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Independent
and
Supplementary
Prescribing
at a Glance

Edited by
Barry Hill
Aby Mitchell

WlLEY Blackwell
Independent and
Supplementary
Prescribing
at a Glance
Independent and
Supplementary
Prescribing
at a Glance
Edited by
Barry Hill
MSc Advanced Practice (ANP), PGC Academic
Practice (PGCAP), BSc (Hons) Critical Care,
DipHE/OA Dip Counselling Skills, Senior Fellow
(SFHEA), Teaching English as a Foreign
Language (TEFL), NMC Registered Nurse (RN),
NMC Registered Teacher (TCH), NMC
Registered Independent Prescriber (V300)
Director of Education (Employability),
Programme Leader and Senior Lecturer,
Northumbria University, Newcastle, UK

Aby Mitchell
RGN, BA (Hons), MSc Advanced Practice
(Healthcare Education), PGCAP, FHEA
Professional Lead for Simulation and
Immersive Technologies, Senior Lecturer Adult
Nursing, University of West London, London, UK

Series Editor: Ian Peate

This edition first published 2023
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Contents

Contributors vii
Preface x

Part 1 Prescribing 1
1 Scope of Practice NMP 2
2 Professional, legal, and ethical issues 4
3 Independent and supplementary prescribing 6
4 Community practitioner nurse prescriber (V150/V100) 8
5 Critical thinking and clinical reasoning 10
6 Exploring interventions 12
7 Evidence-­based diagnosis 14
8 Referring to other members of the multidisciplinary team 16
9 Clinical management plans 18

Part 2 Consideration of non-­pharmacological and pharmacological interventions 21

10 Non-­pharmacological approaches 22
11 Pharmacological treatment options 24
12 Prescribing reference guides 26
13 Medication selection 28
14 How to prescribe 30
15 Risk benefit assessment 32
16 Pharmacodynamics 34
17 Pharmacokinetics 36
18 Holistic assessment 38
19 Quality of life 40
20 Evidence-­based practice 42
21 Medicines and public health 44
22 Infection prevention and control 46

Part 3 Advanced history taking and examination 49

23 Consultation models 50
24 Principles of history taking and physical examination skills 52
25 Preparation for objective structured clinical examination 54
26 History taking for patients who lack mental capacity 58
27 Prescribing and the mental capacity act 60
28 Skin history taking and physical examination 62
29 Neurological history taking and physical examination 64
30 Head, ears, eyes, nose, and throat 66
31 Lymph node assessment 68
32 Endocrine history taking and physical examination 70
33 Respiratory 72
 34 Cardiovascular history taking and physical examination 74
35 Abdominal history taking and physical examination for non-­medical prescribers 76
36 Genitourinary system history taking and physical examination 78
37 Musculoskeletal history taking and physical examination 80

Part 4 Shared Decision-making 83

38 Equality, diversity, and inclusion 84
39 Concordance 86
40 Building relationships 88
41 Inclusive prescribing and informed choices 90
42 Medicine’s optimisation 92
43 Social prescribing 94

Part 5 Prescribing Practice 97

44 Adverse drug reactions 98
45 Frameworks and guidelines 100
46 Prescribing generic products 102
47 Medication calculations 104
48 Non-­medical authorisation of blood components 106
49 Electronic prescribing 108

Part 6 Patient education and health promotion 111

50 Unlicensed medicines 112
51 Record-­keeping and data management 114
52 Adherence 116
53 Patients recognising deterioration 118
54 Patients’ responsibility and self-­management 120

References 122
Index 129

vi
 Contributors
Clare Allabyrne Chapter 26
Associate Professor and Programme Lead in Advanced
Clinical Practice (Mental Health)
London South Bank University, London, UK
Emma L. Bennett Chapters 41, 47
Advanced Critical Care Practitioner (FICM Member)
University Hospital of Wales, Cardiff, UK
Jill Bentley Chapters 14, 21, 49
Lecturer in Advanced Clinical Practice, Non-Medical
Prescribing and Adult Nursing, and Advanced Critical Care
Practitioner (FICM member), Salford Royal Foundation
Trust, Mancester, UK
Sebastian Birch Chapter 27
CAMHS Clinical Nurse Specialist and Senior Lecturer
in Mental Health Nursing University of Roehampton,
London, UK
Roberta Borg Chapter 24
Advanced Critical Care Practitioner (FICM Member)
Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
Joanne Brown Chapter 32
Endocrine Clinical Nurse Specialist
Stockport NHS Foundation Trust, Society for Endocrinology
Early Career Steering Committee and Nurse Committee
Member, England, UK
Ashton Burden-Selvaraj Chapters 34, 35
Trainee Advanced Critical Care Practitioner and Collaborator
Equality, Diversity and Inclusion Working Group
Intensive Care Society, London, UK
Edward Chaplin Chapter 26
Director
Head of the Scientific Committee
European Association for Mental Health in Intellectual
Disability,
London South Bank University, London, UK
Clare Cooper Chapters 6, 15
Advanced Clinical Practitioner and Senior Lecturer
Advanced Practice
University of Northampton, Northampton, UK
ISTUDY fbetw.indd 7
Sian Cooper Chapter 25
Advanced Clinical Practitioner (ACP) in Psychiatry
NHS foundation trust
Manchester, England, UK
Elizabeth Cray Chapter 19
Neurosurgical Advanced Clinical Practitioner
University Hospital Plymouth, Plymouth, UK
Anne Davidson Chapter 48
Education Lead
Patient Blood Management Practitioner Team
NHS Blood and Transplant, Newcastle, UK
Jo Delrée Chapter 26
Associate Professor and Head of Division
Mental Health and Learning Disability Nursing
Institute of Health and Social Care
London South Bank University, London, UK
Simon Ross Deveau Chapter 44
Advanced Clinical Practitioner and Nurse
Visiting Specialist University of Plymouth
Torbay Hospital, Torquay, UK
Sadie Diamond-Fox Chapters 5, 7, 23, 24, 25, 48
Assistant Professor in Advanced Clinical Practice (ACP) &
ACP Lead (Fellow HEA)
Advanced Critical Care Practitioner (FICM Member)
Regional Advancing Practice Supervision and
Assessment Lead
Northumbria University Newcastle, UK
Newcastle upon Tyne Hospitals, UK
Health Education England, UK
Peter Dryden Chapter 46
Assistant Professor
Department of Nursing, Midwifery and Health
Northumbria University, Newcastle, UK
Laura Elliott Chapters 28, 53
Advanced Clinical Practitioner and Senior Lecturer
Advanced Practice
University of Northampton, Northampton, UK
vii
06-02-2023 07:38:22
 Karen Elton Chapter 46
Assistant Professor and Programme Leader,
Senior Fellow (HEA)
Northumbria University, Newcastle, UK
Annette Hand Chapters 3, 9, 12
Assistant Professor of Nursing (Clinical Academic)
Northumbria University and Newcastle upon Tyne
Hospitals NHS Foundation Trust, Newcastle, UK
Hayley Hassett Chapter 42
Senior Lecturer in Non-Medical Prescribing
University of Hertfordshire (Fellow - HEA),
Hertfordshire, UK
Colette Henderson Chapter 18
Programme Lead in MSc Advanced Practice and Deputy
Programme Lead for Non-Medical Prescribing
University of Dundee, Dundee, UK
Barry Hill Chapters 1, 16, 17, 29, 30
Director of Education (Employability), Programme Leader
and Assistant Professor
Northumbria University, Newcastle, UK
Lynne Hughes Chapter 22
Senior Lecturer in Adult Nursing
University of Northampton, Northampton, UK
Tim Kuhn Chapter 34
Advanced Critical Care Practitioner (FICM Member) and
Senior Lead Nurse
Critical Care and Critical Care Outreach Team, Croydon
University Hospital, London, UK
Dorothy Kupara Chapters 45, 51, 54
Senior Lecturer and Course Leader for Learning Disabilities
Nursing, HEA Fellow University of West London,
London, UK
Hazel McPhillips Chapters 8, 38, 40
Lecturer
School of Health and Social Care
Edinburgh Napier University, Edinburgh, UK
Aby Mitchell Chapters 2, 39, 43, 52
Professional Lead for Simulation and Immersive
Technologies and Senior Lecturer in Adult Nursing
University of West London, London, UK
Tichaona Mubaira Chapter 11
Clinical Nurse Specialist in CRHTT West
Berkshire Healthcare Foundation Trust;
Associate Lecturer
University of West London, London, UK
viii
ISTUDY fbetw.indd 8
Kevin Murphy Chapter 4
Programme Lead for the Higher Apprenticeship in
Specialist Practice District Nursing (HASPDN) and
Assistant Professor in Adult Nursing (Fellow - HEA)
Northumbria University
Reuben Pearce Chapter 11
Nurse Consultant in Crisis Resolution and Home Treatment
Services
Berkshire Healthcare NHS Foundation Trust;
Associate Lecturer
University of West London, London, UK
Sam Pearson Chapters 10, 19
Non-Medical Prescribing Programme Lead and Senior
Lecturer in Pharmacy Practice
Edge Hill University, Ormskirk, UK
Ollie Phipps Chapter 50
Senior Lecturer and Course Director for Non-Medical
Prescribing
Canterbury Christ Church University;
Advanced Clinical Practitioner
Maidstone and Tunbridge Wells NHS Trust, Wells, UK
Jaclyn Proctor Chapter 20
Senior Clinical Practice
Edge Hill University Medical School;
Respiratory or Acute Medicine Advanced Clinical
Practitioner and Non-Medical Prescriber Lancashire, UK
Claire Pryor Chapters 3, 9, 12
Subject Lead for Non-Medical Prescribing, Programme
Lead and Assistant Professor
Northumbria University, Newcastle, UK
Christina Rawlinson Chapter 25
Advanced Clinical Practitioner (ACP) in Psychiatry,
NHS foundation trust, Mancester, England, UK
Anosha Sirpath Chapter 36
Senior Lecturer
Course Leader or Module Leader for Independent and
Supplementary Prescribing, Fellow - HEA
University of West London, London UK
Sonya Stone Chapter 35
Assistant Professor of Advanced Clinical Practice
(Advanced Clinical Practitioner)
Faculty of Intensive Care Medicine (FICM)
Clinical Lead for eICM,
School of Health Sciences,
University of Nottingham,
Nottingham, UK
21-02-2023 12:39:52
Maureen Wallymahmed Chapter 20 Lisa Williams Chapter 13
Programme Lead for Non-Medical Prescribing Advanced Clinical Practitioner
and Senior Clinical Practice Rotherham Foundation Trust (TRFT)
Edge Hill University, Ormskirk, UK Hospital at Night, England, UK

Joe Wood Chapter 33

Nicola Weston Chapter 31
Advanced Critical Care Practitioner, Physiotherapist, and
Advanced Critical Care Practitioner
Point of Care Ultrasound Educator
(FICM Member)
Medway NHS Foundation Trust, Gillingham, UK
Department of Critical Care
University Hospitals Sussex NHS Foundation Trust
Nick Worth Chapter 37
Brighton, UK
North West Faculty for Advancing Practice HEE and
Lecturer Non-Medical Prescribing
John Wilkinson Chapter 23 University of Salford;
Anaesthetics Registrar Fellow of the Society of Musculoskeletal Medicine
Northern Deanery, UK England, UK
 Preface
R
egistered nurses, registered midwives, physician associates,
and healthcare professionals who want to become an inde-
pendent prescriber within the United Kingdom (UK) must
successfully complete a Nursing and Midwifery Council (NMC)
or Health and Care Professions Council (HCPC) approved post-­
registration prescribing programme in order to meet the standards
of proficiency necessary for an annotation to be made against an
entry onto their professional register. Independent prescribers are
practitioners responsible and accountable for the assessment of
patients with previously undiagnosed or diagnosed conditions and
for decisions about the clinical management required, including
prescribing. They are recommended to prescribe generically,
except where this would not be clinically appropriate or where
there is no approved non-­proprietary name.
Written by healthcare academics, this book provides an essen-
tial practical and theoretical resource for healthcare students
related to independent and supplementary prescribing. Each part
of this book is mapped against a recognised prescribing frame-
work published by the Royal Pharmaceutical Society (RPS) for all
registered healthcare professionals. This will be the newest and
most up-­to-­date book of its kind in the UK aimed at those study-
ing independent prescribing practice. This is the only book to
address independent prescribing for all permitted healthcare pro-
fessionals based on the RPS Prescribing Framework using litera-
ture from 2021 and addressing NMC and HCPC regulatory body
requirements. This book is at a glance and it makes for the practis-
ing clinician; being only 150 pages, it is the perfect size for busy
healthcare professionals. The snapshot figures and key points
make this book accessible, appealing to a variety of learning styles,
x
and focused for busy healthcare professionals. Literature
informing the book comes from the RPS and Royal College of
Nursing (RCN) Guidance on Prescribing, Dispensing, Supplying
and Administration of Medicines (2020), and RCN and RPS
Professional Guidance on the Administration of Medicines in
Healthcare Settings (2019), and has adopted the RPS Prescribing
Competency Framework as well as the NMC’s standards of com-
petency for prescribing practice. Each chapter is written in a for-
mat that will enable the reader to review the chapter as a complete
unit, and therefore the reader can choose in which order they wish
to read the book.
A multitude of professional bodies have updated guidance on
undergraduate and postgraduate education programmes prepar-
ing students to become prescriber-­ready. The NMC updated future
nurse pre-­registration programme standards, standards for nurses,
standards for midwives, standards for nursing associates, and
standards for post-­registration programmes. Additionally, the
HCPC now advocates the guidance for the same framework mean-
ing that all registered healthcare professionals can use a UK stand-
ard of practice and this book facilitates the key points at a glance.
This book follows the current at-­a-­glance series and provides
information in a concise and comprehensive manner, which will
engage readers by including full-­colour images and graphics, as
well as accurate and useful information, and a user-­friendly over-
view of key prescribing topics utilising prescribing competency
frameworks. The book is also available in a range of formats,
including e-­book, to increase accessibility.
Barry Hill and Aby Mitchell
Prescribing Part 1

Chapters
1 Scope of Practice NMP 2
2 Professional, legal, and ethical issues 4
3 Independent and supplementary prescribing 6
4 Community practitioner nurse prescriber
(V150/V100) 8
5 Critical thinking and clinical reasoning 10
6 Exploring interventions 12
7 Evidence-­based diagnosis 14
8 Referring to other members of the
multidisciplinary team 16
9 Clinical management plans 18
 Scope of Practice NMP
2

1
Part 1 Prescribing

Table 1.1 Who can become an NMP in the United Kingdom. Source: Based on HEE.1

Independent and Supplementary Community practitioner

supplementary prescribers prescribers only prescribers

• Nurses/midwives • Diagnostic Nurses (health visitors

• Pharmacists radiographers and district nurses)
• Physiotherapists • Dieticians
• Podiatrists
• Paramedics
• Optometrists
• Therapeutic radiographers

Table 1.2 A summary of what NMPs can prescribe. Source: RCN / Royal College of Nursing.5

Independent prescriber Supplementary prescriber

CDs Yes – Schedule 2–5 CDs, except Yes – Schedule 2–5 CDs,
diamorphine, dipipanone,or cocaine for except diamorphine,
treatment of addiction dipipanone, or cocaine for
treatment of addiction

Unlicensed Yes – provided they are competent and Yes – covered by the Clinical
medicines take responsibility for doing so.May vary Management Plan (CMP)
for nurse prescribers in Scotland

Off-­label/off-­licence Yes – should only be prescribed where it is Yes – covered by the CMP
prescribing best practice to do so andmust take full
clinical and professional responsibility for
their prescribing

Private prescribing Yes – for any medicine within their Yes – for any medicine
competence covered by the CMP

Non-­Medical Prescribing (NMP) Royal Pharmaceutical Society (RPS)

Doctors are by far the largest group of prescribers, who, along with
dentists, can prescribe on registration. They have been joined by inde-
pendent and supplementary prescribers from a range of other non-­
medical healthcare professions, who are able to prescribe within their
scope of practice once they have completed an approved education
programme. This extension of prescribing responsibilities to other
professional groups is likely to continue where it is safe to do so and
where there is a clear patient benefit. NMP is the term used to describe
any prescribing completed by a healthcare professional other than a
doctor or dentist.1 Non-­medical prescribers (NMPs) include nurses,
midwives, and pharmacists, as well as other allied healthcare profes-
sionals who have completed an accredited prescribing course and reg-
istered their qualification with their regulatory body (Table 1.1). This
enables them to prescribe medications as either community practi-
tioner nurse prescribers (with a v150 or v100 course) or independent
prescribers (with a v200 or v300 course) (Table 1.2).
In January 2019, the RPS and the Royal College of Nursing
(RCN) co-­created Professional Guidance on the Administration
of Medicines in Healthcare Settings.2 The guidance was devel-
oped in response to the announcement of the withdrawal of the
Standards for medicines management by the Nursing and
Midwifery Council (NMC) and will be hosted on the RPS and
RCN websites. Application of this guidance is a multidiscipli-
nary responsibility. All staff groups involved in the administra-
tion of medicines should be involved in developing organisational
policies and procedures. In addition to corporate and clinical
governance responsibilities, registered healthcare professionals
are personally responsible for putting patients first and for a
commitment to ethics, values, principles, and improvement.
They are also responsible for practising within their own scope
and competence, using their acquired knowledge, skills, and
judgement.

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Scope of practice
The Health and Care Professions Council (HCPC) (2020) identifies
3
scope of practice as the activities a healthcare professional carries
out within their professional role. The healthcare professional must
have the required training, knowledge, skills, and experience to
deliver these activities lawfully, safely, and effectively. They must also
have appropriate indemnity cover for their prescribing role. Scope of
practice may be informed by regulatory standards, the professional
body’s position, employer guidance, guidance from other relevant
organisations, and the individual’s professional judgement.
The benefits of NMP
NMP has demonstrated patient care and economic benefits.
Consequently, investing in NMP is seen as ‘an investment to save,’
and encouraging NMP capacity is seen as a vital upskilling priority
and features as a key enabler in the planning and delivery of new
care models and transforming care. NMP training can support
role and career development by enabling practitioners to take on
greater responsibilities for managing patient care. NMP enhances
patient care by supporting patients’ timely access to treatment with
medicines, enabling choice while helping to reduce waiting times
and hospital admissions and maximising the wider skills of the
healthcare team.
NMP healthcare professionals
The British National Formulary (BNF) and the National Institute
for Health and Care Excellence (NICE) (2021)4 identify that to
protect patient safety, the initial prescribing and supply of medi-
cines prescribed should normally remain separate functions per-
formed by separate healthcare professionals. However, there are
several situations whereby simultaneous prescribing and adminis-
tration or supply are required of the same practitioner, such as in
the context of emergency situations.
Registered nurses
Nurse independent prescribers (formerly known as extended for-
mulary nurse prescribers) can prescribe any medicine for any
medical condition. Unlicensed medicines are excluded from the
Nurse Prescribing Formulary in Scotland. Nurse independent pre-
scribers can prescribe, administer, and give directions for the
administration of Schedule 2, 3, 4, and 5 Controlled Drugs (CDs).
This extends to diamorphine hydrochloride, dipipanone, or
cocaine for treating organic disease or injury, but not for treating
addiction. Nurse independent prescribers must work within their
own level of professional competence and expertise.
Pharmacists
Pharmacist independent prescribers can prescribe any medicine
for any medical condition. This includes unlicensed medicines
subject to accepted clinical good practice. They can also prescribe,
administer, and give directions for the administration of Schedule
2, 3, 4, and 5 CDs. This extends to diamorphine hydrochloride,
dipipanone, or cocaine for treating organic disease or injury, but
not for treating addiction. Pharmacist independent prescribers
must work within their own level of professional competence and
expertise.
Physiotherapists
Physiotherapist independent prescribers can prescribe any medicine
for any medical condition. This includes ‘off-­label’ medicines subject
to accepted clinical good practice. They are also allowed to prescribe
the following CDs: oral or injectable morphine, transdermal fentanyl
and oral diazepam, dihydrocodeine tartrate, lorazepam, oxycodone
3
hydrochloride, or temazepam. Physiotherapist independent prescrib-
Chapter 1 Scope of Practice NMP
ers must work within their own level of professional competence and
expertise.
Therapeutic radiographers
Therapeutic radiographer independent prescribers can prescribe
any medicine for any medical condition. This includes ‘off-­label’
medicines subject to accepted clinical good practice. Prescribing
of CDs is subject to legislative changes. Therapeutic radiographer
independent prescribers must work within their own level of pro-
fessional competence and expertise.
Optometrists
Optometrist independent prescribers can prescribe any licensed
medicine for ocular conditions affecting the eye and the tissues
surrounding the eye, except CDs or medicines for parenteral
administration. They must work within their own level of profes-
sional competence and expertise.
Podiatrists
Podiatrist independent prescribers can prescribe any medicine for
any medical condition. This includes ‘off-­label’ medicines subject
to accepted clinical good practice. They are also allowed to
­prescribe the following CDs for oral administration: diazepam,
­dihydrocodeine tartrate, lorazepam, and temazepam. Podiatrist
independent prescribers must work within their own level of
­professional competence and expertise.
Paramedics
Paramedic independent prescribers can prescribe any medicine
for any medical condition. This includes ‘off-­label’ medicines
­subject to accepted clinical good practice. Prescribing of CDs is
subject to legislative changes. Paramedic independent prescribers
must work within their own level of professional competence and
expertise.
Prescribing supervisor
The prescribing supervisor is an independent supervisor who com-
pletes assessment and teaching in practice (previously known as a
designated medical practitioner). The practice supervisor (PS) is a
colleague in practice who must be able to provide guidance and
supervision for your practice-­based learning while you are on the
course. The PS must be someone with whom you normally work,
and they must meet specific criteria as outlined by the higher edu-
cation institution. Support for the PS role is provided by the univer-
sity NMP course leads and NMP leads in organisations.
Following completion of an NMP course
The newly qualified NMP must:
•• Register with the relevant regulator, i.e. GPhC, NMC, or HCPC.
•• Provide confirmation to their employers of their successful
annotation.
•• Complete any other local/employer requirements, e.g. scope of
practice/formulary.
•• Ensure they have appropriate indemnity arrangements.
•• Maintain competence and undertake annual continuing p ­ rofessional
development and revalidation as specified by their regulator.
•• Ensure they have appropriate support to undertake their
­prescribing role.
 Professional, legal, and ethical issues
4
2
Part 1 Prescribing
Table 2.1 Legal, professional, and regulatory frameworks. Source: Adapted from Nuttall, 2020.
Legislation
Prescription-­Only-­Medicines
(POMs) (Human Use) Orders
1997 and Subsequent
Statutory Instruments
Misuse of Drugs Act 1971
Misuse of Drugs
Regulations 2001
Human Medicines
Regulations 2012
Human Medicines
(Amendment)
Regulations 2018
Table 2.2 Prescribing governance
The patient
Circumstances and current
medication
Past medical history
Current and anticipated
health status
Table 2.3 The British Pharmacological Society’s 10 principles of good prescribing – 2021. Source: Adapted from The British Pharmacological
Society, 2021.
Be clear about the reasons for
prescribing
Consider the patient’s medication
history before prescribing
Consider factors that might alter the
benefits and risks of treatment
Consider the patient’s ideas,
concerns, and expectations
Select effective, safe, and cost-­
effective medicines
Adhere to national guidelines and
local formularies where appropriate
Ensure prescriptions are written on
the correct documentation
Monitor the beneficial and adverse
effects
Communicate and document
prescribing decisions and rationale
Prescribe within the limitations of
your knowledge, skills, and
experience
Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Professional Regulatory
NMC (http://www.nmc-­uk.org) Medicines and Healthcare products
Regulatory Agency (http://www.mhra.
gov.uk)
General Pharmaceutical Council (http://www.pharmacyregulation.org) Drugs and Therapeutics Committees
Health and Care Professions Council
(http:///www.hcpc-­uk.org)
General Optical Council’s Standards of Practice for Optometrists and
Dispensing Opticians 2016 (http://www.optical.org)
UK Law for Medicines (https://www.gov.uk/guidance/eu-­guidance-­
documents-­referred-­to-­in-­the-­human-­medicines-­regulations-­2012#:
~:text=The%202020%20Regulations%20have%20been,and%20
advertising%3B%20and%20for%20pharmacovigilance.)
Prescribing practice
A thorough knowledge of the medicine to be prescribed, its therapeutic action, side effects, and interaction
Current patient medication and any potential interactions with new medications
A thorough knowledge of alternatives to prescribing
Previous drugs the patient has taken and full medical history
Frequency of the use of drug and dosage, adherence to current medications, and patient’s perception of health
Prescribers should establish an accurate diagnosis whenever possible and be clear what the patient is
likely to gain from the prescribed medicines
Obtain a list of current and recent medications
Ask the patient/carer about any over-­the-­counter medications, adverse drug reactions, and drug allergies
Consider individual factors, e.g. physiological changes with age, pregnancy, or impaired kidney, liver, or
heart function
Values-­based prescribing is a collaborative approach to prescribing whereby the practitioner takes into
account the wishes, values and principles of the patient when prescribing medication
Consider if the effect of medicines outweighs the extent of potential harms
Review published evidence
Choose the best formulation, dose, frequency, route of administration, and duration of treatment
Select medicines with regard to cost and needs of other patients (healthcare resources are finite)
Access and use reliable and validated sources of information, e.g. The British National Formulary
Be aware of common factors that cause medication errors and how to mitigate risk factors
Identify how beneficial and adverse effects can be assessed
Understand how to alter prescriptions because of information
Knowledge of how to report adverse drug reactions (via the Yellow Card scheme)
Communicate effectively with patients, carers, and colleagues
Use the health record to document prescribing decisions accurately
Be prepared to seek advice and support
Make sure appropriate prescriptions are checked
T
he United Kingdom (UK) prescribing law is ever changing;
therefore, it is important that prescribers consistently update
their knowledge of legislation. There are several legal,
professional, and regulatory frameworks to support prescribing
practice (see Table 2.1). For prescribers, the virtues of openness,
transparency, and duty of candour are imperative and hence these
should be embedded into clinical practice.
All prescribers are required to work within their own professional
boundaries and standards of conduct to provide high-­quality health-
care. Nurse prescribers’ practice is grounded by the professional code
of practice that guides the prescribing with rules and standards. The
introduction of the Royal Pharmaceutical Society (RPS) Prescribing
Competency Framework 2016 has ensured that high standards are
maintained and that capabilities are synonymous between disciplines.
Prescribing accountability is coincident with the components of ‘gov-
ernance’ and prescribers are held accountable for assuring quality
standards are met on the delivery of care. The Nursing and Midwifery
Council (NMC) recognises clinical governance is essential to continu-
ously improve quality and maintain standards of care. Nurse prescrib-
ers practise autonomously within the code of the ethical principles of
non-­maleficence, deontology, and paternalism. Prescribing demands
a higher degree of professional responsibility and accountability
ensuring that the prescriber is responsible for someone or something
and willing to take the consequences of actions or inactions.
Prescribing governance
The RPS Prescribing Competency Framework is structured in two
key domains, i.e. prescribing governance and the consultation
with the patient at the centre. Prescribing governance refers to pre-
scribing safely and focuses on the need to reduce risk and maintain
patient safety. As part of the role, nurse prescribers are expected to
work at an advanced clinical level demonstrating competence in
professional prescribing with evidence of accountability for clini-
cal decisions within legal, professional, and professional bounda-
ries. Legal and professional accountability requires prescribers to
provide a rationale for prescribing for:
•• What is prescribed?
•• When are over-­the-­counter products recommended?
•• When are decisions made not to prescribe or recommend a
product?
In addition, prescribers are expected to have knowledge and 5
competence in patient assessment within certain contexts (see
Table 2.2).
Chapter 2 Professional, legal, and ethical issues
To appropriately prescribe, it is essential that prescribers have a
good knowledge and understanding of pharmacology in relation
to the drugs prescribed; this includes:
Pharmacokinetics and pharmacodynamics: Pharmacokinetics
involves the changes in the serum concentration of a drug in the
body over a set period of time. Absorption, distribution, metabo-
lism, and excretion of the drug bring this about. The last two pro-
cesses also account for the elimination of the drug from the body.
Pharmacodynamics is the term to describe what a drug does to the
body, including therapeutic and adverse effects.
Safety and efficacy remain the key objectives for prescribing.
All prescribes are required to work within the boundaries of their
own standards of conduct and scope of practice. In gaining a pre-
scribing qualification, a practitioner must be fully conversant with
their codes of practice. Prescribers must:
•• Only prescribe within their scope of practice and recognise own
limitations in knowledge and skill.
•• Have a good understanding about common types of medication
errors and how to prevent and avoid these.
•• Identify potential risks associated with remote prescribing,
e.g. over the telephone/by a third party, and minimise risk
factors.
•• Develop and adhere to the process that supports safe prescrib-
ing practice, e.g. transfer of information and repeat prescriptions.
•• Keep up to date with prescribing practice and be aware of
emerging safety concerns relevant to prescribing.
•• Report prescribing errors, near misses, and critical incidences,
and review to prevent recurrence.
In order to ensure safe prescribing and the effective use of med-
icines, all practice should be underpinned by the principles pro-
vided in Table 2.3.
The prescriber must inform the patient: what to expect when
taking the medicine and how to take it; the duration of time they
will be on the medication and what effects and improvements they
are likely to see; and the efficacy of the medication and any
­precautions or likely side effects.
 Independent and supplementary
6

3
Part 1 Prescribing

prescribing
Table 3.1 Prescribing rights and medicines entitlements by profession

Profession Governing body Supplementary Independent prescriber, Independent prescriber,

prescriber excluding controlled drugs including some controlled drugs

Nurse NMC √ √

Midwife NMC √ √

Chiropodist/podiatrist HCPC √ √

Dietitian HCPC √

Paramedic HCPC √ √

Physiotherapist HCPC √ √

Diagnostic radiographer HCPC √

Therapeutic radiographer HCPC √ √

Figure 3.1 The supplementary prescribing partnership Table 3.2 Comparison of supplementary prescribing
and independent prescribing roles and responsibilities

Prescriber type
Named
Independent Supplementary Independent
Prescriber
Accountable for x √
patient initial
assessment and
diagnosis

Assess the As part of the CMP √

patient

Make a diagnosis x √
Patient
Specific CMP Prescribe √ √

Types of Any medication or class of Any that are

medication that medications within the permitted by
can be prescribed agreed CMP and permitted professional
Named
Named by professional relevant relevant legislation
Supplementary
Patient legislation
Prescriber

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
T Supplementary prescribing
his chapter focuses specifically on two types of prescribing –
independent prescribing and supplementary prescribing
(v300 qualification). Chapter 4 details prescribing for nurses
who have undertaken the community practitioner nurse pre-
scribing (v100/v150) qualification.
Following a formal review of prescribing practice in the United
Kingdom, the Crown Report (1999)1 recommended that there
should be two types of nurse prescribers – independent and depend-
ent (where dependent later termed supplementary). Changes to
Section 63 of the Health and Social Care Act 2001 enabled the gov-
ernment to extend prescribing responsibilities to other health pro-
fessions and the introduction of supplementary prescribing.
Amendments to the Prescription Only Medicines Order and
National Health Service (NHS) regulations allowed supplementary
prescribing by suitably trained nurses from April 2003. Amendments
to ‘The Misuse of Drugs Regulations 2001’ enabled the prescribing
of controlled drugs by some supplementary prescribers (SPs) since
April 2005 in line with their regulatory body stipulations.
Nursing and Midwifery Council (NMC) registered nurses and
midwifes may undertake qualification in both supplementary pre-
scribing and independent prescribing. This includes the prescrib-
ing of controlled drugs if it is within their scope of competence,
confidence, and practice area. Conversely, the Health and Care
Professions Council (HCPC)2 makes clear differentiation between
medicines entitlements of their registered professionals and if they
can become both independent and SPs, or SPs only. In addition,
the HCPC specifies which prescribers may prescribe specific con-
trolled drugs. These differences are governed by both law and pro-
fessional registration. As such, they must be adhered to.
For all prescribers, it is paramount that they are aware of these
differences and only prescribe within their permitted entitlements.
These entitlements and considerations are shown in Table 3.1.
(community practitioner nurse prescribing is detailed in Chapter 4.)
Independent prescribing
Independent prescribing is undertaken by independent prescrib-
ers (IPs). It is important to recognise that the terms are not the
same; one relates to the activity and the other relates to the type of
prescriber performing that activity.
The Joint Formulary Committee (2021) defines IPs as:
‘. . .practitioners responsible and accountable for the
assessment of patients with previously undiagnosed or
diagnosed conditions and for decisions about the clinical
management required, including prescribing. . .’
Joint Formulary Committee (2021)3 para 2
IPs take responsibility for the assessment and diagnostic process
that leads to the generation of a prescription (or not). This makes
them responsible not only for the assessment, diagnosis, and pre-
scribing decisions, but also for follow-­up and review of any prescrib-
ing activity and patient care. IPs need to have advanced clinical
assessment skills to assess their patients safely and comprehensively.
They make informed decisions about the patient care and treatment
based on their own appraisal. Central to this is the ability to provide
a clear rational for the decisions that have been made. For some IPs,
this may include assessing previously undiagnosed conditions and
initiating care (including prescribing new medications).
In summary, independent prescribing is based upon the princi-
ples of:
1 Safe and appropriate assessment.
2 The prescribing for diagnosed and potentially undiagnosed
conditions.
3 The inclusion of sound decision-­making management planning
and consideration of issuing a prescription (or not).
(Nuttall and Rutt-­Howard 2020)4
7
As with independent prescribing, supplementary prescribing is
Chapter 3 Independent and supplementary prescribing
intended to provide patients with quicker and more efficient access
to medicines.
Supplementary prescribing is defined as:
‘a partnership between an independent prescriber (a
doctor or a dentist) and a supplementary prescriber to
implement an agreed Clinical Management Plan for an
individual patient with that patient’s agreement’
Joint Formulary Committee (2021)3 para 3
One of the main differences between independent prescribing and
supplementary prescribing is that the SP is not responsible for the
initial assessment or diagnosis of the patient. Supplementary pre-
scribing also provides a move away from the supply and adminis-
tration under group protocols, which are intended to treat groups
of patients, to allow for a greater flexibility over the choice and
range of products for an individual patient.
Once a diagnosis has been established for an individual patient
by an IP, the responsibility for clinical management can be trans-
ferred from the IP (a doctor or a dentist) to another suitably quali-
fied health professional who may complete follow-­up assessments
and reviews, including prescribing from a pre-­agreed range of
medications within stipulated parameters and situations (detailed
on the legal clinical management plan [CMP]).
In this situation, the prescribing of medicines by the second
clinician is defined as supplementary prescribing.
Historically, it was felt that supplementary prescribing would be
most useful for patients with complex long-­term conditions, where
the diagnosis was usually made by a specialist doctor, but the
patient then needed continuing care. An SP could provide this con-
tinuing care by prescribing from within a defined CMP that was
developed following clinical guidelines, or continuing established
treatments by issuing repeat prescriptions, with the authority to
adjust the dose or dosage form according to the patient’s needs.
The supplementary prescribing process
1 An IP (a doctor or a dentist) makes a formal diagnosis and identifies
that a specific patient may benefit from supplementary prescribing.
2 A discussion occurs between the IP, the SP, and the patient to
agree to this process.
3 At this stage, the doctor (or the dentist) becomes formally the
named IP, and the SP is also named individually; Figure 3.1 shows
this partnership.
4 The named IP and named SP agree which medicines may be
prescribed by the SP under an individual patient CMP.
5 The SP is responsible for managing and prescribing for the
condition(s) and medication(s) listed within the agreed CMP
according to patient need (Department of Health, 2005),5 but is
not able to prescribe any other medications.
6 The IP and the SP must maintain communication on an ad hoc
basis while the SP is reviewing and prescribing for the patient.
7 It is recommended that a joint formal clinical review should be
carried out with the IP, the SP, and the patient within a maximum
of 12 months since the start of the CMP. Or earlier depending on
the condition or medication being prescribed.
An outline of the differences between independent prescribing
and supplementary prescribing is shown in Table 3.2.
Supplementary prescribing involves an agreement between a named IP and
an SP or a named patient. The IP or SP cannot change without redrafting
the clinical management plan.
drafted for that individual.
 Community practitioner nurse
8

4
Part 1 Prescribing

prescriber (V150/V100)

Figure 4.1 NMC register statistics – prescribing. Source: NMC.2 Figure 4.2 Nurse Prescribers’ Formulary for
Community Practitioners. Source: Modified from BNF, 2017–2019.
Total number of special/recordable qualification issued to professionals on the
permanent register, sorted from high to low
March March March March March
2017 2018 2019 2020 2021

Nurse independent / Supplementary prescriber

Community practitioner nurse prescriber

36,983

40,612
40,041

40,748
43,717

40,879
47,899

41,049
50,693

41,301
Nurse
SP – District nursing 16,135 15,758 15,609 15,428 15,343 Prescribers’
Formulary
Teacher 4,150 4,505 4,838 5,031 5,078

SP – Adult nursing 4,971 4,870 4,781 4,706 4,649

Lecturer / Practice educator 5,440 4,953 4,532 4,198 3,904

for Community Practitioners
SP – General practice nursing 1,806 1,771 1,741 1,696 1,660

2017
SP – Community mental health nursing 1,394 1,340 1,275 1,220 1,166

Nurse independent prescriber 1,449 1,375 1,292 1,211 1,152

SP – Community children’s nursing 849 863 858 867 864

2019
SP – Mental health 778 749 725 704 696

SP – Community learning disabilities nursing 479 457 438 423 406

SP – Children’s nursing 434 420 405 396 386

SP – Learning disability nurse 59 73 72 71 68

Total 115,539 117,923 121,162 124,899 127,366

SP = Specialist practitioner September 2017–19

Figure 4.3 Prescription example

Pharmacy Stamp Age Title, Forename, Surname & Address
1yr 3mths Master Peter Patient
bnf.org
D.O.B
2/4/2010 Flat 1
50 Stanhope Street
Newtown TE22 1st
Please don’t stamp over age box
Number of days’ treatment
N.B. Ensure dose is stated
5
Endorsements
Amoxicillin oral suspension
125mg/5ml sugar–free
125mg three times daily
Supply 100ml
[No more items on this
prescription]

Signature of Prescriber Date

02/07/11

For Anyborough Health Authority

dispenser
No. of Dr D O Good 345543
Prescns. 7 High Street
on form
Anytown KB1 CD2
Tel: 0111 222 333

FP10NC0105

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
R
egistered nurses who successfully complete a Nursing and
Midwifery Council (NMC) registered community practi-
tioner nurse prescribing course (also known as v100/v150)
can prescribe from the Nurse Prescribers’ Formulary (NPF). The
NMC recognises the qualification as a community practitioner
nurse prescriber (CPNP) and annotates this on the individual’s
NMC record once successful completion of the course has been
done.1 As of March 2021, there are currently 41,301 registered
CPNPs, increasing minimally over the previous five years, poten-
tially reflective of the decreasing numbers of registered district
nurses and health visitors2 (see Figure 4.1). Community nurses are
recognised as the first group of nurses in the United Kingdom
(UK) that can prescribe independently from a list of restricted
products in the NPF (see Figure 4.2).
Significant legislative and policy reforms have formed the land-
scape for current nurse prescribing practice. Although the
Cumberlege Report (1986)3 recommended that community nurses
can prescribe from a limited range of products, it wasn’t until 1998
that nurses got access to the first restricted prescribing formulary.
Prescribing is an integral part of contemporary community nurs-
ing practice, with many nurses not only appearing to highlight the
benefits to patient to validate their prescribing, but also due to the
inherent need to provide patient centred care. Previously seen as
an activity purely exclusive to medical colleagues (with only doc-
tors and dentists being able to prescribe until the 1990s), the
strengthening of the professional role of nurses through safe and
effective prescribing has provided more job control and enhanced
status and credibility.
Although the qualification is recognised equally by the NMC,
there are two different categories of CPNP qualification. V100
refers to an NMC module approved as part of an integrated pro-
gramme of learning, such as the district nursing specialist practi-
tioner (DNSP) or the specialist community public health nurse
(SCPHN) qualification, previously known as health visitors. This
is also often included in school nurse (SN) and sexual health advi-
sor (SHA) programmes of learning. V150 refers to a stand-­alone
prescribing course for those who have not undertaken the V100
qualification as part of an integrated programme and yet wish to
be able to prescribe from the NPF. This can be undertaken by all
registered nurses working in appropriate clinical settings with sup-
port from their employer and in line with specific university entry
requirements.
All nurses undertaking the V100 and/or V150 prescribing
course need to demonstrate competence in numeracy skills and
drug calculations. Nurses need to undertake 10 theory days at an
approved university as well as observed and supported clinical
practice days, working alongside appropriately qualified and expe-
rienced prescribing practitioners. Community nurses previously
required an experience of two years in their current area of prac-
tice to be able to undertake this qualification; however, recent
standard changes from the NMC (2018)4 have stated that this can
be undertaken from the point of qualification as a registered nurse.
Despite this, initial NMC consultation feedback regarding the pro-
posed changes showed that 65% of 706 responders disagreed with
newly qualified nurses undertaking prescribing prior to ­completion
of a preceptorship programme. For non-­medical V300 prescrib- 9
ing, a minimum of one-­year post-­registration experience is
required.
Chapter 4 Community practitioner nurse prescriber (V150/V100)
NMC consultations regarding the incorporation of prescribing-­
related content in pre-­registration academic programmes have high-
lighted potential to increase cost-­efficiency and time benefits for
employers. However, increasing the number of NMP prescribers will
impact the levels of support and resources required across services,
already highlighted as a challenge due to the ongoing implications of
the COVID-­19 pandemic. V100/V150 prescribers have been shown
to reduce National Health Service (NHS) costs and improve effi-
ciency across the multi-­disciplinary team (MDT) as well as improv-
ing outcomes for patients, families, and carers (Griffiths, 2020)5.
Patients have reported that they are able to start treatments sooner,
which reduces waiting times and complications and increases rates of
healing and improvement (McIntosh et al., 2016)6.
The NPF contains a range of medications and products rele-
vant to community settings, including 13 prescription-­only medi-
cines (POMs), dressings, pharmacy (P), general sales list (GSL),
and a range of appliances. CPNPs will also be able to prescribe a
range of products not stipulated in the NPF, including catheters
and catheter equipment, compression garments, and socking
application apparatus. NHS-­employing organisations will often
produce a local formulary for nurses to prescribe from, recom-
mending products based on the latest evidence base and consider-
ing cost-­effectiveness. Many trusts have taken this further, now
holding centralised stores of stock equipment, such as dressings
(Smith et al., 2018)7. These schemes have reduced the need for
many prescribing nurses to prescribe, therefore influencing pre-
scribing patterns. There is an association between the confidence
to prescribe and prescribing rates; confidence is only likely to
emerge if nurses have regular opportunity to prescribe in their
area of competence (see prescription example in Figure 4.3).
Although the V100/V150 offers evidenced benefits, there is a
clear need to review its contemporary effectiveness. Some com-
munity nurses will need the ability to prescribe using a wider
range of available products with less restrictions on what can be
prescribed. Currently, the majority of CPNP prescribing is related
to wound-­management products. Although the formulary is lim-
ited, prescribers should always work within the limitations of their
knowledge and skill. The Nurse Prescribers’ Advisory Group
includes representatives from a range of nursing disciplines and
oversees the list of drugs approved for inclusion in the NPF. Many
nurses perceive prescribing decisions to be highly complex, with
learning to prescribe being one of the most personally challenging
areas of professional development.
Equipped with the history-­taking and assessment skills
obtained through an NMC-­approved V100/V150 programme,
nurses will need to consolidate this learning in clinical practice.
Prescribing is an ongoing learning process, requiring practitioners
to keep up to date with the contemporary evidence base to best
support prescribing decisions. CPNPs should engage with their
prescribing leads and become involved in prescribing supervision
to ensure clinical effectiveness and opportunity for professional
development.
 Critical thinking and clinical reasoning
10

5
Part 1 Prescribing

Figure 5.1 The elements involved in clinical reasoning, Figure 5.2 Traditional findings versus evidence-­based method of
underpinned by a knowledge of basic and clinical sciences. Source: diagnosis. A textbook presents 15 traditional physical findings of
Frain and Cooper9 / John Wiley & Sons. pneumonia (left), along with the assumption that each finding has
similar diagnostic weight. The EBD method (right), based upon
Clinical skills studies of actual patients, shows that five findings accurately
(including
communication increase probability of pneumonia, and only one decreases it.
skills) Source: Frain and Cooper7 / John Wiley & Sons.

Use and Traditional findings Evidence-based approach

Shared
interpretation
decision
of diagnostic 5 findings increase probability
making Fever
tests
Tachypnoea Asymmetrical chest excursion
Clinical Tachycardia Aegophony
reasoning Reduced oxygen saturation Bronchial breath sounds
Grunting respirations Percussion dullness
Understanding Cyanosis Oxygen saturation <95%
Patient-centred Asymmetric chest excursion
cognitive biases
evidence-based Percussion dullness
and human
medicine Diminished breath sounds
factors
Crackles
Aegophony 1 finding decreases probability
Critical thinking Bronchophony
Whispering pectoriloquy All vital signs normal
(metacognition)
Bronchial breath sounds
Pleural rub

Table 5.1 The clinical reasoning process within a consultation. Source: Based on Ross et al.6

Presenting complaint Allow the patient to describe their presentingsymptom(s)

Consider three or more hypotheses Consider the following:

relating to diagnosis • The patient’s presenting symptom(s) and basic demographics (age, gender, etc.)
• Key features of each of the three hypotheses
• Distinguishing features of each of the hypotheses

Refine the diagnosis • Formulate a primary hypothesis

• Formulate a differential diagnosis or diagnoses

Physical examination • Consider what findings are expected given the hypothesis and look for them
• Relevant positives and negatives should refine the hypothesis

Relevant investigations • Consider diagnostic testing if required

• Will the investigation confirm or alter your hypothesis? If not, is it necessary?

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Another random document with
no related content on Scribd:
Robespierre, 178
Rochambeau, 164, 166, 170
Rochefort, 174, 192
Rodney, Admiral, in battle with De Guichen, 155, 159–164
Roman Empire, 301
Rooke, British Admiral, 156, 157
Rosily, French Admiral, 199, 208, 221
Rotterdam, 336
Royal Sovereign, British ship, 123–217
Rozhestvensky, Russian Admiral, 66, 70, 82–84, 257, 265, 270, 274,
276–282
Russia, trade of, 25;
alliance of, 53;
in Asia, 76–78, 153, 300;
in Seven Years’ War, 147;
in Napoleonic Wars, 184–190, 192, 224–226;
a member of the Entente, 305, 317–318;
decreased strength of, 322;
her need of a navy, 327, 355–356.
See Russo-Japanese War
Russo-Japanese War, 56–57, 64, 66, 82–84, 88, 256–282, 355

Sackett’s Harbor, 232, 239

St. George’s Channel, 37
St. Helena, 20, 152
St. Lawrence, Gulf of, 20;
river, true frontier in 1812, 230 ff.
St. Thomas, 103
St. Vincent, Lord, policy of, 5, 193
Saint-André, French Commissioner, 173, 179
Saints’ Passage, battle of, 160, 169
Samana Bay, 103
Sampson, Admiral, #$1#, 241, 249, 250–255
Santa Lucia, 74, 103, 105, 108
Santiago de Cuba, 71, 103, 104, 107, 241, 243, 246, 247;
blockade and battle of, 250–255
Santisima Trinidad, Spanish ship, 214, 215, 217, 218, 220
Sardinia, 37
Scheldt River, 30, 248
Schleswig Holstein, 349
Schley, Admiral, 241, 246
Sea Power, dependence on, a British policy, #$1#;
scope of history of, 3;
elements of, 16–47;
conditions affecting, 21;
growth of British, 141–146, 151–152;
controls communications, 77–78;
decisive in warfare, 98, 99;
an important element in national growth, 154, 286–287;
in Napoleonic Wars, 191–197, 221–224;
a protection against aggressions by land powers, 306–308;
interest in, 326–327
Secession, War of. See Civil War
Semenoff, Russian Captain, quoted, 280
Seven Years’ War, 85–86, 142–144, 147–154, 307
Shafter, General, 269
Sherman, General, quoted, 335
Ship design, unity of purpose in, 61–62
Sicily, 37, 38, 39, 42
Situation, determines strategic value of a point, 69–70, 110
Smith, Sir Sidney, 126
Socotra, 152
Sound, between North and Baltic Seas, 51, 185, 186, 190
South Africa, 290;
war in, 293–295, 347
South America, unstable political conditions in, 148–149;
application of Monroe Doctrine to, 290
Spain, position of, 26;
dependence on sea power, 38, 39;
colonial policy of, 45;
in 18th century, 141–142, 143–144, 151–152;
in Napoleonic Wars, 81, 221, 226;
colonial empire of, lost, 291, 342.
See Spanish-American War
Spanish-American War, strategy of, #$1#, 59–60, 88–90;
Cervera’s fleet in, 241–249;
Santiago blockade, 250–255;
strengthened Anglo-American unity, 291–295;
could not have been avoided by arbitration, 342, 348–349
Speed, of battleships, 61, 246–248
Strasburg, 71, 137
Strategic Lines and Positions, in the Caribbean, 65–78, 100–112;
in the War of 1812, 238–240
Strategy, defined, 4, 12, 49;
value of study of, 5;
in War of 1812, 229–240;
must take into account political conditions, 250–253, 320–327;
illustrated by mistakes, 257;
must be exercised in time of peace, 274;
chief aim of, 311
Submarines, 70, 99
Suez Canal, 26, 28, 51, 70, 77, 152, 252, 261, 289, 290
Suffren, French Admiral, 86, 153
Sully, French Minister, 38
Suvarof, General, 262
Sweden, trade of, 25;
in Thirty Years’ War, 53;
in 1800, 184–190

Tactics, defined, 4, 49;

illustrated in history, 5–7;
in naval combats, 62–64;
formalism in, 155–158;
changes in, at close of 18th century, 159 ff., 168;
chief aim of, 311
Territory, extent of, affecting sea power, 39–42
Texel, 193
Tobago, 160
Togo, Japanese Admiral, 60, 66, 82–84, 90, 270, 276–280
Torbay, 24
Toronto, 231, 236
Torpedo craft, 130–134
Torrington, British Admiral, 242, 248
Toulon, 57, 58, 154, 174, 192, 193, 196, 248
Tourville, French Admiral, 80, 81, 155, 159, 207
Trade. See Commerce
Trafalgar, battle of, 5, 62, 192, 194, 196–223, 248
Trieste, 306
Trincomalee, 86
Triple Alliance, 53, 304–306, 317–318
Triple Entente. See Entente
Tsushima, battle of, 64, 70, 82–84, 88, 265, 276–282
Turkey, 33, 148, 150

Ulm, 50, 71, 76, 191

United States, merchant marine of, 18, 35;
geographical position of, 22;
and Panama Canal, 27–29;
seacoasts of, inadequately protected, 34–36;
exposed only by sea, 39;
deficient in seafaring population, 44;
colonial policy of, 46;
seacoasts of, regarded as a line, 65–67;
naval requirements of, 133–134;
community of interests with Great Britain, 291–295, 306–308,
318–327;
expansion of, 297–298;
and the Open Door Policy, 299;
political ideals of, 302;
policy of, regarding commerce warfare, 331–333.
See Navy, United States
Utrecht, peace of, 141–142

Vengeur, French ship, 180–182

Venice, 306
Victory, Nelson’s flagship, 213–214
Vigo Bay, 157
Villaret-Joyeuse, French Admiral, 178
Villeneuve, French Admiral, quoted, 173;
in Trafalgar campaign, 196, 199, 202, 210–223
Vistula River, 12, 78
Vladivostok, 66, 73, 82, 83, 88;
squadron based on, 256–261, 265, 266, 270, 274;
objective of Rozhestvensky, 276–282
Von der Goltz, General, quoted, 321
War, principles of, 6;
causes of, 148;
preparedness for, 128–134;
beneficial results of, 292–295, 342–354
War of 1812, commerce warfare in, 91–99, 226–228;
strategy of, 229–240
Washington, General, 164;
quoted, 169, 170
Washington, city of, 31
Waterloo, battle of, 82, 239
Weapons, changes in, 6
Wellington, Duke of, 82, 234, 239
West Indies, a source of wealth for Spain, 37;
Nelson in, 196–197, 202.
See Caribbean Sea
William II, of England, 81, 277, 281
Wilkinson, General, 238
Windward Passage, 102
Wireless, in war, 84, 85

Yalu River, 268

Yang-tse River, 276
Yeo, British Commodore, 235
Yucatan Passage, 102, 104

Zuyder Zee, 34
 1. “From Sail to Steam,” p. xiv.
2. “From Sail to Steam,” p. 55.
3. See pp. 328–341.
4. Rear Admiral Bradley A. Fiske, U. S. Naval Institute, January–February,
1915, p. 2.
5. “La Maîtrise de la Mer,” Auguste Moireau, Revue des Deux Mondes,
October, 1902.
6. “Of Kingdoms and Estates.”
7. “The Revival of Naval History,” Contemporary Review. November, 1917.
While the term “political pamphlet” suggests the influence of the book abroad, it is
obviously inappropriate in describing its purpose and method of treatment.
8. “The Kaiser’s Dreams of Sea Power,” Archibald Hurd, Fortnightly Review,
August, 1906.
9. “From Sail to Steam,” p. 303.
10. “Captain Romeo Bernotti,” letter to the editor, April 25, 1918.
11. “A Great Public Servant,” The Outlook, January 13, 1915.
12. “From Sail to Steam,” p. 288.
13. “The Influence of Sea Power upon History,” pp. 1–2, 8–10.
14. “Naval Administration and Warfare,” Objects of the Naval War College
(1888), pp. 193–194, 233–240.
15. In a preceding passage the author shows that American naval thought has
been preoccupied with problems of material.—Editor.
16. “The Influence of Sea Power upon History,” pp. 25–59. Mr. S. G. W.
Benjamin has pointed out (N. Y. Times Book Review, Feb. 2, 1902) that it was in
the preface and opening chapter of this book, “comprising only eighty-nine pages,
that Captain Mahan brought forward his famous presentation of the theory about
the influence of sea power on empire.” The present selection includes the major
part of the first chapter.—Editor.
17. For the author’s later opinion on the need of a navy, see pp. 355–357.—
Editor.
18. Written before 1890.—Editor.
19. By a base of permanent operations “is understood a country whence come
all the resources, where are united the great lines of communication by land and
water, where are the arsenals and armed posts.”
20. “Naval Administration and Warfare,” pp. 199, 206. For the distinction
drawn, see also pp. 4, 12.—Editor.
 21. “Naval Strategy,” pp. 31–53.
22. An interesting instance of the method and forethought which cause
German naval development of all kinds to progress abreast, on parallel lines, is
found in the fact that by the time the three Dreadnoughts laid down in 1911 are
completed, and with them two complete Dreadnought squadrons of eight each,
which probably will be in 1914, the Kiel Canal will have been enlarged to permit
their passage. There will then be a fleet of thirty-eight battleships; including these
sixteen, which will be stationed, eight in the North Sea, eight in the Baltic, linked
for mutual support by the central canal. The programme contemplates a
continuous prearranged replacing of the present pre-Dreadnoughts by
Dreadnoughts.
23. See map on page 278.
24. “Naval Strategy,” pp. 130–163.
25. “Naval Strategy,” pp. 166–167. For illustration and further discussion of
strategic lines, see “General Strategy of the War of 1812,” in this volume, pp. 229–
240.—Editor.
26. “The Problem of Asia” (1900), pp. 124–127.
27. “Naval Strategy,” pp. 266–272.
28. “Naval Strategy,” pp. 277–280.
29. “Sea Power in its Relations to the War of 1812,” Vol. I, pp. 284–290.
30. “History of the United States,” Vol. VIII, chap. VIII.
31. “The Influence of Sea Power upon History,” p. 138.
32. This immunity of enemy property in neutral ships, guaranteed by the
Declaration of Paris in 1856, has been to a large extent nullified in recent practice
by extension of the lists of contraband, to say nothing of the violations of all law in
submarine warfare.—Editor.
33. “Naval Strategy,” pp. 303–304, 356–367, 381–382.
34. “Naval Administration and Warfare” (1903), pp. 5–11.
35. “Naval Administration and Warfare” (1903). pp. 26–31.
36. “Naval Administration and Warfare” (1903), pp. 46–48.
37. These bureaus are seven in number: Yards and Docks, Navigation,
Ordnance, Construction and Repairs, Steam Engineering, Supplies and Accounts,
and Medicine and Surgery. The Chief of Naval Operations, whose office was
created in 1915, stands second to the Secretary and acts as his expert professional
adviser, with the specific task of co-ordinating the work of the navy, preparing
plans, and directing operations in war. He is, ex officio, a member of the General
Board of the Navy, created in 1900, which serves as an expert advisory body.—
Editor.
 38. “Retrospect and Prospect,” pp. 258–259, 270–272.
39. “The Interest of America in Sea Power” (1896), pp. 192–200.
40. Bombardment of undefended ports, towns, etc., is forbidden by
Convention IX of the Hague conference of 1907, with the broad concession,
however, that depots, store houses, and all constructions that serve military
purposes may be destroyed.—Editor.
41. “The Influence of Sea Power upon History” (1660–1783), pp. 197–200.
Admiral Mahan’s major historical works treat consecutively the history of naval
warfare from 1660 to 1815; and his essays and shorter studies cover subsequent
wars. The selections in Part II are arranged in chronological order.—Editor.
42. “The Influence of Sea Power upon History,” pp. 63–67.
43. An interesting proof of the weight attributed to the naval power of Great
Britain by a great military authority will be found in the opening chapter of
Jomini’s “History of the Wars of the French Revolution.” He lays down, as a
fundamental principle of European policy, that an unlimited expansion of naval
force should not be permitted to any nation which cannot be approached by land,—
a description which can apply only to Great Britain.
44. “The Influence of Sea Power upon History,” pp. 323–329. By the Treaty of
Paris, 1763, England secured Canada, all French possessions east of the
Mississippi, and Florida; she also retained Gibraltar and Minorca, and gained
ascendancy in India.—Editor.
45. See Annual Register, 1762, p. 63.
46. Campbell, “Lives of the Admirals.”
47. These remarks, always true, are doubly so now since the introduction of
steam. The renewal of coal is a want more frequent, more urgent, more
peremptory, than any known to the sailing-ship. It is vain to look for energetic
naval operations distant from coal stations. It is equally vain to acquire distant
coaling stations without maintaining a powerful navy; they will but fall into the
hands of the enemy. But the vainest of all delusions is the expectation of bringing
down an enemy by commerce-destroying alone, with no coaling stations outside
the national boundaries.
48. “Types of Naval Officers,” pp. 14–17.
49. A celebrated French admiral, in command at the battles of Beachy Head
(1690) and La Hogue (1692).—Editor.
50. The most famous of these were issued in 1665 by the Duke of York,
afterward James II, who was then Lord High Admiral. They were revised but not
greatly altered in 1740 and again in 1756.—Editor.
51. Byng’s offense, for which he was sentenced to be shot, occurred in an
action with a French squadron off Minorca in 1756.—Editor.
 52. “The Influence of Sea Power upon History,” pp. 377–380.
53. De Grasse, whose victory over Graves off the Chesapeake forced the
surrender of Cornwallis, was afterward defeated by Rodney in the famous battle of
the Saints’ Passage, April 12, 1782. Three days earlier, De Grasse had neglected an
opportunity to attack in superior force.
While the battle of the Saints’ Passage is more celebrated, the action here
described better illustrates Rodney’s merits as a tactician. In his later years Rodney
wrote that he “thought little of his victory of the 12th of April,” and looked upon
this earlier action as “one by which, but for the disobedience of his captains, he
might have gained immortal renown.”—Mahan, “Types of Naval Officers,” p. 203.
—Editor.
54. The black ships, in position A, represent the English ships bearing down
upon the French center and rear. The line v r is the line of battle from van to rear
before bearing down. The positions v´, r´ are those of the van and rear ships after
hauling up on the port tack, when the French wore.—Editor.
55. In a severe reprimand addressed to Captain Carkett, commanding the
leading ship of the English line, by Rodney, he says: “Your leading in the manner
you did, induced others to follow so bad an example; and thereby, forgetting that
the signal for the line was at only two cables’ length distance from each other, the
van division was led by you to more than two leagues distance from the center
division, which was thereby exposed to the greatest strength of the enemy, and not
properly supported” (Life, Vol. I, p. 351). By all rules of tactical common-sense it
would seem that the other ships should have taken their distance from their next
astern, that is, should have closed toward the center. In conversation with Sir
Gilbert Blane, who was not in this action, Rodney stated that the French line
extended Your leagues in length, “as if De Guichen thought we meant to run away
from him” (Naval Chronicle, Vol. XXV, p. 402).
56. “The Influence of Sea Power upon History,” pp. 387–391, 397.
57. Now Cape Haitien, Haiti.—Editor.
58. Bancroft, “History of the United States.”
59. With the reinforcement brought by De Grasse, Lafayette’s army numbered
about 8,000; the troops brought by Washington and Rochambeau consisted of
2,000 Americans and 4,000 French.—Editor.
60. The action itself is more fully described in Mahan’s “Major Operations of
the Navies in the War of American Independence,” from which the diagram on
page 167 is taken. In the diagram, a a indicates the positions of the two fleets when
De Grasse came out of the bay; b b, the positions when the order to engage was
given; f, Graves’s flagship, and h, Hood. Having approached the enemy with his
twelve leading ships, Graves gave the order to bear down and engage, though he
still kept the signal for “line ahead” flying. Whether through inability or
misinterpretation of orders, the rear under Hood failed to get in range.
 Hood afterward criticised his superior severely on the grounds, (1) that the
fleet was not brought into proper position to engage, and (2) that, upon engaging,
the “line ahead” signal should have been hauled down. He interpreted this signal
as meaning that no ship could close beyond a line through the flagship and parallel
to the enemy line.
Graves next day issued a memorandum to the effect that the line ahead was a
means to an end, not an end in itself, and “that the signal for battle should not be
rendered ineffective by strict adherence to the former.” The confusion was such as
frequently arose in this period of transition from one system of tactics to another.
—Editor.
61. “Types of Naval Officers,” pp. 35–37, 41.
62. Chevalier, “Mar. Fran, sous la République,” p. 49.
63. Nap. to Decrès, Aug. 29, 1805.
64. Troude, “Batailles Nav.,” Vol. III, p. 370.
65. Commodore de Rions, a member of the nobility, who was imprisoned at
Toulon and afterward fled from the country.—Editor.
66. “Types of Naval Officers,” pp. 308–317. The “Glorious First of June” is one
of the most important naval actions in the wars of the French Revolution, and
illustrates the work of an officer who stood in his own day conspicuously at the
head of his profession. The selection is interesting also as showing that, when it
suited his purpose, Admiral Mahan could write with notable ease and pictorial
vigor.—Editor.
67. “The Influence of Sea Power upon the French Revolution and Empire,”
Vol. II, pp. 42–47. The campaign is treated more fully in “The Life of Nelson,” Vol.
II, p. 70 ff.—Editor.
68. Nelson’s Letters and Dispatches, Vol. IV, p. 295.
69. Nelson’s Dispatches, Vol. IV., p. 355.
70. Nelson’s Dispatches, April 9, 1801, Vol. IV, pp. 339, 341.
71. “The Influence of Sea Power upon the French Revolution and Empire,” Vol.
II, pp. 117–120.
72. Ibid., p. 106.
73. See “Naval Chronicle,” Vol. X, pp. 508, 510; Vol. XI, p. 81; Nelson’s
Dispatches, Vol. V, p. 438.
74. Pellew’s “Life of Lord Sidmouth,” Vol. II, p. 237.
75. Nelson’s Dispatches, Vol. IV, p. 452.
76. “The Influence of Sea Power upon the French Revolution and Empire,”
Vol. II, pp. 184–197, 199–202, 356–357.
 77. “The Influence of Sea Power upon the French Revolution and Empire”,
Vol. II, p. 181.
78. Napoleon to St. Cyr, Sept. 2, 1805.
79. Napoleon to Decrès, Sept. 15.
80. Ibid., Sept. 4.
81. Nelson’s Dispatches, Vol. VII, p. 80.
82. The following account of Nelson’s arrival and his plan of battle is taken
from the fuller narrative in “The Life of Nelson,” Vol. II, pp. 339–351.—Editor.
83. Inserted by author.
84. Here the narrative is resumed from “The Influence of Sea Power upon the
French Revolution and Empire.”—Editor.
85. Fyffe’s “History of Modern Europe,” Vol. I, p. 281.
86. To the King of Wurtemburg, April 2, 1811; “Corr.,” Vol. XXII, p. 19.
87. “Sea Power in its Relations with the War of 1812,” Vol. I, pp. 295–308; Vol.
II, pp. 121–125.
88. Kingsford’s “History of Canada,” Vol. VIII, p. 111.
89. Drummond to Prevost, Oct. 20, 1814. Report on Canadian Archives, 1896,
Upper Canada, p. 9.
90. Ibid., Oct. 15.
91. Prevost to Bathurst, Aug. 14, 1814. Report on Canadian Archives, 1896,
Lower Canada, p. 36.
92. “Travels,” J. M. Duncan, Vol. II, p. 27.
93. “Life of Brock,” p. 193.
94. Smyth, “Précis of the Wars in Canada,” p. 167.
95. The United States Secretary of War.—Editor.
96. December 17, 1813. Captain’s Letters, Navy Department.
97. “Lessons of the War with Spain” (1899), pp. 75–85.
98. Ibid., p. 157.
99. In this number is included the Emperador Carlos V, which, however, did
not accompany the other four under Cervera.
100. “Lessons of the War with Spain” (1899), pp. 184–191.
101. “Naval Strategy,” pp. 383–401.
102. The Kobe Chronicle, February 25, 1904; an English newspaper published
in Japan.
 103. “Naval Administration and Warfare,” Retrospect upon the War between
Russia and Japan (March, 1906) pp. 167–173.
104. “Naval Strategy,” pp. 416–420.
105. “The rise or fall of the Empire depends upon to-day’s battle. Let every
man do his utmost.”—Editor.
106. “The Interest of America in Sea Power,” Hawaii and Our Future Sea
Power (1893), pp. 51–54.
107. “The Problem of Asia” (1900), pp. 133–144.
108. “The writer has been assured, by an authority in which he entirely trusts,
that to a proposition made to Great Britain (at the time of the Spanish-American
War) to enter into a combination to constrain the Use of our power,—as Japan was
five years ago constrained by the joint action of Russia, France, and Germany,—the
reply was not only a passive refusal to enter into such combination, but an
assurance of active resistance to it, if attempted.”—Mahan, “The Problem of Asia”
(1900), p. 187.—Editor.
109. “Retrospect and Prospect” (1902), pp. 15–17.
110. “The Interest of America in International Conditions,” The Open Door
(1910), pp. 198–202.
111. “The Interest of America in International Conditions” (1910), pp. 38–46.
112. The Mail, April 20, 1910.
113. “The Interest of America in International Conditions” (1910), pp. 161–164.
114. “Retrospect and Prospect,” Considerations Governing the Disposition of
Navies (1902), pp. 151–170.
115. “Naval Strategy” (1911), pp. 104–112.
116. Since this was written, a new Treaty of Alliance between Great Britain and
Japan, operative for ten years, has been signed—July 13, 1911. By its terms either
Power will be released from its military obligation to the other, as against a third
with which it may have a treaty of general arbitration, such as that framed between
Great Britain and the United States.
117. Since these words were written such formal announcement has been
made by a member of the British Cabinet, Sir Edward Grey, the Secretary for
Foreign Affairs, on May 23, 1911. The Mail, May 24, 1911.
118. “Some Neglected Aspects of War” (1907), pp. 171–191.
119. The Napoleonic Wars, the War of 1812, and the American Civil War. For
the effect of commerce warfare in these struggles, see pp. 91–99.—Editor.
120. Vol. I, pp. 146–148.
121. The “Times” of October 14, 1905.
 122. Indirect, I presume.
123. “Some Neglected Aspects of War,” The Peace Conference and the Moral
Aspect of War (1899), pp. 45–52.
124. Lest this be misunderstood to be an allusion to the recent measures of
Japan in Korea, I renew here the caution that in this article all references to the
Peace Conference are to that of 1899.
125. “Some Neglected Aspects of War,” The Hague Conference and the
Practical Aspect of War (1907), pp. 75–80, 90–93.
126. “Naval Strategy,” pp. 445–447.
 TRANSCRIBER’S NOTES
1. Silently corrected obvious typographical errors and
variations in spelling.
2. Retained archaic, non-standard, and uncertain spellings
as printed.
3. Re-indexed footnotes using numbers and collected
together at the end of the last chapter.
*** END OF THE PROJECT GUTENBERG EBOOK MAHAN ON
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