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  • Data were collected using a multi-method approach consisting of semi-structured interviews with stakeholders on nurse prescribing in the Netherlands and an extensive document analysis. Stakeholder interviews provided the primary source of data. We aimed to include representatives of all organizations that were involved in the nurse prescribing debate in the Netherlands. This included representatives of overarching nurses and medical associations as well as more specialist associations, such as the Association for Diabetes Care Professionals (EADV) and the Dutch College of General Practitioners (NHG). A list of key organizations was compiled in consultation with experts on nurse prescribing from the Royal Dutch Medical Association (KNMG) and the Dutch Nurses’ Association (V & VN). Potential informants were also selected in consultation with these experts and were approached by the researchers to take part in the study. Representatives received an information letter explaining the aims of the study, the voluntary nature of participation and an invitation to participate in an interview. Participant consent was assumed upon accepting this invitation and participation in an interview. Of the 16 representatives invited per email and telephone, 13 ultimately participated (see Table 1 for a list of all interviewed stakeholders). Twelve interviews were with a single informant and one was with two representatives of one organization interviewed together. The informants held policy- or board positions within their organization, and their answers represent the organization’s point of view. Every interview was conducted by one or two researchers (MK, LVD, PG and/or AF) who were trained in qualitative interviewing techniques. The interviews were semi-structured and were guided by a topic list that was drafted after the findings of an earlier systematic review of the literature on nurse prescribing [35]. Interview topics were: general information about the informant/organization, vision on nurse prescribing, degree of support for nurse prescribing, introduction of nurse prescribing, the legal-, educational- and organizational conditions for nurse prescribing, and challenges and threats to the work of doctors and nurses because of nurse prescribing. All interviews but one were recorded and a summary of the interview was sent to each representative to be edited, where necessary, as an accurate representation of the organization’s viewpoint. Representatives could mark sections of the interview summary as ‘off the record’, in addition to sections they already noted as ‘off the record’ during the interview itself. All ‘off-the-record’ requests (n=2) were granted in full. One interview was conducted by letter, at the request of the organization. The approved interview summaries formed the basis for analysis. Table data removed from full text. Table identifier and caption: 10.1371/journal.pone.0077279.t001 List of interviewed stakeholders. No ethical approval was deemed necessary for this study as the information that was collected did not refer to peoples’ individual opinions or behaviors but exclusively to organizational points of view concerning nurse prescribing. However, all informants consented that the approved interview summaries, in which their organizations were mentioned by name, could be used in research publications. Moreover, all informants were informed that they could withdraw from the study at any time during or after the interview. All data collected were handled as required by the rules of the Dutch Data Protection Act (Dutch: Wbp- Wet bescherming persoonsgegevens) and the applicable codes of conduct for scientific researchers. Raw data (i.e. the approved interview summaries) are available upon request from the first author, but only after permission from the organization concerned has been obtained. In addition to stakeholder interviews, document analysis provided information that was used to supplement data collected through interviews. Considerable effort was made to obtain relevant documents, such as policy documents, position papers, newspaper articles, letters to the Minister of Health, and government documents regarding nurse prescribing, from various sources. These sources included the websites of the associations that were interviewed, digital archives of their professional journals, digital government archives and the LexisNexis database of national newspaper articles. Because most of these websites lacked advanced search facilities, we used combinations of the following keywords, where possible, to search for relevant documents from the last 10 years: “prescriptive authority”, “nurses”, “nurse specialists”, “prescribing”, “medicines” and “task substitution”. For government archives, the additional search terms “32.196” and “32.361” were used, because these were the numbers of the (draft) bills on prescriptive authority for nurses. Documents selected for inclusion were searched manually to identify further relevant documents. We included all documents in which knowledge claims were expressed by either (a representative of) the medical profession, the nursing profession, or both; where these knowledge claims referred to (the introduction of) nurse prescribing; and where there was no question of individual views. We included a total of 34 documents in the study. The oldest document included dates back to 2003, but the majority of retrieved documents was from recent years. We performed a thematic analysis of the approved interview summaries and documents gathered through the document analysis [36]. Data analysis began at an early stage in the research to introduce any necessary changes in the interview protocol. Data were coded using MAXQDA 2007 qualitative data analysis software [37] and were analyzed both inductively and deductively. Guided by our theoretical model, we searched the data for concepts that were directly linked to interprofessional tensions around nurse prescribing. Additionally, data were analyzed inductively and compared for common statements and claims. Subsequently, recurring themes were identified and classified, and text fragments were sorted according to the thematic framework. Three of the researchers took part in internal discussions of the analysis and themes were discussed until consensus was reached. Analysis of the data identified the following thematic elements: illegal nurse prescribing, professional domains, (exclusive) task/knowledge area doctor/nurse, preconditions for nurse prescribing, protocols/guidelines, comorbidity/polypharmacy and routine aspects of prescribing. Based on these themes, we distinguished the knowledge claims used by the nursing and medical professions. Quotations were chosen to illustrate the knowledge claims. It should be noted that these quotations came from the interview summaries that were approved by the interviewees. Our study has largely been reported according to the COREQ guidelines [38], see Checklist S1.
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