The Healthcare Delivery System - Term Paper Example

Review the recent legislative changes in independent nurse prescribing. Give an account of the impact of these changes on YOUR PRACTICE with particular focus on accountability and responsibility. Introduction: Dramatic advances in medical science and technology have been witnessed in the recent many decades. This has brought about a change in the manner of healthcare delivery around the world. As change occurs to the healthcare delivery system, it is the health professionals including the nursing professionals that are vital spokes in the wheel to ensure that healthcare system evolves to meet the needs of the modern day patient (1). The evolving multi-faceted role of the nursing professionals has had its impact on the involvement of nursing professionals in the area of use of pharmaceutical products in the healthcare system. The essential role that nursing professionals played in the use of drugs was restricted to its administration. The complexity of drug regimens and continuous flow of new drugs by themselves have increased the demands on the nursing professionals (2). Law, 2004, (3), points out that administration of drugs is no longer a simple issue, but a complex one that calls for enhanced knowledge of pharmacology drugs used for beneficial therapeutic effects. Against this background the role of nursing professionals has been enhanced over the last fifteen years to include prescribing of drugs and with that the additional demands on the nursing professionals involved in drug prescribing (4). History of Nurse Prescribing in the United Kingdom: Independent nurse prescribing was initiated by the health authorities as a means to make drugs more freely available to patients and Price, 2003, (5) points out that it has improved patient access to effective remedies for a wide range of common medical problems. Nursing professionals with adequate experience in the various clinical specialties were chosen as capable of handling such an additional responsibility (3). The functioning of prescribing being attributed to the nursing professionals began with the Medicinal Products: Prescribing by Nurses Etc Act, 1992, whereby certain groups of nursing professionals were provided the additional facility of prescribing select drugs (6). This Act was amended in 1994 to enable the implementation of the act. (7). The second Crown Report of 1999, which dealt essentially with the issue of professionals other than doctors initiating and prescribing drugs, while stressing patient safety requirements did allow for an expanded role of nurse prescribers. As a result began initiatives from the government to intensify training of nurses and health visitors to make nurse prescribing a reality (8). The education and training for nurse prescribers began in 2002 and consisted of an exhaustive program spread over a period of three months. Such education and training is a requirement taking into consideration the accountability of the nurse prescribers from legal and professional perspectives. This accountability hence calls for enhanced knowledge in pharmacokinetics, pharmacodynamics, anatomy and physiology, disease processes and patient circumstances, medical history and current medications (9). In 2003 the NHS regulations were amended to allow for supplementary prescribers, made up of first level pharmacists, nurses and midwifes on the basis of a clinical management plan drawn up in consultation with an independent prescriber in the form of a doctor or a dentist (10). This created two distinct forms of nurse prescribers in independent nurse prescribers and supplementary nurse prescribers. According to the NMC position statement on nurse prescribing “independent prescribing means that the prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required, as well as the responsibility for prescribing where necessary and the appropriateness of any prescription”, while supplementary prescribing is defined as a voluntary partnership between and independent prescriber (doctor/dentist) and a supplementary prescriber, to implement an agreed patient–specific Clinical Management Plan with the patient’s agreement” (11). Latter et al, 2005, (12), in their findings reported that the independent nurse prescribers, as a model of non-medical prescribing was on the whole safe, appropriate and effective in practice and viewed positively by nurses, doctors and patients. Such findings have led to further expansion of the role of independent nurse prescribers. From May 1, 2006 Nurse Independent Prescribing was expanded to allow independent nurse prescribers to prescribe any licensed medicine for medical conditions that a nurse prescriber has been found competent to treat, which include some controlled drugs. This has made the capacity for prescribing drugs on nurse prescribers wide ranging, but also brought with it added accountability and responsibility (13). Responsibilities and Accountability in Independent Nurse Prescribing: While patient safety, maximum benefit to patients and the NHS in terms of quicker and more effective access to medicines and their benefits and better use of the skills in the nursing professionals form the basis of independent nurse prescribing, the independent nurse prescribers need also to be prepared for accept higher levels of responsibilities and accountability as a part of it (14). The relevance of these responsibilities and accountability come to the forefront, when the level of independent nurse prescription is as high as one prescription in for every 2.82 consultations and with the independent nurse prescribers having to use a wide range of assessment and diagnostic competencies (15) The first implication for this wide range of assessment and diagnostic competencies is the responsibility to acquire enhanced knowledge and skills. As the role of prescribing in nursing practice has expanded so also has the importance of accurate prescribing requiring current knowledge of applied pharmacology and therapeutics to avoid medication errors. (16). Training programmes are available whereby it is possible to acquire the prescribed knowledge enhancement to be either a supplementary prescriber or an independent prescriber. Knowledge acquiring is a continuous process and more so when the developments in medical science and technology continue bring about a better understanding of disease processes in the body and the means to combat. Independent nurse prescribers have the responsibility of keeping abreast of these developments in medical science and technology, so that patient safety is not compromised and the independent nurse prescriber is in a position to justify prescribing decisions. (17). The National Institute of Clinical Excellence (NICE) brings out guidelines in the clinical management of diseases to maintain the quality and standard of healthcare delivery in the United Kingdom. The independent nurse prescriber with an enhanced role in the clinical management of diseases therefore, needs to be aware of these guidelines to maintain the desired standards. (18) Therefore knowledge requirements on one side deal with the scientific aspects of pharmacology and therapeutics and on the other side with the guidelines in the use of this knowledge through prescribing in the care of patients. In keeping with this the Nursing and Midwifery Council (NMC) has certain standards for education and training. These standards of education and training include numeracy and mandatory assessments for all independent nurse prescribers. There is a basic experience requirement of three years subsequent to registration as a nurse practitioner to provide for professional competence in their field of activity. (19). The NMC requires that only after successful completion of the independent prescribing course and a subsequent entry in the register are nursing professionals to take up the responsibilities of independent nurse prescribing (20). The independent nurse prescriber is responsible for the diagnosis and setting the parameters of clinical management plan within their field of expertise, monitoring and reviewing the progress of the patient and as such is fully responsible for the therapeutic care of the patient. (21).The principle of autonomy of the patient makes it the responsibility of the independent nurse prescriber to involve the patient in the decision making process of the drugs that would be used in the management of the condition of the patient and receive the required consent for it. (22). The independent nurse prescriber is responsible for ascertaining that the prescription instructions are provided to non-prescriber is provided in a comprehensible manner by the non-prescriber and that the non-prescriber is competent to administered the prescribed drug (23). There are two more aspects of responsibility with regard to independent nurse prescribers. The first is with maintenance of records with regards to drug prescription and use and the other is with regard to disposal of drugs. All nurse prescription items need to be recorded in accordance with the prescribed guidelines in the patient or client held documentation when available or onto the general practice or patient/client record at the time of prescribing or within twenty-four hours preferably. (24). Such record keeping allows for evaluation of the safety of patients and appropriate prescribing of independent nurse prescribers and as such need to be unambiguous and legible. (25). Independent nurse prescribers have been allowed to prescribe controlled drugs. This brings with the responsibility of proper use and maintenance of records and disposal of these controlled drugs failing which the independent nurse prescribers are liable for prosecution under the law of murder (26). The NHS has laid down the guidelines for independent nurse prescribers to follow in the maintaining, dispensing and disposal of drugs in the Nurse Prescribing Policy and the independent nurse prescribers are responsible to follow these guidelines. (27). The National Prescribing Centre has provided a framework for the competency of independent nurse prescribers, wherein the responsibilities of independent nurse prescribers are clearly defined (28) Table 1: The UK’s National Prescribing Centre competency framework Clinical and pharmaceutical knowledge Has up-to-date clinical and pharmaceutical knowledge relevant to own area of practice. Establishing options Reviews diagnosis and generates treatment options. Communicating with patients Establishes a relationship based on trust and mutual respect. Sees patients as partners in the consultation. Applies the principles of concordance. Prescribing safely Is aware of own limitations. Does not compromise patient safety, justifies prescribing decisions. Prescribing professionally Works within professional and organisational standards. Improving prescribing practice Actively participates in the review and development to improve patient care. Information in context Knows how to access relevant information. Can critically appraise and apply information in practice. The health service Understands and works with local and national policies and services that impact on prescribing practice. Sees how own practice impacts on the wider health service. The team and individual context Works in partnership with colleagues for the benefit of patients. Is self-aware and confident in own ability as a prescriber. (28) Implications to Practice: The competency framework provides the clues to the impact on implications of independent nurse prescribing on for a practice nursing professional such as myself. Up to date clinical knowledge of diabetes and the drugs used in treating diabetes is the initial requirement. Preventing the onset of type 2 diabetes, adequate glycaemic control and preventing the onset of complications of type 2 diabetes become important aspects in managing diabetes mellitus (29). Insulin, oral anti-diabetic drugs, diet and exercise form the means of adequate glycaemic control and combating complications in type 2 diabetes (30). Exercise enhances insulin sensitivity, improves glucose tolerance and in combination with diet provides a means for weight reduction. Enhanced insulin tolerance sensitivity and glucose tolerance brings about the need for adjustment of insulin and oral anti-diabetic drugs to avoid the possibility of complications like hypoglycaemic shock (31). The requirement of a proper understanding of the disease and the disease processes in the body and the means to combat it are essential as diabetes is a disease that could lead to many complications and death. (32). Such knowledge assists the independent nurse prescriber to make proper diagnosis, and chalk out the clinical management plan and review it according to changes and make the necessary changes (33). Development of communication skills and removal of barriers to communication including perceptions and the environment are a requirement. It is through the use of communication skills that it is possible to build mutual respect between the patient and the independent nurse prescriber to enable a partnership in the decision making process of the drug regimen in the clinical management of patents (34). Policies of nurse prescribing have been formulated by the NHS. In addition guidelines have been laid down for its implementation and given further shape by NMC. In addition there are standard guidelines laid down by NICE. Implications involve knowing the various guidelines and statutory norms and staying within them to avoid running the risk of facing litigations. A simple example in this case is keeping to diagnosis and prescribing within the area of expertise of diabetes. (35). Being accountable and taking responsibility for ones actions is a part of the character of independent nurse prescribing. There should be willingness to review diagnosis and prescribing activities, acknowledge mistakes and learn from them. It is only through this that better quality of care for the patient through independent nurse prescribing will become a meaningful reality (36). Literary References 1. Micevski V, Lori K, Sarkissian S, Virginia M, Shobbrook C, Bellford L & Kells L. University Health Network framework for advanced nursing practice: development of a comprehensive conceptual framework describing the multidimensional contributions of advanced practice nurses. Canadian journal of nursing leadership 2004:17(3); 52-64. 2. Cavell G. Drugs: the nurse’s responsibility. Professional Nurse 2000:15(5); 296. 3. Law A. What are the principles of patient medication? In: ed. John Fowler. Staff Nurse Survival Guide: Essential questions and answers for the practicing staff nurse. London: Quay Books. 2005. pp. 79-114. 4. While A E & Biggs K S. Benefits and challenges of nurse prescribing. Journal of advanced nursing 2004: 45(6); 559-567. 5. Price M. Extended formulary nurse prescribing – another saliva substitute roadblock. Gerodontology 2003: 20(1); 57-59. 6. Medicinal Products: Prescription by Nurses etc. Act 1992 (c. 28). [Online] 2007 July, 16. Available at URL: http://www.opsi.gov.uk/acts/acts1992/Ukpga_19920028_en_1.htm 7. Health Service Circular. Nurse Prescribing. NHS.1998. 2007July 16, [Online] Available at: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=25556&Rendition=Web 8. Stephenson T. Implications of the Crown Report and nurse prescribing. Archives of Disease in Childhood 2000: 83; 199-202. 9. Courtenay M & Butler M. Education and nurse prescribing, Nursing Times 2002: 98(9); 53-54. 10. Root G. Supplementary prescribing — a groundbreaking opportunity. The Pharmaceutical Journal 2003: 270(7230); 19-20 11. NMC. Nurse prescribing and the Supply and Administration of Medication: Position Statement. [Online]. 2007, July 16. Available at URL: http://www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=1219. 12. Latter S, et al. An Evaluation of Extended Formulary Nursing. Policy Research Programme, Department of Health. 2005. [Online] 2007, July 16, Available at URL: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4114084 13. Medicine Matters: A guide to mechanisms for prescribing, supply and administration of medicines. National Practitioner Programme. NHS. Department of Health. 2006. [Online] 2007 July 16, Available at URL: http://www.dh.gov.uk/en/Policyandguidance/Medicinespharmacyandindustry/Prescriptions/TheNon-MedicalPrescribingProgramme/Nurseprescribing/index.htm. 14. Hodgson M. From practice nurse to nurse prescriber. Practice Nurse 2005; 29(4): 35-39. 15. Latter S, Maben J, Myall M, Young A, & Baileff A. Evaluating prescribing competencies and standards used in nurse independent prescribing consultations: An observation study in practice. Journal of Research in Nursing 2007; 12(1): 7-26. 16. Banning M. Medication errors: considerations for nurse prescribers. Nurse Prescribing 2005; 3(2): 68-71. 17. O’Dowd, A. The power to prescribe. Nursing Times 2007; 103(3): 16-18. 18. National Institute for Health and Clinical Excellence. Providing national guidance on promoting good health and preventing and treating ill health. [Online] 2007 July 16, Available at URL: http://www.nice.org.uk/ 19. Barclay L. UK Expands Prescribing Powers for Nurses, Pharmacists. 2005. Medscape Medical News. [Online] 2007 July 16, Available at URL: http://www.medscape.com/viewarticle/517497 20. Nursing Midwifery Council. Standards of Proficiency for Nurse/Midwife Prescribing incorporating Standards for Education and Training to be ‘qualified to prescribe’ and Standards – Prescribing Practice. 2006. [Online] 2007 July 16, Available at URL: http://www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=2023 . 21. Lewis C. & Allen D. General prescribing principles. Supplementary prescribing: an overview. Nursing Standard 2003; 17(51); 2-3. 22. Dustagheer A. Clients’ rights. In eds. Angela Dustagheer, Joan Hoarding & Chris McMahon. Knowledge to care. Second Edition. Oxford: Blackwell Publishing. 2004. pp 1-11. 23. Department of Health. Supplementary Prescribing FAQ. 2007. [Online] 2007 July 16, Available at URL: http://www.dh.gov.uk/en/Policyandguidance/Medicinespharmacyandindustry/Prescriptions/TheNon-MedicalPrescribingProgramme/Supplementaryprescribing/DH_4123034 24. NHS. Policy and Procedures for Nurse Prescribing. [Online] 2007 July 16, Available at URL: http://www.worcestershirehealth.nhs.uk/Intranet1_Library/foi_internet/foi_files/class_9/Clinical_Policies/190704NursePrescribingPolicy-final.pdf 25. Dimond B. Prescription and medication records. British journal of nursing 2005; 14(22): 1203-1205. 26. Griffith R. Controlled drugs and the principle of double effect. British journal of community nursing 2006; 11(8): 352-357. 27. NHS. Nurse Prescribing Policy. 2006. [Online] 2007 July 16, Available at URL: http://www.bradfordcity-tpct.nhs.uk/NR/rdonlyres/38F51B12-ABD2-4CD8-9530-4C60669290CA/0/_NursePrescribingPolicyOctober2005.pdf 28. Hoare K. Nurse Prescribing: safety and accountability. Journal of the New Zealand Medical Association 2006; 119(1230); 174-177. 29. Marshall M & Flyvberg A. Prevention and early detection of vascular complications of diabetes. BMJ 2006; 333(7566): 475-480. 30. Jerreat L. Diabetes for Nurses. London: Whurr Publishers Ltd. 1999. 31. Hillson R. Practical diabetes care. Second Edition. London: Oxford University Press. 2002. 32. Rizvi A A. Type 2 Diabetes: Epidemiologic Trends, Evolving pathogenic Concepts, and Recent Changes in Therapeutic Approach. Southern medical journal 2004; 97(11): 1079-1087. 33. Banning M. Conceptions of evidence, evidence-based medicine, evidence based practice and their use in nursing: independent nurse prescribers’ views. Journal of clinical nursing 2005; 14(4): 411-417. 34. Partridge J & Dustagheer A. Communication. In eds. Angela Dustagheer, Joan Hoarding & Chris McMahon. Knowledge to care. Second Edition. Oxford: Blackwell Publishing. 2004. pp 39-53. 35. Astles J. Extended nurse prescribing: improving care for older people. British journal of nursing 2006; 15(3), 150-151. 36. Fortuna S. Ethics. In eds. Angela Dustagheer, Joan Hoarding & Chris McMahon. Knowledge to care. Second Edition. Oxford: Blackwell Publishing. 2004. pp 12-22. Read More