Non Medical Prescribing Essays On Love
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Nonmedical prescribing: where are we now?
Louise C. Cope,Aseel S. Abuzour, and Mary P. Tully
Louise C. Cope, Drug Usage and Pharmacy Practice Division, Prescribing and Patient Safety Research Room 132, 1st Floor, Stopford Building, Manchester Pharmacy School, Oxford Road, Manchester, M13 9PT, UK;
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Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.
Keywords: nonmedical prescribing, training programme, history, impact, influences
Nonmedical prescribers (NMPs) are healthcare professionals who are not doctors or dentists, but who, after attaining an advanced qualification in prescribing, are legally permitted to prescribe medicines, dressings and appliances. NMPs in the United Kingdom (UK) currently include pharmacists, nurses and certain allied health professionals (AHPs), all of whom are registrants of their relevant professional regulatory body.
Since the inception of nonmedical prescribing in the UK in 1992 [DHSS, 1992], the types of healthcare professionals that are eligible to become NMPs, the numbers of NMPs and the range of medicines they are legally able to prescribe has grown. NMPs are a large and expanding workforce, who play an increasing role in supporting the clinical commissioning programme for the modern NHS [Fittock, 2010]. It is estimated that there are currently 53,572 registered nurse and midwife, 3845 pharmacist and 689 allied healthcare professional (e.g. optometrists, physiotherapists, podiatrists and radiographers) supplementary and independent prescribers in England [i5 Health, 2015]. In total, this is approximately 58,000 NMPs. However, it is recognized that, in real terms, this is a difficult number to accurately predict as not all qualified and registered NMPs are, in fact, using their NMP qualification. For example, 15% of nurses and pharmacists took longer than 6 months to issue their first prescription [Latter et al. 2010].
History of nonmedical prescribing in the UK
Nonmedical prescribing was first proposed in 1986 by the Cumberlege Report [DHSS, 1986], which reviewed the care given to patients in their homes by district nurses and health visitors. The report suggested that patient access to treatment could be enhanced, patient care could be improved and resources used more effectively if community-based nurses were able to prescribe from a limited list of items, such as wound dressings and ointments, as part of their everyday nursing care. It was already recognized that situations existed where a general practitioner (GP) would sign a prescription, despite the assessment having been undertaken by a nurse; and that community nurses often wasted many hours waiting for prescriptions to be written or signed by GPs, once the nurses themselves had already identified their patients’ needs [Department of Health, 1989].
The recommendations from the Cumberlege Report (DHSS, 1986) were reviewed by an advisory group chaired by Dr June Crown, and reported in the first ‘Crown Report’ [Department of Health, 1989]. However, it took a further 3 years until 1992 for changes to be made in legislation, which allowed community nurses to prescribe from the Extended Formulary for Nurse Prescribers within the context of a care plan [DHSS, 1992]. In 1998, after the apparent success and acceptability of community nurse prescribing in this way, and the piloting and evaluation of independent prescribing, the Secretary of State announced that district nurses and health visitors were now legally able to prescribe independently from the renamed Nurse Prescriber’s Formulary.
In 1997 an extensive review of prescribing, supply, and administration of medication commenced, again under the leadership of Dr June Crown [Department of Health, 1999]. It was felt that such a review was needed as the systems that were in use no longer reflected the needs of modern clinical practice. There had been changes in the training and roles of healthcare professionals from all disciplines, changes in the range, potency and formulation of medicines available and a perceived need to allow patients to become more involved in their treatment and to improve access to healthcare for patients [Department of Health, 1999]. This report recommended that other groups of health professionals would be able to apply for authority to prescribe in specific clinical areas, where this would improve patient care and patient safety could be assured. The report [Department of Health, 1999] also spearheaded the expansion of independent prescribing by other nurses, bringing more flexibility and autonomy to the nurse prescriber.
Nurses were now able to prescribe from the original Nurse Prescriber’s Formulary, plus all licensed pharmacy and general sales list medicines, and selected prescription-only medicines. Although increasing the range of medicines able to be prescribed by appropriately qualified nurses for their patients, this was permitted only within a supervised framework, initially termed ‘dependent prescribing’ (as opposed to independent prescribing) [Department of Health, 1999]. Dependent prescribing was later renamed ‘supplementary prescribing’, and is defined as
‘A voluntary partnership between the responsible independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient’s agreement, particularly but not only in relation to prescribing for a specific non-acute medical condition or health need affecting the patient.’ [MCA, 2002]
The period 1999–2002 saw several important reports published by the Department of Health and other agencies which enabled the Government to extend supplementary prescribing responsibilities to other health professions, including pharmacists [Department of Health, 1999, 2001, 2003; MCA, 2002].
In November 2005, it was announced that, from Spring 2006, qualified Extended Formulary Nurse Prescribers would be able to prescribe any licensed medicine for any medical condition (and some specified controlled drugs for specified medical conditions) as independent prescribers and that the Extended Formulary would cease to exist [Department of Health, 2005]. Pharmacists were also now permitted to independently prescribe any licensed medicine for any medical condition, with the exception of controlled drugs (until the relevant additional legislation could be amended). Independent prescribing being defined as: prescribing by a practitioner (e.g. doctor, dentist, nurse, or pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing [Department of Health, 2005; MHRA, 2005].
For many patients it is an AHP, and not a doctor, dentist, nurse or pharmacist who is their lead clinician. Yet these AHPs often do not have access to the appropriate prescribing mechanisms. In 2005 the Department of Health permitted the introduction of supplementary prescribing by physiotherapists and podiatrists [Department of Health, 2005].
Two years later, optometrists joined the ranks of healthcare professionals able to independently prescribe medicines [Department of Health, 2007] and more recently physiotherapists and podiatrists in 2013 [Department of Health, 2013]. All NMPs may prescribe only within their area of competence, such as specific ocular conditions for optometrists or movement disorders for physiotherapists. Earlier this year, after consultation, NHS England announced new legislation permitting independent prescribing by therapeutic radiographers and supplementary prescribing by dietitians [NHS England, 2016].
Nonmedical prescribing internationally
Currently, only pharmacists and nurses have been given prescribing authority outside of the UK, and not AHPs. Florida is the only state in the United States of America (USA) that has permitted independent pharmacist prescribing from a limited list of medications. In at least 16 other states in America, pharmacists prescribe alongside doctors within Collaborative Drug Therapy Management Clinics (Drug and Therapeutics Bulletin, 2006). All other states operate either dependent prescribing (equivalent to supplementary prescribing in the UK), with an agreed management plan, or independent prescribing using locally agreed protocols in clinics such as Veterans’ Affairs Centres run by the Veterans Health Administration (VHA) [Clause et al. 2001]. The VHA is America’s largest integrated healthcare system with over 1700 sites of care, providing free or subsidized healthcare to almost 9 million US veterans each year [USDVA, 2015].
Nurses within the USA, in order to obtain ‘prescriptive authority’ (authority to prescribe), must qualify at postgraduate level as Advanced Practice Registered Nurses, specialize as Nurse Practitioners (NPs) and then, after board certification, must apply for additional credentials which include prescriptive authority [Greenberg, 2010]. However, as the USA nursing profession is state regulated, the extent of prescriptive authority is again dependent on individual state regulation.
Currently, 21 states and the District of Columbia have approved full practice status for NPs, which amongst other practices allows them to prescribe medications independently. Not all states however are in agreement with this, and the remaining states continue to hold reduced or restricted practice regulations for NPs. While the regulations vary depending on the state, all require NPs to prescribe within a signed collaboration agreement with a physician or under the direct oversight of a physician [SSNHS, 2015]. However, in a similar way to pharmacists, NPs employed by the VHA who are credentialed with prescriptive authority may be granted independent prescriptive status as an employee of the VHA [VHA, 1995].
Prescribing by pharmacists is currently not permitted anywhere else in Europe other than the UK. In Canada, pharmacists with prescribing rights are permitted to prescribe independently or in collaboration with a physician when a diagnosis is provided [APA, 2014]. Legislation in New Zealand has also been recently introduced which permits appropriately qualified pharmacists to prescribe [Parliamentary Council Office, 2013]. Pharmacist prescribing in Australia has to date, lagged behind other Anglophone countries. Currently however, Health Workforce Australia is developing a national pathway for prescribing by health professionals other than doctors [Hale et al. 2015]. A number of Western-European and Anglophone countries have introduced nurse prescribing, including countries such as Australia, Canada, Sweden, Finland, Ireland, Netherlands, New Zealand and Spain. All have imposed legal restrictions on the types of nurses that may prescribe, what and who they are legally permitted to prescribe for and to; and whether they are able to do so independently or within a signed collaboration agreement with a physician [Kroezen et al. 2011].
Nonmedical prescribing in the UK
The nonmedical prescribing training programme
One of the many prerequisites for acceptance onto a nonmedical prescribing programme of study is a specified minimum period of post-registration experience. Pharmacists are currently required to have at least 2 years’ appropriate patient-orientated experience; nurses 3 years’ post-registration clinical experience, including 1 year preceding application in the clinical field in which they intend to prescribe; and AHPs, 3 years’ relevant post-qualification experience. The nonmedical prescribing programme encompasses at least 26 days of taught curricula and at least 12 additional days of practical experience known as the Period of Learning in Practice. The practical element of the course requires a medical practitioner to supervise students on the nonmedical prescribing programme. The medical practitioner, otherwise known as the Designated Medical Practitioner (DMP), should have a minimum of 3 years’ clinical experience in the relevant field of practice. They should also be within a GP practice (and be either vocationally trained, or be in possession of a certificate of equivalent experience from the Joint Committee for Post-graduate Training in General Practice Certificate) or be a specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer. In addition, the DMP should have the support of their employing organization or GP practice, to act as the DMP who will provide supervision, support and opportunities to develop the student’s competence in prescribing practice. The DMP should also have experience or training in teaching or supervising in practice [NPC PLUS, 2005].
Quality assurance: competency assessment and framework
The DMPs’ guide describes two formal methods of assessing competencies during the practical stage of the course: summative assessment and formative assessment [NPC PLUS, 2005]. Summative assessment ensures the student has met all the objectives and learning outcomes, and is assessed as a ‘pass’ or ‘fail’. Formative assessment is continuous where both the DMP and student provide feedback on the effectiveness of the learning programme to identify learning needs and future actions. There is no specific method that DMPs are expected to follow in the assessment of prescribing competencies.
However, evidence of clinical competence should be obtained when assessing competence. Higher Education Institutions frequently utilize the NPC’s Single Competency Framework for all prescribers to structure the learning and assessment of NMP students [NPC, 2012; NPC PLUS, 2005]. In turn, DMPs can assess students’ competencies by adhering to this framework during the Period of Learning in Practice. The Single Competency Framework, originally developed by the NPC in May 2012 [now part of the National Institute for Health and Care Excellence (NICE)], is currently under review [RPS, 2015]. The Royal Pharmaceutical Society is managing the updating process, working closely with other professional bodies and organizations.
Students entering a nonmedical prescribing programme are already healthcare professionals with a degree of experience, and therefore already have existing knowledge and skills in their areas of work. It is, therefore, important that the DMP and student are actively involved throughout the training, to be aware of the student’s existing competencies and identify the student’s learning needs. It should, therefore, be assumed that healthcare professionals training to become prescribers should, upon successful completion of the programme, be deemed competent in their area of practice as prescribers.
Impact of nonmedical prescribing
The impact of nonmedical prescribing can be evaluated from the perspective of NMPs themselves, other healthcare professionals and patients, or from the perspective of the outcome of their prescribing. Currently, the literature on the impact of the prescribing practices of physiotherapists, podiatrists and optometrists is very limited, but should be expected to increase when evaluations of their recently acquired prescribing authority have been conducted. Whilst the literature on the prescribing practices of NMPs is scarce, available literature on the views of students on the programme, lecturers and stakeholders has reported positive findings. Students training to become NMPs felt that the programme provided them with adequate knowledge to prescribe [Green et al. 2009; Meade et al. 2011], with some stating that the period of learning in practice was ‘the most valuable part of the course’ [Latter et al. 2010].
NMPs have reported that prescribing authority increases their job satisfaction and self-confidence, makes them more independent, and enables better use of their skills [George et al. 2007; Courtenay and Berry, 2007; Watterson et al. 2009]. They have also reported feeling that it enhances their relationships with patients [Latter et al. 2005]. However whilst NMPs clearly benefit from prescribing authority, some nurse prescribers have highlighted the increased pressure and workload that prescribing duties bring [Watterson et al. 2009].
Both NMPs themselves and doctors have reported feeling that patients accessing nonmedical prescribing receive higher quality care, with more choice and convenience [Courtenay and Berry, 2007; Latter et al. 2010; George et al. 2007; Stewart et al. 2009].
Doctors suggested that working with NMPs improved team work, and either reduced their workload or freed up their time to spend on more acute patient cases [Stewart et al. 2009; Watterson et al. 2009]. However, other healthcare professionals have suggested that working with NMPs can add significant time to their workload because of the support they need to give to the NMPs [Hacking and Taylor, 2010; Watterson et al. 2009].
Patients report similar benefits of nonmedical prescribing to those perceived by doctors and NMPs. Particular benefits noted from contact with nurse independent prescribers in dermatology and diabetes services included greater flexibility and access to appointments, better continuity of care, and a perception of a more caring style of consultation [Courtenay et al. 2011; Stenner et al. 2011]. Patients have also reported feeling that their conditions were controlled better, and that they were happier with their medicines since seeing a NMP [Latter et al. 2010]. This was despite initial concerns by some patients that doctors would provide safer care than NMPs [Stewart et al. 2008; Latter et al. 2010].
In a recent evaluation of the clinical appropriateness of pharmacist and nurse prescribing, there was discussion regarding nurses’ knowledge of pharmacology, and pharmacists’ ability to undertake physical examinations and to diagnose. Raters felt that there was room for improvement in the history taking, assessment and diagnostic skills of NMPs, but concluded that overall NMPs were making clinically appropriate prescribing decisions [Latter et al. 2012].
A similar study evaluating the clinical appropriateness and safety of nurse and midwife prescribers also reported the need for further attention in history taking, drug–drug and drug–condition interactions [Naughton et al. 2013]. These included the potential risk of inappropriate prescribing in vulnerable groups such as older adults, breast feeding women and patients with complex conditions. Nevertheless, nurse prescribers report that their level of pharmacology knowledge does not affect their practice as prescribers [Scrafton et al. 2012]. Reports of these concerns may be attributed to a variety of reasons such as, limited knowledge and skills, difficulty in applying theory to practice, or attitudes and contextual factors that influence prescribing practice.
Prescribing errors by doctors are commonplace, particularly in the secondary care setting. A systematic review of the literature regarding the prevalence, incidence and nature of errors in hospital inpatients by Lewis and colleagues [Lewis et al. 2009] suggests that 7% of medication orders, 2% of patient days and 50% of hospital admissions are affected by them. All of the 65 studies identified in the review were concerned with prescribing errors by medical prescribers. There is currently a dearth of research examining prescribing errors made by NMPs from any perspective.
A more recent study by Ashcroft and colleagues [Ashcroft et al. 2015] examined rates of prescribing errors across 19 acute hospital Trusts in North-West England by reviewing 124,260 medication orders. The study aimed to compare the prevalence of prescribing errors made by first-year post-graduate doctors with that of errors by senior doctors and NMPs. However, the number of prescription orders written by NMPs comprised less than 1% of the overall number of prescription orders examined.
A study by Baqir and colleagues [Baqir et al. 2014] focused on the nature and extent of prescribing and prevalence of errors by pharmacist NMPs, specifically within a UK NHS hospital. Results from this study demonstrated an error rate of 0.3% of medication orders generated by pharmacist prescribers. Baqir and colleagues [Baqir et al. 2014] do however advocate that further larger controlled studies are recommended to validate the results of this study. Further research is clearly required around all aspects of prescribing errors by NMPs in order to evaluate the prevalence, incidence and nature of these errors; and to ascertain the impact of these errors within the context of the wider arena of prescribing.
Influences on prescribing practice
Prescribing is a complex skill that is high risk and error prone, with many factors influencing its practice, whether contextual or psychological [Lewis et al. 2014]. Influences on prescribing are multifactorial, but could be categorized subjectively as the knowledge, skills and attitudes of the individual as well as the context in which prescribing takes place. Examples of such influences include attitudes of NMPs, for example confidence. Confidence is seen to influence the application of theoretical knowledge to practice [Goswell and Siefers, 2009]. NMPs who viewed themselves as experts in their area of practice were found to spend a higher percentage of their time working and prescribing in their specialist areas [Courtenay and Berry, 2007].
Other factors influencing the practical element of prescribing include time since qualifying [Ross and Kettles, 2012], training [Ross and Kettles, 2012; Boreham et al. 2013], good grounding in knowledge [Green et al. 2009; Stewart et al. 2013; Hurst and Marks-Maran, 2011; Meade et al. 2011; Gumber et al. 2012], continuous practice [Dobel-Ober et al. 2013; Green et al. 2009; Stewart et al. 2013], multidisciplinary support [Green et al. 2009] and the use of formularies or guidelines [Dobel-Ober et al. 2013].
Experience as an NMP is also seen to influence prescribing practice, and can be viewed as both a contextual and psychological influence. Experience in practice is working within context, and may lead NMPs to gain more confidence as prescribers in their area of work. This is observed when NMPs report themselves as becoming more familiar with certain drugs and conditions [Gumber et al. 2012], and become more readily able to identify appropriate occasions on which to prescribe [Goswell and Siefers, 2009]. It must also be acknowledged that NMPs are healthcare professionals, who before entering a prescribing programme will have acquired a high degree of professional experience within their differing fields. It is also likely that their nonmedical undergraduate education will influence their knowledge and skills throughout the process of learning to prescribe.
The last 24 years has seen the inception and development of nonmedical prescribing both within the UK and further afield. The practice continues to expand and encompasses an increasing range of nonmedical healthcare professions with steadily increasing numbers of prescribers. Nonmedical prescribing is currently conducted via a number of different models depending on the legal restrictions imposed by the country, and even the sector or specialty within which the NMP is practicing. Several factors have been reported to influence NMPs’ prescribing practice, with confidence being highlighted as being of particular importance.
The impact of nonmedical prescribing has been reported on by NMPs, other healthcare professionals and patients alike; generally overall to have a positive impact. There is however a current lack of research around the impact of nonmedical prescribing, particularly prescribing errors by NMPs compared to prescribing undertaken by doctors. Future research focusing on exploring the impact of nonmedical prescribing and prescribing errors by NMPs is therefore to be encouraged.
Given that the roles of nonmedical healthcare professionals are expanding, an element worthy of future consideration is the evolution of undergraduate nonmedical healthcare education programmes. Adapting these to meet the expectations of students anticipating a future prescribing role could potentially fill the gaps in knowledge and skills currently required in order for healthcare professionals to progress on to qualify as a NMP. This would also encourage positive attitudes, and ensure that nonmedical disciplines have the in-depth theoretical knowledge and early experiential skills to provide a sound foundation for the science and art of prescribing.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest statement: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Louise C. Cope, Drug Usage and Pharmacy Practice Division, Prescribing and Patient Safety Research Room 132, 1st Floor, Stopford Building, Manchester Pharmacy School, Oxford Road, Manchester, M13 9PT, UK.
Aseel S. Abuzour, University of Manchester Pharmacy School, Manchester, UK.
Mary P. Tully, University of Manchester Pharmacy School, Manchester, UK.
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