Download AUTHORS Professor Kevin Gournay Dr Richard Gray

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
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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
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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.
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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
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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.
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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
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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
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(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?
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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
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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
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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
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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.
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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
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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.
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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
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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
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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
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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
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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
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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
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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. However, it is essential that the initiative be
evaluated within the context of a carefully designed multi-centre randomised controlled trial
before being fully implemented.
21
References
Barker P Reynolds W (1996) Rediscovering the proper focus of nursing
Journal of Psychiatric and Mental Health Nursing 3, 76 – 80.
Brooker C. and White E. (1997) The fourth quinquennial national community mental health
nursing census of England and Wales. University of Manchester, Manchester.
Brooker C Gournay K O’Halloran P Bailey D (2000) Mapping the capacity of the English
University System to deliver NSF training priorities. Report to the NHS(E), Leeds.
Carrasco J. L. Diaz-Marsa M. Saiz-Ruiz J. (2000) Sertraline in the treatment of mixed anxiety
and depression disorder. Journal of Affective disorders. 59, 1, 67-69.
Department of Health (1994) Working in Partnership: The review of Mental Health Nursing
London: HMSO
Department of Health (1995) Clinical Standards Advisory Group report on services for
people with schizophrenia. London: HMSO
Department of Health (1999a) Review of prescribing, supply and administration of medicines.
The Stationery Office, London.
Department of Health (1999b) Clinical Standards Advisory Group report on services for
people with Depression. The Stationery Office: London
Department of Health (1999c) The National Service Framework for Mental Health Services.
The Stationery Office: London.
Department of Health (2000a) The NHS Plan. The Stationery Office, London.
Department of Health (2000b) Consultation on proposals to extend nurse prescribing.
Department of Health, London.
Doherty J (1997) Barriers to the diagnosis of depression in primary care.
Journal of Clinical Psychiatry 58, 5 – 10.
Geddes J. Freemantle N. Mason J. et al SSRIs versus other antidepressants for depressive
disorder. (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update
Software.
Gournay K. and Birley J. (1998) Thorn: a new approach to mental health nursing. Nursing
Times, 94, 49, 54-55.
Gournay K (2000) Role of the community psychiatric nurse in the management of
schizophrenia: Advances in psychiatric treatment 6, 243-251.
Gournay K. Denford L. Parr A-M. Newel R. (2000) British Nurses in behavioural
psychotherapy a 25-year follow-up. Journal of Advanced Nursing, 32 ,2 ,343-351
22
Gournay K Thornicroft G (2000)
Letter: Comments on the UK700 case management trial
British Journal of Psychiatry 177, 371.
Gray R. and Gournay K (1999) What can we do about acute extrapyramidal symptoms.
Journal of Psychiatric and Mental Health Nursing, 7, 3, 205-211.
Gray R. (2001) A randomised controlled trial of medication management training for CPNs.
PhD thesis: Institute of Psychiatry: University of London
Kemp R. Hayward P. David A. (1997) The compliance therapy manual. The Bethlem and
Maudsley NHS Trust, London.
Kennedy E, Song F, Hunter R, Clarke A, Gilbody S. Risperidone versus typical antipsychotic
medication for schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 4, 2000.
Oxford: Update Software.
Kisling W. (1994) Compliance, quality assurance and standards for relapse prevention in
schizophrenia. Acta Psychiatrica Scandiniavica, 89, (supplement 382), 16-24.
Laraia M (2000) Psychopharmacology (chapter 28, pp 572-607). In Stuart G Laraia M:
Principles and Practice of psychiatric Nursing: Mosby: St Louis, Missouri.
Lego S (1997) A critique of Gournay’s position on nursing theory and models. Journal of
Psychiatric and Mental Health Nursing, 4, 64-66.
Limoba M. S. Moncrieff J. Drugs versus placebo for dysthimia (Cochrane Review). In: The
Cochrane Library, Issue 4, 2000. Oxford: Update Software.
Luker K Austin L Hogg C Ferguson B Smith K (1998) Nurse patient relationships: the
context of nurse prescribing. Journal of Advanced Nursing 28,2, 235-242.
McDougal C. J. Epperson C. N. Pelton G. H. (2000) A double blind placebo controlled study
of risperidone addition in serotonin reuptake inhibitor-refractory obsessive-complusive
disorder. Archives of General Psychiatry, 57, 8, 794-801.
McGorry P Jackson H (1999)
The recognition and management of early psychosis. Cambridge University Press;
Cambridge.
Marks I. Lovell K. Noshirvani H. et al (1998) Treatment of posttraumatic stress disorder by
exposure and/or cognitive restructuring: a controlled study. Archives of General Psychiatry,
55, 4, 317-325.
Mischoulon D. Nierenberg A. A. Kizilbash L et al (2000) Strategies for managing depression
refractory to selective serotonin reuptake inhibitor treatment: a survey of clinicians. Canadian
Journal of Psychiatry, 45, 5, 476-481.
Patel A. Knapp M. (1998) Costs of mental illness in England. PSSRU Mental Health
Research Review, 5, 4-10.
23
Paykel E Hart D Priest R (1998)Changes in public attitudes to depression during the Defeat
Depression campaign. British Journal of Psychiatry 173, 519 –522.
Stein D. J. Zung-Dirwayi N. van de Linden G. J. H. Seedat S. Pharmacotherapy for (1998)
Post traumatic Stress Disorder (Cochrane Review). In: In: The Cochrane Library, Issue 4,
2000. Oxford: Update Software.
Taylor D. Mace S. Mir S. Kerwin R. (2000) A prescription survey of the use of atypical
antipsychotics for hospital inpatients in the United Kingdom. International Journal of
Psychiatry in Clinical Practice. 4, 41-46.
Taylor D. McConnell D. McConnel H. Kerwin R. (2001) South London and Maudsley NHS
Trust 2001 Prescribing Guidelines. Martin Dunitz, London.
Wahlbeck K, Cheine M, Essali MA. Clozapine versus typical neuroleptic medication for
schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update
Software.
Weiden P. J. Shaw E. and Mann J. (1987) Causes of neuroleptic non-compliance. Psychiatric
Annals, 16, 571-578.
World Health Organisation (1999) The World Health Report. The World Health
Organisation, Geneva, Switzerland.
Wykes T. Parr A-M. Landau S. (1999) Group treatment of auditory hallucinations.
Exploratory study of effectiveness. British Journal of Psychiatry, 175, 180-185.
24