NMP Pre-admission PortfolioProfessional sign-off document for nurses or midwives apply n for e Non-medical Pres r n ourse

1. DOWNLOAD and OPEN this document (preferably using Adobe Acrobat)2. FULLY COMPLETE Pages 1-3 of the document and as much of Pages 4-6 as you

are able to. Only complete portfolio pages 7-15 (Appendix 1) if necessary e.g. requestedby your approver(s) or if you are self-employed.

3. SAVE and SEND to appropriate authorisers to obtain verification / signatures4. UPLOAD the completed PDF to your online University of Derby application5. If unable to obtain electronic signatures; UPLOAD scans of the signed pages

Preferred location: Derby (KR) Chesterfield (SH)

Level of study: Undergrad. (L6) Post-graduate (L7)

Employing Organisation Work / Placement Address

Ward or work area (for placement audit)

Either

INSTRUCTIONS

Name

Preferred course start: September January YEAR:

1.1. Applicant Details

> Please note: if any authorising signatures are hand signed and scanned, they must be separatelyuploaded to your online UoD application or emailed to: Prescribing@derby.ac.uk

*Please note: you should normally have a first degree to study at post-graduate / Level 7; For further information please contact the programme leader.

Other

2. Professional Registration Details / Confirmation No

I have at least 1-year relevant post-qualification clinical experience.

I have an up-to-date enhanced DBS; with no changes since last undertaken

Yes

NMC PIN

DBS Number

Signature DATE

Electronic Signature (image file)

3. Pre-admission portfolio self-assessment check list .How do you meet the professional entry requirements? Use the grid below to note your evidence. For example: professional CPD entries for revalidation, peer review or previous academic courses. Verification of these is by your manager / clinical lead, and by completing the personal statement. Otherwise, pages in Appendix 1 can help provide new / additional evidence*.

Evidence within the pre-admission portfolio

Evidence Source

Critical Reflection

Personal Formulary

Sign-off / Other*

Assessed through the pre-admission calculation test

*Sign-off / OTHER: details verified bymanager; personal statement; Optional: can include entries (as per Appendix 1.1, 1.3)

RPS competence

grid

Calcs quiz

*Self-employed applicants: to complete full pre-admission portfolio for review by programme team

Page 2

*Sign-off / OTHER: details verified bymanager; personal statement; Optional: can include entries (as per Appendix 1.1, 1.2)

*Sign-off / OTHER: details verified bymanager / personal statement; Optional: can include entries (as per Appendix 1.1, 1.2, 1.3)

DBS Date

Are you on the DBS update service?

The date of issue for DBS should be within 3 years of the course start date unless registered with the DBS update service as verified by your manager. Signing below confirms the information to be correct at time of application, you are of good health and character and you agree that changes in circumstances that would alter your fitness to practice or lead to a change in DBS status will be declared.

1. Competence, experience and academic ability to study at the level requiredfor the programme

2. Relevant clinical experience in the area in which you intend to prescribe

3. Appropriate skills in clinical/health assessment; diagnostics / caremanagement; planning and evaluation of care

4. Numeracy skills in relation to medicines

I am a qualified nurse, SCPHN or midwife with current, valid registration with Nursing and Midwifery Council (NMC).

C1c: Typing your name indicates your confirmation of these statements

C1a

C5a

C6

C1

C1

C1

4. Personal Statement

Provide a supporting statement that outlines why you should be considered for entry onto the Prescribing programme. Include short descriptions addressing these points:

1. Your identified area of practice competence2. How prescribing will help improve this practice3. Clinical knowledge and proficiency in your area of intended prescribing practice, in

relation to: Clinical / health assessment; Diagnostics / care management, careplanning and evaluation

Have you commenced a prescribing course before? No Yes

If YES please give details below (eg. place of study and details of non-completion)

Page 3

2.3.

How prescribing will help improve this practice &Clinical knowledge and proficiency in your area of intended prescribing practice

1. Your identified area of practice competence:

C1b

Practice Assessor Name

Placement address (if different from applicant)

Job Title Professional PIN

(e.g. NMC, GMC, HCPC, or GPhC) Phone

Email

5. Practice Assessor details

Suitably qualified practice assessors and supervisors are required for practice assessment (NMC, 2018). A Practice Assessor (who may be a Medical Practitioner - DMP) must be identified and details confirmed for entry onto the programme. The Practice Assessor must be a registered Non-medical prescriber or medical practitioner with at least 3 years recent clinical experience for a group of patients / clients in the relevant field of practice.

Page 4

Please sign below to confirm you have the requisite knowledge, skills and qualifications for signing-off a NMP student. To assure currency of these, a course update is required, so please also confirm you agree to:

1.

2.

3.

Attend the NMP Course update at the University of Derby Re: the student’s programme and practice assessmentOr, if unable to attend: will access video and resources, reflect on these and consider how proficiency can be demonstrated and evidenced by the student. Complete the quiz or send in the update confirmation form. Contact the university / programme leader with any questions or concerns regarding the student and / or their learning experience and / or assessment

YES NO Area of practice:

I confirm I am on the local register / have undertaken training to meet the Standards for Student Supervision and Assessment (NMC 2018) *N/A for DMPs / GMC registrants

YES Date Prescribing Practice Assessor certificate issued:

*NO *If you require Practice Assessor training please email prescribing@derby.ac.ukfor the course enrollment link; online course + Update session details

I confirm that I have attended update / undertaken online learning specific to the NMP course *Previous Assessors / GMC registrants (DMPs) can access this online

I confirm I have 3 years recent prescribing experience in a relevant area of practice:

YES Date of NMP Course Update:

*NO *If you require NMP course update please note published dates via this link and identify intended date :

I confirm I meet the professional requirements as a Practice Assessor or DMP and can provide evidence of continuing to meet the RPS (2016) prescribing competencies:

YES Signature

Date

Electronic Signature (image file)

C2a, C2b

Practice supervisor(s) details

Job Title / Discipline Professional PIN (e.g. NMC, GMC, HCPC, or GPhC)

Email

I confirm I am a qualified prescriber with experience in a relevant area of practice:

YES NO Area of practice:

I confirm I meet the professional requirements as a Practice Supervisor and can provide evidence of continuing to meet the RPS (2016) prescribing competencies:

YES Signature Date

Page 5

Practice Supervisor Name

Phone

Rationale / Overview of practice setting: why is an exception required?

Please identify other practitioners who can support learning / contribute towards assessment Name Job title

Please confirm the following (Manager or Practice Assessor): The lack of an identified supervisor(s) will not limit the learning opportunities or affect the assessment of practice competence.

Where the applicant is self-employed, the Prescribing Learning Environment Audit form has been completed.

As per the NMC (2018) Standards for prescribers, in exceptional circumstances the student can have: One suitably qualified practitioner acting as Practice Assessor and Practice Supervisor As per NMC (2018b) Standards for prescribing programmes: In such instances, the student, practice supervisor / assessor and the AEI will need to evidence why it was necessary for the practice supervisor and assessor roles to be carried out by the same person”. To help provide supporting evidence, please complete the following:

Evidence for exceptional circumstances

Signature

To assure currency of prescribing competence, ability to assess clinical competence, and meet the NMC (2018) and RPS (2019) standards, you are expected to undertake the Prescribing Practice Supervision training. Please confirm you agree to:

Electronic Signature (image file)

1.2.

Access the Prescribing Practice Supervisor training and / or complete the mapping documentAttend the Practice Assessors' / Supervisors' session at the University of Derby Re: the student’s programme (dates of update meetings / webinars tbc).Contact the Practice Assessor and / or University Academic Assessor with any questions or concerns regarding the student, their learning experience or practice assessment.

Electronic Signature (image file)

3.

C2c

6. Line Manager / Professional Lead / Employer Verification

Job Title

Email Address

I have reviewed the applicant's evidence to support their suitability for the non-medical prescribing programme at this time and can confirm:

The information provided by the applicant is correct; they have a recent enhanced DBS (within 3 years), they are in good standing and have valid NMC registration.The applicant has organisational support and will be released from practice for theory and practice supervision The identified Practice Assessor / Supervisor are suitably qualified and have organisational support, including release from practice to attend updates.

There is clinical need within the applicant's role to justify prescribing

There is evidence to verify that the applicant has the competence, experience andacademic ability to study at the level required for this programme; The applicant is capable of safe and effective practice at a level of proficiency appropriate to the programme and their intended area of prescribing practice in the following areas: • Clinical / health assessment;• Diagnostics / care management;• Planning and evaluation of care

YES NO Audit Date:

*Signature

Other:

The evidence has been derived from the following sources (tick all that apply): Development review / NMC revalidation process Previous study (such as ACP / clinical decision making / physical examination module)

Pre-admission portfolio evidence (Appendix 1)

NAME

Date

NAME

Job title / Role

Contact email / Phone

Signature: Date

Page 6

I confirm the necessary governance structures are in place to enable students to undertake, and be adequately supported throughout the programme;

Electronic Signature (image file)

C7 Support of organisation prescribing / professional lead *N/A for areas without this role; confirmation of approvals may also by emailed directly to the course leader

I confirm there is a current Educational Audit at the placement An active placement audit is required; please contact programme leader

Electronic Signature (image file)

C3, C4a, C4b, C5b

(Audit: C4a, C4b)

T e RPS (2016) ompe en y Frame or for all Pres r ers ou l nes e ompe en es a ra nee pres r ers mus a e e on omple on of pres r n pro rammes A sele fe of e ompe en e s a emen s are use n s o umen as a ay for you o self-assess an e en e urren ompe en e n rela on o your en f e area of pra e

Indicator

Competency 1: Assess the patient 1.1 Ta es an appropr a e me al so al an me a on s ory n lu n aller es an n oleran es

1.2 n er a es an appropr a e l n al

assessmen

1.3 A esses an n erpre s all a a la le an rele an pa en re or s o ensure no le e of e

pa en s mana emen o a e

1.4 Re ues s an n erpre s rele an n es a ons ne essary o nform rea men op ons

T s n lu es urren an pre ously pres r e an non-pres r e me nes on-l ne me nes supplemen s omplemen ary reme es ll ru s an a nes

1.1 Relevant experience / clinical skills > RPS (2016) Competence Framework

Case Based Discussion ☐ OSCE report

☐ Other:

Case Based Discussion ☐ OSCE report

☐ Other:

Case Based Discussion ☐ OSCE report

☐ Other:

Case Based Discussion ☐ OSCE report

☐ Other:

Page 7

APPENDIX 1 - Pre-admission portfolio evidence > complete as needed

For your en f e area of l n al or erapeu pra e no e o you urren ly s o ompe en e sele : > e en e sour e s

Indicator For your en f e area of l n al or erapeu pra e no e o you urren ly s o ompe en e > sele e en e sour e s

1.6 n ers an s e on on s e n rea e e r na ural pro ress on

an o o assess e r se er y e er ora on an an pa e response o rea men

1.7 Re e s a eren e o an effe eness of urren me nes

1.8 Refers o or see s u an e from ano er

mem er of e eam a spe al s or a pres r n nforma on sour e en ne essary

1.5 Makes, confirms or understands, the working or final diagnosis by systematically considering the various possibilities

Case Based Discussion ☐ OSCE report☐ Other:

Case Based Discussion ☐ OSCE report☐ Other:

Case Based Discussion ☐ OSCE report☐ Other:

Case Based Discussion ☐ OSCE report

☐ Other:

Page 8

Competency 3: Reach a shared decision 3.2 I en f es an respe s e pa en n rela on o ers y alues el efs an

e pe a ons a ou e r eal an rea men

me nes

3.4 Rou nely assesses a eren e n a non-u emen al ay an un ers an s e

fferen reasons non-a eren e an o ur n en onal or non-

n en onal an o es o suppor pa en s arers

Competency 5: Provide information 5.4 Ensures a e pa en arer no s

a o o f ere are any on erns a ou e mana emen of e r on on f e on on e er ora es or f ere s

no mpro emen n a spe f me frame

Please note the name, job title, professional PIN number of the person signing this off. This should is preferably your PA or a qualified and practicing prescriber who is able to observe you in practice and / or undertake case based discussions.

Name Email

Profession PIN

Job title

Date* Signature:

In the absence of other evidence, cl n al assessmen s ase ase s uss ons mus a e een un er a en n year of e ourse s ar a e

**Please note: a number of clinical observation tools can be found on the pages to follow for your OPTIONAL use to help provide evidence of the above and to prepare for the prescribing course.

Case Based Discussion ☐ OSCE report☐ Other:

Case Based Discussion ☐ CAIIN / OSCE report☐ Other:

Case Based Discussion ☐ OSCE report☐ Other:

Page 9

This form can be optionally signed off by your prospective Practice Assessor. This helps provide evidence of your clinical competence for entry onto the programme, and also provides an opportunity for the Assessor to gain familiarity with practice assessment.

1. Exploratory discussion.2. Making judgements.3. Feedback4. Recommendations for development.

We would suggest at least 20 minutes per 10-minute patient consultation. It is advised to avoid:

Ø Making judgements before the discussion is completed.Ø Not giving feedback.

…and important to:Ø Demonstrate support and a positive approach to the student’s development. The

discussion is intended to enable recommendations for development –moving fromcompetence to confidence and capability within the specialist role. This involvesfeeding forward to inform the next stage of the student journey, and therefore the nextcase-based discussion.

0= Clear Fail: Insufficient, unsafe or unacceptable; (missed / omitted)

1= Fail: Significant weakness identified; needs further attention

2= Pass: Adequate professional performance; Potential for improvement

3= Clear Pass: Excellent; Consistent, sound professional performance

Both of the Case based discussion (CbD) and Consultation Observation Reports (CORs) are used on the course to assess practice. If you have not completed a 'clinical decision making" type module, it would be useful to complete these forms prior to starting the course. Previous students have reported it can be uncomfortable to have your practice examined if you are not accustomed to this, so this is a good way for both you and your practice assessor to gain experience. Below is some brief information on each of these types of practice assessment.

What is CbD? A case-based discussion (CbD) is a structured interview conducted by a supervisor and a trainee focussed on a patient encounter that results in clinical decision-making. It is a process which has both an assessment and a feedback function. For the purpose of the prescribing programmes, the CbD will be based on the critical discussion of a particular case or situation as would be expected as part of routine supervision and assessment of practice. The CbD is recorded as a written report, so as to provide a source of evidence of assessment in practice. Conducting the CbD Timing depends upon the complexity of the case, but sufficient time should be built into the discussion. It is beneficial for learning, particularly early in the course to dedicate time for feedback as well as critical discussion. Briefly, the sequencing of the CbD should be as follows:

Report of an observed clinical assessment (COR / OSCE)

The purpose of undertaking this assessment is to promote the use of a structured approach to consultation and decision-making, by assessing the practitioner using a standardised tool. Another aim is to encourage self-assessment and improvement of consultation skills by measuring against standard criteria and identifying development needs. Other tools are available such as the “Consultation Observation Tool” (COT) or the “Clinical Examination Tool (“Mini-CEX”). Links to these have been made available on the pre-admission website (Prescribing@UOD). Some of these recognised tools have been adapted to underpin assessment of student in the University setting. Practice Assessors are able to select and use one of the following standardised marking criteria / grids for the students’ set assessments as follows: • CAIIN: “The Consultation Assessment and Improvement Instrument for Nurses”

• OSCE for clinical decision-making (“Consultation Observation Record”)

Both of these tools on the pages to follow, use this simple grid to provide a way to measure and feedback about performance:

1.1 Relevant experience / clinical skills > CbD and COR information

Page 10

Name:Date:

Consultation duration: Case based discussion duration:

Presenting problem / summary:

Case-based Discussion (CbD) of consultation Rating

0 1 2 3

Com

mun

icat

ion

and

asse

ssm

ent Communication; listening skills; pace

History taking; data gathering

Information interpretation; picking up on cues

Attention to social / mental well-being

Other:

Other:

Dia

gnos

is a

nd

man

agem

ent

Identification of risky issues or ‘red flags’ or reasons for immediate referral Identification of an evidence based working diagnosis and differential diagnoses (as appropriate) Consideration of the need for appropriate diagnostic investigations or examinations Demonstration of client-informed choice for treatment and referral options Clear explanations and involvement of patient in agreed plan

Consideration of polypharmacy / de-prescribing Other:

Gen

eral

/ O

vera

ll

Professional and ethical practice shown throughout

Awareness of learning needs / limitations; referral

Other:

Overall Fail Pass Notes / Examples of specific competencies met:

1.1 Relevant experience / clinical skills > Case based discussion (CbD) reports

*Please remember to maintain patient confidentiality - use a clearly fictitious name'Name'

Student Signature Date:

Date: Observer Signature

Page 11

Student: Start:

Observer: Finish: Key issue / presenting problem of consultation:

Observed Consultation / decision making for prescribing Score / Rating

Essential

? 0 1 2 3

1

Patie

nt v

iew

of

prob

lem

Listens to the patient, encourages their participation and sharing of the issue

2 Responds to cues; verbal and non-verbal 3 Considers psychosocial context of the complaint(s) 4 Elicits patient’s understanding of health issues

5

Dia

gnos

is /

Def

ines

pro

blem

Considers or excludes likely relevant significant conditions

6 Mental or physical examinations as appropriate 7 Suggests an appropriate working diagnosis 8 Identifies any presenting risky issues or ‘red flags’

9 Considers issues related to medication or polypharmacy

10 Reviews the working differential diagnosis and modifies suggested treatment as indicated

11

Expl

anat

ion

and

solu

tion

Clear explanations in language appropriate for patient 12 Confirms patient’s understanding 13 Offers suitable management plan 14 Involves patient in decisions

15

Oth

er

Safety-netting; ensures patient is aware of risks and where to seek advice

16 Follow-up and monitoring specified as needed 17 Professional and ethical practice shown throughout 18 Shows awareness of limitations, need for referral

Fail Pass

1.1 Relevant experience / clinical skills > Consultation Observation Record (COR)

Observer: Date:

Job role / title Date:

Page 12

DRUG

DET

AILS

BNF Se on Dru lass In a ons

on on e n rea e

Form Rou e Typ al Dose

PHA

RM

AC

OLO

GY

What does the drug do? Pharmacokinetics / pharmacodynamics

Mo e of A on

on ra n a ons

au ons

S e effe s ommon or

mpor an

In era ons ey e amples

Interacts with: Causes:

Spe al Ins ru ons

A e ey po n s

Mon or n nforma on

EVID

ENC

E / N

OTE

S

y s me a on (Guidelines? First line treatment?)

Notes / Reference source(s):

Drug Name

1.2 Up-to-date pharmacological knowledge and EBP: Personal Formulary

Page 13

A personal formulary enables you to make notes about the medicines you are most likely to be prescribing in the future. Knowledge of these medicines or products is crucial as you are expected to be able to advise patients and make sound clinical decisions.

1.3 Critical Reflection on current practice

Competency 2: Consider the options 2.7 Identifies, accesses, and uses reliable and validated sources of information and critically evaluates other information. 2.8 Stays up-to-date in own area of practice and applies the principles of evidence-based practice, including clinical and cost-effectiveness.

Competency 4: Prescribe 4.5 Understands and applies relevant national frameworks for medicines use (e.g. NICE, SMC, AWMSG2 and medicines management / optimisation) to own prescribing practice.

Critical Reflection

2 NICE – National Institute for Health and Clinical Excellence; SMC – Scottish Medicines Consortium; AWMSG – All Wales Medicines Strategy Group

Page 14

In gaining further autonomy within clinical practice through undertaking a prescribing course, a practitioner needs to show how they are working in an evidence based way and have the ability to critically reflect on their practice. Simply stated, can you provide a sound rationale for your clinical decisions? Using the specific statements from the RPS (2016) Competency Framework below, identify how you currently apply evidence for your clinical decision-making, and how you keep this knowledge up-to-date. Consideration of how you will undertake CPD as a prescriber should also be included. Write this in academic essay style using Harvard referencing (see pre-admission website for guidance). Maximum of 1000 words (excluding references).Please note: the use of a Reflective Model is recommended. Examples include: Gibbs (1988): Description > Feelings > Evaluation > Analysis > Conclusions > Action Plan Borton (1970) / Driscoll (2007): What? > So What > Now What?

Critical Reflection (Continued)

References

Page 15

1.4 Declaration / Details for Aesthetic Nurses

To help assure clinical suitability, Aesthetic nurses need to confirm having worked in aesthetic practice for a minimum of two years. Active membership of a Professional Standards Register (related to cosmetic medicine) or practice in a private healthcare environment that is regulated by a Health Care Regulator (CQC) is also required. In addition to the declaration below, clinical governance arrangements such as indemnity arrangements and health and safety measures are also assured through the prescribing educational audit.

Please tick to confirm you:• Are an active and compliant member of a Professional Standards Register (related to

Cosmetic Medicine) or• Are practicing in a private healthcare environment that is regulated by a Health Care

Regulator (e.g. CQC)• Have worked full time within the field of Aesthetic Medicine for least 2 years (or part

time equivalent)• Have professional Indemnity Insurance sufficient to cover all liability risks associated

with private / aesthetic practice

sheet . The outcome grid aims to demonstrate how decisions are made for entry onto the course andmake recommendations for future development. These are provided whether you are offered a place on the course or not. If you have been unsuccessful at meeting the entry criteria at this stage, specific guidance will be provided and you may request a follow-up discussion. While the ability to self-assess learning needs / critical reflection are not strictly professional entry requirements, both have a significant impact on your success on the course, so guidance is important.

A tick indicates the requirement has been met A cross indicates the requirement has not been met at this point

Professional entry requirements > applicant App. PA / Interv Other form LM iew

Active NMC Registration as Nurse, midwife or SCPHN; minimum 1-year experience in a relevant area; Good health and character declaration Up-to-date DBS; declaration of no changes since last undertaken A suitable learning environment in their identified area of clinical practice in which to develop prescribing practice. Relevant clinical experience in their clinical area, suitable as a foundation for prescribing practice. Assessed Requirements 1. Competence, experience and academic ability to study at the

level required for that programme

Feedback and recommendations

2. Relevant clinical or therapeutic experience in the area in whichyou intend to prescribe

Feedback and recommendations

3. Appropriate skills in clinical / health assessment; diagnostics / care;management; planning and evaluation of care

Feedback and recommendations

X

Not Met

FOR OFFICE USE ONLY

Evidence Source

APPENDIX 2 Prescribing course admission decision

Professional entry requirements > applicant Evidence Source

Ability to critically reflect and self-assess development needs (optional)

Feedback and recommendations

Feedback and recommendations

Practice Assessor (DMP) / Supervisorrequirements

Evidence Source App form

DPP Port

UOD Training Other

The employer agrees to release the applicant from practice

They have indicated there is a clinical need within the applicant’s role to justify prescribing

Numeracy skills in relation to medicines

Practice assessor / supervisor(s) are identified and have agreed to supervise practice; (or rationale given).

The practice assessor is a suitably qualified DMP or NMP who has undertaken PA training, and has relevant clinical experience and CPD / revalidation

The Practice Supervisor is a registered healthcare professional with appropriate prescribing rights. If no PS is identified, a rationale has been provided

Clinical governance arrangements in the work setting to meet NMC requirements

App. PA / Interv Other form LM iew

Not Met

Met Not Met

The accuracy of the applicant's information has been verified (eg signatures etc.)

The practice assessor has attended an update or confirmed online update re: the prescribing course.

Not met

Academic Assessor / Admissions Tutor Notes Name / Dates:

APPROVED? Name: Date:Yes No

FOR OFFICE USE ONLY

Specific requirements for aesthetic / self-employed nurses

Learning environment / Manager agreement (as applicable)