1. What patient / client health care needs would be met by extending prescribing
to nurses and midwives?
The extension of prescribing to nurses working in the specialist area of Nephrology
Nursing has the potential to effectively meet the health care needs of patients with renal
impairment under some aspects of their care, such as:

Anticoagulation during hemodialysis sessions

Phosphate binders to counteract renal bone disease

OTC pain killers

Antibiotics

MRSA treatment and prophylaxis
This submission by the Anaemia Special Interest Group under the auspices of the Irish
Nephrology Nurses Association will focus on one specific area of Nephrology Nursing
that is; The Management of Anaemia of Renal Failure. Recent research into ‘The
Status of Anaemia Management in Ireland’ found that nephrology nurses were very
amenable to taking a central role in nurse prescribing (see Appendix 1).
‘Anaemia management’ is an integral part of care for patients who experience renal
failure. Anaemia is a serious and predictable complication of Renal Impairment and can
have a significant impact on the patients health and quality of life. How ever since the
introduction of recombinant human erythropoietin (EPO) treatment in the mid 1980’s the
health of this patient population has greatly improved (Jabs and Harmon, 1996).
Research studies show that effective treatment of anaemia in this patient population can
reduce cardiovascular complications, slow progression of renal failure especially in the
pre renal / low clearance setting and improve patients quality of life (Jenkins, 2005).
There are many different guidelines and standards such as Dialysis Outcomes and Quality
Initiatives Clinical Practice Guidelines for Anaemia of Chronic Kidney Disease (KDOQI, 2000) and European Best Practice Guidelines for the Management of Anaemia in
Patients with Chronic Renal Failure (EBPG, 2000) that govern this area of patient care.
Anaemia management requires the recording of 3 weekly Hemoglobin levels, the
collation of that data into manageable tables, the review of this data by a physician, the
prescribing / or the adjustment of EPO, by a medical physician and the prescribing of iron
supplementation (usually Iron sucrose / Venofer) to supply free iron for the production of
red cells. The patients’ hyper-response or hypo-response to this treatment must be closely
monitored and evaluated by both nurses and doctors. The patients haemoglobin level
should be maintained between 11 g/dL and 12 g/dL
Currently, in Ireland, nephrology nurses work in collaboration with their medical
counterparts to manage their patients’ anaemia (see Appendix 1). Nephrology nurses are
the predominant coordinators of anaemia management. These nurses are often indirectly
involved in the prescribing of EPO / Iron as they have day to day intimate knowledge of
their patients and they often assist in interpreting trends in haemoglobin levels and this
knowledge can influence the doctors decision making process.
Often there is a time lag between the collation of results and the adjustment of EPO or IV
Iron treatment, due to time constraints on the doctors time, which does not fully meet the
needs of these patients in a timely and effective and efficient manner.
100% of Irish Nephrology nurses, when asked recently, were more than willing to
become clinical change agents to recognise, and accept, that they were rightly placed to
improve their patients anaemia outcomes and quality of life. By becoming involved in
prescribing EPO and Venofer they can increase the likelihood of patients achieving and
maintaining stable haemoglobin levels within the recommended target levels (Shanahan
and Walton, 1995).
2. What health care settings, do you consider would benefit from extending
prescribing authority to nurses and midwives?
(Continuing from question 1)
Nurses working in the area of Nephrology nursing are the preferred choice of health
care worker to co-ordinate anaemia management (Lewis et al, 2000) and they have the
specialist training, skill and knowledge to assess the renal patients anaemia, to decide on
early intervention and treatment and to evaluate patient outcomes.
According to Ennis (2002), to achieve the optimum anaemia outcomes for patients
nurses require expert clinical knowledge and experience, effective communication
and management skills and well developed clinical judgement.
In England, America and Australia nephrology nurses have had prescriptive authority
in the area of anaemia management since the 1990’s (Senger, Tenkle and St. John,
1998). Jenkins (2005) asserts that nephrology nurses play a key leadership role in
standardizing and optimizing the treatment of anaemia in patients with renal
impairment but that evidence based practice, the use of recognised guidelines and
standardized management strategies are needed to help to reduce variations in clinical
practices.
In England nephrology nurses have responded to the changing political climate and
increasing service demands by grasping the opportunity of prescriptive authority and
have recognised that the extension of nursing practice has a lot to offer in terms of
efficient and effective nursing care to renal patients and most importantly improved
patient outcomes (Casey, 2001)
The Anaemia Nurses Special Interest Group believes that patients who have renal
impairment would be appropriately served by having those expert nurses who care
for them on a daily basis, over extended periods of time, take responsibility for their
anaemia management.
3. What range of illness / health conditions do you think could be treated by nurses
and mid wives prescribing?
The Anaemia Nurses Special Interest Group believes that patients with renal
impairment or on Renal Replacement Therapy (RRT) could have their anaemia
managed effectively and safely by nephrology nurses.
The management of renal anaemia requires the nephrology nurse to:

Assess the renal patient cohort laboratory results. Basic assessment includes : Hb,
red cell indices, reticulocyte count, serum ferritin, % TSAT, CRP, dialysis
adequacy, nutritional status (PCR)

To identify those results that are outside the recommended clinical guidelines

To assess the patient for signs and symptoms of anaemia

Having knowledge of the patients RRT treatment will also assist nephrology
nurses in the evaluation of reasons for any dramatic fluctuations in the patients
anaemia status. It is important to exclude other causes of anaemia

Assessment of the patients iron stores by interpreting their Iron Studies

Treatment of abnormally low / high haemoglobin by adjusting EPO and / or
IV Iron (Venofer) dosage up or down, currently this is done by doctors only

Evaluate response to this treatment

Observe for any side effects such as Hypertension, Hyperkalaemia, excessive
clotting, access thrombosis
Monitoring and interpretation of this data provides the nephrology nurse with valuable
information regarding current and future erythropoietic response (Ennis, 2002)
Currently nurses can only bring any abnormal blood results to the doctors attention and
must wait until a prescription is written up to address the situation, this often leads to
delays in treatment.
4. A of number of models of nurse / midwife prescribing are used internationally
These include:
(a) Independent nurse /midwife prescribing subject to scope of practice using an
open formulary OR
(b) Independent nurse / midwife prescribing subject to scope of practice using a
limited formulary
What are your views?
(a) Independent nurse /midwife prescribing subject to scope of practice using an
open formulary
In American hemodialysis units, since the late 1990’s, nephrology nurses have been
empowered to coordinate the assessment and management of their patients’ renal
anaemia on a day to day basis. This is achieved through nephrology nurses utilizing an
anaemia management protocol that integrates both EPO and Iron therapy into a single
algorithm.
In an article by Michael (2005) called ‘Anaemia management protocols: providing
consistent haemoglobin outcomes’ American nephrology nurses can assess and modify
EPO and IV Iron treatment to ensure that they their patients reach their target
haemoglobin level. In this prescriptive model, nurses work within a quality improvement
team and are ‘empowered to work in conjunction with physicians to ensure consistent use
of the protocol’ Michael (2005). However it is unclear what prescribing authority
American nurses have in this seemingly restrictive model of prescribing and where
accountability for prescribing lies.
In the UK, the Department of Health (2002) approved supplementary prescribing for
nurses with appropriate experience, training and qualifications.
Garrish (2005) in an article ‘Implementing nurse prescribing within the hemodialysis
unit’ out lines clearly how supplementary prescribing has successfully worked in the area
of nephrology nursing / anaemia management to improve patient anaemia levels and
enhance their quality of life. The model of supplementary prescribing utilized in this
context continues to be a partnership between the medical staff and nursing staff.
However as any medicines are allowable to be prescribed by nurses under this model (i.e.
open formulary) the UK Department of Health has qualified this by stating that the nurse
prescribing should have appropriate experience, training and qualifications to prescribe.
Irish nephrology nurses are individually accountable for their practice there fore they will
be individually accountable for prescribing EPO / Iron when the need arises. As long as
the educational requirements are met and the nurses who are prescribing have taken a
recognised ‘prescribing course’ we believe that an open formulary would be most
appropriate to meet the current and future needs of nephrology nurses and of the patients
in the area of nephrology medicine.
6. What educational / training requirements do you consider are necessary to enable
nurses / midwives to prescribe?
Nurses working in the specialist area of nephrology nursing / hemodialysis have
recognised technical skills and expert knowledge (Hurst, 2002) and are well placed to
care for the unique and complex needs of their patients with ESRD and to manage their
anaemia management needs.
However nurses involved in prescription writing must ensure that they have the necessary
knowledge to do so safely (McCartney et al, 1999)
A comprehensive prescribing course affiliated with an institution of higher education will
be required to ensure that all nurses who are eligible to prescribe have a standardized
high level of knowledge of all the issues around prescribing of medications
(pharmacology, accountability, side effects, ethics and the law).
What level of education will the nephrology nurse be required to have to be eligible to
take this course and become a prescriber? All nurses working in nephrology have
specialist knowledge of their area of expertise however their educational background may
very greatly from certificate through to degree level with many, but not all, staff having
completed a specific Renal Course. Yet all are very aware of their patients anaemia status
and many are directly involved in anaemia management.
We believe that a standardized level of education and / or experience will be required for
nephrology nurses to become prescribers in anaemia management as this will be a very
responsible and demanding undertaking. Those with a recognised Renal Course and / or
degree, at least to begin with, could readily take on this responsible role.
7. What form of enabling environment and relationships with clinical colleagues
should be insured to maximise the effectiveness of nurse / midwife prescribing?
Nurse prescribing would be a new venture for both nephrology nurses and doctors. The
Irish health care system is in a state of flux and rapid change and nephrology nurses are
rightly placed to expand their role and to take on greater responsibility in the provision of
a high quality anaemia management service to their patients.
As in any other area of health care no professionals can work in isolation. To ensure that
patients anaemia is managed consistently and correctly a multidisciplinary approach is
required (Michael, 2005) This cooperative model should be fostered if / when Irish
nephrology nurses achieve prescriptive authority through mentorship with their medical
colleagues and through periodic audit of patient outcomes.
Nurses who treat anaemia of renal failure need to have broad theoretical knowledge of
anaemia and the practical experience to manage those aspects of care that effect
outcomes. The education given to nurse prescribers must be of the highest standard and
must meet the needs of the institution, physicians, nurses and most importantly of the
patients involved.
There needs to be organisational support for nurses who decide to take on this role and
this needs to be formalized by the inclusion of prescribing authority into the individual
nurses job description.
There also needs to be a commitment from the DOH, the employing institutions and
nurses that priority will be given to continuing education and audit will be carried out to
evaluate the impact of nurse prescribing on patient outcomes.
8. Have you any additional views on the plan to introduce prescriptive authority to
nurses / midwives?
Recognising the prescriptive role that our nephrology nurses colleagues had in anaemia
management world wide and in anticipation of the possibility of Irish nurses attaining
prescriptive authority, a survey was recently carried out entitled ‘ The Current Status of
Anaemia Management in Irish Hemodialysis Units’. This survey asked Irish nurses
pertinent question about their current involvement in anaemia management (see appendix
1.) Most importantly for this submission 100% of Irish nephrology nurses, when asked if
they felt that they would be willing to become involved in developing their role and
taking on the responsibility and accountability of prescribing said YES.
This, the Anaemia Special Interest Group believes, gives a resounding endorsement to the
possibility of this exciting development in nephrology nursing practice and we look
forward to taking on this new role and providing a timely, efficient and effective service
for our patients.