The Effectiveness of Simulation in Increasing Nursing Student's Knowledge Regarding Their Role in Adverse Drug Events in an Undergraduate Medical-Surgical Theory Course

Saturday, 7 November 2015

Elizabeth A. Tinnon, PhD, MSN, BSN, RN, CNE
Department of Collaborative Nursing Care, University of Southern Mississippi College of Nursing, Hattiesburg, MS, USA
Rebecca H. Newton, DNP, MSN, BSN, RN, CHSE
Department of Collaborative Nursing Care, University of Southern Mississippi, College of Nursing, Hattiesburg, MS, USA


The purpose of this presentation is to measure the effectiveness of simulation in increasing students’ knowledge regarding their role in recognition of risk factors, identification of errors and their ability to mitigate harm as it relates to adverse drug events.  errors and their ability to mitigate harm. in adverse drug events specifically:

1. Measure the effectiveness of simulation on the student’s ability to recognize risk factors related to adverse drug events

 2. Measure the effectiveness of simulation on the student’s ability to identify errors and harm related to adverse drug events

3. Measure the effectiveness of simulation on the student’s ability to mitigate harm related to adverse drug events


High alert medications have the potential to cause harm to patients with an increased frequency and a greater degree of adverse effects than other medications produce. The Institute of Medicine estimates that 1.5 million preventable adverse events occur yearly in the United States resulting in an estimated $3.5 billion in additional costs sustained my hospitals. The top four high alert medication classification identified as primary contributors to adverse drug reactions include: anticoagulants, opioids, sedative and antidiabetics (Institute for Healthcare Improvement [IHI], 2012).

Reversing the trend of inefficient medication management should not only necessitate reducing errors, but should incorporate changes in the root cause of adverse events. Pharmacology and medication administration are two crucial areas of nursing education that contribute to the knowledge and patterns of behavior nurses develop as primary caregivers with significant responsibilities for medication administration (IHI, 2012). A substantial body of evidence has been amassed scrutinizing the incidence of adverse events related to medication errors sustained by hospitalized patients. Educational preparation, nurse staffing and skill levels, years of clinical experience, communication, teamwork, patient acuity, and process limitations represent a multitude of causes that have been attributed as root causes (Aiken, Clark, Sochalski, Sloane, &Silber, 2002)

As the largest group of caregivers, nurses practice at the point of care and represent the greatest opportunity to intervene and mitigate the risk and potential harm to patients (DeBourgh and Prion, 2011). Experienced nurses understand the impact of systematic measures to ensure patient safety, but nursing students do not have the experience to fully comprehend this. As nurses practice in a clinical environment over time, they become able to identify and foresee patient safety risks. The ability to critically think plays a significant role in patient safety, when the nurse is able to identify potential problems and intercede by catering care to individual patient needs (del Bueno, 2005). Nursing students have not developed critical thinking skills; rather they tend to be task-oriented when providing patient care. Nurse educators must revise the teaching learning experience for pre-licensure nurses to integrate a better understanding of the student role and responsibility in patient safety.

High fidelity patient simulation has become an integral part of nursing education as more research has been conducted to support its use. Merging didactic instruction with large group simulation represents a promising approach to help students develop a critical thinking process by incorporating a skill with theoretical knowledge. Simulation is an experiential learning strategy that provides an environment that promotes student engagement while encouraging peer collaboration and teamwork. Simulation can be adapted to meet the student level of competency allowing for complexity as students progress through a nursing program (Cardoza and Hood, 2012). The simulated environment parallels the clinical environment, but allows students to practice without the possibility of harm. At the conclusion of a simulated scenario, the debriefing process offers an opportunity for reflection and recognition by students of their knowledge and understanding of the situation. The reflection allows students to grasp the larger picture of the events in the scenario and develop their critical thinking ability. 


 A quasi–experimental design will be used with one repeated factor (pre-test, post-test) and one between groups (lecture, lecture + simulation).

The sample consists of seventy-nine second semester nursing students enrolled in the first medical surgical course within an undergraduate curriculum. Other defining characteristics of the sample population are: 65 female students; 14 male students; 11 African American students and 68 Caucasian students. Criteria for inclusion in the study includes: official university student enrolled in Chronic Conditions Across the Lifespan; older than 21 years of age.

Following approval from the university Institutional Review Board (IRB) informed consent will be obtained. Students wishing to participate in the research study will be randomly assigned into either the simulation group or the non-simulation group. The pre-test will be administered to both groups prior to the lecture. At the conclusion of the lecture the non-simulation group will be administered the post test. The simulation group will proceed with the simulation learning. Simulation scenarios will last approximately 15-20 minutes. Students not actively participating in the scenario will be observing the simulation scenarios via live streaming video.  There will be a total of 3 simulation scenarios conducted. The situational simulation scenarios were developed based on the learning objectives which focused on three of the high risk medication classifications (anticoagulant, insulin and opioids).There will be a 15-20 minute debriefing after each of the simulation scenarios. The simulation scenarios will be conducted by Dr. Rebecca Newton and the course faculty member.  At the conclusion of the debriefing the simulation students will be administered the post-test

The pre-and post-test are instructor created exams which are a 10 question multiple choice exams designed to measure student’s ability to recognize risk factors, early signs and symptoms and appropriate nursing action to intervene in adverse drug events. Face and content validity of the exam was determined by 3 medical surgical instructors each with at least 20 years of nursing experience. In addition to teaching med surgical content one instructor is responsible for teaching math calculations and the introduction to med administration. One of the three instructors teaches the pharmacology course in the undergraduate curriculum and the third instructor is a credentialed simulation expert.


Test items will then be analyzed using ParScore® for validity and for adequacy of each question, and overall quality of the exam. Analysis of the data will also include descriptive and mixed factor 2 way ANOVA statistical tests.


It is expected that the use of simulation with lecture will be effective in increasing the student’s awareness of their role in adverse drug events. Nursing is not the only discipline involved in adverse drug events in addition to informing nursing education, the information obtained from the study could also be used within other health care disciplines program of study. Thus exponentially increasing the number of healthcare providers with increased awareness of their role in preventing adverse drug events. Subsequently this may decrease the number of patients harmed around the globe.