Independent and Supplementary Prescribing

A single prescribing competency framework was published by the National Institute for Health and Clinical Excellence (NICE) in (2012) and was updated by the Royal Pharmaceutical Society (RPS) in (2016) to support all prescribers to prescribe effectively. The framework was developed to underpin a set of competencies for health care professionals regardless of their professional background (RPS, 2016).

The framework includes ten competencies in which are divided into two separate domains that concentrate on the consultation with a patient and the prescribing governance in which underpins safe and effective prescribing (NICE, 2016).

Within the evidence statement, the author’s role in non-medical prescribing as a Haematology Clinical Nurse Specialist (CNS) will be demonstrated by examining their professional responsibility for prescribing with evidence from the Royal Pharmaceutical Society (RPS) Framework competencies.

1. Assess the patient

When assessing a patient, it is imperative to gain an appropriate and accurate medical history, the Haematology CNS incorporates predefined diagnostic pathways specific to suspected haematology conditions, which includes a medication history such as allergies and intolerances, and social status (NICE, 2016).

While training to become a non-medical prescriber, the Haematology CNS has utilised the Pendleton’s Consultation Model (1984)  and incorporated it into practice to ensure that they undertake an appropriate clinical assessment which is patient-centred to establish a holistic and comprehensive assessment (Harper & Ajao, 2013).

A clinical assessment of a patient with myeloma requires the identification of symptoms, such as bone pain to enable the Haematology CNS to gain a diagnosis by using a comprehensive workup, this includes sending extensive blood tests to the laboratory and to order appropriate radiologic evaluation such as an MRI skeletal survey which will lead to better decisions concerning disease management (Mangan, 2005).

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The Haematology CNS has the adequate knowledge of myeloma’s clinical manifestations, diagnostic criteria and diagnostic tests and procedures to make an accurate diagnosis and to manage it appropriately (Tariman, 2009). Clinical features of symptomatic or active disease include bone pain, fatigue, weight loss, and common clinical features include anaemia, lytic bone lesions, renal insufficiency, hypercalcaemia and infection (Rajkumar & Kyle, 2005).

Furthermore, the Haematology CNS can reach a timely diagnosis which is critical to prevent serious complications from myeloma by identifying possibilities of myeloma disease relapse from specific alterations in blood test results and symptoms this then contributes to the early diagnosis (Tariman, 2009).

2. Consider the options

When looking at approaches to modify disease and promote health, the Haematology CNS can recognise the need for treatment to be divided in specific or supportive care by assessing the patient holistically by looking at all multi-factorial dimensions (Hoffbrand & Moss, 2012). The major treatment decision is between the use of intensive therapy such as chemotherapy and supportive treatments such as blood products (Hoffbrand & Moss, 2012).

The Haematology CNS can recognise when non-pharmacological approaches are required in patients with extensive disease burden to enhance quality of life, and understands the importance of holistic care needs, a referral to clinical psychology, complimentary therapies, support groups or relaxation exercises may be beneficial to individual patients (Olsen & Zitella, 2013).

Additionally, the Haematology CNS is able to recognise that pharmacological treatment options including optimising doses and stopping treatment are important in patients with myeloma, by assessing a patient’s co-morbidities, performance status, cognition, polypharmacy and inappropriate medicines. Along with assessing a patient’s social support, the Haematology CNS also has knowledge and skills in assessing chemotherapy toxicities in patients and is able to recognise when pharmacological involvement may be required to reverse these toxicities (Wildes, Rosko, & Tuchman, 2014).

For this reason, the Haematology CNS understands the mode of action and pharmacokinetics of medicines used in patients with myeloma and is aware of the careful selection of therapeutic agents such as velcade and steroids (Wildes et al., 2014). Dose and supportive care are imperative to ensure optimal outcomes are achieved, the Haematology CNS understands that attention is required to dosing and route of administration of medicines as this could make a sustainable difference in tolerance of therapy. Factors such cardiac, pulmonary, hepatic or renal dysfunction may warrant a consideration of dose modification (Palumbo et al., 2011).

In particular, the haematology CNS stays up to date in their own practice and applies the principles of evidence-based practice, including clinical and cost – effectiveness of drugs used in myeloma by collaborating with other members of the multidisciplinary team including pharmacists (Gray, 2017).

3. Reach a Shared Decision

Bond, Blenkinsopp and Raynor (2012) highlight that patients have an equal role in the consultation and decision-making about health management, in which, promotes patient empowerment, patient-centred and increases the acceptance that self-care and management can be both clinically and cost-effective approaches to care.

Whilst the Haematology CNS was studying to be a non-medical prescriber, they participated in consultations with patients regarding their management plan and understand that prescribing decision-making is a key skill and essential for patient safety and clinical aspects (McIntosh, Stewart, Forbes-McKay, McCraig, & Cunningham, 2016).

A patients understanding of prescribing specific medications is crucial and therefore the haematology CNS explains the rationale for commencing treatments and the potential risks including side-effects and benefits of management options. Medicines optimisation enables patients to get the best outcomes from their medicines and helps patients to be in partnership of their treatment (RPS, 2013).

4. Prescribe

Non-medical prescribing is thought to lead to improved patient care and patient satisfaction, along with improving patient choice and team working (Crawley, 2018).

The Haematology CNS has performed prescribing decisions under the direct supervision of their medical mentor, and when prescribing medicines, they comply in adherence of clinical guidelines and standards of care that include strategies for prescribing (The Mid Yorkshire Hospitals NHS Trust, 2016).

A balance between pharmacological and non-pharmacological treatment options is important as attention to cost effectiveness and patient safety. The Haematology CNS can meet these demands using evidence-based practices and rational prescribing through the development of prescribing competences, appropriate education and training which provides the essential foundation for practice (Brown & Kaplan, 2012).

5. Provide Information

For patients to make informed decisions about their care and treatment, good communication between the prescriber and the patient is vital. The Haematology CNS applies this by providing evidence-based written information tailored to each patient need ensures that patient receive the correct information about their medications including possible side-effects (NICE, 2009).

The Haematology CNS can recognise and establish the most effective way of communicating with patients by considering different ways of making information accessible and understandable. For example arranging an interpreter or large print of information may be necessary (Crawley, 2018).

According to Coulter (2018) healthcare professionals have reported that it can be extremely time consuming explaining treatment options, including benefits and side-effects. During studying to be a non-medical prescriber, the Haematology CNS has gained skills within consultations with patients to enable patients to gain a better understanding of their medicines, by using a collaborative process to make appropriate choices and reduce the need for unnecessary clinic visits.

6. Monitor and Review

Patients with haematology conditions receive close monitoring and follow-up appointments in clinic in relation to the anticipated response to the treatment and the disease by anticipating variations in condition such as immunosuppressive symptoms (Hoffbrand & Moss, 2012). The Haematology CNS is aware that it is their responsibility to ensure that prescribing decisions are monitored and that the patients are exposed to the least amount of risk (Nuttall & Rutt-Howard, 2011). 

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The Haematology CNS can acknowledge adverse drug reactions and side-effects and how to report these using the yellow card scheme available in the BNF or on the MHRA website and they understand that if undetected, could account for significant levels of morbidity or mortality in patients (Nuttall & Rutt-Howard, 2011). Therefore, this is an important part of the patients ongoing monitoring process that the patient’s allergy status and any adverse drug reactions are to be documented correctly in the patients notes (NICE, 2014).

On-going review of the patient’s knowledge, understanding and concerns about medicines and the patients view of their need for medicines are completed by the Haematology CNS at intervals agreed with the patient to establish patient concordance (NICE, 2009).

7. Prescribe Safely

During studying to be a non-medical prescriber the Haematology CNS understands that they are required to work within the boundaries of their own codes of conduct with the intention of providing high quality standards of care and safeguarding patients (NMC, 2006). Therefore, the Haematology CNS recognises the pharmacology of the medicines that they prescribe and the limits of their pharmacological competence within their practice (NMC, 2006).

According to Velo & Minuz (2009) prescribing errors are common in practice in the act of writing and prescribing faults due to inaccurate decisions which can result in harm to patients, within the Haematology CNS scope of practice error-reporting systems are in place to create an incident report, should an error occur.

Once a non-medical prescriber, the Haematology CNS will regularly discuss their prescribing decisions with other health care professionals involved in the patients care. This aims to reduce the possibility of errors and assist with multidisciplinary team working in order to promote patent safety, cost effectiveness and efficiency (The Mid Yorkshire Hospitals NHS Trust, 2016). The Haematology CNS will also keep up to date records of patient’s prescriptions and medicines management in patients notes to ensure that all healthcare professionals are aware of individual patient medicines management, thus to reduce duplication and minimise interactions of drugs (NICE, 2016).  

8. Prescribe Professionally

The NMC, Code of Conduct (2018) stipulates that it is the non-medical prescriber’s responsibility to remain up-to-date with knowledge and skills to enable to prescribe competently and safely and should never prescribe beyond their professional competence. The Haematology CNS understands the legal and ethical implications and can make prescribing decisions based on the needs of the patient and not their own personal considerations.

When studying to become a non-medical prescriber, the Haematology CNS can demonstrate their own accountability and autonomy by ensuring that their practice is evidence-based and that they respond to patients needs and include them in their own decision-making. Factors may unduly influence prescribing during consultations, diagnosis and complex decision making. Therefore, support and guidance from other prescribers is important for effective patient care management (Franklin, 2017).

9. Improve Prescribing Practice

Employers also have a duty to support the NMC standards for the CPD of non-medical prescribers (NMC, 2018). This is integrated into the non-medical prescribing policy, in which the employer has put into place on behalf of the health-care organisation (The Mid Yorkshire Hospitals NHS Trust, 2016). Similarly, processes need to be in place to ensure that the non-medical prescriber can remain competent within the role and the employer has the duty to develop and uphold these appropriately (Waite & Keenan, 2010).

The Department of Health (2006) stipulate that non-medical prescribers should use clinical supervision as an opportunity for reflection of prescribing, along with raising any issues or concerns that should be reported to the Medicine’s Management Committee.

In order to improve prescribing practice, the Haematology CNS will participate regularly in medical optimisation peer review and discussions with other medical and non-medical prescribers. This will identify relevant changes to practice with evidence-based guidelines to ensure evidence-based, safe, and cost-effective prescribing, thus improving clinical outcomes for patients (NICE, 2016).

10. Prescribe as part of a team

The Haematology CNS regularly participates within formal multidisciplinary team meetings (MDT) once a week. These meetings are attended by members involved in the diagnosis, treatment and care of individual patients such as Haematology Consultants, Medical Oncologist and Hematopathologist’s (NICE, 2016).

A multidisciplinary approach enables an effective way of promoting collaboration between healthcare professionals and facilitates best practice whilst providing a holistic and patient centred approach (NHS England, 2015). The Haematology CNS assists in improving patient experience and safety by co-ordinating the management of patient’s treatments.

Furthermore, the Haematology CNS works in close partnership with their medical mentor and negotiates the appropriate level of support and supervision for the role as a prescriber (The Mid Yorkshire Hospitals NHS Trust, 2016).

This evidence statement has demonstrated that the Haematology CNS has achieved the RPS competencies which has enabled the development to continually improved performance and has enabled the Haematology CNS to work effectively through learning to become a non-medical prescriber. The Haematology CNS has also shown that whilst developing and maintaining prescribing competences they will use evidenced based practice when prescribing to improve patient’s quality of life and support patients with medicines optimisation.

References

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• Wildes, T., Rosko, A., & Tuchman, S. (2014). Multiple Myeloma in the Older Adult: Better Prospects, More Challenges. Journal of Clinical Oncology , 32 (24), 2531-2540. doi: 10.1200/JCO.2014.55.1028.