Laura Croan and Barry Quinn This chapter explores the background and development of non‐medical prescribing through supplementary prescribing and patient group directives to the rapid recent growth of independent prescribing. It discusses the skills and experiences necessary to embark on a non‐medical prescribing course and the importance of adhering to the Royal Pharmaceutical Society Prescribing Framework to ensure safe practice. This chapter also addresses the benefits and challenges of non‐medical prescribing through case studies and summarises how this element of advanced practice can be amalgamated into a clinical nurse specialist role. This chapter will focus on the important role of independent prescribing as part of the evolving scope of practice within clinical nurse specialisms. The nurse prescriber has a fundamental role as part of the response to the growing and changing needs of global health and social care (Noblet et al. 2018; International Council of Nursing [ICN] 2020). There will be an exploration of developments that have led to the current approach to independent prescribing and how these advanced clinical skills will become an increasing part of the clinical nurse specialist (CNS) role. The chapter will then focus on two case studies from clinical practice to illustrate the central role prescribing plays as part of the specialist nurse role and some important issues to consider. The role of the independent prescriber in specialist nursing has evolved to become an important component of nursing practice in meeting the individual receiving treatment, care and support (World Health Organisation [WHO] 2021). Laura Croan has 18 years of experience working in haematology, has been an independent prescriber for 9 years, worked as a lymphoma CNS for 7 years and is currently training to be an advanced nurse practitioner. Barry Quinn has worked in the field of cancer and palliative care for over 30 years in London, United Kingdom (UK) in a variety of roles, including consultant nurse for cancer. He is an independent prescriber and currently a senior lecturer at Queen’s University Belfast. While changes in health and social care may vary in different regions of the world, there is global growth in the number of people living longer with multiple and sometimes complex co‐morbidities (Quinn 2022). Alongside this reality is a predicted shortage of nurses and doctors (WHO 2021). Moving forward, CNSs will be required not only to have expert knowledge of their own specialist area of practice (cardiology, dementia, renal, mental health, learning disability, cancer, childhood diseases) but also to be knowledgeable about other co‐morbidities and social factors that will impact the individual who needs nursing support and for whom the specialist nurse will prescribe (Hand 2019). Across the world, nurses working in specialist roles continue to have a key role in creatively responding to the person and family in need through their advanced skills and by expanding their scope of practice. This reality is reflected in the key pillars required of all CNSs or advanced nurse practitioners: being able to work at an advanced level of clinical practice; an ability to lead and respond to the global, social, political, economic and technological challenges; facilitating education and learning; and delivering advance clinical nurse practice based on evidence research and development (ICN 2020). In recognition of these growing global needs and changes required within the nursing workforce, the WHO (2021), the ICN (2020), the Nursing and Midwifery Council (NMC) of the UK (NMC 2018a,b; 2019), the Royal College of Nursing (RCN) of the UK (2018) and many other national and global professional nursing bodies predict that nurses will need to be better prepared to deliver care to meet these changing and diverse needs. This includes the increasing need for many nurses working in specialist and advanced roles to undertake an expanded scope of practice, including that of the independent prescriber. Whether working as part of a community, a hospital or a combined hospital/community service, there will be an increasing need for suitably skilled nurses to lead services, where nurses work with other members of the multiprofessional team to deliver care in a more holistic and person‐focussed manner (WHO 2021). An increasing number of CNSs working as prescribers will be involved in prescribing treatments to treat the underlying illness or condition, prescribing medicines to deal with the side effects of treatments and complications of disease, or prescribing supportive drugs to help individuals live with chronic and advancing illness (RCN 2018). In 2018, the NMC (2018a), in the context of the UK, recognised that with more people presenting with a range of complex and indeed multiple conditions and more nursing care being delivered in community settings, there was a need for nurses to be prepared with an increasing set of skills and competencies to meet these demands. This included a commitment to delivering high‐quality nursing care in a range of settings aimed at supporting people in need while promoting better health and responding to personal choice. In recognition of this reality, today, newly registered/qualified nurses are being educated and trained to have a higher level of proficiency in skills such as assessment, diagnostics, care planning and management, pharmacology and leadership (NMC 2019). All these skills, which are also essential to nurse prescribers, suggest that more and more nurses will be required to take on the role of the specialist and advanced nurse while working as an independent prescriber. The central role of prescribing in nursing has continued to grow in response to local, regional and national need. Previously in the UK, in order to become a community prescriber or an independent prescriber, nurses needed at least two or three years of clinical practice (NMC 2018b, 2019). However, current requirements no longer focus on years of experience but on the skills required, including clinical and health assessment, diagnostics, care management, planning and evaluating care, all core components of preregistration nurse education (NMC 2019). Nurses working in specialist roles will be vital in leading and role‐modelling these skills required to respond to the increasing and complex needs of those within the health and social care system. The recognition of the vital role of independent prescribing within nursing began with a community‐based focus. In 1986, a community nursing review, The Cumberlege Report, undertaken by the Department of Health and Social Security (DHSS) (1986), recognised that community‐based nurses were spending extended periods requesting prescriptions from doctors, including dressings and ointments, when it was argued that these nurses knew more than community doctors about the suitability of these products for the healthcare needs of those they nursed and supported. The UK Department of Health agreed that a limited number of products could be prescribed by these experienced community nurses as part of their service. Over the next decade, this approach to community nurse prescribing was piloted and subsequently extended to a number of community services within the UK. An evaluation report (Luker et al. 1997) and another report in 2004 (McKenna and Keeney 2004) demonstrated that this approach to prescribing not only benefited the patient and carer but also enhanced the work of nurses, doctors and community services. By the end of the decade, community nurse‐led prescribing, although limited to certain treatments, was widespread within the UK. In another development, the clinical management plan (CMP), also known as supplementary prescribing, was introduced to help support better prescribing and care. The CMP was introduced to enhance the care of people living with chronic diseases including asthma, heart disease and mental illness (James 2006). It is described by the National Institute for Health and Care Excellence (NICE), UK (2015) as an agreed partnership between the patient, the doctor and a supplementary prescriber. Following an initial assessment by a doctor, the nurse or allied health professional can prescribe for the patient using an agreed patient‐specific CMP (Table 12.1). This is usually focused on prescribing for non‐acute medical conditions and/or health needs affecting the chronically ill patient. Once again, this innovative approach to prescribing focuses on better supporting the person in need and in a timelier manner. Table 12.1 The clinical management plan. Source: NICE (2015). Another change to improving patient care and prescribing practice came with the development of patient group directives (PGDs) (NICE 2017). Unlike CMPs, these are not patient‐specific. Today, they are used extensively in clinical areas including emergency departments, urgent care centres and other domains of specialist practice where the individual patient may not be identified before presenting for treatment. The supply and administration of medicines under PGDs are reserved for situations where the PGD offers an advantage for patient care without compromising safety (NICE 2017). This includes consistency with appropriate professional teamworking and accountability. The PGD is drawn up locally by doctors, pharmacists, other health professionals and health and social care agencies. It must meet certain legal criteria, including being signed by a doctor and a pharmacist, and be approved by the organisation in which it is to be used. Only named professionals can administer or supply medicines under an agreed PGD (NICE 2017). Alongside CMPs and PGDs, other developments in prescribing emerged. In recognition of the growing need for better prescribing, the National Prescribing Centre (2001) recommended that suitably qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition within their area of competence. This meant the scope of prescribing practice was being broadened, leading the way for suitably trained nurses and pharmacists to undertake specific training and work as independent prescribers. In each of these developments, the focus was in response to patient needs and on implementing a more person‐centred approach to care and better use of personnel and resources, including better use of patient, nurse, allied health professional and doctor time. The competency framework for prescribers in the UK was first published by the National Prescribing Centre (2012). In 2016, NICE agreed that the Royal Pharmaceutical Society (RPS) (2016) would take the lead on maintaining and updating these competencies in collaboration with, and with endorsement by, other prescribing professions, including the NMC, the nursing and midwifery professional body in the UK. The Competency Framework, which is aimed at all prescribers, sets out what good prescribing looks like. Focusing on the consultation and governance processes, the framework helps to inform and improve practice, ensuring a high standard of care and safety for the patient and the prescriber (Table 12.2). Although the competencies have been set out under the consultation and governance processes, none stand alone, and each set of competencies is necessary to ensure safety and best practice. The RPS recognised that broadening the scope of prescribing practice had the potential to improve the quality of peoples’ lives and healthcare outcomes. However, it was recognised that this approach needed to be undertaken safely, ensuring that each prescriber was able to remain competent to prescribe or not prescribe the correct medicines for each patient and that the increased responsibility of prescribing should not be underestimated (RPS 2016). Recently, the RPS have revised and updated the Competency Framework (2021), which continues to support and guide prescribers in expanding their knowledge, skills, motives and personal traits to continually improve their performance and work safely and effectively (RPS 2021). Table 12.2 Prescribing in practice. Source: Adapted from Royal Pharmaceutical Society (2021). The RPS Competency Framework underpins the professional responsibility required of all those who prescribe as part of their role. Prescribers can use the framework to support their practice, including self‐assessment and clinical reflection, and it guides the prescriber when required to expand or change their prescribing. The competencies also help guide regulators, education providers, professional organisations and specialist groups to inform and support constancy in standards, training, guidance and prescribing advice. Each nurse who is a prescriber is also required to adhere to the core principles of their professional code of practice (Table 12.3). Table 12.3 Principles of professional nursing. All nurses wishing to undertake prescribing as part of their specialist role are required to undertake an approved prescribing course (ICN 2020). Topics may include pharmacotherapeutics, prescribing in practice and health assessment. Each nurse prescriber who has achieved a recognised prescribing qualification is required to be registered as an independent prescriber on the NMC register and on the local register of the Trust where they work. This is vital for patient and prescriber safety and to ensure adherence to clinical governance. Each prescriber is expected to undertake training related to their prescribing role at least annually and to participate in audits and peer reviews of their prescribing practice (NMC 2018b; RPS 2021). In the UK, nurse prescribers are expected to reflect on their prescribing role as part of their professional revalidation process (NMC 2018b). Today, although non‐medical prescribing has become globally accepted, nurse and allied health professional prescribers in the UK are pioneering this role extension and have some of the most extended prescribing rights in the world (Courtenay et al. 2011). Under the RPS competencies, each prescriber is required to have their advanced role of prescribing written into their job description (ICN 2020; RPS 2021). A helpful tool, ‘Preparing to Prescribe’, has been devised and is widely available online to guide those who wish to undertake prescribing as part of their role to ensure that the organisation is able to provide suitable support and effective implementation of the new prescribing qualification (Carey and Stenner 2020). The toolkit comprises questions for guidance, links to current regulations and support, and signposting for those wishing to embark on a prescribing course. Reflecting on the competencies defined by the RPS (2021), CNSs are in an ideal position to provide the service of independent prescribing. The CNS is required to have expertise in their chosen speciality; many have undertaken training in advanced communication skills, have enhanced adherence to medication regimes and deliver more person‐centred informed decision‐making (Nuttall 2013). Nurses in these roles also have experience in performing complex holistic patient assessments and providing information needs and consequently have the opportunity to develop therapeutic relationships to augment a patient’s level of engagement in their care (Kerr et al. 2021). Further reports claim that patients have expressed that they are more at ease talking to nurses, with a feeling of person‐centredness and being treated with compassion (Cannaby et al. 2020). Many CNSs have previously reported frustrations with delays in the prescribing process, waiting for a doctor to prescribe for the management plan the nurse and patient have agreed on or advising junior medical staff on what to prescribe in specialised situations (Omer et al. 2021). Skilled nurses not only provide more streamlined care through fulfilling their patient review in its entirety with prescribing skills but also provide more continuity of care and continue to develop the essential therapeutic relationship to improve medication adherence (Graham‐Clarke et al. 2018; Noblett et al. 2018). A number of reviews into patient satisfaction of nurse prescribers have remained positive; and research suggests that non‐medical prescribing is safe and effective and can provide beneficial clinical outcomes, with multiple case studies demonstrating that specialist nurses can improve the management of symptoms and provide rapid appropriate prescribing (Abuzour et al. 2018; Noblett et al. 2018; Kerr et al. 2021). Although patients have reported positive perspectives regarding their encounters with nurse prescribers, there is still a lack of understanding in the general public, which may account for some of the scepticism about nurse prescribers’ knowledge and expressions of feeling safer when medication is prescribed by a doctor (Graham‐Clarke et al. 2018; Omer et al. 2021). Some of the literature has reported issues with non‐medical prescribers gaining professional credibility on attaining their prescribing qualification, with a lack of support from their nursing colleagues and the medical team, or experiences of an obstructive work environment (Creedon et al. 2015; McHugh et al. 2020). Prescribing is a skill traditionally performed only by doctors; therefore, when nurse prescribers amalgamate their newly acquired abilities into the team, there can be some role ambiguity and blurring of duties or being referred to as a ‘mini‐doctor’ rather than considered an advanced nurse; however, reports demonstrate that these attitudes are quickly disappearing (Nuttall 2013; McHugh et al. 2020). When building the prescribing qualification into a CNS role, it is important for nurses to remember the hidden workload of prescribing and be mindful of the additional time to review interactions with an often long list of already prescribed medications, provide the patient with adequate information regarding the drugs prescribed and monitor medications prescribed or make referrals to do so (Creedon et al. 2015). When contemplating whether to become a prescriber, it is important for each nurse to consider whether it is the right decision for them and their role. CNS roles are diverse, with many varying responsibilities within differing sub‐specialities (Kerr et al. 2021). It has been demonstrated that having access to nurses working in specialist roles is associated with enhanced patient experiences and better psychological outcomes (Alessy et al. 2021); therefore, these nurses are in a prime position to improve service delivery by expanding their professional skills to non‐medical prescribing (Graham‐Clarke et al. 2018). Before embarking on a prescribing qualification, it is imperative that each nurse evaluate their role and consider whether becoming a prescriber will benefit the service user, the role and the specialist service (Hand 2019; NMC 2019). It may be helpful to consider:
12
Non‐Medical Prescribing
Abstract
12.1 Introduction
12.2 Background
12.3 Developments in Nursing Practice and the Role of Prescribing
12.3.1 Community Nurse Prescribing
12.3.2 Clinical Management Plans
12.3.3 Patient Group Directives
12.3.4 The Growth of Independent Prescribing
The consultation
Clinical governance
12.4 Preparing to Prescribe
12.5 Benefits and Challenges of Non‐Medical Prescribing
12.6 Deciding to Become a Non‐Medical Prescriber
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