In keeping with NMC code of conduct (2018) patient confidentiality will be maintained

throughout the three reflections below by changing identifiable details. Gibbs (1988)

reflective cycle has been used with all reflections as I have found Gibbs to be easy to

use in relation to these reflections.

Gibbs, Graham. (1988) Learning by doing: A guide to teaching and learning Oxford:

Oxford Centre for Staff and Learning Development. Available online at

http://www2.glos.ac.uk/gdn/gibbs/index.htm [Accessed 1st April 2020]

Nursing & Midwifery Council. (2018). The code: Professional standards of practice

and behavior for nurses, midwives and nursing associates. Retrieved

from http://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/revised-

new-nmc-code.pdf

(1) Reflection on a patient requesting oral antibiotics, when it is not clinically

indicated as well as how undertaking the prescribing course will change my

practice when dealing with such patients.

Whilst completing clinical hours at an urgent care centre a 24 year old female

presented with what she thought was a chest infection. Miss Smith walked into the

clinic room unaided and with no evidence of shortness of breath or shortness of

breath on exertion; she was immediately able to give history talking in full sentences.

Miss Smith’s vital observations where all found to be within normal range. Miss

Smith advised she has a history of chest infections that always require oral

antibiotics, but no history of any respiratory conditions and was not on any repeat
medication at all. Symptoms had only commenced last night according to Miss Smith

who reported green and yellow sputum, however during assessment patient

appeared to have a dry cough. On auscultation the chest was found to be clear with

no wheeze or crackles.

It was clear from the start of the consultation that the patient wanted a prescription

for antibiotics. When discussing the findings of her examination and her not

requiring any medication at this time she did become upset and felt that she required

the oral antibiotics, despite our reassurance around her not requiring them. The

nurse whom I was shadowing took her time to explain antimicrobial stewardship and

the risks of overusing oral antibiotics. Miss Smith was also was given robust safety

netting advice and reassured she should return if there was no improvement in her

symptoms. Following some further reassurance she appeared to accept the advice.

On this particular occasion the nurse I was shadowing took a lot of time to explain

the reasons behind not prescribing the patient antibiotics however I have noted

anecdotally within my nursing career and whilst doing this module that there are

occasions where antibiotics do appear to be prescribed either due to pressure on the

health care individual or sometimes seemingly lack of time too.

One of the main themes throughout completing the non-medical prescribing course

(NMP) has been around inappropriate prescribing of antibiotics and the risk of

antibiotic resistance organisms. The Standing Medical Advisory Committee in 1998

highlighted that antibiotics that are inappropriately prescribed for patients have the

potential to cause adverse drug reactions, minor and major as well as escalate the

prevalence of antibiotic-resistant organisms within the community. Whilst this was 22

years ago and there is far more current information around antibiotic resistance I find

it worrying that this still seems to be a reoccurring problem despite all the guidelines
and advise. Dolk FC et al, (2018) noted that within primary care 50% of antibiotic

prescribing was for respiratory tract infections (RTIs) according to Smieszek et al,

(2018) this often fails to benefit the patent due to most RTIs being viral and self-

limiting.

Roope et al, (2020) conducted a randomised study where 4000 UK adults received

three different messages around the use of antibiotics and antimicrobial resistance

(AMR), with the intention of inducing fear around AMR to varying degrees. The study

aimed to find what the impact of messages based around fear without and with self-

empowering advice would have on patients in terms of the use of antibiotics and

AMR. Roope et al, found that the use of fear within a campaign could be effective

when reducing unnecessary antibiotic use however they also found it should be in

combination with advice on how to self-manage their symptoms without antibiotics

thereby empowering the patient.

In the case of Miss Smith it would appear that she had often been prescribed oral

antibiotics however with no formal history on her records around having ongoing

respiratory infections or further testing around what may be the cause of these

reoccurring infections. She had no diagnosis of COPD or asthma but was a smoker.

Initially Miss Smith did not seem to understand the risks and or dangers around

antibiotic resistance and managing self-limiting illnesses, despite the ongoing

information from Public Health England (2019). In my experience as a health care

professional, I have noticed that many patients still do not appear to understand the

risk around antimicrobial resistance and feel they are being treated when prescribed

antibiotics or potentially ‘fobbed off’ when not being prescribed them. It has also

highlighted that antibiotics are often prescribed inappropriately; this in turn has

highlighted an ethical dilemma in relation to patient’s best interest and inappropriate

prescribing of oral antibiotics. In terms of my own personal practice I have found that

this has given me tools to be more assertive when discussing the treatment of self-

limiting conditions and ensuring the patient understands the rationale and is given

appropriate and self-empowering advice as well as re-assuring them they can return

at any time should anything worsen.

Dolk FC, Pouwels KB, Smith DR, Robotham JV, Smieszek T. Antibiotics in primary

care in England: which antibiotics are prescribed and for which conditions? J

Antimicrob Chemother. 2018;73(suppl_2):ii2–10.

Public Health England. (2019). Become and Antibiotic Guardian. Available:

https://antibioticguardian.com/keep-antibiotics-working/. Last accessed 3 April 2020.

Roope, L.S.J., Tonkin-Crine, S., Herd, N. et al. Reducing expectations for antibiotics

in primary care: a randomised experiment to test the response to fear-based

messages about antimicrobial resistance. BMC Med 18, 110 (2020).

https://doi.org/10.1186/s12916-020-01553-6

Smieszek T, Pouwels KB, Dolk FC, et al. Potential for reducing inappropriate

antibiotic prescribing in English primary care. J Antimicrob

Chemother.2018;73(suppl_2):ii36–43.

Standing Medical Advisory Committee, Sub-Group on Antimicrobial Resistance

(1998) The path of least resistance. [London]: [Department of Health].

(2) Polypharmacy and deprescribing in the elderly related to a patient seen on

my caseload.

Polypharmacy is seen as the use of numerous or multiple medications by one

person however NICE go on to differentiate between appropriate polypharmacy as

there are occasions where the prescribing of multiple medications is unavoidable, as

opposed to problematic polypharmacy where the intended benefits of the medication

are not experienced by the patient. (NICE 2017)

Often upon assessing patients in their homes there are large quantities of

medications sometimes unopened and unused; when I personally have asked

patients they have given me many different reasons for this but foremost is usually

they struggling with the volume of medication and knowing how to take them or fear

of side effects real and potential. On one particular occasion I was asked to assess a

patient who was struggling with her activities of daily living as well as having

problems with ongoing constipation and loose bowels intermittently. When assessing

Mrs Brown an 86 year old lady with arthritis and chronic back problems she

appeared mostly concerned about her bowels. Upon reviewing her medication I

found Paracetamol, Codeine and Tramadol for pain as well as Senacot, Laxido and

Lactulose for bowels. When taking history it became clear that over the past year

she had input from various areas and medications added but no advice on stopping

previous medications. In terms of her pain she felt it was controlled a lot of the time

but admitted to not always taking her analgesia and felt that this contributed to the

‘bad days’. When discussing her bowels she admitted that she would not take
anything for her bowels despite being on the opiates, until such time she would feel

very constipated and then take all the laxatives ultimately ending up with loose

stools.

Preventing inappropriate polypharmacy in the elderly is highlighted by an older study

completed by Maher et al in 2014 that indicated approximately 50% of older adults

take one or more medications that are potentially not required; as mentioned this is

something that I have noted regularly whilst assessing and reviewing patients in the

community. Sun. W et al (2019) recognise that there are few studies that focus upon

the nursing perception of deprescribing however they do mention studies that are

available, tend to be within residential or long term care settings and mostly around

physicians and how they are influenced by various different factors including nurses.

There does appear to be limited information or studies directly related to nurse

prescribers and deprescribing, though Sun. W et al (2019) also go on to report there

has been some evidence to suggest nurses in general bring a different perspective,

and when collaborating with other healthcare provides they ultimately aided in safer

medication administration as well as prevention of errors.

Deprescribing or ending medications has the same legal implications as prescribing

as discussed by Barnett N and Kelly, O (2017) in their article Deprescribing: is the

law on your side? Using UK case law they have explored the legalities around

deprescribing and noted that ongoing monitoring as well as review of patients

medication and decisions around their medication are required for safe patient care

however all decisions must be in done so with patients informed consent. Patients

must be given all the information with regards to the benefit/risks of being on
medication and or deprescribing medication. I can see that both prescribing and

deprescribing come with risks however using evidence based practice and

guidelines as well as including the patient in all decisions, as well as gaining consent

to make changes is the same when prescribing a drug or deprescribing a drug. The

focus should rely on patient involvement and informed consent. There should also be

robust safety netting advice when starting or stopping any drug.

In the case of Mrs Brown after a thorough physical assessment and excluding any

‘red flags’ we had a discussion about her medication and how she was taking it, part

of her issue was remembering to take them as she felt she had so many different

‘pills to remember’. She was only sporadically taking the Tramadol and therefore we

discussed stopping this. In conjunction with her General Practitioner (GP) we made

some changes by starting her on Co-codamol whilst leaving her with the Laxido for

her bowels. Mrs Brown was given robust advice around constipation as well as how

she could increase the Laxido dose as required. There was also emphasis on

lifestyle advice such as good hydration and diet. Other medication not within our plan

was removed from her repeat by the GP. A review of Mrs Browns progress was

scheduled as well.

What this has highlighted for me is that inappropriate polypharmacy can lead to poor

outcomes or quality of life in patients. In terms of my practice, the importance of

taking a good history including medication and when making any changes including

the patient in all decisions as well as empowering them and encouraging

self-care/management ensuring this is done with consent.

Barnett N, Kelly O, (2017) Deprescribing: is the law on your side? European Journal

of Hospital Pharmacy; 24:21-25.

Maher, R., Hanlon, J., & Hajjar, E. (2014). Clinical consequences of polypharmacy in

elderly. Expert Opinions on Drug Safety, 13(1), 1-11.

National Institute for Health and Care Excellence. (2017). Multimorbidity and

polypharmacy. Available: https://www.nice.org.uk/advice/KTT18/chapter/Evidence-

context. Last accessed 14th April 2020.

Sun, W et al. (2019). Raising awareness about the critical importance of the nursing

role in deprescribing medication for older adults. Perspectives: The Journal of the

Gerontological Nursing Association. 40 (4), p18-22.

(3) How undertaking the Non-Medical Prescribing module will change my

practice and patient experience within my service.

Initially Health Visitors and District Nurses where able to use a small national

formulary in 1998. However since then nurse prescribing has grown considerably

(Royal College of Nursing, 2012). The scope was ultimately widened to include all

medicines within the British National Formulary (Department of Health, 2006).

Prescribing has generally been accepted as the role of a doctor previously however

in more recent times with increasing economic, social and political demands on the

healthcare system there has been a shift in the role of other health care
professionals including the role of prescribing. (Lim et al, 2013) Whilst this is not a

recent article it highlights how long there has been a recognition of the need for non-

medical prescribers within the health care setting.

My team is a community based team that covers an entire county, predominantly

seeing patients for admission avoidance as well as facilitating early discharge from

acute hospitals. Due to the nature of our caseload we are often seeing and

assessing sub-acute patients who potentially require a lot of intervention/monitoring.

Part of the service includes administration of intravenous antibiotic administration as

well as assessing patients for various acute issues and attempting to treat them

within the community where it is safe to do so thereby avoiding admission. Due to

the nature of our patients we have a group of Senior Health Care Professionals who

carry out what we call an initial assessment; this assessment will include a full

consultation with physical examination as indicated. Currently I am working within

this role as a senior nurse and possess the experience and knowledge to carry out

consultation and examination of patient including a diagnosis; however I have been

unable to prescribe and therefore have relied heavily on the patient’s General

Practitioner or other colleagues.

Gerrard et al, (2014) carried a patient survey using 451 patients from 5 different GP

practices in order to ascertain patient preference for profession of prescriber and any

other issues that may influence contact with a health care professional for managing

their minor illness. They found that whilst there was indeed a strong preference for

seeing one’s own GP they were not negative about seeing a nurse prescriber as

long as it was a positive and patient focused outcome, past experiences appeared to

influence preference. Willis (2015) indicates that nurse prescribing within a

community setting may ultimately lead to continuity and quality of care that can be

provided at a time that is best suited to the patient, therefore improving a patient’s

journey in terms of their care. Anecdotally I have noted that patients within our

service appear very receptive to our nurse prescribers and often are grateful for the

time they have to spend with the patients and the continuity in care. They often

appear pleasantly surprised when the nurse visiting is able to diagnose and

prescribe a treatment, there and then. Kroezen et al, (2014) recognised that nurse

prescribing as part of patient care was a recognised measure to aid the reduction of

GP and hospital visits/attendances in turn leading to a more cost effectiveness in

care. Relating this back to my service, this is at the core of what we do. A team of

health care professionals who are able to rapidly see and assess patients, put a

treatment plan in place and avoid admission or facilitate a discharge will ultimately

be more cost effective, as well as patient friendly. Being a non-medical prescriber will

aid the ability to rapidly respond and treat without having to defer to other health care

professionals e.g. GP.

In relation to accountability the Nursing and Midwifery Council (NMC, 2006)

published the Standards of proficiency for nurse and midwife prescribers. In terms of

accountability the NMC specify that the nurse prescriber is accountable for any

prescribing decisions made including actions and omissions and may not give this to

any other person. There is also clear guidance that a nurse prescriber must only

ever prescribe within their area of expertise and or competence.

Undertaking the non-medical prescribing course has been challenging in many ways.

Professionally, as a clinician it has made me see things very differently in terms of

treatment and plans of care. Equally it has made me more aware of my limitations,

even viewing them in a positive way and driving me to learn more and ensure I

remain up to date with policy and guidelines. I am aware now, more than ever of the
importance of continuous professional development and my own accountability.

However, ultimately being able to prescribe will enhance my practice and ensure

patients within my service will benefit from rapid assessment and treatment in turn

leading to better patient outcomes and admission avoidance via our service as well

as potentially being more cost effective in the long term.

Department of Health. Extending Independent Nurse Prescribing within the NHS in

England: a guide for implementation. 2006. Available at:

www.dh.gov.uk/en/PublicationsandStatistics/PublicationsPolicyAndGuideance/

DH_4006775, (accessed 12 March 2020).

Diggle J (2018) How do prescribing nurses demonstrate prescribing proficiency?

Diabetes & Primary Care 20: 81–5

Kroezen M, de Veer A, Francke A, Groenewegen P, van Dijk L. Changes in

nurses’views and practices concerning nurse prescribing between 2006 and

2012:results from two national surveys. J Adv Nurs. 2014;70(11):2550–2561.

https://doi.org/10.1111/jan.12404

Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife

prescribers. NMC, London. Available at: https://is.gd/zjqhgb (accessed 9th April

2020)
Royal College of Nursing (2012) RCN factsheet on nurse prescribing in the UK.

RCN, London. Available at: https://www.rcn.org.uk/about-us/policy-briefings/pol-

1512#tab1 (accessed 12th April 2020)

Willis P for Health Education England. Raising the bar. Shape of caring review.2015.

http://tinyurl.com/y5ocfsn6 (accessed 1st April 2020)