Organisational factors have been identified as a barrier to optimum paediatric non-medical prescribing (Noblet et al, 2017). This can include time for continuous professional development (CPD) once qualified, or even obtaining the required hours during the non-medical prescribing module.
Finding a supportive designated prescribing practitioner (DPP) is paramount, and although the DPP may be a senior member of the non-medical prescriber's (NMP) team, there must be adequate time and effort for training and reflection which must be considered (Jarmain et al, 2023). This can be at risk, especially during the winter months when winter pressures have an impact on paediatric space and resources, including staffing (Royal College of Paediatrics and Child Health (RCPCH), 2019).
Unscheduled care for children needs to be taken into consideration when planning specific supervision time. Having an awareness of course or module commitments and requirements, for both the student and the DPP, can support the student's progress, and organisational planning needs to be carefully considered so as to not to hinder the student's development (Graham-Clarke et al, 2018).
Human factors
DPP supervision during and after NMP training can also be considered as a human factor, despite research showing that DPPs, on the whole, are enthusiastic about supervision (Jarmain et al, 2023). Anxieties regarding the DPP's potential lack of knowledge regarding non-medical prescribing may have an impact on the relationship with the student, but the two-way learning process could be seen as an advantage. This could be related to potential negative thoughts and perceptions of non-medical prescribing from medical colleagues regarding fear of loss of power or control (Noblet et al, 2017). Regular CPD updates for all health professionals can lessen these, re-iterating the essence of multi-disciplinary teamwork.
Other human factors to consider could be due to prescription errors. Most errors are intercepted before the drug administration (Conn et al, 2023), but the actual dosing error is the most common type of error, usually related to weight-based calculations, which, clearly, can be more dangerous in neonates. Human factors have also been highlighted in paediatric intensive care units, where errors have been split into physical attributes (such as fatigue, distraction, and interruption during the prescribing process) and also psychological attributes, including aspects of inexperience or insufficient decision making (Sutherland et al, 2019).
Experience in working with children was raised in a recent scoping review, which found errors are made more often in the beginning of the academic year when new doctors join clinical teams (Conn et al, 2019). While this is not necessarily related to NMPs, new NMPs working with children and young people may be at risk. Knowledge of the differences between children and adults is paramount (Houghton, 2006), including aspects of growth, development and pharmacokinetics. Specific drug calculations based on weight do need to be practised regularly (Eggleton, 2017), and it could be suggested that regular calculation updates for paediatric NMPs – and indeed medical prescribers – could be encouraged.
‘As always, paediatric NMPs need to act in their patient's best interests and scope of practice, and NMPs working within this specialist field need to closely follow legal updates and licensing issues’
Off-label/licensed medications
Experience and knowledge of working with children and young people is not the only challenge – medications that are available to children also need to be considered. Due to a lack of clinical trials and robust evidence (Robertson, 2018), an increased number of unlicensed or off-label medications are available in paediatric practice. Off-label medications are quite often seen in neonatal care; these are licensed medications that are used for unauthorised indications, such as different age groups, dose or administration routes (Davies, 2023). Off-label use in children can be up to 69% of all prescriptions in hospital and up to 100% in primary care (Schrier et al, 2020).
An unlicensed medication does not have a UK licence or is made up as a special product because it is not readily available. Pharmaceutical companies now have to include studies in children for most new medicines development (RCPCH, 2023a), although currently, many medications remain unlicensed for children.
Paediatric NMPs are legally permitted to prescribe both off-label and unlicensed medications as long as the prescribing is within their clinical competence, and follows appropriate safeguarding and consent measures (Royal Pharmaceutical Society (RPS), 2021). They must also ensure that they are adhering to agreed local prescribing guidelines. Again, regular NMP updates could be beneficial in order to provide up-to-date, evidence-based research.
Legal considerations
As well as considering the prescribing of off-label/unlicensed medications, other legal issues may provide a challenge for paediatric NMPs. Aspects of consent to treatment, or consenting to the prescribing process as a whole (i.e., history taking and physical examination), need to be considered, particularly if the child is under the age of 16. The NMP must judge whether their patient has the capacity to be able to consent; in younger children, it is obvious that parents/caregivers have parental responsibility consent for their child (Griffith, 2015). However, even here, the changing demographic of the family needs to be explored, including considering step-parents, parents of the same sex, carers, or parents with acquired parental responsibility. Conversely, older children – although still under 16 – may be able to consent if they are deemed ‘Gillick competent’ (Cornock, 2018), where they have been judged to be emotionally mature and capable, thus ensuring that their consent is legally valid. Paediatric NMPs must stay up to date with their local consent policies, relevant to their own particular area of practice.
The prescribing of controlled drugs must also be carefully considered. While medical-use controlled drugs (for example, morphine) can legally be prescribed if it is within the scope of competence, there has been recent focus on the prescribing of medical cannabis for childhood intractable epilepsy (Ben-Zeev, 2020), such as Dravet syndrome or Lennox Gaustat syndrome. Since 1971, both recreational and medical cannabis was made illegal in the UK under the Misuse of Drugs Act (1971), so research has declined (Zafar et al, 2021).
This law changed in the UK in 2018, but parents of children with epilepsy syndromes have been struggling to obtain prescriptions (RCPCH, 2020), as the specific formulations are not freely available on the NHS (GOSH, 2020), although there is one that is licensed. As always, paediatric NMPs need to act in their patient's best interests and scope of practice, and NMPs working within this specialist field need to closely follow legal updates and licensing issues.
Other avenues of potentially controversial prescribing need to be discussed in the paediatric NMP's multi-disciplinary teams, and it would be inadvisable for the NMP to prescribe wholly autonomously in such situations. This could be relevant in children and young people identifying as transgender, requiring gonadotrophin releasing hormone (GnRH) analogue therapy for pubertal suppression (Carmichael et al, 2021). This practice has been heavily criticised recently, although new data has shown that the prescribing of GnRH analogue therapy is not associated with an increase in the prescribing of cross sex hormones (Nos et al, 2022).
The prescribing of GnRH analogues is, however, frequently prescribed for children with central precocious puberty (Eugster, 2019). Paediatric NMPs working in transgender care, and even in the field of paediatric endocrinology, must work closely with their multi-disciplinary team.
Scope of practice
It is clear that any NMP must prescribe within their scope of practice. Regular audit of prescribing practice can provide insight into the appropriateness of prescribing practice (McHugh et al, 2020), as well as also providing encouragement to maintain accuracy of prescriptions. An emphasis on CPD is also necessary, and local NMP forums or study days run by Trusts or universities can prove to be invaluable to share knowledge, skills and experiences between the novice and more proficient NMP, as well as undertaking clinical supervision (Tatterton, 2017).
Nevertheless, local policy must always be explored, especially if the NMP changes jobs. This can be especially pertinent if linked to off-licence medication use, as there can be the potential for multiple, inconsistent resources; for example, different neonatal units are known to have different prescribing manuals (Conn et al, 2019).
Prescribing confidence
Acting within one's scope of practice, and support with clinical supervision, alongside regular CPD will increase the NMP's confidence in prescribing. This does increase with practice (Scrafton et al, 2012) but, at times, lack of confidence has been cited as a barrier.
The scope of practice among children and young people can be diverse, depending on age and morbidity (Tatterton, 2017), so to reduce potential anxieties NMPs must keep up to date with advances in drug development and licensing aspects (Weglicki et al, 2015).
Childhood obesity
Obesity prevalence in Year 6 children in the UK (ages 10–11 years) decreased from 23.4% to 22.7% in 2022/2023 from 2021/2022 (NHS Digital, 2023) but current levels are still not ideal. The impact of a national lockdown during the Covid-19 pandemic, with limits on leaving the house and playground closures, also led to a more sedentary lifestyle for children.
Many short- and long-term health consequences can result from childhood obesity, such as endocrine conditions (type 2 diabetes, polycystic ovarian syndrome), respiratory conditions (obstructive sleep apnoea), coronary artery disease, and even some cancers (Jebeile et al, 2022). However, medicines management in childhood obesity needs close consideration, with or without the possible co-morbidities that are commonly seen in newly commissioned Complications from Excess Weight (CEW) clinics (Mears et al, 2022).
Drug dosing in children with obesity provides prescribers with uncertainties, with a tendency to adapt the medication dose to the child's actual weight, or possibly consider the ideal weight. However, aspects to consider are complex, and should include calculations of body surface area, the individual's metabolic capacity and drug characteristics, such as lipophilicity and hydrophilicity, which are important pharmacokinetic components (Gaeta et al, 2022).
‘As pharmacokinetics can be altered in obesity, particularly in distribution and clearance, paediatric NMPs should be vigilant on these aspects, and further studies need to be undertaken to inform correct prescribing guidance’
As pharmacokinetics can be altered in obesity, particularly in distribution and clearance, paediatric NMPs should be vigilant on these aspects, and further studies need to be undertaken to inform correct prescribing guidance. Antibiotic prescribing, for example, is common practice in children and reviews highlight that obese children need to be included in clinical trials (Sampson et al, 2013). Paracetamol is also commonly prescribed, particularly for children undergoing surgery, and accurate dosing is paramount in order to avoid hepatotoxicity (Minshull, 2019).
Clinical areas need to implement specific dosing guidelines to ensure safety, such as recording the child's height to ascertain if weight centiles correspond with height centiles (Minshull, 2019). The topic of prescribing for obese children needs to be incorporated into NMP educational programmes and through continuing professional development via regular clinical updates.
Education
Resources for paediatric NMPs need to be clear that, while an interprofessional approach to medication prescribing and education is seen as the way forward (Stewart et al, 2010), taught education courses for paediatric health professionals were limited until a recent paediatric-specific NMP module was designed (Khan, 2019). This is in contrast to views from 2007, where it was argued that only generic programmes should continue and that there were no requirements for paediatric specific programmes (Bewley, 2007).
There are now higher levels of clinical practice for advanced nurse practitioners (ANPs) and advanced clinical practitioners (ACPs) (Woodman and Spencer, 2023), and the way forward is for more paediatric-specific education (Health Education England (HEE), 2017; RCPCH, 2023b).
‘Any barriers and challenges need to be identified early, including not only organisational and human factors, but also challenges related to the specific child or young person’
Covid-19 pandemic
The Covid-19 pandemic interrupted paediatric NMP provision at London South Bank University (LSBU). This interruption, however, re-aligned the focus of education, with academics having to rapidly adjust curricula, not only to reflect pandemic response practices, but also to ensure safe learning experiences for the NMP student (Leaver et al, 2022), many of whom were working in high-risk clinical areas themselves. The impact of Covid-19 is having a lasting effect on lesson design, with learning outcomes being re-designed, forms of academic assessment re-evaluated, and the inclusion of social media tools and advanced technological systems incorporated within teaching (Lockee, 2021).
Online learning and teaching does have its benefits but it comes with challenges, and feelings of isolation, lack of support and poor motivation have all been reported (Cao et al, 2020). Some students prefer online teaching as it fits in with working shifts or home commitments (Haslam, 2021). For both the paediatric and generic NMP cohorts, LSBU provides a hybrid approach, offering both face-to-face and online teaching, and care is taken to engage the student with quizzes and more active participation while appreciating that both on-site and remote teaching will be experienced differently (Raes, 2021).
More support is offered to the student, with both regular group and one-to-one tutorials. The ‘pandemic experience’ of isolation has reinforced the need for student support (Valiga, 2021) and this remains ongoing.
Best practice insights
There should be a focus on the education of future paediatric NMPs and regular CPD for qualified paediatric NMPs. New standards for prescribing programmes have been put forward (Nursing and Midwifery Council (NMC), 2023), following the NMP student's journey, including:
- Selection, admission and progression
- Curriculum
- Practice learning
- Supervision and assessment
- Qualification to be awarded.
The paediatric NMP module at LSBU has developed a specific curriculum (Khan, 2019), including a focus on neonates, legal aspects of prescribing for children and young people, principles of paediatric pharmacokinetics and pharmacodynamics, as well as child and adolescent mental health. Content provides the required balance between theory and practice, using the required range of learning and teaching strategies (NMC, 2023), which have certainly progressed and developed since the Covid-19 pandemic. These still involve lectures, but online resources and quizzes are encouraged, with flipped classroom techniques and blended learning (Omer et al, 2022). Relationships are also formed and attended to between the academics and the DPPs to ensure optimum student support, and to offer further guidance in practice if needed (Jarmain et al, 2023).
Individual Trusts have their own policies and guidelines for NMPs, and some have implemented preceptorship programmes for new NMPs (Allen and Rayment, 2022). This can involve further support to enable more confidence in the new NMP, a barrier which has already been discussed. NMP leads in clinical practice could potentially work with prescribing academics at local universities in order to work together in providing more confident and competent prescribing practitioners.
Interprofessional continuing education has been identified as a vital component of healthcare quality and safety (Regnier et al, 2019), and the advent of a multi-professional framework for advanced clinical practice (HEE, 2017) is ensuring that the core skills and capabilities of advanced clinical practitioners are enhancing the care for the ever-changing needs of the population.
NMP modules are also ensconced within ACP Master's programmes, and although many universities in the UK offer child-specific programmes, the NMP component is largely generic, which prompts the need for a change in the curriculum provided. Nevertheless, working and being educated alongside a variety of practitioners provides the NMP practitioner further opportunities of working with new colleagues, and promoting new ways of thinking (Henderson, 2021).
Collaborative working is highlighted in NMP education (Graham-Clarke et al, 2022), although implementing a paediatric specific module has been shown to be popular and successful.
Conclusion
The way forward in evaluating paediatric NMPs need to be audited and supported through clinical preceptorship programmes, regular clinical updates, clinical supervision, active involvement in local NMP/drugs and therapeutics committees, and continuous professional development. Any barriers and challenges need to be identified early, including not only organisational and human factors, but also challenges related to the specific child or young person.
Paediatric prescribing is challenging, and some aspects have been considered here that are not relevant to generic prescribers, which need to be considered closely to provide safe and efficient prescribing practice.
Key points
- Organisational and human factors can influence non-medical prescribing
- Off-label and unlicensed medications are seen frequently in children and young people
- Legal considerations need to be explored in detail before prescribing
- The increase of childhood obesity can have an impact on drug dosing
- There is a shift towards paediatric specific NMP education
CPD reflective questions
- Consider how NMP preceptorship could support you as a new NMP
- Discuss aspects of controversial prescribing – is this relevant to your clinical practice?
- How can an increased understanding of childhood obesity influence your prescribing practice?