Health

NURSE PRESCRIBING Nurse prescribing: a case for clinical supervision Mark Jukes, Jeannette Millard, Cheryl Chessum he whole fabric and structure of the NHS, nursing and primary health care is currently undergoing rapid change. Recent years have seen many developments in health policy, in particular regarding arrangements for the delivery of primary health care (Box 1). As part of these changes, several key policy documents from the Department of Health (DH) have suggested that nurses’ skills and experience should be developed to enable them to deliver high-quality care in areas that are designated priority clinical targets, or are currently within the professional domain of doctors (DH, 1999a; 2000a,b,c). Since April 2002, level 1 nurses have been given the opportunity, following a period of additional training, to become independent nurse prescribers, enabling them to prescribe from a wide range of drugs. New prescribing rights for nurses, sanctioned in April 2003 – specifically the expansion of the extended independent nurse prescribers’ formulary and the implementation of supplementary prescribing – aim further to revolutionize many aspects of health care. Making a Difference (DH, 1999b) predicted that 23 500 nurses and health visitors would be able to prescribe within a few years, and one of the recommendations made by the NHS Plan (DH, 2000a) is that the majority of nurses should either be prescribing by 2004, or should be supplying and T Box 1. Contextual changes G Introduction of NHS Direct and Walkin centres,one-stop health shops. G The abolition of traditional health authorities which have been replaced by strategic health authorities. G The introduction of primary care trusts that will have responsibility for commissioning all NHS services. G The introduction of care trusts that will act as the single provider for health and social care. British Journal of Community Nursing, 2004, Vol 9, No 7 administering medicines under patient group directions. The aim is to break down the barriers between professions and enable patients to gain easier access to the medicines they need (DH, 2002b). It is the Government’s vision to develop a primary care-focused NHS, with nurses working in extended roles and taking a lead role in service provision. Examples of these new roles include: G Minor illness clinics G Nurse triage G Walk-in centres G One-stop health shops G Personal medical services (PMS) pilots G Working with the homeless, travellers, asylum seekers and refugees G Family planning and sexual health. Some nurses have welcomed the introduction of this delegated work arguing that it enhances the status of nursing. However, others have argued that doing medical ‘tasks’ takes nurses away from the professional pursuit of better nursing practice (McCartney et al, 1999). In support of this view is the British Medical Association’s (BMA) proposed new model for NHS care which, in essence, is designed to create a Mark Jukes is Reader in Learning Disabilities, the School of Primary Health Care, University of Central England, Birmingham. Jeanette Millard is a Senior Lecturer/Practitioner with the School of Health, University of Staffordshire. Cheryl Chessum is a Lecturer/Practitioner with the School of Primary Health Care, University of Central England, Birmingham. Email: Mark.Jukes@ uce.ac.uk ABSTRACT This article will discuss the implications of nurse prescribing in mainstream primary health care and its impact on the fields of mental health and learning disabilities. Complexities and issues which require serious consideration by those nurses wishing to pursue such a specialist and extended role will be discussed in relation to these practice areas. Titchen’s (1998) critical companionship model will be illustrated as an example of one framework for clinical supervision. This is to allow the processes, competencies and contextual issues to be explored by both novice and expert prescribers. The article concludes that for safe, effective and competency-based practice, clinical supervision also assists in mediating the professional and political aspirations in support of supplementary nurse prescribing. Key words: Nurse prescribing, clinical supervision, mental health, learning disabilities, primary care 291 NURSE PRESCRIBING ‘It is imperative that nurse prescribers should be able to provide an informative, accurate and balanced perspective on medication which is understood by the patients.’ solution for the shortfall in GP numbers. It recommends that the first point of contact for patients should be a nurse practitioner (BMA, 2002). This, together with the additional creation of independent and supplementary nurse prescribers in primary care, will undoubtedly contribute towards relieving some of the pressures placed on GPs, freeing them up to concentrate on more complex cases. Corresponding government directives have advocated a reduction in junior doctors’ hours (NHS Management Executive, 1991; DH, 2000c), but there has been little assessment of the impact that this will have on other health professionals and on patient care. Nevertheless, nursing has unique qualities which nurse prescribing training must exploit. Horrocks et al (2002) found that patients reported increased satisfaction with nurse practitioner consultations in relation to GP consultations. This corresponded with the longer consultations they had with nurse practitioners, but patients also appreciated that nurse prescribers gave more information and were better communicators than doctors. Supplementary nurse prescribing in mental health and learning disabilities Since the DH consultation of October 2000 (DH, 2000b), mental health has been discussed as an area where nurse prescribing should take place. Learning disabilities is also an area which could benefit from nurse prescribing. The authors’ practice experience suggests that both arenas of practice share similar complexities in the management of illness, chronic disease management, and neurological and behavioural manifestations and concerns. In both these fields of practice, nurses now have the opportunity to volunteer to become supplementary nurse prescribers if their employing trust wishes to second them for the appropriate training. In many ways, the relationship between doctor and nurse supplementary prescriber is a reflection of current practice in mental health nursing. The supplementary prescriber role is dependent on a respectful partnership with an identified independent prescriber (e.g. a doctor) who will determine, in consultation with the supplementary prescriber (and ideally a pharmacologist), the boundaries of a clinical management plan (CMP) for each individual patient. Nevertheless, prescribing in mental health and learning disabilities presents many unique challenges to prescribing practitioners. The remainder of this article will examine these issues in more detail, and discuss how a model of clinical supervision with potential to help practitioners work through these issues. 292 Unique challenges Prescribing in mental health in particular is a serious process for patient and prescriber. Not only are the drugs prescribed extremely powerful, but the expectancy to comply with prescribed medications is perhaps greater than with many other areas of care (Doran, 2003). This is largely due to the impact and consequences of the illness on the individual,as well as the requirement from society for the individual to conform to social norms through treatment of serious mental illness. As Doran emphasizes, the process of prescribing is also complicated by what patients bring to a consultation for psychotropic medication, which is influenced by a range of factors, including the stigma attached to related diagnosis, side-effects and fear of addictions to such medications. In addition, there are often concerns about such information on personal records and what such information might say about them as an individual. These factors make it imperative that nurse prescribers should be able to provide an informative, accurate and balanced perspective on medication which is understood by the patients. Indeed, the various consumer charters, such as The Patient’s Charter (DH, 1995), Your Guide to the NHS (DH, 2001c) and the Human Rights Act 1998, demand it. Medicine, holism and opportunities In order to prescribe competently and safely, as well as to be able to provide the appropriate level of information to patients, it is critical for mental health and learning disability nurses to have a thorough knowledge of the medications they will be dealing with, including pharmacokinetics and pharmacodynamics. The challenge is to identify how this knowledge affects how the nurse perceives his or her role with service users within a prescribing relationship. A balance must be sought between offering a bio-pharmacological medical perspective and a holistic health promotion perspective. There are many examples where prescribing has made, and can make, a significant contribution to practice. In the case of community mental health, prescribing as part of a therapeutic medication plan within an intensive home treatment team has successfully managed patients in the home (Flowers, 1998). Specialized areas such as clozapine clinics could also greatly enhance patient care through supplementary prescribing. Brown (2002) and Gourney and Gray (2001) extend this suggestion into other specialist areas such as methadone clinics and add that if nurse prescribing is to be successful then it needs to extend beyond simple titration. Hemingway (2003) has commented that the DH British Journal of Community Nursing, 2004, Vol 9, No 7 has also suggested that mental health nurses in primary care may prescribe in areas such as anxiety and depression. There are also many opportunities within learning disability for supplementary prescribing by nurses in primary care, epilepsy, and mental health (dual-diagnosis) services, and in the management of challenging behaviour. Valuing People (DH, 2001b) specifically stated that all people with learning disabilities who display challenging behaviours require a full medical assessment. This is in recognition that psychotropic medication, although effective for some, is sometimes overused as an alternative to adequate staffing. Therefore, when prescribing for patients with learning difficulties, it is important that supplementary nurse prescribers appraise the whole situation as part of the CMP. Thomas (2003) suggests that nurses’ therapeutic relationship with patients enhances their ability to adjust medication within an agreed plan of care, and without having to wait for an outpatient appointment with a psychiatrist. Nurses would be able to advise patients with chronic illness on a variety of medications and symptomatology. In addition, with some outpatient clinics in learning disability, nurses could be involved in developing screening tools for assessing service users for sideeffects. For example, patients could be screened for tardive dyskinesia, where severe adverse sideeffects of certain types of psychotropic medications can induce unpleasant and irreversible sideeffects (Taylor, 2002). Prescribing and the organization of care Prescribing must be seen in the context of changes in the organization of care. The last major surveys showed there were approximately 6700 community mental health nurses in England and Wales (Brooker and White, 1997) and 1275 community learning disability nursing staff in England (Royal College of Nursing, 1988). Neither figure is likely to reflect the situation today – with the development of new service models following the publication of the National Service Framework for Mental Health (DH, 1999c) and Valuing People (DH, 2001b) there are likely to be many more; many of whom are likely to be performing different roles, such as that of health facilitator. By contrast, there is a national shortage of psychiatrists (Gournay and Gray, 2001). This reinforces the argument in favour of nurse prescribing. However, in view of the overall shortage of qualified nurses in the NHS, nurse prescribing can not be simply a ‘bolt-on’ to existing practice caseload British Journal of Community Nursing, 2004, Vol 9, No 7 demands. The appointment of supplementary nurse prescribers requires a systematic review of roles, responsibilities and carefully designed job descriptions which facilitate a sensible and achievable development of the role. Nursing in the fields of mental health and learning disabilities is unique in its case management focus. Prescribing is seen by some as outside this role, as a task-oriented undertaking. However, the holistic element of care is at the heart of supplementary prescribing. As partners in the development of the CMP, nurse supplementary prescribers in mental health and learning disabilities are in an excellent position to ensure that CMPs are well thought out and sensitive, and reflect a positive, ethical, legal and humanitarian perspective which supports and extends the nurse prescriber’s role beyond merely the adjustment of medications. In the case of severe and enduring mental illness, for example, a significant number of mental health nurses have undertaken specific targeted skills training in family work interventions (commonly known as psychosocial interventions), which has resulted in a reduction in the symptoms that service users experience (Brooker et al, 1992) and could be an adjunct or alternative to some medication plans. ‘Nurse supplementary prescribers in mental health and learning disabilities are in an excellent position to ensure that CMPs are well thought out and sensitive, and reflect a positive, ethical, legal and humanitarian perspective.’ Dichotomy of opinions The impetus for nurse prescribing comes from the desire to improve patient care, and as has been discussed, there is potential for prescribing nurses in mental health and learning disabilities to have a significant impact on patient care. However, not everyone is wholly in favour of nurse prescribing. Strong arguments for and against nurse prescribing in mental health care have been aired in the specialist literature. Box 2 illustrates the philosophical and professional differences as discussed by Gray and Gournay (2001) and Cutliffe (2002). Some commentators have suggested the role of the supplementary prescriber in mental health is legitimizing widespread de facto prescribing among nurse practitioners (Gournay and Gray, 2001), but formally instituting the role makes the accountability for practice far more explicit and direct. A study by Nolan et al (2001) reported that nurses are broadly in favour of nurse prescribing. However, in a study by Sodha et al (2002), nurse prescribers identified several areas of concern (Box 3). It is critical that education programmes are sufficiently robust to ensure safe and effective prescribing (Courtenay and Butler, 2002), but also that mechanisms are in place to enable the profession to work through the philosophical, professional and political issues discussed here in order 293 NURSE PRESCRIBING Box 2. Dichotomy of supplementary nurse prescribing issues Gray and Gournay (2001b) G The psychiatric and mental health nursing role needs expanding. G Nurse prescribing is used by psychiatric nurses in the North American health care system. G Management of medication is at the core of nursing. G The current British government endorses the idea and has already established consultation groups. G Good medication management enhances client concordance. G Arguments against nurse prescribing are raised by sceptics who exist in ‘a time warp’ and have something of a ‘Luddite’ attitude. Cutliffe (2002) G Is nurse prescribing really concerned with expanding the role of the nurse, or is it to do with the wider sociopolitical and economic changes and taking on additional ‘cast-offs’ from medicine' G A different health care system exists in America, amid a culture of generic nurse training adopting one scheme, but yet not accepting other values and systems. G Mental health nursing predates widespread use of psychotropic medication. Evidence is such that the interpersonal human-to-human connection is what clients want. G Governments are frequently seen to do u-turns on policies, e.g. community care and purchaser-provider split. G Contradictory evidence relating to concordance. Cannot on its own be regarded as the ‘intervention’ that leads to positive outcomes. G Need to fully debate and conduct a critical examination of all the issues Maintaining competency The publication Maintaining Competency in Prescribing (National Prescribing Centre, 2001a) outlines a framework where extended nurse prescribers need to take into account the scope of their professional practice. This framework has recently been re-engineered specifically to assist in the preparation and support of nurse supplementary prescribers (NPC, 2003). Part of this framework refers to ‘the team and individual context’ (Box 4). This is particularly relevant for nurse prescribers to pursue in order to enhance effective and evidencebased practices. The competencies require increased levels of communication in all forms to achieve transparency of all processes. Interpersonal skills are therefore central to practice and the competencies enshrine the principle of seeking support as well as teamworking and collaborative practice. As expertise develops, the role will extend to supporting novice prescribers and this will assist in promoting further creativity in the art of prescribing, pursued within a framework and process of reflection and clinical supervision. In addition, it is important to have the appropriate clinical support mechanisms, including time and access to resources for keeping updated and to facilitate essential practice development in the trusts. to carve out a sensible and achievable role in professional practice. Supporting nurse prescribers through clinical supervision Prescribing is here: where next' A First Class Service (DH, 1998) provides the framework for quality in the NHS in the form of clinical governance: It is quite clear that the UK Government requires specialist mental health and learning disability nurses to be supplementary nurse prescribers. In order to address the issues raised in this article and fulfil this aspiration, there is a clear necessity for adequate education, strong support, and encouragement and tools to enable reflection on practice. This is especially the case for those who are entering nurse prescribing as a novice in order to allow a successful transition into the role. Box 3. Areas of concern for nurse prescribers G Self-related knowledge and confidence levels in dealing with medication-related matters G Levels of perceived experience in dealing with medication-related problems in practitioner’s daily work G Drug management issues G Posology (issues relating to drug dosages) G Specific drugs and their interactions G Pharmaceutical interventions for specific medical conditions Source: Sodha et al (2002) 294 ‘The emphasis [in clinical governance] is on developing open and supportive frameworks to help individuals, teams and organizations reflect upon their performance and learn from mistakes, rather than seeking to attribute blame. At a clinical level, this includes systems for clinical supervision, continuing professional development and the development of clinical leadership skills.’ There are a variety of models and frameworks for pursuing clinical supervision which focus specifically on elements relating to the role of the supervisor (Farrington, 1995), the supervisory relationship (Sloan and Watson, 2002) and those which emphasize the development process of the supervisory relationship. It is the latter in which the authors would recommend Titchen’s (1998) critical companionship model as an appropriate one for the purposes of developing nurse prescribing. Titchen’s model puts a great deal of emphasis on an experienced and established nurse prescriber as British Journal of Community Nursing, 2004, Vol 9, No 7 being a critical companion (or critical friend), who supports the novice nurse practitioner on entering into nurse prescribing. The model has some parallels with Benner’s (1984) ‘novice to expert’ model, and has been integral within existing nurse prescribing courses at the University of Central England for students to experientially consider issues relating to prescribing practice. The core elements of the critical companionship model focus on the supervisors’ skilled use of dynamic interpersonal processes, which include reflection and critical dialogue. Such discussion will include aspects around the science, art and wider contextual aspects of supplementary prescribing. Once the novice prescriber gains confidence and competency through an intensive process of supervision, opportunities for further development with other prescribers can be initiated in the form of support groups (Collins and George, 2003). Networking is also an avenue to focus on professional development where the overall contribution to the prescribing process contributes to the sustainment of nursing knowledge. This critical dialogue will, it is to be hoped, lead to supplementary prescribing being embraced more confidently as a true extension of role within the existing domains of professional nursing practice. As the role is undertaken, more evidence will emerge in the literature of practitioners disseminating the rewards of being a supplementary prescriber, including findings associated with clinical gains. Table 1 shows a worked example of how the critical companionship model (Titchen, 1998) may be applied as practiced in a safe environment, i.e. a simulation of a prescribing consultation, to be formally assessed at a later stage by an objective structured clinical examination (OSCE). The table also shows where the ‘art’ of consultation can be practiced to pursue a positively structured and processed consultation. Conclusion The present government is fully committed to increasing prescribing powers for nurses across mainstream primary health care and in specialist areas such as mental health and learning disabilities. Nevertheless, as identified from the discussion, there are many complex issues associated with the prescribing process, as well as professional issues about whether nurses should or should not prescribe. If supplementary prescribing is to succeed it needs to be supported through robust education and training, coupled with equally strong clinical supervision and professional development. Primary care trusts have a responsibility and requirement to sup- British Journal of Community Nursing, 2004, Vol 9, No 7 Box 4. The team and the individual context Works in partnership with colleagues for the benefit of patients. Is selfaware and confident in own ability as a prescriber. G Proactively negotiates with the independent prescriber to develop clinical management plans G Relates to the independent prescriber as an equal partner G Maintains the integrity of the prescribing partnership G Thinks and acts as part of a multidisciplinary team G Establishes working relationships with colleagues to ensure that continuity of care is not compromised G Listens to and respects the views of colleagues G Establishes credibility with colleagues G Recognizes and deals with pressures that might result in inappropriate prescribing (e.g. pharmaceutical industry, patients and colleagues) G Is adaptable, flexible and responsive to change G Negotiates the appropriate level of support for role as a nurse supplementary prescriber G Provides support and advice to other team members, where appropriate Source: National Prescribing Centre (2003) port practitioners by providing them with a conducive learning environment. This can be done in conjunction with higher education institutions and can influence curriculum design both in nursing and across other professions as part of shared learning and the promotion of interprofessional practice. I Benner P (1984) From Novice to Expert: Promoting Excellence and Power in Clinical Nursing Practice. Addison-Wesley, Menlo Park British Medical Association (2002) A New Model for NHS Care. BMA, London Brooker C, Tarrier N, Barrowclough C, Butterworth A, Goldberg D (1992) Training community psychiatric nurses for psychosocial intervention. Report of a pilot study. Br J Psychiatry 160(6): 836–44 Brooker C, White E (1997) The Fourth Quinquennial National Community Mental Health Nursing Census of England and Wales. University of Manchester., Manchester. Brown P (2002) Proposal for Supplementary Prescribing in a Clozapine Clinic. Seminar presented at the conference ‘Nurse Prescribing in mental health/learning disabilities services’. De Montford University, Derby. 24 September 2002 Collins G, George K (2003) Development and support of community nurse prescribers. Primary Health Care. 13(2): 36–8 Cooper MC (1995) Can a zero defects philosophy be applied to drug errors' J Adv Nurs 21(3): 487–91 Courtney M, Butler M (2002) Education and nurse prescribing. Nurs Times 98(9): 53–4 Cutliffe JR (2002) Beguiling effects of nurse prescribing in mental health nursing: re-examining the debate. J Psychiatr Ment Health Nurs 9(3): 365–75 Department of Health (1995) The Patients Charter and You. A Charter for England. The Stationery Office, London Department of Health (1998) A First Class Service: Quality in the New NHS. DH, London Department of Health (1999a) Our Healthier Nation: Reducing Health and Inequalities: An Action Report. DH, London Department of Health (1999b) Making a Difference: Strengthening the Contribution of Nurses, Midwives and Health Visitors. DH, London Department of Health (1999c) National Service Framework 295 NURSE PRESCRIBING Table 1. The critical companionship model Processes/ Strategies Consciousness raising Articulation of craft knowledge Problematization Self-reflection Critique Sharing of craft knowledge of the prescribing process which includes the sociopolitical and professional context of nurse prescribing. Could be identified with insecurity, anxious feelings relative to prescribing itself, posology issues, interdisciplinary conflicts. The art of the consultation process. Focus on role, confidence and competency issues. Contracting of the prescribing role and relationships with GP, psychiatrist and pharmacologist in teams. Enabling the expert and novice nurse prescriber to discuss facets of sociopolitical and professional aspects which influence the nurses role in prescribing. Observing, listening and questioning Within ‘role play’ in the form of an objective structured clinical examination (OSCE). Supervisor invites supervisee to explore the approach adopted in the consultation process. Questioning methodology enabling supervisee to further explore style and assessment criteria for diagnosis and prescribing. Develops further insight into personal behaviour and style, e.g. not being assertive enough, passivity. A need to create a balance between listening skills and a more directive dialogue. Insight gave us the opportunity to critique how nurses have been traditionally portrayed, both by the public and the wider health team. Issues such as concordance, prescribing as a means towards patient/client empowerment and education are explored. Feedback on performance Use of observation notes on actual dialogue and practice. Confidence issues in ‘art’ of assessment and prescribing process. Comparative feedback among peers. Issues such as control or passivity in a consultation. Balance in how the patient/client consultation is managed. Prescription of appropriate drugs. Identification of personal behaviours through a heightened exploration of selfawareness and feedback into the consultation process. Theorized about the value of nurse prescribing. Value of knowledge relative to the NPF/BNF. Relationship between clinical effectiveness, evidence-based practice into prescribing is of critical value. High challenge support Observation of actual prescribing. Issues such as contributing ably the knowledge base relative to patients condition or perhaps reticent in contributing to the consultation. Interpersonal qualities of engagement. Supervisee may identify factors such as feelings of uncertainty-especially in seeing new patients/clients. Has to know people for some time before feelings of self-assuredness develop. Starts to think more about an action-rehearsal plan in attempts to make self and patient/client more at ease in a consultation process. Formulates discussion around the value of confidence in support of autonomous practice. Evidence-based practice and prescribing. Sharing knowledge pertaining to pharmacokinetics and pharmacodynamics in practice. Critical dialogue Our theorizations about the socialization of nurses relative to other professionals, raised the awareness and potency attached to concepts such as leadership and change theory. Supervisee like many assumed that once a role had been assigned to, in this case nurse prescribing, everyone else in the health care team would accept that person into the role. No real appreciation of how deep conflict could reveal itself in terms of e.g. power games. Theorized that it is not acceptable to practice without a clear strategy when working collaboratively. To be more aware of the need for more assertive styles and based on personal/ professional knowledge and experience. Critiqued the idea that formal theories of communication (e.g. Heron (1998)) and leadership styles (e.g. Hersey and Blanchard (1988)) needed to be applied on an individual level, and in the prescribing and team context. Role modelling By demonstrating the ‘art’ of By identifying critical aspects the prescribing consultation, of the role play and the supervisor is attempting to consultation. maximize the potential of rolemodelling for the facilitation of critical reflective practice. Supervisee is able to make comparisons with own performance. Supervisee could see that this situation and role was new and invaluable in gaining further insight into the need to adopt a more coherent and structured approach to nurse prescribing. 296 British Journal of Community Nursing, 2004, Vol 9, No 7 Table 1 (continued). The critical companionship model Processes/ Strategies Consciousness raising Using Self When challenging the supervisee about prescribing within simulated OSCEs, supervisor can become more consciously aware of being supportive and genuinely motivated towards the supervisee’s ability to enhance professional knowledge base through further interpersonal confidence and competence. Problematization Self-reflection Critique Supervisor attempts to demonstrate a supportive stance in delivering a constructive critical observation. By using empathy, silence and positive non-verbals, e.g. smiling, eye contact and leaning forward. For the supervisee to receive these as a positive learning experience and not to go away feeling a failure. The supervisor, by generating enthusiasm for specialist nurse practitioners as prescribers. Supervisor needs to encourage this open dialogue to critical debate between nurse prescribers. Source: Titchen (1998) for Mental Health. 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Quay Books, Dinton, Salisbury Titchen A (1998) A Conceptual Framework for Facilitating Learning in Clinical Practice. Centre for Professional Education Advancement, Australia KEY POINTS G Changes in health care policy means that nurses are instrumental in rolling out many of these new initiatives, including nurse prescribing. G The government requires that the majority of nurses to be prescribing by 2004, or supplying and administering medicines under patient group directions. G Many concerns are identified by nurse prescribers which substantiate the need for clinical supervision. G It is critical for mental health and learning disability nurses to have a thorough grounding and knowledge of the medications in the nurse prescribers’ formulary. G It is essential that supplementary prescribing is articulated and evaluated through a sound framework of clinical supervision. 297