Non-medical prescribing (NMP) has evolved from district nursing and health visiting in the 1980s and the development of the community nurses formulary for prescribing dressings and emollients (Department of Health (DH), 1998; 2008). It has a long and complex history that has been driven by legislative changes (Nursing and Midwifery Council (NMC), 2018) as well as changes to the workforce due to the reduction in the numbers of junior doctors. The increasing number of non-medical prescribers has enabled patients to have timely access to medicines, reducing the number of appointments to see additional health professionals as well as leading to service delivery developments (Nuttall and Rutt-Howard, 2016). NMP is now well established and forms part of the wider comprehensive model in the delivery of personalised care that is fundamental to the NHS Long Term Plan (NHS, 2019). Prescribing is also very much a part of the NMC's vision in shaping future developments, with the expectation that newly qualified nurses:
‘will be given the skills to train as prescribers immediately after qualifying.’
(NMC, 2018).
This has led to an increase in the responsibility for practitioners undertaking NMP. This responsibility can be considered onerous for the following reasons:
- The challenges of completing the course academically and practically (which include the high mark required to pass – 100% for the numeracy assessment)
- The responsibility for prescribing decisions (including patient assessment, diagnosis and clinical decision-making to underpin decision making, knowledge of pharmacology, including interactions, contraindications and cautions)
- Managing the expectations of colleagues (who may ask you to prescribe an array of drugs for their patients – who you have not seen or assessed)
- The auditing and monitoring of all prescribing decisions through internal mechanisms/quality arrangements can be perceived as unwanted surveillance. However, prescriber's need to be aware of the management of medicines within the regulations of the Health and Social Care Act 2008. This Act governs the safety of prescriptions and how to use medicines safely, and represents the standards that all decisions are measured against by the Care Quality Commission (CQC) (Nuttall and Rutt-Howard, 2016). The collation of data through audit and monitoring provides the evidence to meet the expectations of good governance and underpins safe and effective prescribing (Royal Pharmaceutical Society (RPS), 2016).
Education/future requirements
Many medical and non-medical prescribing professions now use the RPS's (2016) ‘A Competency Framework for All Prescribers’, which has enabled their prescribing practices to be aligned (RPS, 2016; Allied Health Professions Ferderation, 2017). This process is continuing with the consultation by the Health Care Professions Council (HCPC) about the adoption of the RPS competencies that will further cement prescribing by all health professionals within the same framework. The NMC have dropped the non-medical prefix in the update of the standards, which will ensure that all prescribing decisions are standardised for all health professionals.
The new NMC Standards for Prescribing Programmes have retained the existing 80% pass mark for pharmacology and 100% pass mark required for drug calculation (NMC, 2018). However, the changes include a role for experienced nurse/allied health professional prescribers to mentor and support those undertaking the programme. That all prescribers can act as designated prescribing practitioners (DPPs) reflects the significant progress that they have made in the development of prescribing.
Challenges of prescribing
At the point of registration as a prescriber there is an expectation for the individual to develop a robust evidence-base to support their clinical judgment and decision-making as independent prescribers (Box 1). It is important for new prescribers to develop an array of approaches to support their clinical decisions and practice, which can include the creation of personal formularies and identification of key people to support their development (Nuttall and Rutt-Howard, 2016).
Box 1.Independent prescribing definition‘Prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing.’From: Department of Health (2006)
As a newly qualified prescriber, having open access to all drugs in the British national Formulary (BNF) can be extremely daunting as well as potentially dangerous. However, developing competence as a prescriber can help develop confidence in prescribing decisions.
Sometimes, the constraints of a restricted formulary can inhibit the role of a prescriber. Completion of discharge prescriptions and prescribing medication for acute admissions can be frustrating when having to find a doctor to prescribe one or two medications. Although personal formularies are constantly developed, certain medications, such as warfarin or insulin, should be prescribed by a doctor or a specialist non-medical prescriber with the appropriate knowledge to support their prescribing practice. While it is likely that a prescriber may be asked or feel pressured to prescribe, it is important to recognise that the decision to prescribe rests with the prescriber, not the patient. It is important, therefore, that prescribing decisions are made within the prescriber's levels of understanding and competency. Patient safety is paramount in prescribing and should underpin all prescribing practice (RPS, 2016).
The transcribing of medications for a patient (Box 2) can test a prescriber's knowledge and competency as it is an area that has led to medical errors, which have resulted in patient safety being compromised (Nuttall and Rutt-Howard, 2016). The decision not to transcribe can prove frustrating, particularly when trying to rewrite patients' prescriptions during admission and completing discharge paperwork. There are many issues with this decision, including newly admitted patients not receiving their regular medication on time. In addition, patient flow can be disrupted and discharges delayed. The decision to transcribe medications has to be seen in the context of individual levels of knowledge and competency to ensure effective judgement in prescribing decisions.
Box 2.Transcribing definition‘Any act by which medicinal products are written from one form of direction to administer to another is ‘transcribing’. This includes discharge letters, transfer letters, copying illegible patient administrations chart onto new charts (whether hand written or computer generated).’From: Nursing and Midwifery Council (2018)
Nurse practitioners are often aware of the constraints of not being able to prescribe, and may frequently have to wait for a doctor to become available. Using non-medical prescribers in a ward environment does overcome this problem to some extent; however, the prescriber may be asked to prescribe medications or amend a patient's prescription chart without knowing or reviewing the patient. Nursing staff have been noted to find the non-medical prescribers approachable due to the familiarity and expertise in their clinical field (Bradley and Nolan, 2007; Carey and Stenner, 2011). Although this can be beneficial for patients, it is important that the prescribers is fully aware of the risks involved when making changes/amendments to a prescription. Clinical judgement and experience must be borne in mind to maintain patient safety.
Benefits of prescribing
The key benefit of becoming a prescriber is the enhanced level of autonomy and being able to complete episodes of patient care and treatment (Courtenay and Griffiths, 2010). For example, the authors found that while working as staff nurses, they have encountered patients requiring fluid resuscitation, but there not being a doctor available to prescribe intravenous fluid. For patients, the benefits of non-medical prescribing can be seen in the timely access to medicines and the development of services and delivery of healthcare. Examples include prescribing analgesia for patients with acute pain and aperients to prevent constipation. Through becoming a prescriber, these routine and seemingly straightforward, but important situations can be managed in a timely manner. All prescribing decisions, however, simple or complex must be based on the best intentions for the patient after weighing up the benefits and potential for harm (Beauchamp and Childress, 2009).
The authors' working environment is multidisciplinary in nature and their NMP qualification and competency has ensured that they can provide more support to the team than previously. One of the key relationships in the multidisciplinary team is that between the advanced clinical practitioners and the consultant who provides medical assessment and review of specific patients. Before gaining the NMP qualification, the authors felt restricted due to their inability to prescribe medication, such as bisphosphanates, calcium supplements and analgesia that had been requested by the consultant. Prescribing has enhanced practice and working relationships with other healthcare professionals such as physiotherapists (prescribing nebuliser medication), pharmacists (adding medication to discharge prescriptions or changing inpatient prescriptions), dietitians (discussing and prescribing feeding supplements or regimes), speech and language therapists (changing medications to different preparations in order to make them safer for administration), as well as to the nursing and medical teams (as additional prescribers and enhancing the opportunities to discuss prescription decisions). Although the additional responsibility may be different for different healthcare teams, prescribing has led to changes in the delivery and provision of services. This is an important consideration in developing the role of the prescriber in various teams.
Initially, the additional responsibility may seem daunting. Despite the newly gained knowledge and understanding of pharmacology and prescribing, writing the first prescription can be hard. It is common to check it over and over. Errors do happen and being cautious helps shape a good prescriber and should ensure that prescribing decisions are equally thought through and considered. Managing risk is an important part of all healthcare practice and the responsibility for prescribing decisions needs to be monitored and the National Reporting and Learning System is a central database of patient safety incident reports and part of NHS England and NHS Improvement to identify problem areas, learn from them and manage risk to improve patient care. Prescribing confidence will increase with time and experience.
Who to go to for help
Regardless of how experienced a prescriber is, it is important to know when to ask for help and to make links with key people and know who to approach for advice. There are a number of specialists you could seek support from. This requires an appreciation and understanding of multidisciplinary working and knowing when to refer patients to other professionals and services, which includes requesting expert advice (Nuttall and Rutt-Howard, 2016). Pharmacists may have the most knowledge about drugs and the appropriate prescribing of them and it is important to work collaboratively with them if they are available (Nuttall and Rutt-Howard, 2016). A consultant microbiologist is the best person to contact when prescribing antibiotics, as they are aware of the best drug to be prescribed for specific infections. However, antibiotic therapies vary between regions and hospitals and the responsibility for prescribing should be seen as part of a team effort where all prescribers use the knowledge and skills to inform prescribing decisions.
The authors have found that working more closely with the consultant, who they regularly discuss prescribing issues with either individually or as a team has benefited their prescribing. Being open to challenge and/or acknowledging doubt over prescribing decisions with a nominated supervisor is good practice and a valuable part of continuing professional development. The audit and monitoring of prescribing decisions should be a regular part of this process to review decision making and developing your own personal prescribing formulary (RPS, 2016). The authors have also been willing to discuss different treatment options with each other and other non-medical prescribers as this has enabled them to develop their knowledge and formulary.
It is important to prescribe within your competency and there are certain medications that the authors will not prescribe. This is because some drugs require close monitoring, which cannot be done in the author's department, furthermore, they acknowledge that other practitioners may be more suitable to prescribe these medications.
Deprescribing
The knowledge of pharmacology that is required to understand how drugs work underpin the choice of which drug to prescribe or deprescribe. It is common to have to decide whether to omit, reduce or stop certain medications for many reasons. These can be associated with acute changes while a patient is under a practitioner's care, for example reducing or stopping analgesic or laxative medications prior to discharge. While the author's do not use a specific model in deprescribing, considerations that influence a review of medications include physical, psychological, social and financial factors. Another consideration is the financial gains for the NHS associated with deprescribing with not having to pay for drugs that patients do not require. Furthermore, while in acute care, a prescriber may recognise that patient is on too high a dose or too many medications for certain conditions. Specifically within orthopaedics, bisphosphanate medications such as alendronic acid are commonly deprescribed. This may seem counterproductive given that this medication is usually prescribed to improve bone health. However, there is a strong body of evidence that indicates the prolonged use of bisphosphanates can have a detrimental effect on bone strength and lead to atypical fractures thus having the opposite effect of what it is supposed to achieve (Medicines and Healthcare products Regulatory Agency (MHRA), 2014). The role of a prescriber, therefore, is to recognise if the patient has been admitted with an atypical fracture and therefore should have the medication stopped indefinitely or whether the patient needs a ‘bisphosphanate holiday’ in order to reduce the risks of such fractures (MHRA, 2014).
Our role is not only to help to ensure our patients safety but to also help our colleagues in the primary care setting. Therefore, a review of a patient will include their drugs and change/titration of doses is part of that process and any changes need to be made in partnership with the patient and communicated to the patient's General Practitioner (GP) (RPS, 2016). Frequently patients have no idea why they are on a specific medication. Once again it is the prescriber's responsibility to work with the pharmacists and the patient as well as using our own specialist knowledge to ascertain as to whether this medication is still required. Any changes must be communicated to the patients GP. It is important to stress that stopping certain medications has associated risks and in some cases requires careful planning.
Aside from the possible patient benefits associated with deprescribing there are also financial gains for the health service associated with not having to pay for drugs that patients don't need. A review of patient's medications is an important consideration to ensure the greatest benefit of all medications especially where patients are taking more than one medication (Carey and Stenner, 2011; National Institute for Health and Care Excellence, 2015). Looking at deprescribing from a sociopolitical and socioeconomic perspective, pharmaceutical companies do not endorse or advertise the practice of deprescribing (NHS, 2019). This is because despite developing drugs that can change people's lives and help them live longer, the primary objective of drug companies is to ensure financial gain. Given the competitive/business nature driving healthcare in the modern age and the demands enforced on those who have to provide services on a shoestring budget, close relationships with pharmaceutical companies are inevitable in order to maximise a positive patient experience. All prescribers need to ensure transparency in their unbiased and ethical prescribing practice which includes professional and effective relationships with drug companies and their representatives (RPS, 2016).
Conclusion
Being a prescriber is a privalege and its introduction to other health professions would be advantageous. The benefits of prescribing for patients is evident in the timely access to medicines without further appointments with healthcare staff. For practitioners, it is the sense of fulfilment for completing episodes of care and the autonomy of practice.
The challenges of prescribing include the new situations and drugs that are encountered, and recognising the extent of the responsibility involved in assessing, diagnosing patients and the clinical decision-making involved with prescribing and/or deprescribing. These challenges include the continual development of clinical practice as well as identifying the people who can support you in this process.
Prescribing is a great responsibility. The key to meeting all the challenges is ensuring that your decisions are patient centred and meet their expectations in making informed and shared decisions.
Key Points
- Non-medical prescribing has been driven by the need to improve patient's access to medicines and has led to many changes in service delivery
- Developments in NMP have led to increases in the respnsibility of health professionals
- The benefits of prescribing can lead to an increased sense of professional practice in completing episodes of patient care
- As more health care practitioners undertake prescribing, support from within multiprofessional teams as well as processes to monitor audit prescribing decisions, should be well established to support safe and effective prescribing
CPD reflective questions
- Write down your own strengths and weaknesses that can be used and developed in undertaking the role of prescribing?
- Can you identify potential errors in prescribing decisions within your area of practice to address/prevent in ensuring safe and effective prescribing?
- Who are the key people you can consult to discuss problematic questions around prescribing?
- Can you identify the resources and processes that are available to you, to review your prescribing practice and continuing professional development?
- In what ways can the development of NMP enhance future service delivery within your own service to improve patient's experience?