Unit 4 - Prescribing Partnerships

Assessment and Decision-making


Models of consultation

There are many styles of consultation and patient compliance is heavily influenced by the way a nurse or doctor conducts the assessment. Humphries and Green (2002) discuss four main styles of consultation:

  • The authoritarian consultation
    This method of collecting information has no regard for patient autonomy and uses a 'healthcare professional knows best' style. Patients are not encouraged to ask questions and are expected to comply fully. This is not conducive to compliance/concordance

  • The permissive style
    This style of consultation verges on the laissez-faire. The healthcare professional is keen to be 'the good guy' to please the patient and, in doing so, cannot make professional decisions when necessary. This style is not conducive to compliance/concordance either

  • The psychotherapeutic style
    This style assumes that patients' fears about their treatment are not genuine everyday concerns. The healthcare worker is suspicious of the patients' motives. The clients' responses are not taken at face value but are responded to in a therapeutic way. This style may or may not be conducive to compliance/concordance because the underlying issues may not always be evident

  • The participatory style
    This style encourages patients to have ownership of their medical regime, which is tailored to suit their way of life in a realistic way. The patient is empowered and feels they have a say in their treatment. This style has an extremely positive impact on compliance/concordance.
Discuss

You may find it useful to observe your supervisor during consultations. Try to pick out which models of consultation they are using.

This session may lead to helpful discussion.

Make Notes

In your supervised capacity, observe and write down any differing consultation styles you may see, paying particular attention to the outcomes of the consultation. Would you have reached the same decisions?

Would you have done it differently? You could use this activity as evidence for your profile.

Reading

Baird, A. (2004) Consultation Skills and Decision Making in Courtenay, M. and Griffiths, M. Independent and Supplementary Prescribing: An Essential Guide. London: Greenwich Medical Media. Chapter 3.

Luker, K., Hogg, C., Austin, L., Ferguson, B., Smith, K. (1998) Decision-making: the context of nurse prescribing. Journal of Advanced Nursing. 27 657-665.

It is evident that a diagnosis has to be reached in order for the professional to prescribe. The collection of information — often a large amount — is needed to determine a patient's health status and needs, and to plan appropriate care.

Reflective Activity

Reflective activity

There is controversy in the literature as to whether diagnosis has been an established part of nursing practice for a long time. Reflect on the situations in which you will be prescribing and consider how you will tolerate some of the uncertainties that go with the responsibility of your diagnosis.

Further Reading

Further reading

Carnevali, D.L., Thomas, MD (1993) Diagnostic Reasoning and Treatment Decision Making in Nursing. Philadelphia: Lippincott.

Fitzgerald, M. (1994) Nursing Health Assessment: Concepts and activities. Philadelphia: FA Davis.

Morton, P. (1994) Nurse's Clinical Guide to Health Assessment. Springhouse: Springhouse.

Weber, J., Kelley, J. (2003) Health Assessment in Nursing (2nd edition). Philadelphia: Lippincott.

Seven principles of good prescribing… a stepwise approach

The seven principles of good prescribing listed below can be accessed via the National Prescribing Centre (NPC) web site at:
www.npc.co.uk/nurse_prescribing/bulletins/signposts1.1.htm

  1. Examine the holistic needs of the patient. Is a prescription necessary?
  2. Consider the appropriate strategy
  3. Consider the choice of product
  4. Negotiate a 'contract' and achieve concordance with the patient
  5. Review the patient on a regular basis
  6. Ensure record keeping is both accurate and up to date
  7. Reflect on your prescribing

Each of these seven principles is discussed in detail on the NPC web site. Familiarise yourself with them and get used to using them during your consultations.

The mnemonic WWHAM and the prescribing pyramid — also described on the NPC web site— are used by pharmacists for over-the-counter medications when by applying the first principle of good prescribing.

Have a look at these on the NPC web site and try to incorporate them in your patient assessment.

Reading

Reading

Luker, K., Hogg, C., Austin, L., Ferguson, B., Smith, K. (1998) Decision-making: the context of nurse prescribing. Journal of Advanced Nursing. 27 657-665.

Two models of decision-making are suggested in this article. The first is a scientific or rational approach based on quantitative analysis. The second approach puts more of an emphasis on intuition and experience. The article suggests that these models can be combined, comprising both analytical and intuitive aspects.

Reflection

Consider this in the light of clinical governance and evidence-based practice. Using the Luker article, pay particular attention to the subheadings 'Influences on decision-making' and 'Difficult decisions'. Can you identify with the situations highlighted under the difficult decisions?

Refer Back

Link to 'Professional accountability', 'Legal and clinical liability' and 'Ethical basis of intervention' in Unit 1. Foundations of Prescribing Practice.

To prescribe or not to prescribe

You will face difficult choices when deciding whether or not to write a prescription. There may be many reasons for not providing a prescription.

  • You may advise the patient that it would be cheaper to buy the prescription over the counter
  • You may consider it more appropriate to give advice than to write a prescription
  • You may decide to refer the patient to a colleague with more expertise in a particular field.
Refer Back

Link to 'External influences on prescribing' in Unit 3. Prescribing and the Wider Healthcare Context.

Case studies

Making the right diagnosis is based on integrating many pieces of information:

  • The complaint as described by the patient
  • Detailed history
  • Physical examination
  • Laboratory tests
  • X-rays and other investigations.

Patients' complaints are mostly linked to symptoms. A symptom is not a diagnosis, although it will often lead to one.

Reflection

Consider the following, where you are presented with three patients who all complain of a sore throat:

  • Patient 1 is a man of 54 years. He is apyrexial, has slight redness in his throat and no significant past medical history.

  • Patient 2 is a woman of 23 years. She has slight redness in her throat, slight pyrexia, complains of tiredness and has enlarged lymph nodes in her neck.

  • Patient 3 is a female student of 19 years. She has slight redness in her throat but no fever and no other findings. She is a little shy and has never consulted you before for such a minor complaint.

These examples illustrate that one complaint may be related to many different problems:

  • A need for reassurance
  • A sign of underlying disease
  • A hidden request for assistance in solving another problem.
Reflection

With reference to the seven principles of good prescribing, WWHAM and the prescribing pyramid, think about the questions, and investigations that you would need to consider, in order to form your diagnosis and decide whether to treat a patient conservatively, prescribe appropriately or refer for further examination.

Always remember: never jump to therapeutic conclusions.

Further Reading

Further reading

Barber, N. (1995) What constitutes good prescribing? British Medical Journal 310: 923-925.

Luker, K.A. et al (1998) Nurse-patient relationships: the context of nurse prescribing. Journal of Advanced Nursing 28: 2, 235-242.


Top ©Emap 2006 Disclaimer