Consistent with findings from the prescribing literature 21 of the 26 participants reported themselves to be prescribing. Independent
prescribing was the most common type of prescribing, used by 20 of the 21 participants. None of my participants reported using both independent and supplementary prescribing. It is important here to point out several
specialist nurses for the management of pain working in secondary care settings were invited to take part in this study but declined. The
restrictions to the prescribing of controlled drugs means that these nurses would need to adopt independent and supplementary prescribing for their patients. Practice nurse PN3 and continence nurse specialist NSP 5 had used supplementary prescribing since qualifying but at the time of
interview were only using the framework of independent prescribing. This decisive split towards independent prescribing is not in keeping with the nurse prescribing literature, which suggests supplementary prescribing has greater use than my findings suggest (Bradley and Nolan 2007). They also report that most nurses use both independent and supplementary types of prescribing (Bradley and Nolan 2007).
4.3.1.1. Illustration case MH1: Mental Health Nurse.
Supplementary prescribing.
This nurse working with patients diagnosed with mental illness was the only supplementary prescriber from the sample. It is useful to look at this
single case in more detail to establish why supplementary prescribing was used. The participant is a community mental health nurse who at the point of qualification, was the first nurse prescriber in mental health trust F. My case summary describes him as “an innovative and enthusiastic nurse with vision and determination to use the prescribing qualification”. As is the situation here, Snowden (2006) points out not only that mental health nurses have been slow to train as prescribers but, that those who do find themselves leading the way.
As the first nurse prescriber in the organisation the only examples of prescribing in practice were medical systems of prescribing. MH1 describes how he began to think about how, as a nurse he could use prescribing within his role to improve service delivery and benefit patients with a mental illness. He planned ahead and started to think about how he would use prescribing in his practice whilst still on the prescribing course. Two senior psychiatrists facilitated his mandatory period of medically supervised practice (NMC 2006). Having built on an existing clinical relationship with them through education he decided to explore their expectations. He described their reaction when he asked them how they thought he could use his new prescribing skills.
“I went to the two consultants who had supported me throughout and said where do you envisage me fitting in the service, after they had got up off the floor laughing they sort of went well you might consider doing some of the work that we are doing at a level that is appropriate for you” MH1 page 1.
The fact that MH1 describes their reaction suggests that the question might have been unexpected, perhaps a somewhat forward suggestion to change the division of labour. However, by asking the question the nurse
demonstrates his intention to prescribe for patients with mental illness and seeks their support in achieving this aim. Unusual to this particular case is that the nurse does not intend to integrate prescribing into a current nursing role but to develop a new prescribing role. The request is accepted and the psychiatrists offer the opportunity to develop a new service for the client group. The outcome is a nurse prescriber led non-medical prescribing clinic. In this system, primary care doctors refer clients to the psychiatric consultant. The psychiatrist reviews the client record and refers
appropriate clients to the non-medical prescribing clinic. In this setting the division of labour is changed considerably because the nurse prescriber sees clients who would have otherwise been managed by a psychiatrist. By choosing to integrate nurse prescribing in this way the participant has allowed the psychiatrists to determine the nurse prescribing role and the type of prescribing. The health care trust has a prescribing policy in place which allows independent prescribing and supplementary prescribing. The participant explains that he would feel confident using independent
prescribing and goes on in the interview to justify at some length through an explanation of the differing accountability between independent and supplementary prescribing,
“independent prescribing, I would feel confident going into that arena” MH1 Page 6.
“ legal awareness would, I think, be different, not necessarily the next level up, it would just be a different sphere of prescribing for me”. MH1 Page 6.
The decision to use supplementary prescribing is determined by the consultant psychiatrists;
“ I have spoken to the consultant and he said, well you know in my opinion it will be a challenge for you independent prescribing it is
something we will have to sit down and discuss, and I have sort of said if I feel that I need to do independent prescribing” MH1 Page 4.
There appears to be some conflict between the nurse prescriber and the expectations of the psychiatrists who provide the opportunity for the nurse to prescribe. It is possible that the psychiatrists find supplementary
prescribing professionally comfortable, Lloyd and Hughes (2007) and are therefore reluctant to support the implementation of independent
prescribing. The participant accepts the rationale for caution and offers an acceptable reason for staying with supplementary prescribing
“at the moment I don’t need to because I have got access to two consultant psychiatrists and there is no need for me now to be doing independent prescribing, I am very comfortable with what I am doing “. MH1 Page 4.
MH1 has drawn on a doctor-nurse relationship built through clinical practice and prescribing education in order to create and agree a new division of labour. The psychiatrists support the creation on the non- medical prescribing clinic and both parties show trust and professional respect, which enables this to happen. The final agreement is acceptable to both parties for whilst the nurse prescriber gains the autonomy to prescribe for these patients the psychiatrists retain control of the way services are offered. It appears unlikely that the psychiatrists would agree to support independent nurse prescribing for MH1 at this time. Supplementary prescribing is a tool of compromise which actually enables the integration of nurse prescribing in this case.
4.3.2. Prescribing Practice: supplementary prescribing falls from