Introduction
This essay critically reflects on an episode of care within the context of non-medical prescribing, evaluating the application of systematic appraisal skills and informed decision-making. As a student studying non-medical prescribing, the ability to make evidence-based decisions while considering patient needs, clinical guidelines, and professional responsibilities is paramount. The chosen episode of care involves a patient with hypertension requiring a prescribing decision, which will serve as the foundation for this analysis. The essay aims to explore the processes of clinical assessment, decision-making, and critical appraisal of evidence, while reflecting on the challenges and limitations encountered. Key points to be discussed include the importance of systematic appraisal in ensuring patient safety, the application of evidence-based guidelines, and the personal and professional development gained from the experience. Ultimately, this reflection seeks to demonstrate a sound understanding of non-medical prescribing principles and their practical implementation in a clinical setting.
Context of the Episode of Care
The episode of care under reflection occurred during a clinical placement in a primary care setting, where I encountered a 58-year-old male patient, referred to as Mr. X for confidentiality purposes, who presented with poorly controlled hypertension. Mr. X had a history of non-compliance with previous antihypertensive medication due to side effects and a lack of understanding about his condition. My role as a non-medical prescriber in training involved conducting a thorough assessment, reviewing his medical history, and making an informed decision regarding his treatment plan. This scenario presented an opportunity to apply systematic appraisal skills by integrating clinical guidelines, patient preferences, and evidence-based research into the decision-making process. However, it also posed challenges, such as balancing guideline recommendations with individual patient circumstances, which required critical thinking and professional judgement.
Systematic Appraisal in Clinical Assessment
A systematic approach to clinical assessment is fundamental in non-medical prescribing to ensure accurate diagnosis and appropriate treatment. In Mr. X’s case, I began by following the National Institute for Health and Care Excellence (NICE) guidelines for hypertension management (NICE, 2019). This involved measuring blood pressure readings over multiple visits to confirm persistent hypertension and reviewing his medical records for comorbidities such as diabetes or renal impairment, which could influence treatment choices. Additionally, I conducted a lifestyle assessment to identify modifiable risk factors, such as smoking or poor diet, which are known to exacerbate hypertension (Williams et al., 2018). While this structured approach provided a robust framework, I became aware of its limitations; for instance, the guidelines did not fully address Mr. X’s previous non-compliance or his expressed concerns about side effects. This highlighted the need for a patient-centered approach alongside systematic appraisal, prompting me to consider alternative evidence sources, such as studies on patient education and adherence strategies (Sabaté, 2003).
Furthermore, I critically appraised the reliability of the clinical tools used during the assessment, such as the accuracy of automated blood pressure monitors compared to manual readings. Research suggests that automated devices may sometimes overestimate readings in certain patient groups (Myers et al., 2011), which led me to corroborate findings with manual measurements. This process demonstrated an ability to identify potential limitations in standard practices and draw on relevant resources to address them, ensuring a more informed clinical decision.
Informed Decision-Making in Prescribing
The prescribing decision for Mr. X required a careful balance of clinical evidence, guideline recommendations, and patient collaboration. Based on the NICE guidelines (2019), a calcium channel blocker was initially considered as a first-line treatment due to Mr. X’s age and absence of comorbidities like diabetes. However, I also reviewed primary research on antihypertensive efficacy and tolerability, particularly focusing on side effect profiles that might impact adherence. For instance, a study by Law et al. (2009) indicated that calcium channel blockers are generally well-tolerated but can cause peripheral edema, a side effect Mr. X had previously experienced with other medications. This evidence prompted a consultation with Mr. X to discuss his concerns and explore alternative options, such as an angiotensin-converting enzyme (ACE) inhibitor, which might offer a better balance of efficacy and tolerability.
Indeed, involving Mr. X in the decision-making process was crucial to improving adherence, a factor often overlooked in purely guideline-driven prescribing. I drew on shared decision-making principles, as supported by Elwyn et al. (2012), to ensure that Mr. X understood the rationale behind the chosen treatment and felt empowered to manage his condition. This approach, while time-intensive, arguably enhanced the likelihood of a successful outcome. Nevertheless, I remained aware of my limited experience as a prescriber and sought supervision from a senior clinician to validate my decision, reflecting an understanding of professional boundaries and the importance of accountability in non-medical prescribing (Royal Pharmaceutical Society, 2016).
Reflection on Challenges and Limitations
Reflecting on this episode, several challenges emerged that tested my critical appraisal and decision-making skills. One significant limitation was the time constraint within a busy primary care setting, which restricted the depth of patient consultation. While I aimed to address Mr. X’s concerns comprehensively, I occasionally felt rushed, potentially impacting the quality of shared decision-making. Additionally, although I relied on high-quality sources like NICE guidelines and peer-reviewed research, I found limited literature specifically addressing non-compliance in hypertensive patients from Mr. X’s demographic background. This gap in evidence underscored the importance of tailoring decisions to individual contexts, even when systematic tools and guidelines are in place (Greenhalgh et al., 2014).
Moreover, my inexperience in non-medical prescribing occasionally led to hesitation in confidently asserting my clinical judgement. While supervision mitigated this risk, it also highlighted areas for professional development, such as building confidence in autonomous decision-making. These reflections align with the notion that critical appraisal is not merely a technical skill but a continuous learning process informed by experience and self-awareness (Schön, 1983).
Conclusion
In conclusion, this critical reflection on an episode of care involving a patient with hypertension demonstrates the application of systematic appraisal skills and informed decision-making in non-medical prescribing. By integrating clinical guidelines, evidence-based research, and patient-centered principles, I was able to devise a treatment plan that balanced efficacy with Mr. X’s individual needs, though challenges such as time constraints and evidence gaps were evident. This experience has deepened my understanding of the complexities of prescribing, particularly the need to critically evaluate sources and adapt decisions to unique patient circumstances. The implications of this reflection are twofold: firstly, it reinforces the importance of lifelong learning and supervision in non-medical prescribing to address personal limitations; secondly, it highlights the necessity of advocating for patient involvement in care decisions to enhance outcomes. Ultimately, this episode has provided valuable insights into the practical application of theoretical knowledge, paving the way for improved competence in my future prescribing practice.
References
- Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., … & Barry, M. (2012) Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361-1367.
- Greenhalgh, T., Howick, J., & Maskrey, N. (2014) Evidence based medicine: A movement in crisis? BMJ, 348, g3725.
- Law, M. R., Morris, J. K., & Wald, N. J. (2009) Use of blood pressure lowering drugs in the prevention of cardiovascular disease: Meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ, 338, b1665.
- Myers, M. G., Godwin, M., Dawes, M., Kiss, A., Tobe, S. W., Grant, F. C., & Kaczorowski, J. (2011) Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: Randomised parallel design controlled trial. BMJ, 342, d286.
- NICE (2019) Hypertension in adults: Diagnosis and management. National Institute for Health and Care Excellence.
- Royal Pharmaceutical Society (2016) A competency framework for all prescribers. Royal Pharmaceutical Society.
- Sabaté, E. (2003) Adherence to long-term therapies: Evidence for action. World Health Organization.
- Schön, D. A. (1983) The reflective practitioner: How professionals think in action. Basic Books.
- Williams, B., Mancia, G., Spiering, W., Agabiti Rosei, E., Azizi, M., Burnier, M., … & Desormais, I. (2018) 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal, 39(33), 3021-3104.
