Non-medical Prescribing Research Articles

What's in a name? The complex conundrum of prescribing nomenclature in practice

Health professionals who can legally prescribe medication and medical devices, but who are not doctors or dentists, come from a wide range of backgrounds, including the Nursing and Midwifery Council, General Pharmaceutical Council, and some Health and Care Professions Council registrants. The professionals are often grouped together and defined as ‘non-medical prescribers’. This may or may not be a useful collective term as, depending on professional registration, these professionals may be afforded differing prescribing rights, which may include a combination of independent/supplementary prescribing, independent prescribing (only), supplementary prescribing (only), or community nurse practitioner prescribing activity. This article explores the confusing nomenclature around prescribing, and the impact the names and terms used in practice have on professions. The naming and identification of role should be facilitative, to allow others to understand the legal context of prescribing activity, boundaries, and role expectations.

Anticoagulants in atrial fibrillation

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Influences on paramedic prescribing: student and prescriber perspectives.

Paramedic prescribing has been permitted in legislation from 2018. In 2019 one of the first cohorts of paramedic prescribers in the country was invited to share their experiences, thoughts and perceptions around the new and evolving role of paramedic prescribing practice. To explore the opinions of student and newly qualified paramedic prescribers regarding the impact and effectiveness of paramedic independent prescribing on their clinical practice. A qualitative study was undertaken within the North East of England with a group of experienced paramedics undertaking non-medical prescribing education. A focus group and dyad interview were undertaken with a purposive sample of paramedics recruited from a higher education institution providing V300 independent and supplementary prescribing education. The focus group was undertaken with paramedics on the non-medical prescribing (NMP) programme of study. The dyad interview was undertaken with participants once qualified as prescribers, and actively prescribing. The focus group and interview were audio recorded, transcribed verbatim and subjected to thematic analysis to identify key themes. A total of n = 7 and n = 2 paramedics undertook the focus group and dyad interview, respectively. Paramedics in this sample represented a range of paramedic practice areas. Paramedic NMP students noted four key themes around role, expectations, governance and opportunities and challenges in relation to prescribing practice. The returning sample of paramedics, now practising as prescribers, noted themes of organisational and infrastructure challenges, monitoring of prescribing practice and the evolution of paramedic roles. Paramedic prescribing is rapidly expanding and evolving into new clinical areas. As such, careful consideration should be given to not only the resourcing of prescribers as individuals, but also the wider organisational and technological support and structures needed to be in place to allow paramedic prescribers to fulfil their roles and utilise their advanced practice skills.

Rheumatology and prescribing

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Streptococcal infections (Strep A) in primary care settings

In December 2022, there was a reported increase in the number of infections in the UK, resulting in deaths of young children, occurring as a result of invasive Strep A infections. Margaret Perry explains how these infections can be managed in a general practice setting. Group A streptococcal infections (GAS) are reported to be common and are often carried on the skin or in the throat and are harmless. However, in some cases they cause infection which may be mild, or in some cases the problem becomes invasive (iGAS) resulting in a more serious infection requiring hospital admission and treatment. This article will give an overview of the commonest infections arising as a result of GAS and will look at signs and symptoms, treatment, and complications, with the aim of increasing confidence among practice nurses and non-medical prescribers in the recognition and management of these conditions.

Opioids and prescribing

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Overview of factors influencing successful implementation of non‐medical prescribing

AbstractAimThis study sought to determine the factors influencing successful implementation of non‐medical prescribing (NMP).Data sourcesEMBASE, Medline, CINAHL and reference lists were searched from January 2010 to November 2020.Study SelectionUmbrella review and narrative synthesis of results were utilised. The retrieved reviews underwent title screening, abstract review, full‐text screening and assessment for inclusion. To guarantee the precision of the search results, Participants, Intervention, Control, and Outcomes (PICO) elements were recorded for each study. Studies were included if they were systematic reviews, published in English, published from January 2010 to November 2020, and discussed barriers and/or facilitators to NMP implementation.ResultsOf the 193 studies identified, eight were eligible for inclusion. Most of the reviews (62%) were published in 2017–2018. The majority of the reviews (62%) were focused on the United Kingdom. Three reviews discussed nurse prescribing, two reviews focused on pharmacist prescribing, and three reviews investigated NMP generally. Data were compiled into the Consolidated Framework for Implementation Research to evaluate the factors that influence the success or failure of NMP implementation.ConclusionImplementation of NMP is a complex process which requires fulfilment of all its elements. The success of NMP can be directly related to the extent of the whole system engagement and support, and available funding.

Statin prescribing practice

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Antimicrobial stewardship: Prescribing across the primary care health professions.

We examined the patterns of antibiotic prescribing by medical and non-medical prescribers (dentists, nurse practitioners, and midwives) in Australia. We explored trends in the dispensed use of antibiotics (scripts and defined daily dose [DDD] per 1000 population/day) by Australian prescribers over the 12-year period, 2005-2016. We obtained data on dispensed prescriptions of antibiotics from registered health professionals subsidized on the Pharmaceutical Benefits Scheme (PBS). There were 216.2 million medical and 7.1 million non-medical dispensed prescriptions for antibiotics over 12 years. The top four antibiotics for medical prescribers were doxycycline; amoxicillin, amoxicillin plus clavulanic acid, and cefalexin, constituting 80% of top 10 use in 2005 and 2016; the top three for non-medical were amoxicillin, amoxicillin plus clavulanic acid and metronidazole (84% of top 10 use in 2016). The proportional increase in antibiotic use was higher for non-medical than medical prescribers. While medical prescribers preferentially prescribed broad-spectrum and non-medical prescribers moderate-spectrum antibiotics, there was a large increase in the use of broad-spectrum antibiotics over time by all prescribers. One in four medical prescriptions were repeats. Overprescribing of broad-spectrum antibiotics conflicts with national antimicrobial stewardship initiatives and guidelines. The proportional higher increase in antibiotic use by non-medical prescribers is a concern. To reduce inappropriate use of antibiotics and antimicrobial resistance, educational strategies targeted at all medical and non-medical prescribers are needed to align prescribing with current best practice within the scope of practice of respective prescribers.

P368 Antibiotic prescribing practice of the cystic fibrosis (CF) nursing team at a large tertiary paediatric centre

Non-medical prescribing is now an established role within the CF multidisciplinary team. It is important to monitor prescribing practice and identify changing trends in line with antibiotic stewardship principles, in addition to evaluating service provision.

Nurse practitioner and midwife antibiotic prescribing in Australia.

Antimicrobial resistance is of global significance. To reduce the risk of harm associated with antibiotic prescribing in Australia, a recent strategy to tackle antimicrobial resistance has included non-medical prescribers. Traditionally, antibiotic prescribing has been the domain of the medical profession but, more recently, nurse practitioners and endorsed midwives have been authorized to prescribe antibiotics. This study describes the antibiotic prescribing practices by nurse practitioners and endorsed midwives in Australia, with clinical implications for international settings. This was a retrospective analysis of routinely collected aggregated data of anonymous individuals. Data on dispensed prescriptions of antibiotics were obtained from the Australian Department of Human Services, for the period 2005-2016. All antibiotics were allocated to a spectrum class (narrow, moderate, broad). Analysis using descriptive statistics was undertaken to determine the antibiotic prescribing patterns of nurse practitioners and endorsed midwives. Nurse practitioners have been prescribing within Australia since 2000, and midwives since 2012. Nurse practitioner antibiotic written scripts increased from 3143 during 2005-2011 to 34615 in 2012-2016, while antibiotic written scripts by midwives increased from 2012 (n=2) to 2016 (n=469). Nurse practitioners and midwives prescribed similar classes of antibiotics. These professionals are important non-medical prescribers and are increasingly writing antibiotic prescriptions.Both nursing and midwifery cohorts complete accredited education programs, albeit with some differences in structure. When prescribing antibiotics, nurse practitioners and midwives are following evidenced-based therapeutic guidelines. They are increasingly relevant clinicians prescribing antibiotics, particularly in acute and primary care settings, which has relevance in global antimicrobial strategies.

Examining sustainable practice in prescribing

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Costs, consequences and value for money in non-medical prescribing: a scoping review

ObjectivesNon-medical prescribing (NMP) is a key feature of the UK healthcare system that refers to the legal prescribing rights granted to nurses, pharmacists and other non-medical healthcare professionals who have...

P054 Utilising a pharmacist-designed best value biologic and targeted synthetic shared decision-making tool to empower patients, support clinicians and save NHS resources

Abstract Background/Aims The dynamic pipeline and complex pricing of b/tsDMARD therapies make it challenging for clinicians to compare cost of treatments when undertaking shared decision making with patients in the clinic setting. NHSE have funded development of a Rheumatology Pharmacist designed, web based, best value biologic and targeted synthetic shared decision-making tool (BVBTS-SDMT) using live pricing from the Commercial Medicines Unit. A clinical workbook and treatment pathways have been developed to support the tool. Clinical parameters are entered into the tool, creating a list of available therapies in order of increasing cost relative to the patient’s weight and indication. Treatment pathways are consulted and clinical parameters (e.g. disease phenotype, co-morbidities, response to previous treatment) and patient preferences (e.g. route and frequency of administration, frequency of drug monitoring, personal beliefs) are discussed with the patient and documented in the clinical workbook. Inappropriate therapies are eliminated, identifying the most cost-effective treatment option for the patient synchronously during the consultation. This study explores the potential patient, clinician and cost benefits of adopting the tool in practice. Methods A random sample of 51 patients referred to the rheumatology non-medical prescribing team for starting b/tsDMARDs between 2019 and 2022 were recruited. Electronic records including referral email, patient notes and b/tsDMARD database were evaluated and recorded factors influencing shared decision making were analysed. Two rheumatology specialist pharmacists independently reviewed the historical clinical decision making to determine if the most cost-effective treatment option was chosen once all clinical factors and patient parameters were considered, using a record of historic treatment prices from retrospective homecare invoices and commissioning reports. Differentials between most cost-effective treatment and chosen treatment were calculated. Secondary outcome of comprehensiveness of clinical record was also analysed. Results Between 2019-2022, use of the BVBTS-SDMT would have saved an average of £1,695 per patient in the n = 51 sample. For the 210, 173 and 258 patients newly started on b/tsDMARDs in the years 2019-2020, 2020-21 and 2021-22 respectively, a total of £1,086,495 would have been saved if the tool had been in use. Clinical parameters, patient preferences and cost consideration affecting shared decision making were documented in 49%, 12% and 0% (respectively) of the 51 recruited patients’ clinical records. Conclusion This baseline data collection demonstrates use of the BVBTS-SDMT, in collaboration with treatment pathways and a clinical workbook, has potential to facilitate robust, consistent and methodological shared decision making with patients, encourage accurate reporting in patient records and save NHS money. This is a transformative approach to shared decision making; deviating from the traditional method of giving patients a couple of options to consider and instead working collaboratively through a shared decision-making process to find the most appropriate and cost-effective treatment option for the patient. Disclosure N. Mathews: None. C. McKenzie: None. E. Rose-Parfitt: None.

Urinary tract infection in an older patient: a case study and review

This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study. Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

Examining prescribing in children and adolescents

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Non-medical prescribing for clinical nurse endoscopists: advantages and overcoming barriers

A clinical nurse endoscopist team share their experience of becoming non-medical prescribers and explore the benefits it has brought to their service

Characteristics of prescribing activity within primary care in Scotland 2013-2022 of general practitioners, nurse, pharmacist and allied health prescribers: A retrospective cross-sectional study.

Independent prescribing by nurses, pharmacists and allied health professionals is diversifying into a variety of healthcare settings as pressures mount on existing resources. Primary care was an early adopter of prescribing by non-medical professionals with resulting improvements in accessibility and flexibility of services but also noted barriers. Exploring existing prescribing activity within primary care can support future initiatives that are cognisant of the needs of this specific population and targeted in the use of finite resources. To explore the characteristics of prescribing activity of common drugs dispensed by community pharmacies in Scotland by prescribing groups of general practitioners, nurses, pharmacist and allied health professionals. Specifically, to compare overall drug prescribing frequency by prescriber group and identify emergent prescribing patterns of individual drugs. A cross-sectional study. The data from Public Health Scotland on frequency of the ten most common drugs prescribed and dispensed from community pharmacies between 2013 and 2022 by prescriber group were examined, applying descriptive statistics using secondary data analysis. Prescribing activity in non-medical prescribing groups accounted for 2%-3% of overall prescribing activity in primary care. There is a growing interprofessional approach to prescribing in chronic disease. Proton pump inhibitors were the most commonly prescribed medication overall with a 4-fold increase in nurse prescribing. The decline in prescribing frequency caused by COVID 19 restrictions has since returned to pre-pandemic levels. There is a growing contribution of nurse independent prescriber activity within primary care although still a relatively small proportion compared to medical practitioners. The pattern of increased prescribing of medications for long term and chronic conditions such as proton pump inhibitors by all prescribers is suggestive of multi-disciplinary professionals supporting increased patient demand. This study provides a baseline to evaluate current service provision in further research and enable professional, service and policy development.

Prescribing during pregnancy

Deborah Robertson provides an overview of recently published articles that may be of interest to non-medical prescribers. Should you wish to look at any of the papers in more detail, a full reference is provided

Protocol for a pilot randomised controlled trial to evaluate integrated support from pharmacist independent prescriber and third sector worker for people experiencing homelessness: the PHOENIx community pharmacy study

BackgroundPeople experiencing homelessness (PEH) have complex health and social care needs and most die in their early 40 s. PEH frequently use community pharmacies; however, evaluation of the delivery of structured, integrated, holistic health and social care intervention has not been previously undertaken in community pharmacies for PEH. PHOENIx (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) has been delivered and tested in Glasgow, Scotland, by NHS pharmacist independent prescribers and third sector homelessness support workers offering health and social care intervention in low threshold homeless drop-in venues, emergency accommodation and emergency departments, to PEH. Building on this work, this study aims to test recruitment, retention, intervention adherence and fidelity of community pharmacy-based PHOENIx intervention.MethodsRandomised, multi-centre, open, parallel-group external pilot trial. A total of 100 PEH aged 18 years and over will be recruited from community pharmacies in Glasgow and Birmingham. PHOENIx intervention includes structured assessment in the community pharmacy of health, housing, benefits and activities, in addition to usual care, through weekly visits lasting up to six months. A primary outcome is whether to proceed to a definitive trial based on pre-specified progression criteria. Secondary outcomes include drug/alcohol treatment uptake and treatment retention; overdose rates; mortality and time to death; prison/criminal justice encounters; healthcare utilisation; housing tenure; patient-reported measures and intervention acceptability. Analysis will include descriptive statistics of recruitment and retention rates. Process evaluation will be conducted using Normalisation Process Theory. Health, social care and personal resource use data will be identified, measured and valued.DiscussionIf the findings of this pilot study suggest progression to a definitive trial, and if the definitive trial offers positive outcomes, it is intended that PHOENIx will be a publicly funded free-to-access service in community pharmacy for PEH. The study results will be shared with wider stakeholders and patients in addition to dissemination through medical journals and scientific conferences.Trial registrationInternational Clinical Trial Registration ISRCTN88146807.Approved protocol version 2.0 dated July 19, 2022.