nursing assignment/ references

There are several challenges facing the graduate nurse like myself as I make the transition from the university environment to clinical practice. Medication mangement has been identified as one of the key areas requiring further development as it is a crutial aspect of quality nursing care and clinical governance (Randolph 2013, Edwards & Axe 2015). Although medication mangement incorporates a multi-disciplinary aproach to patient care involving the selection, collection, delivery and prescription of medications, nurses are in the prime position to ensure safety of patients when it comes to medication administration and monitoring of effects requiring knowledge and clinical reasoning skills (Jordan & Kyriacos 2014; Wright 2015). Despite this important role, medication errors commonly exist and novice nurses are associated with a higher risk for errors when compared to experienced Registered Nurses (RNs) (Berklow & Virkstis, cited in Saintsing, Gibson & Pennington 2011, p. 355). The allocation of higher workloads compared to student placements, stress, inexperience and limited clinical reasoning skills have been identified as possible causes of medication errors in novice nurses (Saintsing, Gibson & Pennington 2011). Medication errors account for the second most reported incident occuring in Australian hospitals and are associated with significant morbidity, mortality and economic implications (James, cited in Sahay, Hutchinson & East 2015, p. e21).

I have selected medication management as the focus for this essay as I have found this to be a weakness in my clinical practice while participating in several practical experience placements. The two key areas that I have had difficulty with are the interpretation of the National Inpatient Medication Chart (NIMC) and the preparation of intravenous (IV) medications. On reflection, I can attribute my medication related issues to a noticeable gap between the limited practical opportunities provided in the classroom and the clinical environment, unfamilarity with clinical resources including IV pumps, navigating through conflicting preceptor practices, the doubling up of regular and when required (PRN) medications, drug interactions and correct dosages.

As I review the literature, it would appear that I share similar misgivings with other nursing students on the cusp of graduation. Whitehair, Provost and Hurley found poor student identification of five common prescription errors when interpreting a simulated NIMC including a drug interaction and drug allergy, incorrect direction and indication of use and an incorrect dose of varying medications. The study involved quizzing pre-graduating nursing students in an Australian university (Whitehair, Provost & Hurley 2014). In their study Vaismoradi, Jordan, Turunen and Bondas investigated nursing perspectives from 24 students on the cause of medication errors and found limited and delayed practical experiences to consolidate theory in clinical settings, the fear of making mistakes and unfamiliar and limited resources in the clinical setting to be significant determinants of medication incompetence (2014). Various other authors have extended upon the above causes of medication mis-management in graduate nurses to include poor clinical and communication skills, low confidence, restricted independent practice, poor organisational skills, workplace cultures, exposure to new environments and inadequate clinical support (Parker, Giles, Lantry and McMillan 2014; Berkow et al. and Ebright et al. cited in Sahay, Hutchinson & East 2015; Sahay, Hutchinson & East 2015).

While I can certainly relate to several of the above factors, I am aware that the responsibility of medication management is predominantly mine. As a graduating RN, there are various strategies that I can employ to assist in improving competence in the safe adminstration and monitoring of medications. Despite various strategies targeting the workplace, I will discuss two strategies that I can personally adopt in this regard.

Perhaps the mainstay of best practice for medication administration has been the traditional 6 R’s: medications given to the right person, at right time, in the right form via the right route and right dose and including the right documentation (Harris 2014, p. 403; Krivan 2016, p. 3). However, as the global population moves towards an ageing demographic and the emergence of associated chronic disease processes and significant co-morbidities precipitates advancement in medications and polypharmacy use, there is a greater need for nurses to be aware of the full medication journey (Edwards & Axe 2015; Adhikari et al. 2014). The process includes preparation before, during and after administrating medications to patients, incorporating a multi-disciplinary approach and adding a further 5 rights to the original routine. These include the right to refuse, the right knowledge, the right questions, right advice and the right response (Edwards & Axe 2015, p. 404).

The right to refuse is applicable to both the patient and the nurse. As patient advocates, nurses are obligated to respect the automomy of patients and incorporate their informed wishes into the decision process (Edwards & Axe 2015). Likewise, the nurse is bound by evidence based practice to refuse administration of medications on the grounds of an incorrect prescription (illegible writing, omitted information), patient’s current condition (hypotension), clinical judgement (patient vomiting) and inappropriate stock (incorrect storage stock, form) (Edwards & Axe 2015). For example, Atik found 86.84 % of 1877 medication prescriptions failed to identify an indication for use in his study involving adherance to the Australian NIMC (2013). In such situations the nurse must document the act of refusal and consult with the appropriate clinical staff and or resources for further instructions (Edwards & Axe 2015).

The right knowledge requires the nurse to develop a solid understanding of the pharmocological aspects of medication management including side effects, correct storage, interactions, brand names, toxicity, pharmacokenetics and pharmodynamics while also involving the investigation of hospital policies (correct IV preparation and administration) and acceptable ward practices (Edwards & Axe 2015). The asking of the right questions refers to determining the appropriateness of the drug for the patient’s current conditions (Edwards & Axe 2015). The right advice involves the nurse imparting the correct knowledge to patients including risk factors for and against taking the medication (Edwards & Axe 2015). The final right, the right response is indicative of monitoring the effects once the medication has been given (desired response, allergic reaction, side effects), and ascertaining the continued appropriate use of and consulting with the relevant clinical staff (Edwards & Axe 2015; Elliot & Liu, cited in Randolph 2013, p. 21).

The adoption of the additional rights of drug administration does not guarantee the absence of medication errors (Randolph 2013). However I believe the inclusion of the additional 5 rights to the original process is an effective strategy for improving my medication management. The strategy will equip me with a deeper understanding of medications including drug interactions, facilitate the correct interpretation of the NIMC and encourage me to interact with other health professionals as part of a collaborative approach to care. As a vehicle for acquiring the appropropriate knoweldge base, there has been various studies highlighting the effectiveness of online interactive learning tools. This will constitute my second strategy for developing my skills in medication management.

According to Cant and Cooper (cited in Terry, Moloney, Bowtell & Terry 2016, p. 199), online simulation is merging forward as a permanent fixture in nurse education and a vehicle for self-directed learning. Self directed experiences can offer the pre-graduating nurse opportunuities to increase ‘autonomy, accountability and confidence’ as a means of preparing the nurse to overcome challenges in the clinical setting (Gagnon, cited in Terry, Moloney, Bowtell & Terry 2016, p. 199). One avenue that this is occuring is through emulation technology (computer assisted simulation). Studies have indicated a greater retention of skills and student confidence in clinical practice when compared to instructor led hands on simulations and or in-class sessions (Brydges et al. cited in Terry, Moloney, Bowtell & Terry 2016, p. 199). Following on from previous research, Terry et al. (2016) investigated the effectiveness of an online intravenous pump emulator for training nursing students and found a positive correlation existed between nursing competence when face –to- face and online learning experiences were combined. Likewise, Holland et al. (2013) found the deployment of an online video in best practice clinical skills education to be an effective adjunct to in-class clinical sessions for transferring acquired skills in oral medication administration to practice and also enhancing student satisfaction levels.

In both the examples above, the authors identified the use of online resources as positive supplementary learning tools to face-to-face education. The isolated endorsement of such education tools did not indicate effective means of transferring skills into clinical practice but highlighted the combined use of learning strategies as the best outcome (Terry et al. 2016; Holland et al. 2013).

Although, I have not personally been exposed to or able to access the online learning tools investigated in the above studies, there are various other self directed resources available such as UTube, learning packages in intravenous medication preparation and online courses through professional organisations such as the National Prescribing Service, the Australian Nursing and Midwifery Federation and the Australian College of Nursing. The above websites were recommended to me by my clinical facilitators while on practical exprience placements as additional resources to tap into as suitable strategies for improving my knowledge of patient medications and the use of the NIMC, consolidating practical skills and detecting medication errors.

In addition to assisting me in my medication management, online resources have enabled me to maintain an evidence-based practice of care. As highlighted in the introduction, medication management is an integral component of clinical governance. Clinical governance refers to the reflection and critical analysis of nursing practices as a framework for ensuring ongoing quality and safety of care to patients (Braine 2006). Medication management is applicable to clinical governance as medication errors can precipitate patient morbidity and mortality and endanger patient safety (James, cited in Sahay, Hutchinson & east 2015, p. e21).

With this in mind and as a student on the verge of registration, I must be accountable for my actions, reflective of my practices, demonstrate clinical reasoning and above all operate within my scope of practice. I am able to achieve this through retaining clinical competencies that are applicable to the Nursing and Midwifery Board of Australia’s (NMBA) standards of practice, most notably ‘maintains the capacity to practice, provides safe, appropriate and responsive quality nursing practice’ and ‘thinks critically and analyses nursing practice’ (NMBA 2016). Examples of the above standards would involve performing safe handling of IV pumps, being aware of alternative anticoagulant products and their benefits to warfarin and understanding the pharmacological causes of neuroleptic malignant syndrome in mental health. Such qualities are necessary in order to be the best advocate for my patients, promote autonomy, reduce the likelihood of errors, maintain professionalism and to work within a collaborative environment that incorporates an inter-disciplinary approach to patient care.

The student nurse on the bridge of transition to a registered nurse faces many challenges. Perhaps the biggest hurdle for me has been medication management and adapting my limited experience to the clinical environment. Through the adoption of two strategies including the endorsement of the 11 rights of medications and online resources, I hope to expand upon my knowldege base and adminstration skills to ensure the ongoing safety and best care of my patients. In doing so, I will also fulfil my future role as a registered nurse and operate within a framework to maintain clinical governance.

References:

Adhikari, R, Tocher, J, Smith, P, Corcoran, J & MacArthur, J 2014, ‘A multi-disciplinary approach to medication safety and the implication for nursing education and practice,’ Nurse Education Today, vol. 34, pp. 185-190, viewed 3rd September 2016, Science Direct Database.

Atik, A 2012, ‘Adherence to the Australian National Inpatient Medication Chart: The efficacy of a uniform national drug chart on improving prescription error,’ Journal of Evaluation in Clinical Practice, vol. 19, pp. 769-772, viewed 3rd September 2016, CINAHL Database.