The role of the nurse prescriber: the views of mental health and non-mental health nurses

Factors Influencing Nurses’ Opinions on the Implementation of Nursing Advice in Poland

In the past five years, nursing practice has changed drastically in Poland. Nurses have received many new competencies in response to the need to provide services to patients. The purpose of the study was to analyze nurses’ opinions on the new rights to provide nursing advice and to identify factors that influence their opinions in this regard. A descriptive cross-sectional study was conducted among 798 nurses who work in various medical facilities. The influence of selected variables on nurses’ opinions on the provision of nursing advice to patients was evaluated using logistic regression. The nurses surveyed had a positive attitude towards new competencies and believed that they were able to independently provide the patient with advice within the scope provided by Polish legislation. Logistic regression showed that the factors that statistically significantly influenced nurses’ opinions on particular types of nursing advice were age (p = 0.038), education (p = 0.000), and the place of work of the respondents; that is, hospital (p = 0.016). More research is needed to demonstrate the effectiveness and quality of the implemented nursing advice and its impact on the functioning of the health system.

Perceptions of underlying practice hierarchies: Who is managing my care?

BACKGROUND

The introduction of new health professional roles, such as that of the nurse practitioner and pharmacist prescriber in primary health care can lead to changes in health service delivery. Consumers, having used these roles, often report high satisfaction. However, there is limited knowledge of how these individuals position nurse practitioner and pharmacist prescriber roles within existing practice structures.

METHODS

Semi-structured interviews were conducted with 21 individuals receiving services from these practitioners in New Zealand primary health care. Interviews were recorded and transcribed verbatim for thematic analysis.

RESULTS

Participant views reflect established practice hierarchies, placing advanced practitioners 'below' general practitioners. Participants are unable to articulate what it was about these practitioners that meant they operated at lower tiers and often considered practitioners to act as 'their doctor'. They also highlight structural barriers impairing the ability of these providers to operate within their full scope of practice.

CONCLUSIONS

While seeing value in the services they receive, consumers are often unable to position nurse practitioner and pharmacist prescriber roles within health system contexts or to articulate how they value their practitioner's skills. Embedded structural barriers may be more visible to consumers than their interactions with the health system suggest. This may influence peoples' ability to receive intended or optimal health services. Consumer 'health professional literacy' around the functions of distinct health practitioners should be supported so that they may make informed service provision choices.

The Implementation Process of Nurse Prescribing in Poland-A Descriptive Study

The study aimed to investigate the situation of nurse prescribing, introduced in Poland in 2016, by analyzing the opinions of nurses, expected to be influential on nurses' actual practices, in response to legislative change to enable nurses to prescribe and comparing this with actual nurse prescribing behaviours during the early years of the legislation. The paper fills a knowledge gap and provides baseline data analysis for subsequent research. Nurses' opinions were collected during the period they were preparing themselves for prescribing. That data was compared with data on the character and extent of nurses' actual prescribing practices over the first two years of implementation. The study showed the number of nurse prescriptions increased. Comparing the first and second years of nurse prescribing, the number of nurse independent prescriptions more than doubled. Over the same period, the number of nurse supplementary prescriptions increased almost six-fold. The implementation of nurse prescribing has increased the scope of nursing care, especially in the treatment of the infections, pain and chronic conditions in the elderly.

Nurses' Experiences in using Physical Activity as Complementary Treatment in Patients with Schizophrenia

INTRODUCTION

Schizophrenia is a common disease with a high risk of comorbidity in both psychiatric and somatic diseases. Physical activity is proven effective in reducing symptoms of schizophrenia and increasing overall health. Still it is not used systematically in the care of persons with schizophrenia.

AIM

The aim of this study is to describe nurses' experience, including personal motivation, in using physical activity as complementary treatment in patients with schizophrenia.

METHOD

Interviews in three focus groups with 12 participating nurses were conducted. Qualitative content analysis was used to analyze data.

RESULTS

Physical activity was commonly used. Although several nurses signaled positive patient response, i.e. less anxiety and better quality of sleep, the overall consensus was an uncertainty regarding the benefits. It was perceived as non-evidence based form of intervention.

CONCLUSION

The uncertainty of the benefits of physical activity is evident in nursing staff and poses a resistance to implement systematic physical activity as a complementary treatment in schizophrenia. A new awareness of evidence based nursing is suggested to promote a wider and more receptive attitude to reduce patient vulnerability in persons with schizophrenia.

Perception of nurse prescribing among nurses and psychiatrists in a developing country: A cross-sectional survey

Nurse prescribing has the potential to improve patients' access to, and experiences of, treatment. The aim of the present study was to examine nurse and psychiatrist attitudes about this extended role in a developing country. We conducted a cross-sectional survey using a previously-used, 65-item, seven subscale measure of attitudes to nurse prescribing in mental health. We achieved a 79% response rate. The majority of participants had trained in developing countries where nurse prescribing has yet to be implemented. Across five subscales (general beliefs, impact, uses, training, and supervision), both groups reported positive attitudes about nurse prescribing. Both groups scored the training subscale particularly highly. Compared with psychiatrists, nurses were more confident about the range of clinical settings where nurse prescribing could be applied (e.g. acute inpatient and substance use). Although both groups had less favourable attitudes on the two subscales relating to clinical and legal responsibility, compared to nurses, psychiatrists were more undesirable. Although, overall, clinician attitudes do not seem to represent a barrier towards the potential implementation of nurse prescribing in the study setting, clarity about clinical and legal responsibility needs to be addressed.

Nurse prescribing in primary care: a metasynthesis of the literature

Aim The aim of this metasynthesis was to develop an understanding of the existing theoretical perspectives around nurse prescribing and to identify any gaps in knowledge, which would support further research into the lived experience of the nurse prescriber in the primary care setting.

BACKGROUND

Nurse prescribing has been the focus of many research studies since its introduction, with many benefits to the patient, the prescriber and service identified; however, there remains variation in the utilisation of the prescribing qualification, particularly in primary care settings. Although a range of quantitative and qualitative studies have been undertaken, which aimed to explore the influences on prescribing, few have used a research methodology that supports the in-depth exploration of the nurse prescriber's experience.

METHODS

An extensive literature search was undertaken in April 2015 (20-24), which included UK and non-UK studies since 1999. Inclusion and exclusion criteria were applied to search for studies in which participants included nurse prescribers who practiced in primary or community care settings. Studies that only used a quantitative methodology and those not available in English were excluded. The literature search yielded 124 papers, with 50 papers remaining after the initial screen of full papers against the inclusion/exclusion criteria. The papers were reviewed and graded for their quality, with a further 13 papers excluded. A three-step qualitative analysis technique of metasynthesis was applied to the remaining 37 papers. Identification of similarities and differences enabled first-order interpretations to be identified, which were grouped into broader themes (second-order interpretations) by identifying concepts that applied to two or more studies. Further interpretation through synthesis of translation enabled third-order interpretations to emerge. Findings From the metasynthesis of the 37 papers, nine themes emerged: patient-centred care; benefits to the service; the need for knowledge; professional accountability and boundary setting; safety consciousness; barriers to effective prescribing; role preservation; power-shifts and inter-professional relationships; and culture of prescribing.

Mental health nurse prescribing: the emerging impact

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. 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. 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.

Postgraduate education in psychiatric nursing in Israel: closing the gap

Deinstitutionalization policies are being gradually implemented in Israel. Most recently, an insurance reform has been approved, in which mental health services will be included in the HMO's service package. As most Israeli mental health nurses are currently employed in institutional settings, the Ministry of Health's Nursing Division seeks to estimate their scope of employment in preparation for the anticipated changes. The aim of this study is to describe present-day professional practice characteristics of qualified psychiatric nurses and identify practice areas for which advanced training may be required. The research design is cross-sectional on a national level, including all state psychiatric hospitalization services. A countrywide sample of nurses with post-basic training in state psychiatric hospitals identified areas of practice in which further training may be required: psychotherapy intervention (60% of respondents); consultation for the elderly (60%); care prescriptions (64%); community drug treatment management (69%); and referral to professionals and community resources (56%). Nurses reported gaps in continued care and community rehabilitation activities. These findings have training implications in an era of increased focus on chronic mental illness in the community.

Medicines management: an interview study of nurses at a secure psychiatric hospital

AIMS

To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training.

BACKGROUND

Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs.

DESIGN

An exploratory mixed-methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios.

METHODS

Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012-February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes.

RESULTS

The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1-7), indicating that many participants did not appear to be aware of, or compliant with, current UK medicines management guidance and local policy. Many would not report a 'near miss' or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off-label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self-reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards.

CONCLUSION

The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.

An evaluation of team and individual formularies to support independent prescribing in mental health care

Mental health nurses have been entitled to train to become independent prescribers since May 2006; although the number of trained nurse prescribers seems to have increased steadily, a significant number of them have not actually undertaken prescribing roles on completion of their training or have limited their practice to supplementary prescribing. In order to support existing independent prescribers and to assist those nurses who have trained but are yet to prescribe independently, a mental health trust has piloted the use of individual and team formularies. An evaluation of this project indicated that formularies were well received by existing independent prescribers and were seen as a helpful instrument to support newly qualified and supplementary prescribers in their bid to become independent. Formularies can clarify and formalize each prescriber's area of competence, thus setting clear boundaries, reducing uncertainty and enhancing prescribers' confidence and willingness to take on this new role. Formularies may also be used to enhance communication with service users and further develop shared decision making. Effective procedures need to be in place to ensure formularies are up to date and reflect local practice.

Mental health nurse independent prescribing: what are nurse prescribers' views of the barriers to implementation?

This paper reports a pilot study exploring mental health nurse prescribers' perceptions of barriers to prescribing independently but also includes perceptions of barriers to supplementary prescribing. Current prescribing practice as experienced by mental health nurses suggests a need to identify and highlight these barriers. A mixed methodology explanatory sequential study was carried out over 3 months in Scotland in 2008 as part of a Master's degree. A questionnaire was completed by 33 mental health nurse prescribers. A focus group was conducted with 12 mental health nurse prescribers. Participants' views exposed a number of barriers to prescribing previously unidentified in a review of the relevant literature, and concurred with some previously documented barriers. Sixty per cent of mental health nurse prescribers in the study were not prescribing. Barriers identified in the study included concern about how prescribing impacts on the therapeutic relationship, role conflict, lack of support, inappropriateness of prescriber training, remuneration, qualifying to prescribing time, supervision, prescribing policies, clinical governance and nurse management. Nurse prescribing involves increased accountability and responsibility which is not currently recognized in job status or pay banding. Mental health nurse prescribing has the potential to enhance service provision, but until barriers to prescribing have been identified and addressed as part of the process of organizational change, nurse prescribing cannot achieve its maximum potential.

Does psychopharmacology training enhance the knowledge of mental health nurses who prescribe?

The implementation of Mental Health Nurse (MHN) prescribing in the UK remains disappointing. A much cited critique of MHNs prescribing is that it would be unsafe, as MHN would not have the appropriate knowledge of pharmacology to practise mental health prescribing. The knowledge of pharmacology of MHNs with the prescribing qualification has not been assessed in the UK. In addition, the views of MHNs with the prescribing qualification who have undertaken a psychopharmacology course have not been explored. The aims of this study are to measure the efficacy of a 10-day advanced training programme on psychopharmacology on the knowledge levels of MHNs with the prescribing qualification; and to explore the positive and negative experiences of individual participants of the training in psychopharmacology and how it supported their prescribing practice. A repeated measures design was used in which participants acted as their own controls. Participants were assessed 10 weeks before the training programme and again on day one of the training programme using a Multiple Choice Questionnaire. In addition, a series of focus groups were conducted to explore the helpful and unhelpful aspects of the course in sustaining the MHNs' prescribing practice. Following the training period there were significant increases in the MHNs' knowledge of psychopharmacology in comparison with the two base line means. Participants when interviewed 18 months after completing the training described the training as a helpful though they described it had not resulted in large increases in prescribing practice, citing systemic barriers to its implementation. Short and focussed training for MHNs who prescribe may increase their knowledge of psychopharmacology. The development of such programmes may well be part of the solution to support MHNs with the prescribing qualification to prescribe, supported by the views of the MHNs who participated in the focus groups. However, further work is required to remove organizational barriers. The data raise questions both about the current suitability of nurse prescribing preparation programmes in the UK and the suitability of NHS settings to support MHN to prescribe.

British Association of Critical Care Nurses position statement on prescribing in critical care

BACKGROUND

Nurses in the UK are now one group of non-medical staff who can prescribe. This practice is evolving for critical care nursing staff who care for critically ill patients during their stay in hospital through ward and outpatient follow-up after admission to critical care.

AIM

The purposes of this paper were to present existing information regarding prescribing to support nurses in critical care currently prescribing and to inform those who are intending to prescribe.

METHODS

To develop the position statement, a search of the literature was conducted using key databases. To ascertain the current level and type of prescribing in critical care, a short questionnaire was sent by email to British Association of Critical Care Nursing members, and the results of this are presented in Appendix A.

OUTCOMES/RESULTS

Evidence was found in relation to the history, context in critical care, educational requirements and issues of consent related to non-medical prescribing.

CONCLUSIONS

The position statement is based upon evidence from the literature, National Health Service policy and the Nursing and Midwifery Council regulations. It takes account of the critical care patient pathway before, during and after an admission to critical care.

Nurses' and physicians' educational needs in seclusion and restraint practices

PURPOSE

This study aimed to explore nurses' (N= 22) and physicians' (N= 5) educational needs in the context of their perceived seclusion and restraint-related mode of action and need for support.

METHOD

The data were collected by focus group (N= 4) interviews and analyzed with inductive content analysis.

RESULTS

Participants recognized a need for on-ward and problem-based education and infrastructural and managerial support. The declared high ethical principles were not in accordance with the participants' reliance on manpower and the high seclusion and restraint rates.

PRACTICE IMPLICATIONS

Future educational programs should bring together written clinical guidelines, education on ethical and legal issues, and the staff's support aspect.

Survey of psychiatrists' views of nurse prescribing

For mental health nurses and service users to realize the benefits of non-medical prescribing, psychiatrists need to understand the remit of this role and be actively involved in influencing it. Although healthcare policy in the UK supports the expansion of non-medical prescribing, it requires much more for the successful implementation of such initiatives in practice. The aim of this survey was to explore the attitudes of all grades of psychiatrist working in two mental health trusts in the West Midlands to nurse prescribing. A specifically designed questionnaire was sent out to two groups of psychiatrists to assess their attitudes towards non-medical prescribing. Psychiatrists (n = 147) completed and returned a specifically designed questionnaire of their views. The more senior doctors appeared less concerned about nurse prescribing. Junior doctors expressed equivocation towards the role, suggesting that nurse prescribers be consistently supervised and have limited access to mental health drugs. The findings from this study have considerable implications for teams if junior doctors hold different views to their senior colleagues. Without the assistance of trusts in facilitating role change, the introduction of new roles could potentially heighten conflict between professions.

Views on nurse prescribing: a survey of community mental health nurses in the Republic of Ireland

A nurse prescribing scheme has recently been implemented within the Republic of Ireland. This paper reports on the views of community mental health nurses on nurse prescribing just prior to the implementation of the scheme. Data were gathered through a 13-item questionnaire administered to 103 members of the Association of Community Mental Health Nurses in Ireland. Results indicated a distinct difference of view between male and female community mental health nurses, with female nurses having greater reservations towards the desirability of nurse prescribing in relation to educational preparation and impact on professional relationships. Overall, only 17% of respondents favoured being supervised in their prescribing practice by their consultant psychiatrist. The paper concludes that there is ambivalence towards prescribing in this important group of nurses which may need to be taken into account if nurse prescribing is to be successfully implemented within the Irish mental health service context.

Quantitative analysis of mental health nurse prescribers in Scotland

The UK parliament approved legislation expanding prescribing rights for all registered nurses in 2006. Mental health nurses do not appear to be embracing prescribing to the same degree as their colleagues. For example, mental health nurses represent 14% of the UK nursing population, but only 3% nurse prescribing population. In order to explore this disparity, the paper discusses quantitative analysis of the following objectives: (1) describe the impact of nurse prescribing on nurse prescribers in NHS Greater Glasgow and Clyde; and (2) identify differences between mental health nurse prescribers and other nurse prescribers in NHS Greater Glasgow and Clyde. Following online pilot study, a 26-item questionnaire was posted to 668 nurse prescribers in NHS Greater Glasgow and Clyde. A total of 365 questionnaires were returned (55.4%). Significant differences were found between mental health nurse prescribers and others in terms of age, gender, prescribing practice, academic achievement, method of prescribing, workplace, experience and attitude to prescribing. Possible reasons for these differences are suggested and form the basis of further planned research.