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Oral medication administration : the effect of two instructional techniques on nursing student learning Ettles, Violet Helen 1989

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ORAL MEDICATION ADMINISTRATION: THE EFFECT OF TWO INSTRUCTIONAL TECHNIQUES ON NURSING STUDENT LEARNING by VIOLET HELEN ETTLES BSN, The U n i v e r s i t y o f B r i t i s h Columbia, 1981 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES Scho o l o f N u r s i n g We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1989 © V i o l e t H e l e n E t t l e s , 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department of Date DE-6 (2/88) 11 Abstract This experimental study was designed to examine the effects of two selected instructional techniques on nursing student learning of oral medication administration. The research questions asked in this study concerned the effects of these selected Instructional techniques on cognitive learning, performance, and feeling of sat isfact ion toward the learning experience. The study was conducted 1n a three-year diploma nursing program associated with a large metropolitan hospital . A total of 66 f i rs t -year students participated 1n the study. There were 32 students 1n the experimental group and 34 students 1n the control group. Al l subjects were taught relevant content, prepared "drug cards", and completed a cognitive learning pretest prior to the oral medication administration laboratory. During the laboratory, the experimental subjects were taught by demonstration-return demonstration using simulation and the control subjects were taught by demonstration-return demonstration. Following the laboratory, a l l subjects were administered the pretest as a posttest, a feeling of sat isfact ion questionnaire, and a personal data questionnaire. Addit ionally, they were evaluated through the use of a performance checklist during their f i r s t administration of a medlcatlon(s) to a patient. Data obtained from the cognitive learning tests and performance checklist were analyzed using Independent t - t es ts , and data obtained from the feeling of sat isfact ion questionnaire were analyzed using the chl-square test . Study findings showed that the two groups were similar when compared on selected personal character ist ics. 111 Differences between the groups for cognitive learning, performance, and feeling of sat isfact ion toward the learning experience were revealed not to be signi f icant at the established level of D. = .05. This finding suggests that demonstration-return demonstration using simulation is a viable alternate technique for teaching oral medication administration. 1v Table of Contents Page Abstract 11 L i s t of Tables ix L is t of Figures x Acknowledgements x1 Chapter One: Introduction . 1 Background to the Problem 1 Statement of the Problem ; 3 Purpose of the Study 3 Conceptual Framework . 3 Research Questions . 8 Definit ion of Terms . 10 Assumption 11 Limitations 11 Overview of the Remainder of the Study 11 Chapter Two: Review of the Literature . 13 Introduction 13 Learning the Nursing Activi ty of Oral Medication Administration . . . . 13 Instructional Techniques for Teaching Oral Medication Administration ,. 17 Demonstration-Return Demonstration 17 Simulation 19 Feeling of Satisfaction Toward the Learning Experience 23 V Page Transfer of Learning from the Laboratory to Cl in ical Practice . . 27 Summary 29 Chapter Three: Methodology 31 Introduction 31 . Design 31 Sample . . 32 Setting 32 Procedure for Implementation of the Study . . . . . 32 Common Experiences 1n the Classroom and Laboratory Setting . . 34 Laboratory Practice Session . 35 Cl in ica l Act ivi ty 36 Preparation of the Nurse Educators 36 Instruments 37 Cognitive Measure 37 Oral Medication Administration Checklist 38 Feeling of Satisfaction Questionnaire . 40 Student Data Questionnaire 40 Ethics and Human Rights . 40 Data Analysis . 41 Summary 41 Chapter Four: Presentation and Discussion of the Findings . . . . 43 Introduction 43 Description of the Subjects 43 Age 43 Educational Background . . . . 44 v1 Page Cognitive Learning . . . . 45 Cognitive Learning: Experimental Group 46 Cognitive Learning: Control Group . . . . . . . 46 Comparison of Cognitive Learning Between the Groups 48 Oral Medication Administration 51 Comparison of Performance Involving Cognitive Learning . . . . 53 Comparison of Performance Involving Psychomotor Learning . . . 53 Comparison of Overall Performance 55 Additional Findings 55 Feeling of Satisfaction 57 Statement 1 57 Statement 2 58 Statement 3 58 Statement 4 60 Discussion of Findings 60 Effects of the Selected Instructional Techniques on Cognitive Learning 60 Effects of the Selected Instructional Techniques on Performance 64 Effects of the Selected Instructional Techniques on Feelings of Satisfaction 66 Summary 67 Chapter Five: Summary, Conclusions, Implications, and Recommendations 69 Summary 69 v11 Page C o n c l u s i o n s 71 I m p l i c a t i o n s o f t h e Study 72 R e f e r e n c e s 73 A p p e n d i c e s 79 A: L e c t u r e O b j e c t i v e s 79 B: Format f o r Drug Card 81 C: S t u d e n t L a b o r a t o r y G u i d e f o r A d m i n i s t r a t i o n o f O r a l M e d i c a t i o n 83 D: I n s t r u c t o r ' s G u i d e f o r C o n t r o l Group: D e m o n s t r a t i o n - R e t u r n D e m o n s t r a t i o n 86 E: I n s t r u c t o r s ' G u i d e f o r E x p e r i m e n t a l Group: D e m o n s t r a t i o n - R e t u r n D e m o n s t r a t i o n U s i n g S i m u l a t i o n 91 F: S i t u a t i o n s : D e m o n s t r a t i o n - R e t u r n D e m o n s t r a t i o n U s i n g S i m u l a t i o n 96 G: C o g n i t i v e L e a r n i n g P r e t e s t - P o s t t e s t 101 H: O r a l M e d i c a t i o n A d m i n i s t r a t i o n C h e c k l i s t 107 I : F e e l i n g o f S a t i s f a c t i o n Q u e s t i o n n a i r e 110 J : S t u d e n t Data . . . 112 K: I n f o r m a t i o n f o r D i r e c t o r 114 L: I n f o r m a t i o n f o r C o - o r d 1 n a t o r / N u r s e E d u c a t o r s 117 M: I n f o r m a t i o n f o r S t u d e n t s 120 N: W r i t t e n Consent 123 0: Item A n a l y s i s f o r t h e C o g n i t i v e L e a r n i n g P r e t e s t - P o s t t e s t 125 v111 Page P: Cognitive Learning Pretest-Posttest Scores: Experimental and Control Groups 127 Q: T-test Results of Comparison of Cognitive Learning Pretest-Posttest Scores and Oral Medication Administrative Checklist Behavior Scores 129 R: Oral Medication Administration Checklist Scores: Experimental and Control Groups 132 S: Oral Medication Administration Checklist Overall Satisfactory Behavior Scores: Experimental and Control Groups 134 T: Feeling of Satisfaction Questionnaire Responses: Experimental and Control Groups 136 1x L is t of Tables Table Page 1 Implementation of the Study 33 2 Description of the Subjects by Age 44 3 Education Prior to Enrolment 1n the Nursing Program 44 4 Comparison of Cognitive Learning Pretest and Posttest Scores: Experimental Subjects 47 5 Comparison of Cognitive Learning Pretest and Posttest Scores: Control Subjects 49 6 Comparison of Cognitive Learning Pretest Scores: Experimental and Control Subjects 50 7 Comparison of Cognitive Learning Posttest Scores: Experimental and Control Subjects . . 52 8 Comparison of Oral Medication Administration Checklist Behaviors: Experimental and Control Subjects 54 9 Comparison of Group Responses to Statement 1 Concerning Relevance of the Practice Session 59 10 Comparison of Group Responses to Statement 2 Concerning Opportunities Provided by the Practice Session for Application of New Knowledge 59 11 Comparison of Group Responses to Statement 3 Concerning Usefulness of the Practice Session 61 12 Comparison of Group Responses to Statement 4 Concerning Enjoyment of the Practice Session 61 X L i s t of Figures Figure Page 1 Relationship between Meaning, Feeling and Concepts and the Learning Experience 6 2 Use of Demonstration-Return Demonstration Using Simulation and Demonstration-Return Demonstration for Teaching Oral Medication Administration 9 x1 Acknowledgements I would Hke to express my appreciation to a number of people without whose help th is study would not have been possible. I extend my thanks to the members of my thesis committee, Ethel Warbinek (Chairperson) and Anne Wyness, for their patience and guidance throughout the study. Appreciation 1s also extended to the faculty of the nursing school for their cooperation and support of my research project. In part icular, I would Hke to thank the director of the school for fac i l i t a t ing access to the study sample. A special thanks 1s extended to the students who volunteered to part icipate. Their cooperation 1n completing the tests and questionnaires was essential to the outcome of the study. F ina l ly , I am Indebted to my family, Ron, Scott and Les l ie , for their endless support and encouragement. 1 Chapter One Introduction Background to the Problem Teaching for c l in ica l competence 1s a major challenge for nurse educators (Swendsen Boss, 1985). Given that our society has a right to expect competent practice by health care professionals (Taylor & Cleveland, 1984), the nurse educator must be able to prepare graduates who can perform competently In real l i f e si tuat ions. To perform competently, then, nurses not only need knowledge and s k i l l , they must be able to formulate attitudes and make decisions necessary for carrying out the s k i l l s (Swendsen Boss, 1985). One example of a nursing act iv i ty that demonstrates the need for these requirements 1s that of medication administration. Evidence suggests that medication administration errors are reported to occur as frequently as one 1n f ive doses of medication given to hospitalized patients (Clavreul & Cavlness, 1983; Francis, 1980; Rosati & Nahata, 1983; Solomon et a l . , 1984). Although the greatest number of medication errors involve fa i lure to give a medication at the right time, other common errors relate to wrong route, dose, medication, and patient (Francis, 1980; Rosati & Nahata, 1983). Addit ionally, direct observational studies reveal that only one in ten medication errors 1s reported (Barker & McConnell, 1962; Clavreul & Cavlness, 1983). Even though most nurses were found to be unaware of these errors, others were unwilling to report an error unless a potent medication was involved. Since the average patient receives approximately eight 2 medications during hospital izat ion, 1t 1s possible that every patient 1s at risk for medication error (Markowitz, Pearson, Kay, & Loewensteln, 1981). While a l l medication errors have the potential to adversely affect the patients, "Instances of drug errors that do result 1n morbidity and mortality are reported with alarming regularity, as are potentially serious errors detected just before the drug 1s administered" (Solomon et a l . , 1984, p. 170). Consequently, this potential risk to patient safety strongly suggests the need for effective instruction 1n medication administration. Tradi t ional ly , nursing students have been taught medication administration by the Instructional technique of demonstration-return demonstration. As a result , the emphasis has been on the necessary motor movements or psychomotor s k i l l . Today, however, nurse educators are becoming Increasingly aware of the cognitive learning component entailed in the performance of an act ivi ty (Reil ly & Oermann, 1985). Cognitive learning involves knowledge of concepts and principles necessary for decision-making relative to the performance (Bruner, 1960). Furthermore, cognitive learning is fac i l i ta ted by feelings of sat isfact ion toward the learning experience which increase student motivation for additional learning (Woodruff, 1967). One instructional technique that enhances positive student feeling and cognitive and psychomotor s k i l l learning while allowing for patient safety 1s that of simulation (Becker, 1980; de Tornyay & Thompson, 1987; Infante, 1985; Jeffers & Chrlstensen, 1979). Given that the administration of medications requires competency 1n real H f e situations, simulation may be an effective technique for teaching this nursing act iv i ty . 3 Statement of the Problem Research studies reveal that medication errors are a major threat to the safety of hospitalized patients (Clavreul & Cavlness, 1983; Markowltz et a l . , 1981). Furthermore, these studies demonstrate that graduate nurses make a signif icant number of the errors. Given these medication errors by graduates, i t is possible that the tradit ional Instructional technique of demonstration-return demonstration f a l l s to prepare nursing students to administer medications safely in c l in ica l practice. This fa i lure may be due to the fact that administration of medications by th is technique 1s too unlike actual patient situations. Therefore, the use of an instructional technique that more closely resembles the real H f e situation may fac i l i t a te nursing student learning of medication administration and subsequently reduce the number of errors made by both students and graduates. Purpose of the Study The purpose of this study was to compare two instructional techniques by which oral medication administration was taught to determine their effect on nursing student cognitive learning, psychomotor learning Inherent in performance, and feeling of sat isfact ion toward the learning experience. Conceptual Framework Oral medication administration requires learning in the cognitive, affective and psychomotor domains (Reil ly & Oermann, 1985). For the purpose of th is study, however, the major f o d were on cognitive and 4 psychomotor learning. Affective learning was considered to a lesser extent. To further describe these learning components, Woodruff's (1967) model of learning and instruction provides direct ion. Despite the cognitive nature of this model, 1t 1s found to be relevant to the performance of oral medication administration because eff iciency 1n performance of th is s k i l l 1s based on decision-making behavior, rather than the more obvious motor and reflex behavior. Woodruff's model provides direction for psychomotor learning as 1t allows opportunity to t r i a l behaviors. In addition because the model considers the feeling elements of a learning experience, affective learning 1s incorporated. According to Woodruff (1967), cognitive learning 1s an overall process that Involves a constant interactional relationship between the formation and use of concepts. Therefore, cognitive learning is both a learning and behaving cycle. Concept formation 1s derived directly from perception 1n the form of sensory intake. Perception refers to the mental impression that the learner receives as a result of stimuli from words, concrete objects and events, verbal interaction, and his own feel ings. Given that these stimuli are rendered meaningful, perception is enhanced (Woodruff, 1967). Concept formation is described as the elaboration of mental images into mental constructs or mature concepts. Although mental Images are formulated as a result of stimuli from concrete objects and events, the formation of mature concepts requires verbalization and thus, conscious awareness (Woodruff, 1967). Having been raised to the level of recognition, then, mature concepts can be generalized to many 5 situations while unverbal1zed or incomplete concepts are limited to mediating behavior 1n famil iar si tuat ions. Concept using Involves both decision-making and t r i a l behaviors. Decision-making involves the use of concepts to mediate a si tuat ion. Although learners may decide "to reperceive, to predict outcome and value, or to Init iate an adjustlve move" (Woodruff, 1967, p. 84), the prime Importance of decision-making is that 1t precipitates a behavioral response or action that furnishes Important feedback for the perception stage of learning. The t r i a l stage of concept u t i l i za t ion involves acting out a conceptually based behavior in response to decision-making. Thus, by providing an empirical test of concepts, this stage allows the learner to validate a concept and make necessary modifications as a result of verbal Interaction with the teacher. Subsquently, important feedback is provided in the forms of meaning and feeling to the perception stage for incorporation into the concept (Woodruff, 1967). Although meaning resulting from the learning experience is necessary for concept formation, feelings toward the experience become part of the concept and give r ise to motive formation. Thus, a feeling of sat isfact ion toward the learning experience furnishes positive value which becomes part of the concept and provides motivation for further learning by increasing learner interest in the subject matter (see Figure 1). The stages of Woodruff's framework provide direction for comparing the effectiveness of demonstration-return demonstration, and demonstration-return demonstration using simulation as instructional techniques. 6 MEANING Concept Concept with Positive Value EXPERIENCE—J .-SATISFYING -FEELING-Positive Value LANNOYING Negative Value Concept with Negative Value Figure 1. Relationship between meaning, feel ing, concepts and the learning experience. Note. From Cognitive Models of Learning and Instruction (p. 81) by A. D. Woodruff, 1967. 7 For fac i l i t a t ing perception, demonstration by an Instructor provides both concrete and verbal s t imul i . Spec i f ica l ly , learner perception 1s enhanced through the use of relevant materials, Informative feedback, appropriate sequencing, and emphasis of essential elements (Woodruff, 1967). Concept formation is fac i l i ta ted through verbal interaction between the teacher and student and among students (Woodruff, 1967). Although return demonstration allows for student and teacher Interaction, return demonstration using simulation provides the added dimensions of Interaction between students and group discussion. Decision-making is strongly influenced through the use of return demonstration using simulation. By incorporating the roles, events, and consequences of a real situation or process (de Tornyay 4 Thompson), th is instructional technique provides the student with ample opportunity for decision-making. Tr ia l behavior 1s fac i l i ta ted through the use of both return demonstration and return demonstration using simulation by providing opportunity to manipulate real equipment (Woodruff, 1967). Although both instructional techniques allow for practice of essential motor movements, return demonstration using simulation provides opportunity for the learner to manipulate equipment 1n rea l i s t i c si tuat ions. Furthermore, feedback 1n the forms of meaning and feeling 1s provided through verbal Interaction with the teacher entailed 1n both demonstration-return demonstration and demonstration-return demonstration using simulation. However, simulation which 1s usually 8 preferred by students (de Tornyay & Thompson, 1987) should provide additional feedback 1n the form of learner feelings of sat is fact ion. For teaching oral medication administration, the use of both demonstration-return demonstration and demonstration-return demonstration using simulation should promote nursing student learning (see Figure 2). Although both techniques are designed to f ac i l i t a te the learning and behaving stages of perception, concept formation, and t r i a l , demonstration-return demonstration using simulation provides learners with opportunity to make conscious decisions and t r i a l behaviors 1n rea l i s t i c si tuat ions. Further, whereas both techniques have the potential to generate feelings of sat isfact ion toward the learning experience, simulation should enhance positive learner feeling by providing meaningful feedback as a result of actions precipitated by decision-making. Research Questions 1. What are the effects of the selected instructional techniques on nursing student cognitive learning concerning safe oral medication administration, Including giving the right dose of the right medication, to the right patient, at the right time, via the right route? 2. What are the effects of the selected Instructional techniques on nursing psychomotor learning as evidenced by student performance 1n the f i r s t administration of an oral medicatlon(s) to a patient? 3. What are the effects of the selected instructional techniques on nursing student feeling of satisfaction toward the learning experience? Concept-Forming Concept-Using Processes Processes Concept Formation: Maturation of concepts from mental images as a result of verbalization. Examples: Student-teacher interaction. Student-student interaction. Group discussion. Perception: Sensory intake from concrete objects and events and verbalization of meanings. Examples: Demonstration involving use of relevant materials, appropriate sequencing and emphasis of essential elements. Decision-Making: Uses concepts for making decisions that require a behavioral response. Examples: Written situations. Role played patient situations. T r i a l : Acting out the behavioral response and receiving verbal input necessary for meaning and feeling feedback. Examples: Return demonstration. Return demonstration using simulation. Feedback Figure 2. Use of demonstration-return demonstration and demonstration-return demonstration using simulation for teaching oral medication administration. Note. Adapted from Cognitive Models of Learning and Instruction (p. 63) by A. D. Woodruff, 1967. Definition of Terms Administration of medications; preparing an oral medication safely and giving the right dose of the right medication, to the right patient, at the right time, via the right route (f ive "rights") (Potter & Perry, 1987). Demonstration-return demonstration: the performance of oral medication administration in Its entirety by the nursing instructor occurring 1n the laboratory with a mannlkln, followed by instructor guided return performance of same by nursing students (Eaton, 1987). Simulation: a rea l i s t i c representation of oral medication administration using written situations and a classmate to role-play the patient in the laboratory (de Tornyay & Thompson, 1987). Cognitive learning: refers to acquisition of knowledge of the f ive "rights" of medication administration and application of th is knowledge 1n decision making (Bloom, 1956). Decision-making: the ab i l i ty to apply knowledge to a situation and choose one of the possible alternatives when administering oral medications (Bloom, 1956). Psychomotor learning: refers to the motor movements inherent in the performance of oral medication administration (Bloom, 1956). Performance: refers to the speci f ic act of oral medication administration, in response to cognitive and psychomotor learning (Reil ly & Oermann, 1985). Cr i t ica l behaviors: refers to nursing student responses 1n the performance of oral medication administration that are necessary to ensure patient safety (American College Dictionary, 1959). Affective learning: refers to feelings of sat isfact ion about learning experiences related to oral medication administration (Bloom, 1956). Feeling of sat is fact ion: represents student nurse perception about the positive value of the practice session of the oral medication administration laboratory act iv i ty (Woodruff, 1967). Assumption The Instructional technique used to teach nursing students oral medication administration 1s related to their competency 1n administering oral medications both as students and graduate nurses. Limitations 1. The small sample size prevented generalization of the findings. 2. Because the experimental and control groups were taught by the same nurse educators, a carry-over effect from one group to the other was possible. 3. Objective evaluation was d i f f i c u l t because the nurse educators who taught students 1n the laboratory and c l in ica l area evaluated the students' performance of oral medication administration. Overview of the Remainder of the Study The remaining content of the study consists of four chapters. In Chapter Two, a review of the l i terature focuses on nursing student learning of oral medication administration and Instructional techniques that are used to promote feelings of satisfaction toward the learning experience and transfer of learning to c l in ica l practice. While Chapter Three describes the methodology used 1n this study, Chapter Four 1s an analysis of the data gathered. Lastly, Chapter Five contains the summary of the f indings, the conclusions and Implications drawn, and recommendations for further areas for investigation. 13 Chapter Two Review of the Literature Introduction The l i terature review 1s organized according to the major elements of the study. Oral medication administration as a nursing act ivi ty wi l l be discussed 1n relation to the need for competence 1n c l in ica l practice and effective Instruction in both the cognitive and psychomotor learning domains. Further, the use of two selected instructional techniques for teaching this nursing act iv i ty wi l l be explored with regard to their effect on nursing student cognitive and psychomotor learning, and affective learning as 1t relates to feeling of sat isfact ion toward the learning experience. F ina l ly , the effect of these selected techniques on transfer of learning from the laboratory to c l in ica l practice wil l be explored. Learning the Nursing Activity of Oral Medication Administration Few c l in ica l nursing ac t iv i t ies carry such high risk ramifications as does the administration of medications (Solomon et a l . , 1984). Given that oral medication administration 1s an Integral part of nursing practice, nurse educators must prepare students for the safe performance of this act iv i ty 1n c l in ica l practice. Thus, in teaching students safe oral medication administration, nurse educators strongly emphasize the importance of preparing and giving the right dose of the right medication, to the right patient, at the right time, via the right route (five "rights") (Potter & Perry, 1987). Despite this emphasis on 14 safety, however, medication errors by graduate nurses " . . . are a matter of serious concern 1n a l l hospitals 1n North America" (Dubln, 1983, p. 194). According to the American Society of Hospital Pharmacists (1982), these medication errors Include a dose administered to a patient that deviates from the physician's orders or from standard hospital policy and procedures. Although these authors broadly categorize medication errors 1n terms of wrong-patient, wrong-dose, wrong-route, wrong-medication, and wrong-time, they Include fai lure to administer an ordered dose. Consequently, medication errors by graduate nurses Involve both fa i lure to adhere to the f ive "rights" of medication administration and errors of omission. Further, although these errors are reported to occur as frequently as one 1n every f ive doses of medication administration (Francis, 1980; Rosati & Nahata, 1983), the number of medication errors that are reported by nurses has been found to be much lower than the number observed by researchers using observational techniques (Barker & McConnell, 1962; Clavreul & Cavlness, 1983). Given this large number of medication errors by graduate nurses along with their lack of recognition of the errors, 1t 1s suggested that these nurses consider the f ive "rights" of medication administration to be unimportant (Rosati & Nahata, 1983). Thus, Instruction that promotes valuing of the f ive "rights" of oral medication administration may promote the safe administration of oral medications by graduate nurses. In order to administer oral medications competently, nurses require learning 1n the cognitive, affective and psychomotor domains (Reil ly 4 Oermann, 1985). Cognitive learning Involves the acquisition of knowledge of the f ive "rights" of oral medication administration and 15 application of th is knowledge 1n dedslon-making (Bloom, 1956). Woodruff (1967) suggests that this cognitive learning component Is maximized when the learner has a positive attitude toward the learning experience. Learning 1n the psychomotor domain Involves acquiring the motor movements inherent in oral medication administration (Bloom, 1956) which are necessary for a coordinated, dexterous and sequentially correct performance (Eaton, 1987). Although learning in the affective domain serves to make the performance of a nursing act iv i ty integrated, meaningful, and successful (Reil ly & Oermann, 1985), the administration of oral medications is an example of a nursing act iv i ty that requires the use of concepts for decision-making 1n order to ensure safety 1n performance. Cognitive learning, then, which involves the use of concepts to make decisions, is of prime Importance for performance of this act iv i ty (Woodruff, 1967). According to Woodruff (1967), cognitive learning and the related learning of motor movements can be fac i l i ta ted by influencing the learning process at the Interrelated and interdependent stages of perception, concept formation, decision-making, and t r i a l behavior. While perception furnishes the sensory input required for concept formation, concept using 1n the forms of decision-making and t r i a l behavior serves to provide essential feedback to the perception stage (Woodruff, 1967). I n i t i a l l y , to f ac i l i t a te perception or the formation of a mental Impression, students must be provided with two sources of st imul i , referential and symbolic. While referential stimuli in the form of real objects and events are essential for the formation of concepts, symbolic 16 stimuli which Include words, signs, and numbers function as triggering devices for stimulating recall of concepts already formed. To maximize perception, however, stimuli must be rendered meaningful (Woodruff, 1967). As a direct derivative of perception, the stage of concept formation occurs. This stage which Involves the elaboration of mental Images Into complete or mature concepts requires the verbalization of concepts. Through this verbal ization, concepts are raised to a level of awareness that allows for validation and modification (Woodruff, 1967). Having formulated concepts, learners are required to engage 1n concept using 1n order to empirically test the concept and receive feedback for Incorporation Into the concept being formed. This use of concepts includes the stages of decision-making and t r i a l behaviors. Decision-making which 1s characterized by the use of concepts to mediate a situation 1s a prelude to a behavioral response. While the learner may make any one of the possible decisions to repercelve, to predict outcome and value, or to in i t ia te an adjustive move, the prime Importance of having made a decision is that i t allows the learner to carry out an action and receive necessary feedback. The t r i a l behavior stage as the response to decision-making involves the acting out of a conceptually based behavior. This stage of concept using enables the learner to receive verbal input that provides Important meaning for feedback to the perception stage. Further, the t r i a l experience provides feedback 1n the form of student feel ings. Once perceived and Incorporated Into the concept, feelings toward the experience give r ise to motive formation. Importantly, a feeling of 17 sat isfact ion toward the learning experience should increase the positive value ascribed to the concept being formed and promote interest in further learning (Woodruff, 1967). Based on the fact that the safe administration of oral medications entai ls the use of concepts for decision-making relevant to the f ive "r ights", Woodruff's (1967) model provides direction for the formulation of these essential concepts. Thus, effective instruction 1n oral medication administration should f a c i l i t a t e the learning stages of perception, concept formation, decision-making, and t r i a l behavior. Instructional Techniques for Teaching Oral Medication Administration A review of the nursing l i terature revealed an abundance of Information concerning effective techniques for teaching the cognitive and psychomotor learning components of nursing ac t i v i t i es . However, l i t t l e of the existing l i terature relates directly to the use of techniques for teaching oral medication administration. A variety of techniques have been identif ied as being useful for teaching nursing ac t i v i t i es , two common examples are demonstration-return demonstration and demonstration-return demonstration using simulation. Demonstrat1on-Retu rn Demonstrat1on Demonstration-return demonstration 1s one Instructional technique that has been widely ut i l i zed in the teaching of nursing students (Swendsen Boss, 1985). One of the prime areas in which i t has proven successful is the teaching of basic nursing s k i l l s (Hallal S. Welsh, 18 1984). Given that the demonstration phase provides a representation of how to perform a procedure or task (Reil ly 4 Oermann, 1985), th is phase should be useful for f ac i l i t a t ing the perception stage of cognitive learning Inherent 1n s k i l l acquisition (Woodruff, 1967). In fac i l i t a t ing perception, demonstration provides both referential and symbolic stimuli through the performance of the procedure 1n Its entirety by the teacher and discussion of the underlying principles prior to the demonstration (Reil ly & Oermann, 1985). While stimuli may be provided through the use of various visual and auditory media (Quiring, 1972), the demonstration of a s k i l l by the teacher provides opportunity for verbal interaction between the teacher and learner. Thus, the learner can validate and modify a concept and receive feedback 1n the form of meaning to the perception stage (Woodruff, 1967). For perception to occur, however, students must be able to clearly see the representation and hear the related explanation in order to concentrate on what 1s happening (Infante, 1985). Further, to ensure student concentration, Rei l ly and Oermann (1985) state that the demonstration should be carried out in a laboratory setting as 1t provides few distract ions. The return demonstration of a nursing act iv i ty enhances the t r i a l stage of concept using. Since this Immediate return performance of an act Involves the manipulation of equipment and teacher feedback on performance (Eaton, 1987), students are able to validate and modify their responses. Thus, Important meaning feedback 1s furnished to the perception stage for incorporation into the concept being formed. Addit ionally, by having been involved in an action, students are able to 19 acquire feeling reactions toward the learning experience for feedback to perception. Given that the student's reaction 1s feeling of sat lsfct lon toward the learning experience, the return performance of a nursing act ivi ty provides opportunity for the formation of concepts with positive value. Consequently, the student wi l l be motivated to obtain further learning (Woodruff, 1967). While feedback 1n the forms of meaning and feeling 1s of prime Importance 1n the formation of concepts responsible for guiding a behavioral response, the acting out of the response provides students opportunity to develop motor movements or psychomotor learning Inherent in a nursing act iv i ty (Woodruff, 1967). Although Instruction by return demonstration fac i l i t a tes the acquisition of knowledge and s k i l l , 1t f a i l s to promote decision-making behaviors (Swendsen Boss, 1985). According to Swendsen Boss (1985), students cannot deliver competent care having only knowledge and s k i l l , they must learn how to make decisions. This view is supported by Taylor (1980) who states that 1t 1s of v i ta l Importance that graduate nurses beginning work are capable of making decisions while carrying out nursing practice. S i m u l a t i o n In recent years nurse educators have found that simulation 1s an effective technique for teaching the knowledge, s k i l l , and decision-making Inherent 1n the performance of nursing a c t i v i t i e s . As a rea l i s t i c representation of the structure of a real thing or process, simulation allows students to practice nursing ac t iv i t ies prior to their c l in ica l experience (de Tornyay & Thompson, 1987). Although many 20 act iv i t ies may be categorized as simulations, two common examples are written situations and role playing (Infante, 1985). Written situations which involve providing students with data that require an action (Dahl, 1984) f ac i l i t a te concept formation by allowing opportunity to use concepts 1n decision-making. Having made a decision and acted out the behavioral response, students are able to validate and modify concepts as a result of verbal Interaction with the teacher. Thus, feedback 1n the form of meaning is perceived for incorporation Into the concept (Woodruff, 1967). Although this meaning feedback may be furnished by the behavioral responses entailed in the return demonstration of a nursing act iv i ty , the opportunity for decision-making provided by written situations serves to Increase the amount of meaning perceived. As a result of Init iat ing additional behavioral responses, the use of written situations Increases the amount of verbal feedback provided by the teacher concerning the students' actions during the performance and the discussion following completion of the act ivi ty (Dahl, 1984). Since simulated experiences are risk free, students tend to freely discuss their mistakes as well as their successes (Corbett & Beverldge, 1982). Given that Increased verbalization increases meaning feedback to the perception stage, the use of written situations should fac i l i t a te student feeling of satisfaction toward the learning experience (Woodruff, 1967). Thus, the use of simulation not only provides Increased meaning for incorporation Into the concept being learned but serves to increase the positive value associated with the concept that is responsible for future learning. The use of written situations provides opportunity to f ac i l i t a te decision-making behavior. Based on the fact that th is type of simulation usually requires that some decision be made (Reilly & Oermann, 1985), students are able to receive immediate feedback concerning the accuracy and value of their decision. Thus, in subjecting their decision to scrutiny and val idat ion, students can become aware of the usefulness of decisions to reperceive, make predictions, or carry out an action. In support of the value of written situations for promoting decision-making, Curtis and Rothert (1972) described the use of written and visual situations for teaching nursing students decision-making in the assessment of a patient. In revealing that the students were deeply involved in the Identification of patient needs as a result of having made decisions, these nurses found that the simulated experience succeeded in e l i c i t i n g decision-making behavior. Written situations were used to teach nursing students to make decisions 1n a simulated disaster (Yantzie, 1980). A class of students was divided into small groups of four or f ive , with a maximum of f ive groups participating at one time 1n a simulated disaster s i tuat ion. In evaluating the learning act iv i ty , Yantzie reported simulated situations to be an effect ive technique for teaching decision-making 1n an emergency si tuat ion. The use of written situations enhances the t r i a l stage of learning by allowing students to act out behavioral responses 1n a safe and controlled environment (Cook & Maynard H i l l , 1985). Tradi t ional ly , the laboratory setting has been useful for offering this environment for the 22 practice of nursing act iv i t ies ( E l l i o t t , J U l i n g s , & Thorne, 1982). Given this controlled sett ing, nurse educators can Introduce al l the conditions and constraints present 1n c l in ica l practice (Gomez & Gomez, 1987). Thus, the use of written situations can Improve the quality of practice by providing students unlimited opportunity to perform nursing actions (Hodson, Brigham, Hanson, & Armstrong, 1988) while selectively attending to environmental events (Whiting, 1972). Role playing, as a second example of a simulated act iv i ty , 1s commonly used to teach nursing act iv i t ies (Reilly & Oermann, 1985). As an act iv i ty that usually Involves one student assuming the role of a patient while the other maintains the role of a nurse (Infante, 1985), role playing can be useful for fac i l i t a t ing the formation of concepts. In providing opportunity for verbal Interaction between the two students Involved 1n the act ivi ty (de Tornyay & Thompson, 1987), students receive additional meaning feedback to perception for concept formation (Woodruff, 1967). As wel l , having participated with a classmate in decision-making and the t r i a l of behaviors, Input 1s provided for discussion at the end of the act ivi ty (Swendsen-Boss, 1985). Through this discussion, meaning feedback 1s provided to the perception stage for concept formation. Thus, along with the meaning feedback normally provided by teacher-student interaction and group discussion, the use of role-played situations allows students to receive additional meaning feedback for perception and concept formation as a result of verbal Interaction between students. For promoting the decision-making stage of cognitive learning, the student role playing the patient may be directed to exhibit certain 23 behaviors that require decisions (de Tornyay & Thompson, 1985). By providing students with the opportunity to examine the usefulness of their decisions, they are able to make the necessary modifications (Woodruff, 1967). Role-played patient situations provide opportunity for the t r i a l of conceptually based behaviors 1n a created experience that closely Imitates a real c l in ica l situation (Kolb & Shugart, 1984). By providing the student who role-plays the patient with instructions, teachers can reproduce a variety of the complexities encountered 1n c l in ica l practice (Chaisson, 1980). Davldhizar (1977) ut i l ized role-played patient situations to acquaint nursing students with the possible behaviors that they would encounter with psychiatric patients in c l in ica l practice. Evaluation of the learning experience by means of student feedback Indicated increased abi l i ty to relate theoretical concepts to situations. Thus, these results suggest that the t r i a l behavior was enhanced through the use of th is technique. Feeling of Satisfaction Toward the Learning Experience As a minor focus of this study, the affective domain was addressed in terms of feeling of sat isfact ion toward the learning experience. Since positive feelings toward a learning experience enhance the value ascribed to the concept being t r la led and increase student motivation for further learning (Woodruff, 1967), an effective Instructional technique should fac i l i t a te feelings of satisfaction toward the learning experience. Although there 1s a lack of l i terature directly related to nursing student feeling of sat isfact ion toward the use of demonstration-return demonstration for teaching nursing a c t i v i t i e s , several studies suggest that 1t 1s viewed favorably. In an Inventory of graduate nurses returning to school, Fennell (1972) found that students had a preference for tradit ional learning strategies, such as d r i l l and reci tat ion. This view is supported by several authors. In a p i lot study, Ostmoe, Van Hoozer, Scheffel , and Crowell (1984) developed and administered a learning preference questionnaire to 92 baccalaureate nursing students. Findings revealed that students' usually preferred strategies that were passive 1n nature. These researchers concluded that nursing students prefer strategies that are t rad i t iona l , teacher-directed, and highly organized. Day and Payne (1987), in a recent experimental study that compared the effect of computer-managed Instruction with the passive tradit ional lecture method on nursing student attitude, found computer-managed Instruction to be less useful, less appropriate, less enjoyable, and less satisfying than the tradit ional method of instruct ion. Thus, they reported that nursing students prefer learning strategies that are tradit ional 1n nature and teacher directed. The results of th is study suggest that use of the tradit ional teacher directed technique of demonstration-return demonstration should f a c i l i t a t e feelings of sat isfact ion toward the learning experience. Therefore, given these feelings of sat isfact ion toward the learning experience, use of demonstration-return demonstration should f a c i l i t a t e the formulation of concepts with positive value and Interest in future learning (Woodruff, 1967). Other nursing l i terature suggests that the use of simulated situations during the return demonstration may be more effective than the return performance of the act iv i ty for fac i l i t a t ing student feelings of sat isfact ion toward the learning experience. Hodson et a l . (1988) described a p i lo t study 1n which written situations were used to Increase nursing student performance of basic nursing s k i l l s . The subjects were 16 sophomore nursing students. Written evaluation of the learning experience found that a l l the students who completed the act iv i t ies agreed or strongly agreed that the experience had been beneficial for learning. Similar ly , Johnson and Purvis (1987) used written situations to teach nursing students the nursing process. Feedback from these students indicated that they found the learning experience to be useful as i t enabled them to encounter learning situations they might not experience 1n their c l in ica l sett ing. In addition, Kruse, Hahn, Barry, and Gay (1978) studied student feelings concerning the use of written situations for teaching additional medication administration s k i l l s . There were 162 subjects. Al l subjects were provided with written situations for medication administration and a simulated c l in ica l sett ing. Subsequently, when asked 1f the act ivi ty was a useful learning experience, 123 students responded "yes" and 39 responded "no". Although written student comments revealed a signi f icant amount of frustration as a result of the r e a l i s t i c situations, the mostly positive results Indicate that written situations are a favorable Instructional technique. Role-played patient si tuat ions, as another type of simulation, are believed to be useful for enhancing student feelings of sat isfact ion 26 toward the learning experience. Dav1dh1zar (1977), 1n the evaluation of role-played patient situations for teaching psychiatric nursing, reported that student feedback was very positive both verbally and 1n course evaluations Indicating increased Interest 1n c lass , increased Involvement 1n learning, and greater ab i l i ty to relate concepts to situations. In revealing that students found the learning experience to be useful and Interesting, the results of th is study strongly suggest that role-played patient situations fac i l i t a te student feelings of sat is fact ion. These findings were supported by Lincoln, Layton, and Holdman (1978). Using individuals to role play patients, these researchers employed simulation to teach nursing students patient assessment. Evaluation of the learning experience by means of a rating scale revealed that although some students experienced discomfort and decreased confidence, overa l l , students' comments showed that the activi ty was useful for accomplishing learning. By Indicating that the students perceived the learning experience to be valuable, the results suggest student feeling of sat isfact ion with role-played patient si tuat ions. Given that learning experiences involving both written situations and role-played patient situations are viewed favorably by students, the l i terature suggests that the use of simulated situations fac i l i ta tes feeling of sat isfact ion toward the learning experience. Thus, the use of these situations should result 1n the formation of concepts with positive value and student Interest 1n further learning (Woodruff, 1967). While student feelings of sat isfact ion toward the learning 27 experience may be achieved through the use of demonstration-return demonstration, the use of simulated situations for instruction should increase this sat isfact ion as a result of providing additional meaning feedback and thus, awareness of the usefulness of the learning experience (Woodruff, 1967). Transfer of Learning from the Laboratory to Cl in ical Practice In providing opportunity to t r i a l behaviors and receive verbal feedback necessary for validation and modification, use of demonstration-return demonstration fac i l i ta tes the formation of concepts responsible for performance of ac t iv i t ies 1n the c l in ica l setting (Woodruff, 1967). Although use of this technique f a l l s to develop decision-making entailed 1n a performance (Swendsen Boss, 1985), the t r i a l performance of behaviors has been shown to increase the competence of nursing students in the c l in ica l setting (Hallal & Welsh, 1984). In reporting on the use of demonstration-return demonstration for promoting nursing student psychomotor s k i l l development, Hallal and Welsh (1984) revealed that based on observation, student performance in the c l in ica l setting was Improved. According to de Tornyay and Thompson (1987), the return demonstration of an act ivi ty provides the practice necessary for achieving a smooth and proficient performance. Given that the successful performance of ac t iv i t ies in c l in ica l practice requires rapid automatic actions (Gudmundsen, 1975), the use of th is technique fac i l i t a tes nursing student competence 1n the c l in ica l sett ing. Despite providing for this practice of a c t i v i t i e s , integration of psychomotor s k i l l s using theoretical knowledge 1n actual patient care 1s often d i f f i c u l t for students (Hodson et a l . , 1988). Thus, Hodson et a l . (1988) recommend the use of an Instructional technique that more closely resembles the actual c l in ica l sett ing. Simulation, as a representation of a r e a l - H f e si tuat ion, is believed to Increase the transfer of learning to the c l in ica l setting (Swendsen Boss, 1985). By using simulated situations during the return demonstration phase of the learning experience, students are required to make decisions and to judge decisions made by others (de Tornyay & Thompson, 1987). Having been provided with opportunity to make decisions that give r ise to a response, students are able to receive additional meaning and feeling feedback for the formation of concepts necessary for mediating behavior (Woodruff, 1967). Thus, simulated situations f a c i l i t a t e student performance in the c l in ica l setting by promoting the formation of concepts that can be used for making decisions 1n unfamiliar si tuat ions. As forms of simulation that require active student part icipat ion, both written situations and role-played patient situations may be used to promote transfer of learning. In using written situations to teach nursing students concepts relating to the nursing process, Johnson and Purvis (1987) found that use of this technique was effective for transferring concepts from written situations to c l in ica l practice. Further, these nurses attributed this transfer of learning to the Increased student-to-student and student-to-teacher verbal interaction that use of this technique provided. Dahl (1984) believes that simulated si tuat ions, such as written situations and role-played patient 29 situations enhance transfer of learning as a result of the real i ty of the learning experience. Other nurses, however, report that the decision-making entailed 1n the use of these simulated situations 1s responsible for an Increase 1n transfer of learning. According to Johnson and Purvis (1987), having made decisions during the learning ac t iv i ty , students are better able to transfer their decision-making s k i l l s to unfamiliar situations. Therefore, based on the fact that successful student performance requires decision-making (Swendsen Boss, 1985), transfer of learning should be f a c i l i t a t e d . In review, the l i terature suggests that the use of simulated situations not only promotes cognitive learning through Increased verbalization and practice 1n rea l i s t i c situations, but 1t fac i l i t a tes decision-making as wel l . Thus, simulated learning experiences 1n the laboratory setting should Improve student performance 1n c l in ica l practice. Summary As an example of a nursing act ivi ty that demonstrates the need for competence in c l in ica l practice, oral medication administration requires knowledge, s k i l l , and decision-making a b i l i t y . Although the use of demonstration-return demonstration should promote the acquisition of knowledge and psychomotor s k i l l , simulated learning experiences may be necessary for developing decision-making ab i l i t y . Further, given that simulation is viewed favorably by students, use of this technique could be useful for enhancing the cognitive learning component entailed 1n this nursing act iv i ty . Based on this potential for fac i l i t a t ing both the acquisition of cognitive learning and Its application 1n decision-making, the use of simulated situations may improve student performance 1n c l in ica l practice. Chapter Three Methodology Introduction This chapter describes the research design, sample, sett ing, data col lect ion procedure, data col lect ion instruments, and ethical considerations. A brief description of the procedures used 1n data analysis 1s also Included. Design The experimental method of research was ut i l i zed 1n this study to compare the effectiveness of two Instructional techniques used to teach oral medication administration (Pol l t & Hungler, 1983). One group of subjects constituted the experimental group and was taught oral medication administration by the Instructional technique of demonstration-return demonstration using simulation. The second group of subjects made up the control group and was taught oral medication administration by the instructional technique of demonstration-return demonstration. The effectiveness of these two Instructional techniques was determined by comparing the two groups on cognitive learning before and after the learning act iv i ty and on cognitive and psychomotor learning following the subjects' f i r s t administration of an oral medlcation(s) to a patient. Addit ional ly, the two groups were compared with regard to feelings of sat isfact ion toward the practice session of the oral medication administration laboratory ac t iv i ty . 32 Sample The sample consisted of volunteers from the f i rs t -year nursing class of a three-year diploma program. These students were randomly assigned to one of two groups on registration to the nursing program. One group consisted of 32 students and constituted the experimental group and one group consisted of 34 students and constituted the control group. Setting This study was conducted 1n a three-year diploma nursing program 1n a large metropolitan area. During the f i r s t year of the program, the students received concurrent classroom Instruction and c l in ica l experience. This c l in ica l experience totaled 12 hours per week on alternate weeks. As part of the classroom instruction, students were taught theory concerning oral medication administration by the teacher responsible for teaching the pharmacology content. Having been taught th is theory, the students participated in an oral medication administration laboratory act ivi ty prior to administering oral medications 1n the c l in ica l sett ing. Procedure for Implementation of the Study The study was implemented according to the procedure shown in Table 1. 33 Table 1 Implementation of the Study Both Groups Experimental Group Control Group Prior to Laboratory Activi ty 1. Two-hour lecture on safe oral medication administration. 2. Preparation of "drug cards" on selected medications. 3. Cognitive Learning Pretest During the Laboratory Activity Practice Session 1. Demonstration of oral medication administration using mannikins. Following the Laboratory Act iv i ty 1. Cognitive Learning^ Posttest 2. Feeling of Satisfaction Toward the Learning ^ Experience Questionnaire 3. C l in ica l Performance Checklist'' Return demonstration using simulation' Practice Session Return demonstration3 Note. The experimental group n = 32 and the control group n = 34. independent variable. ^Dependent variable. 34 Common Experiences In the Classroom and Laboratory Setting Al l subjects received a two-hour lecture concerning safe oral medication administration as part of the pharmacology course (see Appendix A). In accordance with the established schedule in the sett ing, this lecture was presented separately to the experimental group and the control group. In addition to the lecture, a l l subjects were Instructed by the pharmacology teacher to co l lect pertinent data on selected medications and record the data on "drug cards" (see Appendix B) in order to prepare them for the oral medication administration laboratory act iv i ty . The selection of these medications was based on the fact that they required decision-making in their administration. One week following the lecture, each group was administered a cognitive learning pretest and participated 1n a normally scheduled four-hour oral medication administration laboratory act ivi ty (see Appendix C). The laboratory act iv i ty was taught by the same f ive nurse educators responsible for teaching the students 1n the c l in ica l sett ing. During the laboratory ac t iv i ty , both the experimental and control subjects were taught oral medication administration by the Instructional technique of demonstration. This technique entailed dividing the experimental subjects and the control subjects into 5 groups. Each group of students, then, was taught by a nurse educator using a mannlkln (see Appendixes D and F) . Both the experimental subjects and the control subjects had access to the Information on their "drug cards" and were required to use them during the practice 35 session of the laboratory act iv i ty 1n the safe administration of selected oral medications. On completion of the practice session, the subjects 1n each group completed the cognitive learning posttest and a questionnaire concerning feelings of satisfaction toward the learning experience. In addition, these subjects were required to complete a student data questionnaire (Appendix J ) . Laboratory Practice Session The subjects in the experimental group were taught by the instructional technique of simulation for practicing the administration of oral medications during the laboratory act ivi ty (see Appendix D). Following demonstration of the administration of selected oral medications by a nurse educator to each of the f ive groups of experimental subjects, these subjects were required to safely administer selected medications in speci f ic simulated patient situations (see Appendix E) . In administering these selected medications, the subjects used "Tic Tacs" for tablets and cranberry juice for l iquid medications. Thus, student patients were required to ingest these simulated medications. Both the directions for using this technique and speci f ic patient situations were designed by the Investigator for the purpose of this study. The subjects in the control group were taught by the technique of return demonstration for the practice session of the oral medication administration laboratory act iv i ty (see Appendix F) . Following the demonstration of oral medication administration, these subjects were required to return the demonstration by safely administering the selected medications using mannikins. 36 In th is study, the laboratory act iv i ty for the control group preceded the laboratory act iv i ty for the experimental group. Thus, a carry-over effect from simulation was minimized. Clinical Activity Following the oral medication administration laboratory ac t iv i ty , subjects 1n both groups were observed during the f i r s t administration of an oral medlcatlon(s) in the c l in ica l setting by the same nurse educator responsible for their laboratory Instruction. The subjects' performance was recorded by the nurse educator using a checkl ist that was an accepted evaluation tool for a l l f i rs t -year nursing students. Preparation of the Nurse Educators During the week prior to the laboratory act ivi ty for the experimental group, the investigator met twice with the f ive nurse educators responsible for instruction 1n both the laboratory and c l in ica l settings and provided instructions for teaching oral medication administration by the technique of demonstration-return demonstration using simulation. Written Instructions for conducting the laboratory act ivi ty (see Appendix D) and speci f ic patient situations (see Appendix E) were provided by the Investigator. Addit ionally, the Investigator emphasized speci f ic facts related to safe oral medication administration that were useful for discussion following each si tuat ion. One week prior to the laboratory act iv i ty for the control group, the Investigator met with the f ive nurse educators col lect ive ly and 37 explained the procedure for teaching oral medication administration using demonstration-return demonstration. A normally used Instructor's guide for the laboratory act iv i ty (see Appendix F) was distributed to these teachers by the Investigator. Instruments C o g n i t i v e Measure For the purpose of measuring cognitive learning, the Investigator designed a paper and pencil test consisting of 20 multiple choice questions related to both knowledge of the f ive "rights" of oral medication administration and application of th is knowledge In decision-making (see Appendix G). The questions developed for th is test were based on objectives for the lecture on safe oral medication administration and the laboratory ac t iv i ty . This test which had a scoring value of 0-20, was constructed to test at the knowledge and application levels (Gronlund, 1985). Content va l id i ty of this Instrument was established through the use of l i terature (Hahn, Barkin, & Oestrelch, 1986; Potter & Perry, 1987) and three of the nurse educators responsible for teaching oral medication administration. These nurse educators were Instructed to review the test Items with regard to knowledge and application of the f ive "rights" of oral medication administration. Spec i f ica l ly , they were requested to determine 1f the Items tested nursing student knowledge of each of the f ive "rights" and the application of knowledge of each of the f ive "rights" in speci f ic situations. Following this review, the test was revised. 38 O r a l M e d i c a t i o n A d m i n i s t r a t i o n C h e c k l i s t To measure the cognitive and psychomotor learning components entailed 1n the performance of oral medication administration, the experimental and control subjects were observed during their f i r s t administration of an oral medicatlon(s) 1n the c l in ica l setting by the nurse educator who provided Instruction to the student 1n the laboratory. These nurse educators evaluated the students' performance by means of an established tool used 1n the school (see Appendix H). This tool consisted of 20 pertinent behaviors related to the administration of oral medications. Fifteen of the total behaviors were designated as being c r i t i c a l to patient safety. Of the 20 behaviors, only four primarily Involved motor movements necessary for the administration of oral medications or psychomotor learning. These behaviors were #6, #12, #13, and #17 on the check!1st, and related to the assembly of necessary materials, simultaneous transfer of medication card(s) and poured medication to the tray, placement of the medication tray at the bedside and positioning of the patient. The remaining 16 behaviors were dependent on the acquisition and application of knowledge of oral medication administration and thus indicative of cognitive learning. Having been evaluated through the use of this Instrument, the nursing students received numerical scores for their performance Indicating the total number of satisfactory cognitive and psychomotor behaviors. For establishing the val id i ty of this Instrument, the checklist was reviewed by the Investigator using current l i terature (Kozler & Erb, 1987; Potter & Perry, 1987) and the f ive nurse educators responsible 39 f o r t e a c h i n g s t u d e n t s o r a l m e d i c a t i o n a d m i n i s t r a t i o n 1n t h e l a b o r a t o r y and c l i n i c a l s e t t i n g s . T h e s e f i v e n u r s e e d u c a t o r s were c o l l e c t i v e l y I n s t r u c t e d by t h e I n v e s t i g a t o r t o r e v i e w t h e c h e c k l i s t w i t h r e g a r d t o c o m p l e t e n e s s and c l a r i t y o f c o n t e n t , c o r r e c t s e q u e n c i n g o f t h e s t e p s o f t h e p r o c e d u r e , and a p p r o p r i a t e n e s s o f t h e d e s i g n a t e d c r i t i c a l b e h a v i o r s . F u r t h e r , t h e n u r s e e d u c a t o r s were r e q u e s t e d t o s u b m i t t h e i r f e e d b a c k 1n w r i t t e n form t o t h e I n v e s t i g a t o r . H a v i n g r e c e i v e d f e e d b a c k from t h e s e n u r s e e d u c a t o r s t h a t I n c l u d e d s u g g e s t i o n s f o r i m p r o v i n g t h e sequence and w o r d i n g o f b e h a v i o r s , t h e I n v e s t i g a t o r u t i l i z e d t h e s e comments t o make minor r e v i s i o n s o f t h e c h e c k l i s t . I n t e r r a t e r r e l i a b i l i t y . To promote i n t e r r a t e r r e l i a b i l i t y , a v i d e o t a p e o f a s i m u l a t e d a d m i n i s t r a t i o n o f o r a l m e d i c a t i o n s was used t o t r a i n t h e f i v e n u r s e e d u c a t o r s . The n u r s e e d u c a t o r s c o l l e c t i v e l y o b s e r v e d t h e v i d e o t a p e d p e r f o r m a n c e o f a s e c o n d - y e a r n u r s i n g s t u d e n t v o l u n t e e r p r e p a r i n g and a d m i n i s t e r i n g o r a l m e d i c a t i o n s t o a r o l e - p l a y e d p a t i e n t and e v a l u a t e d t h e p e r f o r m a n c e u s i n g t h e c h e c k l i s t . T h i s v i d e o t a p e d p e r f o r m a n c e was r e p e a t e d u n t i l 100% agreement was r e a c h e d c o n c e r n i n g both t h e p r e s e n c e and a c c u r a c y o f b e h a v i o r s . In a d d i t i o n , t o m a i n t a i n agreement on t h e b e h a v i o r s , t h e n u r s e e d u c a t o r s c o l l e c t i v e l y o b s e r v e d t h e v i d e o t a p e and e v a l u a t e d t h e pe r f o r m a n c e d u r i n g t h e week p r i o r t o t h e l a b o r a t o r y a c t i v i t y and su b s e q u e n t c l i n i c a l e x p e r i e n c e . T h i s v i d e o t a p e d p e r f o r m a n c e was r e p e a t e d u n t i l 100% agreement among t h e n u r s e e d u c a t o r s on t h e r a t i n g o f t h e pe r f o r m a n c e was a c h i e v e d . One o f t h e o r i g i n a l f i v e n u r s e e d u c a t o r s became i l l p r i o r t o t h e f i r s t l a b o r a t o r y a c t i v i t y and a r e l i e f 40 teacher was required to participate 1n these last two review sessions of the videotape. Subsequently, this same re l ie f nurse educator was responsible for teaching subjects 1n the laboratory and c l in ica l sett ings. Feeling of Satisfaction Questionnaire This Instrument was designed by the Investigator to measure nursing student feelings of satisfaction toward the practice session of the laboratory act iv i ty (see Appendix I). The questionnaire which employed a summated rating scale, consisted of four statements related to student feeling of sat is fact ion. The subjects Indicated their response to each statement using a scale of 1 to 4. Student Data Questionnaire In addition to these Instruments, subjects were required to complete a brief questionnaire reporting their age, educational background, and prior occupation (see Appendix J ) . Ethics and Human Rights Prior to data col lect ion the proposal for th is study was approved by the University of Br i t ish Columbia Behavioral Sciences Screening Committee and the ethical review committee of the inst i tut ion 1n which the study was conducted. Access to the subject pool was gained through the Director of the School of Nursing (see Appendix K). Cooperation of the f i r s t year co-ord1nator and the f ive nurse educators Involved was also obtained (see Appendix L ) . 4 1 Students were Informed of the purpose of the study and that their participation was voluntary (see Appendix M). The fact that nonpartldpatlon would have no effect upon their status within the nursing program was emphasized. When students agreed to participate 1n the study, written consent was obtained (see Appendix N) and these students were given a copy of the consent. 1 One student with previous experience administering oral medication in an Institution received the same learning experiences as the control group. Data Analysis The control and experimental subjects were described according to selected personal characterist ics obtained from the Student Data Questionnaire. These characterist ics Included the subjects' age and educational background. Data in relation to the scores achieved by these two groups of subjects on the Cognitive Learning Pretest and Posttest were analyzed using the Independent t - tes t . The difference between the experimental and control subjects for their scores obtained on the Oral Medication Administration Checklist was subjected to analysis using independent t - t es ts . F ina l ly , the two groups of subjects were compared on the findings of the Feeling of Satisfaction Questionnaire through use of ch1-squared tests . A $. value of <.05 was considered to be s t a t i s t i c a l l y signif icant for a l l tests . Summary This chapter has presented the methodology of the study. A description was given of the design, sample and setting of the study, the procedure followed 1n the preparation and execution of the study and the development and use of Instruments for the col lect ion of data. The ethical considerations and protection of the part icipants' human rights were discussed and the methodology used for analyzing the data was br ief ly outl ined. 43 Chapter Four Presentation and Discussion of the Findings I n t r o d u c t i o n The results of the study are presented and discussed 1n relation to the description of the subjects and the three research questions. Description of the Subjects The subjects 1n both the experimental and control groups are described according to selected personal characterist ics as obtained from the Student Data Questionnaire. These personal characterist ics include the subjects' ages and educational backgrounds. Age A description of the experimental and control subjects by age is contained in Table 2. The majority of the subjects in each group were between 17 and 20 years of age. Of the remaining subjects similar numbers 1n each group were between 21 and 25 years of age while one student in the experimental group was between 26 and 29 years of age. Thus, the experimental group and the control group were homogeneous 1n relation to the characterist ic of age. E d u c a t i o n a l Background The experimental and control subjects were similar with regard to the number whose previous education was limited to completing grade 12. However, the two groups differed concerning post-secondary vocational training and university attendance. Although 3 out of 32 subjects 1n the experimental group had post-secondary vocational t ra in ing, 11 out of 34 subjects 1n the control group had this t ra in ing. The number of subjects 1n both groups that attended university Included 16 out of 32 1n the experimental group and 11 out of 34 1n the control group (see Table 3). Table 2 D e s c r i p t i o n o f t h e S u b j e c t s bv Age Age 1n Experimental Group Control Group Years (Jl = 32) (n = 34) 17-20 25 26 21-25 6 8 26-29 1 — Note. The values represent the number of subjects 1n the selected age group. Table 3 E d u c a t i o n P r i o r t o E n r o l m e n t 1n t h e N u r s i n g P r o g r a m Educational Background Experimental Group Control Group (H = 32) (n = 34) Completed grade 12 13 12 Post-secondary vocational training 3 11 Attended university 16 11 Note. The values represent the number of subjects with the selected educational background. 45 Cognitive Learning A cognitive learning pretest was completed by a l l the subjects prior to the oral medication laboratory act iv i ty and repeated as a posttest following the laboratory. This Instrument was used to answer the f i r s t question asked 1n this study concerning the effects of the selected Instructional techniques on nursing student cognitive learning of oral medication administration. The Cognitive Learning Pretest-Posttest consisted of 20 multiple choice questions with 10 questions testing knowledge of oral medication administration and 10 questions testing the use of th is knowledge to make decisions necessary for the safe administration of oral medications. Following completion of the pretest and posttest by a l l the subjects, these questions were subjected to item analysis. This analysis revealed that 19 out of the 20 questions discriminated 1n a positive direction between the upper quarter and lower quarter. Further, the d i f f i cu l ty factor for the pretest ranged from 0.3 to 0.9 with a mean d i f f i cu l ty factor of 0.66, while the posttest range was 0.4 to 1.0 with a mean d i f f icu l ty factor of 0.69 (see Appendix 0). Although question number seven had a d i f f i cu l ty factor of 0.0 for both the pretest and posttest, this question was retained as part of the test score as 1t measured knowledge of the four essential elements of a physician's order. For the pretest and posttest, each subject obtained three scores (see Appendix P). These scores represented the sum of correct answers for questions concerning knowledge, the sum of correct answers for questions concerning decision-making, and the sum of correct answers on the overall test . Differences 1n scores within and between the two groups were analyzed using Independent t - tes ts . The p. value of .05 was accepted as s t a t i s t i c a l l y s igni f icant . Cognitive Learning; Experimental Group The scores obtained by the experimental subjects for knowledge ranged from 4 to 9 out of a total of 10 (H = 6.7) on the cognitive learning pretest, and 5 to 9 (M = 7.0) on the posttest. For decision making, the scores ranged from 2 to 9 out of a total of 10 (M = 6.8) on the pretest, and 4 to 9 (M = 6.5) on the posttest. The overall test scores ranged from 9 to 17 out of a total of 20 (M = 13.5) on the pretest, and 11 to 16 (M = 13.6) on the posttest (see Table 4). Four subjects on the pretest and 3 subjects on the posttest obtained scores for knowledge below the inst i tu t ion 's pass score of 60%, while 7 subjects on the pretest and 8 subjects on the posttest obtained scores for decision making below this accepted standard. F ina l ly , 7 subjects on the pretest and 3 subjects on the posttest obtained overall scores below 60%. The differences between the pretest and posttest for knowledge scores (± [62] = -1.13, £ = .261), decision-making scores (± C62] = .69, 42 = .495), and overall scores ( i [62] = - .06 , ii = .952) were not s igni f icant (see Appendix Q). Cognitive Learning; Control Group For the control subjects, the scores obtained for knowledge ranged from 4 to 9 (M = 7.1) on the pretest, and 4 to 9 (M = 7.3) on the posttest. The scores obtained for decision making ranged from 3 to 10 47 Table 4 Comparison of Cognitive Learning Pretest and Posttest Scores: Experimental Subjects Pretest Posttest Total Score Frequency Percent Frequency Percent Knowledge 4 - 5 6 - 7 8 - 9 4 20 8 12.5 62.5 25.0 3 19 10 9.4 59.4 31.2 Total 32 100.0 32 100.0 Dec1s1on-mak1ng 2 - 3 4 - 5 6 - 7 8 - 9 2 5 13 12 6.3 15.6 40.6 37.5 0 8 14 10 25.0 43.8 31.2 Total 32 100.0 32 100.0 Overal1 9 - 1 1 12 - 14 15 - 17 7 11 14 21.9 34.4 43.7 3 18 11 9.4 56.2 34.4 Total 32 100.0 32 100.0 Note. Maximum score possible for knowledge = 10. Maximum score possible for decision-making = 10. Maximum overall score possible = 20. (M = 6.9) on the pretest, and 3 to 10 (M = 7.2) on the posttest. Overall test scores ranged from 9 to 18 (M = 14) on the pretest, and 10 to 18 (M = 14.5) on the posttest (see Table 5). While 4 subjects on the pretest and 2 subjects on the posttest obtained scores for knowledge below 60%, 7 subjects on the pretest and 5 subjects on the posttest obtained scores for decision making below this accepted score. Last ly , 3 subjects on the pretest and 3 subjects on the posttest obtained scores below 60% on the overall tes t . There were no signi f icant differences between the pretest and posttest for knowledge scores (± [663 = - .69 , p. = .49), decision-making scores ( i [66] = - .71 , .p. = .48), and overall scores (± [66] = - .92, ii = .362) (see Appendix Q). Comparison of Cognitive Learning Between the Groups Pretest scores. The cognitive learning pretest scores for knowledge ranged from 4 to 9 (M = 6.7) for the experimental subjects, and 4 to 9 (M = 7.1) for the control subjects. For decision making, the experimental subjects' scores ranged from 2 to 9 (M = 6.8) while the control subjects had scores ranging from 3 to 10 (M = 6.9). The overall test scores ranged from 9 to 17 (M = 13.5) for the experimental subjects, and 9 to 18 (M = 14.0) for the control subjects (see Table 6). The differences for pretest knowledge scores (± [64] = 1.09, p. = .279), decision making scores (± [64] = .22, 42 = .825), and overall scores (± [64] = .73, 41 = .469) between the experimental subjects and control subjects were not s igni f icant (see Appendix Q). 49 Table 5 Comparison of Cognitive Learning Pretest and Posttest. Scores; Control Subjects Pretest Posttest Total Score Frequency Percent Frequency Percent Knowledge 4 - 5 6 - 7 8 - 9 4 17 13 11.8 50.0 38.2 2 17 15 5.9 50.0 44.1 Total 34 100.0 34 100.0 Dec1s1on-mak1ng 3 - 4 5 - 6 7 - 8 9 - 1 0 3 11 13 7 8.8 32.4 38.2 20.6 1 11 14 8 2.9 32.4 41.2 23.5 Total 34 100.0 34 100.0 Overal1 9 - 1 0 11 - 12 13 - 14 15 - 16 17 - 18 3 7 11 7 6 8.8 20.6 32.4 20.6 17.6 1 4 13 10 6 2.9 11.8 38.2 29.5 17.6 Total 34 100.0 34 100.0 Note. Maximum score possible for knowledge = 10. Maximum score possible for decision-making = 10. Maximum overall score possible = 20. 50 Table 6 Comparison of Cognitive Learning Pretest Scores; Control Subjects Experimental and Experimental Subjects Control Subjects Total Score Frequency Percent Frequency Percent Knowledge 4 - 5 6 - 7 8 - 9 4 20 8 12.5 62.5 25.0 4 17 13 11.8 50.0 38.2 Total 32 100.0 34 100.0 Decision-making 2 - 4 5 - 7 8 - 1 0 4 16 12 12.5 50.0 37.5 3 20 11 8.8 58.8 32.4 Total 32 100.0 34 100.0 Overal1 9 - 1 0 11 - 12 13 - 14 15 - 16 17 - 18 5 6 7 11 3 15.6 18.7 21.9 34.4 9.4 3 7 11 7 6 8.8 20.6 32.4 20.6 17.6 Total 32 100.0 34 100.0 Note. Maximum score possible for knowledge = 10. Maximum score possible for decision-making = 10. Maximum overall score possible = 20. 51 Posttest scores. On the posttest, the experimental subjects obtained scores for knowledge ranging from 5 to 9 (M = 7.0), while the control subjects had scores ranging from 4 to 9 (M = 7.3). For decision making, the experimental subjects' scores ranged from 4 to 9 (M = 6.5), and the control subjects' scores ranged from 3 to 10 (M = 6.9). Overal l , the test scores ranged from 11 to 16 (M = 13.6) for the experimental subjects and 10 to 18 (M = 14.5) for the control subjects (see Table 7). Although 1t did not reach the established .05 level of s ignif icance, the control subjects' mean score for decision making was higher than the mean scores for the experimental subjects (± C64] = 1.86, a = .068). The control subjects achieved a higher overall posttest mean score than the experimental subjects and approached the level of significance (j; [64] = 1.99, £ = .051) (see Appendix Q). Oral Medication Administration For answering the second research question concerning the effects of the selected instructional techniques on nursing student performance during the f i r s t administration of an oral medicatlon(s) to a patient, data were collected using the Oral Medication Administration Checklist. This checklist consisted of 16 behaviors involving cognitive learning, and 4 behaviors Involving psychomotor learning. Al l the subjects were observed by a nurse educator using the checklist during the f i r s t administration of an oral medlcation(s) to a patient, and their behaviors were scored in terms of satisfactory or unsatisfactory 52 Table 7 Comparison of Cognitive Learning Posttest Scores; Experimental and Control Subjects Experimental Subjects Control Subjects Total Score Frequency Percent Frequency Percent Knowledge 4 - 5 6 - 7 8 - 9 3 19 10 9.4 59.4 31.2 2 17 15 5.9 50.0 44.1 Total 32 100.0 34 100.0 Decision-making 3 - 4 5 - 6 7 - 8 9 - 1 0 1 17 12 2 3.1 53.1 37.5 6.3 1 11 14 8 2.9 32.4 41.2 23.5 Total 32 100.0 34 100.0 Overal1 10 - 12 13 - 15 16 - 18 11 17 4 34.4 53.1 12.5 5 18 11 14.7 52.9 32.4 Total 32 100.0 34 100.0 Note. Maximum score possible for knowledge = 10. Maximum score possible for decision-making = 10. Maximum overall score possible = 20. 53 behaviors (see Appendix R). A checklist score for satisfactory behaviors Involving cognitive learning, psychomotor learning, and satisfactory overall behaviors was obtained for each subject. Differences in the sum of satisfactory cognitive, psychomotor, and overall behaviors between the two groups were analyzed using Independent t - t es ts . The signif icance level was established at p. = .05. Comparison of Performance Involving Cognitive Learning The mean score for satisfactory behaviors Involving cognitive learning was 13.8 for the experimental subjects, and 13.7 for the control subjects. Although a l l the experimental subjects performed more than 50% of these behaviors at a satisfactory l eve l , one control subject performed below this level (see Table 8). The difference between the two groups for satisfactory behavior scores Involving cognitive learning was not signif icant (jt [64] = .17, .p. = .862) (see Appendix Q). Comparison of Performance Involving Psychomotor Learning For both the experimental subjects and control subjects, the mean score for satisfactory behaviors involving psychomotor learning was 3.6. In the experimental group, 62.5% of the subjects performed al l four of these behaviors at a satisfactory l eve l , while 1n the control group 61.8% of the subjects performed a l l four behaviors sat is factor i ly (see Table 8). As shown in Appendix Q, there were no signif icant differences between the two groups for satisfactory behavior scores Involving psychomotor learning (± [64] = .04, D. = .968). 54 Table 8 Comparison of Oral Medication Administration Checklist Behaviors; Experimental and Control Subjects Experimental Subjects Control Subjects Total Score Frequency Percent Frequency Percent Cognitive Behavior 5 - 8 0 0.0 1 2.9 9 - 1 2 5 15.6 5 14.7 13 - 16 27 84.4 28 82.4 Total 32 100.0 34 100.0 Psychomotor Behaviors 2 1 3.1 1 2.9 3 11 34.4 12 35.3 4 20 62.5 21 61.8 Total 32 100.0 34 100.0 Overall Behaviors 9 - 12 0 0.0 1 2.9 13 - 16 11 34.4 7 20.6 17 - 20 21 65.6 26 76.5 Total 32 100.0 34 100.0 Cr i t ica l Behaviors 4 - 6 7 - 9 10 - 12 13 - 15 0 1 7 24 0.0 3.1 21.9 75.0 1 0 7 26 2.9 0.0 20.6 76.5 Total 32 100.0 34 100.0 Note. Maximum score possible for cognitive behaviors = 16. Maximum score possible for psychomotor behaviors = 4. Maximum score possible for overall behaviors = 20. Maximum score possible for c r i t i c a l behaviors = 15. 55 Comparison of Overall Performance The mean score for a l l the behaviors on the checklist performed at a satisfactory level was 17.3 for both the experimental subjects and control subjects. While a l l subjects 1n experimental group performed more than 50% of the behaviors at a satisfactory l eve l , one control subject performed fewer than 50% of the behaviors at th is level (see Table 8). The difference between the experimental subjects and control subjects for overall satisfactory behavior scores was not signif icant ( i [64] = .04, .p. = .966) (see Appendix Q). Additional Findings Additional data were noted related to the performance of designated c r i t i c a l checklist behaviors and behaviors performed differently by both groups. Comparison of performance of c r i t i c a l behaviors. Total l ing 15 in number, the designated c r i t i c a l behaviors were considered to be essential for the safe administration of oral medications. Differences between the groups for satisfactory performance of these behaviors were analyzed using an independent t - t es t . The mean score for satisfactory performance of c r i t i c a l behaviors was 13.4 for the experimental subjects and 13.1 for the control subjects. In the experimental group, a l l the subjects performed more than 50% of these behaviors at a satisfactory l eve l , while in the control group, one subject performed fewer than 50% of the behaviors sat is factor i ly (see Table 8). There 56 was no signif icant difference between the groups for scores concerning performance of c r i t i c a l behaviors (± [64] = .56, .p. = .581) (see Appendix Q). Behaviors performed differently bv the groups. Al l but six behaviors were performed at a satisfactory level by 90.6% of the experimental subjects and 85.3% of the control subjects (see Appendix S). While these six behaviors were a l l cognitive 1n nature, four were designated as being c r i t i c a l to patient safety. The performance of three of the six behaviors demonstrated the greatest differences between the two groups. Two of these three behaviors were c r i t i c a l to patient safety and Included checking the patient's chart for medication al lergies and checking for the presence of an allergy band. While 23 of the experimental subjects (71.9%) and 18 of the control subjects (52.9%) checked the chart for a l lerg ies , 21 of the experimental subjects (65.6%) and 29 of the control subjects (85.3%) checked for the presence of an allergy band. Thus, the experimental subjects committed 9 errors during the In i t ia l allergy check and the control subjects committed 16 errors. However, in the f inal check, the experimental subjects committed 11 errors and the control group committed 5 errors. The third behavior performed differently by the two groups was the non-cri t ical behavior of handwashing. In the experimental group, 13 subjects (40.6%) performed handwashing sat is factor i ly and 1n the control group, 21 subjects (61.8%) performed this behavior at a satisfactory l eve l . Therefore, the experimental subjects committed 19 errors with regard to handwashing and the control group subjects committed 13 errors. 57 Feeling of Satisfaction The evaluation of nursing students' feeling of sat isfact ion toward the practice session of the oral medication laboratory Involved completion of a Feeling of Satisfaction Questionnaire by a l l the subjects. Through the use of th is questionnaire, data were collected to answer the third research question regarding the effects of the selected instructional techniques on nursing student feeling of sat isfact ion toward the learning experience. In completing the questionnaire, the subjects were required to respond to four statements by selecting a number on a scale of 1 to 4 that reflected their feeling of sat isfact ion with each statement (see Appendix T) . Differences for these responses between the experimental and control subjects were analyzed using chi-squared tests . In both groups, the combined responses for numbers 1 and 2 on the scale were fewer than 5 in t o t a l , thus, these responses were combined with those for number 3 on the scale (Devore & Peck, 1986). The groups were compared for each statement on differences 1n the sum of their responses for numbers 1 to 3 on the scale and the sum of their responses for number 4. The accepted level of signif icance was p. = .05. Statement 1 Statement 1, which states "The practice session was relevant to c l in ica l practice", e l i c i ted Identical responses concerning disagreement from both the experimental and control subjects. In both groups, two subjects strongly disagreed with this statement. Agreement with this statement varied between the two groups with 10 experimental 58 subjects agreeing and 20 strongly agreeing, while 7 control subjects agreed and 25 strongly agreed that the practice session was relevant. However, as shown 1n Table 9, the difference was not signif icant (X 2C1] = .48587, p. = .9858). Statement 2 Statement 2, which states "The practice session provided opportunities for application of new knowledge about oral medication administration", received the same responses from both experimental and control subjects with regard to disagreement. However, agreement with this statement differed between the two groups of subjects. In the experimental group, 10 subjects agreed and 20 subjects strongly agreed, while 1n the control group, 8 subjects agreed and 24 subjects strongly agreed. Despite the greater number of control subjects strongly agreeing with th is statement, the difference was not s igni f icant as shown in Table 10 <X2L"1] = .18957, p. = .6633). Statement 3 The third statement, which related to the usefulness of the practice session for c l in ica l practice, e l ic i ted s l ight ly different responses from the experimental subjects and the control subjects with respect to both disagreement and agreement. In the experimental group, one of the subjects strongly disagreed with th is statement, while 8 agreed and 23 strongly agreed. Of the control subjects, 2 disagreed, 6 agreed, and 26 strongly agreed. Although more control subjects 59 T a b l e 9 Comparison o f Group Responses t o S t a t e m e n t 1 C o n c e r n i n g R e l e v a n c e o f t h e P r a c t i c e S e s s i o n Group Response E x p e r i m e n t a l C o n t r o l D i s a g r e e / A g r e e S t r o n g l y Agree 12 20 9 25 T o t a l 32 34 T a b l e 10 Comparison o f Group Responses t o S t a t e m e n t 2 C o n c e r n i n g O p p o r t u n i t i e s P r o v i d e d bv t h e P r a c t i c e S e s s i o n f o r A p p l i c a t i o n o f New Knowledge Group Response E x p e r i m e n t a l C o n t r o l D i s a g r e e / A g r e e S t r o n g l y Agree 12 20 10 24 T o t a l 32 34 60 strongly agreed, the difference as shown 1n Table 11 was not signif icant (X 2 L1] = .02105, p. = .8847). Statement 4 Statement 4, which related to the practice session being enjoyable, received highly similar responses from both the experimental and control subjects. For the experimental group, one subject strongly disagreed with the statement, 12 agreed, and 19 strongly agreed, while 1n the control group, 2 subjects strongly disagreed, 15 agreed, and 16 strongly agreed. Although more experimental subjects strongly agreed that the session was enjoyable, the difference was not signif icant as shown in Table 12 (X 2C1] = .39900, p. = .5276). Discussion of Findings The effects of the two selected instructional techniques on cognitive learning, performance of oral medication administration, and feeling of sat isfact ion toward the learning experience wil l be discussed 1n relation to the conceptual framework, l i terature , and methodological problems of the study. Effects of the Selected Instructional Techniques on Cognitive Learning The study found that there were no signif icant differences in cognitive learning of oral medication administration between nursing students taught by demonstration-return demonstration using simulation and those taught by demonstration-return demonstration. Although the T a b l e 11 Comparison o f Group Responses t o S t a t e m e n t 3 C o n c e r n i n g U s e f u l n e s s o f t h e P r a c t i c e S e s s i o n Group Response E x p e r i m e n t a l C o n t r o l D i s a g r e e / A g r e e 9 8 S t r o n g l y Agree 23 26 T o t a l 32 34 T a b l e 12 ComDarison o f GrouD ResDonses t o Statement 4 C o n c e r n i n a Eniovment o f t h e P r a c t i c e S e s s i o n Group Response E x p e r i m e n t a l C o n t r o l D i s a g r e e / A g r e e - 13 17 S t r o n g l y Agree 19 16 T o t a l 32 34 62 cognitive learning posttest scores for the former group did not register change to the extent expected by the Investigator, there are possible explanations for the f indings. One possible explanation for the lack of s igni f icant change in these posttest scores 1s that the test questions did not accurately measure cognitive learning. For example, while two test questions were related to the nature of enteric coated tablets and the common s i te of absorption, the laboratory practice Involved selecting the appropriate time for administration of th is type of oral medication preparation. The results of this study are not consistent with those of Curtis and Rothert (1972), Dav1dh1zar (1977), and Yantzle (1980) concerning the effectiveness of written and role-played patient situations for fac i l i t a t ing decision-making. Given that cognitive learning requires the use of concepts 1n decision-making and t r i a l behaviors (Woodruff, 1967), i t 1s possible that the number of situations simulated during the practice session was not large enough to provide suf f ic ient opportunity for decision-making and t r i a l behavior. Furthermore, since cognitive learning is dependent in part on communicative feedback related to t r i a l behaviors (Woodruff, 1967), 1t might be that discussion between and among the teacher and subjects was minimal. When the data were analyzed for differences 1n the pretest and posttest mean knowledge scores for the two groups, a s l ight trend toward an increase for the experimental subjects taught using simulation was noted. This suggests that these subjects were able to u t i l i ze concepts related to oral medication administration to make 63 decisions, carry out actions, and receive verbal feedback necessary for further concept formation (Woodruff, 1967). Certain factors may have Influenced the results. It 1s possible that the simulated situations used for teaching need further development. A t r i a l use of these situations prior to the study may have allowed for revision and refinement. Thus, the experimental subjects may have achieved a greater Increase 1n their cognitive learning posttest scores. Addit ionally, the nurse educators were using written situations and role-played patient situations for the f i r s t time. Therefore, 1t 1s possible that a more comprehensive teacher orientation concerning simulation theory and use of written situations and role-played patient situations may have altered the study results. The fact that the same nurse educator taught one experimental group and one control group may have contributed to the findings. It is possible that there was a carry-over teaching effect between the groups which would not have been possible 1f different nurse educators were used to teach the experimental and control subjects. F inal ly , the sample size may have been responsible for the lack of s ignif icant differences between the two groups. Given a larger number of subjects, the differences between the posttest scores of the groups may have been s igni f icant . However, despite the problems Inherent 1n the study, the results suggest that simulation was at least as effective as the established technique for teaching oral medication administration. Thus, with further development of the simulated situations and increased teacher orientation, i t 1s possible that the use of simulation may be more effective than tradit ional learning component of oral 64 Instruction for fac i l i t a t ing the cognitive medication administration. Effects of the Selected Instructional Techniques on Performance Analysis of the data showed no signif icant differences between the groups for performance during the f i r s t administration of a medlcatlon(s) to a patient. It might be that the lack of differences 1n performance between the groups may have been due to both Insufficient laboratory practice using simulated situations and verbal Interaction between the teacher and subjects. As a nursing act ivi ty that requires decision-making in performance (Swendsen Boss, 1985), 1t 1s possible that Increased opportunity for decision-making and t r i a l behavior during the practice session may enhance the transfer of learning to the c l in ica l setting by fac i l i t a t ing the formation of concepts that can be used to mediate behavior 1n unfamiliar situations (Woodruff, 1967). While the results of th is study do not support the findings of Johnson and Purvis (1987) that the use of written situations 1s effective for transferring concepts from written situations to c l in ica l practice, these researchers state that verbal Interaction 1s responsible for this transfer. Therefore, 1t is possible that the amount of discussion regarding the simulated situations 1n the laboratory may have Influenced the findings of th is study. Another reason for the study findings may be that the performance checklist fa i led to accurately measure the cognitive learning component of this nursing act iv i ty . Given that th is checklist ref lects only the 65 subjects' behavioral responses* 1t 1s possible that the experimental subjects may have Improved their decision-making abi l i ty but the Instrument fa i led to measure th is fact . A further point 1s that a l l subjects were aware that their performance was being evaluated. It is possible that the subjects' desire to perform well was a factor that Influenced the results. Because the psychomotor learning component of oral medication administration 1s l imited, only four behaviors relevant to psychomotor learning were included on the performance checkl ist . It 1s possible that th is number of behaviors was too small to ref lect the effect of simulation on psychomotor learning. Problems Inherent 1n this study may have been responsible for the results. Given that the same nurse educator taught the students in the laboratory and evaluated them in the c l in ica l sett ing, 1t is possible that teacher bias regarding the instructional techniques may have influenced the results. Further, the fact that f ive nurse educators evaluated the students' performance may have resulted 1n Inconsistencies concerning evaluation. Therefore, i f one nurse educator who was not Involved in the laboratory evaluated a l l the subjects in the c l in ica l sett ing, the results of the study may have been dif ferent . The additional finding that there was no difference between the two groups for performance of the majority of the designated c r i t i c a l behaviors further suggests that both techniques were equally effective for ensuring patient safety. However, with further development of the simulated situations and increased teacher orientation, simulation may 66 be more effective than tradit ional techniques for decreasing medication errors by nurses 1n c l in ica l practice. Another additional finding was that there were differences between the two groups with regard to checking for medication al lergies and performing handwashing. Given that the use of simulated situations does not Involve carrying out sequential behaviors, 1t 1s possible that errors by the experimental subjects concerning handwashing and checking the chart for medication al lergies were due to a lack of emphasis on these behaviors by the nurse educators. Effects of the Selected Instructional Techniques on Feelings of Satisfaction This study found that there were no signi f icant differences between the two groups for feelings of sat isfact ion toward the learning experience. A possible reason for th is finding may have been the nature of the questionnaire. Given that this questionnaire contained only four simple statements for subjects to rate, 1t is possible that a greater number of statements that reflected values concerning oral medication administration would have registered a larger difference 1n responses between the groups. In addition, since the majority of subjects 1n both groups responded positively on the questionnaire, 1t 1s possible that this laboratory content 1s one of particular Interest. Considering the f indings, 1t 1s possible that additional positive teacher feedback during the t r i a l of behaviors or practice session might have Increased the feeling of sat isfact ion experienced by the subjects taught by simulation (Woodruff, 1967). As a result , the 67 subjects may have been able to formulate concepts with positive value that provide motivation for further learning (Woodruff, 1967). The findings do not clearly ref lect those of Hodson et a l . (1988), Johnson and Purvis (1987), and Kruse et a l . (1978), who found that written situations were viewed as being useful for nursing students, and those of Dav1dh1zar (1977), and Lincoln et a l . (1978), who found that role-played patient situations were perceived as being a useful technique. In this study, possible reasons for the results relate to both the Instruction and the teaching content. Given that the nurse educator who taught both the experimental and control subjects was their c l in ica l Instructor, 1t 1s possible that the relationship between the teacher and subjects Influenced the responses on the questionnaire. Thus, Instruction in the laboratory by a different nurse educator may have resulted 1n different f indings. Had the situations been t r i a l ed , revised and refined, 1t 1s possible that they may have been perceived as more interesting and useful. However, the results suggest that the subjects viewed the practice session using simulation as a positive experience. Given further development of the simulated situations and increased teacher orientation emphasizing the need for positive feedback, 1t is possible that simulation may prove to be more effective than tradit ional Instruction for fac i l i t a t ing Interest 1n learning. Summary The results of the study were presented according to the characterist ics of the subjects and the three research questions 68 concerning the effects of two selected Instructional techniques on cognitive learning of oral medication administration, performance of oral medication administration, and feeling of sat isfact ion toward the learning experience. The results were discussed according to the differences for cognitive learning, performance, and feeling of sat isfact ion between the subjects taught by demonstration-return demonstration, and those taught by demonstration-return demonstration using simulation. The findings revealed that there were no signif icant differences between the two groups of subjects with regard to cognitive learning, performance, and feeling of sat isfact ion toward the learning experience. Thus, 1n this study both Instructional techniques were equally effective for teaching oral medication administration. 69 Chapter Five Summary, Conclusions, Implications, and Recommendations Summary This study was designed to compare the effects of two Instructional techniques on nursing student cognitive learning, psychomotor learning Inherent in oral medication administration, and feeling of sat isfact ion toward the learning experience. A review of the l i terature indicated a definite need for the safe administration of medications by graduate nurses but errors with regard to the "f ive rights" were a common occurrence. As a nursing act iv i ty , oral medication administration was revealed to involve a major cognitive learning component as well as a minor psychomotor learning component. Although demonstration-return demonstration was tradi t ional ly deemed to be the appropriate technique for fac i l i t a t ing these two learning domains of nursing ac t iv i t i es , recent sources suggested that return demonstration involving simulation was more effective because 1t enhanced decision-making required for a performance. Both techniques, however, were found to foster feelings of sat isfact ion toward the learning experience and fac i l i t a te the transfer of learning from the laboratory to the c l in ica l sett ing. The study population consisted of f i rs t -year nursing students enrolled in a three-year diploma program associated with a large metropolitan hospital . The experimental group which consisted of 32 students was taught oral medication administration by demonstration-return demonstration using simulation, and the control group which consisted of 34 students was taught by demonstration-return demonstration. Al l subjects attended a two-hour lecture concerning oral medication administration, prepared selected "drug cards" for use during the laboratory, and completed a pretest concerning knowledge of oral medication administration and the application of this knowledge in making decisions required for the safe administration of medications. Addit ionally, both groups participated separately 1n a normally scheduled laboratory and observed a demonstration of oral medication administration by one of f ive nurse educators. The experimental subjects returned the demonstration using simulation 1n the form of written situations and role-played patient si tuat ions, while the control subjects carried out a return performance of the demonstration. Following the laboratory, a l l subjects completed the pretest as a posttest, and questionnaires regarding feeling of sat isfact ion toward the practice session and selected personal character ist ics. Further, a l l subjects were observed by the same nurse educator during the f i r s t administration of an oral medlcatlon(s) to a patient and their performance of behaviors Involving cognitive and psychomotor learning was scored on a checkl ist . Differences 1n mean scores on the cognitive learning tests and performance checklist within and between the two groups were analyzed using Independent t - t es ts , while differences in responses concerning feelings of sat isfact ion were analyzed using ch1-squared tests . The accepted level of signif icance was p. = .05 for a l l tests . Addit ionally, data collected concerning selected personal 71 characterist ics of the subjects were used to describe the study population. A comparison of the two groups showed there were no signi f icant differences for cognitive learning of oral medication administration and performance during the f i r s t administration of a medlcatlon(s) to a patient. Furthermore, there were no signif icant differences with regard to feelings of satisfaction toward the learning experience. Additional findings revealed that while both groups were comparable with regard to satisfactory performance of behaviors c r i t i c a l to patient safety, three behaviors were performed differently by the experimental and control subjects. Conclusions The small sample size and the fact that the sample was obtained from only one nursing program l imits the general1zab1l1ty of the results, however, the findings of the study suggest the following conclusions: 1. The two selected Instructional techniques were equally effective for fac i l i t a t ing nursing student cognitive learning of oral medication administration. 2. The two selected Instructional techniques were equally effective for f ac i l i t a t ing nursing student performance during the f i r s t administration of an oral medlcatlon(s) to a patient. 3. The two selected Instructional techniques were equally effective for e l i c i t i n g nursing student feelings of sat isfact ion toward the learning experience. 72 Impl ications of the Study The findings of th is study suggest a major Implication for nursing education. Nurse educators are required to prepare graduates who have knowledge, s k i l l , and decision-making a b i l i t y . Tradi t ional ly , the technique of demonstration-return demonstration has been used to f ac i l i t a te nursing student knowledge and s k i l l required for the performance of nursing ac t i v i t i es . However, the findings of this study suggest that the use of simulation during return demonstration is equally as effective for fac i l i t a t ing student learning of these a c t i v i t i e s . When selecting simulation as an instructional technique, nurse educators may maximize student cognitive and psychomotor learning and feeling of sat isfact ion by using a wide variety of simulated situations and providing the faculty with comprehensive orientation concerning th is technique. Addit ionally, time periods for group discussion should be scheduled following completion of each simulated si tuat ion. Given that faculty 1s allowed adequate time for the development of simulated situations and orientation of faculty, the use of simulation may be more effective than tradit ional techniques for teaching nursing a c t i v i t i e s . References American College Dictionary. (1959). New York: Random House. American Society of Hospital Pharmacists. (1982). ASHP standard definit ion of a medication error. American Journal of Hospital Pharmacists, 32» 321. Barker, K., & McConnell, W. (1962). The problems of detecting medication errors in hospitals. American Journal of Hospital Pharmacy* 12, 361-369. Becker, C. (1980). An overview of simulation games and comments on their use 1n baccalaureate nursing education. Nursing Papers, 12 (2), 32-34. Bloom, B. (1956). Taxonomy of educational objectives, the c lass i f ica t ion of educational goals, handbook I: Cognitive domain. New York: David McKay Co. Inc. Bruner, J . (1960). The process of education. New York: Vintage Books, Division of Random House. Chaisson, G. (1980). L i fe -cyc le : A social-simulation game to Improve attitudes and responses to the elder ly . Journal of Gerontological Nursing, £ (10), 587-592. Clavreul, G . , & Cavlness, S. (1983). Unsafe nursing practices and what you can do about them. Nursing L i f e . 3_ (3), 40-45. Cook, J . , & Maynard H111, P. (1985). The Impact of successful laboratory system on the teaching of nursing s k i l l s . Journal of Nursing Education. 2A (8), 344-346. Corbett, N., & Beverldge, P. (1982). Simulation as a tool for learning. Topics 1n Cl in ical Nursing. A (3), 58-67. Curt is , J.» & Rothert, M. (1972, January). An Instructional simulation system offering practice 1n assessment of patient needs. Journal of Nursing Fducatlon, 11 (1), 23-28. Dahl, J . (1984). Structural experience: A r isk- free approach to reality-based learning. Journal of Nursing Education, 21 (1), 34-37. Davidhizar, R. (1977). Use of simulation games 1n teaching psychiatric nursing. Journal of Nursing Education, 16. (5), 9-11. Day, R., & Payne, L. (1987). Computer-managed instruction: An alternative teaching strategy. Journal of Nursing Education, 2£ (1), 30-35. de Tornyay, R., & Thompson, M. (1987). Strategies for teaching nursing (3rd ed.) (pp. 59-67). New York: WHey. Devore, J . , & Peck, R. (1986). S ta t i s t i cs : The exploration and analysis of data. St. Paul: West Publishing Company. Dubin, C. (1983). Report of the Hospital for Sick Children Review Committee. Toronto: Government of Ontario. Eaton, S. (1987). Developing psychomotor s k i l l s . In R. de Tornyay & M. Thompson, Strategies for teaching nursing (3rd ed.) (pp. 59-67). New York: Wiley. E l l i o t t , R., J U H n g s , C , & Thome, S. (1982). Psychomotor s k i l l acquisition in nursing students 1n Canada and US. The Canadian Nurse, Ifi (3), 25-27. Fennel!, B. (1978). Attitudes toward learning styles and se l f -d i rect ion of ADN students. Journal of Nursing Education, 11, 19-22. Francis, G. (1980, August). Nurses' medication "errors": A new perspective. The Journal for Nursing Leadership and Management, 11, 11-13. Gomez, G . , & Gomez, E. (1987). Learning of psychomotor s k i l l s : Laboratory versus patient care sett ing. Journal of Nursing Education. 26. (1)» 20-24. Gronlund, N. (1985). Measurement and evaluation in teaching (5th ed. ) . New York: Co l l ie r Macmlllan. Gudmundsen, A. (1975). Teaching psychomotor s k i l l s . Journal of Nursing Education. 1£ (1), 23-27. Hahn, A . , Barkin, R., & Oestrelch, S. (1986). Pharmacology in nursing (16th ed. ) . Toronto: Mosby. Ha l la l , J . , 4 Welsh, M. (1984). Using the competency laboratory to learn psychomotor s k i l l s . Nurse Educator, 2. (1)> 34-38. Hodson, K., Brlgham, C . , Hanson, A . , & Armstrong, K. (1988). Multl media simulation of a c l in ica l day. Nurse Educator, 12. (1), 10-13. Infante, M. (1985). The c l in ica l laboratory in nursing education (2nd ed. ) . New York: Wiley. Je f fers , J . , & Christensen, M. (1979, June). Using simulation to f a c i l i t a t e the acquisit ion of c l in ica l observational s k i l l s . Journal of Nursing Education, l f i (6), 29-32. Johnson, J . , 4 Purvis, J . (1987). Case studies: An alternative learning/teaching method 1n nursing. Journal of Nursing Education, 2L (3), 118-120. Kolb, S . , & Shugart, E. (1984). Evaluation: Is simulation the answer? Journal of Nursing Education, 21 (2), 84-86. Kozler, B . , 4 Erb, G. (1987). Fundamentals of nursing (3rd ed.) Menlo Park, CA: Addison-Wesley. Kruse, L . , Hahn, C , Barry, J . , 4 Gay, J . (1978). Ut i l i za t ion of a media Instructional support staff in the development of a simulated learning experience: Medication administration. Journal of Nursing Education. H (8), 27-34. Lincoln, R., Layton, J . , 4 Holdman, H. (1978). Using simulated patients to teach assessment. Nursing Outlook. 26, 316-320. Markowltz, J . , Pearson, G . , Kay, B . , 4 Loewenstein, R. (1981). Nurses, physicians, and pharmacists: Their knowledge of hazards of medications. Nursing Research. 3J2 (6), 366-370. Ostmoe, M., Van Hoozer, H., Scheffel , A . , 4 Crowe!1, C. (1984). Learning style preferences and selection of learning strategies Consideration and Implications for nurse educators. Journal of Nursing Education, 21 ( l ) , 27-30. Page, G . , 4 Saunders, P. (1978). Written simulation 1n nursing. Journal of Nursing Education. U (4), 28-32. Po l l t , D., 4 Hungler, B. (1983). Nursing research (2nd ed.) . Philadelphia: Lipplncott. Potter, P. , & Perry, A. (1987). Basic nursing theory and practice. Toronto: Mosby. Quiring, J . (1972). The autotutorlal approach. Nursing Research. 21 (4), 332-337. Re i l ly , D., & Oermann, M. (1985). The c l in ica l f i e l d : Its use in  nursing education. Norwalk, CT: Appleton-Century-Crofts. Rosati, J . , & Nahata, M. (1983). Drug administration errors 1n pediatric patients. Quality Review Bul le t in . 2 (7), 212-213. Solomon, S . , Wallace, E . , Ford-Jones, E . , Baker, W., Martone, W., Kopln, I., Cr1t1z, A . , & Al len, J . (1984, January). Medication errors with Inhalant ep1nephrine-m1m1cking and epidemic of neonatal sepsis. The New England Journal of Medicine, 310 (3), 166-170. Swendsen Boss, L. (1985). Teaching for c l in ica l competence. Nurse Educator, 10 (4), 8-12. Tayler, J . , & Cleveland, P. (1984). Effective use of the learning laboratory. Journal of Nursing Education. 23. (1), 32-39. Taylor, A. (1980, July 10). C l in ica l simulations in nursing. Nursing Times, 1217-1218. Vancouver General Hospital School of Nursing. (1988). Vancouver General Hospital School of Nursing. Nursing 101 Lab Guide. Vancouver, BC: Author. Whiting, H. (1972). Overview of the s k i l l learning process. The Research Quarterly. 43. (3), 266-293. Woodruff, A. (1967). Cognitive models of learning and Instruction In L. Slegel (Ed.) , Instruction: Some contemporary viewpoints (pp. 55-98). San Francisco: Chandler. Yantzle, N. (1980, June). HELP, a simulation disaster game. Canadian Nurse. 33-36. Appendix A L e c t u r e O b j e c t i v e s S a f e O r a l M e d i c a t i o n A d m i n i s t r a t i o n Lecture Objectives Safe Oral Medication Administration Upon completion of the lecture, the student wil l be able to: 1. Describe factors relevant to methods of administration. 2. Identify the standard times for medication administration. 3. Identify the essential elements of the physician's orders. 4. Identify the essential elements of a medication card. 5. Describe nursing responsibi l i t ies relevant to controlled medications. 6. Describe the use of common sources of medication Information. 7. Describe the written format for "drug cards". 8. Identify the essential elements of oral medication administration. 9. Identify principles of safety and comfort In the performance of oral medication administration. 10. Describe reporting and recording of data pertinent to the administration of oral medications. 11. Discuss the signif icance of the "f ive rights". Note. From Nursing 101 Lab Guide by Vancouver General Hospital School of Nursing, 1988, Vancouver, BC. Reprinted by permission. 81 Appendix B Format for Drug Card Format for Drug Card C lass i f ica t ion: Drug Name: Generic: Trade: Action: Use: Dosage: Route: Side Effects: Nursing Responsibi l i t ies: Assessment: Intervention: Evaluation: 83 Appendix C Student Laboratory Guide for Administration of Oral Medication STUDENT LABORATORY GUIDE FOR ADMINISTRATION OF ORAL MEDICATIONS PURPOSE The purpose of the laboratory act ivi ty 1s to assist the student to prepare and administer oral medication. Emphasis is on the application of selected pr inciples, pol ic ies and terms related to the administration of oral medications. OBJECTIVES On completion of the laboratory act ivi ty the student wi l l be able 1. apply selected principles 1n the administration of oral medications relating to - asepsis. - medication administration safety. - anatomy and physiology. - microbiology. - pharmacology. 2. apply VGH pol ic ies speci f ic to the administration of oral medications. 3. use selected terms associated with oral medication administration relating to - oral pharmaceutical preparations. - commonly used abbreviations 1n medication orders. - equipment: medication cups (plast ic & paper) - tray - card -counter; mortar and pestle. 4. demonstrate the preparation and administration of selected oral medications with supervision. 5. record pertinent Information relating to oral medication administration with supervision. PERFORMANCE GUIDELINES FOR THF ADMINISTRATION OF MEDICATIONS Evaluates Performance for the Listed Behaviors. 1. Applies selected principles relating to asepsis, microbiology, medication administration safety and pharmacology 1n the preparation and administration of an oral medication. 2. Applies VGH pol ic ies speci f ic to the preparation and administration of oral medications including: verbal and telephone orders; medication control and wastage; expiry dates; ordering protocols, and personal medications and medication transcript ions. 85 3. Uses terms associated with pharmaceutical preparations and equipment 1n the preparation of oral medications. 4. Prepares and administers selected oral medications. Note; From Nursing 101 Lab Guide by Vancouver General Hospital School of Nursing, 1988, Vancouver, BC. Reprinted by permission. Appendix D Instructors' Guide for Control Group Demonstration - Return Demonstration 87 INSTRUCTOR'S GUIDE ADMINISTRATION QF ORAL MEDICATIONS A. P u r p o s e o f t h e L a b o r a t o r y A c t i v i t y To I n t r o d u c e t h e s t u d e n t t o t h e s a f e s t methods o f p r e p a r i n g , a d m i n i s t e r i n g and r e c o r d i n g m e d i c a t i o n s t h a t may be g i v e n by mouth, and t o p r o v i d e an o p p o r t u n i t y t o p r a c t i c e a d m i n i s t e r i n g o r a l m e d i c a t i o n s . B. O b j e c t i v e s Upon t h e c o m p l e t i o n o f t h i s l a b o r a t o r y a c t i v i t y , t h e s t u d e n t w i l l be a b l e t o : 1. d i s c u s s t h e n u r s i n g r e s p o n s i b i l i t i e s r e l e v a n t t o t h e s a f e a d m i n i s t r a t i o n o f o r a l m e d i c a t i o n s ( c h e c k i n g 5 R s ) . 2. d e m o n s t r a t e t h e c o r r e c t p r e p a r a t i o n o f m e d i c a t i o n s . 3. d e m o n s t r a t e t h e a d m i n i s t r a t i o n o f o r a l m e d i c a t i o n s . 4. p r o v i d e t h e n e c e s s a r y d o c u m e n t a t i o n f o r t h e a d m i n i s t r a t i o n o f a l l m e d i c a t i o n s . 5. d i s c u s s t h e c o r r e c t h a n d l i n g o f n a r c o t i c s and c o n t r o l l e d d r u g s . 6 . d i s c u s s t h e i m p o r t a n c e o f s a f e o r a l m e d i c a t i o n a d m i n i s t r a t i o n . C. P r e p a r a t i o n f o r t h e L a b o r a t o r y A c t i v i t y P r i o r t o t h e l a b o r a t o r y , t h e t e a c h e r w i l l assemble t h e f o l l o w i n g f o r each l a b o r a t o r y g r oup: - CPS/drug handbook - P h y s i c i a n ' s O r d e r S h e e t s - M e d i c a t i o n R e c o r d s - N u r s e s ' Notes - N a r c o t i c C o n t r o l Book - m e d i c a t i o n c a r d s - N a r c o t i c Wastage E n v e l o p e - M e d i c a t i o n I n c i d e n t R e p o r t Form - m e d i c a t i o n t r a y s - m e d i c a t i o n cups ( p a p e r and p l a s t i c ) - s e l e c t e d m e d i c a t i o n s ( l a b e l e d as I n d e r o l , D i g o x i n , M e t a m u c i l , Amp1c1ll1n S u s p e n s i o n , L a s i x , P r e d n i s o n e , C o l a c e , KC1 L i q u i d , E n t r o p h e n , T y l e n o l #3, and Magnolax) - d r i n k i n g cups - a l l e r g y armbands - ID armbands D. P r o c e d u r e f o r t h e L a b o r a t o r y A c t i v i t y The t e a c h e r w i l l : 1. B r i e f l y d i s c u s s t h e p r i n c i p l e s r e l a t e d t o s a f e o r a l m e d i c a t i o n a d m i n i s t r a t i o n . 88 Principles a) The safe administration of medications requires a knowledge of anatomy and physiology as well as a knowledge of the drug and the reason 1t has been prescribed. - expected side effects of medications. - c l ient Indications of medication. - location of expected action of the medication. - drug research is an expectation before administration of any medication. b) The type of drug preparation often governs the method of administration. - some drugs are effective only 1f given ora l ly , eg. ty lenol . - some drugs are not effective 1f given ora l ly , eg. insul in , gentamycin. c) The route of administration of the drug affects the optimal dosage of the drug. - larger dose may be given oral ly than may be given parenterally, eg. Demerol, 50 mg. p.o. vs. Demerol 5 mg. I.V. - any changes 1n the digestive tract may affect the absorption of medication. d) The method of administration of the drug is part ia l ly determined by the age of the patient, his orientation, his degree of consciousness and health problem. - elderly may have d i f f i cu l ty swallowing p i l l s , refuse them when disoriented. - p i l l s may become trapped under dentures or on side of mouth where there is paralysis. - l iqu id preparations are available for many meds. - 1f nauseated, may need an antiemetic prior to taking oral medications. - may need certain f lu ids with some medications to reduce effects on G.I. t ract , eg. milk with aspir in . - reporting and recording are important for any problems. e) The method of administration of the drug 1s part ia l ly determined by the Indications and action of the drug. - longer duration of action via the oral route. - f lu ids or substances that accompany oral medications may Impede or enhance the absorption and effectiveness of medications. f) The time of administration of the drug 1s part ia l ly determined by the make up and action of the drug. - medications should be given when the peak effect wi l l occur when desired. 89 - many medications are maximally effective when the stomach 1s empty, others when the stomach contains food or milk. - medications should be administered when unpleasant effects of the medication occur at a time that is not a safety or rest hazard. - medications are often administered at a time convenient to the nurses not to the appropriateness of the drug. This should be reported and the times changed i f possible. g) Each patient has his own needs for explanations and support with respect to the administration of medications. - should use correct drug names not category names. - explanations should be individualized to the c l i e n t ' s age, education, i l lness and emotional needs. - explanations should be in simple terms, using correct medical terminology. h) The element of error is a possib i l i ty 1n a l l human act iv i ty . To help reduce the element of error there are many safety checks: - checking medication cards. - 5 r ights. - checking label three times. - identifying the c l ien t . - reporting and recording. - medication errors need to be reported Immediately to ensure c l ient comfort and safety. 2. Review VGH Pol ic ies with regard to: a) use of medication cards for prn medications. b) time restr ict ions placed on physicians' orders for narcotics and ant ib iot ics . c) administration of narcotics by student nurses. d) wastage of narcotics. e) use of Medication Incident Report Forms. 3. Review the: a) use of CPS/drug handbook. b) components of a physician's order. c) checking of a medication card. d) checking of a chart. 4. Demonstrate the preparation, administration and recording of the following medications using a mannlkin: a) Col ace 200 mg. p.o. dal ly . b) Magnolax 15 cc . p.o. BID. 90 5. Instruct each student to use a mannikln to practice preparation and administration of: a) regular medication - tablets, capsules and l iqu ids . b) stat dose. c) prn medication. d) narcotic - enter Into narcotic book. 6. Observe the students' performance and provide feedback as necessary. 7. Review the reporting and recording of: a) regular medications. b) stat medications. c) one dose dal ly . d) prn medications. e) medications refused. f) medications le f t at bedside. g) side effects of medications. Note: From Nursing 101 Lab Guide by Vancouver General Hospital School of Nursing, 1988, Vancouver, BC. Reprinted by permission. 91 Appendix E Instructors' Guide for Experimental Group Demonstrat1on-Return Demonstrat1 on Using Simulation 92 Instructors' Guide Administration of Oral Medications A. Purpose of the Laboratory Activi ty To Introduce the student to the safest methods of preparing, administering and recording medications that may be given by mouth, and to provide an opportunity to practice administering oral medications. B. Objectives Upon the completion of this laboratory act iv i ty , the student wil l be able to: 1. discuss the nursing responsibi l i t ies relevant to the safe administration of oral medications (checking 5 Rs). 2. demonstrate the correct preparation of medications. 3. demonstrate the administration of oral medications. 4. provide the necessary documentation for the administration of a l l medications. 5. discuss the correct handling of narcotics and controlled drugs. 6. discuss the Importance of safe oral medication administration. C. Preparation for the Laboratory Activity Prior to the laboratory, the teacher wi l l assemble the following for each laboratory group: - CPS/drug handbook - Physician's Order Sheets - Medication Records - Nurses' Notes - Narcotic Control Book - medication cards - Narcotic Wastage Envelope - Medication Incident Report Form - medication trays - medication cups (paper and plastic) - simulated medications (Tic Tacs and cranberry juice) - drinking cups - printed situations (10 envelopes containing situations for the nurse, and 10 envelopes containing patient responses). - allergy armbands - I.D. armbands D. Procedure for the Laboratory Activity The teacher w i l l : 1. Br ief ly discuss the principles related to safe oral medication administration. 93 Principles a) The safe administration of medications requires a knowledge of anatomy and physiology as well as a knowledge of the drug and the reason i t has been prescribed. - expected side effects of medications. - c l ient Indications of medication. - location of expected action of the medication. - drug research 1s an expectation before administration of any medication. b) The type of drug preparation often governs the method of administration. - some drugs are effective only 1f given ora l ly , eg. ty lenol . - some drugs are not effective 1f given ora l ly , eg. insul in , gentamydn. c) The route of administration of the drug affects the optimal dosage of the drug. - larger dose may be given oral ly than may be given parenterally, eg. Demerol, 50 mg. p.o. vs. Demerol 5 mg. I.V. - any changes 1n the digestive tract may affect the absorption of medication. d) The method of administration of the drug 1s part ia l ly determined by the age of the patient, his orientation, his degree of consciousness and health problem. - elderly may have d i f f i cu l ty swallowing p i l l s , refuse them when disoriented. - p i l l s may become trapped under dentures or on side of mouth where there 1s paralysis. - l iquid preparations are available for many meds. - 1f nauseated, may need an antiemetic prior to taking oral medications. - may need certain f lu ids with some medications to reduce effects on G.I. t ract , eg. milk with aspi r in . - reporting and recording are Important for any problems. e) The method of administration of the drug 1s part ia l ly determined by the Indications and action of the drug. - longer duration of action via the oral route. - f lu ids or substances that accompany oral medications may Impede or enhance the absorption and effectiveness of medications. f) The time of administration of the drug is part ia l ly determined by the make up and action of the drug. - medications should be given when the peak effect wil l occur when desired. 94 - many medications are maximally effective when the stomach 1s empty, others when the stomach contains food or milk. - medications should be administered when unpleasant effects of the medication occur at a time that 1s not a safety or rest hazard. - medications are often administered at a time convenient to the nurses not to the appropriateness of the drug. This should be reported and the times changed 1f possible. g) Each patient has his own needs for explanations and support with respect to the administration of medications. - should use correct drug names not category names. - explanations should be individualized to the c l i e n t ' s age, education, Il lness and emotional needs. - explanations should be in simple terms, using correct medical terminology. h) The element of error is a possib i l i ty 1n a l l human act iv i ty . To help reduce the element of error there are many safety checks: - checking medication cards. - 5 r ights. - checking label three times. - Identifying the c l ien t . - reporting and recording. - medication errors need to be reported Immediately to ensure c l ient comfort and safety. 2. Review VGH Pol ic ies with regard to: a) use of medication cards for prn medications. b) time restr ict ions placed on physicians' orders for narcotics and ant ib iot ics . c) administration of narcotics by student nurses. d) wastage of narcotics. e) use of Medication Incident Report Forms. 3. Review the: a) use of CPS/drug handbook. b) components of a physician's order. c) checking of a medication card. d) checking of a chart. 4. Demonstrate the preparation, administration and recording of the following medications using a mannlkin: a) Colace 200 mg. p.o. dai ly . b) Magnolax 15 cc. p.o. BID. 95 5. Provide directions for the performance of simulated situations. a) Each student wil l perform f ive situations with a classmate role-playing the patient. b) The students wi l l proceed through the ten situations taking turns preparing, administering and recording oral medications. c) Each pair of students wil l perform the same situations concurrently. d) The student administering the medications wil l receive written Information concerning patient data and the patient s i tuat ion, and completed medications cards. e) The student role-playing the patient wi l l receive written Information concerning patient data and the patient response, and I.D. and allergy armbands. f) Students wil l use prepared "drug cards" for administering medications. g) Medication administration times are based on established VGH pol ic ies . 6. Observe student performances and provide feedback as necessary. 7. Discuss each situation with a l l the students col lect ively before they proceed to another s i tuat ion. Appendix F Situations Demonstration - Return Demonstratl Using Simulation 97 Situations In order to f ac i l i t a te nursing student learning of oral medication administration, ten situations have been designed for use within each laboratory group. Following a demonstration of the administration of an oral medication by the nurse educator, each student wi l l perform f ive situations with a classmate role-playing the patient. The students wi l l proceed through the ten situations taking turns administering medications. Each pair of students wi l l perform the same situations concurrently. The student administering the medication wi l l receive written Information concerning patient data and the selected nursing si tuat ion, while the student role-playing the patient wi l l receive written Information concerning patient data and the selected patient response. During the student performances, the nurse educator wi l l observe the performances and provide feedback as necessary. Upon completion of each role-played si tuat ion, the nurse educator and al l participants wil l col lect ive ly discuss the situation before proceeding to the next s i tuat ion. Discussion wi l l Include analysis of what occurred, Identif ication of feelings generated and Insights gained, and exploration of why things happened as they did and how the situation is related to rea l i ty . 98 Situation Mrs. Ann Chase (Unit #34-16-10) is a 83 year old woman who has been admitted to the hospital for Investigation and treatment of right-sided weakness, lung infect ion, and a r th r i t i s . On admission, the medication orders are as follows: May 13/88 Inderal 20 mg. o.d. Dlgoxin 0.125 mg. p.o. dally MetamucH 15 ml. p.o. B.I.D. Amp1c1ll1n Suspension 500 mg. p.o. q6h Lasix 20 mg. p.o. B.I.D. Prednisone 5 mg. p.o. Q.I.D. Colace 200 mg. p.o. dally KC1 Liquid 10 ml. p.o. T. I .D. Entrophen 325 mg. p.o. T. I .D. Tylenol c Codeine gr. 1/2 p.o. q4-q6h p. r .n . Magnolax 15 cc. p.o. B.I.D. Situation #1 (#1 to #10: Student Demonstrations) It 1s 0845 hours and 1t 1s your responsibil i ty to prepare and administer Mrs. Chase's Dlgoxin and KC1 that are due at 0900 hours. The Dlgoxin is only available in 0.25 mg. tablets. Administer these medications. Patient Response: "What 1s th is for?" "Can you help me take the medicine as I can't hold anything since my right hand became weak?" Situation #2 It 1s May 16th, 0845 hours and Mrs. Chase 1s due to receive her Entrophen and Inderal at 0900 hours. Administer these medications. Patient Response: "This must be a new drug, I don't recognize i t . " Situation #3 It 1s 0745 hours and Mrs. Chase is due to receive her MetamucH and Lasix at 0800 hours. Administer these medications. Patient Response: "Can you please leave the MetamucH here so I can take 1t with the orange juice that comes with my breakfast?" 99 Situation U  Part I It 1s May 13th, 1130 hours and the physician has just ordered Amp1c1"N1n. Identify the appropriate time that this medication wi l l be given. Administer the medication. Patient Response: "I hope this Isn't Pen ic i l l in as I think I'm a l lerg ic to Pen ic i l l in even though I don't have an allergy bracelet." Part II It 1s 0845 hours and Mrs. Chase 1s due to receive her Digoxln at 0900 hours. She has also requested Tylenol for pain. Administer these medications. Situation #5 Part I It 1s May 14th, 0700 hours and the physician has just ordered Lasix 20 mg. p.o. stat . Identify the appropriate time that th is medication wil l be given. Administer the medication. Patient Response: "What 1s this for?" "I'm afraid I wi l l wet the bed because I need help walking to the bathroom." "My other doctor warned me that taking water p i l l s would be very dangerous for my heart." Part I I It 1s 1245 hours and Mrs. Chase 1s due to receive her KC1 and Entrophen at 1300 hours. Administer these medications. Situation m It 1s 0845 hours and Mrs. Chase 1s due to receive her Prednisone and Inderal at 0900 hours. Administer these medications. Patient Response: "I can't drink milk products but I Hke orange j u i c e . " "At home I always take th is p i l l with my meals." 100 Situation #7 It 1s 0845 hours and Mrs. Chase 1s due to receive her KCL and Inderal at 0900 hours. Administer these medications. Patient Response: "This l iquid tastes awful, I can't f in ish taking this medication." "Can't you add some water to th is?" Situation #8 It 1s 0845 hours and Mrs. Chase 1s due to receive her Entrophen and Prednisone at 0900 hours. Administer these medications. Patient Response: "I can't take these p i l l s now because I always take them with my meals at home." "Also, you are going to have to crush these p i l l s as I have d i f f i cu l ty swallowing." S i t u a t i o n #9 It is 0745 hours and Mrs. Chase 1s due to receive her Col ace. She requests Tylenol for pain. Administer these medications. Patient Response: "I'm sorry, nurse, but I dropped my p i l l s on the f loor . " "I hope my doctor remembered that I'm a l lerg ic to Aspi r in . " Situation #10 It 1s 2145 hours and Mrs. Chase 1s due to receive her Magnolax and Prednisone at 2200 hours. Administer these medications. Patient Response: "Did you cal l me Ann, my f i r s t name Isn't Ann, 1t is Joan, besides, I'm not taking this Magnolax, I don't need a laxat ive." 101 Appendix G Cognitive Learning Pretest - Posttest 102 Cognitive Pretest-Postest Test of Safe Oral Medication Administration Group: Part I: Knowledge (10 points) Score: Directions: Please c i r c l e the correct response. 1. Enteric coating on tablets serves to 1. delay the action of the drug. 2. prevent deterioration of the drug. 3. prevent I rr i tat ion of the gastric mucosa. 4. protect the drug from gastric secretions. A. 1, 2 and 3. B. 1, 2 and 4. C. 1, 3 and 4. D. 2, 3 and 4. 2. The absorption of Ingested drugs occurs primarily 1n the A. caecum. B. colon. C. small Intestine. D. stomach. 3. The dosage of a drug given oral ly Is usually more than the same drug given parenterally because absorption A. 1s enhanced by gastric a d d . B. 1s less complete. C. 1s limited to the general c i rcula t ion. D. occurs over a shorter duration. 4. The overall goal of the nurse 1n gathering data and assessing the patient before Init iat ion of the planned drug therapy 1s to A. establish friendly rapport with the patient. B. evaluate the patient's compliance with drug therapy. C. prevent secondary or unintended effects of the drugs. D. promote understanding of the drug regimen. 103 5. Safe, therapeutically effective drug administration 1s a major responsibil i ty of nurses. If a nurse believes a drug dose to be erroneous, she should f i r s t A. check with the physician to see 1f there 1s a reason for the unusual dose. B. give the medication as ordered by the physician. C. refuse to give the medication under any circumstances. D. t e l l the pharmacy there is a medication error. 6. The physician orders Demerol 50 mg I.M. stat. The nurse correctly administers th is drug 1f she gives 1t A. according to hospital schedule. B. as necessary. C. Immediately. D. once a day. 7. Which of the following physician orders would you accept as being complete? 1. Colace 100 mg. p.o. p . r .n . 2. Gravol 50 mg. p.o. dally ac breakfast 3. Hydrod1ur1l 25 mg. p.o. dally 4. Metamudl 2 ml. h.s. A. 1, 2 and 3. B. 1, 2 and 4. C. 2 and 3. D. 3 and 4. 8. What 1s the most re l iable method for the nurse to use 1n Identifying a patient before giving medications? A. Ask the patient's name. B. Check the patient's bed label . C. Check the patient's wrist band. D. Rely on memory. 9. Which nursing action would violate the f ive patient rights for safe drug administration? A. Administering a medication that was prepared by another nurse. B. Administering a 9:00 scheduled medication at 9:30. C. Double-checking dosage calculations for medications. D. Reading the medication label three times when preparing the medication. 104 1 0 . W h i c h n u r s i n g a c t i o n w o u l d f a c i l i t a t e t h e management o f c o n t r o l l e d s u b s t a n c e s 1n t h e h o s p i t a l ? A . C o u n t i n g d o s a g e s o f e a c h c o n t r o l l e d s u b s t a n c e a t random t i m e s . B . K e e p i n g a l l d o s e s o f c o n t r o l l e d s u b s t a n c e s I n a l o c k e d c a b i n e t . C . L o o k i n g up i n f o r m a t i o n a b o u t u n f a m i l i a r c o n t r o l l e d s u b s t a n c e s . D. R e c o r d i n g c o n t r o l l e d s u b s t a n c e s I m m e d i a t e l y a f t e r a d m 1 n 1 s t a t 1 o n . Part I I ; D e c i s i o n - M a k i n g ( 1 0 p o i n t s ) S c o r e : C a s e S t u d y M r . J o h n C h a s e ( U n i t # 4 0 - 2 0 - 2 3 ) i s a 80 y e a r o l d man who h a s b e e n a d m i t t e d t o t h e h o s p i t a l f o r i n v e s t i g a t i o n o f a b d o m i n a l p a i n a n d h y p e r t e n s i o n . On a d m i s s i o n h i s s e r u m p o t a s s i u m was 3 . 2 m E q . / L . D u r i n g t h e t h r e e d a y s f o l l o w i n g a d m i s s i o n , h i s B . P . h a s r a n g e d f r o m 1 1 0 / 8 5 - 1 7 0 / 1 0 0 a n d h i s A p e x h a s r a n g e d f r o m 5 6 - 9 2 . T h e p h y s i c i a n ' s o r d e r s a r e a s f o l l o w s : J u n e 2 / 8 8 D i g o x i n 0 . 2 5 mg. d a l l y M 1 n 1 p r e s s 5 'mg. p . o . T . I . D . T y l e n o l #3 t a b s . 1-11 p . o . Q4H p . r . n . F e r r o u s G l u c o n a t e 3 0 0 m g . p . o . T . I . D . H y d r o d l u r i l 50 m g . p . o . d a l l y P e n i c i l l i n 5 0 0 mg. p . o . Q . I . D . D r . B r o w n , M . D . J u n e 4 / 8 8 T y l e n o l #3 t a b s , i i p . o . Q 3 - 4 H p . r . n . D r . B r o w n , M . D . D i r e c t i o n s : T h e f o l l o w i n g s t a t e m e n t s r e f e r t o t h e d a t a i n t h e c a s e s t u d y a b o v e . R e a d e a c h s t a t e m e n t a n d c i r c l e t h e c o r r e c t r e s p o n s e . 1 1 . When p r e p a r i n g t o a d m i n i s t e r D i g o x i n t o h i m , y o u n o t e t h a t t h e o r d e r i s I n c o m p l e t e . Y o u r s h o u l d A . a d m i n i s t e r 1 t by t h e p . o . r o u t e . B . c h a r t " n o t g i v e n " . C . n o t i f y t h e p h y s i c i a n . D. u s e t h e r o u t e t h a t was p r e v i o u s l y u s e d . 105 12. Prior to the administration of Mlnipress (antihypertensive), you assess his B.P. to be 100/75. You should A. administer the medication and chart the B.P. on the Nurses' Notes. B. administer the medication as ordered. C. discard the medication and chart "not given". D. withhold the medication and notify the physician. 13. When checking Mr. Chase's I.D. band prior to medication administration, you discover that the unit number on his I.D. band 1s different from the number on the medication card. You should A. have another staf f member Identify the patient. B. notify the physician for ver i f icat ion of the order. C. recheck the patient's name, then administer the medication. D. withhold the medication until the number has been ver i f i ed . 14. When administering Ferrous Gluconate, you should provide A. carbonated drinks. B. milk or food. C. orange ju ice . D. water. 15. On administration of the 1000 hr. medications, Mr. Chase states that he 1s nauseated. You should A. administer one medication at a time at 10-mlnute intervals. B. administer the medications with small sips of water. C. withhold the medications and chart "refused". D. withhold the medication for 1/2 hour, then attempt readmlnlstratlon. 16. On June 5/88, you prepare to administer Tylenol #3 to Mr. Chase. You should give A. one tablet Q3-4H p . r .n . B. one tablet Q.4H p . r .n . C. two tablets Q3-4H p . r .n . D. two tablets Q4H. 106 17. When preparing to administer Tylenol #3, you should A. add 1t to the medication cup containing Dlgoxin. B. check the Medication Record. C. check the Nurses' Notes. D. sign the narcotic book after 1t 1s given. 18. When administering Mr. Chase's medications, you find he 1s fasting for X-rays. You should A. discard the medication, 1n accordance with agency pol icy. B. leave the medication at the bedside so he can take 1t la ter . C. leave the medication and medication card at the nursing station until he returns to the unit. D. return the medication to the bottle stock. 19. Prior to administering Hydrod1ur1l (diuret ic) , you note that Mr. Chase's serum potassium is 3.2 mEq./L. As a result , you should A. administer the medication and put a notice to the physician on the chart. B. administer the medication with orange ju ice . C. withhold the medication and chart "not given". D. withhold the medication and notify the physician. 20. When you arrive at Mr. Chase's bedside to administer his P e n i c i l l i n , he states that he has some "red, Itchy spots" on his chest. You should A. administer an antihistamine Immediately. B. apply Calamine lotion to the rash. C. continue to administer the Pen ic i l l in as ordered. D. withhold the Pen ic i l l in unti l the physician 1s not i f ied. 107 Appendix H Oral Medication Administration Checklist 108 Oral Medication Administration Checklist Group: Beginning Time: Ending Time: Student Nurse Number: Key: Satisfactory = 1 Unsatisfactory = 0 Student Behavior Preparation * 1. Select the correct medication card(s) for the medication to be given at the designated time. * 2. Compare the medication card(s) with the physician's order(s) on the chart (Including the 5 r ights) . * 3. Compare the medication card(s) with the Medication Record for evidence of previous dose. * 4. Check the patient's chart for evidence of medication a l le rg ies . 5. Wash hands. 6. Assemble a l l necessary materials Including correct f lu id or food to accompany the medlcation(s) as needed. * 7. Select the correct medicatlon(s). * 8. Compare the medication card(s) with the label on the medication contalner(s) before removing the container(s) from the shelf or drawer. * 9. Make correct dosage calculation i f necessary. * 10. Compare the medication card(s) with the label on the contalner(s) before pouring the medlcatlon(s) into the cup. * 11. Compare the label on the medication contalner(s) with the medication card(s) after pouring the medlcatlon(s) Into the cup and just prior to returning the container(s) to the shel f . >) s-o -l-> ra (/) +-> re oo o +-> o « 1/1 E Comments o o u Student Behavior ro Comments Preparation * 12. Transfer the medication card(s) to the tray simultaneously with the poured medication. Administration 13. Place the medication tray on a clean, dry surface at the bedside. * 14. Identify the patient by comparing the medication card(s) with the patient's I.D. band (Including both name and Unit number). * 15. Check for presence of allergy band. 16. Provide accurate Information to patient concerning both the nature and administration of the medlcatlon(s). 17. Position the patient correct ly. * 18. Give the medlcatlon(s) to the patient within 1/2 hour of the' designated time. * 19. Remain with the patient until the medication(s) 1s/are swallowed. * 20. Chart the medlcatlon(s) Immediately after administration on the Medication Record and replace the medication card(s) 1n the appropriate time s lo t . *Cr i t i ca l Behavior Score Total Student Behavior Score Grand Total *Cr i t i ca l Behavior Score = 15 Grand Total Student Behavior Score = 20 110 Appendix I Feeling of Satisfaction Questionnaire Feeling of Satisfaction Questionnaire Please c i r c l e the number to the right of each statement which best represents your response to that statement. The meaning of the numbers i s : 1 = 1 strongly disagree 2 = 1 disagree 3 = 1 agree 4 = 1 strongly agree Statement Response 1. The practice session was relevant to 1 2 3 c l in ica l practice. 2. The practice session provided opportunities 1 2 3 for application of new knowledge about oral medication administration. 3. The practice session was useful 1n preparing 1 2 3 me for administering oral medications 1n the c l in ica l area. 4. The practice session was enjoyable. 1 2 3 Score: Group: Additional Comments: Appendix J Student Data Student Data Please complete the following questions by f i l l i n g 1n the correct box. Age 17 - 20 • 2 1 - 2 5 • 26 - 29 • 3 0 - 3 9 • Education prior to enrolment 1n the VGH Nursing program: Completed Grade 12 \~] Post-secondary vocational training | | Attended university Q Completed university | | Occupation prior to enrolment 1n the VGH Nursing program: Student • Practical Nurse Q Nurse Aide Q Other • Appendix K Information for Director Information for Director 115 Dear Director: In order to complete a Master's Degree Program 1n Nursing at the University of Br i t ish Columbia I have selected to do a thesis . My research 1s 1n the area of Instructional techniques and their effect on nursing student learning of oral medication administration. I would Hke to conduct an experimental study Involving one class of f i r s t level students and their c l in ica l teachers. I propose to have each of the f ive teachers work with both a control and an experimental group. The selected Instructional techniques for teaching oral medication administration are demonstration-return demonstration and demonstration-return demonstration using simulation. The study wi l l take place during the regularly scheduled oral medication administration laboratory ac t iv i t ies and the students' f i r s t administration of oral medications in the c l in ica l area. The amount of teacher time Involved would be approximately three hours 1n addition to her regularly scheduled laboratory ac t iv i t ies and c l in ica l hours. During the three-hour period, orientation to the Instructional techniques and performance checklist would occur. I propose to have students complete a pretest and posttest related to safe oral medication administration, feeling of sat isfact ion questionnaire, and student data questionnaire during the oral medication administration laboratory ac t iv i ty . Their participation 1s entirely voluntary. Non-volunteers wi l l be assigned to the group being 116 taught by the tradit ional technique of demonstration-return demonstration. To explain the study and obtain consent, I would l ike to have approximately one half hour to address the entire class of students. I look forward to hearing from you and working with you. Sincerely, Appendix L Information for Co-ord1nator/Nurse Educators 118 Information for Co-ord1nator/Nurse Educators Dear Colleagues: In order to complete a Master's Degree Program 1n Nursing at the University of Br i t ish Columbia I have elected to do a thesis . My research Is 1n the area of Instructional techniques and their effect on nursing student learning of oral medication administration. I would l ike to conduct an experimental study which would involve both yourself and your two groups of students. Your involvement would entail using different Instructional techniques for A and B groups of students when teaching oral medication administration. In addition, you would be required to complete a performance checklist that 1s an accepted evaluation tool for a l l f i rs t -year nursing students during their f i r s t administration of an oral medicatlon(s). To ensure anonymity of students, you would be required to assign each student a number for placement on the checklist that wi l l be known only to yourself and the student. The f i r s t oral medication laboratory act ivi ty which Involves Group A, wi l l be taught using the established technique of demonstration-return demonstration. Group A, then, wil l constitute the control group. Subsequently, Group B which constitutes the experimental group, wil l be taught by the Instructional technique of demonstration-return demonstration using simulation. The Instructions and situations for th is experimental act iv i ty wi l l be prepared by the investigator. Orientation to the "simulated act iv i ty" and checklist wi l l probably take approximately three hours. Your participation 1n the study 1s entirely voluntary and wi l l 1n no way ref lect on your employment status. If at any time during the study you wish to withdraw, your actions are acceptable. Students wil l be asked to complete a pretest and posttest related to safe oral medication administration, feeling of sat isfact ion toward the learning experience questionnaire, and student data questionnaire. These tests and questionnaires wi l l be identif ied according to the students' group, and wil l be shredded once data 1s analyzed. Grouped findings of the study wi l l be shared with the faculty of this School of Nursing and with the members of the participating class of students. Implementation of the planned act iv i t ies with your students wi l l constitute consent to participate in the study. Thank you for your cooperation. I look forward to working with you. Sincerely, Appendix M Information for Students 121 Information for Students My name 1s V1 Ett les and I am a graduate student 1n the Master's Degree Program 1n Nursing at the University of Br i t ish Columbia. I am conducting a study concerning approaches to nursing student learning of oral medication administration. Findings of the study wil l be of benefit to both faculty and students in enhancing learning. The study has been approved by both the University of Br i t ish Columbia Behavioural Sciences Screening Committee and the ethical review committee of this agency. In addition, the Director of the School of Nursing has approved this study. Your participation in th is study is entirely voluntary. Your participation or nonpartldpatlon 1n this project wi l l not affect your class standing in any way. Alternate established ac t iv i t ies wi l l be available to those students who do not choose to part icipate. For the purpose of the study you wil l be randomly assigned to one of two laboratory groups. Participation involves completion of a pretest and posttest related to safe oral medication administration, feeling of sat isfact ion toward the learning experience questionnaire, and student data questionnaire. Completion of these tests and questionnaires wi l l require approximately 30 minutes of normally scheduled class time. Addit ionally, you wi l l be observed during your f i r s t administration of an oral medlcation(s) by the teacher using a performance checklist that 1s an accepted evaluation tool for a l l f i rs t -year nursing students. Your name wil l not be placed on any tests , questionnaires, study findings and reports. Although tests and questionnaires wil l be 122 shredded once data 1s analyzed, the performance checklist results wi l l be used by the teacher for c l in ica l evaluation purposes since the checklist 1s an acceptable tool for evaluating f i rs t -year students. To ensure that your Identity wi l l not be known to the Investigator, a number wi l l be placed on the checklist that wil l be known only to the teacher and yourself. Further, you may withdraw at any time from the study without prejudicing your education or class standing. Grouped findings of the study may be shared with the faculty of this School of Nursing and with the members of the participating class of students. Addit ionally, the study findings wil l be written up in a thesis and other research a r t i c les . Thank you for your assistance. Appendix N Written Consent Appendix 0 Item Analysis for the Cognitive Learning Pretest-Posttest 126 Item Analysis for the Cognitive Learning Pretest-Posttest Pretest Posttest Item Discrimination Difficulty Discrimination Difficulty Upper Lower Factor Upper Lower Factor 1 15 6 0.6 12 9 0.6 2 17 13 0.8 17 12 0.8 3 16 11 0.8 15 11 0.7 4 12 6 0.6 11 7 0.7 5 17 13 0.9 16 15 0.9 6 17 15 0.9 17 17 1.0 7 0 1 0.0 1 0 0.0 8 15 13 0.8 16 12 0.8 9 15 8 0.7 16 12 0.8 10 9 5 0.5 12 4 0.6 11 17 13 0.9 15 12 0.8 12 13 7 0.6 16 7 0.7 13 17 10 0.8 17 16 0.9 14 11 6 0.5 11 4 0.4 15 15 8 0.7 15 11 0.8 16 14 9 0.7 14 5 0.5 17 12 3 0.3 13 3 0.5 18 14 5 0.6 13 7 0.6 19 13 5 0.6 13 10 0.7 20 16 13 0.9 17 16 1.0 127 Appendix P Cognitive Learning Pretest-Posttest Scores Experimental and Control Groups 128 Cognitive Learning Pretest and Posttest Scores Experimental and Control Groups Experimental Group Pretest Score Posttest Score K D=M Q. K D-M Q. 6 7 9 7 5 12 6 7 13 7 5 12 8 8 16 6 9 15 7 6 13 8 6 14 8 8 16 5 7 12 4 7 11 7 9 16 7 7 14 7 5 12 6 9 15 8 8 16 9 6 15 6 6 12 7 2 9 7 8 15 7 7 14 7 6 13 6 5 11 8 7 15 8 9 17 6 8 14 7 9 16 7 5 12 7 8 15 8 7 15 7 7 14 5 6 11 8 7 15 9 4 13 6 6 12 6 5 11 8 9 17 7 8 15 5 4 9 7 8 15 6 9 15 8 6 14 7 9 16 7 6 13 9 7 16 8 8 16 7 7 14 7 5 12 6 4 10 7 5 12 8 9 17 8 8 16 4 9 13 7 6 13 5 5 10 8 6 14 6 6 12 7 7 14 7 5 12 5 6 11 7 8 15 8 6 14 6 6 12 7 8 15 Control Group PretOSt Score Posttest Score & D-M Q. K D-M Ii 5 4 9 6 5 11 7 6 13 8 7 15 9 7 16 7 6 13 7 7 14 9 9 18 7 6 13 7 8 15 7 5 12 7 6 13 6 7 13 8 6 14 6 6 12 7 8 15 6 9 15 7 3 10 8 6 14 8 6 14 7 7 14 9 9 18 7 7 14 7 9 16 8 10 18 5 7 12 9 8 17 4 7 11 6 6 12 8 5 13 8 6 14 8 9 17 8 10 18 6 8 14 6 7 13 7 7 14 7 10 17 6 7 13 8 4 12 9 5 14 6 3 9 9 9 18 6 10 16 7 8 15 8 5 13 8 8 16 8 9 17 7 5 12 5 7 12 7 8 15 4 8 12 6 10 16 9 9 18 7 6 13 7 7 14 8 9 17 9 6 15 8 8 16 7 5 12 6 8 14 7 8 15 7 6 13 8 8 16 8 6 14 9 7 16 8 8 16 5 5 10 8 9 17 Note. K = Knowledge D-M = Dec1s1on-mak1ng 0 = Overall Appendix Q T-test Results of Comparison of Cognitive Learnl Pretest-Posttest Scores and Oral Medication Administration Checklist Behavior Scores 130 T-test Results of Comparison of Pretest and Posttest Scores Within the Groups Pretest Posttest t Degrees of 2-Ta1l Mean Score Mean Score val ue Freedom Probability Experimental Group Knowledge 6.7 7.0 -1.13 62 0.261* Decision-making 6.8 6.5 0.69 62 0.495* Overal1 13.5 13.6 -0.06 62 0.952* Control Group Knowledge 7.1 7.3 -0.69 66 0.490* Decision-making 6.9 7.2 -0.71 66 0.480* Overall 14.0 14.5 -0.92 66 0.362* *£ = >.05 T-test Results of Comparison of Pretest and Posttest Scores Between the Groups Experimental Control Subjects Subjects t Degrees of 2-Ta1l Mean Score Mean Score value Freedom Probability Pretest Knowledge 6.7 7.1 1.09 64 0.279* Dec1s1on-mak1ng 6.8 6.9 0.22 64 0.825* Overall 13.5 14.0 0.73 64 0.469* Control Group Knowledge 7.0 7.3 0.90 64 0.373* Decision-making 6.5 7.2 1.86 64 0.068* Overall 13.6 14.5 1.99 64 0.051* *p. = >.05 131 T-test Results of Comparison of Oral Medication Administration Checklist Satisfactory Behavior Scores Experimental Control Subjects Subjects t Degrees of 2-Ta1l Behaviors Mean Score Mean Score value Freedom Probability Cognitive 13.8 13.7 0.17 64 0.862* Psychomotor 3.6 3.5 0.04 64 0.968* Overall 17.3 17.3 0.04 64 0.966* Cr i t ica l 13.4 13.1 0.56 64 0.581* *p. = >.05 132 Appendix R Oral Medication Administration Checklist Scores Experimental and Control Groups 133 Oral Medication Administration Checklist Scores Experimental and Control Groups Experimental Group Control Group Total Score Total Score £ £ Q. £ E £ Q. £ 3 15 19 15 3 11 9 6 4 9 18 15 3 6 18 13 3 13 17 14 3 14 18 13 4 12 16 13 4 14 16 11 3 13 19 14 4 14 17 12 3 13 17 13 4 14 18 13 3 14 18 14 4 14 15 13 2 13 19 15 4 15 14 11 4 14 19 14 4 14 17 12 4 14 20 15 3 12 19 15 4 12 19 15 3 15 20 15 4 14 14 11 4 16 18 13 4 14 19 15 2 15 19 14 4 13 16 13 4 12 18 14 3 15 18 15 4 13 18 14 4 16 18 14 3 12 15 13 3 16 19 15 3 14 18 14 4 14 20 15 4 15 16 12 3 13 18 14 4 14 16 12 3 16 17 13 4 15 18 14 3 11 16 12 3 15 17 14 4 15 18 14 4 13 19 15 4 16 16 11 4 14 19 14 4 15 18 14 3 15 20 15 3 16 18 14 4 10 19 15 4 14 15 13 4 15 14 10 4 13 17 13 4 15 18 14 4 15 16 12 3 16 18 14 4 12 13 9 3 13 17 13 4 13 16 11 4 12 18 14 4 14 16 12 3 15 19 14 4 15 16 11 4 15 18 13 4 16 19 14 4 14 17 14 Note. P = Psychomotor C = Cognitive 0 = Overall C = Cr i t ica l 134 Appendix S Oral Medication Administration Checklist Overall Satisfactory Behavior Scores: Experimental and Control Groups 135 Oral Medication Administration Checklist Overall Satisfactory Behavior Scores: Experimental and Control Groups Experimental Subjects Control Subjects Number of Number of Check!1st Satisfactory Satisfactory Behavior Behaviors Percent Behaviors Percent 1* 32 100.0 34 100.0 2* 29 90.6 32 94.1 3* 28 87.5 29 85.3 4* 23 71.9 18 52.9 5* 13 40.6 21 61.8 6 31 96.9 33 97.1 7* 29 90.6 33 97.1 8* 30 93.8 30 88.2 9* 32 100.0 34 100.0 10* 29 90.6 32 97.1 11* 30 93.8 32 94.1 12* 30 93.8 32 94.1 13 29 90.6 32 94.1 14* 24 75.0 26 76.5 15* 21 65.6 29 85.3 16 21 65.6 26 76.5 17 32 100.0 32 94.1 18* 32 100.0 34 100.0 19* 32 100.0 34 100.0 20* 31 96.9 31 91.2 Note * = Designated c r i t i c a l behavior. 136 Appendix T Feeling of Satisfaction Questionnaire Responses Experimental and Control Groups Feeling of Satisfaction Questionnaire Responses Experimental and Control Groups Statements 1 2 3 4 Experimental Group Responses 1 2 3_ A 2 0 7 25 2 0 8 24 2 0 6 26 2 0 15 16 Control Group Responses 1 2 1 A 2 0 10 20 2 0 10 20 0 1 8 23 1 0 12 19 Note. The values represent the total number of subjects selecting the response. 

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