The following assignment will discuss and analyse a prescribing episode, within practice, and furthermore will outline safe prescribing from the Nurse Prescribing Formulary (NPF, 2013-2015). To be able to analyse and reflect on my new role as Community Practitioner Nurse Prescriber (CPNP) I will use Gibbs (1988) reflective model and a structure that will allow the use of a consultation model (Appendix1,Fig1). The focus on prescribing within nursing profession was first brought into discussion by Royal College of Nursing (RCN) in 1980 but has proven to be cornerstone after was part of the government agenda as a result of Cumberlege report in 1996.
This report outlined the need for a nurse to become a prescriber especially in community settings to provide clients with better care, safe and practical access to medication (Nuttal, 2008). Furthermore “The Medicinal Product Prescribing Act“ 1992 outlined changes in circumstances including nurses as prescribers, followed by recommendations made by Crown Reports 1999 which suggest that health visitors (HV) should be authorised to prescribe from a limited list, identified as the nurse prescriber’s formulary (NPF).
For the purpose of this assignment all names has been changed to maintain confidentiality according to NMC (2008). The following scenario is in relation to a situation experienced while on the morning baby clinic working alongside my mentor. A mother Lisa come for a regular weight check for her 4 month old infant called James. While discussing with Lisa her son’s weight progress, she mentioned about her son having very dry scaly skin on scalp since birth, moreover Lisa explained that sometimes skin on the scalp becomes like a patchy crusty rash and James would feel uncomfortable, at times not settling. Edwards (2010) suggests that using a holistic assessment it is very important when coming in contact with a client as the problem presented can have a drastic impact on the quality of life for a child and a family. As a student under the supervision of my mentor we started a holistic assessment of James and finalised with a prescription decision. I started by using open questions related to James’ general health and I asked Lisa if she had any concerns but she confirmed back to me that there were no issues with his health since birth. To make sure that information provided by Lisa was correct and guarantee accuracy in details exposed I repeated back and she confirmed. As a student practitioner prescriber it is very important to maintain good practice and use assessment frameworks and consultation models as a possibility to improve and gain better skills (Nuttall, 2008).
The purpose of the consultation model in prescribing practice is to assist nurses in identifying strategies to deliver a diagnosis and ultimately the appropriate prescription. There are various consultation models used in practice with normative or descriptive character, however, for the purpose of this case scenario I will concentrate on Roger Neighbour 1987 consultation model. Moreover, Neighbour (2005) outlines his model consultation as a journey divided by check point, connecting which is the first point where client establishes the relation with the practitioner. This is essential, followed by summarising, handing over, safety netting and housekeeping. To progress further it is relevant to mention influence of communication skills in consultation process furthermore considering that nurse practitioners don’t need different communication skills in comparison with other professional prescribers (While, 2002).
However (While, 2002) found that the need for appropriate environment that can maintain privacy and confidentiality could be a potential barrier during consultation rather than communication means, especially for those working in client homes. I choose Neighbour 1987 model for consistency and being easy to apply in any circumstances; moreover, it stands as a journey establishing relations with the client through empathy and in the same time identifies the need for balance between practitioner prescriber and client (Tate,2010). Another positive aspect that I took in consideration when choosing the model was also housekeeping as a practitioner have the opportunity through this section to become reflective to avoid any unresolved issues before consultation is complete (Neighbour, 2005). Despite the decision made to use Neighbour 1987 model I will move further and explain the process and prescribing decision using the principles of a good prescribing pyramid (Appendix 1, Fig 2)(NPC, 1999).
Assessment; Consider the Patient
The beginning of consultation according to Neighbour, (1987) is connecting with Lisa and building a relationship, however, in a noisy environment like the clinic I found this difficult. Despite this barrier I managed to find a sitting area that appeared to be more private and had the opportunity to manage a discussion with Lisa to establish that I needed to do a physical examination on James. As James was under 16 years of age, consent from parent or guardian was needed, therefore Lisa gave a verbal consent as she was the biological parent (NMC, 2013). To proceed further I used mnemonic OLDCARD to asses James with Lisa’s assistance trying to interact with her and find out if any physical or affective changes occurred.
Bryans (2000) suggests that during assessment the practitioner should use knowledge, experience, recognition and prioritisation, so to proceed further with a holistic assessment and identify symptoms that will help me to rule a diagnosis I felt I needed to ask Lisa more questions. Following the identified symptoms and physical examination I concluded that this was cradle cap a form of seborrheic dermatitis mainly affecting skin on the scalp with patches and thick scaling and sometimes yellow crusty (Sheffield et al,2007). It is important to rule out other conditions when taking assessments as sometimes cradle cap can turn into atopic dermatitis or fungal infection such as tinea capitis or easily misdiagnosed with crusted scabies (Yoshizumi and Harada, 2008). Further continuing my assessment I was able to conclude that none of this conditions were present in James’ situation.
It was important to discuss with Lisa during consultation family history that could provide additional support for my final diagnostic conclusion. Going through such topic area, Lisa explained that her husband, James’ dad, was suffering from atopic eczema since childhood. This was quite an important piece of information as such conditions like atopic eczema (dermatitis) are often hereditary conditions (National Eczema Society, 2011). Atopic dermatitis or eczema is a chronic skin disorder, inflammatory with pruritic skin that appears mostly on the face, neck, bends of the arms or legs caused by the malfunction in the skin barrier (NICE,2013).
In order to progress further following discussion with Lisa under my mentor’s supervision as a CPNP V100 I made a prescribing decision based on the physical examination and the information provided. I concluded that James was suffering from cradle cup (seborrheic dermatitis)(NICE,2013). Furthermore Lisa confirmed that James did not have any allergies and was not on any medication. It was important to relieve the discomfort and unsettling times for James and I decided to prescribe an emollient and a bath additive. Pendleton et al (1984) suggest that practitioner should discover client expectations, and furthermore should take in consideration other treatment options before prescribing. According to NICE (2013) greasy emollients and soap substitutes or bath additive helps to remove the scales effectively, furthermore regular washing of the scalp and gentle brushing can help to loosen scales. Another stage followed in the Neighbour (1987) is handing over period, but after James’ skin on his scalp was carefully examined, no evidence of infection was identified, so no referral to the General Practitioner (GP) was necessary.
Consider the Choice of Product
According to NPC (1999) practitioners should use mnemonic ‘EASE’ as can be seen in the chart below to choose appropriate cost effective product for clients.
How effective is the product?
It is appropriate for the client?
How safe is it?
Is the prescription cost effective?
To make the appropriate decision for Lisa’s infant, under the supervision of my mentor I used the Nurse Prescribers Formulary (NPF) and decided to prescribe Oilatum Junior bath additive and cream as I considered this combination more effective in James’ treatment. Moreover the packaging was also appropriate as it comes in a pump action and this could reduce the infection risks associated with emollients and types of recipients manufactured (NPF,2013-2015). When deciding the prescription products and quantities I also took in consideration Lisa’s requirements. Furthermore according to NICE guidelines emollients should be prescribed in large quantities, approximately 250-500 grams per week and in the same time are cost effective (NICE, 2007). It is important when prescribing emollients to discuss with clients /parents /carers possible side effects. Even though these products are considered to be quite safe, bath additives should be taken in consideration because they tend to leave the skin slippery after bathing the infant (BNFC,2014).When prescribing a product especially for infants it is important to educate the parent/carer how to use the product and make sure they are aware of any risks and side effects.
Negotiate a contract
According to (Courtenay and Griffiths, 2005) when prescribing we should view the process as a shared decision-making between a client and prescriber. The prescribing decision stands as a contract so it was important to remind myself that I should take in consideration Lisa’s satisfaction with my decisions. To achieve the goal of all my actions it was paramount to have effective communication skills and ability to identify the appropriate therapeutic treatment. Throughout the entire process I think that Lisa felt empowered as I handed the responsibility to apply the emollients on James’ skin over to her (Braid, 2001). As I am not yet a medical prescriber, the prescription for Lisa’s son was written by my mentor and information leaflets regarding seborreic dermatitis were given to Lisa for further guidance.
According to Neighbour (1987) consultation model this step relates to safety netting and to follow up of the consultation and possible outcomes. Furthermore together with my mentor we arranged to follow up in ten days to see if Lisa’s infant was making any progress and if treatment was effective. Through this review in ten day time practitioner can identify any more concerns of the parents and possible side effects of the treatment used (DH,2010b).
Following guidance of the Nursing and Midwifery Council (NMC,2006) it is a practitioner’s accountability to ensure records are maintained accurately and prescription details are recorded in the infant health record (NPC, 1999). Moreover, I ensured that the details of the prescription and the consultation were entered into the general computer system within the next 4 hours following the consultation and the GP also was aware of the consultation and products prescribed. According to (NMC,2006) details of the consultation and prescription should be entered into the computer system within forty eight hours with exception for special circumstances.
Using Gibbs reflective cycle during consultation process with Lisa’s infant I had the opportunity to identify positive and negative aspects and reflect on the scenario. In the same time the final part of Neighbours consultation model refers to Housekeeping and this stands as another stage that gives me the opportunity to reflect on my prescribing decision and consultation. I felt that throughout the whole process I used safe and effective decisions even at times I felt a bit nervous; however, my mentor’s feedback was positive in regards to my performance. One aspect that I found difficult was the environment; at the time the baby clinic was busy and noisy and it was difficult to find a private area to conduct the consultation, but I could reflect on such issues for my future prescribing practice.
Through this experience I am able to develop in my new role as a V100 prescriber using specific tools like the consultation model and good prescribing steps. Furthermore I had the opportunity to apply appropriate communication skills and medical knowledge along with the legislation to conclude with a safe and effective prescribing practice. A new CPNP I can utilize different assessment tools based on a consultation model along with a decision making framework to support my practice and at the same time reflect on my ability to undertake a partnership approach that responds to client needs and concerns. Definitely, this experience has been of great importance for my educational journey as a V100 nurse prescriber.
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