Over a decade ago, educators recognized that the scope of the advanced practice nurse (APN) would continue to expand, mainly as a result of the shortage of healthcare professionals providing care to underserved populations. Since the APN was likely to be in practice alone, they needed to have the educational background with respect to pharmacology and dispensing of medications that would complement their ability to assess, evaluate and treat their patient, including prescribing the required medications. Increased technology, higher patient acuity and patient autonomy is morphing the traditional professional boundaries of nursing and medicine. In addition, advances in science and knowledge make it very difficult for one professional specialty to be the sole expert with respect to patient treatment. Thus, there is more overlap between the APN and the physician so that skills are more appropriately used to provide optimal care to meet the needs of the patient.

Just as with any other competency, there must be a means of ensuring that the APN is practicing or prescribing medications in the safest way possible. Curriculum contains pharmacodynamics and pharmacokinetics of medications, as well as therapeutic / adverse effects, and metabolism, distribution and elimination of medications. APNs are also well grounded in developing individualized care plans, developed in concert with the patients and/or the supervising physician, after assessment and discussion with the patient. Standards of care, practice policies and protocols and consultation with other healthcare professionals may also provide frameworks to guide the APN to ensure safe prescribing practices. What is currently missing is how to determine the effectiveness of the APN's prescribing regimen on the patient's outcomes.

Whether prescriptive authority is in the form of, supplementary prescribing, patient group directions or independent nurse prescribing, outcome measures need to be better delineated to document the effectiveness of the APN's prescribing on the patient. APNs often view the patient from a more holistic perspective than other healthcare professionals. I do know now of any literature that has examined prescribing practices from that viewpoint. There is some research regarding cost-effective prescribing, but the patient seems to be lost when the discussion becomes focused on money—where are the patient outcomes here. If the outcome is good, doesn't that say a lot about cost-effective prescribing more than simply counting the medications the patient is receiving? Does the patient relationship change or does the patient view the APN as a less important healthcare provider if the APN does not have prescription privileges or has a supervising physician? Does the APN who does not prescribe medications see more patients per clinic day than the one who does? I can think of many other such questions where research may unearth some unique findings.

The article, “Effects of nurse prescribing of medication: A systematic review” is timely in that it asks some of these very questions. The purpose of reviewing the 23 studies was to determine the effects of nurse prescribing as compared to physician prescribing, and on patient outcomes, physician and nurse outcomes and the characteristics of the healthcare system. They found that prescribing practices of APNs and physician were more similar than different, and that the clinical parameters were found to be the same or better when the treatment was given by nurses. What could not be answered was how the healthcare system and other healthcare professionals were impacted by the nurse prescribing. Thus, there is a major gap in the literature that should be immediately addressed.

With more countries licensing APNs to prescribe, it is essential that the impact of changing practice be known. I personally think that the expanded scope of practice is a benefit to the APN, patient, healthcare team members as well as the entire healthcare system. But where is the science to back that up? More importantly, what if nurse prescribing is not beneficial? What if there are other avenues that the APN may have a major impact on outcomes, cost and satisfaction? The challenge is how to design investigations to provide robust information regarding the impact of the APN prescribing on a variety of dependent variables. I invite you to engage in serious discourse you're your colleagues to consider creative questions to address these very pressing issues .

No matter what the new, or old skill for that matter, the APN is a part of a complex team of professionals who have a shared goal of restoring or maintaining a person's health. As professional roles continue to evolve, the challenge is for us to continue to work as a sophisticated team in which all members can rely on each other to bring unique talents and knowledge that will enhance not only the patient's health, but the growth of the profession. Having the answers to the above questions will provide substance upon which improvements/enhancements can be made for both professional and patient outcomes.