Safety in numbers 5: Evaluation of computer-based authentic assessment and high fidelity simulated OSCE environments as a framework for articulating a point of registration medication dosage calculation benchmark

This paper reports a key educational initiative undertaken by NHS Education for Scotland (NES), based upon recommendations from a ‘Numeracy in Healthcare’ consultation. We report here the design of a web-based technical measurement authentic assessment environment evolved from the safeMedicate suite of programs that provided a model for an environment within which a medication dosage calculation problem-solving (MDC-PS) benchmark could be articulated. A sample of 63 third-year pre-registration nursing students was recruited from four participating universities in the UK. A counterbalanced design was employed where the virtual authentic assessment environment was evaluated for internal consistency reliability and criterion-related validity against an objective structured clinical assessment (OSCE) undertaken in high-fidelity simulated clinical environments. Outcome measures indicated an extremely high internal consistency of the web-based environment. It was concluded that the combination of a web-based authentic assessment environment and further assessment of safe technical measurement interpretation and dexterity in a practice/practice simulation setting, populated with a benchmark and a criterion referenced rubric validated by the profession, is an innovative, viable, valid and reliable assessment method for the safe administration of medicines. As a result, the rubric for assessment of the appropriate range of calculation type and complexity informed the NMC's revised Essential Skills Clusters for Medicines Management (NMC, 2010a; NMC, 2010b). This inclusion provides a particularly strong example of both research directly influencing policy and of evidence-based regulation.     

Safety in numbers 2: Competency modelling and diagnostic error assessment in medication dosage calculation problem-solving

Accurately defining and modelling competence in medication dosage calculation problem-solving (MDC-PS) is a fundamental pre-requisite to measuring competence, diagnosing errors and determining the necessary design and content of professional education programmes. In this paper we advance an MDC-PS competence model that illustrates the relationship between conceptual competence (dosage problem-understanding), calculation competence (dosage-computation) and technical measurement competence (dosage-measurement). To facilitate bridging of the theory–practice gap it is critical that such models are operationalised within a wider education framework that supports the learning, assessment and synthesis of cognitive competence (the knowing that and knowing why of MDC-PS) and functional competence (the know-how and skills associated with the professional practice of MDC-PS in clinical settings).Within the context of supporting the learning and diagnostic assessment of MDC-PS we explore PhD fieldwork that challenges the value of pedagogical approaches that focus solely on abstract information, that isolate the process of knowledge construction from its application in practice settings and contribute to the generation of conceptual errors. We consider misconceptions theory and the concept of mathematical ‘dropped stitches’ and offer an assessment model and program designed to diagnose flawed arithmetical operation and computation constructs.     

Safety in numbers 3: Authenticity,Building knowledge & skills and Competency development & assessment: The ABC of safe medication dosage calculation problem-solving pedagogy

When designing learning and assessment environments it is essential to articulate the underpinning education philosophy, theory, model and learning style support mechanisms that inform their structure and content. We elaborate on original PhD research that articulates the design rationale of authentic medication dosage calculation problem-solving (MDC-PS) learning and diagnostic assessment environments. These environments embody the principles of authenticity, building knowledge and skills and competency assessment and are designed to support development of competence and bridging of the theory-practice gap. Authentic learning and diagnostic assessment environments capture the features and expert practices that are located in real world practice cultures and recreate them in authentic virtual clinical environments. We explore how this provides students with a safe virtual authentic environment to actively experience, practice and undertake MDC-PS learning and assessment activities. We argue that this is integral to the construction and diagnostic assessment of schemata validity (mental constructions and frameworks that are an individual's internal representation of their world), bridging of the theory-practice gap and cognitive and functional competence development. We illustrate these principles through the underpinning pedagogical design of two online virtual authentic learning and diagnostic assessment environments (safeMedicate and eDose?).     

Safety in numbers 4: The relationship between exposure to authentic and didactic environments and Nursing Students' learning of medication dosage calculation problem solving knowledge and skills

Advancing the art and science of education practice requires a robust evaluation of the relationship between students' exposure to learning and assessment environments and the development of their cognitive competence (knowing that and why) and functional competence (know-how and skills). Healthcare education translation research requires specific education technology assessments and evaluations that consist of quantitative analyses of empirical data and qualitative evaluations of the lived student experience of the education journey and schemata construction (Weeks et al., 2013a). This paper focuses on the outcomes of UK PhD and USA post-doctorate experimental research. We evaluated the relationship between exposure to traditional didactic methods of education, prototypes of an authentic medication dosage calculation problem-solving (MDC-PS) environment and nursing students' construction of conceptual and calculation competence in medication dosage calculation problem-solving skills.Empirical outcomes from both UK and USA programmes of research identified highly significant differences in the construction of conceptual and calculation competence in MDC-PS following exposure to the authentic learning environment to that following exposure to traditional didactic transmission methods of education (p < 0.001). This research highlighted that for many students exposure to authentic learning environments is an essential first step in the development of conceptual and calculation competence and relevant schemata construction (internal representations of the relationship between the features of authentic dosage problems and calculation functions); and how authentic environments more ably support all cognitive (learning) styles in mathematics than traditional didactic methods of education. Functional competence evaluations are addressed in Macdonald et al. (2013) and Weeks et al. (2013e).     

Safety in Numbers 7: veni,vidi, duci: A grounded theory evaluation of nursing students' medication dosage calculation problem-solving schemata construction

This paper evaluates nursing students' transition through schemata construction and competence development in medication dosage calculation problem-solving (MDC-PS). We advance a grounded theory from interview data that reflects the experiences and perceptions of two groups of undergraduate pre-registration nursing students: eight students exposed to a prototype authentic MDC-PS environment and didactic transmission methods of education and 15 final year students exposed to the safeMedicate authentic MDC-PS environment. We advance a theory of how classroom-based ‘chalk and talk’ didactic transmission environments offered multiple barriers to accurate MDC-PS schemata construction among novice students. While conversely it was universally perceived by all students that authentic learning and assessment environments enabled MDC-PS schemata construction through facilitating: ‘seeing’ the authentic features of medication dosage problems; context-based and situational learning; learning within a scaffolded environment that supported construction of cognitive links between the concrete world of clinical MDC-PS and the abstract world of mathematics; and confidence-building in their cognitive and functional competence ability. Drawing on the principle of veni, vidi, duci (I came, I saw, I calculated), we combined the two sets of evaluations to offer a grounded theoretical basis for schemata construction and competence development within this critical domain of professional practice.     

Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach

This paper forms part of a series concerned with the establishment of the mathematical competence necessary for the safe calculation of medication dosages and hence for safe and clinically effective nursing practice.It describes the preliminary work that led up to the development of a new computer based constructivist approach to teaching medication dosage calculation problem solving skills. This arose from observations of the errors committed by novice nursing students in a large UK School of Nursing during written assessments of dosage calculation ability.The paper begins by describing the nature of conceptions which underlie the computation errors observed during initial student selection and early studies at the school. Examples of arithmetic and miscomputation errors are documented. The nature of these errors revealed the need for a new approach to initial numeracy assessment and teaching of computation skills. This was further borne out by analysis of conceptual errors, which contested the usefulness of the existing teaching approach based on didactic methods and abstract word problems.The paper concludes by introducing the constructivist view which informed the development of new computer based learning materials. The nature of these materials and their evaluation in the college and clinical settings are described in the subsequent papers.     

Drug calculations: are they safer with or without a calculator?

The safe administration of medicines is a key nursing activity. The most common type of medication error is administering the wrong dose (Armitage, 2006). To administer medicines correctly, nurses must apply appropriate knowledge specific to the patients receiving medication, and execute the skills required to administer medicines to a high degree of accuracy. This may include mathematical calculations. The potential for errors in child health settings is compounded by the complex calculations often required to ensure children receive the appropriate dose. Nurse educators face dilemmas in both pre- and post-registration settings relating to students' lack of ability to undertake drug calculations without a calculator. This means that students may not be able to follow the Nursing and Midwifery Council (NMC) Guidelines for the Administration of Medicines (NMC, 2004b). Medication dosage calculations continue to be problematic for qualified nurses. It is too early to assess whether changes in state education will improve pre-registration students' abilities to apply skills in basic mathematical principles to drug calculations. In the meantime, it is important that nurses who appear to have a weakness in applying mathematical principles to drug calculations seek, and are offered, the opportunity to develop these skills.     

A written assessment is an invalid test of numeracy skills

Nurses need good clinical numeracy skills to aid them in their clinical practice. There is some concern, however, that the calculation skills learned during pre-registration nurse education have little practical application to nurses. This article discusses the Fitness for Practice initiatives from the Nursing and Midwifery Council which aim to ensure new registrants are numerate. The article argues that written numeracy assessment tools are not a valid test of the numeracy skills candidates will require for clinical practice and that nurse education needs to focus on researching and examining how best to support, assess and develop the numeracy skills of nursing students within their clinical practice placements to ensure that at the point of registration they are fit for practice.     

Developing numeracy in child branch students

The Nursing and Midwifery Council (2002a) reports that one of the most common examples of professional misconduct relates to the failure to administer medicines safely. In educating child-branch nurses, we have a duty to enhance students' calculation skills so that they are safe and can provide the best possible care to children. This paper presents a framework for numeracy within a child-branch curriculum, describing a practical approach to developing students' skills in the mathematical calculations they are likely to encounter in clinical practice. A pass mark of 70 per cent in relevant numeracy tests is considered too low for child branch students. Early identification of mathematical ability and provision of relevant tutorial support will ensure that the majority of students achieve the required standard.     

Safety in numbers: An introduction to the nurse education in practice series

This paper introduces this Nurse Education in Practice ‘Safety in Numbers’ series. We introduce the background and seven papers that explore the outcomes of a 20-year programme of healthcare education translation research and education action research that focuses on medication dosage calculation problem-solving (MDC-PS) education.     

Simulated practice learning in a preregistration programme

Following the publication of the Nursing and Midwifery Council's (NMC) (2007) Simulation of Practice Learning Project, simulated practice learning opportunities are now to be incorporated into preregistration undergraduate nursing programmes across the UK. Since 2008, the Faculty of Health and Life Sciences at Oxford Brookes University has incorporated simulated practice learning into their curriculum to contribute towards students' 2300 direct clinical care hours. This paper presents the findings of an evaluation project that was conducted by academic staff within the faculty to ensure that they could continue to meet the principles set out by the NMC for auditing simulated learning environments used by higher education institutes (HEIs), and to meet the Essential Skills Clusters (NMC, 2010a) for registration as part of the quality assurance processes. The evaluation took place over 2?days, with a total of 52 participants, including practice partners, mentors, practice educators, academic staff and students from all four branches of nursing (adult, mental health, learning disability and children). Results indicated that the support of direct care hours through simulated practice learning can permit students to practice essential clinical skills in a designated clinical skills suite. These learning experiences can also offer positive outcomes and the opportunities to maintain partnership for students, placement partners, and mentors.     

Increasing nursing students' understanding and accuracy with medical dose calculations: A collaborative approach

BackgroundAccurate calculation of medication dosages can be challenging for nursing students. Specific interventions related to types of errors made by nursing students may improve the learning of this important skill.ObjectiveThe objective of this study was to determine areas of challenge for students in performing medication dosage calculations in order to design interventions to improve this skill.DesignStrengths and weaknesses in the teaching and learning of medication dosage calculations were assessed. These data were used to create online interventions which were then measured for the impact on student ability to perform medication dosage calculations.SettingThe setting of the study is one university in Canada.ParticipantsThe qualitative research participants were 8 nursing students from years 1–3 and 8 faculty members. Quantitative results are based on test data from the same second year clinical course during the academic years 2012 and 2013.MethodsStudents and faculty participated in one-to-one interviews; responses were recorded and coded for themes. Tests were implemented and scored, then data were assessed to classify the types and number of errors.ResultsStudents identified conceptual understanding deficits, anxiety, low self-efficacy, and numeracy skills as primary challenges in medication dosage calculations. Faculty identified long division as a particular content challenge, and a lack of online resources for students to practice calculations. Lessons and online resources designed as an intervention to target mathematical and concepts and skills led to improved results and increases in overall pass rates for second year students for medication dosage calculation tests.ConclusionThis study suggests that with concerted effort and a multi-modal approach to supporting nursing students, their abilities to calculate dosages can be improved. The positive results in this study also point to the promise of cross-discipline collaborations between nursing and education.     

Undergraduate nursing curricula: Numeracy and accreditation

BackgroundNumeracy skills are essential for patient safety; therefore, it is vital that registered nurses are proficient in performing calculations, notably medication calculations. However, the literature indicates that a large proportion of undergraduate nursing students and registered nurses are not competent in numeracy. The manifestation of numerical and calculation errors is thought to stem from failing to comprehend key mathematical principles from primary or secondary school, as well as the minimal admission requirements to enter nursing programs. Tertiary education providers teach and assess numeracy within nursing programs using a diverse range of pedagogical and instructional approaches. These programs of nursing study are underpinned by the Australian Nursing & Midwifery Accreditation Council standards, and lead to nursing registration in Australia. These accreditation standards do not incorporate numeracy, placing the onus on the tertiary education providers to design content and assessment types, as well as establish a benchmark to gauge the competence of the student prior to graduating.QuestionWhy the Australian Nursing & Midwifery Accreditation Council does not require graduates to demonstrate numeracy proficiency, and why there are no recommendations for undergraduate numeracy content and assessment in Australia.MethodAn exploratory sequential mixed methods design across 5 stages will be used.FindingsNo data has been collected to date.DiscussionNo discussion has been written to date.ConclusionTo contribute knowledge to improve the competence of undergraduate nursing students in relation to numeracy education, and ultimately the safety of Registered Nurses when calculating medications in practice.     

Achieving clinical nurse specialist competencies and outcomes through interdisciplinary education

Without formal education, many healthcare professionals fail to develop interdisciplinary team skills; however, when students are socialized to interdisciplinary practice through academic clinical learning experiences, effective collaboration skills can be developed. Increasingly, educational environments are challenged to include clinical experiences for students that teach and model interdisciplinary collaboration. PURPOSE: The purpose of this quality improvement initiative was to create an interdisciplinary educational experience for clinical nurse specialist (CNS) students and postgraduate physicians. DESCRIPTION OF THE PROJECT: The interdisciplinary learning experience, supported by an educational grant, provided an interdisciplinary cohort of learners an opportunity to engage in a clinically focused learning experience. The interdisciplinary cohort consisted of CNS students and physicians in various stages of postgraduate training. The clinical experience selected was a quality improvement initiative in which the students were introduced to the concepts and tools of quality improvement. During this 1-month clinical experience, students applied the new skills by implementing a quality improvement project focusing on medication reconciliation in the outpatient setting. The CNS core competencies and outcomes were used to shape the experience for the CNS students. OUTCOME: The CNS students exhibited 5 of the 7 essential characteristics of the CNS (leadership, collaboration, consultation skills, ethical conduct, and professional attributes) while demonstrating competencies and fulfilling performance expectations. During this learning experience, the CNS students focused on competencies and outcomes in the organizational sphere of influence. Multiple facilitating factors and barriers were identified. CONCLUSION: This interdisciplinary clinical experience in a quality improvement initiative provided valuable opportunities for CNS students to develop essential CNS characteristics and to explore practice competencies in the area of systems. IMPLICATIONS: Interdisciplinary clinical experiences offer students opportunities to develop needed collaboration and communication skills. Educators should create interdisciplinary educational experiences for students to better prepare them for their roles in a clinical setting.     

Problem solved: dosage calculation in a nursing program

Patient safety, including the safe administration of medications, is an essential component of nursing practice. However, helping students calculate medication dosages has continually challenged faculty members and students. The authors describe a comprehensive approach to teaching and evaluating dosage calculation. Common barriers to helping students master necessary math skills required for accuracy are addressed.     

Do calculation errors by nurses cause medication errors in clinical practice? A literature review

This review aims to examine the literature available to ascertain whether medication errors in clinical practice are the result of nurses’ miscalculating drug dosages. The research studies highlighting poor calculation skills of nurses and student nurses have been tested using written drug calculation tests in formal classroom settings [Kapborg, I., 1994. Calculation and administration of drug dosage by Swedish nurses, student nurses and physicians. International Journal for Quality in Health Care 6(4): 389 –395; Hutton, M., 1998. Nursing Mathematics: the importance of application Nursing Standard 13(11): 35–38; Weeks, K., Lynne, P., Torrance, C., 2000. Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach. Clinical Effectiveness in Nursing 4, 20–29]; Wright, K., 2004. Investigation to find strategies to improve student nurses’ maths skills. British Journal Nursing 13(21) 1280–1287; Wright, K., 2005. An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today 25, 430–436], but there have been no reviews of the literature on medication errors in practice that specifically look to see whether the medication errors are caused by nurses’ poor calculation skills. The databases Medline, CINAHL, British Nursing Index (BNI), Journal of American Medical Association (JAMA) and Archives and Cochrane reviews were searched for research studies or systematic reviews which reported on the incidence or causes of drug errors in clinical practice. In total 33 articles met the criteria for this review. There were no studies that examined nurses’ drug calculation errors in practice. As a result studies and systematic reviews that investigated the types and causes of drug errors were examined to establish whether miscalculations by nurses were the causes of errors.     

Clinical pharmacology considerations in development of gastrohepatology products

Clinical pharmacology has a key role in advancing candidate drugs from bench to bedside. A thorough understanding of underlying pharmacokinetic (PK) and pharmacodynamic (PD) processes is essential to inform the next steps in any drug development program with the goal of personalized medicine. Development of gastrohepatology drug products faces unique clinical pharmacology challenges that require collaborative efforts from academia, the pharmaceutical industry, and regulatory agencies.     

Delphi technique: identifying the generic competence required for doctors and nurses working in a primary health care

This study aims to identify the generic competence required of doctors and nurses working in a primary health care. It was based on a series of 3 round of the Delphi technique which identified 8 generic competencies: ability to communicate, ability to be community oriented, ability in teamwork, management skills, educational skills, ability to problem solving, professional skills, ability to make-decision. Only the competence management skills there was not consensus by doctors. They disagree that this competence is required by them working in primary health care.