The New Prescriber

An Integrated Approach to Medical and Non-medical Prescribing

Fiona Bath-Hextall, Joanne Lymn, Roger Knaggs, Dianne Bowskill, Fiona Bath-Hextall, Joanne Lymn, Roger Knaggs, Dianne Bowskill

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470519875
• eBook ISBN: 9781118278338
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

The New Prescriber is a comprehensive, accessible textbook that provides essential coverage of the three core components for prescribing: the client/patient, the evidence, and the pharmacology. 

Divided into three sections, this text first looks at the consultation with the patient, and outlines legal, professional and ethical frameworks which guide medical and non-medical prescribing. The second section is devoted to evidence-based practice, highlighting key skills essential to all clinicians. This section encourages the student to identify why evidence-based practice should underpin prescribing decisions. The third and final section is concerned with pharmacology. The student is introduced to basic concepts of pharmacodynamics and pharmacokinetics, adverse drug reactions and variability of response. The importance of these pharmacological principles is highlighted throughout the subsequent discussion of drug groups affecting major body systems.

Key features:

• Pulls together all key elements of prescribing using an integrated approach
• 'Stop and Think' boxes and practice application activities provided throughout, enabling the reader to link theory to practice
• Key terms and glossary provided

This text is invaluable for all nursing, health and medical students taking courses in prescribing and pharmacology.

Section 1

The Patient

1 The consultation

Frank Coffey and Dianne Bowskill

2 Accountability and prescribing

Nigel Plant and Richard Pitt

3 Legal aspects of prescribing

Joy Wingfield

4 The ethics of prescribing

Richard Cooper

5 Prescribing in practice

Dianne Bowskill

6 Record keeping

Fiona Dobson

7 Public health issues

Michael Watson

Quiz answers

Glossary

Section introduction

In this first section we focus on the practical aspects of prescribing for patients. As a new prescriber, you will find there are many factors specific to your patient, your profession and your employer which influence both your decision to prescribe and the prescribing decisions you make. Throughout this chapter you will be encouraged to think about prescribing in practice and we begin with the consultation, the starting point for prescribing. All prescribers must practise within the law and in a manner consistent with professional and public expectations of a prescriber. The legal framework of medical and non-medical prescribing are defined in this section and new prescribers are encouraged to think about their prescribing role in relation to these aspects. Your actions as a prescriber will reach far beyond the patients you prescribe for and this section encourages you to explore the ethical and public health issues associated with prescribing authority. As your prescribing experience grows, you will find it useful to revisit the definitions and the questions raised in this section.

The term non-medical prescriber is used throughout the book and refers to nurses, pharmacists and allied health professionals who, following successful completion of a programme of formal prescribing education, are on the professional record as a prescriber.

1

The consultation

Learning outcomes

By the end of this chapter the reader should be able to:

• recognise and analyse the important elements of a consultation
• identify the components of the traditional medical history
• appreciate the diagnostic process and distinguish between the treatment of symptoms and the treatment of a disease or condition
• identify the elements of the consultation essential for safe prescribing (‘bottom liners’)
• refine their professional assessment/consultation for the prescribing role.

As you begin your prescribing education you already have a wealth of professional experience in your own area of practice. The assessment and consultation skills learnt as part of professional registration are well practised but may need to be refined as you take on prescribing. We are not suggesting that you need to adopt a new or medical model of consultation, although this might be desirable in certain advanced practice roles. For the majority of new prescribers, the focus will be on analysing their current framework of assessment or consultation and identifying adaptations required to support prescribing decisions. In this chapter we will ask you to think about the elements of the consultation that you may need to adapt or work on. We will give practice tips and point out common errors that can affect the quality of a consultation.

Prescribing inherently brings with it a greater requirement to make a diagnosis. This responsibility may be new and quite daunting. Prescribers need to have an understanding of the diagnostic process. In most circumstances, the key factor for accurate diagnosis is eliciting a good history. For this reason we will look in detail at the elements of a history. Examination and investigations are directed by and supplement the history. The depth and focus of the history and examination will vary depending on the setting and your role. Wherever you work, however, it is essential to be thorough and systematic and above all to know the bounds of your competence. History taking, examination and clinical decision making are skills that need to be continuously practised under expert supervision.

Ideally your prescribing will be effective but above all it should be safe. The primary dictum of all healthcare practice is ‘primum non nocere (above all do no harm)’. In the final part of the chapter we will outline the elements of the consultation that are essential for safe prescribing, the ‘bottom liners’ of a prescribing consultation.

The consultation

There are many factors that influence consultations and no two encounters between a practitioner and a patient are the same. The nature of your role will influence the types of patients you treat and the environment in which you see them. Other factors include the purpose of the consultation, the urgency and seriousness of the presentation, time constraints and the personalities, culture, language and medical knowledge of both the patient and the clinician. Previous contact with the patient, autonomy and confidence are other clinician factors. Communication and consultation skills are inextricably interlinked. There are many excellent textbooks available for prescribers who wish to enhance their communication skills (Silverman, Kurtz and Draper, 1998; Berry, 2004).

Elements of a consultation

Although consultations differ in the specifics, there are common elements and generic skills that are applicable in varying degrees to any given situation. Numerous consultation models have been developed over the years, for example Neighbour (2005), Pendleton et al. (2003), Calgary Cambridge in Silverman, Kurtz and Draper (1998). Rather than dwelling on the theory underpinning consultations, we will describe a practical framework, the elements of which can be applied in varying degrees to all consultations – see Box 1.1.

Box 1.1 Elements of a Consultation

(a) Preparing for the consultation and setting goals for it.

(b) Establishing an initial rapport with the patient.

(c) Identifying the reason(s) for the consultation.

(d) Exploring the patient’s problem(s) and ascertaining their ideas, concerns and expectations (ICE) about it.

(e) Focusing questions to obtain essential information.

(f) Gathering sufficient information relating to the patient’s social and psychological circumstances to ascertain their impact.

(g) Coming up with a diagnosis or a number of differential diagnoses in order of likelihood.

(h) Performing a focused physical examination and near-patient tests to support or refute the differential diagnoses.

(i) Interpreting the information gathered and re-evaluating the problem.

(j) Reaching a shared understanding of the problem with the patient.

(k) Considering further investigations if necessary.

(l) Deciding what treatment options, pharmacological and non-pharmacological, are available.

(m) Advising the patient about actions needed to tackle the problem.

(n) Explaining these actions and the time of follow-up if required.

(o) Inviting and answering any questions.

(p) Summarising for the patient and terminating the consultation.

(q) Making a written record of the consultation.

(r) Presenting your findings to another health professional.

It is important for consultations to have a degree of structure. The skill in consulting is to maintain a structure and system that includes all the vital elements and yet does not feel like a straitjacket for the patient or clinician. In the following section we will analyse the different elements of the consultation in more detail and highlight those that are likely to change or need more emphasis for you as you take on prescribing.

Stop and think

Using Box 1.1 as a framework, reflect on your current consultations. What learning and development needs do you have?

(a) Preparing for the consultation and setting goals

Take time to study all the information available to you about the patient prior to the consultation. Study referral letters and available medical records for vital information, including the patient’s past history, medications and allergies. Set goals for the consultation and ensure that the environment is set up appropriately with adequate lighting and privacy.

(b) Establishing the initial rapport

First impressions are very important and will influence your subsequent relationship with the patient. If you have not encountered the patient before, introduce yourself by name and explain your role. Check the patient’s details (name, date of birth, address). Observe the patient’s demeanour and physical appearance. The patient will invariably be feeling nervous. Put them at ease by projecting confidence and warmth and they are more likely to open up to you during the consultation.

(c–g) History taking/diagnosis hypothesis

Elements ‘c–g’ in Box 1.1 are primarily concerned with the taking of a history and the consideration of differential diagnoses. The importanc...

Table of contents

• Cover
• Title
• Copyright
• Contributors List
• Preface
• Section 1: The Patient
• Section 2: Evidence–Based Practice
• Section 3: Pharmacology
• Index