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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  in THE FACULTY OF GRADUATE STUDIES School o f Nursing  We a c c e p t t h i s t h e s i s a s c o n f o r m i n g to the required standard  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  degree freely  at  the  available  copying  of  department publication  this  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his thesis  and  scholarly  or for  her  of  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  I  I further  purposes  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  permission.  Department  study.  of  be  It not  that  the  be  Library  an  advanced  shall  permission for  granted  is  for  by  understood allowed  the  make  extensive  head  that  without  it  of  copying my  my or  written  11 Abstract This experimental  study was designed to examine the e f f e c t s of two  selected instructional techniques on nursing student learning of oral medication administration.  The research questions asked in t h i s study  concerned the e f f e c t s of these selected Instructional  techniques on  cognitive learning, performance, and feeling of s a t i s f a c t i o n toward the learning experience. The study was conducted 1n a three-year diploma nursing program associated with a large metropolitan h o s p i t a l .  A t o t a l of 66  f i r s t - y e a r students participated 1n the study.  There were 32 students  1n the experimental  group and 34 students 1n the control group.  A l l subjects were taught relevant content, prepared "drug cards", and completed a cognitive learning pretest p r i o r 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 s a t i s f a c t i o n questionnaire, and a personal data questionnaire.  A d d i t i o n a l l y , they  were evaluated through the use of a performance c h e c k l i s t during t h e i r f i r s t administration of a medlcatlon(s) to a patient. Data obtained from the cognitive learning t e s t s and performance c h e c k l i s t were analyzed using Independent t - t e s t s ,  and data obtained  from the f e e l i n g of s a t i s f a c t i o n questionnaire were analyzed using the chl-square t e s t .  Study findings showed that the two groups were  s i m i l a r when compared on selected personal c h a r a c t e r i s t i c s .  111 Differences between the groups for cognitive learning, performance, and f e e l i n g of s a t i s f a c t i o n toward the learning experience were revealed not to be s i g n i f i c a n t at the established level of D. = .05.  This  finding suggests that demonstration-return demonstration using simulation i s a v i a b l e alternate technique for teaching oral medication administration.  1v  Table of Contents Page Abstract  11  L i s t of Tables  ix  L i s t of Figures  x  Acknowledgements Chapter One:  x1  Introduction  .  1  Background to the Problem Statement of the Problem  1 ;  3  Purpose of the Study Conceptual Framework  3 .  3  Research Questions  .  8  D e f i n i t i o n of Terms .  10  Assumption  11  Limitations  11  Overview of the Remainder of the Study  11  Chapter Two:  Review of the Literature  .  Introduction  13 13  Learning the Nursing A c t i v i t y of Oral Medication Administration  . . . .  13  Instructional Techniques for Teaching Oral Medication Administration  ,.  17  Demonstration-Return Demonstration  17  Simulation  19  Feeling of S a t i s f a c t i o n Toward the Learning Experience  23  V  Page Transfer of Learning from the Laboratory to C l i n i c a l Practice . .  27  Summary  29  Chapter Three:  Methodology  31  Introduction  31 .  Design  31  Sample  . .  Setting  32 32  Procedure for Implementation of the Study  . . . . .  Common Experiences 1n the Classroom and Laboratory Setting Laboratory Practice Session  32  . .  .  34 35  Clinical Activity  36  Preparation of the Nurse Educators  36  Instruments  37  Cognitive Measure  37  Oral Medication Administration Checklist  38  Feeling of S a t i s f a c t i o n Questionnaire .  40  Student Data Questionnaire  40  Ethics and Human Rights  .  40  Data Analysis  .  41  Summary Chapter Four:  41 Presentation and Discussion of the Findings  . . . .  43  Introduction  43  Description of the Subjects  43  Age Educational Background  43 . . . .  44  v1 Page Cognitive Learning  . . . .  Cognitive Learning:  Experimental Group  Cognitive Learning:  Control Group  . .  45 46  . . . . .  Comparison of Cognitive Learning Between the Groups  48  Oral Medication Administration Comparison of Performance Involving Cognitive Learning Comparison of Performance Involving Psychomotor Learning  46  51 . . . .  53  . . .  53  Comparison of Overall Performance  55  Additional Findings  55  Feeling of S a t i s f a c t i o n  57  Statement 1  57  Statement 2  58  Statement 3  58  Statement 4  60  Discussion of Findings Effects of the Selected  60 Instructional  Techniques on Cognitive Learning Effects of the Selected  Instructional  Techniques on Performance Effects of the Selected  64 Instructional  Techniques on Feelings of S a t i s f a c t i o n Summary Chapter F i v e : Implications, Summary  60  66 67  Summary, Conclusions, and Recommendations  69 69  v11 Page Conclusions  71  I m p l i c a t i o n s o f t h e Study  72  References  73  Appendices  79  A:  Lecture Objectives  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 Guide f o r A d m i n i s t r a t i o n of Oral Medication  D:  I n s t r u c t o r ' s Guide f o r Control Group: Demonstration-Return  E:  Demonstration  86  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: Demonstration-Return  F:  83  Demonstration Using Simulation  Situations:  Demonstration-Return  Demonstration  Using Simulation  91  96  G:  Cognitive Learning Pretest-Posttest  101  H:  Oral Medication Administration C h e c k l i s t  107  I:  F e e l i n g of S a t i s f a c t i o n Questionnaire  110  J:  S t u d e n t Data  112  K:  Information f o r Director  L:  Information f o r Co-ord1nator/Nurse  M:  Information f o r Students  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  . . .  Learning Pretest-Posttest  114 Educators  117  125  v111  Page P:  Cognitive Learning Pretest-Posttest Scores: Experimental and Control Groups  Q:  127  T - t e s t Results of Comparison of Cognitive Learning Pretest-Posttest Scores and Oral Medication Administrative Checklist Behavior Scores  R:  Oral Medication Administration Checklist Scores: Experimental and Control Groups  S:  129  132  Oral Medication Administration Checklist Overall Satisfactory Behavior Scores: Experimental and Control Groups  T:  134  Feeling of S a t i s f a c t i o n Questionnaire Responses: Experimental and Control Groups  136  1x L i s t of Tables Table  Page  1  Implementation of the Study  33  2  Description of the Subjects by Age  44  3  Education P r i o r to Enrolment 1n the Nursing Program  44  4  Comparison of Cognitive Learning Pretest and Posttest Scores:  5  and Control Subjects  and Control Subjects  Experimental  and Control Subjects  50  . .  52  54  Comparison of Group Responses to Statement 1 Concerning Relevance of the Practice Session  10  49  Comparison of Oral Medication Administration Checklist Behaviors:  9  Control Subjects  Comparison of Cognitive Learning Posttest Scores: Experimental  8  47  Comparison of Cognitive Learning Pretest Scores: Experimental  7  Subjects  Comparison of Cognitive Learning Pretest and Posttest Scores:  6  Experimental  59  Comparison of Group Responses to Statement 2 Concerning Opportunities Provided by the Practice Session for Application of New Knowledge  11  Comparison of Group Responses to Statement 3 Concerning Usefulness of the Practice Session  12  59  61  Comparison of Group Responses to Statement 4 Concerning Enjoyment of the Practice Session  61  X  L i s t of Figures Figure 1  Page Relationship between Meaning, Feeling and Concepts and the Learning Experience  2  6  Use of Demonstration-Return Demonstration Using Simulation and Demonstration-Return  Demonstration  for Teaching Oral Medication Administration  9  x1  Acknowledgements I would H k e to express my appreciation to a number of people without whose help t h i s study would not have been possible.  I extend my thanks  to the members of my thesis committee, Ethel Warbinek (Chairperson) and Anne Wyness, for t h e i r patience and guidance throughout the study. Appreciation 1s also extended to the faculty of the nursing school for t h e i r cooperation and support of my research project.  In  particular,  I would H k e to thank the d i r e c t o r of the school for f a c i l i t a t i n g  access  to the study sample. A special thanks 1s extended to the students who volunteered to participate.  Their cooperation 1n completing the t e s t s and  questionnaires was essential to the outcome of the study. F i n a l l y , I am Indebted to my family, Ron, Scott and L e s l i e , for t h e i r endless support and encouragement.  1 Chapter One Introduction  Background to the Problem Teaching for c l i n i c a 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 s i t u a t i o n s .  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 a c t i v i t y 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 i v e doses of medication given to hospitalized patients (Clavreul & Cavlness, 1983; F r a n c i s , 1980; Rosati & Nahata, 1983; Solomon et a l . , 1984).  Although the greatest number of  medication errors involve f a i l u r e to give a medication at the  right  time, other common errors relate to wrong route, dose, medication, and patient (Francis, 1980; Rosati & Nahata, 1983).  Additionally, 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 e r r o r s , others were unwilling to report an error unless a potent medication was involved.  Since the average patient receives approximately eight  2 medications during h o s p i t a l i z a t i o n , 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 r e g u l a r i t y , as are potentially serious errors detected j u s t before the drug 1s administered" (Solomon et a l . , 1984, potential  p. 170).  Consequently, t h i s  risk to patient safety strongly suggests the need for  e f f e c t i v e instruction 1n medication administration. T r a d i t i o n a l l y , nursing students have been taught medication administration by the Instructional demonstration.  technique of demonstration-return  As a r e s u l t , 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 a c t i v i t y  ( R e i l l y & Oermann, 1985).  Cognitive learning involves knowledge of concepts and p r i n c i p l e s necessary for decision-making r e l a t i v e to the performance (Bruner, 1960).  Furthermore, cognitive learning i s f a c i l i t a t e d by feelings of  s a t i s f a c t i o n 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; J e f f e r s & Chrlstensen, 1979).  Given that the  administration of medications requires competency 1n real  Hfe  s i t u a t i o n s , simulation may be an e f f e c t i v e technique for teaching t h i s nursing a c t i v i t y .  3 Statement of the Problem Research studies reveal that medication errors are a major threat to the safety of hospitalized patients (Clavreul & Cavlness, Markowltz et a l . , 1981).  Furthermore, these studies demonstrate that  graduate nurses make a s i g n i f i c a n t number of the e r r o r s . medication errors by graduates, i t Instructional  1983;  i s possible that the  Given these traditional  technique of demonstration-return demonstration f a l l s to  prepare nursing students to administer medications safely in c l i n i c a l practice.  This f a i l u r e may be due to the fact that administration of  medications by t h i s technique 1s too unlike actual patient s i t u a t i o n s . Therefore, the use of an instructional technique that more closely resembles the real H f e situation may f a c i l i t a t e 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 t h i s study was to compare two instructional techniques by which oral medication administration was taught to determine t h e i r e f f e c t on nursing student cognitive learning, psychomotor learning Inherent in performance, and feeling of s a t i s f a c t i o n toward the learning experience.  Conceptual Framework Oral medication administration requires learning in the cognitive, a f f e c t i v e and psychomotor domains ( R e i l l y & Oermann, 1985).  For the  purpose of t h i s study, however, the major f o d were on cognitive and  4 psychomotor learning. extent.  Affective learning was considered to a lesser  To further describe these learning components, Woodruff's  (1967) model of learning and instruction provides d i r e c t i o n .  Despite  the cognitive nature of t h i s model, 1t 1s found to be relevant to the performance of oral medication administration because e f f i c i e n c y 1n performance of t h i s s k i l l 1s based on decision-making behavior, than the more obvious motor and reflex behavior.  rather  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 f e e l i n g  elements of a learning experience, a f f e c t i v e learning 1s incorporated. According to Woodruff (1967), cognitive learning 1s an overall process that Involves a constant interactional formation and use of concepts.  relationship between the  Therefore, cognitive learning is both a  learning and behaving c y c l e . Concept formation 1s derived d i r e c t l y 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 i n t e r a c t i o n , and his own f e e l i n g s .  Given that these  stimuli are rendered meaningful, perception i s enhanced (Woodruff, 1967). Concept formation i s 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 mediating behavior 1n f a m i l i a r  to  situations.  Concept using Involves both decision-making and t r i a l behaviors. Decision-making involves the use of concepts to mediate a s i t u a t i o n . Although learners may decide "to reperceive, to predict outcome and value, or to I n i t i a t e 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 z a t i o n  involves acting out a  conceptually based behavior in response to decision-making.  Thus, by  providing an empirical t e s t of concepts, t h i s stage allows the learner to validate a concept and make necessary modifications as a result of verbal Interaction with the teacher.  Subsquently, important feedback  i s 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 i s necessary for concept formation, feelings toward the experience become part of the concept and give r i s e to motive formation.  Thus, a feeling of s a t i s f a c t i o n  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  Positive Value  -FEELINGLANNOYING  Concept with Negative Value  Negative Value  Figure 1.  Note.  Relationship between meaning, f e e l i n g , concepts and the learning experience.  From Cognitive Models of Learning and Instruction (p. 81) by A. D. Woodruff, 1967.  7 For f a c i l i t a t i n g perception, demonstration by an Instructor provides both concrete and verbal s t i m u l i .  S p e c i f i c a l l y , learner  perception 1s enhanced through the use of relevant materials, Informative feedback, appropriate sequencing, and emphasis of essential elements (Woodruff,  1967).  Concept formation i s f a c i l i t a t e d 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 i s strongly influenced through the use of return demonstration using simulation.  By incorporating the r o l e s , events,  and consequences of a real s i t u a t i o n or process (de Tornyay 4 Thompson), t h i s instructional technique provides the student with ample opportunity for decision-making. T r i a l behavior 1s f a c i l i t a t e d 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 r e a l i s t i c s i t u a t i o n s . 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 f e e l i n g s of s a t i s f a c t i o n . 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 a c i l i t a t e  the learning and behaving stages of perception, concept formation, and trial,  demonstration-return demonstration using simulation provides  learners with opportunity to make conscious decisions and t r i a l behaviors 1n r e a l i s t i c s i t u a t i o n s .  Further, whereas both techniques  have the potential to generate feelings of s a t i s f a c t i o n toward the learning experience, simulation should enhance p o s i t i v e learner  feeling  by providing meaningful feedback as a result of actions precipitated by decision-making.  Research Questions 1.  What are the e f f e c t s 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, v i a the  right  route? 2.  What are the e f f e c t s 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 e f f e c t s of the selected instructional techniques  on nursing student feeling of s a t i s f a c t i o n toward the learning experience?  Concept-Forming 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.  Figure 2.  Note.  Concept-Using Processes  Decision-Making: Uses concepts for making decisions that require a behavioral response. Examples: Written s i t u a t i o n s . Role played patient situations.  Trial: Acting out the behavioral response and receiving verbal input necessary for meaning and feeling feedback. Examples: Return demonstration. Return demonstration using simulation.  Feedback  Use of demonstration-return demonstration and demonstration-return demonstration using simulation for teaching oral medication administration.  Adapted from Cognitive Models of Learning and Instruction (p. by A. D. Woodruff, 1967.  63)  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, v i a the right route ( f i v e "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 r e a 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 i v e  " r i g h t s " of medication administration and application of t h i s knowledge 1n decision making (Bloom, 1956). Decision-making:  the a b i l i t y to apply knowledge to a s i t u a t i o n 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 s p e c i f i c act of oral medication  administration, in response to cognitive and psychomotor learning ( R e i l l y & Oermann, 1985). C r i t i c a 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 s a t i s f a c t i o n about  learning experiences related to oral medication administration (Bloom, 1956). Feeling of s a t i s f a c t i o n :  represents student nurse perception about  the p o s i t i v e value of the practice session of the oral medication administration laboratory a c t i v i t y  (Woodruff,  1967).  Assumption The Instructional  technique used to teach nursing students oral  medication administration 1s related to t h e i r competency 1n administering oral medications both as students and graduate nurses.  Limitations 1.  The small sample s i z e prevented generalization of the f i n d i n g s .  2.  Because the experimental and control groups were taught by the  same nurse educators, a carry-over e f f e c t 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 i n i c a 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 t e r a t u r e focuses on nursing student learning of oral medication administration and Instructional  techniques  that are used to promote feelings of s a t i s f a c t i o n toward the learning  experience and transfer of learning to c l i n i c a l p r a c t i c e .  While  Chapter Three describes the methodology used 1n t h i s study, Chapter Four 1s an analysis of the data gathered.  L a s t l y , Chapter Five  contains the summary of the f i n d i n g s , the conclusions and Implications drawn, and recommendations for further areas for  investigation.  13 Chapter Two Review of the  Literature  Introduction The l i t e r a t u r e review 1s organized according to the major elements of the study.  Oral medication administration as a nursing a c t i v i t y  will  be discussed 1n relation to the need for competence 1n c l i n i c a l practice and e f f e c t i v e domains.  Instruction  in both the cognitive and psychomotor learning  Further, the use of two selected instructional techniques for  teaching t h i s nursing a c t i v i t y w i l l be explored with regard to t h e i r e f f e c t on nursing student cognitive and psychomotor learning, and a f f e c t i v e learning as 1t relates to feeling of s a t i s f a c t i o n toward the learning experience.  F i n a l l y , the e f f e c t of these selected techniques  on transfer of learning from the laboratory to c l i n i c a l practice w i l l be explored.  Learning the Nursing A c t i v i t y of Oral Medication Administration Few c l i n i c a l nursing a c t i v i t i e s 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 p r a c t i c e , nurse educators must prepare students for the safe performance of t h i s a c t i v i t y  1n c l i n i c a l p r a c t i c e .  Thus, in teaching students safe  oral medication administration, nurse educators strongly emphasize the importance of preparing and giving the right dose of the medication, to the right patient, ( f i v e "rights")  right  at the right time, v i a the right  (Potter & Perry, 1987).  Despite t h i s emphasis on  route  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 f a i l u r e to administer an ordered dose.  Consequently, medication errors by graduate  nurses Involve both f a i l u r e to adhere to the f i v e " r i g h t s " of medication administration and errors of omission.  Further, although these errors  are reported to occur as frequently as one 1n every f i v e 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 t h i s large number of medication errors by graduate nurses  along with t h e i r lack of recognition of the e r r o r s , 1t 1s suggested that these nurses consider the f i v e " r i g h t s " of medication administration to be unimportant (Rosati & Nahata, 1983).  Thus, Instruction that promotes  valuing of the f i v e " r i g h t s " 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, a f f e c t i v e and psychomotor domains ( R e i l l y 4 Oermann, 1985).  Cognitive learning Involves the acquisition of  knowledge of the f i v e "rights" of oral medication administration and  15 application of t h i s knowledge 1n dedslon-making (Bloom, 1956). Woodruff (1967) suggests that t h i s 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 a f f e c t i v e domain  serves to make the performance of a nursing a c t i v i t y meaningful, and successful (Reilly  integrated,  & Oermann, 1985), the  administration  of oral medications i s an example of a nursing a c t i v i t y 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, i s of prime Importance for performance of this activity  (Woodruff,  1967).  According to Woodruff (1967), cognitive learning and the learning of motor movements can be f a c i l i t a t e d  related  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 a c i l i t a t e perception or the formation of a mental Impression, students must be provided with two sources of s t i m u l 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. perception, however, stimuli must be rendered meaningful  To maximize  (Woodruff,  1967). As a d i r e c t 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 t h i s v e r b a l i z a t i o n , 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 t e s t 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 s i t u a t i o n 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 i n i t i a t e an adjustive move, the prime Importance of having made a decision i s 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 f e e l i n g s . Once perceived and Incorporated Into the concept, feelings toward the experience give r i s e to motive formation.  Importantly, a f e e l i n g of  17 s a t i s f a c t i o n toward the learning experience should increase the positive value ascribed to the concept being formed and promote interest further learning (Woodruff,  in  1967).  Based on the fact that the safe administration of oral medications e n t a i l s the use of concepts for decision-making relevant to the " r i g h t s " , Woodruff's (1967) model provides direction for the of these essential concepts.  Thus, e f f e c t i v e  five  formulation  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  Instructional  behavior.  Techniques for Teaching  Oral Medication Administration A review of the nursing l i t e r a t u r e revealed an abundance of Information concerning e f f e c t i v e techniques for teaching the cognitive and psychomotor learning components of nursing a c t i v i t i e s .  However,  l i t t l e of the existing l i t e r a t u r e relates d i r e c t l y to the use of techniques for teaching oral medication administration.  A variety  of  techniques have been i d e n t i f i e d as being useful for teaching nursing a c t i v i t i e s , two common examples are demonstration-return  demonstration  and demonstration-return demonstration using simulation.  Demonstrat1on-Retu rn Demonstrat1on Demonstration-return demonstration 1s one Instructional that has been widely u t i l i z e d (Swendsen Boss, 1985).  technique  in the teaching of nursing students  One of the prime areas in which i t has proven  successful i s 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 ( R e i l l y 4 Oermann, 1985), t h i s phase should be useful for f a c i l i t a t i n g the perception stage of cognitive learning Inherent 1n s k i l l acquisition (Woodruff,  1967).  In  f a c i l i t a t i n g 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 p r i n c i p l e s prior to the demonstration ( R e i l l y & 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 c l e a r l y see the representation and hear the related explanation in order to concentrate on what 1s happening (Infante, 1985).  Further, to ensure  student concentration, R e i l l y and Oermann (1985) state that the demonstration should be carried out in a laboratory setting as 1t provides few d i s t r a c t i o n s . The return demonstration of a nursing a c t i v i t y enhances the t r i a l stage of concept using.  Since t h i s 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 t h e i r responses.  Thus, Important meaning feedback 1s furnished to the  perception stage for incorporation into the concept being formed. A d d i t i o n a l l y , by having been involved in an a c t i o n , students are able to  19 acquire f e e l i n g reactions toward the learning experience for feedback to perception.  Given that the student's reaction 1s f e e l i n g of s a t l s f c t l o n  toward the learning experience, the return performance of a nursing a c t i v i t y provides opportunity for the formation of concepts with positive value.  Consequently, the student w i 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 a c t i v i t y  (Woodruff,  Although Instruction by return demonstration f a c i l i t a t e s  1967).  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. (1980) who states that 1t 1s of v i t a l  This view i s supported by Taylor Importance that graduate nurses  beginning work are capable of making decisions while carrying out nursing p r a c t i c e .  Simulation  In recent years nurse educators have found that simulation 1s an e f f e c t i v e technique for teaching the knowledge, s k i l l , and d e c i s i o n making Inherent 1n the performance of nursing a c t i v i t i e s .  As a  r e a l i s t i c representation of the structure of a real thing or process, simulation allows students to practice nursing a c t i v i t i e s p r i o r to t h e i r c l i n i c a l experience (de Tornyay & Thompson, 1987).  Although many  20 a c t i v i t i e s 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)  facilitate  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 i s perceived for incorporation Into the concept (Woodruff,  1967).  Although t h i s meaning feedback may  be furnished by the behavioral responses entailed in the demonstration of a nursing a c t i v i t y ,  return  the opportunity for decision-making  provided by written situations serves to Increase the amount of meaning perceived.  As a result of I n i t i a t i n g 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 (Dahl, 1984).  activity  Since simulated experiences are risk f r e e , students tend  to freely discuss t h e i r mistakes as well as t h e i r successes (Corbett & Beverldge, 1982).  Given that Increased verbalization increases meaning  feedback to the perception stage, the use of written situations should facilitate  student feeling of s a t i s f a c t i o n 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 p o s i t i v e value associated with the concept that i s responsible for future learning.  The use of written situations provides opportunity to decision-making behavior.  facilitate  Based on the fact that t h i s 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 t h e i r d e c i s i o n .  Thus, in  subjecting t h e i r decision to scrutiny and v a l i d a t i o n , 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 s i t u a t i o n s for teaching nursing students decision-making in the assessment of a patient. involved in the Identification  In revealing that the students were deeply 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 i v e , with a maximum of f i v e groups p a r t i c i p a t i n g at one time 1n a simulated disaster s i t u a t i o n . evaluating the learning a c t i v i t y ,  In  Yantzie reported simulated s i t u a t i o n s  to be an e f f e c t i v e technique for teaching decision-making 1n an emergency s i t u a t i o n . 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).  Traditionally,  the  laboratory setting has been useful for offering t h i s environment for the  22 practice of nursing a c t i v i t i e s ( E l l i o t t , J U l i n g s , & Thorne, 1982). Given t h i s controlled s e t t i n g , nurse educators can Introduce a l l  the  conditions and constraints present 1n c l i n i c a 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 s e l e c t i v e l y attending to environmental events (Whiting,  1972).  Role playing, as a second example of a simulated a c t i v i t y ,  1s  commonly used to teach nursing a c t i v i t i e s (Reilly & Oermann, 1985).  As  an a c t i v i t y 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 f a c i l i t a t i n g the formation of concepts. In providing opportunity for verbal Interaction between the two students Involved 1n the a c t i v i t y  (de Tornyay & Thompson, 1987), students receive  additional meaning feedback to perception for concept formation (Woodruff,  1967).  As w e l 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 a c t i v i t y  (Swendsen-Boss, 1985).  Through  t h i s 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 t h e i r 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 i n i c a l s i t u a t i o n (Kolb & Shugart, 1984).  By providing  the student who role-plays the patient with i n s t r u c t i o n s , teachers can reproduce a variety of the complexities encountered 1n c l i n i c a l  practice  (Chaisson, 1980). Davldhizar (1977) u t i l i z e d role-played patient situations to acquaint nursing students with the possible behaviors that they would encounter with psychiatric patients in c l i n i c a l p r a c t i c e .  Evaluation of  the learning experience by means of student feedback Indicated a b i l i t y to relate theoretical  concepts to s i t u a t i o n s .  increased  Thus, these  results suggest that the t r i a l behavior was enhanced through the use of t h i s technique.  Feeling of S a t i s f a c t i o n Toward the Learning Experience As a minor focus of t h i s study, the a f f e c t i v e domain was addressed in terms of f e e l i n g of s a t i s f a c t i o n toward the learning experience. Since positive feelings toward a learning experience enhance the value ascribed to the concept being t r l a l e d and increase student motivation for further learning (Woodruff, technique should f a c i l i t a t e experience.  1967), an e f f e c t i v e  Instructional  feelings of s a t i s f a c t i o n toward the learning  Although there 1s a lack of l i t e r a t u r e d i r e c t l y related to nursing student feeling of s a t i s f a c t i o n 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 t r a d i t i o n a l  learning s t r a t e g i e s , such as d r i l l  view i s supported by several authors.  and r e c i t a t i o n .  This  In a p i l o t study, Ostmoe, Van  Hoozer, S c h e f f e l , 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 r a d i t i o n a l , teacher-directed, and highly organized.  Day and Payne (1987), in a recent experimental study that  compared the e f f e c t of computer-managed Instruction with the passive traditional  lecture method on nursing student attitude,  found computer-  managed Instruction to be less u s e f u l , less appropriate, less enjoyable, and less s a t i s f y i n g than the t r a d i t i o n a l  method of i n s t r u c t i o n .  Thus,  they reported that nursing students prefer learning strategies that are traditional  1n nature and teacher directed.  suggest that use of the t r a d i t i o n a l  The results of t h i s study  teacher directed technique of  demonstration-return demonstration should f a c i l i t a t e s a t i s f a c t i o n toward the learning experience.  feelings of  Therefore, given these  feelings of s a t i s f a c t i o n 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 1967).  (Woodruff,  Other nursing l i t e r a t u r e suggests that the use of simulated situations during the return demonstration may be more e f f e c t i v e than the return performance of the a c t i v i t y f o r f a c i l i t a t i n g of s a t i s f a c t i o n toward the learning experience.  student feelings  Hodson et a l . (1988)  described a p i l o t study 1n which written situations were used to Increase nursing student performance of basic nursing s k i l l s . subjects were 16 sophomore nursing students.  The  Written evaluation of the  learning experience found that a l l the students who completed the a c t i v i t i e s agreed or strongly agreed that the experience had been beneficial f o r learning.  S i m i l a r l y , 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 t h e i r c l i n i c a l s e t t i n g . 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.  A l l subjects were provided with written situations f o r medication administration and a simulated c l i n i c a l s e t t i n g .  Subsequently, when  asked 1f the a c t i v i t y was a useful learning experience, 123 students responded "yes" and 39 responded "no". Although written student comments revealed a s i g n i f i c a n t amount of f r u s t r a t i o n as a result of the r e a l i s t i c s i t u a t i o n s , the mostly positive results Indicate that written situations are a favorable Instructional  technique.  Role-played patient s i t u a t i o n s , as another type of simulation, are believed to be useful f o r enhancing student feelings of s a t i s f a c t i o n  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 Involvement  increased Interest 1n c l a s s , increased  1n learning, and greater a b i l i t y to relate concepts to  situations.  In revealing that students found the learning experience to  be useful and Interesting,  the results of t h i s study strongly suggest  that role-played patient situations f a c i l i t a t e  student feelings of  satisfaction. These findings were supported by L i n c o l n , 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, o v e r a l l , students' comments showed that the a c t i v i t y was useful for accomplishing learning.  By Indicating that the  students perceived the learning experience to be valuable, the results suggest student f e e l i n g of s a t i s f a c t i o n with role-played  patient  situations. Given that learning experiences involving both written situations and role-played patient situations are viewed favorably by students, the l i t e r a t u r e suggests that the use of simulated situations f e e l i n g of s a t i s f a c t i o n toward the learning experience.  facilitates Thus, the use  of these situations should result 1n the formation of concepts with p o s i t i v e value and student Interest 1n further learning 1967).  (Woodruff,  While student feelings of s a t i s f a c t i o n toward the learning  27 experience may be achieved through the use of  demonstration-return  demonstration, the use of simulated situations for instruction should increase t h i s s a t i s f a c t i o n 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 C l i n i c a l 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 f a c i l i t a t e s the formation of concepts responsible for performance of a c t i v i t i e s 1n the c l i n i c a l (Woodruff, 1967).  setting  Although use of t h i s 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 i n i c a 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 i n i c a l setting was Improved.  According to de Tornyay and Thompson (1987), the  return demonstration of an a c t i v i t y  provides the practice necessary for  achieving a smooth and p r o f i c i e n t performance.  Given that the  successful performance of a c t i v i t i e s in c l i n i c a l practice requires rapid automatic actions (Gudmundsen, 1975), the use of t h i s technique facilitates  nursing student competence 1n the c l i n i c a l s e t t i n g .  providing for t h i s practice of a c t i v i t i e s ,  Despite  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). (1988) recommend the use of an Instructional  Thus, Hodson et a l . technique that more closely  resembles the actual c l i n i c a l s e t t i n g . Simulation, as a representation of a r e a l - H f e s i t u a t i o n ,  is  believed to Increase the transfer of learning to the c l i n i c a 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 i s e 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 i n i c a l setting by promoting the formation of concepts that can be used for making decisions 1n unfamiliar s i t u a t i o n s . As forms of simulation that require active student p a r t i c i p a t i o n , 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 t h i s technique was e f f e c t i v e  for  t r a n s f e r r i n g concepts from written situations to c l i n i c a l p r a c t i c e . Further, these nurses attributed t h i s transfer of learning to the Increased student-to-student and student-to-teacher verbal that use of t h i s technique provided.  interaction  Dahl (1984) believes that  simulated s i t u a t i o n s , such as written situations and role-played patient  29 situations enhance transfer of learning as a result of the r e a l i t y 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 a c t i v i t y ,  students are better able to  transfer t h e i r 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 t e r a t u r e suggests that the use of simulated situations not only promotes cognitive learning through Increased verbalization and practice 1n r e a l i s t i c s i t u a t i o n s , but 1t decision-making as w e l l .  facilitates  Thus, simulated learning experiences 1n the  laboratory setting should Improve student performance 1n c l i n i c a l practice.  Summary As an example of a nursing a c t i v i t y that demonstrates the need for competence in c l i n i c a l p r a c t i c e , oral medication administration knowledge, s k i l l , and decision-making a b i l i t y .  requires  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 a b i l i t y .  Further, given that  simulation is viewed favorably by students, use of t h i s technique could be useful for enhancing the cognitive learning component entailed 1n  t h i s nursing a c t i v i t y .  Based on t h i s potential for f a c i l i t a t i n g both  the acquisition of cognitive learning and Its application 1n d e c i s i o n making, the use of simulated situations may improve student performance 1n c l i n i c a l p r a c t i c e .  Chapter Three Methodology  Introduction This chapter describes the research design, sample, s e t t i n g , data c o l l e c t i o n procedure, data c o l l e c t i o n instruments, and ethical considerations.  A b r i e f description of the procedures used 1n data  analysis 1s also Included.  Design The experimental method of research was u t i l i z e d 1n t h i s study to compare the effectiveness of two Instructional  techniques used to teach  oral medication administration ( P o l 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 a c t i v i t y and on cognitive and psychomotor learning following the subjects' f i r s t administration of an oral medlcation(s) to a patient.  A d d i t i o n a l l y , the two groups were compared  with regard to feelings of s a t i s f a c t i o n toward the practice session of the oral medication administration laboratory  activity.  32 Sample The sample consisted of volunteers from the f i r s t - y e a r 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 i n i c a l experience.  This c l i n i c a l experience totaled 12 hours per week on  alternate weeks.  As part of the classroom i n s t r u c t i o n , students were  taught theory concerning oral medication administration by the teacher responsible for teaching the pharmacology content.  Having been taught  t h i s theory, the students participated in an oral medication administration laboratory a c t i v i t y medications 1n the c l i n i c a l  p r i o r to administering oral  setting.  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  During the Laboratory A c t i v i t y  Practice Session  Practice Session  1.  Return demonstration using simulation'  Return demonstration  P r i o r to Laboratory Activity 1.  Two-hour lecture on safe oral medication administration.  2.  Preparation of "drug cards" on selected medications.  3.  Cognitive Learning Pretest  Demonstration of oral medication administration using mannikins.  Following the Laboratory Activity 1.  Cognitive Learning^ Posttest  2.  Feeling of S a t i s f a c t i o n Toward the Learning ^ Experience Questionnaire  3.  C l i n i c a l Performance Checklist''  Note.  The experimental group n = 32 and the control group n = 34.  independent v a r i a b l e . ^Dependent v a r i a b l e .  3  34 Common Experiences In the Classroom and Laboratory Setting A l 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  s e t t i n g , t h i s lecture was presented separately to the experimental group and the control group.  In addition to the l e c t u r e , a l l subjects  were Instructed by the pharmacology teacher to c o l l e c t 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 a c t i v i t y .  The selection of these medications  was based on the fact that they required decision-making in t h e i r administration. One week following the l e c t u r e , each group was administered a cognitive learning pretest and participated 1n a normally scheduled four-hour oral medication administration laboratory a c t i v i t y Appendix C ) .  (see  The laboratory a c t i v i t y was taught by the same f i v e nurse  educators responsible for teaching the students 1n the c l i n i c a l setting. During the laboratory a c t i v i t y ,  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 t h e i r "drug cards" and were required to use them during the practice  35 session of the laboratory a c t i v i t y selected oral medications.  1n the safe administration of  On completion of the practice session, the  subjects 1n each group completed the cognitive learning posttest and a questionnaire concerning feelings of s a t i s f a c t i o n 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 of oral medications during the laboratory a c t i v i t y  administration  (see Appendix D).  Following demonstration of the administration of selected oral medications by a nurse educator to each of the f i v e groups of experimental  subjects, these subjects were required to safely  administer selected medications in s p e c i f i c simulated patient situations (see Appendix E ) .  In administering these selected  medications, the subjects used "Tic Tacs" for tablets and cranberry j u i c e for l i q u i d medications.  Thus, student patients were required to  ingest these simulated medications.  Both the directions for using t h i s  technique and s p e c i f i c patient situations were designed by the Investigator for the purpose of t h i s 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 a c t i v i t y  (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 t h i s study, the laboratory a c t i v i t y for the control group preceded the laboratory a c t i v i t y for the experimental  group.  Thus, a  carry-over e f f e c t from simulation was minimized.  Clinical Activity Following the oral medication administration laboratory subjects 1n both groups were observed during the f i r s t of an oral medlcatlon(s)  activity,  administration  in the c l i n i c a l setting by the same nurse  educator responsible for t h e i r laboratory Instruction.  The subjects'  performance was recorded by the nurse educator using a c h e c k l i s t that was an accepted evaluation tool for a l l  f i r s t - y e a r nursing students.  Preparation of the Nurse Educators During the week prior to the laboratory a c t i v i t y experimental  for the  group, the investigator met twice with the f i v e nurse  educators responsible for instruction 1n both the laboratory and c l i n i c a l settings and provided instructions for teaching oral medication administration by the technique of demonstration using simulation. the laboratory a c t i v i t y  demonstration-return  Written Instructions for conducting  (see Appendix D) and s p e c i f i c patient  situations (see Appendix E) were provided by the A d d i t i o n a l l y , the Investigator  Investigator.  emphasized s p e c i f i c facts related to  safe oral medication administration that were useful for discussion following each s i t u a t i o n . One week p r i o r to the laboratory a c t i v i t y the Investigator  for the control group,  met with the f i v e nurse educators c o l l e c t i v e l y and  37 explained the procedure for teaching oral medication administration using demonstration-return demonstration. guide for the laboratory a c t i v i t y these teachers by the  A normally used Instructor's  (see Appendix F) was distributed to  Investigator.  Instruments C o g n i t i v e Measure  For the purpose of measuring cognitive l e a r n i n g , the  Investigator  designed a paper and pencil t e s t consisting of 20 multiple choice questions related to both knowledge of the f i v e "rights" of oral medication administration and application of t h i s knowledge In decision-making (see Appendix G).  The questions developed for t h i s  t e s t were based on objectives for the lecture on safe oral medication administration and the laboratory  activity.  This t e s t which had a scoring value of 0-20, was constructed to t e s t at the knowledge and application l e v e l s (Gronlund, 1985). Content v a l i d i t y of t h i s Instrument was established through the use of l i t e r a t u r e (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 t e s t Items with regard to knowledge and application of the f i v e "rights" of oral medication administration.  S p e c i f i c a l l y , they  were requested to determine 1f the Items tested nursing student knowledge of each of the f i v e "rights" and the application of knowledge of each of the f i v e " r i g h t s " in s p e c i f i c s i t u a t i o n s . review, the t e s t was revised.  Following t h i s  38 Oral  Medication  Administration  Checklist  To measure the cognitive and psychomotor learning components entailed 1n the performance of oral medication administration, experimental  and control subjects were observed during t h e i r  administration of an oral medicatlon(s)  the first  1n the c l i n i c a 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. behaviors, only four primarily  Of the 20  Involved motor movements necessary for  the administration of oral medications or psychomotor learning. behaviors were #6,  #12,  #13,  These  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 t r a y ,  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 t h i s Instrument, the nursing students received numerical scores for t h e i r performance Indicating the t o t a l number of satisfactory cognitive and psychomotor behaviors. For establishing the v a l i d i t y of t h i s Instrument, the c h e c k l i s t was reviewed by the Investigator 1987; Potter & Perry, 1987)  using current l i t e r a t u r e (Kozler & Erb, and the f i v e 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 behaviors.  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 s e q u e n c e 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 m i n o r r e v i s i o n s o f t h e c h e c k l i s t .  Interrater reliability.  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 nurse educators.  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  observed t h e videotaped performance o f a second-year n u r s i n g student 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 .  This  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 p e 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 s u b s e q u e n t c l i n i c a l experience.  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 p e 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 l a s t two review sessions of the videotape.  Subsequently, t h i s same r e l i e f nurse educator was  responsible for teaching subjects 1n the laboratory and c l i n i c a l settings.  Feeling of S a t i s f a c t i o n Questionnaire This Instrument was designed by the Investigator to measure nursing student feelings of s a t i s f a c t i o n toward the practice session of the laboratory a c t i v i t y  (see Appendix I).  The questionnaire which employed  a summated rating s c a l e , consisted of four statements related to student f e e l i n g of s a t i s f a c t i o n .  The subjects Indicated t h e i r 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 b r i e f questionnaire reporting t h e i r age, educational background, and prior occupation (see Appendix J ) .  Ethics and Human Rights Prior to data c o l l e c t i o n the proposal for t h i s study was approved by the University of B r i t i s h Columbia Behavioral Sciences Screening Committee and the ethical review committee of the i n s t i t u t i o n 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 i v e nurse educators Involved was also obtained (see Appendix L ) .  41 Students were Informed of the purpose of the study and that t h e i r p a r t i c i p a t i o n was voluntary (see Appendix M).  The fact that  nonpartldpatlon would have no e f f e c t upon t h e i r 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 I n s t i t u t i o n received the same learning experiences as the control group.  Data Analysis The control and experimental  subjects were described according to  selected personal c h a r a c t e r i s t i c s obtained from the Student Data Questionnaire.  These c h a r a c t e r i s t i c s 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 - t e s t . between the experimental  The difference  and control subjects for t h e i r scores obtained  on the Oral Medication Administration Checklist was subjected to analysis using independent t - t e s t s .  F i n a l l y , the two groups of  subjects were compared on the findings of the Feeling of S a t i s f a c t i o n Questionnaire through use of ch1-squared t e s t s .  A $. value of <.05 was  considered to be s t a t i s t i c a l l y s i g n i f i c a n t 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 c o l l e c t i o n of data. The ethical considerations and protection of the p a r t i c i p a n t s ' human rights were discussed and the methodology used for analyzing the data was b r i e f l y  outlined.  43 Chapter Four Presentation and Discussion of the Findings  Introduction  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 c h a r a c t e r i s t i c s as obtained from the Student Data Questionnaire.  These personal c h a r a c t e r i s t i c s  include the subjects' ages and educational backgrounds.  Age A description of the experimental contained in Table 2.  and control subjects by age i s  The majority of the subjects in each group were  between 17 and 20 years of age.  Of the remaining subjects s i m i l a r  numbers 1n each group were between 21 and 25 years of age while one student in the experimental Thus, the experimental  group was between 26 and 29 years of age.  group and the control group were homogeneous 1n  relation to the c h a r a c t e r i s t i c of age.  Educational  Background  The experimental  and control subjects were s i m i l a r with regard to  the number whose previous education was limited to completing grade 12. However, the two groups differed concerning post-secondary vocational  t r a i n i n g and university attendance. the experimental  Although 3 out of 32 subjects 1n  group had post-secondary vocational t r a i n i n g , 11 out  of 34 subjects 1n the control group had t h i s t r a i n i n g .  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 b v Age  Age 1n Years  Experimental Group (Jl = 32)  17-20 21-25 26-29  25 6 1  Control Group (n = 34) 26 8 —  Note. The values represent the number of subjects 1n the selected age group.  Table 3  Education P r i o r t o Enrolment  1n t h e N u r s i n g P r o g r a m  Educational Background  Completed grade 12 Post-secondary vocational t r a i n i n g Attended university  Experimental Group (H = 32) 13 3 16  Control Group (n = 34) 12 11 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 a c t i v i t y and repeated as a posttest following the laboratory.  This Instrument was used to answer  the f i r s t question asked 1n t h i s 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 t e s t i n g knowledge of oral medication administration and 10 questions t e s t i n g the use of t h i s 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 a n a l y s i s .  This  analysis revealed that 19 out of the 20 questions discriminated 1n a positive d i r e c t i o n between the upper quarter and lower quarter. Further, the d i f f i c u l t y factor for the pretest ranged from 0.3 to with a mean d i f f i c u l t y factor of 0.66,  0.9  while the posttest range was 0.4  to 1.0 with a mean d i f f i c u l t y factor of 0.69  (see Appendix 0).  Although question number seven had a d i f f i c u l t y factor of 0.0 for both the pretest and posttest, t h i s question was retained as part of the t e s t 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 t e s t .  Differences 1n scores within and between the two  groups were analyzed using Independent t - t e s t s .  The p. value of .05 was  accepted as s t a t i s t i c a l l y s i g n i f i c a n t .  Cognitive Learning;  Experimental Group  The scores obtained by the experimental subjects for knowledge ranged from 4 to 9 out of a t o t a l of 10 (H = 6.7) learning pretest, and 5 to 9 (M = 7.0)  on the cognitive  on the posttest.  For decision  making, the scores ranged from 2 to 9 out of a total of 10 (M = 6.8) the pretest, and 4 to 9 (M = 6.5)  on the posttest.  The overall t e s t  scores ranged from 9 to 17 out of a t o t a l of 20 (M = 13.5) pretest, and 11 to 16 (M = 13.6)  on  on the  on the posttest (see Table 4).  Four  subjects on the pretest and 3 subjects on the posttest obtained scores for knowledge below the i n s t i t u t i o n ' s pass score of 60%, while 7 subjects on the pretest and 8 subjects on the posttest obtained scores for decision making below t h i s accepted standard.  F i n a l l y , 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 . 1 3 , £ = .261), decision-making scores  ( ± C62] = .69, 42 = .495), and overall scores ( i [62] = - . 0 6 , ii = .952) were not s i g n i f i c a n t (see Appendix Q).  Cognitive Learning;  Control Group  For the control subjects, the scores obtained for knowledge ranged from 4 to 9 (M = 7.1) posttest.  on the pretest, and 4 to 9 (M = 7.3)  on the  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 Total Score  Frequency  Knowledge 4-5 6-7 8-9  Total  Dec1s1on-mak1ng 2-3 4-5 6-7 8-9 Total Overal1 9-11 12 - 14 15 - 17  Total  Note.  Posttest  Percent  Frequency  Percent  4 20 8  12.5 62.5 25.0  3 19 10  9.4 59.4 31.2  32  100.0  32  100.0  2 5 13 12  6.3 15.6 40.6 37.5  0 8 14 10  25.0 43.8 31.2  32  100.0  32  100.0  7 11 14  21.9 34.4 43.7  3 18 11  9.4 56.2 34.4  32  100.0  32  100.0  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 t e s t 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 t h i s accepted score.  L a s t l y , 3 subjects on the pretest and 3 subjects on the  posttest obtained scores below 60% on the overall t e s t .  There were  no s i g n i f i c a n t differences between the pretest and posttest for knowledge scores ( ± [663 = - . 6 9 , p. = .49), ( i [66]  = - . 7 1 , .p. = .48),  decision-making scores  and overall scores ( ± [66]  = - . 9 2 , 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) and 4 to 9 (M = 7.1) the experimental  for the experimental  for the control subjects.  subjects,  For decision making,  subjects' scores ranged from 2 to 9 (M = 6.8)  while  the control subjects had scores ranging from 3 to 10 (M = 6.9). overall test scores ranged from 9 to 17 (M = 13.5) subjects, and 9 to 18 (M = 14.0) 6).  for the  p. = .279), decision making scores ( ± [64] = .73, 41 = .469)  experimental  for the control subjects (see Table  The differences for pretest knowledge scores ( ± [64]  scores ( ± [64]  The  = 1.09,  = .22, 42 = .825), and overall  between the experimental  control subjects were not s i g n i f i c a n t (see Appendix Q).  subjects and  49 Table 5 Comparison of Cognitive Learning Pretest and Posttest. Scores; Subjects  Pretest Frequency  Total Score  Knowledge 4-5 6-7 8-9  Total Dec1s1on-mak1ng 3-4 5-6 7-8 9-10  Total  Overal1 9-10 11 - 12 13 - 14 15 - 16 17 - 18  Total  Note.  Control  Posttest  Percent  Frequency  Percent  4 17 13  11.8 50.0 38.2  2 17 15  5.9 50.0 44.1  34  100.0  34  100.0  3 11 13 7  8.8 32.4 38.2 20.6  1 11 14 8  2.9 32.4 41.2 23.5  34  100.0  34  100.0  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  34  100.0  34  100.0  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  Total Score  Knowledge 4-5 6-7 8-9  Total Decision-making 2-4 5-7 8-10 Total Overal1 9-10 11 - 12 13 - 14 15 - 16 17 - 18  Total  Note.  Experimental and  Experimental Subjects  Control Subjects  Frequency  Frequency  Percent  Percent  4 20 8  12.5 62.5 25.0  4 17 13  11.8 50.0 38.2  32  100.0  34  100.0  4 16 12  12.5 50.0 37.5  3 20 11  8.8 58.8 32.4  32  100.0  34  100.0  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  32  100.0  34  100.0  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), control subjects had scores ranging from 4 to 9 (M = 7.3). decision making, the experimental (M = 6.5),  while the For  subjects' scores ranged from 4 to 9  and the control subjects' scores ranged from 3 to 10  (M = 6.9).  O v e r a l l , the t e s t scores ranged from 11 to 16 (M = 13.6)  for the experimental  subjects and 10 to 18 (M = 14.5)  subjects (see Table 7 ) .  for the control  Although 1t did not reach the established .05  level of s i g n i f i c a n c e , the control subjects' mean score for decision making was higher than the mean scores for the experimental ( ± C64] = 1.86,  a = .068).  subjects  The control subjects achieved a higher  overall posttest mean score than the experimental approached the level of s i g n i f i c a n c e (j; [64]  subjects and  = 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 c o l l e c t e d using the Oral Medication Administration C h e c k l i s t . This c h e c k l i s t consisted of 16 behaviors involving cognitive learning, and 4 behaviors Involving psychomotor l e a r n i n g .  A l l the subjects were  observed by a nurse educator using the c h e c k l i s t during the administration of an oral medlcation(s)  first  to a patient, and t h e i r  behaviors were scored in terms of satisfactory or unsatisfactory  52 Table 7 Comparison of Cognitive Learning Posttest Scores; Control Subjects  Total Score  Knowledge 4-5 6-7 8-9  Total  Decision-making 3-4 5-6 7-8 9-10  Total Overal1 10 - 12 13 - 15 16 - 18  Total  Note.  Experimental and  Experimental Subjects  Control Subjects  Frequency  Frequency  Percent  Percent  3 19 10  9.4 59.4 31.2  2 17 15  5.9 50.0 44.1  32  100.0  34  100.0  1 17 12 2  3.1 53.1 37.5 6.3  1 11 14 8  2.9 32.4 41.2 23.5  32  100.0  34  100.0  11 17 4  34.4 53.1 12.5  5 18 11  14.7 52.9 32.4  32  100.0  34  100.0  Maximum score possible for knowledge = 10. Maximum score possible for decision-making = 10. Maximum overall score possible = 20.  53 behaviors (see Appendix R).  A c h e c k l i s t 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 e s t s . p.  The s i g n i f i c a n c e level was established at  = .05.  Comparison of Performance Involving Cognitive Learning The mean score for satisfactory behaviors Involving cognitive learning was 13.8 for the experimental control subjects.  subjects, and 13.7 for the  Although a l l the experimental  subjects performed  more than 50% of these behaviors at a satisfactory l e v e l , one control subject performed below t h i s level  (see Table 8).  The difference  between the two groups for satisfactory behavior scores Involving cognitive learning was not s i g n i f i c a n t (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 s a t i s f a c t o r y behaviors involving psychomotor learning was 3.6.  In the experimental  group, 62.5% of the subjects performed  all  four of these behaviors at a s a t i s f a c t o r y l e v e l , while 1n the control group 61.8% of the subjects performed a l l (see Table 8).  four behaviors  satisfactorily  As shown in Appendix Q, there were no s i g n i f i c a n t  differences between the two groups for s a t i s f a c t o r y behavior scores Involving psychomotor learning ( ± [64]  = .04,  D. = .968).  54 Table 8 Comparison of Oral Medication Administration Checklist Behaviors; Experimental and Control Subjects  Total Score  Experimental Subjects  Control Subjects  Frequency  Frequency  Cognitive Behavior 5 - 8 9-12 13 - 16  Total Psychomotor Behaviors 2 3 4 Total Overall 9 13 17 -  Behaviors 12 16 20 Total  C r i t i c a l Behaviors 4-6 7-9 10 - 12 13 - 15 Total  Note.  Maximum Maximum Maximum Maximum  score score score score  possible possible possible possible  Percent  Percent  0 5 27  0.0 15.6 84.4  1 5 28  2.9 14.7 82.4  32  100.0  34  100.0  1 11 20  3.1 34.4 62.5  1 12 21  2.9 35.3 61.8  32  100.0  34  100.0  0 11 21  0.0 34.4 65.6  1 7 26  2.9 20.6 76.5  32  100.0  34  100.0  0 1 7 24  0.0 3.1 21.9 75.0  1 0 7 26  2.9 0.0 20.6 76.5  32  100.0  34  100.0  for for for for  cognitive behaviors = 16. psychomotor behaviors = 4. overall behaviors = 20. 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 c h e c k l i s t performed at a s a t i s f a c t o r y level was 17.3 for both the experimental control subjects.  While a l l subjects 1n experimental  subjects and  group performed  more than 50% of the behaviors at a satisfactory l e v e l , one control subject performed fewer than 50% of the behaviors at t h i s level Table 8).  The difference between the experimental  (see  subjects and control  subjects for overall satisfactory behavior scores was not s i g n i f i c a n t ( 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 c h e c k l i s t behaviors and behaviors performed d i f f e r e n t l y  by  both groups.  Comparison of performance of c r i t i c a l behaviors.  T o t a l l i n g 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 s a t i s f a c t o r y performance of these behaviors were analyzed using an independent t - t e s t . performance of c r i t i c a l  The mean score for satisfactory  behaviors was 13.4 for the  subjects and 13.1 for the control subjects.  experimental  In the experimental group,  a l l the subjects performed more than 50% of these behaviors at a s a t i s f a c t o r y l e v e l , while in the control group, one subject performed fewer than 50% of the behaviors s a t i s f a c t o r i l y  (see Table 8).  There  56 was no s i g n i f i c a n t difference between the groups f o r scores concerning performance of c r i t i c a l  behaviors ( ± [64] = .56, .p. = .581) (see  Appendix Q).  Behaviors performed d i f f e r e n t l y  bv the groups.  A l l but s i x  behaviors were performed at a satisfactory level by 90.6% of the experimental S).  subjects and 85.3% of the control subjects (see Appendix  While these s i x 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 s i x 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 f o r medication a l l e r g i e s and checking f o r 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 l e r g i e s , 21 of the experimental  subjects (65.6%) and 29 of the control  (85.3%) checked f o r the presence of an allergy band. experimental  f i n a l check, the experimental  However, in the  The t h i r d behavior performed  by the two groups was the n o n - c r i t i c a l In the experimental  handwashing s a t i s f a c t o r i l y  behavior of  group, 13 subjects (40.6%) performed  and 1n the control group, 21 subjects  (61.8%) performed t h i s behavior at a s a t i s f a c t o r y l e v e l . the experimental  allergy  subjects committed 11 errors and the  control group committed 5 e r r o r s .  handwashing.  Thus, the  subjects committed 9 errors during the I n i t i a l  check and the control subjects committed 16 e r r o r s .  differently  subjects  Therefore,  subjects committed 19 errors with regard to  handwashing and the control group subjects committed 13 e r r o r s .  57 Feeling of S a t i s f a c t i o n The evaluation of nursing students' feeling of s a t i s f a c t i o n the practice session of the oral medication laboratory  Involved  completion of a Feeling of S a t i s f a c t i o n Questionnaire by a l l subjects.  toward  the  Through the use of t h i s questionnaire, data were collected  to answer the t h i r d research question regarding the e f f e c t s of the selected instructional techniques on nursing student feeling of s a t i s f a c t i o n 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 t h e i r of s a t i s f a c t i o n with each statement  (see Appendix T ) .  these responses between the experimental analyzed using chi-squared t e s t s .  feeling  Differences  for  and control subjects were  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 t h e i r 3 on the scale and the sum of t h e i r  responses for numbers 1 to  responses for number 4.  The  accepted level of s i g n i f i c a n c e was p. = .05.  Statement 1 Statement 1, which states "The practice session was relevant  to  c l i n i c a l p r a c t i c e " , e l i c i t e d Identical responses concerning disagreement from both the experimental  and control subjects.  groups, two subjects strongly disagreed with t h i s statement.  In both Agreement  with t h i s 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 s i g n i f i c a n t (X C1] = .48587, p. = .9858). 2  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  t h i s statement d i f f e r e d between the two groups of subjects. experimental  In the  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 t h i s statement,  the difference was not s i g n i f i c a n t as  shown in Table 10 <X L"1] = .18957, p. = .6633). 2  Statement 3 The t h i r d statement, which related to the usefulness of the practice session for c l i n i c a l p r a c t i c e , e l i c i t e d s l i g h t l y responses from the experimental  different  subjects and the control subjects with  respect to both disagreement and agreement.  In the experimental  one of the subjects strongly disagreed with t h i s statement, agreed and 23 strongly agreed. agreed, and 26 strongly agreed.  group,  while 8  Of the control subjects, 2 disagreed, 6 Although more control subjects  59 Table 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 the P r a c t i c e Session  Group Response  Experimental  Control  Disagree/Agree  12  9  S t r o n g l y Agree  20  25  Total  32  34  T a b l e 10 Comparison o f Group R e s p o n s e s 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  Experimental  Control  Disagree/Agree  12  10  S t r o n g l y Agree  20  24  Total  32  34  60 strongly agreed, the difference as shown 1n Table 11 was not s i g n i f i c a n t (X L1] = .02105, p. = .8847). 2  Statement 4 Statement 4, which related to the practice session being enjoyable, received highly s i m i l a r responses from both the experimental control subjects.  For the experimental  disagreed with the statement,  and  group, one subject strongly  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 s i g n i f i c a n t as shown in Table 12 (X C1] = .39900, p. = .5276). 2  Discussion of Findings The e f f e c t s of the two selected instructional  techniques on  cognitive l e a r n i n g , performance of oral medication administration,  and  feeling of s a t i s f a c t i o n toward the learning experience w i l l be discussed 1n relation to the conceptual framework,  l i t e r a t u r e , and  methodological problems of the study.  Effects of the Selected  Instructional  Techniques on Cognitive Learning The study found that there were no s i g n i f i c a n t differences cognitive learning of oral medication administration students taught by demonstration-return and those taught by demonstration-return  in  between nursing  demonstration using simulation demonstration.  Although the  T a b l e 11 Comparison o f Group R e s p o n s e s 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 the Practice Session  Group Response  Experimental  Control  Disagree/Agree  9  8  S t r o n g l y Agree  23  26  Total  32  34  T a b l e 12 ComDarison o f GrouD ResDonses t o S t a t e m e n t 4 C o n c e r n i n a Eniovment o f the Practice Session  Group Response Disagree/Agree  Experimental  Control  13  17  Strongly Agree  19  16  Total  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 i n d i n g s . One possible explanation for the lack of s i g n i f i c a n t change in these posttest scores 1s that the t e s t questions did not accurately measure cognitive l e a r n i n g .  For example, while two t e s t questions were  related to the nature of enteric coated tablets and the common s i t e of absorption, the laboratory practice Involved selecting the appropriate time for administration of t h i s type of oral medication preparation. The results of t h i s 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 f a c i l i t a t i n g 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 s u f f i c i e n t opportunity for decision-making and t r i a l behavior.  Furthermore, since  cognitive learning i s 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 i g h t trend toward an increase for the experimental simulation was noted.  subjects taught using  This suggests that these subjects were able to  u t i l i z e 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 r e s u l t s .  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 t h e i r learning posttest scores.  cognitive  A d d i t i o n a l l y , the nurse educators were using  written situations and role-played patient situations for the time.  Therefore,  first  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 r e s u l t s . The fact that the same nurse educator taught one experimental and one control group may have contributed to the f i n d i n g s .  It  group  is  possible that there was a carry-over teaching e f f e c t between the groups which would not have been possible 1f d i f f e r e n t nurse educators were used to teach the experimental  and control subjects.  F i n a l l y , the sample s i z e may have been responsible for the lack of s i g n i f i c a n t differences between the two groups.  Given a larger number  of subjects, the differences between the posttest scores of the groups may have been s i g n i f i c a n t . However, despite the problems Inherent 1n the study, the results suggest that simulation was at least as e f f e c t i v e as the established technique for teaching oral medication administration.  Thus, with  further development of the simulated situations and increased teacher orientation,  it  1s possible that the use of simulation may be more  64 e f f e c t i v e than t r a d i t i o n a l Instruction for f a c i l i t a t i n g the cognitive learning component of oral medication administration.  Effects of the Selected Instructional  Techniques on Performance  Analysis of the data showed no s i g n i f i c a n t 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 I n s u f f i c i e n t  laboratory practice using  simulated situations and verbal Interaction between the teacher and subjects.  As a nursing a c t i v i t y 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 i n i c a l setting by f a c i l i t a t i n g the formation of concepts that can be used to mediate behavior 1n unfamiliar situations (Woodruff,  1967).  While the results of t h i s study do not support the findings of Johnson and Purvis (1987) that the use of written situations 1s e f f e c t i v e for t r a n s f e r r i n g concepts from written situations to c l i n i c a l p r a c t i c e , these researchers state that verbal Interaction 1s responsible for t h i s t r a n s f e r .  Therefore, 1t i s possible that the  amount of discussion regarding the simulated situations 1n the laboratory may have Influenced the findings of t h i s study. Another reason for the study findings may be that the performance c h e c k l i s t f a i l e d to accurately measure the cognitive learning component of t h i s nursing a c t i v i t y .  Given that t h i s c h e c k l i s t r e f l e c t s only the  65 subjects' behavioral responses* 1t 1s possible that the experimental subjects may have Improved t h e i r decision-making a b i l i t y but the Instrument f a i l e d to measure t h i s f a c t .  A further point 1s that a l l  subjects were aware that t h e i r performance was being evaluated.  It  is  possible that the subjects' desire to perform well was a factor that Influenced the r e s u l t s . Because the psychomotor learning component of oral medication administration 1s l i m i t e d , only four behaviors relevant to psychomotor learning were included on the performance c h e c k l i s t .  It  1s possible  that t h i s number of behaviors was too small to r e f l e c t the e f f e c t of simulation on psychomotor l e a r n i n g . Problems Inherent 1n t h i s 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 i n i c a l s e t t i n g , 1t i s possible that teacher bias regarding the instructional techniques may have influenced the r e s u l t s .  Further, the fact that f i v e 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 i n i c a l s e t t i n g , the results of the study may have been d i f f e r e n t . 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 for ensuring patient safety.  effective  However, with further development of the  simulated situations and increased teacher o r i e n t a t i o n , simulation may  66 be more e f f e c t i v e than t r a d i t i o n a l  techniques for decreasing medication  errors by nurses 1n c l i n i c a l p r a c t i c e . Another additional finding was that there were differences between the two groups with regard to checking for medication a l l e r g i e s 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 a l l e r g i e s 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 s i g n i f i c a n t differences between the two groups for f e e l i n g s of s a t i s f a c t i o n toward the learning experience.  A possible reason for t h i s finding may have been the  nature of the questionnaire.  Given that t h i s questionnaire contained  only four simple statements for subjects to rate,  1t i s 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 p o s i t i v e l y on the questionnaire, 1s possible that t h i s laboratory content 1s one of p a r t i c u l a r Considering the f i n d i n g s , 1t 1s possible that additional  Interest. positive  teacher feedback during the t r i a l of behaviors or practice session might have Increased the feeling of s a t i s f a c t i o n experienced by the subjects taught by simulation (Woodruff,  1967).  As a r e s u l t ,  1t  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 c l e a r l y r e f l e c t 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 f o r nursing students, and those of Dav1dh1zar (1977), and Lincoln et a l . (1978), who found that r o l e played patient situations were perceived as being a useful technique. In t h i s study, possible reasons for the results relate to both the Instruction and the teaching content. who taught both the experimental clinical  Instructor,  Given that the nurse educator  and control subjects was t h e i r  1t 1s possible that the relationship between the  teacher and subjects Influenced the responses on the questionnaire. Thus, Instruction  in the laboratory by a d i f f e r e n t  have resulted 1n d i f f e r e n t  findings.  nurse educator may  Had the situations been t r i a l e d ,  revised and refined, 1t 1s possible that they may have been perceived as more interesting and u s e f u l . 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 i s possible that simulation may prove to be more e f f e c t i v e than Instruction for f a c i l i t a t i n g  traditional  Interest 1n learning.  Summary The results of the study were presented according to the c h a r a c t e r i s t i c s of the subjects and the three research questions  68 concerning the e f f e c t s of two selected Instructional  techniques on  cognitive learning of oral medication administration, oral medication administration, learning experience.  performance of  and feeling of s a t i s f a c t i o n toward the  The results were discussed according to the  differences for cognitive learning, performance, and f e e l i n g of s a t i s f a c t i o n between the subjects taught by  demonstration-return  demonstration, and those taught by demonstration-return using simulation.  demonstration  The findings revealed that there were no s i g n i f i c a n t  differences between the two groups of subjects with regard to cognitive learning, performance, and feeling of s a t i s f a c t i o n toward the experience.  Thus, 1n t h i s study both Instructional  equally e f f e c t i v e  for teaching oral medication  learning  techniques were  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 s a t i s f a c t i o n toward the learning experience. A review of the l i t e r a t u r e indicated a d e f i n i t e need for the safe administration of medications by graduate nurses but errors with regard to the " f i v e rights" were a common occurrence.  As a nursing a c t i v i t y ,  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  traditionally  deemed to be the appropriate technique for  these two learning domains of nursing a c t i v i t i e s ,  facilitating  recent sources  suggested that return demonstration involving simulation was more e f f e c t i v e because 1t enhanced decision-making required for a performance.  Both techniques, however, were found to foster feelings  of s a t i s f a c t i o n toward the learning experience and f a c i l i t a t e the transfer of learning from the laboratory to the c l i n i c a l  setting.  The study population consisted of f i r s t - y e a r nursing students enrolled in a three-year diploma program associated with a large metropolitan h o s p i t a l .  The experimental  group which consisted of 32  students was taught oral medication administration by demonstrationreturn demonstration using simulation, and the control group which  consisted of 34 students was taught by demonstration-return demonstration.  A l 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 t h i s knowledge in making decisions required for the safe administration of medications. A d d i t i o n a l l y , both groups participated separately 1n a normally scheduled laboratory and observed a demonstration of oral medication administration by one of f i v e nurse educators.  The experimental  subjects returned the demonstration using simulation 1n the form of written situations and role-played patient s i t u a t i o n s , 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 s a t i s f a c t i o n toward the practice session and selected personal c h a r a c t e r i s t i c s .  Further,  a l l subjects were observed by the same nurse educator during the administration of an oral medlcatlon(s)  first  to a patient and t h e i r  performance of behaviors Involving cognitive and psychomotor learning was scored on a c h e c k l i s t . Differences 1n mean scores on the cognitive learning t e s t s and performance c h e c k l i s t within and between the two groups were analyzed using Independent t - t e s t s , while differences in responses concerning feelings of s a t i s f a c t i o n were analyzed using ch1-squared t e s t s . accepted level of s i g n i f i c a n c e was p. = .05 for a l l  tests.  A d d i t i o n a l l y , data collected concerning selected personal  The  71 c h a r a c t e r i s t i c s of the subjects were used to describe the study population. A comparison of the two groups showed there were no s i g n i f i c a n t differences for cognitive learning of oral medication administration and performance during the f i r s t administration of a medlcatlon(s) patient.  to a  Furthermore, there were no s i g n i f i c a n t differences with  regard to feelings of s a t i s f a c t i o n 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 patient safety, three behaviors were performed d i f f e r e n t l y experimental  to  by the  and control subjects.  Conclusions The small sample s i z e and the fact that the sample was obtained from only one nursing program l i m i t s the general1zab1l1ty  of the  r e s u l t s , however, the findings of the study suggest the following conclusions: 1.  The two selected Instructional  e f f e c t i v e for f a c i l i t a t i n g  techniques were equally  nursing student cognitive learning of oral  medication administration. 2.  The two selected Instructional  e f f e c t i v e for f a c i l i t a t i n g  nursing student performance during the  administration of an oral medlcatlon(s) 3.  techniques were equally  The two selected Instructional  first  to a patient. techniques were equally  e f f e c t i v e for e l i c i t i n g nursing student feelings of s a t i s f a c t i o n toward the learning experience.  72 Impl ications of the Study The findings of t h i s 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 .  Traditionally,  the  technique of demonstration-return demonstration has been used to f a c i l i t a t e nursing student knowledge and s k i l l performance of nursing a c t i v i t i e s .  required for the  However, the findings of t h i s study  suggest that the use of simulation during return demonstration i s equally as e f f e c t i v e for f a c i l i t a t i n g activities.  student learning of these  When s e l e c t i n g simulation as an instructional technique,  nurse educators may maximize student cognitive and psychomotor learning and feeling of s a t i s f a c t i o n by using a wide variety of simulated situations and providing the faculty with comprehensive orientation concerning t h i s technique.  A d d i t i o n a l l y , time periods for group  discussion should be scheduled following completion of each simulated situation.  Given that faculty 1s allowed adequate time for the  development of simulated situations and orientation of f a c u l t y , the use of simulation may be more e f f e c t i v e than t r a d i t i o n a l teaching nursing a c t i v i t i e s .  techniques for  References  American College Dictionary.  (1959).  New York: Random House.  American Society of Hospital Pharmacists. d e f i n i t i o n of a medication e r r o r .  (1982).  ASHP standard  American Journal of Hospital  Pharmacists, 32» 321. Barker, K., & McConnell, W.  (1962).  medication errors in h o s p i t a l s .  The problems of  detecting  American Journal of Hospital  Pharmacy* 12, 361-369. Becker, C.  (1980).  An overview of simulation games and comments  on t h e i r use 1n baccalaureate nursing education. 12 (2), Bloom, B.  Nursing Papers,  32-34. (1956).  Taxonomy of educational objectives,  c l a s s i f i c a t i o n of educational goals, handbook I: domain. Bruner, J .  the  Cognitive  New York: David McKay Co. Inc. (1960).  The process of education.  New York: Vintage  Books, Division of Random House. Chaisson, G.  (1980).  Life-cycle:  A social-simulation game to  Improve attitudes and responses to the e l d e r l y . Gerontological Nursing, £ (10), Clavreul, G . , & Cavlness, S.  Cook, J . , & Maynard H111, P.  587-592.  (1983).  and what you can do about them.  Journal of  Unsafe nursing practices  Nursing L i f e . 3_ (3),  (1985).  The Impact of successful  laboratory system on the teaching of nursing s k i l l s . of Nursing Education. 2A (8),  40-45.  344-346.  Journal  Corbett, N., & Beverldge, P. learning.  (1982).  Simulation as a tool  Topics 1n C l i n i c a l Nursing. A (3),  C u r t i s , J . » & Rothert, M.  (1972, January).  for  58-67.  An Instructional  simulation system offering practice 1n assessment of patient needs. Dahl, J .  Journal of Nursing Fducatlon, 11 (1), (1984).  Structural  reality-based learning.  experience:  23-28.  A r i s k - f r e e approach to  Journal of Nursing Education, 21  (1),  34-37. Davidhizar, R.  (1977).  Use of simulation games 1n teaching  psychiatric nursing. Day, R.,  & Payne, L.  Journal of Nursing Education, 16. (5),  (1987).  Computer-managed i n s t r u c t i o n :  alternative teaching strategy. (1),  & Thompson, M.  nursing (3rd ed.)  Journal of Nursing Education, 2£  analysis of data. Dubin, C.  (1983).  Committee. Eaton, S.  (1987).  (pp. 59-67).  Devore, J . , & Peck, R.  (1986).  Strategies for teaching  New York: Statistics:  WHey. The exploration and  St. Paul: West Publishing Company. Report of t h e Hospital for Sick Children Review  Toronto: Government of Ontario.  (1987).  Developing psychomotor s k i l l s .  In R. de Tornyay  & M. Thompson, Strategies for teaching nursing (3rd ed.)  Elliott,  An  30-35.  de Tornyay, R.,  67).  9-11.  (pp.  59-  New York: Wiley. 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. Nurse, Ifi  (3),  25-27.  The Canadian  Fennel!, B.  (1978).  Attitudes toward learning styles and  s e l f - d i r e c t i o n of ADN students. 11,  19-22.  Francis, G.  (1980, August).  perspective. 11,  Journal of Nursing Education,  Nurses' medication " e r r o r s " :  A new  The Journal for Nursing Leadership and Management,  11-13.  Gomez, G . , & Gomez, E.  (1987).  Learning of psychomotor s k i l l s :  Laboratory versus patient care s e t t i n g .  Journal of Nursing  Education. 26. (1)» 20-24. Gronlund, N. ed.).  (1985).  Measurement and evaluation  in teaching  (5th  New York: C o l l i e r Macmlllan.  Gudmundsen, A.  (1975).  Teaching psychomotor s k i l l s .  Nursing Education. 1£ (1), Hahn, A . , Barkin, R., nursing (16th  23-27.  & Oestrelch, S.  ed.).  Journal of  (1986).  Pharmacology in  Toronto: Mosby.  H a l l a l , J . , 4 Welsh, M.  (1984).  learn psychomotor s k i l l s .  Using the competency laboratory  Nurse Educator, 2. (1)>  Hodson, K., Brlgham, C . , Hanson, A . , & Armstrong, K. media simulation of a c l i n i c a l day.  34-38. (1988).  Nurse Educator, 12.  Multl  (1),  10-13. Infante, M. (2nd e d . ) .  (1985).  The c l i n i c a l laboratory  in nursing education  New York: Wiley.  J e f f e r s , J . , & Christensen, M.  (1979, June).  Using simulation to  f a c i l i t a t e the acquisition of c l i n i c a l observational Journal of Nursing Education, l f i (6),  29-32.  to  skills.  Johnson, J . , 4 Purvis, J .  (1987).  Case studies:  learning/teaching method 1n nursing. Education, 2L (3),  Journal of Nursing  118-120.  Kolb, S . , & Shugart, E. answer?  An alternative  (1984).  Evaluation:  Is simulation  Journal of Nursing Education, 21 (2),  Kozler, B . , 4 Erb, G.  (1987).  the  84-86.  Fundamentals of nursing  (3rd  ed.)  Menlo Park, CA: Addison-Wesley. Kruse, L . , Hahn, C , Barry, J . , 4 Gay, J .  (1978).  Utilization  of  a media Instructional support s t a f f in the development of a simulated learning experience:  Medication  Journal of Nursing Education. H  (8),  L i n c o l n , R., Layton, J . , 4 Holdman, H. patients to teach assessment.  administration.  27-34. (1978).  Using simulated  Nursing Outlook. 26, 316-320.  Markowltz, J . , Pearson, G . , Kay, B . , 4 Loewenstein, R. Nurses, physicians, and pharmacists: hazards of medications.  (1981).  Their knowledge of  Nursing Research. 3J2 (6),  366-  370. Ostmoe, M., Van Hoozer, H., S c h e f f e l , A . , 4 Crowe!1, C. Learning s t y l e preferences and selection of learning Consideration and Implications Nursing Education, 21 ( l ) , Page, G . , 4 Saunders, P.  D., 4 Hungler, B.  Philadelphia:  (1978).  (1983).  Lipplncott.  strategies Journal of  27-30.  Journal of Nursing Education. U Pollt,  for nurse educators.  (1984).  Written simulation 1n nursing. (4),  28-32.  Nursing research (2nd  ed.).  Potter, P . , & Perry, A.  (1987).  Basic nursing theory and p r a c t i c e .  Toronto: Mosby. Quiring, J . 21 (4),  (1972).  The autotutorlal approach.  Nursing Research.  332-337.  R e i l l y , D., & Oermann, M. nursing education.  (1985).  The c l i n i c a l f i e l d :  Its  use in  Norwalk, CT: Appleton-Century-Crofts.  Rosati, J . , & Nahata, M. p e d i a t r i c patients.  (1983).  Drug administration errors 1n  Quality Review B u l l e t i n . 2 (7),  212-213.  Solomon, S . , Wallace, E . , Ford-Jones, E . , Baker, W., Martone, W., Kopln, I.,  Cr1t1z, A . , & A l l e n , J .  (1984, January).  Medication  errors with Inhalant ep1nephrine-m1m1cking and epidemic of neonatal s e p s i s .  The New England Journal of Medicine, 310  (3),  166-170. Swendsen Boss, L.  (1985).  Educator, 10 (4),  Teaching for c l i n i c a l competence.  Nurse  8-12.  Tayler, J . , & Cleveland, P. learning laboratory.  (1984).  E f f e c t i v e use of the  Journal of Nursing Education. 23.  (1),  32-39. Taylor, A.  (1980, July 10).  C l i n i c a 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: Whiting, H.  Author.  (1972).  Overview of the s k i l l learning process.  Research Quarterly. 43. (3),  266-293.  The  Woodruff, A.  (1967).  In L. Slegel ( E d . ) , (pp. 55-98). Yantzle, N.  Cognitive models of learning and Instruction Instruction:  Some contemporary  viewpoints  San Francisco: Chandler.  (1980, June).  Canadian Nurse. 33-36.  HELP, a simulation disaster game.  Appendix A Lecture Objectives Safe Oral Medication  Administration  Lecture Objectives Safe Oral Medication Administration Upon completion of the l e c t u r e , the student w i l l be able t o : 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 r e s p o n s i b i l i t i e s 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 p r i n c i p l e s 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.  Note.  Discuss the s i g n i f i c a n c e of the " f i v e r i g h t s " .  From Nursing 101 Lab Guide by Vancouver General Hospital School  of Nursing, 1988, Vancouver, BC.  Reprinted by permission.  81  Appendix B Format f o r Drug Card  Format for Drug Card  Classification: Drug Name:  Generic: Trade:  Action: Use: Dosage: Route: Side E f f e c t s : Nursing R e s p o n s i b i l i t i e s : 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 a c t i v i t y 1s to a s s i s t the student to prepare and administer oral medication. Emphasis i s on the application of selected p r i n c i p l e s , p o l i c i e s and terms related to the administration of oral medications. OBJECTIVES On completion of the laboratory a c t i v i t y the student w i l l be able  1.  apply selected p r i n c i p l e s 1n the administration of oral medications relating to - asepsis. - medication administration safety. - anatomy and physiology. - microbiology. - pharmacology.  2.  apply VGH p o l i c i e s s p e c i f i c 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 ( p l a s t i c & paper) - tray - card counter; mortar and p e s t l e .  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 L i s t e d Behaviors. 1.  Applies selected p r i n c i p l e s relating to asepsis, microbiology, medication administration safety and pharmacology 1n the preparation and administration of an oral medication.  2.  Applies VGH p o l i c i e s s p e c i f i c 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 transcriptions.  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.  Purpose o f the Laboratory 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 medications.  B.  Objectives 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 administration o f oral medications (checking 5 Rs). 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 medications. 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 importance 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.  Preparation f o r the Laboratory 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 o u p : - CPS/drug handbook - P h y s i c i a n ' s O r d e r Sheets - Medication Records - N u r s e s ' Notes - N a r c o t i c C o n t r o l Book - medication cards - 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 - medication trays - m e d i c a t i o n cups (paper 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 , Entrophen, 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.  Procedure  f o r t h e Laboratory 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 administration.  medication  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 i e n t 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 e f f e c t i v e only 1f given o r a l l y , eg. tylenol. - some drugs are not e f f e c t i v e 1f given o r a l l y , eg. i n s u l i n , gentamycin.  c)  The route of administration of the drug affects the optimal dosage of the drug. - larger dose may be given o r a l l y than may be given parenterally, eg. Demerol, 50 mg. p.o. v s . Demerol 5 mg. I.V. - any changes 1n the digestive t r a c t may affect the absorption of medication.  d)  The method of administration of the drug i s p a r t i a l l y determined by the age of the patient, his o r i e n t a t i o n , his degree of consciousness and health problem. - elderly may have d i f f i c u l t y swallowing p i l l s , refuse them when d i s o r i e n t e d . - p i l l s may become trapped under dentures or on side of mouth where there i s p a r a l y s i s . - l i q u i d preparations are available for many meds. - 1f nauseated, may need an antiemetic prior to taking oral medications. - may need certain f l u i d s with some medications to reduce e f f e c t s on G.I. t r a c t , eg. milk with a s p i r i n . - reporting and recording are important for any problems.  e)  The method of administration of the drug 1s p a r t i a l l y determined by the Indications and action of the drug. - longer duration of action via the oral route. - f l u i d s 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 p a r t i a l l y determined by the make up and action of the drug. - medications should be given when the peak effect w i l l occur when desired.  89 - many medications are maximally e f f e c t i v e when the stomach 1s empty, others when the stomach contains food or milk. - medications should be administered when unpleasant e f f e c t s 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.  2.  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 l n e s s and emotional needs. - explanations should be in simple terms, using correct medical terminology.  h)  The element of error is a p o s s i b i l i t y 1n a l l human activity. To help reduce the element of error there are many safety checks: - checking medication cards. - 5 rights. - checking label three times. - identifying the c l i e n t . - reporting and recording. - medication errors need to be reported Immediately to ensure c l i e n t comfort and safety.  Review VGH P o l i c i e s with regard t o : a) b) c) d) e)  3.  Review the: a) b) c) d)  4.  use of medication cards for prn medications. time r e s t r i c t i o n s placed on physicians' orders for narcotics and a n t i b i o t i c s . administration of narcotics by student nurses. wastage of n a r c o t i c s . use of Medication Incident Report Forms.  use of CPS/drug handbook. components of a physician's order. checking of a medication card. checking of a chart.  Demonstrate the preparation, administration and recording of the following medications using a mannlkin: a) b)  Col ace 200 mg. p.o. d a l l y . Magnolax 15 c c . p.o. BID.  90 5.  Instruct each student to use a mannikln to practice and administration of: a) b) c) d)  preparation  regular medication - t a b l e t s , capsules and l i q u i d s . stat dose. prn medication. narcotic - enter Into narcotic book.  6.  Observe the students' performance and provide feedback as necessary.  7.  Review the reporting and recording of: a) b) c) d) e) f) g)  regular medications. stat medications. one dose d a l l y . prn medications. medications refused. medications l e f t at bedside. side e f f e c t s 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 A c t i v i t y 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 t h i s laboratory a c t i v i t y , the student w i l l be able t o : 1. discuss the nursing r e s p o n s i b i l i t i e s 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 A c t i v i t y P r i o r to the laboratory, the teacher w i 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 p l a s t i c ) - simulated medications (Tic Tacs and cranberry j u i c e ) - drinking cups - printed situations (10 envelopes containing situations for the nurse, and 10 envelopes containing patient responses). - allergy armbands - I.D. armbands  D.  Procedure f o r the Laboratory A c t i v i t y The teacher w i l l : 1. B r i e f l y discuss the p r i n c i p l e s 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 e f f e c t s of medications. - c l i e n t 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 e f f e c t i v e only 1f given o r a l l y , eg. tylenol. - some drugs are not e f f e c t i v e 1f given o r a l l y , eg. i n s u l i n , gentamydn.  c)  The route of administration of the drug affects the optimal dosage of the drug. - larger dose may be given o r a l l y than may be given parenterally, eg. Demerol, 50 mg. p.o. v s . Demerol 5 mg. I.V. - any changes 1n the digestive t r a c t may a f f e c t the absorption of medication.  d)  The method of administration of the drug 1s p a r t i a l l y determined by the age of the patient, his o r i e n t a t i o n , his degree of consciousness and health problem. - e l d e r l y may have d i f f i c u l t y 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 p a r a l y s i s . - l i q u i d preparations are available for many meds. - 1f nauseated, may need an antiemetic p r i o r to taking oral medications. - may need certain f l u i d s with some medications to reduce e f f e c t s on G . I . t r a c t , eg. milk with a s p i r i n . - reporting and recording are Important for any problems.  e)  The method of administration of the drug 1s p a r t i a l l y determined by the Indications and action of the drug. - longer duration of action v i a the oral route. - f l u i d s or substances that accompany oral medications may Impede or enhance the absorption and effectiveness of medications.  f)  The time of administration of the drug i s p a r t i a l l y determined by the make up and action of the drug. - medications should be given when the peak effect w i l l occur when desired.  94 - many medications are maximally e f f e c t i v e 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.  2.  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, Illness and emotional needs. - explanations should be in simple terms, using correct medical terminology.  h)  The element of error i s a p o s s i b i l i t y 1n a l l human activity. To help reduce the element of error there are many safety checks: - checking medication cards. - 5 rights. - checking label three times. - Identifying the c l i e n t . - reporting and recording. - medication errors need to be reported Immediately to ensure c l i e n t comfort and safety.  Review VGH P o l i c i e s with regard t o : a) b) c) d) e)  3.  Review the: a) b) c) d)  4.  use of medication cards for prn medications. time r e s t r i c t i o n s placed on physicians' orders for narcotics and a n t i b i o t i c s . administration of narcotics by student nurses. wastage of narcotics. use of Medication Incident Report Forms.  use of CPS/drug handbook. components of a physician's order. checking of a medication card. checking of a chart.  Demonstrate the preparation, administration and recording of the following medications using a mannlkin: a) b)  Colace 200 mg. p.o. d a i l y . Magnolax 15 c c . p.o. BID.  95  5.  Provide directions for the performance of simulated s i t u a t i o n s . a) b)  c) d)  e)  f) g)  Each student w i l l perform f i v e situations with a classmate role-playing the patient. The students w i l l proceed through the ten situations taking turns preparing, administering and recording oral medications. Each pair of students w i l l perform the same situations concurrently. The student administering the medications w i l l receive written Information concerning patient data and the patient s i t u a t i o n , and completed medications cards. The student role-playing the patient w i l l receive written Information concerning patient data and the patient response, and I.D. and allergy armbands. Students w i l l use prepared "drug cards" for administering medications. Medication administration times are based on established VGH p o l i c i e s .  6.  Observe student performances and provide feedback as necessary.  7.  Discuss each s i t u a t i o n with a l l the students c o l l e c t i v e l y before they proceed to another s i t u a t i o n .  Appendix F Situations Demonstration - Return Demonstratl Using Simulation  97  Situations In order to f a c i l i t a t e  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 w i l l  perform  f i v e situations with a classmate role-playing the patient.  The  students w i l l proceed through the ten situations taking turns administering medications. situations concurrently.  Each pair of students w i l l perform the same The student administering the medication w i l l  receive written Information concerning patient data and the selected nursing s i t u a t i o n , while the student role-playing the patient w i l l receive written Information concerning patient data and the selected patient  response.  During the student performances, the nurse educator  w i l l observe the performances and provide feedback as necessary.  Upon  completion of each role-played s i t u a t i o n , the nurse educator and a l l participants w i l l c o l l e c t i v e l y discuss the situation before proceeding to the next s i t u a t i o n . occurred, Identification  Discussion w i l l Include analysis of what of feelings generated and Insights gained, and  exploration of why things happened as they did and how the situation related to  reality.  is  98 Situation Mrs. Ann Chase (Unit #34-16-10) i s a 83 year old woman who has been admitted to the hospital for Investigation and treatment of right-sided weakness, lung i n f e c t i o n , and a r t h r i t i s . On admission, the medication orders are as follows: May 13/88  Situation #1  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 c c . p.o. B.I.D. (#1 to #10:  Student  Demonstrations)  It 1s 0845 hours and 1t 1s your r e s p o n s i b i l i t y to prepare and administer Mrs. Chase's Dlgoxin and KC1 that are due at 0900 hours. The Dlgoxin i s only available in 0.25 mg. t a b l e t s . Administer these medications. Patient Response: "What 1s t h i s f o r ? " "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  it."  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 j u i c e that comes with my breakfast?"  99 Situation Part  U  I It 1s May 13th, 1130 hours and the physician has j u s t ordered Amp1c1"N1n. Identify the appropriate time that t h i s medication w i l l be given. Administer the medication.  Patient Response: "I hope t h i s I s n ' t P e n i c i l l i n as I think I'm a l l e r g i c to P e n i c i l l i n even though I don't have an allergy b r a c e l e t . " 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 j u s t ordered Lasix 20 mg. p.o. s t a t . Identify the appropriate time that t h i s medication w i l l be given. Administer the medication.  Patient Response: "What 1s t h i s f o r ? " "I'm afraid I w i 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 H k e orange j u i c e . "  "At home I always take t h i s 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 i q u i d tastes awful,  I can't f i n i s h taking t h i s medication."  "Can't you add some water to t h i s ? " 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 c a n ' 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 c u l t y swallowing." Situation  #9  It i s 0745 hours and Mrs. Chase 1s due to receive her Col ace. requests Tylenol for pain. Administer these medications.  She  Patient Response: "I'm sorry, nurse, but I dropped my p i l l s on the "I  floor."  hope my doctor remembered that I'm a l l e r g i c to A s p i r i n . "  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 c a l l me Ann, my f i r s t name I s n ' t Ann, 1t i s Joan, besides, I'm not taking t h i s Magnolax, I don't need a l a x a t i v e . "  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: 1.  Please c i r c l e the correct response.  Enteric coating on tablets serves to 1. 2. 3. 4.  delay the action of the drug. prevent deterioration of the drug. prevent I r r i t a t i o n of the g a s t r i c mucosa. protect the drug from g a s t r i c secretions. A. B. C. D.  2.  and and and and  3. 4. 4. 4. 1n the  caecum. colon. small Intestine. stomach.  The dosage of a drug given o r a l l y Is usually more than the same drug given parenterally because absorption A. B. C. D.  4.  2 2 3 3  The absorption of Ingested drugs occurs primarily A. B. C. D.  3.  1, 1, 1, 2,  1s enhanced by g a s t r i c a d d . 1s less complete. 1s limited to the general c i r c u l a t i o n . occurs over a shorter duration.  The overall goal of the nurse 1n gathering data and assessing the patient before I n i t i a t i o n of the planned drug therapy 1s to A. B. C. D.  establish f r i e n d l y rapport with the patient. evaluate the p a t i e n t ' s compliance with drug therapy. prevent secondary or unintended effects of the drugs. promote understanding of the drug regimen.  103 5.  Safe, therapeutically e f f e c t i v e drug administration 1s a major r e s p o n s i b i l i t y of nurses. If a nurse believes a drug dose to be erroneous, she should f i r s t A. B. C. D.  6.  The physician orders Demerol 50 mg I.M. administers t h i s drug 1f she gives 1t A. B. C. D.  7.  check with the physician to see 1f there 1s a reason for the unusual dose. give the medication as ordered by the physician. refuse to give the medication under any circumstances. t e l l the pharmacy there i s a medication error.  according to hospital schedule. as necessary. Immediately. once a day.  Colace 100 mg. p.o. p . r . n . Gravol 50 mg. p.o. dally ac breakfast Hydrod1ur1l 25 mg. p.o. dally Metamudl 2 ml. h . s . A. B. C. D.  1, 1, 2 3  2 and 3. 2 and 4. and 3. and 4.  What 1s the most r e l i a b l e method for the nurse to use 1n Identifying a patient before giving medications? A. B. C. D.  9.  The nurse correctly  Which of the following physician orders would you accept as being complete? 1. 2. 3. 4.  8.  stat.  Ask the p a t i e n t ' s name. Check the p a t i e n t ' s bed l a b e l . Check the p a t i e n t ' s wrist band. Rely on memory.  Which nursing action would v i o l a t e the f i v e patient rights for safe drug administration? A. B. C. D.  Administering a medication that was prepared by another nurse. Administering a 9:00 scheduled medication at 9:30. Double-checking dosage calculations for medications. Reading the medication label three times when preparing the medication.  104 10.  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 s u b s t a n c e s 1n t h e h o s p i t a l ? A. B. C. D.  of  controlled  Counting dosages of each 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 . Keeping a l l doses of c o n t r o l l e d s u b s t a n c e s In a l o c k e d c a b i n e t . 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 controlled substances. Recording c o n t r o l l e d substances Immediately a f t e r adm1n1stat1on.  Part I I ;  Decision-Making  (10  points) Score:  Case  Study  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 and hypertension. 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 . During t h e t h r e e days f o l l o w i n g a d m i s s i o n , h i s B . P . has ranged from 1 1 0 / 8 5 - 1 7 0 / 1 0 0 and h i s A p e x h a s r a n g e d f r o m 56 - 9 2 . The  p h y s i c i a n ' s o r d e r s a r e as  June 2/88  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 mg. p . o . T . I . D . H y d r o d l u r i l 50 mg. p . o . d a l l y P e n i c i l l i n 500 mg. p . o . Q . I . D . Dr. Brown, M.D.  June 4/88  Tylenol  Directions:  11.  follows:  #3 t a b s ,  i i  p . o . Q3-4H p . r . n . Dr. Brown, M.D.  The 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 study above. Read e a c h s t a t e m e n t and c i r c l e t h e c o r r e c t response.  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 order i s Incomplete. Your should A. B. C. D.  to  him,  a d m i n i s t e r 1 t by t h e p . o . route. chart "not g i v e n " . notify the physician. 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  you  used.  note t h a t  the  105 12.  Prior to the administration of Mlnipress (antihypertensive), assess his B.P. to be 100/75. You should A. B. C. D.  13.  B. C. D.  carbonated drinks. milk or food. orange j u i c e . water.  On administration of the 1000 hr. medications, Mr. Chase states that he 1s nauseated. You should A. B. C. D.  16.  have another s t a f f member Identify the patient. notify the physician for v e r i f i c a t i o n of the order. recheck the p a t i e n t ' s name, then administer the medication. withhold the medication until the number has been v e r i f i e d .  When administering Ferrous Gluconate, you should provide A. B. C. D.  15.  administer the medication and chart the B.P. on the Nurses' Notes. administer the medication as ordered. discard the medication and chart "not given". withhold the medication and notify the physician.  When checking Mr. Chase's I.D. band prior to medication administration, you discover that the unit number on his I.D. band 1s d i f f e r e n t from the number on the medication card. You should A.  14.  you  administer one medication at a time at 10-mlnute i n t e r v a l s . administer the medications with small sips of water. withhold the medications and chart "refused". withhold the medication for 1/2 hour, then attempt readmlnlstratlon.  On June 5/88, you prepare to administer Tylenol #3 to Mr. Chase. You should give A. B. C. D.  one one two two  t a b l e t Q3-4H p . r . n . t a b l e t Q.4H p . r . n . tablets Q3-4H p . r . n . tablets Q4H.  106 17.  When preparing to administer Tylenol #3, A. B. C. D.  18.  B. C.  D.  discard the medication, 1n accordance with agency p o l i c y . leave the medication at the bedside so he can take 1t l a t e r . leave the medication and medication card at the nursing station until he returns to the u n i t . return the medication to the bottle stock.  Prior to administering Hydrod1ur1l ( d i u r e t i c ) , you note that Mr. Chase's serum potassium i s 3.2 mEq./L. As a r e s u l t , you should A. B. C. D.  20.  add 1t to the medication cup containing Dlgoxin. check the Medication Record. check the Nurses' Notes. sign the narcotic book after 1t 1s given.  When administering Mr. Chase's medications, you find he 1s fasting for X-rays. You should A.  19.  you should  administer the medication and put a notice to the physician on the chart. administer the medication with orange juice. withhold the medication and chart "not given". withhold the medication and notify the physician.  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. B. C. D.  administer an antihistamine Immediately. apply Calamine l o t i o n to the rash. continue to administer the P e n i c i l l i n as ordered. withhold the P e n i c i l l i n u n t i l the physician 1s n o t i f i e d .  107  Appendix H Oral Medication Administration Checklist  108 Oral Medication Administration Checklist Group:  Beginning Time:  Ending Time:  Student Nurse Number: Key:  >)  so -l->  Satisfactory = 1 Unsatisfactory = 0  ra  (/) +->  Student Behavior  re oo  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 i g h t s ) .  *  3.  Compare the medication card(s) with the Medication Record for evidence of previous dose.  *  4.  Check the p a t i e n t ' s chart for evidence of medication a l l e r g i e s .  5.  Wash hands.  6.  Assemble a l l necessary materials Including correct f l u i d 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 c a l c u l a t i o n necessary.  if  * 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 j u s t prior to returning the container(s) to the s h e l f .  o +-> o  «  1/1  E  Comments  o o  Student Behavior  ro  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 p a t i e n t ' 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 c o r r e c t l y .  * 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 l o t . * C r i t i c a l Behavior Score Total Student Behavior Score  Grand Total * C r i t i c a l Behavior Score = 15 Grand Total Student Behavior Score = 20  u  Comments  110  Appendix I Feeling of Satisfaction  Questionnaire  Feeling of S a t i s f a c t i o n 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 1.  The practice session was relevant to clinical  2.  Response 1  2  3  1  2  3  1 2  3  1  3  practice.  The practice session provided opportunities for application of new knowledge about oral medication administration.  3.  The practice session was useful 1n preparing me for administering oral medications 1n the clinical  4.  area.  The practice session was enjoyable.  2  Score: Group: Additional Comments:  Appendix J Student Data  Student Data  Please complete the following questions by f i l l i n g  Age 17 - 20  1n the correct box.  •  21-25  •  26 - 29  •  30-39  •  Education prior to enrolment 1n the VGH Nursing program:  Completed Grade 12 Post-secondary vocational t r a i n i n g  \~] |  Attended university Completed university  | Q  |  |  Occupation prior to enrolment 1n the VGH Nursing program:  Student  •  Practical Nurse  Q  Nurse Aide  Q  Other  •  Appendix K Information for Director  115 Information for Director  Dear Director: In order to complete a Master's Degree Program 1n Nursing at the University of B r i t i s h Columbia I have selected to do a t h e s i s . research 1s 1n the area of Instructional  My  techniques and t h e i r e f f e c t on  nursing student learning of oral medication administration. I would H k e to conduct an experimental study Involving one class of f i r s t level students and t h e i r c l i n i c a l teachers. I propose to have each of the f i v e 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 w i l l take place during the regularly scheduled oral medication administration laboratory a c t i v i t i e s and the students'  first  administration of oral medications in the c l i n i c a l area. The amount of teacher time Involved would be approximately three hours 1n addition to her regularly scheduled laboratory a c t i v i t i e s and c l i n i c a l hours. Instructional  During the three-hour period, orientation to the  techniques and performance c h e c k l i s t would occur.  I propose to have students complete a pretest and posttest related to safe oral medication administration, f e e l i n g of s a t i s f a c t i o n questionnaire, and student data questionnaire during the oral medication administration laboratory a c t i v i t y . e n t i r e l y voluntary.  Their p a r t i c i p a t i o n 1s  Non-volunteers w i l l be assigned to the group being  116 taught by the t r a d i t i o n a l technique of demonstration-return demonstration.  To explain the study and obtain consent, I would l i k e  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 f o r 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 B r i t i s h Columbia I have elected to do a t h e s i s . research Is 1n the area of Instructional  My  techniques and t h e i r e f f e c t on  nursing student learning of oral medication administration. I would l i k e to conduct an experimental study which would involve both yourself and your two groups of students. Your involvement would entail using d i f f e r e n t  Instructional  techniques for A and B groups of students when teaching oral medication administration.  In addition, you would be required to complete a  performance c h e c k l i s t that 1s an accepted evaluation tool for a l l f i r s t - y e a r nursing students during t h e i r 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 c h e c k l i s t that w i l l be known only to yourself and the student. The f i r s t oral medication laboratory a c t i v i t y which Involves Group A, w i l l be taught using the established technique of demonstrationreturn demonstration. group.  Group A, then, w i l l constitute the control  Subsequently, Group B which constitutes the experimental group,  w i l l be taught by the Instructional demonstration using simulation.  technique of demonstration-return  The Instructions and situations for  t h i s experimental a c t i v i t y w i l l be prepared by the  investigator.  Orientation to the "simulated a c t i v i t y " and c h e c k l i s t w i l l probably take approximately three hours.  Your participation  1n the study 1s e n t i r e l y voluntary and w i l l 1n  no way r e f l e c t on your employment status.  If  at any time during the  study you wish to withdraw, your actions are acceptable. Students w i l l be asked to complete a pretest and posttest to safe oral medication administration,  feeling of s a t i s f a c t i o n  related toward  the learning experience questionnaire, and student data questionnaire. These tests and questionnaires w i l l be i d e n t i f i e d according to the students' group, and w i l l be shredded once data 1s analyzed. Grouped findings of the study w i l l be shared with the faculty of t h i s School of Nursing and with the members of the p a r t i c i p a t i n g  class  of students. Implementation of the planned a c t i v i t i e s with your students w i 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 f o r Students  121 Information for Students My name 1s V1 E t t l e s and I am a graduate student 1n the Master's Degree Program 1n Nursing at the University of B r i t i s h Columbia.  I am  conducting a study concerning approaches to nursing student learning of oral medication administration. Findings of the study w i l l be of benefit to both faculty and students in enhancing l e a r n i n g .  The study has been approved by both the  University of B r i t i s h Columbia Behavioural Sciences Screening Committee and the ethical review committee of t h i s agency.  In addition, the  Director of the School of Nursing has approved t h i s study. Your p a r t i c i p a t i o n in t h i s study i s e n t i r e l y voluntary.  Your  p a r t i c i p a t i o n or nonpartldpatlon 1n t h i s project w i l l not a f f e c t your class standing in any way.  Alternate established a c t i v i t i e s w i l l be  available to those students who do not choose to p a r t i c i p a t e . For the purpose of the study you w i l l be randomly assigned to one of two laboratory groups.  P a r t i c i p a t i o n involves completion of a pretest  and posttest related to safe oral medication administration, feeling of s a t i s f a c t i o n toward the learning experience questionnaire, and student data questionnaire.  Completion of these t e s t s and questionnaires w i l l  require approximately 30 minutes of normally scheduled class time. A d d i t i o n a l l y , you w i l l be observed during your f i r s t administration of an oral medlcation(s) by the teacher using a performance c h e c k l i s t that 1s an accepted evaluation tool for a l l f i r s t - y e a r nursing students. Your name w i l l not be placed on any t e s t s , questionnaires, study findings and reports.  Although tests and questionnaires w i l l be  122  shredded once data 1s analyzed, the performance c h e c k l i s t results w i l l be used by the teacher for c l i n i c a l evaluation purposes since the c h e c k l i s t 1s an acceptable tool for evaluating f i r s t - y e a r  students.  To  ensure that your Identity w i l l not be known to the Investigator, a number w i l l be placed on the c h e c k l i s t that w i l l be known only to the teacher and y o u r s e l f .  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 t h i s School of Nursing and with the members of the p a r t i c i p a t i n g class of students.  A d d i t i o n a l l y , the study findings w i l l be written up in a  thesis and other research a r t i c l e s . Thank you for your assistance.  Appendix N Written Consent  Appendix 0 Item Analysis f o r the Cognitive Learning  Pretest-Posttest  126 Item Analysis for the Cognitive Learning  Pretest Item  Discrimination  Pretest-Posttest  Posttest 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 K  D=M  6 6 8 7 8 4 7 6 9 7 7 6 8 7 7 7 8 6 8 5 6 7 9 7 6 8 4 5 6 7 7 6  7 7 8 6 8 7 7 9 6 2 7 5 9 9 8 7 7 6 9 4 9 9 7 7 4 9 9 5 6 5 8 6  Note.  Control Group  Posttest Score  Q.  K  D-M  9  7 7 6 8 5 7 7 8 6 7 7 8 6 7 8 5 9 6 7 7 8 7 8 7 7 8 7 8 7 5 8 7  5 5 9 6 7 9 5 8 6 8 6 7 8 5 7 6 4 5 8 8 6 6 8 5 5 8 6 6 7 6 6 8  13 16 13 16 11 14 15 15 9 14 11 17 16 15 14 15 12 17 9 15 16 16 14 10 17 13 10 12 12 15 12  K = Knowledge D-M = Dec1s1on-mak1ng 0 = Overall  Q. 12 12 15 14 12 16 12 16 12 15 13 15 14 12 15 11 13 11 15 15 14 13 16 12 12 16 13 14 14 11 14 15  PretOSt Score  &  D-M  5 7 9 7 7 7 6 6 6 8 7 7 8 9 6 8 8 6 7 8 6 6 8 8 5 4 9 7 9 7 7 8 9 5  4 6 7 7 6 5 7 6 9 6 7 7 10 8 6 6 10 7 10 4 3 10 5 9 7 8 9 7 6 5 8 8 7 5  Posttest Score  Q.  K  D-M  Ii  9  6 8 7 9 7 7 8 7 7 8 9 7 5 4 8 8 6 7 6 9 9 7 8 7 7 6 7 8 8 6 7 8 8 8  5 7 6 9 8 6 6 8 3 6 9 9 7 7 5 9 8 7 7 5 9 8 8 5 8 10 6 9 8 8 6 6 8 9  11 15 13 18 15 13 14 15 10 14 18 16 12 11 13 17 14 14 13 14 18 15 16 12 15 16 13 17 16 14 13 14 16 17  13 16 14 13 12 13 12 15 14 14 14 18 17 12 14 18 13 17 12 9 16 13 17 12 12 18 14 15 12 15 16 16 10  Appendix Q T-test Results of Comparison of Cognitive Learnl Pretest-Posttest Scores and Oral  Medication  Administration Checklist Behavior Scores  130 T - t e s t Results of Comparison of Pretest and Posttest Scores Within the Groups Pretest Mean Score  Posttest Mean Score  t val ue  Degrees of Freedom  6.7 6.8 13.5  7.0 6.5 13.6  -1.13 0.69 -0.06  62 62 62  0.261* 0.495* 0.952*  7.1 6.9 14.0  7.3 7.2 14.5  -0.69 -0.71 -0.92  66 66 66  0.490* 0.480* 0.362*  2-Ta1l Probability  Experimental Group Knowledge Decision-making Overal1 Control Group Knowledge Decision-making Overall * £ = >.05  T - t e s t Results of Comparison of Pretest and Posttest Scores Between the Groups Experimental Control Subjects Subjects Mean Score Mean Score  t value  Degrees of Freedom  2-Ta1l Probability  Pretest Knowledge Dec1s1on-mak1ng Overall  6.7 6.8 13.5  7.1 6.9 14.0  1.09 0.22 0.73  64 64 64  0.279* 0.825* 0.469*  7.0 6.5 13.6  7.3 7.2 14.5  0.90 1.86 1.99  64 64 64  0.373* 0.068* 0.051*  Control Group Knowledge Decision-making Overall  *p. = >.05  131 T - t e s t Results of Comparison of Oral Medication Administration Checklist Satisfactory Behavior Scores  Behaviors Cognitive Psychomotor Overall Critical  *p. = >.05  Experimental Control Subjects Subjects Mean Score Mean Score 13.8 3.6 17.3 13.4  13.7 3.5 17.3 13.1  t value 0.17 0.04 0.04 0.56  Degrees of Freedom 64 64 64 64  2-Ta1l Probability 0.862* 0.968* 0.966* 0.581*  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  Note.  £  £  3 4 3 4 3 3 3 2 4 4 4 4 4 4 3 4 3 4 3 3 3 4 4 4 3 4 4 4 4 4 4 4  15 9 13 12 13 13 14 13 14 14 12 14 14 13 15 16 16 14 13 16 11 15 16 15 16 14 13 15 12 13 14 15  P C 0 C  = = = =  Q. 19 18 17 16 19 17 18 19 19 20 19 14 19 16 18 18 19 20 18 17 16 18 16 18 18 15 17 16 13 16 16 16  Psychomotor Cognitive Overall Critical  Total Score  £  E  £  15 15 14 13 14 13 14 15 14 15 15 11 15 13 15 14 15 15 14 13 12 14 11 14 14 13 13 12 9 11 12 11  3 3 3 4 4 4 4 4 4 3 3 4 2 4 4 3 3 4 4 4 3 4 4 3 4 4 4 3 3 4 3 4 4 4  11 6 14 14 14 14 14 15 14 12 15 16 15 12 13 12 14 15 14 15 15 13 14 15 10 15 15 16 13 12 15 15 16 14  Q. 9 18 18 16 17 18 15 14 17 19 20 18 19 18 18 15 18 16 16 18 17 19 19 20 19 14 18 18 17 18 19 18 19 17  £ 6 13 13 11 12 13 13 11 12 15 15 13 14 14 14 13 14 12 12 14 14 15 14 15 15 10 14 14 13 14 14 13 14 14  134  Appendix S Oral Medication Administration Checklist Overall Behavior Scores:  Satisfactory  Experimental and Control Groups  135 Oral Medication Administration Checklist Overall Behavior Scores:  Experimental and Control Groups  Experimental Subjects  Check!1st Behavior  Number of Satisfactory  Behaviors  1* 2* 3* 4* 5* 6 7* 8* 9* 10* 11* 12* 13 14* 15* 16 17 18* 19* 20*  32 29 28 23 13 31 29 30 32 29 30 30 29 24 21 21 32 32 32 31  Note * = Designated c r i t i c a l  Satisfactory  behavior.  Percent 100.0 90.6 87.5 71.9 40.6 96.9 90.6 93.8 100.0 90.6 93.8 93.8 90.6 75.0 65.6 65.6 100.0 100.0 100.0 96.9  Control Subjects Number of Satisfactory Behaviors 34 32 29 18 21 33 33 30 34 32 32 32 32 26 29 26 32 34 34 31  Percent 100.0 94.1 85.3 52.9 61.8 97.1 97.1 88.2 100.0 97.1 94.1 94.1 94.1 76.5 85.3 76.5 94.1 100.0 100.0 91.2  136  Appendix T Feeling of S a t i s f a c t i o n Questionnaire Responses Experimental and Control Groups  Feeling of S a t i s f a c t i o n Questionnaire Responses  Statements  Note.  Experimental  and Control Groups  Experimental  Group  Control Group Responses  Responses  1  2  3_  A  1  2  1  A  1  2  0  7  25  2  0  10  20  2  2  0  8  24  2  0  10  20  3  2  0  6  26  0  1  8  23  4  2  0  15  16  1  0  12  19  The values represent the total number of subjects selecting the  response.  

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