Methods
This research was guided by the Participatory Action Research (PAR) methodology and explored (1) teaching methods that promote student learning and safe medication administration, and (2) influences to student nurse medication errors and near misses. Student nurses and clinical instructors from years three and four of a Bachelor of Nursing program participated in this study. We used a concurrent mixed methods design, and collected data about safe medication administration and medication teaching and learning via questionnaires from students (n=77) and instructors (n=11) as well as an instructor focus group (n=3). Analysis was conducted using Mann-Whitney U tests for quantitative results. Thematic analysis and triangulation were used for qualitative findings.
Findings
Accounts of student and clinical instructor experiences in the clinical setting emphasized the significance of collaborative practice to safe medication administration by student nurses. Instructor
Students and instructors rated the clinical nursing instructor as having the most positive influence on patient safety and student learning. Students reported supportive instructors increased the chances of them asking for supervision and improved patient safety. Students found it helpful when the instructor had clear expectations, quizzed students about the medications and tested their knowledge.
Peers
The students reported peers as the second most positive influence on learning and safety. Talking to a peer about medications provided students an opportunity to think further about medications and to build their clinical reasoning and critical thinking. While clinical instructors considered peer interactions positive, they did not rank peer learning as highly as the students themselves did.
Staff nurses
Participants reported that the staff nurses have a positive impact on student learning and patient safety. The staff nurses were aware of contextual factors impacting medication requirements and helped the students to link concepts about the patient and the medication. While the instructors rated the staff nurses highly, concerns were stated about student nurses learning unsafe shortcuts. Poor communication between the student and the staff nurses was the leading cause of medication errors in the study.
Conclusion
Collaboration between the student and the instructor; the student and their peers; the student and the staff nurse; and the staff nurse and the instructor are all important to optimize student learning about medications and to enhance patient safety. Elements of the clinical environment that contribute to complexity for teachers and learners include noise, interruptions, communication challenges and time constraints. Medication administration is cognitively complex for students because they must integrate a developing knowledge about medications, the patient’s history, the patient’s current clinical situation and possibly changing condition and other factors to come to decisions about medications. During collaboration, instructors, peers and staff nurses can be the guide a student needs to make the cognitive connections required for learning for clinical decision making.
A lack of collaboration is associated with medication errors. If the student and the staff nurse have tension in their relationship resulting in poor communication, medication errors are more likely (Valdez, Guzman, & Escolar-Chua, 2012). Students are more likely to report an error if they do not fear a negative reaction from the clinical instructor (Gorgich, Barfroshan, Ghoreishi & Yaghoobi, 2016). Faculty development of supervision skills can increase dialog among clinical instructors (Perry & Koharchik, 2014). Valdez et al. (2012) stated "while the emphasis on knowledge of pharmacology and medication safety is essential, equal importance should be given to system failures that impact patient safety. Accordingly, inter-professional partnership should be encouraged so that staff nurses, clinical instructors and other members of the health care team can reinforce the link between theory and practice." (p. 225)
The close relationship with learning and patient safety demonstrates that improvement in student learning will have a direct benefit to patients in the short and long term. One strategy for improvement is to build on the current successes of collaboration and to close the gaps in collaboration that we have found leads to medication errors. Students utilize peers and staff nurses as important resources. Faculty members can build on these relationships by developing teaching strategies that formally and intentionally promote peer to peer and student to nurse collaboration. Transitioning the student from the clinical instructor as supervisor and educator to staff nurse or peer collaboration for medication administration may improve learning and patient safety. Promoting purposeful collaboration for students will also help to build a collaborative skill set to bring forward to future interprofessional practice opportunities.