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


 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 1990s, 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 & 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.


Triage
Dominique-Jean Larrey, a surgeon, first introduced the system of triage in 1797 during the Napoleonic Wars in which medical treatment would be prioritised first for soldiers who were gravely wounded rather than those with higher chances of survival and returning to fight (Robertson-Steel, 2006). It has since saw a shift from wartime to peacetime triage, incorporated into medical institutions and implemented in settings such as the Accident & Emergency Departments (ED) worldwide.
In Singapore, the Ministry of Health has recommended the use of the Patient Acuity Categorisation Scale (PAC) for triage, which involves 4 priority categories, of which patients' are triaged and allocated to the different wait areas whereby the allocation of staff and resources are dependent on the severity of their category (Singhealth, 2004). These categories are numbered as P1, P2, P3 and P4.
P1 is the most severe of its category, with patients' arriving for cardiac arrest, stroke, acute myocardial infarction, asthma attack, open fractures, dislocations and limb amputations. Patients in this category are seen almost immediately in the resuscitation area with a less than 5-minute waiting time. Patients triaged into P2 present with complaints of chest pain, renal complications, closed fractures of limbs, cellulitis, abdominal pain, and acute appendicitis. These patients are non-ambulant and targeted to be seen within 45 minutes.
Patients' triaged to P3 are those with minor injuries and are ambulant such as sprains, colles fracture, clavicle fracture, headache or foreign body of ear, nose throat and eyes. The targeted waiting time is 60 minutes. Those in P4 have the longest waiting time of 2 hours or more for presenting complaints of old scars, sore 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 Department? 5 throat, general medical check-up, non-emergent eye, nose or throat problems. An expanded look into these various categories and diagnosis can be seen in Appendix 1.
Registered nurses will have to undergo an in-house training programme by their medical institutions and complete a set of skills before being deemed as competent to perform triage (National Healthcare Group Polyclinics, 2014). Once competent, triage nurses will be given rights as per their hospital's policies and protocols to order diagnostic treatments such as X-rays, ECGs, blood glucose monitoring, urine dipstick & pregnancy tests as well as blood tests.

Waiting Times
An ED is generally the location whereby patients would arrive for an impromptu immediate treatment on their conditions, which, usually causes congestion and long waiting times right from the offset (Holm & Dahl, 2011). These 'congestions' would result in extended waiting times, a reduction in the standard of care provided and a heightened danger of injurious events (Hoot & Aronsky, 2008). As patients' have to endure the persistently long waiting times at most EDs, there is a need to improve patients' well-being, quality of care and disposition at the EDs, thus, the implementation of a triage system in EDs. The primary goal of triage is to quickly determine which patients are susceptible to deterioration, of which precedes those patients' who can wait to be seen and provide diagnostic and therapeutic interventions (Gilboy et al. 2011).
In Singapore in a report from the Ministry of Health (2004), Singapore General Hospital had seen a total of 113,388 patients' that year alone, averaging 311 daily visits of which a total of 67,000 patients' were triaged in the non-emergent categories. The median waiting times for patients' triaged to critical care (P2) ranged from 29 minutes to 84 minutes while the non-emergent (P3) cases waited 35 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 Department? 6 minutes to 103 minutes prior to being seen by a physician in Singapore General Hospital where as patients' waiting to be seen in critical care at Tan Tock Seng Hospital had to wait between 47 minutes to 125 minutes and those deemed nonurgent, 54 minutes to 127 minutes (Ministry Of Health, 2004). According to a weekly hospital submissions report by the Ministry Of Health, which was published in a local newspaper, The Straits Times (2017) had recorded an increase in those numbers 13 years later with the average waiting times in Singapore increasing to 4-8 hours in Tan Tock Seng Hospital while in Singapore General Hospital, the average wait time had increased to 3-4 hours before any form of treatment could be initiated [Appendix 2]. As evident from 13 years ago till now, waiting times have been increasing in Singapore's Government Hospitals thus, patients' seeking treatment in Singapore's Emergency Departments would have to wait at least a few hours before being consulted by a physician and maybe a while longer given the workload of nurses' that day before receiving treatment.
There are many proposed interventions surrounding the concept of triage, however the author will be highlighting the aspect of a nursing led intervention, namely, nurse-initiated medications (NIM) or nurse-initiated analgesia (NIA) at the point of triage. These interventions are targeted for the early treatment of acute pain in adult patients' arriving at the ED to seek treatment and in turn, reducing the wait till being consulted by a physician, which could possibly be a few hours later as evidenced above.

Acute Pain & Oligoanalgesia
A pinpoint description of pain is a subjective and intimate feeling, which differs from one to another and cannot be modified on how someone else might perceive the pain (International Association for the Study of Pain, 1979& McCaffery, 1979. Pain is the most prevalent chief complaint in the ED (Todd et al. 2002 & Doherty et al. 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 Department? 7 2013). Berben et al. (2008) identified in a study the extent of the complaint of pain in EDs all around the world ranges from 52% to 79%.
Insufficient pain management treatment by physicians was first recorded by 2 psychiatrists, Marks and Sachar (1973) in a historical article where they were called upon to evaluate patients' admitted to the hospital who were addicted to pain medications and concluded that it was simply because their pain was undertreated. Wilson & Pendleton (1989) invented the word "oligoanalgesia" which characterizes the deficiency in caring for pain accordingly.
It was due to the under treatment of pain that Campbell (1996) had conferred the notion of assessing pain as a vital sign in his 1995 Presidential Address to the American Pain Society. Documenting the severity of pain as 'the fifth vital sign' is targeted at developing alertness and understanding in application of pain assessment (Joint Commission on Accreditation of Healthcare Organisations & National Pharmaceutical Council, 2001), which in turn could strive towards an enhancement in acute pain management (Gould et al. 1992). According to Breivik et al., (2008) in order to achieve favorable pain management, pain assessment is fundamental in the forms of the numeric rating scale or the visual analog scale where measurements in pain intensity can be recorded. Venkat et al. (2013) had argued that there are worrying issues circulating ED pain management strategies that have reached catastrophic level in which it must be treated as an ethical conundrum within the profession of emergency medicine.

Nurse Initiated Medications
According to Venkat et al. (2013) the 'ethical conundrum' mentioned would be the breach of beneficence and non-maleficence in the code of ethics whereby the under treatment of pain and the long waiting times in ED have not correlated with doing good and doing no harm towards patients'. The point brought across would be that 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 Department? 8 long waiting times before being consulted by a physician and receiving treatment have not been beneficial towards patients' welfare and have not been kept in sync with the medical and nursing code of ethics. In the United Kingdom, innovations towards pain management protocols such as nurse-initiated medications began towards the end of 1990s (Goodacre & Roden, 1996). Currently, the practice of NIA/NIM has taken effect in the UK and other parts of Europe whereby a teaching session is conducted to keep nurses up to date on contemporary practice (Sampson et al. 2014). The inception of non-medical prescribing in the UK was implemented as an instrument to improve service quality and one of the aims included reducing patients' waiting time to receive analgesia as prescribed by a physician (Department of Health, 2006a). The spotlight on logical and protected nurse and midwife prescribing is wonted due as the incidence of medication lapses surrounding subordinate doctors can range from 2-514 per 1000 prescriptions, involving 4.2-82% of patients (Ross et al. 2009). Given the statistical disadvantage of probable medical medication lapses sparks an inquiry with relation to the competence of the education of nurse and midwife prescribers (Lockwood & Fealy 2008, Stenner et al. 2009).
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 Department? 9 Nurse prescribing in the UK has been incorporated as a prevailing skill with over 54,000 nurse and midwife prescribers (Nursing and Midwifery Council, 2010) with more than 19,000 independent and supplementary nurse prescribers  The advancement of nurses' or midwives being able to initiate prescriptions in Ireland had begun due to propositions in several key reports (Government of Ireland, 1998& An Bord Altranais, 2000. The reports had identified that restricted dispensation of non-prescribed medications could be studied to empower nurses and midwives to effectively care for their patients' daily and a revision of current legislation is warranted to facilitate of nurse-initiated medications.  (Wilhelmsson et al. 2001;Plonczynski et al. 2003;Lim et al. 2007& Berry et al. 2008. The system of NIA/NIM had been confined in various hospitals in the United States for advanced practice nurses or emergency nurse practitioners (Cole, 2003, Plonczynski et al. 2003, Hudson & Marshall, 2008& Hoskins, 2011 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 Department? 11 nurses who have 2 or more years of experience in the ED (Fry & Holdgate, 2002& Fry et al. 2004).
In Singapore, this autonomy is also not provided to nurses of all grades. As it stands, only Advanced Practice Nurses are granted prescribing rights for medications in selected acute care facilities by following a set of identified protocols (Singapore General Hospital, 2013, Tan Tock Seng Hospital, 2013 Our SCDF paramedics and physicians from SGH have concurrently collaborated on teaching sessions to improve pre-hospital care and also quality of care rendered to patients be it acute pain or lifesaving methods. However, this form of autonomy has yet to be initiated by the Singapore Nursing Board towards registered nurses.

Safety
The prevailing concern encompassing nurse and midwife prescribing worldwide is patient safety (Hawkes, 2009, Rana et al. 2009& Stenner et al. 2009). With the countries mentioned, the planned interventions were met with resistance due to issues raised about patients' safety, in this case by empowering non-expert nurses' prescriptive authority and the corrosion towards the physicians' duty (Lockwood & Fealy 2008, Creedon, 2009, Hawkes, 2009, Wells et al. 2009). Queries have also been raised with regards to the nurse-patient consultation, the physical assessment skills, and the differential diagnostic capability of non-medical prescribers that comes before an event of prescribing (Aitken et al. 2006, Courtenay et al. 2009& Young et al. 2009).
A patients' safety is dependent on the prescribing practitioner, be it a physician or a nurse being mindful of the possible side effects, risks, attempting accurate patient evaluation and documentation, and inaugurating vigilant patient monitoring and education (Rundall et al. 2006& Ross et al. 2009

AIM
The aims of this literature review is to identify the increased timeliness of analgesia

METHODS
Evidence has shown that nurse prescribing had first been incepted in 1994 for city nurses and health visitors in Britain (Culley, 2005). The nurses would be able to prescribe medications, wound care products and appliances following a guideline from the 'Nurse Prescriber's Formulary ' (Baird, 2005, Culley, 2005& British National Formulary, 2005. Since then, alterations in legislation have authorised nursed 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 Department? 14 working in specific specialties such as palliative and critical care to prescribe and administer a variety of controlled medications (DOH, 2006).
Evidence based practice is a part of nursing, which improves processes and recommendations every day. With the idea of NIA/NIM, nurses can be given more rights and undertaking much more responsibility towards their patients' and their job scope, if it has shown to have a significant improvement in the care and treatment provided for patients'. Murad et al. (2016) draws on a pyramid of evidence-based medicine, which has put forth several echelons of medical evidence and based its validity in ascending order. Ranked from the bottom, it starts with case series/reports followed by case control studies and above which, is cohort studies with the next being randomised controlled trials and at the peak of the pyramid sits systematic reviews [ Figure 1]. Thus, a literature review using systematic knowledge has been adapted and undertaken for this topic.  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 Department? 16 ScienceDirect is the global champion for scientific, technical, and medical research with a section dedicated to Health Sciences with over 12 million articles from 3,500 journals (Elsevier, 2017). ScienceDirect also shows related search results based on your current search which is a plus point as it brings to light more resources on the topic.
Last but not least, the author has chosen to use Wiley's database, which dates back to 1997 and has a collection of over 6 million articles from 1,500 journals and has been come to known as the global front running society publisher with the most vast collection of various disciplinary literature (Wiley, 2017). Literature could be searched under title and abstract as well, which has proven to be a great resource.
Firstly, the author had to identify an appropriate research question to this study using the acronym PICO that concluded; • Population: Adult patients experiencing acute pain at triage.
• Comparison: Patients' who have not been administered any medications prior to being consulted by a physician in the ED.
• Outcome: Increase timeliness to analgesia and improve pain control.
A title was then derived, "In adult patients' who are experiencing acute pain at triage, will nurse initiated medications increase timeliness to analgesia and improve pain control prior to being consulted by a physician in Singapore's Emergency Department"? This title identifies adult patients who would be aged 18 years old and above that are experiencing any form of acute pain upon arrival and triage at the ED. The proposed intervention of nurse-initiated medications, where nurses would be granted prescriptive authority to be able to administer treatment for these said patients before waiting for their turn to be consulted by a physician. The 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 Department? 17 outcome of this proposal would be an increase in time to analgesia, making patients' pain management prompter and more effective.
The identification of PICO was instrumental in building the title for this literature review after which, keywords were set for a search strategy. There were 7 sets of keywords used for the search strategy, which were performed as a standalone or as a combination. The first two keywords were derived from 'triage' under the 'population' where the location would be (1) emergency department or accident & emergency. The next keyword was straightforward under 'intervention' that was (2) nurse-initiated medications. As the term nurse-initiated medications were quite broad in an initial search, a breakdown by the author was done. Different synonyms were used to replace the word 'initiated'. This brought about (3) nurse initiated or nurse prescribed or non-medical prescribing. The core aspect of 'nurse' was kept thus incorporating (4) nurse or nursing into the search. As the 'intervention' and 'comparison' brought about the word 'medication', different aspects of the term had to be included such as (5) medication, drug or medication protocol. As the 'outcome' would possibly identify if NIM could increase timeliness to analgesia and improve pain control, two more keywords were derived. The main key term (6) oligoanalgesia and a broader search of the same meaning were used in the context of 'under treatment of acute pain' and (7) waiting times or long hours in the A&E.
Boolean operators such as 'AND', 'OR' and 'NOT' have been utilized for a much more systematic approach. Truncation, phrase searching, and wildcards were also incorporated in the 7 sets of key words. The use of these keywords with Boolean operators will be shown in detail in Section 3.2. Whilst the keywords have been identified, an inclusion and exclusion criteria were set by the author as seen below in Section 3.1.
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 Department? 18

Inclusion & Exclusion
The inclusion and exclusion criteria had a further expansion once the title for the literature review had been identified. One standard requirement was that the literature search had to be of the English language. All other languages had to be excluded for this review. As the population had identified adult patients', it was set that the age group implemented would be that of 18 years old and above; which also meant that literature relating to infants or adolescent teens would not be considered for this review.
Infants or adolescent teens in Singapore are seen at a Children's Emergency Hospital, which is 1 out of the 8 public hospitals in Singapore. The author felt that tackling the issue of NIM/NIA at 7 out of the 8 public hospitals in Singapore, which sees adult patients', would bring about a just cause in granting further autonomy to nurses. Also, medications differ between adults and children, different doses have to be carefully measured and given according to the weight of the child, unlike an adult.
Adult patients were also included in the study if they had presented to the ED with acute pain and had not taken any prior medication before their arrival. Patients' who were referred from private clinics or polyclinics or brought in by the ambulance are also included in this review. However, they would be excluded if they were given medications to relieve their pain prior to their visit to the ED, for example, pain medications on board an ambulance administered by the paramedics or at the clinics by their general practitioner.
Research conducted specifically in the EDs was included in this review as the author is looking if there is an increase in timeliness to analgesia and an improvement in pain control if NIM/NIA is piloted. Research articles were excluded if it had been conducted outside of an ED such as a 24-hour clinics or minor emergency clinics.
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 Department? 19 The types of research papers included in this review would be those as shown in Figure 1 above such as randomised controlled trials, cohort studies, case control studies, studies with quantitative design, mixed methods studies, with the exception of systematic reviews as a systematic review is not an original research study.
A further illustration of the inclusion and exclusion criteria will be presented below in Table 1. Nurses who are unable to autonomously prescribe medications without a physician order. Studies that allow the independent administration of analgesia from nurses Patient controlled analgesia Studies with regards to registered nurses or graduate nurses Studies relating to nursing students Patients' who are able to verbalise their pain score and comply with pain assessment tools.

Patients of altered mental state
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 Department? 20 A preliminary search of the topic of NIA/NIM was conducted to gain a general overview on the topic. A reading of government reports from various countries and nursing charters as mentioned in the introduction have seen implementation in the early 1990s and 2000s. From past to present, pain management has seen many improvements both in research and in policy. With evidence based practice paving the way for NIM/NIA, the author warranted a more contemporary research on this topic thus, choosing a 10-year window to narrow down the search strategy to avoid gaps or biasness on this review and also to reflect on current practice to partake in a system of endless learning and enhancement.
Nursing students were excluded from this review, as they do not have the rights to administer medications for patients as compared to registered nurses. Registered nurses, those that have newly graduated from nursing schools with a diploma and undergraduate nurses with a degree were selected for their experience and specialty in the field. This literature review has been targeted for the ED, specifically at triage.

Search Strategy
Tables 2, 3, 4, and 5 details the search strategies and results generated from the four databases selected by the author and presented below. These included the 7 sets of keywords used either as a standalone or combination search with the applied limitations. Searches were first conducted in the four identified databases shown below.
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 Department? 21    inclusion and exclusion criteria set by the author, a study selection process was then undertaken. A total number of 429 literature reviews were retrieved from the searches prior to further scrutiny. Out of the 429 literature reviews found, 65 reviews were removed as duplicates. Next, the remaining reviews had the abstracts screened against the inclusion and exclusion criteria of which 291 were discarded.
These reviews were discarded if the abstracts had mentioned student nurses, included paediatric patients as participants or nurse-initiated medications for patients' coming to the ED for complaints other than acute pain such as diabetes or psychological disorders.
The remaining articles were then screened against the full text for relevance to the review. 63 articles were discarded, mainly because 33 articles had its research    Barksdale et al. (2016) To review the time to provision of analgesics in patients presenting to the ED before and after the implementation of a nurse-driven triage pain protocol.
In the US, over a 27month period, 23 409 patients were included, conducted at an urban safety net level 1 trauma centre: 13 112 received pain medications and 10 297 did not. A total of 12 240 (52%) were male, 12 578 (54%) were African American, and 7953 (34%) were white, with a mean (SD) age of 39 years (13 years). The pain protocol was used in 1002 patients.
Retrospective cross-sectional observational study.
There was a significant change in mean time (minutes) to provision of analgesics between pre implementation (238) and post implementation (168) The assessment of the effect of a medical directive for nurseinitiated analgesia on time to first dose of analgesics, proportion of patients receiving analgesics in less then 30 minutes and total length of stay in the ED.
To determine whether their nurse-initiated protocols improved the timeliness of care according to a prioridefined outcome measures that were specific to each protocol.
1 ED in Canada. 3 groups of nurses. 1st group of 11 nurses with 3-5 years experience, 2 nd group of 10 with 6-8 years and 3 rd group of 8 with 10 or more years. A retrospective, comparative prepost implementation observational study.
This study also highlights pain awareness as the clinical endpoint. Also, its gives nurse the autonomy to prescribe Fentanyl following a protocol. There was an increase in the rate of nursing assessment of pain between the pre-test and post-test period (19% versus 81%; p < 0.0001).
During the post-test period, the time to initial analgesic was shorter (9 min versus 93 min, p < 0.005) and pain reduction score at one hour was greater in the nurseinitiated Paracetamol group then those who waited to see a physician.
Randomization not used and participation had confined timings of 9am to 6pm from Monday-Saturday. Two-time periods for this study. Self-bias reported. Stronger analgesics could be used. Recruitment strategy unknown. Data presented well with 2 control groups.
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 Department? 32

Description Of Included Studies
The descriptions of the included studies have been summarised in Table 6 Figure 4 and Table 8]. The remaining study had been appraised using Pluye et al., [ Figure 5 and Table 9]. The results from the pilot study had shown that it takes around 15 minutes to appraise a study making it efficient and the intra-class correlation at around 0.8 making it reliable (Pluye et al., 2011).
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 Department?
33 Did the trial address a clearly focused issue?
Did the study address a clearly focused issue?

2.
Is a qualitative methodology appropriate? Was the assignment of patients to treatments randomized?
Was the cohort recruited in an acceptable way?

3.
Was the research design appropriate to address the aims of the research?
Were all of the patients who entered the trial properly accounted for at its conclusion?
Was the exposure accurately measured to minimize bias?

4.
Was the recruitment strategy appropriate to the aims of the research?
Were patients, health workers and study personnel 'blind' to treatments?
Was the outcome accurately measured to minimize bias?

5.
Was the data collected in a way that addressed the research issue?
Were the groups similar at the start of the trial?
Have the authors identified all-important confounding factors?
Have they taken account of the confounding factors in the design and/or analysis?

6.
Has the relationship between researcher and participants been adequately considered?
Aside from the experimental intervention, were the groups treated equally?
Was the follow up of subjects complete enough? Was the follow up of subjects long enough?

7.
Have ethical issues been taken into consideration?
How large was the treatment effect? What are the results of this study?

8.
Was the data analysis sufficiently rigorous? How precise was the estimate of the treatment effect?
How precise are the results?

9.
Is there a clear statement of findings? Can the results be applied in your context?
Do you believe the results?

10.
How valuable is the research? Were all clinically important outcomes considered?
Can the results be applied to the local population? 11.
-Are the benefits worth the harms and costs?
Do the results of this study fit with other available evidence? 12.
--What are the implications of this study for practice?
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 Department? 34

2.
Were the participants included in any comparisons similar?

3.
Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?

4.
Was there a control group?

5.
Were there multiple measurements of the outcome both pre and post the intervention/exposure?

6.
Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?

7.
Were the outcomes of participants included in any comparisons measured in the same way?

8.
Were outcomes measured in a reliable way?

9.
Was appropriate statistical analysis used?   2.2. Are measurements appropriate (clear origin, or validity known, or standard instrument; and absence of contamination between groups when appropriate) regarding the exposure/intervention and outcomes? 2.3. In the groups being compared (exposed vs. non-exposed; with intervention vs. without; cases vs. controls), are the participants comparable, or do researches take into account (control for) the difference between these groups? 2.4. Are there complete outcome data (80% or above) and, when applicable, an acceptable response rate (60% and above), or an acceptable follow up rate for cohort studies (depending on the duration of follow-up)? 3. Mixed methods 3.1. Is the mixed methods research design relevant to address the qualitative and quantitative research questions (or objectives), or the qualitative and quantitative aspects of the mixed methods questions (or objective)? 3.2. Is the integration of qualitative and quantitative data (or results) relevant to address the research question (objective)?
3.3. Is appropriate consideration given to the limitations associated with this integration, e.g., the divergence of qualitative and quantitative data (or results) in a triangulation design?
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 Department? 37 Out of the ten studies, only one study had an RCT design (Douma et al. 2016) while three other studies had used a cohort study design (Berben et al. 2008, Dewhirst et al. 2017& Van Woerden et al. 2016. One study by Wong et al. (2007)  Six of these studies had used a pre-test and post-test design (Dewhirst et al. 2017, Muntlin et al. 2011, Pierik et al. 2016, Ridderikhof et al. 2016, Van Woerden et al. 2016, Wong et al. 2007, with risks of selection bias and performance bias. Due to the fact that the above six studies had not selected the interventions to patients' in a randomized way, they had opened themselves up towards selection bias. Performance bias was also a factor due to the fact that there was no mention of 'blindness' in the studies conducted. However, comparisons between analgesia and its effectiveness on certain pain complaints were not the main focus or objective of the studies, thus blinding the patients towards what type of analgesia was administered to them was not undertaken. that an RCT could not be conducted thus, chosen a quasi-experimental study and also mentioned that the Hawthorne Effect could not be avoided as nurses had to be observed, informing of biasness. Attrition bias was evident and reported in 6 studies (Cabilan et al. 2015, Pierik et al. 2016, Berben et al. 2008, Dewhirst et al. 2017& Van Woerden et al. 2016) and unreported in 1 study (Wong et al. 2007).
The ten studies selected were appraised to be of good quality and suitable for use in this review once critical appraisal was conducted. The appraisal represents the validity of the results and the significance it has in this review. Eight of the studies were conducted in a single ED within the researcher's countries and one study by Berben et al. (2008) was conducted within two EDs in the Netherlands and Dewhirst et al. (2017)

in 2 Ottawa Hospital Campuses
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 Department? 39 in Canada. In all ten of the studies, it was noted that the sample sizes of the population was small. With a small sample size, the results could be doubted in further researches, however, a larger sample size could also magnify the discovery of significant differences in results, which may not necessarily be clinically relevant (Altman, 1991). Recruitment strategies or sampling techniques were not mentioned, and patients were recruited into the studies based on the set inclusion and exclusion criteria such as trauma, 18-years old and above and complaints of acute pain. The inclusion criteria set by the studies had accurately identified the patients' that were needed for this review into NIM/NIA.
Ethical considerations were not mentioned in three studies (Barksdale et al. 2016, Dewhirst et al. 2017& Goh et al. 2007). The author acknowledges the fact that eight studies were conducted in Europe and the remaining two studies within Asia and the results generated may not necessarily be applicable in Singapore due to the difference in geographical context, patients' perception of pain, ED work culture and population size. One study by Goh et al., (2007) however was conducted in a local government public hospital in Singapore but there were no follow up studies found from then time till now.
Overall, the ten studies have shown that nurses with prescriptive authority were able to increase timeliness to analgesia and improve pain control for patients' presenting with acute pain to the ED before being consulted by a physician.

Main Findings
The set of themes derived were based on the findings above through close scrutiny, identifying similar traits within them. The results of these themes were segregated into a thematic analysis table (Table 11) and presented below. The themes identified from research of NIM/NIA were narrowed down to timeliness (significant time to analgesia), patient centeredness (pain assessment & measurement), efficiency (length of stay in the ED) and knowledge (training & education for nurses).
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 Department? 40  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 Department? 41

Thematic Analysis
Theme 1 -Increase timeliness to analgesia An increase in the timeliness to analgesia for patients' with complaints of acute pain at triage in relation to NIM/NIA was reported in 9 studies (Barksdale et al. 2016, Dewhirst et al. 2017, Douma et al. 2016, Goh et al. 2007, Muntlin et al. 2011, Pierik et al. 2016, Ridderikohf et al. 2016, Van Woerden et al. 2016& Wong et al. 2007). The tenth study by Berben et al. (2008) had targeted the pain prevalence of patients with the initiation of NIM/NIA at triage and its relationship at admission or discharge. Berben et al. (2008) had not identified an increased timeliness to analgesia however had managed to identify a reduction in pain scores with the initiation of NIM/NIA, which will be discussed in the next section. In the study by Dewhirst et al. (2017) which was conducted in a medical centre in Ottawa, a medical directive was put in place enabling all ED nurses, however, mainly triage nurses to initiate Acetaminophen, Naproxen or Tramadol for patients whose complaints were of pain. In the mean interval time between ED arrival and the administration of first dose of analgesia, two factors that were interlinked with quicker NIM was the study period (160 min before and 118 min after; p < 0.001) and if the medical directive was used vs. not (34 min vs. 131 min; p < 0.001), a significant indicator of the effectiveness of NIM. Also, there was 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 Department? 42 higher proportion of patients receiving analgesics in the first 30 min (20% vs. 4%, p < 0.001). Douma et al. (2016) had focused on the use of acetaminophen for pain and fever during the study. It had resulted in a reduction of average time to analgesia or antipyretic by 186 minutes (95% Confidence Index 76 to 296 minutes). The average time to analgesia was 54 minutes in the intervention group (patients allocated to receive NIM protocol). A significant difference then those allocated to the control group (usual care), which was 240 minutes. Only acetaminophen was reportedly used for patients under the NIM protocol.
In Goh et al. (2007) Pierik et al. (2016) noted that prior to the implementation of NIM at triage, 46.8% of patients with moderate to severe pain were offered analgesia however those figures had increased to 68% post implementation, a 21.2% difference 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 Department? 43 (P<0.01). Before NIM, the average time to analgesia for patients presenting with moderate to severe pain was 10 minutes compared to post NIM protocol where the average time decreased to 7 minutes (Pierik et al., 2016) [P < 0.05] and time to opioids decreased from 37 to 15 min (P < 0.01). In this study, patients with isolated musculoskeletal proximity injuries were selected and acetaminophen was the first choice of analgesia, with diclofenac, ibuprofen, tramadol, morphine, fentanyl and esketamine with midazolam given by following the guidelines and formulary set for the RNs. A pain scale score was used to document patient's pain upon triage before the NIM protocol took place and was also reviewed one-hour post initiation to assess the effectiveness and if unresolved, a second dosage of medications would be 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 Department? 45 given as per NIM protocol making pain a significant measure of a vital sign (Barksdale et al. 2016). It was unclear as to what type of pain assessment tool was used in the study. In the study by Goh et al. (2007) mandatory pain assessment was integrated in the triage nurse's task to identify the severity of pain for patients' as a vital sign in order to partake in the NIM procedures. The pain assessment tool used was a numeric rating scale (NRS). It had to be assessed and documented. However, unlike Barksdale et al. (2016), pain was not assessed or measured after the administration of NIM/NIA or prior to discharge. Berben et al. (2008)  Pain assessment should be done at the point of triage with the use of a NRS scale or a categorical scale, one, which score pain from 0-10 and the other from no pain to most severe. These two pain assessment tools are more than capable to measure pain in adult patients' capable of answering. Pain should also be reassessed after NIM/NIA has been administered for patients' and prior to discharge. Berben et al. (2008) had found significant reduction in pain scores with pharmacological interventions.
Theme 3 -Decreased Length of Stay in the ED Three out of the nine studies had looked into the relationship between NIM at triage and ED-LOS for patients' (Dewhirst et al. 2017, Douma et al. 2016& Pierik et al. 2016 In these three studies, ED length of stay was only significantly reduced in Douma et al. (2016) study with the diagnosis of abdominal pain and remained unchanged in (Dewhirst et al. 2017) and slightly reduced less than 10 minutes in (Pierik et al. 2016). These results highlight a further need to explore the correlation between NIM/NIA and its impact on patient's length of stay in the ED with various diagnosis and treatment measures. While ED-LOS is not a quality indicator for the success of NIM/NIA, it can be a future form of evidence into its effectiveness.

Theme 4 -Training & Education
Five studies had mentioned that training and education had to be conducted for registered nurses prior to the implementation of NIM/NIA at triage (Barksdale et al. 2016, Dewhirst et al. 2017, Goh et al. 2007, Muntlin et al. 2011& Ridderikohf et al. 2016. In this review, training and education for registered nurses was not a measured outcome, but as identified in the introduction of this paper, nurses had to be educated before they were deemed competent to be able to independently prescribe medications for patients', thus this commonality was identified in 5 out of the 10 selected research papers. 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 Department? 48 Barksdale et al. (2016) talks about an orientation phase, which was introduced to train the nurses to become acquainted with the established and approved protocols for NIM prior to its pilot. The official application began once nurses had been educated of the protocols. Similarly, Goh et al. (2007) had mentioned education procedures for physicians and nurses with regards to the NIM protocol and pain assessment and topics of pharmacology, the 5 rights of drug administration and indications and contraindications of medications. This would help facilitate better understanding amongst the team.
In contrast, Dewhirst et al. (2017) informed that ED nurses were given penned reports regarding the medical directive and also a teaching session via a power point delivery, after which, a small teaching group or individual sessions helmed by an in house trainer was conducted, lasting a few weeks which had involved around 250 nurses. In order to be certified competent for NIM, nurses had to undergo and graduate from this teaching session before commencing the protocol. Likewise, Muntlin et al. (2011) mentions that all RNs in the department were appealed to join an educational session regarding acute abdominal pain, pain assessment and analgesic order of morphine, which lasted around 1.5hrs.
Nurses who had completed this session would be able to prescribe morphine for patients with the need for consulting with the physician. The characteristics of acute abdominal pain, quality and location, intensity, analgesic variations and provisional diagnoses were thought to the RNs, improving the output of the session. Ridderikohf et al. (2016) study mentions that before the initiation of a pain management NIM protocol, all RNs had to attend a 1-hour educational class before being able to be certified competent to use it. This was much shorter when compared to the previous studies however; there was no adverse effects or medication errors reported (Ridderikohf et al. 2016).
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 Department? 49 Training & education was being identified as a key measure to be able to implement NIM/NIA in the ED. Nurses who had undergone the sessions were deemed competent thus, giving them prescriptive authority. The study by Ridderikohf et al. (2016) had only identified a one-hour educational class for the nurses, which is too short to cover such extensive topics of pharmacology and the rights to administer medications. Training & education should be a compulsory factor for nurses and the length of time needed for these sessions should be further researched.

Discussion
This literature review was undertaken using systematic knowledge by searching through different databases identifying research based on the hierarchy of the evidence-based model of medicine, which focused on the practice of NIM. Upon analysis of the chosen research, it was well noted that NIM does significantly decrease the time to analgesia in the ED when initiated at the point of triage (Barksdale et al. 2016, Dewhirst et al. 2017, Douma et al. 2016, Goh et al. 2007, Muntlin et al. 2011, Pierik et al. 2016, Ridderikohf et al. 2016, Van Woerden et al. 2016& Wong et al. 2007). Acetaminophen was the first choice of analgesia administered for patients' with complaints of pain however, not limited to other medications such as ibuprofen, oxycodone, diclofenac, tramadol and naproxen, which are common forms of analgesia for pain relief (Barksdale et al. 2016, Dewhirst et al. 2017, Douma et al. 2016, Pierik et al. 2016, Ridderikohf et al. 2016, Van Woerden et al. 2016& Wong et al. 2007). In Singapore's ED, acetaminophen is a form of NIM but applicable to patients' who presents with complaints of fever to the ED, without having taken panadol in the past 6 hours or are not allergic to it.
NIM could be administered in three different routes, oral, intramuscular and intravenous, as it was not restricted in any of the studies to what form could be prescribed and administered. As seen in the study by Goh et al. (2007) highlighting the effectiveness of NIM. Wong et al. (2007) had also evidenced the importance of an increased awareness of pain assessment and nursing assessment during different phases of a patient's treatment. In Singapore, pain assessment is acknowledged as a 5 th vital sign as it in incorporated in the triage process and recorded electronically. Frequent in-house tutorial sessions have also been encouraged for RNs to partake in, for nurses to be kept up to date on contemporary evidence in Singapore.
NIM was not seen as a factor, which affected the length of stay in the ED. From the results of three studies, there was no significant difference on the impact NIM had in correlation towards patients' getting admitted or discharged (Dewhirst et al. 2017, Douma et al. 2016& Pierik et al. 2016. With only waiting times seen as a clinical indicator for patients' care and satisfaction, the earlier they had received treatment was deemed as a much more significant set of results. ED length of stay in Singapore has been talked about in the introduction section and his also highly dependent on the bed situation in each hospital which generates a usually longer waiting time. However, being able to increase timeliness to analgesia would be a greater form of quality improvement for patients. This could also be attributed towards the different disposition the physician decides upon. Regardless of pain relief, patients that need to be admitted will be admitted thus not truly affecting the ED-LOS. Also, patients could have received pre-medication before arriving to the ED thus decreasing their pain scores in which measurements would be inaccurate. Prior to NIM and pain assessment, nurses have to undergo educational and training sessions to understand the concept, the rationale and the function of being granted prescriptive authority. Lessons in triage skills, pharmacology and pain perceptions would have to be undertaken and only trained RNs would be able to graduate and be certified competent before being able to administer NIM. Barksdale et al. (2016) talk about an orientation phase to have nurses familiarised with the process and procedures while Dewhirst et al. (2017) mentions giving nurses written reports of the procedure and a power point 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 Department? 52 presentation with guided teaching sessions. A contrast can be observed from Ridderikohf et al. (2016) where nurses had to only attend a one-hour training session before being certified competent. This session seems to be too casual more than formal, which could lapse in safety concerns, increase in anxiety among staff and reduce confidence.

Recommendations for practice
In order to proceed with the conceptualisation of NIM, policies need to be incepted in order for legislation into this process to be passed. Doctors, nurses and pharmacists would need to be able to create a working protocol, one that nurses could follow and a set of guidelines and a formulary for medications to be prescribed. Also, considerations into safety concerns, workload of ED staff and general perception of nurses have to be taken into account as well. With this in effect, it could then be presented to the medical board. Medical directive regarding NIM was conceptualised by a group of skilled local emergency physicians and nurses which was situated around local prescribing regimens, leading practices and local policy & legislation governing the type of medications that a nurse can prescribe without a physician's order (Dewhirst et al. 2017).
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 Department? 53 In Douma et al. (2016) study which took place in Canada, NIM was already an ongoing establishment for the past 15 years which was created by a multidisciplinary team, through integration and agreement, reviewed and revised the protocols. The essence of these protocols was the fact that its foundation was built on evidence-based practice, culture and acceptance between clinician teams with regards to workload and various physician practice styles. With the help of physicians and nurses for the study, a protocol was initiated by the ED to provide autonomy for triage nurses to prescribe and administer analgesia without having to consult with a physician (Goh et al. 2007). Approval of this NIM was granted by the medical board and taken into effect. In a study by Van Woerden et al. (2016) a clinical committee was created which consisted of healthcare professionals from the departments of emergency department, anaesthesiology and surgical department who had analyzed the current protocol for pain management and to revise it to a more current standard where a nurse would be able to independently prescribe medications for patients.
These recommendations further augment the steps taken in the UK whereby nurses who have completed their NMC qualifications via an NMC qualified prescribing course are able to prescribe medications both independently as well as supplementary well with their capacity (DOH, 2010& NMC, 2006.
Much more research should be undertaken using a standard set of formularies and an identified list of complaints, such as back pain, fractures, strains, sprains and dislocations, just to name a few in order to look closer into the efficacy of NIM. Some studies had only identified specific pain such as abdominal pain or general pain and fever, which is limited in its sense and could have been broader.
A recommendation would be an implementation of a process improvement project whereby a reconfiguration of the ED patient experience from arrival to departure would be measured. This review was not undertaken to measure the correlation between timeliness of analgesia affecting ED-LOS However, further 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 Department? 54 research could be undertaken to identify the correlation between NIM and ED-LOS for patients in the ED for admission or discharge. These results could further solidify the impact and effectiveness of NIM for patients.
The safety of nurse prescribing was not an outcome that was heavily researched upon in this review. In the ten selected studies, the results had identified no medical errors, adverse events or severe reactions from the course of nurse prescribing at triage. A few researches have correlated safety and usefulness of nurse prescribing choices with those of the physicians, which resulted in identical and enhanced algorithms of prescribing by nurses (Venning et al. 2000, Miles et al. 2002, Carey et al. 2008& Jones et al. 2011. As a measure to enhance safety, hospitals could engage in frequent audits of medicines prescribed by the nurses, involve pharmacists to give their recommendations as well as physicians to uphold the values of evidence-based practice in medicine. Future research into the safety of independent nurse prescribing should be undertaken to further expand NIM/NIA and have a more thorough assessment into the long-term implementation of NIM/NIA, avoiding incidences like the catastrophic case of Dr.
The themes identified in NIM are all representative of one another. In order for NIM to be successful, the themes need to be incorporated and worked upon.
Being able to undertake this research has been a fulfilling experience. NIM has been under researched in Singapore and I hope nurses will get more autonomy and responsibility by being able to provide NIM towards patients. As an ED nurse, being able to initiate medications for patients at the point of triage would be more useful in alleviating their pain and relieving their anxiety. NIM would also provide us nurses with more pharmacological knowledge, experience with patients' diagnosis and treatment regimens and familiarity of the various types of medications commonly used in the ED.
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 Department? 55

Limitations
As a novice researcher, undertaking a search strategy, critical appraisal and thematic analysis of results would not have been as in depth compared to a researcher of more experience. Time constraints also hindered the process of searching for more material as well as financial restrictions, which have held back the search or purchases of research that could not be obtained through the school's library. Also, a secondary researcher was not a luxury to me as to be able to help with my searching, critiquing and stitching together of the results and vetting through my research as two pairs of eyes are usually what is needed basically for a systematic review. Grey literature could not be accessed for this review; intra-library searching electronically and physically could not be done based on time constraints. There was also a limitation of research found with study design of RCTs based on NIM to be used for this review. Thus, by following the EBM model, cohort studies were chosen. There was also a lack of studies done locally that could be found except one. NIM has not been researched upon in Singapore as of yet thus, more research could be undertaken in this field.

8.Conclusion
Nurse initiated medications are beneficial for patients' and 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.
Compelling evidence in this review has shown an increase in timeliness to analgesia and an improvement in pain control. By creating a standard and precise set of guidelines and policies in which nurses could follow, NIM would be effectively piloted, granting nurses prescriptive authority. Education and training session would also be warranted to certify the nurses competent as well as evaluative sessions to minimize any risk of potential medication errors.
Measures could be set in place to observe the effectiveness of NIM such as a probationary period before the first review of the pilot progress to gauge the 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 Department? 56 outcomes and any breach of safety if reported. The hospital's management should also stand firm and serve as a support into this initiation. A local research study could be done, preferably a randomised study and also a study based on the perceptions and compliance for nurses towards NIM. With more research into the barriers such as safety, this practice could be further improved, and the autonomy of nurses would be amplified as well as their responsibility.
Prescriptive authority for nurses will be a further step forward in contemporary emergency medicine.

Ethics Approval and Consent to Participate
Ethics approval was not required for this systematic review.

Consent for Publication
Not applicable

Availability of Data and Materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Competing Interest
The authors declare that there is no competing interests.

Funding Statement
There was no funding required for this article.