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COVENTRY UNIVERSITY
How can registered
practitioners be supported
to maintain competence in
the administration of drugs
to their patients
A Literature Review produced by Helen Ford
for the Royal College of Nursing.
June 2011
How can registered practitioners be supported to maintain
competence in the administration of drugs to their patients?
Introduction
Focus on patient safety has been growing in momentum in the past decade, with the
realisation that serious failures in care do occur (DH, 2000). In An Organisation with a
Memory (DH, 2000) statistics are provided which indicate, for example, that:

Adverse events occur in around 10% of admissions to hospital

Adverse events cost £2 billion in additional hospital stays alone
Analysis of incident reports sent to the National Patient Safety Agency’s National
Reporting and Learning System (NPSA NRLS) (2009) in 2007 show that:

there were 72, 482 incidents occurring between 1 January 2007 and 31
December 2007- this formed the basic dataset from which the analysis took place

incidents involving medications were the third largest group of all incidents
reported to the National Reporting and Learning System (NRLS)

the majority of medication incidents had actual clinical outcomes of no harm or
low harm

of 100 reports of death and severe harm, most were caused by wrong
administration (41%), with unclear/ wrong dose or frequency, wrong medicine
and omitted/delayed medicines accounting for 71% of fatal and serious harms

types of medicines most frequently associated with severe harm include
cardiovascular, anti-infective, opioid, anticoagulant and anti-platelet medicines.
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The data does not indicate, however, who the medications were administered by as
medical staff as well as nurses administer medications, for example chemotherapy and
anaesthetic drugs.
System or Human Error?
Clinical governance is defined as a framework through which NHS organisations are
accountable for continuously improving the quality of their services and safeguarding high
standards of care, by creating an environment in which excellence in clinical care will
flourish (A First Class Service: Quality in the New NHS, DH 1998). Clinical governance
requires commitment from the top of the organisation to put care quality and patient safety
at the top of the agenda; a culture of quality, respect and openness, both of patients and
staff; and procedures and practices which enable staff to function effectively. The Audit
Commission (2001) states that hospitals face strategic challenges in relation to medicines,
including linking medicines management to clinical governance. The Audit Commission
further suggests that medication errors occur because of the complexity of the process,
though risk can be minimised by changing the risk management culture, induction and
training, redesigning processes, using computer technology, and developing clinical
pharmacy services.
Building a Safer NHS for Patients, Improving Medication Safety (DH, 2004) highlights two
approaches to error, as described by Reason (2000). The person approach focuses on
errors made by individuals, and seeks to ‘name, blame and shame’. Learning from errors
is not a function of the person approach. By contrast, the systems approach recognises
that human error will occur for various reasons such as understaffing or inexperience, but
that an effective system will have inbuilt safety nets and will learn from error through
generalisation of principles.
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Reason (1990) identified two basic types of error:

slips and lapses where actions do not go according to plan, for example not
administering a dose of medication to a patient prescribed for a particular time,
due to busy nature of the clinical area

mistakes, where the plan is inadequate: for example administering a drug via a
bolus dose through not knowing that it should be diluted.
The Audit Commission (2001) identify that there is a need for continuing training and
competency assessments for all those involved in drug administration, as ‘no-one can prespecify their own ignorance’.
The Professional Perspective
The DH (2004) suggests that current guidance on the standards of administration of
medicines is fragmented and divided between a range of professional and regulatory
bodies. Often written from a uni-disciplinary perspective, guidelines meet professional
rather than organisational aims.
It is estimated that nurses spend about 40% of their time administering medications (Audit
Commission, 2001). The Nursing and Midwifery Council (2004) has set out clear guidance
for nurses on the management of medicines. Its predecessor, the UKCC (2000), stated
that:
‘Administration of medicines is not solely a mechanistic task to be performed in
strict compliance with the written prescription of a medical practitioner. It requires
thought, and the exercise of professional judgement.’
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Single nurse drug administration was condoned in the majority of circumstances by the
UKCC in 1992 and is now the norm for the majority of medication administration. The
NMC (2007) published the Standards for Medicines Management with the intention that in
changing them from the previous ‘guidelines’ to ‘standards’, registrants would believe they
were something that had to be adhered to (Plastow, 2008). Furthermore, Agyemang and
While (2010) state that nurses must adhere to the five ‘rights’ of medicine administration:
the right drug in the right dose to the right patient via the right route and the right time.
Nurses must also know the therapeutic doses of medications and side effects,
precautions, indications and contra-indications, and be able to integrate this knowledge
into the patients care plan. It could be argued that nurses who lack this knowledge are in
contravention of the Code (NMC, 2008). According to the Code (NMC, 2008) it is the
responsibility of the individual practitioner to maintain their competence and ensure that
their skills, knowledge and practice are current.
It would appear, however, that the actual depth of knowledge held by registered
practitioners administering drugs can be open to question, and the DH (2004) suggest that
safe administration cannot be entirely delegated to those actually giving the drug- risk
management must be built into the whole process. This is not necessarily because of lack
of competence; rather it reflects the system approach to medicines management
highlighted above. They recommend:

appropriate training for all staff involved in the handling of medicines

clear drug administration procedures in all settings where medicines are given

double checking by a second person in defined, high risk circumstances eg IV
infusions, complex calculations
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
discussing medication with patients or carers at the time of administration and
involving them in checking where appropriate

storing all medicines safely and in such a way that risk of drug selection errors
are minimised, and controlling availability of high risk drugs.

Utilising IT to support prescribing, dispensing and medication administration.
Research into Drug Errors
There have been numerous research studies examining the incidence and causes of drug
error, and detailed reviews of these have been carried out (for example, Armitage and
Knapman, 2003; Fry and Dacey, 2007; Brady, Malone and Fleming, 2009; Evans, 2009;
McDowell, Ferner and Ferner, 2009.) Relating to drug administration, the following types
of error may occur (DH, 2004):

A patient does not receive a dose of medicine by the time the next dose is due

A patient receives a wrong dose of medicine

A patient receives a medicine which has not been prescribed (wrong drug or
wrong patient)

A drug is administered in a dosage form different from that prescribed (eg slow
release)

A patient receives a medicine at the wrong time

The correct form of a medicine is administered but by the wrong route

The physical or chemical integrity of the medicine has been compromised (eg
past expiry date)

An infusion given at the wrong rate

Inappropriate procedure used during administration of a drug (eg incorrect inhaler
technique)
6

Incorrectly making up a drug prior to administration

Patient receives a dose of medicine in addition to that prescribed

Safety in Doses: Improving the Use of Medicines in the NHS (2009), published by the
National Patient Safety Agency, is designed to enable providers of NHS care to improve
patient safety by learning from medication errors. They define a medication error as
‘….any incident where there has been an error in the process of prescribing,
dispensing, preparing, administering, monitoring or providing medicines advice,
regardless of whether any harm occurred or was possible.’
(NPSA NRLS, 2009:6)
They acknowledge that this definition is broad. The document highlights medication errors
in acute settings, mental health and learning disabilities, primary care, children’s and
elderly patient settings. The numbers of serious medication incidents that caused death or
severe harm is illustrated in Figure 1.
35
30
25
20
death
severe harm
15
10
5
0
prescribing
preparation/
dispensing
administration
monitoring
Stage in medication process
Figure 1. Medication incidents that report death and severe harm by stage of the medication
process (NPSA NRLS, 2009:18).
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Of the administration incidents that resulted in death or severe harm, the NPSA NLRS
(2009) give the following examples:

Administration of potassium chloride as bolus instead of infusion (wrong
administration)

Patient infused insulin instead of midazolam (wrong drug)

Omission of prophylactic heparin (omission)

Trimethoprim to a patient allergic to penicillin/ septrin (wrong drug)

Enoxaparin given to patient with gastrointestinal bleed instead of patient with
similar name (wrong patient)
Additionally, they indicate that injectable medications pose the greatest risk of harm,
though the data do not indicate which professional group was involved in the
administration of these medications. The groups of medications most likely to cause harm
are cardiovascular, anti-infectives, opioids, anti-coagulants and anti-platelets,
chemotherapy, anaesthetics and insulin. The acute sector, of all the patient care settings,
produced the most drug error reports.
It is not the intention to reproduce the NPSA document here, and the reader is directed to
the document for further information. It is clear that analysis of drug errors produces
compelling data for healthcare providers about where resources may be concentrated to
reduce and avoid risk to patients from medications. However, use of error reporting as the
only method of ascertaining staff training needs contains inherent assumptions:
1. That all errors are reported. This is incorrect as the DH in 2004 (p22) stated that
the incidence of medication errors is not known due to low reporting rates. This
has improved since 2004 with the introduction of the National Reporting and
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Learning Service. The acute sector produces the most error reports, followed by
primary care trusts then mental health settings (NPSA, 2009). Actual rates of drug
error reporting in settings where care of vulnerable and traditionally disempowered
clients takes place, for example, is not known.
2. Error reporting is, by definition, the capturing of information when things go wrong
in medicines management. Many thousands of medication doses are administered
to patients each day and seemingly pass without incident. There appears to be
little data on what registered practitioners do know, and how this knowledge is
integrated into everyday practice to ensure the five rights are adhered to.
3. Not all medication administration is conducted by nurses, and error reporting may
not capture information related to profession of the administrator.
4. The actual outcomes in studies measuring drug errors define the term in different
ways. For example, Barber et al. (2009:346) in a study of medicine errors in care
homes for older people used the definition ‘any deviation between the medication
prescribed and that administered’. Ghaleb et al. (2010:114) included deviation
from standard hospital policy and procedure in their definition: ‘……….is the
administration of a dose of medication that deviates from the prescription, as
written on the patient medication chart, or from standard hospital policy and
procedures. This includes errors in the preparation, and administration of
intravenous medicines on the ward.’ Bruce and Wong (2001: 856) further identified
12 operational definitions of drug error upon which to base their observational
study of parenteral medications on an acute medication admissions ward.
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5. The administration of drugs, as defined by the studies above, does not take into
account the ability of nurses to integrate knowledge of medications and
pharmacology into the patient’s care plan, a standard identified by the NMC
(2007). For example, a medication may be omitted precisely because it is not is
not in the patient’s best interests to administer it and is therefore a deliberate,
purposeful act demonstrating thought and judgement.
6. The administration of medications should, where possible, be administered in
partnership with the patient. The changing nature of the relationship between the
patient and professional means that nurses must now provide information for
patients to make informed choices. The definition of a drug error, used in the
majority of studies, is narrow. It does not, for example, include any notion of
information giving at any stage or in any setting: upon discharge from a care
episode or during inpatient treatment for example. Patient concordance with drug
regimes has been shown to increase when they are able to take responsibility for
their own medication (Royal Pharmacological Society, 1997), and it could be
argued therefore that lack of information at the point of care is an administration
error.
7. It is not clear from the research into drug errors whether nurses are expected to
monitor for side effects of or response to treatment as routine.
8. It is widely advised that the administration of medications is the end point of a
series of processes, any one of which carries the potential for error. As such,
incident analysis now aims to identify the root cause rather than blame individuals.
However, for the purposes of the literature review, the wider processes (poor
prescription charts, doctor’s own knowledge, interruptions on the ward) are not of
10
interest; rather the review will seek to concentrate on the knowledge and skills of
the nurse alone. This has meant that most of the literature into drug administration
errors is not relevant to the question of ‘how registered practitioners can be
supported to maintain competence in the administration for medications to their
patients’.
Methodology of the Review
As the review question is broad, initial reading took place to identify a useful direction and
focus for the actual review. Following this wide reading of literature relating to medicine
administration, it was decided that the question could be addressed by two sub-questions:
1. What are the competencies of registered practitioners in relation to medicine
administration?
2. What types of educational and training interventions exist, to support registered
practitioners to maintain competence in drug administration, and how effective are
they?
Search methods
A computerised search of the databases CINAHL, Medline, Science Direct, British
Nursing Index and Academic Search Complete was conducted using the subject headings
and key words of ‘drug administration’ and ‘medicine administration’ and ‘registered’ and
‘practitioners’ and ‘standards’ and ‘nursing’ and ‘education’ and ‘medication errors’ and
‘nursing knowledge’ and ‘competence’ in all combinations. The search was further limited
to literature published between 2000 and 2011, because it was felt that drug
administration standards and competence may have been influenced by the An
Organisation with a Memory (DH, 2000) and A Spoonful of Medicine (Audit Commission,
11
2001) as part of the continuous improvements required by clinical governance. The
reference lists of retrieved papers were also searched.
Inclusion and Exclusion Criteria
Literature was included if it was published in English, from peer-reviewed journals, and
was primary research from any paradigm or a systematic review carried out in any clinical
setting. Evidence from countries other than the United Kingdom was included as it was felt
that it would illuminate the overall concept of competence in medication administration,
despite potential cultural differences. Studies that explicitly concerned qualified nurses’
medication competence in the abstract, literature review or results were included.
Literature was included in the review if it related to any of the aspects of professional
competence as defined by Stuart (2003) in Figure 2.
Studies were excluded from the review if they were related to speciality settings, for
example oncology, and to nurse prescribing. Literature was excluded if it discussed
students, as opposed to registered, practitioners. Narrative literature reviews and audits
were also excluded.
Registered practitioner is defined as a practising registered nurse.
Medication administration is defined as ‘the process by which a medication is or is not
selected for administration to a patient by a qualified practitioner, involving skills and
knowledge of both the patient and the medication, including any patient teaching needed
to facilitate the safe taking of that medication, and monitoring of therapeutic and adverse
effects at any time during the process.’
12
This does not include storage, transportation or disposal of medications. The definition
has been devised by the author.
13
Requires
knowledge and
understanding
Can transfer
skills and
knowledge
Is up-to-date
Competency is
context specific
Self-aware and
knows
limitations
Professional
competence
Maintains
standards of
practice
Can teach
others
Possesses
skills
Is able to deal
with most
contingencies
Follows
polices and
procedures
Recognises
abnormalities
and takes
appropriate
actions
Figure 2: Aspects of Competence (Adapted from Stuart, 2003)
Retrieval of Studies for Review.
The initial computerised search produced a total of 1420 references. The abstracts of
these were assessed for relevance, and if it was not clear from the abstract the article was
skim read. 1076 articles were rejected leaving 344 for further evaluation. Non-empirical
studies were rejected, as were studies whose focus was in a specific setting, related to
nurse prescribing, focussed on a specific medication or method of administration, or
because they focussed on analysis of medication errors. This left 68 articles. From these,
strict application of the inclusion/ exclusion criteria left 16 articles for evaluation. Four were
added from the reference lists of the 16 to total 20 studies.
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The identified literature is summarised in Appendix 1. Each study was analysed critically
on the basis of design, validity and reliability. Ten of the studies were described as
qualitative; one as descriptive correlational; one used mixed methods; three were surveys;
two were case studies; one was descriptive exploratory and one was a systematic review.
Sample sizes were invariably relatively small, using purposive or convenience sampling.
Generalisability and transferability is therefore limited, and conclusions are presented in
light of these limitations.
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Question 1: What are the competencies of registered practitioners in relation
to medicine administration?
Results of the literature review
The data in the 20 studies kept for review was coded into categories. The results and
discussions sections of each study were analysed line by line to identify emerging points.
Each paper was read taking note of points raised individually and in comparison to other
papers read. New points were added as reading took place. To synthesise the data, the
points were categorised into themes. The results of this are presented below.
Policies and Protocols.
Policies and protocols were discussed in 13 of the 20 studies reviewed. Hand and Barber
(2000) conducted semi-structured interviews with seventeen nurses across a variety of
specialties and grades in order to ascertain their beliefs about drug errors. Personal
factors were cited as a main reason why drug errors occurred, resulting in not following
hospital policy. Examples given included not reading the prescription properly and not
reading the dose, frequency or time correctly. Mayo and Duncan (2004) surveyed 983
nurses in the United States and not checking the patient’s name band with the medication
chart was ranked as the seventh highest cause of medication errors, as perceived by the
respondents. The survey respondents had been practising for 1 – 45 years, and
represented medical, surgical, critical care, and maternal child health settings. Mayo and
Duncan attempted to address the low sample size that characterises much research into
drug administration; however the survey used a pre-validated instrument. As such, it is
likely that there are other sources of error not accounted for in the instrument, which,
when combined with the self-reporting may undermine the validity of the results. Manias et
al. (2005) studied 12 graduate nurses in order to explore how they used protocols in
clinical practice and found too that checking patient identity depended on how long they
16
had known the patient; in one instance the identity band was almost illegible yet the nurse
in question did not replace it.
Sanghera et al. (2007) conducted a study to interview staff involved in reported and nonreported medication errors on a 12-bed intensive care unit. Not referring to policy (for
example, intravenous policy) was highlighted as a task-related error- producing situation,
as defined by Reason (1990), whose work provided the framework for the research.
Similarly, Tang et al. (2007) identified that policy was violated by nurses preparing
intravenous drugs in advance of administration time in order to assist the evening staff.
This practice is not recommended due to the possibility of the wrong drug being
administered to a patient or the drug degrading in the interval prior to its eventual
administration.
Other occasions where hospital policy was not followed related to second checking.
Although single-nurse drug administration is the norm in the UK, second checking is
advised in certain circumstances, for example intravenous medication or where complex
calculations are required. Sanghera et al.’s (2007) participants identified that the role of
the second checker in their UK hospital was unclear, and that nurses interpreted the
second check in different ways as the policy did not identify exactly what the second
checker should be checking. Manias et al. (2002) explored hospital nurses’ perceptions of
graduate nurses’ pharmacology knowledge, and some participants acknowledged that the
double checking process was time consuming in a busy ward. This caused the policy to
be ignored as it conflicted with the realities of practice. This instance was repeated in
Manias et al. (2005) where 12 graduate nurses were observed in practice to explore their
use of protocols. They found that although nurses observed their patients taking their
medication in 90% of observed situations, there were instances where nurses left
medication unattended by the patient whilst they carried on with other nursing duties. This
17
was often cited by the nurses as being because of the number of medications a patient
must take, making the process time-consuming.
Although the instances above infer that nurses do not follow policy as a result of personal
negligence, the literature also indicates that policies and protocols are used to guide
medicine administration, as is their intention. Manias et al. (2005) discovered that gradate
nurses use protocols to provide additional security by checking that administration
practices were acceptable, and as a useful source of information, for example how much
fluid to give with certain antibiotics. Manias and Street (2001) investigated nurses and
doctors communicating through medication charts using a critical ethnographic approach.
Nurses used policy as a tool to ensure they were legally covered prior to administering
drugs and to encourage doctors to comply with their role as prescribers, for example
writing a drug in the medication chart rather than expecting the nurse to give it on a verbal
order. Davis et al. (2009) carried out a cross-sectional survey of 278 paediatric nurses
from an emergency department, intensive care unit and medical and surgical wards in
Australia. Their study aimed to describe the explanatory potential of age, paediatric
nursing experience and level of employment on nursing medication practice. With a
response rate of 67%, their findings showed that younger nurses agreed that the person
with whom they checked drugs influenced to what extent they followed hospital policy.
They speculated that this was a function of younger nurses’ desire to lose their outsider
status (no clear distinction was drawn between chronological age and years of experience
however) and to conform to the norms of the clinical area. Thus, the expectations of more
senior nurses were argued to have a role-modelling effect upon younger colleagues. The
mere existence of a policy, they felt, was no guarantee that it would be followed.
Availability of policies was also identified by Davis et al. (2009), as 31% of respondents in
their survey reported difficulties accessing them on the intranet, and the volume of
guidelines, at 30 pages, was too unwieldy to be of practical use. Older nurses were more
18
likely to report a lack of computer literacy, affecting access of protocols, although
multivariate analysis identified this to be time spent on unit rather than chronological age.
Although polices were seen to be of use, the literature also highlights tension between the
clinical judgement of the nurses and the requirements of the policies. Davis et al.
(2009:1294) argue that ‘there needs to be a balance between standardising practice in
protocols and allowing flexibility and autonomous clinical judgement’. Some respondents
to their survey agreed that there were occasions where they did not adhere to the policy
as they were forced to choose between that or acting in the best interests of the child.
Manias et al. (2005) in their observational study found that participants in areas such as
cardiology were able to use structured protocols to provide patient care without having to
seek advice, for example in the management of chest pain. This allowed the nurses to feel
autonomous and aided in decision-making. Eisenhauer et al. (2007) found that nurses
bypassed hospital protocols to expedite getting drugs to patients, such as accepting
verbal orders or initiating intravenous fluid before receiving a prescription. Nurses were
anticipating an order prior to it being written, and felt that it ‘optimized patient care’ (p85).
However, Manias et al. (2005) found that policy could lack a sound basis in evidence,
citing an example concerning inaccuracy in measurement of vancomycin levels.
Conclusions
The literature has explored different grades of nurses but solely in acute settings, from
general or paediatric backgrounds. The literature was conducted in the United Kingdom,
United States, Australia and Taiwan. Tentative conclusions only can be drawn from the
literature from non-UK studies, due to the different cultural settings in which the studies
took place. Nurses may be more or less compliant in different countries, and the
consequences to the nurses of not following policy are unclear. No literature was found
regarding nurses in community, mental health or learning disability settings. The literature
19
was characterised by relatively small scale, qualitative studies that have limited
generalisability, although this was usually acknowledged by the researchers.
Following policies and procedures, as part of nurses’ competence, appears valuable if the
policy is felt to be in accord with clinical practice. Junior nurses found policy to be a useful
source of information, but how well it was followed depended in part on role modelling.
However, nurses demonstrated clinical reasoning both through following policies and
protocols to guide their thinking, and also to deviate from policy where they felt there was
a clinical need. This creates an ethical dilemma. The NMC (2007:2) state that ‘local and
national policies and protocols’ will need to be developed and referred to, to suit local
needs’. It is not clear how such policies are developed, what sources they take into
account in their development, and how they reflect the most up-to-date evidence
available. It is also unclear as to how prescriptive policies need to be, balanced against
the clinical judgement and reasoning skills of registered practitioners.
Nurses’ Knowledge of Pharmacology
If nurses are to make decisions about administration of medications, either within or
without of policy guidelines, then they must have adequate knowledge of pharmacology.
Including pharmacokinetics and pharmacodynamics (Downie et al, 2008), it appears from
the literature reviewed that nurses do not possess sufficient knowledge and understanding
of basic principles. Hand and Barber (2000) studied nurses in a UK teaching hospital, with
a purposive sample of nurses from medical, surgical, and care of the elderly wards, plus
the specialties of haematology, renal, paediatric and neonatal units. All of the nurses in
the sample of 17 identified that errors occurred because of a lack of knowledge of drugs.
Nurses ranked ‘confusion between 2 drugs with similar names’ as the 4th highest error
producing factor in Mayo and Duncan’s (2004) study, yet interestingly, specific
pharmacology knowledge was not included in the causes. Sanghera at al (2007) found
20
that lack of knowledge (such as maximum daily dose of diclofenac) was apparent as a
contributor to medication errors. Tang et al. (2007) asked nurses to identify contributing
factors to a medication error they had experienced. Unfamiliarity with medication was
ranked as the third highest factor, with the elderly being most at risk due to polypharmacy
and the number of contraindications.
Manias et al. (2005) identified that nurses may fail to draw on pharmacological knowledge
prior to administering a drug, citing the example of trying to administer insulin before
checking a patient’s blood glucose level. Hsaio et al. (2009) found in their study of 305
Taiwanese nurses that their knowledge of high-risk medications was inadequate, including
administering bolus doses of intravenous potassium chloride, use of insulin syringes, and
administering epinephrine in allergic reaction. Only 3.6% of the nurses sampled felt they
had sufficient knowledge of such medications, with their self-rated lack of knowledge
perceived as the most significant barrier to safe administration. Clinical nurses in Manias
and Bullock’s (2002) study identified that undergraduate nurses appeared to lack basic
pharmacology knowledge, including lack of understanding of medication family groups
and terminology. Knowledge that was deemed important included medication actions,
therapeutic and adverse effects, allergic tendencies, common medication groups,
competent administration skills and ability to look up information. Ndosi and Newell (2008)
conducted a test of the knowledge of mechanism of action, indications, contraindications,
normal adult dosage, important drug interactions, common side effects and nursing
assessment points of the four most commonly administered drugs. The sample was of 42
surgical nurses with the median level of experience being 10. 87 years post-registration.
The findings showed that knowledge of normal doses, indications and side effects was
adequate but the other types of knowledge was poor, including mechanism of action and
interactions. There was a correlation between years of experience and knowledge.
21
King (2004) conducted a qualitative study in the UK exploring qualified nurses’
pharmacology educational needs. Semi-structured interviews were used to elicit
perceptions of pharmacology needs of 10 staff nurses from an emergency admissions
unit. King found that 7 out of 10 of the respondents had limited understanding of
pharmacology, illustrated by the requirement to discuss anti-hypertensive drugs. Three of
the ten gave information that was factually incorrect, as identified by referring to the British
National Formulary following the interview. Interestingly, when asked about side effects of
medication, King reports that 8 out of 10 were able to identify low blood pressure as a side
effect of anti-hypertensives, while most identified urinary frequency as a side effect of
diuretics. It is remarkable that this very basic knowledge was felt to demonstrate
knowledge of side effects. The respondents did suggest that their pharmacology
education prior to qualifying was inadequate, lacking in content and structure. As a result,
they felt anxious and under-prepared on qualifying. Post-registration education tended to
be related to specialties eg cardiac study days, with little input on medications.
Accountability was highlighted, with nurses in the study saying that they had to be aware
of what they were giving and why. This was echoed by Hand and Barber (2000). Manias
and Bullock (2002) identified that qualified nurses may gain pharmacology knowledge in
one setting but if they move to another then it was difficult to keep pace with change. New
drugs also presented a problem as there was no formal way of updating. Kelly et al.
(2010) identified that casual workers, for example agency staff, may lack setting-specific
knowledge; however length of qualifying appeared to give a false sense of security to one
member of staff in their study, as their length of experience was felt to give them suitable
skills of administering drugs to dysphasic patients. In fact, the member of staff in question
made several errors in the administration of drugs to a dysphasic patient.
Manias and Street (2001) present an alternative view of nurses’ pharmacology
knowledge. In their critical ethnography of nurses and doctors communication through
22
medication charts in an ITU, they identified that the nurses’ knowledge was better than
that of the resident doctors’. This created tension as the nurses’ decisions about
medications was invisible, yet they were they ones advising the doctors who were
represented as the prescriber and holder of knowledge on the medication chart. Manias
et al. (2004a) found that nurses used knowledge of medications in their decision making
when managing patients’ medications, as did Eisenhauer et al. (2007). In the mental
health setting, Duxbury et al. (2010) found that nurses utilised pharmacology knowledge
to ensure patients received the correct dose of medication where there was inaccuracy in
a prescription.
Conclusions
Overall, the literature paints a mixed picture of nurses’ understanding of pharmacology.
The studies reviewed do not include data from paediatric, community or learning disability
settings. Only one represented the mental health setting. Two of the studies were based
in Taiwan, with four from Australia and one from the US. It is not clear from the literature
what level of pharmacological knowledge is sufficient, as the studies reviewed have
concentrated upon observation of nurses’ practice or questioning of nurses about different
drugs. As there is no common benchmark it is impossible to ascertain what nurses should
and should not know, though it appears that nurses’ knowledge varies between settings,
with those in ITU demonstrating a high level of knowledge. The NMC (2007) Standards for
Medication Management require that nurses must know the therapeutic uses of
medications to be administered, normal doses, side effects, precautions and contraindications. However, the position of nurses as the final component in the process of
medication safety serves to highlight that though the NMC standards may encompass all
of the knowledge a nurse requires, it is difficult to see what the difference is between the
knowledge that a nurse as administrator and (usually) doctor as prescriber must possess.
If a prescriber must make a decisions to select a particular drug based on a patients’
23
profile, then the boundary between that act and the nurses understanding of the patients’
care plan and therapeutic actions/ adverse effects of medications has not yet been clearly
delineated.
Treating the Patient
Evidence from the literature suggests that nurses do integrate their knowledge of
medications into their knowledge of the patient. Manias et al. (2004b) identified that
graduate nurses assessed patients prior to administering medications, checking blood
pressure, respirations, pulse and temperature. Other methods of assessment included
cardiac rhythm, clinical signs and pathology tests, for example. This was not uniform
among their respondents however: not all nurses completed checks of vital signs just prior
to administering drugs if they were done within the previous few hours. Evaluation of
pathology results and electrocardiograms (ECGs) was also variable, dependent on
whether the nurses felt they could interpret them or not. Some argued that that was the
doctors’ responsibility. The nurses in Manias et al.’s (2004b) study were graduate nurses,
which is presumed to mean the first year of qualifying, although this is not identified
explicitly.
Eisenhauer et al. (2007) too found that nurses utilised patient information from a variety of
sources in order to make decisions about drug administration, including timing of drug and
dose, where appropriate. The nurses also considered the route of administration, for
example changing from injection of morphine to an oral analgesic. The nurses in this
study were experienced nurses however, with the mean number of years of practice being
11.2. King (2004) identified that three of the ten nurses from her sample suggested they
used vital signs to guide drug administration, citing the example of anti-hypertensives to a
patient with low blood pressure. Blood glucose and oxygen saturations were also given as
examples of patient information used in decision-making about drug administration. In her
24
study, King chose respondents who were not newly qualified, on the basis that those with
experience would have something to contribute to the discussion. Hand and Barber
(2000) interviewed seventeen nurses from one large teaching hospital in the UK, and
suggested that the level of experience may be an influencing factor in how much patient
data nurses take into account when administering medications to patients. Hsaio et al.
(2009) surveyed 305 nurses about high-alert medications using an instrument validated
for its discriminatory power, and found that a higher level of experience contributed
significantly to a higher score on the objective part of their study. Self-evaluation in turn
correlated positively with a high score. Manias and Bullock (2002) found that clinical
nurses’ evaluation of graduate knowledge was lacking, including mechanism of action of
medications, as well as effect (intended or not) on the patient.
Manias et al. (2004a) analysed the decision-making models of graduate nurses and
suggested that hypothetico-deductive reasoning was the most common method of making
decisions, regardless of the disease process being treated and medications prescribed.
This resulted in patient problems being managed in a ‘routine and uniform way’, with the
result that some of the nurses observed did not make appropriate connections between
the medications to be administered and a therapeutic goal. Pattern-recognition was
another decision-making approach, and in a separate article (likely to have used the same
sample of nurses as the Manias et al.’s 2004b study), carefully structured protocols were
highlighted by Manias et al. (2005) as enabling nurses to integrate pharmacology and
knowledge of the patient into a meaningful whole. This occurred particularly in cardiac
settings, more so than in general medicine, rehabilitation and neuroscience. In settings
that utilised such carefully structured protocols, nurses were able to develop awareness of
the types of medications commonly administered to a particular group of patients.
However, a disadvantage of this was that nurses did not always make use of patient cues
to alter drug administration, as in the case of giving heparin to a surgical patient. This is
25
usually correct, except that the patient in question was about to be discharged therefore
did not need the drug.
Eisenhauer et al. (2007) suggested that nurses planned and carried out actions according
to anticipated side-effects of drugs, for example acting on blood glucose results. Nurses
were also able to anticipate adverse reactions and plan interventions or precautions, for
example in the giving potassium to a patient with renal dysfunction. Eisenhauer also
highlighted the giving of analgesia prior to physiotherapy, and in her discussion stated that
nurses were constantly vigilant in ensuring that patients received appropriate medications.
She went on to state that nurses engaged in highly complex thinking to ensure good
patient outcomes. However, with PRN (pro re nata) medications, graduate nurses’
responses suggested a conservative approach according to Manias et al. (2004b), starting
on the lowest prescribed dose and working upwards in response to the patients’ signs.
Patients tended to be given PRN medications if they had been taking them at home or
over the last few days. However, if a PRN medication had not been administered at all
over recent days, the graduate nurses would not administer it, relying on patients to ask.
Chakrabarti (2010), in a systematic review, found that nurses PRN administration of
psychotropic medication was not based on high-quality evidence but reflected clinical
experience and habit. PRN medication, they suggest, was often used to calm upset
patients instead of other spending time with them or exploring other treatment options
may have been of value.
Tang et al. (2007) suggested that prescriptions such as those for the elderly, or with
chronic or critical conditions, could be more prone to error due to the complexity of polypharmacy, making it hard for nurses to identify which drug caused which effects.
26
Following the administration of drugs, evaluation of the effects of medications was found
by Manias et al. (2004a), Manias et al. (2004b), Eisenhauer et al. (2007) and King (2004).
The most commonly assessed signs and symptoms were those relating to the therapeutic
effects of analgesics, aperients and anti-emetics (Manias et al.., 2004b); antihypertensives, analgesics, anti-emetics and medications for agitation (Eisenhauer et al.,
2007). The reason for this was suggested to be that it was easy to ask the patient and get
a response; with other medications, nurses were not able to comprehend the results from
tests analysed outside the ward, for example pathology results. In the mental health
setting, nurses felt that observing for and evaluating side-effects in patients was a key part
of their role (Duxbury et al., 2010).
Conclusions
Overall, it would appear that nurses may not see medication administration as a purely
technical exercise, and that knowledge of pharmacology, patient clinical conditions and
reasoning form part of the process of ensuring patients receive appropriate medications.
The literature would appear to suggest that a higher level of experience in years
correlates with a greater ability to integrate these forms of knowledge into a meaningful
whole. There appears to be an inherent contradiction from the literature however, in that
nurses’ pharmacological knowledge evaluates as being poor, yet studies have found that
they exhibit sufficient knowledge to be able to make complex clinical decisions. It is not
clear how the extent of pharmacological knowledge is related to experience in a clinical
setting, or how this affects ability to think critically and make complex decisions. Protocols
and policies seem to assist in decision-making within certain clinical environments, where
a degree of discretion is required. This is interesting in the context of patient-group
directions (PGDs) and further evaluation of how nurses use these and of the
appropriateness of the decisions made, stratified by factors such as setting and grade,
would be useful to establish patterns of decision making.
27
There appears to be an implicit understanding that nurses will evaluate the therapeutic
outcomes of some drugs and yet others are the responsibility of doctors. How much this
varies from area to area or nurse to nurse, and whether any variation is acceptable, is not
clear. Examples exist whereby long-term therapy is not monitored adequately, either for
therapeutic outcomes or adverse effects: an audit by the Prescribing Observatory for
Mental Health (2006) found that only 11% of records for people using the services of
assertive outreach teams had documented that appropriate physical health tests had been
carried out. How professionals negotiate these understandings is unclear, and whether
assumptions made on the basis of how nurses and other professionals operate in one
clinical area impacts upon another, and the effects on patient outcomes, is not known.
The DH (2001) state that for older people, treatment monitoring should be carried out and
that this should include whether the patient is able to take medications and if any
problems are occurring. There is no evidence from the literature that this is occurring
routinely. Specific administration directions also warrant further investigation, such as the
meaning of PRN to different nurses, again exploring how decisions are made including the
evidence-base, and the factors the practitioners take into account.
Sources of Information Used by Nurses
The explicit focus of only one study (Manias et al., 2005), policies and protocols, as
mentioned above, were a useful source of information about timing and drugs to
administer for specified patients in particular settings such a cardiology. For information
other than this, it has been possible to infer from other studies that nurses utilise a variety
of sources of information about medications, both during the drug administration process
itself, and as methods of updating professional knowledge. When actually administering
drugs, pack inserts were used to provide information on parenteral medications (Manias et
al., 2005). Guidelines on how to mix and administer intravenous medications safely,
28
including amount and type of diluent, route (peripheral or central) and whether a filter is
required or not was identified by nurses in Eisenhauer et al.’s (2007) study. More
experienced colleagues were found to be consulted regularly by graduate nurses in Davis
et al.’s (2009) survey of nurses in an Australian paediatric hospital. However, this could
lead to difficulty according to Hsiao (2009) as inconsistent opinions existed between
nurses themselves about medications, while Manias and Bullock (2002) in their discussion
felt that possibly a lack of pharmacological knowledge among qualified, experienced
nurses prevented them from taking a more active role in teaching junior colleagues.
Other health professionals were identified as being a source of information about
medications and their administration, for example pharmacy (Manias and Bullock,
2002:780) because ‘as a nurse you are not expected to know everything’ (quote from
participant). The pharmacist could be consulted about certain circumstances such as
crushing tablets when administering to a dysphagic patient (Manias et al., 2004b),
although Kelly et al.’s (2010) observational study of two incidents of medication
administration to dysphagic patients suggested that this does not always happen. Of the
two nurses in their study, one had been qualified for some time, and the other was an
agency nurse. Both made errors in the administration of medication to a dysphagic
patient, suggesting that in fact, the need to consult with others is not always apparent.
This may have been a function of experience and over-confidence in ability and
knowledge.
Reference manuals were cited as a resource in King (2004), with nurses learning being
self-directed from the British National Formulary (BMA, RPSGB) or other manuals
(Manias and Bullock, 2002). The accountability of maintaining knowledge was highlighted
in King’s (2004) study, as nurses recognised the importance of ‘knowing what you are
giving and why’. For continuing professional learning, the respondents in King’s (2004)
29
study felt that education was usually related to specialist courses (for example cardiology)
but that pharmacology tended not to be a feature. More structured learning in practice
was felt to be of benefit, rather than increased theoretical knowledge, and the ward
manager could be key in this by testing staff (Hand and Barber, 2000; King, 2004).
Finally, the patient was seen as a resource in Manias et al. (2005), Manias et al. (2004a)
and Manias et al. (2004b). This agreement must be interpreted with caution however, as
each study reports using a sample of 12 graduate nurses from a metropolitan teaching
hospital- it is likely that each article reports on the same sample.
Conclusions
The literature highlights several sources of information that nurses use, both during drug
administration and as resources for professional updating. There appears to be an
acknowledgement that nurses are not expected to know everything, and that being able to
find relevant information is as important as in depth knowledge. Whilst this may be true to
some extent, a wide variation in practice may occur, with the individual nurse’s personally
held expectations of accountability and consequent conscientiousness dictating the
resources consulted. The studies illuminating resources for medication information are
mainly based on small, purposive samples from acute areas, with limited generalisability
to other settings, for example community, where information may be harder to obtain in
the course of everyday practice. How nurses obtain information about new drugs, or
changes in formulation or name, or indeed changes in policy is not clear and further
evaluation of what sources are used, and how often they are consulted in different
settings, including the independent sector, would seem to be warranted here. The
dynamic nature of medication administration would serve to highlight the need for
continual updating, yet relying upon self-directed learning may not be the most reliable
method by which this could occur. The principles of clinical governance suggest that
30
employers must shoulder some of the responsibility for ensuring staff work safely.
Procedures for updating nurses, as well as the content of post-registration study
programmes may also be a fruitful area of enquiry to establish current standards, content
and inadequacies. Evaluation of such programmes in respect of patient outcomes would
provide a baseline from which further development could take place. The setting for
education is also unclear: whether this would be best delivered as an ongoing practicebased activity or as a unit of formal study, for example. If practice-based, how this may be
facilitated and by whom needs to be explored- accompanying nurses on medication
rounds might be useful, but whether this should be the pharmacist, ward manager,
practice facilitator or a combination is, as yet, unexplored. Choice of teaching method
(problem-based learning, teacher directed, reflection, discussion etc) would be a valuable
area for further research, evaluated not only in respect of increased nurses’ knowledge
but also reduced medication incidents and improved patient safety.
Teaching Patients
Patient education regarding medications was identified by Manias et al. (2004a) in the
context of advising a patient about incorrect use of an antibiotic for stomach cramps.
Manias and Aitken (2004b) found that nurses prepared patients for discharge by advising
them about their medications, though some nurses felt this should be the responsibility of
the pharmacist. King (2004) found that nurses needed pharmacology knowledge to be
able to teach patients about their medications during the course of a care episode.
Teaching about medications on discharge (TTOs) was also identified, with six out of the
ten respondents feeling confident to advise, not necessarily because they had the
knowledge but knew where to get it by looking it up. Some respondents in King’s study
echoed Manias and Aitken (2004b) by suggesting that the pharmacist would be the best
person to advise on TTOs. Respondents in King’s study also felt that patients showed
little desire to learn about their medications. This may well have been a function of the
31
emergency admissions unit that the nurses were drawn from, as many patients would
have been acutely ill and possibly elderly, so reflecting the balance of power that lay in the
nurses’ favour.
Rycroft- Malone et al. (2001) evaluated the notion of consumerism in healthcare and
conducted a study of nurse-patient interactions in seven different settings, including
adults, older people, mental health and community. They found that the interactions were
dominated and led by the nurses, offering little opportunity for patient choice. Interactions
in mental health and rehabilitation settings were less likely to be dominated by the nurses
however, with more of a ‘partnership’ approach evident. Interviews with patients postobservation were generally positive with the superficial information given however, though
the authors suggest that later follow-up interviews may have elicited different patient
needs. Findings from three focus groups of carers suggested that in contrast to the
patients themselves, carers would have liked more information on side effects to observe
for, but did not want to appear overbearing by asking specifically.
In contrast, Duxbury et al. (2010) conducted interviews with patients (n=57) and nurses
(n=24) post medication administration in an acute mental health ward. She found that
nurses viewed information sharing as part of the therapeutic alliance with patients, and
they highlighted how they had a duty to provide current and accurate information about
medications to their patients. However, Duxbury et al.’s study highlighted a tension for the
nurses between wanting to care and the need to be authoritative in order to enforce
medication taking. This was echoed by the patients who felt it best to comply whilst they
were in hospital, even despite mixed views on the benefits of medication balanced against
side effects. Patients valued information giving however.
32
Conclusions
The literature evaluating the teaching of patients is patchy and inconclusive. The limited
evidence available suggests that as nurses’ pharmacology knowledge is limited so is the
quality of patient teaching. Effective patient teaching is dependent on assessment of need
and ability to understand and retain information, as well as effective communication skills
on the part of the nurse. In the settings studied to date there appears to be a variance in
the needs of patients, and a lack of agreement between patients and carers as to what
constitutes sufficient information. Further research into the needs of patients in different
clinical settings and specialities is therefore necessary, utilising innovative and sensitive
methods to elicit information from patients reluctant to criticise health professionals, for
example the elderly or mental health clients. Evaluation of different models of information
delivery is also needed, as it is unclear whether one large teaching session is more
effective prior to discharge than smaller, ‘bite size’ interventions spread out over a period
of time, for example.
Furthermore, it is assumed that nurses are those that should deliver patient education
about medications upon discharge, but in the context of evolution of nursing and other
healthcare professional roles, this may be erroneous. Indeed, the role of the patient is
also evolving, and current teaching practices as identified in the literature do not reflect
concordance, whereby there is a sharing of beliefs about medications. Patients with longterm conditions, for example, may purposefully choose not to take a certain medication if
its side effects outweigh the benefits on a particular day, for example. How nurses
integrate this information into a plan of care, and how it is best elicited from patients is
worthy of further investigation. There is increasing evidence that patients purchase drugs
from online sources- this is perfectly legal, but creates conflict for the nurse when advising
on medications. It is unclear whether the nurse should be advising against this outright, or
if there is a place for patient education that acknowledges the benefits as well as the risks.
33
Finally, more inpatient areas are enabling patients to self-administer their own medication
from locked cupboards. While in accordance with the NMC’s Standards for Medicines
Management (2007), further research evaluating the needs of patients and the
effectiveness of teaching interventions when medications are changed is required.
Medication Errors
Hand and Barber (2000) used semi-structured interviews with seventeen nurses who were
purposively selected to produce a heterogenous sample. They found that there was
disagreement over what constituted a medication error. Some nurses referred to ‘anything
not prescribed by the doctor’ while others mentioned the ‘five rights’ of medication
administration. The importance of medication errors was discussed with the main
consequences being medical, psychological effect on the patient, including loss of trust,
and consequences for the nurse. Opinion was divided however, with some nurses
suggesting that an error didn’t count if it did not have any effect on the patient. Not all
errors therefore, were reported and some nurses felt that if they could ‘get way with it’ they
would do so, particularly to avoid blame. However, the types of errors that should be
reported included wrong person, wrong drug, giving a drug too often, controlled drug
errors, intravenous drug errors, errors that had occurred over a number of days and those
with serious side effects, for example gentamycin. The benefits of reporting drug errors
were that staff could learn from them, and avoid a repeat of the incident. What to do in the
event of a drug error was a source of uncertainty: the nurse in charge should be informed
at the time of the incident, plus the doctor. Two nurses would have told the pharmacist.
Telling the patient caused a moral dilemma for the nurses.
Mayo and Duncan (2004) surveyed 983 registered nurses in the United States, and found
similar results: not all errors were reported because there was lack of clarity over what
constituted a medication error. An error was not considered important if the patient was
34
unharmed; this was repeated in Sanghera et al.’s (2007) study conducted within an ITU.
Learning from medication errors was felt to be important, but staff stated that opportunities
for this were limited. Targets were suggested by one nurse as being a reason for not
reporting, as the unit in question wanted to reduce the number of incident reports. Manias
et al. (2004b) also found through observation that graduate nurses were unsure about
what constituted a medication error, and timely debriefing did not always occur.
Conclusions
Although the published evidence to date is limited, it would appear that there is lack of
clarity over what constitutes a medication error. In part, this may relate back to the theme
of policy and protocol, in that nurses may feel that although they may not have followed
policy, a medication error has not occurred if the action was made in the best interests of
the patient. However, lack of knowledge and understanding is highlighted again, and
evaluation of strategies to update and refresh nurses on errors is warranted.
Numeracy
Surprisingly, there were only two studies that met the inclusion/ exclusion criteria for the
review. Grandell-Niemi et al. (2005) assessed the mathematics ability of nurses and
student nurses in Finland and found that there was a significant difference between the
abilities of nurses and students in calculating conversions, tablets, fluid rates, dose/ body
weight calculations and duration of ordered medication pack. However, years of nursing
experience showed no correlation with actual performance in the test. In contrast,
Grandell-Niemi et al. (2003) evaluated the medication skills of 546 Finnish nurses from
one hospital (56% response rate) and found that the youngest nurses felt that
mathematics and dosage calculations were easy and that their skills were adequate, in
comparison to the older nurses who had been qualified for 30 years or more. The
researchers gave the nurses a calculation test involving arithmetic, conversions (e.g.
35
decilitres to millilitres) and dosage calculations such as drop rates. The pass mark was set
at 100%, and not one nurse obtained this mark. The most common arithmetic error was
the incorrect placing of the decimal point, which, as pointed out by the researchers, could
have a large impact upon drug administration safety. Two thirds of nurses answered all
conversions correctly, while in dosage calculations the percentage of correct answers was
85% or the sample.
Conclusions
There is little empirical data to be able to assess the competency of nurses in
mathematics. It appears to be a cause for concern (for example DH, 2004); however there
is little evidence to support or deny that poor nurses’ mathematics skills result in drug
administration errors. Further evaluation of required mathematical skills is needed, set
within the context in which they occur, as Wright (2009) argues that the calculation ability
of nurses is both overestimated as a problem and is context dependent.
Overall Summary
The main points that can be inferred from the literature review into the competencies
required by nurses in order to administer medication safely to their patients are:
1. A lack of clear standards of education, both pre and post-registration means that
nurses must enter and remain in the profession with widely differing knowledge
and understanding, not only of pharmacology, but of legal and policy frameworks,
accountability, numeracy, assessment and evaluation of drug therapy, and
promoting patient safety. This is not new, as the Audit Commission in 2001
identified that there is a need for continuing training and competency
assessments. More research needs to be done to inform the establishment of
minimum standards of knowledge, both upon qualifying and through the bands.
36
2. Nurses appear to be aware of their accountability when administering medications
to patients, but commitment to this accountability is modified by other factors
related to practice in the real world, for example single/double checking
procedures or checking a patient’s identity. Though the NMC’s (2007) Standards
for Medicines Management are clearly worded, it seems that operationalising
these standards is interpreted differently between nurses in different settings.
Competency is acknowledged to be context specific (Stuart, 2003), yet lack of
compliance with the overarching standards of the NMC is tolerated within the
profession. How compliance can be achieved is yet to be tested, and the
methodological weaknesses of the studies reviewed serves to highlight this further,
being small scale and fragmentary.
3. The evidence also reveals a fundamental lack of evaluation of the interprofessional
nature of drug administration. There is little explicit evidence that clearly delineates
the roles and responsibilities between the professions. It is possible that such
delineation is outmoded and no longer relevant to today’s healthcare; however this
is not clear. The impact of each profession’s actions upon the others has not been
explored, and evidence of professions engaged in dialogue to explicate their
respective expectations was not found.
4. Nurses appear to enjoy autonomy, and seem to exercise professional judgement
and make decisions despite fragmented and often self-gained knowledge. This
desire for autonomy should be harnessed, and so policies and procedures should
be constructed to allow autonomy where possible. Discussion needs to take place
to achieve a balance between professional autonomy and the need to minimise
37
risk, otherwise policies become irrelevant to practice. Evaluation of patient
outcomes will test if such a balance can be achieved.
5. Patients vary in their need for information on the medications they take. Further
exploration of how nurses can teach patients effectively, in different settings is
warranted, including user-perspectives. Different models and methods of delivery
of information need to be evaluated.
38
Part 2: What types of training or educational intervention to improve
competence in drug administration exist and how effective are they?
Search Methods
The same databases and limiters were utilised as for Part 1 of this review, using headings
and key words of ‘drug administration’, ‘medication administration’, ‘education’, ‘training’,
‘nurse’, ‘registered practitioner’.
Inclusion and Exclusion Criteria
Literature was included if it was published in English, from peer-reviewed journals, and
was primary research from any paradigm or a systematic review carried out in any clinical
setting. Evidence from countries other than the United Kingdom was included as it was felt
that it would illuminate the overall concept of competence in medication administration,
despite potential cultural differences. Studies that explicitly addressed the education or
training of nurses in relation to drug administration were included.
Studies were excluded from the review if they were related to speciality settings, for
example oncology, and to nurse prescribing. Literature was excluded if it discussed
students, as opposed to registered, practitioners. Narrative literature reviews and audits
would also have been excluded, though none were found.
Retrieval of Studies for Review.
The initial computerised search produced a total of 420 references. The abstracts of these
were assessed for relevance, and if it was not clear from the abstract the article was skim
read. 386 articles were rejected leaving 34 for further evaluation. From these, strict
application of the inclusion/ exclusion criteria left 9 articles for evaluation.
39
The identified literature is summarised in Appendix 2. Each study was analysed critically
on the basis of design, validity and reliability. Sample sizes were invariably relatively
small, using purposive or convenience sampling. Generalisability and transferability is
therefore limited, and conclusions are presented in light of these limitations. Thematic
analysis of these studies has not been done as it was not appropriate; rather the studies
are presented by primary outcome.
Medication Safety
Dennison (2007) conducted a quasi-experimental study evaluating the effects of two
thirty-minute computer-based models designed to improve nurses’ knowledge of
intravenous medication safety. The first module covered general content related to
medication safety while the second, developed by Dennison, was entitled intravenous (IV)
infusion of high-alert medications. Nurses’ behaviours related to IV medication
administration were evaluated on 4 key factors: infusion pre-mixed or pharmacy-made;
labelling of the infusion bag; whether the infusion was ‘in guardrails’ (pre-configured limits
programmed into infusion pumps), and labelling infusion line. Data was downloaded from
the infusion pumps to reveal whether nurses altered guardrails and there was no
statistical difference in scores pre and post education intervention. The only behaviour
that showed statistically significant change was labelling of the bag (p = 0.033). Dennison,
in the discussion, felt that a change in knowledge does not necessarily produce a change
in behaviour. However, in the context of this study, there were numerous threats to
validity: small sample size at a single site, dropout not accounted for, and as Dennison
acknowledges, it was impossible to isolate data from infusion devices for only nurses in
the study so contamination of results may have occurred. The program was felt to be costeffective however.
40
Observed Reduction in Medication Errors
Ford et al. (2010), Franklin et al. (2011) and Schneider et al. (2006) conducted studies
whose primary outcome was reduction in medication errors. Ford et al. (2010) studied the
impact of simulation-based learning versus traditional lecture-style upon medication
administration errors. Twelve nurses from a medical intensive care unit were presented
with a lecture on medication administration errors pertinent to their unit. Medicine
administration error was defined as discrepancy between the dose ordered and the dose
administered. The content of the lecture was derived from pretest observation of
medication administration practices in the unit and included proper techniques, solutions
to common problems and consequences of errors. The other intervention group was 12
nurses from a coronary care unit who attended a simulation-based education intervention
using a human-patient simulator. Case scenarios were presented to the nurses who had
to discover and remedy errors. Each group of nurses were observed administering
medications by trained observers pre and post-intervention to identify medication errors
over 4 hour periods: at baseline, 1-4 weeks after the intervention and 8-12 weeks after the
intervention. Errors were expressed as a percentage of total doses given during the
observed periods. Each nurse also had to take a quiz to ascertain knowledge before and
after the intervention. Ford et al. (2010) concluded that the simulation-based intervention
was effective at reducing error rates (30.8% error rate at baseline compared to 4.0% post
intervention, p < 0.001) whereas for the lecture there was no significant reduction in errors
(20.8% compared with 22.7%, p = 0.672). Interestingly, the error rate rose for the lecture
group, the cause of which was unclear. Both groups of nurses had mean higher quiz
scores after the educational interventions (6.91 ± 1.62 and 8.83 ± 1.03 for the lecture
group; 7.45 ± 0.82 and 9.09 ± 0.94 for the simulation group). Ford et al. concluded that the
simulation-based learning was more effective in effecting a reduction in observed errors;
however the validity of the study is marred by a lack of randomisation of nurses to the
intervention, lack of control and small sample size.
41
Franklin et al. (2011) conducted a study with 19 nurses evaluating the effect of 11 halfhour computer-based modules on subjects related to medication administration, including
using the drug chart, drug omissions, drug calculations, blood, warfarin and infusion
pumps. Observation of drug rounds was conducted by pharmacist observers using a
validated method, pre-intervention and post. The definition of error used was similar to
Ford et al.’s: ‘any dose of a drug given that deviated from the patient’s current drug
orders’. Franklin et al. (2011) concluded that the online modules did not produce any
significant reduction in observed error rates. Prior to the education intervention, the error
rate was 6.9% compared with 5%. This did not reach significance at a 95% confidence
interval. The most common observed errors were omission, wrong dose, extra dose and
fast IV boluses. If fast administration of IV drugs was excluded, the results did show a
significant reduction in errors. Like Ford et al.’s (2010) study however, there was no
control or randomisation of nurses to intervention and the sample size was very small.
This clearly limits the study’s validity. Both Ford et al. (2010) and Franklin (2011) used
opportunity for error as their unit of analysis; however this method does not account for
variation between individual nurses and gives a result of errors overall.
Schneider et al. (2006) studied the effect of an interactive CD ROM programme on
medication administration errors. Thirty nurses from community hospitals were
randomised to either a control group or group using an interactive CD ROM package on
‘basic medicine administration’ and included basic principles of medication administration,
patient allergies, taking and transcribing physician orders, reporting errors and
communication. Schneider et al. (2006) defined medication errors into 3 categories: ‘core
1’ included mainly those activities leading up to the administration of a drug such as
checking the patient’s armband, double checking the drug record, and witnessing the
dose being taken prior to signing. ‘Core 2’ errors were preparation and administration
42
errors including incorrect time or technique of administration while ‘core 3’ errors were
deviations from prescribed therapy. Using the nurse as the unit of analysis, error rates
were calculated for each individual nurse and results presented as the average for all
nurses in each group. The results showed that the nurses in the CD ROM group made
significantly fewer ‘core 1’ errors than at baseline (65% at baseline compared with 55%
post-intervention, p<0.001) compared with the control group (63% at baseline compared
to 74% post intervention, p<0.001). For ‘core 2’ errors, the CD ROM group error total was
higher post-intervention though not statistically significant (4.4% pre vs. 5.9% post)
whereas it went down in the control group (7% pre vs. 5% post). This is explained by the
authors as these types of errors were not featured in the CD ROM package. They
concluded by suggesting that the CD ROM improved adherence to safe medication
practices. It must be noted though that similar threats to validity apply as to the previous 2
studies, and that the improvement to adherence was not seen in all of the observed
categories.
Knowledge and Self- rated Performance
Tsai et al. (2004) evaluated a computer-assisted multimedia training course on nurses’
knowledge and self-perceived performance in intravenous injection. The content of the
course included aims of intravenous injection, blood vessels, equipment, technique,
administering medication and removing IV sets, and was delivered using film, voice, text
and visual images such as graphs. Using a sample of 81 novice nurses assigned to an
experimental or control group, a pretest established participant’s knowledge of
intravenous injection administration. Nurses were randomly assigned to each group; the
experimental group took a 30 minute computerised training package 3 times then took the
first post-test. The test was an intravenous injection knowledge test and satisfaction
questionnaire while the control group had only the knowledge test. Two weeks after the
programme each group took a second knowledge test and self-perceived performance
43
questionnaire; in addition the experimental group took another satisfaction questionnaire.
The results showed that the education programme had a significant effect on the
knowledge of the experimental group (t = 6.754, p < 0.05) and that this effect remained
two weeks after the intervention at the second post-test. No effect was observed for the
control group. Performance was also evaluated using a questionnaire with Likert-scale
questions. After the second post-test, there was no significant difference between the two
groups, but analysis of covariance showed that prior experience of injections did make a
significant difference. Satisfaction with the multimedia programme was rated highly. This
study is interesting in that the multimedia package appeared to produce an increase in
knowledge and self-rated performance; however the fact that performance was not rated
in clinical situations by an independent observer is a weakness of this study. Although the
researchers took pains to randomise the participants, establish that there was no
significant difference between the groups and provide a control, the study used a small
sample.
Sung et al. (2008) explored the effects of a blended learning programme on new nurses’
knowledge of medication, self-efficacy of administration, administration ability and
satisfaction with the programme. They used a sample of 50 nurses randomised into a
control (n = 24) or experimental group (n =26). The experimental group received face-toface instruction and an e-learning package while the control just received the face-to-face
teaching. The content of the e-learning package included understanding drug therapy,
medication process and nursing care, using clinical cases and quizzes. The face-to-face
instruction included lectures (10.5 hours) and practice (11.5 hours). The e-learning group
received 3 hours of lectures, 11.5 hours of practice and 20 hours of e-learning. The results
showed that mean score for knowledge was significantly higher in the education group
(82.21, SD = 8.75) compared with the control group (67.92, SD 7.71) (t = 6.284, p =
0.000). Medication ability post-intervention was 3.91 ± 0.51 for the experimental group
44
compared with 3.94 ± 0.39 for the control (t = 1.017, p = 0.314). It must be noted however,
that like Tsai et al.’s (2004) study, that this was self-evaluated and not established by
independent observer, so many variables such as emotional state of the rater and other
experiential factors would not have been taken into account. Sung et al. (2008) felt that
the blended e-learning programme is an effective method for teaching nurses about
medication administration, and it had the advantages of being able to be accessed at any
time or place by the nurses, making it easy to use and cost-effective.
Service-led Initiatives
McGraw and Topping (2011) presented a case-study of a service led initiative designed to
reduce the actual degree of harm and the potential risk of harm associated with reported
medication errors in one district nursing service in the United Kingdom. To April 2008,
there were 127 adverse incidents reported within the service, with 42% of these related to
medication errors. Twenty-five percent (n=13) of these were rated as ‘low risk’ with 4% (n
= 2) as high (including two patients who were admitted to hospital). The initiative involved
the authors identifying various factors that contributed to medication errors locally by
exploring the medication error data of previous years. Those factors that were amenable
to intervention were isolated, including drug calculation skills, medication-related problemsolving skills and medication charting including transcribing of orders. Following this, they
introduced key interventions including screening of registered nurses using a drug
calculation test at interview, discretionary drug calculations workshops for all nurses within
the service, mandatory problem solving training and introduction of a new medication
chart. The initiative was evaluated positively as the number of incidents where no adverse
consequences were reported increased to 81% from 8% and 25% for the previous two
years. Risk ratings of ‘very low’ in reported adverse incidents shifted from 55% and 42% in
the previous two years to 75%. The authors felt that the systemic initiative was successful
while maintaining an open culture of reporting. This initiative is interesting in that it
45
highlights the multi-factorial nature of drug administration errors; however the evaluation
itself lacks robustness as it is not a ‘true’ research study and has inherent methodological
weaknesses that make it impossible to isolate which factors produced the greatest effect.
By contrast, Kliger et al. (2009) evaluated an initiative that empowered front-line nurses by
developing nurse leadership and medication administration process improvement skills
among 7 hospitals in the Unites States. The Integrated Nurse Leadership Program (INLP)
involved establishing a project team of nurses who were given instruction in leadership
skills related to quality improvement: individual, team, culture and process. Each project
team agreed to work on 6 safety processes related to medication administration:
comparing medication to the chart, labelling medication, checking patient identification,
explaining drug to patient if applicable, charting after administration and minimising
distractions. The naïve-observer method was used to collect the data, where drug
administration was observed and documented then the results compared to the
medication chart after observation not before. The initiative was felt to be successful
because five of the six hospitals that remained in the study showed an increase in
medication administration accuracy (85% at baseline to 92% after 6 months postintervention and 96% after 18 months). This was statistically significant at p < 0.05. The
most prevalent error at baseline was wrong technique and this showed the largest
decrease from 41 errors to 5 at 18 months. Wrong-time errors were those least amenable
to change. ANOVA and ANCOVA was used to isolate the variable thought to improve the
accuracy of medication administration, and the hypothesis that the increasing use of
safety processes would result in increased accuracy was supported. This study is
interesting in that it used a leadership and change strategy to effect improvement in
administration accuracy, and each hospital team was responsible for identifying small
targets within the identified safety processes, customised to their own needs. The most
successful project teams were, according to the authors, those that understood that any
46
changes would only endure if they made sense to frontline staff, and that the teams
themselves seemed to benefit from external support in the form of a consultant to help
drive change. The generalisability of this study may be limited- the article identifies the
hospitals as being from the Bay area of San Francisco though it does not identify the
specialty of these hospitals.
Mathematics and Medicines Calculations
Three studies conducted research into methods to improve the medicines calculations
abilities of qualified nurses. Harne- Britner et al. (2006) used a convenience sample of 53
nurses (31 students and 22 qualified) who self-selected an educational intervention. All
participants viewed a ten minute presentation about medicine errors and then completed a
medication calculation survey. After correcting their own answers the participants selfselected from 4 educational interventions: a 30 minute classroom session (n = 7), selfstudy using a workbook, self-study using their own reference (n = 5 for both types of selfstudy) or no intervention (n = 9). The medication calculation survey was re-administered 4
weeks later. Analysis of the data showed a statistically significant improvement in test
scores for the qualified nurses for all interventions including the ‘no intervention’ group.
This study is methodologically flawed: there was no randomisation to intervention, relying
on nurses to self-select; the sample size was inadequate to have any statistical power; it
is not clear whether the medication calculation survey was changed in any way for the
post-intervention measurement, possibly resulting in measurement effect. The results
must therefore be viewed with caution.
Wilson (2003) evaluated two different approaches to testing nurses’ drug calculation
ability in a crossover trial. Randomised to taking the same drug calculation questions via a
traditional paper test or a simulated test with props first, the convenience sample of 55
nurses had a mean of 7.82 years of experience. Those nurses who took the practical test
47
first scored more highly than those who took the standard test. Wilson (2003) conducted
semi-structured interviews following the tests and 2/3 of the participants said they
preferred the practical test as it seemed more relevant to them than the paper test.
Handling the drugs, fluids and infusion devices gave them time to think and learn,
whereas the paper test did not. Wilson (2003) felt that the practical test enabled the
nurses to conceptualise the problems presented. Of the 1/3 that preferred the traditional
test, their scores were high and Wilson felt it was possible that their maths skills were
strong anyway. This study too is not without its methodological weaknesses, principally
lack of control, small sample size and using a convenience sample of nurses embarking
on an IV training programme.
Sherriff et al. (2011) conducted a quasi-experimental study using a self-selected sample
of 107 acute care nurses who attended training in medication calculations. The main
outcome was to evaluate the relationship between test scores and use of a medication
calculations computer-based educational programme. The programme contained material
in modular form including general mathematics and dosage calculations, and generated
practise questions that allowed nurses to self-test their ability. For the purposes of the
study, the types of questions included oral suspensions, injectables and infusion rates in
millilitres per hour and drops per minute. The programme was available for nurses to use
over the course of one year. The proportion of nurses passing at the medications
calculation test at the first attempt increased over time from 26.3% to 43.1%, while the
proportion passing at second attempt fell from 37.3% to 18.2%. The authors felt that when
undertaking a second attempt, nurses would abandon the test at the first error. A selfefficacy questionnaire was also administered at baseline, soon after recruitment and after
one year. This showed improvement in nurses’ perception of their maths ability and
confidence over the twelve month period. Beginning level skills and interest/confidence in
maths did not reach statistical significance, whereas higher level skills and confidence in
48
dosage calculations did. Finally, the programme evaluated positively with over 70% of the
sample indicating that the programme improved their confidence in calculations. Although
the study appears to indicate that the programme had positive effects, the small sample
size and lack of randomisation or control mean that other effects have not been accounted
for.
Conclusions
A surprising lack of literature evaluating the effects of interventions to improve medication
ability was found. Overall, critical evaluation of the studies shows that though some
studies have attempted to use a control and randomisation, methodological limitations due
to small sample sizes, convenience samples and single sites mean that results must be
interpreted with caution. Tentative conclusions that can be drawn are that:

Educational interventions that encourage conceptualisation of and
engagement with the particular process of concern (for example numeracy
skills, knowledge of injections, medication administration) appear to have
benefits over more didactic styles of teaching and learning. Multi-media
packages and simulation seem to be methods that enhance engagement.
Further evaluation of the effectiveness of these, using adequately powered
samples and control of variables is necessary. Outcomes that demonstrate a
clear increase in accuracy of drug administration should be used, not selfevaluation. Cost-effectiveness of educational interventions must also be
established, balanced with cost of adverse events to the healthcare provider
and patient.

Data from adverse incidents related to medication errors is a valuable source
of evidence as to where to target interventions. Root-cause analysis of
49
adverse events can help managers understand why an adverse event
occurred but it will not address the complexity of the medication
administration process. The literature that explored reduction in adverse
events from a management systems perspective showed promise in
enhancing quality assurance. Multi-faceted interventions are likely to be more
effective than single interventions, but further research to isolate the
important factors of strategies to improve service delivery (for example use of
staff screening and multiple educational inputs) is required, using appropriate
outcome measures. The characteristics of good leadership that influence staff
performance is worthy of further study. Any systematic approach to changing
professional practice should be monitored, evaluated and maintained to
reinforce learning. Further research is required to evaluate effectiveness of
such interventions.

The evidence so far is very patchy and fragmented. Evaluation of the ‘easiest’
aspects of medication administration such as numeracy or particular
techniques means that neglect of other areas such as the inter-professional
or cross-boundary interface is left unexplored. Most of the data so far is from
acute, adult areas. There was no literature from mental health or learning
disabilities nursing environments, and very little from community settings.
Surprisingly, children’s nursing did not produce any literature.

The DH (2004) recommend objective structured clinical examinations
(OSCEs) should be used to assess skills. There is no published evidence of
the use of OSCEs as part of learning beyond registration (LBR).
50

There is no literature discussing structured post-registration educational
programmes in medication administration. It is not clear if they exist.
Research is needed to establish appropriate content, method of delivery,
setting of delivery and suitable assessment, for example.

Induction programmes delivered within clinical settings do not appear to be
evaluated within the published literature. The content and delivery of such
programmes may well vary between health care providers, and it is not clear
what the minimum outcomes should be, or how these are evaluated.

There is no evaluation of staff employed via nurse banks, NHS Professionals
or other agencies. How their needs for LBR are met is unclear.

When integrated into the first part of this literature review, it is clear that if
competency in medication administration is not clearly defined, then it will be
impossible to identify suitable continuing professional development activities.
The setting of standards, both locally and nationally is necessary in order to
provide a benchmark against which measurement can take place.
51
Appendix 1: Summary of Literature Assessing Competencies of Nurses in Relation to Drug Administration
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigour
Main findings
Limitations
Coded by
researcher
according to topic
(?) then finer coding
applied. Themes
derived after coding.
Second checker
tested coding for
reliability and
discrepancies
discussed.
Causes of errors: nurses, doctors,
pharmacy staff and patient (e.g. if spits
meds out).
Personal, contextual and knowledgebased factors cited as causes of errors.
Purposive
heterogenous
sample may bias
findings.
Sample quotes
given to illustrate
themes.
Importance of errors cited as being
medical aspect, effect on patient and
consequences for nurse. IV medications
considered more harmful.
Maintains standards of practice; policies and procedures
Hand & Barber
(2000) United
Kingdom
Qualitative
Semi-structured
interviews
17 respondents in
purposive sample
selected by ward
speciality then
grade. Sampling
intended to
represent crosssection of hospital
wards.
Coding process
not clear.
Fear of disciplinary action cited as most
common reason for not reporting error.
Mayo & Duncan
(2004) USA
Descriptive
correlational
Questionnaire
survey using
Modified
Gladstone
(Osborne et al.,
1999) containing
demographic
data and data
about medication
errors.
983 respondents
drawn from
sampling frame of
9000 nurses unionrepresented
registered nurses
working at 16 acute
hospitals in
Southern California.
5000 questionnaires
sent out to random
sample giving 20%
response rate.
Descriptive statistics
Content validity of
Modified Gladstone
assessed previously
and reliability by
test-retest.
Large sample
Most nurses recalled making 2-5
medication errors over their career, with
weak relationships noted between
number of errors and years of RN
experience (r=0.15, p= 0.001) and
between type of unit and number of
errors (r=0.21, p=0.01).
Sample drawn
from union
nurses so may
not be
representative of
whole nurse
population.
Top ranked causes of errors perceived to
be related to physician handwriting,
distraction and tiredness. Inconsistency in
agreement over what constitutes a drug
error.
Ranking of
causes may
mean some error
sources not
identified.
Number of errors
made relying on
self-reporting.
52
Appendix 1
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigour
Main findings
Limitations
Sanghera et al.
(2007) United
Kingdom
Qualitative
Prescribing,
administration
and
documentation
errors identified
by hospital
pharmacist.
Interviews
conducted with
members of staff,
who made
reported and nonreported errors,
within 96 hours of
the event to elicit
reasons for the
error, why it was
reported (or not)
and general
attitudes to
medication
errors.
16 interviews
conducted; 3
interviews not
included in analysis.
8 interviews with
nurses; 5 with
anaesthetists.
Thematic analysis of
interview data using
Reason’s Accident
Causation Model
(1990) as a
framework.
Coded by hand.
Coding verified by
second researcher.
50 non-reported errors identified by
pharmacist, of low-very low severity.
Selection of
purposive sample
procedure not
made clear.
Focus group and
questionnaire
survey to
establish nurses’
views of
contributory
factors to
medication errors
Snowball sampling
n=72
Tang et al.
(2007) Taiwan
53
Mixed method
Most errors involved skills-based slips
and lapses. This included [lack of]
knowledge, unfamiliar protocol, unfamiliar
drug, unfamiliar drug chart.
Purposive sample
drawn from staff
who made errors
within one ITU.
Barriers to reporting include not being
aware error had occurred, process timeconsuming, no perceived benefit,
motivational factors e.g. fear of loss of
registration.
Perceived benefits of reporting learning
from mistakes reduce chances of
litigation, accountability, prevention of
future errors, improving practice,
reflection on practice.
Second checking
of data coding
procedure not
made clear.
Effect of the
interviewer on
interviewee
responses has
been discussed
as a limitation of
interview
methods.
Staff approached
for interview and
description of
errors presented
in table, but
unclear how
relates to
classification of
errors produced.
80% response rate.
Statements from
questionnaires
coded by two
researchers
independently.
Disagreement or
ambiguity resolved
by participant
checking.
Content and face
validity of
questionnaire
established.
Unfamiliarity with medication accounted
for 31.9% of category selected by the
respondents as having contributed to
their error; unfamiliarity with patients
condition (22.2%); insufficient training
(15.3%). Medical wards and ITU most
common areas for medication errors.
Complicated prescriptions noted for older
patients most frequently. Antibiotics most
common drug involved in error,
speculation that this is due to omission.
Appendix 1
Snowball
sampling may
introduce bias.
Relatively small
sample size from
one hospital.
Procedures and
policies may
differ from UK.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Knowledge and understanding
Chakrabarti et
al. (2010) United
Kingdom
Systematic
review
Data extraction
and statistical
analysis
No randomised
controlled trails
found
None- no studies
met criteria for
review
Method as specified
by Cochrane
No studies identified, leading to the
conclusion that administration of PRN
medication for seriously mentally ill
people in hospital is a function of clinical
experience and habit, therefore lacking in
a sound evidence base.
Exclusion/
inclusion criteria
possibly set too
high.
Eisenhauer et al.
(2007) USA
Qualitative
Semi-structured
interviews
40 registered nurses
in purposive
sample.
Content analysis of
data. First level of
coding by two
research team
members. Second
level of coding by
two-person
consensus.
Attempt to account
for retrospective
nature of interviews
and recall errors by
recording and
analysing nurses’
thinking in real time.
Ten categories of thinking identified
including dose-timing, checking of
component of medication administration
process, assessment of patients’ signs,
evaluation of medication effect, teaching
patients, monitoring for side effects,
deviation from procedure if in patients
interests, anticipatory problem solving.
Small sample
size.
Real-time tape
recordings during
drug
administration
22- 54 years old,
from medical,
surgical units and
ante/post-partum
units. Mean length
of experience 11.2
years.
Care units used
computerised
barcode
technology as
part of
medication
process.
No verification of
coding by
respondents.
Participants
chosen for
expertise.
54
Appendix 1
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Grandell-Niemi
et al. (2003)
Finland
Questionnaire
survey
Self evaluation of
maths skills using
likert scale
546 Finnish nurses
from one hospital.
Data grouped
together into sum
variables of
evaluations and
mastery and
ANOVA or t-test
used.
Content validity of
instrument
established by
reference to
previous research,
textbooks and
evaluation by 5
medication
calculations
teachers.
70% felt dosage calculation skills
sufficient.
Difficult study to
read, making
interpretation
hard.
Response rate 56%.
Test of maths
skills
Correlation
between maths
skills and selfevaluation
Mean age 40 years
(range 22-59).
Mean years of
experience 14
(range 0-37)
Medical, surgical,
paediatric,
midwifery,
psychiatric, public
health, anaesthetic
nurses represented.
Grandell-Niemi
et al. (2005)
Finland
Survey
Completion of
Medication
calculation skills
(MCS) test
Self-evaluation of
maths skills using
likert scale
55
364 registered
nurses and 282
student nurses
Response rate of
68% and 70%
respectively.
Four sum variables
of calculation test
analysed using
Wilcoxon or
Kruskal-Wallis tests.
70% felt their maths skills sufficient.
16% found pharmacology easy.
52% of nurses gave correct answer in
arithmetic operations.
83% of errors made in arithmetic related
to decimal point.
69% of nurses gave correct answers to
conversions.
Correlations used
Spearman rank.
Nurses who maintained dosage
calculation skills by lectures found skill
easy, as did those for pharmacology.
Descriptive statistics
(mean, SD, ranges
and frequencies) for
test scores.
Differences between
nurses and students
used chi square or
Kruskal-Wallis test.
Spearman rank for
association between
self-rated and actual
skills.
Content validity of
MCS established
through review of
literature,
pharmacology
textbooks and pilot
study.
Nurses and students rated own skills as
sufficient though did not find maths easy.
Nurses obtained higher score (mean
78.3%) than students (61.4%) in maths
skills.
Better actual maths skills correlated with
previous educational experience and
regularly calculated drug doses.
Addition, subtraction, injection amounts in
ml, counting tablets found to be easy.
Appendix 1
Contradictory
statements noted
in results.
Not
generalisable.
Low response
rate.
Test not
supervised.
Pharmacology
knowledge not
tested directly.
Test completed
on ward so help/
collusion may
have occurred.
Response bias
as respondents
may be more
knowledgeable
than nonrespondents.
No data for nonrespondents
abilities.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Hsaio et al.
(2009)
Taiwan
Crosssectional study
Questionnaire
evaluating nurses
knowledge of
high-alert
medications and
to analyse known
administration
errors.
385 nurses targeted
using snowball
sampling; 305
responded (79.2%
response rate) from
acute general
hospital nurses.
SPSS for
descriptive
statistics.
Content, face and
construct validity of
instrument
established.
Over 30% of nurses did not understand
concentrated electrolyte solutions (e.g.
KCL) could not be administered as IV
bolus; insulin should be administered as
units using a dedicated syringe.
Taiwanese
nurses training
and education in
medications not
elucidated so
difficult to
compare with UK.
t-test and ANOVA
used to examine
relationships
between nurses
background, selfevaluated
knowledge level,
training need and
total knowledge
score. Scheffe test
used for analysis of
differences among
groups.
Reliability and interrater reliability
established.
Sample size
calculated for power
and effect.
Experience correlated significantly with a
higher score on knowledge questions.
Self-evaluation also correlated correctly
with higher score. Only 3.6% of nurses
had sufficient knowledge of high-alert
medications.
Snowball
sampling may
introduce bias.
Some questions
related to analysis
of known medication
errors coded by
hand.
Kelly et al.
(2010) United
Kingdom
56
Undisguised
observational
study.
Undisguised
observation.
Two qualified
nurses
administering drugs
to dysphagic
patients. Qualified
for 8 and 20 years.
Root cause
analysis.
Not discussed.
Administration of medications suboptimal: mixing drugs, crushing tablets,
giving drink after Nystatin, adding
thickening agent to liquid formulations.
Both nurses felt well prepared to
administer medications to dysphagic
patients. One had post-registration
training, one had not.
Appendix 1
Case study
approach so not
generalisable.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
King (2004)
United Kingdom
Qualitative
Semi-structured
interviews
10 staff nurses in a
purposive sample
from a 30-bedded
emergency
admissions unit.
Length of
experience ranged
from 1 to 19 years.
Burnard’s (1991)
14-stage method for
analysis adapted
from the grounded
theory approach
(Glaser and
Strauss, 1967).
Respondent
checking of
categories formed
during the analysis.
7 out of 10 respondents had limited
understanding of pharmacology.
Small sample
from one
hospital.
Drug administration, patient education,
nurse prescribing requires pharmacology
knowledge.
Dissatisfaction with pharmacology
education as students in 9 out of 10
respondents.
Anxiety common due to lack of
knowledge but high expectations of
accountability.
Manias & Street
(2001) Australia
Ethnography
Participant
observation,
individual and
focus group
interviews,
professional
journaling
6 registered nurses
on a critical care
unit plus one of the
authors as coparticipant.
Textual analysis of
transcripts
examining data in
relation to issues of
communication
between doctors
and nurses via
medication
prescribing and
administration
Most post-registration education selfdirected from British National Formulary.
Interviewer and
respondent bias
a risk of
qualitative
interviews.
Triangulation of
data.
Traditional roles of doctors prescribing
and nurses administering drug blurred.
Specific to critical
care unit.
Exploration and
examination of
assumptions of first
author.
Doctors often relied on nurses to give
information on correct drug and dose to
use before prescribing.
Policies and
procedures may
differ from UK.
Nurses knowledge not acknowledged in
drug charts.
Study represents
views of nurses
only.
Author agreement
following
independent
examination of data.
Participant checking
to verify data
findings and
analysis.
57
Explored nurses’
perceptions; not
necessarily
reflecting what is
happening during
patient contact.
Nurses acted as ‘go-betweens’ informing
consultants about junior doctors’
medication errors.
Nurses policed each other’s medication
administration practice.
Appendix 1
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Manias et al.
(2004) Australia
Qualitative
Semi-structured
interviews
12 graduate nurses
in first year of
hospital clinical
practice postqualifying. Potential
participants
stratified and
selected on basis of
age, gender, work
area and type of
medication
education. Sample
size decided on
when saturation of
data themes
reached and
demographic
characteristics
represented.
Themes identified
by two researchers
but further detail on
how agreement
reached not
provided.
Rater bias reduced
by two coders.
Monitoring of patients before and after
medication administration took place but
not all nurses evaluated the same signs/
symptoms per medication. Vital signs
often checked prior to medication
administration, lab tests less so as some
nurses did not understand them.
Perceived to be doctors role.
Conducted in
Australia so
policies may
differ from UK.
Anti-emetics, analgesia and aperients
most often checked for effect.
Patient’s ability to swallow considered
important by some.
Timing of medications caused concern if
delay occurred that caused deviation
from policy.
PRN medications: relied on patients
asking for them; observation of patients’
behaviour most commonly used as
syndicators’ of need; weakest drug at
lowest dose given most often.
Discharge information on medications felt
to be pharmacist’s responsibility.
58
Appendix 1
Voluntary
participation may
indicate bias due
to participant
interest in topic.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Manias, Aitken
and Dunning
(2005) Australia
Descriptive
prospective
qualitative
Participant
observation
during drug
administration
12 graduate nurses
formed stratified
random sampling
within one hospital.
Transcribed using
five-stage qualitative
process.
Tow researchers
independently
analysed data.
Disagreements
resolved by
negotiation.
Protocols used to check particular
medication administration practices were
acceptable and for information on
quantity of diluent for intravenous
antibiotics.
Single site
studied.
Frequency counts of
adherence to six
commonly used
medication
protocols.
In-depth
interviews
Transcription of
drug
administration
protocols.
Structured protocols eg in cardiology
promoted autonomy and facilitated
decision-making within drug admin.
Observation may
have affected
participant action
by increasing
awareness of/
adherence to
protocols.
Protocols not adhered to: when checking
patient’s identity if familiar with patient,
status of checker when double checking
some medications, watching patients
taking medications.
Medication errors regarded as way of
learning from experience.
Protocols conflict eg medications that
cannot be given at same time.
Manias &
Bullock (2002)
Australia
Qualitative
Focus group
interviews in 2
metropolitan and
2 regional
hospitals
6 focus group
interviews with
between 4 to 12
participants of
clinical nurses.
N=38 in total.
Transcripts
analysed manually
using five-stage
process.
Two researchers
independently
coded data. Results
then compared and
scrutinised.
Reports of data
analysis provided
for respondent
checking.
Pharmacology
experts checked
themes: peer
review.
Overall pharmacology knowledge of
graduate students lacking including
terminology (panadol/ propanalol).
All clinical nurses have knowledge
deficits including new drugs.
Further education important but needs to
be structured.
Single checking may encourage feeling of
responsibility but may also make drug
error easier to hide.
Aspects of pharmacology knowledge
identified as being of importance.
Improvements to education suggested
including pharmacology as a separate
subject.
59
Appendix 1
Australian study
so may not reflect
UK procedures
and policies of
drug
administration,
nor education
content.
Small number of
focus groups in
one city.
Contextual
influences not
accounted for.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Ndosi and
Newell (2008)
United Kingdom
Comparative
correlational
design
Structured
interview and
questionnaire
testing
knowledge of one
of four most
commonly
administered
drugs
42 nurses from
surgical wards; 18
junior nurses, 24
senior nurses.
Median years of
experience 10.87
years.
Differences between
groups’ scores
analysed using
parametric and nonparametric tests.
Inferential statistics
used to establish
dependable
difference between
groups.
Correlational
statistics to study
relationship
between variables.
Face and content
validity of instrument
established by
reference to
pharmacology
textbooks and
literature, and
review by
pharmacist. Pilot
study resulted in
minor changes.
Knowledge of mechanism of action and
drug interactions poor.
Convenience
sample; selfselection may
bias results.
Thematic content
analysis after Morse
and Field (1996).
Not indicated
Correlation noted between experience
and knowledge.
Junior nurses
underrepresented.
Small sample
size from one
clinical specialty.
Inter-rater reliability
tested.
Can teach others
Rycroft-Malone
et al. (2001)
United Kingdom
Case study
Multiple methods
including nonparticipant
observation of
teaching
sessions, postinteraction
interviews with
nurses and
patients/clients,
and audiorecording.
Focus group
interviews with
carers.
7 cases across
adult, older person,
mental health and
primary care.
Purposive sampling
to illuminate
dimensions of the
educative process
Information given to patients generally
given by adult nurses about name of
medication, purpose, colour, number of
tablets and time and frequency to be
taken. Little variation in information given.
Mental health nurses typically gave more
information including monitoring
medication and side effects, evaluating
adherence, working with clients’ beliefs
and motivations. Negotiation more a
feature.
Interactions initiated and controlled by
nurses.
Carers usually happy with level of
information given.
60
Appendix 1
Study conducted
to illustrate
consumerism in
healthcare so
focus not entirely
on nurses’
knowledge.
Explanations of
rigor not explicit.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Duxbury et al.
(2010) United
Kingdom
Survey
Semi- structured
interviews with
mental health
nurses and
patients post
medication
administration
24 nurses and 57
patients in an acute
mental health ward.
Thematic analysis
Information checked
with participant after
interview.
Nurses viewed communication with
patients about their medication as a vital
part of therapeutic alliance.
Relatively small
study in one
hospital.
Questions selected
after literature
review.
Evaluating effectiveness of treatment and
side effects important.
Recognised
problems with
interview data as
respondents
conforming to
social roles.
Convenience
sample.
Prompt cards used
to maintain
consistency of
questioning.
Tension between being caring and need
to be authoritative.
Patients valued interaction but felt it
important to comply whilst in hospital.
Held mixed views about benefits of
medication vs. side effects.
Competency is context specific
Davis et al.
(2009) Australia
61
Descriptive
exploratory
Survey using preidentified
contextual
themes. 5 point
likert scale used
to agree/
disagree with
statements.
185 of 278
questionnaires
returned (67%
response rate).
Mean calculated
overall plus for each
variable (age,
paediatric nursing
experience, level of
employment).
Linear regression
models for each
explanatory variable
univariately then
multivariately.
Face and content
validity of the tool
assessed by panel
of expert nurses.
Majority of nurses had adequate
computer literacy to find policies. Finding
policies on computer can be difficult as
no terminal or intranet not user friendly.
Piloted with
paediatric nurses
outside sample.
Younger nurses felt colleagues could
influence how closely medication policy
followed.
Tension between following policy and
acting in interests of child meant not
following policy acceptable at times.
Strongly linked to clinical judgement.
Appendix 1
Self-report may
lead to bias.
Response bias
as sample selfselecting.
Single site.
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Manias et al.
(2004) Australia
Qualitative
Participant
observation
including taping
of clarifying
questions.
12 graduate nurses
in first year of
clinical practice
post-qualifying.
Potential
participants chosen
to represent broad
cross-section of
practice settings in
hospital.
Transcripts
analysed manually
using five-stage
process.
Two researchers
independently
coded data.
Hypothetico-deductive reasoning most
common decision making model. Vital
signs most common type of patient
information sought to support reasoning.
Asking patients not common.
Presence of
observer may
have changed
behaviour of
participants.
Semi-structured
interviews post
drug
administration.
Observation and
interview data for
nurses considered
together to facilitate
interpretation.
Reports of data
analysis provided
for respondent
checking.
Pattern recognition also used, for
example surgical patients should receive
heparin. Based on similar patients
encountered before. Graduate nurses
therefore able to practise skills of expert
reasoning in familiar situations.
Intuition least common model of
reasoning.
62
Appendix 1
Appendix 2: Summary of Literature Evaluating Training or Educational Interventions to Improve Competence in Drug
Administration for Registered Practitioners
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Dennison (2007)
USA
Pre-test posttest quasi
experimental
design
Assessing
effectiveness of 2
x 30 minute
computer
modules on
medication safety
by
‘medication
safety knowledge
assessment tool’
and ‘climate of
safety’ survey
37 infusions
Independent t-test
used to evaluate
differences in
scores on climate of
safety survey
Medication
knowledge safety
assessment tool
reviewed and
critiqued by
medication safety
nurse experts prior
to piloting and use
No statistical difference in behaviours
before and after education program
Small sample
with high drop out
(30 enrolled
initially). Selfselecting.
Nurses
behaviours
evaluated by
assessing 4 key
behaviours
Number of
medication errors
downloaded from
infusion pumps
63
20 nurses
completed
evaluation of
knowledge
Sample from
coronary care unit
Paired t-test used to
evaluate nurses
medication safety
knowledge
Mann- Whitney u
test to evaluate
behaviours before
and after education
program
Only significant individual behaviour
change after program was labelling
infusion bag
Single centre
No statistical difference between
downloaded error alerts before and after
educational intervention
Differences in
patient acuity and
introduction of
new infusion
pumps during
project may have
affected results.
No control group.
Downloaded data
from pumps
could not be
specifically
attributed to
nurses taking
part in study.
Appendix 2
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Ford et al.
(2010) USA
Single centre,
parallel,
controlled
prospective
study
Participants
undertook
education on
drug
administration
either via
simulation or
lecture.
24 nurses from
medical intensive
care or coronary
care units.
Primary outcome:
difference in rate of
medication
administration errors
between baseline
and posteducational
intervention.
Consistent definition
of medical error
used between data
collectors.
Simulation-based educational session
significantly reduced medication errors is
ITU with sustained effect: 4% compared
to 30.8% pre-intervention; p < 0.001
Small sample
size.
Evaluation of
observed data done
by two critical care
pharmacists not
involved in data
collection.
Lecture improved quiz scores but did not
reduce medication errors in CCU: 22.7%
compared to 20.8% pre-intervention, p <
0.672.
Parallel design
meant nurses
from different
units were
compared.
Potential
differences
between study
groups not
accounted for.
Chi square, Fisher’s
exact, MannWhitney U test as
appropriate.
Training given to
observers to ensure
consistency of
observations.
Single centre.
Data collectors
not blinded to
intervention or
study phase.
No control.
Statistical data
not presented
fully.
Franklin et al.,
2011, United
Kingdom.
Single centre
prospective
design
Participants
completed online
modules in
aspects of drug
administration
19 nurses from
mixed medical ward.
12 completed all
modules available
online
Primary outcome:
reduction in
medication
administration errors
(MAEs).
Observation during
drug administration
carried out by two
trained pharmacists
using ‘validated
methods’ pre and
post intervention
Intervention did not produce significant
reduction in observed MAEs.
Small sample.
Single site.
However, content of modules as
illustrated in article may not have
addressed some causes of observed
MAEs: wrong dose, extra dose and giving
intravenous medication too fast.
Lack of clarity
over content of
modules.
No attempt to
control variables;
intervention given
only.
64
Appendix 2
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Harne-Britner et
al., 2006, USA
Quasiexperimental,
pretest- posttest design
Evaluation of
teaching/ learning
strategies on
performance in IV
medication
calculation tests
Convenience
sample of 31
student nurses and
22 registered nurses
with 4-34 years of
experience.
Outcome:
classroom
education vs.
classroom
education with selfstudy. ANOVA used
to analyse
differences between
groups.
Face and content
validity of
medication tests
established by
advanced practice
nurses.
Nurses average score on test increased
from mean of 15.5 to 18.6 following
educational intervention. Improvement
statistically significant (p < 0.01)
Small sample.
Classroom education + self-study had
greatest improvement in scores; however
not statistically significant.
Participants
selected own
intervention from
choice of 4.
t-test used to
analyse differences
between scores of
students and nurses
Test reliability
established by
Kuder-Richardson
test (0.764)
Pre-test scores correlated to nurse selfrating or frequency of performing
medication calculation (p = 0.017)
Pearson’s r used to
calculate
relationship
between test results
and demographic
and other variables.
Kliger, 2009,
USA
McGraw &
Topping, 2011,
United Kingdom
65
Evaluation of
integrated
nurse
leadership
program
(INLP)
focussing on
accuracy of
medication
administration
Observation of
medication
administration
prior to and
following INLP
interventions
Case study
Delivery of a
bespoke training
and education
programme to
district nurses
Seven hospitals
Descriptive
statistics.
ANOVA and
ANCOVA to isolate
variables
No
randomisation.
Selection of
intervention felt to
be of
convenience.
Sample drawn
from Nurse
Practice Council
which may not be
representative of
all nurses.
Six safety
processes identified
prior to study
Data collection tool
for observation
developed for
consistency
Medication administration accuracy
increased from 85% of doses at baseline
to 92% after 6 months and 96% at 18
months. Significant at p < 0.05
Overall results
presented so
cannot assess
individual hospital
results.
Wrong technique showed greatest
decrease.
INLP effective in increasing use of safety
processes.
Not specified;
district nursing team
Descriptive statistics
only
None- report on
evaluation of a
programme
Number of incidents with no adverse
consequences increased to 81%
compared to 8% and 25% in previous 2
years.
Not generalisable
as single centre.
Appendix 2
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Schneider et al.,
2006, USA
Randomised,
controlled,
non-blinded
study.
Participants
randomised to
control group or
interactive
learning group
(CD Rom on safe
medication
practices)
30 registered nurses
from 3 community
hospitals (10 from
each site). Minimum
of 1 year acute care
experience and
worked full time for
at least 6 months.
Outcome: reduction
in observed error
rates.
Control group.
Small sample
size.
Chi-squared and ttest used to
compare
demographic data.
Observers received
training prior to
study. Observers’
skills observed
during study.
Errors categorised: ‘core 1’ errors
decreased in study group (p < 0.001).
Number of core 2 errors higher but not
statistically significant. Core 3 errors
decreased for study group.
Nurses rated self-efficacy in higher level
maths skills and confidence in dosage
calculation higher after intervention.
Small sample
size.
ANOVA used to
assess differences
over time.
Randomisation.
Observers blinded
to participants.
Logistic regression
analysis for
educational
intervention and
error rates.
Sherriff et al.
(2011) Australia
66
Quasi
experimental
Participants took
computer-based
educational
intervention on
medication
calculations. Selfefficacy
questionnaire,
analysis of
number of
attempts at
gaining 100% in
calculations test,
satisfaction
questionnaire
administered.
107 nurses from 2
general hospitals
who attended
training in
medication
calculations prior to
introduction of new
online program.
Outcomes:
relationship
between nurses test
scores and use of
medication
calculation
programme; use of
programme and
nurses self-efficacy;
level of satisfaction
with programme.
Descriptive
statistics.
Paired t-test used
for comparisons
between mean
number of attempts
to obtain 100% on
test, means scores
at first attempt, selfefficacy subscales
Self-efficacy
questionnaire
developed with
reference to existing
tool and evaluated
for internal
consistency with
Chronbach’s alphas.
Drop out accounted
for.
Maths test
questions randomly
generated.
No control.
Proportion passing at first attempt
increased after intervention from 26.3%
to 43.1%.
Self-selecting
sample
Proportion passing on second attempt
decreased.
90% of sample found program interesting
and enjoyable to use.
Appendix 2
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Sung et al.,
2008, Korea
Quasiexperimental
with nonequivalent
groups
Participants selfselected to have
standard face-toface teaching
(control group) or
standard teaching
plus blended elearning
instruction
50 new nurses from
medical and surgical
wards from single
hospital. Mean age
approximately 23
years old.
Outcomes: the
effect of the elearning program on
knowledge of
medication, selfefficacy of
administration,
ability of
administration,
satisfaction with the
program. t-test used
to analyse results.
Control group
E-learning increased mean score for
knowledge compared with control (t =
6.284, p 0.000)
Small sample
size; single site.
Primary outcome:
evaluation of effect
of multimedia
program on
knowledge and selfperceived
performance.
Simple statistics
(mean, standard
deviation,
frequency, chisquare, t-test) used
to describe subjects.
t-test and paired ttest used to analyse
effectiveness of
program.
Random
assignment of
nurses.
Tsai et al., 2004,
Taiwan
67
Pre-test- posttest control
group quasiexperimental
Participants
randomised to
either control or
experimental
group to test
multimedia
package on
intravenous
medication
administration
Experimental group
n = 42, control
group n = 39.
Novice nurses,
mean age
approximately 23
years old; less than
1 year experience
post- qualifying.
Reliability of
measurement tools
verified with
Chronbach’s alpha
E-learning did not correlate with
increased medication administration
ability (t = 1.017, p 0.314)
No attempt to
control or
account for
variation in
sample.
Self-selection to
control or
intervention
group may
introduce
selection bias.
Content validity of
questionnaires
assessed by nurse
specialists.
Questionnaire
piloted prior to use
for clarity.
Multimedia program had significant effect
on knowledge (t-test 6.754, p < 0. 05).
Small sample
size.
This effect lasted two weeks after the
intervention (t- test 5.624, p < 0.05).
Outcome did not
measure effect
on actual
performance of
administering IV
drugs.
Participants rated the level of satisfaction
with the program highly.
Satisfaction
rating possibly
prone to
response bias
due to small
sample affecting
anonymity of
response.
Appendix 2
Author year &
country
Study type
Methods
Characteristics of
sample
Data analysis
Rigor
Main findings
Limitations
Wilson, 2003,
United Kingdom.
Crossover
study
comparing
efficacy of
practical
approach to
testing drug
calculation
Participants
randomised to
take either a
traditional paper
maths test related
to drug
calculations or a
practical version
using simulated
drug round first.
Convenience
sample of 55 nurses
wishing to train to
administer drugs
intravenously.
Primary outcome to
establish if practical
test resulted in
higher scores.
Randomisation by
alternate allocation
to each group.
Those who took the practical test first
improved their scores more highly than
those that took the standard test (t-test
2.93, p = 0.005, chi-square showed
significance at p = 0.005)
No control group.
Semi-structured
interviews used
one week post
test to ascertain
views on both
tests.
68
Ages 21 to 55
years. Length of
time qualified
ranged from 3
months to 29 years
(mean 7.82).
Data analysed using
chi-square and
unrelated t-test.
Qualitative data
sorted into themes.
Convenience
sample.
Small sample
size.
All aspects of
study carried out
by one
researcher.
Appendix 2
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