Safe Prescribing: Nurse Prescribing in Ireland

This article discusses the role of nurse prescribers in Ireland and the importance of safe prescribing. It covers the practice standards set by the Nursing and Midwifery Board of Ireland and the partnership with the office of Nursing and Midwifery service Director of the HSE. The article also highlights the need for effective communication, decision-making, and leadership skills in nursing practice.

Running head: Nursing as general practise
SAFE PRESCRIBING: NURSE PRESCRIBING IN IRELAND
Setting: GENERAL PRACTICE.
Name of the student
Name of the university
Author’s notes

Running head: Nursing as general practise
Introduction
A nurse prescriber is a healthcare professional who can write a prescription for any
medical condition within their respective competence. According to the Nursing and
Midwifery Board of Ireland (NMBI) the professional responsibility of nurses and midwives
for prescribing practices need to follow 11 practice standards (Ilo.org. 2009). The documents
details clinical decision-making process, communication and history taking, documentation,
prescription writing, prescribing for self, family and significant (Whittake rand McKune
2008). The Nurse and Midwifery Board of Ireland (NMBI) is in a partnership with the office
of Nursing and Midwifery service Director of the HSE. They are updating the Guidance to
Nurses and Midwives on Medication Management and they accompany e-learning
programme. These documents were published in 2007. Since the role of the nurse is
multifarious and it varies from managerial to organizational and clinical skills deficits, they
need to undergo a whole lot a pressure pushing them forward to Excellency. Lack of training
and putting them directly in the field of operation adds the level of stress and their anxieties.
In Ireland pre-registration is university and college based. There are two types nursing
practices in Ireland, this piece of writing is based on the second variant, which is independent
prescribers who have successfully completed NMC independent Nurse Prescribing Course
and these are registered with the NMC as an IP. These nurses are able to prescribe any
medicine as along as it is competent enough for them to do it. These includes the products
licensed under the BNF, where the unlicensed medicines and all drug schedules two-five. In
this paper, I will demonstrate the effective practices as Independent nurse prescribe.
Body
Being a nurse prescriber, it becomes the responsibility of the nurse to be accountable
for the welfare and well-being of the patient. Communication with the patients or the service
user needs an effective reflection. The dual process of communication is based on

Running head: Nursing as general practise
fundamental guideline for safe and effective prescribing practice. The success of a
professional nursing practice depends on four important things, namely professional values,
communication and interpersonal skills, nursing practice and decision making and leadership,
management and team working (nc.org.uk). The duties of the nurses revolves around,
delivering service to the needed. However, the role of nurses working within general practice
is changing. According to the Irish Practice nurses Association (IPNA), there are 17000
practice nurses in Ireland with a sizable number of 3500 GPs. Out of which 211 practice
nurses are accredited with clinical nurse specialists (CNS). Two of them have been accredited
as advanced nurse practitioners (ANP) in primary care and 11 IPNA member are now
registered nurse prescribers. There are proposed plan, which will plan to abolish fees for
GP, and the focus on the Prevention of Illness Management of Chronic diseases will be
involving the completely primary healthcare team. Nurse practice in Ireland represents an
important aspect General Practice. Services like undertaking immunisations, cervical
cytology, screening, health promotion, and phlebotomy, weight management, smoking
cessation, women’s health, men health, wound management, travel vaccinations, ear care and
management of chronic conditions such as asthma, COPD and diabetes. They act to protect
the public and they are responsible for the person-centred or evidence-based nursing
practices. It is expected of them to act with professionalism and integrity, within the agreed
ethical and legal framework. Each patient is case specific, and it is the duty of the nurses to
cater to their well-being by recognizing the way certain living standards and environments
influence their behaviour. Thus the attitude of the nurse must be influenced with the
leadership qualities, as it will help the them to work in partnership (Nmbi.ie. 2015). This kind
of approach can only be successful only when, as a leader, nurse serve and transforms the
negative vibe into positive ones. Owing to this kind of approach, the profession of nursing
will ensure safety and security to the patients and as well as to the wider public. Thus, this

Running head: Nursing as general practise
kind of approach will help the nurse prescribers to do their duty in a dignified manner.
Therefore, she will require leadership qualities to supervise and effectively contribute to the
planning, designing, delivering and improving future services. It is importance for the role of
nursing practices because a nurse has dual role to play, learning leadership qualities will
assist them to have a right approach in the work.
The Global Patient safety Challenges recognizes the patient safety burden and aims to
develop intervention strategies to combat such challenges. Risk not only deals with safety
challenges but it can be related with the very operating it performs, like the one associated
with surgery, post-surgery infection and so on. The role of the practice nurse has expanded so
much that this profession is associated with risks factors. The risk factors included situation,
where the nurse has to work alone, they need to manage their own workload. Especially when
the workload is coupled with inconsistencies and variable opportunities for formal education
and training, the nurse practice become more difficult. Therefore it is important for nurse
practice to involve an effective risk management skills. Thus it important to conduct a
systematic holistic assessment of patient, this will depend upon the competency of the nurse
specifically. Competence is a complex and multidimensional phenomena, and one of the core
criteria of competent behaviour is be able to have problem-solving abilities (Drennanet
al2009). For better dingiest of the patient, a nurse should have a holistic report of the client,
where along with the biological risks, the clinical risk will be mitigated. The nurse must
recognised the elements of risk and also effectively integrate the knowledge available from
the test assessment report. The nurse also has to demonstrate the quality assurance and
quality management to defying the risk that is inherent in dealing to the patient (Fennell
1991). In order for risk-avoidance, the nurse need to combat with five domains of
competence, like professional and ethical practice, that is, one need to make sure, whether the
work which is being carried out has informed consent. No unethical of unscrupulous methods

Running head: Nursing as general practise
were used while dealing with the patients’ diagnostics. The second level of competence deals
with gathering holistic knowledge about the person concerned and it also refers to the
integration of knowledge. In the third level, the interpersonal relation must be focused
because it is very important the nurse to create a relationship of trust and mutual faith wither
his or her client. Clean and clear communication will help to set the pace of such relation, and
it is worthwhile to mention that, communication also works to deter the risk element of
assessment. In the fourth level, it is duty of the nurse to bridge the difference between the
organization and the client so that one can deter the risk associated with clinical procedures
(Who.int. 2007). Last but not the least, it is the amalgamation of the personal and the
professional development procedures, which will help management the risk and understand
the importance of risk management. Developing the proper ability for risk management is
important for nursing practice. This is because being able to deal with viable risk is a part of
learning, and it is the duty of the nurse to render the service. Therefore learning risk
management skills is an important part of the nursing practices.
Clinical governance refer to the framework through which the healthcare teams are
accountable for the quality and safety of those who are the care-receivers. One should
understand the importance of clinical government issues and the role of the nurse in it. It
is very necessary of the nurse to support and take part in the healthcare developmentary
perspectives in order to realise the significance of the clinical governance (Lockwood and
Fealy2008). Clinical governance is wide concept and it includes elements which as follows:
patient first, safety, personal reasonability, defined authority, clear accountability, leadership,
multidisciplinary, supporting working, supporting performance, open culture and continuous
quality improvement. For better understanding the practices of car-management, it is
important to divide that care management in to different types, like, person-centred care,
effective care, safe care and better health and wellbeing. Primarily it is recommended that

Running head: Nursing as general practise
nursing practice should not just focus on their level of genre aiming to reduce the potential
error. In the words of the An Bord Altranais, “the nurse or midwife must make a judgement
as to whether he/she is competent to carry out a particular role or function. The maintenance
of competence and ensuring is continuing development is achieved by engaging in continuing
professional development.” It is expected of the practice nurse to provide evidence based, up-
to-date, quality care. Owing to the Continuing Professional development (CPD) a nurse can
provide up-to-date clinical and regulatory guideline. Thus, it is necessary for nurses to be
trained and competent in order to undertake procedures that are delegated to them. Therefore
is important to follow the guideline of clinical governance in floor of practice. As a nurse
clinical governance will mean referring to the clinical standards and narrowing down the
clinical standards. That one must understand tasks that need to be delivered along with
demonstrating the one have done or is planning to do. In the act of providing safety and
assistance for curing, the person one needs to improve the quality of service delivery and
leadership (Nmbi.ie. 2015). The typology of care, previously stated, will help the nurse to
locate oneself in the entire system of service generation. Since the nurse is placed in the
middle, that is, between the client and the organization, she or he need to deal with the client
and again then deal with the organization. Along with the promotion of the healthy practices,
the nurse must also cater to identifying or preventing the risks of harm. The duties of
independent nurse is to identify, disclose, manage, investigate and escalate the incidents that
can serve as adverse events. The person concerned should try to avoid the dangerous
incidents by protecting the patients and improving the quality over all. The outcome of every
action must be measured properly so that it can serve as a guideline to future action
(Europarl.europa.eu. 2015). The health and the well-being of the individual team members
must be focused so that it generates coordinated action. According the National Standards for
Safer and Better Healthcare, it is important to address the multi-disciplinary teams because

Running head: Nursing as general practise
the improved patient outcome is not just the result of a single effort of the nurse. The
administration works cyclical, in step one, information about prompts are mad available to all
the teams members. In the second step the prompts are analysed, the gaps are identified, in
this step the actions of the owner and the responsibilities of the are also identified. In the third
step, the implementation of the activities to improve safety and quality in patient care will be
executed. The collection of the information to assess the level of performance will also done
in this step. Last but the least in the fourth step, the process continues and regular meetings
will be held by aligning the agenda of the meetings with the social core of the clinical
governance system. Building on the foundation of the Requirements and Standards for
Education Programmes for Nurses and Midwives, Collaborative Practice Agreement (CPA)
(NMBI 2016) remains one of the most important element (Coalition 2002). Collaborative
working is related in the way the work procedure is practiced. Interprofessional collaborative
learning is also encouraged by World Health Organization, interprofessional learning refers
to a situation where people with educational background will work together with the patients,
families, carers and communities and so on. The only target to working is such a
collaborative environment is to deliver high quality service to the client. On the other hand,
inability to do it can put the patient at risk for unsafe care and negative outcomes. Even
though it is a well needed norm, interdisciplinary collaborative working conditions can be a
rare sight. There can be conflict, with opinion, then emotional conflicts within the person.
Therefore, the person will lack energy to participate in the group activity. As a result the
person will get demotivated and will lose all the enthuse to effectively participate in the work
environment. Collaboration leads to cost saving practices and increases the nursing job
satisfaction, with improved teamwork. Thus it is advisable of the nurse in general practice to
collaborative for better resource utilization and customer satisfaction
(Assets.publishing.service.gov.uk. 2016). Effective collaboration depends on good will of the

Running head: Nursing as general practise
customer and also the framework of the ones on mind. There are presence of other contextual
elements that will influence the formation of collaboration include time, status, organizational
value, collaborating participants and the type of problems. Successful collaboration do not
occur when any single person refuses to participate, it demands explicitly an inter-
disciplinary framework (Hse.ie. 2019). The attributes are well defined of a nurse in general
practice to include sharing of planning, making decisions, solving problems, setting goals,
assuming responsibility, working together cooperatively, communicating and coordinating
openly. These actions underlie the value ethics approach such as cooperation, joint practice,
and collegiality and so on. There are ten essentials of collaborative frame work, which are, to
know oneself. The mental model that each one poses should not be judgemental, or should
not hold any bias. Collaboration is essential on understanding mental models for a shared
mental model, partners, and teams can boost up the outcome of the patient care. Therefore,
each organization will try to make different realities to simultaneously exist. There the
emerges the concept of shared values and goals. The second element is to be able learn values
and manage the diversity. Nursing is one of the most gendered-structured occupation in the
UK, sometime gender communication become a diversity and it becomes important to
recognise that diversity(cloudfront.net. 2015). The third element is developing constructive
conflict resolution skills, this is very important because, it aims for coordinating and
collaborating at multiple levels, like interdisciplinary levels, intra-organizational level and
inter-organizational level. This kind of complexity adds the nurse to learn constructive
conflict-negotiation skills. Conflict resolution is the cornerstone of collaborative success.
Conflict is double faced, it both hinder and facilitates collaboration. Depends mostly on how
a person can foresee it or cater to it. The fourth element is to create a win-win situation. In
this case the person has to coordinate conflict properly, use the power to dominate over the
other side. Keeping in mind that dominance is not successful for a long-term commitment,

Running head: Nursing as general practise
because the side which is defeated will again wait for a chance to dominate. The fifth point is
to establish a successful inter personal communication and process the skills. Both inter-
personal skills and successful collaboration skills are needed for successful collaboration.
Important interpersonal attributes include clinical competence, cooperation and flexibility,
self confidence and assertiveness, patience to listen to one another’s rationale and the ability
to take risk and the ability to operate in multicultural contexts, tolerate ambiguity, are self-
reflective and convey a value that places the patient above the needs of the individual health
care members.
Time and again it has been established that cost-effective medication prescribing
forms a significant and multifaceted component of their health provision role. The
professional accountability makes it necessary to demonstrate essential clinical skills, besides
diagnosing and matching drugs suitably (Wilson, Schutte and Abel 2015). However, good
prescribing also encompasses a range of other factors. According to research evidences safe
and cost-effective prescribing involves the recommendation of medication that is both
economically and clinically suitable for the presenting complaints (Gellad and Kesselheim
2017). Taking into consideration the fact that economics for paying for the prescribed
medications is an inadequate resource, nursing professionals are accountable for considering
the socioeconomic status of the patients. Administration of an expensive medicine might
improve patient health, however, cheaper medication are expected to benefit a wider patient
population. Recommendations and familiarity with necessary OTC medications will prove
effective in reducing the cost of medication to PCO budgets and patients (Wright et al. 2017).
Showing adherence to price regulation schemes for pharmaceuticals will also help in
controlling the cost of branded licensed medicines, by directly exerting a control on the
profits that are made by the medicine companies. Left to their own will, a certain section of
patients have started adopting potentially hazardous practices such as, intake of low

Running head: Nursing as general practise
medication dose than prescribed, dissemination of old prescriptions with relatives, and
splitting medicines for saving on prescription costs (Alomari et al. 2015). Hence, offering
patients access to generic medications will act as an effective strategy and uphold their health
and safety. Under circumstances when the health insurance of a patient comprises of
prescription medication plan, certain costs of expensive drugs are often borne by the patients,
which in turn contributes to an increased co-payment. Hence, the role of a nursing
professional makes it necessary to implement and show adherence to tiered drug insurance
strategies, which will allow the consumers to have a share in reduced co-payment for
different generic medications, in comparison to brand-name drugs. Furthermore, evidences
have elaborated on the fact that it is imperative for nursing professionals for evaluating and
clearly defining the presenting complaints of the patients, followed by specifying the
therapeutic objective and selecting an appropriate medication therapy (McLeod, Barber and
Franklin 2015). With the aim of initiating the therapy, necessary information regarding the
medication effects and warnings must also be disseminated. Use of computers and health
information technology will also lower the chances of prescribing errors.
Clinical leadership was defined by Jonas et al. In 2011, this term specifically means
that the “concept of clinical health staff undertaking the roles of leadership, setting, inspiring
and promoting values and vision and using their clinical experience and skills to ensure the
needs of the patients are central to clinical leadership”. Leadership has long past and it
evolved from trait theory to transactional theory to transformational theory. Along with the
changing nature of the demand and supply, fiscal constraint, it essential to have governance,
the effort will aim to maximise the management of care in the hospital setting. It is estimated
that out of 92, 7226 nurses only 532 nurses are nurse prescribers. It is advice that practise
nurse who are not nurse prescribers should be using medication protocols. The medication
protocol involves the authorization of the nurse by the GP. It is important for nurse to ensures

Running head: Nursing as general practise
that they are up-to-dated with the current practice in immunization and that should include
recognition and intervention with side effects or treating anaphylaxis. Thus there is need of
growing leadership capabilities so that the high quality health care system can provide safe
and efficient care to the clients or the service users. However, it is important to note that
effective clinical leadership is link and array of leadership functions like hospital care, system
performance, achievement of health reform objectivities, timely care delivery, system
integrity and efficiency. Clinical leadership is not exclusively in the domain of the health care
system, rather any potential group can identify every potential member of the professional
group. In a secondary analysis, it is shown that exploring the wrong doings in the clinical
environment was also not analysed. The focus of the analysis was on the clinical nurse’s
leader responses, where three forms of avoidant leadership were identified. These are
placating avoidance, equivocal avoidance and hostile avoidance. Along with the proper
leadership qualities, it is also important to raise ones voice when something wrong is
happening. The most innate proem is with its definitional uncertainty, where there is no clear
cut definitions, therefore leadership skills tend to vary, sometimes it is skill driven, and
sometimes it is situational (Courtenay and Carey 2008). Then there are time when it is value
driven, vision driven, it might also include issues like boundary spanning, exchange
relationships, as collective, co produced. In order to achieve healthy work environment it is
essential to draw on the qualities of clinical leadership abilities. In this way one can address
the changes that are occurring at different levels, thus it is important for role of nursing
practices.
Professional accountability also makes it imperative for the professionals to conduct
prescribing audits. Prescribing audits in separate clinical domains are generally undertaken as
an essential component of Quality and Outcomes Framework. In addition, audit for
prescribing services will also act in the form of key performance indicators (KPIs). The major

Running head: Nursing as general practise
advantage of such audit can be associated to the fact that it will help in chronic disease
control and also be used as a type of documentation and self-assessment, during practice.
Opportunities must also be created for such audit since unclear and flawed prescriptions have
proved to be of major danger to patients. Medication administration or dispensing in
contradiction of prescriptions have the probability of causing potential patient injury (Lewis
et al. 2019). Furthermore, significant lawsuit and professional punitive action might also be
taken against the nursing professionals who are involved in different stages of medication
procedure (Elouafkaoui et al. 2016). Hence, the opportunities for audit must comprise of
checking whether the prescriptions are documented in indelible black ink, are legible and
clear, signed, and/or contain a name beside the signature. The audit will also focus on the fact
that bold line must be used across drug administration and name sections. In addition, audit
prescribing must also ensure that the frequency of administration, dosage and additional
information are recorded appropriately (Trietsch et al. 2017). While creating opportunities for
audit prescribing, it is imperative for nurses to prescribe the drugs based on their generic
names, besides elaborating on the device used for administering the prescribing medications.
Opportunities for drug prescribing must also ensure that references are made to any distinct
charts, where the drugs have been recommended.
Leadership theories in nursing includes big bang theory, trait theory, style theory,
situational or contingency theory, transformational leadership, transactional theory, authentic
leadership, break though leadership and servant leadership theory. I will base my
understanding on transformational theory, where leaders work with teams to identity needed
change and also creating the vision to guide the change through inspirations and so on. This
kind of leadership improve motivation, enhances the morale and job performance of the
follower through variety of mechanisms. This kind of leadership not only helps the followers
to inculcate an individual identity but also recognised the requisites of group identity.

Running head: Nursing as general practise
Therefore, it plays an important role in nursing practices because the approach is built on the
purpose of it and thus caters to the need of the people.
Conclusion
Thus it can be concluded that nursing as general practice includes arrays of functions
like risk management, working with the notion of clinical governance, collaborating in
multiple level and also the ethos of clinical leadership. The roles that needs to be performed
by a nurse practicing the general practice must be harboured because of understand the way
to avoid conflict (Craig 1996). The importance communication is mostly important because
and misunderstanding can trigger conflict. Providing care is not the only function because the
nurse is also answerable to the management. Therefore it is important to concentrate on one’s
own piece of mind, because it is equally important to raise concerns when there are injustices
which are going on. Keeping ones voice low will detrimental for the development of hospital
care management skills. Therefore focusing of the transformational form of leadership and
growing the concerns of changing customer patterns of expectations should be validated in
the nursing management.

Running head: Nursing as general practise
References
Alomari, M., Mohamed, F.H., Basit, A.W. and Gaisford, S., 2015. Personalised dosing:
printing a dose of one’s own medicine. International journal of pharmaceutics, 494(2),
pp.568-577.
Assets.publishing.service.gov.uk. (2016). A guide to what is a medicinal product. [online]
Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/759581/012__GN8_-_final_2018_combined_doc_Oct.pdf [Accessed 15
May 2019].
Coalition, M., 2002. National maternity action plan. Birth Matters, 6(3), pp.1-26.
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.
Craig, E.J., 1996. A review of prescriptive authority for nurse practitioners. The Journal of
perinatal & neonatal nursing, 10(1), pp.29-35.
D3n9y02raazwpg.cloudfront.net. (2015). SOLTRANS BOARD OF DIRECTORS AGENDA.
[online] Available at: https://d3n9y02raazwpg.cloudfront.net/soltransride/4d527d8b-e73e-
11e7-a872-00505691de41-cfa15cc7-b08a-4284-b772-bbd9d929b696-1545673287.pdf
[Accessed 15 May 2019].
Drennan, J., Naughton, C., Allen, D., Hyde, A., Felle, P., O'Boyle, K. and Treacy, P.,
2009. National independent evaluation of the nurse and midwife prescribing initiative.
University College Dublin (UCD).
Elouafkaoui, P., Young, L., Newlands, R., Duncan, E.M., Elders, A., Clarkson, J.E. and
Ramsay, C.R., 2016. An audit and feedback intervention for reducing antibiotic prescribing
in general dental practice: The RAPiD cluster randomised controlled trial. PLoS
medicine, 13(8), p.e1002115.

Running head: Nursing as general practise
Europarl.europa.eu. (2015). Medicinal products in the European Union. [online] Available
at: http://www.europarl.europa.eu/RegData/etudes/IDAN/2015/554174/EPRS_IDA
%282015%29554174_EN.pdf [Accessed 15 May 2019].
Fennell, K.S., 1991. Prescriptive authority for nurse-midwives. A historical review. The
Nursing clinics of North America, 26(2), pp.511-522.
Gellad, W.F. and Kesselheim, A.S., 2017. Accelerated approval and expensive drugs—a
challenging combination. New England Journal of Medicine, 376(21), pp.2001-2004.
Ilo.org. (2009). [online] Available at: https://www.ilo.org/wcmsp5/groups/public/---
ed_mas/---eval/documents/publication/wcms_168289.pdf [Accessed 13 May 2019].
Lewis, T., Kennedy, J., Price, G., Mee, T., Woolf, D., Bayman, N., Chan, C., Coote, J.,
Faivre-Finn, C., Harris, M. and Hudson, A., 2019. Palliative lung radiotherapy at the Christie:
audit of prescribing practice and survival analysis. Lung Cancer, 127, pp.S81-S82.
Lockwood, E.B. and Fealy, G.M., 2008. Nurse prescribing as an aspect of future role
expansion: the views of Irish clinical nurse specialists. Journal of Nursing
management, 16(7), pp.813-820.
McLeod, M., Barber, N. and Franklin, B.D., 2015. Facilitators and barriers to safe medication
administration to hospital inpatients: a mixed methods study of nurses’ medication
administration processes and systems (the MAPS study). PLoS One, 10(6), p.e0128958.
Nmbi.ie. (2015). Nurse and Midwife Medicinal Product Prescribing Review of Existing
Systems and Processes. [online] Available at:
https://www.nmbi.ie/nmbi/media/NMBI/Nurse-Midwife-Prescribing-Review-of-Existing-
Systems-Processes-2015.pdf?ext=.pdf [Accessed 15 May 2019].
Trietsch, J., van Steenkiste, B., Grol, R., Winkens, B., Ulenkate, H., Metsemakers, J. and van
der Weijden, T., 2017. Effect of audit and feedback with peer review on general practitioners’

Running head: Nursing as general practise
prescribing and test ordering performance: a cluster-randomized controlled trial. BMC family
practice, 18(1), p.53.
Whittaker, A.G., Smith, F.C. and McKune, E., 2008. The National Security Policy Process:
The National Security Council and Interagency System. Industrial Coll of The Armed Forces
Washington DC.
Who.int. (2007). [online] Available at:
https://www.who.int/medicines/technical_briefing/tbs/Trainer-s-Guide-All-Sessions.pdf
[Accessed 15 May 2019].
Wilson, D.J., Schutte, S.M. and Abel, S.R., 2015. Comparing the efficacy of ophthalmic
NSAIDs in common indications: a literature review to support cost-effective
prescribing. Annals of Pharmacotherapy, 49(6), pp.727-734.
Wright, M., Lawrence, M.P., Kunberger, C. and Hopper, J., 2017. The impact of improving
education about OTC medications for diabetic patients. Nephrology news & issues, 31(5),
p.22.