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.
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 study used a cross-sectional, correlational design to provide detailed information about the practices of community mental health nurses that extend beyond traditional nursing roles. A self-administered questionnaire, developed by the authors, was used to collect data to determine the current extent of expanded practice by community mental health nurses in Victoria, Australia.
The study sampled mental health nurses currently practicing in public community mental health services in Victoria. Ten of Victoria's 21 area mental health services were selected as study sites. Seven services were located in metropolitan areas and three were in rural areas. Ethics approval for the conduct of the study was obtained from the metropolitan and rural sites, as well as from the administering university associated with the study.
Questionnaires and plain language statements explaining the study were distributed to potential participants via the senior nurse of each service. Two hundred and ninety-six questionnaires were distributed through internal mail systems. One hundred and fifty-four completed questionnaires were returned (52% response rate).
The Expanded Practice in Community Mental Health Nursing Questionnaire was specifically developed by the researchers as the data collection tool for this study. The development of the questionnaire was informed by relevant literature and qualitative data collected in an earlier study (Elsom, Happell, & Manias, 2007). The questionnaire was pilot tested with a sample of 20 community mental health nurses. The participants were asked to complete the instrument and to comment about its ease of completion, whether specific questions should be omitted or additional questions included. The data were subsequently analyzed using the Statistical Package for the Social Sciences (SPSS) version 12. The questionnaire was found to have good internal consistency for the pilot study as demonstrated by a Cronbach alpha coefficient of .892. Feedback from the pilot stage suggested that the questionnaire was generally clear, relevant, and easy to complete. Minor amendments were made to the formatting, wording, and ordering of the questionnaire items. At the completion of data analysis for the main study, the Cronbach alpha coefficient was .926 for the nondemographic items of the instrument.
The questionnaire sought information about the current expanded practices of community mental health nurses in relation to the prescription of medication, ordering of diagnostic tests, referral to specialist services, involuntary detention, and authorizing absence from work certificates. Participants were asked to indicate whether they administered medication as prescribed by a medical practitioner, which would be regarded as normal (nonexpanded) nursing practice. They were also asked whether they made suggestions or recommendations to medical practitioners regarding the prescription of medication and whether they made prescriptive decisions. Since actual prescribing of medication is currently not legally possible for community mental health nurses in Australia, it was assumed that any medications prescribed by nurses would be authorized either before or after the fact by a doctor.
Items were included that specifically investigated whether such authorization took place before the nurse made a decision regarding a patient's medication or whether the nurse actually initiated a medication prescription and arranged for a doctor's authorization afterwards. Similarly, items were included that focused on the extent to which the participants made recommendations to doctors regarding other areas of expanded practice, such as ordering diagnostic tests, making referrals to medical specialists, and recommending involuntary treatment.
Most items utilized a five-point Likert scale. The questionnaire also collected demographic information, including age, gender, current employment position, years of experience, and qualifications, in order to identify whether differences in the extent of expanded practice by nurses were related to specific demographic variables either individually or in combination. Participants were also able to provide comments about their perceptions and experiences in relation to the scope of 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.
|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.
|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.
The study findings provide an interesting insight into expanded nursing practice in mental health services. Community mental health nurses regularly engaged in practices that would not be regarded as traditional components of the nurse's role. Most community mental health nurses routinely engaged in making clinical decisions, which have traditionally been the role of doctors. Current legislation in the state of Victoria prevented nurses from acting directly on these decisions in most cases. The way in which the nurses gave effect to their clinical decisions was through providing advice and recommendations to psychiatrists and general practitioners about care and treatment, although there was some evidence of illegal practices in relation to the prescription of medication. In most instances, psychiatrists and general practitioners were required to take responsibility for decisions already made by nurses.
Nurses’ Roles in Medication Prescribing and Administration
The majority of nurse respondents (over 80%) indicated that making suggestions or recommendations to doctors about prescribing medications was a regular aspect of their current practice. This view is also consistent with the findings of a UK study (Nolan et al., 2001) that reported 89% of mental health nurses they surveyed advised doctors about the prescription of medication. Our finding provides evidence to support the assertion (Clinton & Hazelton, 2000) that nurses are already actively engaged in the prescribing process through suggestions to doctors.
The nurse's long-standing role in influencing doctors’ decisions regarding the prescription of medication has been previously noted (Driscoll et al., 2005; Dunphy et al., 2004; Nolan et al., 2001), as has been the capacity to make suggestions or recommendations to doctors about aspects of medical management (Baird, 2001). An earlier UK study (Nolan et al.) found that the majority of mental health nurses advised doctors about the prescription of medications but, at the same time, the majority also reported not feeling confident to prescribe medication themselves. In our work, respondents felt confident to make suggestions or recommendations to doctors with the knowledge that responsibility for such advice remained with the doctor.
The most commonly reported practice was the administration of medication exactly as prescribed by a medical practitioner, with the majority of nurses reporting that they did so either always or often. Nevertheless, it is of some concern that almost 1 in 10 of the nurses reported that they only administered medication as prescribed by doctors sometimes, rarely, or never. It is difficult to interpret this finding since the administration of medication as prescribed is a basic role of the registered nurse. It is possible that some participants were accustomed to working in collaborative relationships with doctors and that their involvement in decisions about medications was, essentially, routine practice. This being the case, nurses may have regarded the practice of simply accepting a doctor's orders in relation to the administration of medication as a rare occurrence. This possibility is made more plausible also by the nurses’ reports that they often worked with relatively inexperienced doctors or in services where there were shortages of fully qualified psychiatrists. This view is supported by the widely documented shortage of psychiatrists and other medical staff in mental health services (Australian Institute of Health and Welfare, 2005; Mental Health Council of Australia, 2005; Senate Select Committee on Mental Health, 2006).
One of the most controversial findings is that 28.1% of surveyed community mental health nurses reported that, at least on some occasions, they initiated a new medication and arranged for this “prescription” to be authorized later by a medical practitioner.
One of the most controversial findings is that 28.1% of surveyed community mental health nurses reported that, at least on some occasions, they initiated a new medication and arranged for this “prescription” to be authorized later by a medical practitioner. An even higher proportion reported changing medications (33.8%) and adjusting dosages (54.9%) without a doctor's prior approval. It must be noted that such practices were a relatively rare event with 71.9% of nurses reporting that they never initiated new medications and two thirds (66.2%) indicating that they never changed medications. However, a significant number of nurses reported that they either did or have engaged in prescribing practices that are currently beyond the legal parameters of clinical practice for nurses who had not been authorized by the nurse regulating body to work as nurse practitioners.
The finding relating to nurses’ initiation of medication is consistent with the assertion (McCann & Baker, 2002) that community mental health nurses employed in rural and regional areas in the Australian state of New South Wales “use an array of quasi legal and, perhaps, illegal measures in prescribing medications” (p. 175) and earlier reports (Luker, Austin, Willock, Ferguson, & Smith, 1997) that covert prescribing by nurses and the use of clinical practices that “were not strictly legal” (p. 33) have been in evidence for some time. It is also supportive of claims (Dunphy et al., 2004; Schober, 2004) that nursing practice has always moved beyond the legal and other regulatory frameworks in response to the healthcare needs of communities.
Demographic factors, such as educational qualifications of the nurses, their experience in mental health nursing, and their practice location, were found to be unrelated to the extent of illegal practice. However, nurses working in CATT were more likely to engage in expanded and illegal practices than mental health nurse case managers. This finding is not unexpected in view of the nature of the work undertaken by CATT nurses and the role of the CATT within mental health services in Victoria. CATT services operate 24 hr per day. They are responsible for assessing all persons who are being considered for hospital admission and determining whether or not a less restrictive setting is more suitable. CATT services also provide treatment and support for people whose acute mental illness can be managed in the community as an alternative to hospitalizations for acutely mentally ill clients. Nurses working in CATT services are, therefore, more likely to encounter clients who are acutely unwell at times and in places where consultation with medical staff is not immediately available.
Areas of Expanded Practice Other Than Prescribing
Community mental health nurses reported that they engaged in expanded practice in relation to ordering diagnostic tests, referral to specialists, recommendations for involuntary treatment, and authorization of sick certificates to a similar extent as for medication prescription. Essentially, nurses reported that making recommendations to doctors about all of these areas of medical practice were regular aspects of their own practices. Compared to prescribing medications, nurses reported higher levels of confidence in regard to ordering diagnostic tests and referring patients to medical specialists, such as psychiatrists. A review of the literature did not disclose any literature examining current practices of community mental health nurses in other areas of expanded practice.
Educational Preparation of Nurses in Relation to Roles in Expanded Practice
The role of nurses in expanded practice raises a critical question in terms of the educational preparation of mental health nurses. Who teaches nurses how to make suggestions or recommendations to doctors about the prescription of medication? While many specialty mental health nursing programs include a psychopharmacology component (Nurses Board of Victoria, 2004), this component focuses on the legal and traditional role of the nurse in relation to medication management. That is, although the curriculum would typically include classifications of drugs, their chemical composition, mode of action, desired effects, unwanted effects, and potential interactions, this curriculum is designed in context of the traditional role of the nurse in medication management. With the exception of nurse practitioner programs, which have a deliberate focus on prescribing, the pharmacology component of many nursing courses is designed to prepare nurses to administer and monitor the effects of prescribed medication. It is not designed to prepare them to prescribe medications. It is also of note that almost a third (30.5%) of nurses surveyed had no academic qualifications, holding only hospital-based certificate qualifications, and almost two thirds (64.9%) held no university-based mental health qualifications.
Notwithstanding their educational preparation for such a role, or the lack of it, approximately 80% of the community mental health nurses who participated in this study indicated that they sometimes, if not often or always, made recommendations to doctors about changing medications, adjusting doses, or commencing new medications. It could be speculated that these nurses were confident to make such recommendations knowing that the responsibility for accepting the recommendation and actually prescribing the medication remained with the treating doctors.
This study relates specifically to the views of community mental health nurses employed in metropolitan and rural settings in Victoria and may not be reflective of experiences and perceptions internationally. Due to a paucity of relevant literature, it is difficult to determine relationships between the findings of this study and existing knowledge. This is the first study to quantify the extent of informal and illegal expanded practice by community mental health nurses.
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.
The authors wish to acknowledge the support for this research provided by the Australian Research Council and Eli Lilly Australia.