Background:Birminghamand Solihull Mental Health NHS Trust uses the principles of supplementary prescribing to expedite access to medicines for service users with a diagnosed mental health disorder. We decided to conduct a pilot to move nurses from supplementary to independent prescribing. A stepped approach for independent prescribing was proposed, which included up to six months’ probationary period practising as a supplementary prescriber after gaining a nurse prescriber qualification, before being formally signed off as an independent prescriber.
Aim:To explore service users’ and mental health care professionals’ views of nurse independent prescribing.
Method:A total of 78 service users were surveyed across two pilot sites during the six-month study period.
Results and discussion: The survey demonstrated that the overwhelming majority of service users were satisfied with the nurse independent prescriber, and had confidence in their ability and competence.
Conclusion:The successful outcome of the evaluation indicated that the stepped approach to independent prescribing is clinically appropriate.
Keywords: Prescriber, Mental Health, Nurse Independent Prescribing
Wix, S. (2007) Independent nurse prescribing in the mental health setting. This is an extended versionof the article published in Nursing Times; 103: 44, 30-31.
Stuart Wix, MA, CPNDip, RMN, RGN, is a forensic nurse consultant, Reaside Clinic Medium Secure Unit, Birmingham, and nurse prescribing lead, Birmingham and Solihull Mental Health NHS Trust.
Nurse prescribing was first proposed in the Crown Report in 1989 (Department of Health, 1999). Early pilots, which tested limited prescribing rights, highlighted the potential for nurse prescribing to improve services, use resources more efficiently and enhance service user satisfaction (Luker et al, 1997; 1998). ‘Supplementary prescribing’ was introduced in 2003 to enhance the care and treatment of people with long-term health conditions.
Supplementary prescribers prescribe in partnership with a doctor (the ‘independent prescriber’). They are able to prescribe all medicines for the full range of medical conditions, provided that they follow the terms of a patient-specific clinical management plan. With the patient’s agreement, this is drawn up following diagnosis by the independent prescriber, and following consultation and agreement between the independent and supplementary prescriber.
New approaches to prescribing and supplying medication require close working between professionals - particularly doctors, nurses and pharmacists - and the development of robust and positive partnerships with service users (Bradley and Nolan, 2005; National Prescribing Centre et al, 2005). Supplementary prescribing is a prime example of how such flexible approaches to the delivery of care and new professional roles can contribute to quality mental health services. Since 2005, physiotherapists, chiropodists/podiatrists, optometrists and radiographers have also been able to qualify as supplementary prescribers.
In April 2006 the Department of Health set out guidance to support the implementation of nurse and pharmacist independent prescribing in the NHS inEngland(DH, 2006).Independent prescribing means that the prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required, as well as responsibility for prescribing where necessary and the appropriateness of any prescription.
Research from theUShas shown that there is no difference in clinical outcomes between service users prescribed drugs by a nurse and those prescribed them by a medical practitioner (Mahoney, 1995; Mundinger et al, 2000). More recent studies, which include other outcomes reported by nurse practitioners in the US, suggest that quality of care and patient satisfaction can increase when nurses prescribe and that nurses are skilled in combining medication with psychological therapies(Talley and Richens, 2001; Nolan et al, 2004). A limited number of studies in theUKhave surveyed the views and experiences of mental health professionals and patients regarding supplementary prescribing (Harrison, 2003; Jones et al, 2007).
Background to evaluation study
Since 2003, experienced nurse prescribers employed byBirminghamand Solihull Mental Health NHS Trust have been able to prescribe medicines in partnership with a doctor, within their sphere of practice and within the framework of supplementary prescribing. The trust recognised this significant development, which benefited service users, and decided to undertake a pilot of nurse independent prescribing within two mental health directorates over a six-month period (June-December 2006). This initiative followed the announcement by the DH of the formal extension of nurse prescribing powers from spring 2006, so that a nurse who has successfully completed a recognised non-medical prescribing course may now prescribe medicine independently of a doctor (DH, 2005).
Nurse prescribers work in a range of services across the trust, including supporting a specialist clinic for specific neurological conditions; continuing care for the treatment of enduring mental health conditions; assertive outreach teams; and primary care liaison. The current mode of practice has been to use the principles of supplementary prescribing as the most appropriate means of expediting access for service users to medicines within a mental health context. A stepped progression towards full independent prescribing was proposed for nurse prescribers. This involved them spending a probationary period of up to six months undertaking supplementary prescribing before being signed off as an independent prescriber.
Two teams from two separate services within the trust were identified as the pilot sites. One involved a CPN based within a continuing care community service with a small caseload of patients, and the other a clinical nurse specialist based within a neuropsychiatry service providing specialist sessions to an outpatient clinic.
Service users were invited to complete a questionnaire by the trust prescribing lead when they attended the clinic (see Appendix). An 18-item questionnaire, with open and closed questions and rating scales, was given out to service users.It was accompanied by a covering letter outlining the study’s aims and inviting service users to participate.It took approximately five minutes to complete.
The questionnaire was divided into two sections. The first section gathered demographic data and the second concerned service users’ subjective experience of nurses prescribing medicines (see Appendix). Open questions and comment sections aimed to elicit respondents’ experiences relating to nurse independent prescribing, giving them scope to express their views and perceptions of this new way of working.Closed questions were predominantly in the form of tick boxes intended to gain specific information that could easily be tabulated and analysed. We designed the questionnaire ourselves, as previous studies, such asHarrison’s study of 2003, have explored the views of mental health service users through focus groups (Harrison, 2003).
In addition, opinions and observations were sought from key professionals working alongside the nurse prescribers involved in the study.
Ethical approval was not sought as the study was considered to be part of an ‘in-house’ practice evaluation.
A total of 78 service users agreed to participate in the survey across the two pilot sites during the six-month study period, and approximately 10 people declined. Some 85% of respondents used the specialist outpatient clinic service, and 76% were female.
All respondents indicated that they were ‘satisfied’ or ‘very satisfied’ with treatment prescribed and monitored by the nurse prescriber. The vast majority (97%) indicated that they had confidence in the ability and competence of the nurse independent prescriber, whereas the remaining 3% were unable to decide. The majority of respondents (95%) also indicated that receiving a prescription from the nurse prescriber had improved their access to care and treatment. More than half (53%) perceived the service that they had received to be ‘better’ than the service they received from a doctor; 32% felt it was ‘somewhat better’; and 15% felt it was ‘about the same’.
Onerespondentcommented:‘My nurse saw me quickly…I like seeing her. I understand what she tells me and I don’t feel silly asking questions.’
This particular finding appears to be associated with the fact that respondents felt that they were given more time with the nurse prescriber than with a doctor, and that as a result they had more time to ask questions about their treatment. When asked how important it was for them that a doctor should retain overall responsibility for their care and treatment, there was a mixed response. Some 20% of respondents felt it was extremely important, 27% felt it was very important, 40% felt it was somewhat important and 13% felt it was not important at all. However, most indicated that they would prefer a doctor to retain overall responsibility, and this was borne out by a significant number of individuals who expressed this preference within their comments.
One respondent commented: ‘The nurse and I discussed my treatment and arranged for the next appointment to be with a doctor. I would not like a decision about change to any new treatment to be taken by a nurse, but feel that for reviewing, increasing or decreasing medication is very good.’
The results of the survey suggest that nurse prescribers provide a different type of service from that of doctors, and that service users are satisfied and comfortable with this service. See Fig 1 for graphs showing the results.
Healthcare professionals’ views
The healthcare professionals involved in the study were the two supervising consultant psychiatrists for both nurse prescribers from the respective teams and the trust head of pharmacy, who had close links with the nurse prescribers. All the healthcare professionals were invited to comment in writing on the positive and negative impacts of nurse prescribing on service users and the service itself. They were also invited to comment on areas of risk associated with the safe prescription of medicines. The formal feedback received from the professionals who were closely associated with the two nurse prescribers involved in the pilot indicated the merits of nurse prescribing from their perspective. One of the supervising psychiatrists commented: ‘The presence of increased knowledge in the team is leading to greater awareness of good practice among all practitioners.’
Someof the professionals outlined the benefits to service users and the potential benefits in the event of medical staffing shortages, when the nurse prescriber would be able to cover such shortages with a neutral cost for the organisation and no clinical disadvantage to the patient. One psychiatrist commented: ‘Recently, there was a crisis in medical staffing, which was much more easily managed because of the presence of the two nurse prescribers. Medical time is saved on a regular basis.’
Equally, those involved in the study believed it was very important that nurse prescribers should only prescribe within their sphere of practice and experience. Overall the professionals thought the practice of the two nurse prescribers involved in the study was of a high standard and conformed to national standards. The pharmacist indicated that their prescribing practice ‘was safe and appropriate’.
There were potential limitations of the study given the disproportionate number of female service users who responded to the survey. Equally the number of nurse prescribers practising within the trust remains very small in comparison with the total nursing workforce. However, where nurse prescribers have operated the anecdotal feedback from service users and clinicians alike has been very positive.
The DH (2006) has stated: ‘A wider range of professionals who can act as independent prescribers provides a wider range of skills and expertise from which to draw, to meet patient needs.’
Overall the results of this study indicate a positive response to nurse prescribers from both service users and clinicians. Service users seemed very satisfied and comfortable receiving their medication from trained nurse prescribers. Many appear to have built up a good relationship with their nurse prescriber over time, and consequently have indicated that they are more comfortable with a nurse prescribing medicines for their medical condition than their doctor. All service users who took part in the study found it more convenient to receive their medication from the nurse than the doctor, which is possibly due to them being more familiar with the nurse and a greater allocation of time for nurse consultations.
The results of this study suggest that service users who have contact with a nurse prescriber receive a different type and quality of prescribing intervention from a nurse than that which they receive from a doctor. It has provided strong evidence that nurse independent prescribing works in specific targeted services and clinical situations; that service users like this way of working; and that it is a safe way of providing medicines to patients. Additionally, the study has indicated that this new way of working should not be considered to be ‘instead of’ traditional medical prescribing, but in addition to medical prescribing.
There are opportunities for organisations to review services where nurse prescribers are present, which could free up clinical sessions for medical staff, where they can focus on more complex cases. It is also important that all nurse prescribers receive regular clinical supervision from their medical colleagues. This study confirmed that implementation of nurse independent prescribing across the trust in specific key areas is both safe and appropriate.
The successful outcome from the evaluation of the pilot indicated that it is clinically appropriate to havea probationary period of up to six months’ supplementary prescribing for nurse prescribers before they are allowed to undertake independent prescribing.
The stepped approach that had been proposed was implemented and forms part of revised policy and guidance on nurse prescribing.
Service users have indicated quite strongly their overall satisfaction with and confidence in an appropriately trained and experienced nurse independently prescribing treatment for their mental health disorder. Nurse prescribers within a mental health setting have demonstrated that their practice is both safe and appropriate because they are prescribing within their sphere of practice and with a robust support mechanism in place.
Independent nurse prescribing pilot
Date of completion / / 06
Service user experience
The patient should complete the following questionnaire where the principles of independent nurse prescribing have been applied. It will not be possible to identify you individually from the questionnaire. However, information obtained from this questionnaire will assist the trust to evaluate the effectiveness of non-medical prescribing, and how access to care and treatment can be further improved for service users.
Information about you.
How old are you?Years
What is your ethnic origin?
White otherplease specify below
Mixed – White and BlackCaribbean
Mixed – White and Black African
Mixed – White and Asian
Mixed otherplease specify below
Asian/Asian British – Indian
Asian/Asian British – Pakistani
Asian/Asian British – Bangladeshi
Asian/Asian British – otherplease specify below
Black/Black British –Caribbean
Black/Black British – African
Black/Black British – otherplease specify below
Where do you live?
2. Family Home
3. Bed and Breakfast
4. OtherSpecify. ……………………………
Was the appointment convenient to you in terms of day and time?
Was the appointment convenient in terms of where you had to go for theappointment?
Did you have the opportunity to rearrange the appointment if it was not convenient?
What treatment did the nurse prescribe for you?
Do not write in this margin
Do not write in this margin
Q1.Please indicate which team have been responsible for your care(Tick one only)
1. Neuropsychiatry team
2. Continuing care team
3. Drug and alcohol teamSpecify ……………….. …….
Q2.Please indicate whether your consent was obtained with regard to anurse prescribing treatment for you.
1. Consent was obtained
2. Unsure/ Don’t know
3. Consent was not obtained
Q3.How much time did the nurse prescriber in comparison to a doctor when discussing medication issues spend with you?
1. More time
2. About the same
3. Less time
Q4.How well do you understand the principle of independent nurse prescribing?
1. Very well
3. Not that well
4. Not at all
Q5.Are you satisfied with the treatment that has been prescribed and monitored bythe nurse prescriber?
1. Very satisfied
4. Very dissatisfied
Q6.Do you agree having contact with a mental health nurse who can prescribe medicines has improved your access to care and treatment?
1. Strongly agree
5. Strongly disagree
Q7.How would you describe the service provided by the nurse prescriber in comparison to that service provided by a doctor?
2. Somewhat better
3. About the same
4. Somewhat worse
Q8.How would you rate the quality of information provided by the nurse prescriber in relation to side effects of medication?
1. Very good
3. Neither poor or good
5. Very Poor
Q9.How confident have you felt with regard to the competency and ability of themental health nurse to prescribe treatment for you?
1. Very Confident
3. Cannot decide
4. Not confident
Q10.How important is it to you that a doctor remains overall responsible for your psychiatric treatment?
1. Extremely important
2. Very important
3. Somewhat important
4. Not at all important
Q11.Are there any other comments that you would like to make in relation to your experience ofindependent nurse prescribing?
Thank you for taking the time to fill in this questionnaire.
Do not write in this margin
Bradley, E., Nolan, P. (2005) Non-medical prescribing and mental health nurses: prominent issues. Mental Health Practice; 8: 5, 16-19.
Department of Health (2006) A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. www.dh.gov.uk
Department of Health (2005) Nurse and pharmacist prescribing powers extended. www.dh.gov.ukwww.dh.gov.uk/en/Publicationsandstatistics/Pressreleases/DH_4122999
Department of Health (1999) Review of the Prescribing, Supply and Administration of Medicines (2nd Crown Report). London: DH.
Harrison, A. (2003) Mental health service users’ views of nurse prescribing. Nurse Prescribing; 1: 2, 78-85.
Jones, M. et al (2007) Mental health nurse supplementary prescribing: experiences of mental health nurses, psychiatrists and patients. Journal of Advanced Nursing; 59: 5, 488-496.
Luker, K. et al (1997) Evaluation of Nurse Prescribing - Final Report. University of Liverpool and University of York.
Luker, K. et al (1998) Nurse-patient relationships: the context of nurse prescribing. Journal of Advanced Nursing; 27: 235-242.
Mahoney, D.F. (1995) Appropriateness of geriatric prescribing decisions made by nurse practitioners. Image Journal of Nursing Scholarship; 26: 1, 41-46.
Mundinger, M.O. et al (2000) Primary care outcomes in patients treated by nurse practitioners or physicians: a randomised trial. Journal of the American Medical Association; 283: 1, 59-68.
National Prescribing Centre et al (2005) Improving Mental Health Services by Extending the Role of Nurses in Prescribing and Supplying Medication: Good Practice Guide. Produced jointly by National Prescribing Centre, the National Institute for Mental Health in England and the Department of Health. www.dh.gov.uk
Nolan, P. et al (2004) Nurse prescribing: the experiences of psychiatric nurses in the United States. Nursing Standard; 10: 18, 33-38.
Talley, S., Richens, S. (2001) Prescribing practices of advanced psychiatric nurses: Part 1 - demographic, educational, and practice characteristics. Archives of Psychiatric Nursing; 15: 5, 205-213.