NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 1 Registered Nurse and Registered Psychiatric Nurse Perceptions and Experiences of Prescribing Opioid Agonist Therapy to People with an Opioid Use Disorder in British Columbia Amanda Lavigne, RPN, BScPN Master of Psychiatric Nursing, Brandon University Author Note Thesis Advisor: Jane Karpa, RPN, PhD Associate Professor, Brandon University, Thesis Committee Members: Sharran Mullins, RPN, BA, BScPN, MPN Assistant Professor, Brandon University Thesis Committee Member: Melissa White, RSW, BSW, MSW, MHSU Transformation Team, Interior Health NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 2 Abstract British Columbia (B.C.) has suffered the loss of multiple lives every day due to the relentless unregulated toxic drug poisoning crisis that has significantly affected this province since 2016 (B.C. Coroners Service, 2023). In September 2020 the B.C. Provincial Medical Health Officer, issued a provincial health order that set wheels in motion to allow registered nurses (RNs) and registered psychiatric nurses (RPNs) to diagnose and prescribe pharmacological treatment for opioid use disorder (Ministry of Health, 2020). This study used a qualitative approach to understand how RNs and RPNs in B.C. experience their expanded role as nurse prescribers of opioid agonist therapy (OAT). Utilizing Sally Thorne’s (2016) Interpretive Description method, a purposeful sample of RNs and RPNs across the province who actively prescribe OAT to people with an opioid use disorder were interviewed about their experience and perceptions. This study was grounded in Patricia Benner’s nursing theory From Novice to Expert, acknowledging prescribing OAT as a new area of professional growth for RNs and RPNs in B.C. Key findings of this study include; insights into the experiences of OAT prescribing RNs and RPNs in Canada; the utilization of SROM (slow release oral morphine) as a medication within scope of RNs and RPNs for the treatment opioid use disorder; unionized position considerations for this nursing practice, and challenging the need for masters preparedness for nurses to engage in OAT prescribing in B.C. Findings within this research are relevant to other Canadian provinces considering implementing RN/RPN OAT prescribing as a strategy to increase access to pharmacological treatment for people with opioid use disorder. Keywords: RPN OAT prescribing, RN OAT prescribing, nurse prescribing, opioid agonist therapy, opioid use disorder, toxic drug supply crisis, overdose crisis NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 3 Acknowledgements Firstly, I want to acknowledge the devastating harm that the dual public health emergencies of the unregulated drug supply and COVID-19 have caused to people who use drugs and the families of people who have lost their lives across Canada. Indigenous peoples and communities who continue to suffer the impacts of colonization, cultural disconnect, racism and stigma, have been disproportionately harmed by these events across this country. Their collective stories of survival shed light on their ability to adapt and grow despite immense hardship and pain. Their resiliency and strength offers hope to people struggling to see a way forward. I would like to acknowledge Dr. Bonnie Henry and her insight to leverage the nursing workforce against the increasing harms caused by the unregulated toxic drug supply crisis in our province. It is her Provincial Health Officer order that set the wheels in motion to allow RNs and RPNs to prescribe medication to treat opioid use disorder and for that I am grateful. I would like to thank my thesis advisor, Dr. Jane Karpa for her invaluable guidance, patience and support throughout my program and thesis research. Thank you to my thesis committee, Melissa White and Sharran Mullins who dedicated their time and expertise to supporting my thesis journey. I want to acknowledge my husband Jesse Lavigne who has supported me unconditionally with love, humor and coffee that kept me afloat when I felt like I was drowning in work. Thank you to my many family members and friends for being my cheer team. Your love was felt and deeply appreciated. Thanks to Laz, Pip and Marshall, my little helpers who shared my lap with my laptop. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 4 Thank you to the RN/RPN OAT prescribers who took the time to share their invaluable experience with me, I am truly honored and I continue to admire the incredibly important work that you do. I feel grateful and privileged in my regional clinical nurse specialist role to be influencing work that spans the beautiful and precious lands of the Dãkelh Dené , Ktunaxa, Nlaka'pamux, Secwépemc, Stl'atl'imc, Syilx, and the Tsilhqot'in First Nations and recognize the strength and wisdom of the Indigenous Peoples’ that have lived, live, and will continue to thrive across these territories. Language Disclaimer: The landscape of language surrounding substance use and addiction is rapidly shifting as people with lived and living experience of substance use vocalize the impact of stigma and misinformation that continues to separate them from access to resources and care they need (BCCDC, 2023). Throughout this study I have replaced the familiar term “overdose crisis” with “unregulated or toxic drug crisis”, which frames the crisis within the context of the poisonous drug supply, and not that the individual has taken too much of their substance of choice. Referring to opioids as “unregulated” is an important distinction to make to remind Canadians who consume alcohol, tobacco and cannabis that they are not at risk of accidental poisoning from unknown substances in their substance of choice (VANDU et al.,2021). Language depicting substance use and addiction is inconsistent throughout the global literature, and terms such as “addict” and “substance abuse” are avoided when representing literature as these terms perpetuate stigma and are not person centered (BCCDC, 2023). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 5 Table of Contents Abstract…………………………………………………………………………………………………………………………………………..……ii Acknowledgements………………………………………………………………………………………………………………………….….iii Table of Contents………….……………………………………………………………………………………………………………….….iv-vi Chapter 1: Introduction.………………………………………………………………………………………………………………………...7 Background………………………………………………………………………………………………………………………………..7 Purpose……………………………………………………………………………………………………………………………………...8 Research Objectives and Questions…………………………………………………………………………………………….8 Chapter overview…………………………………………………………………………………………………………………….….8 Chapter 2: Literature Review………………………………………………………………………………………………………………..10 Contextualizing the Opioid Overdose Public Health Emergency…………………………………………………11 Government policies/ response to the toxic drug supply……………………………………….13 Nursing role within substance use services……………………………………………………………17 Advanced Nursing Scope of Practice…………………………………………………………………………………………18 Nurse Practitioners Prescribing Opioid Agonist Therapy………………………………………..20 Registered Nurses Prescribing Opioid Agonist Therapy………………………………………….22 Registered Psychiatric Nurses Prescribing Opioid Agonist Therapy………………………..23 Chapter 3: Research Design………………………………………………………………………………………………………………….26 Interpretive description as a Research Method…………………………………………………………………………..26 Theroretical Framework………………………………………………………………………………………………………………26 Research Design………………………………………………………………………………………………………………………….27 Research Questions…………………………………………………………………………………………………………………….27 Participant inclusion and exclusion criteria…………………………………………………………………………………28 Data Collection …………………………………………………………………………………………………………………………..28 Data Analysis………………………………………………………………………………………………………………………………30 Ethical Consideration………………………………………………………………………………………………………………….31 Chapter 4: Findings………………………………………………………………………………………………………………………..……..33 Research Questions…………………………………………………………………………………………………………………....33 Participant Group……………………………………………………………………………………………………………………....33 Themes……………………………………………………………………………………………………………………………………….34 Becoming a RN/RPN OAT Prescriber………………………………………………………………………………...34 Just do it…but do it for the right reasons……………………………………………………….….36 Being a RN/RPN OAT Prescriber……………………………………………………………………………..………..37 Benefits…………………………………………………………………………………………………………….39 Challenges………………………………………………………………………………………………………...40 The Future of OAT RN/RPN Prescribing………………………………………………………………………….….43 Recommendations for implementation……………………………………………………………..44 Advice to nurses………………………………………………………………………………………………..44 Chapter 5: Discussion ……………………………………………………………………………………………………………………..……47 Contextual Update……….………………………………………………………………………………………………………..……47 NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 6 Findings and Themes…………………………………………………………………………………………………….……………48 Becoming a RN/RPN OAT Prescriber………………………………………………………………………………...48 Just do it…but do it for the right reasons……………………………………………………….….49 Being a RN/RPN OAT Prescriber……………………………………………………………………………..………..50 Benefits…………………………………………………………………………………………………………….50 Challenges………………………………………………………………………………………………………...51 The Future of OAT RN/RPN Prescribing………………………………………………………………………….….52 Recommendations for implementation……………………………………………………………..52 Advice to nurses………………………………………………………………………………………………..53 Key Findings……………………………………………………………………………………..…………………………………………53 Methodology………………………………………………………………………………………………………………………………54 Theoretical Framework……………………………………………………………………………………………………………….55 Study Strengths and Limitations…………………………………………………………………………………………….……55 Implications for Practice and Administration ………………………………………………………………………………56 Future Research and Recommendations………………………………………………………………………………………56 Conclusion……………………………………………………………………………………………………………………………….….57 References…………………………………………………………………………………………………………………………….………………58 Appendices……………………………………………………………………………………………………………………………………………72 NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 7 Chapter One: Introduction Background The Government of Canada (2021) declared a public health unregulated drug poisoning crisis, determining that 24,626 opioid-related deaths occurred in Canada from January 2016-June 2021. In British Columbia (B.C.) 14,381 unregulated drug toxicity deaths occurred between January 1st, 2013 to Aug 31st,2023 (B.C. Coroners Service, 2023). The number of unregulated drug deaths that occurred in April 2023 [in B.C.] equated to approximately 7.8 deaths per day (B.C. Coroners Service, 2023). The federal and provincial COVID-19 public health emergency was declared in March 2020 creating further vulnerabilities and risk of death for people who use unregulated substances (Government of Canada, 2021). In efforts to reduce the global spread of COVID-19, national border closures cut off access to foreign unregulated drug supplies, resulting in an increase of high potency synthetic alternatives in the local unregulated drug supply in B.C., putting people who use drugs at increasing risk of death (BCCSU, 2022). Opioid agonist therapy (OAT) is an evidence-based treatment for opioid use disorder that provides protective factors against poisoning/death for people consuming high potency synthetic opioids (Pearce et al., 2020). On September 16th, 2020, the B.C. Provincial Medical Health Officer, Dr. Bonnie Henry, announced a temporary order for the approval of registered nurses (RNs) and registered psychiatric nurses (RPNs) to diagnose and prescribe pharmacological treatment for opioid use disorder (Ministry of Health, 2020). Based on this Public Health Order, the B.C. College of Nursing Professionals revised the scope of RN and RPN practice on September 24th, 2020, to include prescribing opioid agonist treatment and adjunct medications to manage precipitated withdrawal to people diagnosed with an opioid use disorder (BCCNP, 2020). The medical model of prescribing pharmaceuticals has historically been allocated to the disciplines of medicine and pharmacy in healthcare within B.C. As such, there is much to learn about nurse’s experience of this change. Nursing practice will benefit from understanding NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 8 how to provide service to people with an opioid use disorder, the challenges and benefits in changing practice and how they are supported across the province to adopt the skill of prescribing. Purpose The purpose of this research was to explore the experiences and perceptions of nurses in B.C. who have acquired provincial training to actively prescribe OAT to people with an opioid use disorder, under a public health order during a dual public health emergency. The qualitative methodology interpretive description was used to understand this phenomenon and present the clinical findings in a way that captured the complexity of this nursing intervention (Thorne, 2016). This study supported planning for the expansion of nurse prescribing both provincially and within the Interior Health Authority. This research may be of benefit to nurses by providing them with an opportunity to share knowledge about their unique roles and experiences in supporting people who use substances. Research Objectives and Questions This study is rooted in qualitative methodology, utilizing Sally Thorne’s interpretive description framework (Thorne, 2016). The objectives of this study are to describe how RNs and RPNs have been impacted by adopting the practice of prescribing OAT to people with an opioid use disorder, and to understand the challenges and benefits in utilizing RNs and RPNs as prescribers of OAT amid dual public health emergencies of COVID-19 and the toxic drug crisis. The three primary guiding questions this study explores are: 1) What are the experiences and perceptions of RNs and RPNs acquiring skills to prescribe opioid agonist therapy in British Columbia? 2) What are the experiences and perceptions of RNs and RPNs prescribing opioid agonist therapy to people with an opioid use disorder? 3) What are the practice implications for adopting the skill set of prescribing OAT for nurses working in substance use services? Chapter Overview NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 9 In Chapter two, global literature is explored, reviewing government and policy response to the public health emergency, as well as the nursing role in substance use services. Additionally, the literature examines advanced nursing practice and the role of prescribing medications for RNs, RPNs and Nurse Practitioners. In Chapter three, I outline the use of the interpretive description methodology in this research, the theoretical framework, and research design process. I also discuss participant selection and managing risks that come with qualitative analysis. Chapter four is an overview of the data and themes that emerged throughout the study of the experience of RN and RPN OAT prescribers. In Chapter five, I outline these findings in a detailed discussion and explain the study’s strengths and limitations as well as make recommendations for future research. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 10 Chapter Two: Literature Review Global literature informed the following topics and sub-topics: • • Contextualizing the Unregulated Drug Poisoning Public Health Emergency • Government policies/ response to the unregulated toxic drug supply • Nursing role within substance use services Advanced Nursing Scope of Practice • Nurse Practitioners Prescribing Opioid Agonist Therapy • Registered Nurses Prescribing Opioid Agonist Therapy • Registered Psychiatric Nurses Prescribing Opioid Agonist Therapy This review included literature from both text and online sources. Online literature was searched utilizing databases: EBSCOhost EJS, E-Journals Database, Academic Search Premier, IngentaConnect Journals, and Open Access Digital library. Literature cited in relevant studies was included. The sources reviewed consisted of both quantitative and qualitative literature. Relevant grey literature (i.e. magazines, organizational policy papers, governmental reports) sourced via government websites was included. The search terms used included: ‘Interpretive Description’, ‘Advanced Nursing Scope of Practice’ AND ‘RN, ‘RPN’, NP’, ‘Nurse Prescribing’, ‘opioid agonist therapy’, ‘Nursing and Addiction Services’, ‘opioid overdose response’, and ‘Government overdose policy’. Literature was included from North America, South America, Europe, Australia, Asia and Africa. Literature publication was between 2000 and 2022, with a priority focus on studies newer than 2010. Literature older than 2000 was minimally referenced to provide context to the history of qualitative research. Approximately 42 qualitative articles, 14 quantitative articles, two mixed method studies, eight book chapters and 22 pieces of grey literature were reviewed for this study. Updated literature relevant to the context of this study was later discovered by subscribing to multiple North American journals on addiction substance use and harm reduction. The following NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 11 journals were screened for relevant literature between May 2022 to September 2023: Canadian Journal of Addiction, Journal of Addiction Medicine, Journal of Substance Abuse Treatment, The American Journal on Addictions, The American Journal of Drug and Alcohol Abuse and the Harm Reduction Journal. Additional grey literature was published since the time of the initial literature review that provides context to the state of the dual public health emergencies (COVID-19 and the unregulated drug supply) in the province of British Columbia. An additional 34 references were included or updated in a secondary phase of the literature review and integrated into the headings below. Contextualizing the Opioid Overdose Public Health Emergency The Canadian Center on Substance Use and Addiction (2020), outlined that 14.42% of the population uses opioids and that social harms and health care impacts, related to the use of opioids, cost Canadians approximately 7 billion dollars in 2020. Since the declaration of the public health emergency in April 2016, B.C. has lost 12,929 individual lives to unregulated drug supply, with the highest rates of death occurring in 2022 (B.C. Coroners Service, 2023). In a B.C. study which outlined the state of the unregulated drug supply between 2018-2019, fentanyl (a concentrated synthetic opioid), was found in 61% of 4,729 heroin samples tested at drug checking sites across B.C. (Long et al., 2020). Taylor et al., (2021) noted that in B.C. and parts of the U.S. the unregulated opioid supply is predominantly supplemented with high potency synthetic fentanyl. The B.C. Coroners Office continues to see fentanyl and fentanyl analogues present in over 85% of unregulated drug toxicity deaths across the province (B.C. Coroners Office, 2023). With the number of deaths related to unregulated drug toxicity rising well into 2022, the B.C. Coroners office coordinated a death review panel of experts across the province to collectively provide a set of provincial recommendations and key areas of focus needed to combat this crisis (B.C. Coroners Office, 2022). The three key areas outlined by this panel were; (1) creating access to a safer drug supply, (2) developing a coordinated, goal driven provincial strategy, and (3) building a comprehensive continuum of substance use care (B.C. Coroners Office, 2022). A recommendation specifically relevant to RN/RPN NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 12 prescribing initiative, made by the multidisciplinary panel was ensuring continued expanded access to OAT and to “develop a practice standard to support health care providers and prescribers…to assess, screen and diagnose patients for substance use disorders, and develop referral mechanisms to link patients to evidence-based services” (B.C. Coroners Office, 2022, p.7). First Nations Health Authority (FNHA) provides monthly community situation reports that outline the impact that the toxic drug supply is having on First Nations people in B.C. In May 2023, FNHA reported that 1,833 First Nations people have lost their lives due to the toxic drug crisis since its declaration in 2016. Due to colonization, First Nations people in B.C. are disproportionately harmed in the toxic drug crisis, making up 3.3% of the B.C. total population, yet represented 21.2% of the population who died of illicit drug toxicity in the month of May, 2023 (FNHA, 2023). The B.C. Center for Disease Control (BCCDC) developed a comprehensive report outlining how measures taken across the province to combat the second public health emergency, COVID-19 pandemic, had negative impacts on the overall mental health and substance use of the province (BCCDC, 2023). BCCDC stated that the societal impacts the pandemic response has had on unregulated drug death rates confirms that “COVID-19 and response measures are increasing the risk of poisoning, illness, and death for people who use substances” (2023). Lott et al., (2023) conducted a survey of 30 multidisciplinary prescribers from the U.S. Department of Veterans Affairs who were surveyed on providing opioid agonist treatment (OAT) during COVID-19. Key changes to OAT practice were identified as; reduction in collection of urine drug screens, increase in patient and provider preference for telehealth appointments, although there was concern noted for specific clients who had a tendency to isolate socially (Lott et al., 2023). Cooper et al., conducted a U.S. study out of Maryland, Baltimore looking at how women who inject drugs were impacted during COVID19, and they found pros and cons that impacted OAT care (2023). Staff shortages during COVID-19 interrupted OAT care access despite attempts to provide increased virtual or mobile services, intake forms required prior to virtual service were overwhelming in length, but overall harm reduction innovations NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 13 were appreciated and hoped to continue (Cooper et al., 2023). Blanco et al., (2020) stated that the unregulated opioid crisis in the U.S. is “unabated to date, is fueled by increased ‘use’ of synthetic opioids, a rise in deaths from psychostimulants, and low rates of treatment entry and retention” (p.1). With other countries comparing themselves to the toxic drug crisis happening in the United States and Canada, researchers are investigating the reasons why their continents have not had to declare the same state of emergency. Pierce et al., (2021) examined the differences between 19 European countries and the U.S. finding that: • Europe does not directly market opioids publicly to patients • Illicitly manufactured fentanyl analogues are not typically an issue in Europe • Diversion and doctor shopping which are an issue in the U.S., are not typical in Europe • There is much higher accessibility to free OAT in Europe compared to the U.S. In a study focused on opioid use along the northern Mexican border, Fleiz et al., (2019) found that access to treatment for opioid use disorder is poor, however the unregulated supply appears to not be tainted with high potency synthetic opioids, as people are recovering from overdoses without medical intervention. Taylor, et al., (2021) conducted a comparative mixed-method study looking closely at countries that have not yet declared an opioid related public health emergency (China, India, Australia, and Mayanmar) and examined factors of resiliency and potential weakness against the intrusion of synthetic opioids. Taylor, et al., (2021) identified that while all countries within the study are at risk of synthetic opioids being introduced into their illicit opioid supply, only Australia is well equipped with the services needed to reduce unregulated drug toxicity death risks. The World Health Organization declared a global pandemic in March 2020 due to the devastating spread of the COVID-19, virus which further complicated the state of the unregulated drug supply by restricting access between countries supplying unregulated substances, (B.C. Center on Substance Use (2022). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 14 Government policies/ response to the unregulated toxic drug supply Since the public health declaration in 2016, the B.C. Government funded the B.C. Center on Substance Use to develop a provincial guideline for the treatment of opioid use disorder and made the required prescribing education free to physicians and NPs across Canada (B.C. Center on Substance Use & B.C. Ministry of Health, 2017; Gorfinkel et al., 2019). Being stabilized on OAT supports people to reduce the use of unregulated opioids and therefore lowers the risk of death amid a toxic drug supply (Pearce et al., 2020). Bardwell & Lappalainen (2021) outlined that Canada’s approach to the toxic drug crisis has been focused on access to opioid agonist treatment, naloxone distribution, and supervised consumption of injectable unregulated substances in urban centers, and that more focus must be placed on rural community needs and access. Bardwell & Lappalainen (2021) highlighted that within a rural region of B.C., injection (23%), inhalation (31%), and intranasal (39%), are the most identified routes of administration for substance use. The Government of Canada (2021) launched an outline of their financial commitment to improve care for priority populations, which includes Indigenous peoples, 2SLGBTQIA+, youth, people living with pain, and people living in rural and remote communities. Key strategies that the Canadian government (2021) is allocating project funding towards are: • increasing access to naloxone • creating safe supply programs to reduce the impact of the toxic drug supply • addressing homelessness • accessing harm reduction services • reducing stigma experienced by patients and families affected by the toxic drug crisis. In response to the worsening impact that COVID-19 has had on unregulated drug death rates due to potent opioids across the province, the B.C. Government further developed toolkits and guidance on overdose response and risk mitigation prescribing (B.C. Center for Disease Control, 2020; B.C. Center on Substance Use, 2022). In September 2020, the B.C. Minister of Health issued a public health order that NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 15 included RNs and RPNs as part of the workforce that prescribes controlled substances for the treatment of opioid use disorder (Ministry of Health, 2020). Interior Health Authority (IHA) Medical Health Officers (MHO) continue to advocate for improved patient outcomes and have focused their 2021 and 2022 annual reports on the unregulated toxic drug crisis within the IHA region. IHA, 2021 MHO report outlines recommendations for IHA care providers to adopt “every door is the right door” philosophy, to understand the impacts of stigma, to provide equitable, trauma informed and culturally safe care, and embed harm reduction practices into care. The subsequent IHA MHO report (2022) outlined barriers to service for people with substance use disorders as not having a phone, lengthy appointment wait times, limited hours of operation, and lack of transportation to services. Key recommendations to IHA made within the 2022 MHO annual report included: commit to anti-racism and anti-stigma, involve people with lived experience at decision making tables, implement a harm reduction policy, and develop substance use standards of care in acute settings. Additional calls to action directed to the B.C. government made by the MHO include the urgent need to address housing shortages, increase transportation in and between rural areas, increase an evidence based continuum of substance use care across the province and regulate alternatives to the unregulated drug market (IHA, 2022). Along with support for many of the changes across B.C., harm reduction and peer lead advocacy groups are calling for decriminalization and regulation of unregulated drugs, noting that toxic drug poisoning will continue without an end to the policy war on drugs which is rooted in stigma and racism. (VANDU et al., 2021). Eastern Canada and Ontario, echo the advocacy for the need for government to support the expansion of safe supply programs to combat the devastating impact of unregulated opioids (Gagnon et al., 2023). People supported with access to regulated substances have reduced hospital utilization, fewer drug poisoning events, increased engagement in care, and improved health and social outcomes (Gagnon, 2023). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 16 Globally, OAT commonly includes methadone and buprenorphine, however in Canada buprenorphine is typically combined with naloxone which increases the safety profile of the medication, decreasing the desirability to divert the medication to be injected or snorted (Bates & Martin-Misener, 2020; Spetz et al., 2021). Cohen (2023) vocalized the continued limitations in the U.S. related to access to opioid agonist therapy (OAT), stating that there is a need to expand government approved medications beyond buprenorphine and methadone for the treatment of OUD. Harder et al., (2021) conducted a study comparing the government toxic drug response in the states of Maine and Vermont between 2016 and 2018 where unregulated poisoning rates were occurring at higher rates than the national average. The states’ primary government response to increasing unregulated poisoning rates in their region were to tighten monitoring and restrictions on opioid prescribing practice (Harder et al., 2021). Harder et al., (2021) concluded that restricting opioid prescribing will reduce events of adverse reactions to opioids in the long term but may increase these events in the short-term as people turn to other non-medical sources of opioids. Priest et al., (2019) compared the differences in government responses to unregulated drug deaths between Canada and the U.S. and note that the need for specialty training, pharmacy access, and negative prescriber attitudes towards people with an opioid use disorder, impacted access to treatment for both countries. The U.S. government, like Canada, faces criticism for perpetuating the “war on drugs”, using enforcement inequitably towards marginalized populations and continuing drug policies that focus on criminal consequences rather than access to treatment (Rosino & Hughley, 2018). Blanco et al., (2020) outlined four themes needed to curb the current U.S. toxic drug crisis and prevent future harms, which are; addressing social determinants of health, person-centered approaches to care, data informed systems of care, and closing the gap between evidence and practice. Alho, (2020) stated that while the continent was not in an official state of emergency, key government strategies were needed in Europe to combat the rising opioid related death rates including interventions in the areas of prevention, screening, harm reduction, and access to treatment. Portugal’s government NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 17 response to managing criminalized substance use has been under review since they launched their model of decriminalization and committee oversight of “substance use offenders” in 1998 (Cabral, 2017). In Cabral’s 15-year analysis of Portugal’s approach to addressing unregulated substance use, the author found that the country experienced a decrease in drug consumption, HIV and AIDS rates, unregulated drug deaths, and an 18% reduction in social harm related costs (2017). Nursing role within substance use services Nurses play critical roles in services that provide resources to marginalized populations, which include providing outreach connection, building trust, prevention, detection and treatment, service navigation and client advocacy in the healthcare system (Hilton et al., 2001; Ford, 2011; Pauly, 2014). Finnell et al., (2019) outlined U.S. national competencies nurses should have when supporting substance use disorders, which include screening and brief intervention, diagnosis of substance use disorders, education in harm reduction, developing care plans and coordination of healthcare services. As of 2021, within B.C. Canada, RNs and RPNs with additional training, are additionally permitted to diagnose, assess, order tests, prescribe opioid agonist therapy and refer to treatment as outlined in the provincial decision support tool (B.C Center on Substance Use, 2021). Common challenges identified in the substance use focused nursing literature were a general feeling that nursing education left them under prepared to support people with substance use disorders, and that substance use nurses experience stigma from peers and the public - being seen as enablers of substance use (Ford 2011; Abram, 2018; Jozaghi & Dadakhah-Chimeh, 2018; Finnell et al., 2019). Intrapersonal challenges for nurses identified in the literature were developing discriminatory negative attitudes towards patients who use substances, related to managing behaviors of manipulation, violence, and irresponsibility (Kelleher & Cotter, 2009; Ford, 2011; Lang et al., 2013; Van Boekel, 2013). Pauly et al., (2015) emphasized that discrimination and stigmatizing attitudes from service providers towards people who use drugs is prevalent in health care services and results in significant negative health impacts NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 18 to this population. Russel et al., (2017) found that stigmatizing attitudes among health care professionals improved following education about stigma and substance use disorders as well as exposure to interacting with people with substance use disorders. Despite the challenges nurses face with limited education to serve marginalized populations, Pauly (2014) indicated that nurses have both a professional and ethical obligation to provide respectful and dignity-preserving care to all people. Clancy et al., (2019) explored the role of substance use nurses across the Netherlands, Ireland, and the United Kingdom, related to care for people with HIV, alcohol use disorder and opioid use disorder. In Ireland, substance use nurse specialists were established in the 1980’s and while they were initially utilized to dispense methadone, their role evolved to include supporting mental health, managing blood borne illness, chronic and acute health issues, pre and post natal care, and supporting navigation of the correctional system (Clancy et al., 2019; Comiskey et al., 2019). As harm reduction was adopted across Ireland the substance use nursing role formally expanded, the first substance use nurse practitioner (NP) came to fruition in Ireland in 2018 (Clancy et al., 2019). In the Netherlands, the nursing role evolved in substance use services as harm reduction was adopted across services from being an alcohol and drug nurse to the more inclusive substance use nurse and masters prepared substance use specialist nurses which includes prescribing of OAT (Clancy et al., 2023). Nurses in the United Kingdom have been working within substance use services as far back as 1955 and have created a formal substance association since the 1980s where the role expanded across hospitals, primary care, community, corrections and harm reduction sites (Clancy et al., 2023). Substance use nurses in the United Kingdom have been prescribing methadone and buprenorphine since 2006, however details of implementation and on-going utilization are limited within literature despite such a significant history (Clancy et al., 2023; Banka-Cullen et al., 2003). Advanced Nursing Scope of Practice NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 19 Four internationally recognized advanced practice nursing (APN) roles implemented across multiple care settings include: clinical nurse specialists, clinical registered nurse anesthetists, certified nursemidwives, and nurse practitioners (Becker & Doherty, 2018; Sheer & Wong, 2008). Role stressors common to APNs include role ambiguity, role overload, role transition and role under qualification, all of which negatively affect team dynamics and patient care (Eagar et al., 2010; Joel, 2018). For APNs whose scope includes prescribing medications, relationships with fellow prescribers can be challenging if physicians perceive them as impacting financially on their practice (Bryant-Lukosius et al., 2004; Kuehn, 2018). Not only does the act of prescribing change relationships with team members, it also changes the relationship, responsibility, and role with the patient (Forbes & Jessup, 2004). Banka-Cullen et al., (2023) conducted a scoping review of nurses prescribing opioid agonist therapy globally, referring to advanced practice nurses and nurse practitioners interchangeably. The language used to describe nurses who are training to prescribe OAT is inconsistent across the literature, making it challenging to identify if they are formally nurse practitioners, registered nurses or registered psychiatric nurses. Regardless of the specific nursing discipline, Banka-Cullen et al. stated that nurses trained in OAT improve access to treatment for people with an OUD, especially in communities within limited resources and rural areas (2023). In a U.S. study examining registered nurses, nurse practitioners and clinical nurse specialists supporting people with the treatment of buprenorphine, numerous challenges were identified in the management of substance use disorders that hindered their success in prescribing (Kameg et al., 2020). The nurse prescribers vocalized concerns with the treatment limitations of buprenorphine in the management of OUD, gaps in obtaining physician oversight, client adherence and suspected diversion, and working within non-ideal work settings to serve the population (Kameg et al., 2020). Mentorship, clinical support and access to free education were factors that the nurses identified as fostering their buprenorphine prescribing practice (Kameg et al., 2020). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 20 Global literature outlined that APNs provided high quality care to patients despite the obstacles experienced; they are cost effective and when given adequate training, capable of treating complex presentations (Elsom et al., 2005; Schober & Green, 2018; Strobbe & Hobbins, 2012). When it comes to being part of the health care response to unregulated opioid related deaths, APNs are a capable workforce when provided with training and the scope to prescribe Buprenorphine/ Naloxone (Strobbe & Hobbins, 2012; Tierney et al., 2015). Kuehn, (2018) outlined strategies for success when shaping collaborative practice between physicians and APNs which include: creating a collegial team, addressing responsibility for growth as a team, using protocols and guidelines appropriately, being clear on language around roles, and being mindful of communication skills when working collaboratively with others. Nurse Practitioners Prescribing Opioid Agonist Therapy Since the inception of Nurse Practitioners (NPs) in the 1960s, there has been significant evolution in their scope of practice, expansions to their areas of practice, and breaking down of barriers related to autonomous prescribing (Kuehn, 2018). NPs have played a critical role in primary care and have paved the way for all advanced practice nurses to prescribe autonomously in the United States (Towers, 2018). Schirle & McCabe (2016) conducted a U.S. wide study which examined the prescribing patterns of benzodiazepines and opioids by advanced practice nurses (APNs) and determined that there is no correlation with increased risk to clients in the prescribing patterns of APNs who are supervised by physicians versus those who were autonomous in prescribing. The Canadian Nurses Association recognized graduate level NPs across Canada as having the clinical skills and medical scope to diagnose autonomously, order assessments, and treat multiple populations within multiple care settings (CAN, 2016). In 2012, NPs across Canada were authorized to prescribe controlled drugs and substances, however, the province of B.C. did not integrate this legislation into NP scope until 2016 (O’Rourke et al., 2019). In 2018 in the Province of British Columbia (B.C.), NPs scope expanded to include prescribing opioid agonist therapy (OAT), and later in November 2021, expanded again to include prescribing of safer supply NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 21 (B.C. College of Nurses & Midwives, 2021; College of Pharmacists B.C., 2022). NPs are required to take the standardized B.C. Center on Substance Use education for prescribing OAT and safer supply, and are considered part of the B.C. provincial response to battling the unregulated drug poisoning public health emergency (B.C. College of Nurses & Midwives, 2021). In a systematic review, Gielen et al., (2014) identified three general types of controls on nurse prescribing practice; independent prescribing, supplementary prescribing, and patient group prescribing (referred to as pre-printed orders in British Columbia). In the United States, NPs prescribing of buprenorphine/naloxone varied state to state; those required to have physician oversight reported it difficult to meet the needs of people with an opioid use disorder (Andrilla, et al., 2020). NPs and physician assistants eligible to obtain the waiver to prescribe, were estimated to be able to increase access to OAT by 15.2% in rural areas; however, the volume of practitioners who adopt the waiver is under-serving the population across the U.S. (Andrilla, et al., 2020). Not applicable in Canada, NPs in the U.S. have a restriction to prescribe buprenorphine to a maximum of 30 patients within the first year and then subsequently a maximum caseload of 100 OAT patients (Nguyen et al., 2022). NPs across the U.S. tend to prescribe well under their maximum patient limit and this is further impacted when the specific state applies additional legislation requiring physician oversite on NP buprenorphine prescribing (Nguyen et al., 2022). Klein et al., (2020) conducted a review of the impact of NPs prescribing Buprenorphine/Naloxone to rural communities in the state of Oregon and found that NPs are a valuable strategy for increasing treatment access in communities with low population density. A U.S. study that examined education interventions on NPs stigmatizing attitudes towards caring for people with an opioid use disorder, determined that education, combined with clinical exposure to vulnerable people, greatly reduced stigma and that as a work force, NPs play a crucial role in providing primary care to this population (Elliot et al., 2021). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 22 Bates & Martin-Misener (2020) interviewed nurse practitioners in Nova Scotia, who had not yet adopted prescribing, about what hindered their decision to integrate methadone prescribing into their practice. NP’s described stigma between colleagues, the public and even over coming stigma themselves towards people who use drugs as a key barrier to engaging in methadone prescribing (Bates & MartinMisener, 2020). Additional factors identified by NPs in Bates & Martin-Misener’s study included: managing the complexity of clients with an opioid use disorder, lack of early and ongoing access to substance use education as well as hurdles to train to prescribe methadone and the health care team uncertainty in accepting NPs as prescribers in the current system (2020). Registered Nurses Prescribing Opioid Agonist Therapy In the province of B.C. growing rates of opioid related deaths led to a public health order expanding Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs) scope to include prescribing controlled substances and adjunct medication for the treatment of opioid use disorder, aimed at increasing access to OAT. The B.C. College of Nurses and Midwives, (2021) revised the RN and RPN scope of practice in October 2020 to include prescribing OAT for opioid use disorder, followed by new limits and conditions on that practice in March 2021, which allowed them to prescribe Buprenorphine/Naloxone, Methadone, and slow release oral morphine (SROM), after completing provincial training. Across the U.S., advanced practice registered nurses were permitted to obtain waivers to prescribe buprenorphine for opioid use disorder management in 2019 (Spetz et al., 2021). The state of New Mexico stands out as unique in the U.S., in that NP’s and advanced practice registered nurses have the fewest regulations related to buprenorphine prescribing, being autonomous prescribers without physician oversite (Spetz et al., 2021). Snowden & Martin (2010) noted that nurses in the United Kingdom (U.K.) had prescribing within their scope for nearly all medications and most conditions since 2006, given that they are trained appropriately, and feel competent to do so. There was no explicit mention however, of prescribing OAT within their study. Outside of the U.K. and this proposed B.C. focused study, little research is available NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 23 that outlines RN roles specifically in prescribing OAT. Comiskey et at., (2019) interviewed a cohort of clients stabilized on methadone treatment in Ireland about the role that substance use nurses play, or could play, in the treatment management of their opioid use disorder. Clients expressed that the nursing role is essential to their physical and mental well-being and advocated that prescribing of methadone should be part of their scope (Comiskey et at., 2019). While the U.K. has a decades long history of nurses prescribing and working in substance use care, Clancy et al., (2019) outlined that around 1997 the government shifted to operate substance use services primarily by non-for profit organizations which drastically impacted the nursing workforce in substance use treatment/care/healthcare. While little is know about substance use nurses working in these sectors across the U.K., Clancy et al., (2019) emphasized that momentum was not lost; in 2006, registered nurses in the U.K. were permitted to prescribe any licensed medication for any condition (including controlled substances like buprenorphine and methadone), however, literature and data on this practice across the U.K. remains limited. In Australia and Finland based studies that examined barriers and enablers of RNs expanding their scope of practice to include prescribing activities, Jokiniemi et al., (2015) & Birks et al., (2019), found that salary, role confusion, workload, and lack of employer support (guidelines, evaluation, team cohesion) were all factors that deterred RNs from wanting to engage in prescribing. Lennon & Fallon (2018) noted similar challenges in their findings in an Ireland based study, but also highlighted RNs positive perceptions of prescribing, which included due diligence in the logistics of prescribing, being able to complete the trajectory of their care, and seeing an improvement in service access for the client. In a comparative study of 39 countries that adopted prescribing as part of RN practice, it is apparent that little consistency exists regarding training pathways, types of medications, autonomy in prescribing, and regulatory oversight (Maier, 2019). Registered Psychiatric Nurses Prescribing Opioid Agonist Therapy NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 24 In Canada, only the provinces of British Columbia, Alberta, Saskatchewan, Manitoba, and the Yukon regulate psychiatric nurses, and as of 2014, prescribing was not a competency for entry level RPNs (Registered Psychiatric Nurse Regulators of Canada, 2014). As noted, RPNs have been included as part of the B.C. College of Nurses and Midwives (2020) scope of practice expansion to include the assessment, diagnosis, and treatment of opioid use disorder. This prescribing scope change was a temporary exemption outlined in a Provincial Health Order and is therefore not formally part of RPN practice recognized Canada wide (Ministry of Health, 2020). The United States recognizes advanced practice level psychiatric nurses across all 50 states, however, there are many inconsistencies when it comes to legislation on prescribing controlled substances and scope of practice between states (Oleck et al., 2010). A qualitative study of U.K. mental health nurses with prescribing privileges, reported positive themes of improving client access to care, and challenging themes including role ambiguity (Snowden & Martin, 2010). Prior to mental health nurses acquiring the universal scope of prescribing in the U.K., Nolan et al., (2001) conducted a survey study regarding perceptions of prescribing amongst RPNs and found that 79.4% of the RPNs expressed a desire to prescribe for mental health issues in primary care, but 91.8% reflected their prescribing competence was a barrier to assuming this role. Literature referencing mental health nursing or psychiatric nurses prescribing for opioid use disorder continues to be limited. Jones et al., (2020) studied the experience of psychiatric nurse practitioners (NP) waivered in the U.S. to prescribe buprenorphine for a veteran’s affairs program, which outlined similar challenges as other NP studies, noting not all waivered NPs are actually engaging in providing buprenorphine treatment for various reasons. Conclusion Based on this literature review, there are several factors, relevant to this research, that impact upon the successful integration and sustainability of nurses prescribing medications for the treatment of NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 25 substance use disorder. Positive factors identified in the literature included provincial training, health authority guidelines for nurse prescribers, and nurses prescribing OAT autonomously. Challenges in sustaining the initiative of nurse prescribing, as identified in the literature, include managing workload, dynamics with other disciplines, and role ambiguity. This study adds to the novel body of knowledge on nurse prescribing by highlighting the utilization of both RNs and RPNs in the prescribing of OAT. This study also informs policy makers and health authorities about the experience of nurses prescribing OAT in rural and remote areas, and how provincial training and guidelines impact the overall success of nurses taking on this change in scope of practice. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 26 Chapter Three: Research Design Interpretive Description as a Research Method Interpretive description is a qualitative research methodology that acknowledges phenomenon can present differently across multiple realities (Thorne, 2016). Building on historical models of qualitative research, interpretive description may be used to provide clinical context and disciplinary relevance to research findings, making it ideal for nursing research (Thorne, 2016). Grypdonck, (2006) stated that qualitative research is key in developing clinical expertise and defines such as “the integration of scientific findings, reflected experience and observations, and knowledge synthesized through the years and continuously adapted to new information and experiences” (p.1382). Subjective experience is valuable in discovering similarities and unique experiences within a phenomenon (Thorne, 2016). The method of interpretive description research takes historical qualitative methods beyond the when, who, and why, to the “so what” and how it is applicable to practice (Thorne, 2016; Polit & Beck, 2017). This study aimed to understand the experience of nurses attaining prescribing skill sets and prescribing opioid agonist therapy to people with an opioid use disorder. Nurse prescribers in Interior Health and across B.C. are spread out across urban, rural and remote communties, each experiencing a unique impact of the toxic drug crisis. Interpretive description is an ideal methodology to examine this phenomenon and the complex interplay between the discipline of nursing and the treatment interventions required to combat this relentless crisis. Theroretical Framework This study is grounded in the discipline of nursing and informed by Dr. Patricia Benner’s Nursing theory, From Novice to Expert (Benner, 2004). Benner’s theory outlines how nurses gain knowledge and skills through experience, with five levels defined as: 1-novice, 2-advanced beginner, 3- competent, 4proficient, and 5-expert (Benner, 2004; Forbes & Jessup, 2004; Petiprin, 2020). From Novice to Expert nursing theory was based on the Dreyfus model of skill acquisition and is used to better understand how NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 27 nurses apply new learning and insights to their clinical practice (Benner, 2004; Dreyfus & Dreyfus, 1980). Benner outlined that at the level of proficient, nurses begin to situate themselves differently in relation to their work as they progress at developing their intuition and skills (Benner, 2004). Forbes & Jessup (2004) acknowledged that during skill acquisition, nurses can struggle with their sense of self as ‘proficient’ or ‘expert’ and return to feeling novice, and possibly vulnerable. Nurse prescribers of OAT within B.C. are at different stages within their nursing practice and have varying degrees of experience with the skill of prescribing. Benner’s nursing theory informed the interview questions of this study to support understanding which skill level nurses perceived they were at when they became a nurse prescriber, and how adding this skill set impacted their practice. See Appendix A for the interview guide of this thesis research. Research Design While interpretive description does not provide explicit steps to conducting research in the same way as other methods, Thorne (2016) outlined approaches and pitfalls for novice researchers to be aware of. Thorne noted that ongoing engagement with the data throughout the study is required for the researcher to “confirm, test, explore, and expand on the conceptualizations that begin to form as soon as you enter the field” (2016, p. 99). Thorne (2016) emphasized how imperative it is for researchers to understand themselves in the context of their ideas and biases, and what they wish to achieve in their research. The lead researcher of this proposed study is a substance use Clinical Nurse Specialist for the Interior Health Mental Health and Substance Use Transformation Team, leading the region wide coordination and implementation of nurse prescribers. The researcher engaged in journaling to explore and reflect on thoughts, feelings, subjective opinions, and personal biases throughout the research process to enhance awareness and development of ideas (Polit & Beck, 2017; Horrill et al., 2021). Data collected was segmented into categories and themes using commonalities and subtle linkages that came from the participant interviews (Morse, 2016). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 28 Research Questions The research questions this study aimed to answer are: 1) What are the experiences and perceptions of Registered Nurses and Registered Psychiatric Nurses acquiring skills to prescribe opioid agonist therapy in British Columbia? 2) What are the experiences and perceptions of RNs and RPNs prescribing opioid agonist therapy to people with an opioid use disorder? 3) What are the practice implications for adopting the skill set of prescribing Opioid Agonist Therapy (OAT) for nurses working in substance use services? Participant inclusion and exclusion criteria Participant inclusion criteria for this study included RNs and RPNs who have completed the B.C. Center on Substance Use RN/RPN Provincial Opioid Agonist Treatment training and are active prescribers of opioid against therapy. Interviewing nurse practitioners is excluded from this study as they have a long-standing relationship with prescribing medication in the province of B.C. as a standard part of their practice. Additional exclusion criteria was RNs and RPNs who have completed the provincial training but are not yet actively prescribing to patients. Data Collection Snowball sampling was used to purposely recruit participants who have experience with the phenomenon of nurse prescribing of OAT within B.C. (Streubert & Carpenter, 2011). Study invitation letters (Appendix B) were distributed to nurse prescribers through managers, knowledge coordinators and clinical nurse specialists for each of the B.C. health authorities, and the provincial nurse prescriber community of practice. Participants responded via email to the invitation and expressed interest in participating in the study. Eleven nurses expressed interest in participating in the study. One nurse was excluded from participating due to not being an active prescriber. Two nurses reached out to express interest in the study but lost contact with the researcher. Eight nurses were deemed eligible to participate and included in initial interviews. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 29 After conducting interviews with the eligible participants, data was then reviewed for saturation. As there was not yet RPN participants, or participants from three of the six B.C. health authorities, it was determined that additional recruitment was required in order to represent provincial participants. An amendment to the Brandon University Ethics Committee (BUREC) was submitted to request additional recruitment efforts. The researcher was permitted by BUREC to distribute the study invitation letter further via the nurse prescriber implementation leads of each health authority. This resulted in further recruitment of an RPN and inclusion of two additional health authorities. Data saturation was again reviewed with the thesis advisor and it was determined that saturation was met with a total of ten study participants. Microsoft Teams was utilized to schedule and conduct participant interviews for this study. In addition to the primary research inquiry, probing questions were used, to understand challenges and successes in each of these areas related to prescribing. Questions related to location and experience were used to help the researcher understand the demographics of nurse prescribers across the province. Interviews were recorded and transcribed using internal Microsoft Teams functions. Consent was reviewed and obtained verbally prior to the start of each interview. Participant interviews lasted 30-40 minutes on average. Participants provided a mailing address at the conclusion of their interview and were mailed a $25 Starbucks gift card and a written card expressing appreciation for their participation. Two participants declined the honorarium. Interview transcriptions were downloaded from MS teams, and copied into word documents. Participant names were de-identified to “participant”. Transcripts were edited by the researcher to correct errors in grammar, transcription errors, and filler words such as “like, umm” or repeated words. One transcription was unsuccessful and the author had to manually transcribe based on the recorded video. Transcriptions were reviewed against the recorded audio for accuracy. Transcription summaries were provided to participants via their secure health authority email addresses for an opportunity for NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 30 reflection of accuracy and additional input. Three participants requested minor edits to wording of 1-2 sentences, otherwise endorsement was provided for each transcript. Data Analysis As per Streubert & Carpenter (2011), qualitative researchers must be aware of their influence on the study in all aspects of the research, otherwise known as reflexivity. Dodgson (2019) emphasized the need for researchers to be transparent and acknowledge their position within the study in order to achieve reflexivity. The researcher, as a trained nurse prescriber and regional implementation lead of nurse prescribing, is aware of the risk of bias and influence on the interpretation of the data findings. The risk of researcher influence was mitigated by embedding self-reflection practices throughout the study via journaling and open discussion with the thesis advisor (Polit & Beck, 2017; Streubert & Carpenter, 2011). Thorne (2016) emphasized the value of researchers ‘recharging their batteries’ at the data analysis phase, ensuring that curiosity and passion remains alive throughout the duration of the research. The researcher managed workload throughout this study process and intentionally reserved energy and resources for the data analysis phase of this study. Thorne (2016) stated that “interpretive description findings do not come easily” and cautions novice researchers on making common mistakes (p. 158). Thorne’s (2016) guidance to researchers around interpretive description data analyses includes: • Being mindful of patterns that are quick to arise in data and to persevere with inquiry • Do not confuse frequency of a data themes with importance • Apply self-reflective strategies and challenge yourself intellectually in a fun and creative way throughout the process • Embrace your interpretive skills when analyzing participant insights • Utilize external critics and opposing perspectives to uncover what you are not seeing in the data • Listen, observe, write, think, repeat. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 31 To achieve Thorne’s recommendations related to data analysis, the researcher utilized coding to support managing the volume of data within this study. While concept coding as a first coding cycle is a primary way of grouping together higher-level concepts, second cycle coding further categorizes and themes data into meaningful patterns (Miles et al., 2020). The researcher utilized In Vivo Coding as a primary coding method which utilizes participant words and phrases directly to group together initial themes that emerge from the data (Miles et al., 2020). The researcher found this challenging at first and initially grouped categories into responses to the interview questions. After reflection and further guidance from the thesis advisor, data was organized differently as words and phrases into an excel spread sheet. Words and phrases were then grouped by likeness into categories, initially provided a generic heading of a letter. Secondary pattern coding was achieved by further grouping the data into categories, causes, relationships, and concepts (Miles et al., (2020). Identification of meaningful participant quotations were flagged in a separate column of the excel spread sheet for later review. Interpretive description findings should focus on what is discovered about the phenomenon rather than what is observed (Thorne, 2016). Thorne et al., (2004) stated that “newer researchers need considerable external guidance to support the kind of disciplined reflexivity required to avoid clinging to the assumptions with which they entered the study” (p.5). The researcher relied on the expertise and guidance of the thesis committee to support maintaining breadth of themes within the findings and present them in a way that honors participant’s experience. Ethical Consideration Ethical approval for this study was obtained from Brandon University Research Ethics Committee (BUREC). Participation in this study was voluntary and limited to RNs and RPNs who have completed the B.C. provincial training for opioid agonist therapy and are actively prescribing to people with an opioid use disorder. All participants were provided a letter of invitation outlining the study expectations NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 32 (Appendix B) and a detailed consent form (Appendix C). There are no perceived risks to participants who consented to this study. Participants were offered a benefit of receiving a $25 coffee gift card via post mail following their participation in the study. All data was collected and de-identified by the researcher, and no participant personal information is shared in the results of this study. Participants’ direct quotes are identified by region or Health Authority within B.C and not by city to reduce potential for identification. Participants were made aware of their rights and reassured that they can withdrawal from the study at any time. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 33 Chapter Four: Findings Research Questions As outlined in Chapter one, the aim of this study was to understand the lived experience of RNs and RPNs prescribing opioid agonist therapy to people with an opioid use disorder in British Columbia. The three primary guiding questions this study explored were: 1) What are the experiences and perceptions of RNs and RPNs acquiring skills to prescribe opioid agonist therapy in British Columbia? 2) What are the experiences and perceptions of RNs and RPNs prescribing opioid agonist therapy to people with an opioid use disorder? And 3) What are the practice implications for adopting the skill set of prescribing OAT for nurses working in substance use services? The guided interview tool used to explore these experiences with participants can be found as an attached questionnaire (Appendix A). This chapter outlines demographic details of the participant group and themes that were identified upon completion of the data analysis. Participant Group Participants of this study consisted of 10 nurses who identified as either Registered Nurses (RNs) or Registered Psychiatric Nurses (RPNs) from various urban cities and rural communities across British Columbia. No participants identified as being dually trained in both disciplines. Participant age and gender were not collected as part of the demographic data as it held no significance to the research questions. All participants had experience prescribing opioid agonist therapy to patients with an opioid use disorder. All participants engaged in a single interview and were later provided an opportunity to review their transcripts to ensure their experience and views were represented correctly. Years of participant nursing experience is outlined below in Table 1, as well as comparative years of working with people who use substances. One participant had additional years working with people with substance use disorders outside of their nursing experience. In an attempt to try to protect the anonymity of participants, information such as employer, health region area, and community have not been shared. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 34 Years of experience as a Years of experience working with people who use nurse substances 33 3 4 4 16 7 4 4 30 25 24 10 4 4 16 3 19 19 9 15 Table 1. Participant Years of Nursing Experience Themes From the participant data, three major themes and five sub-themes emerged. As outlined in Table 2 below, themes from the data included: 1. Becoming a RN/RPN OAT prescriber, with the sub-theme of “Just do it...but do it for the right reasons”; 2. Being a RN/RPN OAT Prescriber, with sub-themes of Benefits and Challenges; and 3. The Future of RN/RPN OAT Prescribing, with sub-themes of Recommendations for implementation and Advice to nurses. Table 2 Themes and Sub-themes of the Experience of RN/RPN OAT Prescribers Themes 1. Becoming a RN/RPN OAT Prescriber Sub-themes 1. “Just do it...but do it for the right reasons” 2. Being a RN/RPN OAT Prescriber 1. Benefits 2. Challenges 3. The Future of RN/RPN OAT Prescribing 1. Recommendations for implementation 2. Advice to nurses 1. Becoming a RN/RPN OAT Prescriber NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 35 This theme is about the experiences of RNs/RPNs throughout their journey completing the provincial OAT nurse prescribing training pathway and their employer’s implementation of the initiative of nurse OAT prescribing. Volunteering or applying to become an OAT nurse prescriber was something all participants “wanted to be a part of” and saw as an opportunity to better support people with an opioid use disorder in their community. “I remember hearing about it initially from Dr. Bonnie Henry [B.C. Provincial Health Officer]. I was really intrigued about what that looked like…just knowing that our community needed more support and people [prescribing OAT], I was all hands on deck” (Participant 8). In addition to wanting to be part of the response to the provincial toxic drug crisis, participants also saw it as an exciting nursing opportunity and a “chance to specialize”. “I think it’s a huge opportunity for new and expanded growth of nursing practice” (Participant 4). While excitement for the opportunity to prescribe was unanimous, participants experienced varying employer support to participate in the provincial training. As per the Provincial Health Officer order, RN and RPN prescribers require pre-approval to participate in prescriber training from the Medical Health Officer that manages the health region with which the nurse is employed (Ministry of Health, 2020). Some participants were well supported by their employer to obtain Medical Health Officer endorsement and access to the provincial training, while others felt they needed to engage in “friendly harassment” and advocate strongly to be considered for the training. “I was surprised how hard I had to fight to become a nurse prescriber. I thought I would have been a natural choice (as an OAT nurse)” (Participant 2). The provincial online portion of the RN/RPN OAT prescriber training was developed in stages, firstly with Buprenorphine/ Naloxone training available in early 2021, then later expanding training to include continuations, titrations and restarts of Methadone and Slow Release Oral morphine (SROM) in the fall of 2021 (BCCSU, 2021). For those participants who experienced the initial version of the provincial education pathway, they found it to be “onerous” and “confusing” at times to navigate. Most notably, participants NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 36 who already worked within OAT services when completing the prescriber training found the education material familiar and easy to navigate. “I felt fairly comfortable already with OAT, which really helps” (Participant 7). Participants expressed appreciation for the preceptorship portion of their training pathway and felt like the training gave them “confidence” to prescribe OAT. Once the provincial OAT prescribing pathway is completed, nurses are registered as an OAT prescriber with their regulatory college, assigned a Medical Services Plan (MSP) number and are then permitted to order controlled substances prescription pads. Participants’ experiences of finally being a prescriber with a prescription pad in hand, was typically filled with mixed emotions, both of excitement and feeling a nervous awareness of being the one to write the prescription. “…Oh my goodness, it's my signature on this prescription. This is my responsibility. I think overall that's positive though, because we do want to provide the best care we can and be thoughtful…”(Participant 7). Another participant echoed this sense of responsibility, “I think that was the only part that was a little bit of anxiety because now I'm like, oh, this person can take this to this pharmacy and get a script under my name” (Participant 10). 1.1 “Just do it…but do it for the right reasons”. This sub-theme of Becoming a Nurse Prescriber is about RNs and RPNs overcoming doubts about why they should engage in nurse OAT prescribing. This sub-theme outlines participant’s advocacy for the expansion of nurse OAT prescribers, but with cautionary reservation about who is suitable for the role. Several participants voiced concern that nurses are expressing interest in applying for RN/RPN OAT prescriber positions because of the appealing hours of service and the hype it is generating in nursing practice. “This isn't a role that you just dabble in, this isn't for novice nurses. This isn't just something you arbitrarily take because you think the hours are appropriate... people who take these roles should commit to staying in the job.” (Participant 3). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 37 “I'm getting a bit of a sense of that across the province that people are very eager, I get asked like almost daily. And it's by staff that have never worked in addictions. It’s great that they're interested, but I just hope it's not just because of the prescribing. But it's actually that they wanna do addictions [care]” (Participant 10). While all participants advocated for more access to RN/RPN OAT prescribers, there was hesitancy and disagreement about required experience and qualifications. One participant raised concern that other nurses “think it’s cool” but have little to no background in working with people who use substances and do not comprehend that “this is serious business”. Some participants held strong feelings about what nursing experience was required to become a nurse prescriber, emphasizing that this was not a role for a “new nurse”. Newer nursing participants (under 5 years of nursing experience) that had spent their entire nursing experience working with people who use substances, did not share the same expectations and were quite comfortable being a nurse prescriber. Regardless of years of nursing experience, participants who were employed within an OAT clinic were the most confident about taking on the role of prescribing and saw it as a seamless inclusion to their work. When I asked participants what advice they had for nurses considering becoming OAT prescribers, all participants felt it was an important nursing step in the response to the unregulated drug poisoning emergency and multiple responded with an emphatic response of “just do it”. “Just do it…I am seeing this save lives so I just want more of us out there” (Participant 9). “…so much of the reasons why people aren't getting their needs met is fear. And the last thing that we need is more people who are scared to [prescribe OAT] because this is what is gonna start to help people…” (Participant 6). 2. Being a RN/RPN OAT Prescriber The second theme of this study is reflective of the participants’ experiences in actively prescribing opioid agonist therapy to people with an opioid use disorder. Participants outlined the benefits and NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 38 challenges, not only of being a prescriber of OAT in an interdisciplinary community, but in supporting people with an opioid use disorder. The participants’ insights into the barriers their clients face every day in accessing health care services drives their advocacy and passion for engaging in the work of prescribing OAT. Participants saw ‘being’ a nurse as a benefit in providing OAT care and felt that they can provide OAT in a flexible way compared to traditional OAT clinics in their community. OAT clinic models vary across the province depending on the physical location, availability of the prescriber and how the clinic is funded and resourced. Participants noted that prescribers at OAT clinics are typically only available on certain days, which can vary from daily, to twice a week to once every two weeks. Many participants voiced that there is an advantage to being a nurse in this work and that they can “be more consistently available” to support client needs. Participants often stated that they “meet people where they are at” in multiple ways by providing “outreach”, supporting with “system navigation” and “intensely following people” who require additional support. Participants four, eight, and nine identified ways of providing OAT care through a nursing lens of harm reduction and person centered approaches. “So for instance, I write a prescription today for someone who I get a referral and I can call them tomorrow and follow up and see how they’re induction is going, or how the increase is affecting them, are there any side effects?” (Participant 4). “I have a lot of flexibility in my role to be able to go out to people too…I can actually go out to them rather than having high expectations for some people to come to appointments all the time” (Participant 9). “We’ll grab our backpacks and we’ve got harm reduction supplies, some basic wound care, food, water, hot chocolate during the winter, and we’ll go to the shelter and just connect. We’ll go to different areas that people typically who don’t have houses will congregate…we have a couple people who do have houses but do have difficulty getting into pharmacy. If they’ve missed quite a few doses and are really dope sick, then we might do some medication delivery” (Participant 8). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 39 2.1 Benefits. The sub-theme of the benefits of being a nurse OAT prescriber, outlines the positive impact the participant scope expansion has on client care of people with an opioid use disorder. Participants saw the added skill of prescribing OAT as benefiting clients and making things easier on these individuals. Prescribing allows them to be able to provide increased access to OAT and “in the moment care”. “They’re ready to do something right at that moment, and I am able to deliver right in that moment rather than saying, let’s sit down and talk and find out what you want then hand you over to someone else…time is of the essence” (Participant 4). “The longer they wait, the higher the risk of overdose and I just love being able to help them when they’re ready to make the change” (Participant 5). “I think patient satisfaction is better because I think things happen quicker, where as you know they might sit there longer waiting a few hours at least (for the doctor). Now I can go see them and we can start things quicker, as opposed to waiting” (Participant 10). Within the sub-theme of benefits to being a nurse OAT prescriber, participants acknowledged that they also see personal benefit to adding prescribing to their practice. Many find the work of prescribing personally “satisfying”, “rewarding” and feel privileged to “play a part” in the response to the toxic drug crisis. Participants are both reflective and appreciative of the added responsibility of writing a prescription. “This is really just one of the most rewarding roles I have ever had in nursing” (Participant 1). “…it’s very legitimizing. It feels good to be able to say ‘yes, I do know this’. Being able to sign [the prescription] means a lot, it just does” (Participant 6). Participant 8 expressed that the most personally rewarding benefit of being a nurse OAT provider was, “the relationships that I’ve been able to create and the movement towards trust in the health care system. I think a lot of times individuals haven’t had the best relationship with it and so it’s sort of the long game, the long goal of being consistent”. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 40 2.2 Challenges. This sub-theme explores the challenges RN/RPN OAT prescribers face in their prescribing role and working with people with an opioid use disorder. Common challenges that were identified were related to prescribing scope of practice, workload, documentation requirements, community factors, client factors and their interdisciplinary team. A frequent challenge expressed by the participants was the limitation in their scope of practice and the inability to prescribe for all patients’ needs. At the time of this study, RNs and RPNs in British Columbia were permitted to prescribe three OAT medications (Buprenorphine/ Naloxone, Methadone and Slow Release Oral Morphine) (BCCSU, 2021). Participants identified that there is a significant need for coprescribed “safe supply” and found that their scope of practice is not meeting clients’ needs. Concerns were voiced that the unregulated drug supply is significantly more potent in compared to the concentration levels of typical OAT interventions and that additional opioid medications are often needed to support client needs and avoid withdrawal. “Without that safe supply it really makes starting people [on OAT] null and void because they’re not going to take it without that” (Participant 2). “I think some of the restrictions on titrations has been a barrier for me just with the heavy use and the knowledge of their tolerance, but also the restriction of only being able to increase day 5 of methadone, those kind of things. It would be nice to have a little bit of freedom knowing the population” (Participant 9). Participant 6 expressed their frustration in general with dosing limitations on safe supply and states that they have to explain to clients “I know you’re 14 dillies [Dilaudid] is totally not enough, but here is where we are politically in this weird moment and you’re in the middle of it unfortunately”. One participant’s experience with scope limitations was unique, as they were a nurse OAT prescriber within a hospital work environment which does not permit them to write orders for inpatients due to hospital bylaws. While they felt successful in supporting their hospital interdisciplinary team by providing OAT NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 41 prescribing assessments, their autonomous OAT prescribing scope was restricted to prescriptions for community discharges. The challenge of workload and documentation requirements was also identified, however, differed between positions and work environments depending on the electronic medical record (EMR) utilized and resources available in community. Participants who were not in dedicated nurse OAT prescriber positions felt the greatest pressures of workload and some felt prescribing was “off the side of their desk”. Participants from smaller rural communities voiced concerns with juggling workload demands from several vacant positions within their team as they perceived the extra work was taking away from their focus of OAT prescribing. Rural participants also vocalized their perception that their community was short OAT providers in general and advocated for the need for additional physicians and nurse practitioners to service the community. One participant was in a temporary role, and felt distressed not “owning” their job as they were concerned about continuity of care for clients if they were to lose their position to another nursing candidate. Participant 9 outlined how a lack of access to client care documentation can be a barrier to providing care; “The EMR [Electronic Medical Record] and documentation piece has been an on-going issue… sometimes I will have to refer if it seems too complex and I am not able to gather the history I feel comfortable with, which is a barrier because a lot of my clients won’t go to the next person”. Other challenges participants identified as impacting their OAT practice were the availability of local resources, in particular, pharmacies. All participants stated that developing relationships with pharmacies was critically important to caring for people with an opioid use disorder. Participants practicing in rural communities expressed that limited access to pharmacy created significant challenges when providing OAT. “Pharmacy is one of the biggest barriers here. As a small town, it’s like an hour long bus ride [if you live out of town] to get to pharmacy. And then you have people who are banned from all the pharmacies. When that starts happening, it’s like essentially impossible.” (Participant 3). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 42 “We have three local pharmacies, one who’s not accepting any clients right now. Another one that’s across the bridge, it’s a bit further to get to and that one sometimes rotates in and out of accepting new clients, and then the third one, if they’re kicked out of that one, then it’s quite the challenge” (Participant 8). Shelter access was a challenge expressed by both participant 4 and 5 that impacted their OAT prescribing practice. “They had to close down one of the shelters here for various reasons, and there was no way to connect with people at the shelter and some prescriptions lapsed…” (Participant 4). “...when [clients] drop off, they’re just gone…because we don’t have a shelter so there’s nowhere that I can go and look for them and see how they’re doing” (Participant 5). Participants passionately expressed empathy, advocacy, and acknowledgement of the challenges their clients have to go through to access OAT care. Commonly acknowledged struggles for clients were “homelessness”, “financial insecurities”, “transportation “, “risk of overdose”, “sex work and subsistence crime” and overall concern for clients “safety”.“[I am] always concerned that they are still going to use illicit substances and potentially pass away” (Participant 5). Participant 3 reflected on their experience of sadness and grief they felt after losing an OAT client to a toxic drug event but expressed appreciation for meaningful interactions with the person’s family at the funeral. The mother of the client stated to the participant, “you bought us time with her, you bought us extra time that we wouldn’t have had otherwise”. Participant 3 stated that, while it was emotional to attend the funeral, “it was really nice to see what more of the client’s life looked like. I only knew her when she was doing really bad… it was just so nice to hear and feel that…”. Participants who worked in colder climate areas of the province acknowledged that weather is a challenging factor for clients trying to access care. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 43 “A lot of folks don’t want to walk to the pharmacy or can’t walk to the pharmacy. They might have limited mobility or don’t wanna ride a scooter. And like minus 25, it’s fucking cold. So there’s that, just the environmental factors of getting to the pharmacy everyday can be really, really difficult for people” (Participant 6). Additional challenges that RN/RPN OAT prescribers found were related to being part of an interdisciplinary team and finding their place amongst other care providers. Many expressed appreciation for their fellow care providers and found they were “well supported” and integrated their practice seamlessly. However, others noted “growing pains”. “…some prescribers are not really on board with what we are doing here…some are really supportive, but there are a couple that are like I’m kind of encroaching on their territory” (Participant 4). This participant felt as though the implementation of their role was “stifled” and they felt impatient with being held back from expanding their scope. One participant expressed concern that the physician provider they worked alongside was “old fashioned” and found it challenging to engage in a collaborative prescribing relationship when the physician was “obstinate” towards safe supply. Participant 9 stated, “it was hard to figure out my role for the first six months, just seeing where I fit in with the clinic and how do I reach my clients, what do I start them at? How do I not overlap with other providers?”. 3. The Future of RN/RPN OAT Prescribing The third theme in this study is about experienced nurse OAT prescribers informing the future of OAT nurse prescribing based on their lived experienced with this new and novice practice. This theme is divided into two sub-themes that focus on recommendations for implementation needs and advice to future nurse prescribers. 3.1 Recommendations for implementation. This sub-theme highlights insights RN/RPN OAT prescribers have regarding the implementation of the nurse OAT prescribing in the province of British Columbia. Participant 2 expressed advocacy for healthcare leadership to involve nurses in the planning NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 44 for implementation of nurse OAT prescribing in communities from the beginning, stating “there’s lots of people that seem to think they know what the nurses should be doing, but they are not nurses”. Multiple participants advocated for improved support from leadership related to communication and integration of their new OAT prescribing role into their interdisciplinary team. “…it would be great to have something for [other health care professionals] to put more trust in us. Or even how we can work together that is cohesive for others, we obviously don’t want to step on anybody’s toes but we want to help these people and not feel like we are being restricted by anybody, so any education for doctors, doctor’s offices and the ER would be awesome” (Participant 9). Several participants mentioned that they were not allocated dedicated “work time” to complete the provincial training and stated that nurses should not need to use their personal time to complete their training requirements. Participant 7 believed in the importance of a “community of practice” so that RN/RPN OAT prescribers are not feeling “isolated” in their practice. Participants also suggested the following ideas to enhance implementation of OAT nurse prescribing; creating “dedicated RN/RPN OAT prescriber positions, incorporating RN/RPN OAT prescribers into acute care and emergency departments, and including “safe supply (prescribed opioids as an alternative to illicit substances)” in RN/RPN OAT prescriber scope. 3.2 Advice to nurses. This sub-theme is about the insights RN/RPN OAT prescribers have in regard to caring for people with an opioid use disorder. Participants spoke about the importance for nurses to reflect on their values, biases and beliefs before moving into OAT prescribing. The participants emphasized the need to be aware of one’s stigmatizing beliefs and actions prior to accepting the responsibility of nurse OAT prescribing. While there was some overlap in topics of advice to other nurses considering OAT prescribing, each participant had unique words of wisdom to share. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 45 “..always stay open and always invite people to come back at any time if they want to reengage…every single person is different and I really have learned that I just need to sit back and hear their story and then we go from there” (Participant 1). “…there’s so many different ways that success can be measured…it doesn’t mean abstinence. It means whatever the person has identified to us is their goal and when we reach that goal, that’s our success” (Participant 1). “…talk to clients. It’s frightening to start out and its frightening to start Suboxone, so just keep people positive about taking the Suboxone” (Participant 2). “I’m all about phone a friend. If you just know the right person to phone, then you can solve problems very easily” (Participant 3). “I think people who have fears or who have had experiences, like critical experience, where they’ve overdosed and been in hospital, they’re genuinely scared. I think [OAT] offers them hope and a possibility of getting to a different place where they wanna be. I think it improves the probability of that” (Participant 4). “you just have to keep on telling [clients] ‘good for you for coming back, I’m so happy to see you’…there’s no judgement and I’m not upset that I have to restart them, I’m just happy that they’re back…I know they don’t get treated that way all the time and it’s very unfortunate. Lot of stigma still out there…” (Participant 5). “Really think about what the reasons are that are telling you you shouldn’t [prescribe OAT] because they’re probably not as serious as you might think. And try to figure out how much of that is related to stigma that this population faces already” (Participant 6). “I think it’s just a really positive thing that we’re able to help meet needs in a population that has a lot of barriers to care, and often as nurses, we’re in those positions where we can break down those barriers a little bit easier” (Participant 7). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 46 “…check what your stigma is…These are people just the same and everybody has a story and everybody got to this place in their life because of circumstances and it is just one point in their life. It’s their lives, just like everybody, it’s still ahead of them. Be compassionate and listen to peoples stories, if they’re willing to share” (Participant 8). “Put together a nice resource binder with the DST [Decision Support Tool] and all sorts of quick resources, guides and all the forms that we need, it has been a life saver. Having that before you go into preceptorship is key, you just feel way more organized and really confident going in and being able to practice…” (Participant 9). “I think every addiction nurse should have the ACTOC [Addiction Care and Treatment Online Course] “ (Participant 10). These findings provide insight into the experiences of nurses prescribing OAT for people with an opioid use disorder across British Columbia. Their successes, challenges and observations are critically important to reflect on when considering expanding the implementation of this nursing initiative. Key reflections of this study’s findings highlight the many challenges people face in accessing health care and the urgent need to increase access to OAT for people who are at risk of overdose from the toxic drug supply. This study’s findings outline the flexibility nurses can provide in optimizing OAT availability in communities and the benefit in applying harm reduction principles to treatment. A key area of advocacy from RN and RPN OAT prescribers is to include nurses in the planning of OAT in their communities to optimize implementation and collaborative practice. Chapter Five discusses these findings in relationship to the current literature and understandings of this scope of nursing practice. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 47 Chapter Five: Discussion This discussion chapter provides an overview of the study themes in comparison to the findings of the current literature and includes contextual background outlining the time this study took place. This chapter reviews the use of interpretive description as the research methodology and the theoretical framework; including how it applies to the skill of prescribing. Lastly this chapter will outline strengths and weaknesses of this study, provide recommendations for future research and outline how this study contributes to the current body of knowledge and informs nursing practice. Contextual Update After reflecting on the time frame that this study took place, there were key events occurring in tandem that are worth noting as relevant to this study. One area of note is the ongoing B.C. provincial implementation planning of RN/RPN OAT prescribing that intends to continue to evolve the prescribing scope for nurses supporting people with opioid use disorder. The B.C. College of Nurses and Midwives announced September 21st, 2023 that their board approved the new practice for opioid use disorder as a certified practice for RNs and RPNs in B.C. (BCCNM, 2023). This moves the practice of OAT prescribing beyond the temporary provincial health order to a permanent practice for nurses in B.C., also making it the first certified practice ever for RPNs in Canada. Additional context to the landscape of the B.C. provincial unregulated drug poisoning emergency was made available in the July 2023 B.C. Coroner’s report, which was published at the time these study findings were summarized. The B.C. Coroner’s report reinforced that fentanyl continues to be detected in 83% of deaths due to unregulated drugs, and that 2023 is trending toward having the highest annual rate of death, with July seeing a rate of 6.4 deaths per day (2023). At the same time of this provincial publication, on August 31st, International Overdose Awareness Day, Interior Health Authority published a Medical Health Officer (MHO) report titled: The Toxic Drug Crisis in B.C.’s Southern Interior Region. This report provides additional context to the barriers people experience when accessing care for substance NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 48 use services, with housing and transport to care being the largest need for focus in rural and remote areas (Interior Health, 2023). A key theme that emerged from the chart review within the Interior Health MHO report was that “only one in seven of those who died from toxic substances had a documented discussion with their health-care provider about harm reduction strategies” (Interior Health, 2023, p. 27). This emphasizes there is a need to incorporate harm reduction strategies alongside treatment care plans, an area of nursing care that this study highlights within the findings. With an influx in recent publications related to the ongoing response to the unregulated drug supply and the impact of COVID-19 on mental health and substance use, Chapter 2 of this study was updated. Literature from 2020 to 2023 was incorporated into Chapter 2 categories to ensure that the following discussion is the most up to date when comparing the findings and themes of this study. Findings and Themes The majority of nursing literature that is referenced in chapter 2 is representative of nurse practitioners or advanced practice (masters level prepared) nurses prescribing opioid agonist therapy. This study includes RNs and RPNs who are not required to be masters prepared, so in that sense the findings are primarily unique. There are however, similar themes in the literature applicable to the disciplines of NPs, RNs and RPNs when it comes to adopting the skill set of prescribing OAT. 1. Becoming a RN/RPN OAT Prescriber. Within the theme of becoming an RN/RPN OAT prescriber, what was unanimous across the NP, RN and RPN disciplines was the acknowledgement of the need for nurses to adopt the practice of OAT prescribing in order to increase access to treatment (Andrilla et al., 2020; Banka-Cullen, 2023; Comiskey et al., 2019; Clancy et al., 2019). While navigating education requirements to become a RN/RPN prescriber was expressed as onerous at times for some participants of this study, the literature is challenging to compare as NPs internationally have inconsistency when it comes to education access and waiver requirements to prescribe OAT (Gielen et al., 2014). NPs in the NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 49 United States have varying levels of oversight and education requirements state to state when obtaining a waiver to prescribe OAT (Andrilla et al., 2020; Klein et al.,2020). Participants of this study, under the public health order were required to obtain a regional Medical Health Officer’s endorsement through their employer in order to prescribe OAT (Ministry of Health, 2020). Now that the endorsement to prescribe OAT in B.C. has been adopted by the provincial nursing college under certified practice, this should resolve inconsistency between employers across the province. In B.C., the provincial program to enable physicians, NPs, RNs and RPNs, to prescribe opioid agonist therapy is centrally managed by B.C. Center on Substance Use and is free to complete (B.C. College of Nurses & Midwives, 2021). North American literature on NPs and RNs emphasized that nurses felt there was a lack of curriculum based education and on-going education available to feel confident to support patients with a substance use disorder (Abram, 2018; Bates & Martin-Misener, 2020; Finnell et al., 2019; Ford 2011; Jozaghi & Dadakhah-Chimeh, 2018). Participants of this study referenced their nursing work experience in substance use and the BCCSU provincial OAT prescriber training as a source of confidence in taking on prescribing of OAT. 1.1 “Just do it...but do it for the right reasons”. Within this theme, participants vocalized concern with the unionized RN/RPN environment within B.C. that enables nurses that do not have experience in mental health or substance use, to apply for positions that incorporate prescribing of OAT based on nursing seniority. Nursing unions or position seniority was not a factor outlined within the literature, relevant to taking on the skill set of prescribing. Within this sub-theme, participants of this study that were employed as an OAT clinic nurse vocalized the most confidence in adopting the provincial OAT prescriber training into practice as they have a foundational understanding of the medication and treatment. While employment settings were not a focus of the literature, the United Kingdom has a decades long history of nurses supporting OAT services, NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 50 which seems to be a natural place to start when it comes to building on the prescribing skill set of RNs and RPNs who support this population (Clancy et al., 2019). 2. Being a RN/RPN OAT Prescriber Participants of this study identified that in order to meet the needs of people with an opioid use disorder, it is critical to expand availability of OAT and be flexible in approaches to care, including providing outreach services to those who struggle to attend clinics in-person. The literature advocates for person centered approaches for people who use substances, such as nursing outreach, building trust and making connections with people to increase their health service utilization (Bianco et al., 2020; Ford, 2011; Hilton et al., 2001; Pauly, 2014). The participants of this study were passionate about using their prescribing skills to increase access to OAT for clients in their communities, particularly in rural areas where OAT clinic access is limited. Global literature emphasized the need for increased access to harm reduction and substance use treatment in rural communities in order to reduce the use of unregulated opioids and lower the risk of death amongst a toxic drug supply (Banka-Cullen et al., 2023; Bardwell & Lappalainen, 2021; Klein et al., 2020; Pearce et al., 2020). The literature, in addition to this study, highlights the potential to optimize the nursing workforce in rural areas to reduce harms caused by unregulated drugs. 2.1 Benefits. The participants of this study emphasized that a benefit of prescribing OAT as a nurse is more than being able to sign the prescription, but meeting people where they are at and providing flexible access to care. B.C. RN/RPN OAT prescribers are required by their regulatory body to ensure clients they treat are supported with continuity of care and referral pathways to other services as needed (BCCNM, 2020). Grey literature and client focused research supports this idea, stating that nurses address holistic health needs and that care should be equitable, trauma informed, culturally safe and rooted in harm reduction principles (Comiskey et al., 2019; IHA, 2021). This study highlights the RN/RPN perceived benefits to OAT care which is a limited perspective in the literature that primarily focuses on nurses NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 51 increasing access to OAT based on population density and waiver to prescribe data (Andrilla et al., 2020; Clancy et al., 2019; Nguyen et al., 2022; Spetz et al., 2021). 2.2 Challenges. The sub-theme of challenges that nurses face in prescribing OAT to people with an opioid use disorder is where the literature aligns the most with the participant experiences of this study. Client challenges such as limited access to pharmacy and transportation, were significant areas of advocacy by the nurses of this study, which is reflected in the literature on rural communities (IHA, 2022; Priest et al., 2019). Addressing the housing needs of clients was another area expressed by the participants of this study as a barrier to stabilizing people on OAT. Specifically Canadian and B.C. government literature supports that this gap is an urgent area to address for people who use substances (Canadian government, 2021; IHA, 2022; Pauly, 2014). International literature supports the challenge of workload burden that participants expressed, noting that when prescribing is ‘added’ to an existing nursing role, it significantly increases responsibility and changes the way nurses engaged with both their team and clients (Birks et al., 2019; Jokiniemi et al., 2015; Lennon & Fallon, 2018). When taking on the role of prescribing OAT, managing the relationship with team members, including other prescribers, was a challenge expressed by some nurses of this study. While other participants of this study felt very supported by their prescribing colleagues to take on this skill, the literature supports that this can be a challenge for nurses universally. The literature outlines that when nurses take on the skill set of prescribing, relationships with physicians and clients ultimately shifts, creating role ambiguity, which can be stressful for nurses to navigate (Bryant-Lukosius et al., 2004; Eagar et al., 2010; Joel, 2018; Kuehn, 2018). For nurses to overcome this challenge, leadership is needed to support and ensure team cohesion as nurses adopt this skill set and establish their role of prescribing amongst an interdisciplinary team (Bates & Martin-Misener, 2020; Birks et al., 2019; Jokiniemi et al., 2015). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 52 An interesting intersection of the literature and this study is with nursing concerns related to medications and their ability to effectively manage opioid use disorder. RNs and RPNs of this study are permitted to prescribe buprenorphine/naloxone, methadone and slow release oral morphine (SROM) within their scope of treating opioid use disorder. Across the U.S., buprenorphine was found to be prescribed as a stand-alone medication in some states and did not have the added safety benefit of naloxone (Bates & Martin-Misener, 2020; Kameg et al., 2020; Spetz et al., 2021). It is evident from the literature that nurse practitioners’ scope to treat opioid use disorder varies from including buprenorphine, buprenorphine/naloxone and methadone (Andrilla, et al., 2020; Clancy et al., 2019; Klein et al., 2020; Strobbe & Hobbins, 2012; Tierney et al., 2015). This study is outlining a possible exception to the typical nursing scope by including the additional medication of SROM for RNs and RPNs. Despite having additional medications within their scope, the participants of this study vocalized that it was, at times, not enough to meet the needs of clients within the current context of the unregulated drug supply. Providing people with access to regulated safer supply (prescribed alternatives to illicit fentanyl) was an area of advocacy from the nurses of this study and is supported in the Canadian literature as key strategies to reducing deaths from the unregulated drug supply (B.C. Coroner’s Office, 2022; Canadian government, 2021; Gagnon et al., 2023; IHA, 2022). 3.0 The Future of RN/RPN OAT Prescribing The literature outlined in this study is unanimous in its advocacy that nurses can and should play a role in increasing access to opioid agonist therapy by prescribing medications that support separating people from the harms of the unregulated toxic drug supply. Nurses as a workforce are capable of integrating essential training and adopting the skill set of prescribing OAT as part of a global strategy against the unregulated drug supply (Clancy et al., 2019; Ministry of Health, 2020; Strobbe & Hobbins, 2012; Tierney et al., 2015). NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 53 3.1 Recommendations for implementation. Overall the literature supports recommendations made by the participants of this study, which is that barriers should be reduced for nurses looking to take on the skill set of prescribing OAT. While the issue of physician oversite was not an implementation factor for RN/RPN OAT prescribers in B.C., the U.S. literature outlines challenges that NPs face when this is a requirement of implementation and advocates to remove this barrier for nurses (Andrilla et al., 2020; Kameg et al., 2020; Nguyen et al., 2022). Participants of this study recommend that RNs and RPNS are supported to build a collaborative community of practice in order to avoid working in isolation. Kameg et al., (2020), echo this recommendation in their study of advanced practice nurses, noting that mentorship and clinical support are important factors to successful prescribing of buprenorphine. A further call to action made by a participant of this study, which is not reflected within the literature, is that nurses should be at the heart of planning when it comes to implementation of OAT nurse prescribing in communities. 3.2 Advice to nurses. While stigma emerged as a significant theme throughout the literature impacting nurses’ decisions to engage in OAT prescribing, it is embedded within this study’s sub-theme of Advice to Nurses. Addressing stigma toward people who use substances is a key area of advocacy within the literature that is directed at broader government strategy (Canadian government, 2021; Elliot et al., 2021; IHA, 2022; Pauly et al., 2015). The participants of this study acknowledged that stigma is present in their communities and embedded within healthcare, which is negatively impacting people and their ability to access care. The literature outlines that nurses not only struggle with managing personal bias towards people who use substances, but are targets themselves of public and colleague stigma, being seen as enablers of substance use (Abram, 2018; Bates & Martin-Misener, 2020; Finnell et al., 2019; Ford 2011; Jozaghi & Dadakhah-Chimeh, 2018). Participants of this study called for nurses to overcome stigma; through self-reflection and personally addressing biases, thoughts and beliefs that might limit their ability to safely prescribing lifesaving treatment to people with an opioid use disorder. Key findings NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 54 Currently the majority of nurse OAT prescribing literature is focused on nurse practitioners and advanced practice nurses in the U.S. and Europe. This study builds on existing literature with the key finding of insights into the experiences of OAT prescribing registered nurses and registered psychiatric nurses in Canada; highlighting the unique contribution to North American literature of the utilization of RPNs to prescribe OAT. This study offers a second key finding in the utilization of SROM (slow release oral morphine) as a medication within scope of RNs and RPNs for the treatment opioid use disorder. The literature on nurse OAT prescribing references only buprenorphine, buprenorphine/naloxone and methadone (Strobbe & Hobbins, 2012; Tierney et al., 2015; Clancy et al., 2019; Andrilla, et al., 2020. Klein et al., (2020). While nursing unions are not a unique environmental factor to British Columbia, the concerns raised by participants that nurses could obtain OAT prescriber positions based on seniority, and not experience or training with substance use, was distinct to this study and could not be found in the body of literature on OAT prescribing. An additional key finding, inimitable to this study, is the formalization of OAT prescribing for RNs and RPNs through certified practice in B.C. Certified practice is the regulatory bodies’ endorsement when a restricted skill is added to the nursing designation after meeting the requirement for additional training and registration (BCCNM, 2023). The international literature on OAT nurse prescribing primarily refers to advanced practice nurses and nurse practitioners which are typically masters level prepared nurses (Banka-Cullen et al., 2023). This study uniquely highlights that RNs and RPNs supported with targeted training are not required to be masters prepared to engage in OAT prescribing in B.C. Methodology As outlined in Chapter three, the method of interpretive description research takes historical qualitative methods beyond the when, who, and why, to the “so what” and how it is applicable to practice (Thorne, 2016; Polit & Beck, 2017). This methodology proved appropriate within this study as it supported NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 55 taking the findings beyond identifying patterns in participant data, into themes that are applicable to nursing practice. Thorne’s (2016) emphasis on how imperative it is for researchers to understand themselves in the context of their ideas and biases, and ensuring they keep the goals of their research in mind was invaluable to this research process; as was the guidance of this study’s thesis advisor to successfully synthesizing the themes into meaningful findings. Theoretical Framework This study was informed by Dr. Patricia Benner’s Nursing theory, From Novice to Expert, which outlines how nurses gain knowledge and skills through five levels of experience: 1-novice, 2-advanced beginner, 3- competent, 4-proficient, and 5-expert (Benner, 2004; Forbes & Jessup, 2004; Petiprin, 2020). Benner’s nursing theory informed the interview questions of this study to support understanding which skill level nurses perceived they were at when they became a nurse prescriber. Forbes & Jessup (2004) acknowledged that during skill acquisition, nurses can struggle with their sense of self as ‘proficient’ or ‘expert’ and return to feeling novice, and possibly vulnerable. The ten nursing participants of this study ranged from 33 years of nursing experience, to 4 years of nursing experience. Participants integrated into existing OAT services vocalized the most confidence with adopting the skill set of prescribing OAT, compared to nurses who were not, regardless of years of overall nursing experience. RNs and RPNs of different stages within their nursing practice are taking on the skill of prescribing OAT across B.C. and should be supported as novice prescribers regardless of years of nursing experience. Study Strengths and Limitations This study is timely, as it highlights the benefits in utilizing the nursing workforce as a strategy in responding to the unregulated drug crisis that continues to devastate the province of British Columbia. This study is a contribution to Canadian advanced nursing literature, including how RPNs can be involved in advanced practice activities, a limitation of the current literature. A strength of this qualitative study NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 56 is the spread of participants across B.C., which included a mix of both urban and rural RN/RPN OAT prescribers. A limitation of participant demographics was that only one in nine participants was an RPN, which is not reflective of the provincial implementation ratios of RN and RPN trained OAT prescribers. At the time of this study, RNs and RPNs in B.C. were permitted to prescribe buprenorphine/ naloxone and had a limited scope of SROM and methadone, with additional select adjunct medications. It is acknowledged that with on-going planning across the province to increase the scope for nurse OAT prescribers, this study does not reflect the nursing experience of applying the broader autonomous practice of initiating methadone and SROM. Implications for Practice and Administration Having RNs and RPNs join the workforce to provide lifesaving medication and treatment to people with an opioid use disorder is just one of the many measures that B.C. healthcare is using to combat this crisis (Ministry of Health, 2020). With RN/RPN OAT prescribing in Canada being a novel phenomenon, the need to build and share clinical expertise is important to research and nursing practice (Hunt, 2009). Understanding the experience and perceptions of nurses expanding their scope and practice to include prescribing OAT is vital to the successful implementation of this initiative. Findings within this research are relevant to other Canadian provinces considering implementing RN/RPN OAT prescribing as a strategy to increase access to pharmacological treatment for people with opioid use disorder. This study is relevant internationally to build upon current literature that primarily focuses on the nurse practitioners role in OAT. Future Research and Recommendations As RN/RPN OAT prescribing continues to expand in B.C., ongoing research and evaluation should be conducted and shared to optimize knowledge translation surrounding this new nursing initiative. This research study focused on the experiences of RNs and RPNs in their journey of becoming OAT prescribers NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 57 of buprenorphine/naloxone, with limited scope in prescribing methadone and SROM. Future research should examine the experience of RNs and RPNs prescribing the full scope of methadone and SROM initiations. Future research should continue to focus on the experience of RNs and RPNs applying advanced practice skills in Canada to support scope optimization of the nursing workforce. Conclusion The province of British Columbia continues to suffer the devastating impacts of the unregulated toxic drug supply, resulting in the highest number of lives lost in 2021 since the declaration of the crisis in 2016, with 2023 trending toward the highest number of preventable deaths on record (B.C. Coroners Service, 2023). RNs and RPNs are a workforce that should be considered as an asset in responding to the unregulated drug poisoning public health emergency. RNs and RPNs provide support to people with an opioid use disorder on the continuum of care, applying harm reduction principles from prevention to treatment. This study outlines RNs and RPNs experience in prescribing OAT, and how to best support this unique and adaptable profession to engage in this important and lifesaving work. 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This study aims to understand the experiences of nurse prescribers and use this information to inform policy and apply to nursing practice. I would like to discuss your experience as a nurse prescriber working with clients diagnosed with an opioid use disorder. I will begin by asking you general information about yourself and your nursing practice. Professional History/ Demographics Are you a registered nurse or a registered psychiatric nurse? How many years have you actively practiced as a nurse? What Health Authority are you currently employed by? What local health region do you practice in? How many years collectively have you worked with people who use substances? What month/year did you register as a nurse prescriber of OAT with BC College of Nurses and Midwives? In your practice, do you primarily serve people in a small community, city or urban setting? Experience of becoming a nurse prescriber I would like to get to know more about your experiences as a nurse prescriber. From your perspective, what was it like becoming a novice nurse prescriber? What made you apply or volunteer for the nurse prescriber training? How did adding prescribing to your practice impact your experience with clients? What, if anything, was challenging about becoming a nurse prescriber? Experience of prescribing opioid agonist therapy to people with an opioid use disorder I would like to understand your experiences in providing opioid agonist treatment to people with an opioid use disorder. Please describe your experience in prescribing opioid agonist therapy. What is challenging about caring for this population? What is positive about caring for this population? What factors (community, work, or otherwise) have an influence on your ability to deliver this intervention? From your perspective, what nursing interventions do you use most in your prescriber role? What advice do you have for nurses who are considering becoming a nurse prescriber of opioid agonist therapy? Thank you, I will send a link to my thesis once it has been completed and is in the Brandon University repository for graduate student theses. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 73 Appendix B Nursing Perceptions and Experiences of Prescribing Opioid Agonist Therapy to People with an Opioid Use Disorder in British Columbia Letter of Invitation Dear RN/RPN Nurse Prescriber, In the province of British Columbia, a Provincial Health Order was issued in September 2020, that allowed Registered Nurses and Registered Psychiatric Nurses the ability to assess, diagnose and treat an opioid use disorder, which includes the prescribing controlled substances. You are being invited to participate in a study to explore RN/ RPN experience of prescribing opioid agonist therapy to people with an opioid use disorder. I am a student in the Master of Psychiatric Nursing Program through the Faculty of Health Studies at Brandon University. My research supervisor is Dr. Jane Karpa. Additionally, I am a clinical nurse specialist in Interior Health B.C. and support the regional implementation and community of practice for nurse prescribing. The information gathered in this study will be published in my thesis manuscript. This study is intended to benefit the future advancement of nursing practice, policy, and education related to nurse prescribing. If you agree to participate in this study, you will be involved in an individual virtual interview with the researcher regarding your experiences and perceptions as a nurse prescriber in the province of British Columbia. I would be happy to share the findings with you following the study via an email link to my thesis once it has been published. At a time convenient to you, I would like to meet virtually to talk about your experiences prescribing opioid agonist therapy to people with an opioid use disorder. Our conversation will be one on one and approximately 60-90min long. The interviews will be audio-recorded and then transcribed using the virtual platform. Your participation will be kept confidential, and confidentiality will be maintained using anonymous coding of participant data. Data from all participants will be aggregated and your name or any other identifying information will not be published or shared. Participation in this study is voluntary and you may refuse to answer any question or withdraw from the study at any time. Participating or declining to participate in this study will not affect your relationship with the researcher, Brandon University, or your Health Authority employer. Should you be interested in participating or have any questions about participating in the study, please contact me directly to further discuss this project. I may be reached at (250) 318-6148 and lavignal16@brandonu.ca. You may also speak with my thesis supervisor, Dr. Jane Karpa at (204)-2921844 and karpaj@brandonu.ca Sincerely, Amanda Lavigne BScPN Master of Psychiatric Nursing Student, Brandon University NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 74 Appendix C Consent Form Title of the Study: Nursing Perceptions and Experiences of Prescribing Opioid Agonist Therapy to People with an Opioid Use Disorder in British Columbia Principal Investigator and Research Team: Amanda Lavigne BScPN, Masters of Psychiatric Nursing, Brandon University Email: lavignal16@brandonu.ca Phone: 250-318-6148 Dr. Jane Karpa, Department of Psychiatric Nursing, Brandon University Email: karpaj@brandonu.ca Phone: 204-292-1844 To help you make an informed decision regarding your participation, this consent form will outline what the study is about, the possible risks and benefits, and your rights as a research participant. If any information provided is unclear, please ask a member of the research team for clarification prior to consenting to participate. You will be provided with a copy of this form for future reference if you choose to participate in this study. Purpose of this Study: You are invited to participate in a research study about the perceptions and experiences of RNs and RPNs who prescribe opioid agonist therapy in British Columbia, Canada. This study aims to understand the experiences of nurse prescribers and use this information to inform policy and apply to nursing practice. Participant Responsibilities: What does participation involve? Participation in this study will consist of an interview over a virtual platform (MicroSoft teams) with the principal investigator of this study. Interviews will take approximately 60 to 90 minutes in length. The interview will be recorded and transcribed using the Microsoft teams’ program. Transcriptions of interviews may be reviewed with participants for further clarity and analysis of data. Who may participate in this study? This study will involve British Columbia RNs and RPNs who are actively prescribing opioid agonist therapy to people with an opioid use disorder as of May 31st, 2022. Participant Rights: Is participation in this study voluntary? You are under no obligation to participate. You participation is voluntary, and you may decline to answer any question (or you may choose to end the interview at any time). You may withdraw from the study at any time, up to (DATE) when it will no longer be possible due to anonymization of the raw data. Withdrawing from this study will have no impact on your employment or relation with your college. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 75 Will I receive anything for participating in this study? There is no payment for participating in this study, however an honorarium coffee card (Your choice of Starbucks or Tim Hortons) worth $20 will be mailed to you following your participation. What are the possible benefits of the study? This study aims to benefit and inform nursing policy and practice related to prescribing. What are the possible risks associated with the study? Participants of this study will be asked questions related to their experience of becoming and practicing as a nurse prescriber of opioid agonist therapy. Participants will be asked to share their perceptions about treating patients with an opioid use disorder. No risks are anticipated by participating in this study. Will my identity be known? Will my information be kept confidential? Participant information collected in this study will be coded and de-identified to protect confidentiality of participants. Participant quotes will be identified by region or health authority, not city, in order to further support anonymity in responses. What will be done with the research findings? Information collected in this study will be used to inform research findings and will be published in a thesis manuscript. A link to the published manuscript will be shared with participants and nurse prescriber implementation stakeholders across British Columbia. The researcher will submit a summary article of this research for publication to a health-related journal. Who should I contact if I have questions regarding my participation in this study? Please do not hesitate to contact the research team members if you should have questions about the study. Amanda Lavigne BScPN, Masters of Psychiatric Nursing, Brandon University Email: lavignal16@brandonu.ca Phone: 250-318-6148 Dr. Jane Karpa, Department of Psychiatric Nursing, Brandon University Email: karpaj@brandonu.ca Phone: 204-292-1844 If you have ethics-related questions or concerns about this study, please contact the Brandon University Research Ethics Committee (BUREC) at (204) 727-9712 or burec@brandonu.ca. Other Information: This study has been reviewed and received ethics approval by the Brandon University Research Ethics Committee (BUREC). This study has been reviewed and received ethics approval by the Interior Health ethics review board. By providing your consent, you are not waiving your rights to legal recourse in the event of researchrelated harm. NURSE PRESCRIBING OF OPIOID AGONIST THERAPY 76 Consent: I have read the information presented in this consent document. I have had the opportunity to ask questions related to the study and have received satisfactory answers to my questions and any additional details. I agree to participate in this research study I agree to my interview being audio-recorded {video-recorded] to ensure accurate transcription and analysis. I agree to the use of quotations in any quotations in any thesis or publication that comes from this research to be presented anonymously.