In this reflective case study assignment, by utilising Benners (1984) framework for critical incidents (appendix 1) I shall analyse and discuss the events surrounding a patient who attended the Emergency Department with an eye problem, who I saw in my capacity as an Emergency Nurse Practitioner and trainee non medical prescriber.Then by critically analysing relevant literature I will demonstrate the rationale of any prescribing decisions and the medico legal and ethical dimensions of the case. Finally I shall conclude the assignment by reflecting on what I learned, how I felt, and the implications for my intended future practice as a non medical prescriber.
Collins English Dictionary (2003) describes a case study as a method of analysing one or more cases to make a generalisation about similar cases. Noor (2008) further supports this and suggests the use of case studies can strengthen and confirm results obtained. A case study is one of several ways of doing research and may be defined as an empirical inquiry that investigates a phenomenon within its real life context (Yin, 2002). However Lamneck (2005), argues that case studies should not be confused with qualitative research as they can be based on a combination of both quantitative and qualitative evidence and they are also a research approach, situated between concrete data taking techniques and methodological paradigms. On the contrary some researchers (Yin, 2002 and Lamneck, 2005), dismiss case study research as useful only as an exploratory tool. Case studies and reflection also form a considerable part of the new revalidation procedure for nurses (NMC 2016).
I have chosen to explore the events surrounding the attendance to the Emergency Department of a 17 year old male with the complaint of possible foreign body in his left eye, to comply with the Nursing and Midwifery Council code of conduct (2015) all names, dates and places will be kept confidential and pseudonyms will be used.
Before discussing the issues surrounding non medical prescribing for children it would seem relevant to first attempt to establish the definition of a child, and explore the issues surrounding consent as well as physical emotional and pharmokinetic differences between children and adults.
The Oxford Dictionary defines a child as, a young human being below the age of puberty or below the legal age of majority. The UN Convention on the Rights of the Child (1989) defines a child as everyone under 18 unless, “under the law applicable to the child, majority is attained earlier”. The UK has ratified this convention. The NSPCC (2016) describes several parameters or situations when the definition of a child may be more precisely described. For the purposes of child protection England, Wales, Northern Ireland and Scotland each have their own guidance for organisations to keep children safe. However they all agree that a child is anyone who is under the age of 18 (HM Government 2015). Vulnerable adults are entitled to extended protection until the age of 21 in England, Wales and Northern Ireland. The legal age for marriage and sexual consent in the United Kingdom is 16 and the age of criminal responsibility is 10 in England, Wales and Northern Ireland.
The law recognises that a child will be competent to give valid consent at any age with the proviso that they have sufficient understanding and intelligence to allow them to fully comprehend what is being proposed. This is supported by the DOH (1989) who state that there is no set age when a child is deemed competent, and instead consent depends on the child as an individual, and the complexity of the proposed care. Under British law this child related competency has been known since 1985 as Gillick competence after the court case Gillick v West Norfolk and Wisbech, where the principle was first established. It can also be referred to as Fraser competence after Lord Fraser’s rulings as the judge at the above mentioned court case. Initially Gillick or Fraser competence guidelines were referred to only by doctors, it is now accepted by the Home Office (2004) that this practice includes other health care professionals including pharmacists, midwives and nurses.
It should be noted that even though a child can consent to treatment, legally under the Family Reform Act (1969) they are not permitted to decline treatment and their decision can be overruled by a persons with parental responsibility or court of law.
Apart from the considerable differences between adults and children relating to consent and the law the non medical prescriber is faced with differences in physiology and the associated impact on pharmacology and pharmokinetics. The British National Formulary (2016) cautions that ‘children, and in particular neonates differ from adults in their response to drugs’ and that many children ‘may require medicines not specifically licensed for paediatric use’. The NMC (2015) states that only nurses with the relevant knowledge, competence and skill should prescribe for children.The BNF (2016) recognises that the informed use of unlicensed medicines or of licensed medicines for unlicensed use is necessary in paediatric care. When prescribing for children the physiological differences between adults and children should be considered closely by the prescriber and the fact that many medicines may not have been extensively tested on children (BNF 2016). Some of the differences between adults and children in phrarmodynamic and pharmokynetic terms are summarised below.
ABSORPTION. Absorption may be affected by slower gastric emptying and intestinal transit times.
DISTRIBUTION. Distribution may be affected by the water to fat ratio in children who have less body fat.
METABOLISM. Metabolism processes are diminished due to immaturity of the liver particularly in neonates which can lead to a prolonged drug half life and therefore there is an increased risk of drug toxicity.
EXCRETION. In the immature renal system glomerular flow is reduced.
(Bane 2016)
As a result of a reduction in all these processes drugs may accumulate in the body (Hung Rosenbaum (2014).
I was working as an Emergency Nurse Practitioner and trainee non medical prescriber alongside an experienced Emergency Nurse Practitioner who is also qualified as a non medical prescriber, when Kieran attended the Emergency Department early in the morning, after he had suffered a disturbed nights sleep due to an uncomfortable and irritated left eye. Kieran attended with his mother (Kieron said that his mother was with him mainly as he relied upon her for transport rather than in her capacity as a guardian).
Courtney and Griffiths (2010) recognises that the concept of nurses and health care workers other than doctors undertaking consultations is a relatively new phenomenon, and cites several consultation models such as Stott and Davies (1979), Neighbour (1987) and the Calgary – Cambridge model (1998). These are then described as falling into two categories ‘normative’ (what should happen in a consultation) and ‘descriptive’ (what does happen in a consultation). A review of the various models shows a variable degree of patient centred or holistic approaches. For example the Byrne and Long (1979) model could be seen as a doctor centred rather than a patient centred or holistic approach due to its emphasis on what the doctor wishes to achieve rather than achieving mutual goals with and for the patient, and recognised that on average doctors interrupted the patient within 18 seconds of the start of the consultation. Whereas the Neighbour (1987) can be seen as more patient centred and holistic in approach due to its constant referencing back to the patients needs and understanding. As the Calgary – Cambridge model is comparatively recent, it appears to be built upon the body of knowledge referred to in other well known models (Courtney and Griffiths 2010) and is a model which balances the perspective of the practitioner against the needs and expectations of the patient. Therefore I feel that this would be an appropriate model to use in this case study. The model can be summarised into five stages
1. Initialising the session.
Establishing initial rapport.
Involving the patient.
2. Gathering information.
Exploration of problems.
Understanding the patient’s perspective.
Providing structure to the consultation.
3. Building the relationship.
Developing rapport.
Involving the patient.
4. Explanation and planning.
Providing the correct amount and type of information.
Aiding accurate recall and understanding.
Achieving a shared understanding.
Planning – shared decision making.
5. Closing the session.
When the patient presented to the Emergency Department his consultation and examination were as follows:
Social history: Garage Labourer, non – smoker, no alcohol intake.
Drug history: Ventolin inhaler when required.
Allergies: Penicillin? (rash as a baby when being treated for Lower respiratory infection).
Previous medical history: Mild exercise induced asthma (rarely used inhaler last 3 years), emergency appendectomy aged 15.
Family medical history: Mother normally fit and well with no significant medical history, Father Myocardial Infarction aged 55.
Presenting complaint: Foreign body? left eye.
History of presenting complaint: Foreign body sensation for four days. Kieran worked part time in a car garage workshop, as he was hoping the work experience may help in his ambition to become an apprentice motor mechanic. The work undertaken often required the use of power tools to grind, sand and prepare metal. On the previous days Kieran had spent a significant amount of time using an angle grinder and sander, whilst wearing safety goggles. On returning home four days prior to attending the Emergency Department Kieran began experiencing irritation and grittiness in his left eye, assuming that this was caused by a foreign body he irrigated his eye with water to little effect, the next morning he awoke with a sticky discharge around his left eye. After researching the symptoms on the internet, and on the advice of the local pharmacist, he had bought over the counter Chloramphenicol 0.5% eye drops, which he was told to use one drop four times a day, for five days, with the caveat to attend the Emergency Department if the symptoms of irritation continued.
On examination: 2 drops of Proxymetacaine hydrochloride were instilled for local analgesia and to facilitate the examination due to photosensitivity, this was prescribed using the Emergency Departments Patient Group Directive (P.G.D). Proxymetacaine causes transient stinging and is useful for children (BNF 2016) ,Kieran was warned that there may be stinging before the drops were instilled. The patient’s pupils were 4mm, equal and reacting. Visual acuity 6/6 both eyes, eye movements normal, anterior chamber clear, photosensitive. Upper lid everted and no abnormality seen, bottom lid slightly red and small amount of sticky discharge, sclera red but not injected. Under slit lamp examination no foreign body was seen. Flurescin was instilled (again as a P.G.D) without uptake i.e. no corneal abrasion, foreign body, ulcer, corneal oedema or other abnormality was seen.
Diagnosis: Bacterial Conjunctivitis.
Treatment: T.T.O prescription Chloramphenicol 1% eye ointment four times a day for five days.
Discharge: Return to the Emergency Department any worsening symptoms.
I saw Kieran in the paediatric area of the Emergency Department which caters for patients up to and including the age of eighteen. Although Kieran was seventeen years of age I felt it difficult to conceptualise him as a child, both due to his height and stature (90kg in weight and 1.9 metres tall) as well as the fact that he worked. Comparatively I am often struck by the incongruity of the scene of what ‘appears’ to be an adult sat in work overalls with a work related injury who is sat alongside of what ‘appears’ to be a child in school uniform with a playground related injury. However it should be recognised that whether adult, adolescent or child blindness or the fear of blindness is ‘one of the greatest catastrophes to befall anyone’ and the practitioner should expect anxiety in the patient presenting with an eye problem (Purcell 2003). Loss of sight is feared more than the loss of any of the other senses, and is listed as one of the top four worst things that can happen to an individual alongside cancer and AIDS (The Association for Research in Vision and Ophthalmology 2014).
I know from my own personal and clinical experience that patients presenting in the Emergency Department are often in a degree of discomfort that would outwardly seem disproportionate to the insult or injury, such as conjunctivitis or foreign bodies and abrasions. As Belmont et al (2015) states eye pain is an unpleasant sensory and emotional experience including sensory – discriminative, emotional, cognitive and behavioural components. I am also cognisant through experience, of the fact that the majority of patients find at least some aspects of a routine but thorough eye examination painful and or alarming, everting the eye lid and instilling flurescin for example. Also the slit lamp is as an object as alien to the patient as it is to many doctors, and the sight of a having a foreign body removed with a blue needle conjures up the image of a modern instrument of torture. To be able to establish this level of trust between the patient and the clinician is very difficult regardless of the skill of the practitioner.
Bickley and Szilagy (2009) state that there are two types of health history taking, the comprehensive assessment and the focussed assessment. The Oxford Emergency Handbook (2006) recognises the need for a focussed and structured eye examination in all patients presenting with an eye problem, and that assessment of patients presenting with a non traumatic red eye is difficult for the non specialist, however Shroeder (2011) states that the main aim of the physical examination is ‘to rule in your working diagnosis’ and to rule out other more serious conditions and differential diagnoses.
To assist the practitioner and non medical prescriber the mnemonics SOCRATES, OLDCART and the ‘surgical sieve’ approach VITAMINDEF are frequently cited as useful models and aide memoirs to give structure and clarity to the consultation and examination (Owens 2016) as is the system based approach – CVS cardiovascular, RS respiratory system, CNS central nervous system etc. This can be demonstrated where the SOCRATES mnemonic can be readily applied to the presentation which is the subject of this case study:
SITE – left eye.
Onset – gradual.
Character – sore, gritty.
Radiation – no radiation.
Associated symptoms – photosensitivity, sticky discharge.
Timing – four days.
Exacerbating/ alleviating symptoms – none.
Severity – mild.
However Schroeder (2011) states that clinicians should be able to ‘adopt a focussed and selective examination tailored to the findings from the history’ which implies that a surgical sieve or systems based approach would not be required or necessary in this presentation.
The diagnosis of bacterial conjunctivitis may seem a simple one, the Oxford English Dictionary (2016) defines it as simply ‘inflammation of the conjunctiva’, the conjunctiva being a thin layer of mucous membrane covering both inner eyelids and folding back onto the outer layer of the eye (Purcell 2006) see diagram below.
However there are myriad differential diagnoses for the patient presenting with red eye, Purcell (2003) states that there are ’some minor, some urgent and at least one that is an outright emergency’ and cites bacterial, viral and allergic as common forms of conjunctivitis.
Some of the presentations and differential diagnoses are serious and sight threatening such as acute uveitis and angle closure glaucoma, which would be unlikely in this presentation as it normally occurs in patients over fifty years of age (Purcell 2003). A review of a reference book such as the Oxford Handbook for Emergency Medicine (2006) will reveal many causes of ‘red eye’ presentations including foreign bodies and corneal abrasions, and the BNF at least three further types of conjunctivitis namely seasonal and perennial conjunctivitis as well as seasonal keratoconjunctivitis.
The diagnosis of bacterial conjunctivitis was based on the existence of cardinal symptoms and the absence of certain red flags. Purcell (2006) describes bacterial conjunctivitis as a red eye with little pain and little or no disturbance of vision and goes on to say that there will be a sticky discharge particularly in the morning and a gritty sensation. Bacterial conjunctivitis is often a Staphylococcus aureus infection that may be treated with Chloramphenicol. One in eight children have an episode of acute infective conjunctivitis every year (Rose et al 2005). The disease accounts for up to 1% of consultations in primary care and 1 million episodes in the UK (Rose et al 2005). Bacterial conjunctivitis is infectious, sufferers are advised not to share pillows or towels to prevent the spread of the disease (NHS Choices). The NHS choices website goes on to give rather confusing or contradictory advice from Public Health England about whether to stay away from school or work if you have the condition, firstly stating only stay away from school or work if the patient feels unwell, and secondly stating to stay away from school or work until the discharge has cleared up.
Viral conjunctivitis on the other hand may present in a very similar way with redness and grittiness but tends to be bilateral (Purcell 2006) and is often caused by the adenovirus (Wyatt et al 2006).
The absence of sudden visual loss or of decreased visual acuity and the presence of minimal discomfort rather than acute pain excludes many eye conditions with a serious pathology (Wyatt et al 2006). Therefore I felt confident that a reasonable and accurate diagnosis had been made.
The decision was made with the non medical prescriber to prescribe Chloramphenicol 1% eye ointment, four times a day for five days, the prescribing decision was made after reference to the BNF (2016) which states that Chloramphenicol is a potent broad spectrum antibiotic suitable for treating bacterial conjunctivitis. Chloramphenicol is not a penicillin based medicine so prescribing it for a patient with an allergy or sensitivity to penicillin is not problematic. An antibiotic can be defined as ‘any of various chemical substances…capable of destroying or inhibiting the growth of micro-organisms especially bacteria (dictionary.com 2016) and the term antibiotic was first used in 1894. Chloramphenicol exerts its antibiotic action by specifically inhibiting the synthesis of bacterial protein, without directly affecting a large number of other metabolic processes Jardetky (1963). Fusidic acid was considered as a possible alternative to Chloramphenicol however Fusidic acid is a narrow spectrum antibiotic used to treat staphylococcal infections and has the advantage of having to be applied twice rather than four times a day (BNF 2016). Although bacterial conjunctivitis is frequently caused by staphylococcus (Purcell 2003) this would be impossible to prove without culture and sensitivity tests and results.The trust’s antimicrobial policy was also consulted which states that the infection can be caused by Staphylococcus aureus as well as Haemophilus influenza, Streptococcus pnuemoniae and group A,C,G streptococci. The trusts antimicrobial policy recommends a treatment regime of Chloramphenicol 0.5% drops two hourly and Chloramphenicol 1% eye ointment at night. In contrast Visscher et al (2009) concluded that there is a high spontaneous remission rate for bacterial conjunctivitis if good practices of hand and eye hygiene are followed, negating the need for a prescription for medicines altogether. Bradley (1991) recognised that there are many influences on the prescriber, including the influence of senior colleagues, apart from the patient. Courtney (2010) states that research seems to suggest that prescribers tend to overrate the patient’s desire of obtaining a prescription and that patients will refuse prescriptions either directly or indirectly by simply not collecting the prescription or not taking the medicine.
Chloramphenicol has the potential to produce serious side effects such as grey baby syndrome and aplastic anaemia, however these are associated with systemic rather than topical use and said to be ‘overstated’ by the BNF (Wyatt et al 2006). The BNF cautions that systemic effects can occur due to the absorption of drugs into the general circulation through the conjunctival vessels, and that this is less likely with ointment compared to drops, of which use of more than one drop should be discouraged. Wyatt (2006) states that the effects of ointment lasts longer than drops and therefore requires fewer frequency of administration, frequency and difficult administration can be seen as a factor in poor concordance regardless of age (BNF 2016).
The National Prescribing Centre (1999) developed a series of ‘signposts’ to assist the prescriber known as the ‘prescribing pyramid’ or the seven principles of prescribing which are summarised by Courtney (2010) and expanded on in relation to this study below:
Consider the patient. The prescriber should give thorough consideration and understand the holistic needs of the patient. A drug history including over the counter (OTC) medicines should be included along with any drug allergies or sensitivities. By exploring Kieran’s social history including his occupation it was possible for me to understand some of Kieran’s needs and aspirations as well as his position on the socioeconomic scale. As he was between school and apprenticeship his income was low. It was also realised by the trainee that the prevention of infection to Kieran’s family is part of a holistic approach, therefore some time was spent discussing how good hand hygiene and not sharing towels could lower the chance of transmission.
Which strategy? Treatment options other than prescribing should always be considered, including explanation, reassurance and recommending the buying of OTC medication. It was explained to Kieran that not treating his condition with antibiotics was an option and that the majority of cases of bacterial conjunctivitis are self limiting. However Kieran and his mother felt that his condition was not improving and impacting on his activities of daily living.
Consider the choice of product. I felt that Kieran’s day to day working life should be considered when deciding whether to prescribe a treatment regime involving two hourly drops compared to ointment alone. I felt that instilling drops at work would be problematic both in terms of frequency and in terms of the environment which is dirty and dusty by its nature. I also felt that an exploration of how Kieran’s self diagnosis and decision to self medicate had arisen may help to understand the case thus far and perhaps help in my prescribing decision making process. A google search using the term ‘red eye’ reveals 29,200,000 results perhaps tellingly the brand name Optrex appears first on the list of results whereas NHS choices appears seventh, this would suggest that the first source of information is likely to be from a commercial body rather than the NHS or another non biased organisation. The Optrex website lists several causes of red eye and several products to cure or mediate the symptoms. If the researcher manages to correctly identify his or her complaint the website then offers its own brand of Chloramphenicol 0.5% eye drops £4.99 per 10ml bottle or Chloramphenicol 1% eye ointment costing £5.99 for a 4g tube. Non branded versions of the ointment which is a pharmacy only medicine (POM) can be purchased for around £4.50, whilst an NHS prescription currently costs £8.40. The NPC suggest the use of the mnemonic EASE to assist in deciding which product to prescribe.
E – how effective is the product? – Chloramphenicol is an effective and potent antibiotic suitable for treating bacterial conjunctivitis (BNF 2016).
A – is it appropriate for the patient?- Chloramphenicol is appropriate for use in children and is the drug of choice for superficial bacterial eye infections (BNF 2016).
S – how safe is it? – there are only minor side effects (transient stinging) the risk of aplastic anaemia is not well founded (BNF 2016).
E – is the prescription cost effective? – the prescription is available OTC at less cost than via the NHS prescription and less than a branded formula (BNF 2016).
Negotiate a contract. Prescribing should be viewed as shared decision making between the patient and prescriber. The decision to prescribe was discussed fully with Kieran and his mother, the discussion included what was to be used for how long and what to do if the symptoms worsened such as an increase in pain or the symptoms persisted longer than the course of treatment.
Review the patient. It is not good practice to issue repeat prescriptions without regular review. The issue of repeat prescriptions seldom arises in the ED, however patients can be reviewed in the ED clinic if the practioner/prescriber feels it necessary although this tends to a review of fractures and wounds rather than eye conditions.
Keep records. The NMC guidelines on record keeping outline the standards expected of all nurses. Wyatt (2006) cautions that failure to record a visual acuity may constitute negligence leading to poor outcomes for patients and which in turn could lead to the prescriber being referred to their governing body such as the NMC or GMC.
Reflect. Reflecting on prescribing decisions, both alone and with colleagues possibly under the umbrella of clinical supervision will help practitioners improve and develop their prescribing practice (Courtney 2010).
In conclusion, prescribing is a complex process that should ultimately provide the right treatment at the right time in a safe way. Prescribing for children adds an extra layer of difficulty not only in terms of pharmacology but also understanding, consent, communication and concordance. I feel that undertaking the non medical prescribing course and this case study has led me to a deeper understanding of the issues and difficulties in diagnosis and effective safe prescribing, particularly for children. However I feel that on successful completion of the course I will be able to offer a more complete and holistic service to patients of all ages, and that being a prescriber will dovetail perfectly with my practice as an Emergency Nurse Practitioner whilst also enhancing the patients journey and improve health outcomes.
APPENDIX 1
CRITICAL INCIDENTS
A critical incident is one:
In which personal action made a difference to the outcome of a situation;
Where an event went unusually well;
Where things failed to go as planned;
Which is ordinary and typical;
That is particularly demanding or challenging.
It is important to include as much information as possible when writing critical incidents.
The following list may help direct your thinking in the early stages.
Where the event occurred, relevance and impact on situation;
When it happened; was this an important factor?
A detailed description of what happened;
Why the incident was critical or significant to you;
How you felt about it;
What were you thinking about as it was taking place;
What was most satisfying;
What was most disturbing;
What might you have done differently;
What action, if any, will you take as a result of this learning;
What impact will this learning have on your future performance?
Benner P. (1984), From Novice to Expert, Addison Wolsey, London.