Expanding Prescribing Scope of Practice

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Publication date: June 2022
Next review date: June 2026

• Introduction

1. Reflect
   • • Domain 1
     • Domain 2
2. Plan
3. Act
4. Evaluate
5. Case Studies
   • • Chen, prescribing Nurse in a GP practice
     • Omar, Pharmacist
     • Sarah, specialist Physiotherapist (part 1)
     • Sarah, specialist Physiotherapist (part 2)
     • Daniel, Optometrist, working in a Optical practice
     • Hazel, Therapeutic Radiographer
     • Timothy, Hospital Pharmacist
6. Checklist

• References and Declaration
• Contributors

Introduction

This guidance is for healthcare professionals wanting to expand their “prescribing scope of practice”.

It provides a structure to support prescribers to identify their developmental needs, highlights ways in which these needs can be met, and offers guidance on how to document the process and outcome. A number of case studies across a range of professions and settings are provided to illustrate the process.

This document is intended to be used alongside the Royal Pharmaceutical Society (RPS) Competency Framework for all Prescribers, which describes the knowledge, skills, behaviours, activities, and outcomes that you, as a prescriber, should demonstrate.

Within the RPS Competency Framework there is a specific competency statement “Prescribes within own scope of practice, and recognises the limits of own knowledge and skill.” This is particularly pertinent when you want to expand, or change your prescribing scope of practice. There are several reasons why you may need to expand your prescribing scope of practice throughout your career.²

This may be due to:

• Being confident in your current prescribing scope of practice but restricting your prescribing to a limited number of medicines
• Being confident in current prescribing scope of practice but identifying further areas that could support patient care, e.g. current scope is management of chronic pain, but a large proportion of these patients are experiencing poor mental health and the management of mental health conditions such as depression would be a natural extension of your role
• A new service being established, e.g. previously prescribing in minor ailments but wanting to prescribe in a pain management service
• Changing job role e.g. original role was prescribing within intensive care and new role is going to be prescribing in cardiovascular disease
• Changing setting, e.g. maintain prescribing for a certain condition but move from primary care into a secondary care setting or vice versa

This guidance document will use the universally accepted Continuing Professional Development (CPD) cycle (reflect, plan, act, evaluate) (Figure 1) to consider potential ways in which you can expand your prescribing scope of practice. We would encourage you to document a record of your CPD cycle, by using the checklist.

Fig 1: CPD cycle

1. Reflect

Identify your learning needs for expanding your prescribing scope of practice

There are a range of scenarios in which you, as a prescriber, may need to expand your prescribing scope of practice (Figure 2).

Fig 2: Infographic to show how a prescriber can expand their prescribing scope of practice

Assess yourself against the RPS Competency Framework

Take time to reread all the competency statements, identifying if you have any developmental needs for your new prescribing scope of practice. You may recognise that you are competent in some areas, but identify learning needs in others.

Look through the different sections of the competency framework and ask yourself if anything you currently do needs to change, or if there are additional points you need to consider.

After you have reflected on the RPS Competency Framework, refer to this table. The first table will look at the consultation (Domain 1) and the second table will focus on the prescribing governance (Domain 2) and considerations you should reflect on prior to expanding your prescribing scope of practice.

Fig 3: Image taken from "The Royal Pharmaceutical Society Competency Framework for all Prescribers"¹

Domain 1

The consultation

Domain 2

Prescribing governance

2. Plan

Planning how you are going to achieve the learning in the expanded prescribing scope of practice.

After you have assessed yourself against each of the competencies, you may have identified some
learning needs.

It is useful to discuss these with a colleague, peer, manager, designated prescribing practitioner (DPP), or another suitable individual who may be prescribing in the same therapeutic area. They can provide ideas about how to achieve the desired learning needs and also help you to clarify your prescribing scope of practice, i.e., what it includes and excludes.

Ensure that you document the inclusion/exclusion criteria for the patient groups you will include in your new prescribing scope of practice before starting to prescribe.

From these discussions, you can create a set of SMART objectives (Figure 4) that will guide your learning around the desired therapeutic area/setting.

3. Act

Undertake learning activities in the desired areas that have been identified for further development.

Acknowledging that everyone learns in different ways, it is important to identify learning activities that both suit your learning style and meet your learning needs. Below are some examples of different approaches that you could consider:

Self-directed learning

• Look at relevant guidance, both local, national and international guidance including NICE, Scottish Intercollegiate Guidelines Network (SIGN), Clinical Knowledge Summaries (CKS), local antimicrobial guidelines etc.
• Distance learning courses on specific therapeutic area where you can work at your own speed
• Higher Education Institute (HEI) provided courses in desired therapeutic area
• Private reading on the subject from a wide range of resources e.g. BNF, SPC, journal articles etc
• Attending conferences
• Attend workshops where you receive teaching from experts in your desired therapeutic area in which you wish to expand your prescribing practice, giving you an opportunity to ask questions.

Peer reviewed discussion

The Designated Prescribing Practitioner playing a facilitative approach to learning

• Meeting with a colleague/peer/mentor/manager for further discussion.
• Mentorship programmes available with the:
  • The Royal Pharmaceutical Society Mentoring Platform is available for pharmacists through the Royal Pharmaceutical Society website
  • eMentoring available for physiotherapists via the Chartered Society of Physiotherapy
• Mentorship programmes available within your own organisation
• Journal clubs or alternative team meetings for peer reviewed discussion and learning.

Observing best practice

• Observing an expert and carrying out consultations under supervision to ensure confidence in your desired prescribing area.

It is important to consider carrying out learning in various activities, to ensure competence in your desired prescribing area.

4. Evaluate

Evaluate your own learning needs would be prudent to ensure all your educational needs have been met.

It is recommended that you evaluate whether your learning needs have been met either in part or in full.

If you do not feel that all the competencies have been met, or you have identified new learning needs, identify ways in which you could achieve the competencies needed and repeat the CPD cycle.

5. Case Studies

• Chen, prescribing Nurse in a GP practice
• Omar, Pharmacist
• Sarah, specialist Physiotherapist (part 1)
• Sarah, specialist Physiotherapist (part 2)
• Daniel, Optometrist, working in a Optical practice
• Hazel, Therapeutic Radiographer
• Timothy, Hospital Pharmacist

Chen, prescribing Nurse in a GP practice

Chen has been prescribing for patients with atrial fibrillation and would like to expand to prescribe for patients with hypertension.

Reflect

Chen identified a number of patients who needed hypertension reviews while he was seeing them for their atrial fibrillation. As a result, he decided to expand his prescribing scope of practice to treat patients with hypertension.

Chen further defined his inclusion criteria which was to see patients with stage 1, stage 2 and stage 3 but those with malignant hypertension would be excluded and he would refer on to the consultant.

Using the RPS competency framework, Chen identified the competencies that he would have to meet when expanding his prescribing scope of practice. 

Chen plans to focus his learning on:

• Assess the patient
• Identify evidence based treatment options available for clinical decision-making
• Presenting options and reach shared decisions
• Prescribing safely
• Provide information
• Monitoring and reviewing the patient.

Plan

Chen discussed his plan for learning with the cardiovascular lead in his GP practice. He created
a SMART objective:

S – Learn about the patient assessment of hypertension and learn the pharmacological and non-pharmacological treatments

M – Chen plans to shadow a GP colleague for a hypertension clinic. He will also spend time with the consultant cardiologist and specialist nurse in secondary care in their hypertension clinics.

A - This will be achievable with the learning set out by both theory and observing the practical application

R - Chen felt this was a relevant target to achieve

T - Chen felt this was achievable within 3 months

For the final month, he plans to be working autonomously and talking through his hypertens management with his GP Cardiovascular lead.

Act

Reviewed CKS guidance on the management of hypertension, found at: cks.nice.org.uk/topics/hypertension

Reviewed the Hypertension | Treatment summary | BNF content published by NICE

Carried out the course online on the Health Education England website Hypertension - elearning for healthcare (e-lfh.org.uk)

Shadowed the consultant cardiologist and specialist nurse in secondary care.

Shadowed GP with special interest in cardiology in a GP surgery.

Learnt both pharmacological and non-pharmacological treatment options for patients.

Evaluate

Chen reflected on his learning. He felt all his identified competencies had now been met, and he was ready to prescribe in this new prescribing area.

Sarah, Specialist Physiotherapist (part 1)

Sarah is a specialist physiotherapist prescribing for patients with Chronic Obstructive Pulmonary Disease (COPD) as part of a multidisciplinary team. She did her initial prescribing course to prescribe doxycycline and prednisolone.

She would like to expand her prescribing practice to include other antibiotics.

Reflect

Sarah identified COPD patients who were experiencing acute exacerbations, were often needing treatment other than prednisolone and doxycycline.

As a result, Sarah wanted to expand to include other antibiotics, including amoxicillin and clarithromycin.

Reflecting on Domain 1, Sarah felt she had a good understanding of the physiology of COPD. Sarah focused her learning on COPD acute exacerbations management looking at how they would present, investigation, management, monitoring, red flags and safety netting.

Reflecting on the RPS competency framework, Sarah decided to focus on:

• Identify evidence based treatment options available
• Presenting options and reach shared decision
• Prescribe
• Provide information
• Monitoring and reviewing the patient.

Plan

As Sarah had a good relationship with her designated prescribing practitioner (DPP), she created a smart objective.

S – Learn about the pharmacology of amoxicillin, and clarithromycin

M – Prior to prescribing to patients alone, Sarah plans to see patients with her DPP ensuring competence and confidence

A - Provided no external factors impact, this objective is achievable

R - Both DPP and Sarah felt this was a relevant objective

T - She would like to be able to prescribe other antibiotics within two months.

Act

Reviewed local guidance regarding prescribing antibiotics for patients with acute exacerbations of COPD and further looked at Clinical Knowledge Summaries regarding acute exacerbations of COPD.

Looked at various resources with regard to the medicines, e.g. BNF SPC.

Attended online webinars and courses about treating patients with acute exacerbations of COPD.

Organised a series of teaching sessions with junior colleagues with her DPP, to teach about the management of acute exacerbations of COPD.

Treated patients with acute exacerbations of COPD with her DPP shadowing.

Evaluate

Sarah evaluated with her DPP and agreed that her learning needs had been met. Both Sarah and her DPP were happy that she was to prescribe for patients with acute exacerbations. They plan to meet frequently in the initial period to discuss complex patients who Sarah may treat and plan to reduce frequency in time.

Sarah, Specialist Physiotherapist (part 2)

Sarah is a specialist physiotherapist prescribing for patients with Chronic Obstructive Pulmonary Disease (COPD) as part of a multidisciplinary team. She has already expanded her prescribing scope of practice as per part 1. Sarah further identified a gap in prescribing of the medicine, roflumilast, she further expanded her prescribing scope of practice.

Reflect

Sarah identified a need for COPD patients who she was seeing on a regular basis, who were having to
be referred to the consultant for the prescribing of the medicine, roflumilast. As a result, she wanted to further expand her prescribing scope of practice to prescribe roflumilast.

Reflecting on the RPS competency framework, Sarah decided to focus on:

• Identifying evidence based treatment options available for clinical decision-making
• Presenting options and reach shared decisions
• Prescribing safely
• Providing information
• Monitoring and reviewing the patient.

Plan

As in part 1 of the case study, Sarah had a good relationship with her designated prescribing practitioner (DPP), she created a smart objective.

S – Learn about the pharmacology of roflumilast and be able to identify when she will use it in practice.

M – Sarah plans to identify patients who she believes need roflumilast treatment. Sarah plans to identify these patients while seeing patients in the community. She will initially discuss the patients she has identified with her DPP ensuring competence and confidence

A – Provided no external factors impact Sarah, she felt this objective is achievable

R – Both DPP and Sarah felt this was a relevant objective

T – She would like to be able to prescribe other roflumilast within two months.

Act

Reviewed national guidance regarding the use of roflumilast. Looked at the NICE technology appraisal of roflumilast to understand the evidence behind its use.

• Looked at various resources with regard to roflumilast and the contra-indications, cautions, adverse reactions, interactions using the BNF and SPC
• Understand when roflumilast should be initiated as per 1 Recommendations | Roflumilast for treating chronic obstructive pulmonary disease | Guidance | NICE
• Created a decision tool resource, to ensure that patients were appropriately identified for roflumilast and subsequently were initiated and treated appropriately. The decision tool resource included information such as:
  • Indication as per local formulary
  • Recording of initial liver function test and up-to-date weight
  • Patient awareness of risks, side effects and cautions of medication
  • Ongoing three monthly monitoring
• Sarah, had this resource tool checked by the respiratory consultants, nurses, pharmacists and physiotherapists within her health trust and signed off as appropriate.
• Sarah, identified patients who she felt were appropriate for roflumilast treatment, she talked
  through her rationale while using the decision tool resource she created.

Evaluate

Sarah reflected on the competencies she had identified and felt that all competencies were met and she felt confident to start prescribing roflumilast for COPD patients.

Hazel, Therapeutic Radiographer

Hazel is a specialist therapeutic radiographer working in neuro-oncology, assessing, monitoring and prescribing for patients undergoing radiotherapy, chemotherapy and their long term follow up. 

Many of her patients are on anti-seizure medication, for which she already prescribes repeat medication if required during treatment.

REFLECT

Hazel had patients presenting with increased seizure activity and initial seizure likely provoked due to radiotherapy chemotherapy. She wanted to look at the implications around prescribing for these patients.

Hazel identified patients who had to be referred to their consultant or registrar if presenting to Radiotherapy with symptoms likely to indicate seizure activity however, as Hazel moves into her Advanced Clinical Practitioner role she identified a patient need for her to expand her prescribing scope of practice.

Plan

Using SMART objectives Hazel planned the areas to be covered and how this would be achieved.

S – Review the literature around provoked seizures due to neurological tumours and their treatments. Review the pharmacology of clobazam and levetiracetam along with indications.

M – Benchmark against NICE epilepsy guidance, discuss with epilepsy specialist and clinical supervisor.

A – Given prior learning and experience desired outcome should be achievable.

R – Given that Hazel has already been in the situation on several occasions of reviewing patients with increased or new seizure activity it is very relevant that in the future her competence to prescribe would be of benefit to patients and the service as a whole.

T – Aim for informative work to be done in one month and final discussion with clinical supervisor within two months.

Act

Reviewed NICE epilepsy guidelines

Searched for literature regarding provoked seizures in the oncology setting

Reviewed SPC and BNF for clobazam and levetiracetam

Looked at provision of patient information and safety netting

Shadowed epilepsy specialist nurse and attended epilepsy CPD sessions

Evaluate

Hazel met with her clinical supervisor and discussed her findings and concerns regarding the lack of clear guidance in the literature.

There was agreement that prescribing should still take place under the guidance of the epilepsy specialist service but that Hazel has sufficient knowledge of the drugs and safety netting to inform patients and relatives/carers around treatment and to provide a suitable prescription whilst awaiting review by a specialist as per NICE guidelines.

Hazel plans to put together an information leaflet for patients that present with their first seizure or an increase in seizure activity whilst on oncological treatment.

As part of ongoing CPD Hazel will look to follow the outcome of a recent trial and any current additions to the literature with an aim to put together further guidance with the input from an epilepsy specialist.

6. Checklist

References

1. Royal Pharmaceutical Society, 2020. A Competency Framework for all Prescribers. London: RPS

2. Department of Health. 2022. Prescribing by Non-Medical Healthcare Professionals | Department of Health. Available at: www.health-ni.gov.uk/articles/pharmaceutical-non-medical-prescribing [Accessed 3 February 2022].

3. Blot SI, Pea F, Lipman J. The effect of pathophysiology on pharmacokinetics in the critically ill patient — Concepts appraised by the example of antimicrobial agents. Advanced Drug Delivery Reviews. 2014;77:3–11. doi: 10.1016/j.addr.2014.07.006

Declaration

This document is guidance only, and does not guarantee individual prescriber competence, this is the professional responsibility of the prescriber.

Case studies have been adapted for the purposes of this document.