Literature review 

Scope of the literature review

This literature review was conducted in October 2015.

Primary objective: Identify any new competencies or standards linked to non medical and medical prescribing that have been established since the publication of the framework in 2012.

Secondary objective: Identify any relevant research on the application of the competency framework in practice and any gaps identified by the research

Population: Non Medical Prescriber and Medical Prescriber

Settings: Europe, Canada, USA, Australia and New Zealand

Interventions: Standards,Competencies, Competency framework or Continuing Professional Development

Exclusion criteria: Undergraduates, Students  

Search fields: Keyword, Abstract, Title  

Year limit, 2012-2015  

Language limit to English

Databases: Embase , Biomedical reference collection corporate edition ,HMIC Health Management Information Consortium , International Pharmaceutical Abstracts, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) , Maternity and Infant Care PsycINFO, SCOPUS,CINAHL PLUS, Pub Med, PsycARTICLES ,Your [email protected], [email protected],
Keywords:  prescr* and competen*, safe or patient oriented and prescribing, non medical or independent and prescriber , regulation or standards or competency frameworks or professional development or continuing professional development or accreditation and independent or non medical and prescriber*

Summary of key findings

1.0 Introduction 1.0 Introduction

In May 2012 the National Prescribing Centre (NPC) as part of the National Institute for health and Care Excellence (NICE) published a single competency framework (1) for all prescribers. The framework outlined common prescribing competencies which when achieved and maintained would assist all prescribers irrespective of their areas of practice or specialities to remain safe and effective prescribers.

Since its publications there have been several legislative changes pertaining to prescribing including; the introduction of independent prescribing by physiotherapists and chiropodists, the extension of controlled drug prescribing rights to nurses, physiotherapists, chiropodists and pharmacist independent prescribers and the introduction of electronic prescribing for Schedule 2 and 3 controlled drugs as part of Electronic Prescription Service(2).

In addition publications such as the Francis report (3),Keogh (4) and Berwick report (5) and the NICE medicine optimisation guidelines (6) have also shaped the approach to healthcare provision within the UK since the publication of the framework.

As part of ensuring that the prescribing framework continues to cover the key competencies required for prescribers and support the development of prescribers in practice within the changing health landscape a literature review has been undertaken.

This review is aimed at:

  • identifying any new competencies or standards linked to non medical and medical prescribing that have been established since the publication of the single competency framework for all prescribers.
  • identifying any relevant research that has utilised the framework for professional development to identify any potential areas of improvement relating to the use of the framework

2.0 Method 2.0 Method

2.1 Search Strategy

Embase, Biomedical reference collection corporate edition ,HMIC Health Management Information Consortium , International Pharmaceutical Abstracts, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) , Maternity and Infant Care PsycINFO, SCOPUS,CINAHL PLUS, Pub Med, PsycARTICLES ,Your [email protected], [email protected] full text,were searched using the key words:

safe OR patient oriented OR e-prescribing OR medication error OR shared decision making OR de-prescribing AND "competenc*; prescr* AND competen*; non medical OR independent AND prescriber ; regulation OR standards OR competency frameworks OR professional development OR continuing professional development OR accreditation AND independent OR non medical and prescrib* The search was limited to articles published in English from January 2012 to October 2015 and search fields to keyword, title, abstract.

A grey literature search for standards ,competencies and competency frameworks  published since 2012 was also performed in NHS evidence, websites for UK healthcare regulatory bodies- General Medical Council, Nursing and Midwifery Council, General Pharmaceutical Council, General Optical Council, Pharmaceutical Society of Northern Ireland, Health and Care Professionals Council as well as international regulators and professional associations websites within countries of interest identified through the website health regulation worldwide http://www.healthregulation.org/ and Google. 

2.2 Study Design

The target population was non medical prescribers and prescribers with all study designs being considered for review. Studies with interventions involving standards, competencies continuing professional development or competency frameworks for non medical or medical prescribers were included. The review focused on studies from Europe, Canada, USA, Australia and New Zealand. Studies were excluded if competencies were for undergraduate students.

2.3 Results

The search strategy generated 4659 abstracts. Following refinement based on the inclusion and exclusion criteria and removal of duplicates 34 papers were identified as suitable for full text review. 15 papers were selected for the final review including a study identified from the grey literature search. Following discussions with a second reviewer the studies were narrowed to 11. A summary of the studies reviewed is included in Appendix 1. 

Seven of the studies involved were primary research (8-14), 1 study was a literature review (7) of existing healthcare professional framework and 3 studies were expert opinion papers (15-17).

Overall 4 studies (7-10) dealt with the development of competencies or prescribing safety standards independent of the single competency framework, whilst 4 studies(11-14) utilised the framework either for professional development or applied the principles of the framework to the development of their own frameworks or models. The remaining 3 expert opinion papers (15-17) provided a general overview of measures required for safe prescribing or de-prescribing.

3.0 Discussion 3.0 Discussion

3.1 Research Studies

A comparison of the primary research studies that did not refer to the use of the NPC framework revealed that competencies in communication, collaborative care, possessing underpinning knowledge and skills in regulatory and clinical matters and professional development were common themes in most of the studies irrespective of speciality or location. This coincided well with the areas of competency identified within the NPC framework. Similarly the opinion pieces on core competencies for safe prescribing and tips for safe prescribing also covered competencies and approaches to prescribing safely and effectively that were included in the single competency framework and overall no new areas of competencies were highlighted in the studies on comparisons.

There was however a difference in emphasis on certain competency areas within individual studies which are likely to be linked to the demands of areas of practice. In those involving identifying core competencies for practice and ranking the importance of individual competencies demonstrating knowledge of importance of quality of life in relation to discussions of treatment options was ranked as important within oncology practice (10) whereas the ability to decline medication requests to patient and explain lack of prescription ranked high in the list of competencies within GP practice (9). De-prescribing was also listed as core competency in itself separate from other medication related processes such as reviewing medicines (9). See also Appendix 1. A safety critical area that was highlighted in relation to consulting safely within GP practice was the ability to safety net both in face to face interactions and when providing telephone advice (8).

In the case of the literature review (7), in addition to new competencies relating to patient care and knowledge of practice being identified there were additional competencies included relating to interpersonal and communication skills and they entailed demonstrating sensitivity, honesty and compassion in dealing with difficult conversations including those involving disclosure of errors or adverse events

The expert opinion paper on de-prescribing (16) provided a useful framework for initiating the de-prescribing process and included information on when to consider de-prescribing in the elderly beyond identifying those exhibiting adverse effects such as those receiving preventative medicines in cases where disease risk is not increased if stopped. It also covered useful strategies for assisting the de-prescribing process including suggesting a series of questions patients should be empowered to ask including what would be considered reasonable grounds for the discontinuation of the use of a drug. By encouraging patients to initiate the conversation on the de-prescribing process they are invited to participate in the shared decision making process.

In relation to the use of the framework and its principles the study published by the parenteral nutrition safety task force for the American Society for Parenteral and Enteral nutrition (13) specifically cites and lists the competencies relating to the domain on prescribing effectively as being relevant to parenteral nutrition prescribing demonstrating the general applicability of the framework in different areas of practice and its recognition beyond UK based practice. The study on the national antimicrobial prescribing and stewardship competences that were published in 2013 for non medical and medical prescribers (11) also indicates that its design was aimed at complementing the generic single competency framework thereby also reinforcing its overall use to support prescribing practice across specialities. On a local level an example is provided on how a previous version of the framework was used to design a local framework to address a specific gap in a given area of practice intravenous fluid (12) thereby demonstrating the versatility of the framework to enable mapping the competencies to specific areas of practice. Finally the study on maintaining competence for non medical prescribers (14) highlights a range of useful tools that were mapped against the framework and used to assess competence thereby demonstrating how its use can be practically implemented in practice to support professional development.

3.2 Grey Literature

As most of the content within the competency frameworks and standards was already covered in the current single framework a summary highlighting areas of interest identified from selected document has been provided below:

3.2.1 PATIENT CENTRED CARE

Patient centred care characterised by empathy and compassion was a common theme in most of the competency frameworks (18, 19, 20). Exploring patients’ concerns and expectations, which may not be limited to just the medicine but also the consultation, their health, their own role and that of the health care professional in managing their health and use of other treatments, as part of patient centred care was highlighted within the National Prescribing Service framework (19)

3.2.2 PROFESSIONAL VALUES AND BEHAVIOUR

Demonstrating openness and transparency (professional duty of candour) in interactions with patients was also a common theme in both the capability frameworks (18) and the code for nurses and midwives(21). Ensuring professional behaviour is exhibited when using communications involving technology is highlighted both in the Canadian competency framework (20) and the NMC code for nurses and midwives (21).

3.2.3 TECHNOLOGY

The CanMEDS framework (20) identifies the need for communication competency in providing “information on assisting patients and their families in identifying, accessing and making use of information and communication technologies that can support their care and manage their health”. In relation to technology for the healthcare professional the framework also highlights the need for competency in “use of health informatics to improve the quality of patient care and optimize safety”.

Within the NHS (England) there is a drive to use technology to empower patients and their carers to take ownership of their health through the provision of information, support and access control (22). Proposals such as ensuring patients have access to their full health care records and the use of accredited healthcare apps as part of the prescribing process and information service could require the development of new skills and knowledge by prescribers to cope with the changing landscape.

3.2.4 SAFETY

An understanding of principles relating to human factors and practice has also been identified both by the NMC code of conduct (21) and the GMC capability framework (18) as elements for ensuring patient safety.

3.2.5 LEADERSHIP

Leadership and health advocacy are also identified as roles within the CanMEDS (20) practice framework with their own competencies with contributing to a culture of patient safety identified as a competency for leadership and as part of the health advocacy role the prescriber aiming to incorporate disease prevention, health promotion and surveillance in his interactions with patients. The advanced nurse practice framework also recognises leadership as a core competency area. (26)

3.2.6 THE CONSULTATION

As part of obtaining a medication history and providing information to patients the GMC guidance on prescribing medicines and medical device (23) has expanded on these two points to suggest enquiring about the purchase of online medication and illicit medicines and in addition to advising patients on the risk and benefits of treatment including information about the burden. In addition as part of reporting ADR the guidance also suggests patients should be provided information on how to report this directly to MHRA.

In relation to remote prescribing the guidance suggests considering issues around remote prescribing such as limitations of the medium, need for physical assessment, access to patient notes (23). The practice standards for consultation skills for pharmacy professionals (24) have included as a core competency in relation to this on ” recognising how consultations undertaken via remote media (telephone & email) differ from face to face and being able to demonstrate skills to compensate for this”

As part of personal accountability when working in collaboration with colleagues the GMC prescribing guidance (23) also highlights the need to ensure if prescribing on the recommendation of a colleague you operate within your limits of competency and similarly when exercising your share of clinical responsibility as part of shared care prescribing .

3.2.7 MISCELLANEOUS

As part of the update of the 2005 physician competency framework CanMEDS by the Royal College of Physicians and Surgeons of Canada the concept of milestones was introduced (27) which are termed as “descriptions of the abilities expected of a trainee or physician at a defined stage of professional development.” The benefits identified for their use are; it would lead to a focus in learning and development activities for learners , mark progression in competency for the entirety of the physicians career, provide defined targets to guide learning and activity and allow assessors to gauge when learners were ready to progress to the next stage of development.

A similar format has been applied to competency frameworks designed for individual healthcare professions in the UK e.g. RPS advanced pharmacy framework with similar competency areas in use e.g. working with others/collaborative practice. Where these frameworks exist although not specifically targeted at prescribers they could provide an additional resource for their professional development similar to the process implemented in Canada when used in synergy with the prescribing framework.

It’s worth noting that the updated GMC prescribing guidance has updated its own definition of prescribing to include medical devices, dressing and providing advice to patients on the purchase of OTC medicine and advises relevant principles to be applied appropriately.

4.0 Limitations 4.0 Limitations

A limited number of research studies on new or revised competency frameworks that were linked to prescribing since 2012 were identified and those that were identified were predominantly aimed at the medical profession. Similarly few studies involving the use of the NPC framework were identified however as it is designed to underpin curricula and legislative changes and for professional development it may be the case that although it’s currently in use in many settings there are currently no research drivers for its use to be reported. It may be the case with the implementation of revalidation for other healthcare professionals excluding medical prescribers we may see an increase in information about its use by non medical prescribers.

5.0 Conclusion 5.0 Conclusion

A comparison of the single competency framework for prescribers against the competency frameworks from Canada, Australia, France, USA, Northern Ireland, Great Britain reveals that common areas of competency exist irrespective of the type of prescriber involved and that the current framework is still relevant and robust.

6.0 References 6.0 References

6. References

  1. National Prescribing Centre. A single competency framework for all prescribers.  2012
  2. Royal Pharmaceutical Society. Medicines ,Ethics and Practice professional guide for pharmacists 39.2015
  3. Francis R .Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry – Volume 3: Present and future. (2013).
  4. Keogh B Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report (2013)
  5. Berwick D  A promise to learn - a committment to act: Improving the Safety of Patients in England (2013)
  6. NICE Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (2015)
  7. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Academic Medicine: August 2013 - Volume 88 - Issue 8 - p 1088–1094 [Accessed 13th October 2015]
  8. Bowie P,McKay J, Kelly M.Maximising harm reduction in early specialty training for general practice: validation of a safety checklistBMC Family Practice.13:62, 2012.[Accessed 12th October 2015]
  9. Fournier JP, Escourrou B,Dupouy J, Bismuth M, Birebent J, Simmons R,Poutrain JC;  Oustric S.Identifying competencies required for medication prescribing for general practice residents: a nominal group technique study. 2014 BMC Family Practice.15:139 [Accessed 12thOctober 2015]
  10. K. Benstead , C. Palmieri , A. Brewster , D. Gilson,  P. Jenkin , J. Booth The minimum competencies in non surgical oncology that medical students need to acquire in order to be safe foundtion year 1 doctors delphi survey. 2015 Clinical oncology 27 (2015) 373-379[Accessed 12th October 2015]
  11. D. Ashiru-Oredope, B. Cookson and C. Fry on behalf of the Advisory Committee on Antimicrobial Resistanceand Healthcare Associated Infection Professional Education Subgroup Developing the first national antimicrobial prescribing and stewardship competencies Journal of Antimicrobial chemotherapy. 2014 Nov;69(11):2886-8 [Accessed 12th October 2015]
  12. Fecher I , Knight J Emerg Nurse.A framework for independent prescribing of IV fluids . 2012 Nov; Emergency Nurse 20(7):30-4.[Accessed 12th October 2015]
  13. Guenter P ,Boullata JI , Ayers P , Gervasio J , Malone A , Raymond
  14. E, Holcombe B, Kraft M, Sacks G, Seres D; Parenteral Nutrition Safety Task Force, American Society for Parenteral and Enteral Nutrition(A.S.P.E.N.). Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Parenteral and Enteral Nutrition Model.2015 Nutrition in Clinical Practice. 2015 Aug;30(4):570-6 [Accessed 12th October 2015]
  15. Caddye W S and Clair-Jones A . Re-accreditation of non medical prescribers maintaining competence .2015 British Journal of Nursing. Jun 25-Jul 8;24(12):640-3 [Accessed 12th October 2015]
  16. Lum, Elaine, Mitchell, Charles and Coombes, Ian The competent prescriber: 12 core competencies for safer prescribing (2013)Australian Prescriber, 36 1: 13-16 [Accessed 12th October 2015]
  17. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D,Gnjidic D, Del Mar CB, Roughead EE, Page A Jansen J, Martin JH.Reducing inappropriate polypharmacy The process of deprescribing. .JAMA Intern Med. 2015 May;175:827-34 [Accessed 12th October 2015]
  18. Duncan Robert Petty.Ten tips for safer prescribing by non-medical prescribers May 2012,Nurse Prescribing, Vol. 10, Iss. 5, 10  pp 251 - 256 [Accessed 12th October 2015]
  19. General Medical Council and Academy of Medical Royal Colleges (2015) Developing a generic capability framework
  20. National Prescribing Service Limited. Better choices, Better health. Competencies required to prescribe medicines: putting quality use of medicines into practice. 2012:
  21. Frank JR, Snell L, Sherbino J, editors. The Draft CanMEDS 2015 Physician Competency Framework – Series IV. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2015 March
  22. Nurse and Midwifery Council (NMC) The Code :Professional standards of practice and behaviour for nurses and midwives 2013
  23. Department of Health Personalised Health and Care 2020: Using Data and Technology to Transform Outcomes for Patients and Citizens A Framework for Action 2014
  24. General Medical Council. Good practice in prescribing and managing medicines and devices 2013
  25. Health Education England and Centre for Pharmacy Postgraduate Education 2014 Consultation skills for pharmacy practice:practice standards for England for all pharmacy professionals.2014
  26. Royal Pharmaceutical Society Advanced Practice Framework 2013
  27. DHSSPSNI Advanced nurse practice framework : Supporting advance nursing practice in health and social care trusts .2014
  28. Frank JR, Snell LS, Sherbino J, et al. Draft CanMEDS 2015 Milestones Guide – September 2014. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2014 Miriam Gichuhi - Pharmacist Consultant Appendix 1 The Single Competency Framework for Prescribers. Proposal for the inclusion of a ‘deprescribing’ competency

Proposal

  • To include a specific and explicit competency around ‘deprescribing’ in the revised single competency framework for prescribers, as part of a wider education-based strategy to contribute to culture change around medication review and deprescribing.

Background and rationale

  1. Polypharmacy has become more prevalent and can be categorised as ‘appropriate’ or ‘problematic’ polypharmacy1
  2. Many patients have several co-morbidities.  If each of these is treated according to  national guidance, patients may end up taking a complicated cocktail of drugs1
  3. As a health system we are often hesitant to stop medicines2
  4. Our work has identified examples of medicines that can be straightforward to review and perhaps ‘hold’ with a view to stopping if appropriate.3  Examples include proton pump inhibitors and quinine sulphate
  5. Little attention has been paid to the need to educate undergraduate and foundation clinicians about medication review and deprescribing, with an absence of learning outcomes and competencies for the prescribing professions.  Recognition of the need for appropriate education has recently emerged4,5
  6. We have identified that junior doctors are often reluctant to stop medicines that have been prescribed by seniors3,6 and that they are often unaware of medication review tools that may help them6
  7. Literature and initiatives to support this proposal
  8. The literature around medication review has grown significantly in the last 5 years
  9. The term ‘deprescribing’ is becoming more prevalent,5 including a website with this name and a Wikipedia entry
  10. CLAHRC NWL has establish what we believe is the first ‘bottom up approach to education in medication review and deprescribing’6
  11. Possible competency statements
  12. A competency must be underpinned by appropriate learning around how to review and stop medicines, for example using deprescribing algorithms.5 A number of us suggest that the term ‘deprescribing’ has merit for common use7 but if not used, this term should be taught as part of prescribing training, with mention in appropriate learning outcomes.8 Here are some possible competency statements for consideration in the single competency framework for prescribers:
  13. Reviews and holds or stops inappropriate medicines when appropriate
  14. Demonstrates the ability to ‘deprescribe’ appropriately
  15. Considers when a medicine should be reviewed having newly prescribed it
  16. Ensures that medicines are reviewed and where appropriate, held or stopped
  17. Conducts effective medication reviews and identifies medicines that could be held or stopped
  18. The wider CLAHRC NWL educational strategy within which our proposal sits
  19. Medication review/deprescribing teaching in the undergraduate pharmacy degrees at King’s College (KCL) and University College London (KCL), with an appropriate examination question (started 2015)
  20. Learning outcome included in the curriculum for foundation pharmacists at the UCL/KCL foundation school (2015)
  21. Learning outcome suggested to the Imperial College Medical school and to be suggested to the KCL and UCL medical schools (discussions ongoing)
  22. Curriculum statement and examination question suggested for the ‘safe prescribing examination’ for doctors (discussions on going)
  23. A themed issue on ‘deprescribing’ in progress for 2016 for the European Journal of Hospital Pharmacy
  24. Suggestion to the new Journal of Medicines Optimisation to extend its scope to include education around medicines optimisation issues (discussions ongoing)
  25. Future initiatives include approaching medical foundation schools, schools of nursing and allied health professions to promote ‘the bottom up approach to education in medication review and deprescribing’; and to ensure that ‘top down’ education is not neglected

References (all online articles accessed 20.10.15)

  1. Duerden et al. Polypharmacy and Medicines Optimisation.  Making it safe and sound.  The King’s Fund 2013
  2. Cahill L. Polypharmacy and deprescribingPresqipp 2014 
  3. Abdul-Saheb et al. Intermediate Care. Geriatric Medicine 2014 
  4. Duerden et al. Regular review is needed for medicines optimisationPrescriber 2015
  5. Scott et al. Reducing inappropriate polypharmacy.  The process of deprescribingJAMA 2015
  6. Jubraj et al. A pilot survey of junior doctors’ attitudes and awareness around medication review: time to change our educational approach? European Journal of Hospital Pharmacy 2015 
  7. Alldred, D.P.. Deprescribing: a brave new word. International Journal of Pharmacy Practice 2014, 22, pp. 2–3
  8. UCL School of Pharmacy Postgraduate Diploma in General Pharmacy Practice Foundation Stage 2 learning outcomes document 2015 (unpublished)

Barry Jubraj, Clinical Senior Lecturer in Medicines Optimisation, King’s College London, and Honorary Pharmacist for Medicines Optimisation, NIHR CLAHRC NW London, November 2015

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