Journal of Nursing Management, 2009, 17, 603–614
Provision of continued professional development for non-medical prescribers within a South of England Strategic Health Authority: a report on a training needs analysis 1 2 D N u r s i n g M A , B A ( H o n s ) , R C N T , R M N , R G N , OLWYN WESTWOOD P h D , B S c , PAM SMITH P h D , 3 4 M S c , B N u r s , R G N , R N T , FIONA PENISTON-BIRD R N , R H V , B S c ( H o n s ) , N I P , P R I N C E 2 * and DAVID HOLLOWAY 5 PhD, MA, BA
ANITA GREEN
1
Lecturer (Clinical), 2Reader in Medical Education, 3Professor of Nurse Education, Centre for Research in Nursing and Midwifery Education, European Institute of Health and Medical Sciences, University of Surrey, Guildford, 4 Independent Non Medical Prescribing Development Consultant, Worthing, West Sussex and 5Principal Lecturer, School of Education and Continuing Studies, University of Portsmouth, Portsmouth, UK
Correspondence Anita Green European Institute of Health and Medical Sciences Level 5 Duke of Kent Building University of Surrey Guildford GU2 7TE UK E-mail:
[email protected] *Previously a non-medical prescribing facilitator.
G R E E N A . , W E S T W O O D O . , S M I T H P . , P E N I S T O N - B I R D F . & H O L L O W A Y D . (2009) Journal of Nursing Management 17, 603–614 Provision of continued professional development for non-medical prescribers within a South of England Strategic Health Authority: a report on a training needs analysis
Aims This paper reports on a Training Needs Analysis for Non-Medical Prescribers commissioned by a south of England Strategic Health Authority. Background The aim of the TNA was to inform future policy, educational provision and practice development and provide nurse managers with significant information on the perceived Continuing Professional Development (CPD) needs of the nonmedical prescribers. Methods Data were collected from a sample of 270 non-medical prescribers using an in-depth questionnaire, and telephone interviews with a purposive sample of 11 key stakeholders. Results The findings report: • The qualifications that non-medical prescribers possess. • The level of confidence described by the non-medical prescribers in their role. • What non-medical prescribers identify as their present and future CPD requirements in relation to prescribing. • What education and training provision non-medical prescribers have attended in relation to their prescribing role since qualifying. Conclusions The findings suggest, first that short courses that were specific to the non-medical prescribers role were considered to be the most popular and useful. However, courses needed to be advertised well in advance. Second, training gaps were identified. Implications for nursing management Pharmacology and prescribing are rapidly changing and require regular CPD in order to keep up to date with the latest developments. Non-medical prescribing is a comparatively new innovation to the NHS, therefore those who are not medically qualified need mentorship from
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experienced prescribers, as well as the encouragement from nurse managers to be confident prescribers themselves and enhance patient care. Keywords: continuing professional development, non-medical prescribing, training needs analysis Accepted for publication: 20 March 2008
retention and CPD of non-medical prescribers and nurse managers.
Introduction This paper reports on a Training Needs Analysis (TNA) for Non-Medical Prescribers commissioned by a south of England Strategic Health Authority completed in Winter 2006/2007. The aim of the TNA was to inform future policy, educational provision and practice development and provide significant information on the perceived Continuing Professional Development (CPD) needs of the non-medical prescribers, to ensure that these needs are met in the future. The TNA was commissioned prior to the publication of the Department of HealthÕs (DH 2006) ÔImproving patientsÕ access to medicines: a guide to implementing nurse and pharmacist independent prescribing within the NHS in England guidelines on prescribingÕ. However, the consultation paper (DH 2005), which informed this TNA, had been circulated, and would have been available to the TNA participants. The TNA was informed by a sample of non-medical prescribers (n = 270) from a total population of 1249 who were surveyed using an in-depth questionnaire, and a purposive sample of 11 key stakeholders who agreed to be interviewed by telephone. The participants were asked about their perceptions of continuing education and training needs in order to inform future provision for those practising in the Primary Care Trusts, Acute Hospital Trusts and Mental and Specialists Care Trusts of the SHA. The aim of this paper is to report on the following elements of the findings of the TNA. • How non-medical prescribers are employed across the Health Authority. • Future education and training needs of non-medical prescribers. • The education and training gaps, deficits and limitations of non-medical prescribers. The paper concludes with a discussion of the findings and their implications for the education, training, 604
Literature review The whole area of non-medical prescribing can be viewed as changing and dynamic. Non-medical prescribing commenced in December 1998 when the Department of Health (DH) introduced nurse prescribing in England. This move has been reviewed over recent years (Latter et al. 2004, Department of Health 2006). From its inception, the PrescribersÕ Formulary for district nurses (DN) and health visitors (HV) enabled district nurses and health visitors to prescribe from a formulary of appliances, dressings and some medicines for patients they were caring for in the community. A recent DH document ÔImproving patientsÕ access to medicines: A guide to implementing nurse and pharmacist prescribing within the NHS in EnglandÕ (April 2006), is an important initiative to support independent prescribing for registered nurses, midwives and pharmacists. There are now large numbers of nurses who practise as independent nurse prescribers. More recently, nurses working in mental health and substance misuse have come forward to qualify as non-medical prescribers and in March 2005 the DH published jointly with the National Prescribing Centre and the National Institute for Mental Health in England a good practice guide ÔImproving mental health services by extending the role of nurses in prescribing and supplying medicationÕ. This was the first time mental health nurses had been addressed in relation to their roles as prescribers.
Origins of nurse prescribing The first documented evidence available of the case for nurse prescribing being articulated appears to be in an Royal College of Nursing (RCN) report from 1978 (RCN 1978). This report referred to the particularly
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frustrating experiences of district nurses who were unable to obtain or deliver simple prescription items (such as sterile dressings) without first having to refer to a doctor. The RCN was presented with an opportunity to lobby for nurse prescribing when the government of the day commissioned a review of community nursing provision. This review, chaired by Julia Cumberledge, was carried out by an expert team in health services and economists. CumberledgeÕs Report (DHSS 1986) acknowledged the case for nurse prescribing to the extent that it recommended that suitably trained community nurses should be able to prescribe from a small range of medicines, dressings and appliances. Further negotiations between the RCN, the British Medical Association (BMA) and the Royal Pharmaceutical Society of Great Britain (RPSGB) resulted in a common position that there was a case for wider nurse prescribing, and particularly for community nurses, to be able to prescribe and deliver any medicines they considered appropriate for the care of their patient using protocols.
Piloting nurse prescribing In order to more fully assess the potential benefits of nurse prescribing, a pilot project was introduced in England in October 1994 for community nurses at eight demonstration sites, one in each Regional Health Authority. The evaluation of this pilot project was carried out by Luker et al. (1997a,b,c,d). Evaluation evidence from the pilot sites reinforced the case made by advocates of nurse prescribing – time saving for nurses, doctors and patients, and a high degree of patient satisfaction.
The expansion of independent nurse prescribing After publication of the data from the evaluation of the pilot nurse prescribing sites, pressure for widespread independent nurse prescribing continued to increase. In 1998, the government announced its intention to proceed with a national programme of nurse prescribing and this was completed in Spring 2001. (This initiative only applied to England, as Scotland, Wales and Northern Ireland have devolved governments.) Access to this programme was restricted to nurses with DN or HV qualifications working in the community and employed by a National Health Service (NHS) trust or general practitioner; engaged in Personal Medical Services pilot schemes or working in an NHS Walk-In Centre.The recommendations of the second Crown Report (1999), that nurse prescribing rights be granted to other groups
of nurses and health professionals, was endorsed in the NHS plan (Department of Health 2000). In May 2001, the government announced the extension of independent nurse prescribing to cover a range of conditions identified within four treatment areas: minor injuries, minor ailments, health promotion and palliative care. Training of nurses to qualify as independent nurse prescribers began in January 2002 and the first nurses completed these programmes in April 2002. The Health and Social Care Act 2001 provided the primary legislation to implement the recommendations contained in the Third Crown Report, Review of Prescribing, Supply and Administration of Medicines (1999). These included extending the legal authority to prescribe to new professional groups and introducing the role of a Supplementary Prescriber. Table 1 provides a timescale of the changes and developments of non-medical prescribing in England.
Recent changes in non-medical prescribing The DH brought about changes to the regulations from 1 May 2006 enabling nurses and pharmacists to train Table 1 Timetable of change: introduction of non-medical prescribers in England Actions introduction of non-medical prescribers in the UK May 2001
Government announced the extension of independent nurse prescribing to cover a broad range of conditions. January 2002 Training of nurses to qualify as independent nurse prescribers began. April 2002 The first nurses completed these programmes and were then able to independently prescribe medicines from the Nurse PrescribersÕ Extended Formulary (NPEF). April 2003 Government approved nurses and pharmacists to train as supplementary prescribers. Supplementary prescribing extended to other professionals such as physiotherapists, radiographers, podiatrists and optometrists who can now prescribe under the terms of a patient specific Clinical Management Plan agreed with a patient and doctor (or dentist). May 2006 ÔImproving patientsÕ access to medicines: a guide to implementing nurse and pharmacist independent prescribing within the NHS in EnglandÕ (DH). Nurse independent prescribers (formerly Extended Formulary Nurse Prescribers) are able to prescribe any licensed medicine (including some Controlled Drugs) within their own level of experience and competence. Pharmacist Independent Prescribers can prescribe any licensed medicine for any medical condition, with the exception of Controlled Drugs within their own level of experience and competence.
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and qualify as independent prescribers (Department of Health 2005, 2006). Accordingly, these professional groups are now able to prescribe any licensed medicines including some Controlled Drugs for medical conditions which come under their area of clinical expertise (Department of Health 2006). However, Community Practitioner Nurse Prescribers (formally known as DN and HV prescribers), whose prescribing is limited to items from the Nurse PrescribersÕ Formulary for Community Practitioners, will only be able to prescribe from a limited formulary.
Learning for practice Continuing professional development (CPD) is mandatory for the occupational groups involved in non-medical prescribing. CPD has been defined as: Ô…the maintenance of and enhancement of knowledge, expertise and competence of professionals throughout their careers according to a plan formulated with regard to the needs of the professional, the employer, the profession and societyÕ (Madden & Mitchell 1993). There is a widely held belief that CPD activity can make a significant contribution to nursesÕ and midwivesÕ ability to improve health and health care for service users and meet service needs. CPD can come in numerous forms, formal and informal, including individual reflection on professional practice, discussions with colleagues, lectures and seminars held locally, conferences, study days and meetings, visits and placements within clinical settings and formally accredited academic programmes. The requirement to ensure that health and health care services are delivered by staff who are up to date with latest developments and properly prepared to carry out their functions is emphasized in many of the policy statements for the NHS issued by the UK government (DH 2001, HM Treasury 2002). They are also reflected in wider statements on the place of CPD in health professional education globally issued by organizations such as the International Council for Nurses (ICN) and the World Health Organization (WHO). The Strategic Health Authority who commissioned the TNA, has invested heavily in education and training to up-date knowledge, skills and their application. However, there is a significant body of educational literature that questions whether or not learning can be transferred from educational institutions to the workplace (Beach 1999, Carraher & Schiemann 2002). Situated learning theories start from the assumption 606
that all learning is context dependent and consequently transfer to other situations is problematic. Such assumptions are evident in research into professional development emphasizing informal learning Ôon the jobÕ (Eraut et al. 1998, Cheetham & Chivers 2001).
Research design and methods The data from the TNA were collected using two methods: postal in-depth questionnaires and structured telephone interviews. The questionnaire was compiled to provide quantitative and qualitative data. The small sample of telephone interviews provided qualitative data which is presented in the study. The postal questionnaires were sent to a sample of 1249 non-medical prescribers who had completed either the Nurse prescriber (DN or HV course) (NMC V100), the extended formulary nurse prescriber course (NMC V200), the extended formulary plus supplementary prescriber course (NMC V300) or the supplementary prescriber (pharmacist, or other health care professional) course as a Ôtop upÕ. The questionnaire was split into four sections: professional details, practice experience, continuing professional development details and demographic information. The findings are reported in the form of simple statistics with additional supporting qualitative commentary from open-ended questions. Telephone interviews were conducted with a purposive sample of key stakeholders: clinical managers, nurse consultants, nurse educators (programme directors), pharmacists and independent medical prescribers (n = 11; see Table 2) A number of the managers had responsibilities as non-medical prescribing leads and the independent medical prescribers were experienced mentors and assessors for students on the non-medical prescribing programmes of study in higher education institutions in the SHA region. The telephone interviews obtained qualitative data on the intervieweeÕs views about CPD provision for non-medical prescribers and future requirements. The sample size reflected a balance of numbers across each stakeholder post, and was not
Table 2 Key stakeholders interviewed Key stakeholders Programme leaders Medical prescribers (assessors) Prescribing leads Senior nurses/managers Pharmacists
n = 11 3 2 3 2 1
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intended to be representative of each grouping. As such it constituted a convenience sample. These professional groupings were chosen because they potentially had the most to say about the CPD needs of non-medical prescribers. They had contact with those who were in the process of or had completed their training. They provided support by allocating time to undertake the programme, mentoring and assessing, sharing of knowledge and experience, and provision of informal or formal CPD for post-qualifying staff. A pharmacist was included in the interviews because this professional group is now coming forward to train and even although the numbers are small these are likely to grow following the changes from 1 May 2006 offering them opportunities to develop their role in prescribing (DH April 2006). We maintained anonymity throughout by ensuring that individuals were not identifiable. Anonymity was further ensured by not identifying the areas of professional practice of each professional group. The data were examined using a qualitative analytical framework. Each interview question was considered separately and the response compared with those provided by the other respondents. This presented an opportunity to undertake a comparative analysis to explore the data for themes. This was used specifically for the data produced that did not ÔsitÕ within the interview questions, for example, when a respondent raised a matter related to non-medical prescribers that was outside the interview schedule.
Findings The findings report: • The qualifications that non-medical prescribers possess. • The level of confidence described by the non-medical prescribers in their role. • What non-medical prescribers identify as their present and future continuing professional development requirements in relation to prescribing. • What education and training provision non-medical prescribers have attended in relation to their prescribing role since qualifying.
Strategic Health Authority Database of nonmedical prescribers Information on the contact details of 1249 non-medical prescribers was obtained from a database of the SHA. The low response rate (23%, n = 270) was investigated
by telephone to ascertain whether the questionnaires had arrived at their destined prescriber. The low rate could be attributed to, in part, the dynamic nature of job changes within the region that meant staff had moved to new posts. Although the response rate of 23% is lower than we had anticipated, it is an acceptable return for a postal questionnaire. We suggest that the findings provide significant insights into the CPD perceptions and the needs of the non-medical prescribers working in this particular SHA. The findings also provide information that can be utilized by nurse managers.
Professional and practice experience details There was one pharmacist and all other respondents were part of the nursing profession with health visitor and district nurse being the most significant number of non-medical prescribers. Others were working in palliative care, general practice or care of the elderly, with smaller numbers in a wide range of medical and mental health specialties.
Nature of the qualifications awarded in order to be eligible to prescribe Some of the respondents had more than one prescribing qualification (hence percentages here add up to >100%). Of those questioned, 72% had the NMC V100, 34% had mentor qualifications, 22% had the extended formulary + supplementary prescribing (NMC V300) and 13% were Extended Formulary Nurse Prescribers (NMC V200). Only 6% were supplementary prescribers and this included the one pharmacist who replied. The 36% who possessed a teaching qualification were mainly nurse consultants, clinical nurse specialists and nurse practitioners (Table 3 and 4). With respect to the appropriateness of their programmes of study, 86% respondents answered ÔYesÕ to the question. The remaining 14% who answered ÔNoÕ suggested the courses were generic rather than related to practice, without enough emphasis on pharmacology. It could be argued that programmes need to be generic owing to the wide scope of practice represented in the student population (Figure 1). Respondents reported two concerns when acquiring, developing and maintaining a new skill: being able to apply knowledge gained from the programme of study completed and the importance of personal confidence in performance. These are crucial to the improvement in the quality of patient care. The vast majority of respondents, irrespective of roles, stated that the content of the programmes studied
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Table 3 General qualifications of respondents to the questionnaire
n RGN RMN DipHE RN (M) DipHE RN(Adult) DN HV Certificate Diploma Degree Masters Post-grad Diploma MPharm Other
All
Pharmacist
Nurse consultant
270 90% 6% 0% 3% 40% 33% 23% 39% 50% 7% 10% 0% 16%
1 – – – – – – – – 100% – 100% 100% –
7 100% – – – – 29% 43% 43% 57% 86% 14% – 29%
Practice nurse
District nurse
Community psychiatric nurse
Clinic nurse specialist
Nurse practitioner
Health visitor
Other
16 100% – – – 50% 19% 25% 44% 31% – – – 13%
66 91% 2% – 5% 92% – 24% 30% 50% 2% – – 6%
6 – 100% – – – – – 33% 67% – 50% – 17%
38 89% 5% – 3% 29% 11% 26% 53% 45% 11% 11% – 16%
23 83% 4% – 4% 9% 9% 22% 35% 78% – 9% – 26%
76 92% 5% 1% 1% 7% 95% 18% 39% 49% 5% 14% – 24%
37 100% 5% – 8% 59% 19% 27% 43% 46% 14% 11% – 14%
Table 4 Prescribing qualifications of respondents to the questionnaire
n Mentor qualifications Extended formulary nurse prescribers (NMC V200) Extended formulary plus supplementary nurse (NMC V300) Supplementary prescriber (inc pharmacists) Nurse prescriber – DN and HV (NMC V100) Teaching Qualification None
Practice nurse
District nurse
Community psychiatric nurse
Clinic nurse specialist
Nurse practitioner
Health visitor
Other
All
Pharmacist
Nurse consultant
270 34% 13%
1 – –
7 43% 29%
16 6% 19%
66 44% 8%
6 83% –
38 42% 18%
23 39% 52%
76 24% 5%
37 27% 8%
22%
–
57%
31%
6%
67%
42%
61%
3%
27%
6%
100%
14%
13%
–
–
8%
30%
–
3%
72%
–
29%
50%
98%
–
42%
17%
93%
78%
36% 1%
– –
43% –
13% 6%
23% 2%
33% –
47% –
39% –
36% 1%
54% 3%
18
Health visitor
82 26
Nurse practitioner
22
Clinic nurse specialist
78 50 50
Community psychiatric nurse
3
District nurse
97 7
Practice nurse
93 14
Nurse consultant Pharmacist
86
1 13
All 0
10
87 20
30
40
50
60
70
provided an appropriate knowledge base to fulfill their role in non-medical prescribing (Figure 1) and were confident in their abilities to prescribe (Figure 2) as they were able to apply the knowledge gained. 608
No Yes
74
80
90
100
Figure 1 Responses to appropriateness of programme content studied to fulfill the role on non-medical prescribing (n = 261).
Confidence was a major issue for respondents in being able to perform as a non-medical prescriber (Figure 2). Briefly, the extremely confident and fairly confident non-medical prescribers appeared to have the
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Extremely confident (n = 23) I work and prescribe only in my area of competency (n = 10) I am confident in my specialty (n = 4) Fairly confident (n = 48) I am happy with what I prescribe (n = 17) I only prescribe within my boundaries (n = 13) Neither confident nor unconfident (n = 10) I have not been given the opportunity to prescribe (n = 4) Fairly unconfident (n = 7) Figure 2 Replies to the statement on respondents' confidence in non-medical prescribing.
Sometimes I have to double check what I can prescribe (n = 2) Insufficient back –up and support from colleagues an GPs (n = 2) Lack of knowledge, experience and confidence (n = 3)
self-confidence to prescribe within their clinical specialty and were: prepared to keep up-to-date by studying, checking out aspects of their prescribing, prescribing within their own professional boundaries and communicating with colleagues who were approachable and supportive. The respondents who were less confident attributed this to: their lack of knowledge, experience and confidence, never having prescribed and needing to update and insufficient support from colleagues.
Non-medical prescribing enhances the professional role (Figure 3) Being able to prescribe tended to improved job satisfaction by enhancing the professional role in 84% of
non-medical prescribers questioned. Briefly, comments on job satisfaction attributed this to the following: a feeling of autonomy that also gives confidence to the patients; appropriate treatment at point of contact; seamless and holistic care for patients; saving time for all patient and non-medical prescribers; and not chasing the doctor for a prescription. Unsurprisingly, the respondents who did not feel prescribing enhanced their role were those who rarely actually prescribed, or used a limited formulary of over-the-counter drugs. With respect to those who stated that they were neither confident nor unconfident there were four respondents who stated that they had not been given the opportunity to prescribe, this could be attributed to them working in unsuitable clinical areas post-qualifying or a change to a non-clinical role.
Strongly agree (n = 75) The comments of those that strongly agreed fell into the following themes: Speeds up treatment for patients and therefore saves time (n = 10) Improves patient care (n = 8) Provides holistic care (n = 14) Allows me to work autonomously and it enhances my role (n = 14) Creates a ‘one stop’ clinic and a complete package of care for patients (n = 10) Agree (n = 66) When I have a chance to prescribe it enhances and provides a better quality of care (n = 10) Saves the patient time (n = 9) Not chasing the GP for a prescription (n = 10) Gives me autonomy (n = 6) Allows seamless care (n = 6) It allows me to provide patients with appropriate treatment at point of contact (n = 7) Neither agree nor disagree (n = 7) It has had little impact on my professional role (HV) (n = 1) Little opportunity to prescribe (n = 3) What I prescribe can be brought over the counter (n = 1) Time saving (n = 1) Convenience to client (n = 1)
Figure 3 Replies to the statement: ÔNon-medical prescribing enhances my professional roleÕ.
Disagree I do not prescribe due to limited formulary Strongly disagree No comments for this box
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Table 5 Length of service in practice area Time (months) Under 12 13–24 25–36 37–48 49–60 More than 60
Per cent and number of respondents 4.4% 3.7% 9.3% 5.2% 7.0% 70.4%
(n (n (n (n (n (n
= = = = = =
12) 10) 25) 14) 19) 190)
Length of service in practice area (Table 5) It could be argued that confidence comes with experience, hence we asked the question, ÔHow long have you been practising in your specialist area?Õ For the majority of respondents, this had been for more than 5 years.
Continuing Professional Development (CPD) data There is currently a widely held belief that effective CPD can improve competence which in turn leads to increased job satisfaction and serves to enhance professionalization. Yet despite 70% of respondents being in practice for more than 5 years, only 29.3% of all respondents were studying for a further academic qualification (n = 79). Of those studying, 48% were engaged in studies related to their specialist areas and only 5% were studying prescribing or pharmacology. Within the 79 respondents who were studying: 40.5% were undertaking a Masters programme (n = 32); 30.4% were undertaking a BachelorÕs degree programme (n = 24); 25.3% were studying for post-graduate diplomas or certificates (n = 20); 3.8% were registered on a professional doctorate programme (n = 3). The data suggest, however, that respondents were engaging in wider CPD activities: 76% of respondents had attended a course or programme specific to the clinical speciality provided by their employer within the last 12 months. Forty-three per cent of respondents had attended courses provided by organizations other than their employers in the past 12 months. Some professional groups [i.e. community psychiatric nurses (17%), DNs (24%), HVs (36%)] were less likely to attend these events than those provided by their employers. Eighty-three per cent of respondents had attended mandatory study days provided by their employer in the past 12 months. Only 13% and 9% of respondents, respectively, attended conferences on non-medical prescribing organized by their employers (13%) or another organization (9%). 610
One day was the most likely duration of the conference organized by both organizations. Of the 270 respondents, only 57 completed the ection requesting information about attendance at national conferences. They provided a mixed response when questioned whether they were able to apply the information received to practice. The benefits of the conferences were stated as: consolidation of learning from previous courses studied, information on new skills, for example, electronic-generated prescriptions and sharing with colleagues. The following responses were obtained from specific questions about the SHA provision. Those who attended the in-house study day with pharmacists, exploring, for example, poly-pharmacy considered this worthwhile. Their responses included: ÔHelped me to use supplementary prescribingÕ, Ômost of the content had been covered within the supplementary prescribing courseÕ and ÔSHA conference on the law of prescribing was not clinicalÕ. The conferences that were subject-specific proved to be the most popular and beneficial by providing a practical focus. For example, the workshops on: eczema and skin updates, diabetes, hypertension, infections and antibiotics, legal issues relating to prescribing, prescribing update and interpreting statistics in order to understand pharmaceutical company data. Respondents were asked to rank their prescribing CPD needs in order of importance. Their needs varied, but the main subject areas that they believed warranted CPD were: patient/client assessment, non-medical prescribing information, support for experienced nonmedical prescribers and decision-making skills. The following areas were not as highly recommended: drug administration, physiology, psychopharmacology and biological sciences. Respondents were asked about their preferences for mode of delivery. The data indicated that they preferred face-to-face and practice-focused delivery of learning: training days, short courses, learning in-practice settings and lectures. They considered the following modes of delivery to be less favourable: self-directed learning, e-learning and distance learning. Of the 270 returned questionnaires, 79 respondents used the open-ended question section at the end of the questionnaire to provide further comments. Four main themes were identified:
Demands for CPD Fifty-one per cent of respondents commented on the importance of further support for non-medical prescribers through study days, conferences, e-learning
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and clinical supervision. Some respondents suggested that the study days/conferences should be mandatory and based locally in order to avoid too much travelling from the workplace. Some of the suggested topics for study days included: more physiology, physical assessment and pharmacology. There were also comments about giving sufficient notice of workshops, with some respondents highlighting the importance of needing to know months in advance of available study days.
Support for CPD in practice Ten per cent of respondents identified the importance of support in their practice settings, with a number indicating that they already received support from medical colleagues, peer groups and managers within their specialist areas. They also commented on the utility of regular contact suggesting that it could be developed even further.
Barriers to CPD Eight per cent of respondents had been made aware of update sessions that they could attend. However, the following were identified as reasons for not attending: a lack of staff cover, other work commitments, and a lack of support for attending from managers, insufficient time being allowed for study and pressure to satisfy mandatory updates.
Barriers to learning in practice Fourteen per cent of respondents requested more support in practice. The word ÔdisappointedÕ was used to reflect the lack of support in practice from colleagues, the health authority and particularly managers. Some respondents commented on the lack of a ÔcascadeÕ effect of information. A small percentage stated that support should take the form of financial incentives for taking on additional non-medical prescribing responsibilities.
ther had attended any of the SHA study days or updates for non-medical prescribers. The following points were raised by both interviewees: the importance of physical assessment skills, highlighting in particular diagnostic skills and being able to make an appropriate diagnosis to prescribe. One interviewee emphasized the importance of the student, once qualified being able to complete physical assessments otherwise their prescribing ability would be greatly limited. Working closely with the student was emphasized by both interviewees and was the importance of ongoing contact after qualifying. They also commented on the importance of national and local networks, the need to practise safely through the testing of competences in prescribing and the need for locally provided CPD to include testing understanding of the legal aspects of prescribing.
Programme leaders None of the programme leaders possessed qualifications in non-medical prescribing. All were aware of CPD study days run by the SHA. Indeed, one respondent had contributed by presenting a paper. All three programme leaders highlighted the higher education curriculum re-validation processes which were underway as an opportunity to address the following issues. First, the pharmacology input to the programme including, for example, the subject area of anti-depressants (this area of pharmacology is relevant to more practitioners than mental health nurses). Second, the coverage of specialist areas, for example, pharmacology. Finally, finding the right teachers and ensuring that the subject is covered adequately. They also stated that the programme was not a pharmacology course but a prescribing programme and argued the need to cover how prescribing works and patient concordance. They also discussed that keeping the curriculum up to date posed problems. They drew attention to the inclusion of other professionals, including radiographers and pharmacists, on the programme and the importance of linking with other faculties in the universities that would have different perspectives on prescribing, particularly pharmacists.
Findings retrieved from telephone interviews Medical assessors
Clinical managers
Both medical assessors were working with students undertaking the programme at the time of the interviews. Both received the relevant information packs relating to the students programme of study and reported that they found the information helpful. Nei-
The managers interviewed did not hold a non-medical prescribersÕ qualification or have any direct responsibilities for non-medical prescribing as facilitators or prescribing leads. They recognized the course demands on students. One manager talked about the need of
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applicants to Ôdo their home workÕ before starting the programme including discussing the programme demands with someone who had completed the programme or shadowing someone who prescribed. A question was posed by one of the managers in relation to mental health nurses – should ÔweÕ be encouraging staff to complete a psychopharmacology course prior to commencing the non-medical prescribing programme? Development of support networks for mental health non-medical prescribers was viewed as embryonic. ManagersÕ suggestions included first, continuation of support from the medical assessors for at least 6 months to be followed up with specific clinical supervision sessions focusing on prescribing. Second, defining roles and responsibilities – how would the non-medical prescribers work alongside other colleagues? What were the expectations of non-medical prescribers once they were qualified. Finally, they suggested setting up joint support groups for medical staff and non-medical prescribers with a senior doctor facilitating who has experience of being a medical assessor.
Prescribing leads Two out of the three interviewees held non-medical prescribing qualifications. One firmly believed that staff embarking on the programme should already be in a role so they could prescribe on successfully completing the programme. In relation to the programme the following comments were made: first, that the Objective Structure Examination (OSCE) should be included as an assessment tool on the non-medical prescribers programme because of the way it assesses prescribing skills (as this study was completed the OSCE has been re-introduced on to the curriculum). Second, it was thought by one prescribing lead that too much of the non-medical prescribersÕ programme content was linked with primary health care. It was suggested that more teaching time be given to the legal aspects of prescribing, decision-making and appropriate prescribing. Prescribing leads were aware that some practice nurses attend CPD in their own time including extended lunchtime periods. When asked to identify the CPD needs of non-medical prescribers, one interviewee stated that individual non-medical prescribers had a responsibility for their own CPD updates as they were experts in their own field of practice. Another suggested that non-medical prescribing conferences and study days provided by the SHA may not meet individual needs and may not cover specialist practice areas. When asked about the reasons given by non-medical prescribers for not attending CPD updates provided locally 612
and by the SHA, interviewees were aware of some staff having to attend in their own time as their managers may not allow CPD in work time and general practitioners may not recognize specific non-medical prescribersÕ CPD requirements. The following suggestions on how Acute and Primary Care Trusts and universities could best provide CPD were the development of local models of CPD – that addressed local issues but not necessarily provided by the universities, and for Trust staff to be asked what do you need/want? However, it was suggested that some staff and Trust managers may not be aware of what they want in relation to CPD.
Discussion The TNA made a number of recommendations directed towards stakeholders, which included nurse managers, responsible for strategic planning and financing of the CPD provision of non-medical prescribers. First, the nature and academic level of pharmacology within the curricula of pre-registration and post-registration nursing programmes should be reviewed. Universities could use validation and review events to examine the content and sequence of pharmacology, psychopharmacology and the related biological sciences through different programmes. This could ensure that each programme of study will ÔfitÕ into an enhanced pharmacology strand and so better equip nurses to understand the subject in relation to their practice. In England, all nurse prescribing modules are required to be revalidated to incorporate the NMC Standards for prescribing by September 2007. This should have provided an opportunity for essential pharmacology within the curriculum to be modified in line with the most recent Department of Health directives on non-medical prescribing. Second, good practice in the design and delivery of CPD recognizes the value of multi-professional activity delivered in a variety of modes in order to widen access to CPD opportunities. The delivery of CPD requires the support and guidance of senior pharmacists (practising and academic) working in the region to address key pharmacology, pharmacy, prescribing and medication management education as part of non-medical prescribers CPD needs. Formal arrangements such as study days and training updates need to be local to the work base and easily accessible during work time. More study days aimed at clinical specialist areas for experienced non-medical prescribers are required. Exploitation of local and informal non-medical prescribersÕ networking and support groups which feedback from the intervie-
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weesÕ suggestions has proved successful for local and specific CPD provision and should be encouraged. Third, the importance of physical and diagnostic assessment skills was an area highlighted by the interviewees across all the professional groupings and viewed as significant to non-medical prescribing practice. This is now incorporated into the NMC standards of proficiency for nurse and midwife prescribers. Consequently, it would be expedient to investigate the possibility of having pre-requisite qualifications of either a first degree or CPD equivalent for those wishing to become non-medical prescribers to ensure subsequent students have the appropriate background knowledge to understand and synthesize the course material and academic level successfully. There should also be more emphasis on diagnostic clinical skills as an element of the extended nurse prescribersÕ and supplementary prescribersÕ programme and as part of CPD, using the expertise of medical colleagues in physical and diagnostic assessment (NMC, 2006). Universities need to be more flexible with respect to CPD short courses offered to non-medical prescribers and more involved in the provision of clinical skills programmes. For example, nurse consultants, as a collaborative partnership, could ensure that the most appropriate and up-to-date assessment knowledge and skills required for nonmedical prescribing are provided. The involvement of medical, pharmacy, senior nurse and university colleagues should be sought to develop those areas where clinical specialties are new to medical and diagnostic skill development as part of non-medical prescribing, e.g. mental health and substance misuse. Conferences, study days and updates need to be clearly advertised well in advance and widely disseminated, offering clear information with aims and learning outcomes to help non-medical prescribers decide on whether these events are relevant to their area of practice. Finally, there is a need to develop quality assurance mechanisms to ensure the maintenance of standards and that CPD activities are Ôfit for purposeÕ. A clear evaluation framework and process should be put in place to provide data relating to all on-going CPD activity for non-medical prescribers, including the informal arrangements organized at trust level. Such an approach to evaluation will enable SHAs to make informed judgements and decisions regarding CPD needs and obtain a clear picture of what works. It should also enable the SHAs to be more responsive in providing a rolling CPD programme. The project also identified other areas for consideration, for example: The importance of clinical skills training linked to non-medical prescribing courses;
close contact with medical assessors after qualifying through support groups or individual networking; a clearly defined role which includes responsibilities for prescribing once qualified as a non-medical prescriber; clarity is needed regarding whether non-medical prescribers who are practising should have mandatory CPD in non-medical prescribing; examples of Ôbest practiceÕ from other health authorities where there are well-established non-medical prescribers, should be examined, and where appropriate, considered for implementation by health providers.
Conclusion The primary aim of CPD should be to improve health and health care delivery and meet service needs. Pharmacology and prescribing is a rapidly changing discipline that requires nurse managers to ensure that staff engaged in nurse prescribing receive regular CPD in order to keep up to date with the latest developments. Likewise, non-medical prescribing is a comparatively new innovation to the NHS, therefore those who are not medically qualified need mentorship from experienced prescribers, as well as the encouragement to be confident prescribers themselves. Our results challenge some existing research findings about the provision of CPD although we acknowledge that our research was not designed to examine aspects of situated learning. Our results suggest that nurse managers need to consider the following: first, that short courses (1-day or 2-day) that were specific to the non-medical prescribers role were generally considered to be the most popular and useful. However, courses needed to be advertised well in advance (at least 6 weeksÕ notice) in order that the non-medical prescribers were able to arrange workload and other commitments around their programme of choice. In addition, clarity by the education provider, for example, providing the learning outcomes on the advertising literature would be helpful for non-medical prescribers to enable them to make their choices. Second, the following training gaps were identified by the non-medical prescribers: eczema and skin updates, diabetes, hypertension, infections and antibiotics, legal issues relating to prescribing, prescribing updates, interpreting statistics in order to understand pharmaceutical company data, basic pharmacology updates and clinical skills training related to scope of practice for the respective non-medical prescribers. In order to enhance the quality of care provision and prescribing, the training gaps need to be addressed by nurse managers when making decisions about CPD provision.
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