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UNIVERSITY OF TASMANIA
Understanding Applied Pharmacology: Perceptions of undergraduate student nurses Final Report for the SNM HDR Committee Ms Juliet Sondermeyer, Dr Christine Spratt, Dr Christine Armatas and Mr Daniel Goss January 2006
FACULTY OF HEALTH SCIENCE
School of Nursing and Midwifery Faculty of Health Science University of Tasmania Launceston TAS 7250 Visit our website at
Contents

Executive summary
Background
In recent years governments in Australia and internationally have become
increasingly interested in promoting what is known as the ‘Quality Use of Medicines'
(QUM) as a central policy platform. QUM is a national strategic priority in health care
policy nationally and internationally. Concurrently with the evolution of the QUM
agenda there has been growing concern in nursing that contemporary undergraduate
curricula do not prepare graduates to be competent in this area. The SNM BN
curriculum has never been reviewed previously in light of the QUM agenda nor had
the School undertaken any systematic research regarding the efficacy of its
pharmacology teaching.
Funding for this project was obtained through an SNM Higher Degrees and Research
Committee Seeding Grant and the project commenced on the 12th of July 2004.
Broadly, the project sought information from 3rd year undergraduate students
regarding their perceived pharmacology knowledge, confidence with the
administration of medicines, and accuracy with drug calculations. In addition an audit
of the Bachelor of Nursing (BN) undergraduate program was conducted to determine
the extent to which it complies with the intentions of the Quality Use of Medicines
framework.
Project objectives
The study aimed to investigate the preparedness of third year undergraduate nursing
students in the administration and management of medicines. A four stage project, it
aimed to provide comparative data about the perceptions and competence of third
year undergraduate nursing students and beginning registered nurses regarding their
understandings in applied pharmacology; by ‘applied pharmacology' we mean
medication management in a clinical setting. It was anticipated that the research
outcomes would inform teaching, learning and curriculum development in the SNM
and contribute to the discipline more broadly.
Stages 1, 3 and 4 of this project aimed to provide comparative data about the
perceptions and competence of third year undergraduate nursing students and
beginning registered nurses in the knowledge and administration of medicines. Stage
2 audited the BN curriculum to determine the extent to which it complied with the
intentions of the Quality Use of Medicines framework.
Method
Students enrolled in CNA315 Acute Care Nursing, in Semester 2 2004 were invited
to participate in the study. The study was conducted between Semester 2 2004 and
Semester 2 2005. A social sciences ethics application was submitted to Human
Research Ethics Committee (Tasmania) Network and ethics approval granted.
The four stage project took a pre-test/post-test design methodology for Stages 1, 3
and 4 which aimed to provide comparative data about the perceptions and
competence of third year undergraduate nursing students and beginning registered
nurses in the knowledge and administration of medicines. Stage 4 also included a
email questionnaire with willing participants. Stage 2 audited the BN curriculum to
1 QUM means selecting management options wisely, choosing suitable medicines if a medicine is considered necessary ad using medicines safely and effectively (Executive Summary National Strategy foe the QUM, 2004) determine the extent to which it complied with the intentions of the Quality Use of Medicines framework. Key findings
The quantitative survey data revealed that although students' perceptions improved
from the start of the study, they only became more positive from the first to the
second occasion, with no change from the second to final administrations. This same
pattern was observed for the test scores, which indicated an initial increase in
knowledge from the first to second tests, but not from the second to third. Despite
improvement in these three measures, perceptions of confidence and competence
with respect to medication did not correlate with pharmacology knowledge as
measured by the test scores. However, the small sample for the final survey makes
drawing firm conclusions about whether there was improvement from the second to
final stages of the study due to a lack of power in the analyses.
At face value, these results suggest that there is an initial and significant
improvement in students' perceptions a few weeks after they start their course, and
that this positive perception persists, but does not increase, across the course. The
difficulties in securing the kinds of rich qualitative data which may have arisen from a
focus group interview to illuminate the findings of the survey data was both
disappointing for the researchers and contributed to the limitations of the study.
While the email questionnaire revealed some thoughtful responses from participants,
responses were received from only five participants. Perhaps the most revealing
comments for us related to the participants' recognition that pharmacology and
medication management is a complex field and that as registered nurses they
recognise their responsibility for lifelong learning and for finding research strategies
to enable them to stay abreast of the field.
While the recognition of the importance of lifelong learning is an admirable outcome
for the BN and reflects the students developing confidence in the field of medication
management through the course of their final year of the BN, we remain concerned
about the poor test results in relation to pharmacology knowledge.
The curriculum audit revealed a lack of an explicit recognition of ‘Quality Use of
Medicines' as an organising framework for the teaching of pharmacology and
medication management across the BN.
Recommendations
The findings from the study give rise to the following recommendations:
1. That the findings of the study are reported to the SNM through the BN Curriculum Committee; 2. That Mrs. Sondermeyer and Dr Spratt conduct series of workshops to ensure the BN better integrates the ‘discourse' of QUM in the curriculum; 3. That Ms Sondermeyer, Dr Spratt and relevant teaching staff review the teaching and assessment of pharmacology practices in the BN in relation to pharmacology and medication management; a. That the potential of extending existing case-based problem-oriented approached to the teaching of QUM informs such discussions; and 4. That a benchmarking exercise be conducted with a comparator nursing school regarding pedagogical approaches to the teaching of pharmacology and QUM in the BN. This report summarises the study, its findings, and makes recommendations for further research in the area of undergraduate medication management in nursing education. Funding for this project was obtained by Ms Sondermeyer and Dr Spratt, through an SNM Higher Degrees and Research Committee Seeding Grant and the project commenced on the 12th of July 2004. In light of the literature and anecdotal evidence of the increase in the number of medication errors made by nurses there is a significant need to investigate the educational preparedness of undergraduate student nurses in the quality use of medicines. A recent Australian study of academic staff engaged in the teaching of undergraduate pharmacology at thirteen universities involved in undergraduate nursing education, found ‘great variation in the number of hours devoted to pharmacology' and further that respondents were ‘dissatisfied with graduates and their knowledge base in pharmacology' (Bullock & Manias 2002). Moreover, graduate nurses have reported ‘limited understanding of pharmacology', and general dissatisfaction with their undergraduate preparation in applied pharmacology which they attribute to causing ‘anxiety after qualifying' (King 2004). As part of the National Strategy for the Quality Use of Medicines, the National Prescription Service undertook a review of undergraduate nursing curricula in 2000 which found that the ‘principles of QUM may not be directly reflected in undergraduate nursing curricula either as specific goals to be taught or as areas of learning to be evaluated' (Griffiths, Hunt, Napthine & Birch 2000, p. 3). Broadly, the project sought information from 3rd year undergraduate students regarding their perceived pharmacology knowledge, confidence with the administration of medicines, and accuracy with drug calculations. In addition an audit of the Bachelor of Nursing (BN) undergraduate program was conducted to determine the extent to which it complies with the intentions of the Quality Use of Medicines framework. Students enrolled in CNA315 Acute Care Nursing, in Semester 2 2004 were invited to participate in the study. Dr Spratt conducted information sessions and requested participation in the study for survey completion and interview participation (See Appendix 1: Study Information Sheet). The study was conducted between Semester 2 2004 and Semester 2 2005. A social sciences ethics application was submitted to the Human Research Ethics Committee (Tasmania) Network and ethics approval was granted. The study took a pre-test/post-test design methodology and was a four stage project. Stages 1, 3 and 4 aimed to provide comparative data about the perceptions and competence of third year undergraduate nursing students and beginning registered nurses in the knowledge and administration of medicines. Stage 2 audited the BN curriculum to determine the extent to which it complied with the intentions of the QUM framework. A two-part survey instrument was developed for this study. For Stage 1 and Stage 3 the same survey was used with the first part the same on each occasion while the second part differed. For Stage 1 and 3 Part 1 of the survey consisted of 12 items designed to assess participants' beliefs and knowledge of their confidence in medication management (see Appendix 2). In Stage 1 & 3 Part 2 consisted of a series of multiple-choice questions to measure students' pharmacology knowledge. Stage 4 Part 1 was similarly structured but with some variability in each item (See Appendix 3). For Stage 4, Part 2 consisted of a case-based scenario with associated short answer questions. For Part 1 on all surveys, each item was scored on a 5-point scale, where 0=Strongly Agree, 1=Agree, 2=Neutral, 3=Disagree, 4=Strongly Disagree. Stage 4 also invited volunteers from the original cohort to participate in a one-hour semi-structured interview to gather more detailed data about participants' beliefs about how prepared they were to practice in relation to pharmacology. Stages 1 and 3: Pre-test/post-test surveys
In Week 1 of Semester 2 2004 students entering third year (n=68) who were undertaking CNA315 were invited to complete a Survey Questionnaire. The survey was repeated at the conclusion of Week 13 of Semester 2 2004 (Stage 3 of the project). The survey asked them to rate a range of perceptions and understandings of applied pharmacology and their beliefs about their competence to practice. It also assessed their knowledge of key areas of applied pharmacology through a series of multiple choice questions. The survey was developed based on a literature review and analysis and the existing expertise of the co-investigators. An expert educational psychologist assisted with survey construction and the survey was piloted with a small group of volunteer third year students undertaking the unit CNA315 in Semester 1 2004. Stage 2: Curriculum audit
A concurrent audit of the BN curriculum was undertaken to determine the extent to which it complied with the intentions of the QUM framework. The co-investigators searched the content and assessment of all the subjects in the BN to establish whether any of the key QUM criteria were articulated within the subjects. Stage 4: Graduate survey and email questionnaire
All students who participated in the study over Semester 2 2004 were invited to complete a different survey questionnaire after they had completed three months practice as registered nurse. This survey was mailed to 60 students in their practice settings, 14 were returned. Participants were also invited to contribute to a focus group interview which we anticipated would be conducted three months after they had graduated and were practicing as registered nurses. As the project progressed and potential interviewees were contacted it became increasingly evident that conducting a focus group interview was implausible. It was also difficult to arrange individual telephone interviews. The research team decided to modify the collection of qualitative data; participants who had agreed to the focus group interview were requested to respond to an email questionnaire, anonymity was assured and consent was implied by response: five participants responded. Data analysis
The multiple choice survey data from Stages 1, 3, and 4 were analysed using SPSS.
The qualitative data was analysed thematically.
The national QUM Policy Framework including the Manual of Indicators to Measure
the Quality use of Medicines in Australia (2002) was used in the audit of the BN.
This was effectively a benchmarking exercise to compare, measure and critique the
content of the BN curriculum against the identified indicators.
The method is summarised in Table 1
Table 1: Research method outline

Method Strategy Timeline/Date
Ethics application
UTAS Ethics committee Submitted May 28th for Meeting June 14th Survey 3rd year students Week 1: Friday July 16th commencement academic program Semester 2 2004 (pre-test) Audit BN curriculum for Concurrently through Survey 3rd year students at Week 13: Friday October 15 conclusion academic program Semester 2 2004 (post-test) At completion of 3 month's Stage 4 participants recruited practice, Survey graduates at commencement of study using different questions: open-ended email questionnaire to solicit qualitative data Results and discussion
The results of the study are presented in three parts in this section. The first part presents the detailed analysis of the quantitative survey data. The second section presents the analysis of the qualitative data. For ease of presentation, the curriculum audit has been documented as a matrix and is included as Appendix 4 and the implications are discussed in the summary. The summary draws conclusions from an integration of the data analysis. Quantitative analysis
Perceptions of practice
Items 1 to 12 were designed to assess perceptions of practice. Factor analysis of the data from the first survey showed that these items formed two factors. The first factor related to perceived confidence and competence with respect to administration of medications. The second factor related to perceptions of the BN course. The items comprising each of these factors are detailed in Table 2 together with descriptives and the reliability coefficients for the scales. As shown in Table 1, both scales showed acceptable reliability. The means for both scales indicate that as a group, these nurses tended to be uncertain about whether their learning experiences in the course prepared them about medications and were uncertain that they were confident regarding the administration of medications. Items 3, 7, and 8 did not fall into either of these factors and are reported individually. The means for these items indicate agreement that understanding pharmacology is important and that weekly tests should improve knowledge in this area. However, the mean for Item 8 indicated that they were uncertain whether the preceptor model would be of assistance in developing pharmacology knowledge. Table 2. Descriptives for scale items for first survey administration Scale items (n=number of items)
Perceived confidence & competence with medications (n = 5) • Item 1 "I feel confident today regarding the prospect of administering medicines in a practice setting"; • Item 9 "I am confident that I would identify a potentially hazardous medication prescription"; • Item 10 "I am not confident that I can practice within the legal guidelines pertaining to medication administration";** • Item 11 "I am confident that I can explain the actions of medications that a patient in my care is taking"; • Item 12 "I am competent in the administration of medications". Perceptions of the Bachelor of Nursing course (n = 4) • Item 2 "I believe that my learning experiences in the Bachelor of Nursing course so far, have prepared me to administer medication • Item 4 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the administration of medicines"; • Item 5 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the pharmacology of medicines"; • Item 6 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the adverse effects of medicines". Item 3 "It is important for me to understand the pharmacological treatment and management of people for who I care." Item 7 "A weekly medication test will help me develop my understanding of pharmacology and safe medication administration." Item 8 "The preceptor model of teaching in clinical practice has not assisted me to develop my pharmacology knowledge." ** indicates item was reverse scored. Knowledge of pharmacology
The distributions of scores on the 15-item multiple-choice test are reported in Table 3. The mean score on the test for the group (n = 68) was 6.34 with a standard deviation of 2.55. The highest score was 11, obtained by two nurses and the lowest zero, also obtained by two students. Generally, knowledge of pharmacology as indicated by the number of correct responses to test items was poor. Table 3. Distribution of test scores Score Frequency
(n) Percentage
Item analysis for the test indicated that Questions 13, 14, 15, 19, 24, and 25 did not discriminate well as they showed low item-total correlations (i.e., less than .2). Questions 17, 18, and 20 showed good discrimination with item-total correlations of .4 and above. The Cronbach's alpha for the entire test was poor at .5175, but improved to an acceptable level when the non-discriminating items were deleted (α = .682). For the abbreviated test, comprising scores for answers to Items 16 to 18, 20 to 23, and 26 to 27, the mean score for the group was 4.38 (sd = 2.27). Relationship between perceptions of practice and test scores
To assess whether test performance was related to responses to items assessing perceptions of practice, the total scale scores for confidence with medications and perceptions of the Bachelor of Nursing course were correlated with test scores. Although scores on both these scales were significantly correlated, neither of the factor scales correlated significantly with total test scores. This indicates that although confidence with respect to medications is related to positive perceptions about how well the course has prepared students, neither of these factors is related to actual pharmacology knowledge as measured by either the 15- or 9-item test. Perceptions of practice
The two scales determined by the factors analysis of items 1 to 12 from the first survey were again analysed. Table 4 details the descriptives and the reliability coefficients for the scales for the second survey. As shown in Table 4, both scales showed acceptable reliability. The means for both scales indicate that as a group, these nurses tended to agree that their learning experiences in the course prepared them about medications and were confident regarding the administration of medications. Scores on these two scales indicated a shift towards a more positive perception of practice than at the first survey administration. Similarly scores on Items 3, 7, and 8 indicate strong agreement that understanding pharmacology is important and that weekly tests should improve knowledge in this area. Furthermore, unlike at the first survey administration, the mean for Item 8 on the second survey indicated that they agreed the preceptor model would be of assistance in developing pharmacology knowledge. Table 4. Descriptives for scale items on second survey administration Scale items (n=number of items)
Mean (sd)
Cronbach's
Perceived confidence & competence with medications (n = 5) • Item 1 "I feel confident today regarding the prospect of administering medicines in a practice setting"; • Item 9 "I am confident that I would identify a potentially hazardous medication prescription"; • Item 10 "I am not confident that I can practice within the legal guidelines pertaining to medication administration";** • Item 11 "I am confident that I can explain the actions of medications that a patient in my care is taking"; • Item 12 "I am competent in the administration of Perceptions of the Bachelor of Nursing course (n = 4) • Item 2 "I believe that my learning experiences in the Bachelor of Nursing course so far, have prepared me to administer medication safely"; • Item 4 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the administration of medicines"; • Item 5 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the pharmacology of medicines"; • Item 6 "I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the adverse effects of medicines". Item 3 "It is important for me to understand the pharmacological treatment and management of people for who I care." Item 7 "A weekly medication test will help me develop my understanding of pharmacology and safe medication administration." Item 8 "The preceptor model of teaching in clinical practice has not assisted me to develop my pharmacology knowledge." ** indicates item was reverse scored. Knowledge of pharmacology
The distributions of scores on the 15-item multiple-choice test are reported in Table 5. The mean score on the test for the group (n = 67) was 10.64 with a standard deviation of 2.45. The highest score was 15, obtained by one nurse and the lowest 4, obtained by two nurses. Generally, knowledge of pharmacology as indicated by the number of correct responses to test items was good. A t-test for independent samples showed a significant difference in scores on the two test administration t(133) = 9.98, p = .000, indicating scores on the second administration of the test were significantly better than on the first. However, this analysis understates the improvement in test scores. On the first test administration, 70% of nurses scored between 5 and 9 on the test. In contrast, for the second survey administration 76% scored between 10 and 15. Table 5. Distribution of test scores on second test administration Score Frequency
(n) Percentage
Item analysis for the second test administration indicated that Questions 14, 16, 24, and 25 did not discriminate well as they showed low item-total correlations. Questions 19 and 26 showed good discrimination with item-total correlations of .5 and above. The Cronbach's alpha for the entire test was adequate at .6283. Relationship between perceptions of practice and test scores
As with the first survey, scores on the two perceptions of practice scales were significantly correlated, but neither of the factor scales correlated significantly with total test scores. This indicates that although confidence with respect to medications is related to positive perceptions about how well the course has prepared students, neither of these factors is related to actual pharmacology knowledge as measured by either the 15-item test. The same survey, with minor alterations, which was used for Stages 1 and 3 of this study was again administered to willing graduates of the initial student cohort. A total of 13 students completed the survey for the final stage. Data from this survey administration were analysed using the two scales derived from the factor analysis conducted on data from the first survey administration. Comparison of scores on these two scales and scores on the pharmacology knowledge test were compared across the three stages of the study. Perceptions of practice
The first scale consisted of Items 1, 9, 11, 12 and the reverse scored item 10 and related to perceived confidence and competence with respect to administration of medications. This scale has a range of 5 to 25, with higher scores indicating a less positive perception. The second scale related to perceptions of the Bachelor of Nursing course and consisted of four items (Items 2, 4, 5, and 6) with a range of 4 to 20. For this scale, higher scores also indicated less positive perceptions. Table 6 details the descriptives and the reliability coefficients for the scales for the Stage 3 administration. As shown in Table 6, both scales showed good reliability. The means for both scales indicate that as a group, these nurses tended to agree that their learning experiences in the course prepared them about medications and that they were confident regarding the administration of medications. Items 3, 7, and 8 were again analysed separately. The means for these items indicate strong agreement that understanding pharmacology is important and agreement that weekly tests should improve knowledge in this area. The mean for Item 8 indicated that they agreed that the preceptor model would be of assistance in developing pharmacology knowledge. Table 6. Descriptives for scale items for third survey administration Scale items (n=number of items)
Mean (sd)
Perceived confidence & competence with medications (n = 5) Perceptions of the Bachelor of Nursing course (n = 4) • It is important for me to understand the pharmacological treatment and management of people for who I care. • A weekly medication test will help me develop my understanding of pharmacology and safe medication administration. • The preceptor model of teaching in clinical practice has not assisted me to develop my pharmacology knowledge. ** indicates item was reverse scored. A one-way analysis of variance (ANOVA) was conducted for each of the scales and the two of the separate items comparing the scores for each across the three stages (Items 7 and 8). Item 3 was not analysed as all respondents returned a response of "Strongly agree" for this stage. As shown in Table 7 there was a significant main effect of survey administration stage for both the scales but not for Items 7 and 8. Examination of the Tukey's post hoc tests indicated that the mean scores for both scales for the second and third survey administrations were significantly higher than for the first occasion. This indicates that participants felt significantly less confident and competent about administration of medications, and had significantly less positive attitudes towards the nursing course, at the start of the study. While they were significantly more positive at the time of the second survey, there was no significant increase in these attitudes and perceptions between the second and final survey administrations. Table 7. Comparison of scale scores across the three surveys Scale Time
Mean (SD)
survey (N)
Stage 1 (N=64) Stage 2 (N=66) F(2, 137) = 62.132, p = Stage 3 (N=13) Perceptions of the Stage 1 (N=61) Bachelor of Nursing Stage 2 (N=64) F(2, 142) = 34.071, p = Stage 3 (N=13) Knowledge of pharmacology
The distribution of scores on the 15-item multiple-choice test is reported in Table 8. The mean score on the test for the group (n = 13) was 11.31 with a standard deviation of 2.46. The highest score was 14, obtained by two nurses and the lowest 5, obtained by only one nurse. Unlike the previous test results, scores for the majority of these students were 10 or higher, indicating a good knowledge of pharmacology. Table 8. Distribution of test scores Score Frequency
(n) Percentage
Item analysis for the test indicated that all students correctly answered Questions 17, and 27 and that Questions 16, 19, 20 and 27 did not discriminate well as they showed low item-total correlations (i.e., less than .2). The remainder of the questions showed good discrimination with item-total correlations of approximately .4 and above. The Cronbach's alpha for the entire test was good at .749. Relationship between perceptions of practice and test scores
To assess whether test performance was related to responses to items assessing perceptions of practice, the total scale scores for confidence with medications and perceptions of the Bachelor of Nursing course were correlated with test scores. As with the previous occasions, although scores on both these scales were significantly correlated, neither of the factor scales correlated significantly with total test scores. This indicates that although confidence with respect to medications is related to positive perceptions about how well the course has prepared students, neither of these factors is related to actual pharmacology knowledge as measured by the 15-item test. Change in knowledge of pharmacology across survey administrations
To determine whether students' knowledge of pharmacology had improved across time, a oneway analysis of variance (ANOVA) was conducted comparing the test scores for each of the three stages. As shown in Table 9., there was a significant main effect of survey administration stage. Examination of the Tukey's post hoc tests indicated that the mean test scores for the second and third survey administrations were significantly higher than for the first occasion. This indicates that participants' knowledge of pharmacology as measured by this test improved after the first survey administration. However, although the mean score for the test was slightly higher on the final occasion, there was no significant difference between test scores on this and the second survey administration. Table 9. Comparison of test scores across the three surveys Mean (SD)
survey (N)
Stage 1 (N=68) Stage 2 (N=67) F(2, 147) = 133.134, p = Stage 3 (N=13) Qualitative analysis
The open ended questions that were sent to participants were structured to elicit data
related to defined areas of the questionnaires that is participants' perceptions of how
clinical experience supported their confidence in medication management practice
and their knowledge of pharmacology. Participants who responded to the email
questionnaire were informed of the overall poor tests results of the research
participants.
The interview data was thematically analysed. The data has been aggregated
accordingly in this reporting. Direct quotes arising from the data is italicized in the
following discussion.
Perceptions of practice: managing and using medicines competently
and safely
The SNM supports a preceptor model of clinical education with its collaborators in the clinical setting. The participants felt that the hands on experience and knowledge gained through the preceptor model of clinical education used in the unit were valuable in learning how to safely administer pharmaceuticals. This was however limited to when the preceptor was interested in and able to precept properly. It was felt that preceptors were valuable and helpful when they were able, but were often limited by time constraints in how they supported student learning. Students who received what they saw as ‘poor' preceptorship perceived that that their ‘learning was stunted' and at worst they felt ‘unsafe'. Pharmacology knowledge development in the BN
There was uncertainty in the participants' opinions as to whether the BN had adequately prepared them to manage pharmaceutical interventions. Only one participant felt that the BN had prepared them to an appropriate level of competence. Other respondents felt that the BN had provided them with a ‘minimum' or ‘general' understanding of pharmacology, which left some areas needing to be covered more extensively once they graduated. It was felt that the BN could have spent more time preparing in medication management, drug administration, and using ‘tools' (such as needles, syringes and intravenous therapy fluids). If this were the case, one nurse commented that they would be: more confident in my surroundings … [have] better utilised the relatively small amount of practical time … able to grow my knowledge base at a greater rate … [and] not asked as many stupid questions Participants perceived that the BN had neglected certain areas of preparation relating to nursing assessment and the management of medicines. This opinion did however come with the understanding that it would be impossible to know ‘everything' before they began practice. One participant felt that the BN should not attempt to provide them with all the knowledge, rather the ability to learn as they practiced. Nevertheless, specific areas which the participants stated were neglected within the BN included: • patient assessment in relation to medication; and • assessing and observing patients in relation to ‘drug seeking' and ‘habitual Participants generally felt positive about the effectiveness of the BN course in developing their feelings of confidence in their ability to manage pharmaceuticals. On the whole the BN gave me good understanding of the most common groups of drugs and the rationales/uses of medications. We knew our role legally and ethically as well as understanding group of commonly used drugs, plus having the confidence and ability to look up and understand the drugs we were not aware of and use them. The participants felt that continued and extended practical experience within the BN is essential for it to adequately prepare students as registered nurses capable and competent in management. One participant stated: During my experience I found that managing medications is the best way to learn about them. It needs to be ensured that all students experience a range of acute care placements. Two of the five participants explicitly stated that frequent testing of pharmacological knowledge (such as that which occurs in the unit CNA315 Acute Care Nursing) is important in ensuring the students nurses' understandings of pharmacology management was to the expected standard of competence. Some participants postulated in their responses on the reasons for the ‘poor test' results; several believed poor test results were a consequence of not having experienced such scenarios in ‘real' practice. They also feel that their ability and competence in administering pharmaceuticals in practice is completely different to how they respond to questions in theory. Lifelong learning about medications as a professional responsibility
All of the participants had developed a commitment to lifelong learning in relation to pharmacology knowledge since becoming a registered nurse. They used approaches such as their own ‘experiential learning', discussion with other staff in their workplace, and also taking it upon themselves to research drugs and their uses. The participants felt that learning pharmacological knowledge was an ongoing task for a nurse. This opinion, alongside the fact that they take a personal responsibility in their learning shows that the participants are committed to the idea that it is a professional duty as a nurse to become better educated in pharmacology. The BN curriculum audit
The audit of the BN curriculum against the QUM standards is annotated in Appendix 4. While the audit revealed that pharmacology and medication management are taught across the curriculum and one can demonstrate the integration pharmacology management across the curriculum, there is little evidence in the documentation of the curriculum (i.e. the unit outlines and related teaching materials used by academic staff), that the discourses of QUM inform the curriculum. Conclusion
Although participants' perceptions of their confidence in medication management improved from the start of the study, they only became more positive from the first to the second occasion of the survey administration, with no change from the second to final administrations. This same pattern was observed for the test scores, which indicated an initial increase in knowledge from the first to second tests, but not from the second to third. Despite improvement in these three measures, perceptions of confidence and competence with respect to medication did not correlate with pharmacology knowledge as measured by the test scores. However, the small sample for the final survey makes drawing firm conclusions about whether there was improvement from the second to final stages of the study, due to a lack of power in the analyses. At face value, these results suggest that there is an initial and significant improvement in students' perceptions a few weeks after they start their course, and that this positive perception persists, but does not increase, across the course. The difficulties in securing the kinds of rich qualitative data which may have arisen from a focus group interview to illuminate the findings of the survey data was both disappointing for the researchers and a major limitation of the study. While the email questionnaire revealed some thoughtful responses from participants, responses were received from only five participants. Perhaps the most revealing comments for us related to the participants' recognition that pharmacology and medication management is a complex field and that as registered nurses they recognise their responsibility for lifelong learning and for finding research strategies to enable them to stay abreast of the field. The recognition of the importance of lifelong learning is an admirable outcome for the BN and reflects the students developing confidence in the field of medication management through the course of their final year of the BN. However we remain concerned about the poor test results in relation to pharmacology knowledge. The curriculum audit revealed a lack of an explicit recognition of QUM as an organising framework for the teaching of pharmacology and medication management across the BN. Recommendations
The findings from the study give rise to the following recommendations:
5. That the findings of the study are reported to the SNM through the BN Curriculum Committee; 6. That Mrs. Sondermeyer and Dr Spratt conduct series of workshops to ensure the BN better integrates the ‘discourse' of QUM in the curriculum; 7. That Ms Sondermeyer, Dr Spratt and relevant teaching staff review the teaching and assessment of pharmacology practices in the BN in relation to pharmacology and medication management; a. That the potential of extending existing case-based problem-oriented approached to the teaching of QUM informs such discussions; and 8. That a benchmarking exercise be conducted with a comparator nursing school regarding pedagogical approaches to the teaching of pharmacology and QUM in the BN. Project Funding:
$4,900.00
Project Costs:
Educational Testing Centre @UNSW for Survey answer sheets QUM Conference: Accommodation/Flights and Registration: Dr Christine Armatas for consulting services: Total Costs:
$ 3961.38
Remaining Funds:
Appendix 1 Information Sheet
Research Project
Understanding applied pharmacology: perceptions of undergraduate student nurses

Dear Student

We would like you to participate in a research project called Understanding applied
pharmacology: perceptions of undergraduate student nurses. This information letter describes
the project. This project, conducted by researchers from the Tasmanian School of Nursing
(TSoN) aims to investigate the perceptions of third year undergraduate student nurses and
beginning registered nurses, of their understanding of pharmacology knowledge and applied
pharmacology procedures in Nursing. The purpose of the research is to provide the TSoN
with comparative data about the perceptions of third year undergraduate nursing students and
beginning registered nurses regarding their competence in applied pharmacology. The study
will also gather data about the way the Bachelor of Nursing curriculum complies with the
Quality Use of Medicine (QUM) framework. QUM is a national strategic policy direction
towards informed and responsible prescribing and dispensing of medicines. It is important
that undergraduate nursing curricular reflect best practice and national standards in this area.
Ms Juliet Sondermeyer, a lecturer in the TSoN is the Chief Investigator. She is the coordinator
of CNA 315 but will not be directly involved with research participants. Dr Christine Spratt a
Senior Lecturer in the TSoN and is the co-investigator. Dr Spratt will be directly engaged in
gathering data and interacting with research participants. The findings of this project will be
used within the TSoN and the University to inform and develop teaching and learning in the
Bachelor of Nursing. It will be used to contribute to the literature in the field through
publication in relevant journals.
Your participation in this study is vital in ensuring that teaching and learning strategies are
meeting student learning outcomes and importantly, that the TSoN is preparing students for
practice to be competent in all areas related to applied pharmacology and QUM.
We have decided to undertake this investigation in CNA315 because it is the practice unit
which involves most direct involvement with applied pharmacology. It is the final practice unit
before you are able to become registered as a nurse. Previous research studies have
reported that undergraduate and newly graduated nurses have limited understanding of
pharmacology, and general dissatisfaction with undergraduate preparation in applied
pharmacology which has been attributed to causing anxiety in the first graduate year of
practice.
The study is a four stage project.
• In Stages 1 and 3 you will be asked to complete the same questionnaire about your understandings in drug knowledge and administration. • In Stage 4 after you have been in practice as a registered nurse for three months you will be asked to complete a different questionnaire about your understandings in drug knowledge and administration. We would also like to invite ten of you to participate in a one-hour semi-structured interview conducted by Dr Spratt and Ms Sondermeyer about your experiences related to pharmacology management as a beginning registered nurse. The purpose of the focus group interview is to gather more detail about your beliefs about how prepared you are to practice in relation to pharmacology. • In Stage 2 we will be looking at the curriculum design of the BN and how it complies with the QUM framework but this will not involve you. We will ask you to indicate to Dr Spratt your willingness to participate in the Stage 4 interview by emailing her as we will need to document your contact details and we will remind you of this again at Stage 3. The survey questionnaires that will be used in the study will not identify you and all data will be aggregated. Further, your involvement in this study has no influence on your studies or the assessment in CNA315 Acute Care Nursing. The questionnaires should take no more than thirty minutes to complete. If you agree to participate in the focus group interview in Stage 4 of the project, you will need to complete and return the Consent Form including your contact details. The focus group interview will be audio-taped and transcribed but comments will be thematised and aggregated. You will not be identifiable. Participant responses will be aggregated in any reporting. If direct quotes from participants are used in the construction of any reports or publications based on the interview data, code numbers will be used so that responses will remain confidential and not attributed to individuals. Participants in the Stage 4 focus group interview will be requested to respect the confidentiality of the group. The hard copy de-identified survey questionnaires will be stored in a locked cabinet in the Chief Investigator's Office in the TSoN. The electronic data will be kept on a secure server in the TSoN. Raw data will be kept by the TSoN for at least 5 years. All data will be destroyed after 5 years—hard copy data will be shredded and electronic data will be deleted from the server and audiotapes will be destroyed. Your participation in this research project is entirely voluntary and you are able to withdraw at any time without any effect on your academic progress or explanation. If you have agreed to participate in the Stage 4 interview any data you have supplied prior to withdrawal will be excluded and the audiotape destroyed. The research project has received ethical approval from the Northern Tasmania Social Sciences Human Research Ethics Committee. Please note that in the event that you don't like something about the study, the University has a complaints procedure. To complain about the study you may contact the Executive Officer of the Human Research Ethics Committee (Tasmania) Network. The Executive Officer can direct participants to the relevant Chair that reviewed the research. Executive Officer Ms Amanda McAully (6226 2763) As students of the University of Tasmania you may also discuss any concerns of confidentially with a University Student Counsellor free-of-charge. University Counsellor: Hobart (03) 6226 2697; Launceston (03) 6324 3787 We are happy to keep you informed of the progress of the study if you wish. If you agree to participate in the Stage 4 interview you will be given a summary of the aggregated data to review. You are also welcome to request a copy of the final report. In the event that you would like a copy of the final report please contact either of the co-researchers directly. You are able to keep copies of the information sheet and statement of informed consent if appropriate to you. Chief Investigator Ms Juliet Sondermeyer Dr Christine Spratt University of Tasmania University of Tasmania Appendix 2: Stage 1 & Stage 3: Survey
questionnaire
Part 1: Perceptions of preparation for practice
1. I feel confident today regarding the prospect of administering medicines in a
practice setting. 2. I believe that my learning experiences in the Bachelor of Nursing course so
far, have prepared me to administer medication safely.
3. It is important for me to understand the pharmacological treatment and management of people for whom I care. 4. I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the administration of medicines. 5. I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of the pharmacology of medicines. 6. I believe my learning experiences in the Bachelor of Nursing have developed my knowledge and understanding of managing the adverse effects of medicines. 7. A weekly medication test will help me develop my understanding of pharmacology and safe medication administration. 8. The preceptor model of teaching in clinical practice has not assisted me to
develop my pharmacology knowledge. 9. I am confident that I would identify a potentially hazardous medication 10. I am not confident that I can practice within the legal guidelines pertaining to
medication administration. 11. I am confident that I can explain the actions of medications that a patient in my care is taking. 12. I am competent in the administration of medications. Part 2: Pharmacology knowledge.
1 Which of the following medications must not be given IM?
a. Penicillin b. Morphine c. Heparin d. Methadone e. Omnopon 2. To which antibiotic group does Gentamicin belong? a. Aminoglycoside b. Beta c. Tetracycline d. Penicillinase e. Cephalosporin 3. Which of the following diuretics is not potassium sparing?
a. Spironalactone b. Amiloride c. Bumetanide d. Frusemide e. Triamterene 4. Which of the following is a potential adverse effect of administering adrenaline a. bradycardia b. hypotension c. tissue necrosis from extravasation d. polyuria e. polydipsia 5. 1.5 grams of Amoxil is ordered. You have stock of 4 grams in 4 ml. Which of the following volumes will you administer? 6. A client is receiving a morphine infusion consisting of 50 mg morphine in 500 ml of dextrose via a volumetric pump. The dose ordered is 2 mg/hr. On which of the followings settings would you set the pump? a. 50ml/hr b. 0.5ml c. 5ml/hr d. 20ml/hr e 2ml/hr 7. A patient is ordered 0 .3mg of Isoprenaline. You have an ampoule that contains 1:5000 in 1 ml (1:5000 = 1g in 5000ml). What is the volume required for this patient? a. 0.2ml b. 1.2ml c. 1.5ml d. 1.3ml e. 1.35ml 8. A client is ordered Midazolam 20mg in 10 ml of saline to be given by syringe driver over 24 hours. You draw up 20 mg of Midazolam and make it up to 10 ml using normal saline. 10 ml=48 millimeters (mm); you now need to set the syringe pump. Which of the following is the correct setting for the pump? a. 4mm b. 1mm c. 2mm d. 2.2mm e. 20mm 9. Based on the information provided in the previous question choose the dose of Midazolam the patient will be receiving per hour? a. 1.5mg/hr b. 0.7mg/hr c. 0.8 d. 8.3mg/hr e. 0.83mg/hr 10. A client is ordered Fentanyl 0.15 mg IV prior to a gastroscopy procedure. You have available ampoules containing 250mcg/5 ml of Fentanyl. Which of the following is the volume you will draw up for the injection? a. 0.03ml b. 1.5 c. 0.5ml d. 3ml e. 0.3 11. Choose the correct dose of Digoxin from the list: c. Digoxin.0.125mg d. Digoxin 12. Of the listed explanations, which best describes a PICC line
a. A percutaneously inserted cardiac catheter b. A palliative internal chemotherapy catheter c. A peripherally inserted central catheter d. A percutaneously inserted cholangio-cannula e. A purpose indicated coronary cannula 13. Which of the following medications can cause an adverse interaction called ‘seratonin syndrome' when taken with a selective seratonin re-uptake inhibitor (SSRI) antidepressant? b. Codeine c. Tramadol d. Sertraline e. Allipuranol 14. A fourteen year old child weighing 51kg was ordered IV Fluconazole. The recommended dose is 4mg to 8mg/kg daily. What is the maximum dose that can be given safely in a 24 hour period? a. 408mg b. 400mg c. 428mg d. 28mg e. 368mg 15. A colleague you are working with gives you a kidney dish containing Penicillin 1g that she says she has drawn up for Mr. Li. She tells you she is going to lunch and asks you to give it for her. What is the most appropriate response? a. Yes, you will give it because she is your preceptor. b. Yes you will give it because you know the patient is on Penicillin. c. No you won't give it because you have not witnessed the preparation of the medication. d. No you won't give it because you have not sighted the drug chart nor witnessed the preparation of the medication. e. Yes you will give it because you always follow instructions. Appendix 3 Stage 4 Survey
Part 1: Perceptions of preparation for practice
13. I feel confident today regarding the prospect of administering medicines in
a practice setting. 14. I believe that my learning experiences in the Bachelor of Nursing course prepared me to administer medication safely. 15. It is important for me to understand the pharmacological treatment and management of people for whom I care. 16. I believe my learning experiences in the Bachelor of Nursing developed my knowledge and understanding of the administration of medicines. 17. I believe my learning experiences in the Bachelor of Nursing developed my knowledge and understanding of the pharmacology of medicines. 18. I believe my learning experiences in the Bachelor of Nursing developed my knowledge and understanding of managing the adverse effects of medicines. 19. The weekly medication test in CNA315 helped me develop my understanding of pharmacology and safe medication administration. 20. The preceptor model of teaching in clinical practice during my undergraduate BN did not assist me to develop my pharmacology knowledge. 21. I am confident that I can identify a potentially hazardous medication 22. I am not confident that I can practice within the legal guidelines pertaining to medication administration. 23. I am confident that I can explain the actions of medications that a patient in my care is taking. 24. I am competent in the administration of medications. Part 2: Pharmacology knowledge
Critical Incident.
You are on a late shift and you are administering your patient's drugs at 6pm. One of your patients is written up for Lithium 600 mg to be given at this time. Before you dispense the drug you notice that ‘withhold' has been written against the Lithium on the chart for the previous three days. There is no signature next to the ‘withhold' instruction, but you think you recognize a colleague's handwriting. You heard nothing about this in handover. You go to the patient's progress notes, and look up entries made over the last four days but can find no reference to the Lithium being withheld. You also look up the patient's most recent serum Lithium levels taken two days prior and note that they are on the low end of the therapeutic range. You talk to the nurse in charge who tells you to withhold the drug and call the treating doctor. The nurse in charge asks you to ask the doctor if she left that instruction. If she did, you are to ask the doctor to come and write it in the patient record. You return to the patient and you notice that he is beginning to look stressed and agitated. He is humming to himself—a behaviour you have not noted before. You phone the doctor who is having her supper and she quite angrily says ‘just give what's on the drug chart'. 1. What is your immediate response? 2. Given the situation list and explain four (4) critical questions that would lead your thinking in solving this problem. 3. What are your responsibilities as a Registered Nurse in this situation? 4. What are the legal implications of this situation? Appendix 4: Curriculum Audit
Subject Code
CNA105 CNA126 CNA127 CNA128 CNA205 CNA215 CNA226 CNA245 CNA246 CNA308 CNA309 CNA315 CNA316 QUM Criteria
Selecting management options wisely by: Considering the place of medicines in treating illness and maintaining health Recognising that there may be better ways than medicine to manage many disorders Choosing suitable medicines if a medicine is considered necessary through taking into account: The clinical condition Risks and benefits Dosage and length of treatment Any co-existing conditions Monitoring considerations Costs for the individual Costs for the community Costs for the health system as a whole Using medicines safely and effectively to get the best possible results by: Monitoring outcomes Minimising misuse, over-use and under-use Improving people's ability to solve problems related to medicine such as negative effects or managing multiple medications Key: Not Evident (A) Implied (B) Explicit (C) Assessed (D) Not Assessed (E)
References
Bullock, S. & Manias, E. 2002, ‘The educational preparation of undergraduate nursing students in pharmacology: a survey of lecturer's perceptions and experiences', Journal of Advanced Nursing, 40, 1, pp. 7-16. Griffiths, D., Hunt, S., Napthine, R., & Birch, M. 2000, ‘Quality Use of Medicines and Undergraduate Nursing Education: A report of a national survey to ascertain the extent of the inclusion of QUM principles within undergraduate nursing programs, Report to the Pharmaceutical Health and Rational Use of Medicines Committee, October. King, R. 2004 Nurses's perceptions of their pharmacology educational needs, Issues and Innovations in Nursing Education, 45, 4, pp. 392-400. National Prescribing Service, 2003, Quality Use of Medicines NPS Annual Report 2002-2003, NPS, Surrey Hills, NSW. PHARM Committee, 2002, Manual of Indicators for the Australian National Strategy for the Quality Use of Medicines, PHRAM, Commonwealth of Australia, Canberra.

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