Legal and ethical perspectives of nurse prescribing
Legal and ethical perspectives of nurse prescribing
Key words: · Legal · Prescribing · Ethics
Prescribing by nurses has been a topic discussed in community nursing practice for many years. However, concrete proposals leading to the reality of nurse prescribing came into place with the review of community nursing led by (1986). The establishment of an advisory group to report on the circumstances in which nurses may prescribe (1989), proved to be a solid foundation on which the legal framework could be enacted, however, nurses need guidance on how to act ethically as well as legally in this new role.
The legal process began in 1991, when a private members bill was introduced to parliament, primarily by (). In 1992 the Medicinal Products: Prescription by Nurses etc. Act was passed, leading to amendments of the Medicines Act 1968 and the NHS Act 1977 (1995). The advisory report describes three classes of prescribing (1989):-
· Initial prescribing - applicable only to district nurses or health visitors, who may prescribe any item from the nurses formulary.
· Supply within a group protocol - applicable to stoma care nurses or continence advisers, who may prescribe items appropriate to their area of practice.
· Altering the timing and dosage of medicines within a patient specific protocol - applicable to diabetic liaison nurses, nurses or community psychiatric nurses.
Presently, the Acts enable registered nurses with a district nursing or health visiting qualification to prescribe, after undertaking additional training, leading to a recordable qualification on the UKCC register (1995). In practice this allows only the first class, of initial prescribing, to take place.
The eight demonstration sites, selected to pilot the initiative, were all fundholding practices with well established primary health care teams (1994). They represented urban, inner city and rural populations and have been described by (1996) as being so successful that the project was extended to 60 other fundholding and non-fundholding practices, within one health district. Again slowly but surely, the pilot programme is expanding to include 10 new Trust sites ( 1997a) with a view to roll nurse prescribing out to full imple-
mentation in April 1998 (1997b).
In terms of ethics, from the deontological perspective, there are conflicts between personal, official and legal senses of duty. The nurse may have criminal or civil liabilities for a breach of duty (1995). This perspective is, therefore, not particularly helpful on its own. However, the main ethical reasoning for this role extension may be argued from the consequentialist utilitarian perspective, using the four ethical principles of autonomy, beneficence, non-maleficence and justice promoted by Beauchamp and Childress (1994) to examine its application to practice.
It must be recognised, however, that the guiding framework for ethical nursing practice, comes from the UKCC (1992) in the form of the Code of Professional Conduct and the Scope of Professional Practice. Without these guiding documents, such role extensions would probably have been unworkable. Their relationship with the ethical principles will be identified and application to practice discussed.
Deontology is derived from the Greek word 'deon', meaning duty and is therefore the study of duty ( 1988). This perspective suggests that actions should be done out of a sense of what is right, regardless of the consequences. Actions which are right, are those which may be regarded as universal law and are only right when done with a sense of duty. These ideas are derived from the work of the moral philosopher (1992), which have value but cannot go uncriticised. (1988) considers that logic, probable outcome and actual outcome are important considerations in a complete ethical assessment not just a pure motive.
Take the example of dressing a patient's wound, there may be two considerations when choosing the type of dressing to use. Firstly the duty to care for the patient in such a way as to do him no harm and secondly a duty, in the cost-conscious NHS, to use a cheap dressing. The nurse decides to prescribe a cheap dressing believing that it would not stick to the wound, but subsequently she finds it to have stuck, causing pain on removal, which makes the patient unhappy. would have no difficulty in defending the decisions because the intentions were right. Yet the consequences cause conflict between the two duties.
Whether nurses should prescribe at all is a difficult question to answer in terms of duty. At present, it is recognised that there is no official duty to prescribe ( 1989), since it has not been a requirement in the community nurses contract of employment. (1995) points out that any decision to allow nurses to prescribe, is entirely at the discretion of the employer. Indeed, to prescribe without authorisation would be an illegal act and grounds for a case of professional misconduct. Therefore, to act out of a personal sense of duty would again lead to conflict.
Whilst knowledge and acceptance of duty are necessary for nurses, there are possible conflicts of duty which must be resolved. Exploration of the theories of moral reasoning (ethics) may provide the answers to resolve these conflicts.
From the utilitarian perspective, what is considered ethical can be summarised in the basic tenet 'the greatest good for the greatest number'. However, (1994) and (1988) draw attention to some the ethical conflicts with this perspective, e.g.
· The fact that this may lead to the exclusion of some minorities for whom treatments are deemed to be less effective for some reason. For example patients being refused cardiac surgery on the grounds that they refuse to quit smoking. It being judged that limited resources should be spent on those who do quit smoking and are likely to have a more prolonged benefit from the surgery.
· It could be argued that involuntary euthanasia could be employed to get rid of old people occupying beds that could be used to treat younger people instead.
In the context of nurse prescribing the utilitarian arguments are as follows: - (1990) identifies the potential benefits to patients, such as isolated dwellers not registered with GPs, who would not therefore be eligible for any 'prescription only' items. The many homeless people living in inner city areas also fall into this category. Neither these people, nor anyone else, need to be registered to be eligible for community nursing care and would not have to wait for a GP appointment, then to be referred onto a community nurse.
Savings in terms of time and travelling costs, for both patients and nurses are identified by the (1989; 1991). In a non-prescribing practice, the nurse has to return to the surgery to request a prescription and wait for the administrative process, before it is available to the patient, who then has to travel to the surgery to collect it. This could be cut by handling a prescription directly to the patient in their home.
Professional conflict or embarrassment between nurse and doctor could be avoided, although there is still the need for teamwork and communication ( 1989). (1990) suggests that 'within the primary health care team, wound management has become the responsibility of the nurse'. The GP could legitimately delegate this role, whilst the nurse would be empowered and no longer have to play the doctor/nurse game of having to appear to ask for an opinion, whilst manipulating the outcome of the interaction.
It is noted that current practice involves 'rubber stamping' of prescriptions written by nurses, awaiting only a signature from the GP, who takes only a cursory glance and knows little of the reasons for it (1989). This situation, of questionable legality and professional responsibility, would be resolved. (1990) and (1994) both argue that a more comprehensive service to the patient would be achieved. The care being patient centred, could be holistic and incorporate treatment, education and health promotion in one package.
The one negative point in utilitarian terms, is the fear that prescription costs would escalate out of control ( 1992), using funds which could be used elsewhere. (1994) and (1991) suggest that nurses may be inclined to prescribe over the counter remedies to patients exempt from prescription charges, thus saving them this cost but increasing the NHS bill. Prescribing brand named items, rather than their generically named, cheaper alternatives is also a suggested cost issue ( 1994). The conflict here appears to be minimal, with the balance of the argument in a morally acceptable, if not desirable area, since regular review of prescribing habits would highlight any irresponsible prescribing in terms of cost.
Nurses, midwives and health visitors are bound by the 'Code of Professional Conduct' ( 1992). The aims of this code can be summarised as:
iii) The expectation the UKCC has of its practitioners;
iii) A definition of their professional accountability;
iii) A statement of professional values;
iv) A means of measuring conduct (1992).
The 'Scope of Professional Practice' ( 1992) is a document, designed to guide nurses in the development of roles sensitive to patients' needs. As such it has enabled a flexibility in widening the boundaries of nursing roles, where previous attempts to extend roles had been task oriented and stifling (1992). (1996) gives examples of the developments enabled by 'scope' such as nurse led clinics and nurse practitioner roles, clearly designed to offer a more holistic service. Together these two documents enable practice to be developed with respect to the four ethical principles of autonomy, beneficence, non-maleficence and justice, promoted by (1994).
Autonomy: Throughout the code of conduct, reference is made to the ways in which nurses must respect patients' autonomy. By acting in their interests (), by working in an open, cooperative manner to foster independence and involvement in their care (), by respecting uniqueness and dignity without prejudice () and respecting confidentiality ().
(1995) argues that prescribing will maximise the nurse's potential to give the patient a better service. Patient centred, holistic care was proposed by Smith (1990) to be enhanced by prescribing. Certainly by working within the code, it is easy to see that one individual able to assess, diagnose, inform, educate and treat the patient could provide a more therapeutic end, because of the relationship and understanding developed throughout this process. Indeed anecdotal evidence from one of the eight pilot sites, seems to indicate that this is so ( 1996).
Clause 9.1 of the 'scope' document stipulates that any role extension must meet the needs and serve the interests of patients. This places a responsibility upon the nurse to respect the autonomy of patients rather than develop roles out of self or organisational interest.
Beneficence and non-maleficence: Guidance in these two, complementary areas comes in the form of clauses 1 & 2 of the code of conduct, whereby the nurse must act to promote and safeguard well-being (beneficence) and ensure that no act or omission is detrimental to patients (non-maleficence). More specifically the 'scope' makes it the responsibility of the nurse to have appropriate knowledge and skills for any role extension ().
The legal precedent case of Wilsher v Essex Area Health Authority, demonstrates that this is not just an ethical issue but a legal one (1994). In this case a junior doctor failed to properly site an oxygen monitoring probe in a new-born infant, the error was not found and indeed repeated by his superior. As a consequence a higher concentration of oxygen than needed was administered, allegedly leading to the blindness, the child was subsequently found to have suffered. It was judged that the doctors were negligent in not having the necessary knowledge or skill for this procedure and should not therefore have undertaken it, although it could not be proved that this led to the injury.
(1990) and (1996) assert that nurses have greater knowledge than doctors in the areas of wound care and continence. However, (1990) warns that a knowledge of side effects and sensitivity reactions are needed, while (1994) and (1994) warn against the temptation to prescribe inappropriately under the influence of company reps or indeed patients.
Prescribing safely and effectively are described by Brew (1994) as components of the training pack, including knowledge of the appropriate use of products. This aspect of the training, combined with the nurses existing knowledge, should ensure ethical practice. However, cause for concern is raised in certain quarters, (1996) describes the training for prescribing to have been 'rushed' whereas describes it as having 'shortcomings', when interviewed by (1995). Further to this (1994) appears cynical of employers ability and willingness to finance the maintenance of nurses knowledge for prescribing.
Substantial evidence exists to indicate that nurses knowledge is poor, particularly in the areas of wound and leg ulcer management (1990; 1993; 1994) which are major areas of the district nursing workload. Specific knowledge of the products available on the nurses formulary was tested by (1993), and found to be limited.
Clearly, the products on the formulary need to be used appropriately for their effects to be beneficent. Where used inappropriately or where adverse reactions go unnoticed their effects could well be deemed maleficent. If it could be demonstrated that the nurse was not acting with sound knowledge, skill and good intention in these circumstances, they would be negligent and subject to civil and professional proceedings. Justice: The code of conduct identifies justice in clause 7, in that the nurse must respond to need for care, 'irrespective of the ethnic origin, religious beliefs, personal attributes, the nature of their health problems or any other factor' ( 1992). This covers not only racial prejudice, issues around diseases like HIV/AIDS, but greater access to prescribers for the homeless or isolated dwellers identified by (1990) and (1989). (1996), (1996) and (1996) all provide anecdotal evidence that this aspect of care is benefiting patients in the timeliness of their treatments and the convenience of less waiting and travelling for their prescriptions.
The accountability and responsibility conferred upon nurses by the Code and Scope of practice ensure that patients have recourse to the law and professional body for compensation and reparation of negligent practice ( 1995).
Nurse prescribing is an initiative long awaited in community nursing, which certainly fits the utilitarian tenet of the greatest good for the greatest number. The early indications of the pilot sites appear to be generally positive and although it is not yet an official duty of the community nurse, the potential is there for newly contracted staff to find it in job descriptions in the near future and for existing staff to be invited to adopt this new role.
The Code of Professional Conduct and Scope of Professional Practice documents (1992) provide a sound ethical grounding for nurses to apply the four ethical principles in practice.
Community nursing, therefore, needs to prepare to expand into this new and challenging role. However, education is needed in the skills of research critique and analysis to enable demonstration of knowledge and competence in areas previously identified as weak. Support is needed by employers to enable nurses to maintain up-to-date knowledge, by ensuring ongoing access to education and up-to-date library facilities. Further research and/or evaluation will be needed to ensure that this process is effective in clinical terms by measuring the outcomes of interventions and in the knowledge of nurses receiving training.
Above all, nurses themselves need the determination and self discipline to ensure that they are competent to fulfil this role in the interests of patients, not just as a means of developing more independent practice. Although, to many community nurses this would seem to be a formalisation and legalisation of current practice, the responsibility and accountability to act legally and ethically is new and should not be taken lightly.
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