• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Supplementary Prescribing in Mental Health and Learning Disabilities

Posted on: Saturday, 23 April 2005, 03:00 CDT

Summary

Nurse prescribing in mental health and learning disability services is a new development. The experiences of nine nurses working in mental health and learning disabilities, who formed part of the first cohort in the UK to undertake the supplementary nurse prescribing course, are described. Experiences of the course and implementation of supplementary prescribing in practice are discussed. The attitudes of nurses, other health professionals and patients to nurse prescribing are also explored.

Keywords

Learning disabilities; Mental health; Prescribing

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit the online archive at www.nursing-standard.co.uk and search using the keywords.

DISCUSSION OF nurse prescribing in the UK began almost two decades ago. The publication of the document Neighbourhood Nursing: A Focus for Care was the first indication that nurse prescribing was being taken seriously with the suggestion that, if community nurses were able to prescribe from a limited formulary, patient care would be improved and resources would be used more effectively ( Department of Health and Social Security 1986). This was followed by the Review of Prescribing, Supply and Administration of Medicines (Department of Health (DH) 1999) and proposals for nurse prescribing (Medicines Control Agency (MCA) 2002), which stated that the government intended to permit supplementary prescribing thus enabling nurses to prescribe for, and manage, more complex medical conditions following an initial assessment by medical staff. These included chronic diseases such as asthma, diabetes, coronary heart disease and mental health problems.

Supplementary prescribers can prescribe any medication that is listed in the British National Formulary (BNF 2003), identified on a clinical management plan, and within their scope of practice. Supplementary prescribing legally allows nurses to prescribe from a wider range of medication applicable to specialist fields of mental health and learning disability than that available within the formulary of independent nurse prescribing. The process of supplementary prescribing is based on clearly documented limitations set out in the clinical management plan, which is drawn up with the agreement of the individual patient and in consultation with an independent prescriber who must be a doctor or a dentist. These plans must be signed by both the doctor and the nurse.

Independent nurse prescribers are able to prescribe nearly 180 prescription-only medicines for about 80 medical conditions from the nurse prescribers' extended formulary. They may prescribe all general sales list and pharmacy medicines currently prescribable by GPs, together with specified prescription-only medicines.

The South Staffordshire experience

The South Staffordshire NHS trust serves a population of approximately 600,000 and it covers about 700 square miles. The trust has a long-term vision of supporting strategies to improve patients' experience of prescribing and taking medication, which includes supplementary prescribing.

Nine nurses from the trust were supported by the trust to attend the supplementary nurse prescribing course that began in January 2003. Of these nine, three were learning disability nurses, five were mental health and one was a paediatric nurse. There were some initial anxieties as this was the first cohort in the UK to undertake the supplementary prescribing course.

One of the early concerns expressed by course members was how their practice would be implemented within the four primary care trusts (PCTs) that the trust served. They wanted the PCTs to embrace nurse prescribing and develop the necessary policies, guidelines and communication channels to support the process. They were aware that service level agreements would be required to enable nurse prescribing practice across the health economy but they were unsure how this might restrict their clinical practice in delivering prescribing interventions. For example, restrictions could involve the formularies used by the trust and the PCTs, and GPs' prescribing incentives.

Training and education

The nurse prescribing course was delivered at Staffordshire University. Course members were required to attend 26 university- based taught days and undertake 90 hours of supervised clinical prescribing practice, of which at least 45 hours was with the respective prescribing mentor, a doctor. The university offered an information day to mentors and supplemented this with support data, including a CD-ROM and guidance notes on the expectations of the mentor. Experiences with mentors varied despite the fact that they all received the same data. Three of the nurses had the same mentor, which was beneficial in terms of peer support. Learning was shared and debated outside the scheduled tutorial time, and expertise and different prescribing practices were explored independently. However, individual time with the mentor was limited. Another two nurses who had the same mentor found this a valuable experience. The nurses had set tutorials once a week which were taught by the mentor. During these sessions the nurses gave feedback to the mentor and each other on the homework they had been given the previous week. One mentor left halfway through the course so the nurse had to find another mentor. However, this was a positive experience because the nurse gained a different perspective on prescribing.

The remaining supervised clinical prescribing practice was spent with clinicians in specialist areas, chosen by the course members. This enriched the nurses' experiences in their own clinical areas. The experiences varied depending on the identified learning needs, and included spending time with extended formulary nurse prescribers, pharmacy advisers and specialist centres in neuropsychiatry, contraceptive and sexual health clinics and nurses working with asylum seekers. The nurses on the course identified their own learning needs but, because it is difficult to anticipate what these will be in practice, a directory of learning opportunities specific to nurse prescribing, and information on individual practitioners who were available, willing and understood supplementary prescribing would have been helpful.

Course members had to develop a 5,000 word professional prescribing portfolio. This provided a reflective account and evidence to support how they had developed their prescribing practice. Assessment of knowledge and skills was achieved by producing evidence from three action-learning sets for the portfolio. Action-learning sets are group activities during which skills and knowledge are shared. It also included a short answer exam, a two-hour written paper, completion of a competency framework and an objective structured clinical examination (OSCE), a practical examination undertaken in formal conditions.

Although there was no criterion to have advanced assessment skills before starting the course, there was an assumption by the university that participants would have these skills in relation to their area of practice. However, in terms of the independent prescribing role, the specialist nurses felt at a disadvantage. Independent prescribing allows nurses to assess and prescribe for specified medical conditions, yet mental health nurses do not have assessment skills or up-to-date knowledge of physical health. Independent and supplementary prescribing is a relatively new concept in mental health and learning disabilities nursing, and it was difficult for nurses and tutors to know what to expect from the course. Although the course was generic to meet the needs of wider professional groups, at the start members felt that they may have gained greater benefit from working with their professional nursing group, rather than other branches of nursing. This was actively discouraged by the tutors and, on reflection, course members felt that their skills and knowledge in independent prescribing benefited from networking with others from a wide variety of backgrounds and practice. There was a shift in thinking during the course and, rather than focusing solely on prescribing, the members considered the broader aspects of care for their patient group.

Having completed the course, members felt that preparation and training for the role of prescribing are essential. They are more aware of the need to regularly update their knowledge and skills in prescribing, products and legislation, as well as the need for further education in neuropharmacology, which was identified as a deficit in the course content for mental health and learning disabilities nurses. The nurse prescribers were invited to attend training sessions with junior doctors, and believe that this not only enables knowledge and skills to be updated, but also allows the questioning of practice and provision of peer support. This approach is supported by Basford (2003 ) who argues that maintaining prescribing competence is not solely the responsibility of the individual, but relies on partnership arrangements with the employing organisation and others such as educational institutions, GPs and the pharmaceutical industry. Basford (2003 ) suggests that the solution to the problem of maintaining com\petency in prescribing should be a 'rich repertoire of behaviours that complement each other'.

Nurses must remain aware of their duty of care towards individual patients, which can be interpreted as being suitably trained and competent, with preparation programmes that equip them to practise safely (Picton and Granby 2002). Competencies in nurse prescribing were outlined in the document Maintaining Competency in Prescribing (National Prescribing Centre 2001). All nurses receive a copy of this document before qualifying as a nurse prescriber. This is useful not only as a developmental tool, but also as a reflective tool to ensure prescribing competence is maintained. Picton and Granby (2002) suggest that the tool could also be used to identify individual learning needs, which could then be used to inform the planning and commissioning of appropriate needs-led continuing professional development programmes.

Having completed the course, the nurses involved found that writing the first prescription was daunting because of fear of adverse reactions and the responsibility involved. The perception before the course was that nurse prescribers would be writing numerous prescriptions for patients but this has not been the reality. In practice we occasionally write a prescription and believe that this is testament to the fact that prescribing is only one aspect of providing holistic patient-centred care.

Attitudes of patients to nurse prescribing

Nurse prescribing appears to have been accepted by the nurse prescribers' respective patient groups. During informal feedback, patients reported positive experiences with nurse prescribers. Comments from patients included: 'It was beneficial to see the nurse after delivery of my baby as I would have had to wait seven days to see the consultant psychiatrist to restart my treatment. This helped prevent relapse.'

'I prefer to see the nurse prescriber as it provides a more timely service and I don't lose money from having to take time off work. I can see the nurse when I need to instead of having to wait for a set outpatient appointment.'

The nurse preservers' experience to date has been in direct contrast to the results of a study by Harrison (2003), which explores the views of people with mental health problems in relation to nurse prescribing. The participants in this study were sceptical about the political and professional imperatives associated with nurse prescribing, although they acknowledged some benefits for patients (Harrison 2003).

Although most of the available literature relates to patients' views on independent nurse prescribing, the nurse preservers' experiences are supported by findings from various studies, which identify that nurses do not use much jargon (Brooks et al 2001, Luker et al 1997, While and Rees 1993). Patients are actively involved in the clinical management plan and have to agree to the nurse prescriber having a more significant role in their care. This enables them to gain more control over their medicines, and increases the likelihood of concordance. With this in mind, medicines should only be prescribed when necessary, and the benefits considered in relation to the risks involved. The patient should also be advised on how to distinguish the side effects of medication (BNF 2003).

More information is available to patients in the form of the clinical management plan, and unpleasant side effects can be reported to the nurse prescriber and acted on more quickly, which helps patients to gain confidence in the nurse prescriber and their medication. It was with interest that one nurse prescriber reported: One lady was prescribed antidepressants by her GP but wouldn't take them until she had spoken to her nurse prescriber, as she felt the nurse had more expertise in mental health.'

Ethical considerations for practice

To practise effectively as nurse prescribers, the ethical issues arising from practice need to be considered. The four ethical domains identified by Beauchamp and Childress (1989) include autonomy, beneficence, non-maleficence and justice, and form the principles of biomedical ethics, which underpin practice and uphold the principles of clinical governance (National Health Service Executive 1999). In mental health and learning disabilities nursing, issues arise in gaining consent to treatment from people with intellectual and cognitive deficits, to ensure their rights are upheld (DH 2001, Nursing and Midwifery Council (NMC) 2002). There is an imperative for consensus decisionmaking in the 'best interests' of the patient (Gillon 1997).

Anecdotally, within south Staffordshire supplementary nurse prescribing appears to be acceptable to patients and carers, and to mental health and learning disabilities nurses in terms of the benefits to patients through preparation and training for the role, and timely interventions in medicines management.

Attitudes to nurse prescribing

Medical staff In 2002, Professor David Haslam, chairman of the Royal College of General Practitioners, stated that he was in favour of supplementary prescribing and, with the right safeguards in place, it would benefit nurses, doctors and patients, saving time and increasing teamwork, skill mix and efficiency (DH 2002). The nurse prescribers' experience supports this view as medical prescribing mentors were supportive of supplementary nurse prescribing and appeared to gain a better understanding of the nurse's role. As independent prescribers, the preparation that medical staff were required to undertake for nurses to become supplementary prescribers assisted them in understanding the concept of the clinical management plan and the scope of professional practice.

This is in contrast to the development of nurse prescribing in some US states, where it took nurses 30 years to gain legislation for prescriptive authority (Plonczynski et al 2003). Hales (2002) states that many physicians in the US had difficulty in accepting nurse prescribing. This is surprising given that American nurses are educated to masters level, whereas the requirement in the UK is that preparation for nurse prescribing is degree level (level 3).

Pharmacists In the authors' experience, nurse prescribing has received a mixed reception from some pharmacists who have expressed reservations about the skills and competencies of nurse prescribers, and appear to underestimate the level of knowledge and skills of nurses in their area of professional practice. This view is supported by Cooper et al (2000) who identify that it represents a professional defence against the prominence of nurses in prescribing discussions, and the potential threat of the marginalisation of the pharmacist role. Other pharmacists, however, have actively encouraged and supported nurses in this new prescribing role.

Nurses Nolan et al (2001) examined the attitudes of mental health nurses to nurse prescribing and suggested that enthusiasm for nurse prescribing was not in short supply. However, the knowledge and skills to make independent decisions were lacking.

In a later study conducted within South Staffordshire Healthcare NHS Trust, skills and knowledge deficits were also identified, alongside a lack of understanding and awareness of how supplementary prescribing would affect teams (Hay et al 2002). However, the considered benefits outweighed the concerns, and one of the conclusions was that some nurses are as good as medical staff at diagnosing, prescribing and promoting recovery. In some instances they are better.

Benefits

Supplementary prescribing has enabled the course members to work in partnership with medical practitioners. This closer working relationship is less time consuming and improves efficacy. Nurses generally spend more time with patients than doctors do and have the skills to promote health education, resulting in improved concordance with medication. Thomas (2003) suggests that, although this may appear to be a return to the 'medical model' of care, supplementary prescribing can enhance patients' experience in the social context, with less emphasis on the demand for medical services and more emphasis at the point of delivery of care, for example, in the home, in a timely, accessible way.

Complexities

Continuing education programmes in relation to updating prescribing practice have been maintained through regular peer group supervision and training sessions. Further training in neuropharmacology has been commissioned through the university to meet ongoing educational needs.

The course content focused on independent nurse prescribing which was considered to be outside the nurse prescribers' scope of practice and may therefore increase the marginalisation of respective patient groups within learning disabilities and mental health.

Another potential complexity is that some consultant psychiatrists working in mental health and learning disabilities often do not write prescriptions during the consultation unless there is a 'shared care' agreement. Generally, they write to the GP advising him or her of the medication to be prescribed, or requesting changes to the patient's medication regimen. However, this can result in patients waiting many weeks for new medication to be started, creating difficulties in managing their care and treatment, and potentially leading to greater patient distress. Nurse prescribes may make recommendations rather than write prescriptions and the effect of this is yet to be evaluated.

Communication barriers in relation to consent to treatment for people with learning disabilities and those with acute mental health needs have to be taken into consideration when developing clinical management plans. This will prove to be one of the most challenging areas of prescribing practice.

Conclusion

The authors' experiences in South Staffordshire have shown that the issues are similar for nurses working in mental health and learning disabilities. Increasing emphasis on integrat\ed team working and defining specific contributions to meet care delivery, mean that nurses from all specialties, and pharmacists, are redefining their role in terms of nonmedical prescribing (MCA 2002). The challenge is for medical staff and others to think about where their skills can be maximised, and perhaps redefine their prescribing practice to encompass the changing needs of the workforce in meeting the current and future needs of patients and carers within a modernised NHS.

It is imperative to have policies and systems in place before embarking on a supplementary nurse prescribing course because some of the initial issues, such as accessing prescription pads, service level agreements with the PCT and policies not being developed and ratified could have been addressed. This would have assisted in improving prescribing practice, enabled it to take place directly after registration with the NMC, and ensured that patients had access to a service that was accessible and timely

Allsop A, Brooks L, Bufton L et al (2005) Supplementary prescribing in mental health and learning disabilities. Nursing Standard. 19, 30, 54-58. Date of acceptance: November 15 2004.

References

Basford L (2003) Maintaining competence in nurse prescribing: experiences and challenges. Nurse Prescribing. 1, 1, 40-45.

Beauchamp T, Childress J (1989) Principles of Biomedical Ethics. Third edition. Oxford University Press, Oxford.

British National Formulary (2003) British National Formulary No. 46. British Medical Association and The Royal Pharmaceutical Society of Great Britain, London.

Brooks N, Otway C, Rashid C, Kilty E, Maggs C (2001) The patient's view: the benefits and limitations of nurse prescribing. British Journal of Community Nursing. 6, 7, 342-348.

Cooper N, Blackwell D, Taylor G, Holden K (2000) Pharmacists' perceptions of nurse prescribing of emergency contraception. British Journal of Community Nursing. 5, 3, 126-131.

Department of Health (1999) Review of Prescribing, Supply and Administration of Medicines. The Stationery Office, London.

Department of Health (2001) Reference Guide to Consent for Examination or Treatment. The Stationery Office, London.

Department of Health (2002) Pharmacists to Prescribe for the First Time, Nurses will Prescribe for Chronic Illness. Press release 2002/0488. The Stationery Office, London.

Department of Health and Social Security (1986) Neighbourhood Nursing: A Focus for Care. HMSO, London.

Gillon R (1997) Philosophical Medical Ethics. Wiley, Chicliester.

Hales A (2002) Perspectives on prescribing: pioneers' narratives and advice. Perspectives in Psychiatric Care. 38, 3, 79-88.

Harrison A (2003) Mental health service users' views of nurse prescribing. Nurse Prescribing. 1, 2, 78-85.

Hay A, Bradley E, Nolan P (2002) Supplementary nurse prescribing. Nursing Standard. 18, 41, 33-39.

Luker KA, Austin L, Hogg C (1997) Evaluation of Nurse Prescribing: Final Report and Executive Summary. University of Liverpool, Liverpool.

Medicines Control Agency (2002) Proposals for Supplementary Prescribing by Nurses and Pharmacists and Proposed Amendments to the Prescription Only Medicines (Human Use) Order 2997 MLX 284. The Stationery Office, London.

National Health Service Executive (1999) Clinical Governance and Quality in the NHS. NHSE, Leeds.

National Prescribing Centre (2001) Maintaining Competency in Prescribing: An Outline Framework to Help Nurse Prescribes. NPC, Liverpool.

Nolan P, Haque MS, Badger F, Dyke R, Khan I (2001) Mental health nurses' perceptions of nurse prescribing. Journal of Advanced Nursing. 36, 4, 527-534.

Nursing and Midwifery Council (2002) Code of Professional Conduct. NMC, London.

Picton C, Granby T (2002) Maintaining and developing competencies in nurse prescribing. British Journal of Community Nursing. 7, 2, 90- 93.

Plonczynski D, Oldenburg N, Buck M (2003) The past, present and future of nurse prescribing in the United States. Nurse Prescribing. 1, 4, 170-174.

Thomas C (2003) The nurse consultant and clinical governance. In Jukes M, Bollard M (Eds) Contemporary Issues in Learning Disabilities Practice. Dinton, Quay Books. 276-288.

While A, Rees K (1993) The knowledge base of health visitors and district nurses regarding products in the proposed formulary for nurse prescription. Journal of Advanced Nursing. 18, 10, 1573-1577.

Authors

Anne Allsop is team leader, health and social care mental health team, St George's Hospital; Leslie Brooks is senior lead for severe and enduring mental health, Castle Integrated Mental Health Team, Tamworth; Lynn Bufton is community mental health nurse, Stone Community Mental Health Team, Stone; Caroline Carr is clinical nurse specialist, St George's Hospital; Yvonne Courtney is clinical co- ordinator community teams, St Michael's Hospital, Lichfield; Christopher Dale is community nurse manager, New Burton House, Stafford; Susan Pittard is community mental health nurse, St George's Hospital; and Caron Thomas is nurse consultant, St George's Hospital, Stafford. Email; anne.allsop@ssh-tr.nhs.uk

Copyright RCN Publishing Company Ltd. Apr 6-Apr 12, 2005

Source: Nursing Standard

More News in this Category