Mental Health Nurses’ Perceptions of Providing Pharmaceutical Care in Saudi Arabia

Working with medication is an important role of mental health nurses. However, little attention has focused on these nurses’ perspectives on where the responsibility of nurses for safe, competent medication management of their patients rests. The aim of this current study was to investigate psychiatric mental health nurses’ perspectives on their role in pharmaceutical care (PC). This study used a qualitative exploratory focus group discussion approach with nine experienced psychiatric mental health nurses. Inductive data were gathered using open-ended probes and theoretical sampling and were analyzed to yield themes and subthemes. Principal themes and subthemes emerged from the data analyzed. These themes illuminated nurses’ experiences with respect to the use of pharmaceutical medication in the mental health setting, including (a) nurses’ responsibilities for psychiatric pharmaceutical medications, (b) work experiences in multi-disciplinary teams, (c) nurses’ knowledge and education regarding medication, and (d) struggles faced by Psychiatric/Mental Health Nurses. Nurses involved in pharmaceutical care need additional education, training, interprofessional collaboration, and clearly codified parameters to guide their professional practice in this aspect of care.


Background
In 2020, the Council of Europe defined pharmaceutical care (PC) as ''the responsible provision of pharmacotherapy for the purpose of achieving definite outcomes that improve a patient's quality of life.''Collaboration, mutual respect, patient-centeredness, and agreement among all members of the interprofessional team of healthcare providers on the care of patients was recognized as instrumental to achieving maximum therapeutic gain with minimal undesirable effects (European Office for the Quality of Medicines and Health Care, 2020).
Profession caring aspects of PC enumerated in that resolution included holistic assessment of patient status and characteristics, identification of medication-related problems, formulation of a client care plan, implementation and monitoring of care, and follow-up on the patient's status (De Baetselier et al., 2020).Dilles et al. (2021) enumerated the scope of nurse PC as the monitoring of client responses to and compliance with medication, prescription and administration of medicines, and provision of patient education and information during clinical practice.The mandated ability to perform these functions varies across Council of Europe member states.The Council of Europe found among member nations mandated nurse PC activities were dependent on levels of experience in practice, type of medicine employed, and educational levels of the nurses in consultation with interprofessional teams comprised of physicians, nurses, and pharmacists (European Office for the Quality of Medicines and Health Care, 2020).
The advantages of nurse PC are that they may allow for more rapid prescription availability, more patient options for access, higher efficacy of patient service, and more efficient utilization of nurses' training and education (Black et al., 2020).Within several of European nations, psychiatric/mental health nurses have variously taken active roles as recommended by the Council in PC for a number of years (Graham-Clarke et al., 2019;Lai et al., 2020).
Nurses' participation in psychiatric patients' PC has subsequently been evaluated.In 2003 in the United Kingdom, additional extensions to psychiatric/mental health nurse prescribers' responsibilities were announced (De Baetselier et al., 2020).Based on the mandated changes, nurses and pharmacists who had undertaken the required training and achieved qualifications in the United Kingdom were sanctioned to provide, using a specialized formulary, prescription drugs for all clinical pathologies.The exception was prescription of controlled drugs such as morphine, which are governed by the UK Misuse of Drugs Regulations body (Graham-Clarke et al., 2019).
In Saudi Arabia, mandated nurse pharmaceutical care roles have not yet been officially formulated.The main structure being employed involves a voluntary contract between physicians, nurses, and pharmacists.This agreement enables health care workers to dispense, monitor, counsel, and educate patients in health care settings, but there is a critical need for a firm framework for use of PC during provision of care which spells out responsibility and accountability of the members of the multi-disciplinary care team charged with psychiatric/mental health care.

Overview of Saudi Arabian Healthcare
The population is comprised of 2/3 residents and 1/3 guest workers with a total of 67% aged 34 years of age or less.As of 2018, in the most recent data available, the Kingdom had a total of 184,656 practicing nurses of which 70,319 were Saudi citizens (Alluhidan, et al., 2020).
The portion of the Saudi GDP spent in 2018 for ongoing health care expenditures was 5.54 % with MH (mental health) care accounting for 4% of these expenditures (worldbank.org, 2023).Moreover, 78% of all MH care spending is utilized by inpatient psychiatric units and hospitals.Outpatient MH care facilities per 100,000 population number 0.08, in comparison to the European Union rate of 0.42 (WHO, 2019).
There are 10.7 mental health nurses per 100,000 population, compared with 23.2 in the European Union (Al-Subaie et al., 2020).According to the World Health Organization (2019), as of 2017 there were 1.3 psychiatrists and 10.7 psychiatric MH nurses per 100,000 population in Saudi Arabia.To date, provision of medication is the purview of licensed physicians in all healthcare settings.
Nursing in Saudi Arabia has been undergoing rapid changes.Until recently, most practicing nurses in Saudi Arabia have been foreign nationals from a variety of nations or diplomate levels reflecting a variety of nursing skills.Saudis are increasingly filling the need for professional nurses trained to meet Saudi standards and needs (Hibbert et al., 2012).However, this dimension of inconsistency has created presence of different levels of skill within the nursing workforce.This dissonance creates a demand for delineation of responsibilities and accountabilities appropriate for various skill levels and presents an important challenge in policymaking and healthcare organizational structure, including PC.
Indigenous professional healthcare providers, when available, are well acquainted with local cultural patterns and prepared to provide culturally competent care for their patients.Based on the Vision 2030 Initiative for renewal and expansion of institutions of Saudi society, robust efforts are being made to increase qualifications and numbers of professional locally trained nurses including provision of bridging programs for Ministry of Health Institute diploma-holding nurses who make up the bulk of Saudi nurses in the workforce.Successful completion of these programs would result in achievement of Master of Nursing.Specialist programs are being offered for graduates of university based undergraduate bachelor of nursing programs.Graduate specialist and doctoral programs have been initiated as well producing graduates (Gov.sa, 2020(Gov.sa, /2021)).

Developments in Provision of PC
Mental health delivery systems in various locales worldwide continue to engage in planning ways to identify, train, and ensure good nursing practices related to pharmaceutical care (Dilles et al., 2021).Patient failure to benefit from medications prescribed during treatment is an ongoing problem in healthcare (Haynes et al., 2002;Osterberg et al., 2005).Clients who receive prescriptions for psychiatric pharmaceuticals may fail to use them as instructed (Han et al., 2017;Teodorini et al., 2020).Kim et al. (2020) documented that 75% of patients with schizophrenia discarded their drugs within 18 months of commencement of dosing.This may be due to inadequate patient education or cultural and social factors that influence compliance.The impact of continuing with a prescribed care plan is important since patients who discontinue use of medication may relapse, exhibit heightened disability, generate greater distress for caretakers, and contribute to the healthcare burden (Barnes, 2020).
Pharmaceutical care by nurses has been a subject of controversy.A EUPRON study of perspectives on nursing professionals' participation in PC found that within the 39 member countries, monitoring medicine effects and adherence, prescribing medicines, and providing patient education/information about medicines-while an important part of nurses' roles-is subject to variations between law and practice (De Baetselier et al., 2021).The study found that patient education and information was seen as an essential activity, monitoring medicine adherence, and monitoring of medication effects was seen as essential activities by practice 78, 73, and 69% respectively among nurses studied.However, only 15% of nurses felt that prescribing was essential to their provision of care.Furthermore, of nurses believed that they should have increased involvement in patient education, monitor for adherence, monitor for positive or negative medication effects, and to prescribe medication 95%, 95%, 91%, and 53% respectively.Nurses rated interprofessional communication between themselves and physicians and pharmacists, at 4/10 and 7/10 respectively.These low rates of suggest the need for increased cooperation between these healthcare teams.
UK studies have reported positive public reactions to the implementation of nurse participation in prescriptive care.In a review article, two recent UK case studies evaluated and psychiatric/mental health prescriptive care by nurses and noted that it was viewed favorably by nurses and clients.Similar outcomes between patients receiving physician-prescribed care and that of nurses was observed (McCurdy et al., 2020;Nuttall, 2018).
In the United States, Kilpatrick et al. (2012) reported that psychiatric/mental health nurses found that being able to prescribe medications, in addition to their previous roles of history collection and follow-up observation, enabled them to offer their patients a more comprehensive care package that included assessment, planning, care, and evaluation of outcomes.Yang et al. (2017) found that medication prescriptions by nurses and doctors were essentially identical regarding content and frequency.Furthermore, when appraising outcomes of medication, such as the observation of adverse events, side effects, and client and family education, nurse prescribers were able to offer their patients more time and acuity than their medical counterparts (Black et al., 2020).
Nursing staff are especially important resources for reinforcing drug compliance and use in individuals with chronic pathologies such as schizophrenia or bipolar disorder (Dobel-Ober & Brimblecombe, 2016;Yang et al., 2017).Due to their greater amount of contact with patients, nurses may identify drug-related adverse events and offer approaches to mitigate them based on patients' individual characteristics and cultural and social backgrounds.
In the United Kingdom, special training is required for nurses to qualify as providers of psychiatric/mental PC.To qualify to dispense medications from a specially designed nurse's formulary, a 26-day training period using a university-based syllabus followed by supervised attachment to a psychiatric care medical professional is required (Dobel-Ober & Brimblecombe, 2016).As of 2008, 14,000 practicing nurses had completed this requirement.In the United States, 16 states have authorized registered nurses to engage in pharmaceutical care activities, including dispensing using a specially defined formulary of medications (Guttmacher Institute, 2022).

Theoretical Model
Sister Callista Roy proposed that personal adaptation occurs due to change in physiologic, self-concept, role function, and interdependence factors.Adaptation to new roles and needs in professional caring abilities in the nursing environment aimed toward to providing improved levels and types of care for patients falls within her four adaptive modes (Roy, 2009).Practicing nurses have a personal and ethical mandate to seek positive change in their abilities through constant interaction with the changing environment, including assumption of new roles and the associated stresses encountered in this change.Nurses in our model desired access to increased education and training, policy mandates, and tools (e.g., a prescribing formulary) in order to adapt to increasingly challenging needs related to their practice.

Aim and Objective
This study was undertaken to illuminate the perceived professional PC-related needs of mental health and psychiatric nurses in Saudi Arabia.At present, there is a dearth of information regarding nurses' PC responsibilities and accountability within Saudi Arabia.The aim of the current inquiry is to investigate these elements from the viewpoint of practicing professional psychiatric mental health nurses and to offer an initial report with respect to their perceptions of roles in, knowledge of, clinical skills for, and experiences with PC in this practice area.

Method
Qualitative methodology was employed to enable participants to illuminate the aspects of their caring role which relate to PC. Nurse participants with experience in psychiatric-mental health settings provided data via focus groups on their PC experiences among inpatients with psychiatric diagnoses.Focus group method used semi-structured interviews to extract of inductive data provided by participants.Resultant inductive codes were grouped to form a conceptual framework of the concerns expressed by participants during semi-structured focus group meetings which were initiated by the investigators who acted as moderators.

Sample
The sample was comprised of a total of nine psychiatric mental health nurses aged 25-40 years with direct professional patient care experience in in-patient psychiatric settings pursuing a master's program in psychiatric mental health nursing.A message to recruit participation was posted on What's App (a popular social media service) to all students in enrolled in the Master of Nursing program.Table 1 shows details of this group.

Data Collection
Data were collected through semi-structured interviews with focus groups.Focus groups are highly instrumental in permitting participants to thoughtfully discuss health care experiences (Kinalski et al., 2017).The sample was broken into two groups which met simultaneously at the university College of Nursing.The investigators who acted as moderators were known to the students but were not involved in graduate instruction.
Meetings convened for approximately 45 minutes each.Two focus groups were formed of four and five participants respectively.Beginning probes were employed by the moderators to elicit feelings about PC experiences (Gioia et al., 2013).Beginning probes used are shown on Table 2. Focus group interviews began with an open-ended question followed by theoretical sampling based on responses to the probing questions based on data produced to further explore conceptual areas which emerged.This process assisted the participants in developing themes and providing a rich description of their experiences and associated feelings.
Cessation of production of new indictive data signaled saturation and sessions were terminated with a review of the central codes that had emerged as a form of member checking (Kinalski et al., 2017).Each statement made by the participants was considered significant and treated as relevant.The researcher planned the sessions to give participants sufficient time to think and reflect on their experiences.

Tabulation and Analysis of the Data
Data were collected on a digital recording device.These data were transcribed and stored as a Word document.Transcribed data were reviewed by the investigators to extract inductive codes through individual analysis.
Themes emerged from the inductive data and were reviewed, analyzed, and grouped by the investigators into preliminary themes characterized by data of similar conceptual content.These data were refined to yield the primary and secondary themes.The researchers accepted the possibility of bias based on their own previous experiences and endeavored to analyze the data in a transparent manner.The resultant themes were reviewed and evaluated by peers.The four themes that emerged are presented and discussed below Findings.

Ethical Considerations
An institutional review board approved the protocol, which conformed to standard research practices.Volunteers who contacted the researchers in response to the recruitment message and met the inclusion criteria of having been employed in direct in-patient psychiatric mental health care for a minimum of 2 years' experience in inpatient psychiatric care as nurses and were aged 20 to 50 years were requested to meet at a specified time at the College of Nursing for a maximum time frame of 2 hours.Participants were not paid and were advised that they could terminate their participation at any time.Purpose of the study was explained and written and verbal informed consent were obtained.The recordings, notes, and transcripts were stored in a locked facility and storage unit.The participants were assured that their contributions would be confidential.

Methodological Rigor
Two researchers independently reviewed the data, codes, and categories before meeting and deciding upon agreed meanings and the significance of the analyzed data.Member checking added to reliability of data.Depth of experiences described by the participants directly impacted the transferability and dependability of the findings.Peer review and the professional status and experiential background of participants enhanced the credibility of the data (Forero et al., 2018;Morse, 2015).

Findings
Four principal themes emerged from the psychiatric/ mental health nurses' focus group sessions with respect to PC (Table 3).These themes are discussed further below to demonstrate the breadth of each thread.
Main Theme 1: Nurses' Responsibilities for Psychiatric Pharmaceutical Medications Focus group participants emphasized the perceived importance of nurses' obligations pertaining to prescription drugs for patients with mental health issues, including psychosis or neurosis, in both in-patient and followup out-patient settings.They believed that medication was invaluable in caring for this population and that the nurse because of the proximity to the patient had a valuable role to fulfill in delivering PC.
Subtheme 1: Patient Education.Nurses discussed that their responsibilities included education of patients and their families (e.g., patient representation, assistance, and encouragement for relatives, and working with multidisciplinary team).Nurses felt that their most significant obligation was to assist patients with their course of medication and offer information to patients and relatives regarding compliance to medication and potential sideeffects to expect.Nurses viewed themselves as frontline educators who were responsible for teaching patients about drug side-effects and helping patients and their carers to understand how to incorporate their medication into their daily activities: I need to inform the patient of the reason for the drugs and the adverse effects as we are the principal teachers.(Participant 1) A basic component of this aspect of the nurses' job is to fully inform patients of potential side-effects.The participants frequently mentioned that understanding this aspect of care was an essential element: It is essential to ensure that patients adhere to their drug regimen.An important component of this is to tell them about the possible adverse effects of the medication and how we can help to deal with them if they arise.(Participant 4) Participants reported that a specifically relevant time for education was during the in-patient stay after a first episode of psychosis, since this was the stage when both patients and relatives experienced the most anxiety regarding the onset of illness and features linked to their drug therapy.For example, one participant expressed the following view: Patients presenting for the first time, who have just received their diagnosis, ask repeatedly about their drugs and their effects, and then we have to say that it will take from one or two weeks to as long as five weeks for them to become effective.(Participant 6) The focus group participants concurred that patients who had experienced multiple admissions were likely to have a good understanding of the drugs they would receive, and so nurses usually waited for these patients to ask any questions: It is anticipated that patients will have a good knowledge of their drugs if they remain constant, whereas a new drug will be discussed with them.However, the patients typically understand their medication, and generally inquire if they have any worries.(Participant 8) Nurses working in the in-patient settings, were cognizant of the importance of learning to incorporate the drug regimen into their patients' daily activities.However, participants felt that this responsibility lacked organization or a patient-centered approach: A probing strategy is taken rather than an organized or compulsory approach.We begin by evaluating how the patient builds their way of life.We then work on how the drug regimen could be incorporated and the degree of organization the patient has.We then gently discuss potential lifestyle alterations or ways to make the drug regimen more suitable for the patient and try to progress in that fashion.(Participant 4) Several focus group attendees felt that warning the client of the implications of failing to comply with the drug regimen was their most important educational role: Subtheme 2: Providing Support for Patients and Relatives.In addition to offering information to patients, nurses felt that their obligations included offering assistance and encouragement to patients and their families.The beginning of an in-patient stay was considered the phase when patients and family members were most open to suggestions and help.Care for patients who were especially agitated also received advanced individualized attention: Our responsibilities are founded on evaluating the way in which our assistance aligns with the patient's psychosocial cognitive function.My feeling is that if a patient is particularly uncooperative, then there are numerous questions that require solutions.It is necessary to inquire further to establish exactly what is going on in their domestic circumstances.(Participant 8) The majority of individuals appear receptive to education, particularly at disease onset, when they are happy to take advice and interact.If a patient has reached the stage where they no longer connect, and they are unwilling to discuss their problems, then we, as carers, should offer further assistance and repeatedly urge them to describe their way of life.(Participant 4) The nurses additionally considered it important to have an underlying rationale for the need for specific drugs, especially when side effects were experienced: Patients frequently report that they don't wish to be treated as an experiment, so you need to comfort them.They often express paranoia that they are being studied to test various types of drugs.Of course, if one fails to be effective, or they have side effects, then the team may replace it with another option.(Participant 7) We should review all medications for potential interaction with new drugs prescribed.(Participant 3).

Main Theme 2: Work Experiences in Multi-Disciplinary Teams
A further opinion amongst the participants was that they represented the patient.The significance of interacting with additional health care team members was also expressed, with reference to how this enabled patient management after discharge.The physician, pharmacist, and community appraisal groups were viewed as essential components of this process: We frequently refer patients to the ward doctors and pharmacist, especially prior to discharge, so that they can go through their drugs with them again with respect to when and how regularly they should be taken, together with potential adverse effects.(Participant 2) Many patients and their families experience exhausting anger with respect to their illness and ask if they are likely to recover in the future.(Participant 1) We engage with multi-disciplinary carers in order to be more aligned with an individual patient, especially in relation to their drug regimen.(Participant 5) We should work as a combined mental health team and work through a single care plan as a group, taking joint responsibility and accountability for decisions, receiving and offering advice regarding the patient's journey.(Participants 8)

Main Theme 3: Nurses' Knowledge and Education Regarding Medication
The nurses experienced concern about the format of their education with respect to psychiatric pharmacology.In the institutions participating in this research, in-service training in this aspect was not prominent.Therefore, nursing staff had to utilize a range of informal sources to self-teach, encompassing written material, lectures from pharmaceutical company personnel, interaction with pharmacists, and experiences from their daily job in the ward.Many stated that they depended on their own motivation and personal endeavor to keep their information and aptitudes regarding PC current.Sample pertinent opinions included: I spent considerable time in the ward to find out information for myself; it was not included in formal training.(Participant 9) It is necessary to acquire more information and conviction regarding drug therapy, and so several training courses and seminars are required.(Participant 3) A patient may have a query, so you would have to find out the information yourself and then return to the patient and tell them of the possible adverse effects.(Participant 5) To reinforce their self-education regarding pharmaceuticals, nurses utilized written materials from their ward environment, such as copying drug information and then sharing it amongst colleagues.One participant described this process as: Additionally, there are some leaflets and other sources of data present in the ward that can be utilized.There is also a reference book about drugs available.No other forms of teaching are offered to us so we must look for it ourselves.(Participant 7) Of note was that all the participants found the data provided by representatives from pharmaceutical companies to be a regular source of information for ward personnel.However, although some nurses appreciated this material, others were skeptical: Drug reps [representatives] visit frequently and offer data, especially relating to new medications.This is useful as there is not much teaching about pharmaceuticals available from other sources, but we are aware that it is based in a business model.(Participant 9) Nurses complimented pharmacists' contributions and indicated their confidence in these professionals as a source of information: We definitely require more in-service training from a pharmacist.(Participants 8)

Main Theme 4: Struggles Faced by Psychiatric/Mental Health Nurses
Nurses noted that there were several hindrances and challenges to their jobs when administering drugs.They raised concerns regarding the delineation of nursing responsibilities and level of experience with pharmaceutical care.
Subtheme 1: Conflicts Associated with Nurses' Roles.Nurses were concerned that their clinical responsibilities restricted their ability to provide patients with information after discharge.This issue was exacerbated by the absence of any structural links between community appraisal groups and ward personnel.While ward personnel were frequently asked to attend combined sessions sponsored by community teams, in practice, they rarely had the opportunity to attend: It is possible to contact the community appraisal workers, but it is not a definitive or organized arrangement.Frequently, many of us are unable to attend meetings because of responsibilities in the ward.We therefore lose the educational opportunity and any discourse relating to specific in-patients that we have cared for.(Participant 3) Further opinions were that psychiatric/mental health nurses spend most of their time reviewing patients and administering pharmaceutical agents at the expense of follow-up care and self-improvement: Our staff just provides ongoing care to patients and delivers drugs.(Participant 6) Most of our work is in the follow-up out-patient setting.We also are tasked with checking the name of the patients and their appointment times.(Participant 1) Our job in the psychiatric sector as a nurse has two obligations: first, to record the drugs when they are prescribed, to ensure that they are itemized in the system, and to check this in the ward files.Second, we confirm with the pharmacy on every shift that drugs are accessible and are rectified according to the doctor's prescription for each patient.(Participant 3) Subtheme 2: Insufficient Experience with Patients.A final noted impediment was the influence of the patient's illness creating a hindrance to efficacious drug management.They noted that when a patient is high acuity, teaching is difficult or impossible until they are stabilized.This was described by the following: Patients in the acute ward are required to read and to take in information.Given their limited ability to focus during that time of significant psychotic disruption, performing this task by the nurse can be very challenging.(Participant 5) Restriction of clinical duties related to PC limited nurses' ability to participate in integrated care, causing frustration: Typically, in our institution, there is a drugs nurse, who is obligated to be given and to monitor all drugs for each patient.We are not involved.(Participant 1) A liaison clinic would be a possibility for a psychiatric/mental health nurse to explain the medication and to offer the patient follow-up, but in our institutional setting, this clinic type is not accessible for nurses to perform this function.This task is reserved for other psychiatric subspecialists in the sector.(Participant 7) There is awareness of the need for a liaison clinic for followup of discharged patients to appraise and to review patients and their drugs, but realistically, this does not happen.(Participant 3) If there are odd symptoms or adverse effects, the drugs will be withdrawn immediately and the doctor informed.We could make that judgement, but it is not in our job description.(Participant 6) We are aware that some nurses might be offered an opportunity to become qualified to prescribe drugs as occurs in other nations.(Participant 8)

Discussion
The results of this exploratory inquiry supplement and complement previously published data.Psychiatric/mental health nurse participants illuminated their concerns about the way drugs are used in their practice.They noted that there is a state of dissonance in PC of patients under their care, which they believe affects patient welfare and their professional practice.
Caring for patients as a professional healthcare provider requires education and training of personnel.In 2003, the UK Royal College of Physicians and Psychiatrists proposed that stakeholders should ensure that the education of health care providers be offered at a high standard (Gwernan-Jones et al., 2020).Curricula for nursing education are well-established internationally.However, changes in practitioners' needs based on the emergence of new work-connected duties, new tech-nology or knowledge, or changes in the demographics of the patient population may justify changes to meet these needs (Fouche´et al., 2016).
The move to increase nurse participation in PC is an example of the need to extend education and training to meet new or developing needs.It would appropriately include concerns related to responsibility of the nurse to provide PC in the caring process and avenues for providing structure in accountability for this type of care.This education and training can occur during nurses' initial professional training or through continuing education after a professional status has been achieved.Continuing education is necessary to assist practicing professionals to upgrade their skills, learn about advancements related to their practice, pursue opportunities for advancement in their careers, and allowing them to be of greater service to their patients and fields of practice (Creamer & Austin, 2017), including in mental health settings (McAllister et al., 2019;Scott et al., 2019).
Participants' responses during this study reinforce findings in recent literature that nurses' preparation and level of knowledge with respect to PC in their caring role is often insufficient (Berhanu et al., 2016;Shorofi & Arbon, 2017;Skingsley et al., 2006).While the nurses in this study had attempted to acquire these necessary skills through their own approaches, they elucidated the need for more organized and formal training to be offered and incorporated into undergraduate study and current continuing education curriculum to provide the ability to assume advanced responsibilities for delivery of care and accountability for that care.This would necessarily include detailed instruction related to psychiatric pharmaceuticals and their administration.
Participants felt that therapeutic collaboration between caring professionals, including interprofessional and multi-disciplinary teams needs to be strengthened.Safety during transition of patients between types of care including discharge planning and follow-up were areas of special concern which they felt demanded structured interaction and cooperation between the sectors of the healthcare team (De Baetselier et al., 2022;Dilles et al., 2021;Mardani et al., 2020;Setter et al., 2012).
The structural position of nurses involved in care employing drugs needs to be clearly delineated in a codified and mandated manner to recognize their responsibilities and accountability for this aspect of their clinical practice.Progress in this area may facilitate an increased recognition of the complicated requirements of providing this care, offer a more sensitive and pertinent strategy, potentially reward those who accept this responsibility, and assist in the establishment of robust multidisciplinary teams constituting nurses, pharmacists, and physicians working together to provide high quality PC (Ajabnoor & Cooper, 2020;Attaran et al., 2019;Dilles et al., 2021;Happell et al., 2019;Hibbert et al., 2017;McEvoy et al., 2021;R€ usch et al., 2019;Setter et al., 2012;Vigo et al., 2019).
Improvement or initiation of specific features of practice regarding nurse role in PC may be particularly useful in the Saudi mental health system.Initiation of these practices may enable changes in organizational structure and policy which apply to roles and duties of psychiatric mental health nurses without altering the quality of care provided to patients.This has been evidenced by reduced readmission rates among patients who are cared for nurses with expanded roles in PC in Europe (Graham-Clarke et al., 2019).Structured expansion of the PC role may assist in reducing caring responsibilities for other members of the interprofessional team (McCurdy et al., 2020;Nuttall, 2018) while providing a safety framework for the prescribing nurse (Canet-Ve´lez et al., 2023).
Awareness and practice of responsibility for pharmacovigilance of all healthcare providers may be instrumental in improving PC and patient safety (Alshammari et al., 2015).Hussain et al. (2021) explored awareness of members of the multidisciplinary healthcare team and found that 49%, 70%, and 76% of physicians, pharmacists, and nurses respectively expressed positive attitudes respectively toward participation in adverse drug reporting.These data signal that nurses consider the PC care of their patients as an important element of proving high quality care to them.
Uniform mandated regulations of permitted prescribing by health care providers, coupled with specialized formularies for various practitioners, including nurses, may improve interprofessional communication, cooperation, and organized distribution of responsibilities and accountability in delivery of PC in psychiatric mental health settings (Canet-Ve´lez et al., 2023;Courtenay, 2010;Skingsley et al., 2006;While & Biggs, 2004).

Limitations
All participants were female gender which may not represent views of nurses of male gender.A small focus group may not represent views of a wider population of participants signaling the possible need for conducting an expanded study related of this topic.

Conclusion and Recommendations
Initiation of the practice of exercising a more robust role in PC care of patients may be of benefit to patients and those who will provide care for them after discharge.Goldman et al. (2016) found limited engagement in interprofessional collaboration and discharge planning between bedside nurses and other healthcare professionals.Nurses charged with daily care of patients may have valuable insights into the needs of patients in all aspects of their care acquired during their involvement with them and their families during the inpatient phase of care.Thus, interprofessional involvement in all types of care planning is appropriate and necessary, including all aspects of PC for patients.
This inquiry may contribute to a better understanding of nurses' self-perceived responsibilities for delivery of high quality PC care and the obstacles they face in doing so in the psychiatric-mental health inpatient environment.The data reinforce that nurses feel that they could be key actors in PC for their patients by expanding their role to include increased responsibilities for provision and accountability in dispensing, patient education, and monitoring of drugs when accompanied by appropriate training and organizational policy and structure.The findings offer an overview of the nurses' desire for information, experiences, and acquisition of skill which may enable them to increase participation in providing PC care for their patients and their families in the inpatient psychiatric-mental health setting the manner of the nations of the European Union and United States (Haynes et al., 2002;Osterberg et al., 2005).

Table 2 .
Probes Employed to Begin Discussion.