Psychiatrists ’ and nurses ’ views of mental health nurse supplementary prescribing : a survey

RESULTS Response rate was 49.5% for psychiatrists and 23% for nurses. Most nurses (96.2%) and psychiatrists (91%) were aware of nurse supplementary prescribing, but more nurses than psychiatrists felt that it will provide patients quicker access to medication (P=0.023) and improve patient care (P=0.0003). Although two-thirds of the nurses felt confident to be a nurse prescriber, only 13% had actually approached a psychiatrist to be their supervisor. Most psychiatrists (54.4%) did not feel confident to act as supervisors. CLINICAL IMPLICATIONS Unlike nurses, psychiatrists were cautious about potential benefits of nurse supplementary prescribing on patient care. Both nurses and psychiatrists expressed concerns. As the expansion of nurse prescribing occurs, it is important for trusts to work actively with nurses and psychiatrists to address these concerns.

A questionnaire survey of psychiatrists and mental health nurses was conducted to look at their awareness of nurse supplementary prescribing and its impact on patient care.

RESULTS
Response rate was 49.5% for psychiatrists and 23% for nurses.Most nurses (96.2%) and psychiatrists (91%) were aware of nurse supplementary prescribing, but more nurses than psychiatrists felt that it will provide patients quicker access to medication (P=0.023) and improve patient care (P=0.0003).Although two-thirds of the nurses felt confident to be a nurse prescriber, only 13% had actually approached a psychiatrist to be their supervisor.Most psychiatrists (54.4%) did not feel confident to act as supervisors.

CLINICAL IMPLICATIONS
Unlike nurses, psychiatrists were cautious about potential benefits of nurse supplementary prescribing on patient care.Both nurses and psychiatrists expressed concerns.As the expansion of nurse prescribing occurs, it is important for trusts to work actively with nurses and psychiatrists to address these concerns.
Nurse supplementary prescribing was introduced in 2003 and the number of qualified nurse prescribers in mental health settings has grown steadily -it is now estimated to exceed 600 across England.
Nurse supplementary prescribing in mental health is a voluntary partnership between an independent prescriber (normally a psychiatrist) and a supplementary prescriber (a suitably trained registered nurse), to implement, with the patient's consent, an agreed patientspecific clinical management plan (Department of Health, 2003).Following the doctor's assessment and diagnosis, the nurse and doctor set out the clinical management plan specifying the medications that can be prescribed by the supplementary prescriber.The nurse supplementary prescriber can then prescribe repeat prescriptions, adjust the dose, switch and stop the medication dependent on the parameters laid out in the clinical management plan.
According to the National Prescribing Centre (2005), the potential benefits of nurse supplementary prescribing are: . quicker and more efficient patient access to medication .increased patient choice .more efficient provision of services .better use of nurse's skills and knowledge.
To become registered prescribers, nurses are required to attend a generic 26-day university-based training programme and undergo a period of supervised practice with an experienced doctor, typically a consultant psychiatrist for those working in mental health settings (Nursing and Midwifery Council, 2003).Since May 2006, a supplementary nurse prescriber is also qualified to be an independent nurse prescriber, potentially able to prescribe medication for any medical condition within their area of competence.However, to date, the majority of nurse prescribing in mental health settings is in the form of supplementary prescribing.
Studies from the US have suggested similar outcomes for nurse and doctor prescribing for a range of conditions (Mundinger et al, 2000), similar prescribing patterns in doctors and nurses for mental health conditions (Fisher & Vaughan-Cole, 2003) and high service user satisfaction for nurse prescribing (Mundinger et al, 2000).
In the UK, each stage of nurse prescribing has had its advocates and detractors (Avery & James, 2007).Studies have suggested that independent nurse prescribing has a positive impact on service delivery and patient satisfaction (Luker et al, 1998), and nurse directors of mental health trusts have been found to be positive about the potential of nurse prescribing to improve services (Gray et al, 2005).At the same time there have been debates about the adequacy of training of the nurse prescribers and risks to patient safety (Avery & Pringle, 2005).However, no studies have looked at the views of the frontline staff -nurses who will provide supplementary prescribing and psychiatrists who will provide support, supervision and opportunities to nurses for prescribing.

Method
A survey of the staff working in the Hertfordshire Partnership NHS Foundation Trust was conducted in early 2006, before the widespread implementation of independent nurse prescribing.The local research ethics committee chair confirmed that formal ethical approval was not required for the survey.Two similar 7-item questionnaires were designed for the study; one for psychiatrists and another for the nursing staff.
The questionnaire was sent by email, along with a covering letter, to all psychiatrists in the Trust, namely consultants, specialist registrars and associate specialist doctors (n=115), and to all mental health nurses in the Trust at grade F and above (n=460).The letter provided information about the survey, basic information about nurse supplementary prescribing and the training required to be a prescriber.
The survey questions required a 'yes/no/don't know' response and there was also a free-text space provided for respondents to expand on their views.A reminder was sent to non-respondents after 6 weeks.The views of nurses and psychiatrists were compared using chi-squared test.

Results
The questionnaires were completed by 57 psychiatrists and 106 nurses, giving a response rate of 49.5% and 23% respectively.At the time of the survey, there were 7 supplementary nurse prescribers in the Trust -4 of the nurses who responded were prescribers.
The majority of nurses (66%, n=70) felt confident that they could carry out supplementary prescribing.However, only 13% (n=14) had approached a psychiatrist to be their supervisor.One interesting observation was that nurses were unaware of a nurse prescriber within their team although there were four nurse prescribers among the responders.
Specific concerns expressed by psychiatrists were around issues of accountability, nurses' knowledge and that supplementary prescribing would increase rather than decrease their own workload.
Where nurses expressed concerns, these related to an increased workload, inadequate training and accountability.Nurses also made suggestions that could make nurse prescribing more attractive to them such as appropriate training and supervision, clarifying issues of accountability and financial recognition.

Discussion
This survey reports the mental health nurses' and psychiatrists' awareness of nurse supplementary prescribing and its impact on patient care.The majority of nurses and psychiatrists were aware of nurse supplementary prescribing, but nurses perceived its impact on patient care as more positive, with a rather cautious view from psychiatrists.This echoes the views of directors of nursing of mental health trusts, who considered that many psychiatrists had either neutral or negative attitude towards nurse supplementary prescribing (Gray et al, 2005).In this survey, overall, psychiatrists were more cautious than nurses about the service's potential -37% felt unsure and nearly 16% actually stated that they did not think that nurse prescribing would improve patient care.
The results from this survey are limited by the fact that they are subject to self-selection bias inherent in such a survey approach.The sample size was large and the response rate good for psychiatrists (49.6%) but relatively low for the nurses (23%), which can result in response bias.
The implications for implementation are that, although there are sufficient numbers of psychiatrists and nurses aware about supplementary prescribing to begin implementation, trusts will need to actively work with their more cautious colleagues to address any concerns and highlight good results from early implementation.Trusts also need to provide appropriate training and support to ensure that psychiatrists feel more confident in being supervisor to nurse prescribing trainees.

Declaration of interest
N.B. is chair of the National Institute for Mental Health in England Non-Medical Prescribing in Mental Health Group.