The National Health Service (NHS) Plan (Department of Health, 2000) emphasises that health services need to change and modernise in order to improve service delivery. The role of psychiatrists is also going through a period of change (Department of Health, 2004). The expansion of nurse prescribing is an important part of this modernisation process. Independent nurse prescribing, from a limited formulary, was first introduced over 10 years ago. Qualitative studies have suggested that independent nurse prescribing has a positive impact on service delivery and patient satisfaction (Reference Luker, Austin and HoggLuker et al, 1998).

Nurse supplementary prescribing (NSP) was introduced in 2003 specifically for use in the management of chronic diseases such as asthma and diabetes, and in mental health, schizophrenia and dementia (Department of Health, 2003). Nurse supplementary prescribing is a voluntary partnership between an independent prescriber (the psychiatrist) and a supplementary prescriber (a suitably trained registered nurse), to implement an agreed patient-specific clinical management plan (CMP) that can include most medicines (Department of Health, 2003). The expected benefits of the introduction of NSP are:

1. • quicker and more efficient patient access to medication

2. • increased patient choice

3. • more efficient provision of services

4. • better use of nurses’ skills and knowledge.

If appropriate and indicated in the CMP, the supplementary nurse prescriber can adjust the dosages of medications, switch and stop medicines (Department of Health, 2003). Nurses are required to attend a 26-day university-based training programme, which is not mental health specific, and undergo a period of supervised practice with an experienced doctor in order that they may become a registered supplementary prescriber (Nursing and Midwifery Council, 2003).

Directors of nursing have a central role to play in the successful implementation of supplementary prescribing in England as it comes into practice. It is timely to map current practice within mental health services, NHS trust preparation, and explore nurse directors’ views and experiences of supplementary prescribing.

Method

A 32-item postal questionnaire was designed and developed specifically for this study by the National Institute for Mental Health in England (NIMHE) National Mental Health Nurse Prescribing Group. Directors of nursing were asked to respond to a series of questions that required factual information about their NHS trust, a yes/no response, or a rating on a three-point Likert-type scale (e.g. very confident, confident, not confident). The survey included questions on numbers and adequacy of preparation of mental health nurse prescribers; perceived benefits of, and barriers to, nurse prescribing; and clinical areas where NSP might be most usefully applied.

Results

A total of 45 questionnaires were returned, giving a response rate of 54%.

Benefits and barriers

The majority of directors of nursing (n=30, 68%) saw NSP as a ‘ very significant’ development for improving the experience of care for service users, with half reporting that their trust had a strategy for implementing nurse prescribing (n=21, 48%) and one-third seeing the implementation of NSP as high priority for their trust (n=14, 32%). The directors reported the main potential benefits from NSP as being:

1. • improving patient care and continuity of care (n=26, 57%)

2. • enhanced career development for nurses/extended nurses role (n=16, 36%)

3. • quicker access to medication (n=15, 33%).

Table 1 shows the service settings where nurse directors believed that NSP may have most potential benefit. Community-based services were those most frequently identified.

Table 1. Where will supplementary prescribing be most useful?

Specialty	Not useful n (%)	Somewhat useful n (%)	Very useful n (%)
Community mental health teams	0 (0)	9 (21)	35 (80)
Older adults (community)	1 (2)	8 (18)	35 (80)
Drug and alcohol services	2 (5)	12 (29)	28 (67)
Assertive outreach	1 (2)	9 (21)	34 (77)
Older adults (in-patient)	10 (24)	20 (49)	11 (27)
Acute in-patient care	11 (27)	20 (49)	10 (24)

Discussion

Nurse supplementary prescribing is an important part of the modernisation process and potentially may make a substantial contribution to the changing roles of psychiatrists (Department of Health, 2004). Although this survey shows that, to date, relatively few mental health nurses have completed supplementary prescribing training or are undertaking a prescribing role, this is likely to change in the future, based on the views found in this survey. Such a major change in mental health practice takes considerable time to implement.

The barriers to the introduction of NSP identified by respondents do not appear to be insurmountable. Concerns about the training may be related to its non-mental health-specific nature. This is being tackled by trusts arranging for additional training. The lack of supervisor support suggests that there is a need to explore further the knowledge, skills and confidence of psychiatrists undertaking a nurse prescribing supervision role. Active resistance to implementation from psychiatrists seems relatively rare and may be tackled by trusts emphasising the potential benefits to both patients and staff by the introduction of NSP and by ensuring that early trials are well evaluated and publicised within trusts. Anecdotal evidence suggests that some resistance may arise from a misunderstanding as to the nature of NSP, with it being confused with independent nurse prescribing which takes place totally independently of a medical opinion.

It will be important for trusts to ensure that they have addressed local implementation issues prior to the commencement of training for mental health nurses as supplementary nurse prescribers.