Posted at 11.15.2018
To illustrate this I am going to utilise the style of reflection designed from (Boud, Keogh and Walker 1985) concerning focus on influences on prescribing, psychology of prescribing working through the consultation, decision-making and therapy, and recommendation.
Being present in the assessment as a non-medical prescriber challenged me to ask questions about my very own practice and the consultant psychiatrist, focussing about how we arrived at our decisions and once in a while resulting in contrasting views.
According to (Butler et al 1998) many authorities suggest that the prime skills associated with the prescribing process are:
Adequate exploration of the patient's worries
Adequate provision of information to the individual regarding the natural processes of the disease being treated
The advisability of self-medication in trivial illness
The issue regarding poor communication has a negative impact with patient-practitioner relationship and was recognized in an educational newspaper by (Britten et al 2000). In the end, every one of the failures of communication were linked with an lack of the patient's engagement during the appointment process.
There is research that failure to actively engage in, or even consider, the patient's perspective is a common failing amidst prescribers. (Britten et al 2000).
Very almost always there is a concentrate on the term conformity and it is only just lately that nurses are focussing on a lot more apt term of concordance. The term compliance was seen as being expert laden (Marinker 1997) where it was expected that patients complied implicitly and without question whenever a prescription was presented with. There is little acceptance that patients would actively participate in your choice making process that bounded the generation of the prescription. (Cox et al. 2002)
Objective identification of the patient's perspectives, requirements and beliefs need to be acknowledged and then the acceptance of any major distinctions between these and the prescriber's needs could be recognized when providing medical care.
It is not only the act of writing down the prescription that is important, but it is the understanding of the operations and dynamics of the interactions that are occurring between prescriber and patient that will be the important key to good prescribing practice (Kuhse et al 2001).
The assessment I chose to give attention to was completed by a consultant psychiatrist who for the purposes of this work shall be known as DR S, with myself as an observer of the appointment.
The patient to be observed was a 45 year old gentleman who will be known for the purposes of this are Mr A, who had been referred by dermatology to the mental health out-patients center as a fresh patient.
Dermatology had referred this gentleman after having a 12 month history of attending their department where Mr A experienced complained of consistent generalised skin soreness, and despite getting treatment with them it came out he may own an underlying mental ailment.
Dr S began the interview by completely reading the referral from dermatology and establishing what have been the concern from other perspective.
The patient was then seen and before Dr S experienced chance to ask the patient anything Mr A indicated that he was baffled as to the reasons he had been described the mental health team, and not dermatology, which he identified his medical issue to be related to.
The English Medical Journal (2000) has recognized a theme among studies of patients in that they have a tendency to favor prescribers (doctors or nurses) who pay attention and provide time for the individual to share their concerns without feeling hurried
Dr S asked Mr A why he previously been participating Dermatology to which Mr A detailed a 12 month background of explaining an itchy scalp, generalised skin discomfort and said no treatment possessed up to now helped him. Mr A then went on to express that he noticed many of these symptoms may be due to a parasite, or a bug which was doing something to him, and described a feeling of the insect weaving something on his face which enveloped his eyes. Other symptoms he explained was that this insect or parasite was on a regular basis making him feel thirsty and taking moisture from his body, and may somehow transpose itself to other folks, including his own GP and friends talking about like a magnetic type impact.
From this primary information it was visible that Mr A was suffering from a delusional disorder which was quite systemised and concrete and Mr A made an appearance not to screen some other symptoms of mental health. A diagnosis of parasitosis delusional disorder was made.
It was clear Mr A needed treatment but the primary factor to consider was that Mr A didn't believe that he any form of mental disorder and therefore there was a real issue bordering concordance with proposed treatment.
Usually, it is difficult to obtain informed consent to treat patients with delusional parasitosis with antipsychotics. Therefore experienced clinicians notify their patients that the antipsychotics work `against the itch' or the `problems with the pests' in order never to have to rest. (Musalek, 1991; Driscoll et al, 1993; Winsten, 1997; Freudenmann, 2002).
This is due to the patients' degree of insight hindering their decision to accept treatment, because they keep a non-reality based idea that this is a somatic disease.
It is therefore found that the individual will as a rule have sought help using their company G. P. , dermatologists and will often be negative to the thought of experiencing a mental health professional
A full health background was taken, looking at any familial medical problems, family structure and looking at the sociable aspects of MR A to add areas of employment, interactions, and any medication/alcohol utilization.
There have been some criticisms of the training of nurse prescribing with regards to the communication skills of nurses, where it is noticed that historically there's been an excessive amount of a concentrate on taking a background and arriving to a analysis.
It was noticeable if you ask me that Dr S had to use his skill as a skilled mental health clinician to task Mr A's idea of his health issues not being related to issues with his mental health
Dr A approached the problem of explaining Mr A symptoms, not discussing mental health or delusions, but describing Mr A's perceived symptoms by informing him that although he assumed that these encounters were real to MR A, that his brain was interpreting fake signals leading to these unusual thoughts. Dr A continued to utilize the analogy of your amputee who perceives that they can still feel is amputated lower leg, through phony interpretations of the brain.
Drew et al. (2001). found that prescribers would emphasise the positive advantages of the medication a lot more frequently than they might discuss the risks and precautions, despite the fact that the patient's notion was that such a discussion is seen as essential.
Therefore looking as of this, this may lead to patient misunderstanding, with patient anxieties, and a amount of ambivalence to medication being offered to them.
It is transparent that when there is a amount of empathic display between that of the individual and the prescriber, there is a greater potential for concordance.
This will preferably lead to an increased level of conformity/concordance and patient satisfaction leading to desired clinical results
Here we face the issue surrounding credibility, integrity, consent and acting in the best interest of the patients in focussing on treatment
The issue of treatment was then reviewed by Dr A, who thought to Mr S that he presumed he could help him by prescribing some medication for him that would help relive the distressing symptoms he was experiencing.
Mr A at first expressed some bafflement once more why he was not seeing dermatology as he recognized the condition needed dealing with by them
This implies that Mr S was still not exhibiting any perception and the questions of concordance issues were reconsidered.
The Country wide Institute for Clinical Quality (NICE 2002) suggests a risk evaluation should be performed by the mental health clinician in charge of treatment and the multidisciplinary team regarding concordance with medication, and depot preparations should be approved when appropriate.
Mr A questioned the proposed medication and it was told him that he would be given a span of Neuroleptic medication of a new medication called Aripiprazole. Dr A said that although medication leaflet would discuss the medication was used for Schizophrenia, that Mr A should not be too concerned about that as that had not been the reason why he would be taking it. Dr A then went on to say that the leaflet would also explain possible side-effects which although it listed quite a few these were quite exceptional.
The paper by (Cox et al. 2000) found that it was common practice for prescribers to initiate the discussions about precisely what medication these were going to prescribe, rarely make reference to the medicine by name and similarly rarely refer to how a recently approved medication is recognized to fluctuate in either action or purpose, to those previously prescribed. Patient understanding is rarely checked out as it is usually assumed following the prescriber has given the prescription. Even though invited to do so, patients rarely take the possibility to ask questions. (Cox et al 2000)
I thought it was the right thing to start pharmacological treatment, although on reading further research encircling the best treatment for Parisitosis I'd question the decision of medication Mr A was commenced on
However, after spending many professional medical hours using this type of Consultant Psychiatrist, I am aware that he has high tendency of prescribing Aripiprazole for the majority of his clients.
On questioning Dr A about his decision for choice of medication, Dr A commented that it's the newest and most effective of the atypical medications with lesser incidence of side-effect relative to other medications in its group. I needed to question myself that there may be other factors influencing in the prescribing decision that have been not based on any of the NICE direction or that of the Uk Journal of Psychiatry. In fact, Dr A replied to me with medical jargon associated with molecular structures of both the brain and chemical substance make-up of Aripiprazole which was hard to follow due to its complexity.
I was mindful that as a advisor psychiatrist of many years experience, I was not certain of the honesty or consequences if I had challenged Dr A about his continuing selection of Aripiprazole against other alternatives of medication any further.
After researching treatment because of this disorder, I experienced that the initiation of a typical antipsychotic should have critically been considered due to its proven faster working efficiency. However, it is well known that typical antipsychotics have an increased prevalence of side-effects. Therefore I got considered the primary use of typical antipsychotics to determine a amount of insight into the beneficence of taking medication, and when it was believed that further pharmacological treatment is required then change to an average antipsychotic as suggested by the NICE rules.
An article in the British Journal of Psychiatry (2007) outlined that delusional parasitosis has shown significant treatment results by using typical antipsychotics. (Trabert's 1995) found that the benefits of typical antipsychotics has considerably advanced remission rates
(Frithz 1979) identified another important treatment in delusional parasitosis is to consider typical anti-psychotic depot medication. This is recommended, as was before highlighted that you of the main stumbling blocks is a lack of insight that causes patients t be unwilling to accept oral medication.
However, the administration of medication in shot form might be looked at by the individual as the answer to their somatic belief of their health problems. It might be hoped that the injection would lead to a degree of insight where in fact the patient may be more open to agree to regular medication
At the finish of the discussion the individual Mr A decided to take the medication as prescribed and was offered a further out-patients appointment in 14 days time.
Ultimately, I acknowledge a clear sign for medication, and in conjunction with this at a later level this may be combined with some cognitive behavioural remedy should symptoms persist.
Clinical Governance performs an important part in relation to prescribing. , and specifically for non-medical prescribers role. (Bradley E and Nolan P 2005) state that classes must continue to be up-to-date and adaptable and must change in respond to changes in federal policy on non-medical prescribing, with nurse prescribing leads being involved in any conversation about course development.