Unit 1 - Foundations of Prescribing Practice

Clinical Governance and Delivering High-quality Care



Use the RCN information guidance for nurses on clinical governance as a resource within this section.
Clinical Governance: An RCN resource guide.


Clinical governance is defined in A First Class Service (Department of Health, 1998) as:

'A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.'

This definition indicates that NHS organisations, health authorities, primary care groups, primary care trusts, GP practices and community pharmacies are accountable for ongoing improvements in service quality and for 'safeguarding' standards, thus 'creating an environment' in which excellence in care can flourish.

Clinical effectiveness is concerned with ensuring that the provision and delivery of clinical services are driven by health outcomes or evidence of effectiveness. It cannot be achieved without the other aspects of clinical governance.

Clinical effectiveness becomes a reality only if clinical professionals, patients and managers make necessary changes in their practice in the light of the evidence available.

NMC Standards of Proficiency for Nurse and Midwife Prescribers

In April 2006, the NMC developed standards of conduct that nurses, midwives and specialist community public health nurses are required to meet in their practice as a registered nurse prescriber. In addition, the document also outlines the standards and proficiencies for the programmes of preparation to be delivered by the universities.

There are 21 standards for prescribing practice listed, which detail comprehensive guidance for prescribers ranging from consent to prescribing unlicensed medicines to computer generated prescriptions. There is also a further section which includes additional guidance on practical matters.

Following publication, the standards for prescribing practice came into immediate effect and have replaced all previous requirements issued by the four National Boards for Nurses, Midwives and Health Visitors for Scotland, England Wales and northern Ireland.

The standards for education and training come into effect from 2007.

NMC Standards of Proficiency for Nurse and Midwife Prescribers (2006)

Clinical Guidelines

Clinical guidelines have been developed in Scotland, England, Wales and Northern Ireland to provide patients, health professionals and the public with robust and reliable guidance on current best practice in managing conditions in specific clinical circumstances. Synopses of the evidence or research on the best treatment of a condition are intended to assist practitioners in the delivery of care based on the best evidence available.

However, there are limitations in the case of evidence-based medicine. For example, there is simply no evidence in this area — in the form of randomised clinical trials — to use as 'gold' standard and, indeed, in nursing practice many subject areas are not suitable for this type of research.


The Scottish Intercollegiate Guidelines Network (SIGN), which was formed in 1993, has published a programme of over 60 evidence-based clinical guidelines on a range of topics. Many SIGN guidelines relate to the NHS priority areas of cancer, cardiovascular disease and mental health.
NHS Quality Improvement Scotland is responsible for technology appraisals.

Scottish Intercollegiate Guidelines Network,



The National Institute for Clinical Excellence was established in 1999 as a special health authority to promote clinical excellence and the effective use of resources in the NHS. The National Institute for Health and Clinical Excellence (NIHCE) produces guidelines in three areas of health:

  • The use of new and existing medicines and treatments in the NHS in England and Wales (technology appraisals)
  • The appropriate treatment and care of people with specific diseases and conditions in the NHS in England and Wales (clinical guidelines)
  • Evaluations of whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use (interventional procedures).

NIHCE and the national service frameworks (produced by the Department of Health and the Welsh Assembly) are responsible for setting clear national guidelines for NHS services and treatments.

You may find it useful to access Medicines and Older People: Implementing medicines-related aspects of the NSF for Older People, which describes how the use of medicines for, and by, older people can be improved.

Northern Ireland

The Northern Ireland Executive is in the process of deciding who will develop guidance for the NHS in Northern Ireland.
The Clinical Resource Efficiency support Team (CREST) was established in 1988 under the auspices of the Department for Health and Social Security (NI) Medical Advisory Structure to promote clinical efficiency and to ensure high standards of clinical practice.

Some tools, such as clinical audit, are aimed at improving and assuring the quality of care delivery and are already in place. Clinical governance provides individuals with a framework within which to build coherent localised programmes for quality improvement. One could, therefore, assume that local groups of nurse prescribers will share discussions centred on best practice, the promotion of evidence-based practice and the new responsibilities prescribing brings.


Do you have a local forum for nurse prescribers to share best practice or a national forum for prescribers from your area of practice? You may like to join these groups.


Clinical audit

Clinical audit is a professionally-led approach to improving the quality and outcomes of patient care. It requires professionals to set standards of care, to undertake a critical analysis of the quality of care in their practice, to introduce any changes required to improve care and to re-evaluate their practice to ensure the changes have been effective (A First Class Service, Department of Health, 1998). Clinical audit is simply a means of evaluating our work and ensuring that we are doing what we think we are doing.

It is an ideal procedure to use with nurse prescribing because it enables prescribing to be analysed objectively as a specific area of practice.

The clinical audit cycle

The Clinical Audit Cycle

Link to another Unit

This topic will be discussed further in the section 'Auditing, monitoring and evaluating prescribing practice' in Unit 5: Prescribing in Practice.

Reflective Activity

Reflective activity

Outline the contribution of legislation towards the safe prescribing of medication, citing one example from your recent clinical experience. This should be in brief note form and should make reference to the evidence base, where appropriate.

You may want to use this as evidence in your portfolio.

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