This article describes the development of a nurse’s role in a memory clinic that resulted in a change from the nurse working as the doctors’ assistant to an autonomous practitioner. It reports on a baseline audit of the nurses supplementary prescribing practice which shows that most patients now receive their prescriptions more quickly.
Higgins, P. (2008) Using supplementary nurse prescribing in a memory clinic. This is an extended version of the article published in Nursing Times; 104: 31; 30-31.
Patricia Higgins, MSc, PG Cert in supplementary and independent prescribing, RMN, is memory service nurse, Bromley Memory Service, Bridgeways Day Hospital, Bromley, Kent
Memory services are recommended as the single point of referral for all suspected cases of dementia (NICE and Social Care Institute for Excellence, 2006) and early diagnosis and intervention is one of the main aims proposed in the new dementia strategy consultation from the DH (2008).
Memory clinics have been in existence in the UK since the late 1980s and have grown in number since the NICE guidelines (2001) recommended cholinesterase inhibitors as a treatment for Alzheimer’s disease.
Patients with Alzheimer’s disease have a deficit of the neurotransmitter acetylcholine in the brain. The three cholinesterase inhibitors donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl) all work in a similar way to prevent the enzyme acetyl cholinesterase from breaking down acetylcholine in the brain. The aim of the treatment is to temporarily improve or stabilise symptoms of Alzheimer’s disease.
Patients attending memory services should have access to brain scanning and blood tests to rule out other reversible causes for their problem or to confirm a diagnosis of dementia. Treatment should be prescribed for patients with Alzheimer’s disease in accordance with NICE guidelines (2007) and they should be followed up by a specialist in the care of people with dementia.
Background to the development
The Bromley memory service is part of Oxleas NHS Foundation Trust in south-east London, which provides mental health and learning disability services for people living in the boroughs of Bexley, Bromley and Greenwich, and specialist services to people living in Lewisham. It was set up in 2002 and there are nearly 600 people on the memory service caseload. The majority of patients under the care of the memory service are prescribed cholinesterase inhibitors. The service has four consultants in old-age psychiatry and each has their own memory clinic.
Patients attend the clinic for an initial assessment of their memory problem and those with Alzheimer’s disease are assessed to see if they are suitable for cholinesterase inhibitors. Patients who are suitable are initially prescribed a month of cholinesterase inhibitors and are followed up in clinic. Sometimes a patient cannot tolerate one of the cholinesterase inhibitors so they are tried on a different one. It can take several months before they are stabilised on an appropriate medication.
The clinic has a shared care protocol with local GPs. Treatment with cholinesterase inhibitors is commenced in the clinic and titrated to the appropriate dose and then prescribing is handed over to the GP. The GP takes over the care when the patient is stabilised on their medication but they continue to be reviewed in the memory clinic every six months.
Limitations of the clinic nurse’s role
The nurse’s role in the clinic was initially established as a doctors’ assistant who saw patients briefly before their appointment with the consultant and completed the Mini Mental State Examination (Folstein et al, 1975) with them.
The nurse did not have time with the patient or their carer to answer questions about their care and treatment.
I started working at the clinic in 2005 and, as a nurse with extensive experience in dementia care, I felt frustrated that I was not able to use my skills and expertise to the full.
I analysed the patients’ experience at the clinic and the way the clinic was run to see if there were any changes I could make to improve services for patients and carers and also increase my job satisfaction. I was aware that other memory clinics had nurse-led services and I was keen to develop my role in this way.
In each of the consultant clinics there was an appointment stream for the consultant and another for their registrar. I proposed adding an additional stream to the clinic for patients to be reviewed by a nurse. I approached one of the consultants with a view to conducting a trial of an additional nurse-led stream in his clinic. This would automatically increase the capacity of the clinic by 50%, enabling more patients to be seen.
Most of the new referrals to the older people’s community mental health teams are for people with memory problems. The clinics were often full, making it hard to find slots for urgent appointments.
I suggested that I could see new patients for their initial assessment as there were pressures to meet waiting list targets. Nurse-led clinics have been used in a number of specialities to reduce waiting times for patients and free up other team members (Bradley and Nolan, 2007).
The consultants agreed with my plan and the nurse-led clinic stream was set up initially with one consultant. Within two months I had extended this service to all four consultants’ clinics, covering the whole of the memory service in Bromley.
Extending the role of the nurse through supplementary prescribing
Despite the introduction of a nurse-led clinic stream, there was an ongoing problem with the supply of repeat prescriptions or prescriptions for new doses of cholinesterase inhibitors that were required between clinic appointments.
Patients or their carers had to telephone the clinic when they required a repeat prescription. The prescription may need to be changed depending upon the patient’s response to treatment or any side-effects that they may have experienced. My office is in the building where the clinics are held but only one of the consultants is also based here. This meant that it could be up to a week before the correct doctor was available to write the prescription. This led to unnecessary delays for patients or time spent contacting the appropriate consultant if a patient’s request was urgent.
Patients attending my clinic also experienced delays if they required a prescription as I had to liaise with a consultant about their treatment.
Barlow (2008) suggests that in the memory clinic the focus is on very specific treatment and this approach is suited to supplementary prescribing. Nurses in memory clinics prescribe only a very limited number of drugs and this enables them to acquire an in-depth knowledge of these treatments (Smith and Hemmingway, 2005). This supports the DH (2005a) view that supplementary prescribing can be beneficial in settings where nurses already have expertise.
It is suggested that non-medical prescribing in the memory clinic can help the nurse to develop their specialist role (Smith and Hemmingway, 2005). Grant et al (2007) interviewed staff at a memory clinic where non-medical prescribing had been introduced and described how it was viewed as a natural development of the nurse’s role in this setting. I felt that training to be a non-medical prescriber would improve my patients’ access to treatment.
Using supplementary prescribing in practice
I undertook a course in supplementary and independent prescribing at the University of Greenwich and have undertaken the role of supplementary prescriber for over a year.
Supplementary prescribing is defined by the DH (2005a) as: ‘A voluntary partnership between the responsible independent prescriber and a supplementary prescriber, to implement an agreed service user specific clinical management plan, with the patient’s agreement’.
I meet the consultants after each clinic to discuss new patients who have been prescribed cholinesterase inhibitors. I follow up these patients in my clinic during the titration phase of their treatment with cholinesterase inhibitors. When I have assessed patients in my clinic stream, I can respond to their telephone calls for repeat prescriptions and prescribe in accordance with their clinical management plan. This is reassuring for service users and carers who are often worried about how they will get their prescription.
I explain to patients and their carers that I will contact the consultant if I have any concerns regarding their medication. Good communication between the supplementary and independent prescriber is an essential aspect of supplementary prescribing. Page et al (2007) report that both patients and carers assumed the consultant would step in if any complication occurred with treatment and were reassured by this.
I also provide patients and the carers with my contact number in case they have any question or concerns after their appointment. This is well received and carers report feeling reassured that there is someone they can telephone between appointments. There is research evidence to support this practice (Page et al, 2007).
Audit of prescribing practice
After the first nine months of prescribing, a baseline audit was carried out to identify patterns of non-medical prescribing and set a baseline for future clinical audit. The audit aimed to find out what impact nurse prescribing had made on the service.
I wanted to identify if patients who phoned for a new prescription received it earlier as a result of my prescribing role. This was calculated by counting from the date the prescription was written to the date their consultant would have been available in the clinic to deal with the request. The details of each prescription had been recorded in accordance with the trust’s non-medical prescribing policy (Oxleas NHS Trust, 2005).
I wrote 113 prescriptions in the first nine months of the nurse clinic stream donepezil (Aricept) was the most frequently prescribed drug, accounting for 81 (72%) of all prescriptions. It is the most frequently prescribed drug in the memory clinics locally and nationally (Prescribing Observatory for Mental Health, 2007).
The main reason for prescribing was titration and accounted for 87 (77%) prescriptions.
The audit looked at whether patients received their prescriptions earlier as a result of a nurse being able to write it. Out of 113, 18 (16%) patients were seen in clinic and received the prescription at their appointment (Table 1). Twelve (11%) received it six days earlier and nine (8%) five days earlier. Before the introduction of supplementary prescribing, a consultant had to become involved in prescribing their treatment, which resulted in a delay in prescribing drugs.
The most important finding of the audit was that 92 patients (81%) who contacted the nurse for their prescription received it earlier because the nurse was able to prescribe.
Table 1. Number of days earlier that patients received their prescription
|Number of days||0||1||2||3||4||5||6||Seen in clinic|
The NHS plan (DH, 2000) set out new ways of working to enhance service users’ care by providing quicker and more efficient access to healthcare. This is achieved through an increased flexible use of nurses’ skills and non-medical prescribing in the memory service is an example of this.
Barlow (2008) reported that non-medical prescribing resulted in quicker access to treatment. Non-medical prescribing has enabled nurses to avoid delays in patients accessing their medication which were caused by obstacles in the healthcare system (Bradley and Nolan, 2007). Grant et al (2007) found that in a memory clinic nurse prescribing resulted in an improvement in the way they worked particularly for service users who had improved access to treatment.
Gibson et al (2003), describing non-medical prescribing in paediatric settings, noted that in nurse-led clinics, nurses often see patients with whom they have established relationships over time and that this helps provide more complete care. The same is true in a memory clinic setting, as we can follow up patients over several years. I have developed relationships with my patients and their carers and this has enhanced the care they receive. Bradley and Nolan (2006) suggested that nurse prescribing improves patient care and I am aware that having this additional skill has enabled me to complete the patient’s episode of care.
None of my patients or their carers have expressed any concerns about a nurse prescribing. Page et al (2007), in their study of a memory clinic, found that all the service users and carers that they interviewed had trust in the competence of the nurse prescriber. This is supported by several authors who also report that nurse prescribing has been well received by patients (Latter and Courtenay, 2004; Luker et al, 1998).
As a result of the changes in my role at the clinic, I now work in a more autonomous way. This has resulted in increased job satisfaction as I have developed new skills and self-confidence as a practitioner. Bradley and Nolan (2006), in interviews with trainee non-medical prescribers, reported that non-medical prescribing enhanced their development as autonomous professionals. Nurses working in memory clinic settings who are non-medical prescribers also report this effect (Smith and Hemmingway, 2005).
The main recommendation from the audit is to extend the nurses prescribing role to independent prescribing. After gaining experience in supplementary prescribing I now feel confident about moving on to independent prescribing. My trust is in the process of developing a protocol to support independent nurse prescribing.
The introduction of nurse prescribing in the memory clinics at Bromley has resulted in a more responsive service. Most patients receive their prescriptions when they request them and without delay. Running a clinic stream and taking on the supplementary prescribing role has helped to develop my role from doctors’ assistant into an autonomous practitioner.
Barlow, M. (2008) Nurse prescribing in an Alzheimer’s disease service: a reflective account. Mental Health Practice; 11: 7, 32-35.
Bradley, E., Nolan, P. (2006) Addressing the concerns of the trainee nurse prescriber. Nursing Times; 102: 11, 34-38.
Bradley, E., Nolan, P. (2007) Impact of nurse prescribing: a qualitative study. Journal of Advanced Nursing; 59: 2, 120-128.
Department of Health (2008) Transforming the Quality of Dementia Care. Consultation on a National Dementia Strategy. www.dh.gov.uk
Department of Health (2006) From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. www.dh.gov.uk
Department of Health (2005a) Improving Mental Health Services by Extending the Role of Nurses in Prescribing and Supplying Medication: Good Practice Guide. www.npc.co.uk
Department of Health (2005b) Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England. A Guide for Implementation. www.dh.gov.uk
Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. London: DH.
Folstein, M. et al (1975) Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research; 12:3, 189–198.
Grant, G. et al (2007) Introducing nurse prescribing in a memory clinic: staff experiences. Mental Health Nursing; 27: 1, 9-13.
Gibson, F. et al (2003) Nurse prescribing: children’s nurses’ views. Pediatric Nursing; 15: 1, 20-24.
Latter, S., Courtenay, M. (2004) Effectiveness of nurse prescribing: a review of the literature. Journal of Clinical Nursing; 13: 1, 26-32.
Luker, K. et al (1998) Nurse patient-relationships: the context of nurse prescribing. Journal of Advanced Nursing; 28: 2, 235-242.
NICE (2007) Alzheimer’s disease - donepezil, galantamine, rivastigmine (review) and memantine TA 111. www.nice.org.uk
NICE (2001) Alzheimer’s disease - donepezil, rivastigmine and galantamine TA 19. www.nice.org.uk
NICE, Social Care Institute for Excellence (2006) Dementia: Supporting People with Dementia and Their Carers in Health and Social Care. www.nice.org.uk
Oxleas NHS Trust (2005) Non Medical Supplementary Prescribing Policy. London: Oxleas NHS Trust.
Page, D. et al (2007) Introducing nurse prescribing in a memory clinic: service user and family carer experiences. Dementia; 7: 1, 139-160.
Prescribing Observatory for Mental Health (2007) Topic 4 report. Benchmarking the prescribing of anti-dementia drugs. London: The Royal College of Psychiatrists.
Smith, M., Hemmingway. S. (2005) Developing as a nurse prescriber in mental health care: a case study. Nurse Prescribing; 3: 3,125-130.