The Textbook of Non-Medical Prescribing

Dilyse Nuttall, Jane Rutt-Howard

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781118276310
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

The Textbook of Non-Medical Prescribing addresses all the key issues relevant to non-medical prescribing, bringing together essential knowledge, key issues, and skills in a single text.

This accessible, engaging and comprehensive resource explores the history of non-medical prescribing; prescribing in context; ethical, legal and professional issues in relation to prescribing practice; factors influencing prescribing; effective consultations; essential pharmacology; the role of the multi-disciplinary team; clinical skills; prescribing for specific groups; and the future of nurse prescribing. With case studies throughout, The Textbook of Non-Medical Prescribing is essential reading for all students on non-medical prescribing courses. It is also of use to qualified health professionals, be they prescribers themselves or interested in the concepts of non-medical prescribing.

Chapter 1

Prescribing in Context

Dilyse Nuttall

Learning objectives

After reading this chapter and completing the activities within it, the reader will be able to:

1 identify the development and current context of non-medical prescribing in the UK

2 critically analyse the implementation of non-medical prescribing in relation to the different professional groups

3 evaluate the different types of prescribing and identify their appropriate application to practice

Non-medical prescribing has been subject to on-going development ever since its inception. This has resulted in changes in both the types of prescribing possible and the related terminology. This chapter explores the different qualifications available in non-medical prescribing and discusses their application in the practice of various professionals, including nurses, midwives, pharmacists and allied health professionals. The discussion incorporates explanation of independent prescribing and supplementary prescribing, differentiating between specific prescribers and making comparisons to highlight their individual benefits and restrictions.

The prescribing journey

The current position of prescribing is the result of its evolution from its origin in district nursing and health visiting to a well-established element of everyday practice for a range of health professionals. The journey has not been as straightforward as many would have hoped, with individual professions having to undertake a period of limited prescribing before being able to use it in a manner that best supports their practice. The introduction of prescribing to the nursing profession was, in many ways, tentative, with the 1992 Medicines Act enabling only a small group within a very large workforce to undertake the necessary programmes of education. Furthermore, the limited formulary imposed a controlled and constrained introduction of prescribing. Nevertheless, this was a welcome development, the benefits of which became increasingly apparent and, ultimately, led to prescribing becoming available to more nurses and more professions.

Arguably, the caution employed in the introduction of prescribing in nursing was, in part, due to the lack of a robust evidence base to support this new element of practice. Although many nurses’ perceived intimation from this cautious approach was that they were more likely to make mistakes, a view unfortunately held by some medical colleagues (Day 2005), the profession was able to develop an increasing evidence base to support the expansion of prescribing. Supported by government-led consultations and evidence gathering from other professional groups and professional bodies, the necessity to introduce prescribing to other professional groups dictated the apposite change in terminology from nurse prescribing to non-medical prescribing.

Defining non-medical prescribing

The issue of terminology has often caused discord and confusion. The term ‘nurse prescribing’ remains an accurate description for nurses, with prescriptions continuing to identify nurses as such. Similarly, the terms ‘pharmacist prescriber’ and ‘allied health professional prescriber’ are used by the professional bodies governing these groups (Health Professions Council (HPC) 2006, Royal Pharmaceutical Society of Great Britain (RPSGB) 2006). Furthermore, the Departments of Health in England, Scotland, Wales and Northern Ireland (Department of Health (DH) 2006a, 2006b, Department of Health, Social Services and Public Safety (DHSSPS) 2006, Scottish Executive Health Department (SEHD) 2006, Welsh Assembly Government 2007, NHS Scotland 2009) continue to differentiate between prescribers. As a result, these terms are reiterated in the names of education programmes and in the evidence base supporting prescribing. Indeed, there is much benefit in this differentiation, from both a safety and a professional development perspective. However, these individual practitioner titles are components of the broader context of prescribing by those health professionals who are not doctors or dentists. The inclusive term ‘non-medical prescribing ’ is now widely used to represent these prescribers. It may be argued that the use of yet another term serves only to add further confusion, particularly to those unfamiliar with the concept of non-medical prescribing. However, the disadvantage of making reference only to individual titles is that there is much potential to support a profession-based approach that detracts from the multidisciplinary approach required for safe and effective prescribing, highlighted in Chapter 6.

Activity box 1.1

Go to the government website relevant to your practice area and search for documents that outline the implementation of non-medical prescribing for your professional group. Consider their content in relation to your practice:

• www.dh.gov.uk
• www.scotland.gov.uk
• www.wales.gov.uk
• www.dhsspsni.gov.uk

The non-medical prescribing vision

In considering the context of non-medical prescribing, it is of benefit to revisit the origins of nurse prescribing to consider its early ethos and vision. The Review of Prescribing and Administration of Medicines: Final Report (DH 1999a) identified five key principles within the terms of reference (Table 1.1). On examining these principles and making comparison to policy and guidance supporting the current position of non-medical prescribing, it is evident that these principles remain steadfast. The Department of Health (2008a), in the document Making the Connections: Using healthcare professionals as prescribers to deliver organisational improvements, clearly identified the benefits of non-medical prescribing and the opportunities for healthcare professionals to enhance their practice by making effective use of prescribing. The benefits of non-medical prescribing presented for patients included increased access, increased capacity and improved choice for patients. This was supported by the professionals’ ability to manage and complete episodes of care for patients, in a variety of settings, reiterating the messages from Medicines Matters (DH 2006b). Although the terminology and focus may have shifted slightly, the underpinning principles remain the same: safe and effective prescribing.

The complex nature of good prescribing was identified by the National Prescribing Centre (NPC) when they released their first Nurse Prescribing Bulletin (NPC 1999). The seven principles of good prescribing identified within this bulletin have provided a core framework for prescribers in their education and development for the past decade. However, it is important to recognise that, although these remain relevant, since their introduction, non-medical prescribing has moved forward significantly, in terms of both the range of treatments prescribable and the range of expertise and settings in which prescribing can now take place. As such, the seven principles should be seen as a foundation on which to build rather than as a measure on which to base effectiveness. The NPC (2001, 2004a, 2006), the UK health departments (DH 2006a, 2006b, DHSSPS 2006, SEHD 2006, WAG 2007, NHS Scotland 2009) and the professional bodies (HPC 2006, Nursing and Midwifery Council (NMC) 2006, RPSGB 2006) have all identified the need to develop and maintain competency in prescribing beyond qualification, developing relevant frameworks and continuing professional development (CPD) strategies. These are discussed further in Chapter 9.

Table 1.1 Key principles of the Crown Report

Patient safety

Effective use of resources

Skills and competencies of various health professionals

Changes in clinical practice

Public expectations

Department of Health (1999a).

Attitude shifts

The evolution and success of non-medical prescribing should not merely be measured from the context of its magnitude. It is recognised that the process has required many legal, professional and ethical changes, as discussed in Chapter 2. Fundamentally, the increase in non-medical prescriber numbers and the strategies employed to support this development have relied on a change much more difficult to measure. It would, therefore, be inappropriate to consider the context of non-medical prescribing without addressing the significant and ongoing shifts in attitude that have enabled non-medical prescribing to flourish. The processes involved in enabling legal and professional changes have often highlighted the concerns and objections of individuals and groups from both the medical profession and colleagues in other health professions. These concerns have ranged from questions of safety to issues of boundaries within professional roles (Day 2005). Importantly, the evidence base developed has addressed many of these concerns. Data from the National Patient Safety Agency (NPSA 2007) identified that, although prescribing errors still occur, most medication errors arise from administration and supply. There is no indication that non-medical prescribing activity results in an increase in prescribing errors. Interestingly, most errors reported to the NPSA (2007) occurred in the acute setting. However, data held by the professional bodies about professionals with a non-medical prescribing qualification indicate that numbers currently remain lower in secondary care than in primary care.

Many of these prescribing errors have been attributed to junior doctors but the cause of these errors has been found to be multifactorial in nature (Velo and Minuz 2009). It is unproductive to utilise the junior doctor as a diversion from the concerns raised regarding non-medical prescribing, but it does highlight issues that should provide some reassurance to those raising the concerns. Significantly, a need for specific education for all prescribers has been identified (Schachter 2009) and the content of this education suggested by Likic and Maxwell (2009) reflects that already undertaken by nonmedical prescribers. It is important that this information should not be seen as a defence of non-medical prescribing, but as evidence of good practice from which others may learn.

Attitudes towards prescribing are becoming increasingly positive, with the benefits brought to specialist roles being recognised (Avery and Pringle 2005). The role of doctors has not diminished as a result of non-medical prescribing, but instead there are numerous examples of how non-medical prescribing can be used by professionals to work alongside doctors to improve the patient experience (Thomas et al 2005, Courtney and Carey 2008). The health professional case studies provide some clear examples of this issue.

It is important also to consider the attitudes of those practitioners undertaking nonmedical prescribing and the impact on the team (both the immediate healthcare team and the wider organisation). Prescribing can increase a practitioner’s confidence and result in greater job satisfaction but any change in role and attitude of an individual within a team can have an impact on the team dynamics as a whole (Bradley and Nolan 2007). Although this can often be a positive change in dynamics...

Table of contents

• Cover
• Title Page
• Copyright
• Contributor list
• Acknowledgements
• Introduction
• Chapter 1: Prescribing in Context
• Chapter 2: Professional, Legal and Ethical Issues in Relation to Prescribing Practice
• Chapter 3: Factors Influencing Prescribing
• Chapter 4: Effective Consultation and ‘the Consultation Umbrella’
• Chapter 5: Essential Pharmacology, Therapeutics and Medicines Management for Non-medical Prescribers
• Chapter 6: The Multidisciplinary Prescribing Team
• Chapter 7: Clinical Skills
• Chapter 8: Prescribing for Specific Groups
• Chapter 9: Enhancing Non-medical Prescribing
• Patient Case Studies
• Health Professional Case Studies
• Index