Royal Pharmaceutical Society

Independent prescribing: Navigating the challenges and preparation

by Helen Yohannas

portrait picture of Helen YohannasOvercoming challenges and preparing for independent prescribing

In November 2018 I attended Bath University for CPD Clinical Pharmacy Practice (Primary Care). My plan at the time was to use that foundation to move on to the Independent Prescribing (IP) course, but COVID had other ideas, so that plan got derailed.

By the time I eventually started the course, it felt like a journey that had been a long time coming. However, the Clinical Diploma had done a good job setting me up for the IP course, and I was mentally prepared for the standard and commitment needed.

Navigating challenges and expanding learning opportunities

Overall, the journey has been a roller-coaster of emotions; I did not anticipate how hard it would be to complete the computer assisted learning hours. Nevertheless, working in an independent pharmacy within a doctor's surgery with 16,000 patients allowed me easy access to GPs and nurses, which was a privilege.

I found part one of the course quite easy as I focused on general consultations. Part two was a bit more challenging in terms of watching observations that were relevant to my treatment plan, as my surgery did not have any cardiovascular disease clinic. The requirement for reflective writing made me more intentional when planning to watch consultations, as I didn’t want to sit in on consultations for the sake of counting hours.

Having to adapt in that way allowed me to think outside the box. I asked family members who work in hospitals for access, and managed to spend time in hospital outpatient clinics, which was invaluable and enjoyable.

Acronyms, styles and techniques in Clinical Pharmacy Practice

Thinking back to the beginning of the course, I can’t quite believe how much I have learnt since then. Seeing the theory applied was really beneficial and it was fascinating to watch a range of prescribers/clinicians. One of the main things I came to understand was that they all have their own style and technique and you have to do what works for you.

At the beginning there were many acronyms to take on board, like SBAR (Situation, Background, Assessment, and Recommendation), SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating and relieving factors, Severity), ICE (Ideas, Concerns and Expectations) and the ‘golden minute’. Now, I can confidently apply them in my consultations.

Integration of ABPM and ECG Monitoring within the clinic

In the second part of the course, I did consultations with my designated prescribing practitioner (DPP) observing me. I was given full control over who came into the clinic - since it was my clinic - as the DPP felt I should decide what I would benefit from. The clinic granted me access to SystemOne from the pharmacy, allowing me to schedule patients for 24-hour Ambulatory Blood Pressure Monitoring fittings (ABPM) with their consent. If necessary, I requested my DPP to authorize relevant bloods and ECG. Then I let admin know to alert the patient to book in with a nurse.

Enhanced patient engagement and rapport through clinic bookings

I booked relevant patients into my clinic when they came to collect medications and required a review. Seeing familiar patients eased my nerves, built rapport and created a patient-centred discussion. Again, talking to peers about their experiences made me realise how lucky I was to have such a level of support from my DPP and the multidisciplinary team in the surgery.

Building confidence and progress in consultations

I made significant progress and enjoyed consultations the most. Initially, I planned to follow portfolio requirements with only six compulsory observed consultations with my DPP. I had expected to observe my DPP for the rest of the time, but she explained that I needed to learn on the job, and she would not be there to hold my hand once I become an independent prescriber.

After some wobbly initial sessions, I really started to look forward to them. The hardest part of being observed by your peers is fearing they will judge you because of possibly looking incompetent. Talking to my colleagues in Bath highlighted that we all had the same fears when coming out of our comfort zone.

My DPP gave positive feedback about my consultation style and reassured me that I would become a good IP. It was also comforting to hear patients tell me I had done well after their consultations finished. One patient thanked me for my care, saying I was 'wonderful and reassuring' after I emailed her some support materials.

Challenges and reflections on the prescribing role

What surprised me the most, is how difficult it is being in the prescribing chair. I took for granted how many factors have to be considered when a prescription comes into the pharmacy. My perspective on doctor delays with electronic prescription service (EPS) scripts changed, as I now respect the complexity of prescribing beyond guidelines and protocols.

At times, I had a specific management plan for patients with high 24-hour ABPM readings (stage 2 blood pressure). If a patient declined, I found myself having to formulate an alternative plan. I would second guess myself, asking whether I tried hard enough to convince the patient, or whether I conveyed the implications clearly enough.

I often found myself thinking about consultations once I got home, about patients who had disclosed mental health struggles, loneliness, cancer diagnosis, life struggles, and more. At times it was emotionally taxing.

At the time I had my DPP there, observing and able to intervene, but the burden of responsibility you bear as a prescriber is unsettling, and even some of the experienced GPs questioned their own decisions after the patient had left. I guess that will come with time, but having a level of unease may not be such a bad thing, so I never became complacent.

Lessons learned and the significance of comprehensive patient history-taking

The biggest lesson I have learnt from the observations and talking to a multitude of prescribers is the importance of taking a good, detailed history.

A cardiac nurse and consultant cardiologist both reiterated that, when dealing with any scenario, I need to be sure what the patient is presenting with and be clear I have made the correct diagnosis. They explained that taking a detailed history of the patient will lead you to the correct outcome.

I saw this in practice, particularly when patients came into outpatient cardiology. From a line of enquiry alone, the consultant could distinguish that a patient was not presenting symptoms that were cardiac related. The consultant didn’t have to ask for any imaging/scans and his questions alone made it clear the underlying cause was something else.

My pharmacy gets a lot of Community Pharmacist Consultation Service (CPCS) referrals, so I have applied my history taking skills to my current role. My boss can see the difference in the way I question patients, both on the phone and in-person.

Improving time management and consultation structure

Where I needed to make improvements was time keeping in consultations. Sometimes I went over by 20 minutes and kept patients waiting. My DPP clarified that patients understood the clinics were for training and were forgiving, but getting flustered could lead to upset and rushed outcomes.

I was advised to have a written plan of what I wanted to cover when conducting consultations. This stopped me becoming distracted and made sure I covered everything on my agenda. Patients sometimes came with a multitude of problems, but my DPP explained I had to be firm and explain if a problem was outside of my scope. My DPP explained that once again, this would come with time and experience.

Plans for the future in hypertension management

After I become a prescriber I’m considering a course on hypertension as part of the Imperial College Preventive Cardiology module, which was recommended by a cardiac nurse I observed. I also want to pursue prescribing in the cardiovascular field and become an expert in hypertension.

I would like to run a clinic in the surgery, as part of cardiovascular risk assessment. Currently, nurses do a health check for the surgery, and refer to a GP if medication is required. However, my DPP felt that if I took on that role, it would avoid the need for a GP and free up the nurses for other roles.

I look forward to seeing where this path will lead me!

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