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Independent and Supplementary Prescribing At a Glance
The market-leading at a Glance series is popular among healthcare students and newly qualified practitioners for its concise, simple approach and excellent illustrations.
Each bite-sized chapter is covered in a double-page spread with clear, easy-to-follow diagrams, supported by succinct explanatory text.
Covering a wide range of topics, books in the at a Glance series are ideal as introductory texts for teaching, learning and revision, and are useful throughout university and beyond.
Everything you need to know about Independent and Supplementary Prescribing at a Glance!
Independent and Supplementary Prescribing At a Glance is an accessible and practical resource for healthcare students looking to become independent and supplementary prescribers. Each part of the book is mapped against a recognised prescribing framework published by the Royal Pharmaceutical Society (RPS) for all Registered Healthcare Professionals, and addresses NMC and HCPC regulatory body requirements. The text presents full-colour images, a user-friendly approach to key prescribing topics, and a structure that allows readers to dip-in and out as needed, appealing to a variety of learning styles.
Topics include:
- Professional, legal, and ethical prescribing considerations; independent and supplementary prescribing; critical thinking and clinical reasoning; exploring interventions and differential diagnosis
- Non-pharmacological approaches and pharmacological treatment options; prescribing reference guides, medication selection and how to prescribe
- Holistic assessment, quality of life, and evidence-based practice; public health, infection prevention and control; consultation models and principles of history taking and physical examination skills
- Building relationships, inclusive prescribing and informed choices; medicine optimisation, adverse reactions, and prescribing generic products
Independent and Supplementary Prescribing At a Glance is a comprehensive and complete learning and study resource for Registered Nurses, Registered Midwives, Physician Associates and Healthcare Professionals who want to become independent prescribers within the UK.
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Table of Contents
Cover
Title Page
Copyright Page
Contributors
Preface
Part 1: Prescribing
1 Scope of Practice NMP
Non‐Medical Prescribing (NMP)
Royal Pharmaceutical Society (RPS)
Scope of practice
The benefits of NMP
NMP healthcare professionals
Registered nurses
Pharmacists
Physiotherapists
Therapeutic radiographers
Optometrists
Podiatrists
Paramedics
Prescribing supervisor
Following completion of an NMP course
2 Professional, legal, and ethical issues
Prescribing governance
3 Independent and supplementary prescribing
Independent prescribing
Supplementary prescribing
The supplementary prescribing process
4 Community practitioner nurse prescriber (V150/V100)
5 Critical thinking and clinical reasoning
Cognitive and metacognitive processes
Dual process theory and cognitive bias in diagnostic reasoning
Integrating the clinical reasoning process into the clinical consultation
6 Exploring interventions
Formularies
Guidelines
7 Evidence‐based diagnosis
Bayes’ theorem
2 × 2 contingency table
The inaccuracies of diagnostic accuracy
STARD statement
Clinical scoring systems
8 Referring to other members of the multidisciplinary team
Written/email referrals
Face‐to‐face referrals
Telephone referrals
Dealing with difficult referrals
Learning to refer
9 Clinical management plans
Drawing up a CMP
Inclusions on the CMP
Medications that can be included on CMPs
Managing the patient using the CMP
Terminating the CMP
Part 2: Consideration of non-pharmacological and pharmacological interventions
10 Non‐pharmacological approaches
Introduction to non‐pharmacological approaches
What are non‐pharmacological approaches?
Social prescribing
Non‐pharmacological interventions
Summary
11 Pharmacological treatment options
12 Prescribing reference guides
The British National Formulary (BNF) and the British National Formulary for Children (BNFc)
Monthly Index of Medical Specialities (MIMS)
Electronic Medicines Compendium (EMC)
13 Medication selection
Communication
Intolerance and allergies
Patient’s personal implications
Existing medical conditions
Interactions between drugs
Polypharmacy
Monitoring for treatment
Limitations to medication choice
14 How to prescribe
Start with the essentials
Information from the patient
Selection of the product
Special groups
The actual prescription
Remember to reflect
15 Risk benefit assessment
Deciding to prescribe
Benefits (efficacy)
Safety
Suitability
Cost
16 Pharmacodynamics
Pharmacodynamics
Agonists
Antagonists
Therapeutic index
Receptor selectivity
Drug efficacy
Drug effectiveness
Drug potency
Dose response
17 Pharmacokinetics
Pharmacokinetics
Absorption
Distribution
Metabolism
Elimination
18 Holistic assessment
19 Quality of life
Ability to cope with regular medications
Patient engagement in self‐management
Regimen simplification
20 Evidence‐based practice
21 Medicines and public health
Public health
Challenges
Opportunity
Responsibilities
Global action
22 Infection prevention and control
Chain of infection
Breaking the chain of infection
Definition of antimicrobial resistance (AMR)
Antimicrobial stewardship
Start Smart ‐ Then Focus
Point‐of‐care testing – C‐reactive protein (CRP)
Patient education
Part 3: Advanced history taking and examination
23 Consultation models
Classification of consultation models
Calgary–Cambridge guide to the medical interview
The cone technique
Ideas, concerns, and expectations (ICE)
Communication
Triggers to consultation
Consultations with an alternative agenda
Consultation and non‐medical prescribing (NMP)
24 Principles of history taking and physical examination skills
History taking
Skills needed to elicit information
History taking and prescribing red flags
General aspects of physical examination
Physical examination for special situations
Evidence‐based physical diagnosis
Conclusion
25 Preparation for objective structured clinical examination
OSCEs: general principles
Revision tools
Marking sheets
Before the examination
During the examination
After the examination
26 History taking for patients who lack mental capacity
Mental capacity
Principles of good prescribing
Supported decision‐making
27 Prescribing and the mental capacity act
Introduction
The MCA 2005
28 Skin history taking and physical examination
Introduction
History
Past medical history (PMH)
Drugs
Allergies
Family and social history
Social history
Psychosocial impact
Review of systems
Examination
Examination key points
Investigations
Documentation
Diagnoses not to be missed
29 Neurological history taking and physical examination
Presenting complaint (PC)
History of presenting complaint (HPC)
Past medical history (PMH)
Family history
Social history (SH)
Drug history (DH)
Review of systems (ROS)
Physical examination
Summary
30 Head, ears, eyes, nose, and throat
Sample of normal examination documentation
Sample of abnormal examination documentation
31 Lymph node assessment
Lymphadenopathy
Assessing lymphadenopathy
Causes of lymphadenopathy
32 Endocrine history taking and physical examination
Introduction
Endocrine history review
Presenting complaint/history of presenting complaint
Past medical and surgical history
Drug history
Social history
Family history
Systematic enquiry
Examination
Inspection
Palpation
Percussion
Auscultation
33 Respiratory
History Taking
Physical examination
Supporting investigations
34 Cardiovascular history taking and physical examination
History taking
Cardiovascular examination
35 Abdominal history taking and physical examination for non‐medical prescribers
History
Clinical examination
Determining the differential diagnosis
Investigations
Laboratory
Radiology
36 Genitourinary system history taking and physical examination
History taking
A complete history of the GU system
Physical examination
External male genital examination
External female genitalia examination
37 Musculoskeletal history taking and physical examination
Part 4: Shared Decision-making
38 Equality, diversity, and inclusion
Age
Ethnicity
Sex
Religion or belief
39 Concordance
Follow‐up and review of medications
40 Building relationships
Communication
Essential elements
Trust
Focus
Anticipate
Know
Evaluate
Deprescribing
Setting boundaries
41 Inclusive prescribing and informed choices
Informed choice and capacity
Shared decision‐making
Decision aids
42 Medicine’s optimisation
Medicine’s adherence
Medicine’s reconciliation
Polypharmacy
Hyper polypharmacy
Appropriate polypharmacy
Deprescribing
Medicine’s review
43 Social prescribing
What are the risks of social prescribing?
Who can make a social prescribing referral?
Embedding social prescribing in practice
Part 5: Prescribing Practice
44 Adverse drug reactions
Type A (augmented)
Type B (bizarre)
Type C (chronic)
Type D (delayed)
Type E (end of use)
Type F (failure)
Reporting ADRs
Black Triangle Scheme
45 Frameworks and guidelines
Introduction
Legal frameworks
Professional standards
Regulatory frameworks
Guidance frameworks (guidelines)
46 Prescribing generic products
Benefits of generic prescribing:
When not to prescribe generically
Anti‐epileptic medication
Summary
47 Medication calculations
Conversions, equivalents, and abbreviations
Ratios
Percentages
Calculate a dose by patient weight
Formula
Critical care calculations
Critical care formulas
48 Non‐medical authorisation of blood components
Blood components versus products
Non‐medical prescribers and authorisation of blood components
Indications, thresholds, and targets
Specific requirements
Risks, complications, and side effects
Reactions
Error
Infection
Long‐term transfusion complications
49 Electronic prescribing
Why move to electronic prescribing
The 5 R’s
Benefits
Drawbacks
Part 6: Patient education and health promotion
50 Unlicensed medicines
Why do medicines have a licence?
Prescribing unlicensed medicines
Prescribing these medicines
Who can prescribe ‘unlicensed medicines’?
Things to consider
‘Special’ medicines
51 Record‐keeping and data management
Introduction
Health (medical) record
Guidance for good record‐keeping
Professional obligations
National guidance for record‐keeping
Guide for making entries in health (medical) records
Principles of good record‐keeping in non‐medical prescribing
Data management
52 Adherence
Suitability for the patient
Ability to cope with regular medications
Patient engagement in self‐management
Regimen simplification
53 Patients recognising deterioration
Introduction
Supporting patients to recognise their own deterioration
Supporting elements to escalation of deterioration
Priorities of patient education regarding deterioration
54 Patients’ responsibility and self‐management
Introduction
Medicine management
Medicines optimisation
Shared decision‐making
Involving patients in decisions about their medicines
Self‐management
References
Part 1: Prescribing
Part 2: Consideration of non‐pharmacological and pharmacological interventions
Part 3: Advanced history taking and examination
Part 4: Shared Decision‐making
Part 5: Prescribing Practice
Part 6: Patient education and health promotion
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Who can become an NMP in the United Kingdom.
Table 1.2 A summary of what NMPs can prescribe.
Chapter 2
Table 2.1 Legal, professional, and regulatory frameworks.
Table 2.2 Prescribing governance
Table 2.3 The British Pharmacological Society’s 10 principles of good presc...
Chapter 3
Table 3.1 Prescribing rights and medicines entitlements by profession
Table 3.2 Comparison of supplementary prescribing and independent prescribi...
Chapter 5
Table 5.1 The clinical reasoning process within a consultation.
Chapter 7
Table 7.1 Statistical terms pertaining to evidence‐based diagnosis
Chapter 11
Table 11.1 Critical appraisal tools
Table 11.2 Example sources of evidence‐based information on pharmacological...
Chapter 12
Table 12.1 Abbreviations of medication categories.
Chapter 13
Table 13.1 Medication route table
Chapter 14
Table 14.1 WWHAM mnemonic
Table 14.2 EASE mnemonic
Table 14.3 SAFE prescribing
Chapter 15
Table 15.1 Examples of some medications that have a narrow therapeutic wind...
Chapter 16
Table 16.1 Narrow therapeutic index examples.
Chapter 17
Table 17.1 ADME
Table 17.2 Drug administration routes
Table 17.3 Important pharmacokinetic terms to explore further
Table 17.4 Factors that affect absorption of drugs
Chapter 19
Table 19.1 Well‐being
Chapter 21
Table 21.1 Asthma – implications at all levels
Table 21.2 Changes and benefits
Chapter 23
Table 23.1 Enhanced Calgary–Cambridge consultation model
Chapter 26
Table 26.1 Guiding principles of the MCA 2005
Table 26.2 Ten principles of good prescribing.
Table 26.3 The Best Interests principle
Chapter 28
Table 28.1 Essential history
Table 28.2 Examination for key considerations
Chapter 29
Table 29.1 HPC mnemonics
Chapter 30
Table 30.1 Common HEENT disorders
Table 30.2 Comment HEENT prescription medications
Chapter 32
Table 32.1 Examples of endocrine disorders
Chapter 33
Table 33.1 Sputum types and differentials
Table 33.2 Pharmaceutical causes of respiratory symptoms
Table 33.3 Common pathologies and their clinical presentations
Table 33.4 Breath sounds
Chapter 35
Table 35.1 Red flags and cardinal signs and symptoms of the abdominal syste...
Table 35.2 Clinical signs
Table 35.3 Clinical findings
Table 35.4 Diagnosis
Chapter 39
Table 39.1 Factors influencing concordance
Table 39.2 FACECARES identified by National Institute for Health and Care E...
Chapter 43
Table 43.1 Factors that affect determinants of health.
Chapter 44
Table 44.1 Types of ADR
Chapter 45
Table 45.1 Definition of key terms.
Table 45.2 Frameworks.
Table 45.3 Regulatory bodies and professional and societies for non‐medical...
Chapter 46
Table 46.1 Complexities in prescribing generic products.
Table 46.2 Prescribing categories for seizure control.
Chapter 49
Table 49.1 Common prescribing errors
Table 49.2 The five rights of medication administration to prevent errors i...
Table 49.3 Electronic prescribing: advantages
Table 49.4 Electronic prescribing: drawbacks
Chapter 50
Table 50.1 Off‐label
Table 50.2 Unlicensed
Chapter 51
Table 51.1 Record‐keeping guidance from professional bodies
Table 51.2 Example of a common systematic approach to making records
Chapter 52
Table 52.1 Causes of non‐adherence
Table 52.2 Forms of medication non‐adherence
Chapter 54
Table 54.1 Four principles of medicines optimisation.
Table 54.2 Medicine management and medicines optimisation
Table 54.3 Information to be included in a medicine self‐management plan
List of Illustrations
Chapter 3
Figure 3.1 The supplementary prescribing partnership
Chapter 4
Figure 4.1 NMC register statistics – prescribing.
Figure 4.2 Nurse Prescribers’ Formulary for Community Practitioners.
Figure 4.3 Prescription example
Chapter 5
Figure 5.1 The elements involved in clinical reasoning, underpinned by a kno...
Figure 5.2 Traditional findings versus evidence‐based method of diagnosis. A...
Chapter 6
Figure 6.1 Example monograph from the BNF.
Figure 6.2 Clinical guideline development process
Chapter 7
Figure 7.1 A two‐by‐two square.
Chapter 8
Figure 8.1 SBAR
Figure 8.2 7 Cs of Referral
Chapter 9
Figure 9.1 Part complete CMP example. NOT FOR DUPLICATION (full co‐terminus ...
Figure 9.2 Part complete CMP example. NOT FOR DUPLICATION (where the SP and ...
Chapter 10
Figure 10.1 Non‐pharmacological approaches
Chapter 11
Figure 11.1 Hierarchy of quality evidence
Figure 11.2 Biopsychosocial model of health.
Chapter 12
Figure 12.1 Example drug monograph.
Chapter 13
Figure 13.1 Prescribing pyramid.
Figure 13.2 Prescribing factors.
Chapter 15
Figure 15.1 Benefits versus risks
Figure 15.2 Risk–benefit assessment worked example,
Chapter 16
Figure 16.1 The step‐by‐step process of second messenger and receptor ion ch...
Chapter 17
Figure 17.1 An integration of ADME and the routes of administration.
Chapter 18
Figure 18.1 Holistic assessment
Chapter 19
Figure 19.1 Quality of life
Chapter 20
Figure 20.1 The spheres of influence of evidence‐based practice in prescribi...
Figure 20.2 (a) The stool illustrating three key components of EBP. (b) One ...
Chapter 22
Figure 22.1 The chain of infection
Figure 22.2 Start Smart ‐ Then Focus.
6
Chapter 23
Figure 23.1 Consultation models and their differing emphasis on four common ...
Chapter 24
Figure 24.1 Process for performing a full physical examination (non‐exhausti...
Chapter 25
Figure 25.1 History taking flash card
Figure 25.2 Abdominal examination flash card
Figure 25.3 Respiratory examination flash card
Chapter 27
Figure 27.1 Five Principles of Mental Capacity Act 2005.
Figure 27.2 Principles of the MCA and four stages.
Figure 27.3 Decision tree.
Chapter 28
Figure 28.1 Skin assessment overview.
Figure 28.2 Skin lesion terminology
Chapter 29
Figure 29.1 Alert Verbal Pain Unresponsive (AVPU).
Figure 29.2 Glasgow Coma Score (GCS).
Chapter 31
Figure 31.1 The lymphatic system.
Figure 31.2 The lymphatic circulation. Schematic illustration of the blood v...
Chapter 32
Figure 32.1 Clinical signs and symptoms of endocrine disorders.
Chapter 34
Figure 34.1 The heart chambers and valves
Figure 34.2 Splinter haemorrhages
Figure 34.3 Roth spots
Chapter 36
Figure 36.1 Male reproductive system.
Figure 36.2 Female reproductive system.
Chapter 37
Figure 37.1 The pain ladder
Figure 37.2 Stages of inflammation
Figure 37.3 The Arachandonic acid cascade.
Chapter 38
Figure 38.1 Protected characteristics.
Figure 38.2 Potential medications containing animal derivatives
Chapter 40
Figure 40.1 SOLER model.
Figure 40.2 Fundamentals of care framework.
Chapter 41
Figure 41.1 What does the Mental Capacity Act do?
Figure 41.2 This is an example of a decision tool for patients deciding abou...
Chapter 42
Figure 42.1 Some of the factors involved in medicine’s optimisation
Chapter 43
Figure 43.1 Determinants of health.
Figure 43.2 Personalised care model
Chapter 47
Figure 47.1 Decimal system
Figure 47.2 Accepted abbreviations
Figure 47.3 Example of incorrect prescription of units
Figure 47.4 Examples of trailing and leading decimal places and zeros
Figure 47.5 Example ratios in solutions
Figure 47.6 Formula to calculate amount of medication required
Chapter 48
Figure 48.1 The ABCDE approach to the transfusion decision‐making process....
Figure 48.2 Framework for safe transfusions.
Chapter 50
Figure 50.1 Hierarchy of risk based on product origin from ‘The Association ...
Chapter 53
Figure 53.1 Standardised communication to prevent delays.
Figure 53.2 Patient safety net advice.
Figure 53.3 The supporting elements to escalation of deterioration.
Chapter 54
Figure 54.1 Shared decision‐making in non‐medical prescribing
Guide
Cover Page
Title Page
Copyright Page
Contributors
Preface
Table of Contents
Begin Reading
References
Index
WILEY END USER LICENSE AGREEMENT
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Independent and Supplementary Prescribing at a Glance
Edited by
Barry Hill
MSc Advanced Practice (ANP), PGC Academic Practice (PGCAP), BSc (Hons) Critical Care, DipHE/OA Dip Counselling Skills, Senior Fellow (SFHEA), Teaching English as a Foreign Language (TEFL), NMC Registered Nurse (RN), NMC Registered Teacher (TCH), NMC Registered Independent Prescriber (V300) Director of Education (Employability), Programme Leader and Senior Lecturer, Northumbria University, Newcastle, UK
Aby Mitchell
RGN, BA (Hons), MSc Advanced Practice (Healthcare Education), PGCAP, FHEA Professional Lead for Simulation and Immersive Technologies, Senior Lecturer Adult Nursing, University of West London, London, UK
Series Editor: Ian Peate
This edition first published 2023© 2023 John Wiley & Sons Ltd
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Contributors
Clare Allabyrne Chapter 26Associate Professor and Programme Lead in Advanced Clinical Practice (Mental Health)London South Bank University, London, UK
Emma L. Bennett Chapters 41, 47Advanced Critical Care Practitioner (FICM Member)University Hospital of Wales, Cardiff, UK
Jill Bentley Chapters 14, 21, 49Lecturer in Advanced Clinical Practice, Non‐MedicalPrescribing and Adult Nursing, and Advanced Critical CarePractitioner (FICM member), Salford Royal Foundation Trust, Mancester, UK
Sebastian Birch Chapter 27CAMHS Clinical Nurse Specialist and Senior Lecturer in Mental Health Nursing University of Roehampton, London, UK
Roberta Borg Chapter 24Advanced Critical Care Practitioner (FICM Member)Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
Joanne Brown Chapter 32Endocrine Clinical Nurse SpecialistStockport NHS Foundation Trust, Society for Endocrinology Early Career Steering Committee and Nurse Committee Member, England, UK
Ashton Burden‐Selvaraj Chapters 34, 35Trainee Advanced Critical Care Practitioner and CollaboratorEquality, Diversity and Inclusion Working GroupIntensive Care Society, London, UK
Edward Chaplin Chapter 26DirectorHead of the Scientific CommitteeEuropean Association for Mental Health in Intellectual Disability,London South Bank University, London, UK
Clare Cooper Chapters 6, 15Advanced Clinical Practitioner and Senior Lecturer Advanced PracticeUniversity of Northampton, Northampton, UK
Sian Cooper Chapter 25Advanced Clinical Practitioner (ACP) in PsychiatryNHS foundation trustManchester, England, UK
Elizabeth Cray Chapter 19Neurosurgical Advanced Clinical PractitionerUniversity Hospital Plymouth, Plymouth, UK
Anne Davidson Chapter 48Education LeadPatient Blood Management Practitioner TeamNHS Blood and Transplant, Newcastle, UK
Jo Delrée Chapter 26Associate Professor and Head of DivisionMental Health and Learning Disability NursingInstitute of Health and Social CareLondon South Bank University, London, UK
Simon Ross Deveau Chapter 44Advanced Clinical Practitioner and NurseVisiting Specialist University of PlymouthTorbay Hospital, Torquay, UK
Sadie Diamond‐Fox Chapters 5, 7, 23, 24, 25, 48Assistant Professor in Advanced Clinical Practice (ACP) & ACP Lead (Fellow HEA)Advanced Critical Care Practitioner (FICM Member)Regional Advancing Practice Supervision and Assessment LeadNorthumbria University Newcastle, UKNewcastle upon Tyne Hospitals, UKHealth Education England, UK
Peter Dryden Chapter 46Assistant ProfessorDepartment of Nursing, Midwifery and HealthNorthumbria University, Newcastle, UK
Laura Elliott Chapters 28, 53Advanced Clinical Practitioner and Senior Lecturer Advanced PracticeUniversity of Northampton, Northampton, UK
Karen Elton Chapter 46Assistant Professor and Programme Leader, Senior Fellow (HEA)Northumbria University, Newcastle, UK
Annette Hand Chapters 3, 9, 12Assistant Professor of Nursing (Clinical Academic)Northumbria University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
Hayley Hassett Chapter 42Senior Lecturer in Non‐Medical PrescribingUniversity of Hertfordshire (Fellow ‐ HEA), Hertfordshire, UK
Colette Henderson Chapter 18Programme Lead in MSc Advanced Practice and Deputy Programme Lead for Non‐Medical PrescribingUniversity of Dundee, Dundee, UK
Barry Hill Chapters 1, 16, 17, 29, 30Director of Education (Employability), Programme Leader and Assistant ProfessorNorthumbria University, Newcastle, UK
Lynne Hughes Chapter 22Senior Lecturer in Adult NursingUniversity of Northampton, Northampton, UK
Tim Kuhn Chapter 34Advanced Critical Care Practitioner (FICM Member) and Senior Lead NurseCritical Care and Critical Care Outreach Team, Croydon University Hospital, London, UK
Dorothy Kupara Chapters 45, 51, 54Senior Lecturer and Course Leader for Learning Disabilities Nursing, HEA Fellow University of West London, London, UK
Hazel McPhillips Chapters 8, 38, 40LecturerSchool of Health and Social CareEdinburgh Napier University, Edinburgh, UK
Aby Mitchell Chapters 2, 39, 43, 52Professional Lead for Simulation and Immersive Technologies and Senior Lecturer in Adult NursingUniversity of West London, London, UK
Tichaona Mubaira Chapter 11Clinical Nurse Specialist in CRHTT WestBerkshire Healthcare Foundation Trust;Associate LecturerUniversity of West London, London, UK
Kevin Murphy Chapter 4Programme Lead for the Higher Apprenticeship in Specialist Practice District Nursing (HASPDN) and Assistant Professor in Adult Nursing (Fellow ‐ HEA)Northumbria University
Reuben Pearce Chapter 11Nurse Consultant in Crisis Resolution and Home Treatment ServicesBerkshire Healthcare NHS Foundation Trust;Associate LecturerUniversity of West London, London, UK
Sam Pearson Chapters 10, 19Non‐Medical Prescribing Programme Lead and Senior Lecturer in Pharmacy PracticeEdge Hill University, Ormskirk, UK
Ollie Phipps Chapter 50Senior Lecturer and Course Director for Non‐Medical PrescribingCanterbury Christ Church University;Advanced Clinical PractitionerMaidstone and Tunbridge Wells NHS Trust, Wells, UK
Jaclyn Proctor Chapter 20Senior Clinical PracticeEdge Hill University Medical School;Respiratory or Acute Medicine Advanced Clinical Practitioner and Non‐Medical Prescriber Lancashire, UK
Claire Pryor Chapters 3, 9, 12Subject Lead for Non‐Medical Prescribing, Programme Lead and Assistant ProfessorNorthumbria University, Newcastle, UK
Christina Rawlinson Chapter 25Advanced Clinical Practitioner (ACP) in Psychiatry, NHS foundation trust, Mancester, England, UK
Anosha Sirpath Chapter 36Senior LecturerCourse Leader or Module Leader for Independent and Supplementary Prescribing, Fellow ‐ HEAUniversity of West London, London UK
Sonya Stone Chapter 35Assistant Professor of Advanced Clinical Practice(Advanced Clinical Practitioner)Faculty of Intensive Care Medicine (FICM) Clinical Lead for eICM, School of Health Sciences, University of Nottingham, Nottingham, UK
Maureen Wallymahmed Chapter 20Programme Lead for Non‐Medical Prescribing and Senior Clinical PracticeEdge Hill University, Ormskirk, UK
Nicola Weston Chapter 31Advanced Critical Care Practitioner (FICM Member)Department of Critical CareUniversity Hospitals Sussex NHS Foundation TrustBrighton, UK
John Wilkinson Chapter 23Anaesthetics RegistrarNorthern Deanery, UK
Lisa Williams Chapter 13Advanced Clinical PractitionerRotherham Foundation Trust (TRFT)Hospital at Night, England, UK
Joe Wood Chapter 33Advanced Critical Care Practitioner, Physiotherapist, and Point of Care Ultrasound EducatorMedway NHS Foundation Trust, Gillingham, UK
Nick Worth Chapter 37North West Faculty for Advancing Practice HEE and Lecturer Non‐Medical PrescribingUniversity of Salford;Fellow of the Society of Musculoskeletal MedicineEngland, UK
Preface
Registered nurses, registered midwives, physician associates, and healthcare professionals who want to become an independent prescriber within the United Kingdom (UK) must successfully complete a Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC) approved post‐registration prescribing programme in order to meet the standards of proficiency necessary for an annotation to be made against an entry onto their professional register. Independent prescribers are practitioners responsible and accountable for the assessment of patients with previously undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. They are recommended to prescribe generically, except where this would not be clinically appropriate or where there is no approved non‐proprietary name.
Written by healthcare academics, this book provides an essential practical and theoretical resource for healthcare students related to independent and supplementary prescribing. Each part of this book is mapped against a recognised prescribing framework published by the Royal Pharmaceutical Society (RPS) for all registered healthcare professionals. This will be the newest and most up‐to‐date book of its kind in the UK aimed at those studying independent prescribing practice. This is the only book to address independent prescribing for all permitted healthcare professionals based on the RPS Prescribing Framework using literature from 2021 and addressing NMC and HCPC regulatory body requirements. This book is at a glance and it makes for the practising clinician; being only 150 pages, it is the perfect size for busy healthcare professionals. The snapshot figures and key points make this book accessible, appealing to a variety of learning styles, and focused for busy healthcare professionals. Literature informing the book comes from the RPS and Royal College of Nursing (RCN) Guidance on Prescribing, Dispensing, Supplying and Administration of Medicines (2020), and RCN and RPS Professional Guidance on the Administration of Medicines in Healthcare Settings (2019), and has adopted the RPS Prescribing Competency Framework as well as the NMC’s standards of competency for prescribing practice. Each chapter is written in a format that will enable the reader to review the chapter as a complete unit, and therefore the reader can choose in which order they wish to read the book.
A multitude of professional bodies have updated guidance on undergraduate and postgraduate education programmes preparing students to become prescriber‐ready. The NMC updated future nurse pre‐registration programme standards, standards for nurses, standards for midwives, standards for nursing associates, and standards for post‐registration programmes. Additionally, the HCPC now advocates the guidance for the same framework meaning that all registered healthcare professionals can use a UK standard of practice and this book facilitates the key points at a glance.
This book follows the current at‐a‐glance series and provides information in a concise and comprehensive manner, which will engage readers by including full‐colour images and graphics, as well as accurate and useful information, and a user‐friendly overview of key prescribing topics utilising prescribing competency frameworks. The book is also available in a range of formats, including e‐book, to increase accessibility.
Barry Hill and Aby Mitchell
Part 1Prescribing
Chapters
1
Scope of Practice NMP
2
Professional, legal, and ethical issues
3
Independent and supplementary prescribing
4
Community practitioner nurse prescriber (V150/V100)
5
Critical thinking and clinical reasoning
6
Exploring interventions
7
Evidence-based diagnosis
8
Referring to other members of the multidisciplinary team
9
Clinical management plans
1Scope of Practice NMP
Table 1.1 Who can become an NMP in the United Kingdom.
Source: Based on HEE.1
Independent and supplementary prescribers
Supplementary prescribers only
Community practitioner prescribers
Nurses/midwives
Pharmacists
Physiotherapists
Podiatrists
Paramedics
Optometrists
Therapeutic radiographers
Diagnostic radiographers
Dieticians
Nurses (health visitors and district nurses)
Table 1.2 A summary of what NMPs can prescribe.
Source: RCN / Royal College of Nursing.5
Independent prescriber
Supplementary prescriber
CDs
Yes – Schedule 2–5 CDs, except diamorphine, dipipanone,or cocaine for treatment of addiction
Yes – Schedule 2–5 CDs, except diamorphine, dipipanone, or cocaine for treatment of addiction
Unlicensed medicines
Yes – provided they are competent and take responsibility for doing so.May vary for nurse prescribers in Scotland
Yes – covered by the Clinical Management Plan (CMP)
Off‐label/off‐licence prescribing
Yes – should only be prescribed where it is best practice to do so andmust take full clinical and professional responsibility for their prescribing
Yes – covered by the CMP
Private prescribing
Yes – for any medicine within their competence
Yes – for any medicine covered by the CMP
Non‐Medical Prescribing (NMP)
Doctors are by far the largest group of prescribers, who, along with dentists, can prescribe on registration. They have been joined by independent and supplementary prescribers from a range of other non‐medical healthcare professions, who are able to prescribe within their scope of practice once they have completed an approved education programme. This extension of prescribing responsibilities to other professional groups is likely to continue where it is safe to do so and where there is a clear patient benefit. NMP is the term used to describe any prescribing completed by a healthcare professional other than a doctor or dentist.1 Non‐medical prescribers (NMPs) include nurses, midwives, and pharmacists, as well as other allied healthcare professionals who have completed an accredited prescribing course and registered their qualification with their regulatory body (Table 1.1). This enables them to prescribe medications as either community practitioner nurse prescribers (with a v150 or v100 course) or independent prescribers (with a v200 or v300 course) (Table 1.2).
Royal Pharmaceutical Society (RPS)
In January 2019, the RPS and the Royal College of Nursing (RCN) co‐created Professional Guidance on the Administration of Medicines in Healthcare Settings.2 The guidance was developed in response to the announcement of the withdrawal of the Standards for medicines management by the Nursing and Midwifery Council (NMC) and will be hosted on the RPS and RCN websites. Application of this guidance is a multidisciplinary responsibility. All staff groups involved in the administration of medicines should be involved in developing organisational policies and procedures. In addition to corporate and clinical governance responsibilities, registered healthcare professionals are personally responsible for putting patients first and for a commitment to ethics, values, principles, and improvement. They are also responsible for practising within their own scope and competence, using their acquired knowledge, skills, and judgement.
Scope of practice
The Health and Care Professions Council (HCPC) (2020)3 identifies scope of practice as the activities a healthcare professional carries out within their professional role. The healthcare professional must have the required training, knowledge, skills, and experience to deliver these activities lawfully, safely, and effectively. They must also have appropriate indemnity cover for their prescribing role. Scope of practice may be informed by regulatory standards, the professional body’s position, employer guidance, guidance from other relevant organisations, and the individual’s professional judgement.
The benefits of NMP
NMP has demonstrated patient care and economic benefits. Consequently, investing in NMP is seen as ‘an investment to save,’ and encouraging NMP capacity is seen as a vital upskilling priority and features as a key enabler in the planning and delivery of new care models and transforming care. NMP training can support role and career development by enabling practitioners to take on greater responsibilities for managing patient care. NMP enhances patient care by supporting patients’ timely access to treatment with medicines, enabling choice while helping to reduce waiting times and hospital admissions and maximising the wider skills of the healthcare team.
NMP healthcare professionals
The British National Formulary (BNF) and the National Institute for Health and Care Excellence (NICE) (2021)4 identify that to protect patient safety, the initial prescribing and supply of medicines prescribed should normally remain separate functions performed by separate healthcare professionals. However, there are several situations whereby simultaneous prescribing and administration or supply are required of the same practitioner, such as in the context of emergency situations.
Registered nurses
Nurse independent prescribers (formerly known as extended formulary nurse prescribers) can prescribe any medicine for any medical condition. Unlicensed medicines are excluded from the Nurse Prescribing Formulary in Scotland. Nurse independent prescribers can prescribe, administer, and give directions for the administration of Schedule 2, 3, 4, and 5 Controlled Drugs (CDs). This extends to diamorphine hydrochloride, dipipanone, or cocaine for treating organic disease or injury, but not for treating addiction. Nurse independent prescribers must work within their own level of professional competence and expertise.
Pharmacists
Pharmacist independent prescribers can prescribe any medicine for any medical condition. This includes unlicensed medicines subject to accepted clinical good practice. They can also prescribe, administer, and give directions for the administration of Schedule 2, 3, 4, and 5 CDs. This extends to diamorphine hydrochloride, dipipanone, or cocaine for treating organic disease or injury, but not for treating addiction. Pharmacist independent prescribers must work within their own level of professional competence and expertise.
Physiotherapists
Physiotherapist independent prescribers can prescribe any medicine for any medical condition. This includes ‘off‐label’ medicines subject to accepted clinical good practice. They are also allowed to prescribe the following CDs: oral or injectable morphine, transdermal fentanyl and oral diazepam, dihydrocodeine tartrate, lorazepam, oxycodone hydrochloride, or temazepam. Physiotherapist independent prescribers must work within their own level of professional competence and expertise.
Therapeutic radiographers
Therapeutic radiographer independent prescribers can prescribe any medicine for any medical condition. This includes ‘off‐label’ medicines subject to accepted clinical good practice. Prescribing of CDs is subject to legislative changes. Therapeutic radiographer independent prescribers must work within their own level of professional competence and expertise.
Optometrists
Optometrist independent prescribers can prescribe any licensed medicine for ocular conditions affecting the eye and the tissues surrounding the eye, except CDs or medicines for parenteral administration. They must work within their own level of professional competence and expertise.
Podiatrists
Podiatrist independent prescribers can prescribe any medicine for any medical condition. This includes ‘off‐label’ medicines subject to accepted clinical good practice. They are also allowed to prescribe the following CDs for oral administration: diazepam, dihydrocodeine tartrate, lorazepam, and temazepam. Podiatrist independent prescribers must work within their own level of professional competence and expertise.
Paramedics
Paramedic independent prescribers can prescribe any medicine for any medical condition. This includes ‘off‐label’ medicines subject to accepted clinical good practice. Prescribing of CDs is subject to legislative changes. Paramedic independent prescribers must work within their own level of professional competence and expertise.
Prescribing supervisor
The prescribing supervisor is an independent supervisor who completes assessment and teaching in practice (previously known as a designated medical practitioner). The practice supervisor (PS) is a colleague in practice who must be able to provide guidance and supervision for your practice‐based learning while you are on the course. The PS must be someone with whom you normally work, and they must meet specific criteria as outlined by the higher education institution. Support for the PS role is provided by the university NMP course leads and NMP leads in organisations.
Following completion of an NMP course
The newly qualified NMP must:
Register with the relevant regulator, i.e. GPhC, NMC, or HCPC.
Provide confirmation to their employers of their successful annotation.
Complete any other local/employer requirements, e.g. scope of practice/formulary.
Ensure they have appropriate indemnity arrangements.
Maintain competence and undertake annual continuing professional development and revalidation as specified by their regulator.
Ensure they have appropriate support to undertake their prescribing role.
2Professional, legal, and ethical issues
Table 2.1 Legal, professional, and regulatory frameworks.
Source: Adapted from Nuttall, 2020.
Legislation
Professional
Regulatory
Prescription‐Only‐Medicines (POMs) (Human Use) Orders 1997 and Subsequent Statutory Instruments
NMC (
http://www.nmc‐uk.org
)
Medicines and Healthcare products Regulatory Agency (
http://www.mhra.gov.uk
)
Misuse of Drugs Act 1971
General Pharmaceutical Council (
http://www.pharmacyregulation.org
)
Drugs and Therapeutics Committees
Misuse of Drugs Regulations 2001
Health and Care Professions Council (http:///www.hcpc‐uk.org)
Human Medicines Regulations 2012 Human Medicines (Amendment) Regulations 2018
General Optical Council’s Standards of Practice for Optometrists and Dispensing Opticians 2016 (
http://www.optical.org
) UK Law for Medicines (
https://www.gov.uk/guidance/eu‐guidance‐documents‐referred‐to‐in‐the‐human‐medicines‐regulations‐2012#:~:text=The%202020%20Regulations%20have%20been,and%20advertising%3B%20and%20for%20pharmacovigilance
.)
Table 2.2 Prescribing governance
The patient
Prescribing practice
Circumstances and current medication
A thorough knowledge of the medicine to be prescribed, its therapeutic action, side effects, and interaction Current patient medication and any potential interactions with new medications
Past medical history
A thorough knowledge of alternatives to prescribing Previous drugs the patient has taken and full medical history
Current and anticipated health status
Frequency of the use of drug and dosage, adherence to current medications, and patient’s perception of health
Table 2.3 The British Pharmacological Society’s 10 principles of good prescribing – 2021.
Source: Adapted from The British Pharmacological Society, 2021.
Be clear about the reasons for prescribing
Prescribers should establish an accurate diagnosis whenever possible and be clear what the patient is likely to gain from the prescribed medicines
Consider the patient’s medication history before prescribing
Obtain a list of current and recent medications Ask the patient/carer about any over‐the‐counter medications, adverse drug reactions, and drug allergies
Consider factors that might alter the benefits and risks of treatment
Consider individual factors, e.g. physiological changes with age, pregnancy, or impaired kidney, liver, or heart function
Consider the patient’s ideas, concerns, and expectations
Values‐based prescribing is a collaborative approach to prescribing whereby the practitioner takes into account the wishes, values and principles of the patient when prescribing medication
Select effective, safe, and cost‐effective medicines
Consider if the effect of medicines outweighs the extent of potential harms Review published evidence Choose the best formulation, dose, frequency, route of administration, and duration of treatment
Adhere to national guidelines and local formularies where appropriate
Select medicines with regard to cost and needs of other patients (healthcare resources are finite) Access and use reliable and validated sources of information, e.g. The British National Formulary
Ensure prescriptions are written on the correct documentation
Be aware of common factors that cause medication errors and how to mitigate risk factors
Monitor the beneficial and adverse effects
Identify how beneficial and adverse effects can be assessed Understand how to alter prescriptions because of information Knowledge of how to report adverse drug reactions (via the Yellow Card scheme)
Communicate and document prescribing decisions and rationale
Communicate effectively with patients, carers, and colleagues Use the health record to document prescribing decisions accurately
Prescribe within the limitations of your knowledge, skills, and experience
Be prepared to seek advice and support Make sure appropriate prescriptions are checked
The United Kingdom (UK) prescribing law is ever changing; therefore, it is important that prescribers consistently update their knowledge of legislation. There are several legal, professional, and regulatory frameworks to support prescribing practice (see Table 2.1). For prescribers, the virtues of openness, transparency, and duty of candour are imperative and hence these should be embedded into clinical practice.
All prescribers are required to work within their own professional boundaries and standards of conduct to provide high‐quality healthcare. Nurse prescribers’ practice is grounded by the professional code of practice that guides the prescribing with rules and standards. The introduction of the Royal Pharmaceutical Society (RPS) Prescribing Competency Framework 2016 has ensured that high standards are maintained and that capabilities are synonymous between disciplines. Prescribing accountability is coincident with the components of ‘governance’ and prescribers are held accountable for assuring quality standards are met on the delivery of care. The Nursing and Midwifery Council (NMC) recognises clinical governance is essential to continuously improve quality and maintain standards of care. Nurse prescribers practise autonomously within the code of the ethical principles of non‐maleficence, deontology, and paternalism. Prescribing demands a higher degree of professional responsibility and accountability ensuring that the prescriber is responsible for someone or something and willing to take the consequences of actions or inactions.
Prescribing governance
The RPS Prescribing Competency Framework is structured in two key domains, i.e. prescribing governance and the consultation with the patient at the centre. Prescribing governance refers to prescribing safely and focuses on the need to reduce risk and maintain patient safety. As part of the role, nurse prescribers are expected to work at an advanced clinical level demonstrating competence in professional prescribing with evidence of accountability for clinical decisions within legal, professional, and professional boundaries. Legal and professional accountability requires prescribers to provide a rationale for prescribing for:
What is prescribed?
When are over‐the‐counter products recommended?
When are decisions made not to prescribe or recommend a product?
In addition, prescribers are expected to have knowledge and competence in patient assessment within certain contexts (see Table 2.2).
To appropriately prescribe, it is essential that prescribers have a good knowledge and understanding of pharmacology in relation to the drugs prescribed; this includes:
Pharmacokinetics and pharmacodynamics: Pharmacokinetics involves the changes in the serum concentration of a drug in the body over a set period of time. Absorption, distribution, metabolism, and excretion of the drug bring this about. The last two processes also account for the elimination of the drug from the body. Pharmacodynamics is the term to describe what a drug does to the body, including therapeutic and adverse effects.
Safety and efficacy remain the key objectives for prescribing. All prescribes are required to work within the boundaries of their own standards of conduct and scope of practice. In gaining a prescribing qualification, a practitioner must be fully conversant with their codes of practice. Prescribers must:
Only prescribe within their scope of practice and recognise own limitations in knowledge and skill.
Have a good understanding about common types of medication errors and how to prevent and avoid these.
Identify potential risks associated with remote prescribing, e.g. over the telephone/by a third party, and minimise risk factors.
Develop and adhere to the process that supports safe prescribing practice, e.g. transfer of information and repeat prescriptions.
Keep up to date with prescribing practice and be aware of emerging safety concerns relevant to prescribing.
Report prescribing errors, near misses, and critical incidences, and review to prevent recurrence.
In order to ensure safe prescribing and the effective use of medicines, all practice should be underpinned by the principles provided in Table 2.3.
The prescriber must inform the patient: what to expect when taking the medicine and how to take it; the duration of time they will be on the medication and what effects and improvements they are likely to see; and the efficacy of the medication and any precautions or likely side effects.
3Independent and supplementary prescribing
Table 3.1 Prescribing rights and medicines entitlements by profession
Profession
Governing body
Supplementary prescriber
Independent prescriber, excluding controlled drugs
Independent prescriber, including some controlled drugs
Nurse
NMC
√
√
Midwife
NMC
√
√
Chiropodist/podiatrist
HCPC
√
√
Dietitian
HCPC
√
Paramedic
HCPC
√
√
Physiotherapist
HCPC
√
√
Diagnostic radiographer
HCPC
√
Therapeutic radiographer
HCPC
√
√
Figure 3.1 The supplementary prescribing partnership
Table 3.2
