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Self assessment, reflection and audit of prescribing practice against the ten competency
dimensions
Jan Keenan Consultant Nurse Cardiology; NMP Lead
• Supporting prescribers to undertake reflection and self assessment of prescribing practice against the ten competency dimensions
• Learning from prescribing practice
• Undertaking an audit of prescribing practice
• Why are so many qualified prescribers not using their prescribing qualification in practice: the barriers to prescribing post qualification
Objectives:
Supporting prescribers to undertake reflection and self assessment of prescribing practice against the ten competency dimensions
• ‘Reflective practice is an active, dynamic action-based and ethical set of skills, placed in real time and dealing with real, complex and difficult situations’
• Reflective practice can be a shared activity • It can be difficult to find time to reflect in a busy work
environment
• Reflection isn’t a tool to learn only from difficult situations
• https://www.skillsyouneed.com/ps/reflective-practice.html • Moon, J. (1999), Reflection in Learning and Professional Development: Theory and Practice, Kogan Page, London
Reflection
The Reflective Learning Process
Identify a situation you encountered in your work or personal life that you believe could have been dealt with more effectively.
Describe the experience
What happened? When and where did the situation occur? Any other thoughts you have about the situation?
Reflection
How did you behave? What thoughts did you have? How did it make you feel? Were there other factors that influenced the situation? What have you learned from the experience?
Theorizing
How did the experience match with your preconceived ideas, i.e. was the outcome expected or unexpected? How does it relate to any formal theories that you know? What behaviours do you think might have changed the outcome?
Experimentation
Is there anything you could do or say now to change the outcome? What action(s) can you take to change similar reactions in the future? What behaviours might you try out?
Reflection
https://www.skillsyouneed.com/ps/reflective-practice.html
Approaches to reflection
• In passing….
– ‘I had the most dreadful experience this morning……’
– ‘Have you a minute…?’ • Peers
• Supervisors
• Peer supervision
• Formal
– Revalidation
– Theoretical approaches
– Clinical supervision
– Appraisal
Competency dimensions
• The Consultation [1-6]
– Assess the patient
– Consider the options
– Reach a shared decision
– Prescribe
– Provide information
– Monitor and review
• Prescribing Governance [7-10]
– Prescribe safely
– Prescribe professionally
– Improve prescribing practice
– Prescribe as part of a team
• Becca – Heart Failure ANP, acute care
• A lady with end stage valve disease – she wanted to go home to her daughter and her dog – this before IV furosemide was available in the community. I ended up prescribing metolazone the day before discharge – usual caution with stable at discharge was
out the window!
• I made sure she had detailed instructions for if she
was offloading too well over the weekend, follow
up for Bloods with the community team - a bold
first prescription!
Heart Failure – Valve disease
Learning from prescribing practice
• Prescribing errors are common, occurring in around one in 20 prescriptions
• Some reasons: – Incomplete patient history – Indication errors – underuse, overuse, misuse – Incomplete medication history – interactions, allergy – Poor response to side effects or adverse reactions – Dosing errors - failure to take account of age (children, elderly
people) – Failure to spot clinical signs that might contra-indicate – Abbreviations – Misinterpretation of verbal orders
Learning from prescribing practice
• Open culture, reflection, supervision, good governance structures for reporting investigation and learning
• Learning from successes - they are more common!
Learning from prescribing practice
• Tamara – Neurosurgical (spinal) ANP
• 35 year old lady 10 weeks after a repeated spinal procedure, persistent and deteriorating pain, taking 4 analgesics but didn’t like side effects of amitriptyline
• Reassured patient still early in recovery; neuropathic pain takes time to settle if at all; happier to try nortriptyline as alternative after discussion
• Wrote to GP to update meds, offered a point of contact and arranged follow up
Neurosurgery
Undertaking an audit of prescribing practice
• ‘Audit’ – ‘conduct a systematic review of’ • Audit is usually against a standard • It isn’t a list of drugs NMPs prescribe • Standards…
– Prescribing review should be undertaken against acknowledged standards, e.g. local formularies, NICE guidance, Trust medicines guidance
– Use an audit of your practice against a published standard in one of these areas
• Audit of NMP doesn’t happen in isolation!
Auditing prescribing practice
• Audit against guideline for the management of a condition – not by a single prescriber but as a team
• Medicines monitoring and safety – Frequency of thyroid function testing in patients receiving Levothyroxine – Regular blood monitoring in patients on Methotrexate – Thyroid function testing in patients taking Amiodarone – U&E testing on initiation of an ACE inhibitor
• Quality or prevention – Aspirin therapy in IHD – Statin use in IHD – Appropriate use of benzodiazepines – ACE / AIIA in diabetic patients with micro albuminurea
• Cost savings or appropriate drug switches – Clopidogrel - appropriate usage – Inappropriate generic use (eg MR calcium channel blockers or theophyllines) – Use of enteric coated v. soluble aspirin
https://gpcpd.walesdeanery.org/index.php/audit-in-prescribing
Auditing prescribing practice
• Jan– ANP, Menopause Service
‘The big problems with HRT are poor efficacy and side effects; (I) updated the formulary that sets out to help prescribers make logical treatment choices and changes so that women are treated effectively’
• Audit prescribing against
the agreed guideline
Medications Guideline
Why are so many qualified prescribers not using their prescribing qualification in practice: the barriers to prescribing post qualification
• ‘Nurse prescribing is not just about sending a patient, FP10 in hand, to the pharmacy and there are many other ways that nurses can, and do, use their prescribing qualification’
• About 90% are prescribing regularly • For those who don’t…
– 13 out of 14 nurse independent prescribers interviewed said additional responsibilities and a lack of financial reward were disincentives to prescribing
– Occasionally noted reasons for not prescribing include pro-cedural delays, e.g. lack of electronic prescribing and access to patient notes, lack of support from employers and managers, and lack of continuing professional development
Really?
http://www.prescriber.co.uk/article/expanding-role-nurse-prescribers/
• Allie – Matron; Dialysis and PD
• Asked to see a patient on dialysis – unresolved UTI; we agreed we would wait for culture and not treat the UTI as they were frequent. As a result of the consultation, I: – Stopped his oral bicarb supplements – not needed
– Increased aranesp and iron to treat anaemia
– Modified his PO4 binders
• ‘Had he seen a junior doctor, they would have discussed urine’
Renal Nursing
