Cover: The Textbook of Non-medical Prescribing, Third Edition by Dr Dilyse Nuttall and Jane Rutt-Howard

The Textbook of Non‐medical Prescribing


Third Edition


Edited by

Dr Dilyse Nuttall

Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Principal Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire


and

Jane Rutt‐Howard

Nurse Prescriber, NMC registrant, Fellow of Higher Education Academy, Principal Lecturer, School of Medicine, University of Central Lancashire, Preston, Lancashire






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Dedication

This third edition of The Textbook of Non‐medical Prescribing is dedicated to the co‐editor, the late Dr Dilyse Nuttall. Dilyse was a dear friend, respected colleague, confidante, exceptional leader, and a true legend in the field of non‐medical prescribing. She is profoundly missed at the University of Central Lancashire, but her legacy and memory live on in all of us. We thank you Dilyse for your brilliance, humour, and everlasting inspiration to write. Rest gently.

Acknowledgements

Sincere thanks are given to the non‐medical prescribing team (Charlotte, Dawn, Georgina, Janice, Katy, Ruth, and Val) for their valuable contributions to this third edition. Special thanks are also given to our families for their patience and support without which this would not have been possible.

Dilyse would like to thank her husband, Paul, and her children, James, Jack, Robert and Rebecca, for their eternal support, encouragement, and inspiration.

Jane would like to thank her husband, Glyn, and her children, Ben and Noah, for their patience and encouragement in helping this to happen for a third time! She also wants to thank her co‐editor, Dilyse, for her inspiration and unwavering support throughout this journey.

Notes on Contributors

Ruth Broadhead, LLM (Master of Laws, Medical Law and Bioethics), BA (Hons) Health Studies, PGCert LTHE, PGCert (Forensic Sexology), DipHE (Community Specialist Practitioner GPN), RN
Independent and Supplementary Prescriber (V300), Nurse Teacher, FHEA, NMC registrant, Course Leader Non‐Medical Prescribing (V300), Senior Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

Janice Davies MRPharmS, MSc, BSc (Hons), FHEA
Co‐course leader Non‐Medical Prescribing, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

Dawn Eccleston, MA, BSc, PGCertEd, RN, RHV
Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Course Lead MSc Safeguarding in an International Context, Senior Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

Val Lawrenson, BA (Hons), MEd
Senior Fellow of Higher Education Academy, Fellow Staff Education Development Association, Senior Lecturer, Centre of Excellence in Learning and Teaching, University of Central Lancashire, Preston, Lancashire

Dilyse Nuttall, PhD, MSc (by research), PGDip, BSc (Hons), RN, RM, RHV
Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Principal Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

Georgina Louise Ritchie, MEd, BSc (Hons), Community Specialist Practitioner DN, Dip HE, RN
Queens Nurse, Nurse Prescriber (V300), Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Senior Lecturer, School of Health, University of Central Lancashire, Preston, Lancashire

Jane Rutt‐Howard, MSc, PGDip, BSc (Hons), Dip HE, RGN
Nurse Prescriber, NMC registrant, Fellow of Higher Education Academy, Principal Lecturer, School of Medicine, University of Central Lancashire, Preston, Lancashire

Charlotte Smith PGDip, BSc (Hons) SCPHN, RN
Nurse Prescriber, NMC registrant, Fellow of Higher Education Academy, Co‐Course Leader Non‐Medical Prescribing/Community Practitioner Prescribing, Senior Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

Kathryn Smyth, MSc, PGCert Practice Teacher, Community Specialist Practitioner GPN, BSc (Hons), RN
Queens Nurse, Nurse Prescriber (V300), NMC registrant, Fellow of the Higher Education Academy, Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancashire

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Introduction

Dilyse Nuttall and Jane Rutt-Howard

This third edition of the Textbook of Non‐medical Prescribing has been developed to provide the reader with an insight into the key issues relating to prescribing in the UK today. The book's team of authors have vast experience in the development and delivery of non‐medical prescribing programmes. This book has been developed in response to the emphasis placed upon prescribing in meeting the needs of a contemporary health service.

The aim of the book is to:

  1. Provide a foundation on which non‐medical prescribing students (V100, V150, and V300 nurses, pharmacists and allied health professionals) can build their knowledge around the key areas and principles of prescribing.
  2. Act as a continued source of information for qualified non‐medical prescribers.
  3. Provide a preparatory text for prescribers of the future, who must learn about the concept and context of prescribing in the modern healthcare (e.g. pre‐registration student nurses, pre‐registration paramedics) arena.
  4. Act as a key source of information for prescribing health professionals, including those considering acting as supervisors and assessors for students undertaking a prescribing programme, who need to understand more about their role and the context of non‐medical prescribing.

This book provides information essential to enable safe and effective prescribing. It also supports and directs the development and expansion of the reader's knowledge base using generic principles to underpin specialist practice. The introduction has a dual purpose: to introduce the reader to the evolvement of non‐medical prescribing and its position in a modern, multidisciplinary health service and to provide guidance on using the book effectively.

The development of prescribing

Over two decades ago, the Cumberlege Report (Department of Health and Social Security 1986), initiated the call for nurse prescribing, recommending that community nurses should be able to prescribe from a limited formulary. Progress was somewhat measured, but The Crown Report of 1989 (Department of Health [DH] 1989) considered the implications of nurse prescribing and recommended suitably qualified registered nurses (district nurses [DN] or health visitors [HV]) should be authorised to prescribe from a limited list, namely, the nurse prescribers' formulary (NPF). The Crown Report II (DH 1999) reviewed more widely the prescribing, supply, and administration of medicines and, in recognition of the success of the nurse prescribing pilots, recommended that prescribing rights be extended to include other groups of nurses and health professionals. By 2001, DNs and HVs had completed education programmes through which they gained V100 prescribing status, enabling them to prescribe from the NPF.

Nurse prescribing was extended in 2002, introducing extended formulary prescribing, which enabled nurse prescribers to prescribe general sales list medicines, pharmacy medicines and specific prescription‐only‐medicines for defined medical conditions. In the same year, further legislative changes enabled supplementary prescribing by both pharmacists and nurses (DH 2002), with physiotherapist, podiatrist and radiographer supplementary prescribing introduced in 2005 (DH 2005). In 2006 saw the introduction of independent prescribing for pharmacists and nurses, eliminating the need for the extended formulary (DH 2006). Subsequently, non‐medical prescribing continued to develop, with independent prescribing for optometrists introduced in 2008 and the V150 Community Practitioner Nurse Prescribing in 2009 (DH 2009).

Many of the more recent legislative changes have focused on expanding the prescribing permissions of independent prescribers, with pharmacist and nurse independent prescribers able to prescribe controlled drugs from 2012. In 2013, independent prescribing was extended to include podiatrists and physiotherapists, with permissions to prescribe from a defined list of controlled drugs agreed in 2015. Independent prescribing for therapeutic radiologists was enabled in 2016, along with supplementary prescribing for dietitians, with 2018 seeing further changes to legislation to enable paramedics working in advanced roles to become independent prescribers.

As the benefits of non‐medical prescribing are increasingly demonstrated in the everyday practice of different professional groups, the potential to expand this continues. A significant example of this is evident in the recent Nursing and Midwifery Council (NMC) (NMC 2018a, b) ‘Standards for pre‐registration nursing programmes’ and ‘Standards for prescribing programmes’, which identify the need for newly qualified nurses to be ‘prescribing ready’ and for access to prescribing programmes to be achieved much earlier in their career than has previously been the case. In the ever‐evolving world of prescribing, it will be interesting to follow the journey of Physician Associates, who following appropriate consultation and regulation, will surely join the expanding list of health clinicians who will be able to fulfil their roles fully and provide optimum and timely patient care.

Using the Textbook of Non‐medical Prescribing

Overview

Each of the nine chapters contained within this book addresses a different issue; all of the issues are directly relevant to non‐medical prescribing, so it is therefore recommended that the reader peruses all the chapters to gain a full insight into non‐medical prescribing. However, it is not necessary to read the chapters in numerical order. The issues and principles considered within each chapter are generic to all prescribing, and it is anticipated that the reader will apply this theory to his or her own practice. This will be helped by undertaking the activities incorporated within each chapter. Where appropriate, and in order to support the reader's understanding, references are made within individual chapters to other chapters in the book.

Core themes

The book has four core themes which are considered significant both to safe and effective prescribing and to modern healthcare in the UK:

  • Public health
  • Social and cultural issues
  • Prescribing competencies
  • Continuing professional development

The four core themes are incorporated into the main body of each chapter and considered at the end of every chapter in a key themes and considerations box.

It is pertinent at this point to introduce A Competency Framework for all Prescribers (Royal Pharmaceutical Society [RPS] 2016) because it is recognised that this may be a new concept to the reader. The original series of frameworks, developed by the National Prescribing Centre (NPC), were profession‐specific. However, in 2012, the NPC, in recognising that the competencies for safe prescribing were common to all prescribers, developed A Single Competency Framework for all Prescribers. This was subsequently reviewed and updated by the RPS, resulting in publication of the current document: A Competency Framework for all Prescribers (RPS 2016). The framework is widely used within prescribing education programmes to assess safe and effective practice of students, as well as supporting the continued development of qualified prescribers.

The core theme of ‘prescribing competencies’ running throughout this book and the related activities, link directly to the Competency Framework for all Prescribers (RPS 2016). It is important to recognise that whilst the framework provides a generic approach which is relevant to all health professionals who prescribe, it should be contextualised through application to the individual prescriber's practice and setting (RPS 2016).

A Competency Framework for all Prescribers (RPS 2016) is structured into two key ‘domains’ of ‘prescribing governance’ and ‘the consultation’, with the patient at its centre. Across the two domains, there are 10 ‘competency dimensions’, within which there are a varying number of related competency ‘statements’. Whilst the framework is summarised here, the reader is advised to become familiar with the full framework by accessing it online.

The consultation

  1. Assess the patient

    This competency dimension includes eight competency statements which relate to the knowledge, skills, and attitudes necessary to make a safe and effective assessment of the patient, in order to reach safe clinical decisions. It includes interpretation of information in order to reach a diagnosis, requiring knowledge of both the condition itself and the anticipated response to any treatment prescribed.

  2. Consider the options

    This second competency dimension requires consideration of all the options available to the prescriber (including non‐pharmacological options), by applying pharmacological knowledge and taking into account the risks and benefits of each option. This includes application of best evidence and taking into account relevant patient factors as well as wider public health issues.

  3. Reach a shared decision

    This third competency dimension identifies the importance of shared decision making in prescribing practice, to ensure that patient preferences and diversities are considered. In addition, it is concerned with the need to promote a partnership approach, where the patient understands the information given, in order to achieve adherence to an agreed treatment plan developed between the patient and prescriber.

  4. Prescribe

    The competency dimension of ‘prescribe’ requires the prescriber to prescribe only those medicines of which he or she has a sound knowledge, using relevant guidance and formularies to inform their decision making, whilst remaining aware of the potential for misuse of medicines. The dimension also relates to the generation of prescriptions and the need for effective record keeping and communication systems. It also includes the appropriate use of unlicensed or ‘off‐label’ prescribing.

  5. Provide information

    This competency dimension reinforces the need for clear and accessible information in order to ensure understanding and commitment to an agreed management plan, supporting self‐management where appropriate. It also identifies key issues in providing a safety net of information, including actions to take in the event of any concerns or deterioration in the patient's condition.

  6. Monitor and review

    Monitor and review is the final competency dimension in the consultation domain. It is concerned with the need to ensure a plan for review is in place in order to monitor the effectiveness, appropriateness, and safety of the treatment plan, with the opportunity to make any necessary adaptations in a timely manner.

Prescribing governance

  1. Prescribing safely

    The competency dimension of ‘prescribing safely’ focuses on the need to reduce risk and maintain patient safety by prescribing within the boundaries of one's competence, having an awareness of potential risks, employing appropriate strategies to minimise risk and ensuring appropriate monitoring and reporting mechanisms are in place and utilised.

  2. Prescribing professionally

    In order to demonstrate competence to prescribe professionally, the prescriber must be responsible and accountable for their clinical decisions and must practice within legal, ethical, and professional boundaries. This includes a responsibility to maintain competence in prescribing practice through continuing professional development and to be aware of and deal appropriately with influences on their prescribing practice.

  3. Improve prescribing practice

    Improving practice is identified as another key competency dimension, highlighting the need to reflect upon practice, make effective use of opportunities to improve practice and to challenge the practice of others if it is seen to compromise patient safety.

  4. Prescribe as part of a team

    This final competency dimension reinforces the need to adapt a multidisciplinary team approach to prescribing practice, based on respectful and trusting relationships, in order to establish appropriate support mechanisms within the team.

In summary, A Competency Framework for all Prescribers (RPS 2016) provides the basis for the development and maintenance of prescribing competence. This common set of competencies supports multidisciplinary expertise and can help guide all prescribers to attain and maintain prescribing effectiveness in their area of practice. Specifically within the core themes of ‘prescribing competencies’ and ‘continuing professional development’, there are activities to complete in each chapter, which will help you to link your continuing professional development within the competencies required as a prescriber. It can provide content for the development of a portfolio to demonstrate your contemporary prescribing practice, support clinical supervision and stimulate debate around prescribing competences and multidisciplinary participation.

Learning objectives

Each chapter has its own set of learning objectives that underpin its content. Achievement of these learning objectives is supported by both engagement with the discussion within the main text of the chapter and undertaking the activities.

Activities

Throughout the book are activities that encourage the reader to develop a deeper understanding of the theoretical knowledge base and to apply theory to individual practice. Activities are present throughout the book and are indicated by the blue activity sign.

A sign displaying a triangle with text “Activity.”

Further activities are available on the companion website: http://www.wiley.com/go/nuttall.

Case studies

The use of this book is supported by the case studies located at the end of the book. Most of the chapters make reference to a number of the case studies provided. This may be as part of the discussion or as an activity within the chapter. The purpose of the case studies is to help the reader to appreciate the benefits of non‐medical prescribing both to the patient and to the different professions. Two groups of case studies are included: patients and health professionals. The patient case studies are numbered 1–12 and form the basis of many of the activities. The health professional case studies are annotated A–M and, in the main, serve to provide relevant examples of the use of non‐medical prescribing by the different professional groups able to prescribe, from both an independent and a supplementary perspective. Further case studies can also be found on the companion website: http://www.wiley.com/go/nuttall.

Chapters and content

Chapter 1: Prescribing in context

This chapter defines and discusses the concept of non‐medical prescribing in the context of a modern UK health service. It explores the different qualifications available in non‐medical prescribing and discusses their application in the practice of various professionals, including nurses, pharmacists, and allied health professionals. This chapter includes explanation of independent, supplementary, community practitioner, V300, V150, and V100 prescribing. It also explores pharmacist and allied health professional prescribing, as well as the concept of ‘prescribing ready’. Comparisons are made between the different types of prescribing to highlight their individual benefits and restrictions.

Chapter 2: Professional, legal and ethical issues in prescribing practice

The development of non‐medical prescribing has depended on changes in professional body regulations, legal frameworks relating to medicines and attitudes of patients and professionals in relation to roles and responsibilities. This chapter explores the ethical issues that impact on safe and effective prescribing. It also identifies the legal frameworks governing prescribing for all professional groups, highlighting the changes undertaken to enable and support non‐medical prescribing. The extension of prescribing to other professional groups meant that the professional bodies had to develop existing regulations and guidance to support and govern this element of practice. This chapter explores these issues, identifying common elements of best practice, including prescription writing.

Chapter 3: Factors influencing prescribing

In addition to ethical, professional, and legal issues, non‐medical prescribing is subject to a variety of other influences that impact on the non‐medical prescriber's ability to prescribe safely and effectively. This chapter explores these issues and identifies strategies to overcome related challenges in order to promote concordance. The issues discussed include patient expectation, media influences, professional conflicts, drug company representatives, competence, and training.

Chapter 4: The consultation umbrella supporting effective consultations

Chapter 4 discusses the holistic needs of the patient, considering these within the framework of existing consultation models. The various elements of the consultation process are explored, focusing on history taking and physical examination in relation to prescribing. The consultation culminates in the development of a management plan, and this chapter explores the strategies used to enable this, including clinical decision‐making. The chapter incorporates an analysis of clinical decision‐making models and theories, from both non‐medical and medical perspectives. It also explores the consideration that all practitioners will experience a shift in their practice in order to address the novice aspect of prescribing. The deconstruction of their own practice can be difficult to manage both personally and professionally.

Chapter 5: Essential pharmacology for non‐medical prescribers

It is recognised that individual practitioners cannot know everything about all medicines but an essential element of good prescribing practice is learning how to find out what we need to know in order to prescribe safely. This chapter directs the reader to trusted resources to develop and maintain knowledge about drugs. It guides the reader through processes to build a relevant knowledge of pharmacology, therapeutics, and medicines management to populate his or her own personal formulary. Non‐medical prescribing is founded on the principle that practitioners will prescribe only within their competence and scope of practice. It is an essential component of the clinical competence of prescribers to have knowledge of both how the drugs that they prescribe work at their site of action and how the drugs are handled by the body. The significance of co‐morbidity and drug interactions is discussed, as are adverse drug reactions (ADRs), in order that the non‐medical prescriber can minimise the risk to patients.

Note that the principles of pharmacology addressed within this chapter aim to equip those practitioners with limited pharmacological knowledge with a foundation on which to build their understanding of the key issues.

Chapter 6: The multidisciplinary prescribing team

An essential aspect in safe and effective prescribing is recognition that prescribing is undertaken in a multidisciplinary context. This chapter examines the meaning of multidisciplinary team working in prescribing and explores the roles of the team members. The support processes provided by the various prescribing team members to individual non‐medical prescribers, in a variety of situations and circumstances, are discussed.

Chapter 7: Clinical skills

Comprehensive and holistic assessment requires the use of appropriate clinical skills in order to inform and support clinical decision‐making and diagnosis. This chapter explores those skills recognised as core to safe and effective prescribing, highlighting relevant resources that can be accessed to incorporate these skills effectively. It is also recognised that a vast array of clinical skills, other than those considered core, will be used by non‐medical prescribers in order to support prescribing in their specialist area of practice. Strategies to identify and develop these skills are discussed, emphasising the requirement for individual non‐medical prescribers to prescribe within their competence.

Chapter 8: Prescribing for specific groups

It is recognised that different groups, such as children, older people, pregnant and breastfeeding women and those with hepatic and renal impairment, require specific attention to ensure that the physiological differences and related risks are recognised and considered when prescribing. This chapter explores the needs of these individual groups in relation to prescribing, making reference to relevant guidance to support the non‐medical prescriber in safe and effective prescribing. In addition to the groups mentioned, it is also recognised that other groups have specific needs that can impact on the ability of the non‐medical prescriber to prescribe safely and effectively. These groups include young people, men, travelling families and black and minority ethnic groups. This chapter examines the needs of these specific groups in relation to prescribing practice.

Chapter 9: Enhancing non‐medical prescribing through reflective practice, evidence‐based prescribing and continuing professional development

Non‐medical prescribing has continued to evolve, enabling more groups of professionals to prescribe a wider range of products. This development will continue as the number of prescribers increases. To facilitate this continuing development, support for practitioners, protection for patients and robust governance structures are necessary, and prescribing practice must continue to rely on sound and up‐to‐date evidence.

This chapter examines these areas in more depth, focusing on both the role of the practitioner and the impact of organisational structure and policy on prescribing practice. The continuing professional development of individual practitioners is paramount and supported by reflection, identifying learning objectives and planning for professional development. At the same time, the environments in which practitioners prescribe need to establish sound medicines management and governance policies. This chapter explores some of the individual and organisational structures which are necessary to support the evolving nature of non‐medical prescribing.

References

  1. Department of Health (1989). Report of the Advisory Group on Nurse Prescribing (The Crown Report). London: The Stationery Office.
  2. Department of Health (1999). Review of Prescribing, Supply and Administration of Medicines: Final Report (The Crown Report II). London: The Stationery Office.
  3. Department of Health (2002). Pharmacists to Prescribe for the First Time, Nurses Will Prescribe for Chronic Illness (Press Release, 21 November 2002). London: The Stationery Office.
  4. Department of Health (2005). Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England. London: HMSO.
  5. Department of Health (2006). Improving Patients' Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. London: Department of Health.
  6. Department of Health (2009). Allied Health Professions Prescribing and Medicines Supply Mechanisms. Scoping Report. London: The Stationery Office.
  7. Department of Health and Social Security (1986). Neighbourhood Nursing – A Focus for Care (The Cumberlege Report). London: The Stationery Office.
  8. National Prescribing Centre (2012). A Single Competency Framework for all Prescribers. London: National Institute for Health and Clinical Excellence.
  9. Nursing and Midwifery Council (2018a). Standards for Pre‐registration Nursing Programmes. London: Nursing and Midwifery Council.
  10. Nursing and Midwifery Council (2018b). Standards for Prescribing Programmes. London: Nursing and Midwifery Council.
  11. Royal Pharmaceutical Society (2016). A Competency Framework for all Prescribers. London: Royal Pharmaceutical Society.