There are many definitions of Independent prescribing, the Department of Health (2006 para 7 & 8)) working definition is: ‘Independent prescribing is prescribing by a practitioner (e. g. doctor, dentist, nurse, and pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. In partnership with the patient, independent prescribing is one element of the clinical management of a patient.
It requires an initial assessment, interpretation of that assessment, a decision on safe and appropriate therapy, and a process for ongoing management. The independent prescriber is responsible and accountable for at least this element of a patients care’ The aim of this case study is to focus on my future role as an independent prescriber. I have applied the seven principles of good prescribing (NMC 1999) and supported the decision making process with the use of Barbers model (Barber1995).
As previously stated within the introduction I will reflect on the process using Gibbs model of reflective practice (Gibbs 1988), (appendix 1). In my role as a specialist nurse I am involved with caring for patients within a community setting and providing a holistic assessment of their needs. This can involve assessing patients as a result of a supported discharge from secondary care or referral from General Practitioners (GP’s) for issues related primarily to their cardiac condition, their general overall health and any other health related issues.
These assessments can take place within the patient’s home or within a clinic setting. These assessments are quite commonly carried out with very little prior knowledge regarding the patient and this is currently an area under review. For the purpose of this case study I will look at a lady who attended a clinic session within a GP’s practice. This lady was referred to the clinic for an annual review of her coronary heart disease (CHD), when she attended it was obvious from the onset that this patient had been wrongly coded by the practice and did not have a diagnosis of CHD.
For the purpose of this case study I will refer to the patient as Betty. Despite this error, I continued to discuss with the patient any other health related issues that she may have. At this point she disclosed that she felt that she was suffering from incontinence. On further verbal discussion it became obvious that the lady appeared to be describing symptoms of a urinary tract infection (UTI). Normally I would have referred this lady back to the GP but as an error had been made with her referral I decided it would be appropriate to assess the patient at this appointment initially.
Previously in situations like this it would not have been unusual for a GP to generate a prescription, following an assessment by a member of the nursing staff. But as I am not yet an Independent Prescriber, nor am I working within the framework of a clinical management plan as a supplementary prescriber, this practice is illegal. I am accountable for my own practice and it is clearly outside the boundaries and legislative framework for me to ask another health care professional to prescribe for a patient that they have not seen or assessed.
As stated in the NMC Standards for Prescribing (2006) I am accountable for all prescribing decisions, including actions and omissions and cannot delegate this responsibility to any other person This is an area of prescribing that has been discussed at length between myself and my mentor as this had implications for all staff who are prescribers and currently there seems to be discrepancies in the information given to nursing staff by some GP’s.
As a specialist nurse it is currently outside the boundaries of my job description to prescribe any form of medication, therefore to provide safe and competent care the GP would also need to consult with the patient. By practising as an independent prescriber the nurse is broadening her professional accountability and responsibility. For nurses extending their role to include prescribing there is much to consider. Revelay (1999) states that, accountability involves an individual giving an account of their actions with the rationale and explanation given for these actions.
The decisions regarding boundaries of practice are firmly placed in the hands of the individual practitioner (Carlisle 1992). Accountability means being able to justify any actions and accepting responsibility for them, and is an integral part of nursing practice (Rowe 2000) The NMC Code of Professional Conduct (2004) states that a nurse is personally accountable for her practice, has a duty of care to patients and must work within the laws of the country.
Examine the Holistic needs of the patient To enable me to comprehensively assess Betty I decided it would be appropriate to use a structured approach to the consultation including history taking and physical examination (Bickley 2004). There a various consultation models, the use of the mnemonic framework PQRST (Atkinson 1993) used for describing pain can be adapted for most physical examinations within a consultation. P Proactive/Palliation Q Quality R Radiation S Severity T Temporal/Timing
Although this framework was used the consultation was essentially based around the well documented and established Calgary-Cambridge model of communication (Silverman et al 2005), which consists of five distinct areas:
1. Initiating the session
- Establishing initial rapport
- Identifying the reason(s) for the consultation
2. Gathering information
- Exploration of problems
- Understanding of patients perspective
- Providing structure to the consultation
3. Building the relationship
- Developing rapport
- Involving the patient
4. Explanation and Planning
- Providing the correct amount and type of information
- Aiding accurate recall and understanding
- Achieving a shared understanding: incorporating the patients perspective
- Planning: shared decision making
5. Closing the session The consultation was initiated by developing initial rapport with Betty who was asked to describe the current problems she was experiencing. It transpired in the course of the consultation that she had experienced pain on micturition, frequency and urgency of urination and nocturnal polyuria for the past 2 days.
She described the pain in her lower abdomen as a constant ‘uncomfortable ache’ giving a pain score of 4/10 with no radiation, no flank pain, no relieving factors, other than some relief after self medicating with over the counter paracetamol, 1 gram, which she had taken 2 hours prior to the consultation. There were no complaints of back pain or fever, she denied any signs of haematuria and there were no other systemic symptoms. She had tried drinking cranberry juice, and increased her fluid intake to try and relieve the symptoms, but with no effect.
Betty’s past medical history was unremarkable, no major medical problems, no hospital admissions/attendances. The discussion revealed she was currently taking no prescribed medication and had no known allergies. Social history revealed she lived with her husband, worked part time and was usually fit and active. Her observations were Blood Pressure 124/68, heart rate 76 beats per minute and temperature 36. 9 degrees centigrade. The current GP’s guidelines would not suggest submitting a mid stream urine sample (MSU) to the laboratory but advise empirical treatment based upon these symptoms and corresponding positive urinalysis test.
Patient urinalysis was performed using Combur-7 test Strips and revealed: ph8, nitrate positive, leucocytes 3+ and blood 3+. The results of the urinalysis combined with the history indicated the diagnosis of an uncomplicated UTI. Loren & Miller (2004) suggest that the symptoms that make a UTI more likely are dysuria, frequency, haematuria and back pain. If a woman has more than one of these symptoms the probability of a UTI is more than 90%.
UTI’s are symptomatic infections of the urinary tract, it is the most common bacterial infection managed within general practice, and accounts for some 5% of women presenting to their GP and between 1% and 3% of all GP consultations (MeReC 1995). Stanton and Dwyer (2000) suggest that ‘50%’ of all women will develop a UTI in their lifetime. Those most at risk include the young and sexually active, however, the elderly population, both male and female, whose advancing age, co-existing illness, institutional care and bladder catheterisation are also at risk and may present with asymptomatic bacteriuria (DOH 2005, Bardsley 2003).
Consider the Appropriate Strategy The treatment of UTI falls within the parameters of independent prescribing (BNF 2009). Courtney et al (2005) reminds us that nurse prescribing has introduced us to a new sphere of accountability and the NMC clearly states that nurses are personally accountable for their practice. In considering the appropriate strategy it is important to consider the following * Has a diagnosis been established * Is the management of this condition within my sphere of competency as a nurse prescriber or is a GP referral required * Is a prescription actually necessary or appropriate?
As stated earlier I would be acting illegally if I allowed a GP to prescribe based on my assessment and diagnosis. I therefore explained the situation to Betty and discussed my findings with her, explaining that the GP would consult with her and provide the appropriate prescription. Following completion of this course as an independent prescriber I will be able to write my own prescriptions, both within a clinic setting and the patient’s home, therefore providing prompt, safe and appropriate care. For the purpose of this portfolio I will continues as if I were an independent prescriber. Consider Choice of Products
Barber (1995) identifies four areas that prescribers should aim to achieve when considering treatment. Using this model enables the independent practitioner to bring together the traditional balance of risks and benefits, the need to reduce costs and the right of the patient to make the right treatment choices. The NMC (2004) states that ‘As a registered nurse I must identify and minimise the risk to patients’ therefore to achieve maximum effect for the patient I need to prescribe the correct anti-biotic at the optimal dose and duration, this will be discussed within the next section of the assignment.
Many issues arise in selecting the correct product for the patient and consideration must be given to the age of the patient, the patient’s level of understanding, patient choice, how the drug is administered and the patient’s ability to adhere to the proposed drug regime. Pharmokenetics, pharmacodynamics and polyphramacy must all be considered when selecting the appropriate product. Pharmacokinetics can be defined as how the body handles a drug (MeReC, 2001). It is known that as we age we are more susceptible to drug effects.
The biggest change is a reduction in renal clearance, this affects drug metabolism and drugs may be excreted at a reduced rate, leading to accumulation and adverse drug events. It is essential that we are aware of these changes and prescribe accordingly. Pharmacodynamics can be described as ‘what a drug does to the patient’ In general, older people have an increased sensitivity to drugs because of changes occurring in the body. Both pharmacokinetics and pharmacodynamics are very complex. It is essential that as a nurse prescriber to have an understanding of these to be able to predict and individualise drug therapy.
Reddy (2006) states that before prescribing for the older patient, we should be sure that the prescription is required and the drug is appropriate. Inappropriate prescribing in this group of people can lead to both over and underuse of drugs. Maximise effectiveness All professionals who are prescribers have a legal responsibility to ensure the item that they select is the most appropriate to meet the needs of the individual patient and that it is safe and effective (Anderson 2002). To achieve maximum effect for Betty, it is important to ensure that the correct antibiotic is prescribed, at the optimal dose and duration.
The Health Protection Agency (HPA 2005) offers advice regarding diagnosing UTI, as do authors Hummers-Pradier and Kochen (2002). They both conclude that ‘dipsticks can be used to examine urine’, and diagnosis of UTI is made with regard to a symptomatic presentation and the presence of nitrates in the urine. The HPA (2005) provide guidelines to the practitioner (as does DOH 2005) in the form of a flow diagram. It explicitly guides the practitioner to follow the results of the dipstick test and offers advice on how to continue, be it ‘reassure and give advice, or treat with a first line agent.
Hummers-Pradier and Kochen (2002) also point out that if both nitrates and leucocytes are negative the probability of a UTI is low and antibiotics should not be given. The HPA (2005) also provide guidelines to aid the practitioner as to when a urine sample ought to be collected and sent to the pathology laboratory for culture and sensitivity. The work by Hummers-Pradier and Kochen (2002) concluded that although there is good evidence for the diagnosis and treatment of uncomplicated UTI’s ‘recommendations are not always followed in daily practice’.
Many authors (DOH 2005, Hummers-Praider and Kochen 2002) suggest the first line treatment of choice for a diagnosed, uncomplicated UTI is short term therapy with an antibiotic. The Standing Medical Advisory Committee (1998) has also issued guidelines on the management of bacterial UTI’s; this also advocates the use of antibiotics for 3 days. As a primary health care team we follow the antimicrobial prescribing guidelines (2006) for uncomplicated UTI. Within these guidelines there are three first line choices: Trimethoprim, Nitrofurantion and Cephalexin. These can all be used for a short term course of three days for women.
The Drugs and Therapeutics Agency (1998) recommend Trimethoprim as a first line agent as this has an efficacy of 70% in cases of uncomplicated UTI. As a PCT the guidelines recommend the use of Trimethoprim as first line treatment as it is currently the most clinically effective as well as being the most cost effective. Prodigy Guidelines (DOH 2005) also suggest an NHS prescription (age from 14 to 75 years) for Trimethoprim tablets for three days and provides evidence that a course of three days is as likely to be as effective as a course of five to seven days and much more cost effective.
Trimethoprim is also known to be tolerated more by the elderly and can be used in those patients with renal impairment, unlike Nitrofurantion, which is contraindicated in patients with renal impairment. Trimethoprim also has a lower level of drug allergy compared to other options. The treatment regime is simple Prodigy guidelines (2005) recommend a dose of 200mgs twice a day for a period of three days. Even when antibiotics are clinically indicated they are sometimes prescribed and used inappropriately. Consideration should be given to the dose, duration of use, interval and likely patient adherence to the regime.
In terms of the various treatment options available for this specific condition, the practitioner has a number of methods available to determine what ‘best practice’ is currently. The multi-disciplinary approach to care within the specialist team, allows for discussion between a numbers of health care professionals, this helps to facilitate discussion and provides all practitioners with invaluable up to date information relating to practice. Minimise risk All drugs are known to have a measure of risk and can cause adverse reactions.
The pharmacodynamics and pharmacokinetics of a given drug may be affected by many factors these include, renal function, body weight, co-existent pathology and other prescribed drugs. These factors are of particular importance in the care of the elderly patient as any of these can lead to an increased risk of drug interaction (Andalo 2003) During my consultation with Betty I established that the only medications that were currently being taken were over the counter paracetamol and cranberry juice of which neither are known to have an interaction with Trimethoprim.
For any drug therapy the nurse prescriber needs to be familiar with any potential adverse drug reactions. An adverse drug reaction (ADR) can be defined as any undesired or unintended effect of drug treatment (Downie et al 1999). Any drug can produce an unintended harmful effect that can be described as an ADR. ADR’s are classified as either A or B.
- Type A – a predictable reaction from the drugs pharmacology caused by excessive or inadequate response to the drug.
- Type B – an unpredictable response from the drugs pharmacology unrelated to the dose.
They are not as common but are clinically more important, for example an anaphylactic reaction to an antibiotic. Courtney (2005) writes that ADR’s are thought to occur in 10-20% of all patients prescribed drugs, cause 4% of hospital admissions and 10% of GP consultations. The Audit Commission (2002) estimated that there were approximately 10,000 serious adverse drug reactions and 1200 deaths caused by prescribed medicines each year The common side effects of Trimephoprim are nausea, vomiting, diarrhoea, pruritus, rashes and erythema as listed in the BNF (2009). There are however more serious adverse reactions which are less common.
One of these being Steven Johnson Syndrome, which is a severe skin reaction. If these occur they should be reported to the Medicines and Healthcare products Regulatory Agency. (MHRA) This can be done via the yellow cards found in the back of the BNF or on-line. A directive to the Committee on the Safety of Medicines acknowledges the changing role and responsibilities of nurses and sees reporting of adverse drug reactions (ADR’s) as part of that changing role. Along with minimising risk to the patient, as a nurse prescriber I need to consider the wider picture and the duty of care to both my individual patients and to society.
The Nursing and Midwifery Council state in the Code of Professional Conduct; ‘Protect and Support the health of individual patients and protect and support the health of the wider community’ The inappropriate use of antibiotics increase patient exposure to the risk of adverse reaction, for most these will be inconvenient but others may be life threatening. The over use of antibiotics also has financial consequences and leads to increased bacterial resistance to the point where they may soon be ineffective.
Antibiotic resistance is seen as a major health problem (SMAC 1998). It is clearly established that over use of antibiotics has contributed to the well publicised increase and problems with hospital acquired infections like Methicillin Resistant Staphylococcus Aureus (MRSA). The main aims of the government strategy are to reduce morbidity and mortality of infections due to antimicrobial organisms and to maintain the effectiveness of antimicrobial agents in the treatment and prevention of infections (DOH 2000).
The government has therefore backed the SMAC Report that suggests the need for a public campaign to handle patient’s expectations and to influence their attitudes towards antimicrobial agents. Patient’s perception of a ‘pill for every ill’ has encouraged over prescribing and ultimately inappropriate health care intervention (Taylor 1999). Within this case study I need to consider the benefits of prescribing antibiotics for an individual against the wider implications of antibiotic resistance.
Due to the mismanagement of antibiotics in both primary and secondary care the drugs are losing their power to heal and as result bacteria are developing a resistance to them. The DOH 2000 perceived this as a major health threat. The World Health Organisation (WHO) 2002 suggests that the misuse of antimicrobials is increasing resistance to such a degree that if a serious effort is not made antimicrobial resistance will set the world back to the pre -antibiotic era. Betty had also been taking cranberry juice prior to her consultation; she was advised to continue with this as evidence shows this to be effective in the treatment of UTI’s.
Bardsley (2003) states that cranberry juice contains compounds that prevent the bacteria, escherichia coli from adhering to urethral epithelial cells and therefore preventing colonisation and concludes that patients should be advised to drink around 300ml of cranberry juice daily. During the consultation Betty was advised that if she experienced any adverse reactions to stop the medication immediately and inform either myself or her GP. I left her with a 24 hour contact number for her general practice and advised her to contact them immediately if her symptoms got worse, to enable her to be reassessed and treatment reviewed.
Minimise Cost When prescribing drugs cost should never be the main consideration. There needs to be a balance between the benefits of prescribing and the risks of not prescribing. (Anderson 1999) If all other things are equal e. g. efficacy and safety we have a duty to prescribe the most cost effective antibiotic. Trimethoprim 200mgs cost ? 0. 88p for 14 tablets in comparison to nitrofurantoin 100mg at ? 4. 34 for 28 tablets and Cephalexin 250mgs at ? 2. 17 for 28 tablets. There will also be a cost benefit to society.
Reduction in antibiotic prescribing and explanations around ‘why not to prescribe’ should educate the public that antibiotics are not the ‘cure for all’ they used to be. Negotiate a Contract and achieve concordance with the patient The Code of Professional Conduct states that in caring for patients a nurse ‘respect the patient as an individual and always act to identify and minimise risks to the patients’ According to Griffith (1990) the advantages of patient participation include, patient responsibility, commitment to health, and promotion of activities which can lead to a positive effect on their outcome.
Barber (1998) states that there are many ethical and practical reasons why patient choices are part of a good prescription. He continues that, at the end of the day, they are the ones picking up the prescription and choosing whether to take it or not. While (2002) discusses that concordance is about asking the patient whether they want that particular drug, discuss the implications of not taking the drug, the benefits of taking it and offer alternatives if appropriate.
There are several reasons why patients do not comply with medication and one of these may be due to the quality of the information that they are given at the consultation (Marinker at al 2003). As a future nurse prescriber my describing decisions should be viewed as a shared contract between the patient and myself, this shared decision making is likely to lead to concordance. To improve concordance I discussed within the consultation the drug regime, the duration of treatment, any possible side effects and any follow up treatment that may be required if necessary. Balancing cost and patient choice can also lead to conflict.
Prescribers are under pressure from government and PCT’s to lower prescribing costs and for that reason may forget to consider patient choice. Barber (1998) agrees and says that resolving the conflicts that arise between risks versus benefit, choice is not easy. Influences on prescriber’s decisions also come from other bodies such as drug and therapeutic committees, pharmacists, medical advisors and commissioning agencies. The consultation was carried out in partnership with Betty and she was given adequate verbal and written information about her condition and treatment in order to maximise concordance.
It is important to take into account that Betty had no mental health problems, other illnesses or conditions that would contribute to decreased comprehension or prevent her from engaging in a two way discussion around her treatment. Such problems can ultimately affect patient decisions, choices and informed consent. In addition future consultations may not be straight forward and future patients may present with more challenging and complex needs. Review the Patient Regular review of the patient is needed to establish whether the treatment prescribed is effective, safe and acceptable to the patient (NPB 1999).
I am also aware that I have a professional responsibility to review and evaluate treatment regimes (NMC 2004, Anderson 1999) I arranged to see Betty again in her GP’s practice three days later to establish if there had been an improvement in her symptoms and to obtain a post treatment MSU. I am aware of the importance of discussing whether Betty suffered any side effects to the medication and the actions to be taken if any adverse drug reactions that she has not reported yet, as outlined previously within this case study. Record Keeping
The sharing of accurate information between multidisciplinary team members is vitally important as is record keeping and effective communication (NPC 2003). It was highlighted by the Crown report (DOH 1989) that good communication between health professionals and patients, and between different professionals, is essential for high quality healthcare. The NMC Code of Professional Conduct (2005) states, that it is essential to keep accurate, up to date records. These records must be maintained regarding assessment, treatments and their effectiveness.
Reveley (1999) states that, records should be legible, understandable, accurate, confidential and untampered with. Good record keeping promotes good quality patient care, safeguards the nurse in case of legal or disciplinary action and enables the nurse to practice to the highest standards of patient care. Dimond (2005) writes that record keeping is an integral part of nursing care and is part of the duty of care owed to the patient. The purpose of record keeping is to have an account of care and treatment, allowing progress to be monitored. They are also a means of communication with colleagues (Griffith 2005).
Details regarding Betty’s assessment, diagnosis, treatment and advice given were all entered into her computerised records at the surgery. Details of the prescription as well as arrangements for review were all entered into the records. The benefit of a computerised system is that one central record exists that all members of the primary care team can access and use. Any subsequent care or decisions can then be made using up to date relevant information. I am aware that when seeing patients at home, computerised systems are not available and we therefore have a duty to ensure that all paper records are accurately completed and maintained.
Reflection Reflective practice is considered to be a tool that enables practitioners to link theory to practice. (Burnard 1991) states, that reflection is seen as a key process in bringing together practice and knowledge in nursing. Nursing knowledge is also seen as a way of addressing the gap between theory and practice. I am very conscious that there will be a significant change to my practice after completion of this course, and I look forward to that with enthusiasm and a degree of caution. I am also aware that changes in health care are becoming more rapid and demands on nurses greater.
I feel it is therefore important to access support in a planned and constructive environment in order to develop prescribing practice safely. The NMC (2004), states that as a nurse I must maintain my professional knowledge and competence, and reflection is seen as a way of achieving this. As stated earlier I will use Gibbs reflective model to enable me to reflect on my transition from currently using Patient Group Directives to my role as an independent prescriber. Gibbs reflective cycle has six stages, the first stage of description of my prescribing has been discussed throughout this case study.
The second stage is to address feelings. Although I have been a nurse for many years and have completed many courses throughout my career, I feel that this has been one of the most challenging. I feel at present that I am back to the novice stage again (Benner 2001). During sessions with my mentor I seemed to be asking questions that had obvious answer’s and suddenly seemed to lack confidence when being asked to make decisions about treatment choice. Although following successful completion of this course I will be able to prescribe independently I feel that I need to address my assessment and diagnostic skills.
I have previously completed a course in clinical skills and although this is an integral part of my role I feel that there is room for improvement. Stages three and four of the cycle allow for evaluation and analysis. Having evaluated the prescribing experience I feel that it is a positive one. The choice of product worked well for the patient and her symptoms resolved. The use of a tool to aid physical examination gave a foundation on which to reach a diagnosis and determine the appropriate choice of treatment. The final two stages are consolidation and I will address these in the final section
Conclusion In conclusion, I am aware that as a future independent prescriber I have a responsibility to practice within the boundaries of my competence and professional limitations. I clearly understand that I need to be able to recognise my own limitations and level of knowledge. I understand that I am accountable for my own actions and that I must posses the knowledge, skills and abilities required for safe, lawful and effective practice (NMC 2004) As a nurse I am responsible for delivering a holistic approach to caring for patients within a community setting. In future the ability to prescribe for
patients both within their own home and in a primary care clinic setting will provide a more efficient and patient centered service. It will also reduce the delay in commencing the appropriate treatment. Literature and research on the subject of nurse prescribing suggest that it will lead to an increased level of satisfaction among patients and provide increased job satisfaction for the nurse. As I reflect on this study I feel that this has been a positive learning experience. I now need to address my role as an independent prescriber within the wider multi disciplinary team.
I need to ensure that my colleagues are aware of my role, and understand my responsibilities and the sphere of my prescribing practice, this will hopefully prevent me from being placed in a vulnerable or difficult position. This case study has helped me appreciate the value of using frameworks to help aid my decision making and recognising the need for audit and self evaluation around my prescribing practice. Prescribing Analysis and Cost data (PACT) will allow me to monitor and analyse my prescribing behaviour in comparison to the local average or to that of other nurses, and how it adheres to local formularies (DoH 2004).
I have a clear understanding that I am accountable for my own actions and in order to practice competently, I must possess the knowledge, skill and abilities required for safe, lawful and effective practice (NMC 2004). I also acknowledge the limits of my professional competence and will only undertake practice and accept responsibilities for those activities in which I am competent (NMC 2004). Training and education are important in keeping up to date with professional and clinical issues.
I have a responsibility to be aware of current research regarding prescribing and the implications that it may have on my professional practice. As clinical supervision is high on the PCT agenda and I am supervised by a member of the medical team within secondary care, who has a great deal of knowledge and experience, within the field of prescribing I intend to incorporate prescribing issues into these sessions. As part of my ongoing development my mentor has agreed to continue to support me as I commence my role as an independent prescriber.
The PCT in which I work have a small support network for nurse prescribers and I intend to utilise this to my benefit and the befit of my patients. Bickley et al (2004) says that over time competence and self confidence grow. Good prescribing is not always easy, writing a prescription is the end result of a process that includes history taking, physical examination, generating a treatment option and including the patient as a partner in the process. Overall I feel that this consultation was a positive.
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