Developing a non-medical prescribers peer supervision group Turner S (2011) Developing a non-medical prescribers peer supervision group. Nursing Standard. 25, 29, 55-61. Date of acceptance: December 22 2010. Summary This article describes the effect and outcomes of a non-medical prescribers peer supervision group in a secondary care mental health and learning disabilities trust two years after its inception. The article highlights how the group has encouraged networking and innovation, which have helped to develop and promote non-medical prescribing in the trust. Author Steve Turner, facilitator, Non-medical Prescribers Peer Supervision Group, Cornwall Partnership NHS Foundation Trust, St Austell; director of the social enterprise Steve Turner Innovations; National Prescribing Centre Plus medicines management trainer for the South West; and associate lecturer, University of Plymouth, Plymouth. Email: steve@stnov8.co.uk Keywords Clinical supervision, non-medical prescribers, nursing role, peer supervision, prescribing These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords. NURSING STANDARD THE CORNWALL PARTNERSHIP NHS Foundation Trust s Non-medical Prescribers Peer Supervision Group was established in February 2008, when there were only a few non-medical prescribers in the trust. Since then, that population has increased. There are 22 non-medical prescribers in the trust and 12 staff members are studying for the Nurse Independent and Supplementary Prescribing (V300) qualification. At the time of writing, the majority of non-medical prescribers were working in substance misuse, care of older people and assertive outreach. The peer supervision group is facilitated by an independent non-medical prescriber under an honorary contract and involves action learning with the aim of improving performance (Turner 2008). Developing the peer supervision group The peer supervision group s progress in achieving its objectives is reviewed annually. The main challenges it experiences include poor attendance at meetings, concerns about the lack of influence on service developments, and ensuring the group operates effectively and is sustainable. The issue of attendance is not particular to this group, but is exacerbated by the distances involved in travelling within the trust. To minimise this, the group has set up an email discussion forum and a shared folder for its members. Those who are unable to attend meetings are encouraged to exchange information by email and add items to the folder, so that it is exchanged and discussed between meetings. When the group produced its first progress report in 2008, it was noted that there was no evidence that non-medical prescribing was part of service planning. Since then a non-medical prescribing strategy, which includes setting out the pathway between supplementary and independent prescribing, has been ratified (Cornwall Partnership NHS Foundation Trust 2009). In addition, non-medical prescribing is now included in the trust s business plan and several service plans. These developments were felt to have been positively influenced by the work of the peer supervision group. The influence of non-medical prescribing is increasing. The group is taking the lead in developing and piloting a framework for continuing professional development (CPD) and appraisals for nurses involved in prescribing. The Cornwall Partnership NHS Foundation Trust s medicines management and governance structure is outlined in Figure 1. Non-medical prescribers attend a bi-monthly formal meeting chaired by the non-medical prescriber lead. This group reports to the medicines management forum, which is a multi-disciplinary group chaired by the professional head of nursing (who is also the trust s non-medical prescriber lead). The peer supervision group attempts to meet march 23 :: vol 25 no 29 :: 2011 55
every other month, although this can vary to accommodate conferences, research projects and CPD events. Action notes are made in the group for use by the attendees and any issues are raised through the formal non-medical prescribers group. Several non-medical prescribers also sit on the medicines management forum. The medicines safety group links with this forum and the service user forum is involved for specific projects. The medical director has overall responsibility for medicines management and reports to the trust s board (Figure 1). A recent survey of the group showed that nearly 90% of those who replied felt the group has been effective or very effective in achieving its objectives. There were concerns about slow progress in certain areas, such as delays from qualifying to being able to start prescribing in the team, and unrecognised potential. Comments included: The group takes a proactive and responsible position in relation to non-medical prescribing (team leader and nurse prescriber). Slow, but making sure progress, unstoppable (clinical nurse specialist). Great to get together to thrash out difficulties in the peer supervision group... we always feel inspired afterwards (group s reflective diary). Comparing current progress of the peer supervision group with the original analysis (Turner 2008), one of the strengths highlighted is the use of reflection and peer interaction. This is supported by Otway (2001) who identified the value of informal interaction with other prescribers, particularly when pressures may limit formal clinical supervision. Other strengths include the ability to measure progress against the original terms of reference and to adapt these as necessary. The group began by examining how the organisation needed to support the development of the group s role, but is now undertaking more detailed work on CPD and appraisals, including clinical peer review as part of annual appraisals. This ability to adapt and be flexible, as advocated by McGill and Brockbank (2004), has helped sustain the group and develop its role. Effect of the group The importance of peer support in helping to develop services and prescribing skills has been reported previously. Otway (2001) described the benefits of informal reflection and sharing experiences, and Young (2009) found lack of peer support to be a barrier to the development of non-medical prescribing. This is supported by experience in Cornwall. The peer supervision group has developed expertise in critical areas, such as effective linking with psychiatrists (Kwentoh and Riley 2009) and other clinicians; implementing robust supervision practices (Earle et al 2010); and team development and strategic planning (Carey et al 2010). The group has had involvement in: 4Developing, documenting and ratifying an appraisal and CPD framework. 4Effective use of action research and audit. 4Developing a training pathway for medicines management and prescribing. CPD framework The non-medical prescribers peer supervision group has developed and is piloting an innovative framework. A draft version of this is shown in Box 1. The document Maintaining Competency in Prescribing (National Prescribing Centre 2001) has been adapted for local use with the aim of producing a simple, safe, locally relevant and adaptable prescribing appraisal form. The FIGURE 1 Outline of Cornwall Partnership NHS Foundation Trust s medicines management and governance structure Medical director Trust board Non-medical prescribers formal group Medicines management forum Service user forum Non-medical prescribers peer supervision group Medicines safety group 56 march 23 :: vol 25 no 29 :: 2011 NURSING STANDARD
group is reviewing the use of the document and investigating who is best placed to agree and sign it as this forms part of the annual appraisal process (bearing in mind that a line manager may not be a non-medical prescriber). A pilot evaluation suggests that the prescribing appraisal form will require two validation signatures, one from a prescriber added before review and sign off by the line manager. The group is also looking at the feasibility of peer review of appraisal forms. The second element of the CPD framework is the requirement for non-medical prescribers to keep a log of their prescriptions, as prescriber-specific data is not available electronically at present. This method is under evaluation. The flexibility of maintaining practitioner-specific records will help in recording all prescribing decisions, but requires each practitioner to be fully compliant with data protection and Caldicott principles (Department of Health (DH) 2010a). It also means that individual prescribers should ensure that information is readily available for audit purposes. The third element of the CPD framework is the requirement for all non-medical prescribers to produce a list of drugs they are competent to prescribe. This needs to be updated when more drugs are added and a copy supplied to the trust s non-medical prescriber lead. This list has a specific section for recording unlicensed and off-licence drugs. It may be produced for an individual prescriber or (as in the case of substance misuse) for a team. This is an efficient way to keep track of fields of competency, and links to the use BOX 1 Draft version of continuing professional development framework for non-medical prescribers Appraisal form 4Listing sources of continuing professional development and evidence. 4Must include evidence of supervision from a prescriber. 4Signed by a manager at annual appraisal copy given to human resources. Prescription log and audit 4Non-medical prescribers each keep a record of their prescriptions. This includes prescribing decisions, such as stopping medicines. Every year non-medical prescribers submit their prescription log (in summary form). Wherever possible this should be accompanied by an audit of a key area (which can be produced individually or by a group). 4Log and audit sent to the head of nursing. Area of competency 4Non-medical prescribers are asked to keep a record of the drugs they are competent to prescribe, type of prescribing (supplementary or independent), and the conditions for which they are prescribed. This can be in a simple format listing drugs or groups of drugs. It must include all unlicensed and off-licence drugs. 4Copy sent to the head of nursing. of locally agreed prescribing procedures and formularies. This model of organisational support, in which front line staff develop guidelines and procedures, fits with the model for action learning illustrated by Keenan (2010). Action research and audit The CPD framework actively encourages non-medical prescribers to participate in action research and audit. Several action research projects are under way. An initial questionnaire-based study carried out by the group has been published, which helped raise awareness of the benefits of non-medical prescribing (Turner et al 2010). Non-medical prescribers are encouraged to undertake action research and are supported by the group s facilitator. Two audits are under way and include: 4Assessing the effect of nurse independent prescribing for older people with dementia in the learning disabilities service. 4Service users views of supplementary prescribing versus usual treatment in a community mental health trust. Training pathway for medicines management and prescribing The group has been influential in helping the trust develop a training pathway for medicines management and non-medical prescribing. Table 1 shows the non-medical prescribing and medicines courses available at the trust. At present, all registered care staff in the trust are expected to keep up to date by attending a full-day medicines management training session every three years, and non-registered staff will be required to undertake an e-learning package. Those wishing to enhance their skills can enrol on a psychiatric medicines and therapeutics course, which is a local prerequisite for the non-medical prescribing programme. The trust is also developing an online resource for all staff that contains learning modules and tests, newsletters, copies of meeting minutes, local reports and presentations, a list of future CPD events and useful links and references. This structured approach to medicines management training is supported by research, which notes how becoming a non-medical prescriber promotes a greater understanding of medicines, and can even reveal previously unknown levels of incompetence (Snowden and Martin 2010). Further update training for prescribers has been introduced. This is tailored to specific service areas, is multidisciplinary and incorporates help with change management where required. This training is also appropriate for those who have experienced a delay between completing the course and prescribing. A pilot study of this approach proved successful and the update training course is now accredited. 58 march 23 :: vol 25 no 29 :: 2011 NURSING STANDARD
Evaluation Since its inception, the peer supervision group has continued to achieve its objectives. Feedback from members indicates that the group is valued and cohesive, even in times of uncertainty and change. This is considered a particularly important benefit of such a group (Otway 2001). Two years on from the initial evaluation (Turner 2008), the group appears to have influenced service planning and helped raise the profile of non-medical prescribing in the trust. The group has instigated research and audits and has put front line clinicians in charge of piloting and developing CPD. The group is also involved in identifying the most effective model for prescribing in appropriate service areas. The immediate issues concern implementing cost savings and the effect this will have on the skill mix of nursing teams. Simply switching from medical to non-medical prescribers may not result in direct cost savings. For example, a recent small study demonstrated that the cost of using non-medical prescribers in mental health was higher (although not statistically significantly so) than that of medical prescribers, while the outcomes remained the same. The study also discussed the need to consider the experience and wellbeing of service users when developing services (Norman et al 2010). This highlights the need to examine the wider context, including possible reductions in avoidable admissions and call outs, and to identify and audit quality-related benefits (Fittock 2010). The group has an important role in highlighting the benefits of non-medical prescribing in terms of the Quality, Innovation, Productivity and Prevention (DH 2010b) agenda. This includes speed of access to medicines and treatments, offering choice and improving outcomes. The initial evaluation (Turner 2008) suggested that the group may evolve into specialty-based groups, as there were concerns that a group encompassing all specialty areas may be of limited value. However, after two years the value of the group has been demonstrated. While individual members are performing action research in their fields, the core group seems set to take an important long-term role in CPD, research and training in non-medical prescribing. Non-medical prescribers feel empowered and motivated by the group. The challenges will be to: 4Sustain the momentum. 4Influence practice and service development appropriately. 4Source and develop effective CPD. 4Forge interdisciplinary links with medical staff, pharmacists and health professionals. TABLE 1 Non-medical prescribing and medicines courses available at Cornwall Partnership NHS Foundation Trust Medicines management training and workshops Psychiatric medicines and therapeutics course Non-medical prescribing course (external course) Non-medical prescribing update training 4Day workshop for registered care staff. 4e-learning module for non-registered care staff. 4Essential training for all care staff. 4Informal self-evaluation and online tests. 4Approved for use towards accreditation of previous learning vouchers for academic credits. 4Commissioned by the trust medicines management forum. 4Links to online information hub for all staff. 4Six taught days. 4Partnership course with the University of Plymouth. 4For registered staff. 4Prerequisite for non-medical prescribing course. 4Examined by workbook and assignments. 440 credits at level 6. 4Commissioned by the trust medicines management forum. 426 taught days plus 12 practice days. 4Strict pre-course requirements. 4Recordable qualification. 4Examined by portfolio, assignments and observed structured clinical examinations. 440 credits at level 6. 4Available at master s level. 4Funded through the strategic health authority or local service budgets as part of business plans. 4Half day tailored to a specific service area. 4Aimed at non-medical prescribers and their clinical colleagues, including GPs. 4Includes relevant policies, operating procedures and a process mapping session. 4Suitable for an interdisciplinary audience. 4Aimed to assist teams to prepare for change. 4Informal self-evaluation. 4Approved for use towards academic credits. 4Links to non-medical prescribing information hub. 4Locally commissioned. 60 march 23 :: vol 25 no 29 :: 2011 NURSING STANDARD
4Find new ways to involve service users in the development of non-medical prescribing. The group has demonstrated the benefits associated with integrating non-medical prescribing into service delivery (Courtenay 2010). Such benefits include implementing non-medical prescribing across teams, rather than the less sustainable (and potentially inequitable) model of being implemented mainly by individuals wanting to undertake the role. Recent studies have supported the development of non-medical prescribing as part of service reconfigurations where it has been assessed as offering the most benefit (Dobel-Ober et al 2010, Fittock 2010). The concept of peer supervision groups taking a lead role in practice development, and providing ongoing support and CPD for colleagues, embraces the move towards a clinician-led NHS (DH 2010c). It is a model that continues to develop and which can be explored in other service areas. Conclusion The non-medical prescribers peer supervision group was set up to help establish the best way to support non-medical prescribers in the trust. Having clear objectives at the outset has enabled the group to measure its progress, and establish its role. The group has exerted a positive influence on the development of non-medical prescribing as a valuable and sustainable service delivery option and promoted its benefits through action research. It is providing important information on the best approach to the introduction of non-medical prescribing NS References Carey N, Stenner K, Courtenay M (2010) Stakeholder views on the impact of nurse prescribing on dermatology services. Journal of Clinical Nursing. 19, 3-4, 498-506. Cornwall Partnership NHS Foundation Trust (2009) Non Medical Prescribing Strategy. http://tiny.cc/mm01609 Courtenay M (2010) Non-medical prescribing: where are we? Journal of Nursing Healthcare and Chronic Illness. 2, 3, 175-177. Department of Health (2010a) Confidentiality. http://bit.ly/hs7j5b Department of Health (2010b) Quality, Innovation, Productivity and Prevention (QIPP) www.dh.gov.uk/ en/healthcare/qualityandproductivity/ QIPP/index.htm (Last accessed: March 3 2011.) Department of Health (2010c) Equity and Excellence: Liberating the NHS. The Stationery Office, London. Dobel-Ober D, Brimbelcombe N, Bradley E (2010) Nurse prescribing in mental health: national survey. Journal of Psychiatric and Mental Health Nursing. 17, 6, 487-493. Earle EA, Taylor J, Peet M, Grant G (2010) Nurse Prescribing in Specialist Mental Health (Part 2): The Views and Experiences of Psychiatrists and Health Professionals. http://dx.doi.org/10.1111/ j.1365-2850.2009.01517.x (Last accessed: March 3 2011.) Fittock A (2010) Non-medical Prescribing: A Quick Guide For Commissioners. National Prescribing Centre, Liverpool. Keenan J (2010) Action learning and learning sets. In Waite M, Keenan J (Eds) CPD for Non-Medical Prescribers: A Practical Guide. Wiley-Blackwell, Chichester, 83-93. Kwentoh M-L, Riley J (2009) Non-medical prescribing: the story so far. Psychiatric Bulletin. 33, 1, 4-7. McGill I, Brockbank A (2004) The Action Learning Handbook. RoutledgeFalmer, London. National Prescribing Centre (2001) Maintaining Competency in Prescribing: An Outline Framework to Help Nurse Prescribers. National Prescribing Centre, Liverpool. Norman IJ, Coster S, McCrone P, Sibley A, Whittlesea C (2010) A Comparison of The Clinical Effectiveness and Costs of Mental Health Nurse Supplementary Prescribing and Independent Medical Prescribing: A Post-test Control Group Study. http://dx. doi.org/10.1186/1472-6963-10-4 Otway C (2001) Informal peer support: a key to success for nurse prescribers. British Journal of Community Nursing. 6, 11, 586-591. Snowden A, Martin CR (2010) Mental health nurse prescribing: a difficult pill to swallow? Journal of Psychiatric and Mental Health Nursing. 17, 6, 543-553. Turner S (2008) Peer support in non-medical prescribing. Association for Nurse Prescribing Journal. 4, 12-13. Turner S, Broom W, O Kelly A, Richardson K (2010) Non-medical prescribing action research: questionnaire study. Nurse Prescribing. 8, 8, 392-395. Young D (2009) Nurse prescribing: an interpretative phenomenological analysis. Primary Health Care. 19, 7, 32-36. NURSING STANDARD march 23 :: vol 25 no 29 :: 2011 61