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Conference
Reports This section features reports from conferences and meetings that will be of interest to nurse prescribers. We welcome your submissions and comments about this section. ANP workshop on extended/supplementary
prescribing training 24 September, 2003 Trudy Granby * and Molly Courtenay+ *National Prescribing Centre; +University of Southampton Lecturers from around 20 higher education institutions (HEIs) delivering the combined extended/supplementary prescribing programme, together with representatives from some Workforce Development Confederations (WDCs), attended this workshop on 24 September at the Novartis Foundation, in London. It was organized by the Association for Nurse Prescribing and facilitated by Trudy Granby, Pam Campbell [Staffordshire University] and Molly Courtenay. Throughout the day the delegates worked in workshop groups to identify the challenges around meeting the needs of a diverse group of students in terms of the practice component of the course, the taught component and the assessment processes. The delegates also had the opportunity to discuss and debate experiences and develop strategies for dealing with the identified challenges. These included: Specialist versus generalist It was agreed that the current nurse prescribing preparation programme is necessarily very generalist as it aims to provide nurses from a wide range of clinical areas with the correct level of knowledge, skill and competence to prescribe safely and effectively. The need to reiterate this was debated as, in some cases, nurses from specialist areas have commented that some elements of the taught component does not relate to their area of practice. It was suggested that future preparation programmes could consider delivering a core element and a range of specialist elements, which might be best delivered via e-learning. Specialist knowledge (such as in mental health and dermatology) could also be developed through continuing professional development (CPD) programmes, before undertaking the prescribing role. Selection of students and mode of delivery In many areas, WDCs and local managers are involved in the selection of students for the programme. Experience indicates that, in some cases, the people involved in this process are unclear as to what the programme involves, which can result in the selection of students from clinical areas where the patient or the service would not currently benefit from nurse prescribing. Although comprehensive information about the scope of nurse prescribing is readily available, it was suggested that this should be reinforced by the Higher Education Institution. As for the mode of delivering the preparation programmes,
the advantages of incorporating some web-based and problem-based learning
into them were identified. The delegates generally agreed that the current assessment
requirement is resource- intensive. Objective structured clinical
examinations (OSCEs) carried out in the clinical area would help to
alleviate this. A pool of OSCES for HEIs would also be helpful. Portfolios
take a long time to mark and the increase in student numbers will only
exacerbate this problem. Supplementary Prescribing for Pharmacists: The Implementation Challenges Aston Business School, Birmingham, UK 30 April 2003
David Webb opened the meeting by speaking about the education and training needs of pharmacist prescribers. He began by setting the scene on how non-medical prescribing had evolved. He briefly explained the roles of independent and supplementary prescribers, the format of the clinical management plan, the curriculum for the supplementary prescribing course and the accreditation of courses. He then expanded on work being done in London to further this government initiative, describing commissioning, implementation, communication and infrastructure. He suggested a few areas where supplementary prescribing may play a role and suggested a few hurdles to clear, such as the availability of designated medical practitioners and access to the medical record for practitioners working in the community setting. Questions from the audience included the legality of non-medical prescribing of parenteral nutrition because of its unlicensed product status. David assured the meeting that steps were being taken to overcome potential problems such as unlicensed specials in hospitals. Heidi Wright spoke next on the subject of support available for pharmacist prescribers. She described the need for pharmacists to change from working with patient populations to working with patients as individuals, including managing a caseload, documenting interventions, working in a private consultation room, developing partnership working and acting as a source of pharmaceutical information for fellow healthcare professionals. Heidi discussed potential sources of learning and support including the National Prescribing Centre (NPC), the Faculty of Prescribing and Medicines Management, Workforce Development Confederations (WDCs) and the Department of Health (DH). She mentioned areas of the curriculum where pharmacists should already be competent, including a detailed knowledge of drugs actions, uses and adverse effects and patient education. Finally, she reiterated that supplementary prescribing aims to complement and not replace GP prescribing. Heidi was questioned about the availability of funding from WDCs to pay medical supervisors. She said that WDCs had recently adopted a more flexible approach to the use of funds, allowing for payment of medical supervisors in some circumstances as well as funding student placements. Helen Marlow described the clinical governance
implications for the pharmacist prescriber. She described the work of the
RPSGB task group in developing a clinical governance framework to be used in
conjunction with the NPC document on maintaining competence in prescribing.
The framework is intended to help pharmacist prescribers themselves, and
also their employers, providing care both to NHS and non-NHS patients. This
was included, of course, because many pharmacists employed within the
community sector work for non-NHS employers such as community pharmacy
chains. Pam Campbell spoke about learning from nurse prescribers' experience from the background of her work at Staffordshire University. She described the learning outcomes and indicative content of the nurse course (essentially similar to those proposed for pharmacists), the course structure and assessment methods and the relationship to the NPC competence in nurse prescribing framework. Pam then discussed the problems arising from the
expectation that nurses come to the course equipped with the appropriate
health assessment and diagnostic skills, which has not always been the case.
She described the basic ingredients of the success of nurse prescribers,
including teaching therapeutics rather than pharmacology, relating
assessment and coursework to actual practice, revisiting accountability and
clinical governance issues, getting the basics right (such as consultation
skills) and clarifying the nursing role. The chairman was particularly
impressed by her slide illustrating the role of a doctor compared with that
of a nurse: 'Medicine aims to cure, is prescribing orientated and seeks to
gain compliance. Nursing aims to care, is educative, seeks to gain
concordance and uses self in the therapeutic process'. The chairman invited
the audience to contribute ideas of an equivalent role of pharmacists. Fiona Dobson described the integrated approach to non-medical prescribing in Nottingham. The Nottingham Extended Prescribing Steering Group has been set up to advise the Area Prescribing Committee. The steering group has representation from primary care trusts, acute trusts and Nottinghamshire Healthcare Trust. Membership includes nurse prescribing leads and nurse prescribers, representatives from community pharmacy services, local medical and pharmaceutical committees, local universities and Trent WDC. The role of the steering group is to develop overarching policies and procedures. The Queen’s Medical Centre in Nottingham has its own prescribing steering group to develop these into Trust-specific operational guidelines. The group has developed many useful tools for supplementary prescribing which Fiona expanded on and which she said they are willing to share:
We hope that some of this work will be developed for Nurse Prescriber. Joanne Low gave us a fascinating insight into her Masters project entitled 'Learning from the Scottish Experience of Pharmacist Prescribers'. She investigated the feasibility of a pharmacist-led breast oncology clinic in Forth Valley by comparing referral and prescribing decisions made in the review of patients receiving adjunctive chemotherapy for breast cancer. Guidelines were drawn up describing review of the patient for continuation of chemotherapy and when a pharmacist might prescribe medication for adverse events such as nausea and vomiting, diarrhoea, constipation and heartburn. Criteria for referral to the oncologist were drawn up according to symptom severity and disease control parameters. As the pharmacist, she recorded her own prescribing decisions and compared them with those of the consultant for 100 cycles of treatment. A multidisciplinary consensus group then ranked the prescribing decisions against the defined guidelines and decided on potential for benefit to the patient. It was found that the doctor and pharmacist's decisions varied in eight cases out of 100. For three of these cases, the pharmacist's decision was judged potentially better for the patient and in no case was the oncologist's decision found to be better than the pharmacist's. It was concluded that the specialist oncology pharmacist was an appropriate person to take over the review of these patients in a follow-up clinic. A Trust procedure has been implemented to support this, though this is strictly illegal at the moment as the pharmacist has not undergone prescriber training. Joanne discussed the lessons she had learned surrounding holistic care of the patient, addressing the patient's concerns which may be nothing to do with medication and the fact that patients do not fall neatly into pre-defined categories. She also stressed the importance of good communication skills, knowing your own limitations, effective documentation and involving the patient group. Examples of how the initiative might be taken forward were given, such as clear definition of roles and responsibilities and systems to ensure patient safety and the appropriateness, effectiveness and acceptability of prescribing. Lynn Aglionby then spoke about managing the risk and acknowledging the legal consequences of prescribing. She discussed issues surrounding the non-medical prescribing such as eligibility to prescribe, professional responsibility within the RPSGB Code of Ethics, and clinical responsibility. She described the difference between criminal and civil liability.
Lynn described the Bolam principle as the legal test of 'reasonable care' where 'a man need not possess the highest expert skill at the risk of being found negligent - it is sufficient if he exercises the skill of an ordinary competent man exercising that particular art'. In other words, a mistake is not sufficient. 'It must be a mistake that no competent, reasonable doctor or pharmacist would make'. The boundaries of existing case law were then extended with the Bolitho principal. In a civil liability case, 'there must be a clearly defined breach of duty of care which has resulted in injury for a patient to be able to bring a successful claim against the healthcare professional. The burden of proof in a civil claim is on the claimant who must prove their claim. The standard of proof in civil law for a successful claim is on the balance of probabilities. A pharmacist could be found negligent if a patient suffers harm because the pharmacist failed to care for them properly when applying the Bolam test (that is, in a way that a reputable, reasonable pharmacist would). The RPSGB Statutory Committee could find a pharmacist guilty of misconduct and remove him/her from the register’. The DH has recommended that all supplementary prescribers should take out professional indemnity insurance. Employers also have a duty to ensure that professional activities under their control are covered by adequate professional indemnity insurance. Although supplementary prescribers employed by the NHS acting in the course of their duties with the consent of their employer will be indemnified by the employer, they will be professionally responsible for their own actions. Lynn also went on to describe strict liability for injury caused by
defective products and the right of patients to sue the supplier (doctor,
nurse or pharmacist prescribers). She also talked about issues surrounding
patient consent. She ended by discussing prescribing errors in hospitals and
by GPs and the associated risk management. She summarised by saying that
pharmacists will be bound by legal standards of care and by a professional
duty of care. They must be responsible for prescribing within their own
competence. They must develop an effective partnership with the independent
prescriber. They must identify risks and implement appropriate risk
management systems. Non-medical prescribing – new roles for nurses and pharmacists London, UK 26 March, 2003
Developments include:
Trudy Granby, of the National Prescribing Centre (NPC), looked at national support for prescribers. It was highlighted that under 50% of district nurses and health visitors, qualified to prescribe, are actively prescribing. Thousands of nurses are using patient group directions (PGDs) and there are currently proposals for PGDs to include controlled drugs (see news article). The NPC is designing a competency framework for PGDs which should be available in the summer. The NPC will have an increasing profile in secondary care in the future and there is an awareness that prescribing knowledge needs to enter pre-registration curricula. Continuing professional development (CPD) for prescribers was emphasised and the NPC is working with Workforce Development Confederations (WDCs) to develop prescribing workshops. These will be delivered locally (i.e., the NPC will train facilitators). Acute and chronic conditions, dermatology and wound care will all be included initially. An overview of the development of supplementary prescribing and a definition of prescribing terms will soon be added to the NPC website. Questions following the presentation highlighted the lack of preregistration prescribing knowledge. It was identified that the lack of trained staff on the wards did nothing to help this situation. Jenny Parry, Senior Lecturer, Community Nursing, Canterbury Christ Church University College, looked at the education of prescribers. Programmes are expensive (i.e. for pharmacists to buy in) and time-consuming (OSCEs). The University College had experienced difficulties getting medical assessors. There were further difficulties persuading doctors to attend study half-days as they were too busy. Students found OSCEs very stressful. An extra two days has been added to the extended prescribing to accommodate supplementary prescribing. These days cover information on clinical management plans (CMPs), negotiating skills, and specific pharmacological areas for chronic diseases. In the future, nurses and pharmacists at Canterbury Christ Church University College will undertake supplementary training together. The organizers hope to develop web-based material for their supplementary prescribing programme. Prescribing knowledge will also be included in pre-registration education for nurses. Chris Ottway, Prescribing Course Leader and
Nicky Brookes, Research Coordinator, De Montfort University, provided an
overview of their research exploring district nurse/health visitor
prescribing. The gains and benefits of prescribing, the current picture, and
areas requiring further evaluation were described.
The very complex issues surrounding extended prescribing
were highlighted by Richard Griffiths, Lecturer, University of Wales.
Miall James, Principal Pharmacist (Community Pharmacy) Basildon and
Thurrock University Hospital Trust looked at some of the pharmaceutical
issues and developments surrounding prescribing. He discussed the need to
separate prescribing and dispensing, and the possibility that hospital
pharmacists are more likely to be involved in prescribing. Birmingham, UK 11-12 February, 2003 Mary Hayward* and Matt Griffiths† *Senior Lecturer, University of the West of
England; nurse-prescriber.co.uk Advisory Board and
ANP commitee The 5th annual conference of the ANP was attended by large audience of nurses, pharmacists and educationists. With supplementary prescribing as an important issue and concerns about the future prospects of extended nurse prescribing, district nurses and health visitors requested that their needs, and the limitations of their formulary, were not forgotten. And so it was with great interest that delegates listened to the chief nursing officers (CNOs) from England, Northern Ireland and Wales and a representative of the Scottish Executive Health department regarding the progress of the prescribing initiative and future developments.
Sarah Mullally, CNO for England, told the conference that a consultation on
proposed additions to the formulary will take place soon (see news item), for all groups of
prescribers, although antibiotics remain problematic. She clarified
proposals to include prescribing preparation in pre-registration nurse
education and said that pre-registration competencies are being prepared.
She reassured delegates that students would not be prescribing but that,
following registration, a skills escalator approach in which they move to
supplying under PGDs to independent prescribing could be implemented.
Stressing that patient safety would be paramount, she told the conference
that she had asked the Committee for the Safety of Medicines to reconsider
the exclusion of off-label medicines, and reiterated that proposals to widen
prescribing of controlled drugs are with the Home Office (see
“Substance abuse nurses to prescribe”
and “Consultation on controlled drugs under
PGD" news items). Rosemary Kennedy, CNO Wales, reported that slower implementation was occurring in Wales. District nurses and health visitors are not prescribing much and there has been a weak response to independent prescribing, which has not yet started. However, a new Task and Finish group for supplementary prescribing will be established and it is hoped that this will include midwives, pharmacists and allied health professions in the future. Judith Hill, CNO for Northern Ireland, envisages a bright future for prescribing in Northern Ireland. The initial prescribing programme was implemented as in England, and a curriculum preparing nurses for both extended and supplementary prescribing is being developed to be delivered as an integrated programme. A robust structure supporting the development of prescribing is being put into place, including a nurse prescribing information system: NINA (Northern Ireland Nurse Analysis). John Frogatt, Nursing Officer from the Scottish Executive Health Department, was upbeat about the progressive developments of prescribing in Scotland. Geographical issues have driven support for nurse prescribing and electronic prescribing. Other speakers at the conference were from a wide range of backgrounds and contributed an exciting mix of presentations including that from Alison Blenkinsopp (Professor, Practice of Pharmacy, Keele University), whose involvement in the extended role of nurses and pharmacists in the management of medicines includes a strong focus on the patient/user and the notion of a concordant approach to prescribing. In addition speakers including Dave Roberts from the Prescribing Support Unit, Trudy Granby from the National Prescribing Centre, and Pam Campbell from Staffordshire University, offered an educational perspective on integrated extended and supplementary prescribing programmes. Barbara Stuttle, the new Chair of the ANP, invited delegates to join the revolution in the promotion and progression of prescribing whilst reminding them about accountability and safety issues. Finally, Baroness Cumberlege, who chaired the second day, asked for a round of applause and paid tribute to the outgoing Chair of the ANP, Anthea Clegg, a founder member of the ANP, who has for so many years campaigned to get nurse prescribing off the ground.
Molly Courtenay and David Coleman The Department of Health (DH) organized roadshows in early February about supplementary prescribing for pharmacists. Supplementary prescribing has been greeted as the fulfilment of long-standing aspirations for pharmacists. The current debate about continuing professional development (CPD) within the profession was presented as an important part of this package. Paul Robinson, the Department of Health policy lead on supplementary prescribing, provided a general introduction to supplementary prescribing, indicating that the legislation for this is at a very developed stage, before explaining that the DH will fund direct training costs. This funding will be available from April 2003 and will be channelled via Workforce Development Confederations. Programmes (delivered by higher education institutions including Schools of Pharmacy) will be spread over 3-6 months and include about 25 days taught and 12 days in practice. Information about training and preparation can be found on the Royal Pharmaceutical Society of Great Britain (RPSGB) website. Likely candidates for training include:
However, it was made clear that there are no plans to provide money for
backfill of locums for community pharmacists.
The National Prescribing Centre is developing a competency framework for pharmacists, which should be available at the end of February. The 25 days training may include some ‘open learning’ once courses are up and running. In primary care, opportunities for supplementary prescribing are likely to focus on primary care pharmacists working in GP practices, possible financed through primary care trusts. In hospitals, the Clinical Management Plan (CMP) will be completed by teams of doctors and pharmacists. Nominations for training must be made early. Candidates will have to demonstrate that they have the opportunity to prescribe and the agreement of their employer. Dr Peter Wilson, RPSGB consultant on continuing professional development, examined pre- and post-registration education and training and CPD. Education and training should now be built into pre-registration training and the importance of CPD must not be overlooked. The curriculum has now been developed and the supplementary prescribing programme will cover:
A range of methods will be used to assess students knowledge and skills, for example Objective Structured Clinical Examinations (OSCE) and viva. Students must pass their learning in practice which will include working with patients, physical examination and team work. Supplementary prescriber pharmacists will be specialists in particular therapeutic areas and will be expected to demonstrate that they have developed an appropriate body of expertise by means of CPD portfolio. The RPSGB will have the following roles:
The panel discussion covered some key issues:
Group discussions highlighted the following areas which need to be addressed to make supplementary prescribing work:
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