Authors: Jacqui Neil  – Transforming Workforce Lead for Nursing (Scottish Care), Derek T Barron – Director of Care (Erskine Homes), Jane Harris – Head of Programme,  Postgraduate and Post-registration Education and Continuing Professional Development (NHS Education for Scotland)
Nurse prescribing was introduced in the UK in 1998 when district nurses and health visitors were given the authority to prescribe from a limited national formulary. Since its introduction in the United States in the late 1960s, (Clarke et al 2019), nurse prescribing has increased worldwide. As other professions have gained prescribing rights, the term ‘non-medical prescribing’ (NMP) is used to describe any prescribing completed by a healthcare professional other than a doctor or dentist (Maier 2020).
In 2006, the Nursing and Midwifery Council published Standards of Proficiency for Nurse and Midwife Prescribers, which drove prescribing forward for all nurses and midwives across the UK. The Scottish Government developed guidance to support the roll-out of non-medical prescribing in Scotland in the publication ‘Non-Medical Prescribing in Scotland: Guidance for Nurse Independent Prescribers and for Community Practitioner Nurse Prescribers in Scotland‘ (Ness et al 2015).
Non-medical prescribing is defined as prescribing by an appropriate practitioner (doctor, dentist, paramedic, nurse, midwife, pharmacist, physiotherapist, podiatrists optometrist, diagnostic and therapeutic radiographer) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required (DOH 2006). In August 2010 the Scottish Government published a progress report on nurse prescribing in Scotland showing that nurse prescribing produced better care for patients, faster access to medicines, better use of nurses’ and doctors’ time RCN (2014), NMP was viewed as improving communication between health professionals and supportive of key health care policy in Scotland, particularly in relation to shifting the balance of care from acute to community services.
In addition, prescribing was seen as responsive to assessment in relation to older people with more complex needs. Cope et al (2016) highlighted that students training to become non medical prescribers felt the programme provided them with adequate knowledge to prescribe with some stating that the period of learning in practice was ‘the most valuable part of the course’.  Nurse prescribing is now well established in Scotland.
Care home nurses in Scotland left behind
Non-medical prescribing is a key step in the chief nursing officer’s 2030 vision to ensure personalising care, preparing nurses for the future. (CNOD 2017).  Nurse who NMP work predominantly within the NHS. A literature review showed no data regarding NMP in UK care homes.  This indicates the sector’s exclusion from NMP, despite the potential positive impact on delivering responsive care at the right time, a key driver within many policy documents (Scottish Government 2010, 2017).  In addition, having on-site prescribers reduces the need and workload for GPs or external advanced nurse practitioners (ANP).
One reason for ‘being left behind’, include the lack of investment in the independent sector to support NMP, resulting in a nursing workforce which has been left behind by their NHS counterparts. Despite numerous calls for this to be addressed over the years it has failed to be achieved (Merryfield 2015).
The pandemic has amplified how crucial a skilled workforce is to deliver safe, effective, person-centred care. Care home nurses are in a prime position as they know their residents better than most external prescribers. In providing 24-hour care to residents, they can notice and act on subtle changes that would prevent unnecessary deterioration, if acted on promptly.
This gap was noted as a frustration in the Scottish Care 2021 Nursing Survey which asked if the organisations supported registered nurses to undertake a prescribing course, if it were available: 89.5 % of respondents said ‘yes’. If this was facilitated, it could promote nurse leadership and autonomy within the sector, which is intrinsic to the sustainability of social care nursing as well as community nursing.
The difficulties for employers
There are difficulties faced by care home nurses who wish to carry out NMP. Although highly skilled and knowledgeable expert generalists, they face a number of systemic challenges.  In 2017 Erskine Veterans care, invested in NMP in two of its homes. Despite NMP being within the registered nurses’ scope of practice for many years embedding it within the care home environment was not easy.
Prescribing liability insurance for NMPs within NHS Scotland is covered by CNORIS (Clinical Negligence and Other Risks Indemnity Scheme).  No such universal cover exists within care homes, as such Erskine required to take out separate cover to insure the NMP duties of their ANPs. The ANPs, although full independent (V300) prescribers, only prescribe from a limited ‘care home’ formulary, developed in Erskine with input from our GPs (Boyd & Barron, 2019).  The insurance industry does not consider NMP part of the every-day duties of a registered nurse, which is covered by the generic nursing duties cover every care home will have.
The most basic pieces of equipment that the NMP requires is a prescription pad.  The local GP practice would not issue a pad for fear that they may be vicariously liable for the prescribing of someone they did not employ.  That left Erskine in the situation of negotiating with the local Health & Social Care Partnership to have a ‘community’ prescription pad issued, in the same way a district nurse has a prescription pad issued. While there are other hurdles to overcome, the journey has been worthwhile. It has led to early intervention from the ANPs when a resident deteriorates, this can be in situations of infection, as well as at end of life. It has led to regular, 12 weekly review of psychotropic medications and covert meds, ensuring both are used as little as possible for as short at time as possible. This puts the residents at the centre of care decisions rather than having medication prescribed and then continued simply because no review had taken place.
The Transforming Roles programme
NHS Education for Scotland (NES) has established education and development pathways from registration through to advanced and consultant practice that support changing service needs. One such pathway, the Integrated Community Nursing (ICN) Pathway, offers targeted post-registration education aiming to maximise the potential of the nurses’ role in Scottish care homes. The Graduate Diploma in Integrated Community Nursing forms the foundation of NES’s ICN pathway. This centrally funded, two year part-time practice-based programme is designed for nurses working in care home, district, prison health or general practice nursing at level 5 (Agenda for Change Band 5 equivalent) of the NES Nursing, Midwifery and Allied Health Professions Development Framework (NES 2021).  Nurses develop a range of new knowledge and skills to enhance their practice and meet people’s physical, mental health, and social care needs.
This new approach puts care home nursing on an equal footing with more established community nursing specialities in terms of access to education and role development. Care home nurses may continue through the pathway completing studies at postgraduate level, first qualifying in their speciality and then with the option to qualify as advanced and consultant nurses.  Safe and timely access to appropriate medication as part of the personalised, rights-based and compassionate care and support that care home nurses deliver is a key outcome of the new pathway. It was designed to include Nurse Independent Prescribing as an optional module in the Graduate Diploma ICN and an essential component of the specialist postgraduate stage. The benefits of a structured and sustainable model for education and development for care home nurses that includes Nurse Independent Prescribing gives employers, education providers, the multidisciplinary team and the nurses themselves the incentive to overcome the current barriers and enable prescribing to become part of care home nurses’ practice.
References
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Cope, L. Abuzour, S and Tully, M.  (2016) Nonmedical prescribing: where are we now? First Published April 2016
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