This article discusses changes that can enhance student learning within a non-medical prescribing (NMP) module for community prescribers, and facilitate wider competence and confidence among prescribers within community teams. The transition from the widely used Nursing and Midwifery Council (NMC) standards for prescribing to a single competency framework by the Royal Pharmaceutical Society (RPS) has encouraged academics to revisit teaching strategies and consider an approach that offers wider student participation in learning. The use of technology-enhanced learning (TEL) in higher education institutions (HEIs) is part of national recommendations to improve the student experience and competence.
Background
Nurse prescribing is an area of professional development that has been a priority for specialist practitioners since it was introduced in the Crown report (Department of Health (DH), 1999). Nurse prescribing within community settings is seen to shape the quality and continuity of care that can be provided in a place and a time that is best for the patient (Willis, 2015).
Nurse prescribing is part of holistic care and has been recognised as a measure to reduce GP and hospital attendance rates, helping to make care cost effective (Kroezen et al, 2014).
Nurse prescribing programmes are provided by approved HEIs with NMC accreditation. In January 2019, a new framework for such programmes was introduced. Instead of the NMC nurse prescribing standards (NMC, 2019a) the council has adopted those of the Royal Pharmaceutical Society (RPS) (2016). The RPS recommends that the new framework should be conceptualised to reflect the various areas of practice and levels of expertise within which prescribers practice.
Developing non-medical prescribing modules
There are two NMP modules for community nurse prescribers:
The two modules are typically delivered in conjunction with each other. There is a three-part assessment process for students to demonstrate their learning and provide evidence of their proficiency in working to the NMP standards.
Traditionally, these modules have used instructionist methods of teaching, with formal lectures delivering knowledge. Students are expected to internalise this information and synthesise it with prescribing skills from practice, using problem-based learning techniques with their practice supervisors to support their prescribing development.
In the author's institution many students did not meet the required NMC standards on their first attempt at a summative assessment, with a significant proportion requiring a second attempt. Student evaluation and feedback processes revealed that students found that this approach to teaching restricts learning when used alone. The RPS framework allows for curriculum development of nurse prescribing programmes and facilitates flexible approaches to teaching that can engage students through blended learning approaches. Blended learning is the formation of teaching strategies that incorporate a range of approaches—such as use of formal lectures and seminars with e-learning and multimedia or TEL systems—into a programme, aimed at providing a comprehensive yet varied approach to teaching and learning (Porter et al, 2014; Cober et al, 2015).
Incorporating blended learning
In recent years, academic researchers have reported that blended-learning approaches increase student satisfaction and achievement and facilitate effective learning pathways (Yang, 2012; Porter et al, 2014; Ho and Kember, 2018). Blended learning also has a recognised positive effect on institutional resources by reducing teaching costs. Professional bodies for higher education stress the importance of blended learning (Health Education Academy, 2019). It can maximise the use of TEL within the modules provided within universities, engaging with an ever-increasing, technologically enabled and diverse student population (Gordon, 2014). Regulators for higher education, the Office for Students, (2019) concluded that effective use of TEL is vital for institutions within the UK to continue providing world-class education. A study by Porter et al (2014) commented on the rapid growth of TEL in higher education, highlighting that blended learning is now considered as the accepted ‘norm’ in curriculum design.
TEL allows students to learn at their own pace using learning methods best suited to individual needs (Scamell and Hanley, 2018). TEL is designed to provide opportunities for feedback, which helps students to reflect on their learning. Reflection is an essential skill that stimulates deep lifelong learning. Professional bodies, such as the NMC, require nursing graduates to be skilled problem solvers who are able to reflect, challenge thinking and take their learning forward into practice. Engaging with TEL can stimulate self-direction in students and prepare them for lifelong learning (Gourlay, 2015).
Researchers have acknowledged that the inclusion of TEL can present challenges to some students (Yang, 2012; McKenney et al, 2015). Although we have moved into an increasingly digital world, not all post-registration students are technically skilled (Petty, 2013). Many post-registration students on NMP modules are mature students who have not grown up with or been trained in using digital technology (Parson et al, 2018). They will require support from teaching staff and student services to ensure that they are able to access TEL resources and gain expertise in the learning tools to support their education.
Literature review
Kroezen et al (2014) reported findings from a Dutch study of nurse prescribers. Of 644 RNs who had gained a NMP qualification, only 12% thought that they had the necessary skills to prescribe. Many said that the training was insufficient to give them confidence in their prescribing decisions. This was a longitudinal study conducted over a 4-year period, with the aim of identifying factors that were preventing qualified NMPs from prescribing in practice. The study found that nurses did not have sufficient confidence in their knowledge of NMP to prescribe in clinical settings. The study recommended that NMP education needed to offer combined approaches that would encourage decision-making and instil confidence in nurse prescribers.
A UK-based survey across 23 primary care trusts (Hall et al, 2006) found that the experiences of UK nurses were similar to those in the Netherlands study. Some 16% of qualified nurse prescribers who responded had not continued using this skill in practice. Having confidence in skill acquisition was given as the main influence on the decisions that they took in practice. Learning to prescribe was cited as being one of the most challenging aspects of nurse development. It involves complex decision-making and poses risks to patients should inefficient practices occur (Smith et al, 2014).
The UK is recognised as one of the pioneers of nurse prescribing, with the most extended nurse prescribing rights in the world (Courtenay, 2018). Education must offer innovative approaches to respond to the concerns of those nurse prescribers who fail to prescribe in practice. TEL could be part of this development and elicit skills to promote critical thinking with independent decision-making (McKenney et al, 2015), enabling nurses to feel confident and capable of making safe prescribing decisions and meeting the whole patient episode of care that the NHS strives towards (Willis, 2015).
A study by Lymn and Mostyn (2010) used TEL approaches in the classroom to assist nurses undertaking an NMP course in their understanding of pharmacology. The approach, which used audience response technology through question-and-answer interactive sessions, was evaluated by the students as promoting learning in a safe environment. The tool prompted students to consider answers and personally respond without fear of embarrassment or ridicule. Participants' feedback revealed satisfaction levels of 100%, with achievement of learning goals reported at 92%. This type of TEL provides instant feedback and guides the learner to reflect on their knowledge, assess their learning needs and seek out further knowledge, ensuring that the key concepts of pharmacology for NMP are understood.
Pharmacology knowledge has been reported as one of the areas that NMP students have expressed as limiting their confidence in prescribing (Bradley et al, 2007; McIntosh et al, 2016). Without in-depth understanding of these concepts, learning and safe prescribing cannot develop. Transformative learning (where a significant change in the learner's ability and perspective occurs around the subject matter) can help students gain confidence in the ability to develop knowledge formation skills that will influence practice (Lymn and Mostyn, 2010; Nemec, 2012; Cober et al, 2015).
The NMP course must provide pedagogical approaches that enable students to assimilate knowledge and integrate it in their clinical practice. It is essential that NMP students feel confident and competent to prescribe throughout their careers. Education needs to produce confident, knowledgeable practitioners who are leaders in health care (Bradley et al, 2007; DH, 2010). Designing the NMP module to include TEL requires efficacy in planning and structuring. Modules that embrace TEL have context at the base of the curriculum rather than the traditional content (Costa and Harris, 2017) In other words, emphasis is given to how nurses learn rather than just what they learn.
Curriculum redesign
In curriculum development, it is essential to consider what aspects of the programme would benefit most from TEL provision. Pickering (2016) suggested that teaching staff need to consider what works well and make amendments to areas that work less well, such as when students appear disengaged, lose focus or report discontent. In NMP, the pharmacology component is the vital element that students need to assimilate for knowledge progression and understanding of prescribing's multiple complexities.
There is an abundance of research (Bloomfield et al, 2013; Lotz-Sisitka et al, 2015) to guide andragogy within higher education. Learning is considered to occur within a social context rather than merely through the transmission of information that lectures provide. If a tutor takes a sociocultural approach to learning, he or she will be an active guide to the gaining of knowledge (Harland, 2003). NMP students will be postgraduates, and are therefore considered to have developed skills that support their ability to assimilate and absorb knowledge. Teaching resources need to provide methodologies that promote students' ability to assimilate this learning and apply it in practice (Ho and Kember, 2018).
Flipped classroom learning
The methodologies used to teach NMP modules could be designed to offer a blended approach, which could allow students to use TEL as a means of developing knowledge around many of the complex topics, such as pharmacology. A ‘flipped classroom’ learning approach allows students to use TEL for self-directed study at their own pace. This would form a base of theoretical understanding that could equip them in subsequent classroom-based activities centred on the topic. This flipped approach to learning would provide structure and help prepare students to take control of their learning, to consider the strengths and limitations they have identified and enable them to engage actively in the learning process (Voogt et al, 2011; Choi et al, 2014).
However, changing the pharmacology part of the module to TEL could undermine learning. Without the oral feedback and explanations provided in lectures and seminars, it would be difficult for a lecturer to track student understanding and identify individual learning needs (Lymn and Mostyn, 2010). Lecturer and student interaction facilitates support for students who may need help interpreting content and require scaffolding strategies to help them learn. Some post-registration students will have been out of formal education settings for a considerable time and may require sessions to underpin their knowledge, as well as the help of university support services (Lotz-Sisitka et al, 2015).
Relying on large-scale lectures on pharmacology alone will also restrict teachers' awareness of individual learners' needs (Rissmann et al, 2012). A wealth of information needs to be transmitted from lecturer to student within this subject area, and a lecture set-up would only minimise student participation in the session (Rissmann et al, 2012; Cober et al, 2015).
The process of developing the NMP curriculum could be a good opportunity to introduce classroom-based TEL within the pharmacology component. This approach would require students to undertake private study before using TEL resources in the classroom. The classroom activity therefore would act to clarify knowledge and add context to the subject matter. Approaches such using audience response technology as used by Lymn and Mostyn (2010) may engage students and empower individuals' confidence in their personal learning. Audience response technology uses interactive devices as part of the assessment strategy to guide students and lecturers in gauging how many of the class understand the questions. Students are able to answer questions via the device and receive instant responses to clarify or correct their understanding. This approach may be particularly suitable for students who feel intimated or less confident in large group situations.
Participatory approaches optimise the student experience and enhance learning outcomes because they give learners the chance to challenge and test theories (Kaveevivitchai et al, 2009; Cober et al, 2015; Gourlay, 2015). TEL designs that encourage participation assist students in creating communities of knowledge-sharing and provide a forum for discussion, which can facilitate a culture of lifelong learning practices (Burrell et al, 1988; Petty, 2013). The RPS framework states that continued learning and professional development is an essential skill for all NMPs (RPS, 2016), and building on this skill within NMP education can enhance the skills and expertise of nurses and enhance educational quality.
NMP education also covers legal frameworks, the licensing of medicines and the principles of prescribing, all topics that would benefit from the use of TEL. Each area provides in-depth coverage of material that is necessary for safe NMP. Each topic would need to be considered independently to assess the optimal approach suited to meet the broad range of individual student learning needs and deliver high-quality content. Participatory learning such as groupwork could enhance TEL further and support blended learning strategies (Rissmann et al, 2012; Gotlib et al, 2016).
Conclusion
Although TEL is part of the future learning curriculum and offers a variety of experiences for the learner, lecturers need to be aware that some students may be disadvantaged and their interpretation of subject knowledge will require support (Horne et al, 2007). Participatory classroom learning activities should help overcome this. The practical aspects of NMP are supported by clinical supervisors, allowing students to transfer theory to practice, facilitate synthesis of knowledge and embed practical experience.
Developing and advancing programmes in nurse education is essential to meet the diverse and rapidly growing needs of modern health care, alongside student expectations. HEIs that use flexible teaching methods and TEL to deliver innovative programmes help to bring teachers and students together, enhancing the student experience and ultimately delivering highly skilled, competent NMPs (Gordon, 2014).