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Engaging Nursing Students in Quality Improvement: Teaching Safe Medication Administration

Background:

Safety and reduction of errors during medication administration is a prominent focus in nursing and nursing education. Developing simulated medication administration experiences that include opportunities for nursing students to manage interruptions in a realistic environment can help improved critical thinking and reasoning for safe administration practices.

Method:

Sophomore nursing students voluntarily participated in a quality improvement project examining nursing management of interruptions during medication administration. Students observed medication administration activities for episodes of interruptions and conducted surveys in a real-time format that encouraged decision-making dialogue.

Results:

After the project, student learning outcomes included improved identification of interruptions, prioritization, critical reasoning skills, and development of management techniques for better safety.

Improving medication safety and quality of care is a priority for health systems both nationally and globally (^{Agency for Healthcare Research and Quality, 2019}). The Joint Commission added medication safety as a National Patient Safety Goal and the Quality and Safety Education for Nurses (QSEN) project was established to improve patient safety in nursing school curricula (^{Cronewett et al., 2009}; ^{The Joint Commission, 2018}). The QSEN initiative identified six key competency areas: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement (QI), safety, and informatics. Medication administration is a significant area of safety that nursing curricula must include to improve nursing students' competencies and quality of care (^{Lee & Quinn, 2019}).

Medication administration commonly is regarded as complex and high risk that often is conducted in a chaotic setting where interruptions are common and multitasking is an inevitable workflow trait (^{Potter et al., 2005}; ^{Thomas et al., 2017}). Nurses in the acute care setting use established protocols and safety measures in the process of medication administration that are critical to the maintenance of safety and prevention of errors. Today's nursing educators are challenged to understand the complexities of medication administration and develop teaching strategies that enhance students' knowledge of error-producing situations, patient safety issues, and identification and management of interruptions to prevent errors. Undergraduate nursing curricula should prepare graduates for such real-world complexities through medication administration education that develops improved critical thinking and influences future practice for greater patient safety.

Background

In undergraduate nursing education, medication administration teaching traditionally focuses on the theory of medication safety, pharmacology, and math calculations (^{Hewitt, 2015}). Students then practice these skills through a variety of strategies such as role-play, laboratory practice, technology aids, clinical experiences, video, on-line learning modules, case studies, and most often, simulation (^{Aggar & Dawson, 2014}; ^{Arthur et al., 2013}; ^{Hewitt et al., 2015}; ^{Lee & Quinn, 2019}). Faculty are continually faced with developing ways to bridge the gap between the theory of medication administration and practice with improved safety as the acute care environment frequently changes and patient care becomes more complex. Current teaching strategies allow nursing students to practice skills of medication administration in an environment such as the laboratory or simulated experience that isolates the task from others. Skills frequently are demonstrated in a controlled area using a rubric, and students do not encounter unexpected interruptions or distractions, thus delaying development of strategies to manage the situation as one would in the real world for the maintenance of safety and focus.

As the emphasis on safety with medication administration and reduction of errors becomes more prominent, recent literature outlines the need for improved fidelity of simulated experiences that include opportunities to manage interruptions in a realistic environment. This aspect provides a richness to the scenario and encourages immersion into the experience for improved development of critical thinking and application of skills (^{Arthur et al., 2013}; ^{Hayes et al., 2017}).

The use of simulation as a teaching strategy for medication administration skills is a strong tool for student development in undergraduate nursing education. However, incorporating real-world experiences that include interruptions and critical thinking would better prepare nursing students for the complexities of practice. Allowing nursing students to observe, participate, and navigate real-world interruptions with RN mentors safely, and to investigate critical thinking and management strategies in real-time situations may result in improved reasoning, prioritization, decision-making, and safety for future practice. This article describes a novel teaching strategy that engaged undergraduate nursing students in a QI initiative to study medication administration in which the students collected real-time data on interruptions and management by RN mentors dur(ing their clinical experiences. The goals of this innovative teaching strategy were student application of QI methods, development of prioritization, and understanding of nurses' reasoning and decision-making surrounding interruptions during medication administration. This teaching strategy may further support development of nursing students' reasoning and instill ideas regarding the creative use of QI in their practice.

Method

A quality QI studying the effects of interruptions on nurses' clinical reasoning, emotions, and medication safety was being conducted on a 32-bed pulmonary medical-surgical unit in a large academic hospital. Although the main findings of this QI project have been reported previously (^{Wagner et al., 2020}), this article focuses on student learning outcomes as a result of participation in the project.

Sophomore nursing students who were assigned to the study unit during the winter semester were invited to participate in this QI project. Two cohorts of students (n = 15) voluntarily participated in the data-gathering aspect of the QI project. Sophomore-level clinical learning outcomes supported the goals of the QI project while further expanding student knowledge on interruptions, reasoning, and safe medication administration practices.

Conclusion

Preparing nursing students for the complexities of patient care involves designing learning experiences that immerse students in realistic scenarios. Incorporating real-world experiences that include opportunities to identify and manage interruptions during medication administration helps nursing students develop better prioritization, reasoning, critical thinking, and management skills for use now and in their future practice. Earlier exposure to these skills allow students to continue to develop broader safety skills and error prevention strategies that support positive patient outcomes and quality care. Additionally, involving nursing students in QI initiatives supports evidenced-based education through the application of QI strategies and may promote future use in their professional practice.