Safe medication administration requires extensive structured clinical judgment. Nursing educators are challenged to find effective approaches to help build nursing students' confidence and competence. The process of developing a free, easily accessible educational initiative to improve student judgment and patient outcomes in medication administration is presented.
Medication errors are among the most common issues addressed in the literature. A recent PubMed search identified almost 9,000 articles in which the primary topic was medication errors. Leape et al. (1995) believed nurses are the last stop in preventing errors in the medication administration process. To keep patients safe, nursing students need a succinct, easy-to-practice reasoning process they can carry into professional practice. These novice learners need a structure to develop sound judgment in medication administration supporting metacognition as they consistently and quickly consider their thought process.
Nursing students must practice analyzing the available information, recognizing what information is missing, realizing what they do not know, and then drawing conclusions about administering or withholding a medication. In addition, nursing students must determine when to return to assess the effects of the medication, what to assess upon return, and what to teach for safety based on the immediate and long-term needs of patients. According to Dickson and Flynn (2012), nursing students must listen to their intuition while dealing with noisy environments, interruptions, and time pressures. All of these issues are real and need to be woven into learning to become the fabric of practice.
Multiple theories exist postulating best practice for teaching clinical decision making (Pelaccia, Tardif, Triby, & Charlin, 2011). In medicine, best practices point to identifying deficiencies in thinking, individualizing instruction, and using deliberate practice that is followed by feedback, self-reflection, and reassessment (Audétat et al., 2013; Kassirer, 2010). Similar to the medical model, nursing uses problem-based learning, integrated clinical experience, case-based learning, deliberate practice, reflection tools, simulation, and narratives in the development of clinical reasoning strategies (Jensen, 2013; McNelis et al., 2014; Yuan, Williams, & Fan, 2008). Sound clinical decisions require practiced application and analysis of knowledge.
Simmons (2010) defined clinical reasoning as:
…a complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions. Core essences of this concept include cognition, metacognition and discipline-specific knowledge. Formal and informal thinking strategies blend decision analysis, information processing and intuition to evaluate the value of patient data.
Herron, Sudia, Kimble, and Davis (2016) noted it is essential to establish a strong foundation early in the undergraduate experience for the development of clinical reasoning. The National Council of State Boards of Nursing's model for measuring clinical judgment embraces three theoretical frameworks from multiple professions, each with their own emphasis. The model has multiple layers, each with different cognitive processes applicable to the critical decisions made in safe medication administration (Dickison, Haerling, & Lasater, 2019).
Tanner (2006) found that learning to think like a nurse, especially learning how to use the complex and high-risk reasoning and judgment required in medication administration, is a difficult anxiety-provoking endeavor for beginning students. How do nurses safely decide to administer or not administer a medication? What reasoning guides their decision process? How is this reasoning taught so students can independently make decisions now and after graduation? Using the classic five rights (i.e., right patient, right drug, right time, right dose, and right route) is crucial but insufficient; more questions need to be answered, more data need to be processed, and more cues need to be noticed and analyzed. Students are true novices with limited cue recognition, and they often are unaware of what cues are needed to guide their clinical judgment (Muntean, 2012).
The aim of this initiative was to develop a set of free access learning tools, i.e., a video simulation, eRecords, and a structured easy-to-remember reasoning guide, that prompts cue recognition and thought processes used in the complex decision to administer or hold a medication. The reasoning guide is needed to support metacognition as well as intuition and would be a guide that nursing students could use throughout school and then take into practice. It is based on dual-process theory, which recognizes the importance of both the development of and control of clinical reasoning (Reyna, 2012).
Sophomore students first learning to administer medications were the focus of the intervention. Development and control of reasoning was captured in an easy-to-remember acronym, WARRIORS:
- Why—What is reason this patient is receiving this medication?
- Allergies–Does the patient have allergies? If so, will I give or hold this medication?
- Right laboratory values and vital signs—What are the laboratory values or vital signs that are trending out of range in the patient? What laboratory and vital signs will be impacted if this medication is administered or withheld? Should I give or withhold the medication?
- Range—What is the correct range? Is this dose incorrect or correct?
- Implications and interactions—What are the implications and interactions of this drug?
- Only—Am I the only nurse giving this medication?
- Return—When should I return for reassessment (minutes/hours/normal surveillance)?
- Safety—What should the patient be taught for safe use now or at discharge?
For oral, injectable, and then intravenous medications, WARRIORS was piloted in laboratory competencies early in the process focusing on two key questions: Did the WARRIORS process capture multiple components crucial in the reasoning process in medication administration? Did the WARRIORS process give students a structure, a way to practice, prepare, identify knowledge gaps, reflect on their responsibility, actively evaluate safety, and plan appropriate surveillance?
Although nurses, thinking like nurses, do all of this automatically, nursing students need to be taught this process and given opportunities to practice “thinking like a nurse.” Typically, in skills testing or in clinical situations, nursing students are quizzed by the instructor. With WARRIORS, rather than the instructor questioning students, the students independently and succinctly state the reasoning process they are using to make decisions. To facilitate deliberate practice, a simple, inexpensive, Web-based electronic health record with six patient charts was developed; each chart had a section that included patient history and physical findings, medication list, laboratory values, and vital signs. This allowed students to independently practice at home to improve their competency.
Intervention: The Practice to Competency Process
Prior to class, students were instructed to review one of the records selected for demonstration. A video ( https://www.youtube.com/watch?v=YkBeGymEMuQ) was posted to demonstrate the complexity of how a nurse reasons. Often, students think the process is easy, but the video and ensuing practice redirects issues with self-inflated overconfidence (Ehrlinger, Mitchum, & Dweck, 2016). Just as students use deliberate practice in learning how to insert a urinary catheter, they also must use the same process to build reasoning skills. Students learn that nurses must know many discrete and continuous points of data, and then begin the clinical judgment process. The data nurses need, in raw form, is in the patients' practice record posted on the eRecord website ( http://www.nursing.pitt.edu/aliceblazeckrn/). Students were instructed to review the medical history and physical findings as well as the most recent vital signs and trends, and note any drifts toward abnormal.
Students also were instructed to review the laboratory data. The chart intentionally did not have ranges posted nor abnormal values highlighted, which motivated students to actually know normal values so they could quickly recognize any values drifting toward abnormal. During practice, students used WARRIORS to state each step in their decision to administer or hold a medication. Holding a medication required a simulated call to the provider, reinforcing communication skills.
Students also practiced judging when to return for reassessment and what they would teach to maintain patient safety either before leaving the room or before the patient was discharged. Thinking aloud also can assist students in the development of clinical reasoning. Reason (1990) described this as “talking ourselves through the action…under new circumstances…our activities are guided by the effortful yet computational powerful investment of conscious attention” (p. 6). The simulation was a focused, realistic practice of clinical reasoning.
For competency testing itself, one patient was selected at random. Again, students had access to all of the charts before the competency examination so that they could prepare in advance, similar to the way that they can prepare for their real patients the night before clinical. Students were allowed to use their WARRIORS prep cards and their notes on laboratory data. During testing, without prompting, students explained their WARRIORS reasoning, stated their final judgment, and executed the entire medication procedure at the rate of 2 minutes per medication.
This expectation of zero prompting for the testing was carried into the clinical arena. Mirroring clinical, many of the six patients presented with at least one cautionary issue or cue, such as allergy interactions, wrong dose when analyzed with other medications given over the last 12 hours, abnormal laboratory or vital signs, no indication for a particular medication, or potentiation of effects with other classifications of medication. Intentionally added external considerations that also needed to be addressed included noise, interruptions, placing a call to a problematic provider, or a patient refusing to take medication. In addition, there were risks for errors because of system inadequacies. All of this practice promotes a fluidity of thought, an assurance of competency, and a realization that while complicated, this is how nurses think; it is not nebulous but organized.
Because tools were free and accessible, all students had equal time to prepare and practice as often as necessary until they were ready for the examination. To decrease anxiety, the first simulation examination was on oral medications. Subsequent examinations built to oral and injectable, and then finally the full menu of patient medication including intravenous medications. Incremental learning is more effective in the metacognition needed for learner-driven learning and a growth mindset for greater self-insight (Cardinale & Johnson, 2017).
When developing this simulation experience, throughout the process, faculty used the Standards of Best Practice developed by the International Nursing Association for Clinical Simulation and Learning (2013, 2016). The students in this study had the potential to use four different charting systems across multiple hospitals. Each of these systems are expensive to lease for students, and teaching documentation across multiple systems was not an objective in teaching clinical reasoning. The necessity of a cost-effective, easy-to navigate “chart” allowing for student access from home was apparent. The Adobe Dream-weaver© tool proved to be a simple, inexpensive way to create web-based charts.
After launch, some problems were apparent. Patient teaching initially was not included. This was addressed with the addition of the “S” in WARRIORS. The issue with real-time dates and times changing constantly had to be addressed for reasonable fidelity with each student's access. To circumvent a massive amount of programing, the “dates” were simply “Today,” “Yesterday,” or “On Admission”; the “times” were 15 minutes past, 1, 2, or 4 hours ago, etc. Changing the doses and intentional errors addressed the issue of overzealous sharing. After launch, students reported being better prepared for medication administration regardless of faculty, clinical unit, or patient complexity. Students also reported the value of honing down reams of information to a succinct WARRIORS medication card, one that they could, with minor individualized adjustment, use from patient to patient. The structured reasoning approach also supported the novice educator. In addition, for upper-level students who were struggling with medication administration, this structure provided a clear focus of what needed to be adjusted in their preparation for success.
The learning tools have been used for 3 years, with unlimited sustainability. The structured clinical reasoning guide, WARRIORS, is now used across all three levels of the undergraduate program. The experienced faculty have reported the value of not needing to quiz students on the key aspects of patient medications; after a student “WARRIORS” the medication, the faculty can validate or correct the student's thought process in real time rather than later after reviewing a lengthy care plan.
Clinical reasoning and clinical judgment skills are critical for today's professional nurse. Using a systematic process to prepare and administer medications reduces errors and promotes positive patient outcomes. This learning initiative supports students' safe and accurate medication administration in nursing school and can be used as they move into practice.
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