shown to be comparable to physicians’ prescribing practices, as measured by the number of medications prescribed as well as the types and doses of the medications chosen [6, 18, 19]. Patients were similarly satisfied or more satisfied with nurses than physicians [18]. A Cochrane systematic review showed that nurses were as effective in prescribing medications as physicians for a range of conditions including chronic diseases [19].

An international survey in ten high-income countries (Australia, Canada, Finland, Ireland, the Netherlands, New Zealand, Spain, Sweden, the United Kingdom and the US) showed that the educational and legal conditions varied across countries [1]. Among high-income countries worldwide, Australia, Canada, New Zealand and the US are commonly cited as having implemented laws granting the prescribing of a wide range of medicines to advanced practice nurses (APN) with a Master’s degree [1, 2]. APN in these countries are authorised to prescribe all or almost all medicines within their specialty. However, differences exist in the regulation of nurse prescribing, namely if collaborative agreements with physicians are required by law [6, 20, 21]. In addition, in Australia, Canada and New Zealand, there have also been recent developments to grant registered nurses limited prescribing rights [21, 22].

In Europe, the United Kingdom (UK) has a long experience with nurse prescribing [6], where two models of nurse prescribing originated [15, 23], independent and supplementary nurse prescribing. While the former model grants the nurses the authority to issue prescriptions independently including initial prescribing of a medicine for the first time, the latter model refers to the continued prescribing after a diagnosis and treatment plan has been made by a physician [15, 23]. Research on nurse prescribing reforms has been limited and mostly focused on selected topics and individual countries, such as in the UK and Ireland on prescribing practices and safety considerations [24, 25] as well as factors enabling implementation of reforms in Ireland [26]. Recently, research in the Netherlands has evaluated task shifting between physicians and nurse specialists with generally positive results [27, 28]. Research in the Netherlands also assessed physicians’ and nurses’ views of introducing nurse prescribing [23] as well as prescribing practices of nurses in hospitals, which were shown to be influenced by national policies as well as individual hospital governance structures [29]. From an international, cross-country perspective, research on nurse prescribing reforms and the extent of prescribing authority of medicines has been scarce. One exception is a review by Kroezen et al. [1]. The review covered 10 countries of which six belong to the European Union (Finland, Ireland, the Netherlands, Spain, Sweden, and the United Kingdom). It showed that at the time of data collection, three countries (Finland, Spain, the Netherlands) were in the process of introducing legislation, suggesting an update of the current state of these reforms is warranted. Moreover, no study to date has systematically covered all countries belonging to the EU’s single market.

The purpose of this study was to analyse which countries in Europe have introduced nurse prescribing reforms, the extent of prescribing and regulations in place. Covering all countries belonging to the EU’s single market is of relevance for its free movement principle across borders which also applies to health professionals. For the nursing profession, the first-level education as professional nurse is automatically recognised, yet no nurse specialisations are covered under the EU regulation [30, 31].

The study was based on an expert survey to identify which countries in Europe have implemented reforms on nurse prescribing of medicines and, in those countries with reforms, an analysis of the extent of prescribing authority, regulatory and oversight requirements.

As of 2019, 13 countries in Europe have laws on nurse prescribing in place, which apply nationwide in 12 countries (Cyprus, Denmark, Estonia, Finland, France, Ireland, Netherlands, Norway, Poland, Spain, Sweden, United Kingdom) and in one region in Switzerland in the Canton Vaud (Table 1).

The four nations of the UK and Sweden were the first countries in Europe which introduced prescribing rights dating back to 1992 and 1994, respectively. Countries that followed were Norway, Ireland and Denmark in 2002, 2007 and 2009. Since 2010, eight additional countries (including the Canton Vaud, Switzerland) have authorised specific groups of nurses to prescribe certain medications. All have adopted laws to officially grant nurses prescribing rights, in some cases followed by the adoption of decrees to define under which conditions nurses are allowed prescribe, for what medications and the regulatory requirements.

The countries vary considerably in the groups of nurses that are authorised to prescribe and their educational requirements: a first group consists of countries in which the prescribing skills and competencies are part of the nurses’ education, e.g. Master’s or Bachelor’s degrees or specific nurse specialisations. Hence, the prescribing skills and competencies are directly integrated in these curricula, e.g. ANP Master nurses in Cyprus, Nurse Specialists with APN degree in the Netherlands, Public Health Nurses in Norway, nurses with Master’s and Bachelor’s degree in Poland, family nurses in Estonia; and nurses with a Bachelor’s degree in Spain. Since courses on pharmacology and pharmacotherapy are routinely part of these curricula, it was only in a few cases possible to single out how many European Credit Transfer Systems (ECTS) points are allocated specifically on skills and competencies related to the prescribing of medicines. For instance, in Cyprus, the curriculum of APN Master-level nurses comprises advanced pharmacology and pharmacotherapy of approx. six ECTS. In Denmark, prescribing is taught as part of a 30 ECTS “cluster” on medical treatment and therapy. In the Netherlands, RNs with a specialisation in diabetes and RNs with a specialisation of lung care are required to have a minimum of 2.5 ECTS on prescribing in their curriculum [32].

Second, some countries have set up a separate educational pathway specifically on nurse prescribing, hence, additional educational courses which lead to a title as nurse prescriber or similar. The countries are Finland, Ireland and the UK. The UK has introduced two models of prescribing, independent and supplementary prescribers. Ireland and Finland have established one role. Educational requirements vary, they range between typically 30 to 45 UK credits in the UK, 20 to 40 ECTS in Ireland and mandatory 45 ECTS in Finland. In 2019, the UK Nursing and Midwifery Council has published new standards for the post-registration programmes which apply since September 2019 [46].

France and the Swiss Canton Vaud are in the process of implementing the 2017 laws on nurse prescribing, pending the agreement of formularies and other minimum requirements as a prerequisite for nurses to officially being authorised to prescribe medicines.

This study shows that in Europe, certain groups of nurses are officially authorised to prescribe medications in 13 countries (nationwide in 12 countries and in one region in Switzerland, Canton Vaud). The majority of the reforms have been introduced over the past decade. Since 2010 alone, eight of the 13 countries newly introduced nurse prescribing (Finland, Netherlands, Cyprus, Estonia, Poland, Spain, France and the region Vaud in Switzerland). Hence, nurse prescribing has been a recent development in several countries in Europe. The extent of prescribing rights varies considerably, with three countries (Ireland, Netherlands, UK) granting certain groups of nurses (nurse prescribers, nurse specialists, independent nurse prescribers, respectively) almost full prescribing authority within their specialty. In the other countries, the number of medications is restricted, defined in a formulary or can be prescribed only after an initial prescription has been made by a physician. All countries have regulated the conditions under which nurses are allowed to prescribe; the majority require additional registration in the prescribing function, some form of physician oversight and other measures to ensure patient safety.

The study faces several limitations. First, it has exclusively focused on nurse prescribing; however, some of the countries have also introduced prescribing for other non-medical professions, such as midwives or pharmacists. Second, while the article provides an overview of the groups of nurses and extent of prescribing rights, the exact types and doses of medicines were not covered in-depth and should be investigated in future research. Third, information on educational requirements for nurse prescribing was difficult to obtain, particularly for countries where nurse prescribing is integrated in basic or advanced educational programmes.

The findings are largely consistent with previous research [1, 3, 4] and provide an update with more European countries covered and recent reforms included. While several studies in the past have focused on Anglo-Saxon countries, with Ireland and the UK frequently covered in research [10, 15], this study has enabled to cover more European countries. This study shows that the extent of nurse prescribing varies considerably across the countries studied and for specific groups of nurses within three countries (Netherlands, Poland, UK), which is consistent with the previous literature (ibid). Most countries in this study restricted prescribing rights to a list of medicines with regulatory requirements including physician oversight. In previous research, due to the differences in country coverage, which covered six European countries (Finland, Ireland, Netherlands, Spain, Sweden, UK) and Australia, Canada, New Zealand and the United States, the findings showed higher levels prescribing rights and independence in prescribing, e.g. for advanced practice nurses [1, 17].

The findings of this study show that there are high variations in the educational requirements, ranging from Bachelor level (e.g. Denmark, Spain, Sweden) to Master level degrees (e.g. Cyprus, Netherlands, Poland). There was no obvious link between the extent of prescribing rights and the length and level of training across the countries. In the three countries with almost full prescribing rights, educational requirements also varied. In the Netherlands, nurse specialists are required to hold a Master’s degree (120 ECTS) as a prerequisite to prescribe medicines. In Ireland and the UK, the competencies are taught in prescriber courses that are approved by the competent authorities, but the length varies and a Master’s degree is not required. There is a paucity of research linking the educational requirements with prescribing practices, the quality of prescribing and patient outcomes. While previous research has analysed the association of higher nurse education (e.g. higher proportion of Bachelor-level nurses or a higher proportion of professional nurses among all nurses) with improved patient outcomes and mortality [48, 49], no research was identified on the association between qualification and prescribing outcomes.

The reforms introducing nurse prescribing in 13 countries span different health systems, educational systems and geographic locations across Europe, including predominantly social health insurance (France, Netherlands) and Beveridge models (e.g. UK, Ireland). The reasons of introducing these reforms and new laws have not been systematically investigated across countries. Previous research suggests several potential drivers, including increasing patient needs and volume, higher education of nurses, higher workloads among physicians, inefficient division of work and high costs, among others [17]. Other research identified the roles, skills and competencies of individual prescribers, professional boundaries, organisational and institutional contexts as potential drivers or barriers [12, 13, 50]. In Ireland, several facilitating factors were identified as having contributed to the successful implementation of nurse prescribing: strong advocacy by the nursing profession, planning for nurse education and practice, support for multiprofessional teams and supportive government action [26]. Overall, it appears that the interplay of different factors, including nurses’ prescribing skills and education, organisational factors as well as government, stakeholder and policy support determine the implementation process. Moreover, reforms appear to take time. In the three countries in our study that grant almost full prescribing rights to specific groups of nurses (Ireland, Netherlands, UK), the policy process was lengthy and evolved over time. In Ireland and the UK, the extent of prescribing rights were initially limited and gradually expanded over time in line with generally positive evaluations [15].

One driver often referred to in Europe is the higher education of nurses in line with the Bologna cycle [17, 51, 52]. This may explain the occurrence of informal prescribing practices among nurses which paved the way towards formalising nurse prescribing, as reported in the Netherlands and Spain [53, 54]. In the Netherlands, this argument was strong in the policy debate on whether to introduce a law; controversially debated between the medical and nursing associations [53]. Overall, there is a lack of systematic cross-country research on the role of various influencing factors acting as barriers or facilitators to the introduction of nurse prescribing. In particular, more research is needed on why nurse prescribing laws have been adopted in the 13 European countries and not others.

In three of the 13 countries, the implementation of the laws is ongoing, pending the adoption of regulatory decrees and capacity building in education. France and the Canton Vaud have in common that the laws have been recently adopted in 2017. In Cyprus, the year of adoption was 2012. In Cyprus, there is no evidence of nurse prescribing officially taking place in practice, as no individual request has been made to authorise prescribing rights.

The fact that to date 13 countries belonging to the EU’s single market grant certain groups of nurses prescribing rights demonstrates that further cross-country research is required from an EU perspective. Research should focus on commonalities and differences in prescribers’ education across Europe, country variations in prescribing practices as well as the extent of prescribing rights and outcomes on specific patient groups. Moreover, with the increase in health professional mobility across Europe, including nurses, a timely monitoring of nurses with prescribing rights is warranted as to avoid skills mismatches when moving borders [55‐57].

A total of 13 countries in Europe have laws on nurse prescribing in place, of which the majority adopted laws over the past decade, suggesting a recent trend expanding the roles of nurses in these countries. The extent of prescribing rights varies considerably, with three countries granting full prescribing rights, whereas the majority of countries have restricted prescribing rights, particularly those with recent reforms. From an EU perspective, future cross-country research is required to monitor the education, prescribing practices and mobility patterns of nurses with prescribing qualifications.