Introduction
This essay explores the role of non-medical prescribing in the management of chest pain within a cardiology clinic setting, focusing on the use of Glyceryl Trinitrate (GTN) spray for a patient presenting with suspected angina. Non-medical prescribing, introduced in the UK to enhance patient access to medications and optimise healthcare delivery, empowers clinicians such as nurses and pharmacists to prescribe within their scope of practice (Department of Health, 2006). This case study will outline the clinical presentation of chest pain, assess the appropriateness of GTN spray as a treatment, and evaluate the legal, ethical, and clinical considerations surrounding non-medical prescribing. Furthermore, it will critically discuss the decision-making process, patient safety, and interdisciplinary collaboration. By integrating evidence-based practice and reflecting on the broader implications for independent prescribers, this essay aims to demonstrate a sound understanding of the field while acknowledging the limitations and challenges of such interventions.
Clinical Presentation and Initial Assessment
Chest pain is a common yet complex symptom encountered in cardiology clinics, often requiring urgent assessment to differentiate between life-threatening causes, such as acute coronary syndrome (ACS), and more benign conditions like stable angina. In this case, the patient, a 62-year-old male, presents with intermittent central chest pain lasting 5–10 minutes, triggered by physical exertion and relieved by rest. These characteristics are suggestive of stable angina, a condition caused by reduced coronary blood flow due to atherosclerosis (NICE, 2016). Other reported symptoms include breathlessness and fatigue, with a medical history of hypertension and a family history of cardiovascular disease.
The initial assessment by a non-medical prescriber involves a systematic approach, guided by frameworks such as the National Institute for Health and Care Excellence (NICE) guidelines on chest pain of recent onset (NICE, 2016). This includes obtaining a detailed history of the pain’s onset, duration, location, and associated symptoms, alongside a physical examination to assess vital signs and rule out acute conditions like myocardial infarction. Importantly, tools such as the Diamond-Forrester score can aid in estimating the probability of coronary artery disease based on age, gender, and symptom characteristics (Diamond and Forrester, 1979). While the patient’s clinical picture aligns with stable angina, the prescriber must remain vigilant for red flags, such as pain at rest or escalating symptoms, which necessitate immediate referral to a cardiologist or emergency services.
Rationale for Prescribing GTN Spray
GTN spray, a fast-acting nitrate, is a cornerstone treatment for angina due to its ability to dilate coronary and peripheral blood vessels, thereby reducing myocardial oxygen demand and improving blood flow (Joint Formulary Committee, 2023). Administered sublingually, GTN provides rapid relief of chest pain, typically within 1–3 minutes, making it an ideal choice for managing acute episodes in a clinic setting. NICE guidelines recommend GTN as first-line therapy for the symptomatic relief of stable angina, provided there are no contraindications such as hypotension or concurrent use of phosphodiesterase inhibitors like sildenafil (NICE, 2016).
For this patient, GTN spray is deemed appropriate given the typical presentation of exertional chest pain relieved by rest. The prescriber’s decision is further supported by the absence of contraindications following a review of the patient’s medical history and current medications. However, it is acknowledged that GTN does not address the underlying cause of angina and should be prescribed alongside longer-term therapies, such as beta-blockers or calcium channel blockers, under a shared care plan with a cardiologist. This highlights a limitation in the scope of non-medical prescribing, as complex or unstable cases often require multidisciplinary input beyond immediate symptom management (Courtenay and Carey, 2008).
Legal and Ethical Considerations in Non-Medical Prescribing
Non-medical prescribing operates within a strict legal framework in the UK, governed by the Medicines Act 1968 and subsequent amendments that expanded prescribing rights to qualified nurses, pharmacists, and allied health professionals (Department of Health, 2006). Independent prescribers are accountable for their decisions and must adhere to professional standards outlined by regulatory bodies such as the Nursing and Midwifery Council (NMC) or the General Pharmaceutical Council (GPhC). In this context, prescribing GTN spray requires a robust understanding of the patient’s condition, clear documentation of the rationale, and informed consent, ensuring the patient understands the benefits, risks, and proper administration technique (NMC, 2018).
Ethically, the principles of beneficence and non-maleficence underpin the prescriber’s responsibility to act in the patient’s best interest while minimising harm. For instance, educating the patient on potential side effects of GTN, such as headache or postural hypotension, and advising on safe usage (e.g., sitting down during administration to avoid falls) is crucial. Additionally, the prescriber must navigate issues of autonomy, ensuring the patient is empowered to make decisions about their care (Beauchamp and Childress, 2013). A challenge arises when patients decline treatment or fail to adhere to advice, prompting the prescriber to explore underlying reasons through effective communication rather than coercion.
Clinical Decision-Making and Patient Safety
The decision to prescribe GTN spray reflects a structured clinical reasoning process, integrating patient assessment, evidence-based guidelines, and individualised care. Models such as the ‘prescribing pyramid’ proposed by Latter et al. (2005) provide a framework for non-medical prescribers, emphasising seven key principles: considering the patient, choosing the product, negotiating a contract, advising on outcomes, reviewing the decision, recording accurately, and reflecting on practice. In this case, the prescriber ensures patient safety by confirming the diagnosis of stable angina through history and examination, selecting GTN as a safe and effective product, and providing clear instructions on its use (e.g., one to two sprays under the tongue at the onset of pain, not exceeding three doses in 15 minutes).
Nevertheless, patient safety remains paramount, and the prescriber must anticipate potential risks. For example, overuse of GTN can lead to tolerance or adverse effects like severe hypotension, necessitating ongoing monitoring and patient education (Joint Formulary Committee, 2023). Additionally, the prescriber collaborates with the wider cardiology team to arrange diagnostic tests, such as an exercise tolerance test or coronary angiography, to confirm the extent of coronary artery disease. This interdisciplinary approach mitigates the risk of misdiagnosis and ensures a comprehensive management plan, illustrating the importance of non-medical prescribers working within their competency limits (Courtenay and Carey, 2008).
Challenges and Limitations of Non-Medical Prescribing
While non-medical prescribing enhances patient access to timely care, it is not without challenges. A key limitation is the potential for diagnostic uncertainty, particularly in a complex presentation of chest pain where differentiating between stable angina and ACS can be difficult without immediate access to advanced diagnostics like electrocardiograms (ECGs) or troponin levels. The prescriber must exercise caution and err on the side of safety by referring ambiguous cases to a medical specialist, which may delay treatment but prioritises patient outcomes (NICE, 2016).
Another challenge lies in the variability of training and experience among non-medical prescribers, which can impact confidence and decision-making. Research suggests that while many prescribers demonstrate competence, ongoing professional development and clinical supervision are essential to maintain standards, particularly in high-risk areas like cardiology (Courtenay et al., 2011). Indeed, the scope of practice for non-medical prescribers is often narrower than that of medical colleagues, necessitating clear protocols and robust referral pathways to address complex or deteriorating conditions.
Conclusion
In summary, this case study illustrates the critical role of non-medical prescribing in managing chest pain within a cardiology clinic, with GTN spray serving as an effective intervention for suspected stable angina. The decision to prescribe is grounded in a systematic assessment, adherence to clinical guidelines, and a commitment to patient safety, underpinned by legal and ethical frameworks. However, challenges such as diagnostic uncertainty and the need for interdisciplinary collaboration highlight the limitations of non-medical prescribing, underscoring the importance of working within one’s scope of practice. For independent prescribers, this case reinforces the need for continuous learning, effective communication, and robust support systems to ensure optimal patient outcomes. Broader implications include the potential to expand non-medical prescribing roles in specialised fields like cardiology, provided that adequate training and resources are in place. Ultimately, this analysis demonstrates a sound understanding of the field while recognising the complexities and responsibilities inherent in prescribing practice.
References
- Beauchamp, T.L. and Childress, J.F. (2013) Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press.
- Courtenay, M. and Carey, N. (2008) Nurse independent prescribing and nurse supplementary prescribing practice: National survey. Journal of Advanced Nursing, 61(3), pp. 291–299.
- Courtenay, M., Carey, N. and Stenner, K. (2011) Non-medical prescribing in the United Kingdom: Developments and stakeholder interests. Journal of Ambulatory Care Management, 34(2), pp. 138–147.
- Department of Health (2006) Improving Patients’ Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. London: Department of Health.
- Diamond, G.A. and Forrester, J.S. (1979) Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. New England Journal of Medicine, 300(24), pp. 1350–1358.
- Joint Formulary Committee (2023) British National Formulary (BNF). London: BMJ Group and Pharmaceutical Press.
- Latter, S., Maben, J., Myall, M., Courtenay, M., Young, A. and Dunn, N. (2005) An Evaluation of Extended Formulary Independent Nurse Prescribing. Southampton: University of Southampton.
- National Institute for Health and Care Excellence (NICE) (2016) Chest Pain of Recent Onset: Assessment and Diagnosis. NICE Guideline CG95. London: NICE.
- Nursing and Midwifery Council (NMC) (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
