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

AIMS AND METHOD

A questionnaire survey of psychiatrists and mental health nurseswas conducted to look at their awareness of nurse supplementaryprescribing 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 nursesupplementary prescribing, but more nurses than psychiatristsfelt that it will provide patients quicker access to medication(P=0.023) and improve patient care (P=0.0003). Although two-thirdsof the nurses felt confident to be a nurse prescriber, only13% 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 benefitsof nurse supplementary prescribing on patient care. Both nursesand psychiatrists expressed concerns. As the expansion of nurseprescribing occurs, it is important for trusts to work activelywith nurses and psychiatrists to address these concerns.

Introduction

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Introduction

Nurse supplementary prescribing was introduced in 2003 and thenumber of qualified nurse prescribers in mental health settingshas grown steadily – it is now estimated to exceed 600across England.

Nurse supplementary prescribing in mental health is a voluntarypartnership between an independent prescriber (normally a psychiatrist)and a supplementary prescriber (a suitably trained registerednurse), to implement, with the patient’s consent, anagreed patient-specific clinical management plan (Department of Health, 2003).Following the doctor’s assessment and diagnosis, the nurseand 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 repeatprescriptions, adjust the dose, switch and stop the medicationdependent on the parameters laid out in the clinical managementplan.

According to the National Prescribing Centre (2005), the potentialbenefits of nurse supplementary prescribing are:

quicker and more efficient patient access to medication
increasedpatient choice
more efficient provision of services
betteruse of nurse’s skills and knowledge.

To become registered prescribers, nurses are required to attenda generic 26-day university-based training programme and undergoa period of supervised practice with an experienced doctor,typically a consultant psychiatrist for those working in mentalhealth settings (Nursing and Midwifery Council, 2003). SinceMay 2006, a supplementary nurse prescriber is also qualifiedto 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 mentalhealth settings is in the form of supplementary prescribing.

Studies from the US have suggested similar outcomes for nurseand doctor prescribing for a range of conditions (Mundinger et al, 2000),similar prescribing patterns in doctors and nurses for mentalhealth conditions (Fisher & Vaughan-Cole, 2003) and highservice user satisfaction for nurse prescribing (Mundinger et al, 2000).

In the UK, each stage of nurse prescribing has had its advocatesand detractors (Avery & James, 2007). Studies have suggestedthat independent nurse prescribing has a positive impact onservice delivery and patient satisfaction (Luker et al, 1998), and nurse directors of mental health trusts have been foundto be positive about the potential of nurse prescribing toimprove services (Gray et al, 2005). At the same time therehave been debates about the adequacy of training of the nurseprescribers and risks to patient safety (Avery & Pringle, 2005). However, no studies have looked at the views of the frontlinestaff – nurses who will provide supplementary prescribingand psychiatrists who will provide support, supervision andopportunities to nurses for prescribing.

Method

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Method

A survey of the staff working in the Hertfordshire PartnershipNHS Foundation Trust was conducted in early 2006, before thewidespread implementation of independent nurse prescribing.The local research ethics committee chair confirmed that formalethical approval was not required for the survey. Two similar7-item questionnaires were designed for the study; one forpsychiatrists 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, specialistregistrars and associate specialist doctors (n=115), and toall 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 andthe 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 forrespondents to expand on their views. A reminder was sent tonon-respondents after 6 weeks. The views of nurses and psychiatristswere compared using chi-squared test.

Results

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Results

The questionnaires were completed by 57 psychiatrists and 106nurses, giving a response rate of 49.5% and 23% respectively.At the time of the survey, there were 7 supplementary nurseprescribers in the Trust – 4 of the nurses who respondedwere prescribers.

Most psychiatrists (91%, n=52) and mental health nurses (96.2%, n=102) were aware of supplementary prescribing. More nurses(75.4%, n=80) than psychiatrists (58%, n=33) felt that supplementary prescribing would provide patients quicker access to medication (P=0.023). Although most nurses (78%, n=83) felt that nurse prescribing would improve patient care, less than half of psychiatrists(47%, n=27) shared this view (P=0.0003).

The majority of nurses (66%, n=70) felt confident that theycould 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 ofa nurse prescriber within their team although there were fournurse prescribers among the responders.

Specific concerns expressed by psychiatrists were around issuesof accountability, nurses’ knowledge and that supplementaryprescribing would increase rather than decrease their own workload.

Where nurses expressed concerns, these related to an increasedworkload, inadequate training and accountability. Nurses alsomade suggestions that could make nurse prescribing more attractiveto them such as appropriate training and supervision, clarifyingissues of accountability and financial recognition.

Discussion

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Discussion

This survey reports the mental health nurses’ and psychiatrists’awareness of nurse supplementary prescribing and its impacton patient care. The majority of nurses and psychiatrists wereaware of nurse supplementary prescribing, but nurses perceivedits impact on patient care as more positive, with a rathercautious view from psychiatrists. This echoes the views ofdirectors of nursing of mental health trusts, who consideredthat many psychiatrists had either neutral or negative attitude towards nurse supplementary prescribing (Gray et al, 2005).In this survey, overall, psychiatrists were more cautious thannurses about the service’s potential – 37% feltunsure and nearly 16% actually stated that they did not thinkthat nurse prescribing would improve patient care.

The results from this survey are limited by the fact that theyare subject to self-selection bias inherent in such a surveyapproach. The sample size was large and the response rate goodfor psychiatrists (49.6%) but relatively low for the nurses(23%), which can result in response bias.

The implications for implementation are that, although thereare sufficient numbers of psychiatrists and nurses aware aboutsupplementary prescribing to begin implementation, trusts willneed to actively work with their more cautious colleagues toaddress any concerns and highlight good results from earlyimplementation. Trusts also need to provide appropriate trainingand support to ensure that psychiatrists feel more confidentin being supervisor to nurse prescribing trainees.

References

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