Clinical inference by nursing students and experienced nurses concerning harmful outcomes occurring after medication errors: A comparative study

Clinical Inference by Nursing Students and Experienced Nurses Concerning Harmful Outcomes Occurring After Medication Errors:A Comparative Study PHD, RN, FAAN,*MARGUERITE S. AMBROSE, MSN, RN, CCRN,t AND HEYWARD MICHAEL DREHER,MN, RN$

ZANE ROBINSON WOLF,

Clinical inference is part of the clinical decisionmaking process and precedes judgment and action. It is an integrated response to patient cues and other evidence and a necessary skill for all nurses. The purpose of thisstudy was to compare undergraduate and graduate nursing students' use of clinical inference in rating harmful outcomes for patients occur= ring after medication errors. The Medication Error Outcome Scale, a simulation methodology using medication error vignettes, was used to compare undergraduate and graduate students' use of clinical inference. Kruskal-Wallis analysis of variance showed that there was a statistically significant difference (P = .04) among freshman, junior, senior, baccalaureate, and Master's students' use of clinical inference in regard to perceived harm occurring after a medication errors. Posthoc Mann-Whitney U tests indicated that senior and baccalaureate students' use of clinical inference differed significantly (P = .005). This study suggests that clinical experience shapes clinical inference. (Index words: Clinical inference; Harmful outcomes; Medication error) J Prof Nurs 12:322-329, 1996. Copy-

right© 1996 by W.B. Saunders Company

URSING FACULTY and other health care professionals are concerned about the clinical inference, critical thinking, and decision-making skills of nursing students, practicing nurses, and other health care providers. This concern becomes evident when mistakes are made that threaten patient safety in various health care facilities, such as hospitals, skilled nursing facilities, and nursing homes. Such mistakes include medication errors. Medication errors are mis-

N

*Professor, School of Nursing, La Salle University, Philadelphia, PA. tAssistant Professor, School of Nursing, La Salle University, Philadelphia,PA. SAssistant Professor, School of Nursing, La Salle University, Philadelphia,PA. Address correspondenceand reprint requests to Dr Wolf: La Salle University,Schoolof Nursing, 1900W OlneyAve,Philadelphia, PA 19141. Copyright© 1996 by W.B. SaundersCompany 8755-7223/96/1205-0012503.00/0 322

takes that involve patients and are associated with drugs and intravenous solutions. They are made during the prescription, transcription, dispensing, and administration phases of drug preparation and distribution (Wolf, 1989). Along with pharmacists, physicians, risk managers, and health agency administrators, nurses have been concerned about the mistakes that involve medication administration. Strategies to eliminate or reduce the incidence of medication errors among practicing nurses have received attention for many years (Bindler & Bayne, 1991; Boggs, Brown-Molnar, & DeLapp, 1988; Keill & Johnson, 1993; Lohman, 1933; Long, 1982; Poster & Pelletier, 1988; Rasic, Boedicker, & Lyon, 1989; Schwartz & Lowe, 1989; Sherman & Clinefelter, 1989; Wolf, 1994). Faculty who teach undergraduate nursing students also have been engaged in efforts to prepare students to administer medications safely and eliminate medication errors (Berger & Williams, 1992; Blais & Bath, 1992). In spite of efforts to improve systems of medication administration and cognitive and psychomotor skills of nurses, students and practitioners still make mistakes. At times the consequences of drug-related incidents are extremely serious. It is imperative that nurses act quickly after a medication error is discovered to assess the patient involved in the incident and reinstitute safety precautions that protect the patient from further harm. Nurses must be able to infer the extent to which the mistake may result in actual or potential harm based on the data at hand. However, few estimates of harm are available nationwide, and those that exist are not used by nurses to interpret the severity of a medication error. Clinical inference needs to be developed by nursing students and refined in practice settings after graduation. However, there are few studies that address the cognitive process of clinical inference as well as its relation to medication errors. Therefore, the purpose of this study was to compare nursing students' clinical

Journal of ProfessionalNursing, Vol 12, No

5 (September-October), 1996: pp 322-329

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CLINICAL INFERENCE OF NURSING STUDENTS

inference regarding perceived harmful outcomes for patients occurring after medication errors using the Medication Error Outcomes Scale (MEOS). In this study, clinical inference is viewed as an intellectual skill and an interrelated part of an analytic process in which determinations are made based on observed data. Clinical inference involves recognizing cues about "an event on the basis of more or less insufficient data" (Hammond, 1966, p. 27). Inference relies on interpretation of subjective or objective data (Carpenito, 1983). Tanner (1989) described clinical decision-making as the rational, analytical process of clinical judgment. Decision-making involves a sequential process much like the nursing process and includes collecting and analyzing data, formulating alternative approaches, and selecting the most appropriate course to follow. Tanner (1983) saw clinical inference as part of clinical judgment. Earlier, Carrieri and Sitzman (1979) positioned inference before the validation, assessment, intervention, and evaluation phases and after the observation phase of the nursing process. Clinical inference in this study is distinguished from clinical judgment and precedes decision making and action.

Clinical inference in this study is distinguished from clinical judgment and precedes decision making and action.

Clinical inference regarding a medication error was measured with the MEOS. The MEOS includes 10 vignettes generated from actual medication errors made by nurses. The vignettes provide nursing students and experienced nurses with a cognitive task in the form of information about specific medication errors. Each vignette cues the nurse with data, such as a specific medication and route of administration, and elicits an inference regarding the degree of harm resulting from the drug error. Perceived harmful outcome is the estimated degree of severity and patient response to a medication error (Wolf, McGoldrick, Flynn, & Warwick, 1995). It is important to compare the differences in clinical inference among groups of nursing students. Likewise, it is useful to apply clinical inference to determinants of harm occurring after a medication error. It is hoped that inference would help nursing students identify and implement corrective measures. Such corrective

measures could serve to minimize patient harm. The investigators considered that dinical and educational experience shape dinical inference. They postulated that differences in harm ratings would reflect progressive skill in clinical inference as influenced by education and experience.

Review of the Literature

Nurses have been concerned about medication errors for many years. However, few studies address errors made by nursing students. None were located that described clinical inference of nursing students regarding medication errors. Blue (1989) recognized the complexity of medication administration for nursing students. She acknowledged the need to individualize the administration and monitoring of drug therapy by requiring that nursing students create a drug-related nursing care plan. Students were directed to relate assessment data gathered while caring for assigned patients to pharmacology and related drug information. Students reported paying increased attention to drugs and side effects and were able to identify adverse reactions within specific drug categories. By measuring students' learning style using the Test of Cognitive Style in Mathematics, Bath and Blais (1993) related cognitive style to students' ability to calculate drug dosage. The investigators encouraged instructors to help students increase their ability to calculate drug dosages by integrating instructional methods that reinforce students' preferred style. Using a sequential step-by-step paper-and-pencil drug dosage test and a global, all-at-once mental processing approach, instructors would be able to help students develop backup skills and flexibility in drug dosage calculation. In contrast, Segatore, Edge, and Miller (1993) examined whether preclinical, baccalaureate nursing students could calculate drug dosage correctly at a level of 85 per cent or greater and what the nature and magnitude were of the errors committed. Students made conceptual errors or errors of form or set-up; these were made more frequently than mathematical errors. Calculators were used during testing. Students admitted that they did not appreciate the potential consequences of the errors made. It is apparent from the previous citations that nurse educators are interested in preparing nursing students to be knowledgeable in medication administration, specifically dose calculation. Faculty witness that

324

students not only are challenged by drug and solution calculations and conversion charts but also are daunted by the vast amount of information needed to correctly and safely administer the many pharmacotherapeutic agents available. Fundamentals of nursing textbooks provide nursing students with many details about medication administration, but they contain little material about medication errors (Kozier, Erb, & Olivieri, 1991). Pharmacology courses and clinical assignments help students to expand their knowledge base regarding medications; however, it is not known the extent to which content regarding the risks associated with medications errors is integrated into nursing curricula. Reports in the literature of medication errors made by nursing students tended to be anecdotal accounts shared by faculty. One anecdotal account of a medication error made by a student was reported by a seasoned nurse many years later. Her embarrassment and fear were evident in her account (Wolf, 1994). It is likely that nursing students lack clinical decision-making and clinical inference skills because they have limited clinical experience. This assumption can be related to medication administration and errors. Furthermore, it is assumed that faculty are interested in helping students develop inference and decision-making abilities during clinical experiences. For the purposes of this investigation, clinical inference is positioned in the context of clinical decision-making. Clinical decision-making is a focus of nursing education and practice. It is a clinical process by which nurses gather patient data, evaluate information, and make judgments that result in patient care (White, NatMo, Kobert, & Engberg, 1992). The process of decision-making is difficult to observe because of the internal processes, such as inference, that take place at the time decisions are made. Benner (1983), a proponent of the phenomenological view of decision-making, suggested that a novice nurse operates from a foundation that includes a context-flee situation at the beginning. Novices, for example, nursing students, have difficulty making decisions that involve unfamiliar situations; they depend on theoretical rules to guide action. On the other hand, expert nurses have extensive experience and base decisions on facts that encompass the whole situation. They use past clinical situations as a framework. Tanner (1983) defined clinical judgment for nursing. According to Tanner, clinical judgment is "1) decisions regarding what to observe in the patient situation; 2) inferential decisions deriving meaning

WOLF, AMBROSE, AND DREHER

from data observed (diagnosis); and 3) decisions regarding actions which should be taken that will be of optimal benefit to the patient (management)" (p. 4). However, Le Breck (1989) contended that this was not a complete account of how judgment is determined. She believed that a complete theory of nursing clinical judgment must encompass hypothesis formulation and evaluation. Timely decision-making and the selection and performance of therapeutic actions also are involved. Tanner and Lindeman (1989) described decisionmaking as a rational, analytical process of clinical judgment. Decision-making involves a sequential process, including collecting and analyzing data, formulating alternative approaches, and selecting the most appropriate course to follow from these approaches. Jenks (1993) connected decision-making to action and patient outcomes. She acknowledged that novice nurses do not have the advantage of experiential knowledge. According to Jenks, experience shapes clinical decision-making. Nurses develop the ability to distinguish actions and gradually assume a greater sense of responsibility for patient outcomes. It is possible that clinical inference in enhanced by experience. Gordon (1972, 1980, 1982, 1987) viewed clinical judgment as diagnostic judgment. Diagnostic judgments are based on reliable and valid cues that nurses observe. Gordon (1980) related clinical inference to the diagnostic process. The task of diagnosis requires inferential reasoning. A nurse recognizes a set of cues, infers the patient's health state, and infers that a health problem exists. The cues are subjective statements or objective indicators. As a nurse interprets the cues, he or she forms a corresponding inference (Carpenito, 1983). Carpenito emphasized the subjective nature of clinical inference and warned against reporting inferEnce as fact. Hammond, Hursch, and Todd (1964), Hammond (1966) and Hammond, Kelly, Schneider, and Vancini (1966, 1967) examined clinical inference in nursing. When nurses responded to patients, they were confronted by "conditions, situations or events which call for cognitive activity involving a clinical inference and a decisioff' (Hammond, Kelly, Schneider, & Vancini, 1966, p. 135). Hammond defined inference as judgment and found that nurses' clinical inferences were not absolute or consistent even when certain patient data were made known. The state of the patient was inferred through the proper use of cues. The nurse weighs evidence and infers a diagnosis over other diagnoses, according to Hammond (1966). Ham-

325

CLINICAL INFERENCE OF NURSING STUDENTS

mond and colleagues' formulations have been expanded by literature on clinical decision-making. Pinkley (1991) suggested that inference involves a process of constructing relationships among units of information. She considered inference to be dependent on the interpretive abilities and the knowledge base of the nurse recognizing the information. Clinical experience may help nurses to develop clinical inference skills. In summary, there is some indication in the literature that clinical inference fits in the conceptual framework of clinical decision-making. In this study, the position is that analytic activities follow in sequence: clinical inference, clinical judgment, decisionmaking, and action.

Nurses and nursing students must infer the degree of harm based on available data so that the safety of the patient can be safeguarded.

RN-to-baccalaureate (senior year) and master's students. Freshman and junior students had not completed a pharmacology course. However, the junior students were exposed to medication administration content and simulations of medication administration in a fundamentals of nursing course. They investigated prescribed medications received by assigned patients. The MEOS is a simulation methodology that uses vignettes generated from actual medication errors to standardize data collection procedures (Flaskerud, 1979), in this case to elicit clinical inference related to medication errors. The perceptions of the nurses on the information provided in the 10 vignettes were elicited on a four-point scale of perceived harmful outcome occurring after medication errors. The MEOS was completed by a convenience sample of 157 nursing students. Demographic characteristics of subjects as identified on a profile form are listed in Table 1. Completion of the instrument implied consent. Confidentiality was guaranteed.

INSTRUMENT

Nurses and nursing students who make medication errors must make decisions after inferring the severity or degree of harm related to those mistakes. For example, as they anticipate or note patient outcomes resulting from error, they might decide to monitor the patient more dosely in case his or her vital signs should change adversely. Nurses and nursing students must infer the degree of harm based on available data so that the safety of the patient can be safeguarded. The influence of the nurse's emotional or subjective response needs to be considered in relation to subsequent decisions (Field, 1987). However, as the nurse makes decisions, the safety of the patient must always come first. Methods DESIGN, SAMPLE, AND SETTING

This comparative, descriptive study used the MEOS to explore differences in clinical inference among baccalaureate nursing students in freshman, junior, and senior years of their program, registered nurse (RN)-to-baccaulaureate students enrolled in upper division courses, and master's students enrolled at two private universities located in a metropolitan area of northeastern United States. For the purposes of this study, nursing students were defined as freshman, junior, and senior baccalaureate nursing students and

The MEOS includes 10 vignettes depicting medication errors reported by registered nurses (N = 48) (Wolf, 1993). Each vignette was generated from actual medication errors that nurses had reported and for which they had identified factors leading to the error (eg, wrong dose, wrong drug, etc). None of the vignettes specifies the sex of the nurse or the patient. Each vignette includes one each of the following medications or intravenous solutions: cefazolin sodium; aminophylline; heparin sodium; acetaminophen; ampicillin sodium; potassium chloride; halopiderol; hydromorphone hydrocholoride; isophane insulin; and total parenteral nutrition 500 mL 8.5% amino acids. Intravenous, intramuscular, subcutaneous, and oral routes of administration were represented in the vignettes. The vignettes represented an array of probable outcomes, from less harmful to more harmful, occurring after medication errors. Additional data were provided in the 10 scenarios, such as, "The patient offered no complaints when questioned by the nurse," and '~n order for ampicillin IV was not given for six doses to a postoperative patient." Subjects judged the harm after the error using a four-point scale measuring perceived harmful outcome: (0 = no harmful effect [improvement in symptoms, condition; no change in symptoms or condition]; 1 = moderately harmful effect [morbidity: symptoms, illness]; 2 = severely harmful effect [mor-

326 TABLE

WOLF, AMBROSE, AND DREHER

1. Demographic Characteristics of Respondents (N = 157)

Age (yr) Sex Female Male No response Marital status Single Married Divorced Widowed Separated No response Race African-American Asian White Hispanic Native American Indian Other No response Nursing student status Freshman Junior Senior Baccalaureate Master's Length of education after high school (yr) 1-2 3*4 5-6 ->7 No response Position Nursing student Staff/charge nurse Nurse manager/assistant nurse manager Supervisor/care coordinator Director of nursing Other No response

Mean

SD

32.47

15.5

n

%

131 24 2

83.4 15.3 1,3

79 58 15 1 1 3

50,3 36,9 9.6 0.6 0.6 1.9

12 6 130 2 1 2 4

7.6 3.8 82.8 1.3 0,6 1,3 2,5

18 36 20 42 41

11,5 22.9 12,7 26,8 26,1

24 66 54 11 2

15,3 42,0 34.4 7,0 1,3

76 48

48,4 30.6

10 9 2 11 1

6.4 5.7 1.3 7,0 0.6

bidity: severe symptoms, permanent disability]; 3 = maximally harmful effect [mortality: death]. They also used a nine-point scale (1 = emotional injury only; 2 = insignificant injury; 3 = minor temporary injury; 4 = major temporary injury; 5 = minor permanent injury; 6 = significant permanent injury; 7 = major permanent injury; 8 = quadriplegia or brain damage; 9 = death) to rank each vignette (Physician Insurers Association of America, 1993). Convergent validity was re-established when the fourpoint scale was compared with the nine-point scale in a pilot study (r = .79, -P = <.001, N = 97), a subsequent study (r = .55, P = <.001, N = 206) (Wolf, Haakenson, Jablonski, & McGoldrick, 1995), and

this study (r = 0.68, P = <.001; rho = 0.57, P = <.001; N = 157) (Alien & Yen, 1979). The MEOS had content and expert validity (Wolf, McGoldrick, 1995). Internal consistency reliability for the 10 vignettes was established with Cronbach's alpha coefficient (cx = 0.80, N = 157). The following coefficients establish the readability level of the MEOS at a standard reading level: Flesch Reading Ease = 45.7; FleschKincaid grade level = 8.3; and Bormuth grade level = 10.8. DATA COLLECTION

The investigators asked students currently enrolled in classes at the two universities to participate in the study. The purpose of the study was described. Students were told that their participation was voluntary. The instrument took 15 to 20 minutes to administer. No names of students were recorded; identification numbers were used for data organization. Results

Descriptive and inferential statistics on subject characteristics and perceived harmful outcome on the 10 vignettes were computed using SPSS-X, version 3 (SPSS, Inc, Chicago, IL). The means and standard errors on the harm scores (four-point scale) for the 10 medication error vignettes for the pilot study (staff nurses and nurse managers, N = 48), undergraduate (N = 74), and combined RN-to-baccalaureate and master's student (N = 83) groups are included in Table 2. The cefazoTABLE2. Group Means and Standard Errors for 10 Medication Error Vignettes

Cefazolinsodium Aminophylline Heparin Acetaminophen Ampicitlinsodium Potassium chleride Halopiderot Hydromorphonehydrochoride Isophane insulin Total parental nutrition 500 mL8.5% amino acids

M*

SE

Mt

SE

MS

SE

.16 .70 .81 .22 2.06 2.72 1.10 1.62 .31

.05 .12 .08 .08 .08 .07 .07 .09 ,08

.25 .86 .81 .27 2.01 2.91 1.15 1.60 .42

.05 ,52 .08 ,06 .06 .03 ,06 .07 .07

.39 £6 1.14 .39 Z02 2.58 1,23 1.48 .28

.07 ,10 .08 .06 .06 .05 .05 ,06 .06

.39 .10

.30 ,06

.31 .06

*N = 48, pilot study, including nurse managers and staff nurses, 1-N = 83, RN-to-baccalaureate and master's students. :i:N = 74, freshman, junior, and senior baccalaureate nursing students.

327

CLINICAL INFERENCE OF NURSING STUDENTS

lin sodium vignette had the lowest means, indicating the less harmful medication error, and the potassium chloride vignette the highest means, or the most harmful medication error. Standard errors suggest that there is little variability among responses to the 10 vignettes (Munro & Page, 1993). The following hypothesis was tested in this study: There is a difference in freshman, junior, senior, RN-to-baccalaureate, and graduate nursing students' use of clinical inference in rating harmful outcomes for patients occurring after medication errors. The Kruskal-Wallis test was used to compare ranks on the nursing students' clinical inference of medication error vignettes (Table 3). The groups differed significantly; thus, the research hypothesis was supported. Post hoc comparisons were made with the MannWhitney U test (Table 4). To protect against a type I error, a Bonferroni correction factor was used. For a comparison to be significant, it had to have a significance level o f P = .005. Mann-Whitney U test results showed that there was a statistically significant difference (19 = .005) in clinical inference regarding perceived harm occurring after medication errors between senior nursing students and RN-to-baccalaureate students. There was a statistically significant difference in clinical inference between senior and freshman nursing students (U = 104.5, P = .02) and junior and RN-to-baccalaureate students (U = 563.0, P = .05).

Discussion

The clinical inference of freshman, junior, senior, RN-to-baccalaureate, and master's students' regarding harmful outcomes occurring after medication errors, as depicted in the vignettes, differed significantly. However, it is striking that the clinical inference of senior baccalaureate nursing students and RN-tobaccalaureate students differed significantly on post hoc testing. One explanation for the difference is the clinical experience of the RN-to-baccalaureate group. TABLE3. Kruskal-Wallis Test of Clinical Inference Regarding Medication Error Vignettes by Nursing Student Status (N = 157) Group Freshman Junior Senior RN-to-baccalaureate student Master's student

Mean X2for Cases Rank CorrectedTies 18 36 20 42 41

69.75 83.13 98.97 64.76 84.28

9,65

P .04

TABLE4. Mann-Whitney U Post Hoc Tests of Clinical Inference Regarding Medication Errors by Nursing Student Status (N = 157) Group Junior Senior Junior RN-to-baccalaureate Junior Master's student Junior Freshman Senior RN-to-baccalaureate Senior Master's student Senior Freshman RN-to-baccalaureate Master's student RN-to-baccalaureate Freshman Master's student Freshman

Mean Rank Cases 26.17 32.70 44.86 34.90 38.57 39.38 29.03 24.44 40.75 27.10 33.75 29.66 23.27 15.31 37.56 46.55 29.70 32.36 31.70 26.14

36 20 36 42 36 41 36 18 20 42 20 41 20 18 42 41 42 18 41 18

U

Two-TailedP

271.0

.14

563.0

.05

722,5

.87

269.0

.30

235.0

.005

355.0

.39

104,5

.02

674.5

,08

344,5

,58

299.5

.25

Experiences with patients and medication administration most likely shape clinical inference. Most RN-tobaccalaureate students are active practitioners and have first-hand knowledge of medication errors. This could reflect a seasoned nurse's reaction to such a mistake. For example, if a patient manifests no symptoms after some medication errors, the nurse assumes that it may not be a "real" medication error. This finding could reflect an almost perfunctory regard of medication administration and drug errors. It is noteworthy that junior baccalaureate students and RN-to-baccalaureate students' inference also differed significantly, although not at the more stringent alpha level. It is less surprising that senior and freshman students' inference regarding harm occurring after medication errors differed significantly. As students progress through a program of studies, pharmacology and other knowledge can be expected to increase along with clinical knowledge gained through experiences caring for patients. The convergent validity of the harm scale of the MEOS was re-established, with the four and ninepoint scales positively correlated and the strength of the relationship moderate. The high reliability coefficient indicated that the subjects performed consistently across the single measure of harm. One limitation of this study is the use of a convenience sample. The external validity of this study

328

WOLE AMBROSE, AND DREHER

is limited because the vignettes presented do not include the complexities of actual clinical situations. The responses of the subjects may not be the same as their responses to medication errors committed in hospitals and other health care agencies (Lanza, 1990). Because the MEOS is a relatively new simulation instrument, additional development of the instrument is warranted. The confounding effect of taking a pharmacology course was not considered because students acquired some knowledge of medication administration and drugs as junior students before taking a pharmacology course in the second semester

of the junior year. However, the investigators recognized that senior nursing students, RN-to-baccalaureate students, and graduate nursing students had greater exposure to pharmacology content through course work and clinical experience compared with freshman and junior students. Future research is needed using the ten vignettes used in this study. An investigation could describe the longitudinal development of clinical inference regarding harm occurring after medication errors in a cohort of students enrolled in a baccalaureate nursing education program.

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