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Enfermería Global

versão On-line ISSN 1695-6141

Enferm. glob. vol.21 no.67 Murcia Jul. 2022  Epub 19-Set-2022

https://dx.doi.org/10.6018/eglobal.505691 

Reviews

The perceptions of nursing students regarding the safe administration of medications

Francisco Miguel Escandell-Rico1 

Nursing department. University of Alicante. Alicante, Spain

ABSTRACT:

Objective:

The purpose of this review was to identify the perceptions of nursing students about the safe administration of medications.

Method:

Original empirical research that describes a method to incorporate concepts of safety in the administration of medicines in nursing education and examine the perceptions of nursing students for review. A search of four electronic databases (Scopus, Cumulative Index to Nursing and Allied Health Literature, MedLine / PubMed and Google Scholar), as well as a manual search to identify original research published between 2017 and 2021. Analysis guidelines were adopted (PRISMA) as the preferred reporting element for systematic reviews and meta-analyzes.

Results:

Twelve original research articles were included for review. Two methods were identified for incorporating safety in the administration of medications in nursing education: process factors or systems in the clinical setting and educational factors in the academic setting. The use of interventions varied, but all focused on analyzing students' experiences to promote skills and knowledge in different settings (academic and clinical).

Conclusion:

Nursing educators must promote theory and clinical experiences in a comprehensive way so that the student learns and internalizes the attitudes, behaviors and values of the profession with a focus of responsibility in all aspects. The perception and training of students could lead to changes in the way drugs are administered, as well as decrease the rate of adverse events in the future.

Keywords: Medication Administration; Patient Safety; Nursing Education; Medication Safety

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 mortality4,5. 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 bombs6,7. Other strategies try to improve the knowledge, skills, and attitudes of health professionals in relation to the medication administration process8,9.

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

Search procedure

To implement the review process, we followed the proposals for improving the publication of systematic reviews and meta-analyses10and the preferred reporting items for systematic reviews PRISMA-ScR extension for scoping reviews (see the supplementary file for a checklist and explanation)11. The following academic databases were consulted to identify articles for inclusion: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, Medline/PubMed, and the Cochrane library. The search terms “nurs*” “educ*”, “students”, “safety”, “medication”, and “medication error*” were used.

Inclusion and exclusion criteria

Articles describing and evaluating the perceptions of nursing students regarding the safe administration of medications were considered to be of interest. Thus, articles that met the following criteria were included: available in English, published in peer-reviewed academic journals, and printed between 2017 and 2021. This search window was used so as to follow best literature review practices11and to use at least a 5-year search frame that would capture relevant and timely publications. Articles describing the perceptions of safe medication administration among health professionals other than nursing students or during graduate programs were excluded.

Data extraction and analysis

Following selection of the articles for inclusion in the review, data was extracted from each one and was organized into a matrix. The extracted data included the year of publication, journal, country of origin, sample size, description of the safety activity, perception or intervention, and results. The accuracy of the data extracted from each article was confirmed and we performed content analysis to identify themes from among the extracted data12that would incorporate the perceptions of the nursing students regarding the safe administration of medications.

RESULTS

Scopus, CINAHL, and Medline/PubMed

A total of 74 articles were found by searching the leading medical databases and selected journals. Four articles were duplicated, leaving 70 articles for review for potential inclusion according to their titles and abstracts, which led to the exclusion of 50 more manuscripts. Of the remaining 20 sources, 7 articles were excluded after reviewing their full texts.

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 

Clinical setting: clinical systems or processes

Three studies13 14 15used questionnaires and interviews about factors associated with systems or processes in clinical settings designed to help students express their perceptions related to the safe administration of medications. Musharyanti et al.13recruited 26 undergraduate nursing students to participate in an interview designed to explore their perceptions and experiences of times when medication errors had been made. The student coordinator divided the participants into 4 groups of 6-7 students each. The results indicated that the students were aware of the importance of nurses in patient and medication safety.

Other researchers analyzed adverse events and factors associated with errors that had been reported by students during their clinical nursing rotations14. A total of 68 adverse events committed by a total of 53 students over a 6-year period were reported. Among the factors that contributed to the occurrence of errors, the most common cause was failure to review the ‘10 rights of medication administration' (85.3%).

Another group analyzed the characteristics of the reporting of adverse events by nursing students during their clinical practice in different care settings15. The study population comprised 4,284 students enrolled in the nursing undergraduate degree at the University of Malaga (Spain) over 7 consecutive years. There were significant differences in medication administration errors between the course years, with second-year students reporting higher levels of clinical adverse events than third and fourth-year students (n= 23; 10.8%;n= 12, 5.7%; andn= 177, 83.5%, respectively; χ2= 88.8,p< 0.01).

Academic environment: academic training

Nine studies reported upon factors associated with nursing student academic training for the safe administration of medications. Four of the 9 studies used simulations to examine the influence of simulation-based learning on the process of safe medication administration. Firstly, Craig et al.16examined the effect of an educational strategy that incorporated enhanced medication safety simulations on the levels of knowledge, skills, and confidence in nursing students learning the medication administration process. Eighty-three third-year nursing students participated and were randomly assigned to an intervention group (n= 45) or a control group (n= 35). There were higher levels of confidence in the intervention group than in the control group.

Kuo et al.17also examined the effects of simulation and problem-based training scenarios on nursing students in terms of the number of medication errors. Students in the experimental (n= 66) and control (n= 27) groups were evaluated for their performance in identifying medication errors. Students in the experimental group received 2 hours of medication administration simulation training in addition to the pre- and post-test problem-based scenarios, while the control group students received only the pre- and post-tests. The performance of the students in the experimental group improved regarding talking about incorrect medications (their talking rate increased from 28.2% to 98.5%,p< 0.01).

Also using simulations, Thelen et al.18analyzed the effects on students of an online synchronous active nursing pharmacology learning classroom design with simulated clinical immersion experiences. The researchers set up a simulation environment to present a hospital room with a large bedside monitor that actually displayed the patient physiology. To provide synchronous learning, the lectures were delivered through Microsoft®Teams using a webcam and laptop. Results from simulated clinical immersions showed improvement in self-efficacy scores.

Abraham et al.19also examined the influence of simulation-based learning of the medication administration process on the satisfaction, self-perceived readiness, and clinical performance of students practicing in the simulated environment, either individually or as a group. Third-year nursing students participated in two consecutive academic courses (78 in the individual sample and 50 in the group sample). The simulation experience increased participant readiness when designed both for individual students and groups of students. Simulation performance was the main contributor to participant preparation among the individual sample (β= 0.51,p< 0.01), while prior preparation was the main contributor among the group sample (β= 0.42,p< 0.01).

In contrast, Pourteimou et al.20determined the effect of a smartphone messaging application on learning about medication error prevention among nursing students. They conducted a quasi-experimental study with 80 nursing students who were randomly divided into intervention and control groups and collected data using a checklist developed by researchers. The learning was conducted for 3 weeks via the Telegram messaging application. The error frequency was higher in the control groups, suggesting that e-learning with the Telegram messaging application had a significant effect on the performance of students in the intervention groups.

Walsh et al.21determined which factors increase the likelihood of nursing students reporting medication errors. This quantitative study used a non-experimental descriptive approach to assess student perceptions of faculty feedback following medication errors. A convenience sample of 106 second, third, and fourth-year nursing students was surveyed. Students indicated that they would be more likely to report an error if given the opportunity to explain the reason for the error (95.2%). Similarly, Preston et al.22described the perceptions of students about the relationship between pharmacological education and clinical safety. Twenty-eight RN-BSN students and 71 traditional BSN students participated. The data was analyzed using conventional content analysis and students described the impact of pharmacology education as a positive or negative effect.

A group of researchers estimated the risk of error among undergraduate nursing students based on their scores on the pharmacology knowledge questionnaire and their self-rated certainty23. They conducted a cross-sectional correlational study with a sample of 147 nursing students. Drug calculation was the subject area in which students had the lowest mean score. Positive correlations were observed between age and pharmacology score and between the last time the pharmacology course was taken and the risk of error.

Finally, another group of researchers8explored the perceptions of nursing students regarding the process of learning mathematical calculations to safely administer medications. Four focus groups were conducted, two with participants who were in the first year of the nursing program and two with participants in the second year. Each focus group comprised 4 to 6 students and lasted between 20 and 40 minutes. The questions were designed to explore the experience and understanding of learning mathematics for medication administration.

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 instrument16 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 practice22,27.

Questionnaires were another instrument often used in the studies included in this review19 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 studies13 16 18 19 20 28provided 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 supervision9 35 36.

Limitations

There are several limitations to this review. First, despite international representativeness among the studies included in this review, most of them had been conducted in the United States and so our findings may not be generalizable to nursing schools at the international level. Furthermore, this review included only studies published in English and so this approach may have excluded relevant evidence published in other languages. Finally, although we conducted extensive database and manual searches, some relevant studies may have been inadvertently excluded from this work.

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.

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Received: December 22, 2021; Accepted: January 13, 2022

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