|Year : 2020 | Volume
| Issue : 3 | Page : 227-231
Experiences of nursing interns with the application of knowledge and skills in drug administration: A qualitative study
Nusrat Bano1, Hend Al Najjar2
1 Department of Pharmacology, King Saud bin Abdulaziz University for Health Hciences, Jeddah, Saudi Arabia
2 Department of Nursing, King Saud bin Abdulaziz University for Health Hciences, Jeddah, Saudi Arabia
|Date of Submission||19-Apr-2020|
|Date of Decision||22-Jul-2020|
|Date of Acceptance||23-Aug-2020|
|Date of Web Publication||07-Nov-2020|
Hend Al Najjar
King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Mail Code 6565, P O Box 9515 Jeddah 21423
Source of Support: None, Conflict of Interest: None
Context: Nursing interns are expected to practice safe medication administration. Pharmacology courses in their undergraduate education prepare them for safe medication administration. Most interns are challenged by the practical implementation of theoretical concepts in pharmacology. Aims: The purpose of this study was to describe the experiences of nursing interns with the application of medication knowledge and skills in clinical practice settings. Settings and Design: A qualitative descriptive design was used in health science university in Saudi Arabia. Subjects and Methods: face-to-face in-depth interviews with nursing interns recruited through purposeful sampling in a health science university in Saudi Arabia. Data were collected from December 2019 to January 2020 following Institutional Review Board approval. Statistical Analysis Used: Graneheim inductive approach was used for the content analysis of the data. Standard principles of trustworthiness were applied. Results: Two major themes emerged as “perceived readiness” and “bracing attributes.” There were two subthemes within each theme, which were populated by 13–23 statements. Conclusions: Nursing interns described certain challenges with the application of knowledge and skills in medication administration. Self-perceived lack of knowledge underlined description of most experiences. Learning acquired with case studies, classroom interactions, clinical exposure, and simulation, in undergraduate education was acknowledged in the context of retention of knowledge.
Keywords: Experiences, interns, knowledge, medication, nursing
|How to cite this article:|
Bano N, Al Najjar H. Experiences of nursing interns with the application of knowledge and skills in drug administration: A qualitative study. Saudi J Health Sci 2020;9:227-31
|How to cite this URL:|
Bano N, Al Najjar H. Experiences of nursing interns with the application of knowledge and skills in drug administration: A qualitative study. Saudi J Health Sci [serial online] 2020 [cited 2021 Jan 20];9:227-31. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/227/300295
| Introduction|| |
Nursing students are expected to demonstrate adequate knowledge and skills required for safe medication administration in clinical practice. Pharmacology courses and clinical training sessions in undergraduate nursing education are aimed to prepare them for safe medication handling and administration. Extant literature shows that nursing interns often lack depth of pharmacological knowledge and thus experience difficulties in demonstrating adequate medication administration skills in clinical practice settings. In some cases, the newly graduated nursing students do not consider themselves capable enough to deliver safe medication care in clinical practice due to a lack of confidence in their medication knowledge. Nursing interns are also perplexed by a full and extensive patient load. Challenges lie mainly around the uneasiness in teaching patients regarding medications and having insufficient groundwork in pharmacology. Nursing interns can make more medication errors compared to experienced registered nurses because they have less knowledge and skills required for drug management and dose calculation. Although studies have shown that medication errors made by nurses are mainly due to increased workload, distractions, interruptions, communication failure, and poor mathematical skills, nonetheless, the length of nursing experience plays an important role. Knowledge of medications is also directly related to the amount of experience and quality of education., The present study is designed to explore the experiences of nursing interns related to the application of skills and knowledge required for safe drug administration in their clinical practice. It will enlighten the readers regarding their specific challenges and coping behavior. Based on these findings, stakeholders in nursing education can refine the learning outcomes of the existing courses and emphasize on proficient teaching strategies, which allow nursing interns to retain relevant concepts and enhance skills, crucial for safe medication administration and patient care.
| Subjects and Methods|| |
The study had a qualitative descriptive design. Institutional Review Board approval of the study (IRBC/2251/19) was attained in King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS). All study participants (mean age 22.03 ± 1.87) were nursing interns and had graduated from KSAU-HS in Jeddah (western region). Participants for the study were recruited by homogeneous purposive sampling. Data saturation was attained after interviews with eight study participants. Data were collected from November 2019 to January 2020. In-depth, face-to-face interviews were conducted for data collection following informed consent. Interviews took place in a calm and secure setting selected by the participants. Participants were informed about the nature of the interview questions prior to interviews. They were given a choice to withdraw from the study at any point. Interviews were audiotaped and transcribed verbatim. Transcripts were returned to interviewees for comments. Notes were taken, and nonverbal cues were noted. Participants were assured that their identities will not be revealed at any stage, and pseudonyms are used.
Content analysis was performed for data analysis, employing the inductive approach proposed by Graneheim and Lundman (2004). At the initial stage, the transcribed data were read and re-read. Specific experiences of the nursing interns pertaining to the application of skills and knowledge required for safe drug administration in clinical practice settings (body of text) were highlighted. In the second stage, significantly similar statements that comprised words, sentences, phrases, and clauses were selected (meaning unit). In the third stage, the statements were summarized after categorization (condensed meaning unit). In the final stage, the summarized content was conceptualized to yield themes and subheadings (coded units). To ensure academic rigor, principles of Lincoln and Guba (1985) were observed to attain trustworthiness. Member checking was done to ensure the credibility of transcribed data. A clear, thorough, and rich description was provided for transferability. Consistency of the findings was verified by an external audit in order to ensure dependability. The researcher conducting the interviews (First author) maintained a reflexive journal. Two qualitative experts assessed the congruency of the data to the finding for confirmability (audit trail).
| Results|| |
Two themes, namely “Perceived readiness” and “Bracing attributes” evolved following data analysis. The themes are presented in [Table 1]. Each theme comprised of two subthemes.
The first theme was “Perceived readiness” with two subthemes that were “scarce knowledge” and “fear to make mistakes.”
The participants were skeptical about their preparedness for safe medication administration as nursing interns. They were not convinced that they had adequate information and knowledge, required for safe drug administration.
“We did not study about medications that should not be crushed in NG tube administration. These are simple things, but we only learned during internship.” (Rawan)
“We did not have knowledge about IV admixtures. It is important; we should at least know its theory before internship.” (Hala)
“We did not know about inotropic drugs at all. During internship we realized that we have no information about them. The course should focus more on high alert medications. It's very, very important.” (Raneem)
“One intern made mistake with heparin and massaged the site, she did not know that.” (Raghad)
“We should know more about black box warnings.” (Shamookh)
“As students, we were never allowed to give IV push medications in clinical days.” (Reem)
The study participants realized that they had deficient dose calculations skills. They spoke about the gap in theory and practice and how they came across disparities.
“We need more practice with dose calculation. This is the most important thing we need. We are confused there… with rate of infusion and making dilutions.” (Basma)
“We used one formula for dose calculation all the time, but in practice we saw that the nurses used IV pump and simply adjusted it. No manual calculations like we kept on practicing. There is a difference with what we learned in class and what is actually happening.” (Rawan)
The study participants expressed fear of making errors because of confusion with drug names, too much mixed up information and distractions compounded with workload. They also felt that making errors will affect their professional dignity as nurses.
“We studied pharmacology in one semester only, there was too much information and now I think I am mixing information and that makes me scared.” (Hala)
“I am more stressed and scared with too many things to do sometimes and when I am working long hours, I think I can make more errors, because it is difficult to recall and understand drug administration instructions when your brain is too tired.” (Abeer)
“I think when I see new infusion device or new type of dose calculation; I get scared because I don't want to make mistakes. I don't want others to know that I know nothing about this.” (Shamookh)
“Sometimes the patients ask many questions about allergies and side effects and when I don't know, I am scared to give wrong information or feeling embarrassed.” (Basma)
“I see some nurses, who don't have good drug knowledge and doctors don't respect them because of that. I am scared to be one of them.” (Hala)
The second theme was “Bracing attributes,” with two subthemes, “cognitive ability” and “Background knowledge.”
Within this theme, the study participants described the factors that strengthened and supported them in the process of application of drug knowledge and skills in safe drug administration. The interns described that classroom activities based on application exercises and practicing in clinical days refined their critical thinking ability, owing to which they can now process new information in an effective manner.
“Before internship, in clinical days, we practiced IM, SC and later also IV infusion. Now I am learning about IV push. I am trained to observe, understand instructions, think critically and perform.” (Raneem)
“We did classroom activities with types of drug interactions with many examples. Now we access an online website to know about potential drug to drug interaction before administration, but from what we learned in class, we know what information we are looking for, we know what it means and how to apply it.” (Raghad)
“Most drugs we studied with case study, we still remember those ones better, and also what we brainstormed during group activity. We are confident with what we know about these drugs.” (Shamookh)
“How we practiced drug administration in simulation, we still remember it, it was too close to reality and it made us very confident.” (Abeer)
They expressed that cognitive abilities in nurses can be refined further if the course included more application exercises.
“Some case studies we solved in class really helped us. If there were more case studies focusing on the nursing process, we would have learned more ways to think critically.” (Raghad)
“We completed assignments on drug profiles and it is really useful information for us in internship but If we had practiced more and more with online drug information resources that the nurses use in the hospitals, we would have been more confident.” (Basma)
“We calculated doses of toxic drugs like gentamycin with online therapeutic drug monitoring calculators and it gave me so much confidence in real practice.” (Raneem)
“I remember from classroom activities like solving cases and learning by games, it is really useful in our internship, because it is very clear information. It is better than too much information crammed in multicolor lecture slides.” (Reem)
“We need to know how to apply what we learn in theory, in our internship, we still have theoretical sessions after every 3 weeks in xxxx [cancer specialist hospital name], I am glad that we are not just learning from hands.” (Hala)
“Since our time in college, we learned about evidence based approach and we relate it now, so important.” (Rawan)
They practiced using mnemonics to remember drug names in course exam preparation and that came in handy for them. They learned to categorize drug properties with classification and recalled key aspects of prototypical drugs.
“As interns, we use guidelines with a checklist for some drugs like diphenhydramine, metochlopramide etc., Because we did a similar exercise in pharma course, it's easier for us.” (Reem)
“We practiced drug names by making codes in class; the teacher gave assignment when we wrote poems comparing sound alike drugs, that information is still in our heads. That's why I know a process to break the fear of difficult drug names in pharmacology class and they tell me that I am very good at drug names.” (Shamookh)
“I use brand names for complicated generic names sometimes, but in my head I can hear my teacher voice that discouraged the use of brand names, so I keep on making extra efforts to learn generic names.” (Abeer)
“I think interest in the course matters a lot. If you enjoyed learning about drug administration, adverse effects, precautions, dose etc., in the course, and you were active in class, you will do good in internship days.” (Basma)
| Discussion|| |
This study describes the experiences of nursing interns with the application of medication knowledge and skills in clinical practice settings. The study yielded two themes, namely “perceived readiness” and “bracing attributes.”
The study participants felt that they lacked some important information as interns, which should be given to them in undergraduate education. It included some basic information, for example, dosage forms that should not be crushed, black box warnings or high alert medications. Their shaken belief on their drug knowledge was compounded with the fear of making mistakes and thus affected their confidence. Some of them feared being judged on their knowledge by peers. They also relayed on that they came across gaps between their knowledge and existing practice, for example, dose calculation skills. These findings are similar to a previous studies reporting self-perceived lack of pharmacological knowledge and skills in nursing students and nurses.,
This study reinforces the need to weave a “golden thread” between undergraduate nursing courses and internship for optimal teaching and learning. This may require revisions in the existing pharmacology course to incorporate knowledge at least about the top five high alert medications e.g., Opiates and narcotics, insulin, intravenous anticoagulants (heparin), injectable potassium chloride (or phosphate) concentrate and sodium chloride solutions (above 0.9%). Nursing handbooks include concise information on black box warnings in drug profiles. Learning tasks in undergraduate education focused on fostering self-directed (drug profile) book reading are required. This can be achieved through incorporating focused learning outcomes in assignments, which cater to the needs of specific knowledge gains required by them in future clinical practice. These findings reiterate the need to assess and review nursing educational curricula, instructional designs, and program to prepare professional nurses. Participants in this study described that the dose calculation skills acquired in undergraduate education did not match the ones that were required in actual practice. Poor mathematical dose calculation skills in graduate nursing students is an age-old phenomenon. Adequate dose calculation skills are crucial for nurses as they dedicate 40% of their time in drug administration. Cross-discipline collaboration between nursing and education is advocated to enhance accurate dose calculation skills in nursing students. It is advised to allocate specific time in curricula for nursing students to learn and practice drug calculation and reinforce it through assessment. This can be ensured by careful revisions in course content, objective peer evaluation of the pharmacology course, and subsequent moderation of exams.
Interns also expressed distaste for multicolored lecture slides filled with enormous information. This finding signifies the importance of the “cognitive load theory,” proposed by Kaylor (2014) as a framework for undergraduate pharmacology in nursing students that deciphers “need to know” information from “nice to know” course content.
During this study, the participants described the strengthening factors in drug administration practice “Bracing attributes” by speaking mainly in the context of learning techniques that polished their “cognitive ability” and laid foundations of “background knowledge.” The interns described that learning acquired in simulation activities and case solving exercises improved their experiences in drug administration tasks in clinical practice. They were appreciative of the classroom activities that prompted active learning via discussions and critical thinking tasks. Critical thinking development is intimately related to active learning processes in adult nurse practitioner students.
In this study, the participants relayed on that bridging concepts in clinical practice was feasible owing to a sound theoretical knowledge base (e.g., drug classification, nomenclature, and properties) formed in undergraduate education. The interns also linked the quality of drug administration experience in practice with interest in learning about medications in undergraduate education. Learning acquired by games or poetry was retained by nursing interns. This supports previous studies showing that such active learning techniques in pharmacology elucidate interest in nursing students and improve learning outcomes., The interns also described that being accustomed to online drug resources for looking up potential drug interactions, dose calculation, etc., proved beneficial in clinical bedside practice. Confidence in fresh nursing graduates regarding the application of pharmacological knowledge to practice is described as a “big stumbling block” in a previous study. On the one hand, findings in this study concur with already existing knowledge that opportunities to practice medication administration skills in clinical training, acquired in undergraduate nursing education are scarce, impacting medication handling preparedness, but on the other hand, it also lends perspectives on the type of learning that proved effective in clinical practice. Previous studies in Saudi Arabia showed that some medication errors by nurses arise due to deficient knowledge regarding medication allergies. It also indicated that the failure to identify a medication error or its effects by nurses leads them to not report the error promptly., Nursing students can overcome these deficiencies by completing specific assignments in pharmacology courses based on drug allergies, its types and the significance of reporting medication errors. Another study from the region showed a significant difference in nursing interns and faculty regarding the effectiveness of clinical education. It is pivotal to align learning outcomes in pharmacology courses with concurrent courses with clinical component. Nursing interns in Saudi Arabia often encounter disappointment as skilled nursing staff may not teach them due to several factors, for example, time constraints, sense of responsibility, etc. Practical stories showcasing such experiences, shared with students in pharmacology class can invoke interest in the acquisition of medication administration knowledge and skills. A previous study on Saudi nursing interns showed that self-directed learning skills are directly related to their perceived confidence and professional maturity in clinical settings. An active learning environment in pharmacology class is thus of utmost importance as it allows students to refine self-directed learning skills needed in clinical practice.
The limitation of this study is that it is small scale and involves only female nursing interns who graduated from the same institution. Data site triangulation is recommended for future studies.
| Conclusions|| |
This article offers an insight into first-hand experiences of nursing interns in drug administration and application of medication knowledge and skills acquired in undergraduate education. Sentiments marked with fear of losing respect among colleagues and wavering self-esteem laced dialogs of the study participants, who were skeptical of their drug administration knowledge and skills. Participants highlighted areas, in which their knowledge was scarce. Description of strengthening attributes was in the context of learning acquired during classroom activities that fostered critical thinking and specifically focused on application skills.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Manias E, Bullock S. The educational preparation of undergraduate nursing students in pharmacology: Clinical nurses' perceptions and experiences of graduate nurses' medication knowledge. Int J Nurs Stud 2002;39:773-84.
Dilles T, Vander Stichele RR, van Bortel L, Elseviers MM. Nursing students' pharmacological knowledge and calculation skills: ready for practice? Nurse Educ Today 2011;31:499-505.
Simonsen BO, Daehlin GK, Johansson I, Farup PG. Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: Comparative study. BMC Health Serv Res 2014;14:580.
Candela L, Bowles C. Recent RN graduate perceptions of educational preparation. Nurs Educ Perspect 2008;29:266-71.
Hughes RG, Blegen MA, Hughes RG. Medication administration safety. In: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. USA: Agency for Healthcare Research and Quality; 2008.
Armitage G, Knapman H. Adverse events in drug administration: A literature review. J Nurs Manag 2003;11:130-40.
Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105-12.
Lincoln YS, Guba EG. Establishing Trustworthiness. Naturalistic Inquiry. USA: SAGE Publications Inc.; 1985. p. 289-331.
Grandell-Niemi H, Hupli M, Leino-Kilpi H, Puukka P. Finnish nurses' and nursing students' pharmacological skills. J Clin Nurs 2005;14:685-94.
Gorgich EA, Barfroshan S, Ghoreishi G, Yaghoobi M. Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Glob J Health Sci 2016;8:220-7.
Cohen M. Patient safety alert: “High-alert” medications and patient safety. Int J Qual Health Care 2001;13:339-40.
Fawaz MA, Hamdan-Mansour AM, Tassi A. Challenges facing nursing education in the advanced healthcare environment. Int J Africa Nurs Sci 2018;9:105-10.
Grandell-Niemi H, Hupli M, Leino-Kilpi H. Medication calculation skills of graduating nursing students in Finland. Adv Health Sci Educ Theory Pract 2001;6:15-24.
Mackie JE, Bruce CD. Increasing nursing students' understanding and accuracy with medical dose calculations: A collaborative approach. Nurse Educ Today 2016;40:146-53.
McMullan M, Jones R, Lea S. Patient safety: Numerical skills and drug calculation abilities of nursing students and registered nurses. J Adv Nurs 2010;66:891-9.
Kaylor SK. Preventing information overload: Cognitive load theory as an instructional framework for teaching pharmacology. J Nurs Educ 2014;53:108-11.
Youngblood N, Beitz JM. Developing critical thinking with active learning strategies. Nurse Educ 2001;26:39-42.
Morales KA. Active learning strategies to enhance nursing students' knowledge of pharmacology. Nurs Educ Perspect 2017;38:100-2.
Kalra J, Singh S, Badyal D, Barua P, Sharma T, Dhasmana DC, et al
. Poetry in teaching pharmacology: Exploring the possibilities. Indian J Pharmacol 2016;48:S61-4.
Cleary-Holdforth J, Leufer T. Senior nursing students' perceptions of their readiness for oral medication administration prior to final year internship: A quantitative descriptive pilot study. Dimens Crit Care Nurs 2020;39:23-32.
Hammoudi BM, Ismaile S, Abu Yahya O. Factors associated with medication administration errors and why nurses fail to report them. Scand J Caring Sci 2018;32:1038-46.
Saleh AA, Barnard A. Barriers facing nurses in reporting medication administration errors in Saudi Arabia. Am J Nurs 2019;7:598-625.
AlThiga H, Mohidin S, Park YS, Tekian A. Preparing for practice: Nursing intern and faculty perceptions on clinical experiences. Med Teach 2017;39:S55-62.
Alharbi AR, Alhosis KF. The challenges and difficulties of the nursing interns during their clinical internship in Qassim Region, Saudi Arabia. Saudi J Health Sci 2019;8:6. [Full text]
Aboshaiqah AE, Tumala RB, Patalagsa JG, Al-Khaibary AA, Fozan HA, Ben JP. Perceptions of confidence among Saudi nursing interns during internship program: A cross-sectional study. Ann Saudi Med 2018;38:288-98.