INTRODUCTION

Medication errors are one of the leading causes of prevenTable injuries and damage to health care systems¹. In fact, the worldwide cost associated with medication errors is estimated at $42 billion annually². The administration of medications is a task performed by nurses³. Medication administration errors are sometimes difficult to prevent before reaching patients, thereby potentially triggering adverse implications in terms of patient morbidity and mortality^4,5. Hence, some initiatives to educate future nurses about safety have been trialed. Some support changing the design of the job or the use of information technologies aimed at reducing errors, such as barcodes or smart bombs^6,7. Other strategies try to improve the knowledge, skills, and attitudes of health professionals in relation to the medication administration process^8,9.

The administration of medications is undoubtedly an area of nursing practice in which safety skills must be employed. In this regard, several initiatives have been put in place at the international level regarding the skills that nursing students must acquire during their studies. These education plans generally focus on patient safety, quality of care, teamwork, communication, and evidence-based information and practice⁹. However, regardless of the possible reforms or changes made to different nursing curricula at the international level, we consider the opinion of the students to be especially important once they have acquired their basic theoretical and practical skills.

Thus, it would be advisable to study new measures or barriers to help avoid adverse events, implement standardized reporting systems and new information technologies (e.g., for dose calculation or infusion pumps, etc.), and even address aspects of communication and therapeutic or psychological relationships. Therefore, the objective of this current review was to identify the perceptions of nursing students regarding the safe administration of medications to see how this can be applied to the invention of new measures or tweaking of existing ones to help avoid medical errors.

METHODS

RESULTS

Google Scholar

Using the same search terms and search limiters, 17,300 articles were found through Google Scholar. Of these, a total of 100 articles were listed, selected, and reviewed for inclusion, in order of relevance. Articles listed after the first 100 hits were not consistently relevant to this present study. Reasons for exclusion included, but were not limited to, the use of samples of nurse practitioners, non-students, other health professionals, and articles on medication errors by students with no report of curricular interventions.

Hence, a final sample of 12 original research articles was finally included in this current review.Figure 1shows the PRISMA diagram for this entire article selection process.

Figure 1.  PRISMA diagram 

Item features

The 12 studies that met the inclusion criteria were reviewed in full. Most of the studies we analyzed had been conducted in the United States. The publication dates of the included studies ranged from 2017 to 2021 and the sample cohorts examined in the articles ranged from 20 to 4,284 nursing students. The characteristics of each article are summarized below inTable 1.

Table 1.  Characteristics of the articles included in this review 

Abbreviations: BNRT, Bachelor of Nursing, Regular Track; BSN, Bachelor of Science in Nursing; ADN, Associate Degree in Nursing.

Evidence summary

After analyzing the content of the 12 articles we included, two relevant themes were identified that incorporated the perceptions of nursing students regarding the safe administration of medications. These topics represented factors associated with drug safety concepts in nursing education: clinical settings (clinical systems or processes) and academic settings (academic training).Table 2shows the results related to these two themes from each included study.

Table 2.  Results and evidence from the publications included in this review related to the issues under study 

Table 2 (cont.).  Results and evidence from the publications included in this review related to the issues under study 

DISCUSSION

It is important to consider how nursing students perceive the safe administration of medications, as well as to use a global curriculum that promotes safety in medication administration practices across all its courses. In addition, the curriculum must ensure that students acquire the skills required to allow them to implement the safe administration of medications from the time they are studying at the academy (theory/simulated environments) to their clinical practice (real environment). The studies included in this review, which were related to factors associated with systems or processes in clinical settings, invite us to explore the experiences and opinions of nursing students regarding the errors found in medical practice and their underlying causes.

During most of their working day, nurses prepare and administer medications²⁴as part of what could be considered one of their most important healthcare roles. Therefore, medication errors are also the most frequent type of error made by nurses²⁴, making the culture of error an important part of undergraduate training. This helps ensure that future health professionals are trained and educated on this subject in order to promote the safety and quality of patient health. However, recent research²⁵has shown that nursing students enrolled in clinical rotations have not been optimally prepared to fulfill their roles in terms of medication safety. This gap was highlighted by the existence of errors related to a lack of adequate knowledge, skills, supervision, and role models during clinical rotations, which led to medication errors by nursing students¹³.

Other factors related to medication errors in the clinical setting can be attributed to inadequate computational skills among students, leading to inaccurate dose calculation, incorrect medication preparation, or the wrong conversion of measurement units¹⁴. In addition, environmental factors such as the presence of noises and distractions, make it harder for students to concentrate and carefully review instructions¹⁴. At some point in their clinical practice, almost all nursing students experience situations in which adverse events compromise patient or student safety. Some reviews²⁶even state that 28-30% of students make medication errors during their clinical practice. Therefore, attention to medication management and the characteristics of adverse event reporting must be prioritized in accordance with the different nursing academic courses or rotations in different clinical practice settings¹⁵.

Regarding factors related to the academic environment, the students perceived training with simulations and scenarios to promote the safe administration of medications as positive experiences. Among the reviews we included in this present work, it is worth highlighting four quasi-experimental studies that used simulation as the study instrument^{16 17 18 19}. They all suggested that nursing educators should consider simulation as a teaching strategy to engage students in the implementation of medication safety practices in clinical settings. Simulation scenarios can be designed to allow students to practice their technical skills while also experiencing clinical reasoning, critical thinking, and decision making in practice^22,27.

Questionnaires were another instrument often used in the studies included in this review^{19 21 28}. Although distinct types of surveys and outcome measures were used, their results all suggest that it would be beneficial to reassess how safety and quality of care is provided in nursing schools, placing emphasis on understanding the varying learning styles of students and teaching strategies of instructors. Other highlights include the fact that learning environments in which students feel supported and feedback from teachers is focused on patient safety²¹, adequate knowledge of pharmacology²⁸, and the teaching of evaluation, critical thinking, and safe administration of medications¹⁹all seem to reduce the risk of error.

The use of information and communication technologies in nursing education via smartphones could also help educators to improve motivation and learning outcomes while also helping nurses to improve their knowledge and skills²⁹. Among the reviews we surveyed, the academic study by Pourteimou et al.²⁰indicated that learning through smartphones by using the Telegram messaging application helped improve the knowledge of student nurses about the prevention of medication errors. Telegram is an immensely popular and free social network application in Iran and so nursing students use this application to read and discuss educational content provided by researchers, helping them to reduce the occurrence of medication errors and improve how they prepare and administer medications.

Johnson et al.⁸used focus groups to explore the perception of nursing students about learning the mathematical calculations required to safely administer medications. Thus, the potential for medication errors became a way for instructors to motivate students to take mathematics more seriously. Therefore, it seems that to successfully transition to mastery of dose calculations, the mathematics taught must be contextual so that the concept itself has meaning to the students. To promote this idea, other studies³⁰propose eliminating student resentment towards the notion of complicated mathematics which they perceive as unnecessary.

Different interventions and outcome measures were used in the 12 studies we reviewed and so it is difficult to reach a conclusion about which intervention was more effective in improving the safe administration of medications in nursing students. Thus, future researchers studying this topic should consider conducting multi-site studies using the same measurement tools to determine the relative effectiveness of their interventions in relation to specific outcomes.

The studies included in this work lacked information regarding the psychometric properties of the measures used. Most of the instruments used had been developed by the same authors or were extracted from secondary databases or reporting systems. For example, Walsh et al. (2018) developed a new questionnaire for their work which mainly used quantitative measures. Furthermore, only 6 studies^{13 16 18 19 20 28}provided information on the reliability or validity of the metrics they had used. For example, Musharyanti et al.¹³conducted interviews with 5 professors and 4 clinical instructors as part of the triangulation method they employed to compare and confirm the validity of the study findings.

Thelen et al.¹⁸used measures of self-efficacy from theMotivated Strategies for Learning Self-Efficacy Questionnairesubscale³¹and measures of student perceptions from theSurvey for the Acquisition and Application of Knowledge³². They showed accepTable levels of reliability and validity using these instruments, with a Cronbach alpha of 0.85 among the population of accelerated nursing students³². In turn, Abraham et al.¹⁹used a validated and reliable 18-item instrument³³to assess the level of participant satisfaction with the simulation they used. This tool consisted of a 5-point Likert scale and the definitive version was adapted and approved by a committee of experts. The Cronbach alpha for the total score and for the 3 subscales ranged from 0.73 to 0.88 for the individual sample and from 0.80 to 0.90 for the group sample.

Craig et al.¹⁶based their work on methods developed by Mariani et al.³⁴and designed and implemented high-fidelity medication administration simulations enhanced by information technology which were integrated into their undergraduate nursing curriculum. Finally, Pourteimou et al.²⁰used a survey that included 50 items on a binary scale (observed = 0 and not observed = 1) and 5 nursing professors and 2 pharmacists confirmed the apparent validity of the checklist. The content validity ratio was 0.80 and they measured the correlation coefficient (r= 0.89) to verify the interrater reliability of the checklist after 10 nursing students completed it.

In conclusion, it will be important to continue analyzing the global perceptions of students regarding the safe administration of medications given that medication errors are the result of many factors, including human error as well as some characteristics related to the healthcare and academic systems. These include the availability of resources, the working/learning environment, care overload, presence of distractions, anxiety, and lack of adequate knowledge, skills, and supervision^{9 35 36}.

CONCLUSIONS

This review provides information about the perceptions of nursing students regarding the safe administration of medications. In the 12 original research studies we reviewed, we analyzed the reported experience of nursing students while building their skills and knowledge in different settings (academic and clinical). Between these studies, different outcomes were measured for similar interventions, which limited our ability to reach a consensus on the effectiveness of each intervention type. Furthermore, we found that discussion of the psychometric properties of the instruments were limited and that reliable and valid instruments to measure the outcome variables had not been employed. Thus, there is a clear need to develop psychometrically sound tools in future research.

The literature suggests that the perception and training of nursing students in safety practices can generate changes in the way medications are administered and can reduce the rate of adverse events in the future. Training and practice in different environments (academic and clinical) could favor the progressive and repetitive application of different tasks until a certain level of skill is achieved, also helping students to reflect upon and avoid mistakes in the administration of medicines.