A recent study revealing that over 61 per cent of Bhutanese nurses are prescribing medicines without legal authority has sparked considerable concern. While this may appear alarming at first glance, the truth is more nuanced. This widespread, albeit unlawful, practice is not a result of negligence or disregard for regulation—it is a response to a healthcare system strained by chronic doctor shortages, particularly in rural and district hospitals. Rather than reprimanding these professionals, it is time for Bhutan’s health authorities to confront the systemic gaps and consider legalizing nurse prescribing under well-defined regulatory frameworks.
Under the regulations of the Bhutan Medical and Health Council, only doctors are permitted to prescribe medication. Nurses, even if designated as “competent persons,” are excluded from this responsibility. Yet, in practice, these regulations are often superseded by urgent realities on the ground. In district hospitals where no doctors are available during nights, weekends, or holidays, nurses are frequently the only accessible healthcare providers. Patients in need of immediate care are left with two options: walk away untreated or be attended to by a nurse willing to assume an unlawful yet ethically necessary responsibility.
What drives nurses to act beyond their legal scope is not ambition or overreach, but a professional and moral obligation. When faced with a sick patient, particularly in emergency units where doctors are absent, nurses are often the last line of defense against deterioration, disability, or even death. Their decisions, made under pressure and often in isolation, highlight not a breach of integrity but a gap in the healthcare system’s responsiveness to real-world needs.
This is not an isolated phenomenon. The study, which surveyed 312 nurses across Bhutan, found that those with one to ten years of experience were more likely to prescribe in the absence of doctors, while more senior nurses refrained unless explicitly directed to do so. Additionally, many nurses reported high levels of stress and anxiety, knowing they were acting without legal protection. This lack of recognition not only compromises their ability to deliver holistic nursing care but also puts their careers and patients at risk.
And yet, no formal complaints have been lodged with the Bhutan Medical and Health Council regarding incorrect prescriptions, which suggests either the competence of these nurses or the absence of sufficient patient awareness and reporting mechanisms. Either way, this silence speaks volumes: the system is functioning in an unofficial capacity because there is no viable alternative.
The solution is not stricter enforcement of existing laws. Instead, Bhutan must consider legalizing nurse prescribing through structured training programs, licensing, and supervision, especially for those serving in under-resourced areas. Internationally, countries such as the United Kingdom, Australia, Canada, and New Zealand have adopted nurse prescribing models with demonstrable success. These frameworks allow qualified nurses—typically those with advanced clinical training—to prescribe medications within a defined scope of practice, ensuring both access and accountability.
Such a transition in Bhutan would involve:
- Developing an Advanced Nurse Prescriber certification program through collaboration with the Khesar Gyalpo University of Medical Sciences of Bhutan.
- Amending the regulations under Bhutan Medical and Health Council to reflect this expanded role.
- Ensuring ongoing supervision and audit mechanisms to maintain quality and safety in prescribing practices.
- Fostering community awareness and strengthening patient feedback systems.
Legalizing and regulating nurse prescribing is not only a matter of professional empowerment—it is a practical, patient-centered solution to a growing crisis in healthcare delivery. It recognizes the capability of our nurses, honors their ethical judgement, and most importantly, ensures that patients, even in the most remote corners of Bhutan, receive the care they need when they need it most.
To ignore this reality, or to criminalize those acting out of necessity, is to priorities policy over people. Bhutan’s health laws must evolve in step with the evolving demands of its healthcare system.
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| Photo courtesy: Nurses Of Bhutan |
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