Mental & Neurological Health 2005

Please note: In this section of the website we aim to cover articles on areas where nurses do prescribe. However, not all the treatments or appliances mentioned are prescribable by nurses. For that reason, nurses should check the up-to-date versions of the Nurse Prescribers’ Formulary for District Nurses and Health Visitors (NPF) and the Nurse Prescribers’ Extended Formulary (NPEF) and Drug tariff if they are in any doubt. Alternatively contact your Regional Nurse Prescribing Lead for clarification.

2003 M&N Health | 2002 M&N Health | 2001 M&N Health

Mental and neurological health
Click on the article title below to read the summaries.


Updated: 04/07/05

Although there are probably only 250-300 mental health nurse prescribers in the country, 50 of them work for South Staffordshire Healthcare Trust. Before nurse prescribing had taken off in the UK, the trust was already thinking about how to educate nurses to improve concordance, a major problem area.

The first nine nurses undertook the three-month course on extended and supplementary prescribing early in 2003, and the trust was careful to choose senior nurses who were “confident and able to challenge decisions”. The article describes the benefits that the policy appears to have delivered for patients and highlights the importance of having a ‘critical mass’ of nurse prescribers working together and providing mutual support.

Website: Health Service Journal (requires subscription)
 

There is wide variation in the extend to which trusts providing mental health services prepared for nurse prescribing, although the evidence suggests that momentum is now growing, according to this survey of directors of nursing. The survey results did suggest that there is concern that the training course does not adequately prepare nurses for prescribing in mental health and some trusts were planning to send nurses on medication management courses as well.
 

This article analyses the relationship between psychiatrists and mental health nurses through the history of mental health care in the UK. Psychiatry remains the most influential profession in mental health, perhaps partly because the profession has incorporated ‘non-medical’ approaches to, and understanding of, mental illness.

The relationship of psychiatry to mental health nursing has, however, changed significantly in the last 50 years, and current developments suggest that this will continue, with new threats to the profession’s traditional authority emerging. The author points out that the current position has arisen through historical processes rather than professional conspiracies. Mental health nurses are now starting to act as supplementary prescribers, which begins to erode one key area that was previously psychiatrists’ exclusive area of expertise. Psychiatrists are also starting to lose the sole right to control hospital admissions. So far, psychiatry has adapted to survive the threats, as mental health nursing has become more professionalized.
 

The initial difficulties with implementing non-medical prescribing in mental health care should not be allowed to prevent it achieving the potential benefits for patient care, according to these authors, who discuss some of the issues that arose at a recent conference. Collaborative and supportive multi-disciplinary relationships will be crucial in realizing the benefits.

One issue is the amount of pharmacological training that nurse prescribers receive, with ongoing requests from qualified nurse prescribers for more education in psychopharmacology, applied therapeutics and adverse drug reactions. This may reflect changes in pre-registration nurse education, with its shift from the medical model of care. One mental health trust has funded its qualified nurse prescribers to attend a ‘top-up’ neuro-pharmacology module, which was well received, but this should not be the only option, according to these authors. The mentor/clinical tutor is vital here, as the training courses do not focus on issues specific to particular nursing specialities and so this must be covered with the mentor. Mentors’ experience varies widely and they receive little training, so this would be a useful area for future research to look at.

Generally, training courses must remain up-to-date and flexible and must change in response to changes in government policy on non-medical prescribing, with nurse prescribing leads being involved in any discussion about course development.

Nurse prescribing training does not finish with the course, and nurses are responsible for maintaining their competence and updating themselves with changes to the formulary. Organizational support is essential here. Discussion at the conference revealed that some supplementary nurse prescribers are writing and signing CMPs with only verbal agreement from their independent prescribers, suggesting that support is lacking.

There has also been debate about the role of the pharmaceutical industry in ongoing education of nurse prescribers [see here for recent coverage: Pharmaceutical influences – Nurse prescribers: eyes wide open; Prescribers’ relationships with pharmaceutical companies; MPs warned that prescribers rely on pharma support for CPD].

Within mental health services in primary care, the authors make a case for nurse prescribers playing a role in a stepped approach. They point out that practice nurses, increasingly working as nurse prescribers, have little training in mental health and yet many people present to primary care practitioners with physical symptoms providing a ‘ticket of entry’ when they have mental health problems. Although the side effect profiles of antidepressants have improved in recent years, drugs used to treat other illnesses have not and so it is vital that supplementary nurse prescribers working in mental health receive training on medication and side effects.
Non-medical prescribing raises issues of safety, given the high error rates of prescribing errors in mental health, which suggest that the system of medical prescribing is not working, raising questions about the policy of extending prescribing rather than addressing fundamental safety issues. Although there is a shortage of pharmacists who specialise in mental health, good collaboration between non-medical prescribers and pharmacists is essential to build good safety systems and checks. The National Patient Safety Agency has also introduced seven steps to patient safety.

Although a range of possible benefits of non-medical prescribing has been identified, there has been little research on the impact of supplementary and extended formula nurse prescribing on service users. At the conference, some of the concerns of service users were outlined and included safety, pharmacological knowledge, training and supervision, non-medical prescribing being a second class service or being a way of advancing a nurses’ career, and worries about CMPs and consent. Despite these, service users did feel that there was the potential to improve the care received by mental health service users through non-medical prescribing.
 

This article describes the experiences of nine nurses working in mental health and learning disabilities who formed part of the first cohort to undertake the supplementary prescribing course. They work for the South Staffordshire NHS Trust (see here for previous article on this).
 
This interesting account highlights some of the issues specific to this group of nurses: that they do not necessarily have up-to-date knowledge of physical health, for example, or that their assumption that they would be writing numerous prescriptions was not borne out, and that they now see this as testament to the fact that prescribing is one aspect of providing holistic patient-centred care. Continuing education has been maintained. The nurses found much of the course content, with its focus on independent prescribing, to be outside their scope of practice. Another complication is that some consultant psychiatrists write to GPs rather than writing prescriptions. Perhaps the biggest challenge in this area is the issue of consent to treatment for people with learning disabilities and acute mental health needs.

The anecdotal evidence in South Staffordshire appears to indicate that nurses, patients and carers all find nurse prescribing in mental health and learning disabilities acceptable. The nurses involved now have a closer working relationship with medical colleagues, which has benefited patients, and interventions in medicines management are seen as more timely. It is important that the systems and policies are established before nurses go on the course so that prescribing can begin after NMC registration.

Website: Nursing Standard

 

This article describes how a mental health nurse running a memory clinic undertook the extended and supplementary prescribing course and incorporated supplementary prescribing of acetylcholinesterase inhibitors into her practice. It discusses the issues that had to be resolved before, during and after the course.

The article highlights the importance of good planning and support, so that the appropriate infrastructures and systems are in place. In this case, the nurse prescriber received good support from the trust throughout: for example, when it became apparent that incorporating supplementary prescribing was going to mean there was too much work for one nurse, another was seconded for six months to complete monitoring reviews. She also obtained backfill for her post during three months of full-time study; for most nurses on her course, this was precluded by financial constraints.