Journal of Psychiatric and Mental Health Nursing, 2015, 22, 529–542

Mental health nurse prescribing: the emerging impact J. D. ROSS

Ph D

MSc

( Di s t i n c t i o n )

BA

(with

Sp

ecialist

Pr

actice)

RN RMN

Advanced Practitioner in Adult Mental Health, Nurse Independent Prescriber, Cognitive Behavioural Therapist, Honorary Lecturer in Advanced Nursing Studies and Midwifery, University of Aberdeen, Aberdeen, UK

Keywords: medication management,

Accessible summary

mental health promotion, non-medical prescribing, nurse prescribing, patient

•

experience Correspondence: J. D. Ross Advanced Studies in Nursing &

•

Midwifery Division of Applied Health Sciences College of Life Science & Medicine University of Aberdeen Polwarth Building Foresterhill Aberdeen AB25 2ZD UK E-mail: [email protected] Accepted for publication: 29 January 2015 doi: 10.1111/jpm.12207

• •

Some mental health nurses have now been prescribing for their clients for several years. When suitably qualified they can prescribe the same range of medication as medical staff. Concern was expressed that nurse prescribers might become more like doctors and as a result would sacrifice their nursing skills. The views of those who have their medication prescribed by mental health nurses as well as views of nurse prescribers, pharmacist prescribers, nurse managers and doctors were explored by using interviews and focus groups. Most participants saw the inclusion of prescribing in the nursing role as a benefit to clients. Rather than detracting from the nurse patient relationship, results from this study suggest that the nurse patient relationship was improved and more holistic care was provided. Nurse prescribing is well received by those who have experienced it. As nurse prescribing effects a change of power dynamics this could result in the need for less involvement of the medical profession in clients’ care. As clients found nurses easier to talk to about their medication than doctors, medication concordance could be increased. Medication reconciliation could also be increased as medications no longer required by clients were more likely to be reduced or stopped by nurse prescribers. Discontinuing medication may indicate a new culture around mental health nurse prescribing. It may be that this trend has an impact on future service provision to clients. Results suggest that clients prefer to have their medication prescribed by nurses.

Abstract Mental health nurse prescribing has been established in some areas in the UK for quite some time. Other than speculation that nurse prescribing would have a detrimental effect on the nurse–patient relationship, little has been written about the impact of nurse prescribing to date. Bradley and Nolan found that prescribing allowed nurses to overcome difficulties in the health-care system which would have previously delayed clients’ access to medicines. Prescribing was believed to compliment many aspects of nursing and integrated previously diffuse aspects of the nursing role. Latter and Courtenay found that clients were generally satisfied with nurse prescribing. The aim of this study was to explore the impact mental health nurse prescribing has had on those involved. The views of clients, nurse prescribers, pharmacist prescribers, nurse managers and doctors were investigated. Questionnaires were used to gather demographic data and basic qualitative data. Focus groups and interviews were undertaken with 57 participants. The study was undertaken within one National Health Service Foundation Trust in England. Data analysis was guided by a framework approach.

© 2015 John Wiley & Sons Ltd

529

J. D. Ross

The majority of participants believed that the inclusion of prescribing in mental health nurses’ roles improved the nurse–patient relationship, and five themes including the relationship, concordance, power, treatment approach and ‘unprescribing’ emerged. Trust was highly valued, and clients found nurses easier to talk to about their medication than doctors. Rather than detracting from the nurse–patient relationship, results from this study suggest that nurse prescribing enables mental health nurse prescribers to provide more holistic care than previously.

Introduction Nurses have been prescribing in various guises in the UK for over 20 years. The Cumberlege report (Department of Health and Social Security 1986) first recommended that nurses should prescribe. This suggestion was supported by the first Crown report (Crown 1999) which highlighted the potential benefit of speedier access to medicines together with professional time savings. This led the way to changes in the 1968 Medicines Act (Department of Health 1968) and in particular which groups of professionals could prescribe. In the UK, prescribing by professionals other than doctors has been a very gradual process and is a result of numerous legislative acts as outlined in Table 1. Recent figures from the Nursing and Midwifery Council (K Szentgyorgyi, pers. comm, 2014) state that there are a total of 61 518 nurse prescribers in the UK. The majority are district nurses and health visitors prescribing from a designated formulary. The remaining 25 812 are qualified as independent and supplementary prescribers, and they are able to prescribe any licensed

medicine including some controlled drugs provided they work within their area of competence. Of this amount, there are 3802 mental health nurse prescribers in the UK, with 3123 in England, 109 in Northern Ireland, 434 in Scotland and 136 in Wales. In order to be able to undertake the prescribing course, candidates in the UK must be qualified as nurses for at least three years. Courses are held at higher educational institutes over three to six months and have 26 days theory plus self-directed learning evidenced by a portfolio, as well as an ‘open book’ and numeracy exam. Although other disciplines of nurses and professionals can qualify to prescribe, this paper focuses on mental health nurse prescribers and in particular how their ability to prescribe impacts on their clients. The word ‘client’ is used throughout this paper, other than when referring to the ‘nurse–patient relationship’. A previous paper (Ross et al. 2014) reporting the same study focuses solely on the nurse–patient relationship aspect of the data. This paper will focus on all five findings including the relationship, concordance, power, treatment approach and ‘unprescribing’.

Table 1 Overview of the legislative history of nurse prescribing in the UK An overview of the legislative history of nurse prescribing in the UK 1906 1950s 1968 1986 1989 1992 1994 1996 1998 1999 2001 2003 2005 2006 2007 2012

530

Amendment to the UK Pharmacy Act of 1869: opiates to be prescribed by doctors Extension of restrictions: psychotropic medicines to be prescribed by doctors Medicines Act: only doctors can prescribe Cumberledge Report: simple remedies and dressings can be prescribed by nurses First Crown report: Patient Group Directives (PGD) (Statutory instrument 2000 No.1917) Changes to Medicines Act: DN/HV prescribing begins First pilot sites in England: DN/HV Phased into Scotland: DN/HV First limited Nursing Formulary Second Crown Report: supplementary prescribing with independent partner DoH announcement: other groups of nurses eligible to prescribe and for a wider range of medicines Scottish Executive announcement: instigation of supplementary prescribing Scottish Executive and DoH announcement: nurse prescribing powers to be extended to permit full independent prescribing DoH announcement: instigation of independent nurse prescribing DoH announcement: Allied health practitioners eligible for supplementary prescribing Misuse of Drugs (Amendment No. 2) (England, Wales and Scotland) Regulations (Statutory Instrument 2012): non-medical prescribers permitted to prescribe controlled drugs within their area of expertise

© 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

Literature review There has been a gradual change in the prescribing literature from potential application to investigating the impact of prescribing. A comprehensive review was undertaken systematically, and of an initial 1139 articles identified, 23 studies related to mental health, with only six empirical studies reporting the views of nurse prescribers or clients who had experience of nurse prescribing. (See Appendix I for flow chart of selection process). The studies were reported prior to the widespread implementation of independent prescribing. The full search strategy and returns obtained is demonstrated in Table 2 below. Jones et al. (2007) interviewed 12 psychiatrists, 11 mental health nurse prescribers and 11 clients who had their medication prescribed by a nurse. Participants from all three groups had a positive reaction to nurse prescribing. The limitations of this study were acknowledged as taking place in a single mental health-care organisation that had made considerable investment in nurse prescribing. The study was undertaken in 2005, and nurses in the study had written relatively few prescriptions. It is not made clear how the sample were chosen or approached. However, the five authors collectively held largely positive views about nurse prescribing and may have introduced bias in the phrasing of questions and how the analysis was performed. Tomar et al. (2008) surveyed psychiatrists and nurses on their views of mental health nurse supplementary prescribing and its impact on care. The questionnaires were completed by 57 psychiatrists and 106 nurses. At the time there were seven mental health nurse prescribers, of which only four participated in the study. More nurses (n = 80) than psychiatrists (n = 33) believed that supplementary prescribing would provide clients quicker access to medication and improve client care. Limitations of this study are that findings are mainly from those who have not experienced mental health nurse prescribing. A further limitation of this study was that although the response rate was good for psychiatrists as 57 of 115 responded, it was relatively low for nurses (106 of 460) indicating a possible response bias. Snowden & Martin (2010) interviewed a convenience sample of six mental health nurse prescribers and two of their clients. Clients viewed nurse prescribers as taking time to explain their medication. The aim of the study was to investigate the impact of prescribing rights on mental health prescribers, and findings suggest that mental health nurse prescribers were possibly not adequately trained in medication management. A limitation is the small number of participants in the study. This paper along with the remaining three papers questioned © 2015 John Wiley & Sons Ltd

whether prescribing conflicted with the nursing role. Bradley et al. (2008) investigated why some mental health nurse prescribers choose not to prescribe. Fifteen qualified prescribers of whom seven were not prescribing were surveyed in focus groups. Concern was expressed regarding the adequacy of the prescribing course and a lack of role clarity. Nurses who were prescribing were more concerned than non-prescribing nurses about client care and service improvement. In contrast, those who were not prescribing lacked conviction that the service was worthwhile. A limitation of this study was that the number of nurses participating was relatively small. Snowden (2008) compared views of 354 adult nursing prescribers with 11 mental health nurse prescribers. Mental health nurses were concerned about the lack of role clarity and the appropriateness of including prescribing in their role. Other nurses were qualified longer than mental health nurses who prescribed rarely in comparison to participants from adult nursing. A limitation of this study was the small amount of mental health prescribers compared to other nurse prescribers. Snowden (2010) surveyed 42 mental health nurse prescribers and found that one quarter of respondents were not prescribing. Results showed that one consistent factor which emerged from the analysis was the depth of thought the 31 practicing mental health nurse prescribers gave to integrating the role of prescriber into their current practice. A limitation of this study was whether it was representative of the sample as it was recognized that only motivated people attended conferences and answered questionnaires. However, this study recognized the importance of the therapeutic relationship and the potential influence it may have on any prescribing decisions for the nurse prescriber. A comprehensive literature review has revealed a dearth of relevant empirical articles which specifically focus on the views of those who have experienced mental health nurse independent prescribing. This suggests an area where further research is required.

Aim The aim of this study was to identify the impact of nurse prescribing on clients in mental health settings and to identify emerging themes.

Methods Design A constructivist design implementing interviews and focus groups was used. The constructivist paradigm is that multiple and intangible realities exist, which are not governed by 531

J. D. Ross

Table 2 Full search strategy criteria Full search strategy criteria

Returns

The author had already amassed literature related to all aspects of nurse prescribing over the course of several years which was included in the literature review. A hand search of all relevant journals and reports was also conducted. An auto alert was set up at the beginning of the study. Auto alert checks against the latest changes and any identified documents are automatically emailed. The results are generated from: Ovid MEDLINE(R) < 1996 to current week Ovid MEDLINE(R) < 2006 to current week (updates since current week) The Nursing Times email information service has been enabled and sends the latest news, practice (including prescribing) and opinion for mental health nurses on a daily basis from Nursingtimes.net For the purposes of initial exploration of the literature, electronic databases were searched through Elton Bryson Stephens Company (EBSCO) host and the Knowledge Network. Cumulative Index for Nursing and Allied Health Literature (CINAHL), Medline, Psychinfo, Embase and others listed below were searched in February 2010 for relevant research papers published after 2003 on nurse prescribing. CINAHL Plus (2003–current) (with full text) and Health Source: Nursing/Academic Edition were searched through EBSCO host with a limit on the year 2000 onwards for the terms: Prescriptive authority, nurse prescribing, drug administration, prescribing, independent prescribing, supplementary prescribing, non-medical prescribing, mental health, psychiatry, community mental health nursing and psychiatric nursing. Medline (1996–current) (with full text) was searched through Object View Interaction Design (OVID) with a limit on the year 2003 onwards for the terms: Prescriptive authority, nurse prescribing, drug administration, prescribing (drugs) independent prescribing, supplementary prescribing, non-medical prescribing, mental health, psychiatry, community mental health nursing, psychiatric nursing and mental health nurses. The search term ‘prescriptive privileges’ was suggested by Medline so was included in the search. Psychinfo (2002–current) was searched through OVID and limit on the year 2003 onwards for the terms: Nurse prescribing, prescribing (drugs), supplementary prescribing, non-medical prescribing, mental health nursing, community mental health nursing and psychiatric nurses. The term ‘Psychiatric’ nurses was used instead of mental health nurses. As Medline and Psychinfo are American, American terminology was used during these respective searches. Embase (1996–current)(with full text) was searched through OVID and limit on the year 2003 onwards for the terms: Prescriptive authority, nurse prescribing, drug administration, prescribing (drugs) independent prescribing, supplementary prescribing, non-medical prescribing, mental health, psychiatry, community psychiatric nursing, psychiatric nursing and mental health nurses. Community psychiatric nursing was used instead of community mental health nursing as this was a term recognized by Embase. Google Scholar. By applying parentheses to ‘nurse prescribing’, ‘psychiatric nursing’, ‘drug administration’, 110 papers were returned. This was reduced by adding the limiter 2003–2010 in the advanced search option. Cochrane Library. The same search terms revealed no results. The key words nurse prescribe* was then used. Pubmed was searched using truncation on the terms ‘nurse prescribing’ or non-medical prescribing’ and ‘mental health’. Internurse was searched for ‘nurse prescrib*’ or ‘non medical prescrib*’ and ‘mental health’. Limit from 2003 then applied. Blackwell Synergy searched of ‘nurse prescrib*’ or ‘non medical prescrib*’ and ‘mental health’. Limit from 2003 then applied. British Medical Journal (BMJ) was searched using the BMJ instant index for papers relating to non medical prescribing. There have been several papers published in the BMJ which have been highly critical of nurses’ prescribing authority, and it was felt pertinent to include these in the search. Most of the papers did not relate directly to mental health. The search term used was ‘nurse prescrib*’.

Forty journal papers returned. The search terms employed were ‘nurse prescribing, non-medical prescribing, prescription privileges, polypharmacy, prescribing drugs, psychiatric nursing and mental health nursing’. Combining two of three key words in each database narrowed these searches.

532

Three hundred fifty-nine papers returned. The search terms ‘Independent prescribing’ and ‘supplementary prescribing’ gave small numbers of hits by themselves, and none when combined with the other terms.

Two hundred thirty-nine papers returned. The search term ‘independent prescribing’ was the only term that did not yield many results.

Three hundred eighty-three papers returned. Drug administration and prescribing (drugs) or prescribing when combined with the mental health-related terms gave results which pertained to types of psychotropic medication rather than who prescribes the medication.

Nine papers were returned. Results were poor and when search terms were combined there were zero papers returned.

One hundred ten papers were returned. Reduced to 56. Two papers which were prior to 2003 were found. Applying truncation increased papers from 20 to 25. 31 papers 30 papers 5 papers

© 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

Table 2 Continued Full search strategy criteria

Returns

Government web sites such as http://www.scotland.gov.uk/Topics/Health were also searched as relevant sources of information relating to nurse prescribing in general. A search using ‘nurse prescribing’ was undertaken. Most papers were not helpful and were outdated. However, a previously unseen document entitled ‘A Safe prescription Developing nurse, midwife and allied health profession (NMAHP) prescribing in NHS Scotland Progress Report August 2010’ was revealed during this search. There was no facility to limit this search which only appeared to have one relevant paper. The national prescribing centre (NPC) web site http://www.npc.nhs.uk/search/ was searched using the words ‘nurse prescribing’, but all documents referred to the practice of prescribing in generic fields which was not helpful. The NPC later amalgamated with the National Institute of Clinical Excellence (NICE), web site: http://www.nice.org References in nurse prescribing papers were checked to obtain further relevant nurse prescribing articles. Salganik and Heckathorn (2004) describe this process as ‘snowballing’.

3001 references to documents

natural laws or by ‘structures that exist independently of us’ (Bhasker 1975, p. 9) which is in contrast to the postpositivist paradigm which assumes that there is a single, tangible, objective reality that is at least partially apprehendable (Wainwright 1997). Constructivism denies the existence of an objective reality and claims that realities are social constructions of the mind. Thus, there exist as many constructions as there are individuals, although many will be shared (Guba & Lincoln 1989, Norton 1999). Social realities are inseparable from the researcher, not least because the researchers construct the worlds they research. The constructivist philosophy is that social reality exists as people experience it and assign meaning to it. Study design information is provided in domain 2 of Table 3 (consolidated criteria for reporting qualitative research [COREQ]) (Tong et al. 2007).

Setting and participants The research setting was Tees, Esk and Wear Valleys National Health Service (NHS) Foundation Trust. For further details of participant selection see item 10 of Table 3.

Data collection Data collection information is provided in domain 3 of Table 3. Written and verbal consent was obtained prior to interviews and focus groups.

Data analysis Data analysis information is provided in domain 3 of Table 3.

Ethical considerations Permission to undertake the research was obtained from the local National Research Ethics Service and NHS © 2015 John Wiley & Sons Ltd

471 references to articles

10 articles

Research and Development. Participants were given the opportunity to ask questions and reminded their participation was voluntary.

Results Five themes Perceptions of a range of stakeholders, including clients regarding nurse prescribing in the mental health context were explored. Four main themes which corresponded with the discussion guide were explored. These were ‘the nurse prescriber patient relationship’,’ concordance’, ‘power’ and ‘treatment approach’. A fifth theme which emerged was the ‘unprescribing’ of medication. A sixth theme of ‘remuneration’ emerged but is not discussed here as it did not appear relevant to the aim of this study. The first theme to be discussed is the nurse–patient relationship. The nurse prescriber–patient relationship This theme was divided into two main subthemes, each of which is explored in detail with the use of verbatim quotes to illustrate specific aspects. Within this section, quotes attributed to nurse prescribers are denoted as NP, to pharmacist prescribers as PP, to nurse managers as NM and for focus groups as FG.

Relationship changes While some believed the relationship had not changed since nurses began prescribing, others had different views: It has made it better because you see the nurse more often than you’d see a doctor so you have a closer relationship with them so it is quicker and easier to get things done and sorted out (Interview 7: Client). 533

J. D. Ross

Table 3 Consolidated criteria for reporting qualitative studies (COREQ) 32-item checklist COREQ 32-item checklist No. item Guide questions/description Domain 1: Research team and reflexivity Personal characteristics 1. Interviewer/facilitator JR conducted the interviews, ‘phone interviews and focus groups 2. Credentials JR at that time had an MSc and was undertaking a PhD. All supervisors had doctorates. 3. Occupation JR was a full-time clinician, and supervisors were either full or part-time academics. 4. Gender Female 5. Experience and training University of Aberdeen qualitative training and guidelines. Experience of conducting previous focus groups. Relationship with participants 6. Relationship established A relationship was established via phone with the lead nurse at Tees, Esk, and Wear Valleys (TEWV) only. 7. Participant knowledge of Participants were informed that the researcher was a mental health nurse prescriber and had undertaken the interviewer an MSc on the subject. They were aware that the research was being undertaken as part of a PhD. 8. Interviewer characteristics The participants were made aware that the researcher had a personal interest in mental health nurse prescribing. Domain 2: study design Theoretical framework 9. Methodological orientation The methodological orientation underpinning the study was governed by a constructivist approach. and theory Content analysis was used to analyse the questionnaire data and framework analysis was used to analyse the focus group and interview data. Participant selection 10. Sampling All mental health nurse prescribers were invited as well as some psychiatrists by the lead nurse at TEWV. Nurse prescribers were asked to invite clients. Purposive sampling was the preferred method, but ultimately convenience sampling was used, and everyone who wished to participate was invited to. There were 13 interviews and nine focus groups. Thirty-five nurse prescribers, three pharmacist prescribers, two nurse managers, seven consultant psychiatrists, one GP and nine clients participated. 11. Method of approach Participants were approached by email and face to face. 12. Sample size Fifty-seven participants were in the study. 13. Non-participation It is unknown how many refused to participate. Seventy participants agreed to take part, but only 57 did. No participants dropped out once they had begun the process. 14. Setting of data collection The data were collected at various settings within TEWV and by telephone. 15. Presence of non-participants An advocate was present at the client focus group. 16. Description of sample Tees, Esk, and Wear Valleys has around 5000 staff, over 840 inpatient beds and 95 community mental health teams and an annual income of £220 million. There were a total of 82 non-medical prescribers. The data were generated in 2010 and 2011. Data collection 17. Interview guide A discussion guide based on questions which had arisen from the literature review as well was used. It was pilot tested (See Appendix II) 18. Repeat interviews No repeat interviews were carried out. 19. Audio/visual recording Audio recording was used to collect the data. 20. Field notes Field notes made during and after the interviews or focus groups. 21. Duration The duration of the focus groups varied from 1 h to 90 min. Interviews varied from 15 min to 1 h. 22. Data saturation Data saturation was discussed with supervisors. 23. Transcripts returned Transcripts were not returned to participants for comment, but findings were summarized and presented to participants for feedback. Domain 3: analysis and findings Data analysis 24. Number of coders JR coded all data, and five transcripts were randomly checked by two supervisors. 25. Description of the coding JR developed a coding tree which was checked by supervisors. tree 26. Derivation of themes Some themes were identified in advance, others derived from the data. 27. Software NVivo 9.2 (QSR International, 55 Cambridge Street, Burlington, MA01803, USA) software was used to manage the data. 28. Participant checking Participants provided feedback on the findings. Reporting 29. Quotations presented Participant quotations were presented to illustrate the themes/findings, and each quotation was identified by a participant number. 30. Data and findings consistent There was consistency between the data presented and the findings. 31. Clarity of major themes Major themes such as the relationship, concordance, power, treatment approach and ‘unprescribing’ are clearly presented in the findings. 32. Clarity of minor themes The minor theme of remuneration is briefly discussed.

534

© 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

Comments from nurse prescribers and clients suggested that the relationship had changed since the nurse became a prescriber and that clients were now more at ease. It was suggested that the relationship was now closer and trusting. Trust was mentioned repeatedly when referring to the nurse prescriber–patient relationship: I feel it is better because I think I can speak to her about anything and I know she keeps it to herself so I trust her one hundred and ten percent. She hasn’t paid me honest! (Laughs) (Interview 10: Client). So you get to know a few nurses quite well and if one of them is off I’d just see another one that I know. I think that is good because you get to build a relationship with them and you trust them and feel comfortable with them (Interview 8: Client).

Clients’ preference of prescriber and consistency Nurse prescribers were of the opinion that clients preferred to see them as opposed to medical staff: They just want to see that one person. So it has got to improve the relationship if you are prescribing for them as well, rather than send them off to an outpatient clinic for somebody else to prescribe. (FG 2: NP 2) A client on his way to an appointment clearly thought his nurse prescriber knew him well. He appeared to be frustrated at having to see yet another doctor and having to tell his life story again. He said to his nurse: Well, who is it this time? Do I have to tell them everything or will you tell them for me? (Interview 2: NP) A psychiatrist was in agreement that clients would prefer to see the same nurse rather than different doctors: I think the most important thing patients like is seeing somebody consistently and I think that if they were given a choice that they would probably prefer a non medical prescriber who is going to be there all the time as opposed to a rotational junior. (FG 8: Psychiatrist 1) Even though there were no clients in the study who stated that they would prefer to have a doctor prescribe for them, one client made this stipulation: I would rather have whoever has an understanding of me and my condition, but within the treatment that I get I think it is entirely appropriate that my nurse can prescribe for me. (FG 9: Client 1)

sion making. This was seen as a very different prescribing style than that of a medical model used by doctors: We negotiate things with the patient and discuss medication and come to some sort of agreement rather than just saying ‘this is what you are getting’. (FG 1 NP 3) Within a different focus group, another nurse reinforced the belief that nurses did not use a paternalistic medical model; rather they encouraged clients to question their treatment: I think that is part of the philosophy really with a nursing approach that you encourage people to challenge and ask questions as opposed to sitting on a pedestal saying to clients ‘you will do this’. (FG 5: NP 6) Psychiatrists fully acknowledged their prescribing style, suggesting they had not been successful in obtaining concordance with clients over the years. Nurse prescribing was seen as an ideal opportunity to greatly enhance concordance: Nurses are much better at engaging people with collaboration and concordance. We doctors tend to be prescriptive. (FG 8: Psychiatrist 2)

Information giving

Concordance The concordance theme was divided into three main subthemes which are explored in turn.

There were comments from all groups of professionals and clients that nurse prescribers were better than doctors at giving clients enough time to impart adequate information on medication and side effects. It was also noted that nurses could speak to clients at their own level and tended to use language that the client could understand which was free of medical jargon. It was believed that clients would rather ask a nurse than a doctor: They will bring the prescriptions in and I will have to go through it. And they will say that I go through it in a language that they can understand and that is what they appreciate. That’s what I’d want. (FG 6: NP 3) Nurses were also seen as being more likely to give clients information away with them and to encourage them to ask any questions: I had a lady in shock because I gave her literature away to read and to decide what she wanted. (FG 5: NP 6) Psychiatrists and clients also agreed that clients were more likely to get the information they needed from their nurse prescribers: Nurses are much better at explaining what they are going to do and why and go through choices more thoroughly. (FG 8: Psychiatrist 4) I think the nurse prescriber is more likely to take the time to explain things to me. (Interview 13: Client)

Negotiating concordance

Side effects

Nurse prescribers were seen as discussing treatment options with clients in some detail, enabling informed deci-

Nurse prescribers were seen as giving clients more information about potential side effects in a manner which they

© 2015 John Wiley & Sons Ltd

535

J. D. Ross

could comprehend and to check that clients understood. Giving clients information to enable them to understand possible side effects was seen as a definite advantage, and because of this approach, concordance was perceived to be enhanced: The patients by and large stick with it a lot more. One patient said after an hour ‘Thanks. I normally just get a prescription shoved in my face, without even telling me what drug it is’. Because they get a thorough explanation of side effects patients tend to stick with the medication a lot more. The patient will stop if the side effects are intolerable- so that is concordance and not non concordance. (FG 5: NP 4) Others saw themselves as having a more realistic view of medication outcomes which they imparted to their clients: We have a more reasonable view of medication outcomes which leads to different expectations from service users. They stick with it a lot more because they know what to expect. (FG 5: NP 3) Nurse prescribers recognized that they now had a much greater interest and heightened awareness of mediation, interactions and side effects: I have a much more avid interest in side effects now that I prescribe. I really want the patients to get well. You have that ownership. (FG 6: NP 4) Power The theme of power is divided into two main subthemes which are discussed in turn.

Empowered The majority of nurse prescribers in the study were not comfortable to describe themselves as having more power now that they could prescribe. However, one nurse acknowledged that she believed she had more power and explained why: It does make me feel more powerful. I have more power to be able to say and to have the confidence to say to the doctor that I would not have had before I did the prescribing course. (FG 3: NP 4) What came across in many interactions was that it was almost considered rude or in bad taste to acknowledge having any power, but using the term ‘empowered’ and explaining the context in which it was used was more acceptable: I feel more empowered and less tied to constraints. Things are not delayed. Someone can see me and walk out with a prescription. (FG 6: NP 2) Empowered means being able to offer the full package. (Interview 2: NP) 536

One nurse prescriber believed her clients were more empowered now that she could prescribe: I think people feel more empowered and want to participate in treatment as opposed to being told ‘you must have this’. They can make decisions and it is like a two way process really. (FG 5: NP 3)

Equality with doctors There were several comments about the knowledge of nurse prescribers being equated with doctors at varying levels of expertise. It was acknowledge that some Senior House Officers (SHOs) did not have the depth of knowledge that nurse prescribers had. One psychiatrist who was supportive of nurse prescribers saw them as equivalent to some doctors: The way I look at it is that the nurse prescriber is like having a good, safe SHO. (FG 7: Psychiatrist 2) Another psychiatrist recognized that his relationship with nurses who could now prescribe had changed: I probably look at them more in terms of an equal rather than directing them to do things. (FG 7: Psychiatrist 3) A nurse prescriber also recognized that her relationship with GPs had changed in that they appeared to acknowledge her expertise and were now more likely to defer to her: It is really good when the GP phones up and says ‘in your opinion should I do this?’ and I will say ‘no you shouldn’t’ and the GP will say ‘right then I won’t’. (FG 5: NP 6) The change in power dynamics was also recognized by a nurse manager who discussed organisational changes that were taking place since nurses incorporated prescribing in their role: Nurse prescribing has started to impact on the power balance in that there are no longer consultant led teams. (Interview 6: NM) Treatment approach The theme of treatment is divided into three main subthemes which are discussed in turn.

From care to cure? Traditionally, the cure model has been the focus of doctors using biomedical approaches. When nurses were asked if they thought prescribing had changed their practice from care to cure, the majority were adamant that it had not. There were some fairly defensive responses suggesting that this was an emotive subject which nurses cared passionately about: © 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

It has made it more caring now as the nurse prescriber has ownership for the prescribing and patient’s care. You genuinely care more if you write the prescription and you invest more in the patient. (FG 6: NP 4) Others also agreed that nurses had not switched from a caring to a curing role: No that is silly basically. Whoever said that should get a life. Nurses are more than capable of switching between the different roles. I don’t think there is an issue about care. (Interview 3: Psychiatrist)

It is another string to their bow and something that they have got that is not going to stop the basic thing that they do which is the holistic approach. It just means they have another tool to use without having to refer to a doctor. (FG 4: PP 1) Nurses believed that although they had always used holistic care in the past, this approach had been enhanced with the addition of prescribing to their role: Nurses are used to a holistic way of working and provide more holistic care now that we are prescribers. We look at the whole picture. (FG 6: NP 4)

Not first option Nurses saw themselves as continuing to care and saw themselves as more likely not to prescribe and that they would consider all other options prior to prescribing: We are more likely not to prescribe or think well we are not going to rush in and prescribe that. (FG 2: NP 5) It is going through a list and trying everything else. You try this and you try that and medication is down at the bottom. (FG 3: NP 9) Clients were seen as having different expectations from a medical or nurse prescriber and it was believed that they would be more likely to accept non pharmaceutical treatments from the nurse because the nurse had a range of interventions to choose from as opposed to a doctor: I think it is the patients’ expectations. I think if they see a doctor they expect to go out with a prescription, whereas with the nurse they are quite happy to accept that we might look at different things before we look at medication. (FG 3: NP 8)

Holistic care Apart from one psychiatrist’s opinion, the general consensus was that nurse prescribers were ideally placed to provide an overall holistic approach to care. The other psychiatrists in the group disagreed with the opinion below, believing nurse prescribers were ideally placed to provide holistic care: I don’t think nurse prescribers would be able to give a holistic view. I don’t think they would have that kind of vision. (FG 8: Psychiatrist 2) The above opinion contrasted sharply with the view of a client who received his care from a nurse prescriber: I think they (nurse prescribers) look at all the care. They will check that the drugs they have prescribed don’t clash with other things. They are interested in my home life. They sit down and take an interest so you don’t relapse. (Interview 9: Client 1) A pharmacist prescriber who had worked closely with nurse prescribers was clear that he thought nurses had always used a holistic approach in their care: © 2015 John Wiley & Sons Ltd

Unprescribing Mental health nurse prescribers referred to reducing or stopping medication as ‘unprescribing’. While this term may be technically incorrect, it was referred to in this way several times and for this reason it has been included as it is. The theme of unprescribing is divided into two main subthemes which are discussed in turn.

Educating others Participants believed other professionals needed to be educated about the nurse prescriber role, in that it was not just about writing prescriptions, but also about reducing or stopping medication: It’s trying to get across to people – actually we could stop this. It is about stopping medication and about the education of nurses and other people. (FG 1: NP 3) Although mental health nurse prescribers saw unprescribing as an important aspect of their prescribing practice, which may benefit their clients, this way of working was not welcomed by all colleagues. Some spoke of difficulty with other nurses accepting their prescribing decisions: It can be difficult in the nursing homes when you are stopping medication if they want you to prescribe something. (FG 1: NP 1) However, some believed others (including medical staff) were taking heed of nurse prescribers’ recommendations regarding the reduction of medication: I am working with GPs to reduce and they are taking a bit of notice when I say ‘that is too big a dose. Can we reduce it?’ (FG 3: NP 13)

Inappropriate prescribing/polypharmacy Some nurse prescribers were surprised at the inappropriate prescribing of medications in general hospitals for their elderly clients. Nurses within this area found that their biggest prescribing impact had been unprescribing these medications: 537

J. D. Ross

In terms of impact if I think about my own situation, the biggest impact I think I have had with patients is stopping medication [lots of agreement] (FG 3: NP 11). So actually what I feel I have done quite a bit is ‘unprescribed’ if you like. I didn’t envisage unprescribing rather than prescribing when I took on the role. (FG 4: NP 1) Medication which was required by a client several years ago may never have been reviewed. Nurse prescribers placed importance on assessing and reviewing medication which may no longer be necessary, causing side effects such as sedation and having a detrimental effect on clients’ quality of life: And you are getting people who patently don’t need them (medications). A man on a galloping horse can see that, but the consultant years ago said ‘you have to take it’. (FG 4: NP 2)

Discussion The aim of this study was to identify the impact of mental health nurse prescribing and to identify emerging themes. Using an exploratory constructivist approach and framework matrix, this paper reports on five themes which impact on clients. The nurse–patient relationship in this study was viewed by some as remaining the same as it was prior to nurses prescribing, but others disagreed, perceiving that the relationship had improved and had become more transparent. Barker (1997), Chambers (1998) and Cutcliffe (2002) claimed that the central or core activity of mental health nursing is the interpersonal relationship between clients and nurses. Within the field of mental health nursing, the relationship between the nurse and the client remains paramount and is based on mutual trust and respect. Without this relationship, therapeutic alliance cannot take place. Cornwell & Chiverton (1997) and Castledine (2000) voiced concerns that nurses might sacrifice nursing skills for the prescribing role. This point is further discussed in the treatment approach (care vs. cure) section below. In the current study, nurse prescribers were seen as easier to speak to, less paternalistic and held in less awe than doctors. If the nurse prescriber–patient relationship is perceived as unchanged or having improved, this would suggest that the primacy of the therapeutic alliance is maintained by nurses when they become prescribers. According to Snowden (2010), this may be due to nurse prescribers’ reflection on whether prescribing would impact on their carefully nurtured therapeutic relationships with clients. The nurse prescriber participants in one study saw prescribing as a means of improving their relationships with clients and of reducing relapse rates (Nolan & Bradley 538

2007). The amount of time nurses spent in developing and sustaining relationships with clients was perceived as leading to improved care when nurses became prescribers (Jones 2006). The consistency of contact with the nurse prescriber was valued by clients, frequently stating that they did not want to repeat their stories to others who did not know their histories. Doctors in a study by Turner (2007) believed nurse prescribing streamlined services in that it enabled ease of access, promptness in receiving prescriptions and negated the need to see a doctor. Nurse prescribers were perceived as well placed to enhance concordance. Concordance is argued to enable care that reinforces the client’s rights and choice via communication (Gray et al. 2002) and within the mental health arena reinforces clients’ need for consultation and participation (De las Cuevas et al. 2011). Nurse prescribers’ relationships with clients placed them in an ideal position to enhance the pre-established relationship and to enable discussion and negotiation about treatment and side effects. They were seen as being able to take the time to ensure informed choice. All these aspects were seen as components of concordance and were seen as demonstrating that nurses were prescribing in a concordant way. This reflected many comments in the literature. Nolan & Bradley (2007) suggested that as nurse prescribers could spend more time with clients that they would be able to give better information and to involve clients in decisions about their care leading to improved concordance. Clients believed they were given more time with nurse prescribers than a doctor, and as a result, they had more time to ask questions about their treatment, and as a consequence were more likely to be concordant (Wix 2007). The subject of power was controversial, and the majority of nurses were uncomfortable with the term. Although some nurses acknowledged that prescribing brought some power with it because they no longer had to wait for a doctor to prescribe on their behalf, others were unwilling to say that they were more powerful. Many nurses preferred to use the words empowered or autonomous to describe how they felt about prescribing. Others saw power as now being more evenly distributed between the nurse and the client. Another view was that the power differential between doctors and nurses had lessened. This view was shared in the literature with comments suggesting that doctors were concerned about the erosion of their role. Patel et al. (2009) found that psychiatrists were concerned that nurses were encroaching on their traditional territory. It appears that those who have experienced nurse prescribing do not undergo the foreseen issues. Cutcliffe & Happell (2009) suggested that the dominance of medical power could be challenged now that prescribing is no longer the monopoly of doctors. Within the current study, © 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

there was a consensus among nurse prescribers that they did not want power. This may have been because of the long-standing medical hierarchy that nurses did not like to think of themselves as having power. It may be that nurse prescribers instead preferred to see themselves as advocates for the client instead of seeing themselves as doctors due to medical hegemony. However, the traditional medical role has been eroded as the long-standing role of responsible medical officer which indicated that only medical staff had responsibility has been replaced by ‘The Responsible Clinician’ role in the Mental Health: New Ways of Working for Everyone document (Department of Health 2007). This permits staff with the right skills, competences and experience to carry out key roles, instead of restricting roles automatically to particular professional groups, and supports a competence-based approach to professional practice. This new role is open to health professionals with the appropriate training and competences, including chartered psychologists, nurses, social workers and occupational therapists, in addition to doctors. A person’s responsible clinician will have overall responsibility for their care and treatment plan. There were repeated comments that nurse prescribers had not exchanged their traditional caring role for a curing role. Cutcliffe & Campbell (2002) described the potential impact of nurse prescribing on mental health as a backward step. They argued that taking on prescribing powers could lead mental health nurses away from the core concepts of the traditional psychosocial or caring approach that underpins nursing. They were concerned that nurses would exchange the caring role for a more medical or ‘curing’ role instead. However it would appear that this fear has not been realized. If anything, nurse prescribers believed that the caring aspect had been increased since they included prescribing in their role, citing ownership of clients’ care as the reason. Clients were of the opinion that their nurse prescribers continued to focus on all their care and that the inclusion of prescribing had enhanced their care. It was acknowledged that the majority of nurse prescribers had a wealth of experience prior to becoming prescribers which meant that they were unlikely to use medication as their first option. Nolan & Bradley (2007) found that nurse prescribers took responsibility for a holistic approach to care, as prescribing brought with it an additional range of duties such as providing regular health checks. Nurses in this study highlighted that much of the time they were reducing or stopping medication rather than initiating medication. This concurs with Snowden (2008) who found that mental health nurse prescribers did not prescribe very often, and believed this was because they considered the impact their prescribing may have on their © 2015 John Wiley & Sons Ltd

relationship with their clients. Unprescribing was seen as empowering for clients as it enabled them to reduce and stop some medications that they had been taking in some cases for many years, when they did not require it. The fact that nurses often knew the clients well before becoming their prescribers meant they were able to weigh up any risks before discussing the possibility of medication reduction. Turner (2007) acknowledged that clients had more ease of access to appointments with nurse prescribers, finding this flexibility enabled the prescriber to stop, start and adjust medication more rapidly rather than having to wait to be seen by a psychiatrist. There was no available literature which specifically related to the reduction or discontinuation of medication to compare the findings of the current study with.

Limitations Any conclusions taken from this study must be viewed with caution as all participants were from one area, which had a particularly high ratio of nurse prescribers. The selfselected nature of clients may not be representative as only clients in favour of nurse prescribing may have chosen to participate giving a one-sided view of nurse prescribing. Also, nurses may only have recruited clients who they believed would be positive about prescribing.

Conclusion Mental health nurse prescribing has the potential to improve client care and appears to be the preferred choice of clients who have experienced it. Implications from this study suggest that concerns about the impact of nurse prescribing on the nurse–patient relationship are unfounded and that it is well received by those who have experienced it.

Implications for practice Rather than detracting from the nurse–patient relationship, results from this study suggest that the nurse–patient relationship was improved. Clients may indicate that they prefer to see a nurse for their medication rather than a doctor which would have an impact on service demand and provision. Working in a collaborative partnership with clients enabled greater disclosure and enhanced understanding of clients’ stories and views of medication, enabling a collaborative process of concordance in partnership. This could impact on practice in that medication is not the only option of treatment provision, and other forms of treatment could be provided. Results from this study suggested nurse prescribers were seen as more powerful 539

J. D. Ross

now that they could prescribe and that power had shifted more towards clients than previously. As nurse prescribing effects a change of power dynamics, this could result in the need for doctors to have less involvement in clients’ care than previously. Including prescribing in the nursing role was not found to detract from the caring role and was seen as enabling more holistic care than previously. Nurse prescribers may be required to include other forms of care in their repertoire as service demands, such as talking therapies and relaxation techniques. The emergent theme of unprescribing indicates a previously unidentified prescribing practice, and discontinuing medication may indicate a new culture around mental health nurse prescribing which should impact on future service provision to clients.

References Barker P.J. (1997) Towards a meta-theory of psychiatric nursing. Mental Health Practice 1,

Acknowledgment The author would like to thank Carole Norris, Lead Nurse for Prescribing at TEWV NHS Foundation Trust, who organized the focus groups and interviews and Professor Alyson Kettles, Professor Christine Bond and Dr Catriona Mathieson (all University of Aberdeen) and Professor Amanda Clarke (University of Northumbria) who supervised the PhD study. [Correction added on 21 July 2015, after first online publication: Acknowledgment was previously omitted and has now been added.]

De las Cuevas C., Rivero A., Perestelo-Perez L.,

Patel M., Robson D., Rance J., et al. (2009) Atti-

et al. (2011) Psychiatric patients’ attitudes

tudes regarding mental health nurse prescribing

cowards concordance and shared decision

among psychiatrists and nurses: a cross sec-

making. Patient Education and Counselling 85,

tional

e245–e250.

Journal of Nursing Studies 46, 1467–1474.

Department of Health (1968) Medicines Act.

18–21. Bhasker R. (1975) A Realist Theory of Science.

HMSO, London.

questionnaire

study.

International

Ross J., Clarke A. & Kettles A. (2014) Mental health nurse prescribing: using a constructivist

Department of Health (2007) Mental Health: New

approach to investigate the nurse–patient rela-

Bradley E., Wain P. & Nolan P. (2008) Putting

Ways of Working for Everyone. Department of

tionship. Journal of Psychiatric and Mental

mental health nurse prescribing into practice.

Health, London. Available at: http://www

Nurse Prescribing 6, 15–19.

.dhgov.uk/publications (accessed 27 January

Leeds Books, Leeds.

Castledine G. (2000) Nurse prescribing: the sensible way forward. British Journal of Nursing 9,

2015). Section 4.5.4. Department of Health and Social Security (1986) Neighbourhood Nursing: A Focus for Care.

454. Chambers M. (1998) Interpersonal mental health

HMSO, London. The Cumberlege Report.

Health Nursing 21, 1–10. Snowden A. (2008) Qualitative analysis of mental health nurse prescribers in Scotland. Journal of Psychiatric and Mental Health Nursing 15, 471–478. Snowden A. (2010) Integrating medicines manage-

nursing: research issues and challenges. Journal

Gray R., Wykes T. & Gournay K. (2002) From

of Psychiatric and Mental Health Nursing 5,

compliance to concordance: a review of the lit-

203–211.

erature on interventions to enhance compliance

Snowden A. & Martin C. (2010) Mental health

Cornwell C. & Chiverton P. (1997) The psychiatric

with antipsychotic medications. Journal of Psy-

nurse prescribing: a difficult pill to swallow?

advanced practice nurse with prescriptive

chiatric and Mental Health Nursing 9, 277–284.

Journal of Psychiatric and Mental Health

authority: role development, practice issues, and

Guba E.G. & Lincoln Y.S. (1989) Fourth Genera-

outcomes measurement. Archives of Psychiatric

tion Evaluation. Sage Publications, Newbury Park, CA.

Nursing 11, 57–65. Crown J. (1989) Report of the Advisory Group on Nurse

Prescribing.

HMSO,

London.

The

Crown Report, Department of Health. Crown J. (1999) Review of Prescribing, Supply and Administration of Medicines. Department of Health, London. Final Report.

Jones A. (2006) Supplementary prescribing: poten-

of Psychiatric Nursing 24, 178–188.

Nursing 17, 543–553. Tomar R., Jakovljevic T. & Brimblecombe N. (2008) Psychiatrists’ and nurses’ views of mental health nurse supplementary prescribing:

tial ways to reform hospital psychiatric care.

a survey. Psychiatric Bulletin 32, 364–365.

Journal of Psychiatric and Mental Health

Tong A., Sainsbury P. & Craig J. (2007) Consoli-

Nursing 13, 132–138.

dated criteria for reporting qualitative research

Jones M., Bennett J., Lucas B., et al. (2007) Mental

(COREQ): a 32-item checklist for interviews

health nurse supplementary prescribing: experi-

and focus groups. International Journal for

Cutcliffe J. (2002) Commentary: the beguiling

ences of mental health nurses, psychiatrists and

effects of nurse prescribing in mental health

patients. Journal of Advanced Nursing 59, 488–

nursing: re-examining the debate. Journal of Psy-

ment into mental health nursing in UK. Archives

496.

Quality in Health Care 19, 349–357. Turner S. (2007) Non-medical prescribing in community mental health settings. Mental Health Practice 11, 29–32.

chiatric and Mental Health Nursing 9, 365–375.

Nolan P. & Bradley E. (2007) The role of the nurse

Cutcliffe J. & Campbell P. (2002) Opinion. Mental

prescriber: the views of mental health and non-

Wainwright S.P. (1997) A new paradigm for

mental health nurses. Journal of Psychiatric and

nursing: the potential of realism. Journal of

Health Practice 5, 14–17. Cutcliffe J. & Happell B. (2009) Psychiatry, mental

Mental Health Nursing 14, 258–266.

Advanced Nursing 26, 1262–1271.

health nurses and invisible power: Exploring a

Norton S. (1999) The philosophical bases of

Wix S. (2007) Independent nurse prescribing in the

perturbed relationship within contemporary

grounded theory and their implications for

mental health setting. Nursing Times 103,

mental health care. International Journal of

research practice. Nurse Researcher 7, 31–43.

30–31.

Mental Health Nursing 18, 116–125.

540

© 2015 John Wiley & Sons Ltd

The impact of mental health nurse prescribing

Appendices Appendix I Flow chart of selection process.

© 2015 John Wiley & Sons Ltd

541

J. D. Ross

Appendix II Discussion guide for clients of nurse prescribers 1. Introduction • Outline purpose of interview/discussion • Ensure participant reads information sheet • Discuss confidentiality and audio recording. One person to speak at a time. • Opportunity for questions • Complete consent form and give copy to participant 2. Perspectives of Service users who have their medication prescribed by a non-medical prescriber. Tell me about your experience of mental health nurse/ non-medical prescribing • What are your thoughts about mental health nurses prescribing independently? • Tell me about the impact that nurse prescribing has had on you • Has nurse prescribing impacted on your care? • Can you give some examples? • What are your thoughts about how nurse prescribing has changed your treatment? • Tell me your thoughts about non-medical staff having prescribing responsibilities/being able to prescribe for you • Has non-medical prescribing changed your relationship with the prescriber? • If so, in what way? • How do you feel non-medical prescribing impacts on communication with you? • Do you feel nurse prescribing has impacted on the nurse-patient relationship? • Can you give some examples? (Prompt: effect on power imbalance) • Do you feel the nurse prescriber-patient relationship is different from the regular nurse patient relationship?

542

• Did you have your nurse before she/he became a prescriber? • If yes how did becoming your prescriber impact on your relationship? • What are your thoughts about prescriptive authority and the balance of power with the non-medical prescriber? • Can you give some examples? • Do you think nurse prescribing has changed the emphasis from care to cure? • Do you think that nurse prescribing affects concordance? • Can you give some examples? • Are you more likely to tell the nurse? • Do you feel that non-medical prescribing has affected access to treatment? • Can you give some examples? • What do you think about the length of time the nurse has to spend with you? • How easy is it to get an appointment with your psychiatrist or nurse prescriber? • Who would you rather have prescribe for you and why? • Prescribing by doctors or prescribing by nurses-what is the difference for you? • (Prompt what does the nurse do that the doctor doesn’t etc?) • Can you give some examples? 3. Ask participants if they have any other comments to make, sum up and close; thanking all for their time and contributions. Inform that I will write a report and will come back down at the end of the year/into next year to give a presentation of the results.

© 2015 John Wiley & Sons Ltd