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A Critical analysis of a prescribing intervention
A Critical analysis of a prescribing intervention essay assignment
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This summative assignment requires you to identify an appropriate patient that you have recently encountered during your practice experience and for whom prescribing would have been one option in your care management strategies. The chosen prescribing intervention will need to be amenable to critical examination and should include an introduction to the prescribing context and the independent /supplementary prescribing role adopted. The assignment must demonstrate the application of a theoretical and evidence based approach to the practice of prescribing with specific reference to assessment and diagnosis, justification of an appropriate management strategy and consideration of the prescribing decision and the professional responsibilities involved.
The assignment should include: –
?A clear introduction which establishes the prescribing context and exploration of the independent/supplementary prescribing role adopted
?An exploration of the assessment and diagnostic process undertaken.
A rationale for the assessment approach
Justification of any investigative strategies used
A review of the clinical reasoning process undertaken
?A critical justification of the chosen therapeutic intervention.
An outline of the chosen pharmacological treatment and its effect
Relevant non-pharmacological interventions
Referral strategies (where appropriate)
The provision of patient information and consideration of non-pharmacological strategies in patient care40%
?A critical examination of the legal, ethical and professional issues associated with the prescribing process including the strategies for achieving concordance.20%
Here is the patient i choose
I was asked to assess a patient with regards to re-start his antipsychotic medication Olanzapine The name of the patient has been changed to Miss Brooker, to maintain confidentiality, as the NMC (2008) states:? You must respect people’s right to confidentiality.”
Miss Brooker is a 24 years old lady, known to the mental health service with an established diagnosis of paranoid schizophrenia and had stopped taking her prescribed medication Olanzapine 10mgs for three weeks, who was brought to the Acute Assessment Centre by his parents during the night due to displaying sign of relapsed (paranoid towards her mother, mother having affairs with her friends
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During one of my shifts as a Senior Nurse Assessor (SNA) (Hospital at night) – Out of hours, I was asked to assess a patient with regards to re-start his antipsychotic medication (Aripiprazole). The name of the patient has been changed to Mr Green, to maintain confidentiality, as the NMC (2008) states:? You must respect people’s right to confidentiality.”
Mr Green is a 34 years old gentleman, known to the mental health service with an established diagnosis of paranoid schizophrenia and had stopped taking his prescribed medication Aripiprazole 15mg for three weeks, who was brought to the Acute Assessment Centre by his parents during the night due to displaying sign of relapsed (paranoid towards his mother, mother having affairs with his friends & delusional beliefs regarding his father is not biologically related to him). The consultation took place in an interview room together with the Duty Doctor & in the presence of his parents. I had to call the Doctor from home, as there is no doctor on site during the night. In order to comply with the NMC (2006): Standards of proficiency for nurse and midwife prescribers-Practice standard 3 ? ` to prescribe for a patient/client you must satisfy yourself that you have undertaken a full assessment of the patient/client, including taking a thorough history and, where possible, accessing a full clinical record`, I had to conduct my own assessment (Appendix 1) and read the information available on the electronic records (RIO) prior consulting Mr Green & his parents. Gibbs reflection cycle model (1998) refers this as stage 1 (Description) of the 6 stages and this reflective cycle encourages to think systematically about the phases of an experience.
As a SNA- out of hours- my role is mainly involved working as or covering for a` junior doctor` and I routinely conduct full psychiatric assessment. Therefore it can be suggested that most of the time I work within the traditional medical model. However, one can argue that medical model gives little consideration for the social, psychological and behavioural dimensions of illness as not everyone with the same illness experiences it in the same way. Models of history-taking are becoming increasingly patient-centred and seek to assess the main components of ill health, the biomedical and the psychosocial component. For this reason, Full history taking using aide memoire template adapted from problem oriented medical record, mental state examination & risk assessment are the essential components for a full psychiatric assessment and they are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis (Jones 2009). Mental state examination is another important part of the clinical assessment process in psychiatric practice and it is a structured way of observing and describing a patient’s current state of mind, under specific domains. This information enables me to make judgements regarding the presence and severity of any mental illness.
As a SNA, I find the aide memoir template as one of many useful options in taking a full history and assessing the mental state, both are crucial to establish and maintain rapport and to be systematic in obtaining the necessary information. A good history is one which reveals the patient’s ideas, concerns and expectations and listening is at the heart of good history taking, without the patient’s perspective the history is likely to be much less revealing. This reflects the holistic needs of the seven principles of good prescribing identified by National Prescribing Centre (NPC) (1999). From a prescribing perspective, this must be done in a systematically way to ensure safety, however, at times patients do not present with a logical and coherent set of symptoms. Therefore, as a nurse prescriber, it will be important to adopt different consultation styles in different situations to maintain safety, as prescribing inherently brings with it a greater requirement to make a diagnosis (Lymn et al 2010).
Numerous consultation models have been developed over the years since the work of Balint (1987) in promoting patient centred approach during the encounter with patients, such as Balint (1986), The Three Function Approach to the Medical Interview (1989), Pendleton, Schofield, Tate and Havelock (1984), Helman?s ?Folk Model? (1981), Calgary?Cambridge approach and many more (Sodha and Dhillon 2009). Most of the consultation models contain similar characteristics to explore interactions between patient & health care professionals (Brookes and Smith 2007). Harper and Ajao (2010) claim that the notion of nurses undertaking consultations is a relatively new dimension & consultation models have historically been researched from a medical perspective. Consultation models must have a degree of structure and should be straightforward, practical and provide guidance that enables advanced nurses to adapt to their new medicalised role (Beaumont, 2012).
In this discussion, I have chosen to use the Calgary-Cambridge consultation model (2000) together with the Roger Neighbour?s (1987) 5 Checkpoints because the consultation was primarily based around concordance issues. Despite the effectiveness of atypical antipsychotics, non-concordance with prescribed antipsychotics is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity (Gray et al 2002). Neighbour?s inner model (1987) describes the consultation as a journey rather than destinations, due to ongoing unfolding of symptoms, problems and feelings, some of which may never conclude as there is always another problem or time to discuss it. According to Munson and Willcox (2007) the Calgary-Cambridge consultation model is a helpful model for achieving concordance through patient-centred discussion and the focus of this model is on building a relationship with a patient as the consultation progresses. Although written specifically for doctors, it is applicable to many nursing consultations and it allows health professionals to examine their communication skills as well as encouraging patients to become involved in the decision-making process. Therefore, it can be strongly argued that communication and consultation skills are inextricably interlinked. The Calgary Cambridge method derives from Pendleton’s approach and is an evidence-based approach to integration of the ‘tasks’ of the consultation and improving skills for effective communication (Epstein 2008). It is divided in five main stages within a framework that provides structure and emphasises the importance of building rapport with patients.
Stage 1- Initiating the session
In any caring settings it is vital to establish rapport with the patient & the carers and to put them at ease. Neighbour?s inner model (1987) refers this as the first Checkpoints (connecting). As a prescriber, connecting is vital to develop a therapeutic alliance, so that patients can recognise the importance of medications. In this scenario, Mr Green & his parents were greeted, introduced ourselves by names & clarifying our roles and provided an outline of what our intentions are and a brief idea of how long the consultation might take. It was our first contact with Mr Green, therefore, it was important to confirm the patient?s name and to check how he prefers to be called as some people like to be addressed by their first name, whilst others may prefer the use of their surname. First impressions are very important, as this will influence the subsequent relation with the patient and it is a chance to demonstrate from the outset of respect, interest and concern (Lymn et al 2010).
Mr Green agreed to be seen in the presence of his parents and they were taken to a quiet consulting room free from interruptions and to maintain confidentiality. The environment was made welcoming and relaxing because patients often find the mental health clinical setting stokes up anxiety. Seating arrangement was made for Mr Green & his parents to sit close to us, rather than confronting them across a desk, as this have the potential to hinder the exchange of information.
The consultation began by asking my Green to outline his concerns `what brought you here tonight?. Open-ended questions are designed to introduce an area of enquiry and allow patients opportunity to answer in their own way and shape the content of their response (Institute 2007). During a psychiatric assessment it is common to use a combination of open-ended and closed questions. Normally, open questions are more commonly asked at the start of the interview with closed questions asked later, as information gathering becomes more focused in an attempt to elicit more detail (Jones 2009). It was important in this opening phase not to interrupt Mr Green as this might inhibit the disclosure of important information. Research has shown that doctors often fail to allow patients to complete their opening statements uninterrupted and yet, when allowed to proceed without interruption, most people do so in less than 60 seconds (Epstein 2008).
Stage 2- Gathering information
Gathering information on the patient?s problems is one of the most important tasks to be mastered in prescribing and in any consultation, a clinician has a number of tasks to perform (Brookes and Smith 2007). Ideally, these should be undertaken in a structured way so as to maximise the efficiency and effectiveness of the process. However, from empirical experience, many factors can impede a consultation, for example, mental state (mute or no insight), time constraints, patients` health beliefs, cultures and language barrier. The ability to take an accurate history from a patient is one of the core clinical skills and an essential component of clinical competence. The consultation influences the precision of diagnosis and treatment, and studies have indicated that over 80% of diagnoses in general medical clinics are based on the medical history (Epstein 2008).
Mr Green was known to the mental health services and had a confirmed diagnosis of paranoid schizophrenia. This provided us with in-depth details about him. A full history (Appendix 1) was taken, this included the history of presenting complaints by his parents, the collateral information from his parents were important, because Mr Green lives with his parents, medical history using the MJTHREADS, this is crucial for safe prescribing for example, prescribing lithium for bipolar affecting disorder would be contradicted in patients with impaired renal system, past psychiatric issues, medication history (prescribed, none prescribed, over the counter & complimentary medications), medication allergies, drugs & alcohol, and social factors. From empirical experiences, substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures. This can lead to poor prognosis, concordance and affect the metabolism of antipsychotics. Therefore, a comprehensive history, including a detailed history of substance use, is not only important in the initial evaluation but also during treatment, since patients may begin or relapse to substance abuse at any time during treatment. The manner in which the interview is conducted, the demeanour of the clinician and the type of questions asked may have a profound effect on the information revealed by the patient (Sodha & Dhillon 2009). As part of the mental state examination, the non verbal clues were noted such as the body language, especially facial expression and eye contact. At times some points needed clarifying.
On reflection, the rationale for attending the centre out of hours needed clarity As the consultation progress, it became apparent that no incident took place, he was not talking to his parents and only tonight he started communication to his parents and he was willing to start treatment, but he had no medication at home, as he did collect his prescription from his GP, subsequently he was brought for an assessment. Gibbs (1998) identifies this as second stage of reflection (feeling)
At this stage it was evident that Mr Green had stopped taking his medication as he felt that he can cope without medication. Over the course of a year about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves (Mitchell & Selmes 2007). The health and social consequences of relapse for people with schizophrenia are catastrophic; it is distressing for the family of the service user and often results in admission to an acute inpatient ward for the person with schizophrenia (Jones 2009). I was pleased to hear that Mr Green was willing to start his treatment, no incidents took place, but my major concern was the parent should not have waited 3 weeks to seek help, given Mr Green was known to the mental health service and his paranoia was directed towards his parent (stage 3- evaluation of Gibbs model of reflection).
Stage 3- Building the relationship
A holistic approach is essential for an effective consultation process. According to Nuttall (2008), a holistic approach reflects the ethos of public health, which is concerned with improving health rather than simply treating diseases. As a prescriber it is vital to use a range of skills to encourage patients to tell their story as fully as possible whilst maintaining a degree of control and maintaining a structure in the collection of information. In addition to empathy, respect and non-judgemental approach, the application of Egan?s model; `sit squarely, open posture, lean forward, eye contact, relaxed and unhurried appearance`, in mental health settings can help nurses to look attentive and this can encourage patients to disclose issues that they may normally find difficult to discuss (Smith 2007). It is equally important to use appropriate language and avoid medical jargon.
Mr Green was encouraged to talk about his paranoia and he was able to recognise his relapse indicators (paranoia & delusional beliefs). This indicated that Mr Green had insight into his illness. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them (Freeman and Garety 2006). During the consultation he did acknowledged that Aripiprazole has been effective in dealing with his paranoia and he did not report any side effects. This gave us the opportunity to discuss medication issues & management plan. El-Sayeh et al (2006) emphasised that Aripiprazole a `third generation’ of antipsychotic is reported to be useful in all phases of schizophrenia. Atypical antipsychotics are antagonistic at a number of receptors in addition to dopamine and serotonin (5-HT) receptors both centrally and peripherally. Knowledge of the receptor affinities of antipsychotic medications permits us to predict their side-effects (Roberts 2007). Aripiprazole is weight neutral and it does not cause acute extra pyramidal symptoms or sedation, as it has a reasonably low affinity for H1 receptors and this can be beneficial, as most patients find the sedative side effects a barrier to recovery (White et al 2007). Given that Mr Green was previously treated with Aripiprazole, he agreed to be treated again with the same medication. This indicated that he consented to treatment, which complies with Practice Standard -5 of the NMC (2006): Standards of proficiency for nurse and midwife prescribers. In order to comply with the NMC (2006): Practice Standard 4, there was a genuine clinical need to prescribe and without medication his paranoia could have increased, risk to self & others, which could have led to hospital admission. Moreover, this reflects stage of 4 (analysing) of Gibbs model and second stage (appropriate strategy) of the NPC (1999) prescribing pyramid.
In conclusion as per Gibbs model and in order to promote concordance (shared contract- principles of good prescribing) he was prescribed 15 mg Aripiprazole. Although Aripiprazole is more expensive than other atypical antipsychotics (28 tablets of 15 mg -?95.74, BNF 2011). In addition, to Mr Green request, he meets the criteria for the mnemonic EASE, E- how Effective is the product? A- is it Appropriate for this patient? S- how Safe is it? E- is the prescription cost Effective principles of good prescribing identified by (NPC 1999). Mr Green was previously treated with 15 mg Aripiprazole with no side effects, which he did find useful.
It is important for nurse prescribers to adopt a value base that respects the beliefs and wishes of the patients, although we had in depth details of the signs, symptoms, treatment efficacy and outcomes built up through clinical experiences and education, patients have a lived experience source of knowledge about their illness. As part of the prescribing assessment, nurses need to consider concordance in all their interactions and an understanding of the patient?s individuality is important, especially when it comes to interpreting and negotiating the management plan (Nuttall and Howard, 2011). This highlighted the importance of respecting patient?s choice. It has been proposed that the introduction of a person-centred prescribing approach, pioneered by nurses with service users, could minimise the risk of relapse through enhanced concordance and the development of treatment packages that work for the service user, is one of the core aspects a person-centred prescribing framework (Jones, 2009)
Murray et al (2007) emphasise that increased involvement by patients in their care and shared decision-making have the potential to improve concordance with treatment plans. Prescribers can achieve this by identifying with patients their preferences for care and respecting these within professional and legal limits. For example, discussing choice of pharmacological treatments with patients that best support their recovery goals. Providing meaningful choice is a core component of a therapeutic relationship, as many mental health patients are often excluded from shared decision-making (Hemingway 2003). According to , NICE guidance on Medicines Adherence (2009) all patients should be adequately informed and involved in the shared decision-making process of whether or not treatment should be prescribed, treatment should be tailored to meet the needs of the individual patients and patients’ concerns and beliefs should be carefully listened to and addressed.
Stage 4- Explanation and planning
Mr Green had good knowledge of the efficacy & side effects of Aripiprazole. Establishing the treatment options, in discussion with the patient, is an important part of any consultation, if a successful outcome for both parties is to be achieved. Within the prescribing context, negotiation is important because it is paramount to ensure that the patient agrees and cooperate with the plan, otherwise the plan will flounder (Nuttall and Howard, 2011). Neighbours (1987) describe summarising as obtaining a sufficiently comprehensive idea of the patient’s real reason for consultation. The concerns expressed by both Mr Green & his parent were repeated back to them to ensure they understood the reasons for attendance. Failure to do this at this stage will result in a failed consultation.
In this scenario, it could be argued that the treatment options were limited, as NICE (2002) recommends that atypical antipsychotic drugs must be considered in the choice of first-line treatments for individuals with schizophrenia, this is in line with the NMC (2006): Standards of proficiency for nurse and midwife prescribers-Practice standard 13- evidence based prescribing. Although Mr Green & his parents were aware about Aripiprazole, as a prescriber it was my duty to explain to them about the medication, safe storage, possible side effects and what to do in case of an adverse effect.
Within the mental health service, follow up is an element of the treatment plan in many respects, as prescriber it is my responsibility to ensure that the prescribing decisions are monitored and the patient is exposed to the least amount of risk. According to Neighbour (1987) safety netting refers to providing the patient with information on what to expect and what to do if they do not improve. General practice has been described as the art of managing the uncertain and provision needs to be made within the consultation for this (Neighbour 1987). Patients will feel more secure if they have a clear outline of what to expect from their treatment and under what circumstances to re-consult. In this situation, Mr Green was referred to Home Treatment Team (HTT) to monitor his mental state & concordance with medication and reviews. NICE (2009) recommendations to improve adherence: Regular medication reviews and follow-up support should be provided whether or not the patient decides to choose to take their medication. This is equally important to adhere to the NMC (2006) Practice standard 19 ? Repeat prescribing -Suitable provision for monitoring each patient/client?s condition is in place and for ensuring that patient/clients who need a further examination or assessment do not receive repeat prescriptions without being seen by an appropriate prescriber and each prescription must be regularly reviewed and is only re-issued to meet clinical need. This reflects the last stage of Gibbs model of reflection (action plan). Both Mr Green & his parents were informed about the role of HTT and the contact number was provided to discuss any further issues. A discharged summary was sent to Mr Green`s GP to comply with the NMC (2006): Practice Standard 6- Communication.
Stage 5- Closing the session
By summarising, both Mr Green & his parents were made aware that, we have listened to their concerns & this provided the opportunity to negotiate management plans, as the parents were expecting for medication to be prescribed and follow up by the mental health team. Mr Green & his parents confirmed that they felt that their concerns have been acknowledged and they are in agreement with the management plans. Neighbour (1987) refers this as Handing-over: making sure the patient is happy with the outcome of the consultation. In case of an emergency, the contact number for the Acute Assessment centre was given as it operates 24 hours. No prescription was issued, because as planned, the HTT would supply & supervise the medication on daily basis. However, a medication chart was written up the duty doctor as HTT is part of the admission team.
Neighbour (1987) acknowledges the need for the practitioner to take care of their own feelings, particularly those brought about by a consultation to provide the best possible care (House- Keeping). If not, the emotions, possibly negative, caused by one consultation, may spill over into the next and this can have a detrimental effect. We have a duty to look after ourselves, this may be the simple requirement for a break, refreshment or the time required for record keeping (Nuttall and Howard, 2011). Another aspect of good housekeeping is reflecting on a consultation and possibly considering how to handle things differently in the future.
To conclude, safety in prescribing is paramount, therefore a systematic approach enhances the safety in decision making and by adhering to the national & local policy. In taking a psychiatric history and assessing the mental state, it is crucial both to establish and maintain rapport and to be systematic in obtaining the necessary information. The purpose of the mental state examination is to obtain a comprehensive cross-sectional description of the patient’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. There are many models which can be used to analyse and shape consultations, and consultation models are relevant to all health care practitioners.
The consultation needs to be performed in a competent and confident manner to achieve a positive result. By studying other?s models, we can develop our own style. If done well, leads to better patient understanding, concordance and fewer complaints. Different consultation styles will be effective in different circumstances. The skills to improve consultation outcomes can be learned and developed through consultation analysis. Such improvements can simultaneously recognise and improve the important relationship between prescribers and patients. Reflecting on prescribing decisions can help to improve prescribing knowledge and practice. A systematic approach to prescribing using the seven step model may help nurses ensure their prescribing is appropriate, evidence-based and cost-effective. The full assessment was documented on RIO to comply with the NMC (2006): Practice Standard 7- Record keeping.
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