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ISSUES AND INNOVATIONS IN NURSING PRACTICE
Mental health nurses' perceptions of nurse prescribing
Peter Nolan BA BEd MEd PhD RMN RGN DN RNT
Professor of Mental Health Nursing, School of Health Sciences, University of Birmingham, Birmingham, UK
M. Sayeed Haque BSc MSc PhD
Applied Statistician, South Birmingham Mental Health NHS Trust, Birmingham, UK
Frances Badger MSc RGN
Research Fellow, School of Health Sciences, University of Birmingham, Birmingham, UK
Robert Dyke MSc RGN RMN CPN
Community Mental Health Nurse, South Birmingham Mental Health NHS Trust, Birmingham, UK
and Imran Khan BSc MSc RMN CPN
Specialist Practitioner in Mental Health, South Birmingham Mental Health NHS Trust, Birmingham, UK
Submitted for publication 22 December 2000
Accepted for publication 20 August 2001
Introduction
Although prescriptive authority in the United Kingdom (UK)
is largely restricted to doctors, nurses (especially community
and practice nurses) have long exercised a major in¯uence
over the prescribing practices of their medical colleagues
(Henney et al. 1993, Downie et al. 1995). These authors
conclude that, by virtue of nurses' close therapeutic alliance
Ó 2001 Blackwell Science Ltd 527
Correspondence:
Peter Nolan,
Professor of Mental Health Nursing,
School of Health Sciences,
University of Birmingham,
Edgbaston,
Birmingham B15 2TT,
UK.
E-mail: [email protected]
N O L A NN O L A N P . ,P . , H A Q U EH A Q U E M . S . , B A D G E R F . , D Y K E R . & K H A N I . ( 2 0 0 1 )M. S . , B A DG E R F . , DY K E R . & K H A N I . ( 2 0 0 1 ) Journal of
Advanced Nursing 36(4), 527±534
Mental health nurses' perceptions of nurse prescribing
Aims. This study aimed to ascertain mental health nurses' perceptions of the
advantages and disadvantages of nurse prescribing and to identify the educational
needs of mental health nurse prescribers.
Design. A questionnaire was designed and administered to a convenience sample in
the UK of 73 mental health nurses in clinical practice, 14 working in in-patient
settings and 59 in the community. Questions included both closed and open-ended
items. Descriptive statistics were used for numerical data, and category analysis of
the open-ended questions was undertaken by two of the researchers independently
and then conjointly.
Findings. The majority of respondents felt that mental health nurse prescribing
would signi®cantly improve clients' access to medication, improve compliance,
prevent relapse and prove cost effective. However, many were anxious that they did
not have suf®cient knowledge and skills to assume responsibility for prescribing.
Conclusions. Although there would be bene®ts to clients and patients, further
training, rigorous supervision and the co-operation of doctors will be required if
mental health nurse prescribing is to yield the anticipated bene®ts.
Keywords: nurse prescribing, mental health nursing, improved mental health
services, compliance, cost-effectiveness
with patients, they have been able to recommend appropriate
medication, monitor side-effects, and advise on when drugs
should be terminated. In the United States of America (USA),
nurse prescribing has been widely adopted, following exten-
sive further education programmes, although the exact nature
of nurses' prescriptive authority varies from state to state.
Nurse practitioners in the USA now assume responsibility for
the treatment and management of such problems as asthma,
diabetes, wound care, contraception, immunization and
depression (Mundinger et al. 2000).
Parker (2000) locates the origins of nurse prescribing in the
UK in the Cumberledge Report (Department of Health and
Social Security [DHSS] 1986) in which it was argued that
nurse prescribing would lead to improvements in the quality
of care, and enable greater numbers of patients to access
treatment earlier. The Report of the Advisory Group on
Nurse Prescribing, also known as the Crown Report (Depart-
ment of Health [DOH] 1989), recommended that health
visitors and district nurses be empowered to prescribe from a
limited formulary within set protocols. A pilot scheme, which
included sites in each of the eight English Health Regions
(Luker et al. 1998a, 1998b2 ) was subsequently set up and
reported in Review of Prescribing, Supply and Administra-
tion of Medicine (DOH 1999a). This Review recommended
that nurse prescribing should be rolled out on a national
basis. Making a Difference (DOH 1999b) predicted that
23, 500 nurses and health visitors would be able to prescribe
within a few years and The NHS Plan (DOH 2000a) advised
that the majority of nurses should be prescribing by 2004.
Moynagh and Worsley (2000) predicted that in a very short
period UK nurses would assume many of the clinical
responsibilities currently held by general practitioners (GP).
The UK DOH has recently suggested that mental health
nurses in primary care might prescribe for certain conditions
such as anxiety and depression (Consultation on proposals to
extend nurse prescribing, DOH 2000b). However, debate
about mental health nurse prescribing in the UK has been
remarkably subdued, perhaps because mental health nurses
are perceived as being unprepared for the associated respon-
sibilities or because of opposition from other professional
groups. However, as the largest group in mental health care,
their involvement in medication management has the poten-
tial to improve the quality of care to many clients whose only
intervention is medication (Jordan et al. 1999).
The study reported here sought to stimulate further debate
about nurse prescribing. It aimed to:
· ascertain mental health nurses' perceptions of nurse
prescribing
· determine nurses' perceptions of the advantages and
disadvantages of nurse prescribing
· identify the educational needs of mental health nurse
prescribers.
Literature review
Some commentators have argued that mental health nursing
is a profession in crisis (Tilley 1997), much of what nurses
claim to do is contested and their work has little or no
theoretical underpinning (Ritter 19983 ). Porter (1993) feared
that mental health nursing was losing the ®ght for survival
in an increasingly evidence-obsessed health climate.
Meddings and Perkins (1999) stated that many mental
health nursing interventions amounted to no more than
`social chatting', although it might be argued that this kind
of interaction is a prerequisite for good quality therapeutic
relationships, without which chemotherapy may have little
effect.
Bond (1992) identi®ed the biological sciences as crucial
to any drive to strengthen the knowledge base of mental
health nursing and enable nurses to appreciate the effects
of mental health problems on the whole person (Mulhall
1990, Trygstad 1994, Clarke 1995, Gournay 1995,
Lankshear et al. 1996, Wynne et al. 1997). Others,
however, recommend a curriculum based primarily on the
social and behavioural sciences (Cooke 1993, Williamson
1999), and an integrated syllabus is preferred by those
who see psychotherapeutic approaches as essential but insuf-
®cient on their own (Brooker et al. 1994, Wray 1994,
Gournay & Beadsmoore 1995, Wooff et al. 1998, Corney
1999).
The Patient's Charter (DOH 1995) and the Human Rights
Act (1998) acknowledge the right of patients to information
about their treatment. Nazareth et al. (1995) and Jordan
et al. (1999) consider that nurses should have up-to-date
knowledge about medications to be able to administer them
safely, provide education for patients and carers, and
promote adherence. While and Rees (1993) advised that
nurses should be able to provide accurate, balanced infor-
mation about medication in language that is accessible to the
client.
However, Maslen et al. (1996) identi®ed psychopharma-
cology as an area in which nurses are especially weak. Godin
(1996) showed that many mental health nursing courses do
not explore medication management practices and the
conditions under which clients derive maximum bene®t from
the drugs prescribed for them. The failure to help mental
health care students understand the signi®cant advances in
psychobiology that have been made over the last two decades
was noted by Frank and Kupfer (2000). Clark et al. (1997)
attribute such shortcomings to the subjugation of mental
P. Nolan et al.
528 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(4), 527±534
health nursing to the general nursing curriculum. Towers
(1999) concluded that as a result of inadequate education,
some nurses resist involvement in medication through a desire
to avoid situations in which their ignorance might be ex-
posed.
The potential bene®ts of mental health nurse prescribing
are acknowledged by Kendrick (2000), who suggests that
nurse prescribers could signi®cantly improve the quality of
care for depressed patients. General practitioners prescribing
of psychotropic medication and referrals to secondary care
could be reduced (Barr & Sines 1996, Bower & Sibbald
2000). Jorm (2000) concludes that patients adhere to treat-
ment regimes if they respect the person who is prescribing,
feel understood and are given suf®cient information. By
incorporating prescriptive authority into a caring relationship
between nurse and client, the widely-held view that medica-
tion deals only with symptoms and not with causes (Fischer
et al. 1999) might begin to change.
The study
The study used a survey design with an opportunistic
sample comprising a group of mental health nurses
attending a 1-day conference on nurse prescribing. Delegates
to the conference, which was held in July 2000, were
registered mental health nurses, currently in contact with
clients, and interested in extending their knowledge of nurse
prescribing.
On arrival at the conference, each delegate was asked to
complete a questionnaire anonymously and return it prior
to leaving at the end of the day. The data collection
instrument consisted of 14 items. It had been previously
piloted with a small sample of mental health nurses whose
responses to the questions and comments shaped the ®nal
version. The questionnaire sought to elicit the following
information:
· demographic data
· current involvement in medication management
· perceptions of the advantages and disadvantages of nurse
prescribing
· educational needs in relation to nurse prescribing.
Descriptive statistics were used to analyse the data with the
occasional use of the chi-squared test to compare responses
from nurses working in in-patient settings, and community-
based nurses. The open-ended questions were analysed by
two researchers (PN/FB) working independently to identify
categories. The categories were then compared to determine
agreement (Denzin & Lincoln 1998).
Formal ethical approval was not required for the study.
Participants were assured that no identi®ers were attached to
the questionnaires that could subsequently lead to identi®ca-
tion of individuals.
Findings
One hundred and ten questionnaires were distributed to the
conference delegates and 73 completed questionnaires were
returned (response rate: 66%). Fifty-nine respondents (81%)
were working in the community; 50 (68%) had over 10 years'
experience and 64 (88%) identi®ed their current grades.
There was no signi®cant association between gender and
work setting (v2 P-value� 0á09). Demographic data are
summarized in Table 1.
Responses to questions
What medication do you currently administer?
Sixty-two respondents (84á9%) stated that they administered
depot injections; 37 (50á7%) antipsychotic medication; 28
(38á4%) antidepressants; 17 (23á3%) anticholinergic medica-
tion; 18 (24á7%) mood stabilizers; 15 (20á5%) benzodiaze-
pines and 4 (5á5%) antidementia medication.
Do you think mental health nurses should be able
to prescribe medication?
Fifty-eight (79á4%) of the sample thought that mental health
nurses should be able to prescribe, and two (2á7%) thought
they should not. Thirteen (17á8%) were undecided.
Table 1 Characteristics of sample
Gender
Male Female Total
Grade
E ± 16 16
F 2 9 11
G 11 22 33
H 2 2 4
Total 15 49 64
Work setting
In-patient 4 10 14
Community 16 43 59
Total 20 53 73
Length of service (years)
<2 3 3
2±5 1 6 7
6±10 4 9 13
11±20 6 26 32
>20 9 9 18
Total 20 53 73
Issues and innovations in nursing practice Perceptions of nurse prescribing
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(4), 527±534 529
How competent do you feel to assume responsibility
for prescribing?
Thirteen (92á9%) respondents working in in-patient settings,
and 54 (91á5%) working in community settings stated that
they were not ready to prescribe and would need additional
training.
In what ways are you currently involved in medication
management?
Respondents identi®ed a variety of roles associated with
medication management. All were involved in the education
of patients, and the majority had responsibilities for monit-
oring and reviewing medication. Sixty-®ve (89%) advised
doctors on what medication should be prescribed for patients
(Table 2).
How do you think nurse prescribing would bene®t clients
and patients in the following areas: (a) treatment of minor
mental illnesses (b) treatment of severe mental illnesses
(c) general health maintenance (d) overall patient care?
Tables 3 and 4 describe the categories of responses under
each of these four headings and indicate how many responses
fell into each category.
Respondents felt that nurse prescribing, especially in
primary care, would lead to easier access to medication for
clients. Prescribing practices would be improved because of
better collaboration between mental health nurses and
general practitioners, with clients bene®ting from the know-
ledge and skills of both. As a result of their regular contact
with clients, nurses could effectively monitor side-effects of
medication and adjust the dosage or type of medication to
minimize side-effects. Twenty-four respondents (33%) felt
that nurses would be better than GPs at prescribing medica-
tion for clients with minor mental illnesses.
Over 50% of the nurses felt that if they could prescribe for
people with minor mental illnesses, clients might not need to
see their GP or be referred to secondary services, thus
reducing distress and stigma. They felt that the unique
knowledge nurses have of their clients would improve
compliance, prevent further deterioration, promote faster
recovery, and thereby prove cost effective. Respondents
highlighted that the treatment and management of depression
and anxiety in primary care would be improved as a result of
nurse prescribing, although 90% felt ill equipped to prescribe
in these areas at present.
For patients with chronic illnesses, respondents claimed
that nurses were more likely than GPs to use the newer, more
effective antipsychotic medications to manage their clients'
conditions. Because of their regular contact with clients,
nurses would be able to manage drug interactions that occur
when clients were taking a range of different medications, so
as to maximize effectiveness and minimize adverse effects.
Nurses would be able to advise clients with chronic illness on
prn medication, and on drugs for pain relief.
Clients with chronic illness would bene®t from nurse
prescribing because their medication could be monitored in
their own homes, thus avoiding the need for GP and hospital
appointments. Forty-two respondents (57á5%) wrote that
Table 2 Current involvement with the administration of medication
(n� 73)
Type of involvement No. (%)
Educating patients about their medication 73 (100)
Monitoring medication 71 (97á3)
Reviewing medication 59 (80á8)
Promoting adherence to medication regimes 68 (93á2)
Assisting in the management of side-effects 69 (94á5)
Advising prescribers 65 (89)
Making decisions regarding prn medications
(pro re nata)
45 (61á6)
For people with minor mental illnesses For people with severe mental illnesses
Ease of access to medication 20 Improved prescribing practice 29
Improved prescribing practice 15 Improved quality of care 24
Early intervention 12 Education of clients 6
Improved outcomes 11 Improved job satisfaction 4
Improved quality of care 11
Table 3 Bene®ts of nurse prescribing
General health maintenance Overall patient care
Improved medication management (15) Improved medication management (20)
Improved mental health assessment (6) Mental health promotion (5)
Will enhance holistic approach (5)
Promote early intervention (2)
Table 4 Bene®ts of nurse prescribing to
general health maintenance and overall
client care (actual number of responses)
P. Nolan et al.
530 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(4), 527±534
clients' and carers' understanding of the illness and its
management would be improved as a result of nurse prescri-
bing. Nurses have more time to spend with clients than GPs
or psychiatrists and are committed to involving clients and
their families in treatment. Nurses could advise GPs on the
management of clients with multiple and long-term needs.
Many issues which had already been identi®ed under the
two previous headings (see Table 3), were repeated under
General Health Maintenance (Table 4). Respondents cited
early intervention and prevention of relapse as bene®ts of
nurse prescribing. Clients' medication could be adjusted
without the need to see a doctor and drug interactions could
be monitored and managed better. Improved adherence to
medication regimes would enable clients to remain in the
community. They would enjoy greater continuity of care thus
reducing stress levels for carers. Fifty respondents (68%)
believed that these bene®ts would accrue because nurses see
clients more frequently than GPs, have more knowledge of
them and form better relationships with them.
Fifty-eight respondents (79%) felt that nurse prescribing
would enable better mental health assessment of clients, and
better management of mental health problems. This in turn
would lead to improved general health. Many respondents
cited the bene®ts for clients' general health maintenance of
nurses being able to prescribe medication such as laxatives,
cold cures and vitamins. In their turn, nurses would bene®t
from being able to prescribe through greater awareness of
their clients' physical health needs.
Respondents did not identify new categories when
discussing the bene®ts of nurse prescribing in relation to
Overall Patient Care, but tended to pick out what they
considered to be the most important things they had
mentioned under the previous three headings. They were
very con®dent that nurse prescribing would lead to better
monitoring of clients' medication, with consequent reduction
in distressing side-effects and improved client compliance
both with medication regimes and with treatment
programmes. Nurses would be able to respond rapidly to
clients' needs, thereby improving the prognosis, preventing
relapse and making treatment and care more cost-effective.
They would be able to promote greater involvement of clients
and their carers in the clients' care, and maximize opportun-
ities for information-giving and health promotion.
What or whom do you consult if you have queries
about medication?
Table 5 records the responses to this question. Using the chi-
squared test, no statistically signi®cant associations were
found between in-patient and community nurses in relation
to their preferred sources of information.
What do you perceive as the disadvantages of nurse
prescribing?
Fear of litigation was a major concern for a third of the
nurses, with lack of appropriate training coming a close
second (Table 6).
In what areas would you need extra training to equip
you for nurse prescribing?
The majority of respondents wanted more training in the
management of antidepressants (Table 7). Community-based
Table 6 Perceived disadvantages of nurse prescribing
Categories of response
No. of
responses (%)
Fear of litigation 25 (34á2)
Currently lack suf®cient education and training 23 (31á5)
Increased responsibility and workload 17 (23)
Would lead to interprofessional con¯ict 16 (21á9)
Will result in doctors having less contact with
clients
8 (10á9)
Lack of appropriate supervision 8 (10á9)
There will be no remuneration for this role 7 (9á58)
It is a disguised way of exhorting nurses to
adhere to the medical model
7 (9á58)
Table 7 Training required in aspects of medication management
Aspect of medication
management
In-patient
nurses
n� 14 (%)
Community-based
nurses
n�59 (%)
Medication management generally 7 (50) 21 (35á6)
Management of anti-depressants 13 (92á9) 54 (91á5)
Management of anti-psychotics 4 (28á6) 25 (42á4)
Management of side-effects 1 (7á1) 15 (25á4)
Management of dosages 5 (35á7) 32 (54á2)
Management of withdrawal 9 (64á3) 41 (69á5)
Management of drug interactions 11 (78á6) 49 (83á1)
Table 5 What or whom do you consult if you have queries about
medication?
Sources of information
In-patient nurses
n�14 (%)
Community nurses
n�59 (%)
The client 12 (85á7) 54 (91á5)
The client's carers 12 (85á7) 46 (78)
The prescriber (doctor) 13 (92á9) 51 (86á4)
Pharmacist 10 (71á4) 41 (69á5)
Journals 2 (14á3) 17 (28á8)
The internet 4 (28á6) 16 (27á1)
Information lea¯ets 8 (57á1) 40 (67á8)
Pharmaceutical companies 3 (21á4) 19 (32á2)
British National Formulary 14 (100) 56 (94á9)
MIMS10 4 (28á6) 18 (30á5)
MIMS�Medical Information Management Systems.
Issues and innovations in nursing practice Perceptions of nurse prescribing
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(4), 527±534 531
nurses and in-patient nurses were compared using the
chi-squared test. No signi®cant differences were found
between the two.
Further comments
In response to the invitation to make further comments, some
respondents stated that they felt nurses should be ®nancially
rewarded for taking on a prescribing role. If they were to take
on the responsibilities of doctors, they should enjoy the pay
and status that doctors enjoy. Others suggested that pilot
studies should be carried out to determine how nurse
prescribing would affect nurses, clients and the relationship
between the two. One respondent wondered whether nurse
prescribing would undermine psychological interventions for
clients with mental health problems.
Three respondents were adamant that there would be no
bene®ts for nurses or clients if nurses were to become
prescribers. They felt that doctors were better equipped to
prescribe for clients, and that nurses would need extensive
training to take on a prescribing role. They were wary of
community mental health nurses prescribing for minor
illnesses not linked to mental health (such as constipation
and nutritional de®ciencies), feeling that their brief does not
extend beyond mental health.
Discussion
This study provides only a snapshot of the opinions of a self-
selecting group of mental health nurses with an interest in
prescribing indicated by their attendance at the study day at
which the data collection instrument was used. It is not
possible to generalize the ®ndings to the entire community of
mental health nurses, although they are very much in line
with what other researchers have found (Gournay 1995,
Corney 1999). A closer analysis of associations between
in-patient nurses and their views, as compared with commu-
nity nurses and theirs, would have been useful, and we intend
to do this in a later study.
The nurses in this study perceived themselves as having
better relationships with mental health clients than either GPs
or psychiatrists. They felt that nurse prescribing authority
would enhance the mental health assessment of clients,
although they did not state exactly how it would work as a
mechanism for enhancement. Their responses indicate that
they are already closely involved with medication, but
nonetheless still consider themselves lacking in knowledge
about what they are doing. It is interesting that when nurses
need to ®nd information about medication, they are more
likely to consult a doctor or the British National Formulary
than to use the internet or professional journals. This ®nding
con®rms the work of Tilley (1997) and Ritter (1998) who
show that mental health nurses undertake many activities
without being clear about the underpinning reasons.
The ®ndings of this small and admittedly limited survey
nevertheless coincide with Bond's observation (1992) of
mental health nurses' inadequate grounding in psychophar-
macology and the biological basis of mental illness. Respond-
ents' enthusiasm for prescribing laxatives and cold cures is
alarming, as these are particularly ill-suited to clients with
depression and psychosis. If, as Usher and Arthur (1997) have
remarked, the education and training that professionals
receive should determine what they do, it is worrying that
mental health nurses identify pharmacology as an area in
which they feel inadequate. This de®cit might be attributable
to the way in which mental health care education in the UK
has developed in the direction of curricula that service the
training needs of many disciplines. The creeping genericism
that is now apparent in most programmes means that certain
interventions may be neglected on the grounds that skills are
located within the team and not the individual.
Early intervention was almost universally considered by
respondents to be the major bene®t of nurse prescribing and
would ensure the implementation of Standard 2 of the
National Service Framework for Mental Health (DOH
1999c). In some instances, respondents felt that early inter-
vention by a nurse prescriber might mean that medication
need not be prescribed at all. They felt that nurses' ability to
monitor the medication of clients on a regular basis and
adjust it to alleviate side-effects would result in improved
compliance, better outcomes and less need for patients to see
a doctor to obtain repeat prescriptions. They also wrote that
mental health nurses would prescribe the best drugs for their
clients, regardless of cost, and this would serve to enhance
nurse±client relationships.
With the exception of three people, respondents were
universally in favour of nurse prescribing. Most respondents
saw it as a logical extension to their current role in
administering medication, although some were anxious that
medical staff would dislike the blurring of professional
boundaries that nurse prescribing might imply. The know-
ledge nurses have of their clients, coupled with the close
relationship they enjoy with clients' carers, mean that they
possess valuable information that would enable ¯exible and
responsive prescribing. The role of the nurse would be
enhanced, while the patient would bene®t from speedier
access to medication and early intervention, especially in
crisis situations. However, respondents were not blind to the
dif®culties that nurse prescribing would put in their path.
There was consensus on the need for further training. Two
nurses even suggested that a quali®cation in medication
P. Nolan et al.
532 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(4), 527±534
management should be made available. Respondents also
wanted access to supervision. The attitudes of GPs and
psychiatrists were identi®ed as critical. Respondents felt that
the whole-hearted support of medical staff would be neces-
sary for nurse prescribing to succeed.
Conclusion
Nurses are already substantially involved in medication
management, and it is appropriate that they should be.
However, there is an urgent need for further education if they
are to become prescribers. The evidence provided by this
survey suggests that enthusiasm for nurse prescribing is not in
short supply, but the knowledge and skills to make inde-
pendent decisions are, and it would surely be a mistake to go
ahead without the guarantee of appropriate, properly funded
educational resources being made available. The psycho-
pharmacological components of mental health nursing curri-
cula need to be strengthened in order to strengthen the
knowledge base of nurses.
Some respondents sounded a note of caution amidst the
general con®dence that nurse prescribing would be a good
thing. While the study suggests that nurses perceive many
bene®ts from prescribing, it is not possible to state exactly
what the bene®ts to patients will be until it is known which
other professional groups will also be granted prescriptive
authority. Should nurses alone be allowed prescriptive
authority, there is a risk of their being overwhelmed by
clients seeking treatment for minor mental illnesses. The
question of drug budgets and who would be responsible for
them would need to be addressed. Evaluation of the ef®cacy
of mental health nurse prescribing in terms of patient
satisfaction, compliance and recovery rates, as well as cost
effectiveness, would be essential in order to obtain an
accurate picture of its effects. Prescribing guidelines, many
of which are currently derived from secondary care, are not in
line with clients' and practitioners' experiences in primary
care. More needs to be known about the ef®cacy of protocols,
audit tools and educational programmes in the primary care
context before personnel assume new clinical responsibilities.
The UK government has indicated its willingness to extend
prescribing rights to mental health nurses and this study
demonstrates that there is a groundswell of support among
nurses themselves. However, unless nurses respond to the
invitation to consult and negotiate more appropriate educa-
tional provision, the momentum may be lost (DOH 2000b4 ).
The example set by the nursing profession in North America is
a useful one, where lobbying decision makers, teamwork and
improved education has resulted in discipline-speci®c nurse
prescribing, to the bene®t of clients and practitioners alike.
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