Should Nurses be Given the Rights to Autonomously Initiate Medications for Adult Patients? Experiencing Acute Pain at Triage Prior to a Physicians? Consult in Singapore?s Emergency Departments? A Systematic Review

Abstract

Gerard Charles

Background: Globally, in most countries, nurses are restricted from independent prescribing however, seven countries have achieved legislation to implement prescriptive authority to nurses with more countries in bid to follow suit. Since the inception of nurse-initiated medications in the 1990’s, the increase in prescribing authority has shown a positive impact on the measured metrics with evidence improving patient care with timeliness to analgesia and greater pain control.

Objectives: The objectives of this review is to rationalise the use of nurse-initiated medications at triage for patients’ presenting with acute pain in the emergency department, to critically analyse the risks and benefits of NIM and to generate ideas and make recommendations about practice implications regarding NIM at triage.

Methods: A literature review using a systematic approach was undertaken. Multiple keyword combinations were incorporated, and an inclusion and exclusion criteria were set. All studies chosen were critically appraised using four different toolkits based on research design for rigour and quality. Ten studies were selected for this review. Thematic analysis was conducted, stitching the similarities identified within the studies and a discussion of the results with a conclusion was written.

Results: Nurses who were given prescriptive authority significantly decreased time to analgesia in nine studies with the initiation of NIM at triage. There were no complaints or mentions of medication errors, special events or adverse reactions reported in the selected research papers. Thematic analysis identified pain assessment as a key indicator for nurses to initiate medications for patients upon triage. The introduction of NIM has attained clinically significant pain reduction scores and increased patient satisfaction. There was, however, little effect between NIM and ED length of stay. Safety concerns, anxiety, and overwhelming workload were identified as barriers for nurse prescribing with measures set in place to combat these issues.

Conclusion: This review has found that nurse-initiated medications are beneficial as it does increase timeliness to analgesia and improve pain control for patients. It also highlights compelling evidence with an increase in timeliness to analgesia and that authority should be given to nurses in Singapore for the rights to autonomously prescribe analgesia for patients’ experiencing acute pain at triage prior to a physicians’ consultation. Prescriptive authority for nurses will be a step forward in contemporary emergency medicine. Further exploration and research should be undertaken about the concept and impact of NIM on safety issues, ED length of stay with randomised studies to solidify this initiation.