Training and assessing independent nurse prescribers: a model for old age psychiatry

AIMS AND METHOD 

The brevity of training and assessment for independent nurse prescribers has caused some concern. We aimed to validate an Objective Structured Clinical Examination (OSCE) for potential nurse prescribers in dementia. Nurses’ performance after 12 days of training for potential prescribers was compared with that of doctors of different grades.

RESULTS 

The performance of doctors, but not nurses, correlated with years of experience. Many nurses, especially those working in memory clinics, scored better than junior doctors.

CLINICAL IMPLICATIONS 

This OSCE provides evidence of potential prescribers’ competency for employers. This could make a significant contribution to maintaining high standards of patient safety with nurse prescribing. This may also be an appropriate addition to the assessment of specialty trainees as well as for revalidation.

The brevity of training and assessment for independent nurse prescribers has caused some concern. We aimed to validate an Objective Structured Clinical Examination (OSCE) for potential nurse prescribers in dementia. Nurses' performance after 12 days of training for potential prescribers was compared with that of doctors of different grades.

RESULTS
The performance of doctors, but not nurses, correlated with years of experience. Many nurses, especially those working in memory clinics, scored better than junior doctors.

CLINICAL IMPLICATIONS
This OSCE provides evidence of potential prescribers'competency for employers. This could make a significant contribution to maintaining high standards of patient safety with nurse prescribing. This may also be an appropriate addition to the assessment of specialty trainees as well as for revalidation.
Legislation in the UK now permits independent prescribing by nurses and pharmacists from the full British National Formulary (BNF) 1 excluding most controlled drugs. 2 Previously independent prescribers utilised the Nurse Prescribers Extended Formulary. The Nurse Prescribers Extended Formulary no longer exists, as all extended formulary nurse prescribers have become 'nurse independent prescribers' and can now prescribe from the full BNF, within their area of competence and if approved by their employer. A 2006 Drugs and Therapeutics review 3 of non-medical prescribing expressed concerns about safety, the brevity of prescribing training for nurses, the potential for drug interactions and the possibility of prescribing outside areas of competence or expertise. Avery & Pringle 4 raised concerns that current training for nurse prescribers is too short to fully equip a professional for independent prescribing practice. They highlighted that additional training and support is needed after a basic prescribing training programme.
The Nursing and Midwifery Council (NMC) published Standards of Proficiency for Nurse and Midwife Prescribers 5 that will allow them to write both National Health Service and private prescriptions. This document also details the content of the proposed programme of education to achieve NMC proficiencies as a nurse prescriber as well as their standards for assessment. However, their proposal omits any didactic, subjectspecific training requirements. They suggest a minimum 26-day programme of teaching about generic prescribing at a higher education institute with just 12 additional days of supervised learning in practice. For distance learning there must be a minimum of eight face-to-face taught days or, if this is not possible, video conferencing is an alternative. There is no mention of any further supervised practice once on the NMC register as an independent prescriber and no subsequent reappraisal of fitness to practice. The only mention of continuing professional development states that it is 'your responsibility to remain up to date with the knowledge and skills to enable you to prescribe competently and safely'. 5 How does an employer satisfy themself of a nurse's competency? The Department of Health document Improving Patients'Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing 6 emphasises that the period of learning in practice will be directed by a designated medical practitioner. They are responsible for assessing and signing off satisfactory completion of the period of learning. The National Prescribing Centre document Training Non-Medical Prescribers in Practice 7 helps these supervising doctors by providing a competency structure including clinical and pharmaceutical knowledge that is expected of potential prescribers. Can competency be assessed after only twelve 6.5 h days with a potential prescriber, particularly when most of the time is to be spent as a learning experience? How much of this assessment will be by direct observation of the skills and knowledge of the potential prescriber? Will a 26-day generic nurse prescribing course be able to provide adequate knowledge of pharmacology, history-taking, physical examination, initiating and interpreting appropriate investigations, diagnostic reasoning and therapeutics? What alternative options are available to supplement these generic courses and provide subjectspecific training? To answer some of these questions, we developed an Advanced Dementia course to provide subject-specific training to supplement the generic training overseen by the NMC. We then developed an Objective Structured Clinical Examination (OSCE) to assess whether, at the end of the course, participants were of a standard that the Trust could be confident was adequate for independent prescribing.
Our objective was to explore the validity of an OSCE designed to assess the competency of nurse prescribers in old age psychiatry.

Method
A twice-yearly Oxford Advanced Dementia course was developed to expand on the generic training available to potential independent prescribers working in old age psychiatry in the Thames Valley region. The course lasted 1 day a week for 12 weeks and was funded partly by a grant from the strategic health authority and partly by pharmaceutical (industry) sponsorship. As well as offering lectures to the 16 participants covering practical prescribing, history-taking, cognitive examination, differential diagnosis and pharmacology, it focuses on the development of practical skills. In sessions led by experienced consultants, the participants practised dealing with drug treatment-specific scenarios such as explaining the action of drugs, discussing treatment options and dealing with the disappointment of poor treatment response. Through role play with actors who had become experienced in the issues, nurses could develop these more advanced practical skills as well as practising basics such as taking a relevant history and cognitive examination. Non-medical challenges that should be routinely addressed in dementia such as discussion of powers of attorney, advanced directives and driving were also included.
Five cohorts of participants have attended the course, of which three culminated in the OSCE exam consisting of eight stations covering a variety of common clinical scenarios. These include history-taking, practical prescribing of cholinesterase inhibitors, dealing with sideeffects and treatment failure, telling a patient they should stop driving, discussion about cholinesterase inhibitors with a general practitioner and discussion about genetic risk. Attendance at the exam was not compulsory and those attending were a self-selected group. All the participants would potentially qualify as suitable to attend an independent prescriber course and understood that the purpose of the course was to help them feel confident enough to take this on. Some, however, were not intending to go on to become nurse prescribers.
In order to validate this process, we compared results of nurse participants in the same examination with volunteer doctors ranging from senior house officers to consultants. The number of years experience in old age psychiatry for each candidate was noted. All three specialist registrars and one of the three staff grade doctors had also attended the course along with the nurses. None of the seven senior house officers or the five consultants taking the exam had attended the course. All doctors were practising in old age psychiatry. The nurses taking the exam included community psychiatric nurses, ward managers and memory clinic nurses.
A structured marking schedule typical of OSCEs was used for each of the eight stations. Three scores were awarded. The first was awarded by examiners for topics discussed and information elicited (the content score) and the second scores were given for overall impression and for communication ability (the communication score). Finally, the actors also scored each delegate based on their own view of the communication style and clarity of information imparted (the actors' score). Grades were awarded based on the number of OSCE stations passed. The total score needed to pass an individual OSCE station was 50%. If six out of eight were passed, it was judged that they were already practising at a level expected of a nurse prescriber. Four or five passes was equivalent to the level expected of a competent community psychiatric nurse in old age psychiatry with some in-depth knowledge of prescribing, but less than that expected of an independent prescriber. Less then four stations being passed resulted in a fail. with 50% of all nurses passing at 'nurse prescriber' level following the course. Memory clinic nurses passed more stations (mean 6.2) than community psychiatric nurses (mean 4.3) or in-patient ward managers (mean 4.6). This was reflected in the pass rates with 80% of memory clinic nurses passing at nurse prescriber level compared with 40% of ward managers and 37.5% of community psychiatric nurses. The mean number of stations passed by nonconsultant doctors was 5.3, with consultants bringing the mean score of all doctors up to 6.1. The mean score of 4.9 for senior house officers and 4.3 for staff grade doctors may reflect the more limited experience and training in this specialty for the doctors in this sample (this ranged from 6 months to 1 year already completed in old age psychiatry for senior house officers and from 6 months to 2 years for staff grades). One hundred per cent of consultants and specialist registrars passed at nurse prescriber level, but only 33.3% of staff grades passed at this level and 43% of senior house officers. The only staff grade who passed at nurse prescriber level had attended the course. None of the senior house officers or consultants had attended the course. Table 2 illustrates that among doctors, the number of years of experience working in old age psychiatry significantly correlated with both the communication score awarded by the examiner, as well as the actors score. There was a strong trend for a correlation of experience with both the content score and number of stations passed. However, among the nurses, there was no correlation between any of the measures of competency and length of experience (Table 3).

Discussion
To our knowledge, this is the first time that the competence of nurses and doctors of different grades has been assessed using the same instrument. The study suggests that experience and self-selection are better determinants of competence than attendance on a course. All specialist registrars and consultants and almost all memory clinic nurses passed the exam. Many nurses at the end of this course scored well, particularly those working closely with doctors prescribing in dementia clinics. However, despite attending a specialist course, and having considerable experience of managing patients with dementia, only a third of community psyciatric nurses performed at a level thought to indicate the necessary level of competence to become a supplementary prescriber. This is important because an expanded cadre of dementia supplementary prescribers would be likely to be drawn from experienced community psychiatric nurses. The competency of the doctors that took part correlated with their years of experience with the competency of junior doctors and staff grades varying considerably. This can be seen as evidence for the validity of the process. This may in part be as a result of their training and ongoing continuing professional development.
Limitations Several features of this work limit the conclusions that can be drawn. First, the senior house officers and all but one of the staff grades who did the OSCE had not attended the course. Second, the number of staff at each grade was small. Third, some course attendees declined to participate in the exam. The experience of being closely examined in this way is particularly unfamiliar to nurses. Fourth, the pass mark and the decision that a pass on six of the eight stations was the appropriate level at which independent prescribing competence was demonstrated was a judgement made by the examiners, who were mostly consultants in old age psychiatry. The examiner who was a nurse was also an experienced independent prescriber in dementia, and endorsed this decision.
Most forms of continuing professional development appraisal are based on attendance at courses, rather than performance, which is an unreliable measure alone. Specialist courses such as this, with appropriate assessment, are a necessary adjunct to generic prescribing courses. If non-medical prescribing is to be successful, OSCEs offer a way of establishing who should have the privilege to prescribe.
An employer risks potential medical litigation if a prescriber is unsafe. This practical examination could provide invaluable information for employers as to which nurses can safely prescribe, which complements the assessment of the designated medical practitioner and the results of a generic prescribing course. Such exams can also be used to establish basic skills levels for recertification purposes for doctors.

Conclusions
This OSCE provides useful evidence of potential prescribers' competency for employers. This could make a significant contribution to maintaining high standards of Cubbin et al Training and assessing independent nurse prescribers education & training

N O R M A N P O O L E A N D P E T E R H U G H E S
A training experience to remember: working in Ghana

AIMS AND METHOD
As part of a pilot project, one of the authors spent 3 months undertaking clinical work, teaching and research in a large psychiatric hospital in Accra, Ghana.The other acted as a UKbased mentor. Both report on the training value of the experience.

RESULTS
It was possible to assimilate into the local healthcare system and effect some modest but sustainable changes. The experience broadened the trainee's understanding of psychiatry, cultural influences and healthcare systems, while also developing autonomy and resilience.

CLINICAL IMPLICATIONS
The post is now an option available to trainees on the rotation. Projects in training and service delivery to benefit the host institution have been identified.
Lord Crisp's Report Global Health Partnerships: The UK Contribution to Health in Developing Countries (2007) has called for UK organisations to foster partnerships with colleagues in low-and middle-income countries that will lead to sustainable improvements in services. 1 In response, the Royal College of Psychiatrists and South West London & St George's Mental Health NHS Trust, with support from Challenges Worldwide, a non-governmental organisation, have developed a scheme that enables specialist registrars to work in Ghana for 3 months as an accredited part of their higher training, though they must sacrifice 1 month's salary. One of the authors (N.P.) has recently returned from the pilot study, investigating whether such placements can fulfil Lord Crisp's aims while at the same time benefiting the trainee.
Here, we discuss the project from the perspective of the trainee and training programme director for specialist registrars at St George's Hospital; P.H also acted as UK mentor.

Psychiatry in Ghana
Mental health problems are widespread in all of Africa 2 but epidemiological research in Ghana is lacking. There is one psychiatrist to 1.5 million people in Ghana and they are primarily based in the urban centres of Accra and Kumasi. 3 The three dedicated psychiatric hospitals lie