The role of nurses and other non-medical healthcare professionals in prescribing has expanded dramatically in the United Kingdom (UK) since the Cumberlege report, which recommended nurses in the community should take on the role of prescribing to improve patient care (Community Nursing Review Team For England et al, 1986).
In 1992, primary legislation (Medicinal Products: Prescription by Nurses etc, 1992) was passed, allowing district nurses and health visitors to prescribe independently from a limited formulary. Following an extensive review of prescribing, supply and administration of medicines in 1999, nurses were permitted to prescribe from the nurse prescribers' formulary, which included all licensed pharmacy and general sales list medicines plus selected prescription-only medicines (Department of Health (DoH), 1999). This was known as dependent prescribing and was later renamed as supplementary prescribing (Cope et al, 2016). In 2006, legislation was passed allowing nurses who had successfully completed an approved prescribing course to independently prescribe any licensed medicines for any condition and a number of controlled drugs within their field of practice and competence (DoH, 2006). In 2009, further changes enabled independent non-medical prescribers (INMPs) to prescribe unlicensed medicines for their patients and to mix medicines themselves or direct others to do so (Medicines and Healthcare products Regulatory Agency (MHRA), 2009).
Consequently, the role of the INMP has become an essential component of evolving healthcare services (Nuttall and Rutt-Howard J, 2020). The DoH (2006) defines independent prescribing as:
‘Prescribing by a practitioner (eg doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required.’
Training to become an INMP is often motivated by a desire to provide autonomous quality care to patients, to progress within the profession or through employment requirements. However, training to become an INMP is daunting, intensive and has ramifications on the nurse's responsibility and accountability. Although nurses work with a significant degree of professional autonomy, responsibility and accountability, holding a prescribing qualification demands these in a higher measure (Broadhead, 2020). A crucial element of an INMP's accountability and responsibility is to be competent and maintain competence in prescribing practice (DoH, 2006; Royal Pharmaceutical Society (RPS), 2016).
Competency
A competency is a characteristic of a person that is related to effective performance in their role, and can be described as a combination of knowledge, skills, attitudes and personal traits (RPS, 2016). Therefore, in relation to prescribing, competency describes the knowledge, skills, attitudes and personal traits required by the practitioner to prescribe safely and effectively. Competency in prescribing is important because it provides professional credibility and allows the public to be confident that the healthcare professional they are seeing is able to perform the duties required to treat them.
The competencies required by an INMP are vast; therefore, the competency framework for all prescribers was developed to detail the key competencies needed by a prescribing practitioner, regardless of their professional background (RPS, 2016). The framework also incorporates the legislative, professional and regulatory requirements the NMP must adhere to (Broadhead, 2020). There are two main domains within the framework: the consultation and prescribing governance. Within these domains there are 10 competencies, each containing sub-competencies (Broadhead, 2020). Although it is out of the remit of this article to discuss all the competencies indicated in the Competency Framework for all Prescribers (RPS, 2016), they can be summarised as:
- Knowledge and clinical skills of patient consultation, assessment, different conditions, decision making, making a diagnosis and problem solving
- Knowledge of pharmacology and ability to consider treatment options for different conditions
- Knowledge and skills of working with others
- Knowledge of professional, legal and ethical issues in prescribing practice
- Knowledge of factors affecting prescribing practice
- Knowledge and skills in prescription writing.
The above competencies demonstrate a requirement for INMPs to have a greater breadth and depth of knowledge, as well as additional skills, when compared to a non-prescribing professional's role. Although nurses have a wealth of professional experience in their own area of practice, and some of the co-requisite skills required to prescribe, they will need to analyse, refine, adapt and develop their current competencies, along with learning new competencies, to become an INMP (Coffey and Bowskill, 2010). The underpinning knowledge and skills relating to prescribing practice are predominantly delivered through an approved prescribing course at a Higher Education Institute (HEI).
Programmes
Legislation in the UK (Medicinal Products: Prescription by Nurses etc, 1992) (DoH, 2006) requires healthcare professionals to have successfully completed an approved programme in prescribing practice in order to register as an INMP with their professional body. Therefore, a nurse must successfully complete an NMC-approved post-registration independent/supplementary prescribing programme and meet the standards of competency necessary for an annotation to an INMP to be made to the Nursing and Midwifery Council (NMC, 2018a) register. The NMC (2018a) standards for prescribing programmes set out the legal requirements, entry requirements, methods of assessment and guidance for all NMC-approved prescribing programmes. HEIs must ensure applicants for independent/supplementary prescribing programmes are a qualified nurse registered with the NMC for a minimum of one year prior to application and have the academic ability and capability of safe and effective practice at a level appropriate to the programme and their area of intended prescribing practice (NMC, 2018a). The overall responsibility for the content, structure and assessment of the prescribing course lies with the individual education institute (DoH, 2006). However, the standards for prescribing programmes (NMC, 2018a) states that all prescribing programmes must be designed to deliver the competencies of the competency framework for all prescribers (RPS, 2016). The DoH (2006) suggests that INMP programmes should include independent and supplementary prescribing at a minimum of degree level and comprise of a minimum of 26 days teaching at a HEI, 12 days of ‘learning in practice’ and self-directed learning. Training and preparation should be over a period of 3–6 months. The DoH (2006) recommendations and NMC (2018a) standards for prescribing programmes acknowledge that whilst delivery through traditional HEI teaching provides the healthcare professional with the underpinning competencies to prepare them to be an INMP, experience and learning in clinical practice is also required.
Clinical practice learning
Prescribing is about providing patients with safe and effective treatments and only occurs in clinical practice. Thus, learning about prescribing in the context of clinical practice forms a large part of a prescribing practitioner's education (DoH, 2006; Paterson et al, 2016; NMC, 2018a). Learning in practice is a way of experiencing the authenticity of prescribing in real life situations and allows trainee INMPs to make sense of, synthesise and transform their learning from HEI teaching into practice (Manninen, 2016). In addition to this, learning in clinical practice provides trainees with the opportunity to work alongside experienced prescribers and experience different prescribing situations that may not be have been taught in the HEI. This also allows the trainee to consider different professional perspectives, learn from their knowledge and skills, as well as providing the opportunity for the trainee to receive valuable feedback regarding their prescribing practice and competencies. It can also be a support mechanism. Therefore, learning about and experiencing prescribing in clinical practice not only leads to the development and synthesis of taught content, it can also lead to a trainee gaining more confidence, and becoming more familiar with medicines, the conditions they treat and when it is appropriate to prescribe (Walls, 2019). However, learning in clinical practice can sometimes result in difficulties for the trainee INMP. There is a risk that at times of increased workload, the trainee INMP is asked to complete other duties instead of learning. In the authors' experience, this issue is common and results in a dilemma for the trainee because they have an obligation to learn and achieve the competencies required to become a prescribing practitioner’ but also have an obligation to their patients and the organisation they work for. The NMC (2008) emphasises that organisations must provide adequate opportunities and support for a student to meet their training objectives in an environment conductive of learning. Therefore, if the trainee INMP is not receiving adequate opportunities to learn, the issue should be raised using the appropriate mechanisms available to them.
Working with other professionals can also result in difficulties. Although the majority of experienced prescribing professionals are very supportive and are happy to help a prescribing trainee learn in clinical practice, some may not be as supportive. In the authors' clinical practice this is usually a result of their workload or because the experienced practitioner is not aware of the trainee's role, education and background. As well as this, professionals don't always agree with each other (Bowskill, 2010). In some cases, experienced prescribers may have picked up bad prescribing habits or their knowledge and ways of prescribing conflict with the trainee's perspective and learning from the HEI. A trainee INMP must acknowledge that difficulties can occur and develop strategies for resolving them. If difficulties arise, adequate communication amongst professionals is key to resolving them (Eccleston, 2020). The trainee should provide information about their role to other healthcare professionals and discuss differences of opinion openly with them so an agreement in the best interests of the patient can be made. If an agreement cannot be reached a second opinion from other experienced professionals can be sought (Bowskill, 2010). When dealing with potential difficulties with other healthcare professionals, the trainee must behave in a professional way and respect the other person's views and opinions (NMC, 2018b). If the trainee feels a colleague is acting inappropriately or conducting unsafe prescribing practice, the competency framework for all prescribers reiterates they should act on this using the appropriate mechanisms (RPS, 2016). One way the trainee may be able to do this is to discuss any issues with their clinical supervisor.
Clinical supervision
The importance of support, supervision and assessment throughout an INMP's training is emphasised by the NMC (2008; 2018a). Confidence and competence to prescribe are more likely to develop when there is adequate support and mentorship in practice (Weglicki et al, 2015). Clinical supervision describes the formal process of guidance and support a student receives from another experienced professional during their training (Lonsdale, 2007).
The clinical supervisor in prescribing programmes is referred to as the designated prescribing practitioner (DPP). Regulatory changes in 2019 enabled experienced independent prescribers to work as DPPs for the practice element of non-medical prescribing training (NMC 2018a; RPS, 2019). This was a role traditionally held only by medical prescribers (Designated Medical Practitioners). Widening the remit to include all experienced independent prescribers, rather than just medical practitioners, created an opportunity to draw on the expertise of different prescribing professions in the development of future NMPs and improved access to prescribing opportunities for the wider workforce. The aim of the DPP role is to oversee, support and assess the competence of NMP trainees, in collaboration with academic and workplace partners, during the period of learning in practice. In relation to the nursing and midwifery professions, HEIs should ensure they support students undertaking prescribing programmes to be able to meet the NMC (2018c) Standards for Supervision and Assessment, and ensure they have both a Practice Supervisor and a Practice Assessor (who will both fulfil the DPP role).
Having a DPP to guide, support and assess a trainee INMP's learning in practice is reported to be a positive experience for most trainee INMPs (Smith et al, 2014; Weglicki et al, 2015). It allows the trainee INMP to discuss potential opportunities available to them and develop strategies to meet the necessary competencies required of prescribing practice (Walls, 2019). Consequently, the trainee INMP and DPP must have an understanding of the competencies required and an understanding of each others' skills, perceptions and expectations at the start of and throughout training (Scrafton et al, 2012). Clinical supervision also provides the trainee with the opportunity to discuss or challenge any issues relating to prescribing in a safe, confidential environment, so they can assume responsibility for their own practice (Lonsdale, 2007). Furthermore, clinical supervision is a means whereby the trainee INMP can obtain feedback on their development and practice (NMC, 2018a).
Feedback
Receiving feedback is an essential part of becoming an INMP. Feedback facilitates learning and improving practice because it can identify areas of discussion between professionals and potential limitations in practice, and encourage the formulation of actions to address potential limitations (Baines et al, 2018). The NMC (2018b) and the competency framework for all prescribers (RPS, 2016) advocates that feedback should be obtained from a variety of sources and emphasises the importance of providing feedback to others to help them develop.
Whilst the majority of feedback a trainee INMP receives might come from colleagues and other healthcare professionals, the competency framework for all prescribers states the importance of the patient's voice and involvement in prescribing practice as well as feedback (RPS, 2016). Ultimately, prescribing is for the benefit of the patient; therefore, inviting them to provide feedback allows the trainee to learn about the patient's perspective and opinions regarding their prescribing practice. Thus, feedback is commonly incorporated into healthcare education, continuing professional development and regulatory initiatives, such as revalidation (Baines et al, 2018). However, feedback is only useful when a healthcare professional reflects and acts on any feedback they have received (RPS, 2016; NMC, 2018b).
Reflection
Reflection can be described as a process of deliberate and in-depth thought about an event, situation or action, so that ideas about what happened and why can be formulated, enabling the person to learn and develop through their experiences (Bulman and Schultz, 2013). Reflective practice is widely endorsed by professional healthcare bodies and continues to influence nursing practice and education (Bulman and Schultz, 2013). The competency framework for all prescribers supports the use of reflection by stating prescribers should learn and improve from reflecting on their own and others' prescribing practice (RPS, 2016). Accordingly, developing critical reflective skills is an integral part of the INMP course and is usually facilitated through the student's portfolio. For a trainee INMP, reflecting on their education and practice experiences helps them to recognise and make sense of the experiences and their own limits. It also allows them to identify areas of good practice or areas where improvement may be needed, and how they might achieve any actions identified. However, reflection is not useful unless the trainee acts any emerging actions from them.
Although the importance of reflection on learning and development is acknowledged by some healthcare professionals, even those with many years of experience find reflecting challenging. In addition to this, heavy workloads, lack of resources, time constraints and a lack of cultural value of reflection can also present barriers to effective reflection (Davies and Smith, 2020). DPPs, HEI staff and managers are a great source of support for reflective practice and, during the INMP course, are usually required to provide feedback on the trainee's reflective accounts and facilitate their development in this area. Reflective practice should also be structured and regular, like other aspects of clinical practice to maintain competence. Therefore, they should be part of the INMPs continuing professional development plan (Davies and Smith, 2020).
Maintaining competencies/continuing professional development
Although the training detailed above equips the trainee INMP with the prerequisite competencies to prepare them to prescribe safely and effectively in practice, the INMP has the responsibility to ensure these competencies are maintained and up to date once they have completed their training (Scrafton et al, 2012; RPS, 2016). A nurse INMP is professionally accountable to the NMC to update their knowledge and ensure their competencies are maintained (Eccleston, 2020). In addition to this, the INMP has a responsibility to their employer and their patients to keep up-to-date and maintain competency (Waite and Keenan, 2009). INMPs are required to identify their own learning needs and address them accordingly (Davies and Smith, 2020). The competency framework for all prescribers (RPS, 2016) can provide the basis for continuing professional development (CPD), education and revalidation.
Although the importance of CPD and keeping up to date as an INMP is widely recognised, some INMPs report that carrying out CPD activities is challenging (Scrafton et al, 2012). Scrafton et al (2012) found that although prescribers accept individual responsibility for maintenance of their competency, a lack of national infrastructure to guide CPD activity specifically for prescribing professionals causes frustration. The General Pharmaceutical Council (2013) acknowledges that CPD is not just about formal training and teaching, and can be achieved through things such as reflection. Feedback from service users or other professionals, peer review and audit can also be used as CPD opportunities (NMC, 2019). Therefore, the onus is on the INMP to seek out CPD opportunities that are adequate to maintain their competency for their field of practice. Identifying CPD opportunities is one challenge for the INMP; however, being able to attend them is another matter. Service pressures can hinder the INMP's ability to attend study or complete CPD opportunities (Tinson, 2007). However, Smith et al (2014) found the majority of INMPs in their study had support from their employers for continuing professional development.
Support
Support for trainee INMPs and for new prescribers is very important (Bowskill, 2010). Although it is generally acknowledged that during training there is a need for support and clinical supervision, this perspective changes once a person becomes qualified, and there may be an expectation that support and supervision is not required as much. However, as previously stated, a person's competency is closely related to their level of experience. A newly qualified INMP may have been deemed to have the competencies required to prescribe, but may not be proficient or confident in prescribing (Eccleston, 2020). Thus, support and mentorship should not be limited to the preregistration phase (Scrafton et al, 2012). Not only does the INMP need support on an individual basis, they need continued support and governance from their healthcare organisation (Davies and Smith, 2020). The competency framework for all prescribers outlines the necessary organisational structures to support prescribers in clinical practice (RPS, 2016). Latter et al (2006) study found that two-thirds of INMPs were receiving support after one year of qualifying. Smith et al (2014) found the majority of INMPs' organisations had support mechanisms in place for prescribers. However, it is the responsibility of the prescriber to negotiate the appropriate level of support and supervision for their role (RPS, 2016). The DoH (2006) suggests a ‘buddy’ system, where other professional colleagues with prescribing experience support each other; this may be especially valuable for newly qualified INMPs.
Conclusions
INMPs have become an important part of contemporaneous healthcare in the UK. To become an INMP, a nurse must complete an NMC-approved programme and achieve the competencies of the Competency Framework for all Prescribers. This usually involves formal teaching at HEIs, learning in clinical practice, feedback from a variety of sources, and reflection. The training is intensive; therefore, clinical supervision and support at an organisational level is required. Once qualified, both the INMP and the organisation they work for have a personal, legal and professional responsibility to ensure they are practising safely and effectively. Part of this responsibility is maintaining prescribing practice competencies through CPD and appropriate support mechanisms. Clinical supervision and support should be commensurate with the level of training that the healthcare professional is undertaking, as well as their level of experience, confidence and competency. The Competency Framework for all Prescribers details the specific competencies that should be acquired and maintained, along with the legislative, professional and regulatory requirements INMPs must adhere to. Therefore, it is an essential resource for all prospective and practising INMPs.
Key Points
- Healthcare professionals are required to successfully complete an approved programme in prescribing practice in order to register as an INMP with their professional body
- INMP training is challenging and consists of higher education training, self-directed study and clinical practice
- Clinical supervision and support at an organisational level is required, as training is intensive
- A crucial element of an INMP's accountability and responsibility is to be competent and maintain competence in prescribing practice
- The Competency Framework for all Prescribers is integral to an Independent Non-Medical Practitioners training and practice.
CPD reflective questions
- Are you interested in becoming an INMP? Does your current role support you to do so? If so, reflect on what skills you already have from your role and how can these be transferred or transformed to support a INMP role.
- What support can you identify that you would need as a trainee INMP and how could you support others who are doing the training?
- How will you ensure your skills are maintained to support safe and competent prescribing?