The case study will critically analyse and reflect on current practice considering, the assessment diagnosis and prescribing process, In order to achieve this, a patient has been chosen to critically analyse the management of their care. discussing the challenges and complexities associated with prescribing, incorporating critical thinking and reasoning to formulate a conclusion to treatment. In addition, the case study will consider issues relating to the patient consultation such as legal, ethical and professional guidance and the use of the seven principles of prescribing as recommended by the National Prescribing Centre (1999). Throughout this work, the anonymity and confidentiality of the patient will be maintained in line with the Nursing and Midwifery Council (NMC) Code of Professional conduct (2008). Confidentiality is a legal obligation derived by law; it is a requirement of our professional code of conduct and is also included in our NHS employment contracts (Department of Health, 2003).
Nurse prescribing first became part of the government’s policy agenda following the Cumberlidge report (DHSS, 1986). It suggested that nurses should be able to prescribe independently, highlighting that patient care could be improved. Subsequently from this evolved the first Crown report (DHSS, 1989) which recommended qualified nurses, district nurses and heath visitors should be authorised to prescribe in defined circumstances, from a limited formulary. The primary legislation that permitted initial prescribing was the Medicinal products : Prescription by nurse’s act 1992, then in 1997 the government set up a review of the prescribing (under the chairmanship of Dr June Crown, 1999) resulting in a second report being published ‘Making a difference’. Extending nurses roles of nurses, midwives and health visitor better use of knowledge and skills, including making it easier to prescribe. Since the publication of this seminal piece of work, non-medical prescribing has been analysed, reflected upon, researched at great lengths and changes in practice made (DoH 1989, 1999, 2006 & 2008; Luker et al 1994; Latter et al 2011) and is still under constant review.
Supplementary precribing was first termed dependant prescribing by Crown (DH,1999) and introduced in 2003. Supplementary prescribing is defining a partnership between an independent prescriber (Doctor or Dentist) and supplementary prescriber to implement an agreed patient specific clinical management plan (CMP) with patient agreement (NMC 2006). However this can only take place once the independant prescriber has made a diagnosis (DH,2003) today this continues in practice particularly for newly qualified nurses prescribers, complex situations, team approach and patients (CMP) that includes the use of controlled drugs. It sets boundaries and parameters for chosen medications in relation to the disease/illness being treated (Nuttall and Rutt-Howard 2011).
formalisation of Legislation came into effect on 31st May 2006. which enables all qualified Extended Independent Nurse Prescribers (now known as Nurse Independent Prescribers) and suitably qualified pharmacists to prescribe any licensed medicine. However the DOH 2006 stipulates although nurses and midwifes are legally able to prescribe any licensed prescription only medicine, they must also prescribe within the scope of practice or competence and are accountable for their own actions and emissions and must adhere to local, national policies, NMC code of conduct, NICE guidelines and framework set out by the DOH when formulating the prescribing process. This change in legislation has provided nurses with greater autonomy, in that they are now often able to complete episodes of care for their patients. However, it could also be perceived as a double-edged sword, given the increased responsibility that this additional qualification brings, .. advocates accountability and safe practice is paramount within this field of practice and puts a lot of responsibility on the non-medical prescriber.
The author implemented Neighbour inner consultation model five stages connecting, summarising, handing over, safety netting and housekeeping (Neighbour,1987) . The author found it easy and simple to remember, whilst covering all areas needed to make an effective consultation and assessment. Neighbour,1997 firmly believes utilising this approach will ‘enable us to consult more skilfully, more intuitively and more efficiently’…. stipulates Neighbour provides us with a model that is structured and easy to recall. Its five steps feel more achievable than Pendleton’s seven steps. It is patient-centred, but also attends to the doctor’s feelings, and tries to tackle the tricky areas leading to dysfunctional consultations. l
Health professionals consider nurses to be more approachable than doctors, better at communicating and more likely to involve patients in discussions about their healthcare (Courtenay et al, 2009a; 2009b; Watterson et al, 2009). Patients also think nurse practitioners ( NPs) offer more patient-centred consultations. This is due to nurses’ approachability, ability to build rapport, listening and communication skills, unhurried style and tendency to invite patient involvement (Stenner et al, 2011; Jones et al, 2007). The author is aware by having these skills make it easier for patients to share information, ask questions, and address problems, meaning they understand their condition and treatment better. It also makes it easier for patients to self-manage long-term conditions and adhere to treatment regimens according to (Courtenay et al, 2011; Stenner et al, 2011).
The author, a nurse practitioner based in an Urgent Care Centre (UCC), In the North West England. The practitioner is currently employed as a trainee nurse practitioner. The role entails working autonomously: taking accurate clinical histories, physical examination, gain differential and working diagnosis and organise a plan of care. There is a need to liaise with a GP to prescribe medication if needed. This at times may cause a delay in a patient receiving their treatment. Completing the independent and non-medical prescribing module will enable the author to prescribe therefore providing the patient with an efficient timely access to treatment when required. advocates that prescribing is an enhanced skill that is vital for comprehensive patient care. In practice prescribing medication requires experience and knowledge and with it carries a range of legal and ethical responsibilities that necessitates a structured approach (While 2002). According to the National Prescribing centre (NPC 1999) writing a prescription starts a process that not only impacts on the patient, but on the prescriber and the NHS. Therefore, a seven-step framework, the ‘Prescribing Pyramid’ (NPC1999,) will be utilised to guide the consultation and prescribing decision. Utilizing the framework in this way ensured all relevant factors would be considered: maximum effectiveness, minimal risk and costs and respect for patient choice.
Step one ‘consider the patient’ (Taking the history ; clinical examination). At the outset of the consultation the author made a formal introduction, explaining the role of the non-medical prescriber, a problem orientated medical record was adapted to achieve a systemic approach to history taking and verbal consent was gained from the patient. The author is aware consultation cannot take place if some form of consent has not been obtained from the patient to make their own judgement. ; Stipulates consent is an integral part and must be obtained before any consultation can take place. Suggest consent should be freely and voluntary given therefore no pressure or unduly influences exerted on patients by health care professionals or relatives. …. for informed consent to be achieved the patient must be fully informed of treatment options available to them. … summarises the law of consent to medical treatment is derived from the ethical principles of desirability of self-determination and respect for integrity. The law on informed consent changed following a Supreme Court judgment, in relation to the Montgomery v Lanarkshire health board, 2015 case, enforcing Doctors must now ensure that patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives.
The author is aware of the importance of listening carefully and acknowledging the ideas and concerns and expectations the patient may have. ; The consultation process is paramount to achieving an effective result, …. The first 90 seconds are vital to establish good repour. It is during this period the patient decide if he / she likes you. …. Suggest its important during pre-consultation phase we address the appropriate consultation. This involves the author having a fully understanding of the patients expressed hypothesis to attendance. It is important during consultation we establish rapport, explore ideas concerns and expectations, ; supports this stipulating if patients increase control over their health involves developing their competencies for making decisions and enacting behaviours that can lead to desired, and ;attainable, health outcomes.
Miss A is a twenty-two-year-old female presenting to the urgent care centre with a three-day history urinary symptom, dysuria ( burning sensation), frequency of urination, lower abdominal pain and micturition. No history fever, loin pain or haematuria. No past medical history ( PMH ) no prescribed over the counter or herbal remedies, medications taken. No known allergies. a full patient history was taken can be found in appendix 1 . advocates the presenting features of lower urinary tract infection include frequent urination or an urgent need to urinate, dysuria, suprapubic pain and turbid or foul-smelling urine. Also fever and non-specific lower back pain may be present. ; concludes Loin pain accompanied by systemic symptoms such as fevers, rigors, nausea and vomiting may suggest an ascending infection or pyelonephritis. However, in elderly patient’s diagnosis is more challenging, as confusion may be the only presenting symptom. It’s also important to consider that UTI may not always be due to infection. Following history taking, a physical examination was carried out, with consent, which consisted of reviewing vital signs, and review of system’s including abdominal and flank examination. History taking can be the most important part of the consultation; Fisherman, 2014 believes that history taking is where 90% of diagnosis are made. From the history and clinical examination and routine urinalysis a differential diagnosis of uncomplicated urinary tract infection (UTI) was formulated. Uncomplicated UTI is one in which there are no structural or functional abnormalities within the urinary tract .Urinary tract infection are caused by an invasion of the tissues of the urinary tract, resulting in effecting one or more parts of the urinary system (bladder, kidneys, ureters and urethral A thorough history, examination and routine investigations can help identify if uncomplicated or complicated urinary tract infections, patients with risk factors, defining more specific investigations culture, bloods, referrals to urology or more prolonged treatment.
To support the examination, diagnostic testing is required & suggests a formal microscopy, culture and susceptibility testing should be performed in most circumstances to ensure patients receive appropriate antimicrobial therapy, especially given the rising incidence of antibiotic resistance. This is particularly important in men, pregnant women and patients with recurrent infections. The author carried out a routine urinalysis dipstick which is a very common in the primary care setting. The results detected Blood +1 and Leukocyte +2 other finding from test within normal parameters in the urine sample. However, Pan Mersey guidelines recommend not to routinely culture as 90% of cases will give a positive result.
When the author considers UTI differential diagnoses other possibilities can include pelvic inflammatory disease, sexually transmitted diseases, urothelial carcinoma and bladder calculi. This highlights the importance of careful diagnosis, investigations and follow-up. To help formulate a diagnose to be confirmed or refuted, clinical examination and investigations are needed.
Urinary tract infections (UTIs) are among the most common bacterial infectious diseases encountered in clinical practice and account for significant morbidity and high medical costs. Escherichia coli is the most predominant pathogen causing 80-90% of community-acquired UTIs and 30-50% of nosocomial-acquired UTIs, research reports UTIs are one of the most frequent clinical bacterial infections in women, accounting 25% of all infections, data supports this advising around 50-60% women will develop UTI in their lifetime.
The second stage of the NPC’s prescribing pyramid comprises consideration of appropriate strategy/treatment plan required. The decision to treat in whiles opinion (2002) accumulation of reaching a diagnosis of achieving concordance with the patient. The patients expectation from the consultation is a prescription for antibiotics, however good prescribing practice does not always lead to a prescription; non-medical prescribers can also decide not to treat, instead providing health education and advice or recommend the purchase of an over the counter medicine ( NMP 1999, While 2002) However in order for the nurse prescriber to be able to reach a decision in forming a diagnosis for the patient it is necessary to have a firm underpinning knowledge of various medical conditions and how they can present in different ways (Douglas et al, 2009).
According to Nice Guidelines antimicrobial resistance poses a significant threat to public health, especially because antimicrobials underpin routine medical practice.
Following Pan Mersey local guidelines ‘ strategies to optimise prescribing of antimicrobial in primary care, a diagnostic algorithm for UTIs in adults should be implemented in the prescribing decision. The guidelines recommend patients who present with severe or more than 3 symptoms and no vaginal discharge or irritation, empirical antibiotic should be prescribed. If the patient has mild or less than two symptoms of UTI. (see appendix 2)
When deciding on empiric therapy for a UTI, local resistance patterns to antibiotics are an important factor in choice of therapy. The decision to prescribe antibiotics is one of the most common treatment decisions faced by frontline primary care clinicians daily, and urinary tract infection (UTI) is one of the most common bacterial infections encountered. Although antimicrobial treatment for UTI is accepted in clinical practice, antibiotic resistance in urinary bacteria is increasing, with rates cited in the literature of between 20% and 40% to trimethoprim and amoxicillin respectively. Bacteria are adept at side-stepping human intervention (for example, antibiotics and vaccines) and are developing resistance to antibiotics faster than the pharmaceutical industry is developing new ones: only two new classes of antibiotics have been developed in the last 30 years. Therefore, given this consideration, antibiotic choice should be based not only on efficacy and safety, but also, on the concept that broad spectrum antibiotics should be spared to safeguard their future effectiveness. Public health England 2017 devised TARGET : Treat Antibiotics Responsibly, Guidance, Education, Tools. The toolkit helps influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing.
Stage 3 – Consider the choice of product.
Miss S met the criteria to prescribe antibiotics, symptomatic having 3 indicating symptoms consistent with the algorithm utilised and a positive urine sample. Before consideration of prescribing the antibiotic its important the prescriber is aware of all known allergies, polypharmacy medications and renal profile, to ensure safety in prescribing.
Using the Antimicrobial Guidelines Summary (2014) which is devised by the NHS Pan Mersey Area Prescribing Committee and the BNF (2014) formulating a decision to prescribe 1st line of recommended drugs for UTI : Nitrofurantoin 100mg MR twice daily for three days . Referring to number of previous studies cited support this decision that short courses of 3 days of antibiotics are as effective as longer courses in uncomplicated UTI & Collaboration with the mnemonic EASE which is recommended by the NPC (1999) was utilised to help ensure an Effective product, which is Appropriate for the patient, which is Safe to use and one that is cost Effective.
The pharmacokinetics of nitrofurantoin are as follows: Nitrofurantoin is readily absorbed and quickly distributed into most of the body fluids. The drug exhibits bacteriostatic or bactericidal effects by inhibiting the synthesis of DNA, RNA, protein and cell wall synthesis. Mechanism of action is activated by bacterial flavoproteins to reduce reactive intermediates, therefore causing inhibition of DNA RNA protein. The overall effect is inhibition of bacterial growth or cell death, partially metabolized in the liver to aminofurantoin. Nitrofurantoin is readily absorbed in GI tract primarily in the small intestine. It is enhanced by food or delayed gastric emptying via enhanced dissolution rate of the drug. It is rapidly excreted in large amounts in bile and urine. Except for the active drug secretion in the kidney tubule and biliary drug transport, nitrofurantoin transfer across body membranes occurs by diffusion. Nitrofurantoin has a short elimination half-life in whole blood or plasma. Its half-life of 0.3-1 hour.
The author also advised over the counter analgesia paracetamol 500mg qds for three days, and ibuprofen tablets 400mgs three time daily with food or after food, for analgesia effects and anti-pyrexia effects. This co-insides with Pan Mersey guidance recommends offering symptomatic relief with paracetamol. If the response is insufficient, offer a nonsteroidal anti-inflammatory drug (NSAID) in addition, such as ibuprofen or naproxen, unless not tolerated or contraindicated.
The author is aware in practice if a patient presents with mild symptoms who has normal immunity, normal renal function, and a normal renal tract, other option to be considered. Treatment can be delayed seeing if symptoms will resolve without treatment, especially if the urine dipstick test is negative for nitrites and leucocyte esterase (indicating a low probability of a UTI). For all other patients start treatment without delay.
Trimethoprim was once the first choice treatment for UTIs before Public Health England (PHE) in 2017 recommended switching to a different antibiotic nitrofurantoin. Due to a comparison study that showed only one in three (34%) of the samples analysed were found to be resistant trimethoprim, compared to 29.1% in 2015.
Negotiating a contract
According to While (2002) the fourth stage of the framework emphasizes the importance of client practitioner partnership through negotiation. The expectation from the patient to prescribe antibiotics was highlighted during the consultation, therefore meeting the patient’s expectations. As discussed and agreed it was clinically indicated to prescribe antibiotics. Miss S conveyed she fully understood the rational for taking antibiotics and she did not express any concerns or anxieties. Also, the pain relief for analgesic and anti-pyrexia effects.
Patients often attend with clear idea of the outcome that they expect, this can be varying from wanting a prescription or sick note to a simple desire for advice or reassurance ( Little 2005). In current practice the demands for a prescription primary care practice can become a challenging ordeal for practitioners as if the decision to prescribe a drug is not made. DOH (2013) recognises that consultations can often be challenging when patients expect antibiotics and may be unwilling to accept when they do not need them. To support Woodhead et al (2005) also argued that some prescribers perhaps prescribe unnecessary antibiotics for clinical reasons that may have no evidence base or for non-clinical reasons such as the desire to reduce attendance of patients, or for example the belief that patients may expect antibiotics simply based on a presenting symptom.
The author is aware of the importance of patients have fully understanding in layman’s terms of how to take the drugs, concordance and side effects. As some patients experience side effects from taking antibiotics and are a common cause of repeat visits to see their GP.(Lim and Macfarlane, 2001). According to the medicines partnership ( 2007), it is becoming increasingly recognised that the notion of concordance or shared decision making is a way for practitioners and patients to come together to make the best use of medications prescribed thus ensuring optimum benefit. Concordance ensures that both parties have their say, A prescribing decision should be a shared contract between the prescriber and the patient. This helps to achieve compliance and adherence (Courtenay and Griffiths 2010). Nurse prescribers appear to place a high priority on respecting patient choice and this could help achieve adherence (Petty 2012). Often non-adherence is due to failure to educate and advise the patient when the prescription is initially given or failure to provide follow-up support. Hall (2010) outlined that if the patient is adequately educated about their treatment they are most likely to concord.
Stages 5, 6 & 7 – The three R’s: Review, Reflect, Record keeping and Reflection.
In an urgent care centre, it is very often difficult to review patients following treatment as the patients often attending are transient, out of area or hard to reach. Therefore, this does not necessities the process criteria / setting to routinely review patients. Fragmentation of primary care for example, in-hours, out-of-hours, walk-in centres, and telephone call centres) makes this more difficult. The patients are giving safety netting advice, should the unforeseen problems occur, the patients’ needs to be informed of when and how to seek further help. Ruth Lonsdale ( 2007) describes safety netting as ‘worst case scenario’. Patients are advised if symptoms don’t improve after treatment or worsening symptoms, reattend urgent care, follow up with their own general practitioner. Clinical red flags are discussed in the event of severe abdominal, loin pain, uncontrolled fevers, vomiting or deterioration of health access their nearest emergency department, or call NHS 111 If there is a recognised risk of deterioration or complications developing then the safety-net advice should include the specific clinical features (including red flags) that the patient or parent/carer should look out for. So, safety-netting is arguably the most important part of the diagnostic process.
Otherwise, the objective must be to empower the patient, parent or carer so that they can take responsibility for monitoring their own situation and are able to take effective action when needed.
It is crucial to understand that the role as a non-medical prescriber includes patient safety, completing clear valid record keeping, effective communication, and documentation. Record keeping is an integral part of a nurse prescriber’s care and treatment that is every bit as important as the direct care you provide to patients. Record keeping also has a vital legal purpose. It provides evidence of your involvement with patients and needs to be detailed enough to demonstrate that you have fulfilled your legal and professional duty of care It is imperative that a high standard of record keeping is maintained and the details of the prescription need to be recorded immediately. Any item prescribed by a designated non-medical prescriber must be entered into all patient records within 24 hours. In accordance the NMC code of conduct (2008) A clear and accurate account of the clinical assessment and examination along with the details of the prescribing decisions were entered into the patients secured electronic records, a copy of which will be forwarded to GP, to ensure continuity of care and safe practice. (Dowell, Williams & Snadden ( 2007) stipulate there are four main roles to & record keeping, assist recall of events enables audit of care, provides communication between colleagues when necessary, provides evidence in litigation. All prescribers are required to keep records, which are accurate, unambiguous and legible in line with requirements of the registering body standards for records.
On reflection, this case study utilised a structured consultation process in non-medical prescribing, resulting in a successful outcome. The health professional needs to be competent in a wide range of skills and competencies, have underpinning knowledge, to ensure effective outcomes (Medicines Partnership Programme 2007). From the onset the patient had a clear expectation of what she wanted. Through a concise history taking, clinical examination and routine testing achieved accurate diagnosis, enabling an evidence-based drug to be prescribed, however prescribing is not just simply the task of writing a prescription, but it is about the knowledge and skills to assess, examine, diagnose and treat the patient. To be truly independent means having the responsibility of assessment and management from start to finish (Strickland-Hodge 2008). The NMC
The author is of the understanding that not all consultations reach a shared agreement, ultimately best practice should demonstrate effective good communication and interpersonal skills, are paramount. However, when patients report they are dissatisfied with their care, it is often a break-down in communication ( While 2002). Misunderstanding can lead to poor outcomes. Barry et al 2000) and inadequate information can result in prescribing errors (Courtenay & Carey 2008). From devising and researching the case study has highlighted and enhanced knowledge of the important areas associated with prescribing such as clinical reasoning, evidenced based research, consultation styles, and legal implications Demonstrated throughout case study was the incorporation of the ‘prescribing pyramid’, Neighbour hoods inner consultation models to help structure the process. It could be argued that there is no correct consultation model and various models which may be used will be effective in different circumstances. Therefore, everyone will need to adapt to suit personal preferences (Coffey and Bowskill, 2010).
The case study focused upon prescribing antimicrobials debate, the prescribers followed local and national guidelines, prescribing the shortest effective course, the most appropriate dose, route of administration. considering the risk of antimicrobial resistance for individual patients and the population. Furthermore, it is essential that Health Professionals follow guidelines and question their decision making prior to issuing a prescription for antibiotic therapy. This will hopefully help to tackle the growing issue of antibiotic resistance development and adverse reactions when taking antibiotics (Rowbotham et al, 2012). Importantly, prescribing of antibiotics should always be cautiously approached at every opportunity.
To conclude Furthermore, when entering a new expansion of role, it may present the employee with additional barriers. Nurse independent prescribers are accountable in four areas of law which are civil, criminal, professionalism and accountability is implied via signing of a contract of employment. It is therefore paramount to add the prescribing role to a job description to get cover by employers’ vicarious liability (Lovatt, 2010). ). Therefore, it could be argued that nurses are accountable to the profession, the individual, our employer and society itself. It is important that nurses keep up to date with prescribing (Caulfield, 2005)
It is crucial to understand that the role as a non-medical prescriber includes patient safety, completing clear valid record keeping, effective communication, team working, risk management and continuous professional development. Also, the importance of keeping up to date with evidence-based practice. As a non-medical prescriber, the author has devised learning outcomes to continue an ongoing portfolio will be used to demonstrate evidence of continued learning. Clinical supervision from non-medical prescribing colleagues within practice, will also be crucial for ongoing professional development and most importantly patient care. This case study has guided the author to define evidence practice and the importance of safe and appropriate prescribing in practice.