Acute psychiatric inpatient wards

This paper will outline and describe how supplementary prescribing (SP) can be applied on acute psychiatric wards. Across England, implementation of nurse prescribing has had a sporadic start [1]. However, there are a number of service examples where it has been used to good effect, namely depot clinics and community mental health teams [2] and acute inpatient nursing teams [3].

Nurse prescribing has its origins from the Cumberlidge report in the mid 1980's, which advocated that community nurses should be able to prescribe from a limited formulary [4]. Following successive changes in legislation and demands from the service [5–7] there are now three main types of prescribing, namely, patient group directives (PGD), SP and independent prescribing (IP).

A PGD is where a health professional can prescribe medication for a group of patients who may not have been previously identified, examples being drugs for immunisation and for mental health, drugs that maybe prescribed at nighttime, such as sedatives [2].

SP is where the nurse or pharmacist is able to prescribe in partnership with a psychiatrist, for a named patient with a clearly established diagnosis and where the medications are listed on a Clinical Management Plan (CMP) [2].

The third type of prescribing is IP, which is where a nurse, that is deemed competent, can diagnose and prescribe for a medical condition from the British National Formulary using any drug (not controlled drugs) they see fit and for which they are trained to prescribe. This type of prescribing would not require a CMP [6].

The introduction of SP is said to produce many benefits, namely the drive to maximise patient access to healthcare and improved patient satisfaction with services [8]. By enabling different types of professions to prescribe medication within the workforce, this in itself produces opportunities for service redesign and the development of a more flexible workforce [2].

Concordance is set to rest on collaboration between the patient and the prescriber [9]. Advocates of SP believe that a nurse has more time to spend with the patient discussing treatment options and building choice into the prescribing relationship and this will support improved concordance with treatment and therefore better patient outcomes [10].

Many studies on nurse prescribing chart a positive impression of nurse prescribing in mental health settings [11,12]. Gaps in knowledge, particularly in psychopharmacology may well lead to nurse's not prescribing medication upon their registration as a nurse prescriber [13]. This has contributed to the claim that implementation deficit has occurred in mental health services with very few nurse prescribers actually using the approach upon registration [14].

Patients are accepting of non-medical prescribing [15,16] although as yet there is no controlled trial demonstrating that SP improves patient outcomes in mental health settings.

Hospital care remains the cornerstone of mental health services, providing a safe clinical environment where symptoms can be assessed, diagnosed and managed and act as the cornerstone to plan longer-term community care. However, countless studies have demonstrated staff have poor engagement with patients and patients have poor satisfaction with hospital care [17]. SP may deliver a more patient responsive service in the hospital setting although this has yet to be demonstrated in a controlled trial. Cautious editorials have also questioned whether nurses have been trained in diagnosis to prescribe medication safely [18]. On top of this, research carried out by Jones [19,20] into perceptions on SP for acute care has found two major factors to consider when implementing the approach.

Relationships between nurses and psychiatrists

Jones [19,20] has carried out a study to explore perceptions held by nurses and psychiatrists towards the implementation of SP on acute psychiatric wards. The first theme revolved around the relationship between the collaborating psychiatrist and the SP and how the process and relationship is infused with the need for the nurse to demonstrate competency in treating patients. Important was the need to learn together about managing patient groups within a CMP. More specifically respondents identified that by writing a CMP, myths about stable diagnosis and efficacy of treatment were dismantled. However, this led to a more realistic outcome of hospital care by identifying clear boundaries of what psychiatrists and nurses do for patients within a prescribing relationship.

Acute inpatient nurse prescribing

The second major factor to come out of the study was how SP would be implemented on psychiatric wards. Three models for implementing SP were identified.

The first model was of a medication specialist who would be a nurse or a pharmacist and who would provide specialist input into medication care plans on psychiatric wards.

The second model is where a ‘cluster’ of psychiatric nurses would be trained to prescribe medication and would all potentially input into the CMP. They would be grouped together as part of a psychiatric team working with a collaborating psychiatrist. This approach may work if crisis teams and inpatient nursing teams were coterminous. This approach has been supported by the National Prescribing Centre (NPC) [2].

The third model and one to be described in detail here is where a nurse consultant (NC) works closely with a collaborating psychiatrist and takes on delegated medical responsibility for organising the patient care episode. SP becomes a tool to be used by the NC in executing acute inpatient care.

A six-step model has been developed to support SP on acute psychiatric wards.

Step 1: Admission and acute care

The patient is admitted on to the ward by the ward staff, usual investigations and observation levels carried out within the first 72 h. Expected outcomes from this period are initial formulation and progress since admission. The patient may not have been started on medication.

Step 2: Clinical management plan formulation

In this second step the NC and the psychiatrist interview the patient together where they would formulate a diagnosis and agree with the patient that they are suitable for a CMP. The range of treatments to be included on the CMP would be agreed and the patient would be given a full explanation of the treatment pathway and this may include information sheets about their medication and information about their illness, if it were deemed appropriate. At this point, delegation of medical responsibility for the inpatient episode to the NC would begin. Patients that are subject Mental Health Act restrictions would remain the responsibility of the Responsible Medical Officer.

Step 3: Care and treatment

During this phase the NC is working with a CMP for a named patient within an SP framework. The NC will be seeing the patient every 2 days, or daily if necessary, carrying out mental state examinations, checking on physical investigations, determining risk and response to the prescribed medication. The NC would in effect be case managing the patient through their hospital care. The NC, as appropriate, would complete medical reports for Hospital Managers hearings and Mental Health Review Tribunals.

Preliminary care coordination activities such as the Care Programme Approach (CPA) on the ward will also be ongoing with the NC being seen as the pivotal point in this for the patient.

The role of the Junior Doctor is to carry out routine and follow up physical examinations. This is especially important given the increased occurrence of co-existing medical conditions such as diabetes, weigh gain and cardiac conditions, for people who take antipsychotic medication [21]. The NC keeps the psychiatrist fully updated on patient progress and if necessary the CMP can be changed to reflect any different formulation and treatment plan.

Step 4: Review focussed CPA

In this phase, the NC interviews the patient with community staff and sometimes takes away the requirement for the patient to be reviewed in a large ward round setting. Patients have found ward round experiences unpleasant [22]. The NC starts discharge planning from the time of admission, which will hopefully lead to more quicker and focussed use of hospital resources.

Step 5: Consultancy when required

In this phase, which in itself is an overlapping phase, the collaborating psychiatrist takes on the role of a ‘Consultant’. By this, the NC would request the psychiatrist to provide a clinical viewpoint on unexplained symptoms or unexpected treatment response. This may require face-to-face assessment on the part of the psychiatrist, although this is not always the case. The CMP may change with new medications added to the list of possible alternatives to meet treatment objectives.

Step 6: Discharge and follow up

Running through this model is the agreement that an NC can assess, diagnose, treat and discharge patients from hospital. The NC and care coordinator will see the patient in his or her own home following a period of leave so that discharge from hospital can take place. Follow up outpatient visits again can occur in the patient's home or in clinic, depending on patient preference. Monitoring of patient response to medication and repeat prescribing of medication within a CMP facilitates this function.

We have seen many benefits from this new way of working, the most obvious being flexible time provided by the psychiatrist to see the most complex patients or those patients who do not appear to be responding to the usual patient pathway. Patients that are subject to a CMP have the benefit of seeing a nurse prescriber much more frequently where their symptoms, medicines and care plan is reviewed.

The model fits comfortably with modernising the role of psychiatrists [23] and developing nursing careers [7]. Psychiatrists see complex patients, leaving a tier of patients that can be managed by an NC. The model described here serves as an initial framework for nurses to use advanced practice nursing skills although much more rigorous training needs to take place for the approach to become more wide spread in acute care. Obvious areas include training in diagnosis and medication management.

Chronic mental health problems like schizophrenia and mood disorder are ideal conditions for a CMP. There has been much said about nurses taking the lead in chronic disease management and this should occur regardless of the setting. It must be remembered that prescribing medication is simply a tool in the nurses' toolkit in order for nurses to take the lead in managing patient groups.

A model of care has been described which hopefully demonstrates a potential role for nurse prescribing in acute inpatient nursing. The approach has benefits for patients and service providers and fits comfortably with the modernisation agenda. We are working towards a hierarchy of need where the most appropriate health care worker sees patients. The model is also flexible to acknowledge that patients have preferences of who they would like to have their care from and the amounts of time they expect from health professionals reviewing and explaining their symptoms, medicines and care plans.

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