Education for new prescribers: a summary of the proceedings of a symposium held at The British Pharmacological Society, December 2005

Chair's Introduction

This symposium was organized as a collaborative venture between the Education Subcommittee and Clinical Section Committee of the British Pharmacological Society in recognition of the slow but steady advent of nonmedical prescribing in the UK, which has created significant opportunities for improved medicines management, together with a crucial responsibility to ensure that new prescribers are appropriately prepared and competent. The intention was to provide a programme that would update Society members on recent developments in the provision of prescribing powers to nurses and other health professionals, and to advertise the Society and its resources to those with a special interest in pharmacology education for new prescribers, who are not currently members of the Society. To this end, the symposium programme focused first on context and then on content. It commenced with a brief history of the extension of prescribing rights (M.A.), followed by an analytical description of an innovatory e-learning programme designed to meet the education-for-prescribing requirements of people from a wide range of health professions (M.B. and M.A.) and an account of related issues and resources from a medical perspective (S.M.). [The DVD referred to in the symposium has since received a gold award from the International Visual Communications Association (presented 25 March 2006).] The second part explored ways in which pharmacology education can be delivered effectively for new prescribers with a limited background in chemistry (H.L.L.), with particular focus on drug interactions and cytochrome P450 (M.L.). This paper provides an overview and summary of the papers, with particular emphasis on the e-learning project.

The extension of prescribing rights

The movement towards what is now referred to as nonmedical prescribing started more than 25 years ago, when the Royal College of Nursing reported on the problems district nurses experienced when trying to obtain dressings [1]. A review of community nursing subsequently identified the time wasted by experienced district nurses waiting for doctors to sign prescriptions for dressings and appliances. The report proposed that qualified community nurses should be allowed to prescribe from a limited list of products, which included medicines, dressings and appliances [2]. Subsequently, the Medicinal Products: Prescription by Nurses, etc. Act 1992 was passed, allowing nurses to prescribe products included in the Nurse Prescribers Formulary. Following evaluation of pilot sites, ‘nurse prescribing’ was rolled out nationally in 1998 and all nurses who held a district nursing and or health visiting qualification became eligible for training to prescribe from that formulary.

Further reviews and consultations [3, 4] led to announcements of Supplementary (formerly ‘dependent’) prescribing [5] being introduced for pharmacists and nurses in 2003 and for other Allied Health Professionals (optometrists, physiotherapists, podiatrists and radiographers) in 2005; then Extended Formulary Nurse Prescribers and pharmacists were authorized to prescribe from most of the British National Formulary (BNF). These rapid developments have necessitatedcareful review of the education required to sustain the implementation of nonmedical prescribing.

The development of interprofessional education for prescribing

At the beginning of 2004 the three strategic health authorities in the North-west of England recognized variability in approach to teaching and assessment, and therefore in student experience, across the nine Higher Education Institutions (HEIs) engaged in the preparation of nonmedical prescribers, even though the syllabus had been developed centrally by several key stakeholders. This was clearly not ideal. Indeed, the need for a different educational approach had been identified more than 10 years ago [6]. Additionally, a growing realization that ‘service’ was struggling to release staff for the required number of days gave impetus to the development of an alternative approach to delivering the syllabus for new prescribers.

Opportunely, the HEIs within the North-west region (University of Chester; St Martins College, Lancaster; University of Central Lancashire; John Moores University, Liverpool; Liverpool University; Manchester Metropolitan University; Salford University; Edge Hill College, Ormskirk; Bolton University) had already established a collaborative working group to share best practice on objective structured clinical examination in prescribing courses, and this group widened its remit to explore an alternative means of delivering the course. They quickly identified the need to use an e-learning approach to deliver generic principles that would be applied in practice by each of the professional groups. Potential problems of professional possessiveness and professional identity [7] were circumvented by fostering a new group identity: higher education providers in the North-west of England.

In partnership with a local multimedia company (e Origen.com), a DVD/website hybrid package was developed. This allows high-quality, multimedia-rich teaching materials to be accessed by each student and web links to key policy documents to be updated on a central server, thus ensuring the currency of the content. The package enables each HEI to adapt the materials to its learning environment. Most have signalled the intention to use a blended learning approach, but the materials can be utilized solely within the classroom or to support distance learning.

The program's instructional design was informed by Salmon's Five Step Model for effective learning (Step 1, Access and motivation; Step 2, Online socialization; Step 3, Information exchange; Step 4, Knowledge construction; Step 5, Development) [8]. Access to the materials and motivation to learn were promoted through the use of a highly interactive and multimedia-rich content which functions independently of the various and often incompatible virtual learning environments adopted by the individual institutions. To be effective, it had to be welcoming and encouraging, and, anticipating the mixed IT abilities of the students, it also had to be simple to use. On-line socialization is facilitated through a blended learning approach, which employs initial introductory days where the cohort begins socializing and bonding, and where the online discussion board and supporting university intranet is introduced. The e-learning is then reinforced regularly by intermittent consolidation days when students are brought together to discuss key points and critique key exercises. Salmon's stage 3, information exchange, is promoted through the various learning materials contained within the DVD, including engaging video scenarios, audio commentary, web links and formative multichoice questions. The students are required continually to take the generic principles illustrated in the video scenarios and text-based learning and apply them through reflective and practical exercises within their own area of practice. The knowledge construction step encourages the students from various professions and lecturers to interact with each other, with the ensuing dialogue encouraging deep learning and conceptual change [9]. Finally, development is consolidated and assessed though a corresponding reflective exercise portfolio, via further multichoice questions, and ultimately through separate summative assessment set by the student's own HEI. This whole process encourages constructivism, which involves students' investigation of their own thoughts and knowledge accumulation process [8].

It quickly became apparent that the server-based library of documents could be expanded to form a domain website (http://www.nmplearningnw.org) with a public access section. Such a site allows the provision of useful precourse information, a central access point for application forms, HEI contact details and, eventually, a focus point for an e-learning community for prescribing.

An interprofessional approach to the prescribing course was adopted following careful consideration of both the potential advantages and publicly expressed reservations about the efficacy of interprofessional education [10, 11]. Since its adoption it has been welcomed widely by students, service managers and the majority of designated medical practitioners.

Evaluation

Although it remains early days in piloting the materials, the project has already proved successful in facilitating interprofessional understanding between staff of the HEIs and between students from nursing, pharmacy, physiotherapy and podiatry backgrounds (radiographers have yet to be recruited). Initial evaluation of the standardized provision and interprofessional approach indicates that such working requires facilitation and practice. There is still little evidence that interprofessional education improves care in practice [12], with the assumed benefits of collaboration [13] having been inferred by reference to its absence [14]. Regardless of the quality of the teaching materials available, effective interprofessional learning requires that students suspend their own professional ideologies and socialization, with which come ascribed or perceived status. This is proving challenging to facilitate, with certain professional groups being unwilling initially to accept another's right to access and ‘own’‘their’ occupational knowledge and the perceived authority of that knowledge, even though all students agreed that the ultimate aim was improved medicines management and effective therapy.

Related issues and resources from a medical perspective

The current interest in initiatives that will consolidate the education of new prescribers should be welcomed by those charged with delivering similar learning opportunities to medical students and junior doctors. Safe and effective prescribing has always been a core competency required of all doctors from graduation onwards, requiring a firm grasp of the disciplines of pharmacology, clinical pharmacology and therapeutics [15]. These skills are particularly important given recent trends such as (i) increased use of medicines in both primary and secondary care, (ii) new drug developments that continuously create novel prescribing indications, (iii) increasing complexity of drug use, (iv) an increasing focus on elderly patients, who are more vulnerable to adverse effects of drugs, and (v) increasing litigation [16]. These pressures have probably contributed to the apparently rapid increase in harm from adverse events related to drug therapy and medication errors [17], yet they also coincide with widespread concerns about the extent to which graduates are prepared by medical schools to assume their responsibilities as prescribers [16, 18, 19].

The publication of Tomorrow's Doctors by the General Medical Council (GMC) in 1993 was extremely influential in reshaping undergraduate curricula, with a move away from teaching individual scientific disciplines towards a more integrated curriculum [20]. Its key objectives were, however, to improve integration with system-based learning and to eradicate the disciplinary and preclinical/clinical divide. One consequence of the seamless integration proposed by Tomorrow's Doctors was the loss of dedicated courses in a variety of established disciplines, including pharmacology, clinical pharmacology and therapeutics. Indeed the guidance stated explicitly that it ‘avoided all reference to traditional subjects and disciplines…. urging the advantages of interdisciplinarity’ (Para. 42). This position substantially weakened the support for retention of pharmacology, clinical pharmacology and therapeutics as recognizable disciplines in many medical schools. In consequence, many abandoned assessed courses or modules in pharmacology, clinical pharmacology and therapeutics that tackled generic issues relating to the use of drugs in a variety of clinical settings. Instead, learning about drugs has been devolved to system-based components of the medical curriculum. The consequence of this change has been low visibility within the curriculum, with too many drugs being introduced within clinical modules, no clear prioritization (and occasional disputes) as to core learning about drugs, a lack of coordination between basic science and clinical teaching, and no source of concise information about the core drugs. Objective feedback from Post-Registration House Officers in Edinburgh has shown that they felt inadequately prepared to prescribe, and similar concerns have been expressed elsewhere by students and teachers [18, 19, 21, 22]. The GMC published a revised version of Tomorrow's Doctors[23] in July 2002, which provided rather more direction about teaching and assessment of therapeutics [24].

Although there is a clear consensus that medical graduates must be safe prescribers, it is less clear how that outcome can best be achieved. Little support exists for the re-emergence of pharmacology or therapeutics as specific courses in the medical curriculum. The real challenge now is to deliver these learning objectives within the framework of an integrated discipline-free curriculum. The Clinical Section of the British Pharmacological Society recently published some guidance on this matter [25] and highlighted the importance of both prioritizing learning around a core list of commonly used drugs (a ‘student formulary’) and enthusiastic leadership.

The systematic medicines-centred educational approach adopted by those charged with delivering competency to new prescribers, often in a relatively limited period and to learners with a more limited background in biomedical sciences, could offer some useful pointers for UK medical schools. There are now too few clinical pharmacologists to take a lead individually in all of our schools but, since most have their own virtual learning environments, there is now an opportunity to provide e-learning materials of the style described above. There are some promising initiatives underway, but it may be more efficient to coordinate such a development at national level involving key stakeholders such as the Department of Health, National Prescribing Centre and the British Pharmacological Society. Such an approach has been developed by the National Prescribing Service in Australia and runs successfully, providing learning materials for medical students, doctors and pharmacists [26].

Pharmacology education for new prescribers with limited background in chemistry

The introduction of extended, independent and supplementary prescribing for nurses and the impending extension of prescribing powers to other health professionals has brought very much to the fore the challenge of enabling students from these professions to obtain a secure grasp of the principles of pharmacology without basing it on any assumed understanding of chemistry or biochemistry. This paper provided a distillation of insights gained and teaching approaches honed during the author's long career in pharmacology education for medical and nursing students, in the hope that it will help others engage effectively in the education of new prescribers. As explained in previous work on this topic [27, 28], the limited familiarity of most nurses with chemistry is the greatest cause of their anxiety in approaching the study of pharmacology, and yet it is unrealistic to argue the case for this subject to be a prerequisite to a career in nursing. The content of any course needs, therefore, to be based on taking a pragmatic view of the need to meet students where they are: making creative use of domestic analogies and images to illustrate pharmacological principles, and respecting and building on the wealth of clinical experience of the prescribing students, particularly in the administration of medicines, while expecting little in the way of bioscience background knowledge. The students may have little idea of what, for example, an ACE, a β-receptor or a proton pump is that is being blocked or inhibited by the medicines their patients are taking, but they do have accurate knowledge about routes and frequency of administration. A logical place to start building their understanding of pharmacology is therefore with the administration of medicines.

It was found helpful, nevertheless, to precede this with some discussion of the classification and naming of medicines, and to take a look at a recent edition of the BNF to see how this standard reference book is constructed. This provided an ideal opportunity to spot some of technical terms such as agonist, competitive antagonist, enzyme inhibitor and enzyme inducer with which the students were unfamiliar, but which need to be understood before the content of the BNF can be as meaningful as it needs to be to support safe prescribing.

This familiarization stage served to provide motivation to engage with topics that were found difficult initially. With that stage completed, it has been found effective to work through a generic pharmacological profile, explaining what needed to be explained and reinforcing and contextualizing knowledge that was already held. The unconventional sequence of topics, with sections on actions and effects and mechanisms of action located between the sections on administration, absorption and distribution and those on metabolism and elimination, is the same as has been adopted in a nursing textbook [29]. This has been found appropriate for nurse education, partly because it reflects the sequence experienced in clinical practice of drugs being administered, producing effects and then being inactivated and eliminated, and also because the discussion of pharmacodynamics between pharmacokinetics sections provides an opportunity to return to relatively familiar ground of actions and effects after the unfamiliar topics of passage of drug molecules across cell membranes and the concept of plasma protein binding, and before the most challenging topic of drug metabolism. Furthermore, this sequence, derived empirically for courses delivered through weekly classroom sessions, has served equally well to support concentrated attention in intensive single-day sessions provided to support a prescribing course, in which pharmacology is studied mainly in distance learning mode.

The paper has focused mainly on ways of engendering understanding of administration, absorption and bioavailability and of drug–receptor interactions to provide an explanatory account of ways in which familiar concepts can be harnessed to help make pharmacological principles readily, and reasonably accurately, accessible to students on prescribing courses without reference to chemical terminology with which they are unfamiliar. Furthermore, the following paper was planned to cover cytochrome P450 and drug interactions. It was concluded that it is possible to provide material that enables students to grasp a wide range of fundamental pharmacological concepts without using chemical formulae or assuming background knowledge of chemistry and that this represents an important and valid way to approach pharmacology education for new generations of prescribers.