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 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 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 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.     

The strive for clinical effectiveness in medication dosage calculation problem-solving skills: the role of constructivist learning theory in the design of a computer-based ‘authentic world’ learning environment

This is the second of three papers in a series describing the design and production of an ‘authentic world’ environment to help students as they learn medication dosage calculation skills. It begins with a brief account of the constructivist view of the role of words as ‘containers of meaning’. This shows that didactic teaching methods may be founded on assumptions which deny the relationship between words and the concepts constructed by each individual as a result of their prior experience. It is suggested that problems experienced by students when taught in this way constitute a very real theory practice divide and may be explained in terms of constructivist learning theory.A fuller explanation of the range of constructivist theories follows and we show how thinking which arose in a number of educational fields, including mathematics education, influenced the adoption of a constructivist approach to the teaching and learning of practical mathematics in nursing.This led to the need to develop a suitable learning environment in which students could acquire medication dosage problem-solving skills. The main body of the paper provides an illustrated account of a prototype computer based ‘authentic world’ environment and the educational theories which informed and shaped its development. The evaluation of this system in both educational and clinical settings is the subject of the third and final paper in this series.     

Trying on the professional self: nursing students' perceptions of learning about roles,identity and teamwork in an interprofessional clinical placement

AimThis study aims to describe how senior nursing students viewed the clinical learning environment and matured their professional identity through interprofessional learning in a student-led hospital ‘ward’.BackgroundUndergraduate nursing and medical student teams participated in a trial of ward-based interprofessional clinical learning, managing patients over 2 weeks in a rehabilitation ward.MethodsQualitative and quantitative program evaluation was conducted using exit student focus groups and a satisfaction survey.ResultsTwenty-three nursing and medical students in three placement rounds provided positive feedback. Five main themes emerged describing their engagement in ‘trying on’ a professional role: ‘experiencing independence and autonomy’; ‘seeing clearly what nursing's all about’; ‘altered images of other professions’; ‘ways of communicating and collaborating’ and ‘becoming a functioning team’.ConclusionsWard-based interprofessional clinical placements offer senior students authentic ideal clinical experiences. We consider this essential learning for future interprofessional collaboration which should be included in senior nursing students' education.     

The impacts of faculty caring on nursing students’ intent to graduate: A systematic literature review

ObjectivesTo examine the current studies about the impacts of faculty caring on nursing students’ intent to graduate and provide recommendations. The nursing profession continues to face nursing shortages. One of the solutions recognized to alleviate the shortage is increasing the number of students graduating from nursing schools. It lacks a literature review synthesizing the current research about the impacts of faculty caring on nursing students’ intent to graduate and indicate areas for future research.MethodsThis is a systematic literature review. The search of the literature was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Databases searched included MEDLINE via PubMed, CINAHL, PsycINFO, and ProQuest Search. Search terms included ‘attrition,’ ‘dropouts,’ ‘graduation rate,’ ‘faculty,’ ‘instructor,’ ‘professor,’ ‘nursing,’ and ‘caring.’ResultsTen articles met the inclusion criteria. The articles were conducted in the Associate Degree of Nursing and the Bachelor of Science in Nursing programs. Nursing faculties played a significant role in students’ intent to graduate by building students’ confidence, creating a compassionate learning environment, and promoting students’ competence. Faculties’ caring behaviors, including respecting students, showing empathy, and using caring communication skills, were essential characteristics to affect students’ learning environments.ConclusionsThe findings indicate that students’ perceptions of faculty caring can affect their perceptions of the learning environment and sense of belonging, and therefore, impact their intent to graduate. Students’ perceptions of their instructors’ caring behaviors are instrumental in motivating them to continue learning. The capacity of faculty caring plays a significant role in students’ success.     

Safety in numbers 1: Essential numerical and scientific principles underpinning medication dose calculation

Registered nurses spend up to 40% of their professional clinical practice engaged in the art and science of medication dosage calculation problem-solving (MDC-PS). In advancing this patient safety critical discipline it is our position that as a profession we must first situate MDC-PS within the context of the wider features of the nursing numeracy, medicines management and clinical pharmacokinetic domains that inform its practice. This paper focuses on the essential relationship between numeracy, healthcare numeracy, medicines management, pharmacokinetics and MDC-PS. We present a taxonomy of generic numerical competencies for the pre-registration curriculum, with examples of essential medication dosage calculation requirements mapped to each skills domain. This is followed by a review of the symbols and measurement units that represent essential components of calculation competence in healthcare and medicines management practice. Finally we outline the fundamental pharmacokinetic knowledge that explains how the body deals with medication and we illustrate through clinical correlations why numeric and scientific knowledge and skills must be mastered to ensure safe dosage calculation and medicines management practice. The findings inform nurse education practice via advancing our understanding of a number of issues, including a unified taxonomy of generic numerical competencies mapped to the 42 revised UK Nursing and Midwifery Council (NMC) Essential Skills Clusters (NMC, 2010a; NMC, 2010b).     

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.     

Clinical competence and its association with self-efficacy and clinical learning environments among Chinese undergraduate nursing students

Evaluation and cultivation of clinical competence in undergraduate nursing students are essential in nursing education. Self-efficacy and good clinical learning environments are expected to have a positive influence on the clinical competence of undergraduate nursing students, but few studies have focused on the relationships among clinical competence, self-efficacy, and clinical learning environments. This study aimed to examine clinical competence and its association with self-efficacy and clinical learning environments among Chinese undergraduate nursing students. A cross-sectional questionnaire survey was conducted with 1518 undergraduate nursing students being recruited from five medical colleges in China. The nursing students’ clinical competence, self-efficacy, and clinical learning environments were assessed using a set of self-reported questionnaires, including Chinese versions of the Holistic Clinical Assessment Tool; General Self-Efficacy Scale; and Clinical Learning Environment, Supervision, and Nurse Teacher Evaluation Scale. Factors significantly associated with the clinical competence of undergraduate nursing students were professional interest, self-efficacy, and clinical learning environments, accounting for 36.1% of the total variance. Self-efficacy played a mediating role between clinical learning environments and clinical competence. The results of this study can be applied as reference for the enhancement of a nursing education program to improve the clinical competence of Chinese undergraduate nursing students.     

Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students

Reid‐Searl K, Moxham L, Happell B. International Journal of Nursing Practice 2010; 16 : 225–232
Enhancing patient safety: The importance of direct supervision for avoiding medication errors and near misses by undergraduate nursing students Medication errors have been the focus of considerable research attention in nursing; however, the extent to which nursing students might contribute to errors has not been researched. Using a grounded theory approach, in‐depth semi‐structured interviews were conducted with undergraduate nursing students based in a university in Queensland to explore their experiences of administering medication in the clinical setting. Almost a third of the participants reported making an actual medication error or a near miss. Where medication errors occurred, participants described not receiving direct and appropriate supervision by a registered nurse. Medication errors by nursing students have the potential to impact significantly on patient safety, quality of health care, and on nursing students' perceptions of their professional competence. Ensuring direct supervision is provided at all times must become an urgent priority for undergraduate nursing education.     

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.     

A predictive model of student nursing competency in clinical practicum: A structural equation modelling approach

BackgroundClinical teaching is the most important element in the development of students' nursing competencies. However, students' learning modalities in clinical settings are unclear.ObjectiveTo analyse path relationships affecting students' learning outcomes in clinical practicum using LISREL software.DesignA cross-sectional survey was administered.Settings and participantsParticipants were 392 senior students who had completed their final internship recruited from two nursing programmes in central Taiwan.MethodsAdministration and completion of the following structured questionnaires: the Competency Inventory of Nursing Students, the Teaching Competence of Nurse Preceptor questionnaire, the Student Evaluation of the Clinical Education Environment, Level of Reflective Thinking, and the Metacognitive Inventory for Nursing Students.ResultsThe results suggested that teaching competence may indirectly affect nursing competence through metacognition and reflection. The clinical learning environment may directly affect nursing competence or indirectly affect nursing competence through metacognition. Both metacognition and reflection have direct effects on nursing competence, and reflection exerts indirect effects on nursing competence through metacognition. The path relationships differed according to the employment plan group.ConclusionsReflection and metacognition are essential skills for the development of nursing competence in clinical settings. Clinical instructors must facilitate student learning by fostering a positive learning environment and teach students the reflective and self-regulation skills necessary to achieve favourable learning outcomes in clinical settings.     

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.     

Clinical learning environment and supervision of international nursing students: A cross-sectional study

BackgroundPreviously, it has been shown that the clinical learning environment causes challenges for international nursing students, but there is a lack of empirical evidence relating to the background factors explaining and influencing the outcomes.ObjectiveTo describe international and national students' perceptions of their clinical learning environment and supervision, and explain the related background factors.DesignAn explorative cross-sectional design was used in a study conducted in eight universities of applied sciences in Finland during September 2015–May 2016.MethodsAll nursing students studying English language degree programs were invited to answer a self-administered questionnaire based on both the clinical learning environment, supervision and nurse teacher scale and Cultural and Linguistic Diversity scale with additional background questions. Participants (n = 329) included international (n = 231) and Finnish (n = 98) nursing students. Binary logistic regression was used to identify background factors relating to the clinical learning environment and supervision.ResultsInternational students at a beginner level in Finnish perceived the pedagogical atmosphere as worse than native speakers. In comparison to native speakers, these international students generally needed greater support from the nurse teacher at their university. Students at an intermediate level in Finnish reported two times fewer negative encounters in cultural diversity at their clinical placement than the beginners.ConclusionTo facilitate a successful learning experience, international nursing students require a sufficient level of competence in the native language when conducting clinical placements. Educational interventions in language education are required to test causal effects on students' success in the clinical learning environment.     

Family nursing telesimulation: Teaching therapeutic communication in an authentic way

BackgroundA nurse's skill in establishing therapeutic communication is central to family nursing. Using a family-centered approach, nurses can facilitate relationship building with members of a family unit. Through authentic learning activities such as simulation, students can practice the competencies required to provide effective family nursing care.DesignOne hundred and one nursing students participated in a two-part family nursing telesimulation. Students were sent an online evaluation about their simulation experience immediately afterwards.ResultsFifty-six percent (n = 57) of the 101 students completed the online evaluation. Students overwhelmingly appreciated the opportunity to apply theory in a real-world manner, engaging in family nursing in an authentic way.ConclusionThe telesimulation strongly supported students’ ability to practice their clinical decision-making skills and respond to changing family needs. Telesimulation is a promising teaching strategy that allowed students to practice their therapeutic communication in the context of family nursing.     

Improvement of learning domains of nursing students with the use of authentic assessment pedagogy in clinical practice

With evolving healthcare demands, nursing educators need to constantly review their teaching methodologies in order to enhance learners’ knowledge and competency of skills in the clinical settings. Learning is an active process in which meaning is accomplished on the basis of experience and that authentic assessment pedagogy will enable nursing students to play an active part in their learning.The study was conducted with an aim to examine nursing students’ learning domains through the introduction of the authentic assessment pedagogy during their clinical practice. A quasi-experimental study (n = 54) was conducted over a period of 10 weeks at a local tertiary hospital. The experimental group was exposed to the authentic assessment pedagogy and were taught to use the assessment rubrics as an instrument to help enhance their learning. Students were assessed and scored according to the assessment rubrics, which were categorized into four domains; cognitive, psychomotor, affective and critical thinking abilities.The findings indicated that an overall score for the four domains between the experimental and control groups were significant, with p value of <0.05. Critical thinking scores were indicative of consistent improvement within the experimental group. The findings confirmed that learning outcomes of the nursing students were enhanced through the early introduction of the authentic assessment pedagogy in the clinical setting.