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									Improving mental health services by
extending the role of nurses in prescribing
and supplying medication:
Good practice guide

Produced jointly by the
National Prescribing Centre, the
National Institute for Mental Health in England
and the Department of Health


March 2005
For further information please visit the websites below:

       www.npc.co.uk      or    www.dh.gov.uk
Foreword




     Together with a range of psychological and social interventions, medication is one of the
     major therapeutic tools available to us to help people with mental health problems. Recent
     developments now allow mental health nurses to change the manner in which medication is
     prescribed and supplied. In particular, the introduction of supplementary prescribing allows
     nurses to improve services by utilising new and existing skills more efficiently and effectively.
     A major priority in mental health care is to make services more responsive to the needs of
     service users. Supplementary prescribing lets nurses, with the agreement of service users, do
     exactly this by being able to immediately make required adjustments to medication based on
     existing clinical management plans.


     New approaches to prescribing and supplying medication require close working between
     professionals, particularly doctors, nurses and pharmacists, and a need to develop positive
     partnerships with service users. Supplementary prescribing is a prime example of how flexible
     approaches to the delivery of care and new professional roles can contribute to providing
     quality mental health services.


     It is early days for these new developments and the introduction of new ways of working
     presents many challenges. This guide provides information and examples of good practice to
     help providers, recipients and commissioners of mental health care, to consider the potential
     benefits available and plan to make any developments safe and sustainable.




                                                                                                 Louis Appleby
                                                                             National Director of Mental Health




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                  Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     Contents



                             Foreword ....................................................................................................................................1


                             Executive summary ....................................................................................................................4


                             1         Introduction ....................................................................................................................6
                             1.1       Purpose of the guide ........................................................................................................6
                             1.2       Target audience ...............................................................................................................7
                             1.3       Definition of terms ..........................................................................................................7
                             1.4       Development of the guide ..............................................................................................8


                             2         Mental health nurses and medication...............................................................................9
                             2.1       The current situation .......................................................................................................9
                             2.2       Why introduce new ways to prescribe, supply and administer medication? ..................9
                             2.3       Mental health nurses and new ways of prescribing and supplying medication ...........10
                             2.4       Research .......................................................................................................................11


                             3         Service users’ perspectives ............................................................................................12
                             3.1       Current experiences .......................................................................................................12
                             3.2       Service users’ views of nurse prescribing .....................................................................12


                             4         Current progress in implementation and future plans ...................................................14
                             4.1       Findings of the survey ...................................................................................................14
                             4.2       The future ......................................................................................................................15


                             5         Nurse supplementary prescribing in mental health settings .........................................16
                             5.1       Aims of this section ......................................................................................................16
                             5.2       Definition of supplementary prescribing ......................................................................16
                             5.3       The concept — a brief overview ...................................................................................16
                             5.4       Frequently asked questions around implementation issues ..........................................17
                             5.5       Frequently asked questions around educational issues .................................................23


                            6          Patient group directions in mental health settings.........................................................27
                            6.1        What are patient group directions? ................................................................................27
                            6.2        When can patient group directions be used? .................................................................27
                            6.3        Who can use patient group directions?..........................................................................28
                            6.4        How can Trusts establish patient group directions for mental health nurses to use?....28
                            6.5        Supply and administration of controlled drugs via patient group directions.................29
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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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7         Prescribing from the nurse prescribers’ extended formulary ........................................30
7.1       Background ...................................................................................................................30
7.2       What training is required? .............................................................................................30
7.3       Can the formulary be used in mental health settings?...................................................30
7.4       When can extended formulary nurse prescribing be used in mental health settings?...31
7.5       When is a nurse ‘competent’? .....................................................................................32
7.6       What needs to be done to establish extended formulary nurse prescribing? ................33


8         Organisational implications of introducing new ways of working ...............................34
8.1       Considerations ..............................................................................................................34
8.2       Service users’ views ......................................................................................................34
8.3       Cost implications ..........................................................................................................34
8.4       Service structures ..........................................................................................................35
8.5       Workforce planning ......................................................................................................36
8.6       Clinical governance .......................................................................................................36
8.7       Relationships with other health care providers .............................................................37


9         Policies .........................................................................................................................38
9.1       Developing policies .......................................................................................................38


10        Good practice in medication management ...................................................................40
10.1      Background ...................................................................................................................40
10.2      Assessment ....................................................................................................................41
10.2.1    Physical assessment .....................................................................................................41
10.3      Medication Management key skills ..............................................................................41
10.4      How can nurses involve carers in order to ensure concordance with medication?.......43


11        Continuing professional development and maintaining competency ...........................44
11.1      Why is continuing professional development important? .............................................44
11.2      Maintaining competency ...............................................................................................45
11.3      What additional training may be helpful? .....................................................................45
11.4      What ongoing supervision do nurse prescribers need? ................................................45


12        Working with the pharmaceutical industry ...................................................................47
12.1      Contact with the pharmaceutical industry .....................................................................47
12.2      Where is guidance available? ........................................................................................47


Appendix A             NIMHE national nurse prescribing group members .......................................48


Appendix B             Nurse supplementary prescribing policy .........................................................50


Appendix C1 An example of a ‘broad’ clinical management plan .......................................53


Appendix C2 An example of a ‘specific’ clinical management plan ....................................54


References .................................................................................................................................55
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     Executive summary




                               1.       Mental health nurses already play a central role in the provision of medication and
                                        have considerable knowledge and experience in this area.


                               2.       Recent policy developments have allowed suitably trained mental health nurses to
                                        prescribe and supply medication in new ways in order to improve services for people
                                        with mental health problems. This good practice guide provides information about
                                        these opportunities, what potential benefits can come from their introduction and how
                                        organisations might go about doing so.


                               3.       Potential benefits of new ways of nurse prescribing and supplying medication include:


                                        a)       Allowing service users quicker and more effective access to medication
                                        b)       Increasing service user choice
                                        c)       Providing services more efficiently
                                        d)       Making better use of nurses' skills and knowledge


                               4.       Studies of nurse prescribing in the USA have demonstrated similar clinical outcomes,
                                        and, importantly, higher levels of user satisfaction compared to medical prescribing.


                               5.       Mental health service users in the UK are generally positive about nurses adopting the
                                        prescribing role, but need reassurance that they have a sound knowledge base and are
                                        suitably trained.


                               6.       To date, Trusts have varied widely in how actively they have been planning to make
                                        use of new opportunities to utilise and develop mental health nurses skills and
                                        experiences.


                               7.       Mental health care in prisons is an important example of an area that also has an
                                        opportunity to embrace innovative new working practices, including nurse
                                        supplementary prescribing.


                               8.       In order to maximise the benefit of new ways of working with medication, a strategic
                                        approach is required by Trusts.




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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9.    Key issues for Trusts and commissioners to consider include:


      a)     Costs — direct and indirect, e.g. spend on medicines, training time, clinical time
      b)     Service structure — particularly the potential impact and benefit on specialist
             clinics and out-of-hour services
      c)     Changing roles of professions — notably psychiatrists and nurses
      d)     Relationships with other organisations — especially primary care trusts
             regarding budgetary arrangements and access to prescription pads
      e)     Existence of supporting policies and clinical governance arrangements to ensure
             safe practice


10.   There are several mechanisms available to nurses for the prescribing, supply and
      administration of medicines. These include extended formulary nurse prescribing,
      supplementary prescribing and the supply and administration of medicines via patient
      group directions.


11.   All nurses trained as supplementary prescribers also have the qualification to prescribe
      from the Nurse Prescribers' Extended Formulary to treat a specified list of around 80
      medical conditions.


12.   Most mental health nurses will not be competent to prescribe for many of the medical
      conditions in the Nurse Prescribers' Extended Formulary. However, specialist services
      may develop training and policies to use the Nurse Prescribers' Extended Formulary to
      improve the care of patients in mental health settings.


13.   Applying the principles of medication management will maximise the benefits
      available from nurse prescribing.


14.   Maintaining competency after completing training is vital and can be achieved in a
      number of ways, e.g. additional training, clinical placements, updating training, clinical
      supervision and reading academic journals / guidelines.




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            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     Introduction




                            1.1      Purpose of the guide

                                     This guide aims to:

                                     l         Help improve the responsiveness of services for people with mental health
                                               problems and the experience of care they receive, by supporting the successful
                                               implementation of new ways for nurses to prescribe, supply and administer
                                               medicines in the NHS in England

                                     l         Provide factual information regarding:
                                               l     Nurse supplementary prescribing
                                               l     Extended formulary nurse prescribing
                                               l     Patient group directions

                                     l         Answer some common queries regarding these approaches that are particularly
                                               pertinent to mental health services

                                     l         Suggest and provide good practice examples to support ways of introducing and
                                               sustaining new practices in a safe manner

                                     l         Provide links to other sources of information



                                     The information specifically relates to new roles for nurses (and medical staff) in
                                     relation to supplementary prescribing. However, as pharmacists, in particular, have a
                                     very important role to play in new prescribing arrangements (both as supplementary
                                     prescribers and in supporting other prescribers) they may also find this guide useful
                                     and informative.


                                     Although this guide covers all mental health specialities, specific issues regarding
                                     children under the age of 16 are not addressed.




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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1.2   Target audience

      The potential developments described in this guide have implications for:

      l      Individual clinical care

      l      The structure and costs of services

      l      The roles of different professions

      l      Clinical governance structures

      l      Educational provision



      It is envisaged this document will be most useful to:

      l      Commissioners of services (for example primary care trusts)

      l      Strategic health authorities and workforce development directorates

      l      National Institute for Mental Health in England (NIMHE) development centres

      l      Local implementation teams

      l      Providers of mental health services working in HM Prison service

      l      NHS Trusts providing mental health services

      l      Nurses, doctors and pharmacists

      l      Higher education institutions

      l      Service user and carer organisations

      l      Acute care forums



1.3   Definition of terms

      This guide refers to the following approaches to the prescribing, supply and
      administration of medicine by mental health nurses:




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                              Supplementary prescribing
                              A voluntary prescribing partnership between an independent prescriber (doctor) and
                              supplementary prescriber (nurse or pharmacist) to implement an agreed service user-specific
                              clinical management plan with the service user's agreement.


                              Extended formulary nurse prescribing
                              Suitably qualified nurses may prescribe from the Nurse Prescribers' Extended Formulary to
                              treat a specified list of around 80 medical conditions. The Formulary and medical
                              conditions are set out in Part XVIIB(ii) of the Drug Tariff, the British National Formulary
                              and the Nurse Prescribers’ Formulary.


                              Patient group directions
                              Written instructions to enable registered nurses and other registered health professionals to
                              supply and administer a specified medication to a group of service users who may not be
                              individually identified before treatment. Patient group directions are not a form of
                              prescribing and there is currently no specific training that health professionals need to
                              undertake before supplying medicines in this way.




                            1.4      Development of the guide

                                     This guide was developed by a national group under the auspices of the NIMHE
                                     Nursing Advisory and Development Group (www.nimhe.org.uk/networks/nadg.asp)
                                     and has been subject to peer review. The group, and its advisors (see Appendix A for
                                     membership), consisted of:


                                     l         Mental health nurses from a wide range of clinical, managerial and academic
                                               backgrounds

                                     l         Service users

                                     l         Pharmacists

                                     l         Psychiatrists

                                     l         Representatives from the Nursing and Midwifery Council, the National
                                               Prescribing Centre and the pharmaceutical industry



                                     To support the development of this guide, the Institute of Psychiatry conducted a
                                     national survey, between March and June 2004, of directors of nursing in NHS Trusts
                                     providing mental health services.1 The survey aimed to provide a snap shot of how
                                     nurse prescribing in mental health settings is being implemented across England and to
                                     gauge attitudes to future developments (see Section 4 for findings).


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2 Mental health nurses and
  medication



     2.1   The current situation

           Mental health nurses strive to provide comprehensive and holistic care to individuals.
           Working with medication is one important part of this overall approach.


           Medication is a central part of treatment for many people with mental health problems,
           together with a range of psychological and social interventions. Medication has an
           important role to play in promoting recovery and / or enhancing the quality of life for
           people with mental health problems. For some individuals, it may be the only treatment
           that offers sustained respite from the most distressing symptoms.2-4


           Mental health nurses have always been intimately involved with the use of medication
           to treat mental health problems. Currently they administer medication, give advice,
           monitor effects and side-effects and, in reality may make de facto prescribing decisions
           by advising junior and / or non-specialist medical staff.



     2.2   Why introduce new ways to prescribe, supply and administer
           medication?

           The NHS Plan: a plan for investment, a plan for reform5 emphasises that health
           services need to change and modernise in order to improve service delivery. The
           introduction of nurse prescribing is part of the overall approach to modernisation and
           increased flexibility in the roles of professionals working in the NHS. The aim for all
           of these changes is to improve the care provided to service users and their experience
           of that care.

      ‘By opening up the prescription pad to nurses, we have given them a powerful and
      symbolic tool. My vision is that non-medical prescribing moves into the mainstream. Nurse
      prescribing sends a powerful message to the public and others that nursing is not
      subservient to medicine but an equal part of the health care team.’
      John Reid, Secretary of State for Health, 2003




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                 Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                                     The development of nurse prescribing was first proposed in the 'Crown Report —
                                     Report of the Advisory Group on Nurse Prescribing' in 1989. Early pilot sites to test
                                     limited prescribing by district nurses and health visitors highlighted the potential for
                                     nurse prescribing to improve services, use resources more efficiently and enhance
                                     service user satisfaction.6-7 Since that time the range of medicines available from the
                                     Nurse Prescribers' Extended Formulary has increased. Supplementary prescribing was
                                     introduced in 2003, specifically to enhance the care and treatment of people with
                                     medium and long-term health problems.



                            2.3      Mental health nurses and new ways of prescribing and supplying
                                     medication

                                     Mental health nurses are generally positive about extending their role to encompass
                                     prescribing responsibilities.8 Nurse prescribing represents an important change in the
                                     way services are delivered to people with mental health problems and reflects an
                                     increasing emphasis on user choice and making services more responsive to service
                                     user needs. It also reflects the need for all professions to grow and develop and enable
                                     the provision of high quality care and treatment.


                                     Mental health nurses who can both prescribe and supply and administer medicines via
                                     patient group directions may confer many benefits which include:


                                     l         Allowing service users quicker access to medication

                                     l         Providing services more efficiently and effectively


                              ‘As a nurse prescriber I feel that I now have much greater knowledge to underpin what I am
                              saying to service users and as a consequence I feel that service users have much more
                              confidence in me. I now see medication in a different light — really appreciating the
                              physical impact that it may possibly have. Nurse prescribing is much more than just writing
                              a prescription. It is about giving valuable knowledge and support to those in contact with
                              our service.’
                              Angie Dutton, Team Leader — Community Mental Health Nurse, South Staffordshire
                              Healthcare NHS Trust


                                     l         Increasing service user choice


                              ‘It really works well for me, as I don’t have to take time off work to attend outpatients
                              appointments. If I have a problem with my tablets I know who to contact to get it sorted
                              out.’
                              Service user receiving supplementary prescribing



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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      l      Making better use of nurses' skills and knowledge



2.4   Research

      Research evaluating nurse prescribing is currently being undertaken by a number of
      groups in England and it is likely that more will be commissioned. Studies establishing
      the safety, effectiveness or acceptability of supplementary prescribing by mental health
      nurses in the UK have yet to be published. However, research from the United States,
      regarding nurse practitioner prescribing, has shown no difference in clinical outcomes
      for service users prescribed medicines by a nurse or a medical practitioner.9-10
      Prescribing patterns of American mental health nurses were also similar in terms of
      number of consultations, practice settings and medications prescribed.11 Other
      outcomes reported by nurse practitioners in the United States are detailed below:


 United States nurse practitioners’ views12
 l     Waiting times to see psychiatrists have been reduced
 l     Quality of care and patient satisfaction can increase when nurses prescribe
 l     Nurses are skilled at combining medication with psychological therapies
 l     Nurse prescribers can avoid fragmenting care by referring patients to other
       professionals less frequently
 l     Nurses have been found to be capable of doing much more than they have
       traditionally been allowed to
 l     The nature of the therapeutic alliance between nurse and service user can improve
       adherence with medication plans
 l     Side-effects from medicines may be less frequently experienced when nurses
       prescribe
 l     The quality of user education can be better when nurses prescribe
 l     Prescribing has raised the level of self-confidence among nurses




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     3 Service users’ perspectives




                            3.1      Current experiences

                                     Many service users see medication as important in maintaining their mental health or in
                                     helping to manage distressing experiences.13 However, many have also had negative
                                     experiences of treatments with psychiatric medication. Service users often perceive that
                                     side effects are not taken seriously, they receive insufficient information about the
                                     purpose and potential effects of medication and they do not feel involved in decisions
                                     about their treatment.14


                                     Poor adherence to medication regimes is common in mental health settings.15 The
                                     present emphasis on medication prescribing, administering and monitoring is that the
                                     concordance (a joint, collaborative decision about treatment) of the service user should
                                     be sought, rather than his or her compliance.3 Concordance and the empowerment of
                                     the individual to manage their own medication is now seen as crucial to the appropriate
                                     and efficacious use of medicines in mental health care alongside other evidence-based
                                     interventions.16-17



                            3.2      Service users' views of nurse prescribing

                                     Below is one service user's view regarding the development of supplementary
                                     prescribing:

                              ‘Supplementary prescribing may benefit mental health service users if delays in prescribing
                              necessary and sometimes urgent medication can be reduced. A closer relationship with the
                              prescriber could also benefit the service user. Consultants may be perceived as distant and
                              inaccessible, and may not have enough time to discuss medication or to monitor patients.
                              Junior doctors, on the other hand, are constantly rotated to different posts. A prescribing
                              nurse working on a more consistent basis with a limited number of patients may have a
                              better opportunity to build relationships.


                              Some risks are also evident. Although some users may feel more comfortable with a nurse
                              than with a doctor, others will fear that a nurse is ‘less qualified’ to prescribe. Nurse
                              prescribers must be able to point to the training and monitoring that goes with the
                              supplementary prescriber's role.’
                              A service user, South Birmingham

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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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These comments echo findings of a recent study18 that found service users generally
welcome mental health nurse prescribing in principle, but have some reservations
relating to nurses' knowledge base and competence. A systematic review of the UK
literature, noted that patients were generally satisfied with nurse prescribing, and nurses
with their new role as prescribers.19




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      Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     4 Current progress in
       implementation and future plans



                            4.1      Findings of the survey

                                     The survey of directors of nursing by the Institute of Psychiatry, provides a useful
                                     snapshot of current plans (mid 2004) for introducing new ways of mental health nurses
                                     working with medication. The 44 Trusts that responded to the survey employed a total
                                     of 26,116 registered mental health nurses. From this population:


                                     l         128 were undertaking extended formulary and supplementary prescribing
                                               training

                                     l         102 had completed extended formulary and supplementary prescribing training



                                     At this time, just four Trusts accounted for 83 (81%) of the mental health nurses who
                                     had completed prescribing training (one Trust alone accounted for 45%). The majority
                                     of Trusts (n=27, 61%) did not currently have any mental health nurses who had
                                     completed or were undertaking extended formulary and supplementary prescribing
                                     training. There was considerable variability in how Trusts were approaching nurse
                                     prescribing.


                                     All of the directors of nursing who responded to the survey reported that
                                     supplementary prescribing, in particular, had either significant or very significant
                                     potential for both improving services and developing nursing. Community based
                                     services were seen as the most promising area for development, although there was
                                     also some interest in developing supplementary prescribing in inpatient areas. As yet no
                                     trusts reported having formal plans to develop services utilising prescribing from the
                                     Nurse Prescribers' Extended Formulary.


                                     Just under half of Trusts (n=18, 42%) surveyed reported that they currently used patient
                                     group directions to supply and / or administer medicines; the majority of these were for
                                     the treatment of minor physical ailments. More were planning to do so in the future.




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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4.2   The future

      Although the speed at which nurse prescribing has been implemented varies widely, the
      survey clearly demonstrates that nurse leaders within Trusts recognise the tremendous
      potential for improving services by introducing new ways of working. This will
      hopefully begin to be translated into practice in the future.


 ‘We have been at the forefront in establishing widespread supplementary prescribing for
 nursing staff because we are convinced that this will make a real difference, by enhancing
 choice for patients, supporting nurses in developing skills and having a significant role in
 the management of chronic illnesses.’
 Neil Carr, Executive Director of Nursing, South Staffordshire Healthcare NHS Trust




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             Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     5 Nurse supplementary
       prescribing in mental health
       settings

                            5.1      Aims of this section
                                     This section will:

                                     l         Define and describe supplementary prescribing

                                     l         Outline training requirements

                                     l         Discuss potential areas of implementation

                                     l         Address some frequently asked questions. These are divided into those relating to
                                               implementation and those relating to educational issues


                            5.2      Definition of supplementary prescribing

                              Supplementary prescribing
                              A voluntary prescribing partnership between an independent prescriber (doctor) and
                              supplementary prescriber (nurse or pharmacist) to implement an agreed service user-specific
                              clinical management plan with the service user's agreement.



                                     Supplementary prescribing is potentially of immense value in providing more responsive
                                     and efficient services for people with mental health problems.


                            5.3      The concept — a brief overview
                                     The key principles underpinning supplementary prescribing emphasise:

                                     l         The importance of communication between the prescribing partners

                                     l         The need for access to shared patient records

                                     l         That the service user is treated as a partner in their care and is involved at all
                                               stages in decision making, including whether part of their care is delivered via
                                               supplementary prescribing. This is underpinned by Clause 2 of the Nursing and
                                               Midwifery Council code of professional conduct: standards of conduct,
                                               performance and ethics 200220 states that:

                                         ‘As a registered nurse, midwide or specialist community public health nurse, you must
                                                                  respect the patient or client as an individual’
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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      In broad terms, supplementary prescribing hinges on the formation of a voluntary
      partnership between an independent prescriber (doctor) and a supplementary prescriber
      (nurse or pharmacist). In certain circumstances, once a diagnosis has been reached, and
      with the service users' agreement, an individual evidence-based clinical management plan
      will be drawn up and agreed by all parties. From this point the future management of the
      identified condition(s) (including prescribing), within the parameters of the clinical
      management plan will be delegated to the supplementary prescriber (see Appendix C for
      examples). This may include: dose titration, stopping medication, switching medication
      and initiating medication. The clinical management plan must also identify any
      circumstances where the supplementary prescriber should refer the service user back to
      the independent prescriber. The clinical management plan should normally be reviewed at
      least annually although it may be considered good practice to review the plan more
      frequently than this.


      More information on supplementary prescribing is available from the Department of
      Health website at www.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAnd
      Industry/Prescriptions/SupplementaryPrescribing/fs/en. The National Prescribing
      Centre's web-based publication ‘Supplementary prescribing — A resource to help
      healthcare professionals to understand the framework’ (September 2003) outlines the
      supplementary prescribing process and provides links to sources of up-to-date
      information (www.npc.co.uk/publications/healthcare_resource.pdf).



5.4   Frequently asked questions around implementation issues

 1     When should supplementary prescribing be used?
 2     How does supplementary prescribing work if a service user cannot give consent?
 3     What medication can be prescribed?
 4     Do nurses need to agree to prescribing from a particular clinical management plan?
 5     Who will bear legal and professional responsibility for the actions of nurse
       prescribers?
 6     How specific does the clinical management plan need to be?
 7     What must be included in a clinical management plan?
 8     Can locum psychiatrists be independent prescribers within a supplementary
       prescribing arrangement?
 9     Can supplementary prescribing be utilised in acute inpatient settings?
 10    How does supplementary prescribing work if more than one supplementary
       prescriber is identified on the clinical management plan?
 11    Are nurse supplementary prescribers able to give directions to a non-prescriber for
       the administration of a medicine?
 12    What is the legal position if a supplementary prescriber prescribes outside the scope
       of the clinical management plan?




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                            1        When should supplementary prescribing be used?
                                     There are no legal restrictions on the conditions to be managed by a supplementary
                                     prescribing arrangement. The decision about whether supplementary prescribing is
                                     appropriate must be based on a judgement as to whether it will potentially benefit
                                     service users. However, it is likely that supplementary prescribing will be most useful
                                     in managing chronic / long term conditions, common in mental health settings.
                                     Nurses already often lead on planning care for individuals with such conditions, as well
                                     as frequently delivering the majority of care. Nurses commonly have in-depth
                                     knowledge of the individual and their problems and are well placed to make timely
                                     prescribing decisions that may include adjustments to existing medication and / or
                                     introducing new regimens.


                                     Directors of nursing indicated in the Institute of Psychiatry’s survey that they saw
                                     potential benefits of introducing supplementary prescribing in the following areas
                                     (1=most beneficial — 6=least beneficial):


                                     1.        Older people's community services
                                     2.        Assertive outreach
                                     3.        Drug and Alcohol teams (particularly once controlled drugs can be prescribed)
                                     4.        Community mental health teams
                                     5.        Older peoples’ inpatient services
                                     6.        Acute inpatient care



                                     When deciding whether or not it is appropriate to provide care via a supplementary
                                     prescribing arrangement to an individual, it is important to consider the:


                                     l         User's engagement with services

                                     l         Severity and complexity of symptoms

                                     l         Complexity of treatment

                                     l         User's views of medicines and nurse prescribing

                                     l         Co-morbid illnesses

                                     l         Level of substance use



                                     Supplementary prescribing by nurses also offers particular benefits in clinic settings
                                     where nurses may already have special expertise, for example:


                                     l         Clozapine clinics

                                     l         Cognitive enhancer or ‘memory’ clinics



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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      l      Methadone clinics (once controlled drugs are added to those medicines that can be
             prescribed by supplementary prescribers)


 Margaret Smith is a mental health nurse who runs a Memory Clinic in Doncaster. She
 prescribes from a range of cognitive enhancers as laid out in clinical management plans and
 following the National Institute for Clinical Excellence Guidance. Margaret is able to use her
 considerable specialist expertise in this area to alter and change medications as required
 through her ongoing assessments of service users within the clinic, thus cutting down waiting
 times and providing a more responsive service.
 Contact: margaret.smith@dsh.nhs.uk

      .
2     How does supplementary prescribing work if a service user cannot give consent?
      Every effort should be made to obtain informed consent. The patient should be able to agree
      to being treated by a supplementary prescriber under a clinical management plan before
      supplementary prescribing (by a nurse or pharmacist) begins. Local guidelines on consent
      and guidance from professional bodies will also be relevant.


3     What medication can be prescribed? Can controlled drugs be prescribed?
      There are no legal restrictions on the medicines that supplementary prescribers may
      prescribe, with the current exception of controlled drugs, and unlicensed medicines unless
      they are part of a clinical trial or have a clinical trial certificate or exemption. Subject to
      Parliamentary approval, the Home Office’s Misuse of Drugs regulations will be amended to
      enable supplementary prescribing of controlled drugs from mid March 2005. Changes to
      NHS regulations will follow as soon as possible.


      Supplementary prescribers are able to prescribe medicines outside of their Summary of
      Product Characteristics indications if this is agreed by the doctor and is set out in the clinical
      management plan with an appropriate rationale.


      The conditions to be managed and the range of medicines to be prescribed to specific service
      users will be identified by the medical judgement of the independent prescriber within the
      individual clinical management plan. The clinical management plan will need to be agreed
      with the supplementary prescriber and should include the limits of their responsibility for
      prescribing and time of review.


4     Do nurse supplementary prescribers need to agree to prescribe from a particular
      clinical management plan?
      Yes, professionally a nurse should not prescribe anything that he / she does not believe to be
      in the service user's best interests nor should he / she be required to enter into a prescribing
      partnership that entails the prescribing of any medicine that he / she does not feel competent
      to prescribe.




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             Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                            5        Who will bear legal and professional responsibility for the actions of nurse
                                     prescribers?
                                     Where a nurse or midwife is appropriately trained and qualified and prescribes as part of
                                     his / her professional duties with the consent of their employer, the employer is held
                                     vicariously liable for his / her actions. In addition, nurse prescribers are individually and
                                     professionally accountable to the Nursing and Midwifery Council for this aspect of their
                                     practice, as for any other, and must act at all times in accordance with the Nursing and
                                     Midwifery Council code of professional conduct and scope of professional practice. All
                                     nurse and midwife prescribers should ensure that they have professional indemnity
                                     insurance, for instance by means of membership of a professional organisation or trade
                                     union.


                            6        How specific does the clinical management plan need to be?
                                     The detail of the clinical management plan is a matter to be formally decided by the
                                     independent prescriber, i.e. the doctor, however the supplementary prescriber also needs to
                                     agree the clinical management plan. Potentially the detail included in clinical management
                                     plans can vary from being quite specific, to fairly broad. For example, the clinical
                                     management plan may identify specific, named medicines and doses, etc., or merely refer
                                     to recognised guidelines for the management of a specific condition. Similarly, the time
                                     between joint reviews may vary depending on individual circumstances (see Appendix C
                                     for examples of specific and broad clinical management plans).



                                 Specific clinical management plan                                          Broad clinical management plan

                                      Specified medicine.                                                   Range of medicines to prescribe
                                     Frequent reviews with                                                     from. Relatively infrequent
                                       prescribing doctor                                                   reviews with prescribing doctors



                                     The level of detail within the clinical management plan will depend on several factors:

                                     l         The experience, expertise and knowledge of the nurse

                                     l         The availability of comprehensive, robust guidance regarding the management of
                                               particular conditions, e.g. National Institute for Clinical Excellence Guidance and
                                               other national guidelines

                                     l         The complexity of the needs of the individual service user

                                     l         As with every area of practice prescribers should consider their personal
                                               accountability as stated in Clause 1.3 of the Nursing and Midwifery Council code of
                                               professional conduct: standards of conduct, performance and ethics 200220 states
                                               that:

                                               ‘You are personally accountable for your practice. This means that you are
                                             answerable for your actions and omissions, regardless of advice and directions
                                                                       from another professional’
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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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7   What must be included in a clinical management plan?
    l    The name of the patient to whom the plan relates

    l     The illness or conditions which may be treated by the supplementary prescriber

    l     The date on which the plan is to take effect, and when it is to be reviewed by the
          doctor or dentist who is party to the plan

    l     Reference to the class or description of medicines, which may be prescribed or
          administered under the plan

    l     Any restrictions or limitations as to the strength or dose of any medicine which
          may be prescribed or administered under the plan, and any period of
          administration or use of any medicine or appliance which may be prescribed or
          administered under the plan. [NB The clinical management plan may include a
          reference to published national or local guidelines. However, these must clearly
          identify the range of the relevant medicinal products to be used in the treatment of
          the service user, and the clinical management plan should draw attention to the
          relevant part of the guideline. The guidelines also need to be easily accessible]

    l     Relevant warnings about known sensitivities of the service user to, or known
          difficulties of the service user with, particular medicines

    l     The arrangements for notification of:
          l      Suspected or known reactions to any medicine which may be prescribed or
                    administered under the plan, and suspected or known adverse reactions to
                    any other medicine taken at the same time as any medicine prescribed or
                    administered under the plan
          l         Incidents occurring with the appliance which might lead, might have led or
                    has led to the death or serious deterioration in the health of the service user.
          l         The circumstances in which the supplementary prescriber should refer to, or
                    seek the advice of, the doctor or dentist who is party to the plan


8   Can locum psychiatrists be independent prescribers within a supplementary
    prescribing arrangement?
    The role of a nurse supplementary prescriber may be particularly important when there is
    a lack of consistency in medical staff due to the employment of locums. However, special
    consideration needs to be given as to whether a locum psychiatrist can be the independent
    prescriber within a supplementary prescribing partnership. Locums are not permanent
    staff and therefore management of an individual by a supplementary prescriber
    partnership risks being compromised when their locum, independent prescriber, leaves the
    service. Trusts will need to consider developing local policy regarding their position on
    this. However, having some consistency in there being a single senior psychiatrist
    offering supervision to any locums in a post is one way that greater consistency can be
    found.




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          Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                            9        Can supplementary prescribing be utilised in acute inpatient settings?
                                     Supplementary prescribing can potentially be used in inpatient areas although a variety
                                     of additional considerations need to be taken into account. Other routes for providing
                                     medication may be more appropriate in some situations (for example, see Section 6
                                     regarding patient group directions). Issues for consideration before establishing
                                     supplementary prescribing in an inpatient area should include:


                                     l         Will a supplementary prescribing relationship benefit the service user?

                                     l         Has a diagnosis been established prior to establishing a clinical management
                                               plan?

                                     l         A single nurse supplementary prescriber will not be continuously present, so
                                               what will happen in his / her absence? (More than one nurse can potentially be
                                               named as supplementary prescriber on the clinical management plan)


                              Supplementary prescribing in inpatient care
                              Hillingdon Primary Care Trust plan to introduce supplementary prescribing in acute mental
                              health inpatient settings. Service users will have daily medication reviews by the nurse
                              supplementary prescriber in combination with psychosocial interventions. A focus of the
                              care and treatment will be on developing medication packages for users which best support
                              their current lifestyle, future aspirations and managing the negative impact of treatment.
                              Contact: Martin.Jones@thh.nhs.uk


                                     l         What is the advantage of supplementary prescribing if medical staff are
                                               available to monitor and adjust medicine?

                                     l         What will the implications be for junior doctor roles where nurses become
                                               supplementary prescribers?


                            10       How does supplementary prescribing work if more than one supplementary
                                     prescriber is identified on the clinical management plan?
                                     Firstly, all of the prescribing partners should be identified on the clinical management
                                     plan and agree to its contents. The service user should also agree to the arrangements.
                                     Secondly, the communication between the prescribers is crucially important, and the
                                     clinical management plan should identify this process. Generally, contemporaneous
                                     notes of prescribing should be made in the health record.


                            11       Are nurse supplementary prescribers able to give instructions for a non-
                                     prescriber to administer a medicine they have prescribed?
                                     A qualified nurse prescriber may give directions for the administration of any product
                                     they are legally allowed to prescribe, i.e. a product that is listed on the clinical
                                     management plan. The prescribing nurse will clearly need to be satisfied that the
                                     person to whom he / she gives the instructions is competent to administer the medicine
                                     concerned.

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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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12    What is the legal position if a supplementary prescriber prescribes outside the
      scope of the clinical management plan?
      If a supplementary prescriber prescribes a Prescription Only Medicine outside a clinical
      management plan they will be acting illegally under the terms of the Prescription Only
      Medicines Order, and could be subject to sanctions under the Medicines Act.


      If something other than a Prescription Only Medicine is involved, supplementary
      prescribers have a dual accountability:

      l      To their employer

      l      To their statutory regulatory body, the Nursing and Midwifery Council



      A supplementary prescriber who prescribes a non-Prescription Only Medicine without
      the agreement of a clinical management plan could potentially be subject both to:

      l      Disciplinary proceedings by their employer

      l      Action by the regulatory body should a charge of professional misconduct follow



5.5   Frequently asked questions around educational issues

 1     What educational preparation is required?
 2     How is the training assessed?
 3     During training what supervised learning in practice is required?
 4     What are the required qualifications of the supervising medical practitioner?



1     What educational preparation is required?
      There are currently around 55 higher education institutions in England that offer the
      supplementary and extended formulary prescribing courses. The Nursing and Midwifery
      Council has now determined a new standard in respect of supplementary prescribing
      training (and independent prescribing from the Nurse Prescribers' Extended Formulary).
      The outline curriculum for the preparation of nurses, midwives and health visitors to
      prescribe from the Nurse Prescribers' Extended Formulary is available at
      www.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAndIndustry/Prescriptions
      /SupplementaryPrescribing/SupplementaryPrescribingArticle/fs/en?CONTENT_ID
      =4068421&chk=cVC8a8.


      The outline curriculum covers:

      l      Consultation, decision making and therapy including referral

      l      Influences on and psychology of prescribing

      l      Prescribing in a team context

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            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                                     l         Clinical pharmacology including the effects of co-morbidity

                                     l         Evidence-based practice and clinical governance in relation to nurse prescribing

                                     l         Legal, policy and ethical aspects

                                     l         Professional accountability and responsibility

                                     l         Prescribing in the public health context



                                     Training programmes for supplementary prescribing (and extended formulary nurse
                                     prescribing) involve at least 26 days theory based learning and 12 days of supervised
                                     learning in practice. Of the 26 days taught element, a substantial proportion should be
                                     face-to-face contact time. However, other ways of learning, such as open and distance-
                                     learning formats are growing in popularity. Preparation for supplementary prescribing
                                     is based on that for extended formulary nurse prescribing with an additional taught
                                     element relating to the nature, context and scope of supplementary prescribing.
                                     Training can be undertaken over a period of up to six months and nurses who complete
                                     the course will hold both qualifications. During the training programme trainee
                                     prescribers cannot actually prescribe medicines.

                                ‘I work as a consultant in old age psychiatry and I recently mentored two G grade
                                community mental health nurses on the nurse prescribing course. I found mentoring an
                                enjoyable experience and supporting two students at the same time enabled us to have three
                                way discussions and bounce ideas off each other. An additional spin-off is that I have
                                examined my own prescribing practice and I am sure this has improved my functioning as
                                well as hopefully educating the students.’
                                Dr G Acey, Consultant in Old Age Psychiatry, South Staffordshire NHS Trust



                            2        How are trainees assessed?
                                     Although methods of assessment may vary throughout England it is a requirement that
                                     students’ clinical competencies are assessed. The Nursing and Midwifery Council's
                                     requirements for supplementary prescribing (and independent prescribing from the
                                     Nurse Prescribers' Extended Formulary www.dh.gov.uk/assetRoot/04/08/39/80/
                                     04083980.pdf) sets out the principle areas, knowledge and competencies required to
                                     underpin the practice of prescribing. The designated supervising medical practitioner
                                     has a key role in assessing whether certain learning outcomes have been achieved.


                                     Strategies for assessment include:

                                     l         Review of portfolio or learning log

                                     l         Objective structured clinical examination, a systematic and detailed examination
                                               of practice within a simulated learning environment such as a skills laboratory

                                     l         Written final examination
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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
Good practice guide
         l      Satisfactory completion of the period of practice experience


3        What does the period of learning in practice involve?
         www.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAndIndustry/Prescriptions/
         NursingPrescribing/NursingPrescribingArticle/fs/en?CONTENT_ID=4068219&chk=
         aVMgDZ. It is a requirement of the successful completion of extended formulary nurse
         prescribing / supplementary prescribing preparation that nurses have 12 days of
         supervised learning in practice in addition to the theoretical component. This period of
         supervised learning in practice is to be directed by a designated medical practitioner who
         will also be responsible for assessing whether certain learning outcomes have been met
         and whether trainees have acquired certain competencies. The designated medical
         practitioner must be a medically qualified practitioner who, normally, works with the
         trainee prescriber. However, it can be agreed that another medical practitioner acts as a
         supervisor if this is deemed more appropriate, for example a doctor working in a
         specialist area in which the nurse would benefit from greater knowledge.



    Learning in practice opportunities
    In Mersey Care NHS Trust, Steve McLoughlin, a community mental health nurse attending
    the nurse prescribing course, was mentored by a general practitioner. ‘I found it helpful to
    work with a general practitioner, particularly as drug interactions between psychotropic and
    general drugs were often highlighted and I also increased my knowledge of how primary
    services function. I believe I finished with a more rounded view of general practice /
    medication and its relationship with psychiatric services’.

4        What are the required qualifications of the designated supervising medical
         practitioner?
         He / she must be a registered medical practitioner who:

         i.     Has normally had at least three years recent clinical experience for a group of
                service users / clients in the relevant field of practice
         ii.    Is within a GP practice and is either vocationally trained or is in the possession of
                a certificate of equivalent experience from the Joint Committee for Post-graduate
                Training in General Practice Certificate
                or
                Is a specialist registrar, clinical assistant or a consultant within a NHS Trust or
                other NHS employer
         iii.   Has the support of the employing organisation or GP practice to act as the
                designated medical practitioner who will provide supervision, support and
                opportunities to develop competence in prescribing practice
         iv.    Has some experience or training in teaching and or supervising




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                Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                     Good practice guide
                              Preparation of doctors
                              As part of the launch of supplementary prescribing within the 5 Borough Partnership NHS
                              Trust, a full day was arranged for doctors entitled ‘Medical supervision for supplementary
                              prescribers’ which was intended to provide information about supplementary prescribing
                              and produce a group of support, informed medical supervisors for our first cohort of
                              students.


                              The topics covered were:
                              l     Background to supplementary prescribing and clinical management plans
                              l     Clinical governance in relation to supplementary prescribing
                              l     Supervisors’ responsibilities
                              l     Implications for medical practitioners and nurses / pharmacists providing ongoing
                                    care
                              l     Supplementary prescribing in the substance misuse service
                              l     Drug-drug interactions


                              Two consultants presented on the principles of effective prescribing / safety aspects of
                              prescribing related to specific therapy areas.


                              The benefits of the day were that we had a group of doctors who were informed and
                              enthusiastic about supplementary prescribing and who could be approached by prospective
                              students to act as their supervisors. Our nurses then began a course with a mental health
                              focus, made up of only nurses employed by the Trust and followed a pilot of the first course
                              of this kind delivered by the same higher education institution involving Mersey Care NHS
                              Trust, Cheshire and Wirral Partnership NHS Trust and ourselves.


                              Contact: enid.harper@warrington-pct.nhs.uk




                              Support from the National Prescribing Centre
                              The National Prescribing Centre have developed an online resource which aims to help
                              doctors prepare for and carry out the role of designated medical practitioner and health care
                              organisations identify who may be suited to that role. This on-line resource ‘Training non-
                              medical prescribers in practice — A guide to help doctors prepare for the role of designated
                              medical practitioner (February 2005) is available from the National Prescribing Centre
                              website (www.npc.co.uk).




26
Improving mental health services by extending the role of nurses in prescribing and supplying medication:
Good practice guide
6 Patient group directions in
  mental health settings


      6.1   What are patient group directions?

       Patient group directions are written instructions to enable registered nurses to supply and
       administer a specified medication to a group of service users who may not be individually
       identified before treatment.



            Patient group directions provide an opportunity for suitably trained and competent
            mental health nurses to improve the responsiveness of services through the supply and /
            or administration of medication to service users in certain circumstances. The supply
            and / or administration of medicines using patient group directions is not a form of
            prescribing. This section provides information regarding patient group directions, when
            they should be used, what steps Trusts would need to take to introduce them and
            answers some frequently asked questions.


            This section should be read in conjunction with the information set out in Health
            Service Circular 2000/026 — Patient Group Directions [England] available from
            www.dh.gov.uk/assetRoot/04/01/22/60/04012260.pdf.



      6.2   When can patient group directions be used?

            In most situations medication should be provided on an individual user-specific basis.
            The use of patient group directions should be reserved for those limited situations
            where this offers an advantage for service user care (without compromising service
            user safety). It must be consistent with appropriate professional relationships and
            accountability. The National Prescribing Centre's on-line resource ‘Patient Group
            Directions — A practical guide and framework of competencies for all professionals
            using patient group directions’ (March 2004) offers guidance on the appropriate use of
            patient group directions and sets out the competencies needed to work with them
            (www.npc.co.uk/publications/pgd/pgd.pdf).




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                   Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                        Good practice guide
                                     Patient group directions may offer advantages when:

                                     l         Relatively large numbers of individuals require the same intervention, e.g.
                                               hepatitis immunisation for individuals receiving services for drug addiction

                                     l         An undue delay or complication can arise from waiting for an individual
                                               assessment by a doctor and for an individual prescription to be completed, e.g.
                                               out of hours community based services where medical cover is not available

                                     l         Service users in inpatient areas experience undue delays in the treatment of
                                               minor physical ailments through having to wait for on-call junior doctors out of
                                               office hours

                              Patient group directions and crisis services
                              Norfolk and Waveney Mental Health Trust has established patient group direction protocols
                              for use in its Crisis / Home treatment Service. This enables individuals seen out of office
                              hours to receive immediate treatment for specified problems that will help them and their
                              carers cope until a full medication review can take place. Written algorithms help the
                              nursing staff to ensure that the patient group direction is appropriate in each case. Patient
                              group directions can be used where sleeping is difficult, or high levels of agitation / anxiety
                              or extra pyramidal side-effects are present.
                              Contact: sarah.ray@nwmhp.nhs.uk




                            6.3      Who can use patient group directions?

                                     Patient group directions can be used by named registered nurses, who are recognised as
                                     competent to do so by their employer, where the provider of mental health services
                                     believes that patient group directions is the most appropriate way to meet defined
                                     needs.



                            6.4      How can Trusts establish patient group directions for mental health
                                     nurses to use?

                                     l         Patient group directions should be drawn up by a multi-disciplinary group
                                               involving a doctor, a pharmacist and a nurse

                                     l         Drugs and therapeutic committee (or equivalent) of a Trust should be involved
                                               in the process of establishing patient group directions

                                     l         A senior doctor and senior pharmacist need to sign the patient group direction
                                               and have been involved in developing the direction

                                     l         The Trust itself needs to formally authorise the patient group direction (this can
                                               be done by the nominated clinical governance lead)

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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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       Additionally Trusts need to establish:

       l      Means of ensuring individual nurses are competent to provide specific patient
              group directions. A named senior nurse should be responsible for this

       l      Means of identifying those individuals and their ongoing competency

       l      Processes and paperwork for recording

       l      Stocks of medication in a format that can be given as individual doses

       l      Means of monitoring usage of patient group directions for clinical governance
              purposes

       l      A process for reviewing every patient group direction at least every two years

 Patient group direction training and monitoring
 Avon and Wiltshire Mental Health Partnership NHS Trust has arranged formal training for
 qualified nurses, to support the introduction of a range of over-the-counter treatments for
 minor physical ailments through patient group directions in inpatient settings. The training
 is supported by a workbook and identifies specific competencies to be met. A refresher
 questionnaire is utilised a year after the initial training, in order to ensure that nurses remain
 up-to-date. An audit tool has been specifically designed to measure the meeting of standards
 in practice
 Contact: Elizabeth.Bessant@awp.nhs.uk or Sarah.Harding@awp.nhs.uk




6.5    Supply and administration of controlled drugs via patient group
       directions

       Nurses can now supply and administer some controlled drugs under the terms of a
       patient group direction. Following discussions with the Department of Health and
       public consultation, the Home Office amended the Misuse of Drugs Regulations on the
       15th October 2003. Since this date nurses have been able to use patient group
       directions for the supply and administration of Schedule 4 and Schedule 5 controlled
       drugs — with the exception of anabolic steroids. For mental health nurses, this means
       that some medicines used for the treatment of anxiety, agitation and night sedation (for
       example, benzodiazepines) can now be supplied and / or administered under a patient
       group direction under certain circumstances.


       The storage, carrrying and monitoring of controlled drugs all have implications for
       services. Nurses need to be able to be confident that mechanisms and policies are in
       place to support their practice and to ensure the security of controlled drugs. The
       carrying of controlled drugs may potentially increase risk to staff and therefore risk
       assessments would be valuable where this is new practice.



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             Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                  Good practice guide
     7 Prescribing from the nurse
       prescribers’ extended formulary



                            7.1      Background

                              Independent nurse prescribing is where the nurse prescriber takes responsibility for the
                              clinical assessment of the patient, establishing a diagnosis and the clinical management
                              required, as well as responsibility for prescribing where necessary and the appropriateness
                              of any prescribing.



                                     The Nurse Prescribers' Extended Formulary provides an opportunity for suitably
                                     qualified and competent mental health nurses to independently prescribe a range of
                                     medicines, to treat a specific list of conditions, in situations where this may offer
                                     benefit to service users. This section will discuss the potential benefits, risks and issues
                                     that may be encountered and provide examples of good practice.



                            7.2      What training is required?

                                     Every mental health nurse who successfully completes the supplementary prescribing
                                     training is also qualified as an extended formulary nurse prescriber (see Section 5 for
                                     training requirements). However, a nurse should only prescribe from the Nurse
                                     Prescribers' Extended Formulary if:

                                     l         The nurse is competent to manage that condition, i.e. has suitable knowledge
                                               and experience

                                     l         Their employer has formally sanctioned that the nurse can practice as an
                                               extended formulary nurse prescriber in the setting in which they work



                            7.3      Can the formulary be used in mental health settings?

                                     The Nurse Prescribers' Extended Formulary does not include medicines to treat mental
                                     health problems, but enables a suitably qualified nurse to prescribe independently to
                                     treat a specified list of medical disorders. However, some of these medical conditions
                                     are commonly seen in mental health care settings.



30
Improving mental health services by extending the role of nurses in prescribing and supplying medication:
Good practice guide
Table 7.1: Some of the conditions treatable by the current Nurse Prescribers' Extended Formulary

 Circulatory                                              Ear
 Haemorrhoids                                             Otitis externa

 Endocrine                                                Eye
 Hypoglycaemia                                            Conjunctivitis — allergic

 Gastrointestinal conditions                              Female genital system
 Constipation                                             Contraception
 Heartburn                                                Emergency contraception

 Musculoskeletal                                          Oral conditions
 Soft tissue injury                                       Aphthous ulcer
 Sprains                                                  Gingivitis

 Substance dependence                                     Urinary system
 Smoking cessation                                        Urinary tract infection (women) — lower
                                                          uncomplicated

 Respiratory                                              Skin
 Acute attacks of asthma                                  Burn / scald
 Laryngitis                                               Chronic skin ulcer
 Rhinitis-allergic                                        Lacerations
 Sinusitis-acute                                          Local anaesthetic for suturing of lacerations



7.4    When can extended formulary nurse prescribing be used in mental
       health settings?

       l      When service users would receive a better service and more timely intervention
              as a result, for example:
              l       By speeding up response times for treatment of the medical condition
              l       By there being benefits in a known nurse prescribing rather than an
                      unknown doctor

       l      When nurses have particular areas of expertise relevant to the condition to be
              treated

       l      When services are for individuals who might otherwise not access ‘mainstream’
              medical services




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             Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                              Potential practice examples
                              l     Nurses working in stand alone units for older people with mental health problems
                              l     Nurses treating minor injuries on acute admission wards
                              l     Nurses working with homeless people who do not receive general practitioner
                                    services or wish to attend health facilities
                              l     Nurses working within substance misuse services offering vaccinations and treating
                                    minor illness




                            7.5      When is a nurse ‘competent’?

                                     This is a matter that needs to be decided. The majority of mental health nurses are
                                     unlikely to be competent to prescribe items from the Nurse Prescribers' Extended
                                     Formulary without additional training and continuing professional development input.
                                     Although some mental health nurses also hold general nursing qualifications, this does
                                     not guarantee that knowledge is up-to-date nor specific regarding the individual
                                     preparations that may be prescribed.


                                     Both the nurse and their employer have a responsibility to ensure competency in all
                                     areas of practice, including prescribing. Clause 6 of the Nursing and Midwifery
                                     Council code of professional conduct: standards of conduct, performance and ethics
                                     200220 states that:

                                  ‘As a registered nurse, midwife or spcialist community publich health nurse, you must
                                                 maintain your professional knowledge and competence’



                                     Furthermore, in areas where prescribing skills may be utilised relatively rarely, it may
                                     be difficult to maintain competency in the absence of regular practice (see Section 11).
                                     The National Prescribing Centre has developed a competency framework for extended
                                     formulary nurse prescribers (www.npc.co.uk/nurse_prescribing/pdfs/
                                     maint_comp_in_prescrib.pdf). This framework sets out the competencies needed to
                                     make a good prescribing decision. It can be used in a number of ways, but essentially
                                     provides individuals and organisations with a tool for monitoring whether
                                     competencies are being maintained, thus identifying outstanding learning needs. This,
                                     in turn should inform the commissioning of appropriate continuing professional
                                     development input at a number of levels.




32
Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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7.6   What needs to be done to establish extended formulary nurse
      prescribing?

      In addition to the general considerations set out in Section 8, the following list
      identifies some other issues which organisations may need to address when
      implementing extended formulary nurse prescribing at a local level.


      l      Identify areas where this may be beneficial to service users and consult service
             users, commissioners, medical staff and pharmacists

      l      Carry out risk assessment

      l      Set up budgetary arrangements

      l      Establish policies

      l      Identify appropriate trainees and supervisors

      l      Secure a place on a training course

      l      Establish clinical governance mechanisms

      l      Establish mechanisms to ensure and monitor ongoing competency and safe
             prescribing following initial training

      l      Engage with and enlist the support of the pharmaceutical services




                                                                                                                 33
            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                 Good practice guide
     8 Organisational implications of
       introducing new ways of working



                            8.1      Considerations

                                     The introduction of extended formulary nurse prescribing and supplementary
                                     prescribing, and patient group directions has major implications for the delivery of
                                     mental health services. Successful implementation will require that NHS Trusts and
                                     commissioners have considered:

                                     l         Service users views

                                     l         Cost implications

                                     l         Service structures

                                     l         Workforce planning

                                     l         Clinical governance requirements

                                     l         Relationships with other health care providers, e.g. primary care



                            8.2      Service users' views

                                     It is vital that service users' views are taken into account when developing new ways of
                                     mental health nursing with regard to prescribing, supplying and administering
                                     medication, as with all types of service development. Consultation should accompany
                                     information giving. As noted in Section 3, service users may have concerns that nurses
                                     may not be adequately prepared for the role, therefore explanation can usefully be
                                     provided regarding the training received and means by which quality and safety
                                     standards are to be maintained. Providing written leaflets may be valuable in this
                                     regard during day-to-day clinical contact.



                            8.3      Cost implications

                                     Mental health nurse prescribing has a number of potentially important cost
                                     implications. The costs for the nurse prescribing courses are currently funded by local
                                     Strategic Health Authority Workforce (Development) Directorates, however further
                                     costs may come from:


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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      l      Other study time to gain or maintain knowledge and competence

      l      Time spent prescribing medicines may mean the nurse could have less time to carry out
             other activities


      Mental health nurse prescribing may, however, also potentially confer cost savings if:

      l      Time is saved because nurses do not have to waste time finding a psychiatrist to write
             the prescription

      l      Psychiatrist's time is saved because they do not need to spend time writing and
             checking prescriptions

      l      Less medicine is wasted through improved concordance

      l      Clinical outcomes improve due to more responsive, and timely prescribing


8.4   Service structures

      New ways of prescribing, supplying and administering medicines by nurses will allow NHS
      Trusts to think more creatively about service structures. Trusts and commissioners will need to
      consider which areas may benefit most from such changes in practice. From the Institute of
      Psychiatry survey, directors of nursing believed that mental health nurse supplementary
      prescribing would be particularly useful in the following areas:

      l      Older adults (community)

      l      Assertive outreach

      l      Drug and alcohol services

      l      Community mental health teams


      In each of these areas mental health nurses could, potentially, take the lead in providing
      individual care and treatment, with psychiatrists providing initial medical assessment and then
      advice as required. There is evidence that some Trusts are considering developing services
      along these lines. Any development of services should be driven by locally identified user and
      carer need. Trusts may consider:

      l      The outcomes prescribers should achieve, both individually and collectively

      l      How the service is provided, emphasising equity of service

      l      Who provides the service

      l      The role of the mental health pharmacist in supporting the nurse prescriber

      l      Service users' needs and expectations for this new service

      l      A vision for the future
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                   Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                            8.5      Workforce planning

                                     Extended formulary nurse prescribing and supplementary prescribing represent part of
                                     a wider shift in thinking about breaking down traditional professionals' roles and
                                     responsibilities. Mental health nurse prescribing and supplying of medication allows
                                     Trusts to think more creatively about how to use the talents of its workforce more
                                     effectively. Mental health nurse prescribing may allow nurses to lead in the care of
                                     many individuals with long-term conditions such as schizophrenia, bipolar disorder and
                                     Alzheimer's disease. Psychiatrists themselves are currently re-examining their role and
                                     looking at ways of focusing their time more effectively (for example by focusing on
                                     working with people with the most complex needs).21 Nurse prescribing will support
                                     this whilst psychiatrists will remain an important resource of consultation when
                                     required. Pressure to reduce junior doctor hours also provides an additional incentive to
                                     reconsider the way in which all professions currently practice.


                                     If nurses are to take on increased responsibilities this may impact on the number of
                                     service users they are able to effectively work with. Overall there may be an increase in
                                     the need for more specialised and consultant nurses. Organisations should also consider
                                     how the introduction of nurse prescribing may affect the role of other health care
                                     professionals, such as pharmacists.



                            8.6      Clinical governance

                                     The Commission for Healthcare Audit and Inspection (www.chi.nhs.uk/eng/cgr/
                                     overview.shtml) defines clinical governance as the system of steps and procedures
                                     adopted by the NHS to ensure that service users receive the highest possible quality of
                                     care. It includes:

                                     l         A patient centred approach

                                     l         Accountability for quality

                                     l         Ensuring high standards and safety

                                     l         Improvement in clinical services and care



                                     Good clinical governance is essential to the effective implementation of mental health
                                     nurse prescribing. Its primary aims are to ensure safety. Clinical governance also
                                     relates to systems for:

                                     l         Gathering service users' views

                                     l         Monitoring training

                                     l         Auditing outcomes


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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      l      Standards of recording and information availability

      l      Sharing good practice



      Mental health nurse prescribing practice should be underpinned by performance
      standards that may include:

      l      Clinical benchmarking groups to disseminate good practice, highlight common
             errors, risks and practice difficulties

      l      A comprehensive programme of quality improvement activities

      l      Reporting in detail in annual clinical governance reports



      Trusts may consider developing local audit procedures that will feedback through
      existing clinical governance mechanisms. Audits of mental health nurse prescribing
      may examine:

      l      Level of prescribing errors

      l      The collaborative development of clinical management plans

      l      Evidence that the process of consent has been undertaken

      l      Prescribing within clinical competence

      l      Adherence to prescribing protocols

      l      Complaints and compliments

 As part of clinical governance arrangements in South Staffordshire, nurse prescribers are
 required to attend monthly meetings. Attendance at these meetings is monitored and nurses
 who miss three consecutive sessions are required to have an individual appointment in order
 to be supported within the Trust to continue with prescribing practice.
 Contact: A.L.Hay@staffs.ac.uk




8.7   Relationships with other health care providers

      In order to allow nurses to successfully prescribe, consideration will need to be given
      to issues of arrangements with other services, in particular primary care trusts. Many
      prescriptions for service users are currently generated by general practitioners although
      often on the written advice of psychiatrists. If nurses are, either, to prescribe directly, or
      to formally advise general practitioners on what to prescribe, then a formal agreement
      between the two Trusts is likely to be required to facilitate such activity. Such
      arrangements cannot be left to individual clinicians to negotiate.

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            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     9 Policies




                            9.1      Developing policies

                                     Extended formulary nurse prescribing, supplementary prescribing and patient group
                                     directions represent a major change in the way that medicines are prescribed and
                                     supplied. A clear policy will provide a framework in which practitioners can safely and
                                     effectively practice. The Institute of Psychiatry’s survey of directors of nursing
                                     suggests that many NHS Trusts providing mental health services will need to consider
                                     amending existing medicines policies or developing new ones. NHS Trusts may wish
                                     to consider the following general points. Further guidance on issues to be covered by
                                     policies is contained in Appendix B.


                              In a joint initiative between 5 Boroughs Partnership NHS Trust, Mersey Care NHS Trust
                              and Cheshire and Wirral Partnership NHS Trust, a new policy for nurse prescribing is being
                              designed before new supplementary prescribers start to prescribe. This policy is to become
                              part of the medicines policy in each of the Trusts. It was felt that it would be beneficial to
                              develop a joint policy for consistency.
                              Contact: avril.haydock@cwpnt.nhs.uk



                                     NHS Trusts may need to consider whether they develop one policy for all medication
                                     issues or have separate policies for independent nurse prescribing, supplementary
                                     prescribing and patient group directions.


                                     Policies relating to nurses prescribing and supplying medication should:

                                     l         Emphasise the multi-disciplinary nature of prescribing and supplying medication

                                     l         Specify who can act as an extended formulary nurse prescriber, or
                                               supplementary nurse prescriber or supply medication under patient group
                                               directions

                                     l         Make specific reference to related policies. For example: medication policy,
                                               generic / medical prescribing policies, record keeping

                                     l         Clearly distinguish between extended formulary nurse prescribing,
                                               supplementary nurse prescribing and patient group directions


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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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County Durham and Darlington Priority Services NHS Trust reviewed their Medicines Code
in anticipation of nurse prescribing. The code now contains the essential elements of a nurse
prescribing policy. Nurses also now have an increased presence and role in the Trust's Drugs
and Therapeutic Committee and Medicines Management Group.
Contact: sarah.mcgeorge@cddps.northy.nhs.uk




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            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     10 Good practice in medication
        management


                               10.1 Background

                                 Medication management is a process of promoting and involving service users in treatment
                                 decisions, exchanging information and monitoring, evaluating and providing feedback about
                                 treatment.22



                                        Good interpersonal and process skills are the foundations of medication management.
                                        These skills include:

                                        l        Interpersonal skills
                                                 l      Use of open ended questions
                                                 l      Reflective listening and summarising
                                                 l      Eliciting and responding to feedback

                                        l        Process skills
                                                 l     Working collaboratively
                                                 l     Agreeing a clear agenda when meeting service users
                                                 l     Emphasising personal choice and responsibility



                                        In order to successfully introduce new ways of working, strong individual clinical
                                        practice is needed as well as strong organisational arrangements. Good medication
                                        management complements and reinforces good prescribing practices and will promote
                                        treatment adherence and improve health related clinical outcomes for service users.23
                                        From the survey, many NHS Trusts reported that they require nurses who have
                                        completed, or who are about to undertake, prescribing training to attend a medication
                                        management training course.


                                        Exchanging information about medication is another key element of medication
                                        management. It involves eliciting from the user what they already know about
                                        medication, finding out what they want to know about medication, providing them with
                                        the information they want and discussing with them how the information you have
                                        provided will affect them.




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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10.2 Assessment

      Medication management involves initial and ongoing assessment and monitoring of the
      effects of medication. In addition to careful clinical examination and observation,
      standard measures may also be extremely valuable. These include:

      l      Psychotic symptoms
             l     The KGV-M version 6.224

      l      Mania
             l     Young Mania scale25

      l      Mood
             l    Calgary Depression scale for Schizophrenia26
             l    Montgomery Asberg Depression Rating Scale27

      l      Cognitive functioning
             l     Mini-mental state examination28

      l      Side-effects
             l      LUNSERS29
             l      Barnes Akathisia30



10.2.1 Physical assessment


      Psychotropic medication can have an adverse effect on many bodily systems. Also
      many preparations carry contra-indications. Regular physical examination, blood
      counts, liver function tests, electro-cardiogram may be required dependent on specific
      clinical circumstances. Treatment changes may be required in the light of the results of
      these examinations. Nurse prescribers may need to instigate these tests and be able to
      interpret the results. This would be underpinned by appropriate training and supported
      by local policy.


      Physical ill health can also result in a deteriorating mental health, for example, an
      infection can be accompanied by a lowering in mood. Prescribers need to be aware of
      the relationship between physical and mental conditions and the individual responses to
      physical illness of the service users they prescribe for.



10.3 Medication management key skills

      A number of techniques have been shown to be useful in helping service users explore
      and discuss their medication. These include:




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              Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                   Good practice guide
                                        l        Problem solving
                                                 l     Often service users have practical problems with medication, e.g.
                                                       remembering to take it. A problem solving approach using the following
                                                       structure can be helpful in enabling user to solve their own problems:
                                                       l      What is the problem?
                                                       l      How would you like things to be different?
                                                       l      What are the possible solutions to the problem?
                                                       l      Action plan

                                        l        Looking back
                                                 l     Facilitating a discussion about past experiences of medication, examining
                                                       what has helped. What has not helped and what can be learnt from
                                                       previous experience and incorporated into a new plan

                                        l        Exploring ambivalence
                                                 l     Most people have some ambivalence about taking medication. It is often
                                                       helpful to explore the good and not so good aspects of taking or not
                                                       taking medication

                                        l        Talking about beliefs and concerns
                                                 l      Naturally most people have some concerns or beliefs about medication,
                                                        e.g. it's dangerous to take it long term. It can be useful to discuss these,
                                                        examining the evidence for and against the belief

                                        l        Looking forward
                                                 l     For many service users medication has very negative connotations (taken
                                                       to treat an illness, prevent a relapse). It is helpful to reframe medication
                                                       as a positive strategy that enables service users to achieve goals and
                                                       promotes recovery. Asking the user to look forward to identify a goal that
                                                       they want to achieve and explore how medication may enable them to
                                                       achieve that goal can promote this

                                        l        Advance directives
                                                 l    Through discussion a plan can be made regarding the type of treatment to
                                                      be prescribed (and treatments to be avoided) when the service user
                                                      becomes acutely unwell — an advanced directive. A written copy of the
                                                      plan should be provided to the service user and their carer if appropriate,
                                                      a copy should also be kept in their case notes and the multi-disciplinary
                                                      team made aware of its existence. An example of an advanced directive
                                                      can be seen at www.kentandmedway.nhs.uk/pdf/Your_health/
                                                      Advance_Directive_for_mental_health_June03.pdf




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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10.4 How can nurses involve carers in order to ensure concordance with
     medication?

     Carers often play a crucial role in assisting service users to take medication and
     monitoring the effects of that medication. Mental health nurses should seek the service
     user's permission to involve carers in discussions and decisions about medication when
     it is indicated. If the service user cannot consent to involvement of their carers,
     decisions should be made in the service user's best interests and documented by all
     active prescribers.




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           Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     11 Continuing professional
        development and maintaining
        competency

                            11.1 Why is continuing professional development important?

                                     In order to ensure that services are of the highest standard it is essential that all nurses
                                     who are prescribing or supplying and / or administering medicines under patient group
                                     directions remain up-to-date and competent to practice. Clause 6 of the Nursing and
                                     Midwifery Council code of professional conduct: standards of conduct, performance
                                     and ethics 200220 states that:


                                  ‘As a registered nurse, midwife or spcialist community publich health nurse, you must
                                                 maintain your professional knowledge and competence’



                                     Nurse prescribers are bound by this code to keep their knowledge and clinical skills
                                     up-to-date. There are many formal and informal ways in which nurses can keep their
                                     knowledge and skills up-to-date:

                                     l         Regularly practising skills

                                     l         Further training

                                     l         Keeping up-to-date with guidance and technical appraisals issued by National
                                               Institute for Clinical Excellence

                                     l         Attendance at relevant conferences

                                     l         Membership of relevant organisations

                                     l         Ongoing clinical supervision

                                     l         Clinical placements

                                     l         Update training

                                     l         Clinical supervision

                                     l         Reading key academic journals




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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11.2 Maintaining competency

     The National Prescribing Centre has produced competency frameworks for independent
     nurse prescribers (www.npc.co.uk/nurse_prescribing/pdfs/maint_comp_in_
     prescrib.pdf), nurse supplementary prescribers (www.npc.co.uk/nurse_prescribing/
     pdfs/nurse_update_framework.pdf) and professionals working with patient group
     directions (www.npc.co.uk/publications/pgd/pgd.pdf). These frameworks can be used
     to:

     l      Facilitate continuing professional development at an individual level

     l      Help managers and individual nurse prescribers identify gaps in their
            competencies

     l      Help identify at an organisational level common training and development needs

     l      Inform the commissioning, development and provision of education and training
            for nurse prescribers



     Organisations have a responsibility to help and support individual nurse prescribers to
     maintain their clinical competencies. The National Prescribing Centre frameworks will
     allow organisations to identify common training and education needs and commission
     appropriate input to help meet these needs.



11.3 What additional training may be helpful?

     The Institute of Psychiatry survey of directors of nursing indicated that the majority of
     Trusts require that mental health nurses should undergo a medication management
     course prior to or after attending the prescribing course as a way of improving
     knowledge.

Additional training
Nurse prescribers in South Staffordshire now have access to a ‘neuropharmacology’ course
run by Staffordshire University and commissioned by their Trust, in order to strengthen
their knowledge of psychopharmacological medication and its use in mental health settings.
Contact: d.r.skingsley@staffs.ac.uk




11.4 What ongoing supervision do nurse prescribers need?

     It is important to distinguish between supervision during training that is part of the
     training programme and supervision once qualified. Mental health nurse prescribers
     will need to receive prescribing related supervision corresponding to their identified



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           Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                                     needs following completion of their training. This could be with the supervisor that
                                     they had during training. Advice should always be available from the independent
                                     prescriber on a supplementary prescribing relationship. Prescribing supervision may be
                                     seen as being additional to routine clinical supervision.


                              Group supervision
                              In South Staffordshire NHS Trust monthly nurse prescribing group supervision meetings
                              have been set up. These meetings provide an opportunity to provide support, advice and
                              information from peers. Within these meetings case scenarios / triggers are presented and
                              using a problem based learning approach small groups work through issues and identify
                              learning needs. It is the intention that these meetings will evolve into peer group supervision
                              sessions.
                              Contact: a.l.hay@staffs.ac.uk



                              Action learning sets
                              In a joint initiative between 5 Boroughs Partnership NHS Trust, Mersey Care NHS Trust
                            a and Cheshire and Wirral Partnership NHS Trust, newly qualified supplementary prescribing
                              nurses attend monthly action learning sets to help with continuing professional
                              development. The local college supports this and will provide additional sessions.
                              Contact: jayne.bridge@merseycare.nhs.uk




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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12 Working with the
   pharmaceutical industry



     12.1 Contact with the pharmaceutical industry

          Once nurses become qualified prescribers they may find they have increased contact
          with representatives of the pharmaceutical industry. Pharmaceutical companies cannot
          directly promote to service users or carers. Their communication is with clinicians and
          therefore it is likely that mental health nurse prescribers will be approached by
          pharmaceutical representatives to discuss their companies' products.


          Pharmaceutical companies' sales and marketing actions are strictly regulated by the
          Prescription Medicines Code of Practice Authority (www.abpi.org.uk/links/assoc/
          pmcpa.asp). Pharmaceutical representatives can be a useful source of information. It is
          important that nurses are able to critically appraise data available to them from all
          sources.


          The pharmaceutical industry is involved in providing educational programmes and
          supporting individual projects related to clinical practice.



     12.2 Where is guidance available?

          The Department of Health has produced guidance regarding the boundaries of
          relationships with the industry. This is available from www.dh.gov.uk/PolicyAnd
          Guidance/MedicinesPharmacyAndIndustry/fs/en.




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                Improving mental health services by extending the role of nurses in prescribing and supplying medication:
                                                                                                     Good practice guide
     Appendix A

     NIMHE national nurse prescribing
     group members

                            Samantha Bateman, Clinical Lead Pharmacist, Oxfordshire Mental Healthcare NHS Trust


                            Jayne Bridge, Nurse Consultant and Nurse Prescribing Lead, Merseycare NHS Trust


                            Neil Brimblecombe*, Acting Director of Mental Health Nursing, National Institute for Mental
                            Health in England


                            Ken Coates, Nursing Relations Manager, Janssen-Cilag Ltd


                            Kathie Flowers, Community Mental Health Nurse, Dorset Healthcare NHS Trust and Regional
                            Co-ordinator — Southern, Mental Health Nurses Association


                            Trudy Granby, Assistant Director: Non-medical Prescribing Support, National Prescribing
                            Centre


                            Richard Gray*, Lecturer and MRC Fellow in Health Services Research, Institute of
                            Psychiatry, Kings College, London


                            Neil Harris, Nurse Consultant, Manchester Mental Health and Social Care Trust and Lecturer,
                            University of Manchester


                            Alison Hay, Senior Lecturer, Staffordshire University and Senior Nurse, South Staffordshire
                            Healthcare NHS Trust


                            Steve Hemingway, Lecturer in Mental Health Nursing, University of Sheffield


                            Martin Jones, Nurse Consultant, Hillingdon Primary Care Trust


                            Edwin Martin, Service user representative, Birmingham


                            Chris May, Consultant Nurse and Joint Prescribing Lead, Avon and Wiltshire Partnership
                            Mental Health NHS Trust


                            Sarah McGeorge, Liaison Nurse Consultant, Mental Health Services for Older People, County
                            Durham and Darlington Priority Services NHS Trust


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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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Ros Meek, Government and NHS Affairs Manager, Wyeth Pharmaceuticals


Graham Newton, Chair of the United Kingdom Psychiatric Pharmacy Group


Peter Nolan, Professor of Mental Health Nursing, South Staffordshire Healthcare NHS Trust


Barbara Norden, Service User representative, Birmingham


Sean Page, Clinical Nurse Specialist, Manchester Mental Health and Social Care Trust


Brian Rogers, Professional Officer for Mental Health, Amicus Health


Stuart Wix, Forensic Nurse Consultant, Prescribing Lead, Birmingham and Solihull Mental
Health Trust


* Joint chairs



Advisers

David Bullock, Professional Advisory Service Team Manager, Nursing and Midwifery Council


Fiona MacMillan , Consultant Psychiatrist, South Staffordshire Healthcare NHS Trust


Maureen Morgan, Professional Officer for Policy and Practice, Professional Leadership Team,
User Experience and Involvement Directorate, Department of Health


Paul Robinson, Section Head: Extending Prescribing Responsibilities and Nurse Prescribing,
Department of Health



External referees

Jon Allen, Director of Nursing, Oxfordshire Mental Healthcare NHS Trust


Peter Hasler, Director of Nursing, West Kent NHS and Social Care Trust



Help and assistance from

Ann-Marie Parr, Research Worker, Institute of Psychiatry, Kings College, London




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             Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     Appendix B

     Nurse supplementary prescribing
     policy

                            The following are examples of some issues that might need to be addressed when drawing up
                            a policy to support supplementary prescribing. If any of these issues relate to other local
                            policies then reference to these can be included.

                            1.       Background to the principles of nurse prescribing within a policy context:
                                     l     Making appropriate reference to key national policy documents

                            2.       Definitions:
                                     l      Of both independent and supplementary prescribing — sources Department of
                                            Health, Medicines and Healthcare products Regulatory Agency

                            3.       Training and professional requirements:
                                     l      Including the outline curriculum and the Nursing and Midwifery Council
                                            Standards for extended formulary nurse prescribing and supplementary
                                            prescribing
                                     l      Annotation to the Nursing and Midwifery Council register
                                     l      The need to adhere to the Nursing and Midwifery Council code of professional
                                            conduct: standards of conduct, performance and ethics 2002
                                     l      The need to follow the Nursing and Midwifery Council guidelines for the
                                            administration of medicines 200431
                                     l      Relationships with the pharmaceutical industry
                                     l      Record keeping

                            4.       Criteria:
                                     l       When and where to use independent and supplementary prescribing in practice
                                     l       When and where not to use independent and supplementary prescribing in
                                             practice

                            5.       Procedure:
                                     l     Should describe good practice in the use of supplementary prescribing,
                                           highlighting safety issues

                            6.       Requirements of the clinical management plan:
                                     l     Including some completed examples of templates to guide practitioners
                                     l     Specify whether the clinical management plan is to be in electronic or hard copy
                                           format
                                     l     Describe the relationship between the clinical management plan and the care
                                           programme approach process

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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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      l      The template clinical management plan should be appendixed to the policy
      l      Arrangements where there is more than one supplementary prescriber

7.    Roles and responsibilities of the independent (medical) prescriber:
      l      Initial assessment and diagnosis
      l      Consultation with the service user
      l      Development of the clinical management plan in partnership with the
             supplementary prescriber
      l      Setting limits of delegated responsibility
      l      Resuming full responsibility at request of supplementary prescriber

8.    Roles and responsibilities of the supplementary prescriber:
      l      Monitoring of service user's progress as per clinical management plan
      l      Prescribing in accordance with clinical management plan
      l      Accepting responsibility for prescribing decisions
      l      Referring back to the independent prescriber when indicated

9.    Supervision:
      l     Who?
      l     How often?
      l     By whom?

10.   Communicating with other prescribers

11.   Maintaining competence:
      l     How to manage poor performance
      l     Utilisation of National Prescribing Centre competencies
      l     Access to continuing professional development opportunities

12.   Indemnity:
      l     The organisation’s responsibility with regard to vicarious liability
      l     Individual responsibility

13.   Audit of practice:
      l      Strategic plan for organisation to evaluate effectiveness
      l      Impact on service users
      l      Registering complaints
      l      Procedure for reporting of adverse incidents
      l      Benchmarking against other services
      l      Monitor prescribing activity

14.   Action for employers:
      l     Maintaining a register of nurse prescribers and their signatures
      l     Security of prescriptions (managing the abuse of prescriptive power)
      l     Having a system in place to address issues such as what happens when either of
            the prescribing partners leaves




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            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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                            15.      Notes for prescribers:
                                     l      Use of abbreviations
                                     l      Generic names
                                     l      Up to date range of generic names that a nurse prescriber can use

                            16.      Date and review date, and who is responsible

                            17.      Acknowledgement of the ratification process, e.g. by clinical governance committee




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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   Appendix C1

   An example of a ‘broad’ clinical
   management plan

Name of patient:                                                                           Patient medication sensitivities / allergies:
MR ANON                                                                                    ALLERGIC TO PENICILIIN
Patient identification e.g. ID number, date of birth:


Current medication:                                                                        Medical history:
FLUOXETINE 20MG DAILY                                                                      NONE OF NOTE / NOT KNOWN

Independent prescriber(s):                                                                 Supplementary prescriber(s):
DR X                                                                                       NURSE Y

Contact details [tel / email / address]                                                    Contact details [tel / email / address]




Condition(s) to be treated:                                                                Aim of treatment:
DEPRESSION                                                                                 REMISSION OF DEPRESSIVE SYMPTOMS

Medicines that may be prescribed by supplementary prescriber:

Preparation:                  Indication:                Dose schedule:                    Specific indication for referral back to the
                                                                                           independent prescriber:
Any antidepressant            Depression                 As indicated in the BNF
listed in the BNF                                        (but not to exceed BNF            Lack of response after six months and / or
(excluding MAOIs and                                     limits)                           after trying at least two antidepressants
tricylcics)

Guidelines or protocols supporting clinical management plan:
REFER TO NICE CLINICAL GUIDELINE 23 — DEPRESSION: MANAGEMENT OF DEPRESSION IN PRIMARY ARE
SECONDARY CARE, DECEMBER 2004

SOUTH LONDON AND MAUDSLEY NHS TRUST 2003 PRESCRIBING GUIDELINES

Frequency of review and monitoring by:

Supplementary prescriber:                                Supplementary prescriber and independent prescriber:
WEEKLY INITIALLY                                         YEARLY

Process for reporting ADRs:
YELLOW CARD AND ON-LINE

Shared record to be used by independent prescriber and supplementary prescriber:
PATIENT MEDICAL / CLINICAL NOTES

Agreed by independent         Date:                      Agree by supplementary            Date:                      Date agreed with patient /
prescriber(s):                                           prescriber(s):                                               carer:




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                                            Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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     Appendix C2

     An example of a ‘specific’ clinical
     management plan

Name of patient:                                                                               Patient medication sensitivities / allergies:
MR ANON                                                                                        ALLERGIC TO PENICILLIN
Patient identification e.g. ID number, date of birth:


Current medication:                                                                            Medical history:
FLUOXETINE                                                                                     NONE OF NOTE / NOT KNOWN

Independent prescriber(s):                                                                     Supplementary prescriber(s):
DR X                                                                                           NURSE Y

Contact details [tel / email / address]                                                        Contact details [tel / email / address]




Condition(s) to be treated:                                                                    Aim of treatment:
DEPRESSION                                                                                     REMISSION OF DEPRESSIVE SYMPTOMS

Medicines that may be prescribed by supplementary prescriber:

Preparation:                     Indication:                Dose schedule:                     Specific indication for referral back to the
                                                                                               independent prescriber:

Fluoxetine                       Depression                 20mg / day                         Lack of response after one month



Guidelines or protocols supporting clinical management plan:
REFER TO NICE CLINICAL GUIDELINE 23 — DEPRESSION: MANAGEMENT OF DEPRESSION IN PRIMARY ARE
SECONDARY CARE, DECEMBER 2004

SOUTH LONDON AND MAUDSLEY NHS TRUST 2003 PRESCRIBING GUIDELINES

Frequency of review and monitoring by:

Supplementary prescriber:                                   Supplementary prescriber and independent prescriber:
WEEKLY INITIALLY                                            THREE MONTHLY

Process for reporting ADRs:
YELLOW CARD AND ON-LINE

Shared record to be used by independent prescriber and supplementary prescriber:
PATIENT MEDICAL / CLINICAL NOTES

Agreed by independent            Date:                      Agree by supplementary             Date:                 Date agreed with patient /
prescriber(s):                                              prescriber(s):                                           carer:




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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
Good practice guide
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Improving mental health services by extending the role of nurses in prescribing and supplying medication:
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