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Nurse prescribing in the field of community mental health nursing

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VOL: 96, ISSUE: 43, PAGE NO: 40

Steve Hemingway, MA, BA, RMN, is lecturer, department of mental health and learning disabilities nursing, University of Sheffield

Katherine Flowers, BSc, RMN, is community mental health nurse, assertive outreach team, Leeds Community and Mental Health Trust

The Crown report (Department of Health, 1999a) identified that the legal authority to prescribe should be extended beyond currently authorised prescribers. It was felt that nurse prescribing would:


The Crown report (Department of Health, 1999a) identified that the legal authority to prescribe should be extended beyond currently authorised prescribers. It was felt that nurse prescribing would:



- Provide a secure means of increasing the range of health professionals authorised to prescribe;



- Improve the quality and accuracy of services to service-users;



- Make better use of skills of professional staff, and therefore make a significant contribution to the modernisation of the NHS.



Recommendation three of the Crown report divided prescribers into two categories, namely independent and dependent.



Independent prescribers are responsible for the initial patient assessment and for devising the broad treatment plan, with the authority to prescribe as part of that plan.



Dependent prescribers are authorised to prescribe certain medicines for patients whose condition has been diagnosed or assessed by an independent prescriber, with an agreed assessment and treatment plan. This includes repeat prescriptions, where they have the authority to adjust the dosage according to the patient’s needs, although there should be provision for regular review by the assessing clinician.



The question arises as to whether there is a role for mental health nurses as dependent or independent prescribers?



Medication and mental health
It is generally accepted that medication is important in helping the mental health service-user manage their own care more effectively (Department of Health, 1999b; Sainsbury Centre for Mental Health, 1998). Indeed, the issues of user noncompliance with treatment is one of the major reasons for the adoption of the assertive outreach approach. The call for the extension of mental health care into a seven day, 24-hour service is also an important background issue. A crisis or psychiatric emergency does not always happen between the hours of 9am and 5pm and it is not always possible for a psychiatrist to be available after hours or at the weekend. In order to ensure medication is part of an effective programme of care for users, particularly those receiving treatment at home, some form of nurse prescribing must be necessary.



Independent versus dependent practitioner
Flowers (1998) described the role of the dependent practitioner when working in the South Leeds Intensive Home Treatment Team. By applying a clear protocol, using a therapeutic medication plan, the nurse was able to alter ranges of psychotropic dosages in consultation with the service-user. The medication was prescribed by the responsible medical officer (RMO) involved in the care of the user and then reviewed every two weeks. The medication that was monitored and altered included antidepressants, mood stabilisers, neuroleptics, sedatives and hypnotics.



The use of the medication plan enabled the community mental health nurse (CMHN) to work concordantly. Service-users presenting with problems were managed at home more successfully than without the plan. Users and their families were able to gain relevant advice from the CMHNs during a visit or by telephone to alter their medication and so decrease distress or manage the side-effects of the tablets taken. This model remains in current practice and is now being considered for further development.



We feel that the process of nurse prescribing for CMHNs needs to be debated. One way forward would be to develop CMHNs as dependent prescribers because there would be major legal implications involved in them becoming independent prescribers (Pridmore, 1998).



If there was a move towards nurse prescribing or independent practitionership for MHNs there would first have to be an exploration of the legal implications. In addition, nurses would have to adhere to strict guidance and policies.



Preece (1993) states: ‘The retrospective signing of prescriptions by a medical practitioner is unlikely to protect a nurse who has prescribed or administered and supplied a medicine inappropriately.’



Consequently, CMHNs must initially aim to become dependent prescribers.



Nurse prescribing in the USA
Nurse prescribing has been adopted in at least 35 US states (Bailey, 1999), where it is described as ‘prescriptive authority’ and efforts are being made to enact the legislation for prescriptive authority in other states (Grimaldi and Cousins, 1998). Bailey also states that prescriptive authority empowers nurses to use their training and expertise to its full potential - the educational background, practical training and clinical experience of CMHNs provides a substantial knowledge-base for clinical assessment and the monitoring of patients. Grimaldi (1998) describes the rigorous training that must be undertaken before the CMHN can gain prescriptive authority. The nurse must be educated to master’s level and operate as an advanced psychiatric nurse practitioner.



Proceed with caution
There are reasons for being cautious concerning the extension of the nurse’s role in any form of nurse prescribing. McCartney et al (1999) propose that the three primary aims behind prescribing for nurses are: saving money, offloading routine medical work, and challenging the professional monolith of medicine.



If CMHNs are to avoid being used as cheap labour or merely to plug the gap due to shortages of RMOs, there has to be serious debate before nurse prescribing can be adopted. A first step must be an extension of their role to being dependent prescribers.



McCartney et al (1999) suggest that the government may subtly be trying to decrease the power of the medical profession. Adopting nurse prescribing as dependent practitioners both extends and substantiates the nurse’s role as well as strengthening the eclectic nature of 24-hour teams.



Finally, in the USA other professions are already using prescriptive authority, for example, psychologists working in the mental illness field. Mental health nurse training includes a thorough grounding in medication issues, with guidance from the pharmacist and appropriate RMO. If CMHNs were allowed work together with clients to manage their medication then they would be able to consolidate their position within the multidisciplinary team.



We feel there is a clear case to progress towards adopting the dependent prescriber role, even though there is a need for thorough training before any initiative is undertaken. The present nurse prescribers’ formulary is limited to mainly topical medications and other less dangerous drugs. The drugs used in psychiatry have a greater degree of toxicity with associated side-effects. There has been a greater emphasis recently on the biological aspects of psychiatric disorder. Knowledge of the physiology and pharmacology of psychiatric disorders, as learned through psychosocial interventions training, allows CMHNs to help clients manage their own symptoms, so facilitating better relationships between the two.



Within mental health nursing the therapeutic relationship is considered essential to improvement in mental health and well-being. The ability of CMHNs to respond effectively and swiftly to adjustments in medication form a strong argument for them to become dependent prescribers.

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