Independent non-medical prescribing (iNMP) has developed over the past 15 years in the UK and is carried out by healthcare professionals who have successfully completed a program of education, and who maintain their competence in all aspects of prescribing. This article will discuss nurse iNMP, which has been shown to be safe and clearly benefit patients, including those receiving palliative and end of life care (Dawson, 2013; National Institute of Clinical Excellence (NICE), 2020; Royal Pharmaceutical Society (RPS), 2016).
St Teresa's Hospice, a registered charity, is a nurse-led hospice that provides palliative and end of life (EoL) care and support to patients from the Darlington and North Yorkshire districts and their family and friends. The hospice provides a range of services for patients with malignant and/or non-malignant palliative care needs, and those at the EoL, including symptom management, crisis response for patients in the community, complementary therapies, and psychological and emotional support. However, this paper will focus on iNMP at the six bedded in-patient unit (IPU) only. The clinical aspects of patient care are predominantly carried out by two nurse consultants, who are both experienced independent non-medical prescribers in palliative and EoL care. The introduction of iNMP into this setting has been key to effective and timely treatment of patients, which is crucial for holistic, quality care, resulting in a positive experience for patients and their significant others (Dawson, 2013; NICE, 2017).
Prescribing for this group of patients can be complex, since symptom management and caring for dying patients relies on sensitive assessment and frequent reviews; clinicians involved require an in-depth knowledge of patients' conditions, and their likely progression. Furthermore, iNMP is not practiced in isolation, but in partnership with the multidisciplinary team (MDT) (including patients and their significant others) both within and external to the hospice, where timely and thorough intra- and interdisciplinary communication is essential.
This paper will review the benefits of iNMP in this care setting and also the challenges for independent non-medical prescribers contrasted against those in medically-led hospices.
Context
In St Teresa's Hospice, iNMP is mostly carried out at the IPU, for palliative/EoL patients suffering complex and enduring symptoms, which cannot be managed by the primary and/or secondary care generic teams. As a nurse-led hospice St Teresa's does not have any resident doctors; we have access to a consultant in palliative medicine, who is allocated 1.5 sessions per week and attends weekly MDT meetings. The consultant also assesses and/or reviews more complex patients when needed. Patients' own GPs remain medically responsible for individual patients. The main role for the GP is to visit their patients every two weeks. Patients' GPs also prescribe most repeat medication, as the hospice does not have a dedicated consultant in palliative medicine, and consequently holds only a small stock of medication on the premises. The hospice relies on a local community pharmacy to supply medications, which are prescribed on FP10N forms.
Prescribing of new medication and changes to doses are undertaken by the two nurse consultants and a third iNMP, a band 6 registered nurse (RN). Currently, only the two nurse consultants prescribe specialist drugs, such as ketamine and methadone, and they also undertake the necessary close monitoring. Each has been an iNMP for over ten years, and has experience of working in other specialist palliative care settings within the UK. The RN has been qualified as an iNMP for two years, and had also had extensive experience of working in palliative care before commencing iNMP training. Significant prior experience in the potential prescribing field is a key element in nurses successfully implementing and continuing with iNMP once qualified; this can help them to be more grounded, productive, and more confident (Bewely, 2007; Courtney et al, 2012). The nurse consultants and RN have successfully completed clinical skills courses, and are experienced in conducting clinical examinations with this patient group, which is arguably essential to prescribing effectively and safely.
Benefits
Nationally, iNMP has proven to be a safe, efficient, effective and economical way of caring for patients (Merryfield, 2015; Nuttall, 2017), and in the author's opinion, this has certainly been the case for patients under the care of St Teresa's hospice. For instance, when medication is prescribed by the hospice iNMP, this is generally available for patients on the same day, providing there are no supply or manufacturing problems (Dawson, 2013). In contrast, before iNMP was introduced to the hospice, it could take up to 72 house for medication to be supplied after the prescription was generated by GPs. Prompt access to medication is important for patients to facilitate timely symptom management, which is paramount for improving the quality of life and death, and to reduce complicated grieving for significant others (Lobb et al, 2010; Parkes, 1998). When patients' symptoms are adequately controlled, they are more likely to die at home, if that is their wish. It is possible for patients who have been admitted to the hospice for symptom management and EoL care to return home to die when their symptoms are controlled. Often, this can lead to a peaceful death, supported by community teams, including St Teresa's Hospice 24 hours Rapid Response Team (Ali et al 2019; Omega National Association of EoL Care, 2019).
Another benefit of iNMP is its contribution to alleviating the stretched health services; this includes reducing GPs' workloads, avoiding inappropriate hospital admissions, and reducing time spent in a hospital bed, particularly at EoL, by transferring patients to the hospice (Stevenson et al, 2018). iNMP, involving expert assessment and review of patients has contributed to meeting these directives and thereby benefits other healthcare services in the area (RPS, 2016). By reducing workloads for GPs and preventing unnecessary hospital admissions, finite resources can be targeted more appropriately (Dowden, 2016). Since the introduction of Nurse Consultants and iNMP to St Teresa's, GP visits have reduced to fortnightly to allow for timely certification of deaths, by avoiding involvement of the coroner when patients have not been seen by a doctor within the preceding fourteen days. During their visits, GPs are not usually required to undertake assessments or reviews, as these have been carried out mainly by the independent non-medical prescribers. An internal audit over a three-month period in 2018 identified that six inappropriate admissions to hospital, and 22 extended stays in hospital had been prevented by admission to St Teresa's Hospice.
Challenges
Evidence-based practice
Among the challenges to iNMP in the palliative and EoL care setting is accessing quality evidence to guide prescribing, which is crucial for safe practice (RPS, 2016). Definitions of evidence-based practice and medicine generally state that practice should be based on best available evidence generated from systematic research, combined with clinical expertise (Sackett et al, 1997; Wee, 2016). Another essential aspect of the definition is that it is also necessary to consider all of the evidence, and not just that which supports your conviction or clinical practice (Davies, 2018); personal observation suggests that the latter is not uncommon among clinicians.
In palliative and EoL care, obtaining evidence from randomised clinical trials can be problematic for a number of reasons. These include small sample sizes, ethical constraints and frailty of subjects, in conjunction with high attrition rates (Fine, 2004; Wee, 2016). Subjects are not reliably able to complete trials because of deterioration resulting in increasing frailty, both physically and mentally, or death (Addlington-Hall, 2007; Aoun and Nekolaichuk, 2014). Additionally, in the authors' experience, several patients have declined to enter clinical trials if there is a chance they will be selected for the placebo arm.
As a result of the barriers to conducting robust experimental studies, significant evidence to guide practice comes from retrospective and observational studies and expert opinion (Khalil and Ristevski2018; Visser et al, 2015). Such qualitative studies can generate rich and valuable data, but generalisability and replicability are much less robust (Craig and Smyth, 2012; Taylor, 2011). Clearly, this is a complex subject, which is too unwieldy to be covered in this article. These aspects of palliative and EoL care are challenging for the NMP, because evidence often varies between organisations, so identifying best practice can be difficult and time consuming. Examples of varying symptom management guidance includes regional guidelines where medication and doses vary for the same symptoms. This may not be apparent to any prescriber who has not had experience in different settings. For example, there are clear variations in points of detail between NHS North England Clinical Networks (2016), Greater Manchester and Eastern Cheshire Strategic Clinical Networks (2019) and Scottish Partnership for Palliative Care (2020) guidelines. This prescribing dilemma is considered below under continuous professional development (CPD).
This inconsistency in practice is highlighted by another ongoing debate. Within prescribing for EoL care, there are differences of opinion as to whether the prescribing of ranges of medication is acceptable and safe (Wilcock et al, 2015). Prescribing a range of medication allows administering RNs to adjust doses according to presenting symptoms. This can vary between organisations within the same locality, as well as nationwide. The argument for prescribing ranges is that it can avoid delays in patients receiving medication and achieving prompt symptom control. By contrast, if ranges are not prescribed, administering RNs have to locate another prescriber, often out of hours, which is time consuming, and such prescribers may not be familiar with prescribing EoL medication. This adds another risk to the prescribing process (Smith and Brown, 2017; Mitchell et al, 2016). Conversely, other clinicians do not prescribe ranges because of the risk that RNs will administer a higher dose before trying the lower. Another argument for not prescribing ranges is that, when the RN makes the decision to administer a higher dose, this is ostensibly a prescribing action. The hospice practice is to prescribe small ranges, such as morphine 2.5 mg–5 mg subcutaneously hourly as needed, and to avoid large ranges. Whether to prescribe ranges depends on the competencies of the administering RNs. Those employed by St. Teresa's Hospice are experienced EoL care nurses, and internal audit, case reviews, incident reports and MDT discussions have consistently shown correct administration from prescribed ranges. However, if medication administration on discharge involves nurses with little EoL experience, such as newly-qualified community or nursing home nurses, ranges are not prescribed. Given the ambiguity, this introduces another element of uncertainty for NMPs.
A useful resource concerning drugs used in palliative and EoL care is provided by www.palliativedrugs.com for use by international health professionals. They also provide a number of useful, contemporaneous resources and research. One service is the online bulletin board, where healthcare professionals (HCP) can post queries, and other HCPs can respond based on experience, sometimes backed up with published evidence. Interestingly, but frequently, for any one query multiple, apparently contradictory suggestions can be given. However, questions and answers are overseen by the expert editor, who comments, signposts readers to relevant research, and offers guidance, where appropriate.
Over the years the Palliative Care Formularies (currently PCF 6, online and printed versions) published by www.palliativedrugs.com have been important sources of pharmacology relating to palliative/EoL care. Several drugs are often suggested to treat the same symptoms, but they include supporting reviews of relevant research. They also examine what medication is most suitable to treat the cause of symptoms, a crucial factor in effective intervention and avoiding exacerbation of symptoms through inappropriate medication. In keeping with most evidence, this is not always clear cut, but can be beneficial to the independent non-medical prescriber, as it prompts literature searches and discussion among colleagues, a vital component of CPD. This is a necessary component of the prescribing process within palliative care, since the majority of prescribing is off licence or uses unlicensed drugs.
It follows that independent NMP within palliative care and in this nurse-led hospice is professionally and personally challenging, can be anxiety-provoking, and can increase the prescribers' vulnerability under the law. Not only can the individual factors examined above create barriers to safe prescribing, but they often occur concurrently and within an emotionally charged environment, which further complicates the prescribing process. This significantly increases the level of complexity for the prescriber, especially when they are often the sole specialist clinician on the premises and it is not always possible to access external, timely, specialist advice. Under such circumstances, to avoid potentially harming the patient (RPS, 2016), and if it were the prescriber lacking pharmacological knowledge of a drug, they do not prescribe it. If they were to prescribe outside their competence (RPS, 2016), and it were identified that there has been a breach of duty to provide a reasonable standard of care for their patient (Bolam, 1957), the prescriber would be accountable to the professional body (RPS, 2016; Nursing and Midwifery Council (NMC), 2006) and face removal from the professional register. Should criminal negligence be suspected, the prescriber would have to testify in a civil or criminal court and their actions would be examined in accordance with case law, such as the Bolam Test (1957).
Continuous Professional Development
For iNMPs to attain and maintain competency in their field of prescribing, they are professionally obliged to engage in CPD and maintain accreditation as an iNMP (RPS, 2016). It is argued here that CPD needs to be embedded in practice, rather than adopting a purely theoretical approach. For this reason, a multidimensional approach to CPD has evolved at St Teresa's Hospice for iNMP.
It is well documented that, in general, CPD access for nurse NMPs can be sporadic and difficult as a result of various barriers, including lack of peer and organisational support (Courtenay et al, 2012; Latter et al, 2007; Tracey et al, 2015), where clinical obligations take precedence over attending participatory CPD sessions. Not allocating time to update and reflect on prescribing practice will have a negative effect on the quality of prescribing (Cole and Gillet, 2015). It can contribute to a loss of confidence in prescribing practice, leading to NMPs relinquishing prescribing, reducing their volume of prescribing, and/or poor staff retention, which is detrimental to their organisation both economically and professionally (Latter et al 2007; Noblet et al, 2017).
When the author joined the hospice 7 years ago, as its first nurse consultant, CPD consisted of peer supervision with a hospital based palliative care team and Community Macmillan clinical nurse specialists (CNS) from various Trusts. Although valuable, this often involved a time-consuming journey, and, as the clinical lead in a nurse-led hospice, it did not cover all aspects of prescribing needs. These included developing practice to include medication other than those used in palliative care, such as antibiotics, keeping up with and implementing legislative changes within the hospice setting, and an awareness of differing prescribing patterns and formularies used by other specialist teams working in palliative care. Currently, CPD consists of the three iNMPs in the hospice. Although this addresses local problems, it is recognised by the individuals involved that this small group lacks diversity and could result in a restricted approach to prescribing. Furthermore, given the problems with accessing evidence, prescribing could become ritualistic, leading to sub-optimal practice. To avoid this, the prescribing team are in the process of developing an iNMP group with other hospices, to enable collaborative work with similar organisations. However, as St Teresa's hospice is the only nurse-led hospice in the region, some anomalies remain, which are addressed in our own dedicated group.
As indicated in Box 1, the weekly hospice MDT meeting is an arena for supervision and learning. At these meetings, attended by the consultant in palliative medicine, patients under hospice care are discussed, treatment options are proposed, and management plans are recommended, in keeping with national guidance (NICE, 2018). In St Teresa's hospice, health and social care professionals attend the MDT and are encouraged to be involved in discussions. This is valuable not only for non-medical prescribers but also for RNs undertaking the course and those who may embark on the iNMP course at a later date (Bewely, 2007). As has been established, this can lead to more effective prescribing. Clearly, this approach is less practicable in larger MDT meetings, where greater numbers of patients are discussed.
Box 1.CPD activity at St Teresa's Hospice
- Identify new research findings from Journal of Prescribing Practice and BMJ Supportive and Palliative Care
- Review any prescribing incidents and devise plans to reduce risk (Standard)
- Completion and signing off competences from RPS Competency Framework (Standard).
- Scrutinise audits relating to NMP and alter policy and/or practice accordingly (Wainright and Canning, 2013)
- Reflection on practice
- Symptom control conferences
- Examine current quality professional articles/research
Attendance at CPD sessions is not the sole source of support for non-medical prescribers in this hospice, more so since the recruitment of the second nurse consultant. Mutual support and critical analyses of practice are now provided opportunistically during most weeks. Occasionally, nurses shadow each other and the medical consultant when assessing or reviewing patients. This has been an effective way of learning and developing iNMP skills, including assessment and decision making (Lim et al, 2018; RPS, 2016). Furthermore, bi-monthly training on symptom management, covering various palliative conditions, is delivered mainly by the consultant in palliative medicine, and also attended by community Macmillan CNS. Although not a dedicated NMP session, it is both informative and supportive for iNMP (Weglicki et al, 2015).
In addition, the author has provided CPD for non-medical prescribers from a variety of professions and backgrounds, presenting sessions on iNMP/symptom management in national symposia (Healthcare UK). This also provides opportunities for self-development, especially regarding new prescribing legislation, which can be fed back to other non-medical prescribers at the hospice. As mentioned at the outset, working in relative isolation can limit progression, so attendance at national symptom management courses has been invaluable. It provides opportunities to gain new knowledge and also gives a wider perspective on current practice. Furthermore, it provides the opportunity to listen and contribute to the complex debates concerning evidence-based practice.
Conclusions
Internal audit, case reviews, and patient/family/friends' feedback have identified that nurse iNMP has improved continuity and responsiveness of care for patients on IPU at St Teresa's Hospice, by delivering more timely symptom management by specialist clinicians. This facilitates improvement in quality of life and can result in more peaceful deaths for patients at the EoL. However, non-medical prescribing in palliative care can be challenging for a number of reasons. These include a dearth of robust evidence in symptom management, varying and conflicting guidelines, and varying prescribing practices within local and national primary and secondary services. In an attempt to address these issues, CPD for independent non-medical prescribers in St Teresa's Hospice takes a variety of forms, including iNMP groups, critical case reviews, shadowing colleagues, attending and presenting or teaching symptom management sessions. This enhances the awareness of the wider prescribing evidence and implications for practice. For prescribing to be safe and effective, it is crucial that non-medical prescribers actively engage in CPD to suit their needs.
Finally, iNMP incorporating clinical skills has enabled the hospice to be more clinically self-sufficient, by providing safe and effective complex symptom management. Safety is paramount and includes withholding prescribing when the pharmacology is outside the knowledge and competence of the prescriber. This upholds the professional responsibility and accountability of the independent non-medical prescribers. Developing and maintaining prescribing competence is an ongoing process throughout all clinicians' professional careers. As well as accessing organised CPD activities, it is important that prescribers are self-motivated to search out contemporary best practice/evidence via any or all of the means illustrated above.
Key Points
- Timely symptom management must be prioritised
- Ensure resources are being used effectively
- Barriers to quantitative research still exist within practice
- Professional and legal accountability must be maintained
- Relevant and accessible to CPD
CPD reflective questions
- Reflect on where you obtain your evidence for prescribing
- Compare guidance a variety of sources
- How are CPD sessions structured? Can you suggest any changes to enhance the experience for the group?