International Journal of Nursing Studies 46 (2009) 1467–1474

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International Journal of Nursing Studies

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Attitudes regarding mental health nurse prescribing amongpsychiatrists and nurses: A cross-sectional questionnaire study

M.X. Patel a,*, D. Robson b, J. Rance c, N.M. Ramirez b,f, T.C. Memon b,f, D. Bressington d, R. Gray e

a Division of Psychological Medicine, Box 68, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UKb Health Service and Population Research, Box 30, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UKc Oxleas NHS Foundation Trust, Pinewood House, Pinewood Place, Dartford, Kent DA2 7WG, UKd Canterbury Christchurch University, North Holmes Road, Canterbury, Kent CT1 1QU, UKe Faculty of Health, University of East Anglia, Norwich NR4 7TJ, UKf Minority Health International Research Training Program NIH Scholar, College of Nursing and Health Sciences, Florida International University, Miami, FL, USA

A R T I C L E I N F O

Article history:

Received 3 October 2008

Received in revised form 26 April 2009

Accepted 27 April 2009

Keywords:

Attitude

Clinical responsibility

Health personnel

Knowledge

Medical education

Prescribing

Psychotropic medication

A B S T R A C T

Background: In the United Kingdom, mental health nurses (MHNs) can independently

prescribe medication once they have completed a training course. This study investigated

attitudes to mental health nurse prescribing held by psychiatrists and nurses.

Method: 119 MHNs and 82 psychiatrists working in South-East England were randomly

sampled. Participants completed a newly created questionnaire. This included individual

item statements with 6-point likert scales to test levels of agreement which were

summated into 7 subscales.

Results: Psychiatrists had significantly less favourable, albeit generally positive attitudes

than MHNs regarding general beliefs (63% vs. 70%, p < 0.001), impact (62% vs. 70%,

p < 0.001), uses (60% vs. 71%, p < 0.001), clinical responsibility (69% vs. 62%, p < 0.001)

and legal responsibility (71% vs. 64%, p < 0.001). More MHNs than psychiatrists believed

that nurse prescribing would be useful in emergency situations for rapid tranquilisation

(82% vs. 37%, p < 0.001), and that the consultant psychiatrist should have ultimate clinical

responsibility for prescribing by an MHN (42% vs. 28%, p < 0.001). Approximately half of all

participants agreed nurse prescribing would create conflict in clinical teams.

Conclusions: The majority of both groups were in favour of mental health nurse

prescribing, although significantly more psychiatrists expressed concerns. This may be

explained by a perceived change in power balance.

� 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?

� T

fa

00

do

o date there are in excess of 400 qualified mental healthnurse prescribers in the UK but uptake has been slowerthan was initially anticipated.

� S ome have suggested that one of the main barriers for

implementation is the unsupportive behaviours ofpsychiatrists.

* Corresponding author. Tel.: +44 020 7848 5136;

x: +44 020 7848 0572.

E-mail address: m.patel@iop.kcl.ac.uk (M.X. Patel).

20-7489/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

i:10.1016/j.ijnurstu.2009.04.010

� A

proportion of the medical profession has expressedgrave concerns about the safety of nurse prescribingwhereas others appear supportive.

What this paper adds

� O

verall both professional groups were in favour ofmental health nurse prescribing, although significantlymore psychiatrists expressed concerns. � G eneral beliefs, impact and uses were inter-related

constructs as evidenced by high correlation co-efficients.

� P sychiatrists in particular were concerned with aspects

of clinical and legal responsibility and the appropriate

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–14741468

setting for use. This may be explained by a perceivedchange in power balance.

1. Introduction

Prior to 2003 only doctors were able to prescribepsychotropic medication in England and Wales. Legisla-tive changes expanded this to nurses and pharmacistsalbeit initially within a restrictive framework, i.e. amental health nurse (MHN) could only prescribe medi-cines listed on a clinical management plan and agreedwith the psychiatrist, nurse and patient (so-calledsupplementary prescribing; Department of Health,2003). Nurses’ prescriptive authority was extended inMay 2006 when the Department of Health declared thatnurses would be able to independently prescribeany licensed medicine for any medical condition withintheir competence (Department of Health, 2006). Thepotential benefits of nurse prescribing include more rapidpatient access to medication, enhanced patient choiceand more efficient provision of services (NPC, 2005). It ishoped that nurse prescribing may foster new ways ofworking for both nurses and doctors. There is interna-tional interest in nurse prescribing as a mechanism forenhancing services with pilot projects in a number ofcountries drawing on lessons learned from the UK(Hughes and Lockyer, 2004).

In the UK attendance at a 26-day training course and aperiod of supervised practice with an experience doctor arethe prerequisites for becoming a registered nurse pre-scriber (NMC, 2003). These training courses are designed toteach a wide group of professional (both nurses andpharmacists) the generic principles of pharmacology,policy and guidelines. Information specific to specialtyareas is not included and is expected to be acquired inpractice. Consequently, an MHN can prescribe psycho-tropic medication without receiving specific formal train-ing in its use (Skingsley et al., 2006) as there is nomandatory requirement for training courses to includedetailed input on psychotropic medication. Nationallythere is considerable variation in how the implementationof MHN prescribing is being supported (NPC, 2005). Someservice providers have provided MHN prescribers withconsiderable additional support to develop their prescrib-ing competence for example through additional training inpsychopharmacology and mentorship programmes (Jonesand Jones, 2008).

Nurse prescribing in mental health settings offersconsiderable potential in terms of new ways of working.There are a several case reports where authors havedescribed the implementation of MHN prescribing, oftenas a new way of working, in a variety of clinical settingswith generally positive findings. For example a case studyreport by Jones and Jones (2008) observed how MHNprescribing in an inpatient setting facilitated a morepatient centered way of working enabling a patient withbipolar disorder to make a more shared choice about theirtreatment. A qualitative study by Jones et al. (2007)explored 11 patients’ experiences of having medicationprescribed by a MHN. Patients reported that MHN

prescribers listened more (than psychiatrists) to theirconcerns and worries and provided them with moreeducation about their medication choices.

To date there are in excess of 400 qualified MHNprescribers in the UK but uptake has been slower than wasinitially anticipated. Some authors have suggested thatone of the main barriers for implementation is unsup-portive behaviour of psychiatrists (Norman et al., 2007).The medical profession has expressed grave concernsabout the safety of nurse prescribing (Avery and Pringle,2005) and it has even been suggested that such practice is‘absolute idiocy’ (Montgomery, 2005). To date no studyhas investigated the attitudes and perspectives ofpsychiatrists and compared them with those of MHNswith regard to mental health nurse prescribing ofpsychotropic medication.

2. Method

2.1. Design

This study entailed a cross-sectional quantitativequestionnaire study of psychiatrists and MHNs in twolarge NHS mental health trusts in South-East England.

2.2. Participants

Participants were sampled from predetermined clinicalstaff lists held at the two trusts namely, the South Londonand Maudsley NHS Foundation Trust and the Oxleas NHSFoundation Trust. A random sample of 299 nurses and 294doctors from each list was identified, representingapproximately 15% of the nursing and 75% of the medicalworkforce across the two trusts.

2.3. Questionnaire

A newly designed questionnaire was created for thisstudy [see Table 3 for items]. Initially, an item pool wascreated by the authors (based, in part, on the literature),together with nine local psychiatrists and six local MHNs,using a brainstorming technique for the phrase ‘‘pre-scribing of psychotropic medication by mental healthnurses’’. Commonly occurring and overlapping themeswere combined to avoid repetition. The questions weredesigned to be generic to cover both supplementary (avoluntary prescribing partnership between the indepen-dent prescriber and a supplementary prescriber, toimplement an agreed patient-specific clinical manage-ment plan with the patient’s agreement) and indepen-dent prescribing (a practitioner responsible for theassessment of patients with undiagnosed or diagnosedconditions and for decision about the clinical manage-ment required, including prescribing). 65 items wereidentified and adapted into statements to create sevensubscales:

(a) G

eneral beliefs (16 items), e.g. ‘In reality, mental healthnurse prescribing will never work’;

(b) Im

pact (22 items), e.g. ‘Mental health nurse prescribingwill . . . Make services more complex’;

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–1474 1469

(c) U

ses (9 items), e.g. ‘Mental health nurse prescribingwill be particularly useful in . . . Acute inpatient wards(out of normal working hours)’;

(d) C

linical responsibility (5 items), e.g. ‘Under a mentalhealth nurse prescribing agreement . . . If a mentalhealth nurse prescribes a medication the consultantpsychiatrist should have ultimate clinical responsi-bility for this’;

(e) L

egal responsibility (4 items), e.g. ‘A prescribing errormade by a mental health nurse should have thefollowing legal implications . . . Only the consultantpsychiatrist may be sued’;

(f) T

raining (7 items), e.g. ‘Prescribing training for mentalhealth nurses should include both theory and clinicalapplication of . . . Prescribing for co-morbid medicaldisorders’;

(g) S

upervision (2 items), e.g. Mental health nurses shouldreceive prescribing supervision from . . . A mentalhealth nurse’.

Items were scored on a 6-point likert scale (stronglydisagree 1, disagree 2, vaguely disagree 3, vaguely agree 4,agree 5, strongly agree 6). Statements were positively andnegatively worded to avoid response set bias. Duringanalysis, scores were reversed as appropriate. Questionspertaining to basic demographic data (sex, age, ethnicity,country and year main psychiatric qualification obtained,years of experience in psychiatry, and clinical speciality)were included. MHNs were also asked to clarify if theywere already mental health nurse prescribers and, if not, ifthey would like to become one.

2.4. Procedure

The participants received an information sheet, thepostal questionnaire and a stamped reply envelope. After 8weeks all non-responders were sent a repeat copy. After afurther 4 weeks the remaining non-responders were sent athird copy. Thereafter, telephone contact was establishedwith non-responders up to a maximum of three times. Datacollection was conducted between October 2006 and March2007. Local ethical approval was obtained for both studysites and research governance procedures were adhered to.

Fig. 1. Professional group comparis

2.5. Analysis

Anonymised data were analysed using the SPSScomputer statistical package (version 15). Simple pro-portions were calculated for individual items.Summary scores for the seven subscales were calculated,reversing scores for negatively worded items [asdetailed in Table 3], and converted into percentage valuesto allow for some missing data on individual items.High scores indicate more positive attitudes for subscalesA–C, F and G. Lower scores indicate more positiveattitudes for subscales D and E regarding clinical andlegal responsibility, respectively. Cronbach’s a values andPearson’s correlation analyses were conducted for thesubscales. Mean subscale scores and mean individual itemscores were compared according to the two mainprofessional groups. As the multiple testing of individualitems in the study is a potential concern, only p valuesp < 0.001 should be considered statistically significant inTable 3.

3. Results

3.1. Response rates and demographic data

From the potential participants identified, 82 psy-chiatrists and 34 MHNs were excluded from thedenominator due to out-of-date and hence incorrectcontact details (e.g. retirement, change of address),resulting in a potential sample size of 212 psychiatristsand 265 MHNs. 82 (38%) psychiatrists and 119(45%) MHNs returned completed questionnaires withmost or all of the likert scales answered. Comparedto psychiatrists, the sample of MHNs were significantly:(i) more likely to be female (57% vs. 37%); (ii) less likelyto be of white ethnicity (46% vs. 54%); (iii) less likely tobe working in general adult psychiatry (36% vs. 53%);(iv) more likely to have obtained their main psychiatricqualification in the United Kingdom or Eire (98% vs. 83%).For both professional groups, the most common agegroup was 40–49 years and the mean number of yearsof psychiatric experience was 15.6 years for MHNsand 14.7 years for psychiatrists (p = 0.468) [seeTable 1]. Six nurses were already MHN prescribers and

ons for the seven subscales.

Table 1

Sample characteristics.

Mental health nurses (N = 119) Psychiatrists (N = 82) Total (N = 201) x2-test p-Value

N % N % N %

Gender

Male 41 34.5 49 59.8 90 44.8

Female 68 57.1 30 36.5 98 48.8 12.84 0.002

Unspecified 10 8.4 3 3.7 13 6.4

Age group

�29 years 7 5.9 7 8.5 14 7.0

30–39 years 30 25.2 24 29.3 54 26.8

40–49 years 48 40.4 26 31.7 74 36.8 1.88 0.758

50+ years 33 27.7 24 29.3 57 28.4

Unspecified 1 0.8 1 1.2 2 1.0

Ethnicity

White 55 46.2 54 65.8 109 54.3

Asian or Asian British 8 6.7 8 9.8 16 4.5

Black or Black British 37 31.1 8 9.8 45 8.0 18.07 0.003

Mixed 3 2.5 6 7.3 9 22.4

Chinese or other ethnic group 10 8.5 4 4.9 14 7.0

Unspecified 6 5.0 2 2.4 8 4.0

Clinical speciality

General adult 43 36.1 43 52.5 86 42.8 26.31 < 0.001

Other 41 34.5 38 46.3 79 39.3

Unspecified 35 29.4 1 1.2 36 17.9

Country of psychiatric qualification

UK/Eire 117 98.4 68 83.0 185 92.0

Other 1 0.8 7 8.5 8 4.0 15.70 <0.001

Unspecified 1 0.8 7 8.5 8 4.0

Nurses only

Mental health nurse prescribers 6 5.0 – – – – – –

Would like to be one 79 66.4 – – – – – –

Would not like to be one 31 26.1 – – – – – –

Unspecified 3 2.5 – – – – – –

Years of psychiatric clinical experience Mean 15.6 SD 9.7 Mean 14.7 SD 8.3 Mean 15.2 SD 9.2 t = 0.73 p = 0.468

Table 2

Subscale correlation matrix (total sample).

A: general beliefs B: impact C: uses D: clinical

responsibility

E: legal

responsibility

F: training

B: impact r = 0.77 p < 0.001

C: uses r = 0.58 p < 0.001 r = 0.59 p < 0.001

D: clinical

responsibility

r = �0.21 p = 0.003 r = �0.26 p < 0.001 r = �0.15 p = 0.037

E: legal

responsibility

r = 0.05 p = 0.452 r = 0.06 p = 0.366 r = �0.06 p = 0.405 r = 0.23 p = 0.001

F: training r = 0.08 p = 0.246 r = 0.02 p = 0.821 r = �0.01 p = 0.896 r = 0.05 p = 0.451 r = 0.05 p = 0.441

G: supervision r = 0.19 p = 0.006 r = 0.20 p = 0.004 r = 0.28 p < 0.001 r = �0.01 p = 0.983 r = �0.05 p = 0.489 r = 0.09 p = 0.217

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–14741470

70% of the remainder (79/113) would have liked tobecome a prescriber.

3.2. Subscales

3.2.1. Total sample

Internal reliability Cronbach’s a values were above0.7 for five subscales (A: 0.75, B: 0.87, C: 0.88, F: 0.81, G:0.76) and were low for the subscales on clinical andlegal responsibility (D: 0.14, E: 0.19). Moderatelystrong positive correlations were detected between sub-scales A–C using Pearson’s correlation [see Table 2]. Other

correlations between the subscales were weak indicatingthat the subscales do not have significant overlap.

3.2.2. Group differences

Psychiatrists had significantly lower scores, withless favourable attitudes than MHNs, on subscalesregarding general beliefs (A, 63% vs. 70%), impact(B, 62% vs. 70%), and uses (C, 60% vs. 71%) [see Fig. 1].Psychiatrists scored significantly more highly, againwith less favourable attitudes than MHNs, onsubscales regarding clinical responsibility (D, 69%vs. 62%) and legal responsibility (E, 71% vs. 64%). Psychia-

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–1474 1471

trists and MHNs agreed on issues detailed insubscales regarding training (F) and supervision (G).

3.3. Individual items

See Table 3 for analyses of the individual items. Mostagreed that: (i) in theory, MHN prescribing was a good idea(MHNs 92%, psychiatrists 74%); (ii) patients will readilyaccept MHN prescribing (73%, 62%); (iii) MHN prescribingwould enhance nurse/patient relationships (84%, 61%); (iv)MHN prescribing will improve patient access to medica-tion (85%, 73%); (vi) MHN prescribing will be useful incommunity mental health team bases (92%, 78%).

Table 3

Individual items on attitudes to mental health nurse prescribing.

Subscale and item

Subscale A: general beliefs

In theory, mental health nurse prescribing is a good idea

I have concerns about the clinical safety of mental health nurse prescribing

Mental health nurse prescribing has an increasingly favourable evidence bas

Psychiatrist prescribing is more cost effective than mental

health nurse prescribing (R)

NHS Trusts should have a specific policy on mental health nurse prescribing

In reality, mental health nurse prescribing will never work (R)

In general, mental health nurses are not interested in prescribing medication

Patients will readily accept mental health nurse prescribing

Patients will be less satisfied with mental health nurse prescribing than

psychiatrist prescribing (R)

Mental health nurse prescribing will create conflict in clinical teams (R)

Appropriately trained mental health nurses should be able to prescribe any

medication listed in the BNF

Nurses of any grade should be eligible to be trained as prescribers

Only mental health nurses that have a demonstrable understanding of

psychopharmacology should be eligible to be trained as prescribers

Mental health nurses should pay for prescribing training (approximately

£3000) and not the NHS (R)

The prescribing competencies of mental health nurses should be formally

assessed at the end of core training by a consultant psychiatrist

Psychiatrists do not need any additional training in order to supervise a

mental health nurse prescribers (R)

Subscale B: impact

(mental health nurse prescribing will. . .)

Increase respect for mental health nurses by other health professionals

Decrease nurses’ job satisfaction (R)

Increase nurses’ autonomy

Enhance continuity of care

Increase nurses’ workload (R)

Increase nurses’ responsibility

Make more efficient use of nurses’ time

Decrease available time for psychosocial interventions (R)

Increase nurses’ levels of anxiety (R)

Decrease nurses’ confidence in their overall ability to practice (R)

Be readily accepted by psychiatrists

Decrease nurses’ levels of stress

Make patient care worse (R)

Enhance nurse/patient relationships

Improve patient access to medication

Reduce patient medication adherence (R)

Make services more complex (R)

Impair nurse/patient communication (R)

Increase need for adequate nurse/psychiatrist communication

Make psychiatrists feel threatened (R)

Decrease psychiatrists’ autonomy (R)

Be readily accepted by mental health nurses

More MHNs than psychiatrists believed that for mentalhealth nurse prescribing: (i) this would enhance continuityof care (98% vs. 60%); (ii) this would be useful in prescribingintravenous medication in emergency situations (54% vs.27%); (iii) training should include prescribing for co-morbidmedical disorders (91% vs. 75%); (iv) the consultantpsychiatrist should have ultimate clinical responsibilityfor prescribing by an MHN (42% vs. 28%). Approximately halfof all participants agreed nurse prescribing would createconflict in clinical teams and 61% of psychiatrists believethat MHN prescribing will make services more complex. Animportant minority of both professional groups think that inreality MHN prescribing will never work (17% vs. 13%).

Psychiatrists Mental health

nurses

t-Test p-Value

Agree % Mean Agree % Mean

74.4 4.23 92.4 4.92 �3.65 <0.001

(R) 78.0 4.40 55.5 3.45 4.99 <0.001

e 49.3 3.41 84.1 4.27 �5.33 <0.001

40.5 3.36 32.5 2.94 2.14 0.034

97.5 5.41 94.1 5.37 0.30 0.765

17.3 2.40 12.8 2.09 1.75 0.081

(R) 30.8 3.13 24.8 2.68 2.31 0.022

61.2 3.64 73.3 4.06 �2.27 0.024

55.6 3.83 42.7 3.27 2.89 0.004

51.9 3.58 55.1 3.46 0.60 0.552

16.0 1.98 48.3 3.45 �6.50 <0.001

1.2 1.43 14.5 2.03 �4.01 <0.001

91.4 5.10 79.5 4.60 2.54 0.012

11.0 2.18 4.2 1.37 4.75 <0.001

79.0 4.47 71.2 4.21 1.14 0.257

25.6 2.76 31.4 2.92 �0.81 0.418

64.6 3.80 83.1 4.43 �3.42 0.001

10.0 2.41 11.9 2.22 1.32 0.190

84.0 4.37 79.7 4.93 �3.58 <0.001

60.0 3.60 97.5 4.99 �7.87 <0.001

82.7 4.49 85.5 4.72 �1.28 0.201

95.1 5.10 98.3 5.36 �1.99 0.048

58.0 3.52 70.9 4.03 �2.65 0.009

63.3 3.97 40.7 3.23 3.54 <0.001

79.3 4.44 56.4 3.58 4.57 <0.001

20.7 2.61 13.8 2.18 2.60 0.010

28.0 2.72 34.2 2.88 �0.90 0.367

6.1 2.22 19.5 2.62 �2.87 0.005

25.9 2.89 12.0 2.04 4.56 <0.001

61.2 3.55 83.6 4.50 �5.77 <0.001

73.2 4.04 84.7 4.64 �3.32 0.001

14.1 2.58 23.5 2.59 �0.08 0.936

60.5 3.90 25.4 2.75 5.76 <0.001

17.3 2.78 12.7 2.31 2.74 0.007

95.1 5.04 85.5 4.63 2.67 0.008

64.2 3.64 49.2 3.45 0.91 0.366

42.7 3.11 31.4 2.75 1.67 0.096

59.3 3.56 68.6 4.04 �2.89 0.004

Subscale and item Drs. Nurse

Agree % Mean Agree % Mean t-Test p-Value

Subscale C: uses

(mental health nurse prescribing will be particularly useful in. . .)

Acute inpatient wards (during normal working hours) 35.4 2.79 63.2 3.86 �5.20 <0.001

Medication for rapid tranquilisation (excluding intravenous medications) 36.6 2.89 82.1 4.36 �7.13 <0.001

Substance use clinic (e.g. methadone) 75.3 4.05 79.3 4.28 �1.18 0.241

Community mental health team bases 78.0 4.10 91.6 4.84 �4.38 <0.001

Home treatment teams 79.3 4.30 89.9 4.73 �2.27 0.025

Clozapine clinics 63.0 3.77 76.3 4.08 �1.49 0.137

Depot clinics 71.6 4.14 79.8 4.24 �0.49 0.623

Acute inpatient wards (out of normal working hours) 67.9 3.77 89.1 4.68 �4.54 <0.001

Intravenous medication in emergency situations 26.8 2.40 54.2 3.42 �4.47 <0.001

Subscale D: clinical responsibility

(under a mental health nurse prescribing agreement. . .)

Consultant psychiatrists should not be solely responsible for the overall

clinical management of patient care and treatment

63.0 3.93 63.0 3.66 1.13 0.258

Psychiatrists (and not mental health nurses) should continue to be

responsible for making clinical diagnoses

87.8 4.95 72.3 4.29 3.58 <0.001

Mental health nurses should be solely responsible for the monitoring

of all side effects from psychotropic medication (R)

13.4 2.34 29.4 2.91 �2.94 0.004

Psychiatrists should be solely responsible for the clinical management

of identified side effects (R)

20.7 2.66 26.9 2.88 �1.12 0.263

If a mental health nurse prescribes a medication the consultant

psychiatrist should have ultimate clinical responsibility for this (R)

28.4 2.60 42.0 3.41 �3.59 <0.001

Subscale E: legal responsibility

(a prescribing error made by a mental health nurse should have the following legal implications. . .)

Only the consultant psychiatrist may be sued (R) 2.4 1.48 10.3 2.04 �3.69 <0.001

Prescribing errors by nurses will be dealt with more punitively than

those by psychiatrists (R)

13.7 2.10 30.2 2.67 �2.87 0.005

Only the mental health nurse may be sued 35.8 3.09 23.9 2.50 2.70 0.008

Both the mental health nurse and the consultant psychiatrist may be sued 53.1 3.40 62.2 3.63 �1.05 0.295

Subscale F: training

(prescribing training for mental health nurses should include both theory and clinical application of. . .)

Drug/drug interactions (between psychotropics and other medicines) 100 5.65 99.2 5.56 0.92 0.361

Pharmacokinetics (psychotropic medicines) 98.8 5.50 99.2 5.53 �0.26 0.793

Drug/drug interactions (between two or more psychotropics) 100 5.63 100 5.56 0.89 0.377

Pharmacodynamics (psychotropic medicines) 100 5.49 100 5.51 �0.27 0.788

Side effect profiles (psychotropic medicines) 100 5.70 100 5.59 1.34 0.179

Drug allergies (general and psychotropic medicines) 100 5.62 96.4 5.51 1.10 0.272

Prescribing for co-morbid medical disorders 74.4 4.50 90.8 5.21 �3.42 0.001

Section G: supervision

(mental health nurses should receive prescribing supervision from. . .)

A consultant psychiatrist 97.5 5.26 95.0 5.27 �0.07 0.942

A mental health nurse 54.5 3.29 60.2 3.58 �1.15 0.254

Table 3 (Continued)

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–14741472

4. Discussion

Overall both professional groups were in favour of andhad positive beliefs about mental health nurse prescribing.General beliefs, impact and uses were inter-relatedconstructs as evidenced by high correlation co-efficients.In comparison to MHNs, psychiatrists had less favourableattitudes across five of the seven sub-scales.

4.1. General beliefs and impact

Approximately two thirds of both groups believed thatpatients would readily accept MHN prescribing. This isconsistent with the expressed aim of nurse prescribingwhich is to provide patients with more cohesive andcomprehensive access to medicines (NPC, 2005; Nolan andBradley, 2007). However, 61% of psychiatrists believe thatMHN prescribing will make services more complex and

proportionately fewer psychiatrists than nurses think thatit will enhance continuity of care. There is limited UKevidence to suggest patient preference for MHN prescrib-ing (Jones et al., 2007), evidence of a beneficial effect onservice delivery come from the United States wherepsychiatric nurses first receive full general nursing training(Nolan et al., 2004; Snowden, 2006). This lack of definitiveevidence for the assertion that nurse prescribing isbeneficial for service delivery may be the reason why halfof psychiatrists disagreed with the notion that ‘‘MHNprescribing has an increasingly favourable evidence base’’.

Only a minority of both groups think that in realitymental health nurse prescribing will never work; perhapsimplying that a majority believe it will. In their qualitativeevaluation of nurse prescribing Jones et al. (2007) reportedgenerally positive experiences from patients, nurses andpsychiatrists. Yet, according to the published data, to daterelatively few mental health nurses have trained as

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–1474 1473

prescribers in the UK (Gray et al., 2005). We specificallysought to sample nurses who were not all already qualifiedfor prescribing, unlike previous studies, and found that themajority wanted to become prescribers. We observed that,perhaps, mental health nurses need to be convinced of thebenefits for themselves, the profession and their patientsof taking on a prescribing role. Perhaps if they are, thepositive attitude towards prescribing we observed will betranslated into increased numbers taking on the role.

4.2. Use and suitable settings

Participants reported that MHN prescribing would beappropriate in a number of outpatient clinical settingsincluding CMHTs, clozapine clinics, depot clinics, andhome treatment services. That MHN prescribing is mostlikely to be useful in community settings has been notedpreviously (Gray et al., 2005). Furthermore, MHN pre-scribing may lead to improvement of the negativeperceptions held by some nurses regarding the role ofdepot administration, particularly if the nurse adminis-trating the depot also prescribed it (Patel et al., 2005).

In acute inpatient ward settings stark differences wereevident between the professionals groups, in that propor-tionately more nurses than psychiatrists endorsed the useof MHN prescribing in that setting and for rapidtranquilisation including the use of intravenous medica-tion in emergency situations. This observation may beexplained by the different clinical experiences of psychia-trists and nurses working in acute units. Psychiatrists, forexample, may perceive that nurse prescribing is notbeneficial because there is medical cover 24 h a day.MHNs on the other hand may perceive that having a nurseprescriber on the unit would mean that medicines can beprescribed quickly and in response to emerging clinicalneed. The positive responses of MHNs to the prescribing ofmedicines for rapid tranquillisation by nurses may beexplained by a perception that it will enable them to takemore effective and timely control of difficult and stressfulsituations where both patients and staff are at risk.Psychiatrists do not appear to share this view; eitherbecause they do not recognise the potential benefits orbecause they are concerned about the competence ofMHNs to prescribe safely and effectively in the emergencysituation. Either way, rapid tranquillisation protocols willneed to be reconsidered to allow for mental health nurseprescribing (McAllister-Williams and Ferrier, 2002).

4.3. Responsibility

With any change in service delivery, health profes-sionals inevitably consider the potential impact on theirown professional role (Kendall, 2000). It is thereforeunsurprising that criticisms arising from doctors’ concernsare seen to be due to nurses being perceived as‘‘encroaching on their traditional territory’’ (Avery andJames, 2007). Jones (2006) conducted focus group studiesof nurses and psychiatrists regarding supplementaryprescribing and noted concerns about nurse prescribingbeing one method by which control can be exerted by thenursing profession over junior or even consultant psy-

chiatrists. However, the presumed competition betweenprofessional groups (Hutschemaekers et al., 2005), regard-ing their respective roles, is not as evident as might beexpected as we note that significantly more MHNs thanpsychiatrists felt that even when a MHN prescribes amedication, it is the consultant psychiatrist who shouldhave ultimate clinical responsibility. Alternatively it maybe that there is a reluctance to assume full responsibilitywhilst developing their prescribing knowledge and com-petence. Bradley et al. (2007) found that nurse prescribersare initially very cautious when developing their prescrib-ing roles. If this is the case then the provision of continuingeducation and support will be important in sustainingprescribing in practice. With changes to the Mental HealthAct in England and Wales, nurses will be able to take on therole of Responsible Clinician (replacing the formerResponsible Medical Officer). This would allow forenhanced autonomous working for MHNs and yet theirreluctance to assume full responsibility for medicationprescribing would limit this.

4.4. Training

Almost all of the participants, both psychiatrists andMHNs, believed that training courses for MHN prescribingshould include details regarding psychotropic medicationsand pharmacokinetics, pharmacodynamics, drug interac-tions and side effects. Interestingly, significantly fewerpsychiatrists than MHNs felt that these courses shouldinclude detail on prescribing for co-morbid medicaldisorders. MHNs who have attended a prescribing coursehave also previously self-identified the need for asubsequent top-up course (Gray et al., 2005). This wouldprovide more specific information about drugs used inmental health, such as the one developed by Skingsleyet al. (2006). Of course, even with top up courses, there isno guarantee that MHNs trained for prescribing with thenutilise their training in practice. However, it should also behighlighted that it is prescribing in practice that appears toprepare MHNs most for their prescribing roles (Jones et al.,2007). In practice this might also be said to be true forjunior doctors, yet they are required to undergo muchmore theoretical training during undergraduate medicaldegree courses. More psychiatrists than MHNs felt thatprescribing courses should be paid for by MHNs them-selves. However, it is anticipated by some that educationregarding prescribing may eventually become moreintegrated with advanced nursing practice development(Avery and James, 2007).

4.5. Limitations

These include the response rate and the use of aquestionnaire that has yet to validated, although the detailwithin the questionnaire has obvious relevance to the aimsthe study and to clinical practice. The response rates werelower than anticipated for the method used and potentialreasons for this might include that a significant proportionof both disciplines have no knowledge or experience ofnurse prescribing or may lack any interest in the subject.This may have resulted in bias with more similarities

M.X. Patel et al. / International Journal of Nursing Studies 46 (2009) 1467–14741474

between the groups than would otherwise be expected.That said, this was the first large in-depth exploration andcomparison of the attitudes and perspectives of MHNs andpsychiatrists. It is a further strength of this study that thesample was of MHNs and not a self-selecting sample orpurposive sample of those undertaking a prescribing role.Thus few respondents would have any direct experience ofworking alongside MHN prescribers which makes theresults of this study more generalisable than they mightotherwise be. This study measures attitudes and perspec-tives rather than actual impact (Snowden, 2006). Furtherwe did not specifically check participant’s knowledgeregarding what MHNs are and are not allowed to prescribeand under what circumstances. This was because we wereprimarily interested in attitudes and beliefs and not levelsof knowledge which we suspected might be minimal. Asparticipants were sampled from South East England thisshould be considered when interpreting the findings of ourstudy.

5. Conclusions

The majority of both groups were in favour of mentalhealth nurse prescribing, although significantly morepsychiatrists expressed concerns. This may be explainedby a perceived change in power balance. Psychiatrists inparticular were concerned with aspects of clinical and legalresponsibility and the appropriate setting for use. Futureobservational research of MHNs’ and psychiatrists’ knowl-edge about and attitudes towards psychotropic medicineswould be informative and guide training to ensureprescribing competence. Further exploration of the orga-nisational barriers and potential solutions for implement-ing MHN prescribing would inform service providers in theUK and internationally. These should specifically considerthe differences in professional roles between mentalhealth nurses and psychiatrists and clarify aspects ofclinical and legal responsibility.

Acknowledgements

With grateful thanks to all participants and to thoseinvolved in the brainstorming stage of designing the newquestionnaire.

Contribution: MXP and RG designed and conducted thestudy, analysed and interpreted the findings and draftedthe article. DR conducted the study, interpreted thefindings and revised the article. JR, NR, TM and DBconducted the study. MXP and RG take responsibility forthe integrity of the data and the accuracy of the analysis.All authors gave final approval of the version to bepublished.

Conflict of interest

MXP has received consultation fees from the Janssen-Cilag, Eli-Lilly and Wyeth and has previously worked ontwo clinical drug trials for Janssen-Cilag. RG has receivedconsultation fees from Astra-Zeneca, BMS, Janssen-Cilag,

Otsuka, Eli Lilly and Wyeth. RG also joint chaired theNational Institute for Mental Health review of mentalhealth nurse prescribing. DR has received consultation feesfrom Astra-Zeneca, Janssen-Cilag and Eli Lilly. DB hasreceived consultation fees from Janssen-Cilag and Eli Lilly.

Funding

Own account.

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