Supplementary prescribing: a new way of working for psychiatrists and nurses

AIMS AND METHOD

To describe the implementation of supplementary prescribingand nurse-led care in an acute in-patient unit. The issuesof delegation and distribution of responsibility were explicitlyaddressed. Structures were developed for training and supervision,to ensure improved medicines management in the acute setting.

RESULTS

We present our five-step model of nurse-led in-patient careand our experience of using a clinical management plan for33 patients.

CLINICAL IMPLICATIONS

Implementation of supplementary prescribing provides a modelfor new ways of working, requiring engagement of both doctorsand nurses, clear delegation and distribution of responsibilities,and well-developed governance structures.

Introduction

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Introduction

Most psychiatrists are currently involved in an active reviewof roles and responsibilities as part of the New Ways of Working (Department of Health, 2005) initiative. Key to this are changeswithin the multidisciplinary team to prioritise consultantworkload and the distribution of responsibility and leadershipacross teams. The General Medical Council has issued guidanceon the legal framework for this process of distribution (General Medical Council, 2005) recognising the independent responsibility of nurses, workingwithin their skills and competencies, for patients, withoutthe responsibilities being in any way delegated or supervisedby a doctor. The guidance also emphasises the important roleof employers in creating a managed, safe environment for this.

Prescribing is no longer a solely medical task, we now havepatient group directives, supplementary prescribing and latelyindependent nurse prescribing (Department of Health, 2006a).Supplementary prescribing is a delegated responsibility, wherethe overall responsibility for patient management remains withthe delegating doctor (General Medical Council, 2006), althoughthe persons delegated to are accountable for their own decisionsand actions. The delegating doctor has responsibilities toensure communication about the patient and the treatment needed,and must ensure that the person delegated to has the necessary qualifications, experience, knowledge and skills.

Supplementary prescribing has the potential to improve patientoutcome (National Prescribing Centre, 2005). However, thereare acknowledged difficulties in implementation. Organisationalbarriers and lack of knowledge and confidence have been identifiedas causes of non-adoption of supplementary prescribing by trainednurse prescribers (Brimblecombe et al, 2005) as has the lackof supervisor support. Gray et al (2005) noted ‘theneed to explore further the knowledge, skills and confidenceof psychiatrists undertaking a nurse prescribing supervisionrole’.

Little has been written about supplementary prescribing fromthe psychiatrist’s perspective; implementation and researchare nurse-led (Jones, 2006; Nolan et al, 2001). The impacton doctors, in terms of changes in the way of working and the training and supervision of prescribers, is barely mentionedin key documents (Department of Health, 2006b). Supplementaryprescribing is repeatedly described as a ‘voluntary partnershipbetween an independent prescribing doctor and a supplementaryprescribing nurse’. However, a partnership assumes thatboth sides work towards a common aim, through an agreed process,on an equal footing. Clearly the prescribing relationship isnot equal; the consultant has a depth and breadth of psychopharmacologicalknowledge and therapeutic experience unavailable to even themost experienced supplementary prescriber.

We have developed a model of acute in-patient care which bothdelegates responsibility for prescribing and distributes responsibilityfor assessment and care management. We offer some observationsbased on our experience.

Method

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Method

Questions
Acknowledging the literature describing the difficulties ofimplementation of supplementary prescribing, we started byposing a series of questions, as follows.

Where do we prescribe?
Most community prescribing is carried out by general practitionerson the advice of psychiatrists, the exceptions being crisissituations and long-term depot or clozapine treatments. Thereis little incentive to take back work from primary care wherethe infrastructure and governance arrangements are well-established;this is contrary to the Director of Nursing survey (National Prescribing Centre, 2005)which saw the community mental health team as the focus for nurse prescribing. Most specialist prescribing occurs in in-patientsettings, an area of medicines management highlighted by theHealth Care Commission (2007) as needing urgent improvement.

How could supplementary prescribing improve on the existing arrangements?
Medical time on the wards has reduced, consultants are more community-focused and trainee time is disrupted by shift-workingand the need to gain community and psychotherapeutic training.Specialist pharmacists are few in number and hard to recruit,and there is an increasing recognition of the effectivenessof nurse-led care in delivering behavioural change and medicinesmanagement (Gray et al, 2004).

How do we obtain the support for systems to change?
Our in-patient services had been through a 2-year refocusingprocess with a number of consultants, teams and wards developingnew, devolved and more patient-focused ways of working. Consultantscan be engaged in a teaching capacity, and a number have goneon to supervise nurses through 72 h of clinical practice aspart of their prescribing course.

New way of working in an acute in-patient setting
Skilled expertise rests with the psychiatrist, but not all patientsnor all aspects of patient care necessarily require the skillsof the psychiatrist. We developed a five-step model where theprescribing responsibility was delegated and the assessmentand care management responsibility distributed from the psychiatristto the nurse consultant.

Acute care plan. Acute care is managed by the admitting nurseand psychiatric trainee, for up to 72 h. Priorities are riskmanagement, management of distress, including emergency tranquillisation,and the exclusion of acute medical pathology.
Formulationand treatment plan. The consultant and nurse consultant interviewthe patient and agree the formulation and managementplan. Within the plan specific responsibilities, such as medicinesmanagementand prescribing, may be delegated by writing a clinicalmanagementplan. Responsibilities such as coordinating careand dischargeare distributed to the nurse consultant and seniornursingteam. Responsibilities for overseeing risk managementand MentalHealth Act decisions are generally retainedby the consultant.
Care and treatment. Patients are reviewed by the nurse consultantat least every other day, with formal assessments of mentalstate and target symptoms, and side-effect monitoring. Thecare management plan is referred to for prescribing and assessmentguidance.
Ward rounds and Care Programme Approach reviews.The nurse consultantleads brief weekly ward rounds, to checkthat all aspects ofcare are being attended to, and progressis communicated tocarers and community staff by written updates.With the relativeinward focus of ward rounds, the Care Programme Approach reviewmeetings become the venue for the consultantto provide expert advice and for the community staff to plandischarge options.
Consultancy when required. The consultant,although less tiedto routine commitments, has to be availablefor urgent consultationthroughout the week, with face-to-face,phone or email contact.

Developing the working relationships
The strength of the relationship lies in the psychiatrist beinginvolved in the supplementary prescribers’ training andongoing personal development including their supervision. Thisallows the doctor to be sure of knowing the supplementary prescribers’strengths and weakness, building trust and understanding. Theprimary syllabus for supplementary prescribing is generic toall areas of medicine, and there is an acknowledged gap in nurseeducation regarding biological psychiatry (Gournay, 2005).Key to the change in working has been the adoption of joint records, written in a shared language, with a shift from thenursing narrative style to the more analytical and hypothesisdriven medical style.

Consultant’s role
This has been an active change to standing back from acute patientcontact and the clinical processes on the wards, and takingon more supervision and consultation work. This has raisedissues of how this new way of working is accounted for in termsof activity, job planning and governance. Patient resistance,and a demand to regularly see the psychiatrist, have not been encountered once the system was up and running.

The central role of the clinical management plan
This is the legally required written plan of treatment whichdelegates prescribing authority; it is also an exercise ingood medicines management. Decision-making is openly sharedwith the patient, who must consent to the plan. The evidencebase is both noted in the plan and used by the supplementaryprescriber. Common reference points for us include the British National Formulary, Maudsley Prescribing Guidelines (Taylor et al, 2005) and National Institute for Health and Clinical Excellence guidelinesfor the treatment of schizophrenia (National Institute for Health and Clinical Excellence, 2002)and mood disorders (National Institute for Health and Clinical Excellence, 2006).A care management plan requires a clear working diagnosis,goals for treatment and a plan of the types of treatments thatwould be offered with reasons for changing. This helps to preventsituations where patients can be admitted with unclear goals,or the discharge point slips as other issues intrude. Goalsalso help to define target symptoms for tracking progress,and this brings the whole in-patient nursing team into usingthe same parameters in their nursing record. The supplementaryprescriber and nursing team are also engaged in tracking side-effects,imparting information and influencing behaviour for positive concordance.

Results

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Results

We have been working in this fashion for 12 months and, to date,33 patients have been treated with a care management plan (Table 1),with only one refusal. We started with simple dose titrations,added in adjunctive and side-effect treatments, progressedto treatment crossovers and now write a care management planthat covers a choice of treatments from the relevant BritishNational Formulary groups. In-patient staff are now engagedin formal mental state assessment and systematic medicinesmanagement.

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Table 1. Types of care management plan

Discussion

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Discussion

We have found that by properly acknowledging the issues of delegationand distribution of responsibility, and building systems whichhelp both sides of the supplementary prescribing relationshipto feel secure, we have been able to successfully implementthis new way of working. This has been accompanied by an extensionin practice, so that medical roles such as mental state recording,side-effect detection and coordinating in-patient care can be distributed. This new way of working has to be accompaniedby a real change in the psychiatrist’s role to educatorand supervisor, with clinical contact confined to only themost complex cases, where delegation of medical work wouldfall outside the competency of even the most highly trained nurses.

References

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