Non-medical prescribing is the term used for the prescribing activity by health professionals who are not doctors or dentists (Cope et al, 2016). This is only permitted following the successful completion of an approved prescribing qualification at a higher education institution, and subsequent attainment of annotation on the associated professional register, and employment permissions. Non-medical prescribing has developed significantly, with many health professionals having access to additional education that leads to the legal right to prescribe. Currently, nurses represent the largest proportion of non-medical prescribers in the UK (Armstrong et al, 2021). This article focuses on the evolution of non-medical prescribing relating to independent and supplementary prescribing (V300 annotation on the Nursing and Midwifery Council (NMC) register) within the nursing profession.
Non-medical prescribing in nursing
Non-medical prescribing was introduced originally to reduce doctors' workloads and to improve patient care (Paterson et al, 2016). This delegates responsibility for full episodes of care to skilled nurses, including patient assessment and diagnosis, leading to treatment of the condition, the organisation of further investigations when appropriate, and making referrals to specialists within the multidisciplinary team (Casey et al, 2020).
Non-medical prescribing has become increasingly important in today's healthcare environment, in line with changes to professional roles, and expansion into advanced practice. The general population is living longer, with multiple comorbidities, increasing demand on healthcare systems, thereby leading to a need for nurses to increase and expand their scope of practice (Fox et al, 2022). For example, people living with long-term conditions such as heart disease, diabetes and mental health conditions may need increased access to their healthcare providers for medication or medical devices (Armstrong et al, 2021).
Prescribing is commenced on a personal basis, taking into consideration the individual needs of a patient. The patient's needs are established by undertaking a comprehensive and holistic assessment, and may or may not lead to a prescription (Summers and East, 2021).
Research has shown that patients often prefer to see a nurse prescriber because they feel that getting an appointment is easier, and they have faster access to their medication (Courtenay et al, 2010). Many patients feel also more involved in the decision-making process around their illness, and consider that nurses have notable levels of knowledge within their specialist area (Anonymous, 2011). Nurse non-medical prescribing has led to increased concordance with medication regimens, and increased patient satisfaction with care (Creedon et al, 2015). Funnell et al (2014) reported that nurse prescribing is as safe as medical prescribing; they found that this is likely to be because nurses are more risk averse than doctors and may often have better clinical judgement because they look at the patient holistically. In comparison, Lennon and Fallon (2018) described how nurses may feel pressured to prescribe to the detriment of their other roles, increasing their workload. However, Lennon and Fallon (2018) also stated that non-medical prescribing provides patients with a full episode of care and increases nurses' job satisfaction.
The origins of non-medical prescribing lie in the Cumberlege report in 1986 (Department of Health and Social Security, 1986), which reviewed the care provided by district nurses and health visitors. The report proposed that allowing this group of nurses to prescribe from a limited formulary would give patients better access to care, and help to use resources more effectively (Cope et al, 2016). It was recognised that these nurses would often carry out an episode of care, and then return to the GP for a prescription. This wasted time for both nurses and patients, as it often led to delays in prescription generation and treatment (Courtenay, 2000).
The recommendations made by the Cumberlege report were reviewed in the first Crown report in 1989 (Department of Health (DH), 1989), but it took 3 years for legislation to be changed (Cope et al, 2016). The Crown report recognised that some patients would benefit from nurse prescribing: this included individuals with stomas and urinary catheters, homeless families not registered with a GP, and patients with postoperative wounds (Nuttall, 2020). In 1992, the legislation was changed to allow district nurses and health visitors to independently prescribe from a limited formulary, known as the Nurse Prescriber Formulary, following amendments of the Medicinal Products: Prescription by Nurses etc. Act 1992. This represented the first iteration of independent prescribing (IP), albeit from a limited range of medications.
In 2001, following a second Crown report, IP was extended to other appropriate health professionals outside community nursing (DH, 1999). The formulary was extended to include 120 prescriptions only: medications for minor conditions and injuries, palliative care, and health promotion, as well as pharmacy medicines and general sales list items (Griffiths and Courtenay, 2022).
An independent prescriber (IP) is a health professional who assesses and examines a patient to obtain a diagnosis that they then treat, prescribe for, if required, and manage (Courtenay and Carey, 2008). Independent prescribing is not only for newly diagnosed conditions, but may also be used for diagnosed or ongoing conditions (DH, 2006).
A supplementary prescriber (SP) is a health professional who works in partnership with an IP (specifically for the SP process, the IP must be a doctor or dentist), and the individual patient.
The IP takes responsibility for the diagnosis, but works in partnership with the SP and the patient to develop an individual, bespoke clinical management plan (CMP) for the patient and the clinical condition requiring management. The CMP outlines the medication that may be used to treat or manage the identified condition (Paterson et al, 2016). The SP can prescribe anything within the terms of the CMP, is entrusted with managing the patient's longer term care; the SP will refer to the IP if there are any problems or a new diagnosis (Stuttle et al, 2022), or if they need support or guidance. It is important to note that the SP may not prescribe outside the terms of the CMP, and there has to be agreement of the patient for supplementary prescribing to be undertaken. Figure 1 illustrates the elements of supplementary prescribing.
Contemporary non-medical prescribing (V300) education teaches independent prescribing and supplementary prescribing in one curriculum, leading to annotation on the NMC register as IP/SP on successful completion.
Supplementary prescribing, which was initially known as dependent prescribing, was first considered in 1999, but the relevant legislation changes were not made until 2003 (Nuttall, 2020). Supplementary prescribing involves a bespoke partnership between a named IP (who must be a doctor or dentist), a named SP and a specific patient. Within this partnership, the SP can review and prescribe for the patient using an agreed CMP that details the condition the SP can treat, and the limitations of medications, dosages and circumstances in which they can prescribe (Pryor and Hand, 2023). Although supplementary prescribing may be perceived to have challenges associated with the time requirements to form the partnerships, it offers a valuable opportunity for nurse prescribing, and is being increasingly used by those Health and Care Professionals Council (HCPC) registrants who cannot become IPs or who are unable to independently prescribe controlled or unlicensed drugs.
Independent prescribing has evolved over the years, along with advancements within the nursing role, due to the redesign and growth of services (Paterson et al, 2016). The development of advanced nursing practice follows on from the increased pressures faced by the NHS as a result of people living longer, and living with multiple and complex comorbidities requiring regular and local care (Eaton et al, 2015).
In 2006, legislation was passed allowing nurses to independently prescribe, within their scope of practice, any licensed medication for any disorder, leading to elimination of the Nurse Extended Formulary (DH, 2006). In 2009, further legislation was passed to allow nurses to prescribe unlicensed medication and amended in 2012 to allow nurses to prescribe any controlled drug from Schedules 2–5 (The Misuse of Drugs (Amendment No.2) Regulations 2012 No 973, 2012). However, there are restrictions when treating patients with addiction (Joint Formulary Committee, 2022). It is important to note that all non-medical prescribing practice is bound by the nurses' scope of clinical practice, competence and employment terms and conditions. As such, independent prescribing could be limited to one condition or may cover many, depending on the area of practice the nurse works in (Wright and Jokhi, 2020).
It is important to recognise the distinct types of nurse prescribing qualifications. These are determined by the approved educational programme of study undertaken (Table 1) and should be detailed in a nurses' employment contract. This supports appropriate professional annotation on the NMC register and dictates prescribing practice within the bounds of law. Nurses can complete education to become community practitioner nurse prescribers or IPs and SPs.
Table 1. Types of nurse prescriber
| Recordable qualification (NMC) | Title | Detail |
|---|---|---|
| V100 | Community practitioner nurse prescriber | With community nursing specialist practice qualification (SPQ) or specialist community public health nurse qualification (SCPHN) |
| V150 | Community practitioner nurse prescriber | Without SPQ or SCPHN |
| V300 | Nurse independent/supplementary prescriber |
Each type of prescribing entails a different NMC-approved programme of study (Gould and Bain, 2022). The V100 course, which is taught within a specialist practice qualification, leads to a community practitioner nurse prescriber qualification. These specialist qualifications may include community public health nursing, health visitors, school nurses and specialist district nursing (Nuttall, 2020). The V150 course is equivalent to V100, but is completed as a standalone programme of study. Both V100 and V150 prescribers are entitled to prescribe only from the Community Practitioner Nurse Prescriber's Formulary, which details a limited list of drugs, appliances and dressings. Examples of the medication it includes are emollients, ointments, laxatives, simple analgesics and wound management items.
Practice standards and education
Initially, nurses were bound to the Standards of Proficiency for Nurse and Midwife Prescribers (NMC, 2006). As non-medical prescribing practice evolved, the prescribing framework of the Royal Pharmaceutical Society (RPS) was adopted by non-medical prescribing professional bodies. This document, the Competency Framework for All Prescribers (RPS, 2021), now represents the standard that all prescribers should demonstrate, forming the basis of non-medical prescribing education and competence assessment. Nurse prescribers (irrespective of type of prescribing qualification) must use the framework to guide their practice while working within their professional code of conduct. More recently, the NMC published the Standards for Prescribing Programmes (NMC, 2018a), ensuring that all approved prescribing programmes use the RPS framework. The RPS framework was designed so that all health professionals understand what good prescribing practice should look like, it ensures that prescribing is standardised and that it is of a high quality (Mitchell and Pearce, 2021).
The framework (RPS, 2021) consists of two domains: consultation, and prescribing governance. The consultation domain consists of six steps: patient assessment, identification of a treatment option, shared decision-making, prescribing, information provision, and ensuring appropriate monitoring and review. The prescribing governance domain covers prescribing both safely and professionally, improving prescribing practice, and prescribing as part of a team. The framework can also be used to continue education and development for the prescriber (Hall and Picton, 2020), alongside the new RPS guidance framework for Expanding Prescribing Scope of Practice (RPS, 2022). This should be used if there is a change of role, work setting or if a new service is being initiated. The framework supports prescribers to reflect on current practice, and how to plan, act and evaluate their knowledge and competence to enhance the scope of prescribing practice by mapping this to the RPS competencies.
Following the publication of the current NMC standards for prescribing programmes (NMC, 2018a), and the adoption of the RPS competency framework, substantial changes to nurse prescribing supervision and assessment provision have been undertaken. The RPS has developed a further framework called A Competency Framework for Designated Prescribing Practitioners (RPS, 2019), which ensures the training of safe and effective non-medical prescribers during their period of learning in practice.
Recent regulatory changes now permit a prescriber from any prescribing professional background, including a non-medical prescriber, to act as a prescribing practice assessor (sometimes known as the designated prescribing practitioner), as long as their specialty is aligned to the student prescriber's professional field of practice. This is a significant shift from historical practice, when only doctors were able to provide clinical supervision and assessment for prescribing students. The expansion of this role to include both non-medical prescribers and medical prescribers has provided better access to training opportunities, potentially increasing the number of non-medical prescribers. This has widened the pool of experienced prescribers, allowing trainee non-medical prescribers to access an assessor who will be beneficial for their practice-based learning (Mott, 2020).
Recent changes within multiprofessional regulations have caused some confusion regarding named roles in assessment and supervision for prescribing students. The adoption of the RPS competency framework and associated guidance has introduced the term ‘designated prescribing practitioner’. This overarching term encompasses a variety of profession-specific terminology relating to people supporting student non-medical prescribers. Nurses undertaking non-medical prescribing must have both a named practice assessor and a supervisor (unless there are exceptional circumstances) (NMC, 2019a). HCPC registrants such as paramedics or physiotherapists require only one individual to undertake both roles. Both the nurse non-medical prescribing student practice assessor and practice supervisor are required to fulfil the ‘designated prescribing practitioner’ criteria, in addition to aligning to the specific NMC role standards for supervision and assessment (NMC, 2019a).
The practice assessor needs to be a registered, experienced prescriber (NMC, 2018a), who takes ultimate responsibility for assessing the competence of the trainee non-medical prescriber, by completing a robust, objective appraisal and confirmation of skill (NMC, 2019a).
The practice supervisor needs to be a registered and experienced prescriber, who can support and supervise the non-medical prescribing student, offering feedback, and supporting development towards competence, and feeding into assessments (NMC, 2019a).
Prior to the new NMC standards for prescribing programmes (NMC, 2018a), nurses were required to have 3 years' post-registration experience, including one year in the clinical area within which they intended to prescribe prior to applying for the non-medical prescribing programme (Cope et al, 2016). The NMC has recently changed undergraduate pre-registration education, resulting in an expectation that, at the point of qualification, nurses will be better prepared to take on a prescribing qualification.
This has been termed prescriber ready, but there has been some confusion about the meaning of the term. It does not mean that nurses exit pre-registration training with a prescribing qualification, nor that they will have automatic permission to enter a prescribing education programme at one year post-qualification. The time from initial annotation on the NMC register to being considered for non-medical prescribing study has been reduced to one year; however the requirement remains to have proficient skills in assessment, diagnostics, clinical skill, care planning and management in the intended area of practice (NMC, 2019b). Newly qualified nurses will be expected to have increased pharmacology knowledge and be aware of how prescriptions are generated, as well as knowledge around prescribing errors, polypharmacy and adverse effects (NMC, 2018b). This change recognises that an individual's skills and knowledge should determine readiness to undertake additional education to become a prescriber, rather than a time frame. However, proficiency 4.17 (NMC, 2018b) specifically discusses applied pharmacology and the ability to progress to a prescribing qualification post-registration, rather than an expectation that all nurses will undertake this. In addition, organisational governance and employer policy must be always followed.
Following the successful completion of a non-medical prescribing programme of study, and annotation on the NMC register, nurse prescribers are responsible for maintaining contemporary skills and evidence-based practice through continuing professional development (CPD). CPD in prescribing practice has often been cited by nurses as being difficult to access, and there is often concern around pharmacology knowledge (Smith et al, 2014). CPD activity varies and can depend on the individual practitioner. According to Watson (2021), forms of CPD may include reviewing journal articles, attending conferences, audit of practice and collaboration between colleagues. These should be specifically tailored to the non-medical practitioner's scope of practice or support practice expansion.
It can be difficult to maintain up-to-date knowledge of medicines when the pharmaceutical industry is constantly changing (Summers and East, 2021). Fletcher et al (2012) found that collaboration between nurses and pharmacists can benefit both types of health professionals and the patient through continuing education on the appropriate use of medicines. This is supported by Weglicki et al (2015), who also found that nurse prescribers drew on support from both medical and non-medical colleagues. Non-medical prescribers may find their organisational non-medical prescribing forums supportive or may wish to set one up if there is not one established locally.
Conclusion
Nurse prescribing has been shown to be beneficial to both service users and practitioners, spanning primary and secondary care. It is an essential and rapidly evolving part of advanced clinical practice, which is vital in the management of service users' health needs in today's busy healthcare environment (Mitchell and Pearce, 2021). It has developed significantly in its short existence and is set to continue to push the boundaries of practice, as the role and education of nurses changes and adapts to changing population healthcare needs.
KEY POINTS
- Non-medical prescribing in nursing can be undertaken after completion of an approved Nursing and Midwifery Council programme of study
- There are several forms of non-medical prescribing. Each has its own parameters, boundaries, and context of use. Health professionals should be aware of these
- Non-medical prescribing is governed by law, and the legal and professional parameters must be adhered to
- Ensuring continuing professional development is a significant part of being a safe and competent prescriber
CPD reflective questions
- Do you consider non-medical prescribing to be a career aspiration? What preparation do you need to make in order to undertake a nurse prescribing role within your organisation?
- How may non-medical prescribing benefit the people you care for?
- What links or networks may you wish to explore to support non-medical prescribing in your area of practice?