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).
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.
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.
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 .
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.