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Introduction
Since time immemorial, administration of medications and drugs through prescription has always represented a paramount aspect especially in healthcare management. While prescriptions has served to lower the levels of morbidities and mortalities due to common illnesses, it has occasioned a jump in the cost of managing illness that is reflected in the skyrocketing budgetary allocation to healthcare. In view of the UK scenario, doctors enjoyed the preserve of acting as the only authorities to prescribe medicine. However, legislative changes introduced by the department of health has seen the conferment of prescribing powered to the nurses and pharmacists in tandem with the increasing demand for healthcare across the UK (Emmerton et al, 2005, p. 76). In addition, the government was compelled to introduce the policy changes in order to maximize on the potential of the healthcare force while ensuring enhanced access to common prescriptions thereby leading to savings brought about by delayed diagnosis.
The paradigm shift to availing of prescriptions by other health related professionals necessitated the introduction of prescribing models in the healthcare system in National Health Service (NHS). Increased lobbying and consultations between the government on one hand and the various professional groups and concerned stakeholders on the other hand led to the inception of supplementary prescribing in 2003. Concerns about the tripartite model of prescribing offered by the supplementary prescribing led the stakeholders to devise another model to encompass all health allied professionals. The allied health professionals felt underutilized and under submission to implement orders given by doctors taking into account the model only allowed them to utilize a clinical management plan, which was patient specific, when prescribing. In line with the envisaged changes, the Department of Health introduced the pharmacist independent prescribing that enhanced the roles of pharmacists while improving the level of efficiency (Emmerton et al, 2005, p. 76; Department of Health, 2005).
Although different types of prescribing are in use in the UK and internationally, training programs have always remained mandatory for the various cadres of health professionals before they are allowed to practice. In line with the developments, accreditation after successful completion of the courses has become the preserve of the single institution in order to streamline the regulatory process subsequently leading to practice. In the case of pharmacists, undertaking the course is required in addition to successful completion of the undergraduate benchmark. The prescribing training has formed the unique feature of the UK healthcare industry with analysts referring it as the keystone. The UK models contrasts with other non medical prescribing alternatives utilized around the world. The UK model provides the best approach to accreditation since it entails following of nationally agreed criteria. In contrast, the United States of America utilizes a devolved system whereby the states have the powers to undertake local assessments and make final submission based on the competencies of each practitioner. Training modes are very diverse with part time and largely distance programs receiving embracement within the UK. Both modes are crucial since they offer the practitioners time to gain engage in clinical practice where there is wide application of the clinical knowledge (Callum et al, 2002, p. 45; Lloyd & Hughes, 2007).
Medical practice has experienced increasing trends of errors with prescribing errors forming a significant proportion buoyed by the high frequency the prescribing takes place. Prescription has become the single most utilized method of treatment in all levels of medical care in the United Kingdom. According to the National Health Service records, about 637 million prescriptions were effected in 2000 with the cost estimated to account for an eighth of the NHS costs (The Audit Commission, 2002, p. 23). Despite the glaring statistics, prescribing has been become a neglected skill with little effort towards improving the outcomes. While there is no single solution, a wide array of solutions is required in order to improve the outcomes in the patients while enhancing confidence levels. Several models have been put into practice in explaining the prescribing errors. Although medical errors have received little research, a model developed by Reason has gained prominence (Lloyd & Hughes, 2007, p. 1846).
The model relies mainly on studying the risk factors mainly from the individual, organizational and the external environment. In view of the above areas of interest, the various cadres in health have faced significant challenges during prescribing. Despite the fact that majority of the challenges are common, variations in the extent has been observed across the groups. Major deficiencies occur in the preparation and eventual practice in the nurses, doctors and pharmacists. The field of therapeutics has greatly suffered from the lack of committed professionals who in turn could help the students to gain invaluable skills in controlling the chances of errors. Doctors admission of failing to secure adequate knowledge on prescription has raised concern among several scholars. To further add weight on the level of failure in prescription, occurrence of mistakes is a common occurrence due to the overreliance eon advice from pharmacists and nurses. While the information provided is usually correct, the coding of the message has remained a major challenge in the field (Callum et al, 2002, p. 45).
In tandem with the changes in the medical fields, doctors are now required to undertake preregistration training before receiving accreditation. In addition, incorporation of advanced prescribing programs has received wide application in the training of doctors, in addition to mentorship from practicing doctors. In line with international trends, demonstrable competence is imperative before the doctors are given the green light to prescribe. More importantly, sensitization on the implications of wrong prescriptions on the body functioning is also important. According to Barber, Rawlins and Franklin (2003), demonstrable competence in the appropriate interpretation of the drug charts while connecting the diagnosis with the right dosages. The modular application is in line with the norms followed by pharmacist and nurses. While the doctors are lagging behind in terms of relating diagnosis with prescriptions, much improvements has been seen in the recent past. In a bid to instill confidence on the treatment, the doctors must overly prescribe for patients by relying on their medical records. Testing through this mode has gained utilization in the recent past with wide replication internationally.
On the nursing field, disparities and contrasting evidence exist on prescribing. While the inception of new guidelines in the 1980s scrapped much of the education regarding pharmacology, emphasis in the clinical practice has not lost momentum (Centre for the Advancement of Inter-professional Education, n.d, p. 4). Shifts in educational philosophy were overly blamed for the development in nursing. More importantly, it heralded the introduction of intense practical lessons whereby nurses were required to demonstrate competence just as in doctors. Incorporation of further training in pharmacology has placed the nurses at a better place to practice and administer drugs. In fact, community nurses have received the green light to prescribe a variety of drugs, albeit after passing accreditation tests. In comparison with the doctors, some clinical nurse practitioners have become accredited to offer prescription in hypertension and diabetes (Barber, Rawlins and Franklin, 2003).
To ensure competency is achieved and the pharmacists are effectively prepared to undertake prescription while offering leadership and mentorship to the other cadres, extension of the training has occurred. Previous studies assert high display of importance in the field of supplementary prescribing with regard to improvement in confidence levels and bolstering of reflective learning (Jones, John & Luscombe, 2007, p. 36; Lloyd & Hughes, 2007, p. 1846). However, the limitations in the course duration owing to work commitments generated wide criticisms. The integration of the training of the pharmacies with other cadres such as nurses in the training programs has elicited debate taking into account the variation in training needs among the various groups. In view of the training needs, the nurses require holistic training in pharmacology unlike the pharmacists who overly desire to involve themselves in patient care and relations (George et al, 2006, p. 1856).
Emphasis on pharmacists training is crucial in order to avert occurrence of major disasters caused by adoption of wrong guidelines in the prescription. Detection of errors has continually formed the major roles of the pharmacists. In view of the above, Dean et al (2002, p. 342) has estimated that 1.5 % of prescriptions in general and medical wards are detected by the pharmacists. Regression modeling has largely contributed largely on the understanding of the occurrence of prescription errors. In fact, regression modeling espouses that the overall experience gained by the pharmacist coupled with the amount of time spent on prescribing in the wards form important parameters and influencers vital in enhancing improved detection rate. The type and the nature of the ward also influence the level of prediction. Improving the resource capacity of the pharmacy department not only forms a core factor in detection of errors in prescribing but also aids greatly in correcting them (Barber, Batty & Ridout, 1997, p. 398). Legal barriers in prescribing have become insignificant with the introduction of training guidelines and policy changes. However, disagreements prevail on the training and responsibilities owing to the limited exposure and interaction with the patients and medical records (Richard et al, 2008). Inadequate involvement in the design of treatment procedures is major factor that creates practice barrier unlike the nurses and doctors. While concerted efforts to ensure their involvement in all aspects of the patient care are being formulated, pharmacists will continue facing barriers especially in offering adherence support (Barber et al, 2003, p. 32; Cooper et al, 2008, p. 37)
Inter-professional learning is a controversial subject that confers both benefits and problems to the care givers during training and subsequently in pharmacology practice (Cooper et al, 2008, p. 37). Calls for the review of the traditional approach where training was carried out based on distinct career lines are laudable since they have brought forward the need for cooperation and development of guidelines on the training for each cadre. More importantly, benefits accrued from enhanced relationships and understanding of values of different professions combined with improved communication confer long term impacts in training while ensuring cordial relations and cooperation in subsequent practice (Elston, 2004, p. 168). The socialization process engineered from the training helps in improving the efficiency in the delivery of healthcare services. Although streamlining of training has been challenged, provision of varying levels of skills in practice remains untenable in modern practice as illustrated in pharmacology training and largely in the numeracy exams (Cooper et al, 2008, p. 37; Richard et al, 2008). Propositions of possible integration of prescribing into the undergraduate training of the studies raises concerns due to lack of empirical evidence denoting how the inclusion such training in the curriculum will enhance the success of the nonmedical courses. In addition, difficulties in compensation of the learning period and the time required to gain enough experience curtails the incorporation into the undergraduate course (Warchal et al, 2006, p. 65).
Antagonism between the various professions
Antagonism persists between the medical practitioners and pharmacists persist despite major policy changes in the last few years that allowed the latter to prescribe albeit with limitations. Concerns regarded the declassification of certain drugs and manner of prescribing finds its genesis from the antagonism between both professions prior to the 90s. While the application of prescribing by nurses, doctors and pharmacists showed improvements in the overall health status of the people in countries such as Denmark, the NHS remained indecisive owing to differing interests from different professional groupings. The ranging conflict between the dispensing doctors on one hand and the nurses and pharmacists on the other hand is mainly fuelled by the business interests. In the run up to the liberalization of prescribing, the representatives remained vocal in curtailing the involvement of pharmacists thereby delaying the enactment of the legislative changes. Taking into consideration the benefits brought by supplementary prescribing, the doctors have embraced the roles of pharmacist while offering them the required support. However, measurable discontent on the extent of involvement of pharmacists in independent prescribing still persist with various quarters arguing that the pharmacists are prone to cause detection errors (Stewart et al, 2009, p. 94). Contrary to the popular perception, Cooper et al (2008) through a review of case studies and interviews with doctors assert that non medical prescribing require protocol type while ensuring the nurses and pharmacists take full responsibility for the whole process.
More importantly, recent studies down play the notion of increased cases of prescribing errors in supplementary prescribing. Whilst little research exists on this field, the findings offer reassurance to discordant voices on the safety and appropriateness of the non-medical prescribing (Avery & Pringe, 2005, p. 76; Latter et al, 2007). However, critical debate is required in the diagnostic field in non medical prescribing to ascertain the predisposition to errors with the aim of informing policy changes in the future. It is worthy noting, similarities on the quality of drugs and prescriptions between the doctor sand pharmacists have been denoted in health management organization in the United States. In view of the assertions made by McGhan et al (1983), pharmacists need more encouragement if they are to continually achieve positive effect on the overall health of the patients. Although differences on parameters regarding blood pressures have occurred, lack of significance on the differences of outcomes denote increasing competence on the part of nurses and pharmacists.
In view of the increasing burden of hypertension in the aging population has reinforced the roles of primary care physician around the world. Effectiveness in the overall management of hypertension has resulted in reduction of about 40 % over the years, which in essence brings much economic savings while bringing substantial impact in clinical practice. Concerted efforts towards the promotion of clinical practice guidelines in the area of hypertension brings into fore the importance of mitigation measures such as blood pressure control while enhancing the integration of clinical evidence into day to day practice. Although there is widespread availability of substantial evidence based guidelines especially on hypertension prescribing, the level and standards in prescriptions remains marginally below average.
In fact, surveys and case studies indicate that slightly above half of the physicians have complied with the guidelines (Psaty et al, 2002, p. 2323; Marques-vidal & Tuomilehto, 1997, p. 214 & Holmes et al, 2004). In contrast, pharmacists adherence on the guidelines remains poor buoyed by the lack of support from the physicians and implementation barriers brought about by the workplace setting. Taking an economic perspective of evidence based practice, it emerges that its application does not confer reduction in the healthcare costs; rather it helps the physicians and pharmacists to initiate and develop efficacious therapeutic options that enhances the improvement of the quality of life for the individual and community in general (Primatesta, Brookes & Poulter, 2001). To this end, Fischer and Avorn (2004, p. 1850) intimate substantial saving with regard to utilization of evidence based guidelines when undertaking hypertension prescription. In support of the Fischer and Avorn (2004) findings, a study conducted among hypertension patients in government hospital in Hong Kong reiterated statistical significance and lowered drug expenditure occasioned by adherence to clinical practice guidelines (Wae et al, 2006).
Models of prescribing
Prescribing has gained prominence especially with the inception of prescribing by nurses in the last few years. While the extent of prescribing varies across the globe, literature is increasing point towards more involvement of pharmacists and other health professional in the future. Considerable debate on the pharmacists prescribing has shown that pharmacists are exhibiting expertise with regard to the evidence based practice. in view of the developments, more pharmacists are involved in prescribing while monitoring the therapeutic process hence complementing the efforts of the medical practitioners. Embracement of prescribing for pharmacists occurred in differing times around the world with increasing more drugs becoming available to the pharmacists for prescribing. A review of international literature shows variations in the models under utilization. The efficacy of the different prescribing models proves difficult to ascertain due to the limitation and implementation barriers coupled with the short duration of application in current practice. The implementation of the different models of pharmacists prescribing is overly reliant on several factors. Emmerton et al (2005, p. 217) asserts that protocols and formularies combined with collaboration exhibited by physicians and pharmacists form the major factors that dictate the method to be embraced. The models illustrate the capacity and autonomy enjoyed by the pharmacists in the initiation, modification and largely in the monitoring of medicines available for prescription. Figure 1 presents a large map of the eight models under utilization across the world while taking into account the level of restriction with regard to aspects of formulary and protocol.
Models of decision making in prescribing
To effectively make an impact on the health of the patient, the medical practitioners and the pharmacists require making the right decisions on the appropriate drugs for certain medical conditions. In fact, the medical and the enormous nursing literature is divided into two dynamic models that have proved vital in understanding the decision making in the health professional with regard to prescribing. Utilization of the scientific model and analytic approach has helped in directing the diagnosis and subsequent offered valuable tips in prescribing. To start with, the scientific model encompasses the logical analysis through the use of decision trees where a numerical value is usually assigned to all possible and relevant outcomes in the diagnostic procedure. Various studies have asserted that the quantitative approach is more dependent on available knowledge to enhance and direct the prognosis hence allowing the correct decision to be arrived at (Miers, 1990; Harbison, 1991). However, limitations in accessing available knowledge and inadequacy in research shows that urgency of clinical cases require the practitioners to arrive at decisions based on available knowledge while applying some element of risk. It therefore becomes necessary for the medical practitioners and pharmacist to weigh the benefits against the negative consequences before prescribing. In view of the above, probability of occurrence of negative consequences is greatly diminished (Wooley, 1990).
The analytical approach espoused by Benner (1982) is overly reliant on the intuitive knowledge achieved through exposure to clinical practice rather than evidence presented in literature. Basing the tenets of the model on the levels passed by a nurse during training, Benner (1982) theory have received support from several researchers who denote that it becomes easier to make decision based on the experience gained over time. Interpretation of Benner model by Hamm (1988) in relation to medical practice revealed similarities with medical novices believed to think analytically based on clinical guidelines while the experts intuitively make decisions on diagnosis. In addition Hamm integrates the concepts of analytical approach with intuitive thinking, rather than viewing them as diverse strategies, hence creating a continuum. In view of the integration, Hamm suggested that increase in the availability of time and information resulted in the tilt of balance towards the analytical end and vice versa.
The ability to inherently alter the combination of prescriptions largely determines the strategies to be utilized in the control of the overall cost and quality (Schumock et al, 2004, 558). While past analyses tend to emphasize prescribing behaviors among the doctors, modern practices in healthcare depict increased roles of pharmacists in decision making. This scenario is evident fin the modern hospital setting where policies regarding medication utilization remain under the custodianship of the therapeutic committee (American College of Clinical Pharmacy, 1993). In addition, the clinical pharmacists largely influence the approval and change in drug therapy. Whilst theoretical models has continually enhanced the understanding of the prescribing behavior in nurses and physicians, variations of the specific factors that influence decision-making exists among the professions. Generalization of models is hence discouraged. Safety and effectiveness coupled with administrative factors influence largely the decision making process. Drug-related factors Understanding of the influencing factors and taking into account the differences on the importance of each factor to the different cadres is imperative in informing the alteration of prescribing behaviors by the policy makers (Schumock et al, 2004, 557).
Decision making in nurses is largely determined by influences from the internal and external environment. The experience garnered through active practice in prescribing (Benner, 1982; Wooley, 1990; Schumock et al, 2004), persuasion from company representatives and the general attitude of the nurses (Hamers et al, 1994) impact greatly on the choice of medication. Inter-professional relationships between the nurses and the other health professional particularly the doctors and pharmacists influenced greatly and affected the self actualization in prescribing. Impaired relationship depicted insecurity and uncertainty in coming up with the appropriate decisions. Radwin (1995) also asserted the extent the decision making was hampered by the client-nursing relationship. Radwin describes the four strategies involved in directing the overall decision making process; starting with empathizing particular in cases where the patient has less encounters with the patient. On the other hand, the nurse tries to balance the preferences in view of the difficulties especially when a great of the medical and personal history of the patient is known to the nurse.
The attitudes of the nurses depicted the time administration of the drug would take place especially in cases where the patient is a child (Hamers et al, 1994). Nurses delayed in administering the medications owing to the assumptions of side effects or worse outcomes. Medical literature depict the same picture with considerable similarities in the factors causing increased influence in the decision making process. While studies have delved on wide range of factors in the social environment, a conclusive study depicting a single-most major influencer has remained elusive. Studies on the role of demographic factors, inter-professional relationships and interaction with company representatives showed differing extent of influence on the overall nature of prescribing in medical fraternity. In fact, Clark et al (1991) asserted demographic factors in the patient contributed immensely in reaching a conclusive decision on the nature of prescription. Age and class explained why there is likelihood for elderly patients to receive prescriptions than younger patients. In comparison with nursing literature, attitude of the doctors and urge to satisfy the expectations of the patients put pressure on the doctor hence influencing the nature of prescription. Familiarity with patients lowers the rationality of reaching the nature of prescription (Clark et al, 1991).
Doctors have a major role of furthering the evidence based practice in prescribing thereby addressing the issue of uncertainty in nurses. While pharmacist roe in influencing the overall prescribing process remains inevitable, better interaction with the other professional is symbiotic since they benefit from the rich experiences in nurses and doctors. In order to effectively reinforce the confidence of pharmacists and nurses, doctors have to shed the notion that they are under threat from the former in terms of their prescribing roles. Similar instances of backlashes experienced in the United States over nursing diagnosis serve as an explicit example of the negatives impacts caused by resent against a certain unavoidable partners at the workplace (Herbert et al, 2004). More emphasis on the harmful effects rather than the benefits of prescribed medications is required to curtail the onset of adverse effects occasioned by rushed decisions. Although taking risk is key to nonmedical prescribing, reflective learning is paramount in enhancing the reaching of informed decisions. Cooperation between the various cadres of professional not only result in enhanced professional development but also instill skills in best practices particularly to the non medical prescribers. In view of the decision making process, the expertise of pharmacists on formularies is tapped into influencing the decision making in the nurses and doctors (Luker et al, 1998, p. 663).
Herbert et al (2004) also found that a combination of evidence based educational interventions with personalized prescribing is imperative in enhancing minimal but pertinent changes in the nature of prescribing undertaken by doctors. To improve the embracement of the interventions, it becomes imperative to design clear-cut messages coupled with proper trial design that allows the deciphering of positive outcomes (Herbert et al (2004). Individualized feedback coupled with specially integrated education model remains effective than utilization of single intervention particularly in cases of hypertension prescribing (Wensing & Weijden, 1998). Evaluation of educational interventions that suggest improvements in the manner of improving prescribing especially in primary care have to been stressed (Grimshaw et al, 2001, p, 997). Modest changes in the educational interventions produce significant impacts on the influence of prescribing behavior exhibited by physicians, which in essence brought about cost effectiveness and more benefits to both the patients and the entire healthcare system (Herbert et al 2004).
The influences exerted by the pharmacists on the prescribing practices can be observed in all clinical situations. Their influences seem inconsequential in the developed countries due to the advancements in the health systems. Similar efforts towards the interventions in the developing countries have significant impacts with major improvements on the patient outcomes. Calls for pharmacists to involve themselves on diseases where they experience the greatest impact have intensified. Expected improvements in areas of HIV and tuberculosis can benefit immensely from the pharmacists input. However the training of pharmacists in the developing countries is hampered by lack of adequate resources in terms of funding and personnel. Taking into account their potential, there is an urgent need for the pharmacists to dedicate and commit their time in the practice thus ensuring the realization of optimum outcomes. While variations in terms of training and resources exist in the health systems, there is agreement that some level of influence in prescribing is achievable at all points in the continuum (Herbert et al, 2004; Cooper et al, 2008).
Practices and implementation issues
Despite the introduction of supplementary prescribing earlier in the decade, Cooper et al (2008, p. 64) indicate modest levels with regard to prescribing by nurses and pharmacists. Triangulating data has indicated that low levels of supplementary prescribing occasioned by implementation difficulties have occurred in the UK NHS. Prescribing software that lacked the ability to generate printed prescriptions curtailed the efficacy in the functioning of the pharmacists. In light of the shortcoming, the pharmacists led to the overreliance on doctors in the prescribing. While the inter-professional socialization was improved, the autonomy of the pharmacist was overly challenged through crosschecking of the prescriptions. The lengthening of the duration of prescription occasioned by hard written copies compounded the barriers in implementation. In fact, recent studies have observed similar implementation barriers with difficulties in overcoming the information technology comes remaining the most prevalent in several settings (Courtenay et al, 2007; George et
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