Daniel, aged 16, attended one evening for his TwinRix ™ (hepatitis A&B) booster in response to a reminder from myself. He had a primary course the previous year prior to visiting India on a school run project to assist with the building of an orphanage in a remote village. As I gave him the injection, we chatted about his experiences abroad, which he had clearly enjoyed immensely.

I already knew Daniel quite well, both from his course of immunizations given prior the trip (which had been quite comprehensive) and from his previous attendances at asthma clinic. I considered that we had quite a good relationship. I noticed this time that he had developed quite extensive acne on his face.

Acne is characterised by excess sebum production, which leads to blockage of the follicle and the development of blackheads and whiteheads. Colonisation of the skin with the bacterium propionibacterium acnes results in inflammation and the development of papules and pustules. Scarring may occur in severe cases (Buxton, 1993). It is usually divided into three categories (Boston, M. 1997):

• Mild acne – open and closed comedones (blackheads and whiteheads) with scattered papules and pustules

• Moderate acne – more extensive and frequent papules and pustules on the face and trunk

• Severe acne – extensive, and may include cysts and nodules, frequently leading to scarring

Treatment of mild acne consists of topical therapies. Topical treatments include antibacterial agents, such as benzoyl peroxide which is sold over the counter under various brand names; topical retinoid preparations which are prescription only products, and topical antibiotics. Moderate acne is treated with oral antibiotics, which should usually be combined with a topical preparations to achieve best results. Severe acne should be referred for a specialist opinion as oral retinoids can be very effective but should only be given under the direction of a consultant dermatologist (BMA and RPCGB, 2002). The list of acne treatments available to the nurse prescriber is fairly extensive, and it is therefore likely that the role of the nurse in this area will expand.

I wondered if Ben might mention the acne to me himself. However, as the consultation drew to a close, it seemed that he was not going to, and somewhat apprehensively, I decided to mention it to him. He immediately appeared releived, and said “Oh yes, I was going to ask you….my mum told me to…..is there anything you could recommend?”

I asked him which over the counter products he had been using, and he said he had used only tea tree oil. I suggested that he buy products containing benzoyl peroxide, but also felt that he would benefit from antibiotics, as the acne was moderately severe in character. He was keen to go ahead with this.

I discussed the situation with the GP who prescribed oxytetracycline 250mg 2 tablets to be taken twice daily. I explained to Daniel that he would not see any immediate improvement, but that he must persevere for at least 3 months with the antibiotics. I advised him as to the possible side effects, and that he should come back and see me if he experienced any of these.

Daniel seemed delighted to have been offered treatment for his skin. I have arranged for him to come back and see me in 3 months, up until which time he can have repeat prescriptions via our computerized system.


Reflection - on case study on acne

Reflective model: Kolb (1984)

The impact of acne

Koo (1995) has said of acne vulgaris: “There is no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic trauma than does acne vulgaris.”

Occurring as it commonly does during the acutely self-conscious years of adolescence, acne can, for many, continue well into adult life. The psychological impact it can have should not be underestimated. Given that in the vast majority of cases a proven and effective treatment is available, it is of concern that more sufferers do not receive this.

For me, the key point in this consultation was whether or not to take a risk in actively raising a potentially very sensitive issue. I had done this on two previous occasions, once with success. However, on the other occasion the patient, a teenage girl who was not well known to me, appeared upset and denied that she had any significant skin problem. Both she and I were embarrassed and I was wary of repeating this experience.

Young (2002) discusses embarrassment in the context of women’s health, but her observations could just as well apply to other embarrassing conditions such as acne. She points out that patients may be too embarrassed to mention the problem, with the result that they never receive adequate treatment. If mentioned at all, such issues may be raised at the end of the consultation (Livesey, 1996) as the patient was previously weighing up the practitioner to see if they could be trusted with such sensitive information. Young (2002) also discusses the fact that nurses are themselves human beings who experience embarrassment and need to find ways of dealing with it.

On this occasion, several things were in my favour. I already knew Daniel quite well, and felt that he trusted me. We had had a successful consultation and friendly chat about his trip abroad. Also, importantly for me, time was on my side. I had had a cancellation and therefore was not rushing to complete the consultation. Such things can greatly influence the quality of care received by a patient.

Nonetheless, I broached the subject with feelings of trepidation and vulnerability. His positive response was a relief, and I felt delighted that by taking this risk, I would be able to make a real difference for this young man.

Prescribing the appropriate treatment

I assessed Daniel’s acne as being moderate and felt that he would benefit from the prescription of oral antibiotics. However, I am not very experienced in the treatment of acne, and approached the GP to discuss the most appropriate antibiotic. He suggested oxytetracycline 250mg 2 tablets to be taken twice daily. Daniel was not allergic to this, and there were no contraindications to its use in this case. However, it was important for him to understand that there would be no immediate improvement and that he should persevere with the treatment for at least 3 months (Scottish Medicines Resource Centre, 1997). By explaining this to him, I hoped to gain his concordance with the prescription.

It is suggested in the BNF that if no improvement has occurred after this time, an alternative antibiotic should be tried.
Oral antibiotics work best when combined with topical treatments. I therefore advised Daniel to buy topical treatments containing benzoyl peroxide. He had been using tea tree oil, and whilst this may be effective, I am not aware of any evidence supporting its use, and therefore felt unable to recommend it in a professional capacity. The nurse who recommends an over the counter product in her professional role remains accountable for her recommendation because of the therapeutic relationship which exists, and which brings about her duty of care to the patient (Donoghue v Stevenson, 1932. Gibson, B 2002).

There is currently an ongoing debate about the serious problem of antibiotic resistance (DoH, 1998) and there was much resistance to the inclusion of oral antibiotics on the nurse prescribers formulary from the MCA. It is perhaps surprising, then, that long- term courses of antibiotics such as those indicated in acne have been made available to nurses, whist short course for conditions such as tonsillitis have not. I would suggest their inclusion can be justified by their proven benefit in acne, as opposed to their dubious value in sore throats. However, this could lead to a conflict between the greater public good and the patients individual need. In ethical terms, this could be regarded as a conflict between nonmaleficence (“above all’ do no harm”) and beneficence (to do good). Beauchamp and Childress (1994) comment that where these two principles conflict, the degree of benefit and harm should be balanced. As a nurse, I would argue that my duty to “promote the interests of patients and clients” (NMC, 2002) in accessing an effective and worthwhile treatment would outweigh the legitimate public health concerns.

Issuing the prescription

In this instance, I was able to issue a computer generated prescription for the GP to sign. However, once qualified as a prescriber, I will have to handwrite all prescriptions as there is not yet any facility for nurse prescriptions to be computer generated. In the light of the stated aims in the NHS plan (DoH, 2000) that “The NHS will have the most up to date information technology systems to deliver services faster and more conveniently for patients” (p48) this is somewhat anomalous. It also brings with it a greater potential for errors. Whilst we have been assured that this issue will be addressed in time, it may prove to be a disincentive to nurses writing their own prescriptions when they could more easily be issued on the computer for the GP to sign. It would also appear that different standards are to be applied to nurse and doctor prescriptions – nurses will have to write everything out in full (DoH, 2002) whilst doctors may use the abbreviations in common usage. No reason is given for this discrepancy, which will make the writing of a prescription more time consuming for a nurse than a doctor. Nurses working in a community setting will also have to enter details of the consultation (not just the medication prescribed, as at present) in the GP records within 48 hours. This could prove to be onerous, and it may be that nurses would decide that is was as easy, or easier, to ask the GP to write the prescription as before, for example by requesting it by telephone.

Taking responsibility

The nurse in this situation has the ability to make a real difference to someone’s well being, both physical and psychological. However, I am personally aware that my knowledge in this area is limited, and have sought to remedy this since the consultation by reading around the subject of acne, discussing it with my GP mentor and studying closely those treatments nurses will be able to prescribe. Benner (1984) comments that the expert nurse entering a new area of practice may be reduced to the level of novice if the area is sufficiently unfamiliar. Although I did not feel deskilled to this level, I was aware of limitations in my experience with this particular condition.

Nurses from the original nurse prescribing scheme have commented that they felt vulnerable when writing their first prescriptions, despite that fact that many had previously written prescriptions for GPs to sign (Luker, 1998). I expect to experience similar feelings of anxiety when I first sign a prescription and am able, for the first time, to take full responsibility for my decision. As a profession, nursing has tended to “avoid responsibility through deference to doctors” (Wainwright, 1994). For the nurse prescriber working within her scope of practice, this will no longer be an option.

Future practice

After this very positive experience, I am more likely to take a risk in future in actively broaching more sensitive subjects with patients, though of course each situation must be judged in its individual merits. I think it is likely that my role in the management of acne, and other skin conditions, will expand. To this end I need to increase my knowledge and expertise, which I hope to do this by spending some time at the hospital dermatology clinic. It would also be beneficial to arrange a practice discussion around the management of skin conditions, and work towards a practice formulary policy on prescribing for a variety of skin conditions, an area which we may have neglected in the past. A further aspect of this would be to look at our appointment system with a view to ensuring that patients get to see the most appropriate clinician, which may well include expanding the nursing contribution in dermatology.

 

References

Beauchamp, TL and Childress, JF (1994). Principles of Biomedical Ethics (4th edition). Oxford University Press, Oxford.

BMA and RPCGB (2002). British National Formulary sections13.6.1 & 13.6.2. BMA and RPCGB, London.

Boston, M. (1997). Treating patients with acne vulgaris. Practice Nursing 8 (15); 27-29.

Buxton, PK. (1993) ABC of Dermatology (2nd edition) BMJ Publishing Group, London.

Benner, P. (1984) From Novice to Expert. Excellence and power in clinical nursing. Wesley, California.

Department of Health, (1998). The path of least resistance; A report by the standing medical advisory sub-group on antimicrobial resistance. DoH, London.

Department of Health, (2000). The NHS Plan. A plan for investment, a plan for reform. The stationery office, London.

Department of Health, (2002). Extending independent nurse prescribing within the NHS in England. The Stationery office, London.

Donoghue v Stevenson (1932) AC 562

Gibson, B (2001). Legal and professional accountability for nurse prescribing. IN: Courtney, M. (Ed). Current issues in nurse prescribing. Greenwich Medical Media.

Koo, J (1995). The psychological impact of acne: patients perceptions. American Journal of Dermatology. 32:S26-30

Kolb, DA (1984). Experiential learning London, Prentice Hall.

NMC (2002). Code of Professional Conduct, NMC, London. (awaiting publication)

Luker, K. Hogg, C. Austin, L et al (1998). Decision making: the context of nurse prescribing. Journal of Advanced nursing 27: 657-665.

Livesey, P (1996). The GP Consultation: a registrars guide. (2nd edition) Butterworth Heinmann, Oxford.

Scottish Medicines Resource Centre, (1997). Management of Acne Vulgaris. Medicines Resource 37: 143-146.

Wainright, P (1994). Professionalism and the Concept of Role Extension. In: Hunt, G and Wainright, P (Eds). Expanding the role of the nurse. Blackwell Science, Oxford.

Young, F (2002). Embarrassment. Practice Nurse 8 March 2002 43-44.