Prescribing Challenges and the Impact on Wider Organizational Practice

Critically reflect upon an issue that you will face as a prescriber within your specialist field; through synthesis of the literature analyse how you will address this issue as a prescriber, and examine how these decisions may impact the wider organisation. Critically examine the relevance of continuing professional development in relation to developing your prescribing competencies. (2,000 words)

3. Critically evaluate the importance of reflecting upon your prescribing practice. Articulate how you may promote continued learning and professional development in relation to prescribing within your own organisation (Reflection 1 and 2).

4. Appraise the impact of individual prescribing decisions from an organisational and leadership perspective (Reflection 1 and 2).

1. Reflect on an issue and how you will address it

2. How decision will impact the organisation and leadership

3. Relevance of continuing PPD

4. Importance of reflecting upon prescribing practice & prescribing competencies

The evolution of non-medical prescribing in the health service allows suitably trained healthcare practitioners to intensify their roles and productively that utilises their skills and competencies to enhance patient care in various settings (DOH, 2020). According to Braun et al., (2016), in England, there are currently 58, 000 estimated independent and supplementary prescribers, and a part of their responsibility is to contribute to a more flexible working in the health service, improve patient care and efficiency in giving time to time medications while maintaining safety. The aim of this reflection is to critically evaluate an issue that the Student Prescriber might face in their specialist field; through synthesis of literature and analysis of how this issue will be addressed. The student prescriber will examine how these decisions may impact the wider organisation. Professional development will be critically examined in relation to development of prescribing competencies. Continued learning and development in relation to prescribing within the organisation will also be evaluated. Finally, the effects of own prescribing decisions from an organisational and leadership perspective will be appraised.

In stroke medicine, dysphasia is a common problem which immensely complicates prescribing as most treatments that have to be given in a timely manner, so as to reduce the likelihood of extreme permanent disability or death. Prescribing and administration of medicines to patients, who suffer from dysphagia following a stroke, bring about substantial challenges to the issue of patient safety, hence ensuring safe medicines management is extremely challenging (Bennett et al., 2013). Clarkson (2011) described Dysphagia as a condition that includes a variety of impairments affecting swallowing. Dysphagia causes further health problems inclusive of aspiration pneumonia, dehydration and malnutrition, which also bring about further challenges and it would potentially lead to the prescribers prescribing other medication to treat the effects of dysphagia if managed inappropriately. Stroke patients with dysphasia often require to be fed and medication administration via enteral route, use of Nasogastric tubes. This increases the risk of medication errors hence Kelly, Wright and Wood, (2011) called upon healthcare practitioners to be more careful upon prescribing, dispensing and medication administration.

Medicines must be prescribed in forms that are acceptable for the forms of administration suitable for the affected individual to avoid patient safety risk through altering solid dose preparations (NICE, 2010). Kelly et al. (2011) suggested formulations such as soluble tablets or solutions to be prescribed for the patients with dysphagia or those on enteral feeding. The challenge is the limited availability of these formulations for various treatments as most stroke patients have other co morbidities. This causes a dilemma, when it comes to clinical decision making and prescribing especially treatments for stroke secondary prevention and also treatments for the diabetes and hypertension, as these should not be withheld or discontinued in appropriately (NICE, 2010).

It takes good specialist knowledge and experience as well as good Multi-disciplinary team work, consulting other professionals like the pharmacist, speech and language therapists and senior medics to provide holistic care and prescribing (White and Bradnam 2011). For instance, some patients are noted to be on antiplatelet medications like dipyridamole modified release, which is in capsule form used as an antiplatelet. While opening the capsule has no effect on the drug properties, the actual opening of the capsule is not licenced making the drug off- label (Wright, 2011). It is therefore vital for the SP to weigh the benefits against the risks, where prescribing decisions are made as the prescribing individual is liable for any adverse reactions that the patient may experience following the use of unlicensed medications (White and Bradnam, 2011). Unfortunately, although a liquid formulation of dipyridamole is available, and it does not have a licence for stroke secondary prevention (BNF, 2020). Moreover, the liquid formula is more costly compared to the capsule the issue of cost of treatments should be taken into consideration at all times while avoiding unnecessary harm to the patient hence a consideration into whether an alternative therapy such as clopidogrel could be prescribed instead (NICE, 2010). Unfortunately, cost may not always be avoidable as most secondary prevention medications in stroke that are complex in the absence of an intact swallow, taking for example lansoprazole capsules are cheaper than the dispersible tablets, and opening the capsule has consequences inclusive of changing the drug to off label and the granules in the capsule cause NG Tube blockage which pauses a challenge to the administration process of the drug (NICE, 2010). This leads to a patient eventually going for long without feeding, leading to a risk in refeeding syndrome./p>

This also applies to crushing medications as that may change the drug efficacy, alter the pharmacokinetic effect of the drug resulting in unrestricted peak plasma concentration which could consequently be toxic to the patient (White 2011). Mitchell (2015) suggested that, concurs reiterating that crushing medications or opening capsules changes the biopharmaceutical features of a drug and its therapeutic outcome, leading to a higher probability of adverse reactions occurring. Furthermore, in patients those are NG fed, some medication like phenytoin, which is a common drug in stroke due to patients experiencing seizure activity to have the potential to interact with the feed. For this reason, it is vital that, clear instructions are written when prescribing as this type of medication may need to be administered at least two-hours post feed (White and Bradnam, 2011). The absence of a complete age-appropriate medication formula that permits a personalisation of medical therapies more-so in dysphagia patients complicates the issue of prescribing, leading prescribers to change solid formulations so as to ease medications administration (Hughes, 2011). All prescribers have an ethical duty to inform the patients about label prescribing and the way of administration for the patient to make an informed consent (Fusco et al., 2016). The SP feels that it is much safer to involve the specialists’ pharmacist where such issues arise as they have more solid knowledge in medications, biopharmaceutics and pharmaceutical technology. The route of compounding medications is said to be hazardous hence Logrippo et al., (2017) adviced that, alternative medicines are necessary to be considered where possible, maybe alternative routes, and adverse events must be cautiously evaluated. Medications such as high dose aspirin may be used in secondary prevention during the dysphasia periods as this can be administered per rectum (BNF, 2020). The SP reiterates that, the patients must be treated as individuals on a case-by-case basis.

The SP intends to practice within the scope of competency as according to the Nursing and midwifery code of professional conduct (2015), which places emphases in non-medical prescribers working within their own standards of conduct and professional boundaries. Nuttall and Rutt-Howard, (2015) suggested that, the NHS put accountability of prescribing the practitioners higher on the clinical agenda, encouraging them to self-assess their prescribing standards via reflective practice, measuring the cost effectiveness of their prescription choices, auditing prescribing decisions and obtaining the service user feedback. This is very important clinical governance that is a principal framework in which NHS services are accountable for improving the quality standards and safeguarding patient safety (RCN, 2021). According to Nuttall and Rutt-Howard (2015), the prescribing practitioner should always ensure that, their prescribing practices are authorised by the employer and anything outside of this falls short of the employer vicarious liability. The NMC Code of Conduct for Non- Medical Prescribers insists that, prescribing practice must always be evidence based and done in according to the relevant local and national guidance. Further, the PSNI (2013) reiterated that, the practitioner must justify any deviation to this practice and patient best interest should always be maintained.

The SP intends to keep and maintain a portfolio as part of evidence for continued professional development. Attending conferences and organised teaching events for NMP’s. The practice portfolios will include personal development plan, a number of prescribing reflections as well as patient feedback. CPD meetings with stroke consultants currently arranged for 3 monthly, ACP study days, ongoing mandatory e-learning as per Trust regulations, medication triannual reviews and every 3 years revalidation will be completed as per NMC regulations. This is supported by the NMC Code of Conduct (2018), who stipulates that, for the nurses to provide high quality, evidence-based care CPD must be at the core of their practice. Further it is of utmost importance particularly for all nurses who take on extended and developing practices such as prescribing (NMC, 2018). Illing et al., (2013) recommended that, the prescribers require a more on the job training prior to being independent with their prescribing careers as this prepares them to being more competent, confident practitioners and better leaders.

In summary, prescribing and medication administration in stroke patients who suffer from dysphagia has a significant risk given the nature of the disease, its treatments and secondary prevention. According to Erdur et al., (2015) without secondary prevention, there is a 50% chance of stroke recurrence within the first 2 weeks of the first event leading to high morbidity and mortality advocating that, there is significant patient benefit from prompt dual antiplatelet therapy. Unfortunately, this is further complicated by dysphagia, the SP has been particularly concerned by the distinct safety and legal aspects, where alteration of medication formulation is concerned for instance opening of capsules or crushing tablets to allow a safe way of drug administration via NG tubes. Kelly et al. (2011) argued that, for medication prescribing and administration in patients with dysphagia to be safe, it is essential for the practitioner to be highly skilled and knowledgeable; hence it is crucial that self-reflection and continuing professional development be a top priority. Mott, (2020) recommended the use of the prescribing framework by the RPS (2016), throughout prescriber’s career stating that, it is vital for the SP to also pass on the knowledge to the new prescribers as this consolidates learning.

The prescribing practitioner’s decisions could have an impact on the organisation through health care costs in the form of extended stay in hospital, hospital readmissions, pharmaceutical expenditure in regards to the costs of prescriptions and managing adverse reactions which may occur, in extreme cases the organisation go through legal costs due to inappropriate prescribing (Moriarty et al., 2019). For the SP working with various other experienced prescribers during her placement in her specialist area has been invaluable experience. Going forward, she will make sure that she is continuously learning, asking for feedback from other prescribers and patients. Seeking help where unsure, accepting own limitations and working closely with the MDT for holistic patient care. Getting patients with dysphasia assessed in a timely manner by the speech and language, reading further on various treatment options for secondary prevention of stroke during the dysphasia period. Finally consolidating communication skills and maintaining personal centred approach to prescribing is important.

Take a deeper dive into Preparing for the Professional Role with our additional resources.

References

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LOGRIPPO, S. et al. (2017) Oral drug therapy in elderly with dysphagia: between a rock and a hard place. Clinical Interventions in Aging, 12, pp. 241-251.

Fusco S, Cariati D, Schepisi R, et al. (2011). Management of oral drug therapy in elderly patients with dysphagia. J Gerontol Geriatr. 2016;64(1):9–20.

Hughes SM. Management of dysphagia in stroke patients. Nurs Older People.;23(3):21–24.

White R, Bradnam V (2011). Handbook of Drug Administration via Enteral Feeding Tubes. Second edition. Pharmaceutical Press, London.

White R (2011). Choice of medication formulation. In White R, Bradnam V (Eds) Handbook of Drug Administration via Enteral Feeding Tubes. Second edition. Pharmaceutical Press, London, 23-34

National Institute for Health and Clinical Excellence (2010). Clopidogrel and Modified-Release Dipyridamole for the Prevention of Occlusive Vascular Events. Available at: https://bnf.nice.org.uk/treatment-summary/stroke.html[Accessed 14/03/21]

Clarkson K (2011). The management of dysphagia after stroke. British Journal of Neuroscience Nursing. 7, 1, 436-440.

Kelly J, Wright D, Wood J (2011). Medicine administration errors in patients with dysphagia in secondary care: a multi-centre observational study. Journal of Advanced Nursing. 67, 12, 2615-2627.

BENNETT, B. et al. (2013). Medication management in patients with dysphagia: a service evaluation. Nursing Standard, 27 (41), pp. 41-48.

Department of Health Northern Ireland (2020). Prescribing by Non-Medical Healthcare Professionals. Available at: https://www.health-ni.gov.uk/articles/pharmaceutical-non-medical-prescribing [Accessed 12/03/21]

KELLY, J., WRIGHT, D. and WOOD, J. (2011). Medicine administration errors in patients with dysphagia in secondary care: a multi‐centre observational study. Journal of Advanced Nursing, 67 (12), pp. 2615-2627.

Nursing and Midwifery Code of professional standards (2015). The Code: standards of Conduct, Performance and Ethics for nurses and Midwives, NMC.

NUTTALL, D. and RUTT-HOWARD, J. (2015). The textbook of non-medical prescribing. Second; 2nd ed. Chichester: Wiley Blackwell.

Pharmaceutical Society Northern Ireland (2013). Pharmaceutical Society NI publishes 2013-14 Annual Report. Available at: https://www.psni.org.uk/news/pharmaceutical-society-ni-publishes-2013-14-annual-report/[Access date,15/03/21]

Royal College of Nursing (2021). Non-medical Prescribers. Available at: https://www.rcn.org.uk/get-help/rcn-advice/non-medical-prescribers

ILLING, J.C. et al. (2013). Perceptions of UK medical graduates' preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job. BMC Medical Education, 13 (1), pp. 34.

ERDUR, H. et al. (2015). In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors. Stroke, (1970), 46 (4), pp. 1031-1037. Online Available at: https://www.ahajournals.org/doi/10.1161/STROKEAHA.114.006886 [access date 15/03/21].

MOTT, A. (2020). Developing a competency framework for designated prescribing practitioners. Journal of Prescribing Practice, 2 (5), pp. 252-256.

MORIARTY, F. et al. (2019). Economic impact of potentially inappropriate prescribing and related adverse events in older people: a cost-utility analysis using Markov models. BMJ Open, 9 (1), pp. e021832. Available at: https://bmjopen.bmj.com/content/bmjopen/11/1/e041460.full.pdf [access date 16/03/21]