The prescription and administration of medicines provides a substantial opportunity to help people make the most of their treatment through teaching the patient about how to use their treatment most effectively. Nurses have an established role in drug administration, ensuring that suitable medication is delivered at the right dose, time and by the appropriate route. Therefore, whether through drug administration or prescription, health professionals have substantial opportunities to ensure suitable treatment selection taking into account patient needs and preferences and taking of medicines to improve treatment adherence and effectiveness. Treatment adherence and successful medicine management are dependent on effective education and support, which if planned and delivered effectively nurse prescribers are well placed to provide. Consideration is needed of the value of investing sufficient time to explain effectively intricate treatment regimens to the patient, and in doing so, take account of their lifestyle so that the guidance is adapted to the individual and their level of knowledge. This is likely to improve the effective use of medicines and their efficacy and reduce the time required to deal with the consequences of poor adherence. Nurse prescribing consultations should prioritise these opportunities for education and support, since invariably their
focus is not on diagnosis.
The prescribing of treatments within dermatology is no longer confined to medical practitioners in some countries, such as the UK, but now by others such as suitably trained nurses, pharmacists and podiatrists. Membership of the Nurse Prescribing sub-group of the British Dermatological Nursing Group continues to increase rapidly.
The mechanisms available for the prescribing supply and administration of medicines is summarised in Box 7.1 (Department of Health, 2006).
| | | | | | Box 7.1 Mechanisms available for the prescribing supply and administration of medicines - Patient-specific directions
- Patient group directions
- Specific exemptions covering supply or administration – as contained in medicines legislation
- Nurse-independent prescribing
- Pharmacist-independent prescribing
- Supplementary prescribing by nurses, pharmacists, optometrists, Physiotherapists, radiographers and chiropodists/podiatrists
| | | | Source: Department of Health (2006). Reproduced under the terms of the Click-Use licence. | |
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These different mechanisms will now be briefly outlined. Note these are only relevant for countries within the UK.
Patient-specific directions A patient-specific direction (PSD) is the traditional written instruction, from a doctor, dentist, nurse or pharmacist-independent prescriber, for medicines to be supplied or administered to a named patient (Department of Health, 2006). The majority of medicines are still supplied or administered using this process. In primary care, this might be a simple instruction in the patient’s notes. Examples in secondary care include instructions on a patient’s ward drug chart. As a PSD is individually tailored to the needs of a single patient, it should be used in preference to a patient group direction (PGD), wherever appropriate.
Patient group directions A PGD is a written instruction for the supply or administration of a licensed medicine (or medicines) in an identified clinical situation, where the patient may not be individually identified before presenting for treatment. Patients may or may not be identified, depending on the circumstances (DH, 2006). A PGD is drawn up locally by doctors, pharmacists and other health professionals and must meet certain legal criteria. Each PGD must be signed by a doctor or dentist, as appropriate, and a pharmacist and approved by the organisation in which it is to be used, typically a PCT or NHS Trust. PGDs can only be used by specified registered health care professionals, acting as named individuals, including nurses, health visitors, paramedics and podiatrists. Each PGD has a list of individuals named as competent to supply/administer under the direction.
Independent prescribing The development of independent prescribing is part of a drive to make better use of nurses’ and pharmacists’ skills and to make it easier for patients to get access to the medicines that they need. From 1 May 2006, ‘Nurse Independent Prescribing’ (formerly ‘Extended Formulary Nurse Prescribing’) was expanded. This allows nurses to prescribe any licensed medicine for any medical condition that a nurse prescriber is competent to treat, including some controlled drugs. It allows virtually any licensed medicine in the British National Formulary (see part XVIIB(ii) of the Drug Tariff) to be prescribed (Department of Health, 2006). Pharmacist-independent prescribing now permits suitably prepared pharmacists to prescribe any licensed medicine for any medical condition that they are competent to treat. In the UK, all first-level registered nurses, registered midwives, registered specialist community public health nurses and registered pharmacists may train to be independent prescribers. Further information on nurse-independent prescribing can be found on the Department of Health (Department of Health, 2008) website, which should be checked regularly for updates.
Supplementary prescribing Supplementary prescribing was introduced in April 2003 for nurses and pharmacists. It was extended to physiotherapists, chiropodists/ podiatrists, radiographers and optometrists in May 2005. Supplementary prescribing is a voluntary prescribing partnership between the independent prescriber (doctor or dentist) and supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP), with the patient’s agreement (Department of Health, 2006). Following agreement of the CMP, the supplementary prescriber may prescribe any medicine for the patient that is referred to in the plan, until the next review by the independent prescriber. There is no formulary for supplementary prescribing and no restrictions on the medical conditions that can be managed under these arrangements. It will also be appropriate in specific situations, for instance, when working within a team where a doctor is accessible or for specific long-term conditions, between medical reviews (Department of Health, 2006).
Supplementary prescribers can prescribe controlled drugs and unlicensed medicines in partnership with a doctor, where the doctor agrees within a patient’s CMP. From July 2006, chiropodists/podiatrists physiotherapists, radiographers and optometrists are also able to prescribe controlled drugs as supplementary prescribers, but only where there is a patient need and the doctor has agreed in a patient’s CMP.
The training for supplementary prescribing is incorporated into nurse and pharmacistindependent prescribing. All professional groups must register their supplementary prescribing qualification with their regulatory body before beginning to prescribe. Further information can be found on the Department of Health (2003, 2008, 2009) website. See Table 7.4 for more sources of information on non-medical prescribing.
| | | | | | Table 7.4 Sources of information on non-medical prescribing. | | 1. | Department of Health (DH) website: The DH website is regularly updated and has comprehensive information on all aspects of prescribing. A section on ‘Non-Medical Prescribing guidance’ can be found in the ‘Policy and guidance A–Z’. This includes ‘Improving Access to Medicines – the DH guide to implementation of nurse- and pharmacists-independent prescribing’ April 2006. www.dh.gov.uk/nonmedicalprescribing | | | 2. | Clinical Knowledge Summaries (CKS): CKS guidance on common conditions and symptoms managed in primary care is available in a variety of formats. Full guidance provides concise information to support decision-making in the consultation and more detailed background information for use as a learning resource. CKS Patient Information Leaflets (PILs) provide guidance for people who are not health care professionals and give an overview of the condition, side-effects, advice on self-management, information on treatment options and sources of further help. CKS Drugs – lists the drugs recommended and links them to the condition and situation in which they are recommended www.cks.nhs.uk | | | 3. | Medicines and Health care products Regulatory Agency (MHRA): The MHRA website contains information about the legal framework governing the prescribing, supply and administration of medicines (www.mhra.gov.uk). | | | 4. | Other useful websites - British National Formulary (BNF): https://bnf.org/bnf/
- Examples of patient group directions (PGDs): www.portal.nelm.nhs.uk
- Medicines Partnership Programme: www .medicines-partnership.org
- National Electronic Library for Health: www .nelh.nhs.uk
- NHS Drug Tariff for England and Wales: https:// www.ppa.org.uk/ppa/edt_intro.htm
- NHS National Practitioner Programme: www .wise.nhs.uk
- National Prescribing Centre: www.npc.co.uk
- Nursing and Midwifery Council: www. nmc-uk.org
- Prescribing news: www.nurse-prescriber.co.uk
- Royal Pharmaceutical Society of Great Britain: www.rpsgb.org
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