Secondary Logo

Journal Logo

Review Article

Conceptual aspects, impact, and state of the art of dependent prescription in Brazil: narrative review

Andrade, Heuler S. PhD; Guimarães, Eliete A.A. PhD; Obreli Neto, Paulo R. PhD; Pereira, Mariana L. PhD; Zanetti, Maria O.B. MSc; Reis, Tiago M. PhD; Baldoni, André O. PhD

Author Information
doi: 10.1097/j.pbj.0000000000000066
  • Open



The global prevalence of chronic noncommunicable diseases, population aging, and the need for medication to treat infectious and parasitic diseases in less developed countries1 have called for a range of workforce strategies in an attempt to address these issues.2 These conditions require health care that includes knowledge of the patient's conditions, financial conditions, family support, and the modality of treatment adopted for each case,3 among other aspects that aim at the integrality of care.

However, this care logic has been influenced by the pressure of the pharmaceutical market, the process of social medicalization, and the irrationality of medication prescriptions. These influences are due to the cultural aspects of the “healing power” of medication, to the lack of strategies to regulate the relations of production, commercialization, and prescription, and especially to the negativity presented by the medical profession on the rational use of medication (RUM), sometimes justified as limiting the freedom of those who prescribe.4,5

Prescription is embedded in the patient-centered care process, and it should occur at a time after careful clinical evaluation. On the contrary, it is considered the starting point of the medication use process and it is a multidisciplinary communication process, involving physicians, pharmacists, nutritionists, and nursing staff, requiring knowledge of adverse effects, doses, optimal routes, medication and food interactions, pharmacokinetics, pharmacodynamics, and effects monitoring.6 However, in many places it has been assumed only by the medical professional, whether for legal or cultural reasons, leading to an overload of work and consequently to the compromise of quality of care and patient safety.7,8

Faced with this problem, several countries have adopted nonmedical prescription as a way to improve the integrality of care, providing a more holistic care to the patient. Studies demonstrate that this practice, by making better use of the knowledge and skills of other professionals, contributes to the expansion of access to health care, improves the patient's health conditions, as well as their level of satisfaction with the service, and generates savings in several health specialities.2,9,10

Nonmedical prescription is a practice performed by professionals who are not doctors who, after obtaining specific qualifications and legal authorization, can prescribe medicines and curatives. The term “nonmedical prescription” appeared in the United Kingdom in 1992, and in 2015 it was estimated that there were 58,000 nonmedical prescribers such as nurses, pharmacists, physiotherapists, among others. The data from the health service show that it is a fast-growing activity, forming a large work force to improve the quality of health care.11

Although nonmedical prescription activity is present in many countries, studies that report this practice, its benefits, and challenges in Brazil, are still scarce. Thus, this study aimed to describe the conceptual aspects and state of the art of this type of prescription in Brazil.


This is a study of a narrative review of the literature. This type of study, being broader, is appropriate to describe and discuss the development or “state of the art” of a given subject from a theoretical or contextual point of view. This basically constitutes a critical analysis of the author, from literature published in books, and articles of printed and electronic magazines.12

To guide the research, the following questions were defined: “What are the conceptual aspects related to nonmedical prescription? and “What is the state of the art of non-medical prescription in Brazil?.”

In order to compose the analysis material, national and international regulations related to the subject were considered as well as articles available, published in electronic journals in different databases. Key terms used were: non-medical prescription, nursing prescription, and pharmaceutical prescription. The coverage period was not restricted.

The publications were read in full and compiled according to the study objectives.


The literature found in this review was quite diverse. As there was no restriction on publication time, guidelines and laws dated from the 1980s were found to articles in high impact magazines in 2019, from different countries, such as England, United States of America, Brazil, and Australia. Most publications were about the advantages and applications of nonmedical prescription for professionals and patients. Some have, however, clearly addressed the problems and challenges surrounding this practice.

Conceptual aspects

Independent prescription

This is a prescription model in which the prescribing professional is solely responsible for the evaluation, diagnosis, and clinical management of the patient. It requires legally defined levels of knowledge and skill that are generally monitored through a licensing process.8 In general, in Brazil, the physician is the only independent prescriber, whereas in the UK and other Western European countries such as Sweden and Ireland, professionals such as nurses, pharmacists, and podiatrists may become independent prescribers after taking preparatory courses, but with restrictions in relation to the therapeutic classes.13,14

Dependent prescription

The dependent prescription is a voluntary partnership, or not, among health professionals, for clinical management of patients and for medication therapy. In this case, responsibility is shared for clinical decisions and patient outcomes. Prescription activities by nonmedical professionals are restricted to protocols and agreements.8 This type of prescription is subdivided into the following categories:

Protocol prescription

This is the most common form of dependent prescription and is directed by an independent prescriber, usually a physician, through a formal agreement (protocol). The protocol is a written directive, an explicit and detailed document that describes the activities that professionals can perform in their prescriptive authority. The level of authority is determined by the assessments of the physician in relation to the professional, the professional in relation to themselves, and the conformity of their competencies. Both assume responsibility for results.8

In the United States, this model of prescription has been approved in 25 states. Health service pharmacists supporting indigenous populations may prescribe medications for diseases such as urinary tract infections, sexually transmitted diseases, systemic arterial hypertension, bacterial and fungal infections, and rheumatoid arthritis.8

Form prescription

The form is a predetermined list of medications, including treatable symptoms, treatment time, criteria for referrals, and limitations on prescription. Prescription medications are generally exempt from this type of medical prescription. Forms should be agreed based on the medical practices where they will be implemented. In the United Kingdom, more than 20,000 nurses are allowed to prescribe by forms. In Scotland, prescription by pharmacists from this model includes 11 therapeutic areas, such as diarrhea, constipation, colds, and lice infestation.8

Renewal prescription

This is aimed at patients who had their stock of medicines exhausted before the next medical appointment. The professional responsible for the renewal should evaluate the patient and the therapy, and then consult the physician if there are problems of effectiveness, safety, or adherence to the treatment. The prescription should be renewed with a sufficient amount until the next consultation with the doctor. This model, like the form, needs to be agreed upon based on the medical practices in which it will be implemented,8 since it is a complex activity that requires communication and collaboration among professionals. Otherwise prescription errors may occur, and also encourage unnecessary polypharmacy. While presenting these risks, this is a model that brings greater convenience to the patient and reduces the workload of the professional. In the United Kingdom it is estimated that in the last 20 years, the number of items that can be renewed by prescription increased from 5.8 to 13.3 items per patient per year.15 In the province of Alberta, Canada, all pharmacists are authorized to renew the prescription.16

Supplementary prescription

Established through protocols or agreements between a physician and an additional prescriber (nurse, pharmacist, or other professional) to implement a specific patient management plan directed to the patient, in accordance therewith. The doctor makes the initial diagnosis and then both prescribers prepare and implement the care plan. Nonmedical prescribers can prescribe within the parameters established in the plan, remaining responsible for their prescribing decisions.17 In the United Kingdom, pharmacists have used this model to solve problems of access of patients with mental illness to specific medication.18

Collaborative prescription

This is the collaborative practice agreement between one or more doctors and qualified clinical pharmacists working within the context of a defined protocol that allows the pharmacist to take responsibility for performing patient evaluations, requesting laboratory tests related to medication therapy, medication administration, and to select, initiate, monitor, continue, and adjust medication therapy regimens.19

In New Zealand, pharmacists have performed collaborative prescribing in several areas, with emphasis on mental health, where there is significant recognition by patients.20

Successful nonmedical prescription experiences

In many countries the adoption of different models of nonmedical prescription is already a reality described in several studies.10,13,16,21,22 In Brazil, these models have been adopted independently and sporadically by some institutions and municipalities.23,24

The United Kingdom is a pioneer in studies and encouragement of nonmedical prescription practices. Since the 1980s, government measures have been adopted to make greater use of the skills and experiences of nonmedical health professionals in relation to the prescription, supply, and administration of medication.25 From 1992, nurses have been authorized to perform prescriptions, and gradually, through the improvement of legislation, in the early 2000s, pharmacists were also authorized, resulting over the years in a jump in the quality of health care and the introduction of new professional categories in the scope of prescribers, such as physiotherapists, dentists, and nutritionists.22,26,27

In the United States since the 1990s, the independent prescription model is authorized for nurses and pharmacists in 21 states, whereas the remaining states28 still adopt dependent prescription. Despite the differences in regulation, nonmedical prescription is an upward trend due to advances in science and social needs, especially in relation to patient safety, which has provided better quality of care.25

Countries such as Canada, Sweden, Finland, Ireland, The Netherlands, Spain, New Zealand, and Australia already have legislation for prescription by pharmacists and nurses. In general, there are some restrictions on certain practices and medications, and most of these countries adopt the independent prescription model and require advanced qualification of the professional who wishes to be a prescriber.25 France approved in July 2019 a bill for health system organization and transformation. Among these modifications are the prescription pharmaceutical protocol and the renewal of prescription.28

In general, the impact of nonmedical prescription has been evaluated positively, having seen the existing evidence and the reports of professionals and patients. Nonmedical prescribers have highlighted as results of this practice job satisfaction and self-confidence, making them more independent and allowing better use of their skills.25 The improvement in teamwork was also highlighted, especially by physicians, as the reduction in workload gave more time to dedicate to more complex patient cases. The latter reported greater access and flexibility to the consultations, more careful style of care, and principally, improvements in their health conditions.27,29

Nonmedical prescription in Brazil

In Brazil, nonmedical professionals, through legislation that regulates the practice of professions, are authorized to prescribe over-the-counter medication and prescription medication through protocols. Nurses have been allowed to prescribe since 198630 and this practice was outlined by the National Policy of Basic Care (Política Nacional de Atenção Básica)31 and by public and private institutions. Since 2013 through resolution 586 of the Federal Council of Pharmacy,32 pharmacists have been allowed to prescribe. Dental surgeons have been able to prescribe independently for dental purposes since 1966,33 whereas nutritionists have been allowed to prescribe nutritional supplements since 2017.34

The Brazilian initiatives that made the practice by nonmedical prescribers possible started mainly from municipalities, through ordinances and protocols with the intention of optimizing care, and assisting medical professionals in the health care of the population. Table 1 describes some of these initiatives.

Table 1
Table 1:
Description of nonmedical prescription types authorized by Brazilian institutions according to year of creation

International evidence shows that despite the benefits, there are innumerous challenges to the consolidation of this activity.14 In this context it is important to emphasize that performing a medication prescription requires, in addition to theoretical knowledge, training and clinical practice. The lack of these skills, besides jeopardizing the care process, can arouse distrust of other professionals and also of users receiving a prescription from a professional other than the physician.35,36

Another issue that has caused a growing and continuing concern is that having more prescribers may result in unnecessary polypharmacy and duplicative therapy. Therefore, the RUM is an important initiative aimed towards reducing the problem of polypharmacy; RUM also encourages improvements in medication regulation and commercialization as well as reducing unnecessary prescribing habits.5,37

The requirement of specific courses for professionals wishing to become prescribers is already a reality in some countries and may be an alternative38 to solve some of these problems, as well as the inclusion of this theme in graduate programs. The Ministry of Education has defined new national curricular guidelines for graduate courses in health and postgraduate courses, seeking among others, to train and qualify professionals with the competencies to assume demands such as dependent prescription.39,40,41 Preparing academics to perform this role can fill knowledge gaps and give them the skills they need for the exercise of the profession.25

In addition, promoting changes in the work process of nonmedical health professionals is necessary so that they can more actively exercise their clinical duties and can effectively insert themselves into the multiprofessional team of patient care. Pharmacists and nurses, for example, spend a significant portion of their work hours on managerial activities, which makes it impossible to dedicate themselves to activities and services to promote RUM, including patient care and the prescription as a strategy in the care plan.42–46

The articles found in this review clearly demonstrate the benefits generated by nonmedical prescription, when adopted responsibly. The consolidation of this activity requires investment by health institutions with regard to its implementation and acceptance by other professionals and patients.

Educational institutions can promote changes in professional training from undergraduate courses, preparing future professionals to fill the knowledge and skills gaps currently needed to become qualified prescribers.

Likewise, it must be considered that prescriptions need registration and formalization and nonmedical prescribers need to be better valued and remunerated, due to the responsibilities and the increased workload that the prescription brings.


The realization of this study made it possible to perceive that the activities of nonmedical professionals are expanding around the world. Despite the difficulties and barriers, it is noted that this practice has ample potential for improving the quality of care and the health conditions of patients.



Conflicts of interest

Declarations of interest: none.


[1]. Akkari ACS, Munhoz IP, Tomioka J, et al. Inovação tecnológica na indústria farmacêutica: diferenças entre a Europa, os EUA e os países farmaemergentes. Gestão Produção. 2016;23:365–380.
[2]. Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev. 2016;11:CD011227.
[3]. Pinto IVL, Reis AMM, Almeida-Brasil CC, et al. Avaliação da compreensão da farmacoterapia entre idosos atendidos na Atenção Primária à Saúde de Belo Horizonte, MG, Brasil. Ciênc Saúde Coletiva. 2016;21:3469–3481.
[4]. Lima MG, Álvares L J, Guerra Junior AA, et al. Indicadores relacionados ao uso racional de medicamentos e seus fatores associados. Rev Saude Publica. 2017;51 (suppl 2):23s.
[5]. Esher A, Coutinho T. Uso racional de medicamentos, farmaceuticalização e usos do metilfenidato. Ciênc Saúde Coletiva. 2017;22:2571–2580.
[6]. Jacobsen TF, Mussi MM, Silveira MPT. Análise de erros de prescrição em um hospital da região sul do brasil. Rev Bras Farm Hosp Serv. 2015;6:23–26.
[7]. Pazin-Filho A, Frezza G, Matsuno A, et al. Princípios de prescrição médica hospitalar para estudantes de medicina. RMRP. 2013;46:183–194.
[8]. Emmerton L, Marriott J, Bessell T, Nissen L, Dean L. Pharmacists and prescribing rights: review of international developments. J Pharm Pharmaceut Sci. 2005;8:215–225.
[9]. Lim RH, Courtenay M, Fleming G. Non-medical prescribing lead roles. Int J Pharm Pract. 2013;21:82–91.
[10]. Lee S, Godwin OP, Kim K, Lee E. Predictive factors of patient satisfaction with pharmacy services in South Korea: a cross-sectional study of national level data. PLoS One. 2015;10:e0142269.
[11]. Department of Health. Non-medical Prescribing – An Economic Evaluation. London: Health Education North West; 2015.
[12]. Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. Diretrizes Metodológicas. Elaboração de revisão sistemática e metanálise de estudos observacionais comparativos sobre fatores de risco e diagnóstico. Brasília. 2014:132.
[13]. Kroezen M, Van Dijk L, Groenewegwn PP, Francke AL. Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature. BMC Health Serv Res. 2011;11:127.
[14]. Hindi AMK, Seston EM, Bell D, Steinke D, Willis S, Schafheutle EI. Independent prescribing in primary care: a survey of patients’, prescribers’ and colleagues’ perceptions and experiences. Health Soc Care Community. 2019;27:e459–e470.
[15]. Price J, Man SL, Bartlett S, Taylor K, Dinwoodie M, Bowie P. Repeat prescribing of medications: a system-centred risk management model for primary care organisations. J Eval Clin Pract. 2017;23:779–796.
[16]. Guirguis LM, Hughes CA, Makowsky MJ, Sadowski CA, Schindel TJ, Yuksel N. Survey of pharmacist prescribing practices in Alberta. Am J Health Syst Pharm. 2017;74:62–69.
[17]. Department of Health Non-medical Prescribing in the Management of Substance Misuse. 2014;XXX, London:2014205.
[18]. Deslandes RE, John DN, Deslandes PN. An exploratory study of the patient experience of pharmacist supplementary prescribing in a secondary care mental health setting. Pharm Pract (Granada). 2015;13:553.
[19]. Academy of Managed Care Pharmacy. Practice Advisory on Collaborative Drug Therapy Management.
[20]. Wheeler A, Crump K, Lee M, et al. Collaborative prescribing: a qualitative exploration of a role for pharmacists in mental health. Res Social Adm Pharm. 2012;8:179–192.
[21]. Stephenson T. Implications of the Crown Report and nurse prescribing. Arch Dis Child. 2000;83:199–202.
[22]. Department of Health. The NHS Plan: A Plan for Investment, A Plan for Reform. Department of Health, 2000.
[23]. Brasil. Prefeitura Municipal de Salto Grande. Portaria no 318, de 22 de junho de 2017. Dispões quanto a sistematização da assistência de enfermagem no Departamento Municipal de Saúde de Salto Grande, conforme consta dos anexos deste instrumento e dá outras providências correlatas.
[24]. Brasil. Prefeitura Municipal de Florianópolis. Protocolo de enfermagem: hipertensão, diabetes e outros fatores associados a doenças cardiovasculares. 2015.
[25]. Cope LC, Abuzour AS, Tully MP. Nonmedical prescribing: where are we now? Ther Adv Drug Saf. 2016;7:165–172.
[26]. Landmark decision gives UK physios a world first in prescribing rights [press release]. London, UK: Chartered Society of Physiotherapy; 2012.
[27]. Courtenay M, Carey N, Stenner K, Lawton S, Peters J. Patients’ views of nurse prescribing: effects on care, concordance and medicine taking. Br J Dermatol. 2011;164:396–401.
[28]. Assemblée Nationale. Projet de Loi relatif à l’organisation et à la transformation du système de santé. Commission mixte paritaire: 586 (2018–2019). Paris; 2019.
[29]. Stenner KL, Courtenay M, Carey N. Consultations between nurse prescribers and patients with diabetes in primary care: a qualitative study of patient views. Int J Nurs Stud. 2011;48:37–46.
[30]. Brasil. Lei no 7.498, de 25 de Junho de 1986. Dispõe sobre a regulamentação do exercício da enfermagem e dá outras providências. Brasília: Diário Oficial [da] República Federativa do Brasil; 1986.
[31]. Brasil. Ministério da Saúde. Portaria no. 2.436 de 21 de setembro de 2017. Brasília: Diário Oficial [da] República Federativa do Brasil; 2017.
[32]. Brasil. Conselho Federal de Farmácia. Resolução no 586, de 29 de agosto de 2013. Regula a prescrição farmacêutica e dá outras providências. Brasília: Diário Oficial [da] República Federativa do Brasil; 2013.
[33]. Brasil. Lei no 5081, de 24 de agosto de 1966. Regula o Exercício Profissional da Odontologia, Brasília: Diário Oficial [da] República Federativa do Brasil; 1966.
[34]. Brasil. Conselho federal de Ntricionistas. Resolução CFN no 402/2007. Regulamenta a prescrição fitoterápica pelo nutricionista, de plantas in natura frescas, ou como droga vegetal nas suas diferentes formas farmacêuticas. Brasília: Diário Oficial [da] República Federativa do Brasil; 2007.
[35]. Auta A, Strickland-Hodge B, Maz J, David S. Pharmacist prescribing: a cross-sectional survey of the views of pharmacists in Nigeria. Int J Pharm Pract. 2018;26:111–119.
[36]. Graham-Clarke E, Rushton A, Noblet T, Marriott J. Facilitators and barriers to non-medical prescribing ± a systematic review and thematic synthesis. PLoS One. 2018;13:e0196471.
[37]. Brasil. Ministério da Saúde (MS). Uso racional de medicamentos: temas selecionados. Brasília: MS; 2012.(Série A. Normas e Manuais Técnicos).
[38]. NHS Education for Scotland. A Guide to Good Prescribing Practices for Prescribing Pharmacists in NHS Scotland. 2012.
[39]. Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução no 6, de 19 de outubro de 2017. Institui as Diretrizes Curriculares Nacionais do Curso de Graduação em Farmácia e dá outras providências. Brasília: Diário Oficial [da] República Federativa do Brasil; 2017.
[40]. Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução no 7, de 18 de dezembro de 2018. Estabelece as Diretrizes para a Extensão na Educação Superior Brasileira. Brasília: Diário Oficial [da] República Federativa do Brasil; 2018.
[41]. Brasil. Ministério da Educação. Conselho Nacional de Educação. Câmara de Educação Superior. Resolução no 1, de 6 de abril de 2018. Estabelece diretrizes e normas para a oferta dos cursos de pós-graduação lato sensu denominados cursos de especialização, no âmbito do Sistema Federal de Educação Superior. Brasília: Diário Oficial [da] República Federativa do Brasil; 2018.
[42]. Silva RNA, Lima AKM, Filha FSSC, Vialnova JM, Silva FL. Conhecimento e entendimento de enfermeiros sobre as ações gerenciais na atenção primária à saúde. Ciência Saúde. 2016;9:21–29.
[43]. Soares MI, Rodrigues Resck ZM, Camelo SHH, Terra FS. Gestión de recursos humanos y su interfaz en la sistematización de la asistencia de enfermería. Enf Global. 2016;15:341–375.
[44]. Reis TM, Guidoni CM, Girotto E, et al. Knowledge and conduct of pharmacists for dispensing of drugs in community pharmacies: a cross-sectional study. Braz J Pharm Sci. 2015;51:733–744.
[45]. Reis TM, Pereira LM. The Brazilian pharmacist's role in dispensing drugs in the pharmaceutical care scenario. J Appl Pharm Sci. 2016;3:11–13.
[46]. Oreagba IA, Ogunleye OJ, Olayemi SO. The knowledge, perceptions and practice of pharmacovigilance amongst community pharmacists in Lagos state, south west Nigeria. Pharmacoepidemiol Drug Saf. 2011;20:30–35.

nonmedical prescription; nursing prescription; pharmaceutical prescription; prescription dependent

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of PBJ-Associação Porto Biomedical/Porto Biomedical Society. All rights reserved.