Non-Medical Nurse Prescribing

This paper will demonstrate the author’s ability to prescribe safely from the Nurse Prescribing Formulary (NPF 2009-2011). A prescribing situation undertaken by myself while supervised by my mentor will be discussed. The patients name, address, date of birth and GP details have been changed to ensure patient confidentiality in accordance with the Nursing and Midwifery Council (NMC)(2004). The patient therefore will be referred to under the pseudonym Prince Charming.

Nurse prescribing was first suggested by the Royal Collage of nursing (RCN) in 1980, it was to take another six years for it to become part of the government’s agenda with the Cumberlege Report in 1986 (Department of Health and Social Security (DHSS)(1986). These two report as well as the Crown report (DH 1989), Prescription by Nurses Act, (1992) and the Medical Prescription by Nurses Act (1994), lead to The Nurse Prescribing Formulary being introduced nationally in 1998.

These acts give community nurse like myself the opportunity to improve their skills and improve patient’s access to care. The patient a 32 year old man attended the district nurse clinic with a laceration to his right shin. Within my practice I assess patients with the use of the Neighbours (1987) consultation model. By using this model i feel that I can build a therapeutic relationship with my patient which helps gain an understanding and concordance with their treatment.

I introduced myself informing him of my name and asked him to explain what the current problem was in his own words. Timmins (2007) believes that by introducing yourself warmly and welcoming you begin to build a good rapport with your patient, thus building a good nurse-patient relationship which is an important aspect of patient concordance Latter (2010). I used open questions to help my patient divulge as much information as possible and then close questions to extract specific information.

With any patient a full holistic assessment is needed, the skill of assessment is more important, however with the introduction of nurse prescribing. While (2002) suggest that nurse need to become more efficient at these skills if they are going to prescribe. I asked Prince Charming if he had any allergies he replied “None that he knew off” I asked if he had experienced any reaction to drugs/dressings in the past he again replied “None that he knew off”.

He advised me that he was not taking any prescription medication from his General Practitioner (GP) and that he did not take any over the counter medication apart from ibuprofen occasional for back pain. He also advised me that he did not use any herbal or homeopathic remedies, Greener (2009) claims that a nurse prescribing any item for a patient should always enquire if they take over the counter, herbal or homeopathic medication as Otway (2004) considered this safe practice Brookes (2007) also agrees with this. He did not have any medical conditions and was normally fit and healthy.

Due to Prince charming answering “None that he knew off” I contact his GP to confirm that there was no record of allergies/reactions that he wasn’t aware off, when prescribing for a patient it is good practice whenever possible to access patients records NMC (2006). Anderson (2002) states that patient’s records should clearly record any allergies or reaction they have had in the pass so mistakes cannot be made. Royal Collage of Nursing (RCN) (2005) would agree and considers accurate record keeping a key issue in limiting misunderstandings and improves communication between GP and Nurse.

Bradley et al (2007) study found that relationships between nurse prescribers and other medical professionals improved greatly with the use of the NPF (2009-2011). However Fisher (2005) disputes this as he feels that GP’s sometimes expect too much of nurse prescribers refusing to prescribe for patients if they know they are, or can be seen by a nurse prescriber. Fisher (2005) also suggests that prescribing complicates the nurses day as they have more to do not less.

Bowden (2005) research has mixed reviews finding some nurse felt that prescription writing added to their work load giving them less time, however some nurses did not express any concerns about increased work load. During my assessment I used the “Seven principles of good prescribing” to aid my decision making (National Prescribing Centre (NPC) 1999). This structured framework allows the prescriber to assess all appropriate factors and problems and make an informed decision whether to issue a prescription or discuss other options with the patient Humphries (2002).

Examples of these options would be offering advice about their condition/problem or informing them that the treatment/items they require would be cheaper over the counter, thus making optimum use of the NHS budget, Prescription Pricing Authority (PPA) (2003). When making the decision to prescribe there are a number of influence you have to consider. It is important to have an awareness of these influences and take them into consideration when issuing a prescription. It is importance to have knowledge of the DOH (2006) Medicines Matters this give guidance on the mechanisms available for prescribing and administration and supply of products.

Team trends and external company’s and there representatives promoting their products have a big influence on your prescribing practice Bradley (2006) found that these influences were of concern to some nurses feeling that their colleague may ask them to prescribe for patients they haven’t seen. Thomas (2008) believes that all nurse who work in first contact care should be nurse prescribers as this would take the pressure of existing nurse prescribers and improve patient care. The sheer number of dressings available can be overwhelming for nurses so they can tend to prescribe the dressings they are familiar with (Miller 1994).

Ropper (2006) identified over 600 wound management products on the market; suggesting that nurses cannot be expected to know them all. After assessing Prince Charming’s wound I decided that a prescription would have to be issued. I decided to prescribe a dressing called Allvyen adhesive. Within my trust we are provided with a wound care formulary, which has a suggested range of dressing they feel would be appropriate for different types of wound. The wound care formulary suggested a foam island dressing for the type of wound my patient had, it being was less expensive than my chosen dressing.

The wound care formulary is meant as a guide and has been designed with cost in mind; as well as patient comfort. Hawkins (2010) recognizes that saving money is becoming an increasing priority within the National Health Service (NHS). I made a decision to prescribe an alternative product based on my own knowledge and current research on both dressings, NMC (2006) states that nurses must always ensure their decisions are based on best available evidence and by nurses maintaining their professional knowledge and competences.

Research carried out by Lewis (2009) found that foam island when used correctly was equivalent to other more expensive foam dressings. However this study was carried out by the actiheal company (manufactures of Foam Island) and was conducted over a short period of time and with a small sample group; it felt by some that research carried out by manufacturing companies can be seen as being biases and in the company’s best interests (Becker-Bruser (2010), (Amoroso 2006). Hawkins (2010) suggested that Foam island dressing worked well on flat, hairless areas of he body but tended to come away when there is body hair present or in an area where there is movement like arms. Legs and elbows and it also tended to come away when it came in contact with water. Hall (2008) found that nurses regarded the adhesive properties of a dressing highly important when choosing a wound care product they felt that wound healing can be affected causing the healing process to slow down as well as patient discomfort, causing the patient not to comply with treatment.

Fletcher (2006) writes that nurses found Actiheal products worse than other simpler dressing for staying in place. My patient wished to continue working and to shower daily therefore it was important that we provided a dressing that meant he could continue his life with little disruption. Hall (2003), States that it is important to prescribe a product that causes minimum disruption to the patient normal daily life, and suggests a waterproof dressing to allow them to shower and a product that fits in with their work and life balance.

When looking at the cost of both products, the chosen dressing was more expensive but it would stay in place and provide the patient with the ability to continue his day to day life. Foam Island is less expensive but due to the adhesive properties the nurse would use twice as many, increasing the cost, Hall (2003) feels that good prescribing should do more than just control cost, it should aim to maximise patient comfort, minimize risk and respect their choice. To archive these goals a nurse must have an open discussion with the patient to achieve concordance.

Concordance is reached after negotiation between patient and nurse by respecting their wishes, beliefs and cultural needs (Ebbesen 2002). The NMC (2006) set out standards for nurses to work towards, one of these standards is being aware of ethical and cultural need when prescribing. The NMC (2004) agrees with this saying nurses are expected to work in an ethical manner at all times in keeping within their code of professional conduct. Amoroso (2006) believes ethical dilemmas is something nurses deals with on a daily bases, causing them to make thought provoking choices.

Seedhouse (1998) developed an ethical decision-making tool to assist nurses when dealing with ethical dilemma, they were convinced by using ethical models and decision tools, nurses would be able to reflect on their decisions helping them understand their feelings and actions (Amoroso 2006). With my patient’s holistic assessment I had to take into account their cultural needs and believe, my patient did not have any religions’ needs or believe that would affect the prescription I would be issuing.

When treating any patient nurses always ask themselves if they have decided on the right course of treatment, but nurse prescribers have to take into account if the prescription they are issuing is legally appropriate for the patients. Diamond (2005), states that nurses are professionally and personally responsible for their prescribing and must take precautions to prevent any foreseeable risks. The NMC (2006) considers accountability at the core of nurse prescribing. Nurses have a higher change of professional litigation when their professional responsibility increases (McHale 2003).

Luker et al (1997) states that nurses have concerns about their increasing accountability, they worry that if they show insufficient knowledge while prescribing a product they could cause injury or harm that could be seen as negligent thus opening them up to liable, civil or professional proceedings (Diamond 2002), ( Griffith 2004). Beldon (2010) questions whether nurses are receiving enough training to keep them abreast of current guidelines and policies, my own trust reviews their prescribing policy every year and all current nurse prescribers receive a copy by email.

I had a lengthy discussion with my patient explaining the treatment planned and what was expected of him. He was happy to come to the district nurse clinic twice weekly for the dressing to be changed and reviewed. I also advised him to return in-between visits if he had any problems or worries. I advised him of the possible side effects from his dressings explaining the action to take if these occurred Berry (2006) study found that information about side effects emerged top of the list in regards to the information patients like to receive from nurses.

I instructed him to either contact the district nurse, his GP or attend A&E if he had any concerns. Nurse should be aware of the contra-indication and interactions of prescribing a product, and report any adverse reactions by using the yellow card scheme NPF (2009-2011). Diamond (2005) states that even an item that appears relatively harmless can have devastating effect to the patient if there are contra-interactions.

As Prince Charming was only 32 and working full time he was not exempt from paying prescription charges Prescription Pricing Authority (PPA 2003). I advised him that he would have to pay for his prescription, he was happy to do this and wished to continue with his treatment plan. I recorded all care given to my patient in his notes so my colleagues would be aware of my decisions and my rational behind them. On reflection I felt I’d assessed and prescribed the appropriate treatment for my patient.

Although I feel I’d had been prescribing on some level for many years by requesting treatment from GP’s, the prescribing situation was much harder than I first thought. Greedon et al (2009 feels nurses have been prescribing informally for many years by requesting prescriptions for GP’s. I feel that I prescribed safely, cost effectively and with ethical consideration, Stuttle (2010) feels that nurse prescribers have proven they have the knowledge and skills to prescribe safely, I agree I feel that nurse prescribing will become an invaluable part of my nursing day.

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