LEGAL, ETHICAL, AND PROFESSIONAL FRAMEWORKS FOR ACCOUNTABILITY FOR PRESCRIBING

In the nursing practice, nurses collaborate with other professionals, families, and communities to promote health, prevent illnesses, and care for the sick and dying people. Among the major roles of nursing, they usually participate in shaping health policy and improvement of health systems management to promote a safe environment for research. Across the world, the aim of the nursing community is to promote quality care for their populations while maintaining the ethical practice, standards, and advancement of research (Courtenay et al., 2019). According to the nursing theory, nurses adopt a holistic care model for all individuals including their emotional, physical, intellectual, spiritual, and social needs. With the use of technology in today’s world, nursing combines social science, physical science, and technology to care for patients wellbeing.

Among the many roles for nurses, medication management and administration is part of their jurisdiction. In the United Kingdom, some nurses that have additional specialist training in their scope of practice are given the right to prescribe any medication to their patients. Although most nurses are mandated to manage medications and administration, professionals in their field such as nurse practitioners and physicians are given full authority to prescribe medicine (Courtenay et al., 2019). However, the nurses are legally responsible for drugs administered on a patient. When there is an error in prescription, the National Health Service (NHS) requires the nurses to record and report the error accordingly. Generally, prescribing in the nursing practice, with the guidance of NHS, have to follow the legal, ethical, and professional frameworks to enhance accountability and responsibility among the practitioners. Therefore, this discussion articulates and debates these frameworks based on how they apply and resonate with the nursing practice in their mandate to provide quality of healthcare.

1. Legal Frameworks

            The legality of medical prescriptions among health professionals is a subject that the law handles very critically. Prescribing within the nursing practice must follow different set protocols to ensure accountability while avoiding errors that may lead to negative health outcomes. In the UK, the Health and Social Care Act 2001 provided the legislative authority for the prescription framework in the practice (Duffull et al., 2018). The Act focused on the expansion of the prescription authority to the nurses, although they had to comply with particular conditions. Therefore, the nurses became part of the prescribing function.

            In the same year (2001), the Government announced four areas of care will be extended to the nurses including minor injuries and ailments, palliative care and health promotion. In this extension, the nurses could prescribe all General Sales List and Pharmacy medicines that general practitioners prescribe. However, they would not have authority to prescribe most of the controlled drugs unless under special conditions. In this light, the nurses did not need a health visitor qualification for them to prescribe. In that regard, they were required to complete an ENB approved programme where they train and prepare for prescribing functions.

            Legal responsibilities

            All nurses engaged in prescribing roles must be aware of legal responsibilities bestowed upon them. In this function, they perform as autonomous practitioners, which means they act on behalf of their employers. In that regard, they are responsible for every mistake or errors done during prescriptions. They are answerable not only to their employers but also their professional bodies, and the courts in the case a prescription case escalates to the court level. To avoid the blame games, the law sets it clear that every nurse is responsible for ensuring that prescriptions administered on a patient are correct and free of errors (Maier, 2019). They will not take the responsibility for errors committed by their colleagues if whatsoever they were not involved in the case. Therefore, personal responsibility must be ensured as a requirement by the law.

            In some other instances, the nurses or midwives may find themselves in situations where they need medicine or their family members. In the practice, it is strongly recommended that nurses should not prescribe medicine for themselves or their families. This is because it may interfere with important clinical examination (Schiller et al., 2019). However, in the case there is no other option than to prescribe for their families or themselves, they will take full responsibility for their decision and the outcomes.

            Supplementary prescribing

            Preliminary to any action, an independent prescriber must determine whether a patient would benefit from supplementary prescribing. After this is settled, the nurse practitioner will enter into a voluntary partnership with an independent prescriber such as a doctor or a dentist. Through this partnership, they can implement a patient-specific Clinical Management Plan with an agreement with the patients (Wilson et al., 2018). In the drafting of the law, the government sought to understand the benefits that patients will have when prescribing is done by the supplementary prescriber or the independent prescriber.

            From the guidelines drafted in the law, supplementary prescribers must;

• Accept professional accountability and responsibility in the clinical practice of prescribing.
• Work with the independent prescriber in case they need to but ensure clinical competence and professional code all the time.
• When the clinical reviews are not done within specified time intervals, the supplementary prescriber will pass the responsibility back to the independent prescriber.

The above are guidelines that the supplementary prescribers must follow to ensure accountable practice. In that regard, this role may be assumed by a first-level registered nurse or midwife and they must be in the NHS register, which means they have undergone essential training (World Health Organization, 2018). The training programme should take place in higher education institute and practical training in a health institution.

• Ethical Frameworks

Among different codes of practice, ethical values are the foundation of the nursing practice. Nurses are the advocates for patients and in this case, they should ensure a balance when administering care to the patients. In the ethical frameworks, four principles are the main, which include justice, autonomy, beneficence, and non-maleficence (Courtenay et al., 2019). For instance, the principle of autonomy recommends that a patient has a right to their decisions based on their values and beliefs. These rights may conflict with the guidelines of the clinical practice of prescriptions.

A nurse with a prescribing role or administering prescriptions should understand the Code of Ethics that lead them to understanding their moral character and integrity. Maintaining this code ensures that the nurses remain true to patient care (Isenor et al., 2018). In that regard, apart from understanding the legal frameworks and requirement of prescriptions, they must also familiarize with their ethical obligations. These is understood through a set of clinical ethical guidelines to ensure that all patients are safeguarded from potential harm. According to a recent study by the World Health Organization (WHO), a third of adults in the United States take more than four medications on a daily basis. It is known that excessive intake of drugs may cause adverse effects on patients.

In the above observation, the WHO has come up with a multi-approach framework for prescribing drugs that would help the nurse practitioners focus on the intent of treatment. Although these guidelines were developed in 2007, they are applicable until today in the practice (World Health Organization, 2018). They include;

• Understanding the patient’s problem first through evaluation and definition
• Before prescribing, the prescriber will determine the therapeutic objective the drug wants to achieve.
• Selection of the correct and appropriate medication for the patient
• The patient will be provided with instructions, warnings, and any other relevant information
• The prescriber should regularly monitor their patients
• They will also consider the cost of drugs and whether the patient is able to afford them.
• To reduce unnecessary errors, the prescriber should use electronic software when prescribing, which reduces prescription errors.
• Also, the patient will be evaluated and their specific special needs obtained, which would determine the prescription approach.

While some of practitioners prefer to prescribe for their friends and family, ethical researchers in the nursing field connotes that it is not a good idea. Although some states and countries have laws that forbid the behaviour, some just advise against it. According to the researchers, close relationships may alter the practitioner’s judgement, which could lead them to making errors or causing other adverse outcomes (Noblet et al., 2017). In fact, in some states, when a practitioner prescribes drugs to their close friends, a legal action is triggered. Therefore, it is crucial for the even family members to understand that it is not ethically right to get prescriptions from their close ones.

            In the prescription of drugs, some medicines are derived from animal ingredients such as gelatin and lactose. In ethical practice, the nurse should ensure that the drug passes through rigorous testing before the medication is released to the market. In this understanding, some patients are vegetarians or vegans, which means they may have dietary restrictions when it comes to animal ingredients. In that regard, the patient should be made aware of the drug content for them to make an informed decision (Mills, Weidmann, and Stewart, 2017). This is because the patient may stop taking the medicines after realizing it has animal content, which may lead to life-threatening consequences. Therefore, it is the responsibility of the nurse to inform patients accordingly for them to make informed decisions.

            Another challenge that nurses should avoid to enhance accountability and responsibility is managing prescription errors. In all nursing scenarios, safety during medications is crucial. This means that nurses should disclose all prescription errors and immediately as identified. Additionally, the nurse will explain to their patient how the error took place and the harmful effects of it including risk mitigation and repeat of the same error (Courtenay et al., 2019). In that regard, several questions are crucial to mitigate errors occurring again in the future. They include;

• Is the drug specifically appropriate for the treatment of the problem at hand?
• Is it the best drug to treat the problem?
• Are there contraindications to this drug on the interface with the patient?
• Is the dosage recommended correct?
• Does the patient demonstrate any sensitivities or allergies to the drug?
• Does the drug have issues of storage?
• Does the drug interfere with the lifestyle of the patient?
• Is the route of administration the best and appropriate?

In other dimensions, the ethical framework covers considerations that nurses should make when prescribing pain medications. Most of the nurse practitioners are legally given the authority to prescribe controlled substances such as painkillers that alleviate the pain in a patient before proper analysis of the health problems is done. However, excessive intake of such drugs without understanding the underlying problem will only lead to adverse effects. Therefore, in the management of pain, the Nurse Practitioner Healthcare Foundation recommended four elements;

• A comprehensive assessment of the pain on a patient and their past efforts to alleviate pain
• Ongoing education on the patient on associated risks
• An examination of other treatment options apart from painkillers
• Effective follow up to mitigate abuse of substance

• Professional Frameworks

Medicines have proven to be the commonly preferred intervention to patients’ management of medical conditions. The regimes of medicine and patients’ health conditions are increasingly becoming complex among populations. To deal with the increasing health challenges, new medicines are being added to the market at an increasing pace. In that regard, prescribers may find it hard to keep up-to-date with the best medicine to cure emerging conditions. Therefore, it would be the responsibility of the nurses and that of NHS to keep track of the changes in the prescriptions.

Apart from the competency development, different principles exist on ways to enhance continuing professional development (CPD) among the nurses and midwife prescribers (Ritter et al., 2018). They include the following;

• In order to meet CPD requirements, prescribing professionals may not be required to undertake additional hours of practice.
• CPD should generally meet a nurse’s individual needs with the understanding that they are accountable, up-to-date in the practice, and competent.
• The appraisal of CPD needs should be done on an annual basis where the review will use a recognized tool.
• CPD requirements and respect should be of no difference between midwife and nurse independent prescribers and community nurse prescribers.
• All CPD needs should be appraised regardless of whether the prescriber works in the NHS, general practice, or an independent sector.
• On their ongoing needs, a prescriber should keep a portfolio to demonstrate these needs.
• All their CPD needs should be recognized by the employer and ultimate satisfaction granted and supported.
• When determining CPD requirements, the employer should determine whether the registrants will be working in areas that cross the practice boundaries.
• Also, registrants should be responsible for these requirements despite that employers will support them in meeting their needs.

Generally, there are three domains of prescribing competency framework in the nursing practice. In each domain, there are three competencies required to be demonstrated. These domains include consultation, prescribing effectively, and prescribing in context.

In the first domain of consultation, three competencies are prioritized, which include knowledge, having options, and shared decision-making processes. In the knowledge competency, understanding the natural progress of the condition in treatment helps to assess the severity of the disease. Also, the nurses are able to understand pharmacological and non-pharmacological approaches that may promote health and elicit the best outcomes (World Health Organization, 2018). The nurse will also seek to be aware of potential for the misuse of medicines.

On the options competency, the prescriber should assess risks and benefits to the patients. They should also maintain a plan of treatment and monitor their wellbeing closely based on preferences. Also, they should communicate information about medicines especially when transferring or sharing the responsibilities of prescribing. On the shared decision making competency, the framework suggests that the prescribing responsibilities should take into account the diversity of people’s nature (Maier, 2019). They should also aim for an outcome that meets the different needs of different patients. Also, they will identify and understand the patient’s values, expectations, and beliefs to ensure competency practice.

The other domain is prescribing effectively. When prescribing the prescribers must ensure the competencies of safety, professionalism, and always improving their practice. On safety, they should know the limit of their skills and knowledge. Also, they should know when to refer the patients and when to seek guidance from other specialists (Mills, Weidmann, and Stewart, 2017). On professionalism, they should ensure that they understand the legal and ethical requirements before prescribing. They should also take responsibility and learn through continuous development of their profession. Also they must strive to keep improving in their profession through use of network support, learning, and reflecting.

The final domain is prescribing in context. In the healthcare system, this domain comprises of three competencies which include the healthcare system, information, and self and others. In the healthcare system, the prescriber must understand the local frameworks for appropriate medicine to be used for a specific function. The prescribers should, therefore, learn safe processes for prescribing while also following the national frameworks for the use of medicine (Noblet et al., 2017). On information, the prescriber will understand the advantages and limitations of the information available for them. Also, the information should reveal the evidence that is behind the therapeutic strategies and thus regular reviews are crucial. Finally, the information should be up-to-date and the accesses should be relevant and also be backed up by credible resources.

References 

Courtenay, M., Lim, R., Deslandes, R., Ferriday, R., Gillespie, D., Hodson, K., Reid, N., Thomas, N. and Chater, A., 2019. Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurses and pharmacists: intervention development and feasibility study protocol. BMJ open, 9(8), p.e028326.

Courtenay, M., Rowbotham, S., Lim, R., Peters, S., Yates, K. and Chater, A., 2019. Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the Theoretical Domains Framework and COM-B. BMJ open, 9(6), p.e029177.

Duffull, S.B., Wright, D.F., Marra, C.A. and Anakin, M.G., 2018. A philosophical framework for pharmacy in the 21st century guided by ethical principles. Research in Social and Administrative Pharmacy, 14(3), pp.309-316.

Isenor, J.E., Minard, L.V., Stewart, S.A., Curran, J.A., Deal, H., Rodrigues, G. and Sketris, I.S., 2018. Identification of the relationship between barriers and facilitators of pharmacist prescribing and self-reported prescribing activity using the theoretical domains framework. Research in Social and Administrative Pharmacy, 14(8), pp.784-791.

Maier, C.B., 2019. Nurse prescribing of medicines in 13 European countries. Human Resources for Health, 17(1), p.95.

Mills, P.R., Weidmann, A.E. and Stewart, D., 2017. Hospital staff views of prescribing and discharge communication before and after electronic prescribing system implementation. International journal of clinical pharmacy, 39(6), pp.1320-1330.

Noblet, T., Marriott, J., Graham-Clarke, E. and Rushton, A., 2017. Barriers to and facilitators of independent non-medical prescribing in clinical practice: a mixed-methods systematic review. Journal of physiotherapy, 63(4), pp.221-234.

Ritter, A.Z., Bowles, K.H., O’Sullivan, A.L., Carthon, M.B. and Fairman, J.A., 2018. A policy analysis of legally required supervision of nurse practitioners and other health professionals. Nursing outlook, 66(6), pp.551-559.

Schiller, C.J., Pesut, B., Roussel, J. and Greig, M., 2019. But it’s legal, isn’t it? Law and ethics in nursing practice related to medical assistance in dying. Nursing Philosophy, 20(4), p.e12277.

 Wilson, D.M., Murphy, J., Nam, M.A., Fahy, A. and Tella, S., 2018. Nurse and midwifery prescribing in Ireland: A scope‐of‐practice development for worldwide consideration. Nursing & Health Sciences, 20(2), pp.264-270.

World Health Organization, 2018. WHO meeting on ethical, legal, human rights and social accountability implications of self-care interventions for sexual and reproductive health, 12–14 March 2018, Brocher Foundation, Hermance, Switzerland: summary report (No. WHO/FWC/18.30). World Health Organization.