the patient.
Knowledge of the patient
Proper prescribing of medications requires careful evaluation of the patient with consideration of the patient’s health history, medication history, and physical assessment. A complete medication history includes herbal and non‐prescription medications, prescription medications, recreational drugs, and all drug reactions. This more comprehensive approach involves assessing allergic responses, drug interactions, and family genetic propensities. Thirty‐three states, the District of Columbia, Guam, Puerto Rico, and the US Virgin Islands have legalized medical marijuana and 14 states and territories have approved adult use marijuana (National Conference of State Legislatures, 2020). It is important to know about patient use of marijuana to be able to effectively guide patients with evidence‐based information when the APRN is authorized by law (see Chapter 9).
One important but often forgotten area of assessment is the patient’s ability to manage his or her own medications. Names of drugs and the purpose of each drug may pose challenges for many patients. Assessment of the patient’s motivation, cognitive abilities, attitudes about medication management, self‐care, readiness to learn, health literacy, occupation, and educational background is essential to avoid false assumptions about the patient’s ability to follow the healthcare plan. For example, a provider may incorrectly assume that a patient who is a nurse does not require the same counseling as other patients about medication side effects. Some patients with unusual chronic problems may be more knowledgeable about their illness and medication management than the APRN. Others may be inexperienced, misinformed, and/or uninformed about the medications they use.
Knowledge of the disease and standard management
APRNs continually gain experience and knowledge of the constantly changing area of pharmacological treatment. Rational prescribing is a method of drug management that is well established in international health and has become a cornerstone for prescribing medications to avoid adverse drug events (ADEs). The World Health Organization (2002) defined the rational use of medicines as follows:
Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community.
The risk factors for ADEs are patient‐related, drug‐specific, and clinician‐specific. Older adults and children are both more vulnerable to an ADE; however, polypharmacy, the strongest risk factor for an ADE, is more common in adults. Four types of medications – antidiabetic drugs, oral anticoagulants, antiplatelet agents, and opioid pain medication – account for more than 50% of emergency department visits for ADEs in Medicare patients (Agency for Healthcare Research and Quality, 2020).
Some medications may not be appropriate for specific populations. The Beers Criteria and Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) can be used in a complementary manner to evaluate potentially inappropriate medications for adults 65 years or older (Blanco‐Reina et al., 2014). The Beers Criteria identify medications that should be avoided because they are ineffective, they pose an unnecessarily high risk, or there is a safer alternative. The criteria also identify medications that should not be prescribed when the person has specific health problems. The STOPP criteria are organized according to physiological systems and overcome some of the limitations of the Beers Criteria.
Rational prescribing also involves prescription drug costs. One way to reduce costs without compromising high‐quality care is the use of generic drugs. Brand‐name drugs are usually prescribed for patients who have a strong preference or when generics fail or are not available. Safety of brand‐name drugs can also be an issue particularly when a medication is new to the market. There is less information about potential adverse consequences that may become apparent only after years of widespread use. Box 2.1 presents some strategies for improving rational prescribing.
Many professional organizations publish clinical guidelines and standards of care that include strategies for prescribing. All APRNs, especially novice practitioners, can benefit from these and other resources. A key aspect of rational prescribing is documentation of decisions. Refer to Chapter 8 for a full discussion on the importance of documentation.
Patient education and shared decision making
One of the greatest strengths of APRNs is the ability to develop a therapeutic relationship with patients and provide education. APRNs also facilitate patient learning about pharmacological and non‐pharmacological options. Shared decision making with the patient will result in an individualized plan of care that the patient is more likely to adopt. Emphasis on “knowing the patient” and exploring their attitudes about medication use helps practitioners avoid prescribing when the patient has no intention of taking a medication. A powerful but often overlooked question is imperative: How do YOU feel about the idea of taking this medication?
Box 2.1 Strategies for improving rational prescribing
Resist prescribing for minor, self‐limiting, or non‐specific symptoms.
Avoid influences that can cloud rational decision making.
Do not accept gifts that even have the appearance of affecting your decision making.
Balance information received from the pharmaceutical industry with objective, unbiased sources.
Encourage patients to seek out non‐biased sources of information.
Use evidence‐based guidelines and electronic or current print references to assist in prescribing.
Review patient medications during each visit.
Emphasize lifestyle changes and always teach non‐pharmacological management.
Simplify and discontinue medications whenever possible.
Avoid empirical treatment.
Reduce the number of pharmacies and providers whenever possible.
Titrate medication slowly.
Monitor non‐prescription drugs and treatments.
Sources: Farrell et al., 2003; Fick et al., 2003; Fulton & Allen, 2005; McVeigh, 2001.
Only the United States and New Zealand have direct‐to‐consumer advertisement about medications with both positive and negative effects on patients (Filipova, 2019). Advertisements inform people about medications and symptoms related to certain disorders, promote information seeking, increase use of appropriate drugs when underuse is present, and improve the patient’s perception of their interactions with providers. Advertisements may also influence consumers to request unnecessary or inappropriate medications or interfere with medication adherence, all of which makes rational prescribing more difficult (DeFrank et al., 2019). APRNs, through education and counseling, can help patients understand these external influences and make an appropriate decision that reflects rational treatment choices.
Shared decision making should include
