Is the Australian nursing workforce ready to embrace prescribing under supervision? A cross‐sectional survey

Abstract Aim The aim was to explore nurses' preparedness to expand their practice to prescribe medicines under a supervision model. Design This was a cross‐sectional study. Methods A convenience sample of Australian nurses recruited from memberships of State‐based Nursing and Midwifery Unions and professional bodies from diverse care settings. Nurses undertook an online researcher‐constructed survey between March and July 2021 to identify current prescribing practices, motivations for undertaking education in prescribing and perceived barriers to implementation of nurse prescribing under supervision. Data related to demographics, nursing experience and barriers to becoming a prescriber were analysed descriptively. Logistic regression was used to model nursing experience variables with desire to become a prescriber. Results A total of 4424 nurses participated with the majority (n = 3645, 82%) reporting they were highly likely to expand their practice to prescribe medicines under supervision. The main motivations to prescribe were to enhance patient care and job satisfaction. Nurses were more likely to want to prescribe if they had <10 years experience (95% CI = 0.3–0.5, p < 0.001), held a bachelor's degree (95% CI = 1.3–2.2, p < 0.001) or higher qualification (95% CI = 1.8–2.9, p < 0.001). Most reported lack of acknowledgement of increased responsibility and workloads (n = 4098, 93%), and insufficient organizational support (n = 4197, 95%) may prevent uptake of nurse prescribing. Conclusions Most Australian nurses demonstrated their preparedness to embrace the role of prescribing under supervision. The perceived barriers identified in this study can inform future implementation of this expanded nursing role. Impact The Nursing and Midwifery Board of Australia has proposed a standard of practice to enable nurses to prescribe under supervision. Models of nurse prescribing are being considered globally to address population needs. Successful adoption of this practice is dependent on aspects such as key personnel's acceptance of the initiative. The workforce readiness and barriers highlighted in this study can inform implementation at policy and organizational levels.


| INTRODUC TI ON
Extension of nursing roles has been touted as the quickest and most cost-effective means to universal health coverage (Crisp et al., 2018).
Universal health coverage ensures that individuals are provided with quality health services based on their health needs without financial hardship (WHO, 2021). The International Council of Nurses (ICN) has made a global call to action and published guidelines on prescriptive authority for nurses to facilitate a common understanding of nurse prescribing to enhance access to medicine, improve patient outcomes and optimize the knowledge and skills of the nursing workforce (Stewart et al., 2021). The ICN recognize that although labelled with various titles, nurse prescribing practice falls into three categories, independent, supplementary and prescribing via a protocol or arrangement (Stewart et al., 2021). Nurse prescribing has been implemented in many countries including Canada, China, Cyprus, Denmark, Finland, Israel, New Zealand, Sweden, United Kingdom and others (Ladd & Schober, 2018). Role expansion is occurring worldwide (Maier, 2019); however, reframing professional boundaries requires associated changes to legislation and policy (Niezen & Mathijssen, 2014). In 2018, the Nursing and Midwifery Board of Australia proposed the introduction of a Registered Nurse Prescribing Standard of Practice according to a supervised model (NMBA, 2018). Within this model, independent prescribers are practitioners with the authority to prescribe medicines autonomously (i.e. medical practitioners, nurse practitioners). The supervised model reflects the Health Professionals Prescribing Pathway Model 2 and will enable registered nurses to prescribe under the supervision of an independent prescriber (HWA, 2013).

| BACKG ROU N D
Globally, nurses practise within varying prescribing models. In some countries such as Australia, Canada, New Zealand and the United States of America, a limited number of master's degree qualified, advanced practice nurses are authorized to independently prescribe medicine (Maier & Aiken, 2016). Other countries employ a supported model involving the nurse and an independent prescriber, for example, the task sharing model adopted in Madagascar, Ethiopia and Pakistan (Ladd & Schober, 2018). Non-medical professionals have been prescribing according to both independent and supplementary prescribing models for over 30 years in the United Kingdom, (Maier, 2019) where this practice is well accepted by clinicians and patients and provides benefits for patients, the organization and nurses (Armstrong, 2015;Casey et al., 2019;Gielen et al., 2014).
Role expansion to include prescribing in most cases is preceded by the need for nurses to complete specific prescriber education.
Despite the success of nurse prescribing in the United Kingdom, some healthcare settings have experienced limited, or slow uptake of non-medical prescribing associated with nurse concerns about inadequate educational preparation and remuneration for the additional responsibilities (Boreham et al., 2013;Ross & Kettles, 2012). Lennon and Fallon (2018) report that around 57% of Registered Nurse Prescribers in Ireland were using their prescriptive authority. Studies conducted in Ireland report that motivation to undertake prescribing educational programs and accept increased levels of responsibility is driven by the desire to improve patient outcomes and job satisfaction (Casey et al., 2019;Lennon & Fallon, 2018). Alternatively, there are concerns about increased workload and stress associated with prescribing medicine (Armstrong, 2015;Maddox et al., 2016).
Whilst nurse practitioners in Australia are authorized to prescribe independently, registered nurses do not currently have prescribing rights. In a study of Australian mental healthcare professionals (49 nurses, 7 medical practitioners, 26 allied health professionals), participants reported that the introduction of nurse prescribing under supervision would potentially improve patient access to medicines but also voiced concerns about prescribing accuracy and patient safety (Muyambi et al., 2018). Research on nurse prescribing is dominated by the United Kingdom experience and whilst this is valuable, exploring local contextual considerations and involving key personnel during implementation is imperative (Fox et al., 2021).

| Aim
The aim of this research was to provide a national overview of registered nurses' views towards implementation of nurse prescribing in Australia. Specifically, the study aimed to identify nurses' acceptance of the prescribing under supervision model, current prescribing practices, predictors of willingness to prescribe, motivation to undertake education in prescribing and perceived barriers to implementation of nurse prescribing under supervision.
The workforce readiness and barriers highlighted in this study can inform implementation at policy and organizational levels.

K E Y W O R D S
advanced practice, expanding scope, models of care, nurse, nurse prescribing, policy, workforce preparation

| Design
A national survey was conducted between March and July 2021 and is reported here according to the STROBE statement for cross-sectional studies where relevant (von Elm, Altman, Egger, et al., 2007). This study mainly used a quantitative approach with sections where further free-text responses were permitted and encouraged.

| Participants
A convenience sample of nurses registered with the Nursing and Midwifery Board of Australia were invited to take part in this research. Enrolled nurses (diploma-prepared nurses who practise within their scope of practice under the direct/indirect supervision of a registered nurse), registered midwives who were not registered nurses, student nurses and assistants in nursing were excluded. As the primary aim of the study was exploratory and descriptive, no 'a priori' sample size was calculated; however, a final sample with a minimum of 500 participants was sufficient to adequately power the logistic regression analyses (Bujang et al., 2018).

| Data collection, validity and reliability
An online survey was developed by the research team (RJC, AF, RJ, LC, PY, DT, LN) comprising senior academics with expertise in nursing, nurse-led models of care, policy, pharmacy and non-medical prescribing and informed by a recent integrative review conducted by the research team (Fox et al., 2021). The content validity of the initial survey was assessed by 10 experts who participated as panel members using the Content Validity Index in terms of relevance and clarity (Grant & Davis, 1997;Lynn, 1986). Criteria for selection of the panel included having: (i) a minimum education level of a master's degree, (ii) a minimum of 3 years of experience in nursing/pharmacy/ implementation science/survey design. Informed by the qualitative comments of the Expert Panel, changes were made to the survey by the research team where there was no consensus on the relevance and clarity of items. Subsequently, the updated survey was distributed to 10 registered nurses who checked usability and face validity (time needed to complete the questionnaire; their views on clarity of questions and whether the questions are understandable and easy to answer). With the feedback from these 10 nurses, further minor changes were made to the survey to enhance clarity.
The final 32-item survey comprised three sections, Section A: demographic characteristics and nursing experience, Section B: views towards nurse prescribing as a role expansion and Section C: beliefs around educational requirements for the extended role including qualifications and continuing professional development. The results presented in this manuscript relate to Section B which included six questions. Participants' views about the expected outcomes of nurse prescribing under supervision (11 items) and factors enabling implementation of nurse prescribing (12 items) were measured on a five-point Likert response scale with responses 0 = strongly disagree, 1 = disagree, 2 = neutral or disagree, 3 = agree to 4 = strongly agree to statements such as Implementing nurse prescribing will improve healthcare delivery and Support from colleagues in the nursing profession will enable nurse prescribing under supervision. The likelihood of wanting to become a prescriber if nurses were able to complete education was measured in a single-item question with five responses: 1 = extremely unlikely, 2 = somewhat unlikely, 3 = neither likely nor unlikely, 4 = somewhat likely, 5 = extremely likely. Current prescribing practices were grouped into five categories based on the Health Professionals Prescribing Pathway Project (HWA, 2013) definition and included: independent prescribing, initiating medicine based on a protocol or formulary, adjusting medicine based on a protocol or formulary, ceasing patient medicines or not prescribing medicine with participants able to select multiple options. Participants were provided with five motivations for becoming a prescriber and asked to rank the items from 1 = highest motivation to 5 = lowest motivation. Finally, participants were asked to select from a list of seven items, those that would make them unlikely to want to become a prescriber, with participants able to select multiple.

| Ethical considerations
Ethics approval was granted by the Queensland University of Technology Human Research Ethics Committee (#2000000418).

| Data analysis
All statistical analyses were performed using IBM SPSS Statistics (version 27). Descriptive statistics were calculated (count and percentage) for demographic data, data relating to nursing experience and items that made it unlikely for nurses to want to become a prescriber. Current prescribing practices across states, qualification level and years of experience were explored by computing crosstabulations. Counts and percentages as well as means and standard deviations were calculated for Likert scale items relating to participant views and ranked motivations. Normality of the distribution was tested with the absolute values of the skewness and kurtosis because of the large sample size (Kim, 2013). All data were normally distributed.
A binary variable was created to represent whether nurses wanted to become a prescriber or not, with responses to the item 'If nurses were able to complete education to prescribe medicines, how likely are you to want to become a prescriber?' coded as 'No desire' = extremely unlikely, unlikely and neutral and 'desire' = extremely likely and likely. Univariate and multivariate logistic regression was used to model nursing experience variables (level of qualification, years of experience, workplace setting) and state with the desire to become a prescriber. These variables were included as past research has indicated that experience has an impact on views towards nurse prescribing (Ling et al., 2021). Statistical significance was defined as p < 0.05. Missing data were deemed 'missing completely at random', and as such, only complete case analysis was carried out.  Table 1 provides detailed information about the demographic characteristics and nursing roles of the nurse participants.

| Prescribing practices
Current prescribing practices are reported in Table 2. The majority of nurses were not prescribing medicines (n = 3163, 71.49%,) with just over one-quarter of nurses involved in initiating medicines based on a protocol or formulary (n = 1166, 26.35%). Prescribing practices appeared to vary according to state, years of experience and level of qualification with larger proportions of nurses prescribing, initiating, adjusting or ceasing medication in Queensland and New South Wales, amongst those with a post-graduate qualification or higher, and for participants with less than 10 years nursing experience.

| Views about implementation of nurse prescribing
Participants' views about the implementation of nurse prescribing under supervision and the factors that may enable this practice are Participants could select more than one thus % does not add up to10.
The shaded row indicates the initial question in the survey and how responses were compared across state, education and experience. The most common reasons for participants to be unlikely to become a prescriber are available in Supplementary Table S1 and included: not believing there would be organizational support (43.15%), not changing the patient care they provide (21.02%) and not being prepared to take on extra responsibility (15.80%).

TA B L E 3
Participants' attitudes towards implementation and enablers of registered nurse prescribing ╪ scale ranked 0-4

Strongly disagree
Disagree Neutral Agree

Strongly agree
Implementing registered nurse prescribing will:

| DISCUSS ION
To our knowledge, this is the first study in Australia to explore the readiness of the nursing workforce to embrace prescribing under supervision. We believe the findings from this study are not only relevant to the nursing profession, but to a range of stakeholders including policymakers; independent prescribers (i.e. medical and nurse practitioners) and healthcare organizations planning to introduce expanded prescribing practices. The vast majority of the participants expressed the high likelihood of undertaking further study to expand their practice to prescribe medicine under a supervision model. Most nurses working in Australia do not currently prescribe medicines, however as many as one-third are already engaged in initiating, adjusting or ceasing medicines using formulary and protocols.
Compared to other states, nurses working in Victoria were most likely to have the desire to become prescribers. It is difficult to speculate the true reason. It is important that future research explores system-level contextual factors. Participants aged less than 50 years, with less than 10 years experience and those with higher qualifications were more likely to want to become a prescriber than nurses over the age of 50 years, with more than 10 years experience or those with certificate level qualifications. This finding is consistent with research by Pool et al. (2015) who found that age influences a nurse's motivation to undertake ongoing education, in particular that younger nurses were motivated to gain experience and build on their career. Additionally, participants expressed strongly the need for changes to funding schedules such as patient access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. This will require significant legislative review and collaboration to ensure a workable solution.
Nurses perceived that prescribing under supervision would improve use of nurse knowledge, skills and capability, as well as support nurse-led models of care improving patient experiences. Their key motivation to prescribe were improving patient care and gaining greater job satisfaction. Those who were unlikely to become a prescriber did not believe their organization would support it. Evidence suggests that lack of organizational support for service innovation will prevent initial adoption and sustainability (Fox et al., 2017), suggesting that successful implementation will require guidance for organizational support.
The results of this national study are consistent with research undertaken in the United Kingdom where nurses reported greater work satisfaction and being motivated by the opportunity to improve access to medicine for patients (Casey et al., 2019;Gielen et al., 2014). However, this research highlights the desire of nurses to expand their practice but also the need for support from colleagues. Research undertaken post implementation of independent nurse prescribing and broader non-medical prescribing models in the United Kingdom has shown that financial recognition of the increased responsibility is desired (Maddox et al., 2016). An Australian study exploring the perspectives of 1205 registered nurses on expanding their scope of practice (not specific to prescribing) reported the most frequently cited barrier was a lack of financial incentive, organizational guidelines and support (Muyambi et al., 2018).

TA B L E 4
Crude and adjusted odds ratios from logistic regression analyses identifying associations between selected nursing characteristics and desire to become a prescriber, n = 4334 As the NMBA progresses, the relevant standard in this study indicates support from the profession for the planned change.
The implementation of nurse prescribing under supervision is also dependent upon independent prescribers' preparedness to supervise nurses' training and practice and internal organizational structures to support this practice. To date, no study has been published that explores the motivations or willingness of independent prescribers or healthcare organizations to support the introduction of supervised nurse prescribing. Along with supportive policy and legislation, understanding the view of all key stakeholders prior to implementation will enable successful implementation of this nurse expanded scope of practice. It is hypothesized that better planning will facilitate better adoption of prescribing under supervision.

| Limitations
The results of this survey are limited to the participants who took part and therefore participant bias of those most interested in pre-

| CON CLUS ION
This study is the first to explore the attitude of Australian registered nurses towards nurse prescribing under supervision and their desire to become a prescriber. As such, it provides necessary baseline information to inform the progress of nurse prescribing in Australia.

RJC receives salary support from the National Health and Medical
Research Council (APP1194051).

CO N FLI C T O F I NTE R E S T
None.

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15367.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data used and collected whilst conducting this research are available on request. Please contact the corresponding author for more details.

T WIT TER
Amanda Fox @AmandaF1232