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Nursing students and the supervision of medication administration
Collegian (2013) 20, 109—114
Available online at www.sciencedirect.com
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Nursing students and the supervision of medication administration Kerry Reid-Searl, RN, RM, Bhlth Sc, MClin Ed, PhD., MRCNA a,1, Brenda Happell, RN, RPN, BA (Hons), Dip Ed, BEd, MEd, PhD a,∗, Karena J. Burke, BA (Hons) PhD b,2, Cadeyrn J. Gaskin, BBS (Hons), MBS, PhD a a
Central Queensland University, Institute for Health and Social Science Research, and School of Nursing and Midwifery, Bruce Highway, Rockhampton, 4702 Queensland, Australia b Central Queensland University, Institute for Health and Social Science Research, and School of Health and Human Services, Australia Received 17 October 2011; received in revised form 2 March 2012; accepted 20 April 2012
KEYWORDS Clinical education; Nursing education; Medication administration; Nursing students; Patient safety; Supervision
Summary Up to one in five medication administrations in Australian hospitals involve an error. As registered nurses (RNs) are at the forefront of medication administration, they have been the focus of attempts to reduce errors. Given that nursing students have reported errors or experiences of near misses, their practices, as well as the supervision they receive from RNs, also deserves investigation. The aim of this study was to investigate student nurses’ experiences of supervision while administering medications. Students (N = 45) completed a questionnaire on their supervision experiences while administering medications. The findings revealed that 88% of students agreed that they had been directly supervised during the entirety of administration procedures. Although 7% of students reported not receiving supervision throughout medication administration, higher percentages of students indicated that they received lower levels of supervision when wards were busy (66%), when they felt under pressure to comply with the wishes of RNs (40%), when students had been in clinical settings for extended periods of time (51%), and when the RNs trusted the student nurses (37%). Approximately one third (29%) of student nurses disagreed that RNs followed the six rights when administering medications. These findings suggest that student nurses are not always adequately supervised and are at
∗
Corresponding author. Tel.: +61 7 49232164; fax: +61 7 49306402. E-mail addresses: [email protected] (K. Reid-Searl), [email protected] (B. Happell), [email protected] (K.J. Burke), [email protected] (C.J. Gaskin). 1 Tel.: +61 7 49309741; fax: +61 7 49309871. 2 Tel.: +61 7 4930 9908; fax: +61 7 4930 6402. 1322-7696/$ — see front matter © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.colegn.2012.04.003
110
K. Reid-Searl et al. times administering medications outside the parameters of the law. Healthcare organisations need to adapt their policies and practices to ensure that the legal requirements surrounding student nurse administration of medications are being met, as well as the educational and welfare needs of neophyte nurses. © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction Medication errors have been consistently identified as a major cause of illness and death in the health care system (Evans, 2009; Fogarty & McKeon, 2006). Research conducted in Australia has shown error rates of between 15% and 20% when ward stock (i.e., medications stored in bulk in wards that staff measure and dispense to patients) is administered and between 5% and 8% when individual patient supplies were used (Runciman, Roughead, Semple, & Adams, 2003). In approximately one-fifth of these cases, the administration errors had clinically significant outcomes. As nurses are principally involved in the administration or medications (Brady, Malone, & Fleming, 2009), they are responsible for ensuring that all safety checks have been adhered to and that the patient receives the right type and dose medication via the right route and at the right time. Additionally registered nurses are role models for students and are responsible for the appropriate supervision of students when undertaking the process of administering medications as students too can make errors. In one small Australian study 9 of 28 student nurses (32%) reported making a medication error or experiencing a near miss (ReidSearl, Moxham, & Happell, 2010). Given that this error rate appears to be higher than that published in other Australian research (Runciman et al., 2003) RN supervision of students is an area that may require research attention. Registered nurses (RNs) are the clinical professionals who most commonly administer medications in hospital settings and, in doing so, hold significant responsibility for the occurrence of medication errors (Evans, 2009; Reid-Searl, Moxham, & Happell, 2010; Reid-Searl, Moxham, Walker, & Happell, 2008). Given that errors occur frequently (Runciman et al., 2003), a significant amount of research has been undertaken to identify factors that contribute to the medication errors that nurses make (Fogarty & McKeon, 2006; Fry & Dacey, 2007). The findings from these studies suggest that the main factors contributing to errors include (i) interruptions from patients, visitors, and ward activity (Fry & Dacey, 2007); (ii) individual nurse factors, such as inaccuracy in calculations (C ¸ inar, Akuduran, & Dogan, 2006; Evans, 2009; Fry & Dacey, 2007; HarneBritner et al., 2006) and non-adherence to protocols (Jones, 2009); and (iii) the impact of the broader organisational climate on individual nurses (Fogarty & McKeon, 2006; Jones, 2009). Given the extent and potentially serious consequences of errors during medication administration, numerous strategies have been developed to assist RNs to reduce the frequency and severity of medication errors. This includes double checking (Hodgkinson, Koch, Nay, & Nichols, 2006; Jensen, Merry, Webster, Weller, & Larsson, 2004); single checking (O’Connell, Crawford, Tull, & Gaskin, 2007);
ongoing education in the calculation of medication doses (Fry & Dacey, 2007; Harne-Britner et al., 2006; Jones, 2009), including the use of personal digital assistants (Greenfield, 2007); and strategies to avoid interruptions during medication administration rounds (Evans, 2009; Jones, 2009). RNs have generally been the focus of these strategies, because they have legal responsibility at the point of administration (Reid-Searl et al., 2008; Reid-Searl, Moxham, Walker, & Happell, 2010b). Every year in Australia, however, thousands of nursing students undertake clinical experience in health care settings during which they may be given the responsibility of administering medications. When student nurses perform this complex skill they should be under the personal supervision of the registered nurse. (Queensland Government, 1996). Qualitative evidence, however, suggests that the level of supervision provided can be quite variable (Reid-Searl et al., 2008). Given that one third of students report making medication administration errors or experience near misses (Reid-Searl, Moxham, & Happell, 2010), this area of student supervision needs closer examination. Despite the numbers of nursing students in the health care system there is surprisingly little research focusing on the contribution they make to medication errors. Most research with student nurses had focused on the calculation of drug dosages (C ¸ inar et al., 2006; Craig & Seller, 1995; Evans, 2009; Grandell-Niemi, Hupli, Puukka, & LeinoKilpi, 2006; Harne-Britner et al., 2006) and the integration of pharmacological knowledge into clinical practice (Honey & Lim, 2008). Although there is a stated legal requirement for students to be supervised when administering restricted medications (e.g., Queensland Government, 1996), there is a paucity of research addressing the quality of supervision provided. In a recent review of the literature on reducing medication errors (Evans, 2009), for example, the supervision of nursing students was not mentioned. One way in which a deeper understanding of student nurse medication administration experience can be gained is through investigation of the supervision they receive during this process. The aim of this study was to investigate student nurses’ experiences of supervision while administering medications.
Methods Setting and participants This research was conducted in a university in Queensland Australia. The potential participants targeted for this research were the 85 undergraduate nursing students who were in their third year of a three-year Bachelor of Nursing program.
The supervision of medication administration
111
Table 1 Types of placements reported as having been undertaken by third year nursing students. Placement type
Frequency (n)
% of total sample
Medical Surgical Paediatric Aged care Preoperative Emergency Mental health Community Other
28 34 8 15 10 10 13 13 21
62 76 18 33 22 22 29 29 47
Note: N = 45.
The participants were 45 students (response rate = 53%), most of whom were female (98%, n = 44). The ages of respondents ranged from 19 to 61, with the mean age being 28.80 (SD = 10.89) years. At the time of data collection, all participants had undertaken at least five clinical placements in a range of settings. The administration of medication was a specified learning outcome in four of these placements, giving students sufficient experience to inform the research study (see Table 1).
Questionnaire A 10-item questionnaire was developed to explore student experiences of supervision during medication administration. The content of the questionnaire was based on literature pertaining to students’ experiences of medication administration and discussions with registered nurses. Drafts of the questionnaire were shown to registered nurses and nursing academics to obtain their perspectives on the appropriateness and thoroughness of the questionnaire. Participants responded to each item on a 5-point Likert scale, anchored with strongly disagree and strongly agree. The questionnaire also had items on gender, age, and types of placements undertaken.
Procedures Following ethical approval, the principal researcher (first author) emailed third year nursing students with a brief overview of the study and asked them to reply if they would like further information. The students who made contact were provided with additional information and a copy of the plain language statement and questionnaire was sent to them by email. They were asked to complete the survey and return it in a reply paid envelope to the researcher if they were willing to participate. No identifying details were included to protect their identity. The data from completed questionnaires were entered into an electronic database and used for the analyses.
Data analysis For each of the supervision items in the questionnaire, the frequencies of responses and a measure of central tendency (median) were calculated.
Results Most students (88%) indicated that they were directly supervised during medication administration procedures (see Table 2). Although over half of the students (58%) agreed, to varying extents, with the premise that the RN followed the six rights of administration when the students were administering medication, 29% of students disagreed with the statement. Two-thirds of students (66%) agreed, to varying extents, that the busyness of the ward adversely affected supervision levels. Most students (89%) reported that they insisted on receiving supervision at times when it was not initially provided. Most students agreed, to varying extents, that the enthusiasm of the RNs (82%) and the understanding of RNs about what students are allowed to do (78%) influenced the levels of supervision provided. There was wide variation in responses to the question as to whether students perceived that they were under pressure to do what RNs asked, even if that meant administering without supervision; 36% agreed that they were under pressure, and 31% disagreed that they felt under pressure. About one-third (35%) of students perceived that their grades would have been affected if they did not do what the RNs asked of them. Half of the students (51%) reported agreeing, to some extent, that the longer they spent in a given clinical area, the less direct supervision they received. The students tended to disagree slightly with the premise that if the RNs trusted them they were more likely to administer medications without direct RN supervision.
Discussion Although few participants disagreed (or held neutral positions) that they were directly supervised during the entirety of medication administrations, the fact that some participants did disagree with the statement may have large implications. The finding suggests that Queensland law is not being consistently upheld with regard to the supervision of nursing students who are administering medications. This finding is consistent with previous research that suggests that the levels of supervision students receive can be highly variable (Reid-Searl, Moxham, Walker, & Happell, 2010a). Given the potentially serious consequences of the unsupervised practice of student nurses (e.g., medication administration errors leading to exacerbation of illness or death), Educational institutions (such as University nursing programs) health care organisations and the educators of neophyte nurses need to pay urgent attention to the supervision of nursing students occurring in clinical settings. The findings of the present study highlight circumstances in which student nurses may not have received adequate supervision. Similar to previous work in this area (Reid-Searl et al., 2010b), these circumstances include when wards were busy, when student nurses felt under pressure to
112 Table 2
K. Reid-Searl et al. Frequency and percentage of student nurse agreement or disagreement with each statement.
Question
SD
D
N
A
SA
Median
1. I am directly supervised by an RN during medication administration, for the entire administration procedure. 2. The RN follows the ‘six rights’ of medication administration when I am administering medications with them. 3. When the ward is busy I am likely to receive a lower level of supervision by the RN during medication administration. 4. I will insist on receiving direct supervision when administering medication if this is not initially provided by the RN. 5. I feel that the enthusiasm the RN has for my clinical experience influences the level of supervision he or she gives to me during medication administration. 6. I feel the RN’s understanding of what I am permitted to do in administering medication influences the amount of supervision they give me during medication administration. 7. I feel pressure to do what the RN asks of me even if it means administering medication without direct supervision. 8. I feel that if I do not do what the RN asks when administering medication my academic grades will be affected by their evaluation. 9. I feel that the longer time I have in a clinical area, the less direct supervision for medication administration I am given. 10. If the RN trusts me I am more likely to administer medication without the RN directly supervising me.
0 (0%)
3 (7%)
2 (4%)
29 (64%)
11 (24%)
A
1 (2%)
12 (27%)
6 (13%)
21 (47%)
5 (11%)
A
2 (4%)
7 (16%)
6 (13%)
20 (44%)
10 (22%)
A
0 (0%)
0 (0%)
5 (11%)
13 (29%)
27 (60%)
SA
0 (0%)
3 (7%)
5 (11%)
15 (33%)
22 (49%)
A
1 (2%)
3 (7%)
6 (13%)
13 (29%)
22 (49%)
A
7(16%)
14 (31%)
6 (13%)
16 (36%)
2 (4%)
N
7(16%)
18 (40%)
4 (9%)
10 (22%)
6 (13%)
N
2 (4%)
9 (20%)
11 (24%)
19 (42%)
4 (9%)
A
6(13%)
13 (29%)
9 (20%)
11 (24%)
6 (13%)
N
Note: N = 45. SD, strongly disagree; D, disagree; N, neither agree nor disagree; A, agree; SA, strongly agree.
comply with the wishes of RNs, when students had been in clinical settings for extended periods of time, and when the RNs trusted the student nurses. Although not all students reported receiving suboptimal levels of supervision, any deviation from direct supervision is legally and clinically significant. Any time that student nurses administer medications without direct supervision represents a breach of the laws under which they practice and an occasion during which they could potentially harm patients. The present study’s findings also raise questions about whether all RNs are adequate role models for student nurses with regards to medication administration. Almost one third (29%) of students disagreed with the statement that RNs follow the six rights when they are administering medications with students, and a further 13% gave neutral responses. Such poor modelling of safe medication administration practices may have contributed to the errors and near misses that students have reported during their undergraduate preparation (Reid-Searl, Moxham, & Happell, 2010), and is likely to contribute to the maintenance of error
rates that have been found in Australian healthcare settings (Runciman et al., 2003). Education providers and healthcare organisations have moral and legal obligations to provide adequate support to students during their clinical placements. Although students are generally well aware of the likelihood of medication errors and their potential implications for patient safety (Reid-Searl, Moxham, & Happell, 2010; Reid-Searl et al., 2008), they also place high value on the need to gain acceptance from the RNs with whom they work. Clinical placements can be highly stressful situations for students (Bond, 2009; Hegge & Larson, 2008; Jimenez, Navia-Osorio, & Diaz, 2010; Shipton, 2002), and the relationships between students and RNs are pivotal in reducing anxiety and promoting positive and constructive learning environments (Myrick, Yonge, & Billay, 2010; Tanda & Denham, 2009; Vallant & Neville, 2006; Waldock, 2010). Given the power differential in the relationships between students and RNs, students cannot be expected to continually seek direct supervision when faced with various forms of opposition to providing
The supervision of medication administration such supervision. Although most students (89%) reported that they insisted on supervision, 40% also reported feeling under pressure to do what RNs instruct them to do, including medication administration without direct supervision, 35% stated that they believed their grades would be affected if they did not do as RNs ask, and 51% agreed that the longer they spent in clinical settings, the less direct supervision they received. With the power dynamics that exist between student and RN, the onus is clearly on educators, healthcare organisations, and RNs to provide adequate support to students. This study was conducted with a relatively small group of nursing students from the one university in Australia. Therefore, the findings of this study cannot be widely generalised. Given the gravity of the findings, however, further investigation into the adequacy of student supervision would seem to be urgently required. Administering medication is a high risk procedure in that, if errors are made, serious injury or death can result (Evans, 2009; Evans et al., 2006; Fry & Dacey, 2007; Hodgkinson et al., 2006). As registered nurses of the future, nursing students need to learn to administer medication safely and responsibly (Evans, 2009; Reid-Searl, Moxham, & Happell, 2010). The findings of this study, however, reveal that students may not be receiving adequate supervision when administering medications. Educators, healthcare organisations, and RNs need to review their policies and practices to ensure students receive adequate supervision during the administration of medication.
Acknowledgements The authors extend their thanks to the registered nurses and students who completed the questionnaires, and to the many people who assisted with the questionnaire development.
References Bond, M. E. (2009). Exposing shame and its effect on clinical nursing education. Journal of Nursing Education, 48(3), 132—140. Brady, A., Malone, A., & Fleming, S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal of Nursing Management, 17(6), 679—697. C ¸ inar, N., Akuduran, F., & Dogan, A. (2006). Mathematical skills of the nursing and midwifery students of Sakarya University School of Healht [sic] Sciences. Revista Eletrônica de Enfermagem, 8(2), 174—184. Craig, G. P., & Seller, S. C. (1995). The effects of dimensional analysis on the medication dosage calculation abilities of nursing students. Nurse Educator, 20(3), 14—18. Evans, J. (2009). Prevalence, risk factors, consequences and strategies for reducing medication errors in Australian hospitals: A literature review. Contemporary Nurse: A Journal for the Australian Nursing Profession, 31(2), 176—189. Evans, S. M., Berry, J. G., Smith, B. J., Esterman, A., Selim, P., O’Shaughnessy, J., et al. (2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality & Safety in Health Care, 15(1), 39—43. Fogarty, G. J., & McKeon, C. M. (2006). Patient safety during medication administration: The influence of organizational and
113 individual variables on unsafe work practices and medication errors. Ergonomics, 49(5—6), 444—456. Fry, M. M., & Dacey, C. (2007). Factors contributing to incidents in medicine administration. Part 2. British Journal of Nursing (BJN), 16(11), 676—681. Grandell-Niemi, H., Hupli, M., Puukka, P., & Leino-Kilpi, H. (2006). Finnish nurses’ and nursing students’ mathematical skills. Nurse Education Today, 26(2), 151—161. Greenfield, S. (2007). Medication error reduction and the use of PDA technology. Journal of Nursing Education, 46(3), 127—131. Harne-Britner, S., Kreamer, C. L., Frownfelter, P., Helmuth, A., Lutter, S., Schafer, D. J., et al. (2006). Improving medication calculation skills of practicing nurses and senior nursing students: A pilot study. Journal for Nurses in Staff Development, 22(4), 190—195. Hegge, M., & Larson, V. (2008). Stressors and coping strategies of students in accelerated baccalaureate nursing programs. Nurse Educator, 33(1), 26—30. Hodgkinson, B., Koch, S., Nay, R., & Nichols, K. (2006). Strategies to reduce medication errors with reference to older adults. International Journal of Evidence-Based Healthcare, 4(1), 2—41. Honey, M., & Lim, A. G. (2008). Application of pharmacology knowledge in medication management by final year undergraduate nursing students. Contemporary Nurse: A Journal for the Australian Nursing Profession, 30(1), 12—19. Jensen, L., Merry, A., Webster, C., Weller, J., & Larsson, L. (2004). Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia, 59, 493—504. Jimenez, C., Navia-Osorio, P. M., & Diaz, C. V. (2010). Stress and health in novice and experienced nursing students. Journal of Advanced Nursing, 66(2), 442—455. Jones, S. W. (2009). Reducing medication administration errors in nursing practice. Nursing Standard, 23(50), 40—46. Myrick, F., Yonge, O., & Billay, D. (2010). Preceptorship and practical wisdom: A process of engaging in authentic nursing practice. Nurse Education in Practice, 10(2), 82—87. O’Connell, B., Crawford, S., Tull, A., & Gaskin, C. J. (2007). Nurses’ attitudes to single checking medications: Before and after its use. International Journal of Nursing Practice, 13(6), 377—382. Queensland Government. (1996). Health (drugs and poisons) regulation — Reprint No. 10G. Office of the Queensland Parliamentary Counsel. Reid-Searl, K., Moxham, L., & Happell, B. (2010). Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students. International Journal of Nursing Practice, 16(3), 225—232. Reid-Searl, K., Moxham, L., Walker, S., & Happell, B. (2008). Shifting supervision: Implications for safe administration of medication by nursing students. Journal of Clinical Nursing, 17(20), 2750—2757. Reid-Searl, K., Moxham, L., Walker, S., & Happell, B. (2010a). Nursing students administering medication: Appreciating and seeking appropriate supervision. Journal of Advanced Nursing, 66(3), 532—541. Reid-Searl, K., Moxham, L., Walker, S., & Happell, B. (2010b). Supervising medication administration by undergraduate nursing students: Influencing factors. Journal of Clinical Nursing, 19(5—6), 775—784. Runciman, W., Roughead, E., Semple, S., & Adams, R. (2003). Adverse drug events and medication errors in Australia. International Journal for Quality in Health Care, 15(Suppl. 1), i49—i59.
114 Shipton, S. P. (2002). The process of seeking stress-care: Coping as experienced by senior baccalaureate nursing students in response to appraised clinical stress. Journal of Nursing Education, 41(6), 243—256. Tanda, R., & Denham, S. A. (2009). Clinical instruction and student outcomes. Teaching & Learning in Nursing, 4(4), 139—147.
K. Reid-Searl et al. Vallant, S., & Neville, S. (2006). The relationship between student nurse and nurse clinician: Impact on student learning. Nursing Praxis in New Zealand, 22(3), 23—33. Waldock, J. (2010). Facilitating student learning in clinical practice. Kai Tiaki Nursing New Zealand, 16(1), 14.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/coll
Nursing students and the supervision of medication administration Kerry Reid-Searl, RN, RM, Bhlth Sc, MClin Ed, PhD., MRCNA a,1, Brenda Happell, RN, RPN, BA (Hons), Dip Ed, BEd, MEd, PhD a,∗, Karena J. Burke, BA (Hons) PhD b,2, Cadeyrn J. Gaskin, BBS (Hons), MBS, PhD a a
Central Queensland University, Institute for Health and Social Science Research, and School of Nursing and Midwifery, Bruce Highway, Rockhampton, 4702 Queensland, Australia b Central Queensland University, Institute for Health and Social Science Research, and School of Health and Human Services, Australia Received 17 October 2011; received in revised form 2 March 2012; accepted 20 April 2012
KEYWORDS Clinical education; Nursing education; Medication administration; Nursing students; Patient safety; Supervision
Summary Up to one in five medication administrations in Australian hospitals involve an error. As registered nurses (RNs) are at the forefront of medication administration, they have been the focus of attempts to reduce errors. Given that nursing students have reported errors or experiences of near misses, their practices, as well as the supervision they receive from RNs, also deserves investigation. The aim of this study was to investigate student nurses’ experiences of supervision while administering medications. Students (N = 45) completed a questionnaire on their supervision experiences while administering medications. The findings revealed that 88% of students agreed that they had been directly supervised during the entirety of administration procedures. Although 7% of students reported not receiving supervision throughout medication administration, higher percentages of students indicated that they received lower levels of supervision when wards were busy (66%), when they felt under pressure to comply with the wishes of RNs (40%), when students had been in clinical settings for extended periods of time (51%), and when the RNs trusted the student nurses (37%). Approximately one third (29%) of student nurses disagreed that RNs followed the six rights when administering medications. These findings suggest that student nurses are not always adequately supervised and are at
∗
Corresponding author. Tel.: +61 7 49232164; fax: +61 7 49306402. E-mail addresses: [email protected] (K. Reid-Searl), [email protected] (B. Happell), [email protected] (K.J. Burke), [email protected] (C.J. Gaskin). 1 Tel.: +61 7 49309741; fax: +61 7 49309871. 2 Tel.: +61 7 4930 9908; fax: +61 7 4930 6402. 1322-7696/$ — see front matter © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.colegn.2012.04.003
110
K. Reid-Searl et al. times administering medications outside the parameters of the law. Healthcare organisations need to adapt their policies and practices to ensure that the legal requirements surrounding student nurse administration of medications are being met, as well as the educational and welfare needs of neophyte nurses. © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
Introduction Medication errors have been consistently identified as a major cause of illness and death in the health care system (Evans, 2009; Fogarty & McKeon, 2006). Research conducted in Australia has shown error rates of between 15% and 20% when ward stock (i.e., medications stored in bulk in wards that staff measure and dispense to patients) is administered and between 5% and 8% when individual patient supplies were used (Runciman, Roughead, Semple, & Adams, 2003). In approximately one-fifth of these cases, the administration errors had clinically significant outcomes. As nurses are principally involved in the administration or medications (Brady, Malone, & Fleming, 2009), they are responsible for ensuring that all safety checks have been adhered to and that the patient receives the right type and dose medication via the right route and at the right time. Additionally registered nurses are role models for students and are responsible for the appropriate supervision of students when undertaking the process of administering medications as students too can make errors. In one small Australian study 9 of 28 student nurses (32%) reported making a medication error or experiencing a near miss (ReidSearl, Moxham, & Happell, 2010). Given that this error rate appears to be higher than that published in other Australian research (Runciman et al., 2003) RN supervision of students is an area that may require research attention. Registered nurses (RNs) are the clinical professionals who most commonly administer medications in hospital settings and, in doing so, hold significant responsibility for the occurrence of medication errors (Evans, 2009; Reid-Searl, Moxham, & Happell, 2010; Reid-Searl, Moxham, Walker, & Happell, 2008). Given that errors occur frequently (Runciman et al., 2003), a significant amount of research has been undertaken to identify factors that contribute to the medication errors that nurses make (Fogarty & McKeon, 2006; Fry & Dacey, 2007). The findings from these studies suggest that the main factors contributing to errors include (i) interruptions from patients, visitors, and ward activity (Fry & Dacey, 2007); (ii) individual nurse factors, such as inaccuracy in calculations (C ¸ inar, Akuduran, & Dogan, 2006; Evans, 2009; Fry & Dacey, 2007; HarneBritner et al., 2006) and non-adherence to protocols (Jones, 2009); and (iii) the impact of the broader organisational climate on individual nurses (Fogarty & McKeon, 2006; Jones, 2009). Given the extent and potentially serious consequences of errors during medication administration, numerous strategies have been developed to assist RNs to reduce the frequency and severity of medication errors. This includes double checking (Hodgkinson, Koch, Nay, & Nichols, 2006; Jensen, Merry, Webster, Weller, & Larsson, 2004); single checking (O’Connell, Crawford, Tull, & Gaskin, 2007);
ongoing education in the calculation of medication doses (Fry & Dacey, 2007; Harne-Britner et al., 2006; Jones, 2009), including the use of personal digital assistants (Greenfield, 2007); and strategies to avoid interruptions during medication administration rounds (Evans, 2009; Jones, 2009). RNs have generally been the focus of these strategies, because they have legal responsibility at the point of administration (Reid-Searl et al., 2008; Reid-Searl, Moxham, Walker, & Happell, 2010b). Every year in Australia, however, thousands of nursing students undertake clinical experience in health care settings during which they may be given the responsibility of administering medications. When student nurses perform this complex skill they should be under the personal supervision of the registered nurse. (Queensland Government, 1996). Qualitative evidence, however, suggests that the level of supervision provided can be quite variable (Reid-Searl et al., 2008). Given that one third of students report making medication administration errors or experience near misses (Reid-Searl, Moxham, & Happell, 2010), this area of student supervision needs closer examination. Despite the numbers of nursing students in the health care system there is surprisingly little research focusing on the contribution they make to medication errors. Most research with student nurses had focused on the calculation of drug dosages (C ¸ inar et al., 2006; Craig & Seller, 1995; Evans, 2009; Grandell-Niemi, Hupli, Puukka, & LeinoKilpi, 2006; Harne-Britner et al., 2006) and the integration of pharmacological knowledge into clinical practice (Honey & Lim, 2008). Although there is a stated legal requirement for students to be supervised when administering restricted medications (e.g., Queensland Government, 1996), there is a paucity of research addressing the quality of supervision provided. In a recent review of the literature on reducing medication errors (Evans, 2009), for example, the supervision of nursing students was not mentioned. One way in which a deeper understanding of student nurse medication administration experience can be gained is through investigation of the supervision they receive during this process. The aim of this study was to investigate student nurses’ experiences of supervision while administering medications.
Methods Setting and participants This research was conducted in a university in Queensland Australia. The potential participants targeted for this research were the 85 undergraduate nursing students who were in their third year of a three-year Bachelor of Nursing program.
The supervision of medication administration
111
Table 1 Types of placements reported as having been undertaken by third year nursing students. Placement type
Frequency (n)
% of total sample
Medical Surgical Paediatric Aged care Preoperative Emergency Mental health Community Other
28 34 8 15 10 10 13 13 21
62 76 18 33 22 22 29 29 47
Note: N = 45.
The participants were 45 students (response rate = 53%), most of whom were female (98%, n = 44). The ages of respondents ranged from 19 to 61, with the mean age being 28.80 (SD = 10.89) years. At the time of data collection, all participants had undertaken at least five clinical placements in a range of settings. The administration of medication was a specified learning outcome in four of these placements, giving students sufficient experience to inform the research study (see Table 1).
Questionnaire A 10-item questionnaire was developed to explore student experiences of supervision during medication administration. The content of the questionnaire was based on literature pertaining to students’ experiences of medication administration and discussions with registered nurses. Drafts of the questionnaire were shown to registered nurses and nursing academics to obtain their perspectives on the appropriateness and thoroughness of the questionnaire. Participants responded to each item on a 5-point Likert scale, anchored with strongly disagree and strongly agree. The questionnaire also had items on gender, age, and types of placements undertaken.
Procedures Following ethical approval, the principal researcher (first author) emailed third year nursing students with a brief overview of the study and asked them to reply if they would like further information. The students who made contact were provided with additional information and a copy of the plain language statement and questionnaire was sent to them by email. They were asked to complete the survey and return it in a reply paid envelope to the researcher if they were willing to participate. No identifying details were included to protect their identity. The data from completed questionnaires were entered into an electronic database and used for the analyses.
Data analysis For each of the supervision items in the questionnaire, the frequencies of responses and a measure of central tendency (median) were calculated.
Results Most students (88%) indicated that they were directly supervised during medication administration procedures (see Table 2). Although over half of the students (58%) agreed, to varying extents, with the premise that the RN followed the six rights of administration when the students were administering medication, 29% of students disagreed with the statement. Two-thirds of students (66%) agreed, to varying extents, that the busyness of the ward adversely affected supervision levels. Most students (89%) reported that they insisted on receiving supervision at times when it was not initially provided. Most students agreed, to varying extents, that the enthusiasm of the RNs (82%) and the understanding of RNs about what students are allowed to do (78%) influenced the levels of supervision provided. There was wide variation in responses to the question as to whether students perceived that they were under pressure to do what RNs asked, even if that meant administering without supervision; 36% agreed that they were under pressure, and 31% disagreed that they felt under pressure. About one-third (35%) of students perceived that their grades would have been affected if they did not do what the RNs asked of them. Half of the students (51%) reported agreeing, to some extent, that the longer they spent in a given clinical area, the less direct supervision they received. The students tended to disagree slightly with the premise that if the RNs trusted them they were more likely to administer medications without direct RN supervision.
Discussion Although few participants disagreed (or held neutral positions) that they were directly supervised during the entirety of medication administrations, the fact that some participants did disagree with the statement may have large implications. The finding suggests that Queensland law is not being consistently upheld with regard to the supervision of nursing students who are administering medications. This finding is consistent with previous research that suggests that the levels of supervision students receive can be highly variable (Reid-Searl, Moxham, Walker, & Happell, 2010a). Given the potentially serious consequences of the unsupervised practice of student nurses (e.g., medication administration errors leading to exacerbation of illness or death), Educational institutions (such as University nursing programs) health care organisations and the educators of neophyte nurses need to pay urgent attention to the supervision of nursing students occurring in clinical settings. The findings of the present study highlight circumstances in which student nurses may not have received adequate supervision. Similar to previous work in this area (Reid-Searl et al., 2010b), these circumstances include when wards were busy, when student nurses felt under pressure to
112 Table 2
K. Reid-Searl et al. Frequency and percentage of student nurse agreement or disagreement with each statement.
Question
SD
D
N
A
SA
Median
1. I am directly supervised by an RN during medication administration, for the entire administration procedure. 2. The RN follows the ‘six rights’ of medication administration when I am administering medications with them. 3. When the ward is busy I am likely to receive a lower level of supervision by the RN during medication administration. 4. I will insist on receiving direct supervision when administering medication if this is not initially provided by the RN. 5. I feel that the enthusiasm the RN has for my clinical experience influences the level of supervision he or she gives to me during medication administration. 6. I feel the RN’s understanding of what I am permitted to do in administering medication influences the amount of supervision they give me during medication administration. 7. I feel pressure to do what the RN asks of me even if it means administering medication without direct supervision. 8. I feel that if I do not do what the RN asks when administering medication my academic grades will be affected by their evaluation. 9. I feel that the longer time I have in a clinical area, the less direct supervision for medication administration I am given. 10. If the RN trusts me I am more likely to administer medication without the RN directly supervising me.
0 (0%)
3 (7%)
2 (4%)
29 (64%)
11 (24%)
A
1 (2%)
12 (27%)
6 (13%)
21 (47%)
5 (11%)
A
2 (4%)
7 (16%)
6 (13%)
20 (44%)
10 (22%)
A
0 (0%)
0 (0%)
5 (11%)
13 (29%)
27 (60%)
SA
0 (0%)
3 (7%)
5 (11%)
15 (33%)
22 (49%)
A
1 (2%)
3 (7%)
6 (13%)
13 (29%)
22 (49%)
A
7(16%)
14 (31%)
6 (13%)
16 (36%)
2 (4%)
N
7(16%)
18 (40%)
4 (9%)
10 (22%)
6 (13%)
N
2 (4%)
9 (20%)
11 (24%)
19 (42%)
4 (9%)
A
6(13%)
13 (29%)
9 (20%)
11 (24%)
6 (13%)
N
Note: N = 45. SD, strongly disagree; D, disagree; N, neither agree nor disagree; A, agree; SA, strongly agree.
comply with the wishes of RNs, when students had been in clinical settings for extended periods of time, and when the RNs trusted the student nurses. Although not all students reported receiving suboptimal levels of supervision, any deviation from direct supervision is legally and clinically significant. Any time that student nurses administer medications without direct supervision represents a breach of the laws under which they practice and an occasion during which they could potentially harm patients. The present study’s findings also raise questions about whether all RNs are adequate role models for student nurses with regards to medication administration. Almost one third (29%) of students disagreed with the statement that RNs follow the six rights when they are administering medications with students, and a further 13% gave neutral responses. Such poor modelling of safe medication administration practices may have contributed to the errors and near misses that students have reported during their undergraduate preparation (Reid-Searl, Moxham, & Happell, 2010), and is likely to contribute to the maintenance of error
rates that have been found in Australian healthcare settings (Runciman et al., 2003). Education providers and healthcare organisations have moral and legal obligations to provide adequate support to students during their clinical placements. Although students are generally well aware of the likelihood of medication errors and their potential implications for patient safety (Reid-Searl, Moxham, & Happell, 2010; Reid-Searl et al., 2008), they also place high value on the need to gain acceptance from the RNs with whom they work. Clinical placements can be highly stressful situations for students (Bond, 2009; Hegge & Larson, 2008; Jimenez, Navia-Osorio, & Diaz, 2010; Shipton, 2002), and the relationships between students and RNs are pivotal in reducing anxiety and promoting positive and constructive learning environments (Myrick, Yonge, & Billay, 2010; Tanda & Denham, 2009; Vallant & Neville, 2006; Waldock, 2010). Given the power differential in the relationships between students and RNs, students cannot be expected to continually seek direct supervision when faced with various forms of opposition to providing
The supervision of medication administration such supervision. Although most students (89%) reported that they insisted on supervision, 40% also reported feeling under pressure to do what RNs instruct them to do, including medication administration without direct supervision, 35% stated that they believed their grades would be affected if they did not do as RNs ask, and 51% agreed that the longer they spent in clinical settings, the less direct supervision they received. With the power dynamics that exist between student and RN, the onus is clearly on educators, healthcare organisations, and RNs to provide adequate support to students. This study was conducted with a relatively small group of nursing students from the one university in Australia. Therefore, the findings of this study cannot be widely generalised. Given the gravity of the findings, however, further investigation into the adequacy of student supervision would seem to be urgently required. Administering medication is a high risk procedure in that, if errors are made, serious injury or death can result (Evans, 2009; Evans et al., 2006; Fry & Dacey, 2007; Hodgkinson et al., 2006). As registered nurses of the future, nursing students need to learn to administer medication safely and responsibly (Evans, 2009; Reid-Searl, Moxham, & Happell, 2010). The findings of this study, however, reveal that students may not be receiving adequate supervision when administering medications. Educators, healthcare organisations, and RNs need to review their policies and practices to ensure students receive adequate supervision during the administration of medication.
Acknowledgements The authors extend their thanks to the registered nurses and students who completed the questionnaires, and to the many people who assisted with the questionnaire development.
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