Background: The incidence of errors in healthcare are largely impacted by the competence of those providing direct patient care. As the primary care provider at the bedside, nurses must be prepared to prevent mistakes like medication errors that cause patient harm.
Objective: The purpose of this study was to describe the medication administration performance of nursing students over time. Specific aims were to describe graduating nursing students’ medication administration performance, compare first and final semester performance, determine the long-term effect of participation in an Individual Simulation Experience (ISE), and determine if nursing assistant experience impacts medication administration performance.
Participants: Sixty-eight baccalaureate nursing students participated in the study.
Method: The study was a longitudinal, descriptive experimental two group pretest posttest design. Nursing students were randomly assigned to an ISE or a traditional practice session when they learned the skill of medication administration. The Medication Administration Safety Assessment Tool was used to assess medication administration performance of nursing students during their first semester of nursing courses as a pretest, after the ISE or traditional practice session as a posttest, and during their final semester of nursing courses as a posttest.
Results: Most nursing students were not prepared for medication administration as they approached graduation. The ISE did not impact nursing student medication administration performance over time.
Conclusion: Nurse educators must examine the reality of medication administration education in their programs. The impact of repeated exposure of teaching strategies like simulation should be investigated to determine the long-term impact on safe medication administration practice.
Keywords: nursing education, medication administration, competence, individual simulation experience, simulation, baccalaureate
Nursing Student Medication Administration Performance: A Longitudinal Assessment and Randomized Trial
The incidence of errors in healthcare are largely impacted by the competence of those providing direct patient care. As the primary care provider at the bedside, nurses must be prepared to prevent mistakes like medication errors that cause patient harm. Medication safety is a priority in healthcare, so it consistently remains as a Hospital National Patient Safety Goal (The Joint Commission, 2019). Nurses are responsible for administering medications, so they have the last opportunity to prevent an error before it reaches the patient.
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Nurse educators aim to produce nurses who can provide safe patient care, and therefore, patient safety concepts are incorporated throughout nursing education. In a study of nurse leaders, educators, and clinicians, 98% of participants agreed that medication administration is an essential skill of new nurse graduates and this skill was also ranked as the fifth most important (Brown & Crookes, 2016). However, nurse leaders are not satisfied with new nurse graduate competence in medication administration (Berkow, Virkstis, Stewart, & Conway, 2009). Further, in a study of 5,000 new nurses, despite having passed the National Council Licensure Exam (NCLEX), only 23% were assessed as safe to practice independently by a competency assessment tool designed to identify gaps in critical thinking like problem recognition and problem management (Kavanagh & Szweda, 2017).
An education to practice gap exists because even though recent graduate nurses report being well-prepared during school for medication administration (Aggar & Dawson, 2014; Jones & Treiber, 2017), they report experiencing a significant amount of stress related to administering medications and keeping patients safe while doing so (Murray, Sundin, & Cope, 2019). They also describe feeling terrified, incompetent, and fearful after making a medication error (Jones & Treiber, 2017). Jones and Trieber (2017) identified new nurses who made a medication error as a “second victim” and proposed that nursing education should not only include strategies to improve the medication administration competence of nursing students, but should also teach about coping with errors made.
Medication administration education is integrated throughout nursing curricula, but competence in this complex skill requires repeated opportunities to practice. Teaching strategies like use of expert role modeling videos (Holland et al., 2013), e-learning (Lee & Lin, 2013), technology aids like an automated medication dispensing unit (Ferguson, Delaney, & Hardy, 2014), and simulation-based learning experiences (Jarvill et al., 2018; Mariani, Ross, Paparella, & Allen, 2017; Pauly-O’Neill, 2009; Sears, Goldsworthy, & Goodman, 2010) have been shown to positively contribute to nursing student practice of safe medication administration. However, there are also alarming findings in the literature regarding nursing student administration competence. Amster, Marquard, Henneman, and Fisher (2015) used an eye-tracking device to assess senior nursing students during simulation scenarios and 40% of participants administered a contraindicated medication to a patient. The authors suggested the errors were due to lack of knowledge about the medication because the tracking was similar between students who made the error and students who did not make the error (Amster et al., 2015). Schneidereith (2014) assessed nursing student medication administration competence during simulation scenarios and compared junior students to senior students. The researcher concluded that the junior level students had safer behaviors than senior level students (Schneidereith, 2014).
The purpose of this study was to describe the medication administration performance of nursing students over time. The specific aims were to: 1) describe graduating nursing students’ performance of the medication administration rights; 2) compare nursing student medication administration performance during their first and final semesters; 3) determine if participation in an Individual Simulation Experience (ISE) during the introduction of medication administration education significantly improved long-term medication administration performance compared to participation in a traditional practice session; and 4) determine if experience as a nursing assistant impacted medication administration performance.
A convenience sample (n=68) of baccalaureate nursing students enrolled in their final semester of nursing courses were recruited from an advanced adult medical-surgical course at a large Midwestern public university for phase two of this study. These nursing students were selected because they previously participated in phase one of this study, which was an experimental two group pretest posttest study to evaluate the effect of an ISE on medication administration competence of first semester nursing students. Students in the ISE group scored significantly higher on the posttest than students in the traditional practice session group (Jarvill et al., 2018). There was a one to one student to facilitator ratio for the ISE rather than the traditional simulation model using groups of students.
The university institutional review board approved the study and the Medication Administration Safety Assessment Tool (MASAT) authors granted permission to use the instrument. The study followed a cohort of nursing students throughout a nursing program. Phase one of data collection occurred in the fall semester of 2016 and phase two of data collection occurred in the spring semester of 2018.
A longitudinal, descriptive experimental two group pretest posttest design was used to describe nursing student medication administration performance over time and determine if there was a long-term effect of an ISE on nursing student medication administration competence. The MASAT, developed by Goodstone and Goodstone (2013), is used to evaluate medication administration performance of nursing students in the simulation or clinical setting. It is a performance based, eight-item checklist to assess adherence to the six rights of medication administration. A total score of eight indicates proper demonstration of each step of the medication administration process (Goodstone & Goodstone, 2013).
During phase one of data collection, each student participated in a pretest, a randomly assigned medication administration practice session, and a posttest. Each laboratory section (n=6) was randomly assigned to the control (n=43) or the intervention (n=42) group by the researcher using a random numbers table. The college advisor randomly assigns students to each laboratory section. During phase two of data collection, each student participated in a second posttest. Consent was obtained separately for participation in phase two of data collection. Of the 77 eligible participants, 68 consented to participate. Participants in phase two represented the ISE practice session (n=34) and the traditional practice session (n=34). All data collection took place in the university’s nursing simulation laboratory. The nursing simulation laboratory’s homegrown electronic medication administration record (MAR) and medication carts were used for all pretests, posttests, and the control group traditional practice experience. The MAR is used throughout the psychomotor skills course and in all simulation experiences in this program. The MAR and an automated dispensing medication unit were used for the ISE intervention.
Phase One Pretest
During the first semester of nursing courses, each nursing student demonstrated administration of one oral medication to establish a pretest score. This assessment was completed after the medication administration process was presented in the psychomotor skills theory course and practiced in the associated laboratory course. The researcher evaluated performance using the MASAT.
Phase One Intervention
Nursing students designated to the intervention group participated in a 30-minute ISE focused on oral medication administration. The ISE included a prebriefing, simulation experience, and debriefing. The protocol is fully described in the results of phase one article by Jarvill and colleagues (2018).
Phase One Control Group
Nursing students designated to the control group participated in a 30-minute traditional practice session. Laboratory assistants guided students during the practice sessions. Students repeated the medication administration process until they were comfortable with the procedure.
Phase One Posttest
During the first semester of nursing courses, each nursing student demonstrated administration of one oral medication after the assigned practice session, but before final evaluations by the faculty, to establish a posttest score. The same process was implemented for the posttest as the pretest, but included a different patient and MAR. The researcher evaluated performance using the MASAT.
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Phase Two Posttest
During the final semester of nursing courses, each nursing student demonstrated administration of one oral medication to establish a second posttest score. The same process was implemented for the second posttest as previously described, but included a different patient and MAR. The researcher evaluated performance using the MASAT.
SPSS version 25.0 (IBM Corporation, Armonk, NY) was used to perform statistical analysis. Of the 68 participants, 82% were female (n=56) and 18% were male (n=12). The average age of the participant was 22.6 (SD=3.3) with a range from 20 to 40 years.
Specific Aim One
The average MASAT score was 7 (SD=1.01) with a range of scores from 3 to 8. Only 33.8% (n=23) of all students achieved a perfect score of 8, which represents accurate demonstration of the medication administration rights. Three items on the MASAT are related to identifying the patient: asking the patient to state their name and date of birth aloud; checking the name and date of birth against the MAR; and checking the patient’s identification band for the name and date of birth. Most students (57.4%, n=39) failed to perform at least one item related to patient identification.
Specific Aim Two
There was no significant difference between posttest scores collected during the first semester (M=6.88, SD=1.09) and the posttest scores collected during the last semester (M=6.99, SD=1.01), t(66)=-.57, p=.57. Cohen’s effect size value (d=0.10) indicated a small effect. Of the participants in this study, only 33.8% (n=23) during the first semester posttest and only 33.8% (n=23) of students during the final semester achieved a perfect score.
Specific Aim Three
There was no significant difference on the posttest scores during the final semester between nursing students in the ISE group (M=6.85, SD=1.05) and the students in the traditional practice session group (M=7.11, SD=0.98), with the pretest scores held constant, F(1, 67)=1.60, p=0.21. Cohen’s effect size value (d=0.27) indicated a small effect. Only 35.3% (n=12) of the students in the ISE group and 32.4% (n=11) of students in the traditional practice group achieved a perfect score during the posttest in the final semester.
Specific Aim Four
Participants were asked if they had healthcare experience and 52.9% (n=36) reported working as a nursing assistant. It was hypothesized that working as a nursing assistant would provide greater exposure to the medication administration process and would positively impact medication administration performance. Although the last semester posttest scores of nursing students who worked as nursing assistants (M=7.19, SD=0.82) were higher than nursing students who did not work as nursing assistants (M=6.75, SD=1.16), it was not significant t(66)=-1.83, p=0.07.
Results of this study demonstrate that nursing students preparing to graduate are not yet competent in performing the medication administration rights. This contradicts findings that nursing students perceive themselves to be well prepared for medication administration after traditional education (Aggar & Dawson, 2014; Jones & Treiber, 2017) and prepared to manage risks for errors like interruptions during medication administration (Hayes, Jackson, Davidson, Daly, & Power, 2017). However, the findings of this study add to other literature demonstrating nursing students are not competent in medication administration when nearing graduation (Schneidereith, 2014) and the when entering the workforce (Berkow et al., 2009).
In this study, nursing students who participated in an ISE initially scored higher on a medication administration competence assessment than their peers who participated in a traditional practice session. However, during their final semester, the ISE group scored lower than the control group. This indicates the immediate gain from participating in the ISE during the first semester was not maintained throughout the program. Avraham, Shor, Hurvitz, Shvartsur, and Kimhi (2018) also studied the effect of a one on one simulation and found performance of medication administration in the clinical setting was improved and students felt prepared for practice in the clinical setting. Repeated exposure to experiences like the ISE throughout a nursing program may prove to be beneficial. Further study is needed assessing the effects of repeated exposure to medication administration opportunities, with assessment and feedback on nursing student medication administration performance.
Only one third of nursing students approaching graduation were achieved a perfect score on the medication administration performance assessment. Failure to properly identify the patient was specifically noted as a deficit, which is similar to findings from other researchers (Bowling, 2015; Schneidereith, 2014; Stanley, Philips, & Galatzan, 2014). This creates a significant risk for error, which is why identifying patients properly using two identifiers remains a Hospital National Patient Safety Goal (The Joint Commission, 2019).
This study focused on the administration of one oral medication and there are more complex concepts to consider. Other researchers have studied the use of simulation in managing interruptions (Hayes et al., 2017) and distractions (Thomas, McIntosh, & Allen, 2014), administering pediatric intravenous medications (Pauly-O’Neill, 2009), and advanced medication administration skills (Kelly et al., 2018). Simulation may be tailored to address specific student needs in medication administration like gaps in competence, lack of opportunities to practice in the clinical setting, or lack of opportunities to practice handling high risk situations.
There are several limitations to this study to consider. First, the use of a convenience sample from a single cohort of students from a single university limits generalizability. Second, all data collection was done by the researcher. However, a scatterplot analysis of scores in the order collected revealed no pattern. Third, no attempt was made to assess the frequency of medication administration experience in the clinical, simulation, or laboratory settings, which may have affected the results. Third, this study does not address competence in the clinical setting.
This study adds to the growing literature regarding the medication administration competence of nursing students. Findings suggest nursing students are not prepared for medication administration upon graduation. Educators should carefully examine how nursing students are taught the medication administration process and the reality of the frequency of opportunities nursing students have to practice this skill throughout their education. Purposeful integration of strategies throughout a program, rather than a focus on the initial teaching of the skill, may better support students in achieving and maintaining medication administration competence. Study of the long-term outcomes of simulation as a strategy in preparing nurses for safe medication administration practice may further substantiate its’ use.
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