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AUTHORS Professor Kevin Gournay Deputy Head, Health Service Research Department, Institute of Psychiatry Dr Richard Gray Health Service Research Department, Institute of Psychiatry The views expressed in this Discussion Paper are those of the authors, and do not necessarily reflect those of their colleagues, or the views of the South London and Maudsley NHS Trust, or the Institute of Psychiatry. The contents of this discussion paper are the copyright of the Institute of Psychiatry ISBN: 0 9500289 4 0 1 SHOULD MENTAL HEALTH NURSES PRESCRIBE? MAUDSLEY DISCUSSION PAPER Number 11 Kevin Gournay and Richard Gray, Health Service Research Department, Institute of Psychiatry, Kings College, London INTRODUCTION In March of 2000, the Government announced that it would accept and take forward the main recommendations of the review of prescribing and the administration of medicines (Department of Health, 1999a). The NHS plan published in July of 2000 reinforced the Government’s commitment to extend nurse prescribing to a wider range of nurses from an expanded nurse prescribers formulary (Department of Health, 2000a). In turn, the Queen’s Speech in late 2000, set out proposals for making changes to the Medicines Act, thus paving the way for more radical changes in prescribing. In October 2000, the Department of Health issued a consultation paper on proposals to extend nurse prescribing, and in that suggested that mental health might be an area where nurse prescribing should take place (Department of Health, 2000b). The consultation period for this paper ended in January 2001. The Secretary of State has already announced that an extra £10 million will be provided to train nurse prescribers between 2001 and 2004. The consultation paper points out that there are already 23,000 district nurses and health visitors who have authority to prescribe from the Nurse Prescribers Formulary (NPF; Department of Health, 2000b). However, this formulary is limited and concentrates mainly on dressings and appliances, although it does include a number of medicines, including some Prescription Only Medicines (POMs). At present it is possible to add a POM to the NPF, but this involves 2 an application (for each individual POM) to the Medicine Control Agency (MCA), consideration by the Committee of the Safety of Medicines (CSM) and a period of public consultation prior to Ministers taking a decision on amending the order. This process takes several months. Obviously if there were radical changes in nurse prescribing, with a very large number, and wide range, of POMs added to the list, this process would rapidly become unworkable and a new system would need to be set in place. The consultation paper sets out five options for nurse prescribing. Option 1 - No change to current arrangements; Option 2 – Expanding the scope of nurse prescribing to all General Sales List (GSL) medicines and pharmacy medicines, but maintaining the current situation regarding POMs, such that adding any of these to the nurse prescribers formulary would involve individual applications prior to amendment of the POM Order; Option 3 – Include all GSL and pharmacy medicines and a specified range of POMs to cover certain conditions - for example, asthma, hypertension, and diabetes; Option 4 – Nurses able to prescribe all GSL and pharmacy medicines and all licensed POM medicines, with the exception of controlled drugs and a limited number of POMs which would be deemed unsuitable for nurse prescribing; Option 5 – The most radical of the options. Nurses to prescribe all GSL and pharmacy medicines and all POMs, with the exception of controlled drugs. However, the consultation paper makes the point that even in the case of controlled drugs, it may be sensible to allow nurses to prescribe some controlled drugs - for example, opioid analgesics in palliative care. It is worth noting at this point that midwives already have the authority to prescribe opioid analgesics. 3 The consultation paper sought views on these options and a number of other matters, including which nurses should prescribe and the issue of the educational preparation and training for nurse prescribing. At the time of writing this discussion paper in February 2001, the consultation responses are still being considered. THE ISSUES This discussion paper will consider a number of inter-related issues concerning nurse prescribing in psychiatry. These are: 1. Should mental health nurses be provided with any prescriptive authority? 2. If mental health nurses are to prescribe, should this be confined to specific diagnostic categories and certain classes of drugs? 3. What level of independence should they have if they are to prescribe? 4. What are the training issues? 5. How could mental health nurse prescribing be evaluated? THE CONTEXT Before discussing the specific questions regarding nurse prescribing in psychiatry, it is worth considering some important matters of context. One might argue that the proposed changes in legislation to provide nurses with prescriptive authority are merely endorsing long established practice. It is widely acknowledged that nurses working in a wide range of areas in medicine make important prescriptive decisions. For example, senior nurses in acute surgical wards and intensive care units adjust dosage and timing of opioid analgesics and anti emetics, with the physician writing a prescription, which may then be "interpreted" by the nurse. Pain control nurse specialists carry out detailed assessments on patients and write a drug treatment plan that is endorsed by the physician. Diabetic clinic nurses give patients detailed and 4 frequent advice regarding insulin dosage, while the actual face-to-face contact of patient with doctor may be limited to twice yearly reviews. We should also remember that midwives have had the legal authority to prescribe controlled drugs for many years and this practice is simply accepted by all involved. Finally, we also need to remember that patients are also empowered to take prescriptive decisions because of innovations in pain control (patient controlled analgesia) and of course have the ability to buy, of their own accord GSL medicines, some of which, nurses are currently unable to prescribe. There is no doubt that there have been major advances in the pharmacological treatment of psychiatric problems. Apart from the obvious advances in the treatment of depression (Limoba and Moncrieff 2000; Geddes et al 2000) and schizophrenia (Kennedy et al 2000; Wahlbeck et al 2000) by medications with more acceptable side-effect profiles and, arguably, greater efficacy, many would also argue that we have also become more effective in treating more complex disorders, such as refractory depression, by various combinations of medicines, such as fluoxetine and olanzapine (Mischoulon et al, 2000). Recently the use of new generation anti-depressant drugs have brought benefits to patients with a wider range of problems, such as obsessive compulsive disorder (McDougal, 2000), general anxiety (Carrasco et al 2000) and post traumatic stress disorder (Stein et al 2000). There is also an increasing recognition that in both chronic mental illnesses and neurotic conditions, psychological treatments and psychosocial approaches are beneficial both on their own (for example CBT for PTSD Marks et al 1998) and in combination with treatment with medication (for example Group CBT for voice hearers Wykes et al 1999). However, on a more downbeat note, drug treatments in psychiatry fail dismally for a whole variety of reasons, to reach their true potential, in day-to-day clinical practice. As a result there is substantial untreated psychiatric morbidity and mortality. 5 Perhaps one of the most fundamental problems is that of recognition and diagnosis. For example, in general practice the detection rates for depression may be as low as 30% (Doherty, 1997). While depression, and indeed other psychiatric disorders, may never be detected, in schizophrenia the picture is somewhat different. The problem here is that detection is often greatly delayed (McGorry and Jackson 1999), leading to severe and often tragic consequences. However, once an appropriate diagnosis has been made, there are still enormous problems with both patient adherence to treatment regimens and appropriate prescribing (in all diagnostic groups). Kisling (1994) has argued that if patients taking antipsychotic medication were completely compliant, approximately 15% of patients would relapse each year. Currently, around 50% of patients relapse within a year of achieving a remission. Much of the failure of drug treatments to achieve their potential in alleviating mental distress can be attributed to unnecessary side effects caused by poor prescribing. It has long been recognised that unless clinicians use valid and reliable measures of symptoms and side effects, many potentially distressing side effects may go unrecognised. For example, Weiden et al (1987) observed that psychiatrists, using their clinical judgement, only detect about 26% of patients with akathisia and 60% with drug induced Parkinsonism. In a survey of Community Mental Health Nursing (CMHN) practice (Gray 2001) found that fewer than a quarter of CMHNs surveyed routinely used recognised measures to screen for side effects. ( Community Mental Health Nurse is now the official title for a Community Psychiatric Nurse (CPN)). It was also found that CMHNs frequently avoided asking patients about important side effects such as sexual dysfunction. On a more positive note the same study found that if CMHNs had received psychosocial intervention 6 training, which develops clinicians skills in using a variety of measures, there was a significant increase in the proportion who report using assessment tools. Although the precise prevalence of untreated side effects from psychotropic medication is largely unknown, surveys of antipsychotic prescribing suggests that there is a substantial proportion (perhaps even a majority) of patients experiencing distressing and probably unnecessary side effects (Taylor et al 2000). Recognising that prescribing medicines is an increasingly complex and challenging process Professor Robert Kerwin founded the Maudsley prescribing guidelines in 1994. For the first time the guidelines gave prescribers practical advice in making treatment decisions that would enable them to maximise the efficacy and minimise the side effects of psychotropic medication. The first edition was published in 1994 and was predominantly used by clinicians working in the Bethlem and Maudsley NHS Trust. The fifth edition, published in 1999, sold more than 20,000 copies all over the world. The most recent edition (the sixth; Taylor et al 2001) is a comprehensive text which offers evidence based guidance to clinicians on the treatment and management of a range mental illness and includes an extensive section on the treatment of the side effects of psychotropic medication. However, we know that psychiatrists often fail to "comply" with prescribing guidelines and unacceptable levels of polypharmacy, inappropriately high dosages and an under utilisation of new treatments persist (Taylor et al 2000). With regard to adherence to treatment, there is no doubt that this is partially determined by the more general health beliefs of the general public (Paykel et al, 1998). However, adherence to medication is also compromised by side effects, especially extrapyramidal symptoms, sexual dysfunction, weight gain and sedation 7 (Gray and Gournay 1999). Nevertheless, it is important to remember that side effects are not the only reason for non-compliance. There are a number of other factors associated that influence compliance including patient's awareness of the seriousness and nature of the problem (their insight) clinician behaviour, the convenience of taking medication (e.g. the frequency of dosing), and the involvement of carers (Kemp et al 1997). On a more positive note, it is also known that adherence in depression and schizophrenia may be improved by brief targeted psychological interventions (Department of Health 1999b; Kemp et al 1997; Gray et al 2001). What is the cost of treating mental disorders? Psychiatric disorders are the commonest cause of premature death and years of life lost, with a disability accounting for some 23% of the burden of disease in high income countries (WHO, 1999). In purely financial terms this equates to cost of £32 billion in England alone each year. According to Patel and Knapp (1998) this includes £12 billion in lost employment and approaching £8 billion in benefit payments. There are now a plethora of new pharmacological and psychological treatments for psychotic and affective disorders. Without doubt these treatments are under (and often inappropriately) utilised. One of the great challenges facing psychiatry is how to use a limited resource to most effectively treat one of the most disabled groups in our society. Is nurse prescribing one way of addressing this challenge? 8 1. Should mental health nurses be provided with any prescriptive authority? One might argue that before we provide nurses with prescriptive authority, we should attempt to address what are undoubtedly widespread poor standards of practice among psychiatrists, through initiatives improving adherence to guidelines and algorithms and using clinical governance mechanisms to increase the use of outcome measures. However it is clear that there is a national shortage of psychiatrists and that this is worse in areas of great need, i.e. the inner cities, where there is a higher incidence of mental illnesses and social deprivation. A simple calculation involving the number of general psychiatrists, the number of people on the caseloads of community mental health teams, the numbers of in-patients in psychiatric beds in the NHS and the much larger number of people with identified common mental disorders who cannot be adequately managed by primary care services, demonstrates clearly that there is only a meagre amount of psychiatrist time available for each patient. To compound the problem further, one also needs to consider the additional burdens on the average clinical psychiatrist of bureaucracy, management and legal duties. Simply put, no average psychiatrist, working in an average NHS Trust would be able to attain best prescribing practice on all patients on their caseload. At the present time there are approximately 57,000 registered mental health nurses on the UKCC Register who work in mental health settings: in 1996 some 6,700 (in England and Wales) of these worked as CMHNs; Brooker and White, 1997). It therefore seems logical that at least some of these nurses could be trained to take some delegated prescriptive functions from trained psychiatrists. Indeed, there is widespread anecdotal evidence that many nurses, particularly CMHNs, are de facto prescribers. We know, for example, that they may often give patients advice on changing the timing of doses and the dosage itself, pending discussion with the psychiatrist. Furthermore, we also know that psychiatrists often seek the advice of an 9 experienced CMHN regarding whether medication dosage should be increased or decreased, or indeed whether the patient should be switched to another medication. It seems logical, therefore, to recognise some of these functions and support them with adequate training, supervision and evaluation. In the USA this model has been successfully introduced and nurse prescribing in psychiatry is a reality in every state (Laraia 2000). In a minority of states, nurses have been provided with independent and unlimited prescriptive authority, including controlled drugs. Far from being problematic, there seems in the USA to be a growing widespread support of providing nurses with prescriptive authority from within the various mental health professions and the general public. However, as in the UK, there has been a paucity of research evaluating the impact on practice and clinical outcome of nurse prescribing. Having set out some important reasons why nurses might be given prescriptive authority, it is worth noting that there are also some arguments why a move to confer prescriptive authority on mental health nurses may not be beneficial. Returning to the issue of numbers of nurses; whilst it is true that nurses are a more numerous group than psychiatrists, there is still a grave national shortage. For example in the South London and Maudsley Trust, there are more than 300 long-term vacancies across all grades, out of a nursing workforce of 2,500. As we have already observed, in England and Wales there are some 6,700 CMHNs. Nevertheless, as the last quinquennial survey demonstrated, (Brooker and White, 1997), this number does not adequately cater for the existing needs of people with schizophrenia and there is an increasing demand on CMHNs to provide services which are much more diverse than those to people with long term serious mental illnesses. The National Service Framework for Mental Health (Department of Health, 1999c) sets out a wide range of proposed improvements to mental health care, including the setting up of assertive community treatment teams with small 10 caseload sizes, and an increasing use of psychological and psycho-social treatment methods. At the present time, according to the quinquennial survey, the average caseload size for a CMHN is 37. However within the proposed assertive community treatment teams, which should be fully implemented across the country within the next few months, the average caseload size of a CMHN should be, at the very most, 15. Therefore, if one assumes that a significant number of CMHNs are to be employed within such teams, the caseload sizes of other CMHNs are certain to increase. In addition, CMHNs are now expected to deliver specialist interventions, such as cognitive behaviour therapy and family interventions for schizophrenia. As nurses are now acquiring training in these additional skills in programmes such as the Thorn initiative ( Gournay and Birley 1998) the expectations on a relatively small workforce of CMHNs will surely grow to unrealistic proportions. If nurses are to be given prescriptive authority some difficult decisions will have to be made on the range of services nurses can deliver. While there is a firm commitment to increase funding for mental health services within the NHS, it is difficult to see where the funding for additional CMHNs will come from. Indeed, even if such funding were readily available, there would remain the problems of recruitment and retention of people in such posts. Another factor that needs to be taken into account when considering the problems associated with providing CMHNs with prescriptive authority is that with this would almost certainly cause a further reduction in contact of the patient with medically qualified staff. This area of concern exposes another important consideration: that of co-morbid physical health problems. This is particularly important when treating mental illnesses where it has long been recognised that there is a higher standardised mortality rate (Department of Health 1995). One might argue that the contact of a qualified physician with a patient in order to provide prescriptive functions also provides an opportunity to assess physical health status and take 11 any action necessary. Furthermore, the high incidence of co-morbidity with physical health problems may make prescriptive functions in themselves, more complex because of the issues related to interactions between psychotropic and other drugs and the interactions between psychotropic drugs and various physical problems. Despite some anecdotal evidence from other clinical specialities that nurses are better at adhering to prescribing guidelines or protocols than doctors, there appears to be little empirical evidence to substantiate this claim. Indeed a search of the electronic databases Medline and Embase found no randomised or even controlled trials evaluating nurse prescribing. The evidence that exists in the UK comes from qualitative studies. For example, Luker et al (1998) interviewed 148 patients on the caseload of a District Nurse, Health Visitor or Practice Nurse (who had been trained to prescribe from a limited formulary) about their experiences of nurse prescribing. The overwhelming majority of patients were in favour of nurse prescribing. A number of patients reported that the nurse was more knowledgeable than the Doctor in certain areas (such as skin and wound care). Patients also reported that they like nurse prescribing because the nurse had more time and they felt they had formed a better relationship with them. It was also observed that Nurses were also easier to access than the Doctor. Therefore it seems likely that patients in psychiatry are likely to find CMHN prescribing useful and convenient. This may confer a number of practical advantages; because of more frequent and prolonged contact with the nurse, side effects can be identified and appropriate treatment can then be initiated; prodromal symptoms may be identified at an early point and any necessary changes in medication made. However, there is currently no evidence that the "liking" of nurse prescribing by patients results in improved clinical and social outcomes. 12 2. If mental health nurses are to prescribe, should this be confined to specific diagnostic categories and certain classes of drugs? If one accepts that nurses should, at least in principle, be given prescriptive authority in psychiatry, the next question to be addressed is how far should this prescriptive authority extend? The two central issues are first, which diagnostic groups should be targeted and second, which medications should be included? Given that the last Review of Mental Health Nursing (Department of Health, 1994) stated that the primary focus for mental health nurses should be people with serious and enduring mental illnesses, the obvious response to the first question is that prescriptive authority should be confined to the major mental illnesses, primarily psychotic disorders where CMHNs have most knowledge and experience. However, it is clear that one should also consider whether there would be some benefit in providing prescriptive authority to nurses working in primary care settings (and are therefore working predominantly with patients with neurotic disorders) and, indeed, whether some non-psychiatrically trained nurses, e.g. practice nurses should be trained to prescribe for common mental disorders, particularly depression. The Clinical Standards Advisory Group Report on Services for People with Depression (Department of Health 1999) showed clearly that people with depression often remain completely untreated by either pharmacological or non-pharmacological treatment methods. Perhaps the recommendation of the Mental Health Nursing Review, regarding the focus of mental health nursing, needs revisiting and policy makers need to consider whether there is indeed a role for mental health nurses in primary care working principally with people with depression. Given the enormous burden of depression, in terms of impairment to quality of life, work activities and relationships, it is clear that we need to consider strategies that will improve services to people with this diagnosis. Indeed, it is worth reiterating that there are predictions that depression will become 13 the second most important condition (in the world) in terms of disability days lost by the year 2020 (World Health Organisation 1999), If one assumes that the same problems of capacity apply to general practitioners as to psychiatrists (and this is debatable), then there is an obvious role for nurses. Indeed, the argument about using non-psychiatrically trained nurses needs to be put into the context of a workforce of some 637,000 Registered Nurses, Midwives and Health Visitors in the United Kingdom; by far and away the largest single workforce of any professional group. The question of which medications nurses should or should not have prescriptive authority is important. An obvious example of a drug that should probably always remain under the authority of a psychiatrist is clozapine because of the complexity of dose titration and risk of blood dyscrasias. However one might also argue that in Clozapine clinics, a specially trained nurse prescriber would add tremendous value by increasing the capacity of an expert multi disciplinary team where practice is likely to be good and expertise concentrated. The same case might be made for nurse prescribers in Methadone clinics. There are other examples where nurse prescribing would be problematic such as lithium augmentation in patients with refractory depression where complex physiological variables may need the consideration of a physician . However, if nurse prescribing is to be effective in achieving its aims then it will need to extend beyond simple dose titration. Careful consideration will need to be given to a range of other issues, for example whether nurses should be able to switch patients experiencing acute extrapyramidal symptoms or apparently developing tardive dyskinesia to atypical or novel antipsychotics. 14 3. If nurses are to prescribe, what level of independence should they have? If it is concluded, as seem logical, that mental health nurses should simply confine their efforts to people with serious and enduring mental illness, there are still a number of issues that need to be addressed. First, at what point should the nurse take over prescriptive functions? Should this be early on in treatment – i.e. once a firm diagnosis has been established and a treatment regime commenced? Or should nurses take over prescriptive functions once a period of remission or stability is reached. There are obviously differences in treatment response times in various mental illnesses and, indeed, within the same illness the time to treatment response may vary considerably. Furthermore, if a patient suffers an acute onset of schizophrenia for the first time, and the nurse takes over prescriptive authority once a treatment response has been obtained, does there come a point at which the nurse discontinues or reduces medication for a trial period? Decisions of this sort of course bring the difficulties associated with prescriber independence (and accountability) into the picture. In some states in the USA nurses have complete independence in their prescriptive authority, while retaining some responsibility to ensure that they have access to appropriate advice/supervision. Therefore, even if one assumes that nurses should have prescriptive authority, the degree of independence of prescribing needs to be very carefully considered. The less radical option may be that nurses should not have the power to initiate new prescriptions, but merely to vary timing and dosage. However as we have already argued, this is, already happening in practice and therefore this option will not move matters much from the status quo. One solution to the problem of who (in terms of diagnosis) could be safely managed by a nurse prescriber and what drugs may be used, should probably be the subject of a decision/treatment algorithm, perhaps a more detailed/explicit version of the Maudsley 15 prescribing guidelines. For example, nurses would take over prescriptive functions in patients with a single diagnosis, without significant physical co-morbidity and with a certain degree of stability in their symptoms and function. Even if one was to adopt such an exclusive approach, it is likely that this would still involve a substantial proportion of patients of the Community Mental Health team being managed by a nurse prescriber. The obvious benefit of this would be that psychiatrists would be able to concentrate efforts on patients with complex problems, those who were refractory to treatment and patients with associated medical conditions. If one makes the assumption that some nurses could have prescriptive authority and manage certain groups of patients within a treatment algorithm, there would still be a need to define the level of supervision in terms of quality, intensity and frequency. The issue of supervision begs another set of questions. Who should supervise? Could a GP provide supervision? Do supervisors need special training? More contentiously is it acceptable (to the Nursing profession) for a doctor to supervise a nurse? 4. What are the training issues? With regard to training, we could of course learn a great deal from the experience of psychiatric nurses in the USA. However, the systems of nurse training are quite different between the UK and the US and, indeed, within the USA there are considerable variations in training between different states. One matter which distinguishes newly-qualified nurses in the USA from nurses in the UK is that, by and large, nurses in the USA have a much greater grounding in a number of core subjects, notably neuroscience and psychopharmacology. Furthermore, the concept of the advanced practice registered nurse in the USA is arguably much more developed than the similar concept of the nurse practitioner in the UK. In the UK the nurse led clinic is still seen as "new". However in the USA the concept of the Nurse Practitioner or Advanced Practice Nurse running (and being accountable for) their clinics is 16 long established. There are very large numbers of these specialist nurses fulfilling duties, which 20 years ago would have been the sole province of the physician. Additionally, it should be noted that in the USA indemnity issues have been resolved, and although the position varies from state to state, both the nurse and the general public are protected financially should malpractice occur. There is widespread recognition that the UK university-based Project 2000 courses are deficient in a number of core areas and, following a recommendation by an Education Commission set up by the UKCC in 1999, Project 2000 is being revamped. Under the new arrangements, all student nurses will undertake a one-year Common Foundation Programme, which comprises theory and an introduction to general nursing concepts, with a limited amount of clinical experience. This will be followed by 2 years of speciality training in one of four areas: general nursing, learning disability nursing, children’s nursing or psychiatric nursing. This contrasts with the current system where students spend 18 months in a common foundation programme and only 18 months in their chosen speciality. At present graduating nurses have little experience of working independently. Without doubt, new graduates in psychiatric nursing require a substantial amount of further education, training and experience before they can work autonomously - for example, training for work in CMHN roles. It is also worth noting that many training programmes for mental health nurses are dominated by an “anti-medical model” philosophy. There are certainly a number of leading figures in psychiatric nursing who challenge current concepts of mental illness and argue that mental health nurses should have nothing to do with diagnoses and/or "medical treatments” (Barker and Reynolds, 1996; Lego 1997). On the other hand, there are approximately 70 institutions of higher education that offer nurse education and training, and some programmes do offer students sound evidence-based theory and skills training. What perhaps needs to be 17 emphasised is that there is a great variation in the nature of undergraduate preparation for psychiatric nursing, and this needs to be taken into account when considering important issues such as prescribing. Having made the criticisms about pre-registration psychiatric nursing, it is worth remembering that British mental health nursing probably leads the world in initiatives aimed at training highly skilled specialists. Since 1972 the Maudsley Hospital has trained nurses on the famous Nurse Therapy Programme (initiated by Professor Isaac Marks), and over the past 28 years some 300 nurses have qualified to become specialist cognitive behavioural practitioners. This programme has been extensively evaluated and followed up (Gournay et al, 2000). This programme has demonstrated that nurses are able to acquire skills in assessment and treatment just as well as their colleagues in other professional disciplines. In the area of serious mental illness there is now nearly 10 years of experience of training within the Thorn Programme (Gourney and Birley 1998), which sets out to train nurses in evidencebased methods, including assertive community treatment, psychological interventions and family work with people with schizophrenia. The Thorn programme has shown that nurses can be trained to use valid and reliable measures of psychopathology and social function and that these skills are transferable to ordinary clinical (rather than research) settings (Gournay, 2000). With regard to medication management, there is now strong trial evidence (Gray 2001) that CMHNs working in ordinary clinical settings can be trained to deliver evidence-based approaches aimed at improving medication adherence. In the Gray (2001) study provided with the training package produced significant improvement in patients’ psychopathology over CMHNs in a no training control condition. This package of training includes the 18 acquisition of skills in the use of valid and reliable measures of psychopathology, the use of side effect rating scales, basic psychopharmacology and treatment principles and the use of cognitive behavioural strategies to improve engagement and collaboration. This training programme takes some 80 hours of contact time between teacher and students and it is difficult to see how such skills can be learned in significantly lesser time. Although the results of the Gray (2001) study provide cause for optimism that CMHNs can be taught to help patients manage their medication more effectively, it should be pointed out that the teaching contact time for nurse prescribers in the USA is usually at least 200 hours, plus additional supervisory contact. Six hours of contact time constitutes a normal teaching day on most educational programmes in the UK. The current cost of training in the UK (assuming that the students are taught in classes of approximately 15) is approximately £50 per student per day. If one adds to this figure the cost of replacing the nurse while training takes place and adds incidental expenses, a rough estimate is that training in prescribing will cost approximately £4,000 per nurse. Thus, even if we only set out to train 1,000 of the country’s 6,700 CMHNs, the training budget would need to be some £4million. Given that the entire training budget for the three year period announced by the Secretary of State was £10m to cover all nurse prescribing across all areas of healthcare, it is difficult to see how nurse prescribing in mental health could be a realistic prospect without diverting money from other initiatives, or indeed from services. On the other hand, even if the money was to become available, there are probably insufficient numbers of suitably qualified personnel to train nurse prescribers. A recent study for the NHSE (Brooker et al, 2000) demonstrated that there is an acute shortage of personnel who are suitably qualified and experienced in teaching evidence-based approaches. Thus, if nurse prescribing in psychiatric nursing was to be implemented, the numbers of nurses trained would be relatively small and it would be some 19 years before we obtained a sufficient infrastructure of trainers. In a sense, therefore, the problem concerned with shortage of trainers solves the problem of the relatively small training budget! 5. How could nurse prescribing be evaluated? Although we have seen a tremendous number of changes in health policy in the past few years, many of these developments remain unevaluated. Indeed, nurse prescribing in the USA, which is so widespread, does not appear to have been evaluated within any controlled trials. The same may be said of various training programmes in the UK where we spend huge amounts of money to train workforces in various approaches, but seldom, if ever, evaluate the impact of such training on patient outcomes or, indeed, on the skill acquisition of the trainees (Gournay and Thornicroft, 2000). The prospect of nurse prescribing provides the unique opportunity to evaluate a new health policy and also to examine a wide range of issues concerned with treatment by medication. A randomised controlled trial carried out in several centres would allow evaluation of the policy of nurse prescribing by concentrating on outcomes such as patient psychopathology, treatment adherence and the costs and possible cost benefits of the approach. In addition such a study would need to measure nurse skill and knowledge and capture the patient perspective. A group of researchers from the Institute of Psychiatry, the University of Manchester, the University of Birmingham, Imperial College and the University of Cambridge have collaborated to plan a suitably powered randomised controlled trial. This group estimate that the costs of a full evaluation of nurse prescribing in psychiatry will be between £800,000 and £1million, spread over a three to four year period. Obviously, such a sum is very large. However, one needs to juxtapose this sum of money 20 against, the costs of not knowing whether the implementation of nurse prescribing in psychiatry leads to any positive (or negative) changes. CONCLUSION There seems little doubt that the present government is committed to increasing prescriptive authority for nurses. Furthermore, Psychiatry may be one area nurse prescribing will develop. As we have discussed there is no simple answer to the question “Should mental health nurses prescribe?” In many ways prescriptive authority for nurses is merely a logical extension of the nurse's role and much in keeping with the changes in nursing over the years. Provided that the initiative is supported by robust education and training and followed up by not only clinical supervision but also continuing professional education, there is, theoretically, no reason why nurse prescribing should not lead to an improvement in the quality of patient care and treatment. Having said that, this discussion paper has set out a range of problems associated with the concept, not least the stretching of an already overburdened workforce of nurses. Nevertheless, one might conclude that nurse prescribing is something which should be gradually and cautiously introduced. 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