Second Edition
Edited by
Dilyse Nuttall
MSc (by research), PGDip, BSc (Hons), RN, RM, RHV
Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher
Education Academy, Principal Lecturer, School of Health, University of
Central Lancashire, Preston, Lancashire
and
Jane Rutt-Howard
MSc, PGDip, BSc (Hons), Dip HE, RGN
Nurse Prescriber, NMC registrant, Fellow of Higher Education Academy,
Senior Lecturer, School of Health, University of Central Lancashire,
Preston, Lancashire
This edition first published 2016 © 2016 by John Wiley & Sons, Ltd
Previous edition © 2011 Blackwell Publishing Ltd
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Library of Congress Cataloging-in-Publication Data
The textbook of non-medical prescribing / edited by Dilyse Nuttall and Jane Rutt-Howard. – Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-118-85649-9 (pbk.)
I. Nuttall, Dilyse, editor. II. Rutt-Howard, Jane, editor.
[DNLM: 1. Drug Prescriptions–Great Britain. 2. Allied Health Personnel–Great Britain. 3. Clinical Competence–Great Britain. 4. Medical Staff Privileges–Great Britain. 5. Nurses–Great Britain. 6. Pharmacists–Great Britain. QV 748]
RM138
615′.1–dc23
2015018487
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Jane Alder, PhD, BSc (Hons)
Lecturer in Pharmacology, School of Pharmacy, University of Central Lancashire, Preston, Lancashire
Alison Astles, MPhil, BPharm (Hons), Dip Pres Sci, MRPharmS
Lecturer in Clinical Pharmacy, School of Pharmacy, University of Central Lancashire, Preston, Lancashire
Anne Bentley, MSc, BPharm (Hons), PGD, PGCertEd, MRPharmS
Medicines Optimisation Lead Pharmacist, East Lancashire CCG, Nelson, Lancashire
Ruth Broadhead, LLM (Master of Laws, Medical Law & Bioethics), BA (Hons), RGN, PGCert, DipHE (Specialist Practitioner)
Nurse Prescriber (V300), NMC registrant, Fellow of Higher Education Academy, Senior Lecturer, University of Central Lancashire, Preston, Lancashire
Janice Davies, MSc, BSc (Hons), MRPharmS
Clinical Tutor, School of Pharmacy, University of Central Lancashire, Preston, Lancashire
Dawn Eccleston, MA, BSc, PGCertEd, RN, RHV
Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Course Lead SCPHN, Senior Lecturer, School of Health, University of Central Lancashire, Preston, Lancashire
David Kelly, MPharm, MRPharmS
Pharmacist, Blackpool, Lancashire
Val Lawrenson, BA (Hons), MEd, CPT, RN, DN, NP
Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Senior Lecturer, School of Health, University of Central Lancashire, Preston, Lancashire
Anne Lewis, MSc, BNurs, RN, RHV, DNcert
NMC registrant, Service Integration Manager, Lancashire Care Trust NHS Foundation Trust, Preston, Lancashire
Dilyse Nuttall, MSc (by research), PGDip, BSc (Hons), RN, RM, RHV
Nurse Prescriber, Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Principal Lecturer, School of Health, University of Central Lancashire, Preston, Lancashire
Jane Rutt-Howard, MSc, PGDip, BSc (Hons), Dip HE, RGN
Nurse Prescriber, NMC registrant, Fellow of Higher Education Academy, Senior Lecturer, School of Health, University of Central Lancashire, Preston, Lancashire
Jean Taylor, MSc, BA (Hons), RN, RM, RHV
Nurse Teacher, NMC registrant, Fellow of Higher Education Academy, Associate Dean, School of Health, University of Central Lancashire, Preston, Lancashire
Samir Vohra, BPharm, MRPharmS
Pharmacist, Preston, Lancashire
Sincere thanks are given to the non-medical prescribing team (Dawn, Janice, Jean, Ruth and Val), our colleagues from the School of Pharmacy (Alison, Jane and Samir), our guest lecturer (Lizz) and our colleagues in clinical practice (David and Anne) for their valuable contributions to this second edition.
Special thanks are also given to our families for their patience and support without which this would not have been possible.
Dilyse would like to thank her husband, Paul, and her children, James, Jack, Robert and Rebecca, for their eternal support, encouragement and inspiration.
Jane would like to thank and dedicate this second edition to Jenny and Louise: forever guiding and supporting.
Don’t forget to visit the companionwebsite for this book:
www.wiley.com/go/nuttall
There, you will find valuable material designed to enhance your learning, including:
• Interactive multiple-choice questions • True/false quizzes • Case studies • Numeracy exercises • Web links
Scan this QR code to visit the companion website
Dilyse Nuttall and Jane Rutt-Howard
The Textbook of Non-medical Prescribing has been developed to provide the reader with an insight into the key issues relating to prescribing in the UK today. The book’s team of authors have vast experience in the development and delivery of non-medical prescribing programmes. This book has been developed in response to the needs of health professionals undertaking non-medical prescribing programmes and to the views of qualified non-medical prescribers and their colleagues.
The aim of the book is to
This book provides information essential to enable safe and effective prescribing. It also supports and directs the development and expansion of the reader’s knowledge base using generic principles to underpin specialist practice. The introduction has a dual purpose: to introduce the reader to the evolvement of non-medical prescribing and its position in a modern, multidisciplinary health service and to provide guidance on using the book effectively.
It had long been recognised that nurses spent a significant amount of time visiting general practitioner (GP) surgeries and/or waiting to see the doctor in order to get a prescription for their patients. Although this practice produced the desired result of a prescription being written, it was not an efficient use of either the nurses’ or the GPs’ time. Furthermore, it was an equally inefficient use of their skills, exacerbated by the fact that the nurse had usually themselves assessed and diagnosed the patient and decided on an appropriate treatment plan. The situation was formally acknowledged in the Cumberlege Report (Department of Health and Social Security 1986), which initiated the call for nurse prescribing and recommended that community nurses should be able to prescribe from a limited list, or formulary. Progress was somewhat measured, but The Crown Report of 1989 (Department of Health (DH) 1989) considered the implications of nurse prescribing and recommended suitably qualified registered nurses (district nurses (DN) or health visitors (HV)) should be authorised to prescribe from a limited list, namely, the nurse prescribers’ formulary (NPF).
Although a case for nurse prescribing had been established, progress relied on legislative changes to permit nurses to prescribe. Progress continued to be cautious with the decision made to pilot nurse prescribing in eight demonstration sites in eight NHS regions. In 1999, The Crown Report II (DH 1999) reviewed more widely the prescribing, supply and administration of medicines and, in recognition of the success of the nurse prescribing pilots, recommended that prescribing rights be extended to include other groups of nurses and health professionals. By 2001, DNs and HVs had completed education programmes through which they gained V100 prescribing status, enabling them to prescribe from the NPF. The progress being made in prescribing reflected the reforms highlighted in The NHS Plan (DH 2000), which called for changes in the delivery of healthcare throughout the NHS, with nurses, pharmacists and allied health professionals being among those professionals vital to its success. The publication of Investment and Reform for NHS Staff – Taking Forward the NHS Plan (DH 2001) stated clearly that working in new ways was essential to the successful delivery of the changes. One of these new ways of working was to give specified health professionals the authority to prescribe, building on the original proposals of The Crown Report (DH 1999). Indeed, The NHS Plan (DH 2000) endorsed this recommendation and envisaged that, by 2004, most nurses should be able to prescribe medicines (either independently or supplementary) or supply medicines under patient group directions (PGDs) (DH 2004).
After consultation in 2000, on the potential to extend nurse prescribing, changes were made to the Health and Social Care Act 2001. The then Health Minister, Lord Philip Hunt, provided detail when he announced that nurse prescribing was to include further groups of nurses. He also detailed that the NPF was to be extended to enable independent nurse prescribers to prescribe all general sales list and pharmacy medicines prescribable by doctors under the NHS. This was together with a list of prescription-only medicines (POMs) for specified medical conditions within the areas of minor illness, minor injury, health promotion and palliative care. In November 2002, proposals were announced by Lord Hunt, concerning ‘supplementary’ prescribing (DH 2002). The proposals were to enable nurses and pharmacists to prescribe for chronic illness management using clinical management plans. The success of these developments prompted further regulation changes, enabling specified allied health professionals to train and qualify as supplementary prescribers (DH 2005).
From May 2006, the nurse prescribers’ extended formulary was discontinued, and qualified nurse independent prescribers (formerly known as extended formulary nurse prescribers) were able to prescribe any licensed medicine for any medical condition within their competence, including some controlled drugs. Further legislative changes allowed pharmacists to train as independent prescribers (DH 2006) with optometrists gaining independent prescribing rights in 2007. The momentum of non-medical prescribing continued, with 2009 seeing a scoping project of allied health professional prescribing, recommending the extension of prescribing to other professional groups within the allied health professions and the introduction of independent prescribing for existing allied health professional supplementary prescribing groups, particularly physiotherapists and podiatrists (DH 2009). In 2013, legislative changes enabled independent prescribing for physiotherapists and podiatrists. As the benefits of non-medical prescribing are demonstrated in the everyday practice of different professional groups, the potential to expand this continues, with consultation currently under way to consider the potential for enabling other disciplines to prescribe.
Each of the nine chapters contained within this book addresses a different issue; all of the issues are directly relevant to non-medical prescribing, so it is therefore recommended that the reader peruses all the chapters to gain a full insight into non-medical prescribing. However, it is not necessary to read the chapters in numerical order. The issues and principles considered within each chapter are generic to all prescribing, and it is anticipated that the reader will apply this theory to his or her own practice. This will be helped by undertaking the activities incorporated within each chapter. Where appropriate, and in order to support the reader’s understanding, references are made within individual chapters to other chapters in the book.
The book has four core themes – public health, social and cultural issues, prescribing principles and continuing professional development and competence – which are considered significant both to safe and effective prescribing and to modern healthcare in the UK. The core themes are incorporated into the main body of each chapter and considered at the end of every chapter in a key themes and considerations box. Continuing professional development and competence is a new core theme including within this second edition of the textbook. The core themes are:
It is pertinent at this point to introduce the prescribing principles (National Prescribing Centre (NPC) 1999) because it is recognised that this may be a new concept to the reader. These were developed originally to support the first nurse prescribers in their decision-making but have continued to be an essential tool in supporting prescribers from all health professional groups able to prescribe. The ‘seven good principles of prescribing’ were developed by the NPC (1999) with the aim of providing a structured approach to the process of prescribing.
The principles are ‘a stepwise approach’ and are widely used both theoretically and practically. They are diagrammatically represented within the original Prescribing Nurse Bulletin (NPC 1999) as a pyramid, commencing at the base and working upwards. All the principles of prescribing are as important as each other, and therefore, an alternative representation could be the use of a staircase, being stepwise (Figure I.1).
Figure I.1 A ‘stepwise’ representation of the seven principles of good prescribing (NPC 1999).
Each of the seven principles requires the practitioner to have specific skills to support the prescribing process and to consider the relevant issues at each stage.
This requires the non-medical prescriber to make a thorough assessment in order to determine the appropriate course of action. This assessment should typically include medical and social history together with a detailed drug history with a record of any allergies. In many instances, this assessment would include a physical examination too. A consultation model can help to structure a holistic needs assessment of the patient.
This highlights that the writing of a prescription is only one option and other treatment options might be more appropriate than drugs in some instances. Equally, to ensure that a prescribed treatment is most effective, it may need to be used alongside another strategy such as health promotion or referral to another health professional.
This prompts the prescriber to ensure that the product prescribed is that most appropriate for the patient, considering the clinical and cost-effectiveness. The NPC (1999) developed the mnemonic EASE to assist this process:
This stresses the importance of involving the patient in decision-making in order to achieve concordance with the patient. The treatment option eventually undertaken should be the result of negotiation between the patient and prescriber, taking into account the patient’s views, experiences and expectations.
This requires that the prescriber maintain prescribing safety by regularly reviewing the patient to ensure that the treatment remains effective and appropriate.
This reiterates the importance of accurate and up-to-date records in prescribing.
This acknowledges the importance of reflection in enabling the prescriber to maintain competence and continue to develop professionally.
The Single Competency Framework (NPC 2012) provides the basis for continuing professional development and competence. This common set of competencies replaces the previous profession-specific competences, thus supporting multidisciplinary expertise and can help guide all prescribers to attain and maintain prescribing effectiveness in their area of practice. Specifically within this theme, there is an activity to complete in each chapter, which will help you to link your continuing professional development within the competences required as a prescriber. It can provide content for the development of a portfolio to demonstrate your contemporary prescribing practice, support clinical supervision and stimulate debate around prescribing competences and multidisciplinary participation, as well as many others.
Each chapter has its own set of learning objectives that underpin its content. Achievement of these learning objectives is supported by both engagement with the discussion within the main text of the chapter and undertaking the activities.
Throughout the book are activities that support the reader in developing a deeper understanding of the theoretical knowledge base and in the application of theory to individual practice. Activities are present throughout the book and are indicated by the blue activity sign.
The use of this book is supported by case studies at the end of the book. Most of the chapters make reference to a number of the case studies provided. This may be as part of the discussion or as an activity within the chapter. The purpose of the case studies is to help the reader to appreciate the benefits of non-medical prescribing both to the patient and to the different professions. Two groups of case studies are included: patients and health professionals. The patient case studies are numbered 1–9 and form the basis of many of the activities. The health professional case studies are annotated A–J and, in the main, serve to provide relevant examples of the use of non-medical prescribing by the different professional groups able to prescribe, from both an independent and a supplementary perspective.
This chapter defines and discusses the concept of non-medical prescribing in the context of a modern UK health service. It explores the different qualifications available in non-medical prescribing and discusses their application in the practice of various professionals, including nurses, pharmacists and allied health professionals. This chapter includes explanation of independent, supplementary, community practitioner, V300, V150 and V100 prescribing. It also explores pharmacist and allied health professional prescribing. Comparisons are made between the different types of prescribing to highlight their individual benefits and restrictions.
The development of non-medical prescribing has depended on changes in professional body regulations, legal frameworks relating to medicines and attitudes of patients and professionals in relation to roles and responsibilities. This chapter explores the ethical issues that impact on safe and effective prescribing. It also identifies the legal frameworks governing prescribing for all professional groups, highlighting the changes undertaken to enable and support non-medical prescribing. The extension of prescribing to other professional groups meant that the professional bodies had to develop existing regulations and guidance to support and govern this element of practice. This chapter explores these issues, identifying common elements of best practice, including prescription writing.
In addition to ethical, professional and legal issues, non-medical prescribing is subject to a variety of other influences that impact on the non-medical prescriber’s ability to prescribe safely and effectively. This chapter explores these issues and identifies strategies to overcome related challenges in order to promote concordance. The issues discussed include patient expectation, media influences, professional conflicts, drug company representatives, competence and training.
Chapter 4 discusses the holistic needs of the patient, considering these within the framework of existing consultation models. The various elements of the consultation process are explored, focusing on history taking and physical examination in relation to prescribing. The consultation culminates in the development of a management plan, and this chapter explores the strategies used to enable this, including clinical decision-making. The chapter incorporates an analysis of clinical decision-making models and theories, from both non-medical and medical perspectives. It also explores the consideration that all practitioners will experience a shift in their practice in order to address the novice aspect of prescribing. The deconstruction of their own practice can be difficult to manage both personally and professionally.
It is recognised that individual practitioners cannot know everything about all medicines but an essential element of good prescribing practice is learning how to find out what we need to know in order to prescribe safely. This chapter directs the reader to trusted resources to develop and maintain knowledge about drugs. It guides the reader through processes to build a relevant knowledge of pharmacology, therapeutics and medicines management to populate his or her own personal formulary. Non-medical prescribing is founded on the principle that practitioners will prescribe only within their competence and scope of practice. It is an essential component of the clinical competence of prescribers to have knowledge of both how the drugs that they prescribe work at their site of action and how the drugs are handled by the body. The significance of co-morbidity and drug interactions is discussed, as are adverse drug reactions (ADRs), in order that the non-medical prescriber can minimise the risk to patients. The drug that the patient doesn’t take is the most expensive drug of all. Patients can pay a high price in unresolved illness and lost earnings, while the NHS wastes valuable resources. This chapter discusses issues of concordance and adherence and guides the reader through processes by which negotiated consultations are encouraged.
Note that the principles of pharmacology addressed within this chapter aim to equip those practitioners with limited pharmacological knowledge with a foundation on which to build their understanding of the key issues.
An essential aspect in safe and effective prescribing is recognition that prescribing is undertaken in a multidisciplinary context. This chapter examines the meaning of multidisciplinary team working in prescribing and explores the roles of the team members. The support processes provided by the various prescribing team members to individual non-medical prescribers, in a variety of situations and circumstances, are discussed.
Comprehensive and holistic assessment requires the use of appropriate clinical skills in order to inform and support clinical decision-making and diagnosis. This chapter explores those skills recognised as core to safe and effective prescribing, highlighting relevant resources that can be accessed to incorporate these skills effectively. It is also recognised that a vast array of clinical skills, other than those considered core, will be used by non-medical prescribers in order to support prescribing in their specialist area of practice. Strategies to identify and develop these skills are discussed, emphasising the requirement for individual non-medical prescribers to prescribe within their competence.
It is recognised that different groups, such as children, older people, pregnant and breastfeeding women and those with hepatic and renal impairment, require specific attention to ensure that the physiological differences and related risks are recognised and considered when prescribing. This chapter explores the needs of these individual groups in relation to prescribing, making reference to relevant guidance to support the non-medical prescriber in safe and effective prescribing. In addition to the groups mentioned, it is also recognised that other groups have specific needs that can impact on the ability of the non-medical prescriber to prescribe safely and effectively. These groups include young people, men, travelling families and black and minority ethnic groups. This chapter examines the needs of these specific groups in relation to prescribing practice.
Non-medical prescribing has continued to evolve, enabling more groups of professionals to prescribe a wider range of drugs. However, the development of non-medical prescribing will continue as the number of prescribers increases. To support this process, infrastructures are necessary at all levels. The development of guidelines and policies to enable the non-medical prescriber to practise is only one aspect of a wider organisational approach. This chapter explains this infrastructure and discusses how it supports non-medical prescribing and promotes its development. The continuing professional development of individual practitioners is paramount and supported by reflection, identifying learning objectives and planning for professional development. This chapter explores the strategies in place to support this process.