ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED

METHODS

Medication knowledge and willingness to nurse-initiate medications

in an emergency department: a mixed-methods study
C. J. Cabilan, Robert Eley, James A. Hughes & Michael Sinnott

Accepted for publication 10 September 2015

Correspondence to C.J. Cabilan: C A B I L A N C . J . , E L E Y R . , H U G H E S J . A . & S I N N O T T M . ( 2 0 1 6 ) Medication

e-mail: carajoyce.cabilan@health.qld.gov.au
C. J. Cabilan RN MACN
Clinical Research Officer/MAppSci
(Research) Candidate
Department of Emergency Medicine,
Princess Alexandra Hospital, Brisbane,
Queensland, Australia
Robert Eley MSc PhD FRSB
Academic Research Manager
Department of Emergency Medicine,
Princess Alexandra Hospital, Brisbane,
Queensland, Australia and
The University of Queensland, School of
Medicine, Brisbane, Queensland, Australia
James A. Hughes RN MAdvPrac
Nurse Researcher/PhD Candidate/Adjunct
Lecturer
Department of Emergency Medicine,
Princess Alexandra Hospital, Brisbane,
Queensland, Australia and
School of Nursing and Midwifery, Griffith
University, Brisbane, Queensland, Australia
Michael Sinnott MBBS FACEM FRACP
Senior Staff Specialist/Adjunct Professor
Department of Emergency Medicine,
Princess Alexandra Hospital, Brisbane,
Queensland, Australia and
The University of Queensland, School of
Medicine, Brisbane, Queensland, Australia
[Correction added on 28 December 2015
after initial publication online on 4
November 2015. James Hughes’ initial has
been corrected to read James A. Hughes.]
knowledge and willingness to nurse-initiate medications in an emergency depart-
ment: a mixed-methods study. Journal of Advanced Nursing 72(2), 396–408. doi:
10.1111/jan.12840
Abstract
Aims. To assess the medication knowledge of emergency department nurses and
determine the factors affecting their nurse-initiated medication practices.
Background. Nurse-initiated medications is a vital practice for all nurses in
emergency departments which improves pain assessment, provides safe pain
management and reduces time-to-analgesia and other meaningful treatments.
Design. Mixed methods. Between September 2014–January 2015, data were
collected by questionnaire assessing medication knowledge and face-to-face
interviews determining factors affecting practice.
Results. Nurse-initiated medications frequency of the Registered Nurses ranged
from 0-36 times per week dependent on employed hours and emergency
department area worked. Medication knowledge was consistent among nurses,
but there was an overall deficit in nurses’ knowledge of mechanism of action.
Four major themes were identified from the 24 interviews: patient-centred care,
caution and safety as principles of practice; continuing support and education;
improvement of practice over time. All nurses regard the practice positively and
to be extremely beneficial to patients. Although apprehensive at the start of their
nurse-initiated medications practice, confidence improved with exposure and
experience. Nurses sought additional information from colleagues and the
available evidence-based resources.
Conclusion. Medication knowledge is not the sole determinant of nurse-initiated
medications practice. The practice is motivated by multiple factors such as
patients’ needs, safety and nurses’ confidence.
Keywords: accident and emergency, clinical decision-making, medication, mixed
method design, non-medical prescribing, nurse prescribing, nursing

396 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department
Why is this research needed?
• The autonomy to nurse-initiate analgesia and other medica-
tions is essential for ED nurses. However, little is known
of nurses’ willingness or preparedness to nurse-initiate.
What are the key findings?
• Nurses’ willingness to nurse-initiate is not influenced by
medication knowledge, rather it is dependent on patients’
needs and directed by the principles of safety.
• When medication knowledge is insufficient but needed,
nurses routinely refer to the available resources to safely
nurse-initiate.
How should the findings be used to influence policy,
practice, research and education?
• Institutions that support the nurse-initiating practice must
ensure that nurses are supported by putting systems in
place that maintain safety, such as access to evidence-based
resources and continuing education.
Introduction
Pain is the most common presenting complaint in the
emergency department (ED) (Todd et al. 2002, Doherty
et al. 2013). However, pain is often inadequately assessed,
insufficiently documented and undertreated (Todd et al.
2007, Australian Council on Healthcare Standards, 2012).
These deficiencies in pain management in the ED, which
are most commonly referred to as oligoanalgesia (Wilson
& Pendleton 1989), are acknowledged worldwide. Conse-
quently, several strategies have been suggested and imple-
mented to improve pain management practices (Rupp &
Delaney 2004, Doherty et al. 2013). In the USA, focus on
the accuracy and promptness of pain assessment and con-
tinuing education of clinicians, patients and relatives about
the treatment of pain, prompted changes in hospital policy
and protocol about pain management (Berry & Dahl
2000). In the UK the pain management protocols or algo-
rithms commenced in the late 1990s (Goodacre & Roden
1996). Currently, this intervention accompanied by an
educational component is commonly practiced in the UK
and in other parts of Europe (Sampson et al. 2014). In
Australia, a similar intervention known as nurse-initiated
analgesia (NIA) is being employed successfully in major
EDs, where nurses are able to autonomously administer
analgesia including opioids as clinically indicated from a
formulary (Fry et al. 2011, Shaban et al. 2012, Doherty
et al. 2013).
© 2015 John Wiley & Sons Ltd
NIA is a component of non-medical prescribing, where a
list of medications that can be administered is pre-approved
(such as in a formulary or protocol) and limited according
to the patient’s condition and signs and symptoms
(National Health Workforce Planning & Research Collabo-
ration, 2010). Experimental studies have demonstrated sig-
nificant beneficial effects and the safety of NIA without any
reported adverse effects. Australian studies showed that
among patients who presented with acute pain, time-to-
analgesia (Fry & Holdgate 2002, Kelly et al. 2005) and
pain intensity at discharge (Fry et al. 2004) were signifi-
cantly reduced. Similar results were seen in Hong Kong
among patients with minor musculoskeletal injuries and the
implementation of NIA also enhanced the compliance of
nursing pain assessment (Wong et al. 2007). A study in
Sweden did not find significant reductions in pain intensity
at discharge; however, found significant reductions in time-
to-analgesia, increased analgesia use and improved the satis-
faction of care in patients who presented with abdominal
pain (Muntlin et al. 2011).
In 2002, the study ED participated in a national initiative
to prioritize the improvement of time-to-analgesia (National
Institute of Clinical Studies, 2004). Consequently, the NIA
and nurse-initiated medications (NIM) practice was devel-
oped to enhance patient care and clinical outcomes by
improving pain assessment, providing safe pain management
and reducing time-to-analgesia. The practice of NIA/NIM
was restricted in many hospitals for advance practice nurses
or emergency nurse practitioners (Cole 2003, Plonczynski
et al. 2003, Hudson & Marshall 2008, Hoskins 2011) or
experienced ED nurses (≥2 years) (Fry & Holdgate 2002,
Fry et al. 2004). However, in the study ED a unique
approach has been taken in that all Registered Nurses (RNs)
are mandated to complete the NIA/NIM competency within
a month of commencing with annual re-assessment. The
competency has two components: (1) complete the evidence-
based NIA/NIM Medication Online Learning Package (only
available to nurses in the department); and (2) achieve at
least 90% mark of all five online quizzes. When this has
been accomplished, the ED RNs have the autonomy to
nurse-initiate the following medications without a medical
order: paracetamol, ibuprofen, paracetamol/codeine, mor-
phine, fentanyl, naloxone, metoclopramide, oxybuprocaine
eye drops and adult diphtheria tetanus (ADT) vaccine. The
institutional policy that regulates the NIA/NIM in the ED
satisfies the legislative requirements set by the Queensland
Government’s Health (Drugs & Poisons) Regulation 1996
(Queensland Government and Nursing Act 1992 (Queens-
land Government, 1992).
397
C.J. Cabilan et al.
I am lot more confident, because I have been doing it for a little
while now. I feel confident in my assessment skills and clinical
judgment what’s appropriate for analgesia, rather someone to tell
me what’s required. (Interview 13)
Nurses also tend to nurse-initiate simple analgesics when
they first started:
I give more drugs now, because I know a little bit more. I under-
stand a bit better and how it works due to confidence and experi-
ence. (Interview 16)
The apprehension was also felt by the less-experienced
nurses. Their responses indicated that confidence can
increase with experience and appropriate support:
Obviously I am a lot more confident, in my own nursing abilities;
obviously I still got a lot to learn but I think you get used to get to
know what requirements and what medication to probably give a
patient for certain pain levels for example. And that is going to
come with practice still even now I’d still question myself as to
which analgesia would be better and sometimes I’d talk to someone
else but as you kind of get a bit more confident and you get more
experience you wouldn’t need to do it as much. (Interview 24)
The familiarity of patients’ conditions, which is corre-
lated with experience, influenced confidence and practice:
Confidence is something that builds up knowing the patient’s con-
dition, knowing how to intervene and the awareness of what to
anticipate. (Interview 22)
Discussion
The results suggest that nurses’ medication knowledge, to a
small extent, is determined by how often a medication is
nurse-initiated and their perception of the importance of
certain pharmacological components. Many studies
described nurses’ medication knowledge as somewhat lack-
ing for practice (Markowitz et al. 1981, Boggs et al. 1988,
Sodha et al. 2002, Ndosi & Newell 2009, Simonsen et al.
2011). The overall data denote that although knowledge
deficit is apparent when tested, nursing staff are aware of
their own limitations and act in a manner to provide safe
care.
Blind prescribing can only exist when a prescriber exhi-
bits willingness to prescribe despite being ill-equipped with
knowledge and the deficiency of information-seeking beha-
viours when warranted (Starmer et al. 2013). A small per-
centage of nurses showed evidence of blind prescribing.
There was no evidence of the widespread blind prescribing
previously shown in Starmer et al.’s (2013) study in junior
doctors. While there are a very small proportion of nurses
404
who demonstrated inadequate knowledge of a medication
they frequently initiate, there are also nurses whose knowl-
edge exceeds their nurse-initiating capability. Nurses whose
willingness and the ability to nurse-initiate was mediated by
awareness of their scope of practice and patients’ needs
rather than knowledge solely. Additionally, blind prescrib-
ing was negated by their inclination to safety and informa-
tion-seeking behaviour through the use of reference
materials during uncertainty, by seeking workplace assis-
tance from medical officers and other senior nursing staff
and actively participating in ongoing education and train-
ing.
To date, there have been no studies that investigated the
context of decision-making related to nurse-initiating in the
ED; however, there are similar studies (Luker & Kenrick
1992, Luker 1998, Bradley et al. 2007, Offredy et al. 2008,
Daughtry & Hayter 2010) that evaluated the topic mainly
in community settings. Published during the advent of nurse
prescribing in the UK, one study emphasized how lack of
knowledge and confidence incited anxiety, which in a way
impeded the practice (Luker 1998). This finding was
repeated in this study, where nurses initially held reserva-
tions towards nurse-initiating and understandably so when
the foreign practice is inherent with accountability and
responsibility. However, knowledge and confidence do not
remain stagnant; they improve with time as also previously
reported by prescribing nurses (While & Biggs 2004, Brad-
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
from colleagues. Similarly, Offredy et al. (2008) discussed
that pharmacological knowledge of nurse prescribers was
insufficient and often intuition was relied on, which was
labelled ‘potentially problematic’ (p 825). However, our
findings are in disagreement with the latter study because
while nurses’ knowledge when assessed may be incomplete,
it is not implicit that knowledge is not pursued when
required. For example, nurses routinely consult with the
available resources to attain the knowledge necessary to
safely nurse-initiate a drug.
The context of nurses’ decision-making when nurse-initi-
ating is multifactorial and complex (Latter & Courtenay
2004); hence, it cannot be explained solely by cognitive rea-
soning theories such as analytical or intuitive theories (Muir
2004, Banning 2008) as previous studies have done (Luker
& Kenrick 1992, Offredy et al. 2008). Rather, nurse-initiat-
ing practices should be explained by predictive behavioural
theories (Godin et al. 2008), such as theory of planned
behaviour (Ajzen 1991). The theory of planned behaviour
explains that a behaviour, in this case, nurse-initiating
© 2015 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department
Manias E. & Bullock S. (2002) The educational preparation of
undergraduate nursing students in pharmacology: perceptions
and experiences of lecturers and students. International Journal
of Nursing Studies 39, 757–769.
Markowitz J.S., Pearson G., Loewenstein R. & Kay B.G. (1981)
Nurses, physicians and pharmacists: their knowledge of hazards
of medications. Nursing Research 30, 366–370.
Milton C.L. (2012) Altruism. Nursing Science Quarterly 25,
222–224.
Morrison-Griffiths S., Snowden M.A. & Pirmohamed M. (2002)
Pre-registration nurse education in pharmacology: is it adequate
for the roles that nurses are expected to fulfil? Nurse Education
Today 22, 447–456.
Morse J.M. (2015) Data were saturated. Qualitative Health
Research 25, 587–588.
Muir N. (2004) Clinical decision-making: theory and practice.
Nursing Standard 18, 47–52.
Muntlin A., Carlsson M., S€afwenberg U. & Gunningberg L. (2011)
Outcomes of a nurse-initiated intravenous analgesic protocol for
abdominal pain in an emergency department: a quasi-experimental
study. International Journal of Nursing Studies 48, 13–23.
National Health Workforce Planning and Research Collaboration
(2010) Non-medical Prescribing: An Exploration of Likely
Nature of and Contingencies for, Developing A Nationally
Consistent Approach to Prescribing by Non-medical Health
Professionals. National Health Workforce Taskforce.
National Institute of Clinical Studies (2004) National Emergency
Department Collaborative Report. NICS, Melbournce.
Ndosi M.E. & Newell R. (2009) Nurses’ knowledge of
pharmacology behind drugs they commonly administer. Journal
of Clinical Nursing 18, 570–580.
Offredy M., Kendall S. & Goodman C. (2008) The use of
cognitive continuum theory and patient scenarios to explore
nurse prescribers’ pharmacological knowledge and decision-
making. International Journal of Nursing Studies 45, 855–868.
Plonczynski D., Oldenburg N. & Buck M. (2003) The past, present
and future of nurse prescribing in the United States. Nurse
Prescribing 1, 170–174.
Queensland Government. Nursing Act 1992 (Act No. 55 of 1992).
Viewed January 6, 2014. Queensland Government, Brisbane.
Queensland Government (1996) Health (Drugs and Poisons)
Regulation 1996. Queensland Government, Brisbane, Australia.
Viewed January 6, 2014.
© 2015 John Wiley & Sons Ltd
Rupp T. & Delaney K.A. (2004) Inadequate analgesia in emergency
medicine. Annals of Emergency Medicine 43, 494–503.
Sampson F., Goodacre S. & O’cathain A. (2014) Interventions to
improve the management of pain in emergency departments:
systematic review and narrative synthesis. Emergency Medicine
Journal 31, e9–e18.
Shaban R.Z., Holzhauser K., Gillespie K., Huckson S. & Bennetts
S. (2012) Characteristics of effective interventions supporting
quality pain management in Australian emergency departments:
an exploratory study. Australasian Emergency Nursing Journal
15, 23–30.
Simonsen B.O., Johansson I., Daehlin G.K., Osvik L.M. & Farup
P.G. (2011) Medication knowledge, certainty and risk of errors
in health care: a cross-sectional study. BMC Health Services
Research 11, 175.
Sodha M., Mclaughlin M., Williams G. & Dhillon S. (2002)
Nurses’ confidence and pharmacological knowledge: a study.
British Journal of Community Nursing 7, 309–315.
Starmer K., Sinnott M., Shaban R., Donegan E. & Kapitzke D.
(2013) Blind prescribing: a study of junior doctors’ prescribing
preparedness in an Australian emergency department. Emergency
Medicine Australasia 25, 147–153.
Todd K.H., Sloan E.P., Chen C., Eder S. & Wamstad K. (2002)
Survey of pain etiology, management practices and patient
satisfaction in two urban emergency departments. Canadian
Journal of Emergency Medicine 4, 252–256.
Todd K. H., Ducharme J., Choiniere M., Crandall C. S., Fosnocht
D. E., Homel P., Tanabe P. & Group P. S. (2007) Pain in the
emergency department: results of the pain and emergency
medicine initiative (PEMI) multicenter study. The Journal of Pain
8, 460–466.
Von Dietze E. & Orb A. (2000) Compassionate care: a moral
dimension of nursing*. Nursing Inquiry 7, 166–174.
While A.E. & Biggs K.S. (2004) Benefits and challenges of nurse
prescribing. Journal of Advanced Nursing 45, 559–567.
Wilson J.E. & Pendleton J.M. (1989) Oligoanalgesia in the
emergency department. The American Journal of Emergency
Medicine 7, 620–623.
Wong E.M., Chan H.M., Rainer T.H. & Ying C.S. (2007) The effect
of a triage pain management protocol for minor musculoskeletal
injury patients in a Hong Kong emergency department.
Australasian Emergency Nursing Journal 10, 64–72.
407
C.J. Cabilan et al.

Table 1 Questions for semi-structured interviews. Table 2 Participant characteristics. N=80.

Semi-structured interview questions Item Categories n %

Please describe your own nurse-initiating medications practice Age group 21-30 41 36
9
Do you have any concerns about the nurse-initiating medications 31-40 21 28
4
practice? 41-50 13 23
4
Describe the factors that influence your willingness to nurse-initiate 41-60 5 11
3
medications and how? Qualifications Bachelor of nursing 78 95
1
Describe your confidence in nurse-initiating medications (university-trained)
What influences your confidence? Bachelor of nursing 2 4
9
(hospital-trained)
Post-graduate Grad Certificate/Diploma 17 11
9
qualifications (n = 30) Masters 13 8
8
Post-registration 0-2 11 4
8
Data analysis
experience (in years) 3-5 21 18
3
Quantitative statistical analysis was conducted using IBM 6-10 29 37
8
11-15 5 8
7
SPSS Statistics version 23 (IBM Corporation, St Leonards,
16+ 14 30
4
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 37
8
and satisfaction. Medication knowledge data were non-nor- 6-10 21 35
mally distributed, therefore Kruskal–Wallis and Mann– 11-15 4 8
9
16+ 3 8
3
Whitney U-tests was used to describe associations between
Competency <3 months 7 3
4
medication knowledge and other variables. Qualitative Inter- last achieved 3-6 months 21 20
5
view data were analysed using Braun and Clarke’s (2006) >6 months 52 76
1
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

The nurses’ medication knowledge is presented in Figure 2.

Results
Descriptive statistics
Of the 159 nurses eligible to participate, 106 agreed to par-
ticipate and 80 questionnaires were returned and com-
pleted. Nurses ranged in age from 21-60. The total nursing
experience and NIA/NIM experience varied across cate-
gories as shown in Table 2. Almost all nurses (95
1%) indi-
cated that the existing NIA/NIM education package in the
department met their learning needs.
Nurses’ NIA/NIM activity were up to 36 times per week
(median = 5, IQR = 6) with the actual number dependent
on employed hours and the area of ED where nurses are
assigned. A Kruskal–Wallis test revealed that NIA/NIM
activity did not significantly vary between categories of
nursing experience (v2(4) = 5
4, n = 80, P = 0
2) and years
of nurse-initiating experience (v2 (4) = 1
5, n = 80, P = 0
8).
The most commonly nurse-initiated medications were
paracetamol (87
5% of cohort), oxycodone (70%), mor-
phine (62
5%), ibuprofen (57
5%), metoclopramide
(36
3%), fentanyl (21
3%), adult diphtheria tetanus vaccine
(6
3%), oxybuprocaine (2
5%) and naloxone (1
3%).
More than 70% of nurses thought that generic name, indi-
cations, contraindications, side-effects, dose and route were
the most essential. The medication knowledge in contrast
to what nurses thought they should know was inconsistent.
For example, for narcotic medications knowledge of dose
was rated as essential by 98
8% of nurses, yet only 20%
and 65% correctly answered the dose for fentanyl and oxy-
codone respectively. Inversely, less than 50% of nurses
believed that brand names are essential to know but most
had correct answers for oxycodone (91
3%) and metoclo-
pramide (88
8%).
Using the criteria set out by Starmer et al. (2013) and
Eley et al. (2014) of adequate knowledge being at least
80% (overall score of at least 5) on medication knowledge
of essential components, 80% of nurses achieved this for
oxycodone, 62
5% for metoclopramide, 52
5% for ADT,
35% for fentanyl and 27
5% for oxybuprocaine. To test
the phenomenon of blind prescribing we directly compared
the proportion of nurses who had adequate knowledge to
their nurse-initiating frequency. Results show that there is a
small number of nurses whose medication knowledge is
limited but frequently nurse-initiated. While this is evidence

400 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department

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

20·0 %correct ADT

vaccine
10·0

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.

© 2015 John Wiley & Sons Ltd 401

C.J. Cabilan et al.

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 0
604
N 30% (24) 20% (16) 5 (2-6)
Metoclopramide
Y 36
3% (29) 62
5% (50) 5 (2-6) 642
5 0
313
N 63
7% (51) 37
5% (30) 5 (3-6)
Fentanyl
Y 21
3% (17) 35% (28) 4 (1-6) 470
50 0
429
N 78
7% (63) 65% (52) 4 (0-6)
ADT
Y 6
3% (5) 52
5% (42) 6 (4-6) 105 0
091
N 93
7% (75) 47
5% (38) 5 (0-6)
Oxybuprocaine
Y 2
5% (2) 27
5% (22) 4
5 (4-5) 45
50 0
309
N 97
5% (78) 72
5% (58) 4 (0-6)

Medication knowledge and NIA/NIM experience
A Kruskal–Wallis test showed that there was no statistically
significant association between tested knowledge of any of
the nurse-initiated medication and the length of nurse-
initiated experience. The exception to this was oxybupro-
caine which showed a positive association between years of
nurse-initiating experience and the knowledge scores
(v2(4) = 16
9, n = 80, P = 0
002); however, only two nurses
indicate that they would nurse-initiate this medication.
get busy. Without the programme, it can mean more wait for
the patient. But if you can nurse-initiate analgesia, patients
would not have to wait. So yeah it has a place in patient care.
(Interview 13)
Additionally, most nurses aim for patients to be pain-
free. A nurse said this on the issue of nurses’ willingness to
nurse-initiate:
The transcendent aim [is] to get patients pain-free. No one should
be in pain. (Interview 9)

Some nurses suggested expanding the list of medications

Semi-structured interviews
Forty-nine nurses consented to be interviewed, 24 inter-
views were completed at which point data saturation was
reached. Six nurses of the interviewed nurses had less than
two years of NIA/NIM experience, 14 between three and
ten years and two more than ten years. Four major themes
were identified: (1) patient-centred care; (2) caution and
safety are principles of practice; (3) continuing education;
and (4) improvement of practice over time.
they can nurse-initiate, particularly adding diazepam in the
mental health unit:
I think diazepam in mental health would be good. It is good for
the benefit of nurses and patients, particularly in preventing patient
aggression from treatment delays. (Interview 18)
There was also a common belief that the practice reduces
time-to-analgesia. One commented that ‘intuitively it does’
but it needs to be quantified.

Caution and safety are principles of practice

Patient-centred care
Without exception all 24 nurses viewed the NIA/NIM prac-
tice as a valuable competency as an ED nurse because it
benefits the patients:
When it comes to patient care and putting patients first – it is a
brilliant programme. It is an emergency department that works
on a triage system, so if there are consecutive patients doctors
There was no indication of reluctance to initiate, rather
nurses exercised caution and safety when nurse-initiating
was purely for the safety of the patients and to protect
themselves from litigation. Three essential elements of cau-
tion and safety were apparent: patient assessment, initiating
within their scope and reassurance.
Nurses stressed that patient assessment is a pre-requisite
for NIA/NIM because patients’ subjective and objective

402 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department
cues determine the type of drug they require or the inter-
ventions they need to receive:
You meet your patient, get their history, during that process you
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.
(Interview 3)
Nurses acknowledged that their knowledge of a particu-
lar medication impacted on the decision-making process.
They stated that they are more inclined to nurse-initiate
medications that they are ‘comfortable’ that they have
adequate knowledge of:
As far as feeling confident, I only give medications that I am confi-
dent giving. One for example is oxybuprocaine. I don’t actually
work in the area that would see eye injuries. I would think twice
before giving it, I do know the contraindications for it, but it is
something I’d be very mindful of giving. (Interview 8)
Others were also mindful of their professional safety
when nurse-initiating:
I do not want to give something and then to have a side-effect and
myself look like an idiot . . . to feel like I’ve caused more harm to
this person, not having been safe about administering something
I’m putting my name to. (Interview 19)
However, this is not implicit that nurses will withhold a
drug when needed, rather nurses routinely ask for a second
opinion from other nurses or doctors prior to nurse-initiat-
ing, or seek additional information from the readily avail-
able resources. This was reported by all participants:
If I was looking at initiating something and wasn’t very certain, I
would approach senior staff or CNCs (clinical nurse consultants)
just to clarify any confusion I had. . . .staff are always amenable to
questions. (Interview 10)
Reassurance is often required to ensure that a drug can
be given safely to patients and also safe for the nurses to
give:
And even if I nurse-initiate I’d get the doctor’s opinion first . . . just
more for my own safety and patient’s safety. Just to cover myself
really. (Interview 23)
Reassurance is not only sought from colleagues but also
secured from evidence-based sources such as the Monthly
Index of Medical Specialities (MIMS) or the online learning
package:
You do ask people, but I think it is best to do your own investiga-
tions and go through your own process, like looking up MIMS,
© 2015 John Wiley & Sons Ltd
then you know it’s accurate. Whereas people would have a differ-
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
15)
Continuing education
All nurses found the content of the NIA/NIM education
package adequate because it provides baseline knowledge
necessary for nurse-initiating:
The package is good, because it runs you through each medication.
It gives you criteria that have to be met, before you can nurse-initi-
ate. It gives you guidelines or parameters that you are looking for.
You get enough basic knowledge to feel comfortable in what you
are doing. (Interview 13)
There were no concerns expressed in terms of reviewing
the education package and renewing the competency annu-
ally. In fact, a few suggested that the competency assess-
ment should be more frequent; however, this was only
expressed by nurses who had less than 2 years of experi-
ence:
NIA/NIM assessment should be more frequent for grads. (Interview
23)
Some said that frequent assessments are unnecessary and
could be a potential burden. One nurse commented that
this would be an individual preference:
It’s probably alright yearly, but if you did not use it as frequently
and it wasn’t as familiar you’d need to do it more, like every six
months or something. Or if you weren’t feeling confident in doing
things, you’d be needing it more sooner. (Interview 24)
Others have called for stringent mode of assessment as
opposed to having it as an open book because of the possi-
bility that it lends itself to abuse:
. . . it is easy to consult another RN. The testing conditions are not
very strict, so maybe that’s where there is a downfall? (Interview 1)
Meanwhile, others do not see this as a disadvantage;
rather they believe that this is to benefit them.
Improvement of practice over time
All nurses admitted to some anxiety when they first started
initiating and some had initial reservations towards NIA/
NIM. To some extent, this impacted on the type and the
number of medications being nurse-initiated initially. How-
ever, with practice and exposure, nurses said that as their
confidence and knowledge improved, the number of medi-
cations they nurse-initiate also increased:
403
C.J. Cabilan et al.
I am lot more confident, because I have been doing it for a little
while now. I feel confident in my assessment skills and clinical
judgment what’s appropriate for analgesia, rather someone to tell
me what’s required. (Interview 13)
Nurses also tend to nurse-initiate simple analgesics when
they first started:
I give more drugs now, because I know a little bit more. I under-
stand a bit better and how it works due to confidence and experi-
ence. (Interview 16)
The apprehension was also felt by the less-experienced
nurses. Their responses indicated that confidence can
increase with experience and appropriate support:
Obviously I am a lot more confident, in my own nursing abilities;
obviously I still got a lot to learn but I think you get used to get to
know what requirements and what medication to probably give a
patient for certain pain levels for example. And that is going to
come with practice still even now I’d still question myself as to
which analgesia would be better and sometimes I’d talk to someone
else but as you kind of get a bit more confident and you get more
experience you wouldn’t need to do it as much. (Interview 24)
The familiarity of patients’ conditions, which is corre-
lated with experience, influenced confidence and practice:
Confidence is something that builds up knowing the patient’s con-
dition, knowing how to intervene and the awareness of what to
anticipate. (Interview 22)
Discussion
The results suggest that nurses’ medication knowledge, to a
small extent, is determined by how often a medication is
nurse-initiated and their perception of the importance of
certain pharmacological components. Many studies
described nurses’ medication knowledge as somewhat lack-
ing for practice (Markowitz et al. 1981, Boggs et al. 1988,
Sodha et al. 2002, Ndosi & Newell 2009, Simonsen et al.
2011). The overall data denote that although knowledge
deficit is apparent when tested, nursing staff are aware of
their own limitations and act in a manner to provide safe
care.
Blind prescribing can only exist when a prescriber exhi-
bits willingness to prescribe despite being ill-equipped with
knowledge and the deficiency of information-seeking beha-
viours when warranted (Starmer et al. 2013). A small per-
centage of nurses showed evidence of blind prescribing.
There was no evidence of the widespread blind prescribing
previously shown in Starmer et al.’s (2013) study in junior
doctors. While there are a very small proportion of nurses
404
who demonstrated inadequate knowledge of a medication
they frequently initiate, there are also nurses whose knowl-
edge exceeds their nurse-initiating capability. Nurses whose
willingness and the ability to nurse-initiate was mediated by
awareness of their scope of practice and patients’ needs
rather than knowledge solely. Additionally, blind prescrib-
ing was negated by their inclination to safety and informa-
tion-seeking behaviour through the use of reference
materials during uncertainty, by seeking workplace assis-
tance from medical officers and other senior nursing staff
and actively participating in ongoing education and train-
ing.
To date, there have been no studies that investigated the
context of decision-making related to nurse-initiating in the
ED; however, there are similar studies (Luker & Kenrick
1992, Luker 1998, Bradley et al. 2007, Offredy et al. 2008,
Daughtry & Hayter 2010) that evaluated the topic mainly
in community settings. Published during the advent of nurse
prescribing in the UK, one study emphasized how lack of
knowledge and confidence incited anxiety, which in a way
impeded the practice (Luker 1998). This finding was
repeated in this study, where nurses initially held reserva-
tions towards nurse-initiating and understandably so when
the foreign practice is inherent with accountability and
responsibility. However, knowledge and confidence do not
remain stagnant; they improve with time as also previously
reported by prescribing nurses (While & Biggs 2004, Brad-
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
from colleagues. Similarly, Offredy et al. (2008) discussed
that pharmacological knowledge of nurse prescribers was
insufficient and often intuition was relied on, which was
labelled ‘potentially problematic’ (p 825). However, our
findings are in disagreement with the latter study because
while nurses’ knowledge when assessed may be incomplete,
it is not implicit that knowledge is not pursued when
required. For example, nurses routinely consult with the
available resources to attain the knowledge necessary to
safely nurse-initiate a drug.
The context of nurses’ decision-making when nurse-initi-
ating is multifactorial and complex (Latter & Courtenay
2004); hence, it cannot be explained solely by cognitive rea-
soning theories such as analytical or intuitive theories (Muir
2004, Banning 2008) as previous studies have done (Luker
& Kenrick 1992, Offredy et al. 2008). Rather, nurse-initiat-
ing practices should be explained by predictive behavioural
theories (Godin et al. 2008), such as theory of planned
behaviour (Ajzen 1991). The theory of planned behaviour
explains that a behaviour, in this case, nurse-initiating
© 2015 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department
Factors that influence nurse-initiating practices in the ED
Safety, personal
Attitudes preference, and/or
practice appraisal
Patient expectations,
Subjective code of conduct,
Intention to
norms and/or
nurse-initiate
guidelines/policies
Experience,
Perceived knowledge,
behavioural competency
control confidence, and/or
resources
Figure 3 Theory of planned behaviour (Ajzen, 1991) applied in nurse-initiating practice.
practice, is a product of intention and perceived beha-
vioural control (Ajzen 1991) (Figure 3). Nurses’ attitudes
towards nurse-initiating are mainly motivated by patient
benefits and influenced by safety. Putting it simply, it could
be because altruism and compassionate care are inherent of
the nursing profession (Fagermoen 1995, Von Dietze &
Orb 2000, Milton 2012). Moreover, nurses are likely to
give attention to what could go wrong as a result of their
actions (Luker 1998), which is perhaps why there is strong
emphasis on safety. However, it is also possible that the
accountability and responsibility associated with nurse-initi-
ating underpin safety and cautious practice (Bradley et al.
2007). Subjective norms are determined by social expecta-
tions to accomplish or not to accomplish a behaviour
(Ajzen & Madden 1986, Ajzen 1991). This includes
patients’ expectations, organizational expectations, depart-
mental guidelines or policies, or professional code of con-
duct, which guide the actions of nurses. Perceived
behavioural control directly influences both intention and
behaviour. Behavioural control is motivated by previous
experience, existing knowledge, competency and the confi-
dence to accomplish the behaviour (Ajzen & Madden
1986, Ajzen 1991). Therefore, when nurses perceived them-
selves as competent and confident they are thought to have
more control. This is evident in the qualitative findings
when nurses’ only tend to nurse-initiate simple analgesics at
the start, but as with clinical exposure they grew confident
and so did the list of medications they would nurse-initiate.
It is mandatory that systems that enable the maintenance
of patients’ and nurses’ professional safety are in place in
institutions that support the practice of NIA/NIM. This
includes, but should not be limited to, access to evidence-
based resources and continuing support and education for
nurses. The NIA/NIM is a well-used practice in this ED
and is a growing practice in Australia. The practice is ade-
© 2015 John Wiley & Sons Ltd
Nurse-initiating
practice
quately explored in terms of patient endpoints (e.g. satisfac-
tion, pain) and clinical efficiency (e.g. time-to-analgesia,
length of stay) but less so in clinician outcomes (e.g. knowl-
edge, willingness), which is essential to expand and improve
this component of non-medical prescribing in the ED. For
example, future research could address the compliance of
NIA/NIM. Furthermore, the qualitative findings imply that
nurses employ safety practices when nurse-initiating, which
has not been tested. This could be addressed in a study
comparing the quality of prescribing between nurses and
doctors, or medication errors related to NIA/NIM.
Limitations
The study is confined to one ED which may limit the trans-
ferability of results, notwithstanding it could serve basis for
future explorations of nurse-initiating practices in other
EDs. At the time of report, empiric evidence of the depart-
ment’s time-to-analgesia and experience of pain relief,
which is hypothesized to be affected by NIA/NIM, is being
extracted by Hughes and colleagues (unpublished). The rep-
resentativeness of the study population could be limited to
experienced nurses, but it is worth noting that efforts have
been made so that views of nurses from all levels are repre-
sented.
Conclusion
Nurses’ medication knowledge is modest. In this study, the
medication knowledge was not significantly different
between nurses who frequently and infrequently nurse-initi-
ate and was comparable among nurses with different levels
of experience. Nevertheless, the nurse-initiating practice is
not motivated by knowledge alone, but influenced by
patients’ needs, nurses’ scope of practice and principles of
405
C.J. Cabilan et al.
safety such as information-seeking behaviours. It is appar-
ent that support, continuing education and access to
resources are fundamental to nurses to practice safely.
Nurse-initiating practice is an expanding component of
non-medical prescribing and future research is welcome to
further the practice. Studies could address some aspects that
require more investigation, for example, compliance, medi-
cation safety and clinician satisfaction.
Funding
The authors acknowledge the Queensland Emergency Medi-
cine Research Foundation for funding the qualitative com-
ponent of this study.
Conflict of interest
The authors have no conflicts of interest to declare.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/recommendations/)]:
• substantial contributions to conception and design,
acquisition of data or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content.
References
Ajzen I. (1991) The theory of planned behavior. Organizational
Behavior and Human Decision Processes 50, 179–211.
Ajzen I. & Madden T.J. (1986) Prediction of goal-directed
behavior: attitudes, intentions and perceived behavioral control.
Journal of Experimental Social Psychology 22, 453–474.
Australian Council on Healthcare Standards (2012) Emergency
Medicine Version 5. Retrospective Data in Full. Australasian
Clinical Indicator Report 2004–2011. ACHS, Sydney, NSW.
Banning M. (2008) A review of clinical decision making: models
and current research. Journal of Clinical Nursing 17, 187–195.
Berry P.H. & Dahl J.L. (2000) The new JCAHO pain standards:
implications for pain management nurses. Pain Management
Nursing 1, 3–12.
Boggs P., Brown-Molnar C.S. & Delapp T.D. (1988) Nurses’ drug
knowledge. Western Journal of Nursing Research 10, 84–93.
Bradley E. & Nolan P. (2007) Impact of nurse prescribing: a
qualitative study. Journal of Advanced Nursing 59, 120–128.
Bradley E., Hynam B. & Nolan P. (2007) Nurse prescribing:
reflections on safety in practice. Social Science & Medicine 65,
599–609.
406
Braun V. & Clarke V. (2006) Using thematic analysis in
psychology. Qualitative Research in Psychology 3, 77–101.
Cole F.L. (2003) Emergency care advanced practice nursing in the
US: an overview. Emergency Nurse 11, 22–25.
Daughtry J. & Hayter M. (2010) A qualitative study of
practice nurses ‘prescribing experiences. Practice Nursing 21,
310–314.
Doherty S., Knott J., Bennetts S., Jazayeri M. & Huckson S. (2013)
National project seeking to improve pain management in the
emergency department setting: findings from the NHMRC-NICS
National Pain Management Initiative. Emergency Medicine
Australasia 25, 120–126.
Eley R., Spencer L., Starmer K. & Sinnott M. (2014) Prescribing
knowledge revisited: time for action and awareness. Emergency
Medicine Australasia 26, 211–212.
Fagermoen M.S. (1995) The Meaning of Nurses’ Work: A
Descriptive Study of Values Fundamental to Professional Identity
in Nursing. Dissertations and Master’s theses, The University of
Rhode Island.
Fry M. & Holdgate A. (2002) Nurse-initiated intravenous
morphine in the emergency department: efficacy, rate of adverse
events and impact on time to analgesia. Emergency Medicine 14,
249–254.
Fry M., Ryan J. & Alexander N. (2004) A prospective study of
nurse initiated panadeine forte: expanding pain management in
the ED. Accident and Emergency Nursing 12, 136–140.
Fry M., Bennetts S. & Huckson S. (2011) An Australian audit of
ED pain management patterns. Journal of Emergency Nursing
37, 269–274.
Godin G., Belanger-Gravel A., Eccles M. & Grimshaw J. (2008)
Healthcare professionals’ intentions and behaviours: a systematic
review of studies based on social cognitive theories. Implement
Science 3, 1–12.
Goodacre S. & Roden R. (1996) A protocol to improve analgesia
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
literature review. International Emergency Nursing 19, 125–140.
Hudson P.V. & Marshall A.P. (2008) Extending the nursing role in
emergency departments: challenges for Australia. Australasian
Emergency Nursing Journal 11, 39–48.
Kelly A.-M., Brumby C. & Barnes C. (2005) Nurse-initiated,
titrated intravenous opioid analgesia reduces time to analgesia
for selected painful conditions. Canadian Journal of Emergency
Medicine 7, 149–54.
King R.L. (2004) Nurses’ perceptions of their pharmacology
educational needs. Journal of Advanced Nursing 45, 392–400.
Latter S. & Courtenay M. (2004) Effectiveness of nurse
prescribing: a review of the literature. Journal of Clinical
Nursing 13, 26–32.
Latter S., Rycroft-Malone J., Yerrell P. & Shaw D. (2001) Nurses’
educational preparation for a medication education role: findings
from a national survey. Nurse Education Today 21, 143–154.
Luker K.A. (1998) Decision making: the context of nurse
prescribing. Journal of Advanced Nursing 27, 657–665.
Luker K.A. & Kenrick M. (1992) An exploratory study of the
sources of influence on the clinical decisions of community
nurses. Journal of Advanced Nursing 17, 457–466.
© 2015 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – MIXED METHODS Nurse-initiated medications in the emergency department
Manias E. & Bullock S. (2002) The educational preparation of
undergraduate nursing students in pharmacology: perceptions
and experiences of lecturers and students. International Journal
of Nursing Studies 39, 757–769.
Markowitz J.S., Pearson G., Loewenstein R. & Kay B.G. (1981)
Nurses, physicians and pharmacists: their knowledge of hazards
of medications. Nursing Research 30, 366–370.
Milton C.L. (2012) Altruism. Nursing Science Quarterly 25,
222–224.
Morrison-Griffiths S., Snowden M.A. & Pirmohamed M. (2002)
Pre-registration nurse education in pharmacology: is it adequate
for the roles that nurses are expected to fulfil? Nurse Education
Today 22, 447–456.
Morse J.M. (2015) Data were saturated. Qualitative Health
Research 25, 587–588.
Muir N. (2004) Clinical decision-making: theory and practice.
Nursing Standard 18, 47–52.
Muntlin A., Carlsson M., S€afwenberg U. & Gunningberg L. (2011)
Outcomes of a nurse-initiated intravenous analgesic protocol for
abdominal pain in an emergency department: a quasi-experimental
study. International Journal of Nursing Studies 48, 13–23.
National Health Workforce Planning and Research Collaboration
(2010) Non-medical Prescribing: An Exploration of Likely
Nature of and Contingencies for, Developing A Nationally
Consistent Approach to Prescribing by Non-medical Health
Professionals. National Health Workforce Taskforce.
National Institute of Clinical Studies (2004) National Emergency
Department Collaborative Report. NICS, Melbournce.
Ndosi M.E. & Newell R. (2009) Nurses’ knowledge of
pharmacology behind drugs they commonly administer. Journal
of Clinical Nursing 18, 570–580.
Offredy M., Kendall S. & Goodman C. (2008) The use of
cognitive continuum theory and patient scenarios to explore
nurse prescribers’ pharmacological knowledge and decision-
making. International Journal of Nursing Studies 45, 855–868.
Plonczynski D., Oldenburg N. & Buck M. (2003) The past, present
and future of nurse prescribing in the United States. Nurse
Prescribing 1, 170–174.
Queensland Government. Nursing Act 1992 (Act No. 55 of 1992).
Viewed January 6, 2014. Queensland Government, Brisbane.
Queensland Government (1996) Health (Drugs and Poisons)
Regulation 1996. Queensland Government, Brisbane, Australia.
Viewed January 6, 2014.
© 2015 John Wiley & Sons Ltd
Rupp T. & Delaney K.A. (2004) Inadequate analgesia in emergency
medicine. Annals of Emergency Medicine 43, 494–503.
Sampson F., Goodacre S. & O’cathain A. (2014) Interventions to
improve the management of pain in emergency departments:
systematic review and narrative synthesis. Emergency Medicine
Journal 31, e9–e18.
Shaban R.Z., Holzhauser K., Gillespie K., Huckson S. & Bennetts
S. (2012) Characteristics of effective interventions supporting
quality pain management in Australian emergency departments:
an exploratory study. Australasian Emergency Nursing Journal
15, 23–30.
Simonsen B.O., Johansson I., Daehlin G.K., Osvik L.M. & Farup
P.G. (2011) Medication knowledge, certainty and risk of errors
in health care: a cross-sectional study. BMC Health Services
Research 11, 175.
Sodha M., Mclaughlin M., Williams G. & Dhillon S. (2002)
Nurses’ confidence and pharmacological knowledge: a study.
British Journal of Community Nursing 7, 309–315.
Starmer K., Sinnott M., Shaban R., Donegan E. & Kapitzke D.
(2013) Blind prescribing: a study of junior doctors’ prescribing
preparedness in an Australian emergency department. Emergency
Medicine Australasia 25, 147–153.
Todd K.H., Sloan E.P., Chen C., Eder S. & Wamstad K. (2002)
Survey of pain etiology, management practices and patient
satisfaction in two urban emergency departments. Canadian
Journal of Emergency Medicine 4, 252–256.
Todd K. H., Ducharme J., Choiniere M., Crandall C. S., Fosnocht
D. E., Homel P., Tanabe P. & Group P. S. (2007) Pain in the
emergency department: results of the pain and emergency
medicine initiative (PEMI) multicenter study. The Journal of Pain
8, 460–466.
Von Dietze E. & Orb A. (2000) Compassionate care: a moral
dimension of nursing*. Nursing Inquiry 7, 166–174.
While A.E. & Biggs K.S. (2004) Benefits and challenges of nurse
prescribing. Journal of Advanced Nursing 45, 559–567.
Wilson J.E. & Pendleton J.M. (1989) Oligoanalgesia in the
emergency department. The American Journal of Emergency
Medicine 7, 620–623.
Wong E.M., Chan H.M., Rainer T.H. & Ying C.S. (2007) The effect
of a triage pain management protocol for minor musculoskeletal
injury patients in a Hong Kong emergency department.
Australasian Emergency Nursing Journal 10, 64–72.
407
C.J. Cabilan et al.

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

Reasons to publish your work in 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).

408 © 2015 John Wiley & Sons Ltd