nurse prescribing case study examples

• Research article
• Open access
• Published: 24 November 2020

A comparative case study of prescribing and non-prescribing physiotherapists and podiatrists

• Nicola Carey   ORCID: orcid.org/0000-0003-2841-1760 1 ,
• Judith Edwards 1 ,
• Simon Otter 2 ,
• Heather Gage 3 ,
• Peter Williams 4 ,
• Molly Courtenay 5 ,
• Ann Moore 2 &
• Karen Stenner 1  

BMC Health Services Research volume  20 , Article number:  1074 ( 2020 ) Cite this article

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Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists.

to compare outcomes of physiotherapist and podiatrist Independent Prescriber (PP- IP) patients with those of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications.

Design: a mixed method comparative case study.

Using mixed methods of data collection, outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015–2016).

489 patients were recruited: n  = 243 IP sites, and n  = 246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life ( p  > 0.05) and patient satisfaction ( p  ≤ 0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than PP-NP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 min).

This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

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As life expectancy increases, and the world’s population continues to grow [ 1 , 2 , 3 ], many countries are shifting the focus of their health system from acute to chronic diseases, alongside managing increasing service demands [ 4 ]. Recent data from the United Kingdom (UK), United States (US) and across Europe confirms 25% of adults take three or more medicines each day [ 2 , 5 ] and that by 2020 the world’s population will receive 4.5 trillion doses of medicine each year [ 5 , 6 , 7 ].

There is however, a worldwide deficit of 18 million health workers [ 8 ], with a predicted 350,000 shortfall in the UK, and a third of the current workforce due to retire by 2030 [ 9 ]. Inadequacies with traditional doctor/physician-led care systems mean that in order to maintain patient access to prescription medicines, new approaches are imperative [ 9 , 10 ]. Allied Health Professionals, (health professionals who are not medical doctors, physicians, nurses. Pharmacists or dentists), e.g. therapeutic radiographers, paramedics, podiatrists and physiotherapists (AHP) have in particular been identified as having an integral role to the required transformational change [ 11 ].

Extending prescribing rights to nurses, pharmacists and allied health professions [ 12 , 13 ] has been the focus of a UK policy drive to improve services and access to medicines by making better use of existing skills and support service innovation [ 11 , 14 , 15 , 16 ]. Of the 907,000 UK healthcare professionals entitled to undertake prescribing training [ 17 ], over 90,000 of the eligible workforce are now qualified as prescribers [ 17 ], placing the UK as the forerunner in the development of non-doctor prescribing, also known as non-medical prescribing, worldwide.

In the UK, Independent Prescribing (IP) and Supplementary Prescribing (SP) are two different forms of non-doctor prescribing. Training typically involves 27 classroom days, a mandatory aspect of supervised practice, and robust academic and practice assessment [ 18 , 19 , 20 ], a dual qualification in IP and SP being awarded to registered nurses, pharmacists, radiographers and paramedics, podiatrists and physiotherapists. Supplementary prescribing rights were extended to some allied health professions in 2005, with further changes to legislation in 2013 permitting physiotherapists and podiatrists to prescribe medicines independently [ 21 , 22 , 23 ]. Apart from some restrictions around independent prescribing of controlled drugs and in line with other allied health professions, physiotherapists and podiatrists, normally with 3 years relevant post qualification experience, are able to independently prescribe any medicine within their area of competence without the need for a doctor. By contrast supplementary prescribing defined as dependent prescribing, is based on an initial diagnosis by a doctor and an agreed clinical management plan detailing medicines that can be prescribed [ 24 ].

Although several other countries, including Australia, Ireland, and Netherlands, have seen similar developments in non-medical prescribing, approaches to training, accreditation and models of prescribing practice are varied [ 25 , 26 , 27 , 28 ]. Physiotherapists have for example, authorisation to provide advice about and/or to administer or supply medicines in some states in Australia, New Zealand and Canada, but only those in the US military can prescribe [ 29 , 30 ]. Podiatrists have similar authority in Australia and some European countries but are only entitled to prescribe in some Canadian provinces [ 29 , 31 ].

When used by nurses and pharmacist, independent and supplementary prescribing are reported as acceptable and beneficial to patients, with some evidence of enhanced clinical outcomes compared to doctors [ 26 , 32 , 33 , 34 ]. A recent systematic review reported that non-medical prescribing has no adverse impact upon patient outcomes, patient satisfaction or resource utilisation [ 35 ]. Reviews on the impact of extended physiotherapist roles reveal research hampered by small numbers, role variation and poor role definition [ 36 , 37 ], literature dominated by service descriptions and audit with positive reporting bias [ 29 , 36 , 37 ], and a lack of evidence regarding podiatric practice [ 29 ]. Whilst physiotherapist and podiatrist supplementary prescribing helps streamline service delivery [ 38 , 39 ], independent prescribing is expected to bring additional benefits in line with nurse and pharmacist prescribing [ 40 , 41 ]. Exploration of clinical and cost effectiveness in this area is limited with inconclusive findings [ 42 , 43 , 44 , 45 , 46 , 47 ]. As most evidence relates to nurses and pharmacists, it is important to evaluate the impact of prescribing by allied health professionals in order to inform commissioning and implementation of non-medical prescribing services where they are beneficial.

Seven years after the introduction of current legislation enabling physiotherapists and podiatrists to independently prescribe medicines, there were (as of October 2020) 1295 physiotherapists and 442 podiatrists with an annotation as independent prescriber, with a further 108 physiotherapists and 67 podiatrists registered as supplementary prescribers [ 48 ]. There is a lack of evidence of reporting on physiotherapist and podiatrist independent prescribing practice, or the medicines they prescribe and no studies available which quantify the impact of podiatrist and physiotherapist independent prescribing on patient satisfaction, access to services, quality of life or report cost-implications of care delivery [ 29 ]. This is important given the increasing emphasis in the UK and around the world on extending prescribing rights to nurses, pharmacists and allied health professionals as a key strategy in addressing workforce deficits and ensuring patients have ongoing access to medicines [ 8 , 9 , 10 , 49 ].

Was to compare the outcomes of patients managed by physiotherapist and podiatrist independent prescribers (PP- IP) with those under the care of physiotherapist and podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and costs.

Study design

This study was commissioned to undertake concurrent evaluation of physiotherapist and podiatrist independent prescribing reflecting the 2013 regulatory changes introduced to both professions. A comparative case study methodology used in situations when no single outcome measure is available was adopted [ 50 , 51 ]. Outcomes were compared between 7 sites where patients received care from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites where care was provided by a PP-NP without a prescribing qualification (3 podiatrist and 4 physiotherapist non-prescribers) [ 52 ]. Mixed methods (including interviews, structured observation of consultations, patient questionnaires) were used to collect data at each of the 14 sites during a 5-day period of observation of practice. Details of data collection tools, methods and piloting are shown in Table  1 .

The original intention was to collect data on patient follow-up treatments and re-consultations by audit of clinic records at 2 months. It was evident that this was limited and inconsistent during data collection at the first four sites. The protocol was therefore amended to include a second patient questionnaire for self-report usage of health services in the 2 months after the index consultation. Data collection took place simultaneously January 2015–March 2016.

Sample size

Anticipating patient satisfaction and ease of access to services being best expressed as positive or negative responses, in order to detect an absolute underlying difference of 40% between PP-IP and NP-PP, with size = 5% and power = 80%, a minimum of 24 subjects were needed in each PP-IP and NP-PP site. Allowing for a dropout rate of 20%, to enable a statistically sound comparison to be made between any specific pair of PP-IP and NP-PP sites, a target recruitment of 30 patients per site (total n  = 420), collected over a maximum of 5 working days, was set.

Initial sample estimates, based on information provided by physiotherapists and podiatrists in clinical practice, indicated that full-time PP-IPs/NP-PPs have up to 60 consultations, lasting approximately 20–40 min each, per week, generating data on potentially 840 patient care episodes across 14 sites, indicated that, even allowing for repeat patient visits and inclusion criteria failures, such a recruitment was feasible.

Sites with physiotherapist and podiatrist independent prescribers were purposively selected from an earlier study phase [ 52 ] to include diversity with respect to care setting, geographical location and patient demographics across England.

Recruitment

Podiatrists and physiotherapists.

Initial email/ telephone contact was made with physiotherapist and podiatrist independent prescribers who had completed an earlier survey whilst undertaking independent prescribing training ( n  = 70) and indicated willingness to participate in further research [ 52 ]. Those who expressed an interest were provided with a participant information sheets and supplementary information on case site involvement and requested to ensure organisational and local Research and Development support.

Non-prescribing physiotherapist and podiatrist sites, matched on professional role, care setting, geographical location and using NHS Agenda for Change (Afc) national pay scale banding [ 69 ], were either nominated by PP-IPs, identified through personal contacts of the project advisory group or enquiries from individual Research and Development departments via the National Institute of Health Research (NIHR) portfolio. These matched NP-PPs were, with consent, contacted by a member of the research team and recruited following the same process as for PP-IPs. Written informed consent was taken from PP-IPs and NP-PPs on the first day of each case site visit by JE, who assured on-going consent with each PP-IP or NP- PP at the beginning of each contact day.

At each case site a consecutive sample of patients who had scheduled appointments with physiotherapist and podiatrist independent prescribers/ non-prescribers providing adult services during a 5-day (up to 37 h) site visit by the study researcher (JE) were recruited in NHS sites by trained research nurses, and private sites by a second study researcher (EK) between March 2015 and February 2016. Informed written consent was obtained from those who were willing to participate.

A screening log of all patients approached for participation in the study ( n  = 563) was recorded; both those recruited to the study ( n  = 488, 86.7%) and those declining participation ( n  = 75,13.3%), including hospital/unit medical record numbers, gender and the date of consent, by the local research nurse/ study researcher. Following the observed consultation (see Table 1 ) those who agreed to participate completed and posted Patient Questionnaire 1 into a box in the clinic area or returned using pre-paid envelopes.

Data collection

An initial telephone interview, informed by previous work in the area [ 70 ] was conducted with the physiotherapist and podiatrist from each site using semi-structured questions to gather information on site characteristics, and professional role. Details of the data collection and instruments, informed by the study patient and public involvement and advisory groups, are presented in Table 1 . All data collection instruments were piloted in a non-study physiotherapist independent prescriber NHS outpatient clinic in January 2015, with only minor corrections to wording required (see Table 1 ).

Outcome measures

Baseline questionnaire 1.

Informed by previous work [ 70 ] and several validated tools [ 53 , 54 , 55 , 56 , 57 , 71 , 72 ] a patient questionnaire was constructed to ensure that the generic questionnaire developed to evaluate prescribing by nurses and midwives in the Republic of Ireland [ 56 ] was appropriately adapted.

Section 1 recorded patient satisfaction with services received at the time of consultation using 10 medical interview satisfaction questions [ 55 , 56 ] and ‘ease of access’ to services using 7 additional questions [ 58 ].

Section 2 comprised 4 statements measuring patients’ attitudes to physiotherapist and podiatrist independent prescribers (65, 68) and 14 statements about the advice/information they may have received from physiotherapist and podiatrist independent prescribers/ non-prescribers during the consultation including side effects, action of use and dose schedule and medicines adherence [ 54 , 55 , 56 , 57 ].

Section 3 employed the validated EQ-5D-5L quality of life profile measure of five dimensions (mobility, self-care, usual activities, pain, anxiety/ depression) rated on five levels (no problem to severe problem/ unable questionnaire [ 60 ]. Although the standardized extended EQ-5D incorporates a vertical 20 cm visual analogue scale (VAS) rating scale, patient and public involvement group members consistently reported difficulty indicating numerical values for how they felt at any one time point. It was therefore decided to exclude this from the questionnaire.

Section 4 comprised 7 items related to general demographics in order to describe respondent characteristics including age, living arrangements, employment, ethnic group and educational attainment.

Follow up questionnaire 2

Comprised of 5 questions relating to health resource use in addition to a second completion of the EQ-5D-5L asked over telephone. Patients were asked if they had, in the 2-month period following consultation received medicines prescribed/recommended by the physiotherapist and podiatrist independent prescribers/ non-prescribers, undergone diagnostic tests (e.g. radiology, blood tests), returned to the physiotherapist and podiatrist independent prescribers/ non-prescribers for follow-up treatment, been referred to other services/professionals, or received unplanned treatment for the same condition following the initial consultation (list of 10 potential services) (see Table 1 ).

Data analysis

Quantitative data were entered on to SPSS© Version 22. Descriptive statistics were used to summarise the data and reported where open text data (specifically in relation to medication details and requested tests from the observation diary) had been converted to numeric data. Patient satisfaction and ease of access to services were measured on a 5-point Likert scale or as Yes/No responses. The Likert scale responses were easily reducible to positive or negative responses.

When assessing change in EQ-5D-5L descriptive health score from Patient Questionnaire 1 to Questionnaire 2, a paired t-test was used.

When comparing 2 subgroups for normally distributed outcomes (notably change scores from Questionnaire 1 to Questionnaire 2, such as for overall EQ-5D-5L score), an unpaired t-test was utilised.

When comparing 2 subgroups (in particular prescribing and non-prescribing) for an ordinal outcome, a Mann-Whitney U test was utilised. When comparing 2 subgroups (notably Podiatry and Physiotherapy or prescribing and non-prescribing) for a categorical outcome, the Chi-Squared test was used, reverting to a Fisher’s Exact test in 2 × 2 cross tabulations if 1 or more expected cell count was found to be < 5.

Economic analysis

Seven resource implications of independent prescribers compared to non-prescribers were originally considered: rates of prescribing tests ordered; referrals to other health professionals; frequency of follow up; consultation duration; time spent discussing the patient with other colleagues; unplanned consultations for the same condition within two months of the index consultation. Data were gathered through the observation diary, except for tests (from the retrospective audit) and unplanned consultations (from the patient follow up questionnaire). Group level comparisons of independent prescribers compared to non-prescribers for physiotherapists and podiatrists were undertaken separately for each of the seven variables.

The cost implications (British pounds 2015) of differences in consultation length and colleague’s time spent in discussion were examined by applying nationally valid unit costs [ 73 ]. A comprehensive micro level costing analysis could not be conducted because data on tests and unplanned consultations were only gathered for a sample of patients and insufficient details were available on medications, referrals and planned follow up to enable costs to be reliably ascribed. Costs that could be estimated were considered in relation to outcomes (satisfaction with consultation, satisfaction with advice, changes in health-related quality of life (EQ-5D-5L) between baseline and follow up) in a simple cost consequences framework.

Characteristics of participants

PPs and case sites

Seven matched pairs of sites, (3 podiatry and 4 physiotherapy) were recruited. Sites were based across 8 Academic Health Science Networks in England ( https://www.ahsnnetwork.com/ ), provided adult services, a mixed range of settings, including private practice ( n  = 2), primary care ( n  = 6), secondary care (n = 6), social enterprise (n = 2) and were well matched by professional role, care setting and agenda for change banding (see Table  2 ). All physiotherapist and podiatrist independent prescribers had been qualified for at least 12 months prior to data collection. A total of 488 patients were recruited: 243 across the PP-IP sites with 245 across the NP-PP sites.

Nearly all consultations ( n  = 474), both independent prescribers and to non-prescribers, were face to face ( n  = 473, 99.8%), duration 2–203 min. There was considerable variation in the location of services: 39.2% ( n  = 186) of consultations were provided in NHS hospital outpatients, 25.1% ( n  = 119) NHS community clinics, 20.3% ( n  = 96) private practice, 9.7% ( n  = 46) general practice, 4.4% ( n  = 21) social enterprise and 1.3% ( n  = 6) community service. Of the observed consultations 112 (23.6%) included a medicine related activity, where either a new medication, repeat medication (same dosage) or repeat medication with a change to dosage was required, with patients requiring a total of 124 items of medicine (see Table  3 ).

Almost all medicines related activity within physiotherapy sites, both independent prescribers and non-prescribers, was related to pain and movement control, either via pain medication or through injection therapy. There was one incident where a patient was advised to alter contraception use following surgery by an independent prescriber. A wider range of medication types were used by podiatrists, both independent prescribers and to non-prescribers, the most common being anti-microbial/anti-fungal topical creams, antibiotics and pain medication. Patients requiring medicines recommended by non-prescribers, both podiatrists and physiotherapists, were subsequently referred to a medical doctor in the usual way.

Demographic data (see Table  4 ) were collected from 315/ 468 (67.3%) patients who consented to and returned patient questionnaire 1: 49.5% ( n  = 156) were from prescribing and 50.5% ( n  = 159) from non-prescribing sites. A lack of benchmark data with which to compare the patient data means it is not possible to confirm how representative our sample is with respect to the larger population. However, the samples, from the prescribing and non-prescribing group in this study were similar in terms of age, employment status, level of formal education, and ethnic group ( p  > 0.05).

A response rate of 73.7% (197/267) was obtained for questionnaire 2. This sample excluded the 175 participants from the first 4 sites (Sites 1, 2, 4, 7) (see Table 2 ). Of the remaining 313 participants, 285 consented to follow-up, however contact details were incorrect or missing for 18 participants, leaving 267 eligible to participate.

Patient outcomes

Satisfaction and access to services

The majority of patients (75.9%, n  = 239) agreed that physiotherapists and podiatrists should be able to prescribe medicines for patients, however 23.2% ( n  = 73) would prefer a doctor to prescribe. Levels of satisfaction for the sample as a total were high, with over 60% positive agreement on all items other than ability to contact the service in an emergency ( n  = 144, 44.4%). Satisfaction with 17 specified aspects of the consultation and services provided by physiotherapists and podiatrists indicated a significantly higher level of satisfaction among the patients of physiotherapist and podiatrist independent prescribers than those of non-prescribers in 8 instances (Table  5 ).

With respect to service access, patients of podiatrist independent prescribers were more satisfied with ‘the ease of making an appointment’ and ‘the ability to contact the service by phone or in times of emergency’ (see Table 5 ) than patients of the non-prescribing podiatrists, with no notable difference evident in patients attending physiotherapist prescribers compared to patients of non-prescribing physiotherapists.

There was no effect on the remaining four items reporting on ease of access on the acceptability of: i) waiting time to obtain an appointment; ii) obtaining an appointment on a convenient day or hour; iii) waiting time or iv) seeing the physiotherapist or podiatrist at the appointed time between patients attending a physiotherapist or podiatrist independent prescriber when compared to those attending a non-prescribing physiotherapist or podiatrist.

Patients of a physiotherapist or podiatrist independent prescribers were more likely to receive medicines information or advice during the consultation (58 out of 146 (39.7%) vs 37 out of 151 non-prescribing physiotherapist or podiatrist patients (24.5%); p  = 0.005), with varying levels of satisfaction reported (see Table  6 ). Compared to patients of non-prescribing physiotherapist or podiatrists, patients of physiotherapist or podiatrist independent prescribers were significantly more likely to: ‘be told when’ and ‘how often’ to take their medicine, ‘intend to take their medicines’ and ‘find it easier to follow the physiotherapists’ advice’ ( p  ≤ 0.05).

Quality of life- EQ-5D-L

Indications at baseline were that patients who saw physiotherapist independent prescribers had lower generic quality of life than those seeing the non-prescribing physiotherapists, due to lower scores on the mobility dimension. However, there was no statistically significant difference between physiotherapist or podiatrist independent prescribers and non-prescribing physiotherapist or podiatrist groups on either individual items or overall EQ-5D-5Lscore ( p  ≥ 0.05) (Table  7 , individual dimension scores not shown).

Quality of life overall scores in both physiotherapist and podiatrist independent prescribers and non-prescribing groups improved significantly between baseline and follow-up. Differences in change scores between the physiotherapist and podiatrist independent prescribers and non-prescribing physiotherapist or podiatrists, however, were not statistically significant (Table 7 ). The sample for which data at both time points were available was limited ( n  = 116).

iv. Economic analysis

Amongst physiotherapists, the independent prescribers had significantly longer consultation duration than non-prescribers (27.6 vs 20.8 min) (Table  8 ). Amongst podiatrists, the frequency with which medications i.e. a new medication, repeat medication (same dosage), or repeat medication (dosage changed) and tests were ordered were significantly higher in independent prescribers than non-prescribers (Table 8 ). There was a trend for consultation duration to be longer for independent prescribers (23.4 vs 19.9 min) (Table 8 ).

Comparing physiotherapists and podiatrists, planning of follow up consultations was higher by podiatrist independent prescribers than physiotherapist independent prescribers, but no significant differences were found between independent prescribers and non-prescribers within the professions. After removing unplanned consultations in the two months after the original consultation that were considered (by two independent reviewers) to be unamenable to treatment delivered in the index consultation, only four items of unplanned service utilisation remained across the whole sample of patients of physiotherapists and podiatrists, all of which were related to pain relief (Table 8 ).

Costs of consultations

Difference in costs of consultation duration of independent prescribers compared to non-prescribers for physiotherapist and podiatrist groups were based on Agenda for Change (AfC) band 8a, which was the most frequent grade of physiotherapist and podiatrist independent prescribers in the study, i.e. £70 per hour [ 73 ]. Compared to the cost of a non-prescriber consultation, the independent prescriber consultation was, on average, more costly by £7.95 for physiotherapists (£24.30 vs £32.25) and £8.62 (£19.69 vs £28.31) for podiatrists. The salary of a grade 9 professional is twice that of grade 8a, so at that higher level, the differences in the cost of consultations between independent prescribers and non-prescribers would be doubled. Use of grade 7 instead of grade 8a would reduce the differences between independent prescribers and non-prescriber by about £1.20 per consultation. Amongst the podiatrists, the independent prescribers were at band 7 (advanced / team leader), 8a (principal) and 9 (consultant); two of the non-prescribers were band 9 and the third was band 6 (specialist). Participating physiotherapists were all band 8a, except one non-prescriber (grade 8c), and one independent prescriber (grade 7).

Costs could not be estimated for the other elements of activity that might differ between independent prescribers and non-prescribers due to data availability problems. Information on tests ordered were drawn from a small sample of records (n = max 15 per site) in each site (the audit); reporting of the type and dose of new medications, referrals and frequency of planned follow up was incomplete.

Discussions with colleagues

The independent prescribers in the physiotherapist group consulted colleagues about patients significantly more often than the non-prescribers (17.8% vs 0.9% of consultations), and most discussions were with medical colleagues, averaging 9.5 min per discussion (Table  9 ).

Podiatrists held discussions with colleagues for > 10% of consultations (14.8% IPs, 10.5% NPs, (Table 9 )), for around 7 min. Independent prescribers discussed a higher proportion of patients with medical colleagues, than a colleague from the same profession, thereby likely to be incurring higher costs. However, information on colleagues consulted was not precise, so calculations were indicative only. Some podiatrists were band 9 (consultant), so reporting discussions with ‘same’ professional would imply higher costs than are indicated in the table, which are based on AfC band 8a.

Cost implications

The available data suggest that for both physiotherapists and podiatrists in this study, care delivery by independent prescribers is more resource intensive and costly than non-prescribers due to longer consultations for physiotherapists and taking more time of colleagues to discuss patients. Whilst not costed, podiatrist independent prescribers had higher frequency of ordering medications and tests than non-prescribing podiatrists. Analysis of the changes in self-reported health status between baseline and 2 months follow up using EQ-5D-5L found no difference in change scores of independent prescribers and non-prescribers for either physiotherapists or podiatrists, but these data were only available for a small sample of participants.

This is the only known national evaluation of physiotherapist and podiatrist independent prescribers in the UK or the world, and the first to adopt a comparative case study design to compare outcomes and costs for patients managed by physiotherapist and podiatrist independent prescribers/ non-prescribers. Unlike nurses and pharmacists, where prescribing has been explored in some detail using self-reported outcomes [ 26 , 47 , 70 ], there is a dearth of equivalent information in the allied health professions, including either physiotherapy and/ or podiatry [ 29 , 35 ] and/ or studies adopting direct observation of outcomes [ 26 ]. Our study demonstrates that care provided by physiotherapist and podiatrist independent prescribers is equivalent, in terms of quality of life and patient satisfaction, to care provided by non-prescribing physiotherapists with prescribing undertaken by doctors. Independent prescribing by physiotherapists and podiatrists was found to be effective, and highly acceptable, with higher levels of patient satisfaction in some aspects of medicines information also reported than for non- prescribers.

Importantly, it appears that physiotherapist and podiatrist independent prescribing is developing in line with original policy intention to improve access to medicines and quality of care across a range of settings [ 74 , 75 , 76 ]. The evidence generated in this study demonstrates that physiotherapist and podiatrist independent prescribers can provide a high standard of care. Extending non-medical staff, such as physiotherapists’ and podiatrists’, scope of practice to include independent prescribing is key to supporting effective delivery of the NHS Long Term Plan [ 9 , 49 , 77 ], and creating a step change in developing the capacity and capability of the workforce to deliver innovative models of service delivery [ 4 , 9 ]. The severity of the workforce deficit makes changes, such as the increased level of clinical autonomy, associated with independent prescribing an attractive option to commissioners who seek to address gaps in service delivery. As the world leader in extending prescribing rights to nurses, pharmacists and allied health professions the findings are of significant importance to international policy makers who seek to learn from the pioneering advancement of prescribing rights in UK [ 25 , 28 ] to inform their own approach to addressing the workforce deficit.

Internationally it is now common for physiotherapists, nurse practitioners, pharmacists, social workers, and psychiatric nurses to be located within extended primary care teams [ 78 ] with plans to extend this further recently announced [ 9 , 11 ]. Nearly 50% of appointments in UK general practice are for example, already provided by non-medical staff, i.e. nurses, pharmacists and allied health professionals [ 9 , 79 ]. In addition to the current shortage of 2500 general practitioners, this is important for several reasons: i) the current deficit in primary care looks set to continue [ 80 , 81 ]; ii) the recent proposal for home visits to be removed from the GP contract, and iii) the government pledge to create 50 million more GP appointments year by 2024/25 [ 81 , 82 ]. As the third largest workforce in health and care in England, allied health professionals have, through the introduction of a further 20,000 non-doctor roles in primary care [ 83 ], great potential to contribute to transforming care and ensuring ongoing access to medicines [ 11 ].

Having a robust economic evaluation of physiotherapist and podiatrist independent prescribing is particularly important, given that identifying a sustainable solution that i) improves the worldwide deficit of health workers, and ii) makes best use of limited resources is essential to ensuring ongoing access to medicines [ 9 , 11 ]. Our cost appraisal from the case sites suggests that physiotherapist and podiatrist independent prescriber care delivery is more resource intensive than non-prescribing physiotherapists and podiatrists. This arises through longer consultation duration, more ordering of medicines and tests (podiatrists) and more discussions with colleagues (physiotherapists). These costs, however, need to be considered in relation to benefits, particularly clinical outcomes, many of which could not be measured in this study. Only a limited economic analysis was possible meaning that the findings should be treated with caution. Whilst the original intention had been to undertake a patient level micro costing analysis, data deficiencies limited what could be included. Further research is required to understand how team configuration affects care delivery, patient outcomes and costs.

The most complete data were available for consultation duration, and the calculation of associated costs showed independent prescribers to incur slightly higher consultation costs than non-prescribers in both the podiatrist and physiotherapist groups (£8.62 and £7.95 respectively). It is important to note however that consultation duration and associated costs may simply be driven by professional differences and clinic practices. The complexity of these arrangements means that the differences in cost could equally reflect service differences which would exist regardless of independent prescribing status. Furthermore, the time spent in discussion with colleagues may reflect the multi-professional service that many case sites provided. Multi-professional, or team-working is a fundamental component of health care delivery in the UK and central to current government policy [ 84 , 85 , 86 ]. There is increasing emphasis on establishing systems, rather than single episodes of care, that dissolve traditional boundaries [ 87 , 88 ] to support the increasing number of people with long-term conditions.

There is limited evidence available with which to compare our study findings [ 26 , 35 , 45 , 46 , 89 ]. Despite positive findings that non-medical prescribing is safe, and provides beneficial clinical outcomes [ 26 , 28 , 70 ], the impact on the health economy, as reported in two recent systematic reviews examining clinical and cost effectiveness, remains unclear [ 45 , 46 , 89 ]. The authors, as in this study, highlight the difficulty in separating non-medical prescribing effects from the contributions of healthcare team members, and a lack of adequately powered randomised controlled trials examining non-medical prescribing across clinical specialities, professions and settings [ 25 , 45 ]. Given that extended prescribing rights to nurses, pharmacists and allied health professions offers a sustainable approach to improving the global workforce deficit, there is a pressing need to establish economic benefits, or otherwise of non-medical prescribing to inform future international policy developments. A different approach, involving highly targeted specific outcomes, and or longitudinal studies is therefore required. The development of a minimum data set of important outcome measures for non-medical prescriber assessment would as Noblet et al. suggests [ 45 ], be highly beneficial, and generate the required evidence to evaluate the overall benefit of non-medical prescribing and inform future developments in the UK and around the world.

Strengths and limitations

In the first study to explore allied health professional prescribing, the 14 case sites supported an in-depth evaluation and comparison of physiotherapist and podiatrist independent prescribers to non-prescribers in a range of care settings. Use of multiple methods of data collection, including an observational component, strengthens the trustworthiness of the findings. Physiotherapist and podiatrist independent prescriber participants were selected from a larger sample ( n  = 70) who completed a trainee physiotherapist and podiatrist independent prescriber survey and indicated that they would be willing to be involved in further research [ 52 ].

Despite challenges in matching sites, given the diversity of service settings, roles, and patient needs, between and within the two professions, patient characteristics indicated good matching on most factors. For future research, matching at a patient/condition level would ensure a comparative sample. Additionally, as patients were predominantly retired, house owners, and lacked ethnic diversity, reflecting study locations, caution must be applied with respect to generalizing the findings to other groups of the population. Furthermore, there are limitations and methodological challenges associated with using the same evaluation measures on two different professional groups for whom separate measures might have been more appropriate. The economic analysis was constrained as described above. An analysis of effectiveness was not possible because it was not feasible to collect data on specific indicators for change across the wide variety of conditions treated within physiotherapist and podiatrist consultations. Our ability to link each of the various aspect of patient data (i.e. observation, questionnaires, record audit) was also very limited as patients, in line with good ethical practice, had the option to select which aspects of data collection they agreed to. As a result, it was not possible to match patients across the different data sets, or to complete some of the intended analysis.

Conclusions

This study provides new knowledge about physiotherapist and podiatrist independent prescribing, the high level of care and patient satisfaction they provide. Given that extending prescribing responsibilities to nurses, pharmacists, and allied health professionals is increasingly being recognised as effective way to alleviate shortfalls in the global health workforce and ensure ongoing access to prescription medicines around the world this is important. PP-IP care delivery was found to be more resource intensive than NP-PP. However, this study is limited, and findings needs to be verified through further research, including a full economic analysis. A more focussed longitudinal exploration within each profession with targeted outcome measures would enable a more robust comparison of the impact of physiotherapist and podiatrist independent prescribing across the United Kingdom and inform further developments around the world.

Availability of data and materials

The study did not receive ethics approval, or participant consent, to place a study dataset in the public domain. The data, and tools used for its collection in this study can be made accessible to qualified researchers upon reasonable request pursuant to any restrictions required to ensure the privacy of human subjects involved. Access to data will be subject to a data sharing agreement approved by University of Surrey. Researchers interested in accessing USEFUL data should send their request to the Director of Research, Professor Emma Ream (e.ream @ surrey.ac.uk ).

Abbreviations

Accident and Emergency

Blood pressure

British National Formulary

Computerised tomography

EuroQol 5-D

General Practitioner

Medicines Management Activities

Magnetic Resonance Imaging

Non- medical prescriber

NON-prescribing Physiotherapist & Podiatrist

Over the counter

Patient Group Direction

Podiatrist independent prescriber

Podiatrist non-prescriber

Physiotherapist & Podiatrist

Physiotherapist & Podiatrist Independent Prescriber

Patient Specific Direction

Physiotherapist independent prescriber

Physiotherapist non-prescriber

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Acknowledgements

We would like to thank the physiotherapists and podiatrists, team members, patients and stakeholder participants who took part in our study, and our project advisory group and patient public involvement group for their advice and contributions throughout. Special thanks to assistance from Clareece Kerby, with data preparation and analysis, and Emma Konstantara with recruitment in private healthcare settings.

This work was funded by Department of Health Policy Research Programme (PRP) grant number: PR-R19–0617-21001. The funding body had no role in the design of the study, collection, analysis, and interpretation of data nor in writing the manuscript. The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the PRP or the Department of Health.

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NC was overall project lead with responsibility for execution of the study. All authors: NC; KS; JE; MC; SO, AM, HG, PW contributed to the design of the study. JE undertook data collection. HG and PW undertook analysis of heath economics data. PW provided expertise on data analysis. All authors (NC; KS; JE; MC; SO, AM, HG, PW) participated in interpretation of data. NC & KS drafted the manuscript. All authors (NC; KS; JE; MC; SO, AM, HG, PW) read, commented on and approved the final manuscript.

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Carey, N., Edwards, J., Otter, S. et al. A comparative case study of prescribing and non-prescribing physiotherapists and podiatrists. BMC Health Serv Res 20 , 1074 (2020). https://doi.org/10.1186/s12913-020-05918-8

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• Physiotherapy
• Independent prescribing
• Comparative case study

Influencing policy and practice in non-medical prescribing (NMP)

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Medical and Health Sciences:  Nursing ,  Public Health and Health Services

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Summary of the impact.

Our ground-breaking research has driven major changes in non-medical prescribing (NMP) legislation. As a result of our research, over 19,000 nurses and 2,000 pharmacists now independently prescribe medicines directly to patients across the most comprehensive range of medicines in the world. This amounts to four million prescriptions per year in England. NMP has improved the quality and efficiency of health care: patients can now access prescribed medicines faster and NMP has reduced the number of professionals required. Study results have also contributed significantly to a recent extension of independent prescribing powers to physiotherapists and podiatrists. Our research is widely cited in international NMP policy development, and our survey methods and evaluation measures are used to assess NMP quality and safety internationally.

Underpinning research

The prescription of medicines is probably the most common intervention patients receive for the management of medical conditions. In 2011, 961 million items were prescribed in England — on average 17.8 items per head of the population. The UK is a world leader in progressive policy and practice for non-medical prescribing; this is underpinned by our research which has shifted prescription from a doctor-only model to one that now allows a range of healthcare professionals including nurses, pharmacists and optometrists to independently prescribe a wide range of medicines. This new policy and practice has been a key part of NHS modernisation since 2008.

Pioneering research by Professor Sue Latter at the Faculty of Health Sciences, University of Southampton (since 2008), has helped drive the direction of this revolution in prescribing. Our research included the first Government-funded national evaluations of NMP in the world, providing large-scale independent evidence on the quality, safety and acceptability of NMP.

The first multi-disciplinary study [Research grant 1; 2003-2005] was led at Southampton by Latter with Dr Jill Maben, Senior Research Fellow (left 2004); Dr Michele Myall, Research Fellow (left 2005); Dr Molly Courtenay, Lecturer (left 2004); Amanda Young, Research Fellow (left 2005) and Dr Nick Dunn, Senior Lecturer, Faculty of Medicine. The study evaluated the extension of prescription powers, first to community nurses and later, in progressive stages, to other appropriately qualified nurses and pharmacists who were allowed, initially, to prescribe a limited number of medicines or with limited independence. We conducted a national survey of nurse prescribers and investigated case studies of different practice settings [3.1, 3.4] and this directly informed UK Government prescribing policy. This research was the first large scale international study to move beyond self-report data to provide direct, objective evidence of the quality and safety of NMP, by including observation of nurse prescribing consultations [3.2, 3.3] and an independent analysis of patient records and nurse prescriptions. Data collection with key stakeholders — prescribing nurses, other healthcare professionals and patients — was conducted to assess on a national scale the benefits of independent prescribing by nurses, and demonstrated the limitations of restricted prescribing which failed to make effective use of health professionals' skills and did not deliver efficient NHS practice. The results of the research paved the way for a significant Government consultation on extending NMP later in 2005, culminating in legislation in 2006 which resulted in a radical extension of NMP over following years.

Building on our reputation, we conducted further Southampton-led multi-centre (Southampton, Keele, London School of Economics) multi-disciplinary (nursing, pharmacy, medicine, health economics and statistics) research to evaluate nurse and pharmacist independent prescribing [Research grant 2; 2008-2010], once NMP was extended to allow nurses and pharmacists to prescribe any licensed medicine for any medical condition — except controlled drugs. The research was with Southampton staff: Dr Karen Gerard, Reader; Dr Peter Nicholls, Senior Research Fellow (left 2012); Dr Alesha Smith, Senior Research Fellow (left 2009) and Professor Paul Little, Faculty of Medicine. Building on and extending the methodology of the first study, including the first ever direct observational data internationally of pharmacist prescribing [3.5], we concluded that prescribing by nurses and pharmacists was generally safe, clinically appropriate [3.5] and acceptable to patients [3.6] and other healthcare professionals. Findings highlighted that training for NMP roles was satisfactory overall, but also found there were some indications that assessment and diagnostic skills associated with prescribing could be improved [3.5].

References to the research

Research grant 1: An Evaluation of Extended Formulary Independent Nurse Prescribing

3.1 Latter S, Maben J, Myall M, Young A. (2007a) Perceptions and practice of concordance in nurses' prescribing consultations: findings from a national questionnaire survey and case studies of practice. International Journal of Nursing Studies 44 (1): 9-18 www.sciencedirect.com/science/article/pii/S0020748905002099

3.2 Latter S, Maben J, Myall M, Young A. (2007b) Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis. Quality and Safety in Health Care 16: 415-421 www.ncbi.nlm.nih.gov/pmc/articles/PMC2653174/

3.3 Latter S, Maben J, Myall M, Young A. (2007c) Evaluating nurse independent prescribers' prescribing consultations: an observation study of practice in England. Journal of Research in Nursing 12 (1): 7-26 http://jrn.sagepub.com/content/12/1/7.abstract

3.4 Latter S, Maben J, Myall M, Young A. (2007d) Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: findings from a national survey in England. Nurse Education Today 27: 685-696 www.sciencedirect.com/science/article/pii/S0260691706001687

Research grant 2: Evaluation of nurse and pharmacist independent prescribing

3.5 Latter S, Smith A, Blenkinsopp A, Nicholls P, Little P, Chapman S. (2012) Are nurses and pharmacists making clinically appropriate prescribing decisions? An analysis of consultations using the Medication Appropriateness Index. Journal of Health Services Research and Policy 17: 149-156 www.ncbi.nlm.nih.gov/pubmed/22734082

3.6 Gerard K, Tinelli M, Latter S, Blenkinsopp A, Smith A. (2012) Valuing the extended role of prescribing pharmacist in general practice: Results from a discrete choice experiment. Value in Health 15 (5): 699-707

Research Grants:

Research grant 1 — Latter S (Chief Investigator), Courtenay M, Dunn N. An Evaluation of Extended Formulary Independent Nurse Prescribing. Commissioned and funded by the Policy Research Programme at the Department of Health 2003-2005, £200,000.

Research grant 2 — Latter S (Chief Investigator), Blenkinsopp A, Gerard K, Chapman S, Little P, Nicholls P, Dorer G. An evaluation of nurse and pharmacist independent prescribing. Commissioned and funded by the Policy Research Programme at the Department of Health 2008-2010, £338,000.

Details of the impact

Reach and significance of impact: number of Non-Medical Prescribers and patients

Our research reports were published by the Department of Health (DH) [5.11] and made available on their website [5.1 and 5.2]. The Executive Summaries of our research reports have been downloaded 1698 times [Research grant 1] and 6495 times [Research grant 2] from the University website. Working closely with the DH Policy Lead for NMP, our research findings on the positive contribution of NMP to health care made a direct impact on NMP legislation and NHS modernisation in England, providing key evidential support for Government policy change [5.11]. As a result, the number and range of health care professionals able to train as prescribers has significantly increased, as well as the number of medicines that they can prescribe. Our research has helped extend the role and accountability of the largest sector of the health care workforce such that by 2012, 19,000 nurses across England had qualified as Nurse Independent Prescribers — up from only 6,600 in 2006. Nurse prescribers are now employed across approximately 93% of the 376 NHS Trusts in England, with the majority prescribing for more than 11 patients per week, and a significant minority (15%) prescribing for more than 50 patients per week [5.2]. In 2013, the number of pharmacist prescribers had grown to 2000, and the total number of items prescribed by Non-Medical Prescribers in England had risen from 2.4 million (January — March 2008) to 4 million (July — September 2011).

As a direct result of her research, Latter was invited to join a Government Project Board, chaired by the Chief Health Professions Officer, on allied health professions prescribing in 2009. The Board's report [5.3] cited her research as evidence that NMP training adequately prepared nurses for practice and thus could be adapted for new prescriber categories (e.g. allied health professionals). Our findings on the safety and acceptability to patients of nurse and pharmacist prescribing were the sole research evidence cited in DH consultation documents on extending physiotherapist and podiatrist prescribing [5.4 and 5.5]. These national consultations resulted in widespread support for extending prescribing by physiotherapists and podiatrists and in July 2012, new prescribing powers, enabling these groups to independently prescribe medicines, were announced. Our research was also the sole evidence cited in the Government's consultation document on proposals to introduce prescribing rights for paramedics [5.6]. Building on the research findings, the DH announced in April 2012 that the list of medicines nurse and pharmacist prescribers can prescribe will be expanded to include controlled drugs.

Impact on prescribing quality and efficiency

To ensure effective transfer into health care professional practice, Latter et al presented preliminary findings at a workshop of key stakeholders comprising 43 senior healthcare policy makers, managers and commissioners influential in NMP policy and practice nationally [5.2]. Stakeholders corroborated the value of the study findings and identified priorities for action; these included the development of a cross-profession common competency framework for all prescribers [5.2]. This action has since been taken forward by the National Prescribing Centre, culminating in the 2012 publication of a single competency framework for all prescribers which is the national standard to underpinning quality and safety in prescribing. Following completion of the 2010 study, Latter was invited by DH to present the results and recommendations to the DH Non-Medical Prescribing Programme Board, chaired by the Chief Nursing Officer, and including the Chief Pharmaceutical Officer for England and the DH NMP Policy Lead [5.11]. Latter was also invited to present findings to the Nurse Prescribing Advisory Group of the British National Formulary in 2011 [5.11].

As a direct result of the insights gained from her research, Latter was invited to join the NICE Concordance Guideline Development Group as an expert peer reviewer. The group's recommendations were the foundation for NICE's clinical guideline 76 on Involving patients in decisions about prescribed medicines and supporting adherence , published in 2009, setting a clear template for how patient discussions about medicine are conducted and assessed professionally.

A 2011 Nursing Times review provides evidence of the significance of extending prescribing rights for nurses: NMP has benefited both the nursing profession (through greater autonomy and job satisfaction) and patients, for whom it means timely access to medicines and treatment and reduced waiting times [5.7]. NMP has reduced the number of health professionals that need to be involved in an episode of care, and economic analysis of NMP [5.2] highlights the potential cost savings made by shifting prescribing workload from doctors to nurses. For example, the cost of one hour of patient contact for a GP is £127, compared to £43 for a practice nurse (PSSRU 2011). These data highlight the efficiency and cost savings achieved through expanding NMP and the resulting improvements in patient care.

The key changes in UK prescribing policy resulting from our research have been widely reported across the national news media and more extensively still in professional journals such as the Nursing Times, whose 300,000 monthly readers include nurses in the UK and abroad.

International Impact

Our research findings have been utilised internationally for policy and practice. Study results were cited as key international evidence in a series of Australian Government Consultation Papers [5.8] recommending a new national prescribing pathway to extend prescribing rights to the 268,000 registered nurses in Australia. This represents a radical increase from the current position in which nurse prescribing is limited to around 400 nurse practitioners. With the UK now a global leader in NMP, our study methods and evaluation criteria have been adopted internationally for studies including: a national evaluation by the Netherlands Institute for Health Services Research of nurse prescribing in the Netherlands (Kroezen 2013); an evaluation of diabetes nurse specialist prescribing for the New Zealand Society for the Study of Diabetes in New Zealand [5.9]; a survey of pharmacist prescribing in Canada (Guirguis et al 2012); and Drennan et al's (2009) Health Services Executive funded national evaluation of nurse and midwife prescribing in Ireland [5.10]. Studies' results have led to further impact: for example, the study of nurse prescribing in New Zealand has stimulated national legislation to enable further roll-out of nurse prescribing to other nurses; in Ireland, the number of registered nurse prescribers in 2009 in Drennan's et al's national evaluation was 57; this had risen to 453 in June 2012. Our research findings are also cited in influential international reviews of NMP policy and practice (International Council of Nurses 2009; Kroezen et al 2011).

Southampton-led research on NMP has provided unique evidence to the Government that has significantly influenced national policy on expanding NMP, resulting in higher quality patient care and improved health service efficiency. Our research has informed international policy on NMP and studies drawing on our methods and results have contributed to the expansion of prescribing authority to a greater number of nurses and pharmacists around the world, with an ability to prescribe a greater range of medicines for patients.

Sources to corroborate the impact

5.1 Latter S, Courtenay M, Dunn N. (2005) An Evaluation of Extended Formulary Independent Nurse Prescribing. Final Report.

5.2 Latter S, Blenkinsopp A, Smith A, Chapman S, Tinelli M, Gerard K, Little P, Celino N, Granby T, Nicholls P, Dorer G. (2011) An evaluation of nurse and pharmacist independent prescribing. Final Report www.gov.uk/government/publications/evaluation-of-nurse-and-pharmacist-independent-prescribing-in-england-key-findings-and-executive-summary

5.3 Department of Health. (2009) Allied health professions prescribing and medicines supply mechanisms scoping project report (page 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_103948

5.4 Department of Health. (2011a) Consultation on proposals to introduce independent prescribing by physiotherapists (pages 18, 22 and 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129983

5.5 Department of Health. (2011b) Consultation on proposals to introduce independent prescribing by podiatrists (pages 18, 22 and 23) http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Consultations/Liveconsultations/DH_129981

5.6 Department of Health. (2010) Proposals to introduce prescribing responsibilities for paramedics. London: Department of Health (page 6)

5.7 Carey K, Stenner N. (2011) Does non-medical prescribing make a difference to patients? Nursing Times (July 4) www.nursingtimes.net/nursing-practice/clinical-zones/prescribing/does-non-medical-prescribing-make-a-difference-to-patients/5032082.article)

5.8 Health Workforce Australia. (2012) Health Professionals Prescribing Pathway Project www.hwa.gov.au/sites/uploads/Final_HPPP_Phase_One_Interim_Report.pdf (page 5)

5.9 Wilkinson J, et al (2011) Evaluation of the diabetes nurse specialist prescribing project www.healthworkforce.govt.nz/sites/all/files/DNS%20Final%20evaluation%20report.pdf (page8)

5.10 Drennan J, et al (2009) National independent evaluation of the nurse and midwifery prescribing initiative. Health Services Executive Ireland www.hse.ie/eng/services/Publications/services/Hospitals/prescribing_initiative.pdf (page ix)

5.11 Corroborator: John Wright, Policy Lead, Non-Medical Prescribing. Reports were made available on DH website and provided key evidential support for Government policy change expanding NMP, resulting in higher quality patient care and improved health service efficiency. Latter presented results to the DH Non Medical Prescribing Programme Board and the Nurse Prescribing Advisory Group of the British National Formulary.

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• v.19(1); 2018 Jan

Nurse prescribing in primary care: a metasynthesis of the literature

Dilyse nuttall.

Principal Lecturer, School of Community Health and Midwifery, University of Central Lancashire, Preston, Lancsashire, UK

The aim of this metasynthesis was to develop an understanding of the existing theoretical perspectives around nurse prescribing and to identify any gaps in knowledge, which would support further research into the lived experience of the nurse prescriber in the primary care setting.

Nurse prescribing has been the focus of many research studies since its introduction, with many benefits to the patient, the prescriber and service identified; however, there remains variation in the utilisation of the prescribing qualification, particularly in primary care settings. Although a range of quantitative and qualitative studies have been undertaken, which aimed to explore the influences on prescribing, few have used a research methodology that supports the in-depth exploration of the nurse prescriber’s experience.

An extensive literature search was undertaken in April 2015 (20–24), which included UK and non-UK studies since 1999. Inclusion and exclusion criteria were applied to search for studies in which participants included nurse prescribers who practiced in primary or community care settings. Studies that only used a quantitative methodology and those not available in English were excluded. The literature search yielded 124 papers, with 50 papers remaining after the initial screen of full papers against the inclusion/exclusion criteria. The papers were reviewed and graded for their quality, with a further 13 papers excluded.

A three-step qualitative analysis technique of metasynthesis was applied to the remaining 37 papers. Identification of similarities and differences enabled first-order interpretations to be identified, which were grouped into broader themes (second-order interpretations) by identifying concepts that applied to two or more studies. Further interpretation through synthesis of translation enabled third-order interpretations to emerge.

From the metasynthesis of the 37 papers, nine themes emerged: patient-centred care ; benefits to the service ; the need for knowledge ; professional accountability and boundary setting ; safety consciousness ; barriers to effective prescribing ; role preservation ; power-shifts and inter-professional relationships ; and culture of prescribing .

Introduction

Nurse prescribing is increasingly being recognised as an important activity in nursing practice, with countries including Spain, Norway, Finland, Sweden, Ireland, The Netherlands, New Zealand, South Africa, Colombia, Australia, Canada and the United States of America enabling nurses to legally prescribe (Kroezen et al ., 2012 ; Gielen et al ., 2014 ; Weeks et al ., 2016 ); however, the application of nurse prescribing varies between countries, with some, including the United Kingdom, enabling independent prescribing, and others applying strict conditions and supervision (Kroezen et al ., 2012 ). In the United Kingdom, the Royal College of Nursing ( 2012 ) identified that there were 54 000 nurses and midwives qualified to prescribe in 2012. Of these, 35 000 were Community Practitioner Nurse Prescribers (CPNPs), with the remaining 19 000 being independent and supplementary prescribers. Figures presented in Health Education North West’s ( 2015 ) large-scale economic evaluation of non-medical prescribing (NMP), suggested that although numbers in secondary care are increasing, there continues to be more (non-medical) prescribers in primary and community care settings. Despite the steady rise in nurse prescriber numbers, there is evidence that some nurse prescribers choose not to prescribe (Earle et al ., 2011 ) whereas others do not prescribe to their full potential (Coull et al ., 2013 ).

The primary focus of research in NMP to date has been on its impact, identifying an overall positive effect on patients, practitioners and the service (Courtenay et al ., 2006 ; Bissell et al ., 2008 ; Hacking and Taylor, 2010 ; Gielen et al ., 2014 ; Health Education North West, 2015 ). In addition to the range of benefits, these and other studies identified a number of barriers to effective prescribing. Watterson et al .’s ( 2009 ) Scottish study found that prescribing was inhibited by a range of issues, which included a lack of access to training and a lack of support; however, the study also identified motivators, such as job satisfaction and the opportunity to improve patient care, which were linked to increased prescribing activity. It is evident that there are wide-ranging influences on nurses’ prescribing, including the trust of other members of the team (Bowskill et al ., 2013 ), the prescriber’s confidence (Downer and Shepherd, 2010 ), their experience (Hall et al ., 2008 ), the expectations of others (Nolan and Bradley, 2007 ) and the legislative controls enforced by different countries (Kroezen et al ., 2012 ).

Although there have been numerous studies with a focus on nurse prescribing, there is still much more to discover. Many of the themes emerging from previous studies, such as confidence, competence and changes in role and relationships, suggest that the individual lived experiences of nurse prescribers are worthy of further exploration. There appears to be a need for a clearer insight into experiences and perceptions in prescribing practice in order to identify more effective ways to motivate and support nurse prescribers to prescribe more effectively. It is important to note that although many of the larger studies, such as those of Latter et al . ( 2012 ) and Health Education North West ( 2015 ) acknowledged that NMP in the United Kingdom was still predominantly undertaken in the primary care setting, many did not include CPNPs. As such, there is a clear need to learn from the lived experiences of our current prescribers in order to support them and our future NMPs more effectively.

This metasynthesis formed part of phase one of a phenomenological study aiming to explore the lived experience of the nurse prescriber in the community or primary care setting in the United Kingdom. The aim of the metasynthesis was to develop an understanding of the existing theoretical perspectives around nurse prescribing in order to identify any gaps in knowledge and any potential for new ideas.

Metasynthesis

Systematic review utilises transparent, structured processes to review literature and this approach is equally important when reviewing qualitative literature as it requires the identification of clear criteria to support credibility, transferability, dependability and confirmability (Bearman and Dawson, 2013 ). Metasynthesis is a systematic approach to the synthesis of findings from qualitative studies, allowing key ideas and concepts to be identified (Erwin et al ., 2011 ) while clearly identifying the quality measures employed throughout the process. This iterative approach enables a focus on the question being asked (Downe, 2008 ) and can introduce an additional layer of interpretation to those identified by the authors of the individual studies (Bearman and Dawson, 2013 ).

Literature search

The literature search was undertaken in April 2015 (20–24), using a range of databases and resources selected because of their relevance to the subject area ( Table 1 ). In order to gather an insight into factors that could impact the lived experience of the nurse prescriber, a broad approach was applied to the literature search, which included qualitative and mixed-methods papers. As such, the literature search included other reviews as well as primary studies. Studies that only gathered quantitative data were excluded as it was felt that the methodologies used would not provide data with the depth necessary to be relevant to a phenomenological study. International literature was included in the search, excluding only those not available in English. As the aim was to explore the perspectives and experiences of the nurse prescriber, studies that only explored the perspectives of other prescribers (doctors, physicians, pharmacists, physiotherapists, radiographers, podiatrists/chiropodists, optometrists and dentists), other staff or patients were excluded. Relevant professional nursing groups with prescribing rights were included (independent nurse prescribers; supplementary nurse prescribers; V100; V150; and V300) but this was limited to those practicing in a community or primary care setting. Although no lateral searches were undertaken, search terms were tested using Medical Subject Headings to ensure that terms used in the final searches captured all relevant data. Inclusion and exclusion criteria are identified in Table 2 . The outcome of each stage of the literature search process is recorded in Figure 1 .

Literature search and quality assessment process.

Databases and resources included in the literature search

Search strategy

Qualitative analysis techniques

Walsh and Downe’s ( 2005 ) qualitative analysis technique was used, which ‘attempts to integrate results from a number of different but inter-related qualitative studies’ and, as such, was seen as appropriate for analysis of the range of data yielded from this literature search. In support of this technique, an adaptation of the Template for Metasynthesis and the grading system developed by Downe et al . ( 2009 ) were utilised. The first stage of Downe et al .’s ( 2009 ) approach required an initial screening of the full-text papers, resulting in 15 papers being rejected as the inclusion criteria were not met, a factor not clear on initial reading of the abstracts. The quality of the remaining 50 papers was reviewed by the author and two other members of the research project supervisory team, using the Quality Assessment Tool questions shown in Table 3 . This stage of the qualitative analysis process gave consideration to the clarity of the aims, appropriateness of the sample, design and methodology, as well as provided evidence that the findings were justified. The review also considered reflexivity, ethical issues and rigour. On the basis of the quality assessment, papers were graded using Downe et al .’s ( 2009 ) grading system ( Table 4 ) in which failure to meet any of the quality measures was identified as a flaw. The final grades were agreed upon by the three reviewers. In view of significant flaws evident in the papers graded D, these were excluded. Although acknowledging that the papers graded C contained some flaws that may affect credibility, transferability, dependability and/or confirmability, it was deemed that they added to the overall data and met the initial inclusion criteria. After exclusion of the 13 papers graded D, 37 remained and were included in the metasynthesis.

Quality assessment tool (Downe et al ., 2009 )

Grading system (Downe et al ., 2009 )

Participants in the included papers represented nurse prescribers from a range of countries: United Kingdom, United States of America, Canada, Botswana, Zimbabwe, Australia, Ireland, New Zealand and Sweden. Of the 37 papers, 23 were qualitative studies, whereas 11 used mixed methods. Qualitative data from four of the mixed-methods studies were collected using surveys or questionnaires that incorporated open questions, with the remainder also using either interviews or focus groups. Only the qualitative data from the mixed-methods papers were used for this metasynthesis; however, it is important to acknowledge that, in some of the studies, it was not always possible to clearly determine whether the themes identified by the authors were based solely on the qualitative data.

The final three papers were reviews of other studies (two literature reviews and one metasynthesis). Consistency of the findings of these three papers, with the data cited from the primary studies, was reviewed. The process used by the authors to assess the quality of the papers they included was also reviewed. The rigour of this process was used to inform the grade awarded to each of the three studies. Darvishpour et al .’s ( 2014 ) metasynthesis included 11 papers that met their inclusion criteria. The quality of the included papers was assessed using both the AMSTAR tool and the CASP tool, with all papers graded as either strong or moderate with both tools. Similarly, the systematic review by Bhanbhro et al . ( 2011 ) used the CASP tool, and of the 23 papers identified, six were excluded following quality review, because of insufficient detail on the research design and/or methodology used. Although the scores were not stated, the detail provided in the supplementary appraisal notes were suggestive of the quality of all included papers being strong or moderate. Harris and Taylor’s ( 2004 ) literature review included 44 papers that met the inclusion criteria. The quality of these was assessed using an evaluation tool devised by the authors, which included review of the evidence typologies used. Again, the detail provided in the evaluation matrix aligned the quality of all included papers to grades of strong or moderate. The characteristics of the 37 studies are identified in Table 5 .

Characteristics of papers included in metasynthesis

Walsh and Downe ( 2006 ) identify a three-step approach to metasynthesis, which begins by identifying relationships or differences in the studies by comparing and contrasting the data. The next stage, reciprocal translation, attempts to translate the findings of one study into another by identifying concepts that could apply to both studies. Walsh and Downe’s ( 2006 ) final stage is that of synthesis of translation, where the reciprocal translations are synthesised to identify new concepts or develop a more enhanced meaning. This approach was used by the author and nine themes were identified from the literature ( Table 6 ). These themes were agreed upon by two other members of the supervisory team.

Three-step approach to metasynthesis

NMP=non-medical prescribing; CPD=continuing professional development; NP = nurse prescribers

Emerging themes

The need to provide patient-centred care.

The theme of ‘the need to provide patient-centred care’ was identified from 15 papers, two of which were literature reviews, one was a metasynthesis and three were mixed-methods studies. A benefit of nurse prescribing, which featured in many of the studies was the nurse prescriber’s ability to provide and improve patient-centred care, suggesting a need to integrate care into prescribing by using a holistic approach. The district nurse prescribers interviewed in Bowden’s ( 2005 ) and Downer and Shepherd’s ( 2010 ) studies, referred to an improved or better quality of care as a positive outcome of NMP. Support for these findings was demonstrated in studies by Mahoney and Ladd ( 2010 ) and Carey et al . ( 2014 ) as well as by a metasynthesis by Darvishpour et al . ( 2014 ). A variety of factors influenced the nurse prescriber’s ability to provide patient-centred care through prescribing, including the ability to increase effectiveness through the timely delivery of complete episodes of care (Bhanbhro et al ., 2011 ). The importance of timeliness was reflected by Lewis-Evans and Jester ( 2004 ) and by Coull et al . ( 2013 ) in their Scottish study, specifically referring to NMPs having time to explain treatments. In addition, the ability to tailor prescribing to the needs of the patient was identified as a key enabler in studies by Hall ( 2006 ) and Stenner and Courtenay ( 2008b ), with the desire to benefit the patient and to avoid harm identified as important.

The drive to provide patient-centred care through nurse prescribing activity, however, may not be without its consequences. Luker and McHugh ( 2002 ), who carried out a postal survey across three UK Primary Care Trusts, found that nurse prescribers sometimes felt that patients expected more from them than they were able to offer. Similarly, the 2011 large-scale study by the Department of Health (DH), identified that NMP does not enable all nurses to meet the needs of all patients, largely because of concerns about prescribing for patients with co-morbidities; however, it would be fair to suggest that this issue is not exclusive to prescribing.

Benefits to the service

In addition to benefiting the patient, seven of the papers, including one literature review and two mixed-methods studies, indicated that prescribing has a positive impact on the service in which it is implemented. Bhanbhro et al . ( 2011 ) identified a perception by nurses that their prescribing activity reduced doctors’ workloads but as a consequence, nurses’ workloads increased. Interestingly, doctors themselves did not recognise any reduction in their workload. It is worthy to note that nurse prescribers acknowledge time saved for other colleagues as a benefit, suggesting a shared responsibility for patient care and the ability (and willingness) to see benefits from a wider perspective. Davies ( 2005 ) also identified that prescribing could save time for doctors and for the patient themselves, but that this required them to spend more time with the patient. As a result, the extra time spent with one patient was often at the expense of the time available to other patients; however, some of the nurse prescribers in the study by Hall ( 2006 ) offered a degree of counter-balance, suggesting that the extra time that the nurse prescriber had to spend with individual patients (compared with GPs) meant they were able to undertake a more thorough assessment, a finding shared by Lewis-Evans and Jester ( 2004 ). As a consequence, they were able to fully explore the appropriate strategy and, therefore, were actually less likely to prescribe, supporting Coull et al .’s ( 2013 ) finding that NMP was perceived to result in a better use of resources and improved cost-effectiveness. Importantly, the improved access and appropriate prescribing of medicines through NMP is seen as having the potential to manage the many demands on health services and, consequently, has the potential to reduce patient dissatisfaction (Bhanbhro et al ., 2011 ).

The need for knowledge

An issue featuring in 19 of the papers, including seven mixed-methods papers, a metasynthesis and a literature review, was the need for adequate knowledge by nurse prescribers. This included the need for knowledge required to initiate prescribing following a programme of education and for on-going updates and continuing professional development (CPD) opportunities (Bowden, 2005 ). The Scottish Government ( 2009 ) found that nurses who had undertaken a prescribing programme generally felt that it was fit for purpose, equipping them to make more appropriate use of their skills and to be more effective as nurses (Coull et al ., 2013 ); however, Hall ( 2006 ) identified the desire for on-going education amongst nurse prescribers and, additionally, the desire for feedback on their prescribing practice to ensure that this remained effective. The on-going nature of learning and development is supported by Coull et al . ( 2013 ) who found that the prescribing skills of the participants in their study appeared to have increased over time. Bowskill ( 2009 ) referred to this as ‘an assimilation of knowledge’ whereby nurse prescribers continue to gather knowledge as they prescribe, a concept also identified by Stenner and Courtenay ( 2008b ).

Unfortunately, despite this need for knowledge and CPD, nurses prescribers had experienced difficulties in accessing it, particularly CPD arranged by the employers (Luker and McHugh, 2002 ; Harris and Taylor, 2004 ). Although acknowledging that these studies were undertaken relatively early on in the lifespan of nurse prescribing, the later study by Hall ( 2006 ) also found this to be the case. More recently, Cousins and Donnell’s ( 2012 ) study, which focussed on job satisfaction and work-related stress in general practice, again identified a lack of access to updates and a lack of support from general practice for their CPD; however, it is noteworthy that nurses had differing perceptions of whose responsibility it was to provide CPD opportunities, with some accepting it as their own and actively seeking CPD activities, whereas others expected their employer to provide this for them (Hall, 2006 ). As such, the CPD accessed varied, with some seeking support from colleagues and using information from drug companies and journals to update themselves, whereas those in more specialised fields of practice accessed CPD that was more specialised (Luker and McHugh, 2002 ; Carey et al ., 2007 ; Carey et al ., 2010 ). The reality of the situation was effectively summarised by the Scottish Government ( 2009 ) who suggested that a lack of support for CPD could compromise patient safety.

Professional accountability and boundary setting’

In 10 of the qualitative papers, four of the mixed-methods papers and in the metasynthesis paper, the theme of ‘professional accountability and boundary setting’ emerged. Nurse prescribers demonstrated accountability in a range of guises, including awareness of boundaries, competence and confidence. The perception of accountability differed depending on the prescribing situation, particularly when prescribing products (or for patients), where the risk was perceived as greater (Bowden, 2005 ). A prominent factor linked to accountability was the use of formularies and guidelines in setting boundaries and supporting the nurse’s prescribing practice. Stenner et al . ( 2010 a; 2010b ) found that nurse prescribers were more likely than GPs to follow guidelines and used these to support their decision-making, whereas deviation from these was linked to a higher level of decision-making, acknowledging the individual’s accountability for complex decisions. Similarly, Hall ( 2006 ) found that nurse prescribers who did deviate from guidelines and formularies tended to be more experienced nurse prescribers.

Darvishpour et al . ( 2014 ) identified competence as one of the key facilitators of prescribing and having clear links to professional accountability and to the need for knowledge. Maddox ( 2011 ) aimed to examine factors that influenced competency in NMPs and found that even though they perceived themselves as competent, they were less sure that other health professionals were able to make that same judgement about them. The nurses in the study related their competence to their level of pharmaceutical knowledge, their skill in considering differential diagnoses and establishing a diagnosis and an ability to effectively monitor and modify the treatments prescribed.

Many studies that explored nurse prescribers’ experiences identified confidence as a key influence on their prescribing activity. Stenner and Courtenay ( 2008b ) reported an increased confidence in recommending medications amongst nurse prescribers, with Carey et al . ( 2014 ) similarly reporting a general increase in confidence. Interestingly, confidence was seen as developmental (Luker and McHugh, 2002 ; Downer and Shepherd, 2010 ), in that there was a perception of building up confidence to prescribe. In fact, lack of opportunity to build up and develop confidence was seen as a barrier to prescribing (Hall et al ., 2003 ; Bradley et al ., 2007 ). Completion of the prescribing programme was seen by nurse prescribers as a starting point from which confidence would grow, with many using their colleagues as a conduit for developing competence (Bradley et al ., 2007 ). It is apparent that nurse prescribers give much consideration to their professional accountability and that they set boundaries on their prescribing practice in line with this.

Safety consciousness

Safety featured in four of the mixed-methods studies, the metasynthesis paper and in nine of the qualitative studies reviewed, with evidence of nurses adopting their prescribing practice to maintain the safety of their patients. Bradley et al . ( 2007 ) found that nurse prescribers perceived their current prescribing practice as safer than the ‘by proxy prescribing’ practice previously used, as they were prescribing on the basis of their own assessment of the patient’s needs. Nurses were able to identify key processes and practices in prescribing as supporting safety, including accountability, accepting responsibility for keeping up to date and undertaking regular audits of their practice (Bradley et al ., 2007 ); however, Carey et al . ( 2014 ) identified that the increased responsibility for nurse prescribers often resulted in increased anxiety, with nurses worrying about making mistakes or being penalised for their prescribing decisions. Interestingly, although there was no evidence of any mistakes having been made, the nurse prescribers in Jones et al .’s ( 2007 ) study identified concern about making mistakes as a barrier to prescribing, suggesting that nurse prescribers perceive a blame-culture.

Factors that nurse prescribers considered as risks emerged in a number of studies and were closely linked to the desire to avoid harm. Maddox ( 2011 ) identified that nurse prescribers perceived a ‘degree of risk’ with certain prescribing situations, such as prescribing outside of guidelines, prescribing high doses or off-label and prescribing high-risk medicines. Other concerns related specifically to characteristics of the patient, with some nurses feeling uncomfortable if prescribing for the very old and/or the very young (Hall et al ., 2003 ). Both Maddox ( 2011 ) and Carey et al . ( 2014 ) identified that nurse prescribers appeared more concerned about safety when the patient had co-morbidities and were therefore considered to be at a higher risk, compounded in situations in which support for the nurse prescriber was not readily available. It is evident from the literature that a range of strategies are used by nurse prescribers to maintain the safety of their patients. A personal formulary was often used to support safe prescribing as it was exclusively made up of drugs that the nurse felt she/he was competent and safe to prescribe but with the decision made not to prescribe when there were safety concerns (Maddox, 2011 ). It would seem that nurse prescribers have a safety consciousness that influences their prescribing practice, although it is unclear whether this is as a result of prescribing or whether it is already inherent in their nursing practice.

Barriers to effective prescribing

Unsurprisingly, factors identified as supporting prescribing, featured as barriers when absent, a theme that emerged in the metasynthesis paper as well as in four of the mixed-methods studies and seven qualitative studies. A lack of pharmaceutical knowledge was acknowledged as a self-imposed factor in preventing nurse prescribers writing a prescription (Carey et al ., 2007 ; Coull et al ., 2013 ; Darvishpour et al ., 2014 ). As such, when training and support were perceived to be lacking or inadequate, this was seen as a further barrier (Davies, 2005 ; Carey et al ., 2014 ; Carey et al ., 2007 ; Maddox, 2011 ; Cousins and Donnell, 2012 ; Coull et al ., 2013 ; Brodie et al ., 2014 ). Brodie et al . ( 2014 ) identified time and resources as barriers to prescribing, as well as the act of prescription writing itself, which Bowden ( 2005 ) referred to as the ‘chore’ of writing prescriptions. This perception of prescribing as time-consuming was mirrored in the initiation and implementation of clinical management plans when using supplementary prescribing (Carey et al ., 2007 ) and in the prescribing of controlled drugs (Maddox, 2011 ). In these instances, referring the patient to the GP was seen as a quicker method of ensuring the patient received the necessary medicines.

For some, the clinical setting added to the challenge of prescribing. Hall et al . ( 2006 ) found that the challenges of documenting the prescribing activity was exacerbated by the setting itself. Health visitors identified busy clinics as settings where prescribing was particularly difficult because of time constraints, with some nurse prescribers choosing not to reveal that they were able to prescribe. For others, the legal limitations of their prescribing rights and formulary limitations meant that they did not initiate prescribing, as they were concerned about providing a fragmented service (Davies, 2005 ). Although all the barriers identified so far have emerged from data collected from studies within the United Kingdom, Klein ( 2015 ) reported on Clinical Nurse Specialists in Oregon, with some similar findings. Although some of the barriers, such as insurance costs, clearly reflected the US system, others, such as role restrictions and time pressures, were consistent.

It appears that the barriers to prescribing are, at least, in part, attributable to a general lack of infrastructure to support prescribing (Scottish Government, 2009 ). Coull et al . ( 2013 ) identified fragmented implementation of prescribing policy that resulted in variations in implementation. Two of the initial barriers to prescribing were difficulty in getting a prescription pad and a lack of agreement regarding budgetary arrangements (Hall, 2006 ; Hall et al ., 2006 ; Carey et al ., 2007 ; Coull et al ., 2013 ). The lack of preparation for prescribing was reflected in the need for some nurse prescribers to build relationships with GPs to gain agreement to prescribe across practices (Hall, 2006 ; Carey et al ., 2014 ) and some nurses experienced explicit objection to their prescribing (Hall, 2006 ; Hall et al ., 2006 ). Interestingly, even though they were able to identify a number of benefits to the patient and to their role, a number of studies made reference to the nurse prescriber’s assertion that they undertook the role of prescriber without ‘reward’ through grade or pay (Davies, 2005 ; Scottish Government, 2009 ; Downer and Shepherd, 2010 ; Cousins and Donnell, 2012 ; Darvishpour et al ., 2014 ). This desire for recognition by many nurse prescribers of the additional work and responsibility that nurse prescribing brings, may be associated with their perception of the nursing role itself.

Role preservation

A concept represented in a third of the studies reviewed (14 qualitative, three mixed-methods and a metasynthesis) was that of ‘role’, with a desire to preserve the nursing aspect of this. Prescribing was seen as an essential component of the nurses’ role, particularly for specialist nurses (Bowskill, 2009 ; Carey et al ., 2014 ). The nurse prescribers in Maddox’s ( 2011 ) study stated they would not prescribe if they did not feel that it was within their role, yet the perception of how prescribing was accommodated within a nursing role varied. Bradley and Nolan’s ( 2007 ) study produced some rich data in relation to this issue, with some nurses feeling it legitimised their role by enabling them to ‘integrate caring and curing’, a perspective mirrored by Mahoney and Ladd ( 2010 ) who identified that nurses felt they were ‘more than a prescriber’; however, some nurses did make a distinction between prescribing and nursing, using terms such as ‘spending more time on prescribing than nursing’ and ‘wearing lots of different hats’, demonstrating that some nurses did not see it as integral to their nursing role (Bradley and Nolan, 2007 ). What appears to emerge from many studies is that there is a desire to differentiate the role of the nurse prescriber from that of the doctor.

‘Medicalisation’ of the nursing role was identified as a concern by nurses in a number of studies (Bradley and Nolan, 2007 ; Scottish Government, 2009 ; Coull et al ., 2013 ), with a clear resistance to the suggestion that prescribing leads to medicalisation (Davies, 2005 ; Bowskill, 2009 ; Stenner et al ., 2010 a; 2010b ). Brodie et al . ( 2014 ) identified that in view of prescribing moving from an activity once exclusive to doctors, there had to be a necessary shift in power to enable this, reflecting what Carey et al . ( 2010 ) termed ‘shared territory’. Indeed, prescribing was found to bring with it more job control and enhanced status (Cousins and Donnell, 2012 ), suggesting a strengthening of the professional role of nurses through increased status and trustworthiness (Wilhelmsson and Foldevi, 2003 ), increased recognition and respect (Scottish Government, 2009 ; Coull et al ., 2013 ; Darvishpour et al ., 2014 ) and an ‘increased credibility and confidence to recommend medicines’ (Stenner and Courtenay, 2008b ).

Power-shifts and inter-professional relationships

Of the papers reviewed, 17 that included five mixed-method papers, a metasynthesis and 11 qualitative studies presented data that were representative of the theme of ‘power-shifts and inter-professional relationships’, identifying a need for adjustments in professional relationships in order to enable effective implementation of prescribing. Bowden ( 2005 ) found that nurse prescribers experienced inappropriate expectations from other health-care professionals, indicating a lack of understanding of the professional and legal boundaries of the role. Further, some prescribers experienced resistance, which some perceived as professional rivalry (Bowskill, 2009 ). Although nurse prescribers felt support from nursing colleagues was desirable (though not essential) (Bowskill, 2009 ) when prescribing in more complex situations in which clinical decisions were perceived to be of a higher risk, a team approach to prescribing was seen as a necessity (Lewis-Evans and Jester, 2004 ; Stenner and Courtenay, 2008 a; Carey et al ., 2010 ; Stenner et al ., 2010 a; 2010b ).

Indeed, nurse prescribing has provided an opportunity to develop relationships with other health professionals (DH, 2011 ; Coull et al ., 2013 ; Darvishpour et al ., 2014 ), with the nurse–pharmacist relationship most frequently cited (Bowden, 2005 ; Hall, 2006 ; Bradley et al ., 2007 ; Stenner and Courtenay, 2008 a). Pharmacists are perceived by NMPs to have a key role in safety (Bradley et al ., 2007 ) and are a key source of support (Klein, 2015 ). Similarly, the nurse prescriber–doctor relationship was seen as important in supporting prescribing (Bradley et al ., 2007 ; Northern Ireland Practice and Education Council for nursing and midwifery (NIPEC), 2007 ; Bowskill, 2009 ; Stenner et al ., 2010 a; 2010b ). Some nurse prescribers encountered a lack of understanding by doctors of the boundaries of their role and their awareness of budgetary issues (Wilhelmsson and Foldevi, 2003 ; Carey et al ., 2010 ), sometimes to the extent that they would not support nurse prescribing (NIPEC, 2007 ). In addition, some nurse prescribers perceived that doctors considered the prescribing rights of nurses as a threat to their own profession (Bradley et al ., 2007 ) and that prescribing should be exclusive to their profession (Wilhelmsson and Foldevi, 2003 ), to the extent of employing financial or managerial control on nurse prescribing without having any authority to do so (Fisher, 2010 ); however, others had a more positive experience, with doctors trusting nurse prescribers to set their own boundaries (Carey et al ., 2007 ; Bowskill, 2009 ; Mahoney and Ladd, 2010 ). Prescribing was felt to have given nurses increased confidence to debate with doctors (Bradley et al ., 2007 ) and provided more opportunity for co-operation between them (Wilhelmsson and Foldevi, 2003 ). Indeed, it was recognised that new boundaries of practice had to be agreed in order to work collaboratively and to enable nurses to define their prescribing role (Bowskill, 2009 ).

Culture of prescribing

It appears that for nurse prescribing to flourish, it needs to be recognised, understood and be integral to the organisation’s processes, demonstrating a culture supportive of prescribing; a theme that emerged in six of the included qualitative studies as well as in two of the mixed-method studies and a literature review. A clear policy on NMP, access to CPD, formal support mechanisms and a learning environment that encourages knowledge sharing across professions and the opportunity to influence policy were perceived as key factors indicative of a supportive organisation (Stenner and Courtenay, 2008 a). The ease with which nurse prescribing is implemented appears to be influenced by how prepared the organisation was in relation to CPD, structures and processes (Jones et al ., 2007 ; Stenner and Courtenay, 2008 a; Stenner et al ., 2010 b). Stenner et al . ( 2010 b) also made reference to support structures and culture, identifying that a range of CPD mechanisms were needed to achieve structures and cultures supportive of nurse prescribing. Where good inter-professional working relationships existed, this helped to promote a supportive culture for NMP and the support of the doctor was seen as key to this; however, the large-scale study by DH ( 2011 ) found that only half of the Trusts had a strategy for the development of NMP and that it was largely driven by the practitioner to enhance existing services rather than to enable service re-design, suggesting that its benefits are not yet fully appreciated in some areas. Indeed, even when the benefits are recognised by patients, colleagues and stakeholders alike, there is still evidence of fragmentation in policy and implementation (Coull et al ., 2013 ).

Limitations

One of the key objectives of undertaking this metasynthesis was to provide context for the author’s subsequent research exploring the lived experience of the nurse prescriber in primary care, utilising a phenomenological approach. As such, a broad approach was applied to the literature search to capture the wide range of possible influences on nurse prescribing. In doing so, mixed-method studies were included; however, because of the limited participant quotes provided in some of these papers, it was not always possible to clearly determine whether the themes identified by the authors originated from qualitative data, quantitative data or a combination of both.

Summary and implications

This metasynthesis was undertaken in order to gain an insight into the factors that might influence the lived experience of the prescriber. Only a limited number of studies used a research methodology appropriate for exploring the lived experience to the depth associated with a phenomenological approach; thus, the decision to include other qualitative studies was important in order to provide sufficient context for further research. Unsurprisingly, in view of the numerous settings and specialities in which nurse prescribers practice in primary care, a wide range of themes emerged. This was reflected in the metasynthesis of literature reviews and systematic reviews in nurse prescribing undertaken by Darvishpour et al . ( 2014 ), who identified eight themes from the 11 papers included.

As the health service remains under increasing financial pressures, staff are increasingly required to identify positive outcomes from the interventions they undertake. As such, it is to be expected that many of the studies in nurse prescribing identify benefits to the patient and to the service, with the recent systematic review undertaken by Weeks et al . ( 2016 ) reflecting this; however, of particular interest in this metasynthesis is the understanding that nurse prescribers not only appear to express a need to benefit the patient in order to validate their prescribing but also that they have an inherent need to provide patient-centred care, although this is not directly explored in the studies.

A number of themes emerged from the review of these studies, which influenced the scope of the nurse prescriber’s prescribing activity, and many of these were reflective of the professional and ethical frameworks associated with nursing. These themes include ‘professional accountability and boundary setting’ and ‘the need for knowledge’. Perhaps, not surprisingly, safety was also a consideration but it appeared to present itself as a ‘safety consciousness’ that spanned the breadth of the prescribing process, rather than simply as an awareness of safety issues. The source of this safety consciousness was not directly explored in any of the studies.

Relationships and their importance to prescribing was identified, with the nurse prescriber–doctor and the nurse prescriber–pharmacist relationships having some prominence. The challenges of taking on a role that was once exclusive to doctors, appear to have resulted in some internal conflicts regarding identity in some practitioners, leading to activities to support ‘role preservation’. A number of studies provided a picture of what the issues relating to role are but the impact of these on the experience of the nurse prescriber was unclear. The context in which these challenges exist and how organisations and teams can support prescribing was also explored in some of the studies. It appears that the research to date is suggestive of the need for an environment in which prescribing is embraced in order for it to be effective; however, this has to be supported by a range of other factors such as policy, recognition and knowledge sharing. In other words, it would appear that a culture shift is needed, and although the literature often addresses the issues individually, the concept of culture warrants further consideration and it is evident that more needs to be discovered about nurse prescribing in order to effectively support it.

The systematic review of quantitative studies undertaken by Gielen et al . ( 2014 ), which made comparisons between physician and nurse prescribing, provides a useful perspective from which to consider this metasynthesis. Although Gielen et al .’s ( 2014 ) quantitative study maintained the need for further quantitative randomised control trials, it did acknowledge that nurse prescribing is embedded in the context of other nursing activity, which could impact the findings. As such, this metasynthesis of qualitative studies offers an insight into the issues and influences which contribute to that context.

Acknowledgement

The authors express thanks to the supervisory team for their support and contributions to the quality assessment process.

Financial Support

This metasynthesis was undertaken as part of MPhil/PhD studies that were partially funded by the Continuing Professional Development monies from the Faculty of Health and Wellbeing, University of Central Lancashire.

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Independent Prescribing Case Study

There are many definitions of Independent prescribing, the Department of Health (2006 para 7 & 8)) working definition is: ‘Independent prescribing is prescribing by a practitioner (e. g. doctor, dentist, nurse, and pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. In partnership with the patient, independent prescribing is one element of the clinical management of a patient.

It requires an initial assessment, interpretation of that assessment, a decision on safe and appropriate therapy, and a process for ongoing management. The independent prescriber is responsible and accountable for at least this element of a patients care’ The aim of this case study is to focus on my future role as an independent prescriber. I have applied the seven principles of good prescribing (NMC 1999) and supported the decision making process with the use of Barbers model (Barber1995).

As previously stated within the introduction I will reflect on the process using Gibbs model of reflective practice (Gibbs 1988), (appendix 1). In my role as a specialist nurse I am involved with caring for patients within a community setting and providing a holistic assessment of their needs. This can involve assessing patients as a result of a supported discharge from secondary care or referral from General Practitioners (GP’s) for issues related primarily to their cardiac condition, their general overall health and any other health related issues.

These assessments can take place within the patient’s home or within a clinic setting. These assessments are quite commonly carried out with very little prior knowledge regarding the patient and this is currently an area under review. For the purpose of this case study I will look at a lady who attended a clinic session within a GP’s practice. This lady was referred to the clinic for an annual review of her coronary heart disease (CHD), when she attended it was obvious from the onset that this patient had been wrongly coded by the practice and did not have a diagnosis of CHD.

For the purpose of this case study I will refer to the patient as Betty. Despite this error, I continued to discuss with the patient any other health related issues that she may have. At this point she disclosed that she felt that she was suffering from incontinence. On further verbal discussion it became obvious that the lady appeared to be describing symptoms of a urinary tract infection (UTI). Normally I would have referred this lady back to the GP but as an error had been made with her referral I decided it would be appropriate to assess the patient at this appointment initially.

Previously in situations like this it would not have been unusual for a GP to generate a prescription, following an assessment by a member of the nursing staff. But as I am not yet an Independent Prescriber, nor am I working within the framework of a clinical management plan as a supplementary prescriber, this practice is illegal. I am accountable for my own practice and it is clearly outside the boundaries and legislative framework for me to ask another health care professional to prescribe for a patient that they have not seen or assessed.

As stated in the NMC Standards for Prescribing (2006) I am accountable for all prescribing decisions, including actions and omissions and cannot delegate this responsibility to any other person This is an area of prescribing that has been discussed at length between myself and my mentor as this had implications for all staff who are prescribers and currently there seems to be discrepancies in the information given to nursing staff by some GP’s.

As a specialist nurse it is currently outside the boundaries of my job description to prescribe any form of medication, therefore to provide safe and competent care the GP would also need to consult with the patient. By practising as an independent prescriber the nurse is broadening her professional accountability and responsibility. For nurses extending their role to include prescribing there is much to consider. Revelay (1999) states that, accountability involves an individual giving an account of their actions with the rationale and explanation given for these actions.

The decisions regarding boundaries of practice are firmly placed in the hands of the individual practitioner (Carlisle 1992). Accountability means being able to justify any actions and accepting responsibility for them, and is an integral part of nursing practice (Rowe 2000) The NMC Code of Professional Conduct (2004) states that a nurse is personally accountable for her practice, has a duty of care to patients and must work within the laws of the country.

Examine the Holistic needs of the patient To enable me to comprehensively assess Betty I decided it would be appropriate to use a structured approach to the consultation including history taking and physical examination (Bickley 2004). There a various consultation models, the use of the mnemonic framework PQRST (Atkinson 1993) used for describing pain can be adapted for most physical examinations within a consultation. P Proactive/Palliation Q Quality R Radiation S Severity T Temporal/Timing

Although this framework was used the consultation was essentially based around the well documented and established Calgary-Cambridge model of communication (Silverman et al 2005), which consists of five distinct areas:

1. Initiating the session

• Establishing initial rapport
• Identifying the reason(s) for the consultation

2. Gathering information

• Exploration of problems
• Understanding of patients perspective
• Providing structure to the consultation

3. Building the relationship

• Developing rapport
• Involving the patient

4. Explanation and Planning

• Providing the correct amount and type of information
• Aiding accurate recall and understanding
• Achieving a shared understanding: incorporating the patients perspective
• Planning: shared decision making

5. Closing the session The consultation was initiated by developing initial rapport with Betty who was asked to describe the current problems she was experiencing. It transpired in the course of the consultation that she had experienced pain on micturition, frequency and urgency of urination and nocturnal polyuria for the past 2 days.

She described the pain in her lower abdomen as a constant ‘uncomfortable ache’ giving a pain score of 4/10 with no radiation, no flank pain, no relieving factors, other than some relief after self medicating with over the counter paracetamol, 1 gram, which she had taken 2 hours prior to the consultation. There were no complaints of back pain or fever, she denied any signs of haematuria and there were no other systemic symptoms. She had tried drinking cranberry juice, and increased her fluid intake to try and relieve the symptoms, but with no effect.

Betty’s past medical history was unremarkable, no major medical problems, no hospital admissions/attendances. The discussion revealed she was currently taking no prescribed medication and had no known allergies. Social history revealed she lived with her husband, worked part time and was usually fit and active. Her observations were Blood Pressure 124/68, heart rate 76 beats per minute and temperature 36. 9 degrees centigrade. The current GP’s guidelines would not suggest submitting a mid stream urine sample (MSU) to the laboratory but advise empirical treatment based upon these symptoms and corresponding positive urinalysis test.

Patient urinalysis was performed using Combur-7 test Strips and revealed: ph8, nitrate positive, leucocytes 3+ and blood 3+. The results of the urinalysis combined with the history indicated the diagnosis of an uncomplicated UTI. Loren & Miller (2004) suggest that the symptoms that make a UTI more likely are dysuria, frequency, haematuria and back pain. If a woman has more than one of these symptoms the probability of a UTI is more than 90%.

UTI’s are symptomatic infections of the urinary tract, it is the most common bacterial infection managed within general practice, and accounts for some 5% of women presenting to their GP and between 1% and 3% of all GP consultations (MeReC 1995). Stanton and Dwyer (2000) suggest that ‘50%’ of all women will develop a UTI in their lifetime. Those most at risk include the young and sexually active, however, the elderly population, both male and female, whose advancing age, co-existing illness, institutional care and bladder catheterisation are also at risk and may present with asymptomatic bacteriuria (DOH 2005, Bardsley 2003).

Consider the Appropriate Strategy The treatment of UTI falls within the parameters of independent prescribing (BNF 2009). Courtney et al (2005) reminds us that nurse prescribing has introduced us to a new sphere of accountability and the NMC clearly states that nurses are personally accountable for their practice. In considering the appropriate strategy it is important to consider the following * Has a diagnosis been established * Is the management of this condition within my sphere of competency as a nurse prescriber or is a GP referral required * Is a prescription actually necessary or appropriate?

As stated earlier I would be acting illegally if I allowed a GP to prescribe based on my assessment and diagnosis. I therefore explained the situation to Betty and discussed my findings with her, explaining that the GP would consult with her and provide the appropriate prescription. Following completion of this course as an independent prescriber I will be able to write my own prescriptions, both within a clinic setting and the patient’s home, therefore providing prompt, safe and appropriate care. For the purpose of this portfolio I will continues as if I were an independent prescriber. Consider Choice of Products

Barber (1995) identifies four areas that prescribers should aim to achieve when considering treatment. Using this model enables the independent practitioner to bring together the traditional balance of risks and benefits, the need to reduce costs and the right of the patient to make the right treatment choices. The NMC (2004) states that ‘As a registered nurse I must identify and minimise the risk to patients’ therefore to achieve maximum effect for the patient I need to prescribe the correct anti-biotic at the optimal dose and duration, this will be discussed within the next section of the assignment.

Many issues arise in selecting the correct product for the patient and consideration must be given to the age of the patient, the patient’s level of understanding, patient choice, how the drug is administered and the patient’s ability to adhere to the proposed drug regime. Pharmokenetics, pharmacodynamics and polyphramacy must all be considered when selecting the appropriate product. Pharmacokinetics can be defined as how the body handles a drug (MeReC, 2001). It is known that as we age we are more susceptible to drug effects.

The biggest change is a reduction in renal clearance, this affects drug metabolism and drugs may be excreted at a reduced rate, leading to accumulation and adverse drug events. It is essential that we are aware of these changes and prescribe accordingly. Pharmacodynamics can be described as ‘what a drug does to the patient’ In general, older people have an increased sensitivity to drugs because of changes occurring in the body. Both pharmacokinetics and pharmacodynamics are very complex. It is essential that as a nurse prescriber to have an understanding of these to be able to predict and individualise drug therapy.

Reddy (2006) states that before prescribing for the older patient, we should be sure that the prescription is required and the drug is appropriate. Inappropriate prescribing in this group of people can lead to both over and underuse of drugs. Maximise effectiveness All professionals who are prescribers have a legal responsibility to ensure the item that they select is the most appropriate to meet the needs of the individual patient and that it is safe and effective (Anderson 2002). To achieve maximum effect for Betty, it is important to ensure that the correct antibiotic is prescribed, at the optimal dose and duration.

The Health Protection Agency (HPA 2005) offers advice regarding diagnosing UTI, as do authors Hummers-Pradier and Kochen (2002). They both conclude that ‘dipsticks can be used to examine urine’, and diagnosis of UTI is made with regard to a symptomatic presentation and the presence of nitrates in the urine. The HPA (2005) provide guidelines to the practitioner (as does DOH 2005) in the form of a flow diagram. It explicitly guides the practitioner to follow the results of the dipstick test and offers advice on how to continue, be it ‘reassure and give advice, or treat with a first line agent.

Hummers-Pradier and Kochen (2002) also point out that if both nitrates and leucocytes are negative the probability of a UTI is low and antibiotics should not be given. The HPA (2005) also provide guidelines to aid the practitioner as to when a urine sample ought to be collected and sent to the pathology laboratory for culture and sensitivity. The work by Hummers-Pradier and Kochen (2002) concluded that although there is good evidence for the diagnosis and treatment of uncomplicated UTI’s ‘recommendations are not always followed in daily practice’.

Many authors (DOH 2005, Hummers-Praider and Kochen 2002) suggest the first line treatment of choice for a diagnosed, uncomplicated UTI is short term therapy with an antibiotic. The Standing Medical Advisory Committee (1998) has also issued guidelines on the management of bacterial UTI’s; this also advocates the use of antibiotics for 3 days. As a primary health care team we follow the antimicrobial prescribing guidelines (2006) for uncomplicated UTI. Within these guidelines there are three first line choices: Trimethoprim, Nitrofurantion and Cephalexin. These can all be used for a short term course of three days for women.

The Drugs and Therapeutics Agency (1998) recommend Trimethoprim as a first line agent as this has an efficacy of 70% in cases of uncomplicated UTI. As a PCT the guidelines recommend the use of Trimethoprim as first line treatment as it is currently the most clinically effective as well as being the most cost effective. Prodigy Guidelines (DOH 2005) also suggest an NHS prescription (age from 14 to 75 years) for Trimethoprim tablets for three days and provides evidence that a course of three days is as likely to be as effective as a course of five to seven days and much more cost effective.

Trimethoprim is also known to be tolerated more by the elderly and can be used in those patients with renal impairment, unlike Nitrofurantion, which is contraindicated in patients with renal impairment. Trimethoprim also has a lower level of drug allergy compared to other options. The treatment regime is simple Prodigy guidelines (2005) recommend a dose of 200mgs twice a day for a period of three days. Even when antibiotics are clinically indicated they are sometimes prescribed and used inappropriately. Consideration should be given to the dose, duration of use, interval and likely patient adherence to the regime.

In terms of the various treatment options available for this specific condition, the practitioner has a number of methods available to determine what ‘best practice’ is currently. The multi-disciplinary approach to care within the specialist team, allows for discussion between a numbers of health care professionals, this helps to facilitate discussion and provides all practitioners with invaluable up to date information relating to practice. Minimise risk All drugs are known to have a measure of risk and can cause adverse reactions.

The pharmacodynamics and pharmacokinetics of a given drug may be affected by many factors these include, renal function, body weight, co-existent pathology and other prescribed drugs. These factors are of particular importance in the care of the elderly patient as any of these can lead to an increased risk of drug interaction (Andalo 2003) During my consultation with Betty I established that the only medications that were currently being taken were over the counter paracetamol and cranberry juice of which neither are known to have an interaction with Trimethoprim.

For any drug therapy the nurse prescriber needs to be familiar with any potential adverse drug reactions. An adverse drug reaction (ADR) can be defined as any undesired or unintended effect of drug treatment (Downie et al 1999). Any drug can produce an unintended harmful effect that can be described as an ADR. ADR’s are classified as either A or B.

• Type A – a predictable reaction from the drugs pharmacology caused by excessive or inadequate response to the drug.
• Type B – an unpredictable response from the drugs pharmacology unrelated to the dose.

They are not as common but are clinically more important, for example an anaphylactic reaction to an antibiotic. Courtney (2005) writes that ADR’s are thought to occur in 10-20% of all patients prescribed drugs, cause 4% of hospital admissions and 10% of GP consultations. The Audit Commission (2002) estimated that there were approximately 10,000 serious adverse drug reactions and 1200 deaths caused by prescribed medicines each year The common side effects of Trimephoprim are nausea, vomiting, diarrhoea, pruritus, rashes and erythema as listed in the BNF (2009). There are however more serious adverse reactions which are less common.

One of these being Steven Johnson Syndrome, which is a severe skin reaction. If these occur they should be reported to the Medicines and Healthcare products Regulatory Agency. (MHRA) This can be done via the yellow cards found in the back of the BNF or on-line. A directive to the Committee on the Safety of Medicines acknowledges the changing role and responsibilities of nurses and sees reporting of adverse drug reactions (ADR’s) as part of that changing role. Along with minimising risk to the patient, as a nurse prescriber I need to consider the wider picture and the duty of care to both my individual patients and to society.

The Nursing and Midwifery Council state in the Code of Professional Conduct; ‘Protect and Support the health of individual patients and protect and support the health of the wider community’ The inappropriate use of antibiotics increase patient exposure to the risk of adverse reaction, for most these will be inconvenient but others may be life threatening. The over use of antibiotics also has financial consequences and leads to increased bacterial resistance to the point where they may soon be ineffective.

Antibiotic resistance is seen as a major health problem (SMAC 1998). It is clearly established that over use of antibiotics has contributed to the well publicised increase and problems with hospital acquired infections like Methicillin Resistant Staphylococcus Aureus (MRSA). The main aims of the government strategy are to reduce morbidity and mortality of infections due to antimicrobial organisms and to maintain the effectiveness of antimicrobial agents in the treatment and prevention of infections (DOH 2000).

The government has therefore backed the SMAC Report that suggests the need for a public campaign to handle patient’s expectations and to influence their attitudes towards antimicrobial agents. Patient’s perception of a ‘pill for every ill’ has encouraged over prescribing and ultimately inappropriate health care intervention (Taylor 1999). Within this case study I need to consider the benefits of prescribing antibiotics for an individual against the wider implications of antibiotic resistance.

Due to the mismanagement of antibiotics in both primary and secondary care the drugs are losing their power to heal and as result bacteria are developing a resistance to them. The DOH 2000 perceived this as a major health threat. The World Health Organisation (WHO) 2002 suggests that the misuse of antimicrobials is increasing resistance to such a degree that if a serious effort is not made antimicrobial resistance will set the world back to the pre -antibiotic era. Betty had also been taking cranberry juice prior to her consultation; she was advised to continue with this as evidence shows this to be effective in the treatment of UTI’s.

Bardsley (2003) states that cranberry juice contains compounds that prevent the bacteria, escherichia coli from adhering to urethral epithelial cells and therefore preventing colonisation and concludes that patients should be advised to drink around 300ml of cranberry juice daily. During the consultation Betty was advised that if she experienced any adverse reactions to stop the medication immediately and inform either myself or her GP. I left her with a 24 hour contact number for her general practice and advised her to contact them immediately if her symptoms got worse, to enable her to be reassessed and treatment reviewed.

Minimise Cost When prescribing drugs cost should never be the main consideration. There needs to be a balance between the benefits of prescribing and the risks of not prescribing. (Anderson 1999) If all other things are equal e. g. efficacy and safety we have a duty to prescribe the most cost effective antibiotic. Trimethoprim 200mgs cost ? 0. 88p for 14 tablets in comparison to nitrofurantoin 100mg at ? 4. 34 for 28 tablets and Cephalexin 250mgs at ? 2. 17 for 28 tablets. There will also be a cost benefit to society.

Reduction in antibiotic prescribing and explanations around ‘why not to prescribe’ should educate the public that antibiotics are not the ‘cure for all’ they used to be. Negotiate a Contract and achieve concordance with the patient The Code of Professional Conduct states that in caring for patients a nurse ‘respect the patient as an individual and always act to identify and minimise risks to the patients’ According to Griffith (1990) the advantages of patient participation include, patient responsibility, commitment to health, and promotion of activities which can lead to a positive effect on their outcome.

Barber (1998) states that there are many ethical and practical reasons why patient choices are part of a good prescription. He continues that, at the end of the day, they are the ones picking up the prescription and choosing whether to take it or not. While (2002) discusses that concordance is about asking the patient whether they want that particular drug, discuss the implications of not taking the drug, the benefits of taking it and offer alternatives if appropriate.

There are several reasons why patients do not comply with medication and one of these may be due to the quality of the information that they are given at the consultation (Marinker at al 2003). As a future nurse prescriber my describing decisions should be viewed as a shared contract between the patient and myself, this shared decision making is likely to lead to concordance. To improve concordance I discussed within the consultation the drug regime, the duration of treatment, any possible side effects and any follow up treatment that may be required if necessary. Balancing cost and patient choice can also lead to conflict.

Prescribers are under pressure from government and PCT’s to lower prescribing costs and for that reason may forget to consider patient choice. Barber (1998) agrees and says that resolving the conflicts that arise between risks versus benefit, choice is not easy. Influences on prescriber’s decisions also come from other bodies such as drug and therapeutic committees, pharmacists, medical advisors and commissioning agencies. The consultation was carried out in partnership with Betty and she was given adequate verbal and written information about her condition and treatment in order to maximise concordance.

It is important to take into account that Betty had no mental health problems, other illnesses or conditions that would contribute to decreased comprehension or prevent her from engaging in a two way discussion around her treatment. Such problems can ultimately affect patient decisions, choices and informed consent. In addition future consultations may not be straight forward and future patients may present with more challenging and complex needs. Review the Patient Regular review of the patient is needed to establish whether the treatment prescribed is effective, safe and acceptable to the patient (NPB 1999).

I am also aware that I have a professional responsibility to review and evaluate treatment regimes (NMC 2004, Anderson 1999) I arranged to see Betty again in her GP’s practice three days later to establish if there had been an improvement in her symptoms and to obtain a post treatment MSU. I am aware of the importance of discussing whether Betty suffered any side effects to the medication and the actions to be taken if any adverse drug reactions that she has not reported yet, as outlined previously within this case study. Record Keeping

The sharing of accurate information between multidisciplinary team members is vitally important as is record keeping and effective communication (NPC 2003). It was highlighted by the Crown report (DOH 1989) that good communication between health professionals and patients, and between different professionals, is essential for high quality healthcare. The NMC Code of Professional Conduct (2005) states, that it is essential to keep accurate, up to date records. These records must be maintained regarding assessment, treatments and their effectiveness.

Reveley (1999) states that, records should be legible, understandable, accurate, confidential and untampered with. Good record keeping promotes good quality patient care, safeguards the nurse in case of legal or disciplinary action and enables the nurse to practice to the highest standards of patient care. Dimond (2005) writes that record keeping is an integral part of nursing care and is part of the duty of care owed to the patient. The purpose of record keeping is to have an account of care and treatment, allowing progress to be monitored. They are also a means of communication with colleagues (Griffith 2005).

Details regarding Betty’s assessment, diagnosis, treatment and advice given were all entered into her computerised records at the surgery. Details of the prescription as well as arrangements for review were all entered into the records. The benefit of a computerised system is that one central record exists that all members of the primary care team can access and use. Any subsequent care or decisions can then be made using up to date relevant information. I am aware that when seeing patients at home, computerised systems are not available and we therefore have a duty to ensure that all paper records are accurately completed and maintained.

Reflection Reflective practice is considered to be a tool that enables practitioners to link theory to practice. (Burnard 1991) states, that reflection is seen as a key process in bringing together practice and knowledge in nursing. Nursing knowledge is also seen as a way of addressing the gap between theory and practice. I am very conscious that there will be a significant change to my practice after completion of this course, and I look forward to that with enthusiasm and a degree of caution. I am also aware that changes in health care are becoming more rapid and demands on nurses greater.

I feel it is therefore important to access support in a planned and constructive environment in order to develop prescribing practice safely. The NMC (2004), states that as a nurse I must maintain my professional knowledge and competence, and reflection is seen as a way of achieving this. As stated earlier I will use Gibbs reflective model to enable me to reflect on my transition from currently using Patient Group Directives to my role as an independent prescriber. Gibbs reflective cycle has six stages, the first stage of description of my prescribing has been discussed throughout this case study.

The second stage is to address feelings. Although I have been a nurse for many years and have completed many courses throughout my career, I feel that this has been one of the most challenging. I feel at present that I am back to the novice stage again (Benner 2001). During sessions with my mentor I seemed to be asking questions that had obvious answer’s and suddenly seemed to lack confidence when being asked to make decisions about treatment choice. Although following successful completion of this course I will be able to prescribe independently I feel that I need to address my assessment and diagnostic skills.

I have previously completed a course in clinical skills and although this is an integral part of my role I feel that there is room for improvement. Stages three and four of the cycle allow for evaluation and analysis. Having evaluated the prescribing experience I feel that it is a positive one. The choice of product worked well for the patient and her symptoms resolved. The use of a tool to aid physical examination gave a foundation on which to reach a diagnosis and determine the appropriate choice of treatment. The final two stages are consolidation and I will address these in the final section

Conclusion In conclusion, I am aware that as a future independent prescriber I have a responsibility to practice within the boundaries of my competence and professional limitations. I clearly understand that I need to be able to recognise my own limitations and level of knowledge. I understand that I am accountable for my own actions and that I must posses the knowledge, skills and abilities required for safe, lawful and effective practice (NMC 2004) As a nurse I am responsible for delivering a holistic approach to caring for patients within a community setting. In future the ability to prescribe for

patients both within their own home and in a primary care clinic setting will provide a more efficient and patient centered service. It will also reduce the delay in commencing the appropriate treatment. Literature and research on the subject of nurse prescribing suggest that it will lead to an increased level of satisfaction among patients and provide increased job satisfaction for the nurse. As I reflect on this study I feel that this has been a positive learning experience. I now need to address my role as an independent prescriber within the wider multi disciplinary team.

I need to ensure that my colleagues are aware of my role, and understand my responsibilities and the sphere of my prescribing practice, this will hopefully prevent me from being placed in a vulnerable or difficult position. This case study has helped me appreciate the value of using frameworks to help aid my decision making and recognising the need for audit and self evaluation around my prescribing practice. Prescribing Analysis and Cost data (PACT) will allow me to monitor and analyse my prescribing behaviour in comparison to the local average or to that of other nurses, and how it adheres to local formularies (DoH 2004).

I have a clear understanding that I am accountable for my own actions and in order to practice competently, I must possess the knowledge, skill and abilities required for safe, lawful and effective practice (NMC 2004). I also acknowledge the limits of my professional competence and will only undertake practice and accept responsibilities for those activities in which I am competent (NMC 2004). Training and education are important in keeping up to date with professional and clinical issues.

I have a responsibility to be aware of current research regarding prescribing and the implications that it may have on my professional practice. As clinical supervision is high on the PCT agenda and I am supervised by a member of the medical team within secondary care, who has a great deal of knowledge and experience, within the field of prescribing I intend to incorporate prescribing issues into these sessions. As part of my ongoing development my mentor has agreed to continue to support me as I commence my role as an independent prescriber.

The PCT in which I work have a small support network for nurse prescribers and I intend to utilise this to my benefit and the befit of my patients. Bickley et al (2004) says that over time competence and self confidence grow. Good prescribing is not always easy, writing a prescription is the end result of a process that includes history taking, physical examination, generating a treatment option and including the patient as a partner in the process. Overall I feel that this consultation was a positive.

References:

• Latter, Sue, et al. “Evaluation of nurse and pharmacist independent prescribing.” (2011).
• Avery, Anthony J., and Mike Pringle. “Extended prescribing by UK nurses and pharmacists: With more evidence and strict safeguards, it could benefit patients.”  BMJ: British Medical Journal  331.7526 (2005): 1154.
• Courtenay, Molly, and Nicola Carey. “Nurse independent prescribing and nurse supplementary prescribing practice: national survey.”  Journal of Advanced Nursing  61.3 (2008): 291-299.
• Latter, Sue, et al. “Evaluating nurse prescribers’ education and continuing professional development for independent prescribing practice: Findings from a national survey in England.”  Nurse education today  27.7 (2007): 685-696.

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Akhtar N, Lee L Utilization and complications of central venous access devices in oncology patients. Current Oncology.. 2021; 28:(1)367-377 https://doi.org/10.3390/curroncol28010039

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Clare S, Rowley S Best practice skin antisepsis for insertion of peripheral catheters. Br J Nurs.. 2021; 30:(1)8-14 https://doi.org/10.12968/bjon.2021.30.1.8

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Case Studies

Gema munoz-mozas.

Vascular Access Advanced Nurse Practitioner—Lead Vascular Access Nurse, The Royal Marsden NHS Foundation Trust

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Colin Fairhurst

Vascular Access Advanced Clinical Practitioner, University Hospitals Plymouth NHS Trust

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Simon Clare

Research and Practice Development Director, The Association for Safe Aseptic Practice

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Intravenous (IV) access, both peripheral and central, is an integral part of the patient care pathways for diagnosing and treating cancer. Patients receiving systemic anticancer treatment (SACT) are at risk for developing infections, which may lead to hospitalisation, disruptions in treatment schedules and even death ( Centers for Disease Control and Prevention, 2021 ). However, infection rates can be reduced and general patient outcomes improved with the evidence-based standardisation of IV practice, and the adoption of the appropriate equipment, such as peripheral IV cannulas, flushing solutions and sterile IV dressings ( Easterlow et al, 2010 ).

Cancer treatment frequently involves the use of central venous catheters (CVCs)-also referred to as central venous access devices (CVADs)—which can represent a lifeline for patients when used to administer all kinds of IV medications, including chemotherapy, blood products and parenteral nutrition. They can also be used to obtain blood samples, which can improve the patient’s quality of life by reducing the need for peripheral stabs from regular venepunctures ( Taxbro and Chopra, 2021 ). CVCs are relatively easy to insert and care for; however, they are associated with potential complications throughout their insertion and maintenance.

One serious complication of CVC use is catheter-related bloodstream infections (CRBSIs), which can increase morbidity, leading to prolonged hospitalisation and critical use of hospital resources ( Akhtar and Lee, 2021 ). Early-onset CRBSIs are commonly caused by skin pathogens, and so a cornerstone of a CRBSI prevention is skin antisepsis at the time of CVC insertion. Appropriate antisepsis (decontamination/preparation) of the site for CVC insertion can prevent the transmission of such skin pathogens during insertion, while reducing the burden of bacteria on the CVC exit site ( Loveday et al, 2014 ).

Evidence-based practice for the prevention of a CRBSIs and other healthcare-associated infections recommends skin antisepsis prior to insertion of a vascular-access device (VAD) using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution. This is recommended in guidelines such as epic3 ( Loveday et al, 2014 ), the Standards for Infusion Therapy ( Royal College of Nursing, 2016 ) and the Infusion Therapy Standards of Practice ( Gorski et al, 2021 ). A strong evidenced-backed product such as BD ChloraPrep™ ( Figure 1 ) has a combination of 2% chlorhexidine gluconate in 70% isopropyl alcohol that provides broad-spectrum rapid-action antisepsis, while the applicators facilitate a sterile, single-use application that eliminates direct hand-to-patient contact, helping to reduce cross-contamination and maintaining sterile conditions ( BD, 2021 ). The BD ChloraPrep™ applicator’s circular head allows precise antisepsis of the required area, and the sponge head helps to apply gentle friction in back-and-forth motion to penetrate the skin layers ( BD, 2021 ). BD ChloraPrep’s rapidacting, persistent and broad-spectrum characteristics and proven applicator system ( Florman and Nichols, 2007 ) make it a vital part of the policy and protocol for insertion, care and maintenance of CVCs in specialist cancer centres such as the Royal Marsden. Meanwhile, the use of BD PosiFlush™ Prefilled Saline Syringe ( Figure 2 ), a prefilled normal saline (0.9% sodium choride) syringe, is established practice for the flushing regime of VADs in many NHS Trusts.

The following five case studies present examples from personal experience of clinical practice that illustrate how and why clinicians in oncology and other disciplines use BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe in both adult and paediatric patients.

Case study 1 (Andy)

Andy was a 65-year-old man being treated for metastatic colorectal cancer at the Royal Marsden NHS Foundation Trust specialist cancer service, which provides state-of-the-art treatment to over 60 000 patients each year.

Andy had a peripherally inserted central catheter (PICC) placed at the onset of his chemotherapy treatment to facilitate IV treatment. While in situ, PICCs require regular maintenance to minimise associated risks. This consists of a weekly dressing change to minimise infection and a weekly flush to maintain patency, if not in constant use. For ambulatory patients, weekly PICC maintenance can be carried out either in the hospital outpatient department or at home by a district nurse or family member trained to do so. Patients, relatives, carers and less-experienced nurses involved in PICC care (flushing and dressing) can watch a video on the Royal Marsden website as an aide memoir.

Initially, Andy decided to have his weekly PICC maintenance at the hospital’s nurse-led clinic for the maintenance of CVCs. At the clinic, Andy’s PICC dressing change and catheter flushing procedures were performed by a nursing associate (NA), who, having completed the relevant competences and undergone supervised practise, could carry out weekly catheter maintenance and access PICC for blood sampling.

In line with hospital policy, the PICC dressing change was performed under aseptic non-touch technique (ANTT) using a dressing pack and sterile gloves. After removal of the old dressing, the skin around the entry site and the PICC was cleaned with a 3 ml BD ChloraPrep™ applicator, using back-andforth strokes for 30 seconds and allowing the area to air dry completely before applying the new dressing. As clarified in a recent article on skin antisepsis (Clare and Rowley, 2020), BD ChloraPrep™ applicator facilitated a sterile, single-use application that eliminates direct hand-to-patient contact, which help reduce cross-contamination and maintaining ANTT. Its circular head allowed precise antisepsis around the catheter, and the sponge head helped to apply gentle friction in back-and-forth strokes to penetrate the skin layers.

Once the new dressing was applied, the NA continued to clean the catheter hub and change the needle-free connector. Finally, the catheter lumen was flushed with 10 ml of normal saline (0.9% sodium chloride) with a pre-filled saline syringe (BD PosiFlush™ Prefilled Saline Syringe). This involved flushing 1 ml at a time, following a push-pause technique, with positive pressure disconnection to ensure catheter patency. The classification of these syringes as medical devices enables NAs and other nonregistered members of the clinical team to support nursing staff with the care and maintenance of PICCs and other CVCs, within local policies and procedures. Using pre-filled syringes can save time and minimise the risk of contamination of the solution ( Ceylan et al, 2021 ).

The use of pre-filled 0.9% sodium chloride syringes facilitates home maintenance of PICCs for patients. When Andy did not need to attend hospital, his PICC maintenance could be performed by a family member. Patients and relatives could access the necessary equipment and training from the day-case unit or outpatient department. Home PICC maintenance is extremely beneficial, not just to providers, but also to patients, who may avoid unnecessary hospital attendance and so benefit from more quality time at home and a reduced risk of hospital-acquired infections. Many patients and relatives have commented on the convenience of having their PICC maintenance at home and how easy they found using the ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe ‘sticks’.

Case study 2 (Gail)

Gail was as a 48-year-old woman being treated for bladder cancer with folinic acid, fluorouracil and oxaliplatin (FOLOX). She was admitted for a replacement PICC, primarily for continuous cytotoxic intravenous medication via infusion pump in the homecare setting. Her first PICC developed a reaction thought to be related to a sutureless securement device (SSD) anchoring the PICC. The device was removed, but this resulted in displacement of the PICC and incorrect positioning in the vessel (superior vena cava). Now unsafe, the PICC was removed, awaiting replacement, which resulted in a delayed start for the chemotherapy.

A second PICC placement was attempted by a nurse-led CVC placement team, and a line attempt was made in Gail’s left arm. Skin antisepsis was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution (ChloraPrep™). A BD ChloraPrep ™ 10 ml applicator was selected, using manufacturer’s recommendations, as per best practice guidance for CVC placement ( Loveday et al, 2014 ) and to comply with local policy for the use of ANTT. The BD ChloraPrep™ applicator allowed improved non-touch technique and helped facilitate good key-part and key-site protection, in line with ANTT ( Clare and Rowley, 2021 ).

The inserting clinician failed to successfully position the PICC in Gail’s left arm and moved to try on the right. On the second attempt, Gail noted the use of BD ChloraPrep™ and stated that she was allergic to the product, reporting a severe skin rash and local discomfort. The line placer informed the Gail that she had used BD ChloraPrep™ on the failed first attempt without issue, and she gave her consent to continue the procedure. No skin reaction was noted during or after insertion of the PICC.

BD ChloraPrep™ has a rapid-acting broad-spectrum antiseptic range and ability to keep fighting bacteria for at least 48 hours ( BD, 2021 ). These were tangible benefits during maintenance of the CVC insertion site, in the protection of key sites following dressing change and until subsequent dressing changes. There are reported observations of clinicians not allowing the skin to fully dry and applying a new dressing onto wet skin after removing old dressings and disinfecting the exit site with BD ChloraPrep™. This has been reported to cause skin irritation, which can be mistaken for an allergic reaction and lead the patient to think that they have an allergy to chlorhexidine. In our centre’s general experience, very few true allergic reactions have ever been reported by the insertion team. Improved surveillance might better differentiate between later reported reactions, possibly associated with a delayed response to exposure to BD ChloraPrep ™ at insertion, and local skin irritation caused by incorrect management at some later point during hospitalisation.

Staff training is an important consideration in the safe and correct use of BD ChloraPrep™ products and the correct use of adhesive dressings to avoid irritant contact dermatitis (ICD). It is worth noting that it can be difficult to differentiate between ICD and allergic contact dermatitis (ACD). Education and training should be multifaceted (such as with training videos and study days), allowing for different ways of learning, and monitored with audit. Local training in the benefits of using BD ChloraPrep™ correctly have been reinforced by adding simple instructions to ANTT procedure guidelines for CVC insertion and maintenance. Education on its own is often limited to a single episode of training, the benefit of using ANTT procedure guidelines is that they are embedded in a programme of audits and periodic competency reassessment. This makes sure that, as an integral part of good practice, skin antisepsis with BD ChloraPrep ™ is consistently and accurately retrained and assessed.

Gail’s case illustrates the importance of correct application of BD ChloraPrep ™ and how good documentation and surveillance are vital in monitoring skin health during the repeated use skindisinfection products. Care should be taken when recording ICD and ACD reactions, and staff should take steps to confirm true allergy versus temporary skin irritation.

Case study 3 (Beata)

Beata was a 13-year-old teenage girl being treated for acute myeloid leukaemia. Although Beata had a dual-lumen skin-tunnelled catheter in situ, a peripheral intravenous cannula (PIVC) was required for the administration of contrast media for computed tomography (CT) scanning. However, Beata had needlephobia, and so the lead vascular access nurse was contacted to insert the cannula, following ultrasound guidance and the ANTT. After Beata and her mother gave their consent to the procedure, the nurse gathered and prepared all the equipment, including a cannulation pack, single-use tourniquet, skin-antisepsis product, appropriate cannula, PIVC dressing, 0.9% sodium chloride BD PosiFlush ™ Prefilled Saline Syringe, sterile gel, sterile dressing to cover ultrasound probe and personal protective equipment.

Prior to PIVC insertion, a 4x5 cm area of skin underwent antisepsis with a 1.5 ml BD ChloraPrep ™ Frepp applicator, with back-and-forth strokes for 30 seconds, and was allowed to air-dry. The vascular access team prefer to use BD ChloraPrep ™ Frepp over single-use wipes, as the former is faster acting and provides the right volume to decontaminate the indicated area using ANTT ( Clare and Rowley, 2021 ).

Following insertion, the PIVC was flushed with a 10 ml BD PosiFlush ™ Prefilled Saline Syringe syringe, using a pushpause pulsatile technique, with positive pressure disconnection. Local policy recommends the use of pre-filled saline syringes, as they save time and minimise infection risk compared with manually drawn saline flushes ( Ceylan et al, 2021 ). The Trust also permits competent non-registered members of staff to perform PIVC insertion, which is more cost-effective than depending on registered nurses.

In Beata’s case, the team considered the use of BD ChloraPrep™ and BD PosiFlush™ Prefilled Saline Syringe to be essential for the prevention of VAD-associated infections, as well as increasing the quality of nursing care by saving time in the day-case and inpatient settings alike.

Case study 4 (Emma)

Emma, a 43-year-old woman diagnosed with acute lymphoblastic leukaemia, was scheduled for an allogenic stem-cell transplant and associated chemotherapy. To facilitate this, she attended the vascular access service at University Hospitals Plymouth NHS Trust for the insertion of a triple-lumen skin-tunnelled catheter. This was identified as the best VAD for her needs, because of its longevity, multiple points of access and decreased infection risk compared with other devices, such as PICCs.

This was Emma’s second advanced VAD insertion, having previously received an apheresis line due to poor peripheral venous access, to facilitate the prior stem-cell harvest. She was yet to receive any treatment, and, therefore, no immunodeficiency had been identified prior to the insertion procedure.

Trust policy for skin disinfection prior to the insertion or removal of PICC lines is a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™. There is an exception for patient history of allergy or sensitivity to BD ChloraPrep™, where 10% povidone iodine is used instead. Emma had received BD ChloraPrep™ before, with no sign allergy or sensitivity, and so the vascular access team decided to use this product again for insertion. BD Chloraprep™ was used, in preference of other skin antisepsis options, due to the applicator’s ability to effectively penetrate the layers of the epidermis, as well as the ability to eliminate direct hand-to-skin contact between the operator and patient ( Clare and Rowley, 2021 ).

Insertion of a skin-tunnelled catheter first requires disinfection of a large area, including the neck and upper chest. Following the manufacturer’s coverage recommendations, a 10.5 ml BD ChloraPrep™ applicator was selected as most suitable to cover an area of 25x30 cm ( BD, 2022 a).

The applicator was activated by pinching the wings to allow the antiseptic solution to properly load onto the sponge. To ensure proper release of the solution, the applicator was held on the skin against the anticipated site of insertion until the sponge pad became saturated. Then, a back-and-forth rubbing motion was undertaken for a minimum of 30 seconds, ensuring that the full area to be used was covered. The solution was then left to dry completely, prior to full-body draping, leaving the procedural area exposed for the procedure. Generally, drying time takes from 30 to 60 seconds, but local policy is not restrictive, as allowing the solution to fully dry is of paramount importance ( Gunka et al, 2019 ). BD Chloraprep™ is effective against a wide variety of microorganisms and has a rapid onset of action ( Florman and Nichols, 2007 ). Therefore, it was felt to be the best option for procedural and ongoing care skin asepsis in a patient anticipated to be immunocompromised during treatment.

It is the normal policy of the Trust’s vascular access service to flush VADs using BD PosiFlush™ Prefilled Saline Syringes with 0.9% sodium chloride. Likewise, BD PosiFlush™ Prefilled Saline Syringes Sterile Pathway (SP) are used to prime all VADs prior to insertion and to check for correct patency once inserted. BD PosiFlush ™ Prefilled Saline Syringe were used in preference of other options, such as vials or bags, due to the absence of requirement for a prescription in the local organisation. They are treated as a medical device and, therefore, can be used without prescription. The advantage of this is that flushes can be administered in a nurse-led clinic, where prescribers are not always available. Aside from the logistical advantages, the use of pre-filled syringes reduces the risk of microbial contamination through preparation error and administration error through correct labelling ( National Patient Safety Agency, 2007 ) In Emma’s case, three BD PosiFlush™ SP Prefilled Saline Syringes were used to check patency and/or ascertain venous location following the insertion of the skin-tunnelled catheter.

In this case, both BD ChloraPrep ™ and BD PosiFlush ™ Prefilled Saline Syringe proved simple to use and helped achieve a successful procedural outcome for the patient.

Case study 5 (Frank)

Frank was a 47-year-old man who had been diagnosed with infective endocarditis following a trans-oesophageal echo. A few days later, to facilitate his planned treatment of 6 weeks of intravenous antibiotics to be administered 4-hourly every day, he was referred to the vascular access service for insertion of longterm IV access. To facilitate this administration, the decision was made to place a PICC.

Frank’s referral included a history of illegal intravenous drug use and details of the consequent difficulty the ward-based team had in finding suitable veins to obtain vascular access. His medical history also included infected abscesses in the left groin and methicillin-resistant Staphylococcus aureus (MRSA) colonisation.

First, Frank was administered suppression therapy for MRSA decolonisation. Following this and prior to PICC insertion, the skin antisepsis procedure was undertaken using a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution, BD ChloraPrep™, in adherence to Trust policy ( Loveday et al, 2014 ). Specifically, BD ChloraPrep™ applicators are selected for their single-use application. They have been demonstrated to reduce the risk of infectious complications (catheter colonisation and local infection) by 92% compared with 5% povidone iodine (PVI) 69% ethanol ( Guenezan et al, 2021 ). A 3 ml BD ChloraPrep™ applicator was considered suitable to decontaminate an area sufficient for the intended PICC insertion procedure, as recommended by the manufacturer ( BD, 2022 b). It was applied using a back-and-forth motion for a minimum of 30 seconds and left to fully dry ( Loveday et al, 2014 ). Staphylococcus aureus bacteraemia’s have a mortality rate of 20-40% and are predominantly caused by VAD insertion ( Ishikawa and Furukawa, 2021 ), and, therefore, the need to reduce this risk was of particular importance for this patient due to the history of MRSA colonisation.

In Frank’s case, the use of BD ChloraPrep™ during the insertion procedure and for each subsequent dressing change episode participated in an uneventful period of treatment. The clinical challenges posed by the patients’ presentation of MRSA colonisation meant the risk of infection was increased but, through correct antisepsis, no adverse events were noted, and the full course of treatment was successfully administered through the PICC.

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Urinary tract infection in an older patient: a case study and review

Advanced Nurse Practitioner, Primary Care

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Gerri Mortimore

Senior lecturer in advanced practice, department of health and social care, University of Derby

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This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

One of the growing community healthcare delivery agendas is that of the advanced nurse practitioner (ANP) role to improve access to timely, appropriate assessment and treatment of patients, in an attempt to avoid unnecessary health deterioration and/or hospitalisation ( O'Neill et al, 2021 ). The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England recognises the application of essential skills, including sound consultation and clinical decision making for prescribing appropriate treatment ( Health Education England [HEE], 2020 ). This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin by a ANP for a suspected symptomatic uncomplicated urinary tract infection (UTI), in a patient living in a care home. Focus will be around the consultation and decision-making process of non-medical prescribing and will explore and critique the evidence-base, examining the local and national guidelines and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Mrs M, an 87-year-old lady living in a nursing home, was referred to the community ANP by the senior carer. The presenting complaint was reported as dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The carer reported a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy and poor oral intake the next morning. The SBAR (situation, background, assessment, recommendation) tool was adopted, ensuring structured and relevant communication was obtained ( NHS England and NHS Improvement, 2021 ). The National Institute for Health and Care Excellence ( NICE, 2021 ) recognises that cloudy, foul-smelling urine may indicate UTI. Other symptoms include increased frequency or pressure to pass urine, dysuria, haematuria or dark coloured urine, mild fever, night-time urination, and increased sweats or chills, with lower abdominal/loin pain suggesting severe infection. NICE (2021) highlight that patients with confusion may not report UTI symptoms. This is supported by Gupta and Gupta (2019) , who recognise new confusion as hyper-delirium, which can be attributed to several causative factors including infection, dehydration, constipation and medication, among others.

UTIs are one of the most common infections worldwide ( O'Grady et al, 2019 ). Lajiness and Lajiness (2019) define UTI as a presence of colonising bacteria that cause a multitude of symptoms affecting either the upper or lower urinary tract. NICE (2021) further classifies UTIs as either uncomplicated or complicated, with complicated involving other systemic conditions or pre-existing diseases. Geerts et al (2013) postulate around 30% of females will develop a UTI at least once in their life. The incidence increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point. Further increased prevalence is found in patients who live in a care home, with up to 60% of all infections caused by UTI ( Bardsley, 2017 ).

Greener (2011) reported that symptoms of UTIs are often underestimated by clinicians. A study cited by Greener (2011) found over half of GPs did not record the UTI symptoms that the patient had reported. It is, therefore, essential during the consultation to use open-ended questions, listening to the terminology of the patient or carers to clarify the symptoms and creating an objective history ( Taylor, 2016 ).

In this case, the carer highlighted that Mrs M had been treated for suspected UTI twice in the last 12 months. Greener (2011) , in their literature review of 8 Cochrane review papers and 1 systematic review, which looked at recurrent UTI incidences in general practice, found 48% of women went on to have a further episode within 12 months.

Mrs M's past medical history reviewed via the GP electronic notes included:

• Hypertension
• Diverticular disease
• Basal cell carcinoma of scalp
• Retinal vein occlusion
• Severe frailty
• Fracture of proximal end of femur
• Total left hip replacement
• Previous indwelling urinary catheter
• Chronic kidney disease (CKD) stage 2
• Urinary and faecal incontinence
• And, most recently, vesicovaginal fistula.

Bardsley (2017) identified further UTI risk factors including postmenopausal females, frailty, co-morbidity, incontinence and use of urethral catheterisation. Vesicovaginal fistulas also predispose to recurrent UTIs, due to the increase in urinary incontinence ( Stamatokos et al, 2014 ). Moreover, UTIs are common in older females living in a care home ( Bradley and Sheeran, 2017 ). They can cause severe risks to the patient if left untreated, leading to complications such as pyelonephritis or sepsis ( Ahmed et al, 2018 ).

Mrs M's medication included:

• Paracetamol 1 g as required
• Lactulose 10 ml twice daily
• Docusate 200 mg twice daily
• Epimax cream
• Colecalciferol 400 units daily
• Alendronic acid 70 mg weekly.

She did not take any herbal or over the counter preparations. Her records reported no known drug allergies; however, she was allergic to Elastoplast. A vital part of clinical history involves reviewing current prescribed and non-prescribed medications, herbal remedies and drug allergies, to prevent contraindications or reactions with potential prescribed medication ( Royal Pharmaceutical Society, 2019 ). Several authors, including Malcolm et al (2018) , indicate polypharmacy as a common cause of adverse drug reactions (ADRs), worsening health and affecting a person's quality of life. NICE (2015) only recommends review of patients who are on four or more medications on each new clinical intervention, not taking into account individual drug interactions.

Due to Mrs M's lack of capacity, her social history was obtained via the electronic record and the carer. She moved to the care home 3 years ago, following respite care after her fall and hip replacement. She had never smoked or drank alcohol. Documented family history revealed stroke, ischaemic heart disease and breast cancer. Taylor (2016) reports a good thorough clinical history can equate to 90% of the working diagnosis before examination, potentially reducing unnecessary tests and investigations. This can prove challenging when the patient has confusion. It takes a more investigative approach, gaining access to medical/nursing care notes, and using family or carers to provide further collateral history ( Gupta and Gupta, 2019 ).

As per NICE (2021) guidelines, a physical examination of Mrs M was carried out. On examination it was noted that Mrs M had mild pallor with normal capillary refill time, no signs of peripheral or central cyanosis, and no clinical stigmata to note. Her heart rate was elevated at 112 beats per minute and regular, she had a normal respiration rate of 17 breaths per minute, oxygen saturations (SpO 2 ) were 98% on room air and blood pressure was 116/70 mm/Hg. Her temperature was 37.3oC. According to Doyle and Schortgen (2016) , there is no agreed level of fever; however, it becomes significant when above 38.3oC. Bardsley (2017) adds that older patients do not always present with pyrexia in UTI because of an impaired immune response.

Heart and chest sounds were normal, with no peripheral oedema. The abdomen was non-distended, soft and non-tender on palpation, with no reports of nausea, vomiting, supra-pubic tenderness or loin pain. Loin pain or suprapubic tenderness can indicate pyelonephritis ( Bardsley, 2017 ). Tachycardia, fever, confusion, drowsiness, nausea/vomiting or tachypnoea are strong predictive signs of sepsis ( NICE, 2021 ).

During the consultation, confusion and restlessness were evident. Therefore, it was difficult to ask direct questions to Mrs M regarding pain, nausea and dizziness. Non-verbal cues were considered, as changes in behaviour and restlessness can potentially highlight discomfort or pain ( Swift, 2018 ).

Mrs M's most recent blood tests indicated CKD stage 2, based on an estimated glomerular filtration rate (eGFR) of 82 ml/minute/1.73m 2 . The degree of renal function is vital to establish prior to any prescribing decision, because of the potential increased risk of drug toxicity ( Doogue and Polasek, 2013 ). The agreed level of mild renal impairment is when eGFR is <60 ml/minute/1.73 m 2 , with chronic renal impairment established when eGFR levels are sustained over a 3-month period ( Ahmed et al, 2018 ).

Previous urine samples of Mrs M grew Escherichia coli bacteria, sensitive to nitrofurantoin but resistant to trimethoprim. A consensus of papers, including Lajiness and Lajiness (2019) , highlight the most common pathogen for UTI as E. coli. Fransen et al (2016) indicates that increased use of empirical antibiotics has led to a prevalence of extended spectrum beta lactamase positive (ESBL+) bacteria that are resistant to many current antibiotics. This is not taken into account by the NICE guidelines (2021) ; however, it is discussed in local guidelines ( Barnsley Hospital NHS FT/Rotherham NHS FT, 2022 ).

Mrs M was unable to provide an uncontaminated urine sample due to incontinence. NICE (2021) advocate urine culture as a definitive diagnostic tool for UTIs; however, do not highlight how to objectively obtain this. Bardsley (2017) recognises the benefit of an uncontaminated urinalysis in symptomatic patients, stating that alongside other clinical signs, nitrates and leucocytes strongly predict the possibility of UTI. O'Grady et al (2019) points out that although NICE emphasise urine culture collection, it omits the use of urinalysis as part of the assessment.

Based on Ms M's clinical history and physical examination, a working diagnosis of suspected symptomatic uncomplicated UTI was hypothesised. A decision was made, based on the local antibiotic prescribing guidelines, as well as the NICE (2021) guidelines, to treat empirically with nitrofurantoin modified release (MR), 100 mg twice daily for 3 days, to avoid further health or systemic complications. The use of electronic prescribing was adopted as per local organisational policy and the Royal Pharmaceutical Society (2019) . Electronic prescribing is essential for legibility and sharing of prescribing information. It also acts as an audit on prescribing practices, providing a contemporaneous history for any potential litigation ( Lovatt, 2010 ).

Pharmacokinetics and pharmacodynamics

Lajiness and Lajiness (2019) reflect on the origins of nitrofurantoin back to the 1950s, following high penicillin usage leading to resistance of Gram-negative bacteria. Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010, despite other antibacterial agents being discovered ( Wijma et al, 2020 ). Mckinell et al (2011) highlight that a surge in bacterial resistance brought about interest in nitrofurantoin as a first-line option. Their systematic review of the literature indicated through a cost and efficacy decision analysis that nitrofurantoin was a low resistance and low cost risk; therefore, an effective alternative to trimethoprim or fluoroquinolones. The weakness of this paper is the lack of data on nitrofurantoin cure rates and resistance studies, demonstrating an inability to predict complete superiority of nitrofurantoin over other antibiotics. This could be down to the reduced use of nitrofurantoin treatment at the time.

Fransen et al (2016) reported that minimal pharmacodynamic knowledge of nitrofurantoin exists, despite its strong evidence-based results against most common urinary pathogens, and being around for the last 70 years. Wijma et al (2018) hypothesised this was because of the lack of drug approval requirements in the era when nitrofurantoin was first produced, and the growing incidence of antibiotic resistance. Pharmacokinetics and pharmacodynamics are clinically important to guide effective drug therapy and avoid potential ADRs. Focus on the absorption, distribution, metabolism and excretion (ADME) of nitrofurantoin is needed to evaluate the correct choice for an individual patient, based on a holistic assessment ( Doogue and Polasek, 2013 ).

Nitrofurantoin is structurally made up of 4 carbon and 1 oxygen atoms forming a furan ring, connected to a nitrogroup (–NO 2 ). Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels ( Wijma et al, 2018 ). It works by inhibiting bacterial cell growth, breaking down its strands of DNA ( Komp Lindgren et al, 2015 ). Hoang and Salbu (2016) add that nitrofurantoin causes bacterial flavoproteins to create reactive medians that halt bacterial ribosomal proteins, rendering DNA/RNA cell wall synthesis inactive.

Nitrofurantoin is administered orally via capsules or liquid. Greener (2011) highlights the different formulations, which originally included microcrystalline tablets and now include macro-crystalline capsules. The increased size of crystals was found to slow absorption rates down ( Hoang and Salbu, 2016 ). Nitrofurantoin is predominantly absorbed via the gastro-intestinal tract, enhanced by an acidic environment. It is advised to take nitrofurantoin with food, to slow down gastric emptying ( Wijma et al, 2018 ). The maximum blood concentration of nitrofurantoin is said to be <0.6 mg/l. Lower plasma concentration equates to lower toxicity risk; therefore, nitrofurantoin is favourable over fluoroquinolones ( Komp Lindgren et al, 2015 ). Wijma et al (2020) found a reduced effect on gut flora compared to fluoroquinolones.

Distribution of nitrofurantoin is mainly via the renal medulla, with a renal bioavailability of 38.8–44%; therefore, it is specific for urinary action ( Hoang and Salbu, 2016 ). Haasum et al (2013) highlight the inability for nitrofurantoin to penetrate the prostate where bacteria concentration levels can be present. Therefore, they do not advocate the use of nitrofurantoin to treat males with UTIs, because of the risk of treatment failure and further complications of systemic infection. This did not appear to be addressed by local guidelines.

The metabolism of nitrofurantoin is not completely understood; however, Wijma et al (2018) indicate several potential metabolic antibacterial actions. Around 0.8–1.8% is metabolised into aminofurantoin, with 80.9% other unknown metabolites ( medicines.org, 2022 ). Wijma et al (2020) calls for further study into the metabolism of nitrofurantoin to aid understanding of the pharmacodynamics.

Excretion of nitrofurantoin is predominantly via urine, with a peak time of 4–5 hours, and 27–50% excreted unchanged in urine ( medicines.org, 2022 ). Komp Lindgren et al (2015) equates the fast rates of renal availability and excretion to lower toxicity risks and targeted treatment for UTI pathogens. Wijma et al (2018) found high plasma concentration levels of nitrofurantoin in renal impairment. Singh et al (2015) indicate that nitrofurantoin is mainly eliminated via glomerular filtration; therefore, its impairment presents the potential risks of treatment failure and increased ADRs. Early guidelines stipulated the need to avoid nitrofurantoin in patients with mild renal impairment, indicating the need for an eGFR of >60 ml/min due to this toxicity risk. This was based on several small studies, cited by Hoang and Salbu (2016) , looking at concentration levels rather than focused on patient treatment outcomes.

Primary research by Geerts et al (2013) involving treatment outcomes in a large cohort study, led to guidelines changing the limit to mild to moderate impairment or eGFR >45 ml/min. However, the risk of ADRs, including pulmonary fibrosis and hepatic changes, were increased in renal insufficiency with prolonged use. The study participants had a mean age of 47.8 years; therefore, the study did not indicate the effects on older patients. Singh et al (2015) presented a Canadian study, looking at treatment success with nitrofurantoin in older females, with a mean age of 79 years. It indicated effective treatment despite mild/moderate renal impairment. It did not address the levels of ADRs or hospitalisation. Ahmed et al (2018) conducted a large, UK-based, retrospective cohort study favouring use of empirical nitrofurantoin in the older population with increased risk of UTI-related hospitalisation and mild/moderate renal impairment. It concluded not treating could increase mortality and morbidity. This led to guidelines to support empirical treatment of symptomatic older patients with nitrofurantoin.

Dosing is highly variable between the local and national guidelines. Greener (2011) highlights that product information for the macro-crystalline capsules recommends 50–100 mg 4 times a day for 7 days when treating acute uncomplicated UTI. Local guidelines from Barnsley Hospital NHS FT/Rotherham NHS FT Adult antimicrobial guide (2022) stipulate 50–100 mg 4 times daily for 3 days for women, whereas NICE (2021) recommends a MR version of 100 mg twice daily for 3 days.

In a systematic literature review on the pharmacokinetics of nitrofurantoin, Wijma et al (2018) found that use of a 5–7 day course had similar strong efficacy rates, whereas 3 days did not, potentially causing treatment failure, equating to poor patient outcomes and resistant behaviour. Deresinski (2018) conducted a small, randomised controlled trial involving 377 patients either on nitrofurantoin MR 100 mg three times a day for 5 days or fosfomycin single dose treatment after urinalysis and culture. It looked at response to treatment after 28 days. Nitrofurantoin was found to have a 78% cure rate compared to 50% with fosfomycin. Therefore, these studies directly contradict current NICE and local guidelines on treatment dosing of UTI in women. More robust studies on dosing regimens are therefore required.

Fransen et al (2016) conducted a non-human pharmacodynamics study looking at time of action to treat on 11 strains of common UTI bacteria including two ESBL+. It demonstrated the kill rate for E. coli was 16–24 hours, slower than Enterobacter cloacae (6–8 hours) and Klebsiella pneumoniae (8 hours). The findings also indicated that nitrofurantoin appeared effective against ESBL+. Dosing and urine concentrations were measured, and found that 100 mg every 6 hours kept the urine concentration levels significant enough to reach peak levels. This study directly contradicted the findings of Lindgren et al (2015) , who conducted similar non-human kinetic style kill rate studies, and found nitrofurantoin's dynamic action to be within 6 hours for E. coli. Both studies have limitations in that they did not take into account human immune response effects.

Wijma et al (2020) highlighted inconsistent dosing regimens in their retrospective audit involving 150 patients treated for UTIs across three Australian secondary care facilities. The predominant dosing of nitrofurantoin was 100 mg twice daily for 5 days for women and 7 days for males. Although a small audit-based paper, it creates debate regarding the lack of clarity around the correct dosing, leaving it open to error. It therefore requires primary research into the follow up of cure rates on guideline prescribing regimens. Dose and timing remains an important issue to reduce treatment failure. It indicates the need for bacteria-dependant dosing, which currently NICE (2021) does not discuss.

Haasum et al (2013) found poor adherence to guidelines for choice and dosing in elderly patients in their Swedish register-based large population study. It highlighted high use of trimethoprim in frail older care home residents, despite guidelines recommending nitrofurantoin as first-line. A recent retrospective, observational, quantitative study by Langner et al (2021) involving 44.9 million women treated for a UTI in the USA across primary and secondary care, found an overuse of fluoroquinolones and underuse of nitrofurantoin and trimethoprim, especially by primary care physicians for older Asian and socio-economically deprived patients. Both these studies did not seek a true qualitative rationale for choices of antibiotics; therefore, limiting the findings.

Legal and ethical considerations

NMP regulation of best practice is set by the Royal Pharmaceutical Society framework (2019) , incorporating several acts of law including the medicines act 1968, and medicinal products prescribed by the Nurses Act (1992). As per Nursing Midwifery Council (2021) Code of Conduct and Health Education England (2020), ANPs have a duty of care to patients, ensuring that they work within their area of competence and recognise any limitations, demonstrating accountability for decisions made ( Lovatt, 2010 ).

Empirical treatment of UTIs is debated in the literature. O'Grady et al (2019) summarises that empirical treatment can reduce further UTI complications that can lead to acute health needs and hospitalisation, without increased risk of antibiotic resistance. Greener (2011) states that uncomplicated UTIs can be self-limiting; therefore, not always warranting antibiotic treatment if sound self-care advice is adopted. Chardavoyne and Kasmire (2020) discuss delayed prescribing, involving putting the onus on the patient and carers, which was not advisable in the case of Mrs M. Bradley and Sheeran (2017) found that three quarters of antibiotics in care home residents were prescribed inaccurately, hence recommended a watch and wait approach to treatment in the older care home resident, following implementation of a risk reduction strategy.

Taylor (2016) recommended an individual, holistic approach, incorporating ethical considerations such as choice, level of concordance, understanding and agreement of treatment choice. This can prove difficult in a case such as Mrs M. If a patient is deemed to lack capacity, a decision to act in the patient's best interest should be applied ( Gupta and Gupta, 2019 ). Therefore, understanding a patient's beliefs and values via family or carers should be explored, balancing the needs and possible outcomes. The principle of non-maleficence should be adopted, looking at risks versus benefits on prescribing the antibiotic to the individual patient ( Royal Pharmaceutical Society, 2019 ).

Non-pharmacological advice was provided to the carers to ensure that Mrs M maintained good fluid intake of 2 litres in 24 hours. NICE (2021) advocates the use of written self-care advice leaflets that have been produced to educate patients and/or carers on non-pharmacological actions, supporting recovery and improving outcomes. The use of paracetamol for symptoms of fever and/or pain was also recommended for Mrs M. Prevention strategies proposed by Lajiness and Lajiness (2019) included looking at the benefits of oestrogen cream in post-menopausal women in reducing the incidence of UTIs. Cranberry juice, probiotics and vitamin C ingestion are not supported by any strong evidence base.

There is a duty of care to ensure that follow up of the patient during and after treatment is delivered by the NMP ( Chardavoyne and Kasmire, 2020 ). Clinical safety netting advice was discussed with the carers to monitor Mrs M for any deterioration, and to seek further clinical review urgently. Particular attention to signs of ADRs and sepsis, and the need for 999 response if these occurred, was advocated. A treatment plan was also sent to the GP to ensure sound communication and continuation of safe care ( Taylor, 2016 ).

Professional development issues

The extended role of prescribing brings additional responsibility, with onus on both the NMP and the employer vicariously, to ensure key skills are updated. This is where continued professional development involving research, training and knowledge is sought and applied, using evidence-based, up-to-date practice ( HEE, 2020 ). Adoption of antibiotic stewardship is highlighted by several papers including Lajiness and Lajiness (2019) . They advise nine points to consider, to increase knowledge around the actions and consequences of the drug by the prescriber. Despite no acknowledgment in NICE (2021) guidance, previous results of infections and sensitivities are also proposed as vital in antibiotic stewardship.

The use of decision support tools, proposed by Malcolm et al (2018) , involves an audit approach looking at antibiograms, that highlight local microbiology resistance patterns to aid antibiotic choices, alongside a risk reduction team strategy. Bradley and Sheeran (2017) looked at improving antibiotic use for UTI treatment in a care home in Pennsylvania. They employed a programme of monitoring and educating clinical staff, patients, carers and relatives in evidence-based self-care and clinical assessment skills over a 30-month period. It demonstrated a reduction in inappropriate antibiotic prescribing, and an improvement in monitoring symptoms and self-care practices, creating better patient outcomes. It was evaluated highly by nursing staff, who reported a sense of autonomy and confidence involving team work. Langner et al (2021) calls for further education and feedback to prescribers, involving pharmacists and microbiology data to identify and understand patterns of prescribing.

UTIs can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines. Continued monitoring of nitrofurantoin use requires priority, due to its first-line treatment status internationally, as this may increase reliance and overuse of the drug, with potential for resistant strains of bacteria becoming prevalent.

Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained. The use of competent clinical practice, up-to-date evidence-based knowledge, good communication and understanding of individual patient needs, and concordance are essential to make sound prescribing choices to avoid harm. As well as the prescribing of medications, the education, monitoring and follow-up of the patient and prescribing practices are equally a vital part of the autonomous role of the NMP.

KEY POINTS:

• Urinary tract infections (UTIs) can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines
• The incidence of UTI increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point
• Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010. Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels
• Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained

CPD REFLECTIVE PRACTICE:

• How can a good clinical history be gained if the patient lacks capacity?
• What factors need to be considered when safety netting in cases like this?
• What non-pharmacological advice would you give to a patient with a urinary tract infection (or their carers)?
• How will this article change your clinical practice?

• Pharmacist Independent Prescriber Course
• Minor Illnesses And Acute Conditions Course
• Setting Up A Private Clinic
• Nonmedical prescribing essay examples
• Non-Medical Prescribing

What is the V300 nurse prescribing course?

The V300 nurse prescribing course is a qualification that allows nurses to prescribe medications from the British National Formulary (BNF) for specific clinical conditions. The course provides nurses with the knowledge and skills to prescribe safely, effectively, and appropriately within their area of practice.

V300 nurse prescribing course covers the following topics:· The principles of prescribing· Legal and ethical aspects of prescribing· Pharmacology for prescribing· Therapeutics for prescribing· Patient assessment for prescribing· Monitoring and evaluation of prescribing.

What is the pharmacist independent prescribing course?

The pharmacist independent prescribing (PIP) course is a postgraduate qualification that allows pharmacists to prescribe medications from the British National Formulary (BNF) for specific clinical conditions. The course provides pharmacists with the knowledge and skills to prescribe safely, effectively, and appropriately within their area of practice. The PIP course covers the following topics:· The principles of prescribing· Legal and ethical aspects of prescribing· Pharmacology for prescribing· Therapeutics for prescribing· Patient assessment for prescribing· Monitoring and evaluation of prescribing.

What is the difference between the V300 nurse prescribing course and the pharmacist independent prescribing course?

The main difference between the V300 nurse prescribing course and the pharmacist independent prescribing course is that the latter is a postgraduate qualification. In terms of content, both courses cover the same topics related to prescribing.

Who can take the V300 nurse prescribing course?

The V300 nurse prescribing course is open to all qualified nurses who want to prescribe from the British National Formulary (BNF).

Who can take the pharmacist independent prescribing course?

The pharmacist independent prescribing course is open to all qualified pharmacists who want to Prescribe from the British National Formulary (BNF).

What are the benefits of taking the V300 nurse prescribing course?

The main benefit of taking the V300 nurse prescribing course is that it enables nurses to prescribe medications from the British National Formulary (BNF) for specific clinical conditions. This can save time and money for patients who would otherwise have to see a doctor for a prescription. In addition, the course provides nurses with the knowledge and skills to prescribe safely, effectively, and appropriately within their area of practice.

What are the benefits of taking the pharmacist independent prescribing course?

The main benefit of taking the pharmacist independent prescribing course is that it enables pharmacists to prescribe medications from the British National Formulary (BNF) for specific clinical conditions. This can save time and money for patients who would otherwise have to see a doctor for a prescription. In addition, the course provides pharmacists with the knowledge and skills to prescribe safely, effectively, and appropriately within their area of practice.

What are the entry requirements for the V300 nurse prescribing course?

The entry requirements for the V300 nurse prescribing course are as follows:· You must be a qualified nurse with a valid Nursing and Midwifery Council (NMC) PIN number.

• You must have completed a recognised accredited prescribing course within the last three years.
• You must have a minimum of two years’ post-registration experience.· You must have completed a recognised accredited pharmacology course within the last three years.
• You must have a minimum of two years’ post-registration experience in a clinical area.

What are the entry requirements for the pharmacist independent prescribing course?

The entry requirements for the pharmacist independent prescribing course are as follows:· You must be a qualified pharmacist with a valid General Pharmaceutical Council (GPhC) registration.

• You must have a minimum of two years’ post-registration experience.
• You must have completed a recognised accredited pharmacology course within the last three years.

What will I need to do in order to complete my nonmedical prescribing course?

In order to complete your nonmedical prescribing course, you will need to pass all of the assigned assessments, which include exams, essay writing and completion of a portfolio.

These assessments will cover all of the topics related to prescribing that are covered in the course. In order to pass the course, you will need to demonstrate that you have a good understanding of all aspects of prescribing and that you can apply this knowledge in a clinical setting.

How long will it take me to complete my nonmedical prescribing course?

The length of time it takes to complete a nonmedical prescribing course varies depending on the provider, but most courses can be completed within six to twelve months. Some providers offer distance learning options which can allow you to study at your own pace and complete the course in a shorter timeframe.

Is the nonmedical prescribing course difficult?

The nonmedical prescribing course can be difficult for some students. However, with hard work and dedication, most students are able to pass the course. The assessments that need to be completed in order to pass can be challenging, but with a good understanding of the material and plenty of practice, most students are able to do well.

And it appears most nurse prescribing, and pharmacist independent prescribing students struggle with the completion of the essay component of the nonmedical prescribing course. 

Therefore in this article, MEDLRN has provided an example of a nonmedical prescribing essay, such that you do not need to outsource your essay writing to an external and paid-for essay writing service. Furthermore, the essay written below is also suitable for allied healthcare professionals who are also looking to undertake a nonmedical prescribing course.

What is the nonmedical prescribing portfolio and essay?

While you’re independent prescribing course (as a pharmacist wanting to undertake the pharmacist independent prescribing or a nurse wanting to complete the V300 nurse prescribing course) – you will be required to complete an independent prescribing practice portfolio and write an essay on your scope of practice.

The nonmedical prescribing portfolio is a collection of documents that you must submit to demonstrate that you have met the requirements for the V300 nurse prescribing course.

The essay is one component of the portfolio and is mandatory. It must be submitted with the other documents.

The purpose of the essay is to assess your ability to critically appraise information and to communicate your thoughts and findings in a clear and concise manner. The essay should be no more than 2,500 words in length (however, this can vary from university to university). It must be well-structured and organised and must include a reference list.

What are the benefits of writing essays?

There are many benefits to writing essays, including the following:

• Essays allow you to demonstrate your understanding of the material.
• Essays allow you to communicate your thoughts and findings in a clear and concise manner.
• Essays help you to develop your critical thinking skills.
• Essays help you to develop your research skills.
• Essays can be used to support your application for further study or training.

What are the key points to remember when writing a nonmedical prescribing essay?

There are a few key points to remember when writing a nonmedical prescribing essay, including the following:

• Make sure that you understand the question that has been asked.
• Make sure that you research the topic thoroughly.
• Organise your thoughts and ideas in a logical manner.
• Write in a clear and concise manner.
• Edit and proofread your essay before submission.

Nonmedical prescribing essay example on hypertension

A supplementary prescribing episode.

The following prescribing episode is based on an actual patient and supervised by the DMP; information that contains patients’ details has been anonymised, and consent was gained throughout in accordance with the guidance published by the General Pharmaceutical Council (2017).

For the purpose of this episode, the patient will be known as Bob.

1. Presenting Compliant

Mr Bob, aged 56, was referred to the hypertension clinic due to concerns over consistently high blood pressure readings.

This is a supplementary prescribing episode; supplementary prescribing represents a tripartite collaboration between an independent prescriber, a supplementary prescriber and a patient. The independent prescriber provides the initial diagnosis, and the supplementary prescriber is given the authority to implement an agreed patient-specific clinical management plan(CMP) with the patient’s consent (Department of Health 2005, pg 8 and Bissell, et al.,2008).

As such, in the summary of the above, the three-way partnership involves:

• An independent prescriber who is responsible for the initial assessment of the patient, including the diagnosis and the development of the CMP (NHS File,2009 and Department of Health, 2005)
• The supplementary prescriber is responsible for confirming the diagnosis during each review of the patient and must prescribe within the agreed CMP (NHS File,2009)
• The patient must be aware of and agree to initiate his/her care through a CMP (The textbook of nonmedical prescribing,2011).

The benefits of supplementary prescribing for patients include increased access and improved choice for patients (Department of Health, 2008) and for the prescriber include; increased job satisfaction and better use of their skills (Louise, Aspell and Mary, 2016)

 LO2, LO4, LO6

The Calgary-Cambridge model was utilised to undertake the patient consultation. The consultation model is based on “a patient-centred approach”, as such promoting a collaborative partnership (Silverman, Kurtz and Draper, 1998) and providing a structure which complements a holistic approach (Munson and Willcox, 2007). The model involves five main stages, which provide me with an easy-to-follow structure allowing me to ask the appropriate questions, enhance patient safety and make informed decisions (Jane Rutt-Howard 2011, p123).

Initiating the session

I welcomed the patient and informed him I am a trainee independent prescriber under the supervision of my DMP. I explained the reason for the consultation and gained consent.

Gathering information

2. History of presenting complaint

Bob had previously been diagnosed with essential hypertension at stage 1 with no evidence of target organ damage. As such, Bob was offered a non-pharmacological approach to manage his hypertension (NICE,2016). However, at an annual review with the G.P., he was found to have an average systolic blood pressure reading 160mmHg over two weeks of repeated measurements.

3. Health status

Past medical history

Essential hypertension – 2017

Family History

Both parents suffer from hypertension

Social History

Bob works as a taxi driver and lives with his wife. He enjoys going for walks and does not drink or smoke

Drug history

Bob does not take any prescribed, herbal, OTC or recreational drugs

Physical Information

•  A review of systems  Included average hypertension readings over two weeks (refer to appendix 1).
• Differential diagnosis

The secondary cause of hypertension:

• Chronic Kidney disease – Excluded as upon investigation of blood tests, no abnormalities in particular potassium or creatinine were found indicative of renal disease (Weber  et al.,  2014)
• Excessive aldosterone secretion- Excluded as no abnormalities in serum potassium (Weber  et al. , 2014)
• Pheochromocytoma – Excluded as no symptoms of flushing, headache etc. (Viera  et al., 2010)
• Sleep Apnea – Excluded as upon questioning on any other signs and symptoms, no problems identified (Viera and Neutze, 2010)

LO3A, LO5, LO6

1. Definitive diagnosis

Essential hypertension stage 2 –  The diagnosis can clearly be made as demonstrated by the blood pressure results taken over a two-week period and having excluded any secondary causes of raised blood pressure. In addition, the patient’s past medical history and NICE guidelines (2016) also affirm the diagnosis characterised by clinic blood pressure of at least 160/100 mmHg and subsequent home blood pressure measurements average of at least 150/95 mmHg.

1. Prescribing options

Antihypertensive as per clinical management plan, e.g.;

Calcium channel blocker(CCB)

Ace Inhibitors

Angiotensin receptor blockers

Thiazide diuretics

LO1, LO5, LO6

1. Prescribed medication

Amlodipine 5mg tablets ONCE daily (NICE, 2016 and BNF, 74) – CCB

Cost:  80p for 28 tablets

LO1, LO5,LO6

Pharmacokinetics  (MHRA, 2008 and Abernethy,1992)

Absorption:  Peak blood levels between 6-12 hours post-dose

Distribution:  97.5% protein-bound

Metabolism:  Extensively metabolised in the liver with no significant pre-systemic metabolism

Elimination:  Excreted in the urine with an elimination half-life of 35-50 hours

Pharmacodynamics

Amlodipine is known as a calcium ion channel inhibitor of the dihydropyridine group and inhibits the transmembrane influx of calcium ions into both cardiac and vascular smooth muscle (Fares H  et al .,2016). As such, its antihypertensive effects are due to its direct relaxant effect on vascular smooth muscle, which reduces the total peripheral resistance against which the heart works (MHRA, 2008).

LO1,LO5, LO6

1.  Contraindications (BNF, 74)

• Non relevant

1. Side effects (BNF, 74)

• Abdominal pain
• Ankle swelling

1. Drug interactions

Bob is not currently on any medication that would interact.

Explanation, planning and closing of the session

Bob was reviewed in the presence of my DMP, and a clinical management plan was agreed upon (Appendix 2).

Bob explained that the diagnosis of hypertension is not in itself serious, but the control of blood pressure is necessary to prevent serious complications such as heart disease and stroke (Weber  et al.,  2014 NICE., 2016). Therefore, a calcium channel blocker (Amlodipine) was prescribed in line with current national guidelines (NICE, 2016) to reduce his blood pressure and prevent the development of cardiovascular complications (Fares H  et al.,  2016).

Bob was signposted to the NHS choices website, and an information sheet on hypertension and its management was given to reiterate and further explain what had been mentioned in the consultation.

In addition, it was explained to Bob to continue to exercise regularly and reduce his salt intake, both of which can reduce blood pressure (Weber  et al.,  2014). Bob was also advised to book a follow-up appointment after two weeks to review drug therapy (Nice., 2016) and should he have any questions or concerns, to contact me or the G.P.

LO3A, LO4 LO5, LO6

Hypertension is a major risk factor for cardiovascular events such as myocardial infarction, heart failure etc., stroke and chronic kidney disease (Weber  et al.,  2014; NICE, 2016). As such, the above suggests Bob, a 56-year-old gentleman, is at an increased risk of suffering a major cardiovascular event in the future should his systolic blood pressure remain greater than 140mmHg. This highlights the need for a prompt diagnosis and treatment according to NICE guidelines (2016).

Nice (2016) has provided an algorithm for the treatment of uncomplicated hypertension, which advises the use of a calcium channel blocker for adults above the age of 55 with stage two hypertension. As such, Bob has prescribed a calcium channel blocker known as Amlodipine.

Evidence: LO1,LO3A,LO5,LO6

1. Amlodipine Efficacy

The efficacy of Amlodipine in the management of hypertension has been demonstrated in many large-scale randomised controlled trials (Health Service Executive, 2016), which include:

• The 2007 ACCOMPLISH trial- the trial compared Amlodipine plus an Angiotensin Converting Enzyme (ACE) inhibitor to a thiazide plus an ACE inhibitor. The study showed both groups reduced blood pressure (B.P.) from baseline over the course of the trial. However, the combination of an ACE inhibitor plus Amlodipine was found to be superior to an ACE inhibitor plus a diuretic in reducing the risk of cardiovascular events and death (Jamerson K.  et al.  2008).
• The 2004 Value trial- the trial investigated if Valsartan would reduce cardiac morbidity and mortality more than Amlodipine in patients who were hypertensive at high cardiovascular risk showed both groups lowered B.P., however, Amlodipine was found to reduce B.P. significantly more than Valsartan, especially in the first month of treatment (Julia S  et al .,2004).
• The 2004 CAMELOT trial- the trial compared Amlodipine to Enalapril in order to determine the effects of these drugs on cardiovascular events in patients with coronary artery disease. The study showed both antihypertensives were found to significantly lower B.P. compared to placebo (Nissen S  et al .,2004).
• The 2005 ASCOT-BPLA trial- the trial investigated the prevention of cardiovascular events with Amlodipine which was compared to Atenolol-based regimens. The study showed a lower B.P. in the Amlodipine treatment regimen throughout the trial. In addition, The primary endpoint of nonfatal MI or fatal CHD was 10% lower in the Amlodipine regimen when compared to the Atenolol regimen (Dalholf B  et al ., 2005).
• The 2002 ALLHAT trial- was one of the largest trials of antihypertensive therapy conducted ( Alejandro de la Sierra ., 2007) and showed Amlodipine reduced systolic B.P. from baseline levels and significantly lowered diastolic B.P. than Chlorthalidone and Lisniproil (ALLHAT, 2002 and Health Service Executive, 2016)

As such, international guidelines from Europe (European Society of Cardiology/ European Society of Hypertension,2013 ), America (American College of Cardiology/America n Heart Association, 2014) including the U.K. (NICE,2016., British Hypertension Society,2008 and Scottish Intercollegiate Guideline Network, 2007) all recommend a calcium channel blocker in their respective hypertension treatment algorithms (Health Service Executive, 2016).

Moreover, in line with the NICE guideline, a recently published formulary to promote the safe, clinically effective and cost-effective use of prescribed medicines in Northern Ireland recommends Amlodipine as the first-choice treatment for hypertension (Health Service Executive, 2016). In addition, other NHS trusts such as County Durham, NHS Lothian, and Darlington NHS trust and the Dorset Cardiology working group on hypertension also have selected Amlodipine as the first choice calcium channel blocker (Health Service Executive, 2016). 

2. Amlodipine dosage and frequency

Bob has prescribed Amlodipine initially at a low dose of 5mgs once daily for four weeks; this was because NICE (2016), the BNF (74), and other guidelines (Qi Chen et al., 2017) recommend that a calcium channel blocker is indicated to prescribe a CCB that is taken once daily and to start initially at low doses.

In addition, NICE(2016) and the BNF (74) recommend titrating dosages at four-weekly intervals to maximum licensed dosages. Consequently, a major advantage of using an initial low dose approach and titrate dosages slowly is that it can lower the possible incidence of adverse effects and improve adherence(Qi Chen et al., 2017 Health Service Executive,2016).

Prescribing Issues

The benefits of lowering blood pressure are well known (Nice,2016). However, despite the overwhelming clinical evidence supporting the benefits of antihypertensive treatment, it has been reported that less than 50% of treated hypertensives have good blood pressure control (Izzat,2009), with lack of adherence to antihypertensive medication being reported as a well-recognised cause for poor blood pressure control (Izzat,2009).

Adherence can be defined as ‘The extent to which the patient’s behaviour matches agreed-on recommendations from the prescriber’ (National Health Service Delivery and Organisation R&D, 2005).

Reasons for non-adherence are complex and multi-factorial; as such, from a patients perspective, barriers to adherence to medication include side-effect profile of drugs, poly-pharmacy, the complexity of treatment schedules, lack of understanding of treatment targets and limited patient involvement in treatment decisions (National Health Service Delivery and Organisation R&D, 2005 and Izzat,2009).

As such, during the consultation, Bob was assessed to identify if there were any factors which would prevent him from taking his medication; however, no issues were identified. Furthermore, in order to encourage adherence to the use of antihypertensives prescribed to Bob, the following steps were taken:

A patient-centred approach to prescribing

Bob was thoroughly explained and given information leaflets as well as signs posted on websites such as ‘Patient.co.uk’ and the ‘British Hypertension Society’ in an attempt to empower and educate him on hypertension and its diagnosis and benefits of its management in order to create an incentive for adherence to his medication which has been shown to be beneficial when dealing with chronic, asymptomatic conditions such as hypertension (Izzat, 2009).

Moreover, in order to ensure Bob understood the contents of the leaflets and websites etc., he was asked to suggest what changes he would implement as a result of the new knowledge he has gained and encouraged to contact his g.p or me should he have any questions.

Medication specific factors 

Simplified dosage regimen:

Bob has prescribed a once-daily dosage regimen as it has been shown simplification of the treatment schedule and a reduced number of daily doses is effective in increasing adherence to medication (Izzat, 2009; NICE,2016.). Furthermore, Bob was encouraged to take his medication in the morning wherever possible in an attempt to make this part of his morning routine.

Adverse drug reactions(ADRs):

Bob was informed about the possible likely ADRs associated with Amlodipine and the likely hood of Bob suffering from the ADRs. Bob was informed of the interaction between grapefruit juice and Amlodipine, which may increase the plasma concentration of Amlodipine and lead to ADRs (Emc, 2018) and reduce Bob’s adherence to the medication. Therefore, it was explained to Bob to avoid the consumption of grapefruit juice and Amlodipine (Emc, 2018).

In addition, Bob was explained Amlodipine is widely used in hypertension, well-tolerated and safe (HSE, 2016). However, Bob was encouraged in the event of these ADRs to contact either myself or his G.P. in order to review the treatment regimen.

Health Education

Numerous lifestyle interventions have been shown to lower blood pressure, and these interventions are also implemented when managing most other cardiovascular risk factors (Weber  et al.,  2014).

Regular exercise

Bob explained the importance of exercise and how it helps make your heart and blood vessels more efficient and flexible, thus, lowering blood pressure (weber  et al.,  2014) and keeping you fit (The blood pressure association, 2008). It was explained to Bob that different kinds of exercise have different effects on the body; with activities that help your heart and blood vessels being shown to be most beneficial in lowering blood pressure, such as aerobic exercises (weber  et al. ,2014 and The blood pressure association,2008), e.g. walking, swimming, jogging, tennis, brisk walking, mowing the lawn etc. (The blood pressure association, 2008).

As such, Bob was encouraged to undertake 30 minutes of moderate exercise five times a week to become more fit and healthy, and in order to achieve this, the following was explained, and practical tips were given:

• A moderate exercise is an exercise that should be enough to make you breathe harder and feel warmer; however, you should still be able to talk without panting between words) (The blood pressure association, 2008).
• Increase your activity by small amounts allowing you to build up to the full 30 minutes over a few weeks by setting small goals that add up, i.e. initially split your 30 minutes into two 15 minutes or three 10-minute sessions, enabling you to build up your strength as well as helping you get accustomed to your new activity. 
• If you feel the idea of exercise is boring, then try to get others involved, e.g. your wife, which can make it a lot more enjoyable (The blood pressure association,2008).

Salt reduction

Bob has explained the importance of reducing his salt intake and how a low salt diet can help contribute to reducing his blood pressure (Weber  et al. ,2014). In addition, Bob was informed that the recommended salt intake for healthy adults is 6g per day, with NICE (2010) recommending that we all should aim to have less than 3g per day of salt by 2025.

Bob was given the following tips in order to identify high salt foods:

• Look for the ‘traffic light’ label on foods to help you make a healthier choice. ‘Traffic light’ colours help you to see at a glance if food is high, medium or low in salt, with green being low, orange being medium and red being high(British dietetic association,2018).
• For foods that do not yet display the ‘traffic light’ labelling, then 0g-3g of salt per 100g of food is low, 0.3g-1.5g of salt per 100g of food is medium and more than 1.5g of salt per 100g of food is high (British dietetic association,2018).  

In addition, Bob was given the following practical advice to reduce salt intake (British dietetic association, 2018):

• Use little or no cooking salt instead; use extra herbs and spices such as black pepper
• Cut down on processed and ready meals and try to make your own food
• Compare salt levels among similar foods to choose those with lower salt
• Ask restaurants and takeaways for no added salt
• Be wary of salt substitutes as these product ranges may still likely add some form of salt to your diet.

Bob explained fats are an important part of our diet; however, eating too much fat can be unhealthy as it increases the chances of becoming overweight and developing serious health problems such as type 2 diabetes and some cancers (British dietetic association, 2018).

In addition, it was explained to Bob some fats are better than others, and there are three main types of fat; saturated (found in fats on meat, butter, cakes, biscuits,

takeaway meals etc.), Trans fats (found in cakes and pastries and may appear in the list of ingredients as ‘partially hydrogenated vegetable fats/oils) and unsaturated (found in plant foods such as seeds/grains, nuts, vegetables and fruits), i.e. polyunsaturated, monounsaturated and omega-3 (also known as essential fats found in oily fish such as salmon or plant foods, e.g. rapeseed oils etc.) with saturated and trans fats being considered to be less healthy as they increase our blood cholesterol levels and increase the risk of heart disease (British dietetic association, 2018).

Furthermore, Bob was explained when cooking to use small amounts of oil, ideally using pure vegetable, rapeseed, olive or sunflower oils etc. and was advised that a tablespoon of oil is enough for four people (British heart foundation, 2014). In addition, Bob was explained when having meat try to choose lean cuts of meat and remove any visible fats (Food standards agency, 2005)

Therefore, the following practical tips were given to Bob to allow him to make healthier choices (British dietetic association,2018 and NHS Choices, 2015 ):

• Where possible, look for the colour-coded system of food labelling to quickly see at a glance what key nutrients and calories there are in food, i.e. foods with over 17.5g fat per 100g would be red (i.e. high in fat), and those containing 3g per 100g of would be amber (medium) while those foods containing less than 3g per 100g of food would be green (low in fat).
• When buying meat, look for the leanest options. (e.g. turkey, chicken or fish etc.). As a rule of thumb, the more white you can see on the meat, the more fat it contains.
• Limit processed meat such as sausages, beef burgers, salami etc. and meat products in pastries, e.g. pies, sausage rolls etc
• Cut off any visible fat and skin before cooking and try to grill meat rather than frying.
• Roast meat on a metal rack above a roasting tin so fat can run off.

Fruit and Vegetables

Bob explained the benefits of eating plenty of fruits and vegetables, which include lowering the risk of many heart diseases and reducing blood pressure(British dietetic association, 2018). Therefore, Bob was encouraged to eat at least five (80gs) portions of a wide variety of fruits and vegetables a day

The following practical tips were given to Bob in order to achieve the five-a-day target (British dietetic association):

• Opt for fresh produce in the season
• Eat a variety of different coloured fruits and vegetables.
• Be careful not to consume more than 30g of dried fruit which counts towards your five-a-day target as fruit; once dried can become a concentrated source of sugar and calories (British dietetic association 2018).
• Check for nutrition information on food labels when selecting foods based on the ‘5-a day’ logo as some vegetables contained in convenience foods such as ready meals may also be high in salt, sugar or fat.
• Be aware that no matter how much fruit juice or varieties of fruit juices are consumed in a day, a glass (150mls) of unsweetened 100% fruit vegetable only counts as one portion of the five a day.
• Cut down on your portion of meat and increase your portion of vegetables.

 Appendix 1

 Review of Patient

 General:  A middle-aged gentleman who exercises regularly and feels fit and healthy with no other symptoms

Neurological:  No history of headaches, alert and orientated

ENT:  No problems identified

Eyes:  No visual disturbances, optic fundi was checked, and no problems identified.

Respiratory examination:  No shortness of breath or chest pains indicative of coronary artery disease

Skin:  No problems identified

 Renal:  No problems identified

 Cardiovascular:

Pulse: Normal

ECG: Normal Sinus rhythm

No ankle swelling

Overall no problem was identified

 Investigation

Blood pressure readings

Two weeks average blood pressure readings: 160mmHg/90mmHg

Clinic blood pressure average O/E 160mmHg/90mmHg

Urea and electrolytes

NA+: 133 (133-146) mmol/L

K+: 4 (3.5-5.3) mmol/l

Creatinine: 80 (50-120) Umol/L

Urea: 3 (1.7-7.1) mmol/L

Full blood count

Haemoglobin estimation: 15.9 (13-17) g/dL

Total White cell count: 5.41 (4-11) x1o*9/L

Platelet count: 233 (150-400)x10*9/L

Haematocrit: 0.456 (0.4-0.5)L/L

Red blood (RBC) count: 5.48 (4.50-5.50)x10*12/L

Mean corpuscular volume (MCV): 83.2 (83-105) fl

Mean Carpusc. Haemoglobin (MCH) 29 (27-32) pg

Mean Corpusc. Hb conc (MCHC) 34 (31.50-34.50) g/dl

Neutrophil count: 2.81 (2-7) x10*9/L

Lymphocyte count : 1.79 (1-4)x10*9/L

Monocyte count: 0.43 (0.2-1) x10*9/L

Eosinophil count: 0.38 (0-0.5) x10*9/L

Basophil count: 0.05 (0-0.1) x10*9/L

Haemoglobin: 15 (13.5-18)g/DL

Liver function Tests

Bilirubin:15 (,17) umol/L

ALT: 20 (5-40) umol/L

AST: 15 (12-40) umol/L

ALP: 50 (39-117) umol/L

Albumin: 40 (35-50) g/L

Total Cholesterol: 4 (<5) mmol/L

Non HDL Cholesterol: 3.5 (<4) mmol/L

LDL- Cholesterol: 2 (<3) mmol/L

Fasting Triglyceride :1.9 (<2) mmol/L

Thyroid Function tests

TSH: 0.6 (0.4-4) mU/L

FT4: 12 (9-25) pmol/L

FT3: 3.9 (3.5-7.8) pmol/L

Fasting Glucose: 4 (<5.5) mmol/L

Urine albumin:creatinine ratio: 2.4 (<2.5) MG/mmol

O/E height: 181cm

Weight O/E: 80 kg

QRISK 2 cardiovascular disease ten-year risk score: 10.4%

Alcohol consumption: 0 U/week

Smoking status: Never smoked

Smoker: Never smoked

The ranges shown in brackets are the normal ranges taken from Dickinson et al. (2005), and all clinic blood pressure readings were carried out in line with best practice guidelines (Weber  et al.,  2014, NICE 2016)  

Reference List

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Dalhof B, Sever P, Poulter N et al.  Prevention of cardiovascular events with an antihypertensive regimen of Amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the AngloScandinavian Cardiac Outcomes Trial- Blood Pressure Lowering Arm (ASCOT-BPLA) . The Lancet 2005; 366: 895-906.

Department of Health ( 2005 )  Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/ Podiatrists, Physiotherapists and Radiographers within the NHS in England . London : The Stationery Office .

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Dickinson, J. (2005). The hand: A philosophical inquiry into human being.  Clinical Medicine , 5(1), pp.78-79.

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Fares, H., DiNicolantonio, J. J., O’Keefe, J. H., & Lavie, C. J. (2016). Amlodipine in hypertension: a first-line agent with efficacy for improving blood pressure and patient outcomes.  Open Heart , [Online]  3 (2), e000473.  http://doi.org/10.1136/openhrt-2016-000473

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General Pharmaceutical Council, 2017.  In practice: Guidance on confidentiality .[pdf] General Pharmaceutical Council.

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https://www.pharmacyregulation.org/sites/default/files/in_practice-_guidance_on_confidentiality_may_2017.pdf [Accessed 18 February 2018].

Health Service Executive, 2016 . Medicines Management Programme Preferred Drugs Calcium Channel Blockers (dihydropyridine derivatives) for the treatment of hypertension and stable angina  [pdf] Available at: < https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/calcium-channel-blockers-report.pdf > [Accessed 25 February 2018].

The Blood Pressure Association, 2008.  Healthy lifestyle and blood pressure .[pdf]. The blood pressure Association. Available at: > [Accessed 11 March 2018].

Jamerson K, Weber M, Bakris G et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in highrisk patients.  New England Journal of Medicine  2008; 359 (23): 2417-2428.

Julius S, Kjeldsen S, Weber M et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine:  the VALUE randomised trial . The Lancet 2004; 2022-2031.

Joint Formulary Committee.  British National Formulary . [74] ed. London: BMJ Group and Pharmaceutical Press; [2017]

Izzat, L.,2009.  Antihypertensive concordance in elderly patients  [Online] Available at < https://www.gmjournal.co.uk/media/21571/gm2april2009p28.pdf > [Accessed on 28 February 2018]

Medicines and Healthcare Products Regulatory Agency (MHRA), 2008. Summary of product characteristics [pdf] Available at:  http://www.mhra.gov.uk/home/groups/par/documents/websiteresources/con028435.pdf  [Accessed 25th February 2018].

Munson E, Willcox A (2007)  Applying the Calgary-Cambridge model . Pract Nurs 18(9): 464–68

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NHS FIFE(2009)  Best practice guidance-supplementary prescribing  [Online]. Available at  http://admin.fifedirect.org.uk/weborgs/nhs/uploadfiles/publications/c64_BESTPRACTICEGUIDANCE-SupplementaryPrescribingMay09.pdf  [Accessed 12 October 2017].

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https://www.nhs.uk/conditions/high-blood-pressure-hypertension/prevention/ [Accessed 5 March 2018].

National health service, 2015.  Nhs Choices meat in your diet . [Online] Available at: https://www.nhs.uk/Livewell/Goodfood/Pages/meat.aspx [Accessed 5 March 2018].

National Health Service Delivery and Organisation R&D, 2005.  Compliance, Adherence and Compliance in Medicine Taking .[Pdf] National Health Service. Available at:< https://www.researchgate.net/profile/Rachel_Elliott/publication/303259597_Concordance_adherence_and_compliance_in_medicine_taking/links/573ed36808ae298602e8d8bc/Concordance-adherence-and-compliance-in-medicine-taking.pdf > [Accessed on 28 February 2018]

Qi Chen.,  Qi‐Fang Huang.,  Yuan‐Yuan Kang.,  Shao‐Kun Xu.,  Chang‐Yuan Liu.,  Yan Li.,  and  Ji‐Guang Wang..,2017. Efficacy and tolerability of initial high vs low doses of S‐(‐)‐Amlodipine in hypertension. The Journal of Clinical Hypertension.[e-journal] 19(10), pp. 973-982.  https://doi.org/10.1111/jch.13022 .

Rutt-Howard, J 2011 ,  ‘Effective Consultation and the ‘Consultation Umbrella” in D Nuttall and J Rutt-Howard (eds)  “The Textbook of Non-Medical Prescribing”  Blackwell publishing, pp 123-161

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The ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomised to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: The antihypertensive and lipidlowering treatment to prevent heart attack trial (ALLHAT). JAMA 2002; 2981-2997.

Weber, MA, Schiffrin, EL, White, WB, Mann, S, Lindholm, LH, Kenerson, JG, Flack, JM, Carter, BL, Materson, BJ, Ram, CVS, Cohen, DL, Cadet, JC, Jean-Charles, RR, Taler, S, Kountz, D, Townsend, RR, Chalmers, J, Ramirez, AJ, Bakris, GL, Wang, J, Schutte, AE, Bisognano, JD, Touyz, RM, Sica, D & Harrap, S.B. 2014,  ‘Clinical Practice Guidelines for the Management of Hypertension in the Community: A Statement by the American Society of Hypertension and the International Society of Hypertension Clinical Practice Guidelines for the Management of Hypertension in the Community:’  A Statement by the American Society of Hypertension and the International Society of Hypertension Weber et al.’ Journal of Clinical Hypertension, vol 16, no. 1, pp. 14-26. DOI:  10.1111/jch.12237

Author:  Faheem Ahmed

Pharmacist Prescriber, 2x Award-Winning Pharmacist, Pharmacy and Clinic Owner, Founder of MEDLRN and loves sharing his experience with pharmacists.

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Supplementary prescribing case study

Affiliation.

• 1 Leeds Teaching Hospitals Trust.
• PMID: 17193911
• DOI: 10.7748/paed.18.10.14.s14

A principle aim of supplementary prescribing is to enable faster access to medicines for people who have a chronic condition. The example of a young person with diabetes is used to demonstrate the benefits of nurse specialists being able to prescribe. The way in which prescribing requirements, such as clinical management plans, relate to existing multi-disciplinary team management of children with chronic illness is also illustrated. Having the young person and family as partners within the team is essential; use of management plans reinforces this partnership and allows care to be delivered in a structured way.

• Diabetes Mellitus, Type 1 / drug therapy*
• Health Services Accessibility
• Hypoglycemic Agents / administration & dosage*
• Insulin / administration & dosage*
• Insulin / analogs & derivatives
• Nurse Clinicians*
• Organizational Case Studies
• Patient Care Team / organization & administration*
• Patient Compliance
• United Kingdom
• Hypoglycemic Agents

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A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system

• Research Article
• Open access
• Published: 09 November 2020
• Volume 43 , pages 884–892, ( 2021 )

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You have full access to this open access article

• Fahad Alshahrani 1 , 2 ,
• John F. Marriott 1 &
• Anthony R. Cox   ORCID: orcid.org/0000-0003-2294-3440 1  

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Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important.

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Avoid common mistakes on your manuscript.

Impacts on practice

When implementing e-prescribing a system-wide review of prescribing, including characteristics and behaviours of prescribers, patients and the work environment should be undertaken to design out error.

Prescribers from all professions describe similar difficulties with electronic prescribing, so training provision should be provided for all and should be multi-professional.

Those implementing electronic prescribing systems should warn users of the distinct new forms of prescribing error that can occur.

Introduction

Medication errors, defined as ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’ [ 1 ], are responsible for significant morbidity and mortality, as well as increased costs of healthcare [ 2 , 3 ]. The World Health Organisations Third Global Patient Safety Challenge is focused on a reduction in medication errors by 50% [ 4 ] and reducing prescribing errors is a key part of this drive. In the UK, prescribing errors are estimated to occur in 8.9 to 14.7% of hospital inpatients and discharge medications [ 5 , 6 , 7 ].

Computer Physician Order Entry systems (CPOEs) are seen as essential for improving both efficiency and patient safety in relation to prescribing [ 2 , 8 , 9 , 10 ]. CPOE enables prescribers to enter drug prescriptions via a computer application rather than paper. Evidence suggests that the use of CPOE reduces the prevalence of prescribing errors, [ 11 , 12 , 13 , 14 , 15 ] by removal of legibility issues, guiding prescribers to appropriate prescribing decisions, and providing a robust system of audit.

Although the overall error reduction from CPOEs is uncontroversial, novel types of error have emerged associated with CPOE [ 16 , 17 , 18 ]. Some case studies of CPOE implementation have showed an increase in the number of higher severity medication errors [ 19 , 20 ]. Malfunctions of clinical decision support systems (CDSS) in CPOE can also impact on patient safety [ 21 ] and can arise from the complexity of coding clinical concepts in hierarchies within CPOE [ 22 ]. Staff perceptions of prescribing safety following CPOE introduction may also be counter-intuitive. Davies et al. [ 23 ] found that health care staff’s perception of safety culture deteriorated after electronic prescribing was introduced. Despite this, CPOE remains a key part medication error prevention [ 24 ].

CPOE design choices can also make some errors more likely; e.g. as a result of an incorrect selection on a drop-down menu, an electronic prescription for diamorphine was created at 70 times the required dosage [ 25 ]. Similar unintended adverse consequences of CPOE systems have been reported [ 16 , 26 , 27 ].

Qualitative research on prescribing errors has examined multiple influences of prescribing errors in secondary care [ 5 , 28 , 29 , 30 ], highlighting insufficient training and high workloads. A meta-synthesis of integrating CDSS into clinical work found problems with useability and socio-technical issues on implementation [ 31 ].

In many countries non-medical prescribing is becoming more common [ 32 ], but there are no qualitative studies of prescribing errors by medical and non-medical prescribers in the context of CPOE.

Aim of the study

The study aimed to examine the views of pharmacists, nurses, and medical prescribers on the causes of electronic prescribing errors in a CPOE system in one large, multi-speciality UK NHS hospital.

Ethical approval

The study was approved by the University of Birmingham Research Ethics Committee (ERN_15-0161), Research and Development Department at the University Hospitals Birmingham NHS Foundation Trust (UHBFT) in September 2016 and NHS ethics committee.

The study used a qualitative design, employing semi-structured interviews exploring the potential causes and contributing factors of prescribing errors in an electronic prescribing context. Thematic content analysis was combined with critical incident technique (CIT), to explore the factors influencing prescribing errors. CIT allows interviewees to describe an event, allowing collection of facts, and subsequent evaluation of a cause. It is well suited to studying the interaction of subjects with technology, having been first developed with pilots [ 33 ]. CIT informed the interview guide, as well as prior studies investigating prescribing errors [ 6 , 28 ]. Three case studies of prescribing errors were used to provoke discussion of error in a non-threatening manner, since participants might not be willing to talk comfortably about errors of their own or others owing to fear of incrimination. The final interview guide (See Supplement 1) was piloted with four experienced pharmacists to ensure clarity and face validity. The interview guide also examined prescribers’ specific views on CPOE design; these results will be reported elsewhere. The analysis of the views and experience of three groups of prescribers, with differing standpoints, additionally provided a form of data triangulation.

Study location

Participants were recruited from an academic tertiary care hospital in the West Midlands, which operates a locally developed electronic prescribing system (Patient Information Communication System—PICS). The system includes integrated clinical decision support features, such as dose range checking, drug interactions alerts and contraindications (e.g. drug-disease, allergies). The system is used for in-patient, out-patients, and day care prescribing.

Participants

A purposive sampling methodology was used in order to target varied groups of prescribers. All active medical and non-medical licensed prescribers (pharmacists and nurses) working in the trust were eligible for inclusion.

The prescriber types approached in this study were:

Junior doctors: All training and non-training grades (Foundation Year 1 and Foundation Year 2, Specialty Registrars, Junior Specialist Doctors).

Senior doctors: Staff Grades and Consultants.

Independent Pharmacist Prescribers.

Independent Nurse Prescribers.

All medical and non-medical prescribers in the hospital were contacted via email and invited to interview. All prescribers who expressed an interest received an email consisting of an invitation letter and participant information leaflet. It was made clear to participants that any individuals involved in errors should not be named, and that no blame would be assigned to them as a result of the interviews. Interviews were arranged at a mutually convenient time and place for the interview, in a workplace setting (such as a quiet office). No third parties were present at interviews. Consent was obtained before the interview commenced and participants were provided with a brief explanation of the purpose of the study.

Data collection

The face to face interviews were conducted between 5th December 2016 and 25th April 2017. Interviews were recorded and discussions lasted between 20 and 30 min. Interviews were conducted by a male investigator (FA), a qualified pharmacist of several years clinical experience undertaking a fulltime PhD in electronic prescribing. The interviewer had no prior relationship with any of the participants. Participants were not given transcripts for correction.

Data analysis

Interview data was transcribed verbatim into an anonymous format, which was loaded into NVivo® version 10 for data management. Data analysis and recruitment was conducted in parallel, with ongoing analysis informing the researcher. A response rate could not be calculated there was no reliable figure for the total number of prescribers within the organisation. However, participants were recruited until data saturation was achieved, when it was judged that no new additional themes were arising from the analysis [ 34 ].

An inductive and deductive approach was used in this study, to develop a thematic analysis of the data. Inductively, this was based on the interviewees' responses. The deductive approach was based on a framework for analysing risk and safety in clinical medicine [ 35 ] which is based on frameworks used in the human factors field. It includes institutional contexts, organisational factors, the work environment, team and individual factors, task factors, and patient characteristics. Coding was carried out on a line by line analysis. All transcripts were coded by FA. Following initial analysis, codes were refined and combined where appropriate, and clustered into broad themes. Coding accuracy and thematic analysis was cross-checked by two additional researchers (ARC, JFM), with differences resolved via consensus.

Characteristics of the participants

A total of 23 medical and non-medical prescribers were interviewed. No one who responded to the initial study email refused to participate. We were unable to estimate a response rate, since we have no reliable figure for the total number of prescribers within the organisation. The demographics of the study participants are in Table 1 .

Participants’ perspectives on prescribing errors

Six major themes influencing prescribing errors in CPOE systems emerged from the analysis, which are illustrated in the conceptual framework in Fig.  1 . While these emergent themes were clear, they were interconnected, with participants describing a complex process during the process of prescribing. Multiple causes could contribute to a prescribing error. The following sections describe these major themes.

Conceptual figure of the interaction of the six major themes leading to the production of a prescription

Issues related to the CPOE design were common. Selection of the wrong item from an electronic dropdown list was identified by most participants (18/23). These included juxtaposition errors, where a medication with an entirely different indication than intended, listed before or after the desired medication, is erroneously chosen. Prescribers felt that such issues would not happen when using handwritten order systems.

it’s easy to click on the wrong drug, not double check it and just click again and obviously you are responsible for that’s being tracked, uh, and I think when you are doing written prescribing, you know what you’re writing. Whether you write it fast or slow, you know what you’re writing…” Junior Doctor 2

Prescribers also noted that on entering the first few letters of a drug name, the system would “suggest” a medicine name, which could be easily selected in error. Prescribers suggested the imprecision of touch screen computers worsened this risk.

Prescribers noted that errors can occur by selecting the wrong patient owing to the nature of the patient list structure; the correct medication being prescribed to the wrong patient (which was also linked to prescribing away from the physical location of the patient). The ability to prescribe for patients remotely rather than attending the patient directly, was also believed to lead to a disconnect between the act of prescribing and clinical assessment of the patient.

if you prescribe something without assessing the patient, so if someone rings and says oh, they need some painkillers, you might prescribe a painkiller that they shouldn’t have, based on their clinical picture. Junior Doctor 3

Auto-population of information by the CPOE, such as drug dosing frequencies, to a default setting, led to prescribers allowing defaults stand when inappropriate to the specific patient. Not correcting them led to reduced conflict with the CPOE system. An example of prescribing error from auto-population was:

I had a patient that was prescribed baclofen. We changed it from tablet to oral solution. They were on 10 mg once a day before they changed it, so it was prescribed fine on PICS, baclofen 10 mg tablets once a day. But they had swallowing difficulty, so we changed it to oral solution which defaulted the dose to 5 mg of TDS. Senior Doctor 2

Participants described an expectancy that CPOE’s safety measures would intervene to prevent errors, that they felt made them complacent. Yet, at the same time prescribers described over-riding alerts without conscious jugement. This was due to a perception of too many warnings and alert fatigue.

After a while, you get used to the warnings, so you, sometimes, you probably don’t read them as well as you should so you just keep clicking the warning off and you might miss a warning and still prescribe a drug for a patient that probably shouldn’t be having it. Junior Doctor 3

Prescribers noted the complex nature of electronic prescribing systems and how the rigidity of the process of prescribing medicines has the potential to lead to errors. This was noted particularly for non-standard intravenous products.

The prescriber

Participants noted a lack of knowledge including deficits in drug knowledge for appropriate drug dosing (e.g., giving the wrong dose for renal or older patients) and failure to apply a protocol (e.g. modifying the dose in the presence of renal failure).

there would have needed to be a knowledge by the prescriber about the correct dosing of the enoxaparin and really you should not need a computer to…I would expect a doctor in renal medicine to know what the correct dose was and prescribe the correct dose. Nurse 2

Participants reported that high work load caused rushed working practices that led to prescribing errors. Prescribers’ emotional status and their stress levels and tiredness were described by them as being likely to contribute to an error.

if the doctor is very busy and particularly they’re on call and they have got a lot of things to do; they tend to forget things, we’re human beings and we tend to forget things and when you forget, you make errors. Senior Doctor 1

Participants reported that errors were caused by slips in attention or lapses of memory. Memory lapses included situations such as prescribing a medication to which a patient has an allergy. Forgetting to navigate from the current patient’s profile to prescribe for another patient was reported as an example of slips.

I saw four patients. The nurse comes to me. I’ve got PICS opened up and nurse tells me that your patient has got a heart rate of 200. So I want to prescribe a beta-blocker. Then I look for the patient but I usually don’t concentrate because I’m still stuck with another patient. In the, doing the work, I’m looking after another patient and I’m prescribing medicine in another. So I ended up prescribing a medicine for my patient, the one who I was looking after now. So these are very common errors I see. Senior Doctor 2

Negligence in following standard procedures was identified as a contributing factor to prescribing errors. Those prescribers accustomed to a paper based system were incautious within an e-prescribing system.

it's because people don't understand how electronic prescribing system works, they don't know how to read and follow through because we are so used to paperwork and people are not really, I hate to say this, but people do things without even reading exactly what they are doing, that could cause an error. Nurse 1

The patient

Patients with complex comorbidities receiving multiple medications were cited by many participants as a high risk area for prescribing. These could include issues involving routes of administration, as well as dose and drug choice.

on the critical care particularly the routes that are normally available on the ward are not always appropriate for my patients. So, something that they were previously swallowing is now going down a nasogastric tube – so, we have to make a lot of dose adjustments for going between IV and oral routes, or oral and other enteral routes, so there are quite a lot of errors there” Pharmacist 5

Errors arising from mis-remembered medication history from patients was also raised.

Sometimes patients think they’re on a specific dose, but they’re not on that dose, so you might go from patient information and then you prescribe the wrong dose, but it’s on what the patient said as well. Junior Doctor 3

Prescribing errors were reported to occur when a medication history is unavailable or irretrievable when patients are admitted to hospital.

it becomes a detective case and, and again, that’s not a very safe way of prescribing because, but, you know, the …You're faced with, out of hours you're faced with the option of not prescribing any drugs—and waiting for the next day until the GP surgery opens or a family member can bring in the prescription. Junior Doctor 4

Prescribers reported how unfamiliarity with the patients contributed to their prescribing errors, even in the presence of a good medical history. Treating a patient under the care of others while oncall was a common example given:

You’re asked to prescribe this or, you are asked to see them because they’re deteriorating, you want to prescribe this or that, and you don’t know them as well. Junior Doctor 2.

The task of prescribing was a strong theme. Prescribers noted that errors occur because a medication history is unobtainable, especially after business hours. During these periods GP surgeries are closed and the patient could be unable to provide an accurate medication history. Lack of access to patient records were identified as a contributing factor leading to prescribing errors.

the doctors don’t have access to summary care records so it’s hard for them to get a drug history properly especially if a patient comes in when they’re confused….I’ve seen that sometimes patients say oh, I’m on bisoprolol but they don’t know the dose, so the doctors just prescribe bisoprolol and they just go with the default on PICS” Junior Doctor 4

Prescribers noted that some medications (such as morphine or HIV medications) are not shown on patient records as they may be prescribed by specialists, which could lead to medication omissions. The difficulties of sharing or transferring information between hospital and primary health care sectors was noted. Outdated discharge summaries and modifications to therapy by GPs or out-patient prescribers that had not been updated in care records were cited as specific examples of causes of inaccurate medication histories, inevitably associated with prescribing error.

I mean there is always the barrier in certainly between community and hospital. We don’t have access to their records, they don’t have access to our records. Junior Doctor 4

Prescribers also noted that errors can occur when they want to prescribe a medication in the absence of essential laboratory results.

So sometimes, um, you’ll prescribe a medication before the blood results are back.[.] You might put them on a diuretic before they know they’ve got acute kidney injury. Senior Doctor 4

Several prescribers highlighted poor communication between team members. As an example, using bed numbers rather than patient’s name was reported to cause prescribing errors. Inadequate communication between healthcare professionals when patients were being transferred, or during care team hand-over, was noted as a cause of prescribing errors.

if someone has told you—so you mix them up, yeah, so if someone has told you bed 4 needs paracetamol and bed 5 needs codeine, you might mess it up. Especially when they don’t use names, if they use bed numbers, you could mix it up because it is a pressured environment” Junior Doctor 3

Staffing levels were also mentioned as being associated with prescribing error. Inadequate staff numbers, staff turnover and providing cover for absent colleagues were highlighted to increase workload and thus predispose to error generation.

The environment

Interviewees suggested that the working environment is a major contributor to prescribing error. Heavy workload, time pressures, a chaotic, distracting environment and the need to perform more than one task simultaneously, in the context of the CPOE system, were commonly mentioned.

On differences between non-medical and medical prescribers

This study involved participants from across three differing prescribing professions and found no systematic differences in the experiences of CPOE based on professional background. Although pharmacists’ role as a clinical reviewer of other professions’ prescribing led them to volunteer examples of other professions’ prescribing practice, reflections on their own prescribing practice was similar to that of other professions.

Our study found that the causes and contributing factors to electronic prescribing errors described by prescribers from different professions are multifactorial and interconnected. They have been classified into six high-level categories (the computer system, the prescriber, the patient, the task, the team and the work environment) that contributed to prescribing errors. The causes and contributing factors of electronic prescribing errors reported from different prescribers (medical and non-medical) were similar to many of the prescribing errors that occur with conventional handwritten prescribing [ 5 , 28 , 29 ] with the addition of errors related to the electronic system specifically. A qualitative study of implementing CDSS, rather than CPOE, found some similar categories, including issues such as people, culture, communication, as well as the more technical issues one might expect [ 36 ]. Implemention of CPOE needs at least as much thought put into the human and organisational implementation, as it does the technical implementation.

Types of errors

Electronic prescribing systems reduce prescribing errors overall and they can create or propagate new issues which have been highlighted in previous studies [ 18 , 37 , 38 , 39 ]. Our study confirms this with medical and non-medical prescribers. Whether these errors arise from design interface problems resulting from densely populated medication lists causing juxtaposition problems, prescribers relying on potentially inappropriate default doses, or human factor considerations, the recognition of such problems and their consequences by system designers should improve outcomes when implementing new alerts in e-prescribing systems. Inflexible or complex ordering processes made prescribing particularly difficult and users noted that this could result in forced errors.

Distractions and over-reliance

Also, distracting features of electronic systems caused by excessive alerts generated by the system during prescribing were cited as a disruptive effect by prescribers. A series of best practices have been suggested for alerts in CPOE and CDSS systems [ 40 ], but the evidence base for optimal amount of alerts and nature of such alerts, is weak [ 41 ].

Prescribers in our study also noted the potential for over-reliance on CPOE systems. Such automation bias has been studied in experimental conditions and over-reliance on CDSS in CPOE led to increased prescribing errors [ 42 ].

Prescriber knowledge and training

A lack of knowledge of medication appears to be a major contributor to prescribing errors in previous studies [ 5 ] and arises in our study. Addressing knowledge deficits has been a long term concern [ 43 ], with continuing professional education for safe prescribing practice essential. Online resources such as the eLearning programme tool called Standard Computerised Revalidation Instrument for Prescribing and Therapeutics (SCRIPT) [ 44 ] can promote safer prescribing in both medical and non-medical prescribers ( https://www.safeprescriber.org ).

Hospitals should ensure all users have access to adequate training before accessing the system. Learning outcomes for the electronic prescribing records have recently been published [ 45 ], and similar is required for electronic prescribing systems. A literature review of the training offered in electronic prescribing to qualified prescribers found only seven papers, which rarely covered the potential downsides of electronic prescribing [ 46 ].

However, training may not always be effective. A small randomised control trial of feedback and training in relation to electronic prescribing found little effect and the authors argued that re-designing electronic prescribing systems would change prescriber behaviour more than education [ 47 ]. Latent failures built into CPOE provide the conditions in which prescribing errors occur, when high work load pressure and working environment distractions appear [ 48 ]. However, compulsory condensed technical training on how to use the system effectively, particularly during the “shakedown” phase of implementation would seem prudent [ 49 ].

Socio-technical issues

Our study found prescribing errors related to the hierarchy, culture and poor communication between team members. These errors were mainly owing to barriers in communication between healthcare professionals and the inability to access insufficient drug information and guidelines at the time of prescribing. Prior research on the effect of CPOE on pharmacist-physician communication has shown increased frequency of communications between pharmacists and physicians [ 50 ] provoked by many of the causes of error (such as lack of knowledge of the prescribing system) was also found in our study. A systematic review of the implementation of CDSS found similar socio-technical issues to those we found, including communication issues [ 51 ].

A complex problem

Our study indicated that inadequate access to a medication history of patients across health care sectors leads to prescribing errors. Franklin et al. [ 6 ] found that a lack of information of patients’ medication histories from primary care settings contributed to prescribing errors in hospital settings. Significant improvements in medication histories and documentation of allergies has been shown when pharmacists are given this responsibility [ 52 ].

Our finding that medical and non-medical prescibers described prescribing errors as multifactorial is consistent with previous studies [ 5 , 29 , 30 , 53 , 54 ]. All of these factors would be common to different prescribing professions and all would be subject to the same human cognitive biases, so it is perhaps not surprising that little difference between professions in the experience of CPOE was apparent.

Reducing prescribing errors

Recommendations for implementation of CPOE have been published [ 55 , 56 ] and it is clear that socio-technical changes to interprofessional and patient communications caused by CPOE are also an outcome of CPOE implementation. Many issues are common to both CPOE and paper-based prescribing systems. We did not distinguish between these, since this is not a comparative analysis. We argue that CPOE systems should be examined as a whole, and it can be difficult to make the judgement about whether the CPOE was or was not involved in any particular event.

A policy brief summary analysing 40 systematic reviews, suggested actions dealing with prescribing error, including education for prescribers, incorporating computerised alerts, incorporating tools to guide prescribing, and encouraging multidisciplinary teams, including pharmacists, to care for patients [ 57 ]. This underlines that CPOE is only one intervention to reduce prescribing errors.

Strengths and limitations

This is the first qualitative study to explore the causes of prescribing errors made by different grades of medical as well as non-medical prescribers in an hospital CPOE system setting. Previous research has focussed on prescribing by junior doctors and trainees [ 5 , 29 ].

The interview guide was piloted in clinical pharmacists only. While they have professional insight into prescribing errors, wider piloting with other professions could have given additional insight. Interviewees were not asked for feedback on the interpretation of their interviews. Our study was carried out in one hospital site operating a single CPOE system, limiting the generalisability of the findings, however our results reflect themes found in the wider literature.

Medical and non-medical prescribers have similar experience of prescribing errors when using CPOE, with the broad areas of concern aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. Solutions focused on a single factor, such as system design or training, may only result in only limited impact on prescribing errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical and environmental aspects of practice remain important.

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Acknowledgements

We would like to thank the participants in this study for their time and interest.

The study was funded by the University of Birmingham, and The Saudi Cultural Bureau funded Fahad Alshahrani’s PhD studies.

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Alshahrani, F., Marriott, J.F. & Cox, A.R. A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system. Int J Clin Pharm 43 , 884–892 (2021). https://doi.org/10.1007/s11096-020-01192-0

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DOI : https://doi.org/10.1007/s11096-020-01192-0

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HX NMP The case study will critically analyse and reflect on current practice considering

HX NMP 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.

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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. Review 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.

Record Keeping 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.

Reflection 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.

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A Supreme Court abortion pill case with potential consequences for every other drug

Nina Totenberg

The Supreme Court of the United States building is seen in Washington, D.C., on March 15, 2024. Celal Gunes/Anadolu via Getty Images hide caption

The Supreme Court of the United States building is seen in Washington, D.C., on March 15, 2024.

Abortion is back at the Supreme Court Tuesday. This time anti-abortion doctors are challenging the FDA's regulatory actions making abortion pills more accessible.

More than half of American women who choose to terminate a pregnancy do so using a two-drug combination of pills. So you might call this case "daughter of Dobbs ," the Supreme Court's 2022 decision reversing Roe v. Wade and leaving the legality of abortion to the states.

Only this time, there is more at stake than abortion rights. It's the entire structure of the FDA's regulatory power to approve drugs and continually evaluate their safety—a system that until now has been widely viewed as the gold standard for both safety and innovation.

On the line, a challenge to the FDA's scientific expertise

"It would be traumatizing to the system," says Marsha Henderson, a former FDA associate commissioner for women's health and a 22-year veteran of the agency.

Shots - Health News

What's at stake in the supreme court mifepristone case.

"We have a very clear scientific approach...it's not just a helter-skelter set of ad hoc opinions," Henderson says. "There are teams of scientists and researchers that participate over many years, starting from phase one pre-clinical all the way through post market...and the information, the data evolve, and they collectively help to enhance the whole research world."

If you start putting politics or junk science into the mix, she warns, the system will collapse.

The challenge in this case was brought by the Alliance for Hippocratic Medicine, an association of anti-abortion doctors founded just months after the Dobbs decision. The group quickly filed a lawsuit seeking to get rid of abortion pills altogether. After a tortuous and tumultuous series of lower court rulings, the Supreme Court intervened to prevent any change to the status quo while it considers the case.

No longer at issue is the FDA's initial approval of the pill, which occurred nearly a quarter century ago and is no longer subject to challenge. Instead, at issue are many of the conditions which were imposed on the drug when it was first approved, conditions that have since been lifted.

Medication abortion is still possible with just one drug. Here's how it works

Siding with the FDA in this case are virtually all of the major medical associations in the country, as well as pharmaceutical and bio-tech companies, big and small. On the other side is the Alliance for Hippocratic Medicine, which contends that the FDA's loosening of restrictions is unjustified and unsafe.

A senator's wife becomes a new star in the anti-abortion legal world

Arguing in the Supreme Court Tuesday on behalf of the anti-abortion doctors is Erin Hawley, wife of Republican Sen. Josh Hawley.

"Regardless of one's views on abortion," she says, "we should want women to take those drugs with sufficient safeguards, as well as want the FDA to do its job." It didn't do that, she contends.

The drug at the center of the case is mifepristone , marketed by Danco Laboratories as Mifeprex. There is also a generic version of the drug. Since approving mifepristone 24 years ago , the FDA has authorized changes in the drug's dosing, and over time, has lifted many of the initial restrictions on dispensing it.

The dosage was changed in 2016 to reduce the amount of mifepristone by two thirds, and to increase the amount of a second drug, misoprostal, a combination that the FDA found decreased serious complications. That change has not been challenged. What is before the court Tuesday are other FDA decisions that over the last seven years have made access to abortion pills easier.

The FDA lifts some restrictions

In 2016, the FDA approved the use of mifepristone for up to 10 weeks of pregnancy, instead of the previous seven weeks; it reduced the required number of in-person visits to doctors from three to one, and lastly, it permitted the drug to be prescribed and dispensed not just by doctors but, in states that allowed it, also by specially certified midwives and nurse practitioners.

In April 2021, at the height of the pandemic, the FDA temporarily dropped the in-person dispensing requirement, citing the health emergency. That allowed patients, who previously had to go to a clinician's office for their pills, to instead get their prescriptions filled at pharmacies or by mail.

Despite bans in some states, more than a million abortions were provided in 2023

The pandemic changes become permanent.

Eight months later, the agency looked at data collected during the "natural experiment" created by the pandemic. It found no difference in serious adverse events whether the drug was dispensed in person or not.

"The safety profile remains the same," whether the pills were taken after an in-person visit or without one, says Jessica Ellsworth, who represents Danco Labs. In a circumstance like this, Ellsworth adds, the federal law which authorizes the FDA to regulate medications, "specifically directs" the agency to loosen restrictions when they are shown to be unnecessary. That's what the agency formally did in 2023, after finding that there was no uptick in serious complications after getting rid of the in-person visit requirement.

Hawley, the lawyer for the anti-abortion doctors association, counters that the data the FDA relied on is inadequate to justify the changes that make mifepristone more accessible.

"We have just a couple of years under this regime," she says. "We have not a lot of data to support it."

The challenge to the 2016 changes

She also maintains that the data also doesn't support the 2016 changes—for example, the agency's decision to increase approval of the drug for use during the first 10 weeks of pregnancy, instead of the original approval for seven weeks.

"The child is larger, the pregnancy tissue is larger, and for that reason, the record shows...that the risk of complications goes up...tenfold from seven weeks to 10 weeks," Hawley says.

"Not true," responds Ellsworth, counsel for Danco. "Not true at all."

Abortion pills that patients got via telehealth and the mail are safe, study finds

She says that in making the 2016 changes—including adjusting the dosing regimen and extending approval for use up to ten weeks of pregnancy—the FDA looked at data that showed fewer complications than when the drug was initially approved for just seven weeks in 2000.

"The number of women who need any follow-up care...went from roughly eight percent to somewhere between two and three percent," Ellsworth says. "So they're just wrong when they suggest that there is some kind of additional complications that were brought on by moving to 70 days."

The procedural hurdle that could throw the case on the dump heap

This entire debate could be for naught at the Supreme Court Tuesday because the anti-abortion doctors first have to get over an important procedural hurdle. Namely, whether they have legal standing to challenge the FDA's mifepristone decisions, since none of their members prescribe the drug for their patients.

Hawley is adamant that they do have standing. "The fact that our pro-life doctors have oriented their practices and even their lives to avoid elective abortion procedures, I think goes to show that those doctors do have standing here."

She also maintains that the FDA's regulations on mifepristone would "conscript" emergency room doctors into performing dilation and curettage procedures after patients come in with incomplete abortions.

But the government counters that the Alliance has been unable to identify a single such occurrence.

Reproductive rights in America

Access to a key abortion drug is in legal limbo. here's how medication abortion works.

No matter which side prevails, a single aspect of this case is truly remarkable. One would be hard pressed to find another case in which the government regulator, the regulated industry, and even the independent watchdog group that frequently criticizes the agency are all on the same side.

"This is a dagger at the heart of the entire industry," says Jeremy Levin, CEO of Ovid Therapeutics, one of the many pharmaceutical companies siding with the government in the case. If the court rules in favor of the anti-abortion doctors, Levin cautions, "the industry would be thrown into complete disarray. Finding new medicines will be nearly impossible to do."

A decision in the case is expected by summer.

• abortion pills
• Supreme Court