Nurse Education Today 34 (2014) 619–624

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Nurse Education Today

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Effectiveness of a Clinical Skills Workshop for drug-dosage calculationin a nursing program

Anna Maria Grugnetti 1, Annamaria Bagnasco ⁎, Francesca Rosa 2, Loredana SassoDepartment of Health Sciences, University of Genoa, Via Pastore 1, I-16132 Genoa, Italy

⁎ Corresponding author at: Tel.: +39 3472721175 (mE-mail addresses: a.grugnetti@smatteo.pv.it (A.M. Gr

Annamaria.bagnasco@unige.it (A. Bagnasco), francescarL.sasso@unige.it (L. Sasso).

1 Tel.: +39 339 5338980 (mobile).2 Tel.: +39 3487951066 (mobile).

0260-6917/$ – see front matter © 2013 Elsevier Ltd. Allhttp://dx.doi.org/10.1016/j.nedt.2013.05.021

s u m m a r y

a r t i c l e i n f o

Article history:

Accepted 31 May 2013

Keywords:Nursing educationDrug administrationStudentsDrug calculation skillsClinical simulationPatient safety

Background: Mathematical and calculation skills are widely acknowledged as being key nursing competencesif patients are to receive care that is both effective and safe. Indeed, weaknesses in mathematical competencemay lead to the administration of miscalculated drug doses, which in turn may harm or endanger patients'lives. However, little attention has been given to identifying appropriate teaching and learning strategiesthat will effectively facilitate the development of these skills in nurses. One such approach may be simulation.Objectives: To evaluate the effectiveness of a Clinical Skills Workshop on drug administration that focused onimproving the drug-dosage calculation skills of second-year nursing students, with a view to promoting safe-ty in drugs administration.Design: A descriptive pre-post test design.

Settings: Educational. Simulation center.Participants: The sample population included 77 nursing students from a Northern Italian University whoattended a 30-hour Clinical Skills Workshop over a period of two weeks.Methods: The workshop covered integrated teaching strategies and innovative drug-calculation methodolo-gies which have been described to improve psychomotor skills and build cognitive abilities through a greaterunderstanding of mathematics linked to clinical practice.Results: Study results showed a significant improvement between the pre- and the post-test phases, after theintervention. Pre-test scores ranged between 0 and 25 out of a maximum of 30 points, with a mean score of15.96 (SD 4.85), and a median score of 17. Post-test scores ranged between 15 and 30 out of 30, with a meanscore of 25.2 (SD 3.63) and a median score of 26 (p b 0.001).Conclusions: Our study shows that Clinical Skills Workshops may be tailored to include teaching techniquesthat encourage the development of drug-dosage calculation skills, and that training strategies implementedduring a Clinical skills Workshop can enhance students' comprehension of mathematical calculations.

© 2013 Elsevier Ltd. All rights reserved.

Introduction

Mathematical and calculation skills are widely acknowledged asbeing the key nursing competences if patients are to receive carethat is both effective and safe. Indeed, weaknesses in mathematicalcompetence may lead to the administration of miscalculated drugdoses, which in turn may harm or endanger patients' lives. Nursesmust therefore be well prepared and able to perform drug-dosagecalculations (Bindler and Bayne, 1991; Blays and Bath, 1992;Grandell-Niemi et al, 2005; Harvey et al, 2010; Wright, 2004; Elliottand Joyce, 2005).

obile); fax: +39 0103538552.ugnetti),osa@live.it (F. Rosa),

rights reserved.

One of the earliest reports on drug calculation difficulties in nursingdates back to over seventy years (Faddis, 1939). Current internationalnursing research confirms that weak mathematical skills in drug calcu-lation remain a major concern, and a number of studies have shownthat nursing students often fail mathematics and drug calculation as-sessment tests (Brady et al., 2009, Blays and Bath, 1992; Bliss Holtz,1994; Grandell-Niemi et al., 2001, 2005; Harvey et al, 2010; Wright,2004, 2005, 2006).

According to some investigators, the fact that nurses performpoorly in drug calculation tests may be associated with 10–20% ofall the mistakes that occur during clinical practice (Wilson, 2003;Wright, 2004). Other authors believe that such tests do not reflectperformance in clinical practice (Jukes and Gilchrist, 2006; Hutton,1998, 2010; Wright, 2007, 2009). Hutton (1998), however, positthat math tests help highlight calculation weaknesses in studentnurses, which can then be addressed within a clinical setting.

Several of themistake types reported in the literature have to dowithsolving equations or with simple arithmetic (Blays and Bath, 1992; Rice

620 A.M. Grugnetti et al. / Nurse Education Today 34 (2014) 619–624

and Bell, 2005; Dilles et al., 2011;Weeks et al, 2000;Wright, 2005, 2007).Mistakes in arithmetic can be avoided by using a calculator, but conceptu-al errors still cause problems (Wright, 2007). Indeed, calculating a drugdose correctly requires both computational and conceptual skills.

Background

To perform drug dosage calculations confidently and effectivelynursing students need to acquire andmaster three skills: 1) basicmath-ematics; 2) conceptualizing clinical information and identifying thedata that will allow the problem to be formulated and solved throughmathematical calculations (Wright, 2004), and 3) the ability to con-struct a mental image of the units of measurements needed to performdrug-dose calculations (Wright, 2005). However, little attention hasbeen given to identifying appropriate teaching/learning strategies thatwill effectively facilitate the development of these skills in nurses(Wright, 2007). One such approach may be simulation, an interactiveteaching/learning environment where tutors act as facilitators and stu-dents take on active roles (Jeffries, 2005).

It has been suggested that including simulations in pre-registrationnursing programs may facilitate the development of competence inthe clinical skills required for fitness for award, practice and purpose(McCallum, 2007). According to Brown and Knight (1998) simulationwith peer assessment promotes the interchange of ideas as well as in-volvement, group work, leadership, teamwork, creative thinking, andproblem-solving, and thus motivates students.

Furthermore, Moule et al. (2008) state that simulation may en-courage collaborative work between education providers and clinicalstaff while Houghton and colleagues recently indicated that, with theappropriate use of teaching strategies the Clinical Skills Laboratoryshould provide an authentic learning environment (Houghton et al.,2012; Struys et al., 2008).

Active learning strategies foster critical thinking by activating cogni-tive processes, and critical thinking is paramount in nursing if safe andeffective care is to be given. Nurses apply critical thinking to problemsolving (Popil, 2011) and using clinical case studies as a teaching devicepromotes critical thinking and encourages students to develop theirproblem-solving skills to the fullest, thereby nurturing the ability tobring theory and practice together (Popil, 2011).

Costs of simulator-based educational programs include facility,equipment and personnel.

According to Good (2003), additional studies are needed to assessthe effectiveness of patient simulators in achieving learning and per-formance assessment objectives.

Methods

Aim

The purpose of this study was to evaluate the effectiveness of aClinical Skills Workshop (CSW) on drug administration. The aim ofthe CSW was to improve the medication-dosage calculation skills ofsecond-year nursing students from a Northern Italian University.

Study Design

Assessment was performed by administering pre- and post-tests.We implemented a quasi-experimental, pre- and post-test design inorder to reflect the natural setting.

Participants and Setting

In December 2011 our work-team set up a CSW that aimed to en-courage undergraduate nursing students to develop their conceptual,mathematical and practical skills concurrently. To this purpose, anewly devised, integrated-strategies teaching approach was adopted.

The CSW lasted 30 h and took place over a period of two weeksduring the first semester of the academic year. It was attended by77 second-year nursing students who were all enrolled in the sameundergraduate nursing program. Their curriculum includes progres-sively sequenced classes on drug administration and drug-dosage cal-culation skills at every year of the program. None of these classes,however, include practical work.

The students were divided into 4 groups of 19–20 participants each,with two tutors per group. Each participant had the opportunity to tryout and simulate drug-dose calculations by using the methodologicalapproaches taught during the direct input stage.

Training Strategies

The CWSwas designed by the course planners to envisage a real-lifeclinical setting. Drug dosage calculation practice was built into eachclinical case study, featuring real-life medical prescriptions reportedonmedication charts, aswell asmedical equipment and aids that are ac-tually used in clinical settings. Proportional, scalar and problem solvingapproaches were adopted to teach mathematical calculations (Fig. 1).Fig. 2 exemplifies a clinical situation requiring students to calculate adrug dosage.

This teaching approach and the CSW aimed at helping students ac-quire the following: increased knowledge and understanding of mathe-matical calculations; the ability to use the pharmaceutical formularyand handbook and read medication labels on drug packages effectivelyand efficiently; the ability to correctly identify medical prescriptionsreported on medication charts; the ability to clearly identify and useequipment and aids needed to prepare and administer drugs; the abilityto prepare and appropriately administer drugs via different infusionroutes (oral, im, iv, sc). The latter was achieved through practice,using the full range of equipment needed for the preparation and ad-ministration of drugs to simulation mannequins.

Ethics

This study was given written approval by the University AcademicCommittee. All of the participants were given detailed information re-garding the study aims andmethodologies, the CSW and the intendedteaching and learning process. They were also informed that, whiletest results would be disclosed to each of them individually, all the re-sults would be deemed confidential for study-related purposes andanonymized prior to being entered into a database and analyzed. Fi-nally, participants were asked to fill in and sign an informed consentform.

Data Collection Tool

The tool deployed in this study was divided into two sections: thefirst was used to collect general demographics, such as age, sex, na-tionality and education; the second focused on the assessment test,called the Maths Skill Test, which was compiled by a panel of experttrainers and included 30 problem-questions ranging over 3 main sub-ject areas: 1) low complexity drug calculations (10 questions), 2) in-termediate complexity drug calculations (10 questions), and 3) highcomplexity drug calculations (10 questions).

Data Collection

The calculation abilities of nursing students were evaluated by wayof a pre and post-maths/drug calculation test. The participants weregiven 90 min to complete the test. They were asked to describe themethod they chose to answer the questions, to justify their choice andto explain why their answer made sense. Calculators were not allowed.

Pre- and post-test problemswere identical, except for post-test dos-age data, and the problem-solving strategies required to engage with

Proportion Method One of the most common drug calculations in practice involves proportional reasoning. Proportional problems occur when one variable varies in relation to another variable. Here is an example:Prescription: Carbocysteine Syrup 500 mgPackaging available: 50 mg / ml 1 ml : 50 mg = x ml : 500 mgX = 1 ml x 500 mg = 500 ml = 10 ml

50 mg 50

Scalar Method The Scalar approach focuses on the relationship between the variables being constant and uses this to manipulate both variables until the desired dosage or figure is ascertained

Here is an example: If Acetyl Salicylic Acid should be administered at ?125 mg., then 50 x2 e1/2 (o 2,5) = 125 or 50 +50 + (1/2 of 50) 25 = 125 Example: If a patient weighing 15 kg.s was prescribed 0.6 mcg/kg, and the ampoules available are 10 mcg/1 ml (is this sentence complete?).This approach does not require any formal mathematical operations, such as long divisions or multiplications or fractions.Step IStudents first need to calculate 0.6 mcg per kg, and how many mcg. for 15 kg., which we obtain by multiplying 0.6 by15 = 9 mcg. or0.6 by 10 and 0.6 by 5 kg and by adding the result of each to obtain 9 mcg.Step IIIf there are 10 mcg. per 1 ml, how many millilitres give 9 mcg.? The answer can be worked out by using one of the Scalar approaches; dividing both by 10 to get 1 mcg in 0.1 ml And then byMultiplying the result by 9 to get 9 mcg. in 0.9 ml. At no point did the numbers ever become devoid of their meaning. (Wright, 2009)

Problem solving (io porrei le domande in prima persona, come se fosse lo studente a parlare ...)There are four main steps to solve a mathematical problem that can be applied to drug calculations:

1. Understanding the problem

- What is the problem you need to solve? - What solution do you need to find? E.g.: volume to be administered, drops/m', units / h

2. Develop a plan - How do you solve the problem? - Are there several steps that need to be resolved? Which steps do you need to take first? - Do you recognize the problem type? - Have you come across this problem before? What worked then? Can you use the same approach again? ? - Which method do you think should be used to solve the problem?

3. Carry out the plan - Carry out the plan for the solution of this problem. - Check each step for accuracy and ensure that results make sense and are instrumental in solving the problem.

4. Examine the solution obtained - Is the solution logical and reasonable according to your clinical knowledge? - What solutions do you think should be adopted? Does your solution fit this estimate / assessment? - Based on your understanding of the problem, does your solution make sense?

(Wright, 2009b)

Fig. 1. Methodological approach.

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each problem were similar. Tests were administered prior to and afterthe CSW attendance.

Data Analysis

Each completed problem was awarded one point; incomplete an-swers were classified as incorrect, as were blanks and non-responses.

The test scores ranged between 0 and 30 points.Descriptive analysis of frequency, percentages, mean and standard

deviation were used to analyze demographic data and compare pre-and post-test results. A Repeated Measures-Analysis of Variance(Kruskal–Wallis Test) was used to evaluate differences in drug calcula-tions and pre-test scores according to nationality, geographical area,

and type and level of educational background. A mean value of correctanswers was calculated for each of these areas. A non-parametric signtest was used to compare pre- and post-test scores. A p-value b 0.05was deemed non-significant. All calculations were performed usingthe Stata 12 (StataCorp, College Station, TX, USA) software package.

Results

The age of our sample population ranged between 20 and 41 years,with a mean age of 22.98 (SD 3.88). Sixty-one (79.22%) participantswere female, 16 (20.78%) were male; 72 (93.51%) were Italian, and(6.49%) were not Italian. 46.75% had a scientific background, 23.38%had a liberal arts background, 3.9% held a university degree in science,

Clinical case: Medication infusion – infusion rate

Mr. White is currently hospitalized in the cardiology unit/ward for acute myocardial infarction. He is fasting and has a peripheral venous catheter in his left arm.

The Doctor has prescribed:Heparin 20,000 IU in 1,000ml physiological saline solution to infuse by infusion pump – Heparin 1,200 IU/h

Underlying clinical mathematical reasoning:

Step I:Question: What is the problem? We need to define what is the problem Answer: We have to administer 1,000 ml of physiological saline solution containing 20,000 IU of Heparin at a rate suchas to infuse 1,200 IU Heparin per hour.

II step Question: What do we need to administer? What solution do we need to find? Answer: We need to know how many ml/h the infusion should be set to.

III step What the data should we consider? -Amount of physiological saline solution to be administered: 1,000 ml -The amount of Heparin diluted in physiological saline solution: 20,000 IU -The amount of Heparin to be administered in 1 hour: 1,200 IU

Mathematical Procedure – Proportion system

20,000 UI : 1,000 ml = 1,200 UI : x ml X = 1,000 ml x 1,200UI = 120 ml = 60 ml

20,000 UI 2 The infusion should be set to 60 ml/h

The student must prepare the saline solution and start the infusion by setting the infusion pump at 60 ml/h. Standard operating procedures for infusion therapy require that nurses check that following data are correct before administering drugs:1. Right patient 2. Right drug 3. Right administration route 4. Right dose5. Right time6. Right dilution fluid compatibility 7. Right infusion rate 8. Right monitoring 9. Right documentation

Fig. 2. Example of simulation center drug calculation teaching approach.

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3.90%held a university degree in the liberal arts and 22.08% came fromavariety of different backgrounds.

Table 1Pre- and post-test differences.

N. students Mean SD Min P25 P50 P75 Max

Pre test 76 15.96 4.85 0 15 17 19 25Post test 75 25.2 3.64 15 22 26 28 30Pre/post test differences 74 9.09 4.74 −1 4 9 11 25

P b 0.001.

Test Results

Correlating pre-test results and educational background or nation-ality revealed no significant differences.

The pre-test response rate was 98.7% (n = 76), with 56.5% (n =43) of the participants scoring a negative mark (b50% of answerscorrect). Of the participants who scored a positive mark, only 1.3%(n = 1) answered 76% of the questions correctly.

The post-test response rates were 97.4% (n = 75), with 2.6%(n = 2) students scoring low score; though the latter two did recordsome degree of improvement (pre-test = 0; post-test = 15) afterthe learning process. Only 5.3% (n = 4) of the students answeredall the post-test questions correctly, and 12% made one mistake.

Pre-test scores ranged between 0 and 25 out of a possible 30, witha mean score of 15.96 (SD 4.85) and a median score of 17; post-testscores ranged between 15 and 30 out of a possible 30, with a meanscore of 25.2 (SD 3.63) and a median score of 26, p b 0.001.

The differences between pre- and post-tests are reported in Table 1;mean differences per area in the pre- and post-tests are reported inTable 2.

Results from two participants who did not take the post-test andfrom one participant who did not take the pre-test but scored 30 pointson the post-test were excluded from pre-and post-test comparisons,which therefore took into account a total of 74/77 participants.

Discussion

The main aim of the study was to assess the effectiveness of a CSWon drug administration that focused on improving the drug-dosagecalculation skills of undergraduate nursing students.

Some of the pre-test results suggest that a preparatory course inbasic mathematics should be included in the first-year curriculum ofthe nursing program to improve students' familiarity with and under-standing of basic mathematical concepts. Such a course would benefit

Table 2Outcome comparison between different areas of the pre- and post-tests.

Students Law complexity area questions 1–10 Medium complexity area questions 11–20 High complexity area questions 21–30

N Min. score Max score Mean SD Min. score Max score Mean SD Min. score Max score Mean SD

Pre test 76 0 10 8.78 2.16 0 10 6.56 2.62 0 6 0.6 1.08Post test 75 6 10 9.34 0.89 1 10 9.01 1.41 0 10 6.84 2.41Pre/post test differences 74 −2 10 0.5⁎ 2.19 −3 9 2.38⁎⁎ 2.51 0 10 6.21⁎⁎ 2.33

⁎ p = 0.99.⁎⁎ p b 0.001.

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second-year students, who are required to apply mathematical calcu-lations to pharmacotherapy.

During the initial stage of the CSW, tutors offered direct input onbasic mathematics. Students who performed poorly in basic mathe-matics during the pre-test were asked to revise relevant conceptsand assigned self-study remedial work. Once completed, outcomesand issues were discussed with a tutor.

During the input stage of this teaching/learning process, tutorsobserved that a large number of participants experienced consider-able difficulties with arithmetic, especially where fractions, ratios,decimals and multiplications were involved, as reported by others(Weeks et al, 2000). Above all, as found elsewhere (Hutton, 1998;Weeks et al., 2000), participants struggled to conceptualize prob-lems. At later stages of the learning process and especially duringthe practical simulation of drug preparation, tutors realized how im-portant it was for attendees to be able to visualize medication charts,syringes, needles, vials, bottles, infusion lines and routes if the learn-ing of calculation strategies was to be facilitated (Weeks et al., 2000;Wright, 2008).

Students also struggled to come to termswith the newly introducedscalar method and initially claimed the already-known proportionalmethod to be better. However, on completing the learning process, par-ticipants commented on how useful the scalar method had actuallyproved to be to solve a number of problems and stated that the propor-tional method would not have allowed them to reach the correct out-come. This clearly highlights the importance of giving input thatcovers different methodological approaches and empowers studentsto choose the approach that best suits the situation at hand (Wright,2005).

Pre-test scores for low-complexity problemswere acceptable (mean8.78), and showed a slight improvement at the post-test stage (mean9.34) Clearly, however, a number of students still had difficulty withthe low-complexity area. Some participants made mistakes convertingmcg into mg, not because they did not know about conversions, but be-cause they had set off from an incorrect mathematical standing point,got confused somewhere along the calculation process and lost sightof the part of the equation they were trying to solve. This appears tosuggest that certain students lack clinical–mathematical reasoningand problem-solving skills, whereas others (i.e. those whowere unableto performcorrect calculations throughout the process) failed to take allthe given case information into due account.

Having a 19–20 to 2 student/tutor ratio gave tutors the opportunityto re-group at each step of the teaching/learning process to discuss andfurther tailor necessary interventions. A case in point was the idea ofmixing students with weaker-mathematical skills with students withstronger skills, which sprang from an open discussion among tutors.By doing this, tutors consciously opted to promote team-building andpeer-support. The self-study approach that tutors encouraged provedextremely useful, as it allowed participants to engage with calculationsand practice problem-solving in a stress- and anxiety-free environment.

The educational approaches used for this CSWwere instrumentalin engaging the participants and encouraging them to take on re-sponsibility for their own learning (Jeffries, 2005). In particular,real-life prescriptions reported on real-life medication charts within

the framework of an authentic clinical case study enabled students toenvisage and connect with relevant and meaningful clinical aspects(Hutton et al., 2010;Weeks et al., 2000;Wright, 2008, 2010). Despitebeing clearly not keen on mathematics, participants reported thatthe teaching of mathematics and arithmetic was reasonably compre-hensible and not excessively taxing.

The teaching of different approaches to calculation was closelyrelated to a meaningful clinical setting at all times, so that a connec-tion between mathematics and the administration of drugs wasmade possible by placing both in a clinical setting. This appears tobe in keeping with K. Wright (2010), who advocates the importanceof context where the teaching and assessment of such competencesare concerned.

The distinctive feature of the teaching/learning process describedhere lies in the fact that pre- and post-testing problems closely echoedinput presented during the CSW, and that participants were mainlyasked to deploy workshop-acquired approaches and strategies.

Direct observation proved that identifying both the vial and the sy-ringe does indeed help students with calculations, especially whengauging and evaluating whether or not results are acceptable (Wright,2010). At some stages in the workshop, “stronger students” becamebored and inattentive. However, when the tutors attempted to rekindlethese participants' interest with more challenging topics, the weakerparticipants were clearly unable to keep up. Thus, the tutors' abilitieswere put to the test throughout the workshop, though all agreed thatmixed ability groups should be kept.

This study informed tutors' needs to devise best possible practicesand to foster mentoring by stronger attendees' towards their weakercolleagues.

Drug CalculationWorkshops could usefully become an integral partof the undergraduate nursing curriculum, with summative assessmentsfollowing each academic year and throughout clinical placements. Cre-ating an on-line platform to upload case studies with drug prescriptionrequiring the use of an active calculation would allow for on-going as-sessment of nursing students' learning progress.

Study Limitations

A limitation of this study may lie in the fact that the participantswere divided into rather large groups. Also, this study involved a sin-gle university with a relatively small sample population, which mayhinder the generalizability of our findings.

Further studies are required to assess the competences acquiredover time, as well as participants' retention of drug-calculation skills.

Conclusions

The learning process designed and implemented in this study aimedat developing cognitive competences in clinical judgment and criticalthinking in second-year nursing students. These goals were reachedby implementing integrated teaching strategies that will help improvestudents' performance in providing effective, efficient and risk-freecare to patients in their future professional life.

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This CSW allowed for the development of discussed methodologicalapproaches, in accordancewith the conceptualmatrix strategy advocatedby the Bologna Process, thereby facilitating the transition from theory toskills-applied competences and establishing the basis for problem-basedlearning.

Our experience confirmed that the application of skills-based work-shopswithin a simulation center impacts directly on clinical practice byencouraging teachers and students' alike to transfer theory to clinicalpractice (Wright, 2010).

The teaching/learning process designed and implemented in thisstudy encouraged cognitive processes and stimulated the develop-ment of clinical understanding and critical thinking (Alinier et al,2004; Popil, 2011). It also fostered the development of technical andpsychomotor abilities by encouraging students to acquire the compe-tences that they need to provide effective and confident care duringtheir clinical training.

Conflict of Interest

This research has not received sources of support.

Acknowledgments

We thank our team of Teachers/Educators and all the studentswho took part in the study. We thank Piaggio Alexia for languagesupervision.

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