Frequently Asked Questions about Prescriptive Authority

The impetus for the introduction of nurse and midwife prescribing first emerged in 1998 from the Report of the Commission on Nursing: Blueprint for the Future (Government of Ireland). Subsequently the Review of the Scope of Practice for Nursing and Midwifery: Final Report  (An Bord Altranais, 2000) recommended a review of legislation to support prescriptive authority by the professions. In 2001 An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery conducted a project entitled Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products. The Final Report of this project published in 2005 provided a number of key recommendations to support the expansion of practice of nurse and midwife prescribing.

In early 2006 the Irish Medicines Board (Miscellaneous Provisions) Act was introduced which contained an enabling provision for prescriptive authority for nurses and midwives. The Minister for Health and Children in May 2007 signed into law the medicines regulations providing the regulatory framework for this national initiative.

Further detail about the background and introduction of prescriptive authority for nurses and midwives can be found in these publications.

- Review of Nurses and Midwives in the Prescribing and Administration of Medicinal Products: Final Report (An Bord Altranais and the National Council for the Professional Development of Nursing and Midwifery, 2005) This report examined the international developments and research in nurse and midwife prescribing and describes the project activities exploring its expansion to Ireland.

- Introduction of Nurse and Midwife Prescribing in Ireland: An Overview (An Bord Altranais, Department of Health and Children, National Council for the Professional Development of Nursing and Midwifery and the Health Service Executive, (2007) provides an overview of the prescribing initiative and illustrates the roles of these key partners in forwarding this agenda.

Current updated information about the Board’s activities in supporting prescriptive authority for nurses and midwives can be  viewed on Updates on Nurse/Midwife Prescribing.

An Bord Altranais provides for the registration, control and education of nurses/midwives and for other matters relating to nurses/midwives and the practice of nursing/midwifery and sees its overall responsibility to be in the interest and protection of the public. Prescribing is an expansion of a nurse's/midwife's scope of practice, beyond the skills, competence and knowledge an individual practitioner possesses at the point of registration.

The professional regulatory framework for the nurse/midwife prescribing is established through the Nurses Rules, 2007, which allows for the creation of a division of the Register for Nurse Prescribers. The Requirements and Standards for the Education Programme for Nurses and Midwives with Prescriptive Authority (2007) defines the competencies that must be attained through successful completion of the programme. Building upon these foundations are the remaining elements of the Board's framework, which are:

- the Decision-Making Framework for Nurse/Midwife Prescribing (2007), which is a graphic representation of the structures and processes that should be in place for the nurse or midwife to prescribe. The diagram illustrates a rational step-by-step approach in which to consider the context and appropriateness of prescribing and the necessary clinical governance supports

- the Collaborative Practice Agreement (CPA) (2007), drawn up with the agreement of the Registered Nurse Prescriber (RNP), the medical practitioner they are working with and the employer outlining the parameters of the RNP's prescribing authority (i.e. her/his scope of practice),

- the Practice Standards for Nurses and Midwives with Prescriptive Authority(2007). The professional responsibilities of the nurse and midwife are addressed in the Practice Standards and should be viewed as the overarching mechanism with which a nurse/midwife is expected to practice.

Currently this course is being offered by two Higher Education Institutions - the School of Nursing and Midwifery, Royal College of Surgeons in Ireland,  and Catherine McAuley School of Nursing and Midwifery, University College Cork. For further information on the course contact the Programme Co-ordinators within these Higher Education Institutions

Chanel Watson
RCSI House, 121 St Stephen's Green,Dublin 2.
Tel: 01 4022706 - Email chanelwatson@rcsi.ie

Rena Creedon
Catherine McAuley School of Nursing and Midwifery,
Brookfield Health Science Complex, University College Cork.
Tel: 021-4901495 - Email r.creedon@ucc.ie

The Requirements and Standards for Education Programmes for Nurses and Midwives with Prescriptive Authority(2007) set minimum entry requirements for admission to education and training programmes leading to registration in the Nurse Prescribers Division of the Register. These include:

- registration as nurse or midwife in the live register of An Bord Altranais

- minimum of 3 years post-registration clinical experience (within the past 5 years with at least one year in the area in which prescribing is proposed)

- possession of competencies recognised at Level 8 of the National Qualifications Authority of Ireland framework

- demonstration of continuous professional development and ability to study at Level 8

- possess a competent level of information technology (IT) literacy.

In addition to the above education requirements, An Bord Altranais requires a number of other structures to be in place within the health service employer to support the nurse and midwife with prescriptive authority. These are detailed in the Decision-Making Framework for Nurse and Midwife Prescribing and the Collaborative Practice Agreement (CPA) for Nurses and Midwives with Prescriptive Authority.

Hospitals and other health service employers also must meet site selection criteria as determined by the Resource and Implementation Group of the Department of Health and Children and Health Service Executive in order to participate. For further information on these requirements contact  the Office of the Nursing Services Director:

Elizabeth Adams
Director of Nursing and Midwifery,
HSE, Office of Nursing Services Director.
Email: elizabeth.adams2@hse.ie  Tel: 087 251 3843

Annette Cuddy
Assistant Director of Nursing and Midwifery (HSE West),
Office of Nursing Services Director.
Email: annette.cuddy@hse.ie  Tel: 087 931 7039

Maureen Flynn
Assistant Director of Nursing and Midwifery (HSE Dublin Mid Leinster), Office of Nursing Services Director.
Email: maureen.flynn@hse.ie  Tel: 087 931 7014

Clare MacGabhan
Assistant Director of Nursing and Midwifery (HSE South)
Office of Nursing Services Director.
Email: clare.macgabhan@hse.ie  Tel: 087 931 7025

Rose Lorenz
Assistant Director of Nursing and Midwifery (HSE Dublin North East) Office of Nursing Services Director
Email: rose.lorenz@hse.ie  Tel: 087 286 4075

Yes, you must submit the Application Form for Entry in the Candidate Register - Post-Graduate no later than thirty days after starting the prescribing education programme. This needs to be done in conjunction with your Higher Education Institution. If you have a change of name or address during the programme you must inform An Bord Altranais of this as per the Nurses Rules, 2007.

Only appplicants who have successfully completed an education programme for Prescriptive Authority approved by An Bord Altranais and are presently employed may apply for registration in the Nurse Prescribers Division. To register with An Bord Altranais on the Nurse Prescribers Division of the Register you must submit a completed Application Form for Registration in the Registered Nurse Prescribers Division and a completed Collaborative Practice Agreement (CPA) Form. Both these forms and a Flowchart detailing the registration process can be downloaded from the ABA website, or requested from An Bord Altranais by contacting the Project Office at projectoffice@nursingboard.ie 

To maintain your registration with An Bord Altranais as a nurse prescriber you must pay your annual retention fee. Failure to pay the retention fee will result in your name being erased from the Register of Nurses under section 39(1)(b) of the Nurses Act, 1985. In addition, in order to comply with An Bord Altranais prescriptive authority requirements a Nurse Prescriber must resubmit a renewed CPA annually. Notification will be sent to you and your employer (e.g. the Director of Nursing/Midwifery) prior to the expiration date of the CPA to allow you sufficient time to review and update your CPA within your organisation before submitting to the Board.

Following successful completion of the education programme the individual nurse or midwife seeking to be registered as a nurse prescriber must submit the following:

- Application Form for Registration in the Registered Nurse Prescribers Division

- Collaborative Practice Agreement (CPA) Form

- Appropriate Fees

The Nurse Prescriber applicant will receive confirmation of registration within 10 working days. Notice will also be sent to the Director of Nursing/Midwifery or authorised individual of the health service employer.

Yes. Any member of the public can check the register for the nurse's unique Personal Identification Number, the nurse's full name and the divisions in which the nurse is registered. If your name is listed on the Nurse Prescribers Division of the Register an additional section states if your CPA is on file. Checking the register can be done by logging onto www.nursingboard.ie and going to the Check the Register tab at the top of the homepage on the website. Further instructions are provided on the Check the Register webpage. Alternatively a person may telephone 1890 200116 (An Bord Altranais Call Centre) to request a check for an individual's registration. Both services are available 24 hours a day, 7 days a week.

Registered Nurse Prescribers can prescribe controlled drugs independently, but are subject to conditions for MDA schedule 2 and 3 drugs. Schedule 8 of the Misuse of Drugs (Amendment) Regulations of 2007 outlines the drugs which the RNP may prescribe within MDA Schedules 2 and 3 as follows:

Part 1 - Drugs for pain relief in hospital

I. for the pain relief of a person in a hospital in respect of probably myocardial infarction, II. for the relief of the acute or severe pain of a person in a hospital after trauma, or for the post-operative pain relef of a person in a hospital who has had either condition described in I or II.

- morphine sulphate oral, intravenous, intramuscular
- codeine phosphate oral

Part 2 - Drugs for Palliative Care

- morphine sulphate, oral, subcutaneous
- hydromorphone oral, subcutaneous
- oxycodone oral, subcutaneous
- buprenophine transdermal
- fentanyl transmucosal, transdermal
- methylphenidate oral
- codeine phosphate oral

Part 3 - Drugs for the Purpose of Midwifery

- pethidine intramuscular

Part 4 - Drugs for Neonatal Care in Hospital

- morphine sulphate oral, intravenous
- fentanyl intravenous

No. The law does not allow for nurses to prescribe unlicensed medicines. An unlicensed medication has not been approved for licensing or authorisation as per the Irish Medicines Board or the European Medicines Evaluation Agency and therefore there are issues of accountability and responsibility (and possibly indemnity) regarding a nurse/midwife prescribing these medications. See Practice Standard 4 of the  Practice Standards for Nurses and Midwives with Prescriptive Authority  (An Bord Altranais), 2007.

As per medicines regulation - Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations 2007 and the Misuse of Drugs (Amendment) Regulation 2007 you are only authorised to prescribe if you are employed by a health service provider. In addition the Nurses Rules, 2007 require a person whose name is entered in the Nurse Prescriber's Division of the Register to notify the Board of any change in the name or address of the employer or the location of the place of employment.

The Collaborative Practice  Agreement is specific to your current position as a Registered Nurse Prescriber. An Bord Altranais requirements state that all CPAs are considered null and void on the termination or movement of employment for which the CPA is originally intended. See following examples:

Example 1. If you decide to leave your current place of employment, you must inform An Bord Altranais. Cessation of employment will result in termination of the CPA and the RNP must inform An Bord Altranais in writing within 5 working days outlining the reason for same (e.g. change of employment).

Example 2. If you change the practice area within your current place of employment, for example, you move from working in the Accident and Emergency Department to working in an Orthopaedic Unit, you must inform the Board. This in effect will result in termination of the CPA and the RNP must inform An Bord Altranais in writing within 5 working days outlining the reason for same (e.g. change of practice area). In such a case, if the RNP wishes to continue prescribing, she/he will need to fulfil the CPA requirements again for the new practice area. This means she/he will have to resubmit a CPA form to the Nursing Board.

The Check the Register section on the Board's website will show that the Registered Nurse Prescriber no longer has a valid CPA, prohibiting the person from prescribing until another CPA is submitted with new details as required by An Bord Altranais.

You can direct your query to the Project Office either by email: projectoffice@nursingboard.ie or by contacting the Project Team as follows:

Kathleen Walsh, Project Officer Tel: 01 6398502 

Denise Carroll, Project Assistant Tel: 01 6398557

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What is a Collaborative Practice Agreement?

A Collaborative Practice Agreement (CPA) is an agreement between the nurse/midwife, registered medical practitioner and health service employer which outlines the parameters of the prescriptive authority of the nurse/midwife.

What is the purpose of a CPA?

- It serves as a mechanism to ensure that the communication and referral mechanisms have been established between the registered nurse prescriber (RNP) and the medical practitioner regarding the care of their patients and agreed by the employer.

- It defines the parameters of the RNP's scope of practice. Whilst recognising the responsibility of the medical practitioner to the patient, the individual nurse/midwife is accountable for her/his prescribing practice. This means that she/he is professionally accountable as an individual for her/his prescribing decisions. This encompasses the consultation and referral arrangements when a patient's care extends beyond the RNP's scope of practice.

- It provides a template for the development, audit and evaluation of the RNP's prescribing practices within the health care setting.

The principles of professional accountability, responsibility, competence and clinical governance underpin the CPA.

Who can develop and initiate a CPA?

The candidate nurse prescriber, collaborating medical practitioner(s) and the employer work together to establish the written agreement. Each health care organisation may require additional input from the prescribing site co-ordinator, Drugs and Therapeutics Committee and/or others to assist with writing the CPA.

What do I need to include in the CPA?

An Bord Altranais provides a specific Application Form to be used for the CPA. You should read the Collaborative Practice Agreement for Nurses and Midwives with Prescriptive Authority (December 2007) before completing the form as it gives detailed information on the CPA criteria required by the Board. Especially important is the information required on your practice setting, including the patient/client population and conditions for which you will be responsible for.