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Patient group directions: training practitioners for competency

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Patient group directions (PGDs) are written directions relating to the supply and/or administration of named medicines to a specified group. Their introduction in the Christie Hospital NHS Trust raised a number of issues about the most appropriate way to implement them in a specialised setting and how to put in place a robust system of competency.



VOL: 99, ISSUE: 22, PAGE NO: 30

Helen Flint, MRPharmS, MSc, BPharmS, is PGD pharmacist, Linda Scott, BSc, RGN/RSCN, SP, is senior nurse, professional development, both at Christie Hospital NHS Trust, Manchester



Patient group directions (PGDs) are written directions relating to the supply and/or administration of named medicines to a specified group. Their introduction in the Christie Hospital NHS Trust raised a number of issues about the most appropriate way to implement them in a specialised setting and how to put in place a robust system of competency.



The trust is a single-site regional cancer centre in Manchester, with patients attending for treatment with chemotherapy, radiotherapy and/or surgery. It is one of the largest centres of its kind in Europe, treating over 10,000 patients each year.



Expanding roles



Through the different stages of their cancer care in the trust, patients become involved with a range of health care professionals. Some of these practitioners operate autonomously, making clinical decisions about patients’ treatment. These include nurse clinicians who conduct independent patient consultations, for example, for patients with lymphoma, and for those with colorectal, breast and upper gastrointestinal cancers. In addition, a number of specialist nurses routinely perform minor procedures such as central venous line insertion, which require the administration of local anaesthetics, while others run clinics and make decisions such as selecting appropriate wound dressings.



Other professionals in the trust also have roles that differ from the norm in many NHS settings. For example, the senior clinical pharmacists are key members of a multidisciplinary team leading a self-medication scheme for inpatients and supporting outpatient clinics, while radiographers advise on appropriate products for radiotherapy toxicity.



Having so many practitioners with such specialist skills meant that there was the potential to expand the role of some of these health professionals so that they would be able to use PGDs when medicines needed to be supplied or administered in a timely, structured way. Furthermore, because patients with cancer have specific treatment needs, it seemed that PGDs would be appropriate for them because anti-emetic drugs and oral and bowel care treatments following chemotherapy could be incorporated into PGDs. Some of the steps taken to ensure that staff were competent to use PGDs are outlined below.



Developing the PGDs



Health Service Circular 2000/026 (NHS Executive, 2000) specifies the legal requirements for using PGDs and contains guidance for their development. It also identifies that PGDs must be reserved solely for those occasions when there is a direct clinical benefit; thus, prescribing should always be used in preference. A team comprising a senior nurse, senior doctor and senior pharmacist should be responsible for drawing up appropriate PGDs for a given practice area and for ensuring that qualified and trained professionals operate within them.



In order to support the development of PGDs within the trust, a pharmacist was appointed as coordinator in August 2001. The role included taking a lead in providing education and training and in ensuring documented assessment of the health professionals involved. A multi-disciplinary group of specialist nurses, pharmacists, radiographers, rehabilitation professionals and professional development staff was set up to address all issues related to PGDs, extended nurse prescribing and supplementary prescribing. It was chaired by the director of nursing and operations, and met every four to six weeks.



The lists of priority medicines to be incorporated into the PGDs were collated, and a hospital template for PGDs was approved by the Drug and Therapeutics Committee (DTC). This committee acted (and continues to act) as an advisory and regulatory body with regard to PGD development, and takes a lead role in involving the medical profession. Each PGD was approved by the DTC, with signatures obtained from the DTC chair, the director of nursing and operations, the medical director (as clinical governance lead) and the chief pharmacist.



Assessment of competency



In order to work within a PGD, practitioners need to be assessed to ensure they have achieved a safe and effective standard of clinical practice. It was vital, therefore, to devise a means of assessing competency. To this end a competency framework was prepared by a PGD subgroup (Box 1), based on the NMC’s competencies of professional and ethical practice, care delivery, care management and personal and professional development.



The National Prescribing Centre’s (2001) competency framework for nurse prescribing was adapted to ensure that specific competency statements were set that clearly related to the use of PGDs. In addition, a Christie Hospital framework was devised, covering both theoretical and practical learning issues that were to be used for the assessment of each individual, so ensuring consistency (Box 2).



If a practitioner does not demonstrate competency at assessment, a development plan must be completed, and a review date is then set for the assessment.



Training and documentation



The coordinating pharmacist established a training programme to prepare staff for assessment. Each practitioner now attends an introductory session which covers the legal requirements of PGDs and the local procedure, and receives a learning pack containing background information and essential reading, such as Health Service Circular 2000/026 (NHS Executive, 2000), The NHS Plan (Department of Health, 2000) and professional codes of conduct.



Specific clinical sessions are provided as required on subjects such as anti-emetics and bowel care, with updates on pharmacology, guidelines to good practice and evidence-based medicine. Clear documentation is vital to ensure that all practitioners are clear about which medicines they can supply, and to whom.



All practitioners have personal portfolios of PGDs for which they have been approved as being competent to use, together with the associated competency assessments and clear review dates. Practitioners’ competence is reassessed every two years.



Limitations and uses of PGDs



While PGDs are suitable for a range of staff and clinical situations, they should be considered only where there is direct clinical benefit to the patient without compromising safety. The requirement to develop specific in-house training and competency assessment means that practitioners can use PGDs only in the place where they are assessed as being competent.



We have concluded that PGDs are most appropriate at the Christie Hospital for nurses who are undertaking minor procedures, and for radiographers and ward-based nurses. Other trusts will need to consider the applicability of PGDs to the range of clinical conditions within their particular settings.






Patient group directions offer an alternative to prescribing in situations where there is direct clinical benefit to a patient, and they should be used only for this purpose. A multidisciplinary team approach is essential if PGDs are to be developed and to ensure that their introduction is planned.



If health care professionals are to practise safely and accountably, demonstrate sound clinical judgement, apply the knowledge and skills indicative of safe practice, and maintain the necessary knowledge to practise both confidently and competently in a consistent manner, a robust training programme and competency framework is vital.
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