Improving Nurse Practitioner Practice through Rational Prescribing

Direct-to-consumer advertising effects on nurse-patient relationship, authority, and prescribing appropriateness

BACKGROUND:

Discussing direct-to-consumer advertising of prescription drugs during a visit could affect prescribing practices and provider-patient relationship.

RESEARCH OBJECTIVES:

The study examines advanced practice nurse prescribers' perceptions of direct-to-consumer advertising and its effects on nurse-patient relationship, prescriptive authority, and appropriateness of patient clinical requests.

RESEARCH DESIGN:

A cross-sectional survey design was implemented.

PARTICIPANTS AND RESEARCH CONTEXT:

The random sample consisted of 316 nurses (27.17% response rate) in one of the Midwestern states in the United States. Pearson's chi-square analysis and multiple/multinomial logistic regression analyses were used.

ETHICAL CONSIDERATIONS:

Permission to conduct the study was obtained from the university's Institutional Review Board. Participation was voluntary, and measures were taken to protect the anonymity and confidentiality of consenting participants.

FINDINGS:

Most nurses (69%) believed that patients were "poor or very poor" at assessing the relevance of drug advertisements, 61% reported that the increase in drugs advertisements directed at patient was "a bad or a very bad thing," and only 16% thought the advertisements were accurate to "a very or to a great extent." Improved nurse-patient relationship was associated with factors such as the patient not bringing printed material, seeking nurse's opinion only, taking responsibility for their health, and not challenging nurse's prescriptive authority.

DISCUSSION:

Advertising discussion during a visit could improve as well as pose a challenge to a nurse-patient relationship and nurse's prescriptive authority.

CONCLUSION:

The positives of discussing advertising information can be maximized and the negatives minimized through enhanced interpersonal nurse-patient communication.

Community pharmacists' attitudes toward dispensing errors at community pharmacy setting in Central Saudi Arabia

PURPOSE

The main objective of this study was to survey pharmacists' attitudes toward dispensing errors in community pharmacy settings in Saudi Arabia.

METHODS

A cross-sectional survey of community pharmacists in Riyadh region, Saudi Arabia was conducted over a period of 6 months from March through September 2012. A stratified random sample of eight hundred registered pharmacy practitioners was collected all over Riyadh region. Statistical analysis was done using SPSS version19.0 for windows (SPSS Inc., Chicago, Illinois).

RESULTS

The response rate was almost 82%. The majority of the respondents are young adults (90.2%). The median for years of registration of respondent pharmacists was 9 years (range 1-37 years). About 62% (407) of the respondents have a positive response while only 37.8% (n = 248) have a negative response in this respect. The major factors identified were pharmacist assistant (82.2%) and high workload (72.5%). The most appreciated factors that help reducing dispensing errors are improving doctors' hand writing and reducing work load of the pharmacist (82.9% and 82.8% respectively), having drug names that are distinctive (76.1%) and having more than one pharmacist in duty (75.5%).

CONCLUSION

In conclusion, majority of community pharmacists indicated that the risk of dispensing errors was increasing and most of them were aware of dispensing errors. It is obvious from the study results that dispensing errors is a big concern for community pharmacy practice in Saudi Arabia. Therefore, there is an urgent need for the professional organizations and Pharmacy Boards in Saudi Arabia to determine standards for the profession.

A case study using the beers list criteria to compare prescribing by family practitioners and geriatric specialists in a rural nursing home

Previous studies have concluded that inappropriate medications and/or too many medications can lead to adverse events in older adults. The Beers List of potentially inappropriate medications (PIMs) for use in the elderly was developed to help guide clinicians to safely prescribe medications. Moreover, in the United States, policies exist regulating the number of prescriptions nursing home residents may take. Few studies have compared family and geriatric providers' prescribing trends. The aim of this study was to compare prescribing by family and geriatric providers in a rural U.S. nursing home using a nonequivalent 2-group analysis design with data collected via retrospective chart audits (N=92). Nursing home residents in the nongeriatric provider group had fewer total comorbidities (U=p<.001) and were less likely to have congestive heart failure (χ2=p<.001), coronary artery disease (χ2=p<.001), and degenerative joint disease (χ2=p<.001). Despite this, on average, providers who were not geriatric trained prescribed twice as many drugs per patient (U=p<.001). The odds were significantly greater of being prescribed 9 or more drugs (odds ratio 13.15, 95% confidence interval 4.3-39.5) or being prescribed at least 1 PIM (odds ratio 6.25, 95% confidence interval 1.3-29.0) if the prescriber was not geriatric trained. The prevalence in this nursing home of receiving at least 1 PIM and polypharmacy were 36.9% and 72.8%, respectively. Promethazine accounted for 46.9% of all PIMs prescribed. Geriatric education appears to have influenced prescribing patterns at this facility, with geriatric-trained providers adhering more closely to evidence-based guidelines for older patients. As geriatric educational content is incorporated into nongeriatric specialty areas, pharmacology and prescribing competencies should be an area of ongoing focus for educators.

Towards understanding the nature of conflict of interest and its application to the discipline of nursing

Most incidences of dishonesty in research, financial investments that promote personal financial gain, and kickback scandals begin as conflicts of interest (COI). Research indicates that healthcare professionals who maintain COI relationships make less optimal and more expensive patient care choices. The discovery of COI relationships also negatively impact patient and public trust. Many disciplines are addressing this professional issue, but little work has been done towards understanding and applying this moral category within a nursing context. Do COIs occur in nursing and are they problematic? What are the morally appropriate responses to COI for our discipline and for individual practicing nurses? In this paper I examine the nature of 'conflict of interest' as a general ethical category, its characteristics and its application to our discipline. Conflict of interest is an odd moral category that may actually or potentially result in immoral decisions. The moral justification for COI is grounded prime facie by the moral value of respect for persons and principle of fidelity from which trust is developed and maintained. In review of the historical development, there appears to be consensus on some qualities of COI that are presented. I conclude that making judgements about COI are challenging and often difficult to determine from a nursing perspective. Improving nurses' and professional organizations' awareness of COI and sharpening our ability to respond appropriately when COI arise can reduce potential harm and promote trust in those whom we serve.

Public Perceptions of Health Care Professionals' Participation in Pharmaceutical Marketing

Trust in the nurse—patient relationship is maintained not by how professionals perceive their actions but rather by how the public perceives them. However, little is known about the public's view of nurses and other health care professionals who participate in pharmaceutical marketing. Our study describes public perceptions of health care providers' role in pharmaceutical marketing and compares their responses with those of a random sample of licensed family nurse practitioners. The family nurse practitioners perceived their participation in marketing activities as significantly more ethically appropriate than did the public responders. Further research is warranted before conclusions can be drawn, but these early findings suggest that nurse practitioners should consider a conservative approach to participating in pharmaceutical marketing.

The afterlife of drugs and the role of pharmEcovigilance

The prescribing and usage of medications (for both humans and domestic animals) have ramifications extending far beyond the traditional objectives of conventional medical care. The healthcare industry has an environmental footprint that includes the active pharmaceutical ingredients (APIs) from medications, residues of which can establish themselves as environmental pollutants. This occurs by a variety of routes, but primarily from excretion, bathing and disposal. Many parallels exist between healthcare and the protection and remediation of the environment, spanning the stages from symptomology and diagnosis to treatment. The critical role played by pharmacovigilance in healthcare has a counterpart with the ecological environment. The term ecopharmacovigilance has been used with respect to the unforeseen consequences APIs can have once they enter the environment. We propose that conventional pharmacovigilance could be expanded to encompass environmental concerns--a concept we term pharmEcovigilance--as a way to unify the parallel but interconnected needs for protecting both human and ecological health.To convey the scope of a pharmEcovigilance programme, we provide an overview of the occurrence of APIs as environmental pollutants, their ramifications for human health and the environment and some of the ways in which their impact could be reduced or minimized. The major areas discussed include: (i) the routes by which APIs become contaminants in the environment; (ii) the hazards of leftover drugs as a result of stockpiling and from disposal to sewage, which can also eventually contribute to the contamination of drinking water; (iii) why drugs accumulate unused; and (iv) the benefits for humans and the environment that could accrue from reducing the accumulation of leftover drugs and the subsequent introduction of APIs into the environment. A broad spectrum of actions could be taken by prescribers (including veterinarians) and the healthcare industry at large (including manufacturers and insurers) to reduce the release or introduction of APIs to the environment. Most significantly, however, a major reason to consider implementing a pharmEcovigilance programme--beyond reducing the environmental footprint of healthcare--is the previously unforeseen collateral benefit in making further progress in optimizing the delivery, effectiveness, outcomes and cost of healthcare, as well as improving safety for humans, pets and wildlife. For this reason, the relationships that healthcare professionals and patients have with medications might also include consideration of pharmEcovigilance. Like any profession that deals with chemicals, perhaps a major challenge to be faced is how to ensure the sustainability (and minimize the life cycle exposure hazards) of a chemical-based, chemical-centric society in the most cost-effective and safest manner. Given that the medical community is a major source of numerous 'exotic' chemical pollutants in the environment (with thousands of chemically distinct APIs in current use), albeit at very low levels, an imperative could be created for designing and implementing approaches for reducing and controlling this source of pollution. With reduced wastage of medications, in part driven by appropriate or rational prescribing and dispensing, the ecological footprint of medicine could be greatly reduced, with concomitant improvements in many aspects of healthcare.