Independent Nurse Prescribing - Case Study Example

Recent Legislative Changes In Relation To Independant Nurse Prescribing Introduction: Independant nurse prescribing had been in agenda for a considerably long time. In 1989, the legislative recommendation for endorsing nurse prescribing came into force, and community nurses were able to prescribe as a part of their every-day practice from a limited list of items (1). The 1992 Prescription by Nurses etc., Act empowered the nurses to prescribe independantly in their practice (2). Despite a sizable resistance due to its demonstrable benefits as against the conventional practice, such as, improvement in patient care, betterment of time management, and incorporation of cure and care by the nurses who could provide more time to the patients in a cost effective manner, within the year 2000, many independant nurse prescribers started practicing after training and approval by NMC (3). This was a success, and in May 2001, it was decided that nurse prescribing would be extended to more nurses and to wider range of medicines (4). This would cover four broad areas of practice, namely, minor ailments, minor injuries, health promotion, and palliative care. Guided by the success of the previous project, it was contemplated that this extension would provide the patients with quicker and more efficient access to medicines that can be prescribed by the skilled nursing force while patient safety would be ensured by restricting the areas of prescription (5). Legislation did also ensure that the nurses would be trained in the proper field so that they are able to prescribe all general sales list and pharmacy medicines, except controlled drugs. Their prescription would also include a list of prescription-only medicines (6). Their areas of prescription also included supplementary prescribing after initial assessment of a patient by the doctor, to prescribe according to the clinical management plan (7). This extended the arena of practice of the nurse prescribers to patients with enduring conditions, such as, asthma, diabetes, heart disease, or mental illness (8). It is evident that over the years, there has been a demonstrable shift in healthcare management to one in which nurses have taken on some roles previously assumed by the doctors (9). This shift of provision of care from secondary to primary settings has taken place mainly due to efforts to reduce costs, increased specialisation in medical care, rapid advancement of technology, and reallocation of care funds. As a result, medical practice and healthcare have accepted new models of care delivery and consequent restructuring of healthcare workforce (10). Boosted by training and employment of independent nurses and the satisfactory role played by them to supplement deficient standards of care and NHS’s stress on promotional health care, there has been increasing employment of the practice nurses, and their workload has been increasing(11). Studies in UK have concluded that the greatest potential of these independent prescribers lie in primary care where they can share and reduce the case load of the general practitioners in the community notwithstanding the fact that these nurses acting as practitioners would provide better access, would reduce waiting time for care, and the patients considered this model to be a better provision (12). It would be worthwhile to establish the definitions before going into the recent changes in legislation. Independent nurse prescribers are qualified nurses as practice nurse, health visitor, district nurse, or a nurse practitioner who have undertaken nurse prescribing qualification (13). This includes the nurses that may be practicing as community nurses, practice nurses in general practice, and nurse practitioners. This would also include extended nurse prescribers who are first level registered nurses or midwives who have undertaken the extended prescribing qualification and supplementary nurse prescribers who have taken supplementary prescribing qualification. Nurse independent prescribers are currently able to prescribe 12 controlled drugs independently, solely for specified medical conditions (14). The legislation is designed to improve quality of service to the patients without compromising patient safety by making better use of skills of healthcare professionals, namely, the trained nurses in this area (15). Since nurses are more accessible, this would contribute to a more flexible teamwork within the NHS since in case of a problem, the nurse can access the general practitioner or higher medical advice(16). It will make easier for patients to access and get medicines they need. Controlled drugs are subject to special legislative controls provided by the misuse of drugs as they are considered sufficiently dangerous or otherwise harmful with the potential for diversion or misuse (17). For reasons of patient and public safety, it is necessary to regulate or govern these drugs. As a result, the intention is not to impede legitimate use in case of an appropriate clinical indication ensuring responsibility and accountability of the prescribers so that tight governance is implemented to all the prescribers to safely manage prescriptions and drugs (18). Factually as a result of robust governance, monitoring, and training arrangements being in place, the independent nurse prescribers are subject to same standards of accountability as the doctors in practice (19). The independent nurse prescribers, hence, are responsible to ensure patient safety as the paramount practice principle. The nurse prescribers are required to prescribe within their competence or speciality. The training requirements for the independent nurse prescribers must be in place, and they must be monitored, validated, and quality assured, and must include legal requirements of prescribing controlled drugs. Clinical governance is an important part for purposes of surveillance (20). The central concept of the expansion of independent prescribing is prescription within competence areas. The responsibility of the nurse hence is to conform to the framework of NMC guidelines and to maintain that competence. In respect of prescribing, the NMC has developed detailed standards, which independent nurse practitioners must satisfy. The competency framework of the nurses must cover consultation, which includes competencies in diagnosis, prescribing effectively, and most importantly, prescribing in context (21). The accountability issues are stringent in this legislation. The nurse prescribers are expected to prescribe in accordance with the information about medical conditions or indications and the itemised list (22). They are educationally prepared for this competency. They are accountable in the sense that they are supposed to have indemnity insurances for any liability issues. They are required to enter the patient demographic data in a clear way. Entry of the age is a legal requirement. They should use the product description as listed in the British National Formulary (23). In my practice in the Women’s Health and Midwifery within the General Practice setting, the prescription would contain the name of the prescribed item, formulation, strength, dosage, frequency, and quantity of a drug to be dispensed. The quantity prescribed should always bear the need to avoid waste, and this must be appropriate to the patient’s needs (24). Some medicines are only available in patient packs, and the quantity contained would be prescribed provided the clinical and economic appropriateness (25). For example the antenatal iron and folic acid supplement for a period of one month would be prescribed with a quantity of 30 tablets even if they come in packs, and one pack or OP should not be written. The names of the medicines would be written in clear, approved generic titles. This would not be applicable for dressings, appliances, modified release medicines that lack proprietary names (26). The directions would be recorded in an explicit manner about how to use these medications. For the sake of clarity different entries in a form with multiple items would be separated with a line. To prevent subsequent fraudulent addition of extra items beyond the prescription, the unused space in the prescription area would be blocked out with a diagonal line. It must follow the prescriber’s signature and date, and the appropriate prescriber code needs to be entered (27). Applied to my practice area, I need to ensure that the prescription is cost effective and that it meets the clinical needs of the patient. For example, a patient presenting with menopausal symptoms with osteoporosis would need calcium and vitamin D supplements, but an iron and folic acid supplementation would be superfluous unless the patient has associated iron deficiency or nutritional deficits leading to megaloblastic anaemia. Such patients may be prescribed non-steroidal anti-inflammatory agents for pain, but when the need for long-term treatment is perceived, it would be my job to arrange or undertake a clinical assessment to establish a clinical guideline so that their clinical management and medical product needs are regularly assessed, and the prescription issued should reflect the assessed need (28, 29). A patient with enduring condition like a post caesarean section wound infection would require continuing medications and dressings. I as a nurse would need to balance the patient’s convenience and NHS resources (30). Only sufficient supplies should be prescribed to enable the fulfillment of the care plan, normally up to the re-evaluation date. Current best practice allows the nurses to issue a regular prescription up to 28 days. The most important aspect of accountability and responsibility is that the patients must be informed about the scope of limitations of nurse prescribing, and they should be guided to alternate and higher levels of care if need arises (31, 32, 33). Nurses are accountable for their practices at all times, and if situation arises when they find themselves in a position to prescribe for themselves or family, they must accept accountability for that decision (34). It is advisable that they do not prescribe in such situations where judgement may be impaired and important clinical examination is precluded (35). It is the responsibility of the prescribing nurses to maintain unambiguous and legible records at the time of writing prescriptions. The prescription together with other details of the consultation should be entered in the general patient record as soon as possible (36). It should be marked to indicate that this is nurse or midwife prescription and would include the prescriber’s name (37). Arrangements for sharing all records and all relevant patient information would be made, and they should be available in case there is need for some other relevant practitioner to intervene in the care. Where practicable, electronic records should be used, and prescriptions should be generated via these systems (38). In my practice, when a patient developed allergic reactions to a non-steroidal anti-inflammatory drug, I needed to report this event immediately to the general practitioner. The Yellow Card Adverse Drug Reaction Reporting Scheme was utilized to report the medicines control agency. Serious reactions comprise of reactions that are fatal, life threatening, disabling, incapacitating, or are medically significant (39). The liability of the employer is also an important part. When a nurse or midwife is appropriately trained or qualified and prescribes as part of her professional duties with the consent of the employer, the employer is held vicariously liable for their actions. In addition, the nurse prescribers are individually and professionally accountable to the NMC for this aspect of their practice and must act all times in accordance with the NMC code of professional conduct (40). Despite all these facts, it must be mentioned that there is no clear patient allocation to nurse prescriber consultation. There is no clear defined procedure in practice. In most of the situations, the work is large organised around general practitioner’s activities or on a similar basis, so my practice is actually a general practitioner substitute. As a result to clearly define the areas, the legislation attempts to harmonise the wide variation of practice, and its attempts to identify the drugs that would be prescribed where an independent nurse prescriber is prescribing (41). The new legislation also attempts to compare these with existing nurse formulary. The effect of independent function of the nurse prescriber on the standard of service to the patients within the practice as directly related to current government policy on clinical governance to guarantee consistency of quality of service to patients and to make local health services responsive to patients’ needs is paramount. This also involves the issues in practice, such as, evidence-based practice, clinical risk management, appropriate use of protocols in independent prescription, and patient prescription in service delivery (42). The most important contribution, perhaps, would be that intervention by a trained nurse independent prescriber would result in significant reduction in number of patients taking a particular drug in a particular practice area. This would also include the patients where the drug is not specifically indicated (43). The deficit in health service in terms of accessing care even in the lowest primary level is very significant in that the patient often waits for their appointment to reach the doctor. In the interim, the patients often continue older prescriptions that lead to inappropriate extension of dosage of a drug that is not at all indicated. Interference of an independent nurse prescriber would reduce the inordinate dosage of that drug that is not actually indicated mainly due to the fact that they are more accessible than the physicians (44). A significant derivative of such practice is that the legislative authority does not find any methodological problems with such nurse prescribing roles, rather within areas of practice and expertise, there are no differences between independent nurse prescribers and general practitioners in terms of quality of care, number of visits per patient, use of the Accident and Emergency, and prescribing. This imparts a larger and more significant independence and autonomy to the prescribers than intended to, and the responsibility, liability, and accountability becomes higher. There is no major difference in selected patient outcomes, and there is evidence of higher patient satisfaction in terms of care (44). The latest policy change refers to extended independent nursing programme, where the nurses can consult, make clinical decisions, institute therapy, and can refer. This would enable them to prescribe in a team context and in the public health context ensuring that professional accountability and ethical aspects of practice are maintained. Although this is yet immature to comment on the effects of this, benefits of such a policy might be very visible. Apart from the benefits reported by patients that include accessibility and approachability of the nurse, the nurses’ style of consultation, specialist expertise and information provision, and provision of timely, continuous, and convenient care, this policy has potential to change the job satisfaction of the nurses, a status of autonomy, and the ability of the nurses to deliver complete episodes of care. The doctors, however, perceive this extended independent/supplementary nurse prescribing as a means to improve professional relationship, an opportunity of reduced workload, and as a chance to refresh knowledge. In Spring 2006, the nurses were able to prescribe the full range of medicines described in the BNF. Although the benefits are evident, the nurses need to improve their responsibility by seeking additional education on specialist prescribing knowledge and pharmacologic knowledge base, physical assessment skills, and clinical skills. It is important that prior to entering into this area, the prescribing nurses re-evaluate the clause of accountability, and to be responsibly accountable, they need to be equipped with appropriate professional knowledge to make the transition from nurse prescriber to specialist nurse prescriber a smooth one. It is also important that the nurses are provided with continuing professional development programmes to develop a safe and effective prescribing practice. This will be increasingly necessary as the formulary and nurses’ area of practice increase (3). To make this a successful model, it is imperative that the improved patient satisfaction and outcomes over practice by either profession alone is synthesised with independent nurse prescriber and general practitioner collaborative practice where the patients would benefit most from the combination of complementary skills where the limited prescribing rights of the nurses remain no longer a limitation by collaboration. In this way, this legislation change would bring about cost and quality of care improvements (29). Reference List 1. Department of Health, Improving patients access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England. 2. 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British Journal of Community Nursing; 6(9): 467-71. 40. Sodha, M., McLaughlin, M., Williams, G., and Dhillon, S., (2002). Nurses confidence and pharmacological knowledge: a study. British Journal of Community Nursing; 7(6): 309-15. 41. Hall, J., Cantrill, J., and Noyce, P., (2006). Why dont trained community nurse prescribers prescribe? Journal of Clinical Nursing; 15(4): 403-12. 42. Young, G., (2005). The nursing professions coming of age. British Medical Journal; 331: 1415. 43. Jordan, S., (2002). Managing adverse drug reactions: an orphan task. Journal of Advanced Nursing; 38(5): 437-48. 44. Ponto, J., Sabo, J., Fitzgerald, M.A., and Wilson, D.E., (2002). Operationalizing advanced practice registered nurse legislation: perspectives from a clinical nurse specialist task force. Clinical Nurse Specialist; 16(5): 263-9. Read More