Journals Watch 2002

This section features a regularly updated list of recently published articles relevant to nurse prescribing.

Abstracts of the papers are included and users are encouraged to submit their views about published papers through the feedback section.

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.

Click here to visit the 2001 archive of Mental and Neurological Health

Mental and neurological health
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  • Collaborative approach between professions crucial


Ramcharan P, Hemingway S and Flowers K. A client centred case for nurse prescribing. Mental Health Nursing 21(5):6-11.

Collaboration between CMHNs, doctors and allied professions involved in the prescribing process is required if nurse prescribing is to improve mental health services, according to an analysis of questionnaire responses from CMHNs.
Initial analysis of the results of the questionnaire, about the attitudes of CMHNs to nurse prescribing, has already been published (see 'Views of community mental health nurses' article).

Of the 2250 questionnaires distributed to CMHNs, 10.9% (245) were returned. Most respondents (71%) thought that nurse prescribing would be a positive development for mental health care but 14% did not. Respondents were more likely to think dependent rather than independent prescribing would be effective.

Most respondents (89%) said they were already de facto prescribing (for example, by influencing or advising GPs, consultants or patients). Nurses’ ability to influence prescriptions seemed to depend to some extent upon the doctors’ attitudes to nurse prescribing and became less likely higher up the medical hierarchy.

The authors stress that if nurse prescribing is to succeed it must be based upon teamwork, not on patronage by the medical profession as it sees fit. Many nurses had reservations about GPs making prescribing decisions in mental health. If nurses are in the best position to get to know the client and understand drug side effects, then a client-centred process must incorporate such knowledge.

The authors draw a distinction between ‘the prescription’ and ‘the prescribing process’. Most nurses claiming they were de facto prescribing were involved in the latter, perhaps in a role similar to that under supplementary prescribing. The authors discuss the notion of a collaborative, multi-disciplinary process, with the client at the centre, and look at the changes that would have to take place to make this approach successful. [back]

  • Mental health prescribing in Australia

McCann TV et al. Community mental health nurses and authority to prescribe medications: the way forward? J Psychiatr Ment Health Nurs 2002; 9: 175-182

Community mental health nurse practitioners supported getting prescribing authority for medications used to treat mental illness, although some nurses did have reservations, in this study from New South Wales, Australia. The views of the respondents strike a chord in the light of the ongoing UK debate.

The nurse practitioners who supported the idea viewed prescribing of psychotropic medications and the drugs used to control their side effects as embedded within their scope of practice, highlighting the way it would avoid delays. Even they, however, raised concerns about adding prescribing to what is seen as an already onerous workload.

For other nurse practitioners, prescribing was not consistent with their perception of the scope of nursing practice. Some also felt that the level of knowledge and experience needed was being underestimated, or that the imperative to prescribe was to cut costs.

Whether the education available would enable them to deal with the complexities of the medical problems they might encounter was another concern. Many also felt that even if supervision and support were provided initially, this would not be maintained.

  • Nurse prescribing and the care gap

Jordan S. Managing adverse drug reactions: an orphan task. J Adv Nursing 2002; 38(5): 437-448

Information-giving and monitoring of adverse effects were once clearly part of doctors’ roles but now lie on the interprofessional boundaries between medicine, nursing and pharmacy. In practice, this may mean that no one professional group views them as “their job”. Nurse prescribing initiatives and other proposals need to address questions raise by the identification of such vacant professional territory: the ‘care gap’.

Medication management issues can be particularly pressing for those with enduring mental illness, where side effects can be extremely problematic. This study sought to investigate whether the use of nurse-administered evaluation checklists could provide some of the support needed if community mental heath nurses are to expand their roles in medication management to help fill the care gap.

All patients were receiving antipsychotic medication regularly, administered by community mental health nurses. The use of the evaluation checklists increased the numbers of adverse events detected and actioned by nurses and also helped to structure care, apportion responsibility and prevent physical health problems from being overlooked.
Nurse prescribing initiatives could be designed to have an effect on both groups of problems identified: those that required changes to antipsychotic medication to resolve them and those that did not.

For many of the problems, the nurse was able to offer practical advice on, for example, weight loss, dental care and diet. In some cases the lack of prescription authority hampered nurses’ efforts to offer practical help: mouthwashes and artificial saliva sprays could have been useful for xerostomia for example. The authors suggest that many items from the NPF, for example laxatives (with caveats), emollients and mouthwashes would have been useful. The scope for items available under the NPEF to be used with these patients is also explored.

Decisions were more equivocal in cases where reductions in antipsychotic medication would be needed to address adverse effects: there was little evidence that evaluation checklists made a difference, in the time-frame of the study. Realistic concerns were expressed that reductions could lead to relapse. One example of dose titration was seen in 80 nurse/client interactions but this practice may become more widespread with the move towards supplementary prescribing.

The author suggests that mental health nurse prescribing could be introduced in stages, each accompanied by education programmes. Medications to alleviate adverse reactions should be prescribable first (quantities where the simultaneous ingestion of the entire prescription would cause problems should be excluded). If that was successful, a dose titration initiative based on individual protocols could be introduced. Client-centred evaluations of adverse events and controlled trials of clinical effectiveness will be important in both.

  • Debate needed on mental health nurse prescribing

The beguiling effects of nurse prescribing in mental health nursing: re-examining the debate. Cutcliffe JR. J Psychiatr Ment Health Nursing 2002; 9:365-375

Nurse prescribing in mental health should not be introduced on a widespread basis without a thorough and rigorous debate, according to this author who discusses the controversy that has arisen in this area. The debate should include feedback and evaluations from service users.

Increased status and professionalism for some nurses are insufficient grounds for embracing nurse prescribing, as are the arguments that it has been introduced in North America (in a very different healthcare system), or that the government endorses it. Whether medication management is at the core of nursing is another issue, as is whether the suggested expansion is really to do with expanding nursing or filling in the gaps left by doctor shortages and reductions in junior doctors’ hours.

The author accepts that there may be scenarios where nurse prescribing within psychiatric and mental health nursing would benefit both clients and nurses but argues for a pause for thought and re-examination of all the issues involved.

Gournay K and Barker P. Prescribing: the great debate. Nursing Standard 2002; 17(9): 22-23

The week before a debate at the Institute of Psychiatry in London about prescribing for mental health nurses and psychologists, two protagonists outlined their views.

Professor Kevin Gournay argues that given the commitment by government to extend the roles of nurses and the better training and education that underpin these policies, equipping nurses with the skills they need to supplement the medical workforce is a natural development. He argues that there will never be enough doctors to carry out all the functions of consultant psychiatrists. Experienced CPNs with appropriate education and training could take on routine prescribing and medication management, freeing consultants’ time. They have been advising doctors for many years. Nurse prescribing for mental health nurses would benefit patients and the healthcare system but would also improve job satisfaction for nurses and give them greater autonomy.

Robust education and training must be in place, as well as evaluation of pilots, benefit analysis and funding for more posts so that nurses can give the time to this role that it deserves.

Phil Barker argues that this argument is a distraction from the main agenda, which should be about developing the care needed for people in mental distress. He warns that a caring discipline could be converted into “one that is about control, draconian laws and injections” and argues that there is no value in giving limited prescribing privileges to nurses. The important point is health promotion and achieving recovery and there is much to be done.

Website: www.nursing-standard.co.uk