Documente Academic
Documente Profesional
Documente Cultură
METHODS
I am lot more confident, because I have been doing it for a little who demonstrated inadequate knowledge of a medication
while now. I feel confident in my assessment skills and clinical they frequently initiate, there are also nurses whose knowl-
judgment what’s appropriate for analgesia, rather someone to tell edge exceeds their nurse-initiating capability. Nurses whose
me what’s required. (Interview 13) willingness and the ability to nurse-initiate was mediated by
awareness of their scope of practice and patients’ needs
Nurses also tend to nurse-initiate simple analgesics when
rather than knowledge solely. Additionally, blind prescrib-
they first started:
ing was negated by their inclination to safety and informa-
I give more drugs now, because I know a little bit more. I under- tion-seeking behaviour through the use of reference
stand a bit better and how it works due to confidence and experi- materials during uncertainty, by seeking workplace assis-
ence. (Interview 16) tance from medical officers and other senior nursing staff
and actively participating in ongoing education and train-
The apprehension was also felt by the less-experienced
ing.
nurses. Their responses indicated that confidence can
To date, there have been no studies that investigated the
increase with experience and appropriate support:
context of decision-making related to nurse-initiating in the
Obviously I am a lot more confident, in my own nursing abilities; ED; however, there are similar studies (Luker & Kenrick
obviously I still got a lot to learn but I think you get used to get to 1992, Luker 1998, Bradley et al. 2007, Offredy et al. 2008,
know what requirements and what medication to probably give a Daughtry & Hayter 2010) that evaluated the topic mainly
patient for certain pain levels for example. And that is going to in community settings. Published during the advent of nurse
come with practice still even now I’d still question myself as to prescribing in the UK, one study emphasized how lack of
which analgesia would be better and sometimes I’d talk to someone knowledge and confidence incited anxiety, which in a way
else but as you kind of get a bit more confident and you get more impeded the practice (Luker 1998). This finding was
experience you wouldn’t need to do it as much. (Interview 24) repeated in this study, where nurses initially held reserva-
tions towards nurse-initiating and understandably so when
The familiarity of patients’ conditions, which is corre-
the foreign practice is inherent with accountability and
lated with experience, influenced confidence and practice:
responsibility. However, knowledge and confidence do not
Confidence is something that builds up knowing the patient’s con- remain stagnant; they improve with time as also previously
dition, knowing how to intervene and the awareness of what to reported by prescribing nurses (While & Biggs 2004, Brad-
anticipate. (Interview 22) ley et al. 2007). Moreover, Luker and Kenrick (1992) high-
lighted that decisions of community nurses’ were mainly
influenced by experiential knowledge sourced personally or
Discussion
from colleagues. Similarly, Offredy et al. (2008) discussed
The results suggest that nurses’ medication knowledge, to a that pharmacological knowledge of nurse prescribers was
small extent, is determined by how often a medication is insufficient and often intuition was relied on, which was
nurse-initiated and their perception of the importance of labelled ‘potentially problematic’ (p 825). However, our
certain pharmacological components. Many studies findings are in disagreement with the latter study because
described nurses’ medication knowledge as somewhat lack- while nurses’ knowledge when assessed may be incomplete,
ing for practice (Markowitz et al. 1981, Boggs et al. 1988, it is not implicit that knowledge is not pursued when
Sodha et al. 2002, Ndosi & Newell 2009, Simonsen et al. required. For example, nurses routinely consult with the
2011). The overall data denote that although knowledge available resources to attain the knowledge necessary to
deficit is apparent when tested, nursing staff are aware of safely nurse-initiate a drug.
their own limitations and act in a manner to provide safe The context of nurses’ decision-making when nurse-initi-
care. ating is multifactorial and complex (Latter & Courtenay
Blind prescribing can only exist when a prescriber exhi- 2004); hence, it cannot be explained solely by cognitive rea-
bits willingness to prescribe despite being ill-equipped with soning theories such as analytical or intuitive theories (Muir
knowledge and the deficiency of information-seeking beha- 2004, Banning 2008) as previous studies have done (Luker
viours when warranted (Starmer et al. 2013). A small per- & Kenrick 1992, Offredy et al. 2008). Rather, nurse-initiat-
centage of nurses showed evidence of blind prescribing. ing practices should be explained by predictive behavioural
There was no evidence of the widespread blind prescribing theories (Godin et al. 2008), such as theory of planned
previously shown in Starmer et al.’s (2013) study in junior behaviour (Ajzen 1991). The theory of planned behaviour
doctors. While there are a very small proportion of nurses explains that a behaviour, in this case, nurse-initiating
Manias E. & Bullock S. (2002) The educational preparation of Rupp T. & Delaney K.A. (2004) Inadequate analgesia in emergency
undergraduate nursing students in pharmacology: perceptions medicine. Annals of Emergency Medicine 43, 494–503.
and experiences of lecturers and students. International Journal Sampson F., Goodacre S. & O’cathain A. (2014) Interventions to
of Nursing Studies 39, 757–769. improve the management of pain in emergency departments:
Markowitz J.S., Pearson G., Loewenstein R. & Kay B.G. (1981) systematic review and narrative synthesis. Emergency Medicine
Nurses, physicians and pharmacists: their knowledge of hazards Journal 31, e9–e18.
of medications. Nursing Research 30, 366–370. Shaban R.Z., Holzhauser K., Gillespie K., Huckson S. & Bennetts
Milton C.L. (2012) Altruism. Nursing Science Quarterly 25, S. (2012) Characteristics of effective interventions supporting
222–224. quality pain management in Australian emergency departments:
Morrison-Griffiths S., Snowden M.A. & Pirmohamed M. (2002) an exploratory study. Australasian Emergency Nursing Journal
Pre-registration nurse education in pharmacology: is it adequate 15, 23–30.
for the roles that nurses are expected to fulfil? Nurse Education Simonsen B.O., Johansson I., Daehlin G.K., Osvik L.M. & Farup
Today 22, 447–456. P.G. (2011) Medication knowledge, certainty and risk of errors
Morse J.M. (2015) Data were saturated. Qualitative Health in health care: a cross-sectional study. BMC Health Services
Research 25, 587–588. Research 11, 175.
Muir N. (2004) Clinical decision-making: theory and practice. Sodha M., Mclaughlin M., Williams G. & Dhillon S. (2002)
Nursing Standard 18, 47–52. Nurses’ confidence and pharmacological knowledge: a study.
Muntlin A., Carlsson M., S€afwenberg U. & Gunningberg L. (2011) British Journal of Community Nursing 7, 309–315.
Outcomes of a nurse-initiated intravenous analgesic protocol for Starmer K., Sinnott M., Shaban R., Donegan E. & Kapitzke D.
abdominal pain in an emergency department: a quasi-experimental (2013) Blind prescribing: a study of junior doctors’ prescribing
study. International Journal of Nursing Studies 48, 13–23. preparedness in an Australian emergency department. Emergency
National Health Workforce Planning and Research Collaboration Medicine Australasia 25, 147–153.
(2010) Non-medical Prescribing: An Exploration of Likely Todd K.H., Sloan E.P., Chen C., Eder S. & Wamstad K. (2002)
Nature of and Contingencies for, Developing A Nationally Survey of pain etiology, management practices and patient
Consistent Approach to Prescribing by Non-medical Health satisfaction in two urban emergency departments. Canadian
Professionals. National Health Workforce Taskforce. Journal of Emergency Medicine 4, 252–256.
National Institute of Clinical Studies (2004) National Emergency Todd K. H., Ducharme J., Choiniere M., Crandall C. S., Fosnocht
Department Collaborative Report. NICS, Melbournce. D. E., Homel P., Tanabe P. & Group P. S. (2007) Pain in the
Ndosi M.E. & Newell R. (2009) Nurses’ knowledge of emergency department: results of the pain and emergency
pharmacology behind drugs they commonly administer. Journal medicine initiative (PEMI) multicenter study. The Journal of Pain
of Clinical Nursing 18, 570–580. 8, 460–466.
Offredy M., Kendall S. & Goodman C. (2008) The use of Von Dietze E. & Orb A. (2000) Compassionate care: a moral
cognitive continuum theory and patient scenarios to explore dimension of nursing*. Nursing Inquiry 7, 166–174.
nurse prescribers’ pharmacological knowledge and decision- While A.E. & Biggs K.S. (2004) Benefits and challenges of nurse
making. International Journal of Nursing Studies 45, 855–868. prescribing. Journal of Advanced Nursing 45, 559–567.
Plonczynski D., Oldenburg N. & Buck M. (2003) The past, present Wilson J.E. & Pendleton J.M. (1989) Oligoanalgesia in the
and future of nurse prescribing in the United States. Nurse emergency department. The American Journal of Emergency
Prescribing 1, 170–174. Medicine 7, 620–623.
Queensland Government. Nursing Act 1992 (Act No. 55 of 1992). Wong E.M., Chan H.M., Rainer T.H. & Ying C.S. (2007) The effect
Viewed January 6, 2014. Queensland Government, Brisbane. of a triage pain management protocol for minor musculoskeletal
Queensland Government (1996) Health (Drugs and Poisons) injury patients in a Hong Kong emergency department.
Regulation 1996. Queensland Government, Brisbane, Australia. Australasian Emergency Nursing Journal 10, 64–72.
Viewed January 6, 2014.
Please describe your own nurse-initiating medications practice Age group 21-30 41 369
Do you have any concerns about the nurse-initiating medications 31-40 21 284
practice? 41-50 13 234
Describe the factors that influence your willingness to nurse-initiate 41-60 5 113
medications and how? Qualifications Bachelor of nursing 78 951
Describe your confidence in nurse-initiating medications (university-trained)
What influences your confidence? Bachelor of nursing 2 49
(hospital-trained)
Post-graduate Grad Certificate/Diploma 17 119
qualifications (n = 30) Masters 13 88
Post-registration 0-2 11 48
Data analysis
experience (in years) 3-5 21 183
Quantitative statistical analysis was conducted using IBM 6-10 29 378
11-15 5 87
SPSS Statistics version 23 (IBM Corporation, St Leonards,
16+ 14 304
New South Wales, Australia). Descriptive statistics were NIA/NIM 0-2 18 10
used to present nurses’ characteristics, NIA/NIM frequency experience (in years) 3-5 34 378
and satisfaction. Medication knowledge data were non-nor- 6-10 21 35
mally distributed, therefore Kruskal–Wallis and Mann– 11-15 4 89
16+ 3 83
Whitney U-tests was used to describe associations between
Competency <3 months 7 34
medication knowledge and other variables. Qualitative Inter- last achieved 3-6 months 21 205
view data were analysed using Braun and Clarke’s (2006) >6 months 52 761
thematic analysis technique (Braun & Clarke 2006): (1) data
familiarization; (2) coding; (3) searching for themes; (4)
reviewing themes; (5) defining themes; and (6) final analysis.
Medication knowledge
100·0
90·0
%essential
80·0 narcotics
70·0
60·0
%correct
50·0
endone
40·0
30·0
20·0 %correct
fentanyl
10·0
0·0
N
BN
ss
oA
ns
ns
te
n
ct
os
rin
tio
G
ou
la
tio
tio
M
ffe
ta
ito
C
R
ca
ca
-e
en
on
di
di
de
um
M
In
in
Si
tra
oc
on
D
C
100·0
%essential
90·0 non-narcotics
80·0
70·0 %correct
metocloprami
60·0 de
50·0
%correct
40·0 oxybuprocaine
30·0
0·0
N
BN
ss
oA
ns
ns
te
n
ct
os
rin
io
G
ou
la
io
tio
M
fe
at
D
ito
C
at
R
ef
ca
t
en
c
on
-
di
di
de
um
M
In
in
Si
tra
oc
on
D
C
Figure 2 Top: medication knowledge and importance rating (%Essential) of narcotic medications; Bottom: medication knowledge and
importance rating (%Essential) of non-narcotic medications. GN=Generic name. BN=Brand name. MoA=Mechanism of action.
of blind prescribing, it is not apparent that this is a wide- more likely to nurse-initiate there was no evidence that
spread practice as there are also those who are adequately increased knowledge led to a greater likelihood of
prepared to nurse-initiate but do so less frequently nurse-initiating. Conversely, greater nurse-initiating fre-
(Table 3). In identifying what medications nurses were quency did not translate to increased medication knowledge.
Table 3 The proportion of nurses who possessed adequate medication knowledge in contrast to nurse-initiating frequency.
%(n) who %(n) of nurses
frequently who scored ≥80% in Median Mann–Whitney
Medication nurse-initiate medication knowledge (Range) U-test (F) P value
Oxycodone
Y 70% (56) 80% (64) 5 (3-6) 626 0604
N 30% (24) 20% (16) 5 (2-6)
Metoclopramide
Y 363% (29) 625% (50) 5 (2-6) 6425 0313
N 637% (51) 375% (30) 5 (3-6)
Fentanyl
Y 213% (17) 35% (28) 4 (1-6) 47050 0429
N 787% (63) 65% (52) 4 (0-6)
ADT
Y 63% (5) 525% (42) 6 (4-6) 105 0091
N 937% (75) 475% (38) 5 (0-6)
Oxybuprocaine
Y 25% (2) 275% (22) 45 (4-5) 4550 0309
N 975% (78) 725% (58) 4 (0-6)
get busy. Without the programme, it can mean more wait for
Medication knowledge and NIA/NIM experience
the patient. But if you can nurse-initiate analgesia, patients
A Kruskal–Wallis test showed that there was no statistically
would not have to wait. So yeah it has a place in patient care.
significant association between tested knowledge of any of
(Interview 13)
the nurse-initiated medication and the length of nurse-
initiated experience. The exception to this was oxybupro- Additionally, most nurses aim for patients to be pain-
caine which showed a positive association between years of free. A nurse said this on the issue of nurses’ willingness to
nurse-initiating experience and the knowledge scores nurse-initiate:
(v2(4) = 169, n = 80, P = 0002); however, only two nurses
The transcendent aim [is] to get patients pain-free. No one should
indicate that they would nurse-initiate this medication.
be in pain. (Interview 9)
cues determine the type of drug they require or the inter- then you know it’s accurate. Whereas people would have a differ-
ventions they need to receive: ent opinion and might not be super accurate so it’s best to check it
yourself. But there is no stigma when asking questions. (Interview
You meet your patient, get their history, during that process you
15)
discuss their pain and medications they’ve taken for their pain prior
to ED presentation. Because this can affect what you are going to
give them or whether you need to discuss it with the doctor first. Continuing education
(Interview 3) All nurses found the content of the NIA/NIM education
package adequate because it provides baseline knowledge
Nurses acknowledged that their knowledge of a particu-
necessary for nurse-initiating:
lar medication impacted on the decision-making process.
They stated that they are more inclined to nurse-initiate The package is good, because it runs you through each medication.
medications that they are ‘comfortable’ that they have It gives you criteria that have to be met, before you can nurse-initi-
adequate knowledge of: ate. It gives you guidelines or parameters that you are looking for.
You get enough basic knowledge to feel comfortable in what you
As far as feeling confident, I only give medications that I am confi-
are doing. (Interview 13)
dent giving. One for example is oxybuprocaine. I don’t actually
work in the area that would see eye injuries. I would think twice There were no concerns expressed in terms of reviewing
before giving it, I do know the contraindications for it, but it is the education package and renewing the competency annu-
something I’d be very mindful of giving. (Interview 8) ally. In fact, a few suggested that the competency assess-
ment should be more frequent; however, this was only
Others were also mindful of their professional safety
expressed by nurses who had less than 2 years of experi-
when nurse-initiating:
ence:
I do not want to give something and then to have a side-effect and
NIA/NIM assessment should be more frequent for grads. (Interview
myself look like an idiot . . . to feel like I’ve caused more harm to
23)
this person, not having been safe about administering something
I’m putting my name to. (Interview 19) Some said that frequent assessments are unnecessary and
could be a potential burden. One nurse commented that
However, this is not implicit that nurses will withhold a
this would be an individual preference:
drug when needed, rather nurses routinely ask for a second
opinion from other nurses or doctors prior to nurse-initiat- It’s probably alright yearly, but if you did not use it as frequently
ing, or seek additional information from the readily avail- and it wasn’t as familiar you’d need to do it more, like every six
able resources. This was reported by all participants: months or something. Or if you weren’t feeling confident in doing
things, you’d be needing it more sooner. (Interview 24)
If I was looking at initiating something and wasn’t very certain, I
would approach senior staff or CNCs (clinical nurse consultants) Others have called for stringent mode of assessment as
just to clarify any confusion I had. . . .staff are always amenable to opposed to having it as an open book because of the possi-
questions. (Interview 10) bility that it lends itself to abuse:
Reassurance is often required to ensure that a drug can . . . it is easy to consult another RN. The testing conditions are not
be given safely to patients and also safe for the nurses to very strict, so maybe that’s where there is a downfall? (Interview 1)
give:
Meanwhile, others do not see this as a disadvantage;
And even if I nurse-initiate I’d get the doctor’s opinion first . . . just rather they believe that this is to benefit them.
more for my own safety and patient’s safety. Just to cover myself
really. (Interview 23) Improvement of practice over time
All nurses admitted to some anxiety when they first started
Reassurance is not only sought from colleagues but also
initiating and some had initial reservations towards NIA/
secured from evidence-based sources such as the Monthly
NIM. To some extent, this impacted on the type and the
Index of Medical Specialities (MIMS) or the online learning
number of medications being nurse-initiated initially. How-
package:
ever, with practice and exposure, nurses said that as their
You do ask people, but I think it is best to do your own investiga- confidence and knowledge improved, the number of medi-
tions and go through your own process, like looking up MIMS, cations they nurse-initiate also increased:
I am lot more confident, because I have been doing it for a little who demonstrated inadequate knowledge of a medication
while now. I feel confident in my assessment skills and clinical they frequently initiate, there are also nurses whose knowl-
judgment what’s appropriate for analgesia, rather someone to tell edge exceeds their nurse-initiating capability. Nurses whose
me what’s required. (Interview 13) willingness and the ability to nurse-initiate was mediated by
awareness of their scope of practice and patients’ needs
Nurses also tend to nurse-initiate simple analgesics when
rather than knowledge solely. Additionally, blind prescrib-
they first started:
ing was negated by their inclination to safety and informa-
I give more drugs now, because I know a little bit more. I under- tion-seeking behaviour through the use of reference
stand a bit better and how it works due to confidence and experi- materials during uncertainty, by seeking workplace assis-
ence. (Interview 16) tance from medical officers and other senior nursing staff
and actively participating in ongoing education and train-
The apprehension was also felt by the less-experienced
ing.
nurses. Their responses indicated that confidence can
To date, there have been no studies that investigated the
increase with experience and appropriate support:
context of decision-making related to nurse-initiating in the
Obviously I am a lot more confident, in my own nursing abilities; ED; however, there are similar studies (Luker & Kenrick
obviously I still got a lot to learn but I think you get used to get to 1992, Luker 1998, Bradley et al. 2007, Offredy et al. 2008,
know what requirements and what medication to probably give a Daughtry & Hayter 2010) that evaluated the topic mainly
patient for certain pain levels for example. And that is going to in community settings. Published during the advent of nurse
come with practice still even now I’d still question myself as to prescribing in the UK, one study emphasized how lack of
which analgesia would be better and sometimes I’d talk to someone knowledge and confidence incited anxiety, which in a way
else but as you kind of get a bit more confident and you get more impeded the practice (Luker 1998). This finding was
experience you wouldn’t need to do it as much. (Interview 24) repeated in this study, where nurses initially held reserva-
tions towards nurse-initiating and understandably so when
The familiarity of patients’ conditions, which is corre-
the foreign practice is inherent with accountability and
lated with experience, influenced confidence and practice:
responsibility. However, knowledge and confidence do not
Confidence is something that builds up knowing the patient’s con- remain stagnant; they improve with time as also previously
dition, knowing how to intervene and the awareness of what to reported by prescribing nurses (While & Biggs 2004, Brad-
anticipate. (Interview 22) ley et al. 2007). Moreover, Luker and Kenrick (1992) high-
lighted that decisions of community nurses’ were mainly
influenced by experiential knowledge sourced personally or
Discussion
from colleagues. Similarly, Offredy et al. (2008) discussed
The results suggest that nurses’ medication knowledge, to a that pharmacological knowledge of nurse prescribers was
small extent, is determined by how often a medication is insufficient and often intuition was relied on, which was
nurse-initiated and their perception of the importance of labelled ‘potentially problematic’ (p 825). However, our
certain pharmacological components. Many studies findings are in disagreement with the latter study because
described nurses’ medication knowledge as somewhat lack- while nurses’ knowledge when assessed may be incomplete,
ing for practice (Markowitz et al. 1981, Boggs et al. 1988, it is not implicit that knowledge is not pursued when
Sodha et al. 2002, Ndosi & Newell 2009, Simonsen et al. required. For example, nurses routinely consult with the
2011). The overall data denote that although knowledge available resources to attain the knowledge necessary to
deficit is apparent when tested, nursing staff are aware of safely nurse-initiate a drug.
their own limitations and act in a manner to provide safe The context of nurses’ decision-making when nurse-initi-
care. ating is multifactorial and complex (Latter & Courtenay
Blind prescribing can only exist when a prescriber exhi- 2004); hence, it cannot be explained solely by cognitive rea-
bits willingness to prescribe despite being ill-equipped with soning theories such as analytical or intuitive theories (Muir
knowledge and the deficiency of information-seeking beha- 2004, Banning 2008) as previous studies have done (Luker
viours when warranted (Starmer et al. 2013). A small per- & Kenrick 1992, Offredy et al. 2008). Rather, nurse-initiat-
centage of nurses showed evidence of blind prescribing. ing practices should be explained by predictive behavioural
There was no evidence of the widespread blind prescribing theories (Godin et al. 2008), such as theory of planned
previously shown in Starmer et al.’s (2013) study in junior behaviour (Ajzen 1991). The theory of planned behaviour
doctors. While there are a very small proportion of nurses explains that a behaviour, in this case, nurse-initiating
Patient expectations,
Subjective code of conduct,
Intention to Nurse-initiating
norms and/or
nurse-initiate practice
guidelines/policies
Experience,
Perceived knowledge,
behavioural competency
control confidence, and/or
resources
practice, is a product of intention and perceived beha- quately explored in terms of patient endpoints (e.g. satisfac-
vioural control (Ajzen 1991) (Figure 3). Nurses’ attitudes tion, pain) and clinical efficiency (e.g. time-to-analgesia,
towards nurse-initiating are mainly motivated by patient length of stay) but less so in clinician outcomes (e.g. knowl-
benefits and influenced by safety. Putting it simply, it could edge, willingness), which is essential to expand and improve
be because altruism and compassionate care are inherent of this component of non-medical prescribing in the ED. For
the nursing profession (Fagermoen 1995, Von Dietze & example, future research could address the compliance of
Orb 2000, Milton 2012). Moreover, nurses are likely to NIA/NIM. Furthermore, the qualitative findings imply that
give attention to what could go wrong as a result of their nurses employ safety practices when nurse-initiating, which
actions (Luker 1998), which is perhaps why there is strong has not been tested. This could be addressed in a study
emphasis on safety. However, it is also possible that the comparing the quality of prescribing between nurses and
accountability and responsibility associated with nurse-initi- doctors, or medication errors related to NIA/NIM.
ating underpin safety and cautious practice (Bradley et al.
2007). Subjective norms are determined by social expecta-
Limitations
tions to accomplish or not to accomplish a behaviour
(Ajzen & Madden 1986, Ajzen 1991). This includes The study is confined to one ED which may limit the trans-
patients’ expectations, organizational expectations, depart- ferability of results, notwithstanding it could serve basis for
mental guidelines or policies, or professional code of con- future explorations of nurse-initiating practices in other
duct, which guide the actions of nurses. Perceived EDs. At the time of report, empiric evidence of the depart-
behavioural control directly influences both intention and ment’s time-to-analgesia and experience of pain relief,
behaviour. Behavioural control is motivated by previous which is hypothesized to be affected by NIA/NIM, is being
experience, existing knowledge, competency and the confi- extracted by Hughes and colleagues (unpublished). The rep-
dence to accomplish the behaviour (Ajzen & Madden resentativeness of the study population could be limited to
1986, Ajzen 1991). Therefore, when nurses perceived them- experienced nurses, but it is worth noting that efforts have
selves as competent and confident they are thought to have been made so that views of nurses from all levels are repre-
more control. This is evident in the qualitative findings sented.
when nurses’ only tend to nurse-initiate simple analgesics at
the start, but as with clinical exposure they grew confident
Conclusion
and so did the list of medications they would nurse-initiate.
It is mandatory that systems that enable the maintenance Nurses’ medication knowledge is modest. In this study, the
of patients’ and nurses’ professional safety are in place in medication knowledge was not significantly different
institutions that support the practice of NIA/NIM. This between nurses who frequently and infrequently nurse-initi-
includes, but should not be limited to, access to evidence- ate and was comparable among nurses with different levels
based resources and continuing support and education for of experience. Nevertheless, the nurse-initiating practice is
nurses. The NIA/NIM is a well-used practice in this ED not motivated by knowledge alone, but influenced by
and is a growing practice in Australia. The practice is ade- patients’ needs, nurses’ scope of practice and principles of
safety such as information-seeking behaviours. It is appar- Braun V. & Clarke V. (2006) Using thematic analysis in
ent that support, continuing education and access to psychology. Qualitative Research in Psychology 3, 77–101.
Cole F.L. (2003) Emergency care advanced practice nursing in the
resources are fundamental to nurses to practice safely.
US: an overview. Emergency Nurse 11, 22–25.
Nurse-initiating practice is an expanding component of Daughtry J. & Hayter M. (2010) A qualitative study of
non-medical prescribing and future research is welcome to practice nurses ‘prescribing experiences. Practice Nursing 21,
further the practice. Studies could address some aspects that 310–314.
require more investigation, for example, compliance, medi- Doherty S., Knott J., Bennetts S., Jazayeri M. & Huckson S. (2013)
cation safety and clinician satisfaction. National project seeking to improve pain management in the
emergency department setting: findings from the NHMRC-NICS
National Pain Management Initiative. Emergency Medicine
Funding Australasia 25, 120–126.
Eley R., Spencer L., Starmer K. & Sinnott M. (2014) Prescribing
The authors acknowledge the Queensland Emergency Medi- knowledge revisited: time for action and awareness. Emergency
cine Research Foundation for funding the qualitative com- Medicine Australasia 26, 211–212.
Fagermoen M.S. (1995) The Meaning of Nurses’ Work: A
ponent of this study.
Descriptive Study of Values Fundamental to Professional Identity
in Nursing. Dissertations and Master’s theses, The University of
Rhode Island.
Conflict of interest
Fry M. & Holdgate A. (2002) Nurse-initiated intravenous
The authors have no conflicts of interest to declare. morphine in the emergency department: efficacy, rate of adverse
events and impact on time to analgesia. Emergency Medicine 14,
249–254.
Author contributions Fry M., Ryan J. & Alexander N. (2004) A prospective study of
nurse initiated panadeine forte: expanding pain management in
All authors have agreed on the final version and meet at the ED. Accident and Emergency Nursing 12, 136–140.
least one of the following criteria [recommended by the Fry M., Bennetts S. & Huckson S. (2011) An Australian audit of
ICMJE (http://www.icmje.org/recommendations/)]: ED pain management patterns. Journal of Emergency Nursing
37, 269–274.
• substantial contributions to conception and design, Godin G., Belanger-Gravel A., Eccles M. & Grimshaw J. (2008)
acquisition of data or analysis and interpretation of Healthcare professionals’ intentions and behaviours: a systematic
data; review of studies based on social cognitive theories. Implement
Science 3, 1–12.
• drafting the article or revising it critically for important
Goodacre S. & Roden R. (1996) A protocol to improve analgesia
intellectual content. use in the accident and emergency department. Journal of
Accident & Emergency Medicine 13, 177–179.
Hoskins R. (2011) Evaluating new roles within emergency care: a
References
literature review. International Emergency Nursing 19, 125–140.
Ajzen I. (1991) The theory of planned behavior. Organizational Hudson P.V. & Marshall A.P. (2008) Extending the nursing role in
Behavior and Human Decision Processes 50, 179–211. emergency departments: challenges for Australia. Australasian
Ajzen I. & Madden T.J. (1986) Prediction of goal-directed Emergency Nursing Journal 11, 39–48.
behavior: attitudes, intentions and perceived behavioral control. Kelly A.-M., Brumby C. & Barnes C. (2005) Nurse-initiated,
Journal of Experimental Social Psychology 22, 453–474. titrated intravenous opioid analgesia reduces time to analgesia
Australian Council on Healthcare Standards (2012) Emergency for selected painful conditions. Canadian Journal of Emergency
Medicine Version 5. Retrospective Data in Full. Australasian Medicine 7, 149–54.
Clinical Indicator Report 2004–2011. ACHS, Sydney, NSW. King R.L. (2004) Nurses’ perceptions of their pharmacology
Banning M. (2008) A review of clinical decision making: models educational needs. Journal of Advanced Nursing 45, 392–400.
and current research. Journal of Clinical Nursing 17, 187–195. Latter S. & Courtenay M. (2004) Effectiveness of nurse
Berry P.H. & Dahl J.L. (2000) The new JCAHO pain standards: prescribing: a review of the literature. Journal of Clinical
implications for pain management nurses. Pain Management Nursing 13, 26–32.
Nursing 1, 3–12. Latter S., Rycroft-Malone J., Yerrell P. & Shaw D. (2001) Nurses’
Boggs P., Brown-Molnar C.S. & Delapp T.D. (1988) Nurses’ drug educational preparation for a medication education role: findings
knowledge. Western Journal of Nursing Research 10, 84–93. from a national survey. Nurse Education Today 21, 143–154.
Bradley E. & Nolan P. (2007) Impact of nurse prescribing: a Luker K.A. (1998) Decision making: the context of nurse
qualitative study. Journal of Advanced Nursing 59, 120–128. prescribing. Journal of Advanced Nursing 27, 657–665.
Bradley E., Hynam B. & Nolan P. (2007) Nurse prescribing: Luker K.A. & Kenrick M. (1992) An exploratory study of the
reflections on safety in practice. Social Science & Medicine 65, sources of influence on the clinical decisions of community
599–609. nurses. Journal of Advanced Nursing 17, 457–466.
Manias E. & Bullock S. (2002) The educational preparation of Rupp T. & Delaney K.A. (2004) Inadequate analgesia in emergency
undergraduate nursing students in pharmacology: perceptions medicine. Annals of Emergency Medicine 43, 494–503.
and experiences of lecturers and students. International Journal Sampson F., Goodacre S. & O’cathain A. (2014) Interventions to
of Nursing Studies 39, 757–769. improve the management of pain in emergency departments:
Markowitz J.S., Pearson G., Loewenstein R. & Kay B.G. (1981) systematic review and narrative synthesis. Emergency Medicine
Nurses, physicians and pharmacists: their knowledge of hazards Journal 31, e9–e18.
of medications. Nursing Research 30, 366–370. Shaban R.Z., Holzhauser K., Gillespie K., Huckson S. & Bennetts
Milton C.L. (2012) Altruism. Nursing Science Quarterly 25, S. (2012) Characteristics of effective interventions supporting
222–224. quality pain management in Australian emergency departments:
Morrison-Griffiths S., Snowden M.A. & Pirmohamed M. (2002) an exploratory study. Australasian Emergency Nursing Journal
Pre-registration nurse education in pharmacology: is it adequate 15, 23–30.
for the roles that nurses are expected to fulfil? Nurse Education Simonsen B.O., Johansson I., Daehlin G.K., Osvik L.M. & Farup
Today 22, 447–456. P.G. (2011) Medication knowledge, certainty and risk of errors
Morse J.M. (2015) Data were saturated. Qualitative Health in health care: a cross-sectional study. BMC Health Services
Research 25, 587–588. Research 11, 175.
Muir N. (2004) Clinical decision-making: theory and practice. Sodha M., Mclaughlin M., Williams G. & Dhillon S. (2002)
Nursing Standard 18, 47–52. Nurses’ confidence and pharmacological knowledge: a study.
Muntlin A., Carlsson M., S€afwenberg U. & Gunningberg L. (2011) British Journal of Community Nursing 7, 309–315.
Outcomes of a nurse-initiated intravenous analgesic protocol for Starmer K., Sinnott M., Shaban R., Donegan E. & Kapitzke D.
abdominal pain in an emergency department: a quasi-experimental (2013) Blind prescribing: a study of junior doctors’ prescribing
study. International Journal of Nursing Studies 48, 13–23. preparedness in an Australian emergency department. Emergency
National Health Workforce Planning and Research Collaboration Medicine Australasia 25, 147–153.
(2010) Non-medical Prescribing: An Exploration of Likely Todd K.H., Sloan E.P., Chen C., Eder S. & Wamstad K. (2002)
Nature of and Contingencies for, Developing A Nationally Survey of pain etiology, management practices and patient
Consistent Approach to Prescribing by Non-medical Health satisfaction in two urban emergency departments. Canadian
Professionals. National Health Workforce Taskforce. Journal of Emergency Medicine 4, 252–256.
National Institute of Clinical Studies (2004) National Emergency Todd K. H., Ducharme J., Choiniere M., Crandall C. S., Fosnocht
Department Collaborative Report. NICS, Melbournce. D. E., Homel P., Tanabe P. & Group P. S. (2007) Pain in the
Ndosi M.E. & Newell R. (2009) Nurses’ knowledge of emergency department: results of the pain and emergency
pharmacology behind drugs they commonly administer. Journal medicine initiative (PEMI) multicenter study. The Journal of Pain
of Clinical Nursing 18, 570–580. 8, 460–466.
Offredy M., Kendall S. & Goodman C. (2008) The use of Von Dietze E. & Orb A. (2000) Compassionate care: a moral
cognitive continuum theory and patient scenarios to explore dimension of nursing*. Nursing Inquiry 7, 166–174.
nurse prescribers’ pharmacological knowledge and decision- While A.E. & Biggs K.S. (2004) Benefits and challenges of nurse
making. International Journal of Nursing Studies 45, 855–868. prescribing. Journal of Advanced Nursing 45, 559–567.
Plonczynski D., Oldenburg N. & Buck M. (2003) The past, present Wilson J.E. & Pendleton J.M. (1989) Oligoanalgesia in the
and future of nurse prescribing in the United States. Nurse emergency department. The American Journal of Emergency
Prescribing 1, 170–174. Medicine 7, 620–623.
Queensland Government. Nursing Act 1992 (Act No. 55 of 1992). Wong E.M., Chan H.M., Rainer T.H. & Ying C.S. (2007) The effect
Viewed January 6, 2014. Queensland Government, Brisbane. of a triage pain management protocol for minor musculoskeletal
Queensland Government (1996) Health (Drugs and Poisons) injury patients in a Hong Kong emergency department.
Regulation 1996. Queensland Government, Brisbane, Australia. Australasian Emergency Nursing Journal 10, 64–72.
Viewed January 6, 2014.
The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·527 – ranked 14/101 in the 2012 ISI Jour-
nal Citation Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries
worldwide (including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).