Teaching–learning experiences, including interprofessional education, continue to be a topic of great interest in the health sciences, including within the fields of medicine and nursing. (Hale, Cahan, & Zanetti, 2011; McGettigan & McKendree, 2015; Turrentine et al., 2016). Millions of Americans have asthma or chronic obstructive pulmonary disease, and a large percentage of these patients use metered-dose inhalers (MDIs) (Center for Disease Control, 2016; National Institutes of Health, 2007). Incorrect inhalation technique with MDI is associated with reduced disease control. (Melani et al., 2011). Unfortunately, not only do many patients have poor technique with inhaling from MDIs, but numerous studies have also revealed that health care professionals have poor skill in using MDIs (Self, Arnold, Czosnowski, Swanson, & Swanson, 2007).
National guidelines recommend that health care professionals, including physicians, pharmacists, nurses, and respiratory therapists, should educate patients about asthma, including the correct use of its medications (NIH, 2007). The purpose of the current study was to evaluate the effectiveness of medical students teaching nursing students skill in using MDIs.
Two fourth-year medical students were the instructors in this institutional review board-approved study. BSN students enrolled at the University of Tennessee Health Science Center (UTHSC) were eligible to participate. Most BSN students were second-year students, and none had taken a rotation in pulmonary medicine. Recruitment was conducted via flyers on campus and announcements in BSN classes. A participation incentive was a Starbucks™ gift card.
The faculty advisor for the study reviewed correct inhalation technique with the fourth-year medical students via discussion, demonstrations, and observation of the students' use of placebo MDIs (National Institutes of Health, 2007). In addition, the faculty advisor conducted role-playing with the M4S to ensure correct scoring with various inhalation technique errors. The faculty advisor at UTHSC lectures on this topic, cares for patients with asthma and chronic obstructive pulmonary disease in the hospital and ambulatory settings, and has several peer-reviewed publications about the correct use of inhalers.
Each BSN student was educated by a fourth-year medical student about MDI technique in one-to-one sessions. After a pretest (i.e., BSN student use of placebo MDI), the medical student briefly discussed and demonstrated the use of a placebo MDI followed by a posttest (i.e., BSN students' repeat use of MDI). A standardized scoring form that listed each step (Table) was used for each BSN student for the pretest and posttest. The entire process lasted approximately 10 minutes.
Nursing Students' Scores with MDI Technique
Data for individual steps were analyzed using the Sign test. Participants also had total number of correct steps recorded for both before and after the educational session. Data for total performance with MDI were analyzed with paired t tests. Twenty students were required to detect a difference of one standard deviation with a two-sided paired t test alpha of .05 and a power of .80.
Consistent with previous studies of graduate health care professionals and health science center students, the BSN student participants in our study showed a lack of skill in using MDI, followed by marked improvement after a brief educational session (Table) (Chafin, Tolley, Demirkan, Burbeck, & Self, 2000; Self, Kelso, Arheart, Morgan, & Umberto Meduri, 1993). Individual steps that revealed the largest improvements after the teaching–learning experience included the following: remove cap and inspect for foreign objects, exhale gently and completely, press down once and at the same time inhale slowly, inhale slowly and deeply over 4 to 5 seconds, hold breath for 10 seconds, and exhale slowly. Among these BSN students, 40% had a history of childhood or adult asthma; however, consistent with numerous investigations, inhaler skill was still less than optimal.
This study shows the effectiveness of a time-efficient teaching–learning session with fourth-year medical students teaching BSN students the correct inhalation technique of an MDI. There was a statistically significant improvement in overall MDI technique following a short education session (p < .0001). Two previous similar studies at UTHSC were also successful in teaching correct use of MDI (Chafin et al., 2000; Self et al., 1993). In these two studies, practicing nurses were taught by clinical pharmacy faculty in one study, and medical students were taught by clinical pharmacy faculty and residents in another study.
National guidelines recommend that health care professionals educate patients on asthma and the correct use of asthma medications, and it is the authors' experience that nurses are often responsible for providing this education to patients (NIH, 2007). The application of similar teaching–learning sessions to practicing physicians and nurses in the community could improve nurses' MDI technique and ultimately improve patient education.
The current study does have potential limitations. Because the educational sessions were conducted by two fourth-year medical students, the possibility of an observer-dependent difference in pretest and posttest scoring exists, as well as in the administration of the teaching–learning session. To decrease this bias, the fourth-year medical students underwent clinical training with the same clinical pharmacy faculty in proper MDI use and in the evaluation and teaching of MDI technique.
Moving forward, it would be of interest to see the level of skill that was retained over a longer time period. Further directions for study could include longer-term follow-up cohorts. This study was a longitudinal project by the fourth-year medical students, and it is the authors' hope that other medical students and nursing students in bachelor's, master's, or doctoral programs will conduct further similar studies and extend these findings. Given the role of health care providers as teachers, it would also provide further studies the direction to assess BSN students' ability to effectively teach the MDI technique after being a part of this teaching–learning exercise.
- Centers for Disease Control. (2016). COPD facts. Retrieved from https://www.cdc.gov/copd/maps/index.htm.
- Chafin, C.C., Tolley, E., Demirkan, K., Burbeck, J. & Self, T.H. (2000). Effect of a brief educational intervention on medical students' use of asthma devices. The Journal of Asthma, 37, 585–588. doi:10.3109/02770900009090813 [CrossRef]
- Hale, J.F., Cahan, M.A. & Zanetti, M.L. (2011). Integration of basic clinical skills training in medical education: An interprofessional simulated teaching experience. Teaching and Learning in Medicine, 23, 278–284. doi:10.1080/10401334.2011.586934 [CrossRef]
- McGettigan, P. & McKendree, J. (2015). Interprofessional training for final year healthcare students: A mixed methods evaluation of the impact on ward staff and students of a two-week placement and of factors affecting sustainability. BMC Medical Education, 15, 185. doi:10.1186/s12909-015-0436-9 [CrossRef]
- Melani, A.S., Bonavia, M., Cilenti, V., Cinti, C., Lodi, M. & Martucci, P.Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. (2011). Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine, 105, 930–938. doi:10.1016/j.rmed.2011.01.005 [CrossRef]
- National Institutes of Health. (2007). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute.
- Self, T.H., Arnold, L.B., Czosnowski, L.M., Swanson, J.M. & Swanson, H. (2007). Inadequate skill of healthcare professionals in using asthma inhalation devices. The Journal of Asthma, 44, 593–598. doi:10.1080/02770900701554334 [CrossRef]
- Self, T.H., Kelso, T.M., Arheart, K.L., Morgan, J.H. & Umberto Meduri, G. (1993). Nurses' performance of inhalation technique with metered dose inhaler plus spacer device. The Annals of Pharmacotherapy, 27, 185–187.
- Turrentine, F.E., Rose, K.M., Hanks, J.B., Lorntz, B., Owen, J.A., Brashers, V.L. & Ramsdale, E.E. (2016). Interprofessional training enhances collaboration between nursing and medical students: A pilot study. Nurse Education Today, 40, 33–38. doi:10.1016/j.nedt.2016.01.024 [CrossRef]
Nursing Students' Scores with MDI Techniquea
|MDI Step||Preeducation||Posteducation||p Value|
|1. Remove cap; inspect for foreign objects||10||90||<.0001|
|2. Shake well||80||100||.13|
|3. Hold MDI upright||100||100||—|
|4. Exhale gently and completely||40||90||.002|
|5. Place between lips||95||100||.99|
|6. Press down once and at the same time inhale slowly||35||95||.0005|
|7. Inhale slowly and deeply over > 4 to 5 seconds||10||85||<.0001|
|8. Hold breath for 10 seconds||35||90||.004|
|9. Exhale slowly||25||100||<.0001|
|Total number steps correctb||4.3 + 0.4||8.5 + 0.2||<.0001|