**2. Nurse prescribing challenges**

Worldwide, there are challenges to nurse prescribing, which include the following:


In the beginning, some countries, including Britain, had a negative view of prescription other than physicians, and the passage of time and the favorable performance of nurses have been effective in modulating this view [21]. Today, nurse prescription policies are different in countries; for example, in US, several years after the legalization of the role of nurse prescription, it is still associated with the opposition of physicians, which has led to a lack of trust between nurses and physicians [16]. Some physicians, regardless of the positive aspect of nurse prescription and full knowledge, consider this role to be the handing over of routine medical work to nursing and are against increasing the authority of nurses in prescribing and believe that the expansion of this role is based on hierarchical norms or the same view. From top to bottom, it undermines that the physician is always at the top of decision making and the nurses are the ones who execute their orders, which has resulted in unfair strictures in nursing prescriptions [22].

Carey and colleagues [23] consider the lack of cooperation and support of the health care team in clinical management programs to be the problem of supplementary prescribing by nurses [23]. Other problems in the field of nurse prescription include the lack of government support in terms of finances and budget allocation, the lack of cooperation of insurances with nursing prescriptions and neglect of the training of prescribing nurses, as well as the lack of support of nurses from each other and the limited number of training courses [8]. Increasing the knowledge and expertise of nurses, increasing teamwork, supporting each other's colleagues, clinical supervision by the supervisor and continuous professional development, and increasing the support of officials are mentioned as suitable ways to reduce and solve this challenge [24].

Failure to pay attention to the evaluation of the professional qualifications of nurses will cause irreparable damage to health care system. According to Afseth and Paterson's study [25], it is very important to pay attention to the way of practice in the examination of professional competence, and the clarification of professional qualifications should be done in nurse prescription before designing and prescribing permission to nurses through the participation of stakeholders [25]. Qualification criteria for nurses are important in relation to pharmacology knowledge and drug calculations, which is one of the most important qualifications required for independent nursing prescription, having at least 3 years of clinical work experience and participating in specialized training courses [18].

According to Ax's study [26], weakness in drug calculations and inaccuracy in determining the appropriate drug dosage are one of the obstacles to obtaining a legal license in nursing prescription. Careful training of nurses solves the problem to a large extent. Many pharmaceutical companies have solved the problem of complex pharmaceutical calculation in new pharmaceutical products [26]. In all the countries where there is a nursing prescription, nurses need to pass a special training course for a drug prescription in order to be allowed to prescribe medicine [27]. In the UK, there is no specific course required to prescribe a Patient Group Guide (PGD). The training course and the conditions and qualifications required for prescribing nursing are different in different countries; for example in Australia, US, Canada, and New Zealand, nurses are required to be allowed to prescribe medicine independently before completing advanced nursing education, while in Ireland and England this condition is not required and nurses in the United Kingdom have the right to prescribe widely [28]. Also, the criteria for entering the drug prescribing period by nurses in different countries are different, so in England it is at least 3 years of work experience, in New Zealand 4 years, and in Australia 5 years [28].

Competencies and nursing training courses in England include a 39-day period, which lasts 3 to 6 months. This course includes 27 days of theory and 12 days of

### *Nurse Prescribing DOI: http://dx.doi.org/10.5772/intechopen.110744*

internship, which is done under the supervision of a mentor. The theory part can be presented remotely and in its own way. The things that are studied in the nursing training program are as follows: (1) psychological and therapeutic effects of the nurse prescribing, (2) counseling, decision making, treatment, and referral, (3) prescribing within a team context, (4) clinical pharmacology and complications, (5) evidencebased care, (6) legal and ethical aspects of prescribing, (7) professional responsibility and accountability, and (8) prescribing in the public health. The practical part and internship, which is done very strictly and accurately, includes the OSCE functional test and the final exam of pharmacology and its use in practice [29].

In many countries, nurse prescribing is associated with legal restrictions, and usually, nurses are allowed to prescribe drugs that are OTC or are allowed to prescribe from a specified list of drugs [21]. The opposition of physicians to the approval of this role, the lack of familiarity of policymakers with non-medical prescription, and fear of making mistakes in the opinion of nurses are mentioned as the reasons for legal restriction [16]. However, according to the study by Carberry et al. [30] an audit in the prescriptions of nurse practitioners (Advanced Nurse Practitioners in Critical Care) was done. And out of 388 drugs prescribed by nurses only 2 errors (0.6%) were found, while, in relation to physicians out of 984 drugs 32 errors (3.4%) were found. Based on the results of this audit, the error score was significantly different between groups, and the highest error score was related to physicians [30].

From the past, nursing has had the appearance of being dependent on physician as an executor of physician's orders, and this issue has been very confusing for nurses and has weakened social identity and public trust. By increasing the professional independence of nurses, it is hoped that these pressures will be reduced. According to Grad et al.'s study [20], due to a lack of knowledge about the nurse prescribing, despite being satisfied with the consultation with the nurses, patients are more willing to continue the examination and consultation with the physician, and even some patients can refer to the physician [20]. In some studies, the clinical outcome of patients who were prescribed medication by nurses was similar to medication administered by physicians [31].

Various factors may prevent the implementation of nurse prescribing in some countries, for example, in Iran, including patients, physicians, and officials' distrust of nurses' prescriptions, low awareness of the benefits of nurse prescribing, low self-confidence of nurses, medical staff's critical view on this issue, nurses' fear of responsibility and legal issues, and ignoring the experiences of other countries in this regard [32]. The recent master nursing curriculum alterations in Iran, which indicates the specialization of nursing and the further development of the role to include nurse prescribing, is considered a set in the right direction to enhance the nursing profession. In Iran, master nursing students are required to pass 1–2 units of pharmacology, which can help them in taking on the role of prescribing [1]. Also, in Iran, unlike some countries including the United States, there is no DNP (Doctor of Nursing Practice) degree, and the only doctoral degree is in the form of a Ph.D. During this 4–5-year period, 45 units of study are offered to students, and nursing doctoral students have no pharmacology unit. However, after graduating from nursing schools, as academic staff, they are required to teach theoretical and clinical units that require knowledge of pharmacology [33]. Despite the changes that have occurred in Iran's graduate nursing education curriculum, it seems that these changes are not enough for Iranian nurses to benefit from the prescribing role, and more measures are needed in this regard.
