This article is an exploratory study of perceptions in mental health nurses who are qualified to prescribe yet choose not to do so. In-depth semi-structured face-to-face interviews, field notes and analysis of documents were used to investigate the perceptions of the non–prescribing nurse prescriber. A mapping exercise was conducted to identify potential participants. Interview data analysis was based on the principles of descriptive phenomenology and the research was theoretically framed within concepts of power, structure/agency and culture. This study has contributed to understanding the views of non-prescribing mental health nurse prescribers on why they do not use their prescribing qualification. The findings from this study suggest that there are complex, interlocking factors: power and knowledge; culture; and structure and agency, which may enable or prevent mental health nurse prescribers from independently prescribing.

BACKGROUND:People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established. OBJECTIVES:The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis. DESIGN:This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation. SETTING:The trial was set in hospital neurology clinics and community services. PARTICIPANTS:Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent. INTERVENTION:The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks. MAIN OUTCOME MEASURES:The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant. RESULTS:Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported. LIMITATIONS:The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation. CONCLUSIONS:This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis. FUTURE WORK:Future research should evaluate the selection of those who may benefit from cognitive rehabilitation. TRIAL REGISTRATION:Current Controlled Trials ISRCTN09697576. FUNDING:This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.

Background People with severe mental illnesses such as schizophrenia are three times more likely to smoke than the wider population, contributing to widening health inequalities. Smoking remains the largest modifiable risk factor for this health inequality, but people with severe mental illness have not historically engaged with smoking cessation services. We aimed to test the effectiveness of a combined behavioural and pharmacological smoking cessation intervention targeted specifically at people with severe mental illness. Methods In the smoking cessation intervention for severe mental illness (SCIMITAR+) trial, a pragmatic, randomised controlled study, we recruited heavy smokers with bipolar disorder or schizophrenia from 16 primary care and 21 community-based mental health sites in the UK. Participants were eligible if they were aged 18 years or older, and smoked at least five cigarettes per day. Exclusion criteria included substantial comorbid drug or alcohol problems and people who lacked capacity to consent at the time of recruitment. Using computer-generated random numbers, participants were randomly assigned (1:1) to a bespoke smoking cessation intervention or to usual care. Participants, mental health specialists, and primary care physicians were unmasked to assignment. The bespoke smoking cessation intervention consisted of behavioural support from a mental health smoking cessation practitioner and pharmacological aids for smoking cessation, with adaptations for people with severe mental illness-such as, extended pre-quit sessions, cut down to quit, and home visits. Access to pharmacotherapy was via primary care after discussion with the smoking cessation specialist. Under usual care participants were offered access to local smoking cessation services not specifically designed for people with severe mental illnesses. The primary endpoint was smoking cessation at 12 months ascertained via carbon monoxide measurements below 10 parts per million and self-reported cessation for the past 7 days. Secondary endpoints were biologically verified smoking cessation at 6 months; number of cigarettes smoked per day, Fagerstrom Test for Nicotine Dependence (FTND) and Motivation to Quit (MTQ) questionnaire; general and mental health functioning determined via the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) questionnaire, and 12-Item Short Form Health Survey (SF-12); and body-mass index (BMI). This trial was registerd with the ISRCTN registry, number ISRCTN72955454, and is complete. Findings Between Oct 7, 2015, and Dec 16, 2016, 526 eligible patients were randomly assigned to the bespoke smoking cessation intervention (n=265) or usual care (n=261). 309 (59%) participants were male, median age was 47.2 years (IQR 36.3-54.5), with high nicotine dependence (mean 24 cigarettes per day [SD 13.2]), and the most common severe mental disorders were schizophrenia or other psychotic illness (n=343 [65%]), bipolar disorder (n=115 [22%]), and schizoaffective disorder (n=66 [13%]). 234 (88%) of intervention participants engaged with the treatment programme and attended 6.4 (SD 3.5) quit smoking sessions, with an average duration of 39 min (SD 17; median 35 min, range 5-120). Verified quit data at 12 months were available for 219 (84%) of 261 usual care and 223 (84%) of 265 intervention participants. The proportion of participants who had quit at 12 months was higher in the intervention group than in the usual care group, but non-significantly (34 [15%] of 223 [13% of those assigned to group] vs 22 [10%] of 219 [8% of those assigned to group], risk difference 5.2%, 95% CI -1.0 to 11.4; odds ratio [OR] 1.6, 95% CI 0.9 to 2.9; p=0.10). The proportion of participants who quit at 6 months was significantly higher in the intervention group than in the usual care group (32 [14%] of 226 vs 14 [6%] of 217; risk difference 7.7%, 95% CI 2.1 to 13.3; OR 2.4, 95% CI 1.2 to 4.6; p=0.010). The incidence rate ratio for number of cigarettes smoked per day at 6 months was 0.90 (95% CI 0.80 to 1.01; p=0.079), and at 12 months was 1.00 (0.89 to 1.13; p=0.95). At both 6 months and 12 months, the intervention group was non-significantly favoured in the FTND (adjusted mean difference 6 months -0.18, 95% CI -0.53 to 0.17, p=0.32; and 12 months -0.01, -0.39 to 0.38, p=0.97) and MTQ questionnaire (adjusted mean difference 0.58, -0.01 to 1.17, p=0.056; and 12 months 0.64, 0.04 to 1.24, p=0.038). The PHQ-9 showed no difference between the groups (adjusted mean difference at 6 months 0.20, 95% CI -0.85 to 1.24 vs 12 months -0.12, -1.18 to 0.94). For the SF-12 survey, we saw evidence of improvement in physical health in the intervention group at 6 months (adjusted mean difference 1.75, 95% CI 0.21 to 3.28), but this difference was not evident at 12 months (0.59, -1.07 to 2.26); and we saw no difference in mental health between the groups at 6 or 12 months (adjusted mean difference at 6 months -0.73, 95% CI -2.82 to 1.36, and 12 months -0.41, -2.35 to 1.53). The GAD-7 questionnaire showed no difference between the groups (adjusted mean difference at 6 months -0.32 95% CI -1.26 to 0.62 vs 12 months -0.10, -1.05 to 0.86). No difference in BMI was seen between the groups (adjusted mean difference 6 months 0.16, 95% CI -0.54 to 0.85; 12 months 0.25, -0.62 to 1.13). Interpretation This bespoke intervention is a candidate model of smoking cessation for clinicians and policy makers to address high prevalence of smoking. The incidence of quitting at 6 months shows that smoking cessation can be achieved, but the waning of this effect by 12 months means more effort is needed for sustained quitting. Copyright (C) 2019 The Author(s). Published by Elsevier Ltd.

The aim of this service evaluation was to understand the factors affecting meal provision on a dementia ward and assess whether meals-based dietary intake met estimated mean energy requirement and reference nutrient intake (RNI). A mixed-methods approach was adopted: 1. Mapping the dietary intake for a cohort ( n =6) of inpatients with advanced dementia over a period of four consecutive days. 2. Semi-structured interviews to explore the experiences of the professionals ( n =5) involved. Two of the participants' four-day mean intakes did not meet their estimated energy requirement based on meal provision. All participants apart from one met the target of 0.75g of protein per kg body weight per day for the general population. Several of the nutrients consumed were at or exceeded the RNI for adults of this age, although participants' mean dietary vitamin D intake was substantially below the RNI for the general population. The themes included communication, time pressure and the continuity of service provision. The meals provided were nutritionally sound. Individuals' nutritional status was improved through staff supporting them with eating. The contribution of drinks and snacks to nutrient intake warrants further exploration. Effective communication between food providers and ward areas is important. Mealtimes should reflect patient need - for example, having the main meal in the evening and a lighter option at lunch. This does not clash with the benefits of a flexible breakfast time.

Background There is a high prevalence of smoking among people with severe mental ill health (SMI). Helping people with SMI to quit smoking could improve their health and longevity, and reduce health inequalities. However, those with SMI are less likely to access and engage with routine smoking cessation services than the general population. Objectives To compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual stop smoking services for people with SMI. Design A pragmatic, two-arm, individually randomised controlled trial. Setting Primary care and secondary care mental health services in England. Participants Smokers aged ≥ 18 years with SMI who would like to cut down on or quit smoking. Interventions A BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual care. Main outcome measures The primary outcome was self-reported, CO-verified smoking cessation at 12 months. Smoking-related secondary outcomes were self-reported smoking cessation, the number of cigarettes smoked per day, the Fagerström Test for Nicotine Dependence and the Motivation to Quit questionnaire. Other secondary outcomes were Patient Health Questionnaire-9 items, Generalised Anxiety Disorder Assessment-7 items and 12-Item Short-Form Health Survey, to assess mental health and body mass index measured at 6 and 12 months post randomisation. Results The trial randomised 526 people (265 to the intervention group, 261 to the usual-care group) aged 19 to 72 years (mean 46 years). About 60% of participants were male. Participants smoked between 3 and 100 cigarettes per day (mean 25 cigarettes per day) at baseline. The intervention group had a higher rate of exhaled CO-verified smoking cessation at 6 and 12 months than the usual-care group [adjusted odds ratio (OR) 12 months: 1.6, 95% confidence interval (CI) 0.9 to 2.8; adjusted OR 6 months: 2.4, 95% CI 1.2 to 4.7]. This was not statistically significant at 12 months ( p = 0.12) but was statistically significant at 6 months ( p = 0.01). In total, 111 serious adverse events were reported (69 in the BSC group and 42 in the usual-care group); the majority were unplanned hospitalisations due to a deterioration in mental health ( n = 98). The intervention is likely (57%) to be less costly but more effective than usual care; however, this result was not necessarily associated with participants’ smoking status. Limitations Follow-up was not blind to treatment allocation. However, the primary outcome included a biochemically verified end point, less susceptible to observer biases. Some participants experienced difficulties in accessing nicotine replacement therapy because of changes in service provision. Efforts were made to help participants access nicotine replacement therapy, but this may have affected participants’ quit attempt. Conclusions People with SMI who received the intervention were more likely to have stopped smoking at 6 months. Although more people who received the intervention had stopped smoking at 12 months, this was not statistically significant. Future work Further research is needed to establish how quitting can be sustained among people with SMI. Trial registration Current Controlled Trials ISRCTN72955454. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 23, No. 50. See the NIHR Journals Library website for further project information.

Purpose – The purpose of this paper is to share the lessons learnt during the implementation of a Peer Support Worker (PSW) pilot project within Child and Adolescent Mental Health Services (CAMHS). The project aimed to reduce the barriers experienced by young people and carers during the process of transition between child and Adult Mental Health Services (AMHS). Design/methodology/approach – The paper combines reflections of staff, PSWs and trainers in order to share the lessons that may be taken from this project. This includes a rough guide for those hoping to employ PSWs to support transitions. Findings – The PSWs provided the vehicle to support the process of transition by empowering young people and their carers to use their strengths to facilitate a hopeful and timely transition. Recommendations regarding support for peers, staff and the organisation during the process of training and employing peers are discussed. Research limitations/implications – The paper provides a purely reflective account of the pilot project. These reflections may provide guidance for others wishing to develop peer support positions within CAMHS so that an evidence base for the effectiveness of peer support within transitions may continue to grow. Originality/value – Rotherham Doncaster and South Humber NHS Foundation Trust are the first NHS Trust in the UK to employ PSWs specifically to support transitions between CAMHS and AMHS. This paper builds on the work of Oldknow et al. (2014) to highlight the first attempts to use peer support to support transitions.

A peer support worker employment initiative was developed to help young service users with the transition from child and adolescent to adult mental health services, an area that needs improving nationally. This article describes how the initiative was set up and its effectiveness.

Helen Oldknow and colleagues present a personal account of a young man with a learning disability who has become a role model for service users

Prescribing medication was once the exclusive role of the doctor, however following in-depth training, and under particular circumstances, members of the nursing profession has been recognised as highly capable of providing this component of care. The authors of this article are conducting a research study to explore the experiences and perceptions of mental health nurse prescribers who have not prescribed. This paper outlines the methodology, and the preliminary findings of their study.

The NHS Plan ( Department of Health, 2000 ) envisaged that widening the scope of nurse prescribing would offer service improvement by reducing delays incurred through waiting for a doctor to prescribe. To date, 14% of the mental health nurse prescribers in Rotherham, Doncaster and South Humber NHS Trust are prescribing independently. The Transforming Community Services initiative, with its transfer of community practitioners, has highlighted differences in prescriptive authority. This article describes how research into non-medical prescribing within Rotherham, Doncaster and South Humber NHS Foundation Trust has been used to inform service delivery.

Helen Oldknow and colleagues describe a project in which service users and their families, carers and advocates are involved in service development

This article discusses the history of non-medical prescribing and how a team of doctors and nurses in community settings within the mental health service for older people moved from supplementary to independent prescribing, and how the pilot was evaluated gaining the views of colleagues and patients.

This article outlines an initiative to provide rapid access to specialist services for older people with mental health difficulties living in care homes. It outlines the main aims of the service and its impact. The service has significantly reduced unnecessary hospital admissions.