Nurse Prescribing and the Management of Epilepsy

The United Kingdom (U.K.) health system is organized in a hierarchical way with general practitioners (GPs) acting as gatekeepers to the system. Most people are registered with a GP who is contracted to provide free general medical services. Patients in need of specialist intervention are referred by their GP to local hospitals. However, a shortage of specialists in epilepsy exists, and in some socially deprived areas, GPs are scarce. Patients with epilepsy in these areas are at higher risk of SUDEP (sudden unexplained death from epilepsy). GPs treat many patients with refractory epilepsy, although they may be unfamiliar with complex epilepsy and with new treatments. The consequences include inadequate treatment and increased morbidity and mortality (1-4). Up to half of the >1,000 epilepsy-related deaths each year might have been prevented by optimal antiepileptic drug (AED) treatment or epilepsy surgery (1). The National Institute for Clinical Excellence (responsible for clinical governance and the use of evidence-based management within the health system) has issued clinical guidelines for the management of epilepsy. They include recommendations that specialists diagnose epilepsy and review patients with refractory epilepsy and that patients have access to epilepsy nurse specialist (ENS) services (5). A new contract established for GPs offers incentive payments for having a register of patients with epilepsy, recording seizure frequency, and performing medication reviews (6). Calls have been made for nurses to take responsibility for the management of chronic conditions and, in consultation with the multidisciplinary team, to provide health assessments, arrange and interpret investigations, plan and implement treatment, and prescribe medications (7). With the shortage of medical staff in the U.K., ENSs are increasingly involved in the management of epilepsy, improving patients' quality of life and reducing morbidity and hospital attendances (8-11). However, ∼350,000 patients with epilepsy and only 100 ENSs, with large caseloads, live in the U.K. (12). At least 300 additional specialist nurses are needed to provide adequate services. ENS services also vary according to the nurse's qualifications and experience, the practice setting, and clinical support and supervision (12-16), so, whereas most ENSs supervise treatment and provide information about AEDs, fewer than half provide nurse-led clinics, advise the patient and primary care team on management, and take responsibility for giving treatment advice (12). The variation in roles and competencies raises concerns about patient safety and the unrestricted use of the title Nurse Specialist. To address these concerns, a postgraduate registration and title, Advanced Nurse Practitioner, has been proposed (17). An Advanced Nurse Practitioner needs a specific Master's degree, and the ability to take responsibility for case management, make differential diagnoses, plan and provide care, and, where appropriate, prescribe medicines. The trend toward postgraduate Master's Degree programs and registration is in keeping with worldwide developments, amid debate that nursing is becoming too medicalized and calls for more specialized courses to improve nurses' clinical effectiveness (18, 19). The New Zealand Nurse Practitioner degree program includes substantial clinical content, whereas the United States programs have been criticized for their generic and nonclinical content. The educational requirement for the proposed U.K. Advanced Nurse Practitioner is also generic rather than clinically focused. Thus an Advanced Nurse Practitioner without further qualifications in epilepsy will be required to “take responsibility for case management, make differential diagnoses, plan and provide care and treatment” without necessarily having knowledge of neurophysiology, neuroimaging, seizure semiology and syndrome classification, the genetics of epilepsy, differential diagnosis, medical and surgical treatment, pharmacology, neuropsychology, and psychosocial aspects of epilepsy, which is taught in a degree with a focus in epilepsy. In the U.K., the aims of nurse prescribing are to improve patients' access to medicines, maximize the use of nurses' skills, and reduce waiting times for outpatient appointments (20). Since 1998, 28,000 District Nurses and Health Visitors have completed a training program and are registered as independent prescribers; they prescribe appliances, dressings, and some medicines from a limited Nurse Prescribers' Formulary. The formulary has now been extended to include all licensed pharmacy and General Sales List medicines prescribable at NHS expense, together with >180 specified prescription-only medicines, and further increases in the range of prescription-only medicines have been proposed. The independent nurse prescriber takes responsibility for diagnosis and prescribing for a wide range of conditions under the categories of mild ailments, minor injuries, health promotion, and palliative care, and, under the new proposals, also emergency care. (21, 22). At least 3,000 independent nurse prescribers have completed an extended supplementary prescribing course with theoretical and practical components. Supplementary nurse prescribing is aimed at nurses with the knowledge, skills, and competence to prescribe medications for patients with chronic conditions requiring long-term management. Almost all medications in the British National Formulary can be prescribed according to a clinical management plan that is drawn up and agreed on between the physician, nurse, and patient. This specifies the range of medicines to be used and the circumstances in which the drug, formulation and dose can be varied. The physician retains responsibility for diagnosis and the range of medications to be prescribed while the nurse undertakes management of the condition, including considering differential diagnoses and advice on all aspects of the drugs used and supplying a prescription for which she or he is clinically responsible and professionally accountable. Evaluations of nurse prescribing relate mainly to independent prescribers in primary care who prescribe from a limited formulary. Patients are generally supportive and comment that nurses have a good knowledge of the products and are more accessible than GPs (23). Nurses' role satisfaction and autonomy is enhanced, but some nurses find it only moderately helpful in practice and write few prescriptions. Many lack confidence to prescribe and report anxiety in relation to diagnostic uncertainty or are limited by the range of products in the Nurse Prescribing Formulary. Criticism is made that the prescribing course contains insufficient pharmacology content, and the lack of pharmacology knowledge prevents nurses from prescribing (24, 25). Nurse prescribing has undergone considerable change since 1998 and continues to evolve. A recent proposal is to allow all nurses to prescribe any medication from the British National Formulary (26). This would eliminate the need for nurses to form supplementary prescribing partnerships and adhere to a clinical management plan. Supplementary nurse prescribing potentially restricts and downgrades the practice of experienced ENSs who currently take responsibility for recommending medications and advising physicians on the treatment, as it requires the physician to recommend the medications that can be prescribed. It may also encourage nonspecialist nurses to form supplementary prescribing partnerships with GPs and prescribe medications to meet targets (27). Without the necessary competencies to provide epilepsy consultations and prescribe AEDs, this practice would breech the Nurses' Code of Professional Conduct and may jeopardise patient safety. In conclusion, in the U.K., the scarcity of specialists and the cost of health care underlie government-driven directives that nurses take responsibility for prescribing medications and the management of patients with chronic illness. The generic qualifications and competencies required by nurses to undertake the role, however, may not protect patient safety or improve management. To prescribe AEDs and improve the management of epilepsy, specialist nurses require an appropriate qualification with the focus on epilepsy. Improving access to specialists is the most effective way of improving patients' quality of life and reducing epilepsy-related morbidity and mortality (1, 3, 28). Development in this area will have to be continuously monitored and evaluated.