Nurse Education Today 34 (2014) 985–990

Contents lists available at ScienceDirect

Nurse Education Today journal homepage: www.elsevier.com/nedt

Experiences of nurses as postgraduate students of pharmacology and therapeutics: A multiple case narrative study Anecita Gigi Lim a,⁎, Nicola North b, John Shaw c a b c

School of Nursing, The University of Auckland, Auckland, New Zealand School of Population Health, The University of Auckland, Auckland, New Zealand School of Pharmacy, The University of Auckland, Auckland, New Zealand

a r t i c l e

i n f o

Article history: Accepted 8 January 2014 Keywords: Non-medical prescribing Advanced nurses Prescribing education Pharmacology Therapeutics

s u m m a r y Background: Pharmacology and therapeutics are essential components of educational programmes in prescribing, yet little is known about students' experiences in studying these subjects for a prescribing role. Objective: To investigate the views and experiences of nurses as postgraduate students who were studying pharmacology and therapeutics in preparation for a prescribing role. Design: Qualitative study using a multiple case narrative approach. Settings: The participants were undertaking or had recently completed a Master's degree programme; they worked in a range of clinical areas and services in the Auckland region. Participants: Twenty nurses, with advanced clinical backgrounds and experience engaged in postgraduate studies in pharmacology and therapeutics. Methods: A semi-structured interview of approximately 1 h was undertaken with each participant. Transcripts were analysed within and across cases using Narralizer® software to support thematic analysis. Results: There were four broad thematic areas. In the first, ‘prescribing in the context of advanced nursing practice’, participants reflected on why prescribing authority was important to them. In the second theme, ‘adequacy of prior pharmacology knowledge’ they discussed the relative lack of pharmacology in their undergraduate programmes and in nursing practice. In the third, ‘drawing on clinical experience in acquiring pharmacology knowledge’, participants discussed how, as they grappled with new pharmacological science, they drew on clinical experience which facilitated their learning. In the fourth theme, ‘benefits of increased pharmacology knowledge’ they discussed how their studies improved their interactions with patients, medical colleagues and as members of multi-disciplinary teams. Conclusions: All nurses viewed their studies in pharmacology as fundamental to their roles as prescribers, through knowledge development and an increase in confidence. Although pharmacology theory was new to many participants, their learning was facilitated because they were able to reflect on previous clinical experience and apply this to theory. © 2014 Elsevier Ltd. All rights reserved.

Introduction The authority to prescribe has traditionally been the domain of medical and dental practitioners. In recent years, a number of other health professional groups, including midwives, nurses and pharmacists, have attained the right to prescribe medicines within their scope of practice (Department of Health, 2006). In the United Kingdom (UK), for example, accredited nurses and pharmacists have been able to register as supplementary prescribers since 2003 and independent prescribers since 2007 (Latter and Blenkinsopp, 2011). While the important contribution of pharmacists as prescribers is acknowledged,

⁎ Corresponding author at: School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Building 505, 85 Park Road, Grafton, Auckland, New Zealand. E-mail address: [email protected] (A.G. Lim). 0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2014.01.002

the focus of this paper is on the educational preparation of nurse prescribers, using nurse practitioners (NPs) in New Zealand (NZ) as a model. Accredited NPs in NZ have been able to register as independent prescribers since 2005 (Lim et al., 2007). Recent amendments to the Medicines Act have extended independent prescribing authority to accredited diabetes clinical nurse specialists and pharmacists (Ministry of Health, 2011), and more widely to other clinical nurse specialists as delegated prescribers (Ministry of Health, 2013). To be approved as an NP in NZ, a nurse must have worked in a specific area of clinical practice (commonly referred to as a ‘scope of practice’) for at least five years, and to have a completed a clinical Master's degree in Nursing. Pharmacology and therapeutics are included in the Master's programmes, or as stand-alone courses for nurses who have already completed a Master's degree (Lim et al., 2007). Building on courses in advanced clinical practice, applied biomedical sciences and assessment/ diagnostic reasoning, the core prescribing courses are in principles of

986

A.G. Lim et al. / Nurse Education Today 34 (2014) 985–990

pharmacology and therapeutics, together with a practical course (termed the Practicum) in which students commence prescribing under the direction of a medical mentor. It is pertinent to note that students can be either hospital- or community-based, although the majority are from the hospital sector. For this reason, the courses in the principles of pharmacology and therapeutics are ‘generic’ while the Practicum is ‘contextual’ and determined by the individual's area of practice. Other countries that have introduced nurse prescribing also require practitioners to complete pharmacology and therapeutics courses before they can prescribe, but the educational levels and depth at which these subjects are integrated into the preparation of nurse prescribers differ considerably (Hemingway and Davies, 2006). Expanded roles for nurses including diagnosis and prescribing, and calls to include specific training and education in pharmacology at both the undergraduate and postgraduate levels, have posed new challenges for educationalists in reviewing the underlying holistic philosophy of nursing with its emphasis on ‘caring’, rather than ‘curing’ (Morrison-Griffiths et al., 2002). Undergraduate nursing education has been criticised for not providing nurses with a sufficient grounding in the biomedical sciences including anatomy, physiology, biochemistry, microbiology, pathophysiology and pharmacology (Bradley et al., 2007; Courtenay et al., 2009; King, 2004; Latter et al., 2007). However, the issue of ‘how much’ bioscience (the preferred term in the discipline of nursing) is required remains unresolved (Jordan, 1994). Some authors have argued that although integrated curricula enhance the “epistemological basis of holism in nursing”, the development of a separate core pharmacology module in pre-registration programmes would raise the profile of pharmacology and provide nurses with a sound knowledge base for safe and effective medication management (Larcombe, 2003; Morrison-Griffiths et al., 2002). With the advent of nurse prescribing, the need to prepare the nurse prescriber with the skills to assess clients, make judgements about symptoms, read and interpret diagnostic findings and decide on a prescription, suggests that the medical model, with its emphasis on biomedical sciences, may be more appropriate for nurse prescribers (Courtenay et al., 2007). Several studies have indicated that the gaps in biosciences and pharmacology preparation at the undergraduate level later present difficulties for many nurses taking on extended roles, especially in prescribing (Banning, 2004; Bradley et al., 2007; Courtenay et al., 2009). Banning (2003) argued that education should prepare nurses to be capable practitioners, not merely competent to undertake specific tasks; for this objective to be achieved, educational curricula need to include not only medication management, but also skills in clinical reasoning and decision-making (Carr, 2004). The mixed findings and perspectives in the literature highlight the need for further research to elucidate the place of biomedical sciences and pharmacology in preparing nurses for a prescribing role. The present study was part of a wider study which explored the experiences of nurses participating in postgraduate prescribing programmes. The focus of this paper is to present their views and experiences of studying pharmacology and therapeutics in preparation for a prescribing role, and to reflect on the value of the current educational programme for nurse prescribers in New Zealand. Methods This study was guided by a constructivist narrative approach using a multiple case narrative strategy. It was undertaken in Auckland, NZ, from 2006 to 2009, ten years after the introduction of prescriptive authority for nurse practitioners. The University of Auckland Human Participants Ethics Committee approved the study (Ref. 2007/249). Participants There were 43 participants in the wider study, including nurses, medical practitioners and midwives. The participants reported here

were a sub-set of 20 registered nurses with advanced skills in a specific clinical practice area (their scope of practice), who were or had recently been engaged in postgraduate pharmacology and therapeutics courses as part of a prescribing programme during the period 2002–2004. They were recruited using a purposive sampling process, whereby the researcher (AL) selected potential participants from a list of postgraduate students. The first twenty students who agreed to participate comprised the sample, described in Table 1. The majority (15) were hospital-based practitioners, and five based in the community. Data Collection In-depth interviews are common to many qualitative research designs (Lincoln and Guba, 2000), and in multiple case narratives are used to understand the experiences of participants and the meanings they make of their experiences. An interview schedule was developed, comprising open-ended questions, informed by the literature and the researchers' experiences as academics in nursing, pharmacology and prescribing. Semi-structured individual interviews lasting approximately 1 h were conducted and audio-recorded. Participants were asked to reflect on their experiences as learners and to identify their strengths and weaknesses in relation to pharmacology, therapeutics and prescribing. The interview approach allowed participants to expand on aspects of particular interest and to add issues not specifically addressed in the questions. This allowed for emergent avenues of questioning to be incorporated into subsequent interviews. Data Analysis The interviews were transcribed and analysed thematically. Data collection and analysis proceeded simultaneously in an iterative manner, so that new data informed analysis and preliminary analysis informed interviewing: issues emerging as particularly important were identified and subsequent participants also asked about those issues. The ‘Narralizer®’ software was used to generate and develop categories and provided a tool for the researcher to link ‘bits’ of data extracted from text where thematic analysis was employed to analyse blocks of text (and not separated words) as the analysis unit. In analysing multiple case narratives to establish core categories and themes, the procedure followed was based on a continual stage approach. Each level was constructed based on the level ‘below’ it (Shkedi, 2005). Trustworthiness Trustworthiness in interpretation of the findings ensured through establishing an audit trail following the stages of analysis, namely categorisation, mapping, and focused analysis, with all researchers consulting over themes and categories, illustrating the rigour of analysis undertaken to ensure credibility. The use of verbatim quotes to illustrate themes authenticates the findings. Results The findings fell into four broad thematic areas. In the first, ‘prescribing in the context of advanced nursing practice’, participants reflected on why it was important to their nursing practice that they were able to prescribe and how they reconciled prescribing practice (historically the domain of medical practitioners) with nursing. The second theme focused on the ‘adequacy of prior biomedical and pharmacology knowledge’ developed in the undergraduate pre-registration nursing programme and in nursing practice. In the third theme, “drawing on clinical experience in acquiring pharmacology knowledge”, participants discussed how, as they grappled with new pharmacological science, their learning was facilitated by drawing on clinical experience. Finally, in the fourth theme, ‘benefits to patients and healthcare teams of nurses' increased pharmacology knowledge’ they discussed how their studies

A.G. Lim et al. / Nurse Education Today 34 (2014) 985–990 Table 1 Participant characteristics. Participant

Gender

Area of specialty practice

Specialty practice experience (years)

A B C D E F G H I J K L M N O P Q R S T

Female Female Male Female Female Female Female Female Male Female Female Female Female Female Female Male Female Female Female Female

Ophthalmology Public health youth Mental health Ear specialist Paediatrics Sexual health Emergency care Primary care Gerontology Primary care Primary care Ophthalmology Paediatric cardiology Respiratory Palliative care Emergency Liver transplant Primary care Cardiology (adult and paediatrics) Paediatric and family

10 10 8 10 12 15 10 15 15 10 10 15 10 10 15 10 15 15 15 10

influenced the way in which they viewed their medical colleagues, and their interactions as members of multi-disciplinary teams. Prescribing in the Context of Advanced Nursing Practice Prior to completing the pharmacology and therapeutics courses, the participants were already working in a professionally autonomous manner in advanced roles within their chosen practice area (see Table 1 for the practice areas of participants). This prior experience, related to a specific area of practice, was viewed as advantageous. “We [nurses] have time within our chosen scopes to select that field, to really grow in it, and to know it well. Moreover, I think, because we know that field so well, and we do not go out of that scope or that field, I think we are experts in it.” (Participant A) While describing themselves as “experts”, the participants were also conscious of the limitations of their knowledge and roles. Awareness of one's scope of practice was a core category to emerge. Numerous examples were given of working within their scope of practice, outlining where their scope began and ended. “I think we all practise within our scopes of practice. We know our limitations, our strengths and weaknesses and if we come across a situation that we cannot deal with, we refer these patients to the doctors.” (Participant M) Like most nurses with extensive experience in medication management, the participants had developed advanced skills in relation to their area of practice. Reflected in their interviews was a pattern of having built experientially upon the pharmacology knowledge learned as a student in nursing, to a point where they believed they knew what a medical colleague would prescribe; indeed, sometimes a nurse advised a particular treatment. “… as my role developed I would actually often go along and say to somebody that this is what I would recommend … the treatment that was needed. My experiences with patients of similar conditions in the past have shown me this drug will work … and I have seen doctors prescribing it.” (Participant S) Although working within the holistic model of nursing and being able to practise in an extended role were highly satisfying for

987

participants, they also outlined the limitations posed by being unable to prescribe. Participants conveyed a sense of frustration in what they described as being unable to complete an “episode of care.” “… I need a prescribing role to finish episodes of care and I think what it allows me to do is actually complete the whole event of care for the patient.” (Participant A) The majority believed that they participated in and influenced clinical decisions. They expressed frustration at having to find a doctor to sign the prescription or “rubber stamp” the treatment advice they (the nurses) had given, decisions that they felt they were capable of making. Indeed, being unable to prescribe limited their ability to work autonomously. “… because of my role now … not being able to prescribe can be frustrating; it is so hard, difficult to do, not prescribing.” (Participant A) Prescribing was therefore viewed as an important additional tool to their advanced practice. At the same time, participants were quick to point out that in the light of medical practitioners' grounding in the biomedical sciences, there were episodes of care needing to be completed by doctors. In those cases, participants were clear about their limits and felt that another member of the interdisciplinary team, usually a medical colleague, was best suited to provide that clinical management. “… I may have a good idea about what should be happening, but I'm not a 100% sure of the diagnosis and for patient safety, I do often consult with our [specialist] ….” (Participant Q) Adequacy of Prior Biomedical and Pharmacology Knowledge Having settled into a scope of practice and developed their clinical role within that scope to increasingly autonomous levels, the lack of pharmacology knowledge was seen as inhibiting advancement. Although for the majority of participants, biosciences were included in their undergraduate education, they indicated that it was limited level compared to the biomedical sciences in medical programmes, and respected medical colleagues for their expertise. “But I do feel nervous that I don't have that biomedical background, but it's interesting, when I do listen to [doctors], they have the ability. They have more knowledge in the realm of diseases.” (Participant I) Participants observed that while the knowledge and skills learnt from their undergraduate training and education provided a “generic knowledge base” considered relevant to basic nursing practice, it was inadequate for a prescribing role. In contrast, medical students were being prepared to prescribe from the time they began practising, and education in biomedical sciences and clinical therapeutics reflected this. As well as respecting the knowledge and expertise of medical colleagues, a consequence of participants' acknowledging the limitations of their own biomedical and pharmacological knowledge was a cautious approach to prescribing practice. “When I entered nursing I had no notion that I would ever prescribe a medication, whereas … a doctor admittedly started medical training knowing that someday they're going to be prescribing. So, I've had 20 odd years of nursing without any intention of prescribing.” (Participant S) Drawing on Clinical Experience in Acquiring Pharmacology Knowledge Some participants found that the study of pharmacology was particularly challenging as they grappled with new knowledge and an unfamiliar science. Participants cited examples that showed how the learning process was facilitated by being able to draw on clinical situations, helping them to make sense of new pharmacology knowledge

988

A.G. Lim et al. / Nurse Education Today 34 (2014) 985–990

during their postgraduate programme in prescribing. Participants' experiences in their specialised clinical area enabled them to quickly grasp and apply the new knowledge, as they recalled clinical situations where side-effects and sometimes adverse effects had been experienced by some patients they had been caring for. “I've seen that risk factors are a problem … especially in the use of medication for older people. Usually the polypharmacy aspects of prescribing is a problem for them, you get drug-to-drug interactions. So that knowledge, [pharmacokinetics] is important for my practice.” (Participant T) Pharmacology and therapeutics were seen as only one aspect of the required knowledge base. Participants described how they needed to integrate the principles of biomedical sciences with therapeutics to understand the potential effects of insufficient and compromised liver and renal functions to prescribing some drugs; in this, too, drawing on clinical experience facilitated learning. “And I think that you pick up a lot of clinical knowledge around prescribing advice from your medical colleagues that you work with, but what I learnt (pharmacology and therapeutics) was actually making my own decisions based on a depth of knowledge that I didn't have before, rather than just watching what my medical colleagues were doing.” (Participant O) Benefits to Patients and Healthcare Teams of Nurses' of Increased Pharmacology Knowledge Participants described how new learning added to their knowledge of different aspects of medication management. They gave examples that illustrated how pharmacology knowledge contributed to their understanding of the drug and its “side-effects,” and how this improved their practice in terms of monitoring “how patients were managing these side-effects”. Participants believed that as their understanding of pharmacology increased, educating patients about their regimens also improved, particularly as to therapeutic effects, side-effects and adherence. Increased pharmacology knowledge also fed back immediately into patient management. While still students in prescribing, they were able to integrate the new pharmacology knowledge gained during their education directly to the practice setting.

doctors provided opportunities to have feedback on suggestions and decisions. “Learning pharmacology was actually a good experience, because you felt reinforced and you get some positive feedback about your ability to practice or prescribe.” (Participant B) “I think it builds your confidence … that your decisions were right.” (Participant K) Although participants had previously been reticent about contributing to decision-making in the context of team meetings with doctors and pharmacists, the knowledge and skills gained during their pharmacology education provided them with the needed confidence to participate in discussing prescribing decisions. “I would attend multi-disciplinary team meetings and make suggestions of medication regimes that I might not have done before. It has definitely influenced a couple of cases that I've worked on. Actually, in both instances, I felt the person was under-treated and I pushed for not only a change in medication, but also a change in the whole treatment plan.” (Participant S) For some participants, confidence was directly related to their increased pharmacological knowledge, reducing the knowledge gap between themselves and medical colleagues. They described this knowledge as giving them the ability to more effectively advocate for patients in their care, empowering participants to change their strategies from indirectly influencing decisions to active engagement in clinical discussions. One participant described pharmacological knowledge as a “tool” to actively discuss medication practices, which in turn can make a difference to their patients' clinical situations. “Learning pharmacology and therapeutics does help prepare you for the role. It's sort of a sharp point in time where, you know, your attitude does change … my confidence immediately got a big boost. Often, when you work with people (other medical health professionals) more regularly, they're kind of starting to get to know you, they're starting to get to trust you, you kind of build up a relationship and you can discuss issues with them on an even playing field.” (Participant S)

“… so basically I went down and said “Look, this [drug] is what he's on and he's sitting there breathless [adverse effect] on my chair, he's [patient] got to come off it [drug]” … and there was no argument [referring to the doctor]. And I've had a couple of patients like that.” (Participant D)

In addition to enhanced confidence in presenting their viewpoints, participants felt that a greater understanding of pharmacology gave them the language to discuss their prescribing decisions with other prescribers and their mentor. It gave them a “common language” in which to engage.

Increased knowledge in pharmacology enhanced participants' patient assessment and clinical management skills. For example, the ability to think through which of the potential drugs would commonly be used in a specific situation increased their confidence and involvement in decision-making.

“And, I think one thing is, it makes you speak the same language, gives you a language to speak to the doctors as well. So we have this common language around medications, you know, which we can then translate to clients.” (Participant A)

“The pharmacology paper was very fascinating, the teacher at the time was very encouraging, it was very straightforward, it was very well explained, and it really sort of made me realise how much I already know and how much I don't know … I know a lot more about medications now and it's sort of like the holy grail of medicine in a way that, you know, it is hard to touch and it's scary to touch, but I think the preparation pathway that I did allowed me to understand more about side effects and why they happen. It (knowledge of pharmacology) has improved the way I educate my patients.” (Participant S)

The educational preparation also provided participants with the knowledge to discuss medications more in-depth with pharmacist. They felt that pharmacists have been “excellent source[s] of information about drugs”. Having a better understanding of pharmacology and therapeutics put them in a better position to ask the pharmacist the right questions: “I feel that I am better able to ask pharmacists questions about drugs. I can understand where pharmacist are coming from when they say … you must always give that drug with food”. (Participant L) Discussion

Another benefit was related to professional self-image, reflecting participants' experiences in being listened to, and consulted with, on prescribing decisions. The opportunity to discuss prescribing decisions with

A number of international studies have shown the benefits of the nurse practitioner–prescriber role in terms of service delivery,

A.G. Lim et al. / Nurse Education Today 34 (2014) 985–990

timeliness and patient satisfaction (Hales and Dignam, 2002; Horrocks et al., 2005). Nevertheless, nurse prescribing continues to be debated amid continuing claims that nurses' knowledge in pharmacology, which underpins prescribing, is inadequate (Bradley et al., 2007; Latter et al., 2007). Other literature suggests that many nurses lack knowledge not only in pharmacology, but also in biomedical sciences in general (Courtenay, 2008; Creedon et al., 2009). How nurses learn to become safe prescribers is not well researched, and there is a need to investigate the perspectives and experiences of nurses themselves, to further elucidate the important elements in their educational preparation (Offredy et al., 2008). During the period of this research, no other studies that investigated the educational preparation of nurse prescribers were located, a gap also noted in another recent study (Boreham et al., 2013). Prescribing was perceived as just one element of an expanded role, rather than an end in itself, and participants saw prescribing as being compatible with a holistic philosophy of nursing practice. For many, the ability to prescribe was regarded as a natural progression in their professional development. Although they perceived themselves as “experts” in their chosen area of nursing practice and were already involved in the management of medications prescribed for patients, the choice of drugs was generally made by doctors and participants felt precluded from the process of decision-making. This was despite other studies highlighting that nurses frequently influence doctors' prescribing decisions (Castledine, 2006; Jutel and Menkes, 2010). Many participants observed that they wanted to prescribe so as to be able to “complete an episode of care”. At the same time, they felt they lacked experience in clinical decision-making and a sound knowledge of the factors to be taken into account in deciding whether drug treatment was an option; hence, pharmacology education was viewed as a fundamental step to building the knowledge and skills required to prescribe safely and competently. They were concerned about gaps in their pharmacology and biomedical knowledge, and that this was a constraint to their ability to provide optimal patient care. Similar concerns have been echoed in other studies that argued pharmacology education, especially at the nursing undergraduate level, was either lacking altogether (While and Rees, 1993) or was inadequate (Sodha et al., 2002). Most participants in this study acknowledged the limitations of their prior education in pharmacology and biomedical sciences. A lack of diagnostic knowledge was a major issue of concern for many, and they felt that this would be reflected in their practice as prescribers, where they would proceed cautiously. As experienced nurses with advanced knowledge and skills in their area of practice, the participants as learners came with attitudes and experiences important to learning. Although they found studies in pharmacology and therapeutics to be challenging, past clinical experience meant that they were able to quickly grasp and apply new knowledge into patient care. The prescribing courses increased their knowledge and confidence about: the choice of treatment against non-treatment; the need for monitoring and evaluation; dosing considerations as they related to efficacy of treatment; and, importantly, the role of patient adherence and non-adherence to treatment and its consequences. Knowledge of side effects of medications, how drugs interacted with other drugs, food, or the patients' lifestyle, patient education about their drugs, and monitoring considerations were all seen as major benefits. Participants observed that the pharmacology and therapeutics courses had given them a broad overview of drugs generally, in addition to an increased understanding of those used in their specific area of practice. This is an important observation as the reality of clinical practice is that patients may be taking a number of drugs (including non-prescription and complementary medicines, and illicit drugs) unrelated to the particular clinical condition of interest. Learning pharmacology and therapeutics greatly increased participants' confidence, and empowered them by giving them a “common language” and “the tools” to engage more fully in clinical decisions. They were better able to act as advocates for their patients and engage in more productive decision-making in association

989

with doctors and other health professional colleagues. Since our study, a similar finding was reported in Scotland (Boreham et al., 2013). There, pharmacology programmes contributed to the growth in nurses' knowledge, confidence and personal autonomy, which facilitated communication with doctors and pharmacists. There are some limitations to the current study. While the use of multiple case narratives has extended our understanding of the place of pharmacology in nurse prescriber education and of the relationship between prior clinical experience and learning, generalisability of findings to other populations of nurses studying prescribing is limited for the following reasons. The participant selection process utilised purposive, not randomised, sampling. With a single exception, the participants were all from one university and region in New Zealand, partly because it was where the majority of nurses initially undertook prescribing education. In addition, the participants were drawn from the earlier cohorts of prescribing students (reflecting the period when data was collected), and the courses have been refined and updated since then. In their narratives, participants tended to emphasise their respect for, and relationships with, medical colleagues more than those of other professions essential to the practice of safe prescribing, such as pharmacists. It is likely that this reflects the central role of the medical mentors (also the senior colleagues) for the nurse prescribing students, rather than a lack of recognition of the pharmacist as the ‘medicines expert’ and pivotal to safe prescribing practice. Indeed, there are a number of studies which emphasise the important role of pharmacists in supporting nurse prescribing education. The hierarchical relationship and differences in power between the mentor (in the role of senior colleague, medical specialist, healthcare team leader, and teacher) and the nurse (a majority of prescribing students were female, members of a historically less ‘powerful’ health profession used to carrying out medical orders) may also explain why a number of participants identified empowerment as an unexpected consequence of their increased pharmacology knowledge and emphasised the superior knowledge and expertise of medical colleagues (Davies, 2003; Gjerberga and Kjolsro, 2001). While the study provides a broad description of the phenomenon from the perspectives of nurses, it doesn't necessarily apply to other health professionals (e.g. pharmacists, podiatrists, and physiotherapists) who have also recently gained prescribing authority; further research into their perspectives is warranted.

Conclusion The study has built on previous research into nurse prescribing by providing insights into nurses' experiences as postgraduate students engaging in the new and challenging material of biomedical and pharmacological sciences. This study offers an optimistic perspective to nurse prescribing. While previous research has tended to emphasise nurses' deficits in these areas, this research found a readiness among participants to grapple with new theory, and in doing so, to draw on their extensive clinical experience to facilitate learning. Moreover, they could immediately apply new knowledge to their work. An unexpected finding was that nurses learning to prescribe did not abandon the role and identity of being a nurse, a concern reflected by some critics of nurse prescribing. Indeed, for these nurses, prescribing was simply an additional tool in their skillset as advanced nurses; one that enabled them to more completely care for their patients. An implication of our findings is that research on nurse prescribing needs to be interpreted in the contexts of nursing policy and educational programmes pertaining to the country where the study was conducted. A possible reason for our overall optimistic findings was that all the participants were in advanced roles; they were supported by their medical (mentor) colleagues and were motivated to be engaged in NZ's extended and rigorous process for being approved to prescribe.

990

A.G. Lim et al. / Nurse Education Today 34 (2014) 985–990

Conflict of Interest The authors declare that there are no conflicts of interest. Funding The study was undertaken as part of the first author's (AL) PhD degree, who was supported by the University of Auckland Doctoral Research Funding. There was no other specific funding. Acknowledgements The authors acknowledge the contribution of the 20 postgraduate nursing students who participated in the study. References Anon., 2011. Medicines (Designated Prescriber–Registered Nurses Practising in Diabetes Health) Regulations, 2011. Ministry of Health, Wellington, New Zealand. Anon., 2013. Medicines (Designated Pharmacist Prescribers) Regulations 2013. Ministry of Health, Wellington, New Zealand. Banning, M., 2003. Pharmacology education: a theoretical framework of applied pharmacology and therapeutics. Nurse Educ. Today 23 (6), 459–466. Banning, M., 2004. Nurse prescribing, nurse education and related research in the United Kingdom: a review of literature. Nurse Educ. Today 24 (6), 420–427. Boreham, N., Coull, A.F., Murray, I.D., Turner-Halliday, F., Watterson, A.E., 2013. Education programmes preparing independent prescribers in Scotland: an evaluation. Nurse Educ. Today 33 (4), 321–326. Bradley, E., Hynam, B., Nolan, P., 2007. Nurse prescribing: reflections on safety in practice. Soc. Sci. Med. 65 (3), 599–609. Carr, S., 2004. A framework for understanding clinical reasoning in community nursing. J. Clin. Nurs. 13 (7), 850–857. Castledine, G., 2006. Prescribing is not the only issue for nurses and drugs. Br. J. Nurs. 15 (15), 837. Courtenay, M., 2008. Nurse prescribing, policy, practice and evidence base. Br. J. Community Nurs. 13 (12), 563–566. Courtenay, M., Carey, N., Burke, J., 2007. Independent extended and supplementary nurse prescribing practice in the UK: a national questionnaire survey. Int. J. Nurs. Stud. 44 (7), 1093–1101. Courtenay, M., Stenner, K., Carey, N., 2009. Nurses' and doctors' views about the prescribing programme. Nurse Prescr. 7 (9), 412–417.

Creedon, R., O'Connell, E., McCarthy, G., Lehane, B., 2009. An evaluation of nurse prescribing. Part 1: a literature review. Br. J. Nurs. 18 (21), 1322–1327. Davies, K., 2003. The body and doing gender: the relations between doctors and nurses in hospital work. Sociol. Health Illn. 25 (7), 720–742. Department of Health, 2006. Improving Patients' Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing Within the NHS in England. The Department of Health, London, United Kingdom. Gjerberga, E., Kjolsro, L., 2001. The doctor–nurse relationship: how easy is it to be a female doctor co-operating with a female nurse? Soc. Sci. Med. 52, 189–202. Hales, A., Dignam, D., 2002. Nurse prescribing lessons from the US. Kai Tiaki Nurs. N. Z. 8 (10), 12–15. Hemingway, S., Davies, J., 2006. Non-medical prescribing education provision: how do we meet the needs of the diverse nursing specialisms? Nurse Prescr. 2 (4), e11. Horrocks, S., Anderson, E., Salisbury, C., 2005. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 324, 819–823. Jordan, S., 1994. Should nurses be studying bioscience? A discussion paper. Nurse Educ. Today 14 (6), 417–426. Jutel, A., Menkes, D., 2010. Nurses' reported influence on the prescription and use of medication. Int. Nurs. Rev. 57, 92–97. King, R.L., 2004. Nurses' perceptions of their pharmacology educational needs. J. Adv. Nurs. 45 (4), 392–400. Larcombe, D., 2003. Who is best qualified to teach bioscience to nurses. Nurs. Stand. 17 (51), 38–44. Latter, S., Blenkinsopp, A., 2011. Non-medical prescribing: current and future contribution of pharmacists and nurses. Int. J. Pharm. Pract. 19, 381–382. Latter, S., Maben, J., Myall, M., Young, A., 2007. Evaluating nurse prescribers' education and continuing professional development for independent prescribing practice: findings from a national survey in England. Nurse Educ. Today 27 (7), 685–696. Lim, A.G., Honey, M.L.L., Kilpatrick, J.A., 2007. Framework for teaching pharmacology to prepare graduate nurses for prescribing in New Zealand. Nurse Educ. Pract. 7 (5), 348–353. Lincoln, Y.S., Guba, E.G., 2000. Paradigmatic controversies, contradictions, and emerging confluences, In: Denzin, N.K., Lincoln, S.L. (Eds.), The Handbook of Qualitative Research, 2nd ed. Sage Publications, London, United Kingdom, pp. 163–188. Morrison-Griffiths, S., Snowden, M., Pirmohamed, M., 2002. Pre-registration nurse education in pharmacology: is it adequate for the roles that nurses are expected to fulfil? Nurse Educ. Today 22 (6), 447–456. Offredy, M., Kendall, S., Goodman, C., 2008. The use of cognitive continuum and patient scenarios to explore nurse prescribers' pharmacological knowledge and decisionmaking. Int. J. Nurs. Stud. 45, 855–868. Shkedi, A., 2005. Multiple Case Narrative: A Qualitative Approach to Studying Multiple Populations. John Benjamins Publishing Company, Philadelphia, PA. Sodha, M., McLaughlin, M., Williams, G., Dhillon, S., 2002. Nurses' confidence and pharmacological knowledge: a study. Br. J. Community Nurs. 7 (6), 309–315. While, A.E., Rees, K.L., 1993. The knowledge base of health visitors and district nurses regarding products in the proposed formulary for nurse prescription. J. Adv. Nurs. 18 (10), 1573–1577.