This Case study will critically analyse the complex clinical challenges posed by

Table of Contents

This Case study will critically analyse the complex clinical challenges posed by a 37-year-old female patient, presenting with a urinary tract infection following a referral to into the community for pressure area care and monitoring. The role and responsibilities of a non-medical prescriber (NMP) and their prescribing actions will be critically analysed and evaluated in the view of the evidenced based, at the same time highlighting the benefits of the NMP role within the community. During the prescribing journey the Seven Principles of Prescribing (1999) will be used to provide structure to the assessment. PUT 7 REF IN Nurses’ capacity to prescribe has been a long journey deriving from district nurses and health visitors, recommendations were proposed by the Cumberlege Report (1986) to allow nurses to take on the prescribing role. The Crown Report (1989) supported nurse prescribing with strict limitations, a private members bill led to primary legislation the Prescription by Nurses Act: Medicinal Products (1992) gave nurses the right to prescribe. Amendments and revisions were made (1994), first prescribing pilots by nurse and introduction of Nurse Prescribers’ Formulary for district nurses and healthcare visitors came into place, underpinned by the Medicines Act (1968). Extensive review of prescribing identified the evolving needs of modern clinical practice and the potential for extending nurse prescribing to other groups of healthcare professionals, Crown report (1999). Nonetheless, independent NMP experienced reservations, primarily from doctors (Hawkes 2009; Coombes 2009) argued, nurses lacked skills to demonstrate competencies. However, (National Prescribing Centre (NPC) 2012; Cope, Aseel, & Tully, 2016; Latter et al., 2012) strongly advocated, NMP has improved patient care, demonstrated safe effective prescribing and proved patient satisfaction. The UK is now one of the pioneers on NMP, holding the most prescribing rights worldwide (Courtenay, 2018) roughly 58,000 registered NMP’s saving the National Health Service (NHS) over £777, million per year (Health Education North West, 2015). The prescribing ability of the nurse expanded further, succeeding the Nurse Prescribers Extended Formulary (2001). Legislation of 2003, introduced supplementary prescribing for nurses and pharmacists, encouraging a partnership in accordance of a clinical management plan between an independent prescriber and a nurse prescriber, in agreement with the patients consent. Supplementary prescribing gave the nurse the responsibility to prescribed medication from a clinical management plan (mangle et al, 2014). Additionally, independent prescribing commenced for both nurses and pharmacist (2006), following legislation (2005) which introduced supplementary prescribing for allied healthcare professionals. Recognition of improvement to patient access and nurses already assessing patients prior to G.Ps writing a prescription, had been identified, situations that supressed nursing care and wasted valuable time (Cope et al 2016). The commencement of independent prescribing permitted nurses to prescribe medications from the British National Formulary, with the exception of controlled drugs (Dimond 2015). However, the Department of Health (DOH) announced amendments for nurses and pharmacists, consequently, regulation changes (2012) to the Misuse of Drugs Act (1971) allowed appropriately qualified nurses and pharmacists to prescribe controlled drugs. Unlike previous programmes the V300 replaced the V200 programme, arguably the V300 incorporates all foundations of independent prescribing, allowing for more superior range of medicines to be prescribed. Therefore, earlier programmes such as the V100 and V150 are restrictive and have limited purpose (Nutall & Rutt-Howard 2016a). Being a nurse NMP necessitates accountability, to your patient, profession, society, yourself, the public and employer, whilst also being answerable for acts and omissions in adherence to (Nursing Midwifery Council Professional standards of practice and behaviour for nurses, midwives and nursing associates NMC, 2018), and is essential to ensure patient safety (Griffith, 2015). In order, for nurses to practice within their competencies they are required to complete a post -registration prescribing programme, from January 2019, all programmes must meet The Royal Pharmaceutical Society Competency Framework for all Prescribers (RPS, 2016). Nurses are obliged to retain these standards throughout their career to maintain prescriber status. Prescribing is a complexed process, NMP’s must adhere to the law, to be able to do so they must be aware of legal, ethical and professional issues that are prerequisite for prescribing. It is expected that they preserve the credibility of their profession as they are in a privileged position involving safe and legal management of medicines (Nutall & Rutt-Howard 2016b). Medicine storage, supply and administration legislation stems from the Medicines Act (1968) later reinforced by the Misuse of Drugs Act (1971) further secured by 2012 regulations and revised in 2014.Nurses are bound to a duty of candour and confidentiality, a legal obligation, ensuring patients are informed about their care and to make sure patient information is shared correctly (NMC, 2018b). Patient information is held under legal and ethical obligations, standards for prescribing must respect the principles of Data Protection Act (1988) newly revised (2018). The Caldicott report (1997) enforced strict standards for all organisations to protect identifiable patient information. NMP’s are expected to have strategic knowledge of legislation to achieve ethics of confidentiality (Human Rights Act 1998, Freedom of Information Act 2002).In preparation for the consultation the NMP has used a consultation model, known as the Calgary–Cambridge model. The chosen model is a five-stage process that is, patient centred, integrating the physical, social and psychological characteristics of a consultation, deemed to be very practical (Silverman et al, 2008). Certain consultations models are very doctor orientated such as; M Balint (1957) or Pendleton (1957), these models focus on obtaining information, task completion, the problem and how can it be solved (Nuttall, Rutt-Howard (2016) Wilcox et al, 2007). There are others which are extremely patient centred, maybe much more suited in the mental health setting or supportive therapies, therefore, they are not applicable for this context or this patient. The chosen model combines both, it enables the NMP to remain very patient focussed, whilst using the structured biomedical model approach Calgary Cambridge Guide (1996).Consultation aides safe prescribing, the theory of safety must be of main concern to the NMP (Benner 1984) therefore, the employment of a consultation model provides structure, augments safety for practitioner, patient and organisation (Nuttall and Rutt-Howard 2016). Consultation is considered to be the shared process of information exchange between healthcare professional and patient. In essence, a consultation can be advanced by the healthcare professional to introduce health promotion, an ideal opportunity to addresse public health issues, allowing the NMP to influence UK public health objectives, or initiated by the patient when they are unwell (Denness, 2015). Consultation models as a rule have been developed and researched for G. P’s (Baird 2004; Denness, 2015). On the other hand, Sprague (2005) Castledine (2003) and Duxbury (2002), highlighted that nurses must ignore the dividing lines, use the models to advance into their new role with caution, not neglecting the fundamental elements of nursing focussing on patient centred care, which is key to nurse development. The use of the Calgary Cambridge Guide allows the NMP to ensure the consultation is complete, gather the relevant information, gain a trusting relationship with the patient, whilst develop a rapport.Therapeutic communication is a crucial element in the delivery of quality healthcare to patients, tying in with clinical decision making, for effective consultation both need to be strong and robust (Nutall and Rutt-Howard 21016; Amoha et al; 2019). The NMP role consists of making decisions regularly, awareness of the patient individuality aides interpretation of the information gathered. Recognition of ones’ own attributes is vital to secure an honest connection between practitioner and patient, significantly the quality of communication defines the outcomes of the prescribing decisions to be made by the NMP (Cohn 2007, NPC 1999, Ellis et al, 1995, Kullberg et al, 2015, Neese, 2015 and Neighbour 2005). In contrast, (Blake 2019, Ross et al, 2016 Halter, 2014) dismiss this notion, maintaining that therapeutic relationship needs time to grow, due to being a highly complexed skill that must be embedded from a fresh to allow safe prescribing. That aside, the NMC (2018c) emphasise that nurses must have good interpersonal skills as one of their main areas of nursing practice to qualify, being present is enough to validate patient trust to work together collaboratively towards achieving the best outcomes (Rossiter et al 2014, Brownie et al, 2016).Nonetheless the literature highlights consultation models are successful only when there are good communication skills from the practitioner directing the consultation. Rogers (1956) introduced the concept of the person-centred approach, identifying ethical and professional issues implicated when taking on the prescriber role. Likewise, his person-centred theory supports consultation as a key factor for the NMP to become advanced, by being engaged, demonstrating unconditional regard, feeling empathy and communicating these attitudes. Equally the NMP will need to enrich consultation with non-verbal and verbal communication to facilitate the patient, use of own body language, introducing yourself to the patient in combination with spoken word enhances communication potential (Egan 2013, Lloyd and Bor 2009 and Cohn 2007).