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- Implications for Nursing Practice
PURPOSE. This study aims to determine the extent to which community mental health nurses are currently practicing beyond the traditional scope of nursing practice.
DESIGN AND METHODS. A self-administered questionnaire was distributed to community mental health nurses in Victoria, Australia.
FINDINGS. The majority of participants reported routine involvement in practices that would normally be considered beyond the scope of nursing practice, such as prescribing, ordering diagnostic tests, and referral to specialists.
PRACTICE IMPLICATIONS. The extent to which the current mental health service system is dependent upon nurses transgressing professional and legal boundaries warrants further study. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.
The process of deinstitutionalization and the move to community-based mental health care in Australia have substantially altered the practice of most mental health professionals (Bland et al., 2007; Rosen & Callaly, 2005). This trend has led to the expansion of the role of the community mental health nurse as a member of the multidisciplinary care team (Sands, 2004). The relevant literature suggests that nurses play a large role in recommending variations to mental health treatment to medical practitioners, including medication and the instigation of involuntary admission to hospital (Clinton & Hazelton, 2000; McCann & Baker, 2002; Nolan, Haque, Badger, Dyke, & Khan, 2001). The degree to which these responsibilities extend the legally recognized role of the community mental health nurse is not clearly understood. In Australia, only nurses who have been authorized to practice as nurse practitioners are permitted to undertake expanded practices, such as prescribing medications and ordering diagnostic tests. Given the focus on community-based mental health care and the development of nurse practitioners in Australia (Driscoll, Worrall-Carter, O’Reilly, & Stewart, 2005; Gardner & Gardner, 2005; Jamieson & Williams, 2002) and worldwide (Bigbee & Amidi-Nouri, 2000; Dunphy, Youngkin, & Smith, 2004; Fairman, 2001), it is timely that the topic of expanded practice roles for nurses be further investigated along with the implications of this role for the delivery of mental health services.
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- Implications for Nursing Practice
Fifty percent of the 154 respondents were women, 41.6% men, and 8.4% did not respond to this question. The mean age was 43.3 years, with a range of 24–60 years. The participants worked 37.7 hr per week on average. Years of experience demonstrated a mean of 20 years in nursing, 17.2 years in mental health nursing, and 9.2 years in the community. Sixty-three percent of participants had completed a hospital-based course in psychiatric nursing and 26% in general nursing. Nearly one third of the respondents (30.5%) did not have university qualifications, and only 8.4% were undertaking a university program at the time.
Information about the current scope of practice of community mental health nurses is presented in Table 1. For all questions in this subscale, the scores ranged from 1 (never) to 5 (always). The most commonly reported practice was the administration of medication exactly as prescribed by the doctor. It is of note, however, that 5 respondents (3.3%) reported that they never administered medication as prescribed, and another 10 (6.6%) reported only doing so rarely or sometimes.
Table 1. Current scope of practice summary (n = 154)
|Question: Currently in your mental health nursing practice do you:||Never||Rarely||Sometimes||Often||Always|
|Suggest or recommend to a medical practitioner that a medication dose be adjusted?|| 6.5|| 4.5||26.0||57.8|| 5.2|
|Suggest or recommend to a medical practitioner a change of medication?|| 6.5|| 7.2||40.5||41.2|| 4.6|
|Suggest or recommend to a medical practitioner the commencement of a new medication?|| 9.7||10.4||38.3||36.4|| 5.2|
|Adjust the dose of a medication having previously obtained approval to do so from a medical practitioner?||12.3|| 6.5||31.8||36.4||13.0|
|Change medication having previously obtained approval to do so from a medical practitioner?||15.8||14.5||33.6||23.7||12.5|
|Initiate a new medication having previously obtained approval to do so from a medical practitioner?||16.2||13.6||28.6||30.5||11.0|
|Adjust the dose of a medication and arrange for a medical practitioner to authorize (sign for it) later?||45.1||23.5||13.7||14.4|| 3.3|
|Change medication and arrange for a medical practitioner to authorize (sign for it) later?||66.2||17.5|| 8.4|| 5.2|| 2.6|
|Initiate a new medication and arrange for a medical practitioner to authorize (sign for it) later?||71.9||14.4|| 7.2|| 5.2|| 1.3|
|Administer medication exactly as prescribed by a medical practitioner?|| 3.3|| 2.0|| 4.6||32.7||57.5|
|Recommend to a medical practitioner ordering of diagnostic tests (e.g., blood tests, X-rays, computed tomography scans)?|| 3.9|| 9.7||39.0||38.3|| 9.1|
|Recommend to a medical practitioner that a patient be referred to a medical specialist?|| 2.0||23.5||43.1||25.5|| 5.9|
|Recommend to a medical practitioner that a patient be recommended for involuntary treatment?|| 1.9|| 4.5||37.0||46.1||10.4|
|Recommend to a medical practitioner that a community treatment order be revoked?|| 5.9|| 7.2||34.2||40.8||11.8|
|Recommend to a medical practitioner the discharge of an involuntary patient?||17.0||18.3||31.4||26.8|| 6.5|
|Recommend to a medical practitioner the writing of certificates for sick leave or benefit purposes?||13.6||22.7||26.6||28.6|| 8.4|
The least common practices reported were those that involved initiating or changing medication without prior approval of a doctor. However, 28.1% reported that they sometimes initiated a new medication and arranged for it to be authorized later by a doctor and 6.5% did so often or always. One participant offered an extra written comment that suggested another form of expanded nursing practice that was not included in the questionnaire:
One question not asked was do we give out medication not prescribed as a once off and not get an order later. I think this happens a lot. That is: extra 5 mg of diazepam PRN [pro re nata or as required] when the client needs it and it's not prescribed.
Suggesting or recommending to a doctor that medication doses be adjusted was a regular practice. Similarly, recommending to a doctor a change of medication and suggesting the commencement of a new medication were common practices. The nurses reported that changing medications, adjusting dosages, and initiating new medications, and having previously obtained a doctor's approval to do so were common practices, with more than 70% of participants doing this sometimes or more often.
Making recommendations to doctors regarding other domains of expanded practice were also regular occurrences for many of the community mental health nurses surveyed. More than half of the nurses often or always made recommendations to doctors concerning involuntary treatment of patients. Although not as common, the majority of the nurses at least sometimes recommended ordering of diagnostic tests, referral to medical specialists, or writing of sick certificates.
The majority (65.6%) of participants reported that they were more likely to engage in expanded practices now than they were in the past. Twenty nurses (13%) commented that a lack of medical resources in relation to supply of either general practitioners or psychiatrists made expanded practice a necessity and that this practice was more apparent now than in the past. Eight nurses (5%) commented on the poor abilities of some doctors in regard to treatment of people with mental illness, and four specifically commented on the problem created by doctors with poor English language skills:
General practitioners [GPs] make decisions concerning psychotropic medication prescriptions frequently and from a usually shallow knowledge base. An experienced community based psychiatric nurse is likely to have a fuller understanding of indications, contraindications, interactions, and side-effects than a GP where psychotropic medications are concerned.
Participants were asked whether their suggestions to doctors regarding patient treatment were generally welcomed and valued. Three separate questions sought to investigate whether the nurses’ experiences differed depending upon whether the doctor was a general practitioner, a psychiatric registrar (fully qualified doctor training to become a psychiatrist), or a fully qualified psychiatrist (see Table 2). Most nurses reported that their suggestions regarding patient treatment were usually welcomed and valued by doctors, with psychiatric registrars being slightly more receptive than qualified psychiatrists who, in turn, were more welcoming of nurses’ input than general practitioners. This finding was also evident in the comments made by six participants (3.9%) that, in their experience, general practitioners were less receptive to their suggestions or recommendations regarding medical treatment than were psychiatrists.
Table 2. Nurses’ experiences of doctors’ responses to their suggestions (n = 154)
|Do you find that your suggestions to general practitioners regarding patient treatment are generally welcomed and valued?||4.6||60.8||32.7||1.3||0.7|
|Do you find that your suggestions to psychiatric registrars regarding patient treatment are generally welcomed and valued?||7.2||68.4||23.7||0.7||0|
|Do you find that your suggestions to psychiatrists regarding patient treatment are generally welcomed and valued?||7.2||63.4||24.8||4.6||0|
Crisis Assessment and Treatment Team (CATT) mental health nurses reported more expanded practice (M = 52.4, SD = 11.3) than mental health nurse case managers, M = 47.1, SD = 9.6; t(112) = 2.47, p = .015. By examining participants’ scores for items pertaining to practices that are currently illegal in the state of Victoria (and indeed, in other Australian states) for nurses who were not authorized as nurse practitioners, an illegal practice subscore was obtained. Scores ranged from 3 to 15, with a mean score of 5.15 (SD = 2.88). Once again, CATT mental health nurses (M = 6.45, SD = 3.47) reported significantly more illegal practices than case managers, M = 4.63, SD = 2.23; t(39.26) = 2.73, p = .009.
No significant relationships were found between any measures of experience and scores for current scope of practice. In addition, no significant differences in current scope of practice were found between the rural and metropolitan services. The nurses from one rural service reported that their suggestions were more welcomed by doctors (M = 6.07, SD = 1.59) than one of the metropolitan services, M = 7.09, SD = 1.34; t(80) = –3.08, p = .003. No differences were found between the other rural and metropolitan services. No other significant relationships existed between experience, qualifications, hours worked per week, age, or gender and current scope of practice.
Implications for Nursing Practice
- Top of page
- Implications for Nursing Practice
The increased autonomy within nursing practice as a consequence of community-based care is altering the relationship between mental health nurses and medical practitioners. This study has revealed that mental health nurses are routinely engaged in practices that have been considered the sole remit of physicians. The extent to which mental health service delivery is dependent upon mental health nurses undertaking such practices is unknown.
Expanded practice roles for nurses are having and will continue to have significant implications for mental health service delivery in areas such as medication prescribing, clinical decision-making about client assessment, and involuntary admission to hospital. It is critically important that professional bodies and nurse regulatory authorities recognize the current extent of expanded mental health nursing practice in order to develop appropriate policy frameworks. It is also necessary for these practice realities to be appropriately reflected in university curricula and professional development programs for mental health nurses and other mental health professionals. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.