Challenges to Nurse Prescription in Iran: A Narrative Analysis

Extended Abstract

Background
Nurse prescription is a relatively new and developing subject, with many critics and advocates worldwide. However, it is expanding rapidly and is being implemented in many countries. Until 2019, 16 countries approved nurse prescription, including Australia, Cyprus, Denmark, Estonia, Finland, France, Ireland, Canada, the Netherlands, Norway, New Zealand, Poland, Spain, the United Kingdom, South Africa, and the United States. However, nurse prescription is still prohibited in Iran. Some reasons that make the legalization of nurse prescriptions necessary include the lack of physicians, patients' need for more medicines, the development of nurses' roles, better use of nurses’ professional and scientific skills, and saving treatment time and costs. Prescribing is highly important for nurses, so, some consider it a key factor in the specialization of the nursing profession. It also positively affects the quantity and quality of care, time, and costs.

Methods
This study is a narrative review of the English or Persian articles on nurse prescription in Iran and around the world.

We collected data by searching the international databases PubMed, ScienceDirect, and Scopus, and the local databases SID, Magiran, and Iran Medex for the keywords “nurse prescribing”, “nurse prescription”, “prescribing factors”, “prescribing effect”, “prescribing facilitation”, “prescribing barriers”, “prescribing benefits”, “prescriptions”, “medication and nursing”, “independent nurse prescribing”, “supplementary nurse prescribing”, “independent prescribing”, “nurse prescriber”, “prescribing”, and the possible combinations. We retrieved all related articles published between 2010 and the end of 2022. In order to maximize the comprehensiveness of the search, the bibliographies of all articles were manually reviewed to find other possible sources. The inclusion criteria included the English or Persian articles on nurse prescription, which were reported as quasi-experimental, questionnaire, qualitative, and letter to the editor and related to identifying the field of activity, challenge, and consequences of nurse prescription. Articles dealing with the consequences of non-nurse prescriptions or in the form of posters and lectures that were not related to the research objectives were excluded. Article screening was performed in four stages based on the PRISMA process. The required data were extracted using a checklist, which included the type of study, study time, and results. To increase the strength of the research methodology and to evaluate the quality of the articles, another researcher reviewed the articles separately in terms of title, abstract, introduction, methodology, and results. First, thematically unrelated articles or repetitive ones in various databases were removed. Then, the articles’ abstracts and objectives were studied and irrelevant items were excluded. The remaining articles were then evaluated, and any information deemed unnecessary to the study was excluded.

Results
Numerous factors led to the introduction and implementation of nurse prescription. The scope of a nurse's ability to prescribe medication varies significantly from one country to the next, with some countries permitting the nurse to prescribe only from a limited list under the supervision of a physician, while others permit the nurse to administer medication without such restrictions. Different types of nursing prescriptions have been mentioned in sources and articles, such as independent prescribing, which is usually done from a drug list containing a limited number of prescribed drugs or an open formulary; supplementary prescribing, which is defined as a partnership between an independent prescriber such as a doctor or dentist and a complementary prescriber, who is usually a nurse or a pharmacist; and patient group directions (PGDs), formerly known as group protocols, which refer to written instructions for the preparation and administration of drugs in a specific clinical situation. These instructions are prepared by a multidisciplinary team (including a doctor, pharmacist, and nurse) and prescribed specifically for a group of patients. Except for specific medications, nurses are incompetent to prescribe medication timing and dosage. Even after the approval of nurse prescribing in many countries, this new role is facing many legal restrictions. So, nurses may only prescribe over-the-counter medications, or they must prescribe from a limited list of drugs. Considering that there is no mention of legal prescription in Iran in the reviewed articles and that no positive steps have been taken to institutionalize this issue, we are facing an unprepared environment in which prescription needs to be supported. In order to face this challenge in Iran, it is necessary to establish suitable infrastructures, such as training nurses based on clinical work experience, providing legal protection for nurses, and creating a suitable environment and conditions.

Conclusion
Nurse prescribing has been found to have positive results for patients, nurses, and doctors in countries where it is widely practiced. Due to the unprepared environment in Iran, it is vital to provide assistance for prescribing. Prescription training is the basis for gaining actual competence in prescribing medicine as a nurse, and the main strength in conducting that training is clinical practice with supervised drug prescribing. Given the numerous benefits of prescription, practical steps have yet to be taken in Iran to make this issue operational. Numerous factors play a role in implementing nurse prescription in Iran, so it is necessary to use the successful experience of countries that have been pioneers in nursing prescription. It is suggested that health policymakers take steps toward implementing the training of prescribing nurses at the master's and doctoral levels or establishing a new profession of nurse prescription.