Independent prescribing in the UK has a long and rich history. Before 1992, doctors, dentists, and veterinary surgeons were the only health professionals who could prescribe legally. However, non-medical prescribing had started with the 1986 Cumberledge Report, which recognised the value of training community nurses to prescribe (Griffiths, 2005). The 1992 Prescriptions by Nurses Act indicated that qualified Health Visitors and District Nurses were the only independent professionals permitted to prescribe a few medicines such as in dressings.
The 1998 Crown Report identified key benefits emanating from nurse prescribing namely: enhanced patient care, improved utilisation of nurses, patients, and GP’s time, and improved communication between the health care team owing to increased clarity in professional roles and responsibilities (Peninston-Bird 2007). The 1999 Crown Report recommended that both Independent and Supplementary prescribers to be included among the legally recognised prescribers. The 2001 Health and Social Care Act allowed non community qualified nurses to train as Independent prescribers, thereby granting them increased access to more, albeit limited, medications, for such conditions as simple headaches and acne. In 2003, pharmacists and nurses received the go ahead to prescribe as Supplementary prescribers and in 2005 podiatrists, radiographers, chiropodists, physiotherapists and optometrists were added to the list of Supplementary prescribers. In 2006, Pharmacists were allowed to commence training towards becoming Independent Prescribers. In 2008, community staff nurses started receiving training to become prescribers within the Community Nurses Formulary. In 2012, the legislation was changed to permit pharmacists independent practitioners and Nurses independent practitioners to undertake independent prescribing of controlled drugs of controlled drugs.
How practice will change with change in legislation
The significant growth and development in nurse prescribing in the UK over the past decade has largely been successful owing to concerted efforts of key stakeholders (for example, the Department of Health, nursing regulators, GP (general practitioners) supporters, nursing professional bodies), as well as significant policy and legislative reforms that have supported and encouraged nurses to assume prescribing roles and community and acute settings. In April 2012, NIPs (nurse independent prescribers) were permitted to prescribe certain controlled drugs based on individual level of competency. They were also allowed to regularise mixing of medicines that also entails controlled drugs. As a result of the adoption of the nurse prescribing model, there has been a drastic reduction on waiting times for referrals to doctors but more importantly, the new found role of nurses as independent prescribers enables them to administer treatments to patients in a timely manner.
Nurses providing care to individuals with type 2 diabetes have regular contact with the patients. In addition, such nurses are well informed about the evidence base upon which diabetes treatment and management hinges on. However, considering that diabetes is a chronic condition, it is important to ensure timely and effective prescribing as a key element of treatment. In this case, change of legislation to permit independent prescribing will help build on the existing services in secondary and primary care, thereby leading to positive effect on the overall patient care. Moreover, independent prescribing will enable the nursing staff to put their skills in diabetes care and management to better use.
Personally, I feel that nurse prescribing has been really been instrumental in transforming my practice. For example, I feel that training as an independent nurse prescriber shall allow me to fully complete the patient consultation process starting from assessment up to and including treatment, without having to refer the patient to a medical practitioner who will prescribe the diabetes medication. Another way in which the change in legislation will impact on my practice is that the process affords me the rare opportunity to discuss treatment options and care planning with an individual patient (Carey & Courtenay 2008). Thereafter, it becomes easier to follow up on prescribing at the clinic setting. I also feel that nurse prescribing will enable diabetes patients to easily access clear and timely advice and information on disease progression. Moreover, the increased autonomy will allow me to clarify question that my patients might have on such issues as dosage calibration, medication side effects, adherence, and correct use of medication.
Nurses possess sound interpersonal skills and I believe that this will prove valuable in their role as prescribers. As professional nurses, we tend to be, by and large, highly approachable, understanding, empathetic, possess the ability to offer clear information, and treat patients as individuals (Brooks et al., 2001; Page et al., 2008). Considering that the health care professional attaches a lot of importance to the patient-centred approach as a means of matching patient requirements to service delivery (Stenner, Courtenay & Carey 2011), I am of the opinion that nurse prescribing will go a log way in improving care delivery to diabetic patients.
I am also optimistic that the change in legislation to permit nurse prescribing will result in other desirable benefits such as improved patient satisfaction with care provided. This is because the increased autonomy to patient care means that I now get to spend more time with the patient, clarify his/her misconceptions on treatment, and answering any questions that they might have on their illness. As a professional nurse, I also hope to enhance my knowledge in diabetes treatment. Some of the areas that I feel will prove beneficial include interpretation of blood glucose results and insulin treatment, dose and insulin regimens adjustments, better knowledge of how various diabetes drug interact, and knowledge of new devices and new pens.
How the change in legislation will affect your accountability/responsibility
PNs (practice nurses) have historically played a key role in facilitating diabetes management through medication, administering medication, and advising patients on adjustments to diabetes medicine. These roles have constituted a basic element of their job description, even though the PNs and DSNs may not have had qualifications or formal training in such activities (James 2004). Being a prescriber may have put some PNs under immense pressure because the change in legislation affords them more autonomy and responsibility (Public Health Agency 2011), of which the prescribing role is now part of. On the other hand, other nurses have been very receptive of the increased autonomy, viewing it as an improvement in access to and efficiency in care delivered to patients (Courtenay et al, 2007). The number of people with type 2 diabetes is rising, and this necessitates increased involvement of nurses in the provision of diabetes services. This means that those of us in the nursing profession will encounter mounting pressure to extend our prescribing responsibility. Avery and James (2007) have identified prescribing as a powerful tool that enables various healthcare professionals enhance service delivery. Besides, prescribing improves continuity of, and access to care. Nonetheless, prescribing could also result in patient harm, thus necessitating the need for knowledge, training, and expertise to ensure competence (Smith 2004). In specifying its standards for prescribing practice, the NMC (Nursing and Midwifery Council), notes that one can only prescribe upon successful completion of a prescribing programme approved by the NMC. In addition, the NMC register should reflect that the health professional has successfully completed such a programme (NMC 2006).
I welcome the increased responsibility and autonomy to patient care that comes with the change in legislation on independent prescribing. I am however well aware that this comes with increased responsibilities in that I will now be expected to prescribe alone as opposed to doing so as part of a healthcare team. This is likely to negatively impact on my confidence to prescribe owing to lack of peer support (Courtenay & Carey 2008). Nonetheless, I believe that having access to appropriate clinical mentoring will go a long way in improving confidence in prescribing. As a practice nurse, I will also be held accountable for what I generate on a patient’s prescription as failing to abide by the current guidelines by the NMC on prescribing would amount to poor practice (NMC 2009). Therefore, I feel responsible to ensure that I am fully acquainted with the current NMC Guidelines on administration of medicines, as well as the existing NMC Standards on Prescribing. Prescribing and administering medication comes with a lot of ethical, legal and safety issues and as an Independent prescribing Nurse, I will be held accountable for any questionable practice. to ensure that I remain accountable in my practice as an independent prescriber, I plan on implementing the competency framework for nurse prescribers that has been developed by the NPC (National Prescribing Centre) (NPC 2003), as a starting point for reflective practice. This will go a long way in enabling me to identify gaps and learning needs in my practice. As a result, I will ably undertake my prescribing role.
Another area of my responsibility as an independent practitioner that will be affected by the change in prescribing legislation is that I shall now be required to devout more time to mentoring as I prepare to embrace the new role (Hallworth 2004). Such devotion is important because this affords me with the opportunity to [play an active role in improving care to patients with diabetes.
Health Policy Part
Having noted that the prevalence of type 2 diabetes is on the increase, there is need for concerted effort by all healthcare professionals to ensure effective care and management of patients. Towards this end, the National Service Framework has been developed. It encompasses 12 different standards that seek to prevent diabetes, diagnose, empower, care for and manage people with diabetes (National Service Framework for Diabetes 2014). The proposed health policy for this paper is Standard 4 of the NSF for diabetes which is concerned with providing high-quality care to adults with diabetes. This should be carried out throughout their lifetime, and should also encompass optimising the patient’s control of blood pressure and blood glucose in order to avoid the development of various complications of diabetes such as retinopathy, cardiovascular diseases, and leg amputations, among others. Control of blood glucose and blood pressure levels is crucial in preventing or delaying the onset of the aforementioned complications. In the case of type 2 diabetes patients, increased physical activity and weight loss constitutes the first line of intervention, especially for the newly-diagnosed cases. Raised cholesterol and blood pressure levels is also a key concern for adults with Type 2 diabetes and both have been implicated in increased risk of developing miscrovascular complications and cardiovascular disease. It follows therefore that effective lipid-lowering therapy to lower cholesterol levels and tight blood pressure control help to reduce such complications and improve health outcomes in type 2 diabetes patients. As a nurse prescriber, I would be actively involved in helping type 2 diabetes patients improve their blood pressure and blood glucose levels as a means of reducing the risk of developing cardiovascular disease and microvascular complications. I should also be an active participant in structured diabetes care programmes that involves review and regular recall of type 2 diabetes people which has been shown to result in better glycaemic control, enhanced quality of diabetes care, and reduced mortality rates, reduced risk of cardiovascular complioacatio0ns, reduced rates of long-term complications, and improved overall quality of life (National Service Framework for Diabetes 2014).
In the short-term, I Plan on running special clinics that seek to create awareness on the importance of proper diabetes control, targeting adults with Type 2 diabetes. The proposed special clinics will commence in February 2017 and will run for 6 months. During the clinic sessions, patients will be sensitised on the importance of adherence to treatment which has been noted to be a key issue in such chronic diseases as diabetes (Donnan et al 2002). Adherence helps to control blood glucose levels and blood pressure, effectively preventing major diabetes complications. Patients will also be sensitised on proper glucose monitoring techniques as it is a key requirement in altering insulin dose (Bodington 2011).
In the long-term, I plan on involving the local health care professionals such as dieticians, social workers training instructors so that we can extend the programme at the community level. Annual charity walks shall also be organised as a means of creating awareness on the need to prevent type 2 diabetes and more importantly, on the importance of diagnosis so that those found to have the condition can be immediately put on a care and management programme. The goal is to ensure that people with Type 2 diabetes are assisted to modify their lifestyle so that they partake in physical activity, adopt healthy eating habits, and for those who are obese, help them lose weight. Other key goals are to improve compliance to diabetes management, reduce risk to complications, and improve the health and wellbeing of type 2 diabetes patients.
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