Registered nurses’ prescribing powers expanded

Eligible registered nurses (RNs) are set to have their scope of practice expanded from mid-next year to prescribe approved medicines, despite previous pushback from the RACGP.
 
The change enables trained RN prescribers to prescribe Schedule 2, 3, 4 and 8 medicines in partnership with an authorised health practitioner under a prescribing agreement.
 
While those eligible RN prescribers will not be able to diagnose conditions themselves, the RACGP holds concerns specifically about the prescribing of Schedule 8 medicines.
 
The college has previously warned that expanding RNs’ scope may lead to fragmented care and risks to patient safety, and proposed the option to instead enable RNs to expand their scope of practice to prescribe only Schedule 2, 3, and 4 medicines under designation or supervision.
 
The decision comes after the final Health Ministers Meeting for the year on 6 December, where the new Registration standard: Endorsement for scheduled medicines – designated registered nurse prescriber was approved.
 
Coming into effect mid-2025, the Australian Health Practitioner Regulation Agency (AHPRA) Nursing and Midwifery Board says the endorsement, registration standard and guidelines will require governance frameworks and coordinated legislation to support implementation.
 
Chair of the RACGP Expert Committee – Quality Care Professor Mark Morgan told newsGP that ensuring patient safety must remain paramount.
 
‘Schedule 8 medicines are those with significant risk of abuse, dependency and harm, and prescribing of these should remain the role of the clinician ultimately responsible for patient care and management,’ he said.
 
‘Medicine is complex and … requires very rigorous and comprehensive scaffolding of medical science followed by structured clinical training and supervision.
 
‘If there are barriers to timely prescribing, then identifying ways to reduce these should be the focus of effort.’
 
Professor Morgan added that the proposal is a ‘watering down of existing governance arrangements where the TGA advises scheduling of medications on the basis of risk and complexity’.
 
‘What is the role of the TGA going forward when state and territory drugs and poison legislation can undermine the TGA’s recommendations?’ he said.
 
‘Will the PBS be amended to provide patients funding to access medicines prescribed by RNs?’
 
The college has long raised concerns around prescribing powers for RNs – highlighting in a recent submission that while the important role nurses have in supporting patient care is recognised, multidisciplinary teams remain the best models of care.
 
‘Patient safety is paramount and best protected where multidisciplinary teams which include a GP, are working together to provide coordinated, collaborative and continuous patient care,’ the submission states.
 
Professor Morgan also notes while the model mentions provision of improved access to medicines in rural and remote areas with shortages of primary care providers, there is a lack of detail about how or if RN prescribing will be restricted to areas of unmet need.
 
AHPRA stipulates that to apply for the endorsement, RNs ‘must meet stringent requirements’, including completing postgraduate qualifications and ‘demonstrating adequate clinical experience’.
 
An additional requirement of a six-month period of clinical mentorship with an authorised health practitioner post-endorsement will provide a ‘confidence safeguard.’
 
Under the new model is a prescribing agreement formalising the partnership between the designated RN prescriber and authorised health practitioner. It defines the roles and responsibilities of both parties and outlines any conditions within the designated RN prescriber’s scope of practice.
 
‘It is unclear what the “partnership arrangements” and “prescribing agreements” with an authorised health practitioner actually look like,’ Professor Morgan said.
 
‘A model in which a suitably qualified RN works closely with a doctor to titrate a medication to meet patient need seems entirely reasonable.
 
‘Shared patient records and an agreed management plan for that patient would be part of this model – I could see this working with some chronic condition management within a general practice team.’
 
The expansion of RNs scope comes shortly after the Nurse Practitioner Collaborative Arrangement came to an end on 1 November, granting nurse practitioners greater autonomy to prescribe and provide Medicare services without a GPs’ oversight – a move the RACGP remains opposed to.
 
It also serves as yet another example of the evolving scope of practice landscape, which the college continues to use as an opportunity to support collaborative prescribing models, with GPs best placed to manage complexity in primary care.
 
Professor Morgan says the secure future of Australia’s healthcare system relies on several models.
 
‘The Scope of Practice review, various state-based pharmacy prescribing programs and recently proposed changes to state drugs and poisons legislation all point to a sudden realisation in governments that Australia is facing a medical workforce cliff edge,’ he said.
 
‘Medicine itself has gotten a whole lot more complicated as more evidence is generated. This is reflected in clinical practice guidelines where “best practice” is more complex than ever before.
 
‘Complexity takes more time and requires a bigger workforce.’
 
He said while solutions include training more doctors and providing incentives to distribute doctors in location and speciality according to need, role substitution as a solution, if done poorly, is ‘fraught with risk’.

‘We know policies that damage general practice by undermining working conditions of GPs will result in a worsening of workforce challenges,’ he said.
 
‘Substitution can lead to fragmentation, patient-harms, increased health system costs and out-of-pocket costs.
 
‘There is an opportunity for many GPs to … provide guidance, governance and support for the primary care team to deliver care. It is vital that models of care where RNs, general practice-based pharmacists and others directly deliver a greater proportion of care need to be tested.
 
‘None of us want to see excellent Australian primary care system drift towards the cut-price care factories we hear about under the UK’s NHS.’
 
In collaboration with the Australian Nursing and Midwifery Accreditation Council, the Nursing and Midwifery Board has developed the new Registered nurse prescribing accreditation standards to ensure that designated RN prescribers meet the national Prescribing Competencies Framework.
 
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