Across the nation, family nurse practitioners (FNPs) have varying degrees of prescriptive authority over medications, controlled substances, medical devices, and medical services. In addition to understanding the legal implications of prescribing medications, FNPs must also understand their ethical obligations, particularly in light of the ongoing opioid crisis.
In 22 states and the District of Columbia, FNPs have full legal practice authority, including prescriptive authority. In the remaining states, FNPs must either work collaboratively with a physician or pass a probationary period before earning practice and prescriptive authority.
FNPs and other providers who have the legal authority to prescribe must follow ethical guidelines to ensure patients are safeguarded from harm. Responsibility starts with providers being educated about the new medications and specialty drugs on the market, according to Alison Mitchell, MSN, and Catherine M. Oliphant, PharmD, in “Responsibility for Ethical Prescribing.”
“The responsibility of conducting a comprehensive patient interview and obtaining a complete medication list [is] just the beginning of the critical analysis of possible interactions and side effects,” Mitchell and Oliphant said in a guest editorial in CrossMark.
For FNPs and other providers, the responsibility of prescriptive authority is more than just simply writing a prescription correctly. Providers must understand drug interactions and possible side effects. Advanced practice registered nurses (APRNs) who are seeking a post-master’s FNP online certificate must be able to apply their knowledge of pharmacological agents to individuals through the stages of their life, especially for patients who are taking multiple medications.
Considerations in Ethical Prescribing
Studies show nearly one-third of adults in the United States takes five or more medications daily. The more medications a person takes, the greater the chance of adverse drug events, the U.S. Department of Health and Human Services said.
The World Health Organization suggests a multi-step approach to prescribing that may help providers better focus the intent for the treatment. The guidelines were established in 2007 and are still applicable today.
- Evaluate and define the patient’s problem.
- Determine the therapeutic objective of drug therapy.
- Select an appropriate medication.
- Provide patients with information, warnings, and instructions.
- Monitor the patient regularly.
- Consider drug costs when prescribing.
- Use appropriate tools, such as prescribing software and electronic drug references, to reduce prescription errors.
A major component of ethical prescribing is an examination of each patient’s distinct needs and situation. For clinicians, many ethical challenges from the past decades are still present today. Some of them include:
Prescribing to family and friends
Healthcare attorney Carolyn Buppert, MSN, said while some practitioners prescribe for family and friends, the practice is “generally not a good idea.” Laws and regulations differ by state — some states expressly forbid providers from prescribing medications to family and friends, while others simply advise against it.
“There is an ethical problem in that the close relationship could cloud the practitioner’s judgment,” Buppert said in the Legal and Professional Issues for Nurses section of Medscape Nurse.
Depending on the state, FNPs could face legal implications for prescribing to family and friends. If a state requires FNPs to have a collaborative relationship with a physician to practice and prescribe, that authority is limited to the practice setting. Writing a prescription for a friend in a social setting could trigger legal action.
In a state where FNPs can independently practice and prescribe, the major complication would focus on what is best for the patient and whether local boards of ethics have opinions on the matter. The defense is usually difficult, Buppert said.
Prescribing animal-derived medications
Animal-derived ingredients such as lactose and gelatin are commonly used in prescription drugs. Extensive animal testing is often used before prescription medication is put on the market. Patients who are vegetarians or vegans, or who have other dietary restrictions, need to know about the animal ingredients and testing to make an informed decision about treatment.
While patients are responsible for telling medical professionals about their beliefs and lifestyle choices, clinicians also should provide information that allows patients to make informed decisions.
“If this topic is not discussed, patients discovering that their medication contains animal products may stop taking it, with potentially life-threatening consequences,” practitioners said in “Ethical and Practical Considerations in Prescribing Animal-Derived Medication” published in BMJ.
Managing prescription errors
When faced with the choice between disclosing a prescription error and not disclosing, clinicians should always choose the former. In any nursing scenario, medication safety is vital. If a problem does occur, FNPs should be forthcoming, said Randi Tollison, MSN, in an article titled, “The Ethics and Legalities of Medication Error Disclosure.”
Tollison said FNPs should explain to the patient how the error happened, explain how the harmful effects of the error will be ameliorated, and provide steps that will be taken to ensure the error does not happen again.
Tollison said to prevent future errors, clinicians should ask themselves several questions before prescribing any medication:
- Is this drug needed to treat the presenting problem?
- Is this the best drug for the problem?
- Are there any contraindications to this drug with this patient?
- Is the dosage correct?
- Does the patient have allergies or sensitivities to the drug?
- What drug treatment does the patient currently use, and will the potential new drug interact with the patient’s other drugs or treatments?
- Is there a problem with the storage of the drug?
- Does the dosage regimen interfere with the patient’s lifestyle?
- Is the route of administration the most appropriate one?
- Is the proposed duration of treatment too short or too long?
Prescribing pain medication
In states where FNPs have prescriptive authority, many are also legally authorized to prescribe controlled substances, including opioid painkillers.
Opioids were once a cornerstone for treating chronic and disabling pain. Now, they have driven a drug-addiction epidemic that claims the lives of 115 people in the United States every day. In many cases, the use of opioids leads to the use of heroin, fentanyl, and other narcotics.
State and federal agencies are trying to rein in opioid use by setting limits on prescriptions. Clinicians are being urged to prescribe with caution.
The Nurse Practitioner Healthcare Foundation said clinical chronic care pain management requires four elements:
- A comprehensive assessment of the pain and past efforts to treat pain
- An examination of a wide range of treatment options besides opioids
- Ongoing patient education about the associated risks
- Vigilant follow up to mitigate possible substance abuse
FNP Nursing and Medication Safety
Medical professionals from the Nurse Practitioner Healthcare Foundation also said FNPs are in a position to align practice, policy, and research to optimize pain treatments while minimizing the risk for opioid abuse.
“NPs on the front line of care delivery are well-positioned to bring forward these messages because we will not gain if good practice outcomes are not guided by policy and we will not gain if good practice outcomes do not guide policy,” practitioners said in “Pain and Opioids: Call for Policy Action.”
Indeed, APRNs who pursue a post-master’s FNP online take coursework in pharmacology to better understand the effects of pharmacological agents on people through their lifespan. FNP students also study potential drug interactions and the use of clinical judgment.
At Duquesne University, the nurse practitioner curriculum also explores the APRN’s roles and responsibilities associated with prescribing medications, nursing, and medication safety.
About Duquesne University’s Online Post-Master’s Certificate Program — Family Nurse Practitioner
Duquesne University’s online Post-Master’s Family Nurse Practitioner Certificate provides an opportunity for APRNs to treat patients across a lifetime, from infants through adults. The coursework prepares students for the American Academy of Nurse Practitioners Certification Board (AANPCP) and American Nurses Credentialing Center (ANCC) Family Nurse Practitioner certification examinations to become FNPs. The post-master’s FNP online program encourages leadership skills to prepare APRNs for work as a primary care provider, either in collaboration with a physician or in private practice.
Duquesne University also offers post-master’s certificates in Forensic Nursing, Nursing Education and Executive Nurse Leadership & Health Care Management
Journal for Nurse Practitioners, “Responsibility for Ethical Prescribing”
Patient Safety Network, “Medication Errors and Adverse Drug Events”
American Family Physician, “Appropriate Prescribing of Medications: An Eight-Step Approach”
MedScape, “NPs: ‘Can I Prescribe for My Elderly Father?'”
LinkedIn, “The Ethics and Legalities of Medication Error Disclosure”
Postgraduate Medical Journal, “Ethical and practical considerations in prescribing animal-derived medication”
Center for Disease Control & Prevention, “Understanding the Epidemic”
Nurse Practitioner Healthcare Foundation, “Managing Chronic Pain with Opioids: A Call for Change, 2017”
The Journal for Nurse Practitioners, “Pain and Opioids: Call for Policy Action”