The nursing profession has encountered a significant evolution over the recent years with new roles, especially in specialist areas being adopted by nurses (Hoeve et at. 2014). Independent prescribing (IP) has been figured out to be among the roles and skill being taken up as the changes unfold. According to Hoffmann, & Del Mar, (2015), IP is not the only recommendation of treatment but also a choice of prescription and a treatment plan that take into consideration the patients’ values, beliefs, preferences, expectations and diversity. With the IP, the nurse is accountable and responsible for the decisions concerning the management of the patients in the clinical setting including prescribing and also the assessment of patients (National Institute for Health and Care Excellence (NICE), 2018).
The IP concept seeks to achieve modernization of service, enusure delivery of quality care and considers the choice of the patient without compromising safety guidelines. IP work to tranform the traditional compliance model, which involved the patient being guided by the prescriber’s directions to a change in culture of concordance, where prescription is made and medicine taken depending on a well-established collaboration between the professional and patient. As a result, the delivery of quality care and proper management of diabetes has been noted by several care givers and even individuals as being critical (American Diabetes Association, 2013). The people living with diabetes have reported IP to have led to an improvement in the case management (Courtenay et al. 2010).
About 463 million people have been diagnosed diabetes globally, hence showing that it is at epidemic levels (International Diabetic Federation (IDF), 2019). Wylie et al. (2019) has shown that individuals diagnosed with diabetes feel left out when making a decision relating to their health. They, therefore, feel that this limited involvement frustrates them. Tabesh et al. 2018 illustrated that most of the cases are managed in the primary care level, where the key role players are nurses who have elaborate skills, for example, non-medical. Therefore, there has been advocacy for alteration in the primary care where a patient centred model for care should be used and also the non-medical staff have to improve their skills. This, however, can only be achieved through combined efforts working together for better health.
The author is in a primary care setting as a practice nurse, engaging nurse-led clinics in baby vaccinations, chronic disease management, travel vaccinations, complex care management which includes type 2 diabetes management. Being a practice nurse provides a perfect opportunity to deliver patient-centred care which entails establishing a rapport and assessment of the individual needs. The author looks forward to being an independent nurse prescriber upon successful completion of the non-medical prescribing course, which is pursuing currently. The practitioner will, therefore, be able to provide care that is holistic to the patients and also gets to focus on conditions that are more complex (McArdle, 2017).
Compared to its initiation in the 80s nurse prescribing has grown significantly according to the Cumberlege report (Dowden 2016). Royal Pharmaceutical Society competency framework now controls the nurse prescribing (RPS 2016). The framework needs that the prescription is done safely and accurately. Moreover, the prescriber should be patient-centred while prescribing. Critical application and demonstration of how legal, ethical and professional factors have been applied in decision-making processes by the involvement of the patient and enabling the patient to get better results from their treatment. The framework is split into two sectors that entail ten competencies (RPS 2016).
The case study of a client diagnosed with type 2 diabetes in 2017 based on the RPS framework will be discussed by the author. The primary issues were medication adherence and a language barrier. The author will further take into consideration the legal, ethical and professional factors in line with prescribing. To maintain confidentiality and privacy, the identity of the client has been altered in accordance with the Nursing and Midwifery Council codes (NMC 2018). The author performed an assessment that is holistic on the patient, taking into consideration the past and medical history, past and current medication and psychosocial history, as verified by the NMC (2018).
The client named JAZI is a 52-year-old Syrian man who attended the clinic for review of diabetes. He had several co-morbidities including hypertension, sarcoidosis, hyperlipidaemia, s and skin rashes. Jazi is an ex-smoker and non-drinker. He is married with four daughters. Jazi’s current diabetic treatment consisted of Sukkarto 2 tablets twice a day with meals and Canagliflozin 300 one tablet daily. He had been on three different diabetes drugs prevously; however, all were stopped as a result of the side-effects reported, including weight gain.
According to NICE (2009), failure to adhere to medication is divided into two groups – unintentional and intentional. It is termed unintentional when a patient can adhere to drugs as prescribed but cannot adhere because of barriers that are beyond their control. This was the case with Jazi. His HBA1c at 73 mmols/mol showed that he had substandard diabetic control. The goal of management of diabetes is to get glycaemic control that will make the general health patients better and delay or prevent complications (Davies et al. 2018). According to NICE (2017), 53 mmols/mol should be targeted during treatment. However, there is a need for the targets to be individualized. The glycaemic targets people that are old have to be in line to functional status, and the polypharmacy, co-morbidities, pharmacodynamics and pharmacokinetics should be put into consideration.
Jazi is a morbidly obese man with a body mass index of 40 ug/m2, a blood pressure reading of 164/90 and total cholesterol of 6.2 mmol/litre and all of these parameters were above the recommended targets. His hypertensive drugs had already been reviewed and were being followed up. Unfortunately, statin medication was not tolerated by the patient. On physical examination, Jazi had no open wounds and there was low risk according to diabetic foot assessment.
The management of type 2 diabetes according to NICE (2017) encourages lifestyle modifications, diet reinforcement, and strict adherence to the medication. Using a non-judgemental approach, the author studying Jazi’s personal health beliefs as related to his diabetic condition. This is significant in order to figure out the patient’s preferences and perceptions (NICE 2009). Non-pharmacological interventions were talked about with Jazi, including possible lifestyle interventions. Jazi felt that he could not make many alterations in diet. He felt that his exercise capability was limited because of his other medical conditions, particularly his obesity. With the help of an interpreter, treatment options were discussed with him, using the evidence that was best reachable as confirmed by the NMC (2018). However, psychological counselling skills or motivational interviewing may lead to better results with adherence to diabetic medication (IDF, 2012). The ethical and legal implications must be put into consideration by the prescriber whenever prescribing any medication.
Lovatt (2010) mentioned that nurse independent prescribers (NIP) are responsible in 4 areas – criminal law, professional liability, civil law, and employment law. The NMC (2018) underpins professional accountability and competency and also ensures that prescription is within the NIPs scope of practice (2018). Lovatt (2010) also stick to the fact that the ethical principles of non-maleficence, beneficence, autonomy and justice have to guide decisions of the prescriber. Moreover, Beauchamp and Childress (2009) indicated that the significant ethical principles to be noted in healthcare during decision-making include; non-maleficence, beneficence, justice and autonomy. The ethical dilemmas have to be balanced
Any patient factors that are relevant have to be taken into consideration, as illustrated in the RPS (2016) competency framework. Nursing and Midwifery Council (NMC) (2018) requires that nurses should be vigilant of likely harm associated with their practice and minimize this as far as possible. This is supported by Lovatt (2010) who elaborated that reducing risk, taking into consideration the best interest of patients every time and practicing to high standards upholds legal and professional accountability. Once the decision has been reached, the prescriber must obtain consent before that treatment starts. The consent is only valid if it is given voluntarily, well informed, and the patient is marked as competent to provide that consent. The NMC (2018) Code further endorses the principle of consent. The author partnered with Jazi and obtain verbal consent for the treatment plan agreed. His diabetic management was also reviewed by a GP colleague, with the help of an interpreter.
The RPS (2016) framework requires the provision of adequate information to enhance the concordance of medication by the patient. Jazi was given with a patient information booklet on diabetic medications and a general information leaflet. He was advised about websites where he could watch and listen to videos in the Arabic language. Jazi was given a contact for the nurse practitioner and an appointment for follow-up for one month. The Northern Ireland Medicines Optimisation Quality Framework needs that when patients with chronic conditions, who are started on medications or have their medications changed or stopped, they should be reviewed to make sure the medications are safe and effective. Jazi was reviewed at one month and again at three months. At his three months review, his HBA1c had improved and was down to a level of 61 mmol/mol, and he had lost weight. Jazi had issues with adherence to his diabetic treatment. This led to the author encountering a prescribing challenge. With the help of RPS (2016) competency framework, the author was enabled to apply a patient-centred model to help concordance on the part of the patient, in an endeavour to obtain better health outcomes for Jazi and at the three months review it certainly showed some improvements.
According to the Prescribing governance, the prescriber should prescribe in a safe and professional manner. It also seeks to improve the practice of prescribing and to make prescription as a team (RPS 2016). Cost-effective choices must be considered while prescribing professionally. In 2017/18, 53.4 million items were allocated for diabetes, with a costing of £1012.4 million (NHS Digital 2018). NICE (2009) highlighted that about half of all drugs prescribed for chronic conditions are not adhered to. Prescribers should avoid undue influence from representatives of a pharmaceutical when making decisions. We also have to look into our prescribing practices and listen carefully to feedback received from patients, carers and colleagues.
To sum up, NIPs have been aware of the legal, ethical, and professional factors that guide them as prescribers, thereby ensuring efficiency and safety while prescribing. Moreover, there should be detailed structure and measures on how the issue of adherence can be handled. This is because despite making effective and safe decision during prescription, treatment can fail due to poor adherence. The measures should be geared towards ensuring that patients fully adhere to the medication. Lastly, multidisciplinary approach should be encouraged in the management of a patient. This is to ensure that the patient is assessed adequately by the various healthcare staff who are part of the multidisciplinary team and hence individuals needs identified and addressed adequately. This leads to a patient-centred approached and hence better healthcare service.
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