PHARMACOLOGY KNOWLEDGE ACQUISITION - OhioLINK ...

Running head: PHARMACOLOGY KNOWLEDGE ACQUISITION i

THE RELATIONSHIP OF SELECTED ACADEMIC, NONACADEMIC,

AND CLINICAL VARIABLES AS FACTORS INFLUENCING

PHARMACY KNOWLEDGE ACQUISITION IN ASSOCIATE DEGREE

PRE-LICENSURE NURSING STUDENTS

By

DIANE M. STAUFFER

Submitted in partial fulfillment of the requirements for the degree of

Doctor of Nursing Practice

Committee Chair: Marilyn Lotas, PhD, RN, FAAN

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

August 2016

ii

CASE WESTERN RESERVE UNIVERSITY

FRANCES PAYNE BOLTON SCHOOL OF NURSING

We hereby approve the scholarly written project of

Diane M. Stauffer

Committee Chair

Marilyn Lotas, PhD, RN, FAAN

Committee Member

Deborah Lindell, DNP, RN, CNE, ANEF

Committee Member

Joni Goldwasser, DNP, APRN, FNP-BC

Date of Defense

June 10, 2016

We also certify that written approval has been obtained for any proprietary material

contained therein.

iii

Abstract

Effective medication management is critical to safe practice. The Institute of

Medicine reports that medication errors are common and adversely affect patient

outcomes. In order for nurses to effectively manage medications and ensure safe

patient care, a comprehensive knowledge of pharmacology is required. However,

studies suggest nurses are inadequately prepared and do not have sufficient

knowledge. The lack of pharmacology knowledge is attributed to a variety of factors

that impact nursing education including the lack of biological sciences, ineffective

teaching, superficial learning strategies, inadequate time devoted to pharmacology,

and barriers or lack of opportunities for clinical application. Identifying factors that

contribute to academic success or failure enables educators to pinpoint high-risk

students early, provide counseling and academic support, and optimize student

performance. This study used a descriptive correlational design to examine academic,

non-academic, and clinical variables for pre-licensure nursing students in an

Associate’s degree program. The purpose of the study was to determine the

correlation between selected variables and pharmacology knowledge acquisition as

demonstrated by scores on a standardized pharmacology assessment. A second

purpose of the study was to determine any correlation between student perceptions of

clinical experience opportunities for medication management and performance on the

pharmacology assessment. Seven variables were analyzed for the nature and strength

of relationships including nursing grade point average (GPA), science GPA, previous

college credit or degree, previous health care experience in direct patient care,

working hours per week, family responsibilities, and clinical experience opportunities

for medication administration and decision-making. The study found a significant

correlation between nursing grade point average (GPA) and pharmacology test

scores, and science GPA and pharmacology test scores. These findings are consistent

with the literature that demonstrates science GPA as a predictor for academic success

in nursing, and nursing GPA as a predictor for standardized testing and NCLEX-RN

success. No other variables were found to be significant in the correlational analysis.

Further study is recommended to examine the selected variables in a larger more

heterogeneous population, and to analyze pharmacology knowledge acquisition

among programs with varying clinical experience opportunities for medication

management.

iv

Copyright© 2016 by Diane M. Stauffer, MSN, RN, CNE

v

Dedication

This scholarly project is dedicated to all students of the Good Samaritan College of

Nursing and Health Science in honor of their commitment to nursing education, and

to the class of May 2016 for their support of nursing research through participation in

this study. Throughout my career as a nurse educator, I have been overwhelmed by

the adversity students overcome to be successful in the nursing program, yet I

continue to witness a genuine compassion, caring, and advocacy for all patients. To

all nurses and nursing students, thank you for your amazing work, and for all of your

efforts to ensure safe and quality patient care in a very challenging health care

environment.

vi

Acknowledgements

I would like to acknowledge the contributions and support of the following

individuals in the completion of this research project and toward achievement of

my goal to obtain a doctoral degree in nursing practice.

Thank you to Dr. Marilyn Lotas, the chairperson of my committee for her

guidance through the research process. Her direction enabled me to focus on the

essential elements of the study, and to improve my scientific writing with clear

and concise communication. Thank you to committee members, Dr. Lindell and

Dr. Goldwasser for their time and valuable feedback for the study proposal

through the final defense. Thank you to Dr. Goldwasser for her friendship,

empathy and reassurance that I would survive this journey.

Thank you to Dr. Joy Dienger, Nurse Researcher at TriHealth, Inc. for her

guidance in developing the clinical experience survey questionnaire, and for her

invaluable assistance in obtaining IRB approval and navigating the complex

Institutional Review Board process.

Thank you to Dr. Gregory Graham and Dr. Mary Ann Heverly for their statistical

expertise and assistance in determining and conducting the statistical analyses for

the study. Dr. Heverly was especially instrumental in helping me to conduct the

analysis and interpret the results of the study.

Thank you to the Good Samaritan College of Nursing and Health Science faculty

and administration. The encouragement, accommodation, and support of

administrators and colleagues have been unwavering throughout my doctoral

education. A special thank you is extended to Dr. Teresa Getha-Eby for her

guidance and meticulous work in editing this final scholarly project.

Thank you to my sister, Debbie Young and dear friend, Randi Carnahan. Their

love and support is unconditional and means the world to me. Thank you both for

always offering a listening ear and shoulder to lean on. To my sister, I would not

have been able to devote the time necessary to complete this educational endeavor

had it not been for you.

vii

Table of Contents

Title Page i

Committee Approval Page ii

Abstract iii

Copyright Page iv

Dedication v

Acknowledgements vi

Table of Contents vii

List of Figures xi

List of Tables xii

Chapter 1: Introduction 1

Introduction/Background 1

Problem 2

Purpose 3

Significance of the Problem 4

Significance to Nursing 5

Theoretical Framework 7

Research Questions 13

Conceptual Definitions 14

Summary 15

viii

Chapter 2: Review of the Literature 17

Pharmacology Knowledge Level for Nurses, New Graduate

Nurses, and Nursing Students

18

Inadequate Pharmacology Knowledge as a Factor for

Medication Errors

28

Factors Influencing Pharmacology Knowledge

34

Strategies to Enhance Pharmacology Knowledge 45

Gaps in the Literature

50

Chapter 3: Methodology 52

Design 52

Setting 52

Study Population 53

Recruitment 55

Inclusion and Exclusion Criteria 57

Sample Size Determination 57

Measurements 59

ATI RN Pharmacology Assessment 59

Clinical Experience Survey Questionnaire 65

Demographic Information Form 66

Data Collection Procedure 67

Data Management 69

Statistical Analysis 70

Protection of Human Subjects 75

ix

Chapter 4: Data Analysis 79

Sample Demographics 79

Analyses of Research Questions 81

Research Question 1 81



Summary 95

Chapter 5: Discussion 97

Discussion 97

Level of Performance on ATI Pharmacology Assessment 98

Relationship between Selected Variables and ATI Performance 100

Relationship between Clinical Experiences and ATI Performance 104

Utility of the Theoretical Framework 107

Limitations 108

Implications for Nursing and Nursing Education 110

Future Research 112

Conclusion 114

References 117

Appendices

Appendix A - Script for Introduction and Description of Study 130

Appendix B – Notice of Study 131

x

Appendix C - Original Survey Questionnaire and Summary of Reviewer

Feedback

132

Appendix D - Final Revised Clinical Survey Questionnaire 136

Appendix E - Demographic Information Form 138

xi

List of Figures

Figure 1 – Differences between Pedagogy and Andragogy 8

Figure 2 - Scatter Plots for Continuous Variables 82

Figure 3 - Histogram of ATI Pharmacology Assessment Scores 83

Figure 4 - Histograms of Clinical Experience Survey Average Scores 91

xii

List of Tables

Table 1 - Perceived Factors Influencing Pharmacology Knowledge

Acquisition

36

Table 2 - Categories and Competency Areas that Establish Medication

Competence

47

Table 3 – Associate Degree Nursing Program Curriculum 55

Table 4 - ATI RN 2013 Proctored Pharmacology Assessment

Concepts and Content Areas

60

Table 5 - ATI RN 2013 Pharmacology Assessment Cut Scores

and Proficiency Level Definitions

63

Table 6 - RN CMS 2013 Test Statistics for the Pharmacology

Assessment

65

Table 7 - Study Participants’ Age, Gender, Ethnicity 80

Table 8 - Descriptive Statistics for ATI Pharmacology Assessment

Scores

84

Table 9 - Descriptive Statistics for Academic Variables 86

Table 10 - Descriptive Statistics for Non-Academic Variables 88

Table 11 - Correlations for Selected Variables and ATI Pharmacology

Assessment Score

89

Table 12 - Descriptive Statistics for Clinical Experience Survey 92

Table 13 - Frequency Distribution for Clinical Experience Survey

Responses

93

Table 14 - Correlational Statistics for Clinical Survey Questionnaire 94

PHARMACOLOGY KNOWLEDGE ACQUISITION 1

Chapter 1: Introduction

Nurses have key responsibilities in the management of medication therapy,

and fulfill a number of roles that require pharmacology knowledge. In addition to

roles and responsibilities, the importance of pharmacology knowledge for nurses is

reinforced by the magnitude of drugs on the market, the use of multiple drug

therapies, changing regimens involving new drugs, and complex fast-paced health

care environments (Adhikari, Tocher, Smith, Corcoran, & MacArthur, 2014; Ndosi &

Newell, 2008). Effective medication management is critical to safe practice; however,

in order for nurses to successfully manage the diverse roles of medication therapy and

promote safe patient care, a comprehensive knowledge of pharmacology is essential

(Adhikari et al., 2014; Dilles, Vander Stichele, Van Bortel, & Elseviers, 2011; King,

2004; Manias & Bullock, 2002a, Manias & Bullock, 2002b).

Despite the need for pharmacology knowledge and the role of nurses in

medication administration, many nurses have insufficient knowledge and are

inadequately prepared in this area (Adhikari et al., 2014; Bullock & Manias, 2002;

Dilles et al., 2011; Honey & Lim, 2008; King, 2004; Latter, Rycroft-Malone, Yerrell,

& Shaw, 2000, 2001; Ndosi & Newell, 2008; Simonsen, Daehlin, Johansson, &

Farup, 2014). Novice nurses or new graduates, in particular, have difficulty

comprehending pharmacology and applying it to practice (Adhikari et al., 2014;

Manias & Bullock, 2002; Simonsen et al., 2014). The limited understanding of

pharmacology is attributed to a variety of academic factors including the lack of

biological sciences in nursing education, difficulty understanding the biological


sciences, dissatisfaction with teaching, a gap between theory and practice, inadequate

time devoted to pharmacology, and barriers or lack of opportunities for clinical

application (Bullock & Manias, 2002; Clancy, McVicar, & Bird, 2000; McVicar,

Clancy, & Mayes, 2010; Dilles et al., 2011; King, 2004; Morrison-Griffiths,

Snowden, & Pirmohamed, 2002). The academic issues described in the literature

reflect potential deficiencies in nursing curriculum design or teaching methodologies.

Several studies have explored the influence of course design, teaching strategies, and

other classroom factors (Adhikari et al., 2014; Dilles et al., 2011; Honey & Lim,

2008; King, 2004; Latter et al., 2001; Manias & Bullock, 2002a, 2002b); however,

few studies have examined specific variables unique to the student, or the impact of

clinical opportunities for medication management on pharmacology knowledge

acquisition.

Nursing education is responsible to ensure graduates have acquired the

knowledge and skills to provide safe and effective patient care inclusive of

medication management. Accordingly, it is imperative that nurse educators recognize

the increasing significance of pharmacology education, examine and evaluate

pharmacology curricula, identify variables that impact science comprehension, and

employ effective teaching strategies to support the acquisition of adequate

pharmacology knowledge in pre-licensure nursing students.

Problem

Nurses have a major role in medication administration; however, the knowledge

base for safe medication administration and patient education is inadequate for many


nurses and nursing students. The complexities surrounding the acquisition of

pharmacology knowledge are well documented in the literature including, but not

limited to, the task of incorporating adequate pharmacology in nursing curricula, the

difficulty students have with the biological sciences, the lack of faculty expertise or

effective teaching strategies, the extensive amount of content to learn, and the lack of

clinical opportunities for medication administration and decision-making. In order to

improve pharmacology knowledge acquisition by nursing students, it is essential for

nurse educators to better understand the factors contributing to the current

pharmacology knowledge deficit. However, few studies exist in the literature

examining factors that influence or predict pharmacology knowledge acquisition for

nursing students.

Purpose

The purpose of this study was to examine the relationship of selected

academic and non-academic variables in pre-licensure Associate Degree nursing

students, and pharmacology knowledge acquisition as demonstrated by performance

on a final standardized pharmacology assessment. A second purpose of the study was

to evaluate the medication administration and decision-making experience as self-

reported by Associate Degree nursing students, and determine if there was any

correlation between student perceptions of clinical experience opportunities for

medication management and performance on the final pharmacology assessment.


Significance of the Problem

Advancements in medical science and technology over the past several

decades have improved the ability to diagnose and manage complicated health

conditions. As a result, patients with chronic illnesses live longer, and are

increasingly dependent on complex therapeutic regimens (Adhikari et al., 2014).

Likewise, changing demographics reveal an aging patient population with multiple

co-morbidities, and many of these patients require more than one prescriptive

medication (Ndosi & Newell, 2008). The acuity of hospitalized patients has risen

significantly, resulting in many patients who are receiving a variety of

pharmacological therapies. These complex regimens potentially compromise safe

patient care as the risk of medication error rises in proportion to the number and

variety of drugs a patient receives (van den Bernt, Egberts, & Lenderink, 2000).

Quality care and patient safety have been targeted intensely for improvement

in health care institutions over the past decade. Reports by the Institute of Medicine

(IOM) of the National Academies have demonstrated that medical errors are common

and adversely affect patient outcomes (IOM, 1999). Current estimates for annual

deaths in the United States related to medical error are as high as 400,000, and

adverse drug events are evolving as a leading cause of death for Americans (James,

2013). Medication errors are costly to patients, families, employers, hospitals, health

care providers, and insurance companies. It has been difficult to determine reliable

estimates of cost, but the IOM suggested that each preventable adverse drug event

occurring in a hospital in 2006 added approximately $8,750.00 to the cost of the


hospital stay; the total annual cost of adverse drug events was estimated at three to

five billion dollars (IOM, 2006). Unequivocally, medication errors potentially create

physical, emotional and economic distress for patients and families, cost human lives,

prolong hospital length of stay, and have serious financial consequences for providers

and health care institutions.

Medication management is a complex, multi-stage, multidisciplinary process.

Medication errors may occur at any stage of the medication process, but are most

frequently noted during the prescribing and administration phases (Cohen, 2006;

IOM, 2006). Of the disciplines involved in the medication process, nurses are most

frequently responsible to administer medications to patients. Medication

administration is a high-risk area, and medication errors are noted as a persistent

problem in nursing practice (Armitage & Knapman, 2003; O’Shea, 1999). There are

numerous factors associated with medication errors involving nurses and nursing

students; cited among these factors are the issues of inadequate pharmacology

knowledge and limited clinical experience opportunities for medication management

(Brady, Malone & Fleming, 2009).

Significance to Nursing

Nurses assume a primary role in the administration of medications, and are

regarded as the final link in the defense for medication safety (Adhikari et al., 2014).

It is estimated that nurses spend as much as 30-40% of their time administering

medications (Armitage & Knapman, 2003; Keohane et al., 2008). While studies

confirm that nurses do, in fact, follow the traditional “five rights” principle of


medication administration, expertise beyond the “five rights” is needed in order to

ensure holistic medication safety (Adhikari et al., 2014; Eisenhauer, Hurley, & Dolan,

2007). In consideration of the nursing time spent on medication administration, the

high-risk nature of the process, the impact of adverse drug events, and the complexity

of the clinical environment, it is essential for nursing to develop effective strategies to

enhance pharmacology knowledge.

Ensuring that graduates are prepared to function in the current health care

environment is a priority for nurse educators; therefore, it is important that educators

examine factors that contribute to or detract from pharmacology knowledge

acquisition. Evidence reveals that medication errors are high among the prevalent

errors involving new graduate nurses (Cebeci, Karazeybek, Sucu, & Kahveci, 2015;

Smith & Crawford, 2003), and that novice nurses struggle to understand and apply

pharmacology knowledge to clinical practice (Adhikari et al., 2014; Manias &

Bullock, 2002b; Simonsen et al., 2014). Over 6000 drugs are currently approved by

the Food and Drug Administration (FDA), and 25-50 new drugs are added to the

market every year (U.S. FDA, 2013). In addition to preparing students to function as

a beginning clinician, students must also develop effective skills for lifelong learning

in a subject that is constantly changing (Lim & Honey, 2006). The incidence of errors

and the need for effective skills for ongoing learning have wide-ranging implications

for curriculum development, teaching methodologies, and transition to practice. The

findings are also important for administrators with respect to mentoring, orientation

programs, staffing levels, and continuing education.


Factors that hinder or promote academic success in nursing and on the

NCLEX-RN examination are highly relevant for nursing education. Updates to the

NCLEX-RN blueprint in 2004 reflected an increase in content associated with

pharmacology and physiological integrity. Additionally, a very recent change in the

NCLEX-RN is the exclusive use of generic names for test items addressing

medications (National Council State Boards of Nursing, 2015). Nurse educators have

a responsibility to identify students who are at risk for failure, and implement early

interventions to promote success or counsel students for an alternative course of

action. Unsuccessful student performance in academia or on the NCLEX-RN

examination has significant consequences for students, programs of nursing and

health care institutions. These consequences include financial burden, emotional

distress, nursing shortages, hiring and training costs, and issues related to nursing

program accreditation. The volume of learning required to master the body of

knowledge necessary for safe nursing practice is overwhelming for students and

continues to rise. All of these factors are significant for nursing education and

pharmacology curricula.

Theoretical Framework

In a 2012 survey of student demographics from Schools of Nursing, the

National League for Nursing (2013) identified that fifty percent of the population of

Associate Degree students are greater than thirty years of age. The Health Resources

and Services Administration (HRSA) under the United States Department of Health

and Human Services (2010) also reports that the average age of nursing students who


graduated from their initial nursing education program after 2004 is 31 years. Clearly,

the entry level for the majority of nursing students is well beyond adolescent years,

and therefore, most students are categorized as adult learners. For this reason, adult

learning theory was used to inform the study.

Adult Learning Theory

Andragogy is a term used to refer to the art and science of adult learning or to

the education of adults, which holds a set of assumptions about how adults learn

(Peterson & Ray, 2013). There are several explanations of the Greek origin of the

word, andragogy, which are based on the stems aner, andr or Andros (Henschke,

1998). All explanations of the stems or term, andragogy, denote a meaning of “man,

not boy” or “adult man guiding himself” versus pedagogy, which is explained as

“leader of child” (Henschke, 1998). The term, andragogy, was coined by Alexander

Knapp, a German educator, as early as 1833; however, Malcom Shepherd Knowles

(1913-1997) is primarily credited as pioneering andragogy in America and

developing andragogy into a theory of adult learning (Peterson & Ray, 2013).

The concept of andragogy specifically focuses on differences in how adults

learn that warrant methods of teaching unlike those used in Pedagogy, the education

of children. Figure 1 demonstrates the difference in relationships between the

instructor and the student in pedagogy as compared to andragogy. In pedagogy, the

learner (child) is dependent on the teacher who controls all learning and the learning

environment. In andragogy, the learner is self-directed and involved in the learning

process, and the teacher is a facilitator of learning.


Figure 1

Differences between Pedagogy and Andragogy

Pedagogy Andragogy

Content Centered Learner Centered

(Teacher) (Learners)

Knowles identified four assumptions about the characteristics of adult learners

that focus on self-concept, experience, readiness to learn, and a problem-centered

orientation to learning (Chan, 2010; Pappas, 2014). Self-concept refers to the need for

adult learners to direct their plan for learning, have autonomy and be independent.

Experience reflects the knowledge, skills and past experiences that adults bring to the

classroom. In this way, learners themselves are a resource for learning as they tend to

learn by drawing from their previous experiences. Readiness to learn indicates that

adults are focused and have a reason for learning. They desire to learn about those

things that are relevant to themselves, family or work. Orientation to learning clarifies

that adults are problem centered rather than content centered. Adults are task-

oriented, life-focused and learn for immediate application (Chan, 2010). In 1984,

Knowles (as cited in Pappas, 2014) added a fifth assumption of motivation, which

Student Student

Student Student

Teacher

Teacher

Student

Student

Student

Student


recognizes that learning is internally motivated, and there is a sense of urgency about

learning. Billings and Halstead (2012) provide a contemporary and succinct

description of adult learners as “… increasingly self-directed and have experiences

that serve as a rich resource for their own and others’ learning” (p. 221).

In the 1980’s, Knowles also identified four principles that are applied to adult

learning. These principles overlap with some of the assumptions and are described as

the need for adults to be involved in their instruction, the recognition that experience

(including mistakes) provides the basis for learning activities, the need for learning

content that has immediate relevance, and the focus of learning on problems rather

than content (Pappas, 2014). Adult learners are thought to perform well when they

use their prior experience, and apply new knowledge to solve real problems. Two

additional characteristics of adult learners relevant to the theory are that adults have

preferred differences in personal learning style, and have responsibilities and life

situations that provide a social context that affects their learning (Jackson and

Caffarella as cited in Billings & Halstead, 2012). For the adult learner, school is often

secondary to other activities and responsibilities. Knowles emphasized that educators

must understand that adults return to school for specific reasons and to gain specific

knowledge. Educators must also recognize the prior knowledge that adult learners

bring and build on that knowledge.

Holton, Swanson and Naquin (2001) extended the core model of Andragogy

to develop the Andragogy in Practice Framework. This framework offers an

expanded conceptualization of andragogy that incorporates domains that influence the


application of core principles. It applies andragogy across multiple domains of adult

learning, and identifies three dimensions in practice: goals and purposes for learning,

individual and situational differences, and core adult learning principles (Holton,

Swanson, & Naquin, 2001). The three rings of the model interact offering a process to

understand adult learning situations. The goals and purposes for learning create the

experience and may be categorized as institutional, societal or individual (Holton,

Swanson, & Naquin, 2001). Individual and situational differences represent variables

that impact adult learning and include subject matter differences, situational

differences and learner differences. The “individual differences” category

incorporates variations in cognitive ability, personality and prior knowledge.

Situational differences during learning include a full range of social, cultural, and

situation-specific factors that may impact the learning transaction (Holton, Swanson,

& Naquin, 2001). The core adult learning principles have been described in the

preceding paragraphs. The model recognizes that learning is multi-faceted, and that

individuals vary in their approaches, strategies and preferences for learning activities

(Holton, Swanson, & Naquin, 2001).

Both Andragogy, or Adult Learning Theory and the expanded Andragogy in

Practice serve as a framework for this study. In a 2012 survey of student

demographics from Schools of Nursing, the National League for Nursing (2013)

identified that fifty percent of the population of Associate Degree students are greater

than thirty years of age. The Health Resources and Services Administration (HRSA)

under the United States Department of Health and Human Services (2010) also


reports that the average age of nursing students who graduated from their initial

nursing education program after 2004 is 31 years. Clearly, the entry level for the

majority of nursing students is well beyond adolescent years, and therefore, most

students are categorized as adult learners.

Individual and situational differences as described in the Andragogy in

Practice framework can be applied as variables that influence knowledge acquisition

for adult learners. The core principles of andragogy also incorporate factors that may

be studied as variables that contribute to or impede learning for adult students. For

example, prior experience such as health care experience, or prior knowledge as a

result of earning another degree or college credit may serve to enhance learning.

Cumulative grade point average in nursing and in the sciences reflects cognitive

abilities, which is a component of individual differences in the Andragogy in Practice

model. As adult learners and non-traditional students, employment and family

responsibilities are potential variables that interfere with academic performance and

success in nursing.

Andragogy emphasizes that adult students must find relevance in what they

are learning. This assumption may be applied in relation to the value of clinical

experiences and the opportunities for medication management. In these practical

experiences, the significance of pharmacology to nursing practice is clearly evident

and appreciated by most students. Furthermore, since andragogy emphasizes that

adults tend to learn from previous experiences, it is reasonable to infer that a potential

relationship exists between a student’s cumulative clinical experience in medication


management and pharmacology knowledge acquisition. In consideration of the

premise of the theory, the core principles, and the expanded contextual factors, the

Theory of Adult Learning - Andragogy and Andragogy in Practice provides an

appropriate framework to structure the study. Selected academic and non-academic

variables that are especially relevant to adult learners will be evaluated in the study in

order to identify any correlation with pharmacology knowledge acquisition in

Associate Degree pre-licensure nursing students. The quality of students’ clinical

experiences in relation to medication management will also be examined as a

potential factor influencing knowledge acquisition as evaluated by the ATI

standardized pharmacology assessment.

Research Questions

The specific research questions guiding the study were as follows:

1) What is the level of performance for the study group on the final ATI

standardized pharmacology assessment?

2) What is the bivariate relationship between certain academic variables (nursing

grade point average and science grade point average) and non-academic

variables (previous college credit or degree, previous health care experience,

working hours per week, and family responsibilities) and performance on the

final ATI standardized pharmacology assessment?

3) What is the bivariate relationship between students’ self-reported perceived

clinical experiences in medication management and performance on the final

ATI standardized pharmacology assessment?


Conceptual Definitions

The following definitions were identified in relation to the specific research

questions, the underlying theoretical framework, and selected variables in the study:

1. Andragogy – The theory of the education of adult students or adult learners.

2. Clinical Experience in Medication Management – Perceived opportunities for

experience in medication administration and decision-making as self-reported

by students.

3. Family Responsibilities – financial responsibility as head of household,

responsibility for dependent children, or responsibility as a caregiver.

4. Health Care Experience – Any current or previous work experience related to

direct patient care in a health care setting.

5. Nursing Grade Point Average - the cumulative grade point average achieved

in three prior nursing clinical courses.

6. Pharmacology Knowledge Acquisition – the acquisition of pharmacology

knowledge expected for a newly licensed, entry-level registered nurse as

demonstrated by scores on the ATI Pharmacology Assessment test that meet

the content-specific assessment benchmark.

7. Science Grade Point Average – the cumulative grade point average achieved

in three prior biological science courses.

Summary

Effective medication management is critical to safe practice, and nurses have

key roles and responsibilities in the administration of medications. In order for nurses


to successfully manage the roles and responsibilities of medication management and

ensure safe patient care, a comprehensive knowledge of pharmacology is required.

Research indicates that nurses do not have sufficient knowledge and are inadequately

prepared in pharmacology. The limited knowledge of pharmacology by nurses and

nursing students is attributed to a variety of factors that impact educators and

academia. Nurse educators are responsible to ensure that graduates have sufficient

knowledge and skills for safe practice. Medication competence is a priority for

nursing education, and requires educators to carefully assess pharmacology curricula,

implement effective teaching methodologies, provide ample clinical opportunities for

medication decision-making, and identify variables that impact pharmacology

knowledge acquisition.

Research has identified a correlation between pharmacology course grades or

standardized assessments, and performance on the NCLEX-RN. A number of studies

have been conducted to determine variables that predict successful NCLEX-RN

performance; however, few studies have investigated variables that influence

pharmacology learning. The purpose of this study was to examine selected academic,

non-academic, and clinical variables for nontraditional second-year students in an

Associate Degree nursing program, and determine if any of these variables correlated

with successful acquisition of pharmacology knowledge. There was a large

population of nontraditional students in the selected program, and nontraditional

students are perceived as a potential group at risk for retention and academic

performance issues. Identifying valid predictors of academic success or failure


enables nurse educators to pinpoint high-risk students, provide needed academic

support, and optimize student performance. Empirical evidence of the relationship

between standardized assessments in pharmacology and NCLEX-RN performance

also supports the need to further investigate factors that influence or predict

pharmacology knowledge acquisition.


Chapter 2: Review of the Literature


academic and non-academic variables to pharmacology knowledge acquisition by

undergraduate nursing students as demonstrated by performance on a final

standardized pharmacology assessment. A second purpose of the study was to

evaluate the medication administration and decision-making experience as self-

reported by students, and determine if there was any correlation between student

perceptions of opportunities for medication management during clinical experiences,

and performance on the final standardized pharmacology assessment. This chapter

contains a review of the current literature in relation to four primary areas: 1) studies

of pharmacology knowledge level in nurses, new graduate nurses, and nursing

students; 2) studies identifying inadequate pharmacology knowledge as a factor for

medication errors; 3) studies of factors influencing pharmacology knowledge

acquisition; and 4) strategies faculty have used to enhance pharmacology knowledge

acquisition.

The process used to review the literature was consistent for all primary areas

to be presented. Several web-based searches were conducted with a variety of

keywords or search terms through PubMed (inclusive of MEDLINE), Cumulative

Index for Nursing and Allied Health Literature (CINAHL), and Education Resources

Information Center (ERIC). Additional searches were completed through OVID, a

software available through the hospital and college library service, which

incorporates MEDLINE, Pre MEDLINE, CINAHL, Evidence Based Medicine


(EBM) Reviews, Cochrane Database of Systematic Reviews, Cancerlit, and Excerpta

Medica Database (EMBASE). The database searches were primarily limited to the

past ten years, although some earlier key studies that have been cited frequently in the

literature were also reviewed and are included in this discussion.

Pharmacology Knowledge Level for Nurses, Graduate Nurses, Nursing Students

Effective medication management is critical to safe practice, and dependent

on adequate pharmacology knowledge of the nurse. However, a number of studies

present evidence that nurses have insufficient pharmacology knowledge, lack

confidence in their knowledge, or are inadequately prepared in this area. Twelve

research studies ranging from 1996 to 2015 were examined regarding the adequacy of

pharmacology knowledge, factors impacting this knowledge, and recommendations to

improve pharmacology education. For purposes of this study, articles solely

addressing mathematical skills and drug calculations were excluded from the review.

The research is presented in reverse chronological order and organized under the

following subject headings: inadequate pharmacology knowledge for nurses and new

graduates and inadequate pharmacology knowledge for nursing students. The

following discussion focuses on the more prominent studies that reported on the level

of pharmacology knowledge in nurses, new graduates, and nursing students.

Inadequate pharmacology knowledge for nurses, new graduate nurses.

The first study in this section addressed pharmacology knowledge level for

both nurses and nursing students. Adhikari et al. (2014) conducted an ethnography-

style observational study utilizing qualitative interviews and group discussions to


study the medication management systems and practices of two hospital wards. This

study also sought to clarify nursing education on medication safety in three Higher

Education Institutions (HEIs) in Scotland. The researcher spent 63 hours shadowing

health care professionals, and conducted seven interviews with charge nurses and

registered nurses. Data was also collected from 21 final year nursing students in three

HEIs using peer and focus group discussions. While the authors found that nursing

staff did, in fact, follow the “five-rights” principle of medication administration, they

concluded that this principle alone is inadequate to ensure holistic medication safety.

The study reported that nursing students expressed a lack of confidence and concerns

of limited knowledge in pharmacology, and insufficient understanding of how

medications work. Furthermore, the depth of learning experiences and clinical

exposure in pharmacology during clinical placements varied among the group.

Eisenhauer et al. (2007) also emphasized that medication administration requires

professional expertise beyond the technical application of the “five-rights” principle.

This conclusion was based upon semi-structured interviews and real-time tape

recordings of 40 nurses at a large tertiary care teaching hospital. Eisenhauer et al.

(2007) analyzed nurses’ thinking processes during medication administration, and

revealed that nursing judgment was required for dosage, timing, and selection of

specific medications.

A comparative study examining medication knowledge, certainty and risk of

error between graduating Bachelor of Science in nursing (BSN) students and

experienced nurses was completed by Simonsen et al. (2014). A multiple-choice test


in pharmacology, drug management and drug dose calculations was administered to

243 graduating students and 203 registered nurses. The participants were required to

assign a self-estimated level of certainty for accurately answering each question. The

risk of medication error was then defined based on the combination of knowledge and

certainty for each question. Medication knowledge of experienced nurses was

superior to graduating students with the largest difference in drug management and

dosage calculations. Overall, the knowledge of both experienced nurses and nursing

students was still considered insufficient as the study revealed that one out of four

(25%) answers to test questions on drug management would have led to a high risk of

error. The authors noted that the findings of their study were consistent with an

integrative review by Killam et al. (as cited in Simonsen et al., 2014), which

emphasized lack of knowledge, skill incompetence, and overconfidence as

characteristics of students who are at risk for unsafe nursing practice.

A non-experimental causal comparative and correlational design was used in a

study by Ndosi and Newell (2008) to determine if nurses had adequate knowledge of

the drugs they commonly administer. Data was collected by structured interview and

questionnaire methods from 42 nurses working in surgical wards in England.

Participants blindly selected one out of four drugs they commonly administer, and

were required to answer standard questions focusing on specific pharmacology

knowledge. Knowledge scores ranged from 20-90% with a mean score of 60%. The

majority (n=31, 74%) scored below 80%, which was considered insufficient

knowledge by the authors. The median experience of the participants was 10.87


years, and a correlation was found between test scores and years of experience. The

study suggested that nurses have inadequate pharmacology knowledge, especially for

drug interactions and mechanism of action, and that supplementary education focused

on common drugs is needed in clinical settings to promote safer medicine

management.

A descriptive study by King (2004) attempted to identify nursing roles that

require pharmacology knowledge, and evaluate nurses’ preparation for practice

through undergraduate pharmacology education. A qualitative approach was used to

collect data from 10 staff nurses of a 30-bed emergency admissions unit in northern

England. Semi-structured interviews were audiotaped, transcribed, and analyzed

using Burnard’s 14-stage method for analysis (Burnard as cited in King, 2004).

Participants indicated that they did not have sufficient pharmacology knowledge,

were dissatisfied with their pharmacology education, and experienced anxieties

related to potential harm as a result of insufficient preparation. Lack of structure,

insufficient time spent on pharmacology, and over-emphasis of the behavioral

sciences were cited as issues in undergraduate education. The author concluded that

improved teaching might increase nurses’ confidence in performing drug

administration and patient education, and decrease anxieties related to these roles.

Manias and Bullock (2002a, 2002b) completed two separate studies to explore

the perceptions and experiences of lecturers, students, and clinical nurses regarding

the educational preparation of undergraduate nursing students in pharmacology. The

second study (Manias & Bullock, 2002b) specifically focused on the perceptions and


experiences of clinical nurses regarding graduate nurses’ medication knowledge. In

this descriptive study, six focus group interviews were conducted with 38 nurses at

metropolitan and regional hospitals in Victoria, Australia. Four themes emerged from

the interviews including the knowledge base of graduate nurses, continuing education

needs of graduate nurses, aspects of pharmacology knowledge perceived as important

for nursing practice, and improvements for undergraduate nursing education. Clinical

nurses identified that the pharmacology knowledge base of graduate nurses was

severely inadequate. Furthermore, the study revealed that some experienced nurses

also lacked knowledge resulting in a reluctance to mentor or teach new graduate

nurses. Recommendations for pre-licensure education included the need for more

structured clinical experiences, pharmacology as a separate course, and self-directed

learning strategies for lifelong continuing education.

Ives, Hodge, Bullock, and Marriott (1996) have been cited in many articles for

their descriptive study to identify first year registered nurses’ actual and self-rated

pharmacology knowledge. A questionnaire survey was completed by 363 first year

nurses requiring participants to self-rate their knowledge in five categories of

pharmacology, and to answer questions designed to test their knowledge of the same

five categories. The survey also asked participants to rank the value of pharmacology

teaching strategies used in their undergraduate education. Test scores ranged from

16% to 92% with a mean score of 55.8%, and 35% of respondents scored less than

50% on the test. The study found that longer experience as a registered nurse

correlated with higher test scores. Respondents indicated that first year practical


experience and undergraduate clinical experience were the most important

contributions to their current pharmacology knowledge. Overall, the authors

concluded that many new nurses have an inadequate knowledge of pharmacology.

Allocating more time to pharmacology (35.3%), teaching pharmacology as a separate

subject (30.9%), and improved teaching methods (20.6%) were cited by nurses as

factors that would have improved undergraduate pharmacology education.

Inadequate pharmacology knowledge for nursing students.

A descriptive cross-sectional study of nursing education in Flanders, Belgium

was conducted by Dilles et al. (2011), which sought to describe pharmacology

education, evaluate graduating students’ pharmacology knowledge and calculation

skills, and describe their self-rated readiness for safe medication practice. Twenty-

nine schools participated in the study, and findings showed considerable diversity in

pharmacology curricula. These differences were noted in hours of content, specific

content topics, background or profession of the instructor, and integrated versus

separate pharmacology modules. A total of 613 graduating students also participated

in a correlational survey using the Medication Knowledge and Calculations Test

(MKC test). The mean score on the knowledge component of the MKC test was 52%

for diploma students (n=404) and 55% for baccalaureate students (n=209). On a scale

of 1-10, 27% of students rated readiness perception as < 5, and only 15% rated

themselves at eight or higher. No relationships were identified with the organization

of pharmacology as a separate or integrated module, the amount of hours per study

year, or the background of the instructor. However, the authors concluded that


graduating nursing students’ pharmacology knowledge and calculation skills are

insufficient to deliver safe medication care, and identified the need for defining a

framework with clear goals for pharmacology education.

Honey and Lim (2008) conducted a qualitative descriptive study to explore

nursing students’ perceptions of clinical practice situations and the ability to apply

pharmacology knowledge. Following completion of a final clinical rotation, 54

students in a class of 60 (90%) participated in the survey. An iterative method of

content analysis was used to identify phrases and themes from the survey responses.

The lack of time, accessible drug resources, opportunities to practice decision-

making, and role modeling by preceptors were identified as practice setting and staff-

related barriers. Lack of confidence in their depth and ability to apply pharmacology

knowledge, and information overload were two additional themes that emerged.

Some students (20%) indicated that academic preparation for pharmacology was

inadequate, and perceived the amount of information to learn as a barrier to

integrating pharmacology. Feelings of stress, lack of confidence in retaining

information, and the need to learn both trade and generic names of drugs were cited

as contributing factors to information overload. The authors emphasized the need to

explicitly link theory with clinical practice, and that students should learn

fundamental principles of pharmacology rather than attempting rote memorization of

multiple drugs.

The first study completed by Manias and Bullock (2002a) explored the

perceptions and experiences of lecturers and students regarding the educational


preparation of undergraduate nursing students in pharmacology. This study involved

fourteen focus group interviews at ten university settings in Victoria, Australia.

Participants comprised second and third year undergraduate students, and lecturer

participants included both nursing and bioscience faculty. In relation to pharmacology

knowledge level, the study found that basic pharmacological principles were rarely

addressed, and learning was superficial as students focused on memorizing isolated

and numerous facts about individual medications without understanding

characteristics of a group of medications. In addition to superficial learning, the study

identified that fast-paced clinical practice settings precluded productive learning

experiences in medication administration and management.

A study by Latter et al. (2001) reported on findings from a national survey

conducted to evaluate the educational preparation of nurses for a medication

education role in practice. A postal questionnaire was distributed to all higher

education institutions delivering pre and post-registration education in England.

Respondents were queried regarding curriculum design, time allocated to

pharmacology, learning outcomes, teaching methods, assessment strategies, and

integration of learning. The survey revealed a general dissatisfaction with the amount

of pharmacology included in the curricula, and the predominant model for teaching

pharmacology was as an integrated subject within other courses. The study also found

a lack of clarity regarding the pre-requisite knowledge required for practice as

reflected by imprecise learning outcomes and competencies, particularly for

medication education. The authors emphasized the need to establish outcomes and


competencies within the national policy framework for nurse education in order to

delineate knowledge and skills that should be included, and the amount of time that

should be devoted to the subject.

Summary of inadequate pharmacology knowledge and education.

In relation to a lack of pharmacology knowledge and education, the studies

reviewed primarily presented descriptive qualitative research. Two studies were

identified as comparative research designs; one of these two studies was a non-

experimental causal comparative and correlational design. One study in the review

was identified as a cross-sectional descriptive study. Sample populations were

comprised of staff registered nurses (including experienced and graduate nurses),

nursing students and nursing educators. A large percentage of the collective sample

encompassed first-year graduate nurses and final-year nursing students. In all studies

reviewed, data was collected through semi-structured peer, individual, and focus

group interviews, as well as surveys and questionnaires. One study incorporated real-

time tape recordings during medication administration, and four studies incorporated

some method of testing for pharmacology knowledge and drug calculations.

All of the studies included in this section of the review of the literature

queried subjects regarding medication safety practices and the adequacy of

pharmacology knowledge for nurses and nursing students. One study sought to

document nurses’ thinking processes during medication administration, and one study

focused on student perceptions of clinical experiences for application of

pharmacology knowledge. Many studies questioned about the perceptions of nurses,


nursing students and nurse educators regarding pharmacology education,

pharmacology curricula, and factors that influence the quality of pharmacology

knowledge acquisition. A collective summary of the research in relation to

pharmacology knowledge and education for nurses (including new graduate nurses)

and nursing students is presented.

Registered Nurses. Many clinical nurses acknowledge a lack of confidence

and knowledge in pharmacology, particularly in relation to patient medication

education, understanding of mechanism of action, and drug interactions. The lack of

nurses’ pharmacology knowledge, combined with the complex fast-paced nature of

the clinical setting hinders mentoring and teaching for both graduate nurses and

undergraduate students. It is also suggested that inexperienced new graduates are

potentially unable to recognize high-risk situations with medications, or may not be

prepared to manage adverse events, particularly in the context of multiple distractions

in the clinical setting. The demand for multi-tasking further increases the risk of error.

Pharmacology knowledge does tend to increase with length of experience, but

seasoned nurses are also noted to have knowledge deficits. Clinical nurses and new

graduate nurses consistently express dissatisfaction with undergraduate pharmacology

education, and indicate that more time needs to be allocated to pharmacology

curricula. Nurses, educators, and researchers agree that post-licensure supplemental

education is also important to consolidate pharmacology, but nurses observe the need

for continuing education programs that focus on mechanism of action, adverse

effects, and drug interactions rather than safe administration of medication.


Nursing Students. The research suggests that students’ pharmacology

knowledge and calculation skills are inadequate to support safe medication care.

Throughout the literature students identify that the amount of time spent on

pharmacology curricula does not match the extent of time nurses spend in practice for

managing patient medications. Overall, most students believe that academic

preparation for pharmacology is inadequate. Students lack confidence in their depth

of pharmacology knowledge and in the ability to apply that knowledge. The literature

identifies that students typically resort to superficial learning strategies as a result of

information overload, faculty expectations, and lack of guidance in self-directed

learning. Drug calculations and mathematical skills remain an ongoing problem area

for pre-licensure students, but conceptual skills in relation to extracting clinical data

and logically constructing a problem have been emphasized as a leading source of

math deficiency rather than calculation skills.

Inadequate Pharmacology Knowledge as a Factor for Medication Errors

Research studies addressing adverse drug events or medication errors in the

healthcare environment, particularly involving nurses and nursing students, were

examined to validate inadequate pharmacology knowledge as a contributing factor to

error. A total of fourteen articles published from 1999 to 2015 were reviewed, and the

sample population for each study targeted nurses or nursing students. All studies

sought to identify perceptions and factors contributing to medication errors, and data

was primarily collected by direct observation, surveys, or focus-group semi-


structured interviews. An overview of the most prominent of these exploratory

descriptive studies is presented.

Three studies presented a review of the literature on medication error factors

based upon a comprehensive computerized data search (Armitage & Knapman, 2003;

Brady, Malone, & Fleming, 2009; O’Shea, 1999). Brady, Malone, and Fleming

(2009) completed a review of the empirical literature on factors contributing to

medication errors from 1988 to 2007. Twenty-six quantitative and qualitative studies

were selected for specific review from an initial search generating 93 papers. The

authors determined that multiple complex factors impacted medication errors

inclusive of both system and individual issues. In the category of knowledge and

skills, the literature review revealed a high percentage of drug errors related to a

nurse’s lack of knowledge and experience with either the drug or equipment.

Confusion over drug names, lack of safety knowledge (i.e. compatibility issues),

miscalculations of dosage, and inability to conceptualize clinical information to

formulate a mathematical calculation were specific subsets of knowledge and skill

factors contributing to medication errors.

Armitage and Knapman (2003) utilized the ten factors for the role of the nurse

in drug administration as identified by O’Shea (1999) as a framework for their review

of adverse events. Contributing factors to adverse events included workload, staffing

shortages, failure to follow policy, distractions or interruptions, lack of

communication, and lack of pharmacology knowledge, particularly in relation to a

lack of conceptual mathematical skills. Evidence for length of experience and


educational level was inconclusive, but a Japanese study of 2800 errors (Kawamura,

as cited in Armitage & Knapman, 2003) did identify poor knowledge of recent

graduates as a key factor for intravenous drug errors. In addition to new graduates,

many studies reviewed by Armitage and Knapman (2003) indicated that nurses new

to the job, hospital, or clinical unit were more likely to make errors despite years of

experience.

O’Shea (1999) is cited by many authors for her literature review on factors

contributing to medication errors. She identified these factors as the following:

mathematical skills of nurses, nurses’ knowledge of medications, length of

experience, length of nursing shifts, workload, staffing levels, medication delivery

systems, single-nurse drug administration, policy and procedures, distractions and

interruptions, and quality of prescriptions. The lack of mathematical proficiency was

related to math calculations, conceptual issues, and measurement inabilities.

Three prominent studies examined factors contributing to medication errors as

perceived by nursing students (Cebeci et al., 2015; Harding & Petrick, 2008; Wolf,

Hicks, & Serembus, 2006). Cebeci et al. (2015) completed a cross-sectional survey of

324 students in Turkey over one academic year noting 402 reported errors, of which

124 (38.3%) actual errors occurred. The leading causes of error as identified by

students were performance deficit (n=141, 43.4%) and knowledge deficit (n=133,

41%). Harding and Petrick (2008) conducted a retrospective review of 77 medication

errors made by baccalaureate nursing students over a three-year period. Of the 77

errors, 28 (36.4%) were associated with limited knowledge and understanding of the


student. Forty-two percent of omission errors were related to the inexperience of

students in reading or accurately interpreting the medication administration record

(MAR). A descriptive, retrospective, secondary analysis study by Wolf et al. (2006)

examined 1135 medication administration errors by nursing students as reported to

MEDMARX, a national voluntary, internet-accessible medication error database.

The majority of errors were omission errors, followed by errors of administering the

wrong dose of a drug. Performance deficits (51.01%) and lack of knowledge

(26.52%) were prevalent causes of error, and inexperienced staff (77.71%) was a

leading contributing factor to error.

Two studies examined factors for medication errors as perceived by nurses

(Smith & Crawford, 2003; Tang, Sheu, Yu, Wei, & Chen, 2007). Smith and Crawford

(2003) attempted to determine the degree to which newly licensed nurses are involved

in medical errors, and the challenges novice nurses experience with beginning patient

assignments. Stratified random samples of 1000 recently registered nurses (RNs) and

1000 licensed practical/vocational nurses (LPN/VNs) were selected for a survey

questionnaire. Almost all of the RNs (97%) were working for an average of 6.8

months, and 87% were employed in hospitals. Forty-nine percent of RNs had been

involved in errors, and medication errors were cited as the most frequent type of error

(75%). Inadequate staffing was identified as the most frequent factor contributing to

all errors (70%), followed by communication issues (44%) and long work hours

(23%). Approximately 20% of RNs believed that their initial and current patient

assignments were too difficult.


Tang et al. (2007) administered a questionnaire to seventy-two registered

nurses who were required to choose from a classification of eight categories and 34

conditions when assigning contributing factors to medication errors. “Personal

neglect” (86.1%), “heavy workload” (37.5%), and “new staff” (37.5%) were the three

main factors in the eight categories. The need to “solve other problems while

administering drugs” (47%), “new graduate” (31.9%), and “advanced drug

preparation without rechecking” (29%) were ranked most frequently of the 34

conditions. Unfamiliarity with the medications, drug names, and mechanism of action

were also involved in a number of errors in the study.

Simonsen et al. (2014) conducted a study that compared the risk of medication

errors between graduating students and working registered nurses. A multiple-choice

test in pharmacology, drug management, and drug dose calculations was administered

to 243 graduating students and 203 registered nurses. Medication knowledge of

experienced nurses was superior to graduating students with the largest difference in

drug management and dose calculations. Overall, the knowledge of both experienced

nurses and nursing students was still considered insufficient as the study revealed that

one out of four (25%) answers to test questions on drug management would have led

to a high risk of error.

Summary of Inadequate Pharmacology Knowledge as a Factor for

Medication Errors.

A recurring theme in the literature is the conclusion that because many factors

and confounding variables contribute to medication errors, any attempt to clearly


pinpoint causation is extremely difficult (Armitage & Knapman, 2003). Factors

contributing to medication errors primarily center on the following themes:

medication reconciliation, medication distribution systems, the quality of

prescriptions, deviations from policies and procedures, distractions during medication

administration, excessive workloads, staffing shortages, breakdowns in

communication, and nurses’ knowledge of medications. It was interesting to note that

some authors interpret the lack of drug knowledge as a consequence of systems

failure.

Knowledge deficits contributing to drug errors have been related to dosage

miscalculations, lack of knowledge for mechanism of action, unfamiliarity with the

medications, lack of conceptual mathematical skills, confusion with drug names, and

lack of safety knowledge such as compatibility issues, drug interactions, and drug

side effects (Adhikari et al., 2014; Bullock & Manias, 2002; Honey & Lim, 2008;

King, 2004; Latter et al. 2001; Morrison-Griffiths et al., 2002; Simonsen et al., 2014).

The findings for length of nursing experience as a contributing factor to errors have

been inconsistent; however, several studies report a higher prevalence of errors with

new staff, novice nurses, or new graduates (Armitage & Knapman, 2003; Simonsen et

al., 2014; Smith & Crawford, 2003; Tang et al., 2007).

In general, it is agreed that medication errors are relatively common in

hospitalized patients, potentially result in patient morbidity and mortality, and

increase the cost of healthcare. The literature emphasizes that the nature of

medication errors is complex, multifaceted, and involves an increasing number of


system issues. The association of systems issues or systems failure with medication

errors is discussed at length in many studies; however, the literature also consistently

identifies knowledge deficits in pharmacology as a significant factor contributing to

the risk of error.

Factors Influencing Pharmacology Knowledge Acquisition

A number of studies in the literature address variables that influence academic

success and performance on the NCLEX-RN examination in general. However, only

one study was found that specifically evaluated factors correlating with pharmacology

knowledge acquisition. Strayer and Beitz (2010) conducted a comparative descriptive

design study to analyze the nature and strength of the relationship between academic

and nonacademic variables (including the Kolb Learning Styles Inventory III), and

final pharmacology course grades. The relationship of selected variables to

pharmacology course grades was also compared between traditional and

nontraditional students. A convenience sample of 58 traditional students and 73

nontraditional students comprised the initial study population with a final sample of

100 participants. As demonstrated in numerous studies on academic performance,

overall grade point average (GPA) showed a positive correlation with pharmacology

course grades. Lower pharmacology course grades were noted with the nontraditional

student group; the authors suggested that students with nonacademic responsibilities

such as family dependence and the need to work to support themselves do not

perform as well academically. “Program format and learning styles revealed a weak

significant negative correlation suggesting that teaching and testing methods did not


fit the learning styles of the nontraditional students”(Strayer & Beitz, 2010, p. 305).

Also, in contrast to earlier studies in the literature, learning style did not play a

significant role in pharmacology knowledge acquisition. Regression analysis revealed

GPA and family dependence as the variables that contributed to the prediction of

pharmacology success or failure.

There is an overlap of studies that have documented inadequate pharmacology

knowledge with studies that have identified potential factors influencing

pharmacology knowledge acquisition. Several investigators report barriers to

pharmacology knowledge as perceived by students and graduate nurses, as well as

recommendations from nurses and students for enhancing pharmacology knowledge

and education. Table 1 presents a summary of the studies discussed previously in

Chapter 2 that also described factors believed to promote or impede pharmacology

knowledge acquisition. The type of study, measures used, and population sample

have been described in the previous section. The recommendations presented by

researchers were based upon data collected from nurses, students, and educators

through interviews, surveys and/or questionnaires.

Table 1

Perceived Factors Influencing Pharmacology Knowledge Acquisition

Authors

Type of

Study

Factors that Influence Pharmacology Knowledge

Acquisition

Adhikari et

al., 2014

Dilles et al.,

2011

Honey &

Lim, 2008

Qualitative

Descriptive

Study

Descriptive

Cross-

sectional

Study

Qualitative

Descriptive

Study

1. Nurses and students identified that knowledge

acquisition would be improved with additional

training in drug groups, polypharmacy/drug

interactions, side effects, and contraindications.

2. Graduate nurses and students identified that

greater consistency and additional clinical

opportunities are needed for administration and

decision-making.

3. Novice nurses or new graduates were noted as

having difficulty comprehending pharmacology

and applying it to practice indicating lack of

practice experience as a factor.

1. No relationships were identified with

pharmacology as separate or integrated, amount

of hours per study year, or background of the

instructor.

2. Medication administration competencies need to

be tested regularly in nursing education to

determine adequate knowledge.

3. A framework with clear goals for pharmacology

education needs to be defined to facilitate

knowledge acquisition.

1. The practice setting and unit staff were perceived

by students as both opportunities (46%) and

barriers (22%) to application of pharmacology.

2. Lack of time, lack of accessible drug resources,

lack of opportunities for decision-making, and

lack of role modeling were identified as barriers.

3. Information overload was a factor; stress,

inability to retain information, and the need to

learn both trade and generic drug names

contribute to information overload.

4. Twenty percent (20%) of students indicated that

academic preparation was inadequate to achieve

confidence in depth of pharmacology knowledge

and ability to apply knowledge.


King, 2004

Manias &

Bullock,

2002a,

2002b

Qualitative

Descriptive

Study

Qualitative

Descriptive

Studies

5. Linking theory with clinical practice and having

students learn fundamental principles of

pharmacology rather than rote memorization of

multiple drugs was proposed as a means to

enhance pharmacology knowledge.

1. Lack of structure, lack of time spent on

pharmacology, and over-emphasis of the

behavioral sciences were cited as issues in

undergraduate education that negatively

influence knowledge.

2. The theory-practice gap in the pharmacology

education was another barrier.

3. Improved teaching might increase nurses’

confidence in performing drug administration

and patient education, and decrease related

anxiety.

1. Faculty conflicts in balancing nursing and

pharmacology content lead to over-laden

curricula; this reduces time spent on

pharmacology content, which may influence

knowledge.

2. Students and nurses believed pharmacology

should be taught as a separate course to enhance

knowledge.

3. Basic pharmacological principles are often not

addressed.

4. Students use superficial learning strategies as a

result of difficulty with science content,

information overload and attempts to memorize

numerous isolated facts.

5. Focusing on characteristics of drug

classifications would enhance learning.

6. The busy fast-paced clinical environment

precludes productive learning experiences in

medication management.

7. More structured clinical experiences for

medication management are needed.

8. Nurses with limited experience had greater

difficulty comprehending pharmacology and

applying it to practice.


Bullock &

Manias,

2002

Latter et al.,

2001

Ives et al,

1996

Qualitative

Descriptive

Analysis

Study

Qualitative

Descriptive

Study

Qualitative

Descriptive

Study

9. Self-directed learning strategies for lifelong

continuing education are needed to maintain

adequate pharmacology knowledge.

1. Inadequate time was dedicated to pharmacology;

a greater number of hours was allocated when

taught as a separate subject.

2. Additional time for pharmacology would be at

the expense of other needed curricular content.

3. Factors impeding pharmacology knowledge

included lack of reinforcement of theory in

clinical, timing of clinical opportunities with the

timing of theory content, and expectations of

students by the instructor.

4. The hectic environment of the clinical setting,

and the need for more consistent exposure in

clinical experiences were also identified as

factors influencing pharmacology

5. Educators believed that pharmacology

application is enhanced by faculty who have a

nursing background.

1. Pharmacology taught as an integrated subject

may contribute to the lack of adequate

pharmacology content.

2. There is a lack of clarity for the pre-requisite

pharmacology knowledge required for practice; a

national policy framework is needed to identify

learning outcomes, skills, and the amount of time

that should be devoted to the subject.

3. Faculty need to be able to apply theory to

practice to enhance pharmacology.

1. First year practical experience and undergraduate

clinical experience were identified as the most

important factors for pharmacology knowledge.

2. Allocating more time to pharmacology (35.3%),

teaching pharmacology as a separate subject

(30.9%), and improved teaching methods

(20.6%) were cited as factors that would have

improved undergraduate pharmacology

education.

Two studies not previously discussed that identified potential factors

influencing pharmacology knowledge included a study by Morrison-Griffiths et al.

(2002), and a study by Courtenay (1991). In 2002, Morrison-Griffiths et al.

distributed survey questionnaires to 52 university nursing departments in England to

identify the pharmacology education provided for pre-registration (pre-licensure)

nurses. Thirty-three questionnaires from three different types of programs were

completed for a 63.5% response rate. The results of the study showed wide variation

in pre-licensure pharmacology education. This variation is noted in terms of hours

allocated, specific content included, resources and teaching methodologies, and

assessment of learning outcomes. Interestingly, it was found that the least number of

hours were allocated in the program with the greatest number of students. The

majority of programs indicated that nurses were involved in the planning of

pharmacology content, and methods of teaching varied significantly, although lecture

was still the most common method.

Nurses and nursing students traditionally identify the biological sciences,

including pharmacology, as difficult subjects to understand (Caon & Treagust, 1993;

Courtenay, 1991; Clancy et al., 2000; McVicar et al. 2010; Tse & Lo, 2008). A

landmark study by Courtenay (1991) explored the teaching and learning of the

biological sciences in nursing, and found several issues related to pharmacology

education. A questionnaire was sent to 140 third-year nursing students (62% response

rate) and 43 nursing faculty (67% response rate) to evaluate the importance of

behavioral and biological sciences, level of knowledge taught, adequacy of


preparation, and teaching methods. Both students and teachers felt themselves to be

inadequately prepared in pharmacology and microbiology, and 68.2% of students

identified the subject of pharmacology to be taught at a low level. Although self-

directed learning was the teaching method most frequently utilized by faculty (36%),

it was perceived by students as the least effective method. Problem areas identified by

faculty included lack of guidance with regard to the depth and breadth of content

(31.3%), difficulty linking theory to practice (25%), and lack of instructor knowledge

(18.8%). Only 6.3% of the faculty identified teaching methods as an issue, while most

students evaluated teaching methods to be ineffective. The author suggested that

nurse educators may lack the skills and expertise to use self-directed learning

effectively, and therefore, may be unable to facilitate an adequate knowledge base for

students if the educators themselves do not feel adequately prepared.

In addition to the issue of behavioral versus biological sciences in nursing

education, teaching pharmacology as an integrated rather than separate course has

been a source of controversy, and warrants special comment in this discussion. As

noted previously, nurses and students consistently identify the need and preference

for a separate pharmacology course. On the other hand, most faculty value integration

of pharmacology for consistency of an integrated curriculum and as a measure to

facilitate clinical application. Several studies found that students were actually

exposed to more hours of pharmacology when it was taught as an integrated subject

(Lim & Honey, 2006; Meechan, Mason, & Catling, 2011; Zellner, Boerst, & Semling,

2003). Lim and Honey (2006) described the integration of pharmacology through a

http://www.ncbi.nlm.nih.gov/pubmed/?term=Zellner%20K%5BAuthor%5D&cauthor=true&cauthor_uid=12705115


http://www.ncbi.nlm.nih.gov/pubmed/?term=Semling%20K%5BAuthor%5D&cauthor=true&cauthor_uid=12705115



three-year undergraduate curriculum, and indicated that students perceived the

material to be more relevant with integration. They also highlighted ways in which

integration supported other content in the curriculum such as legal and ethical issues,

communication, and physiology. Zellner et al. (2003) conducted a nonexperimental

descriptive exploratory study to retrospectively compare integrated and separate

pharmacology. Data was collected from a convenience sample of 299 students

completing a computerized adaptive pharmacology test. The study investigators

found that teaching pharmacology as a separate course did not result in an increase in

test scores.

Ninety percent (90%) of the institutions surveyed in the study by Morrison-

Griffiths et al. (2002) taught pharmacology as an integrated subject in the nursing

curriculum. Even though this is consistent with many other schools of nursing,

shortcomings of integration have also been described. These issues include dilution of

content, inadequacy of addressing the basic pharmacological principles of

pharmacokinetics and pharmacodynamics, inadequate inclusion of the biological

sciences for a true holistic approach, and lack of clear learning objectives specific to

pharmacology (Latter et al., 2001; Manias & Bullock, 2002a; Morrison-Griffiths et

al., 2002; Sulosaari, Suhonen, & Leino-Kilpi, 2011). In the descriptive cross-sectional

study by Dilles et al. (2011), 619 students participated in a correlational survey and

medication testing, which revealed no relationships between pharmacology as a

separate or integrated module and performance on the medication test. Regardless of

whether pharmacology is integrated or offered separately, the literature demonstrates

http://www.ncbi.nlm.nih.gov/pubmed?term=Suhonen%20R%5BAuthor%5D&cauthor=true&cauthor_uid=20738454

http://www.ncbi.nlm.nih.gov/pubmed?term=Leino-Kilpi%20H%5BAuthor%5D&cauthor=true&cauthor_uid=20738454


that nurses still do not have adequate pharmacology knowledge. Some study

investigators advocate for both approaches proposing the development of a core

pharmacology module or dedicated pharmacology course in addition to integrated

pharmacology teaching (Morrison-Griffiths et al., 2002).

Summary of Factors Influencing Pharmacology Knowledge Acquisition

Fifteen studies were reviewed in the literature that addressed factors for

pharmacology knowledge acquisition, and all of these studies presented qualitative

descriptive research. Data in the studies was gathered from nurses, graduate nurses,

students, and nursing faculty through various surveys, questionnaires or interviews.

Only one study in the literature directly examined factors that correlate with

pharmacology knowledge. In this study, cumulative GPA and anatomy and

physiology GPA correlated positively with pharmacology grades. Nontraditional

students with family dependence or financial responsibilities were found to perform

at a lower level, and therefore, correlated negatively with pharmacology course

grades.

There is consensus in the literature that a more comprehensive knowledge of

pharmacology is essential for safe clinical practice, and that pharmacology education

may be inadequate or ineffective. There is a mutual perception of inadequate

pharmacology preparation and knowledge by most groups involved - clinical nurses

(both experienced and graduate nurses), students, nurse educators, and researchers.

Several themes emerged in the literature with respect to factors that influence

pharmacology knowledge as perceived by nurses and nursing students. First and


foremost, nurses and students believe that inadequate time is devoted to

pharmacology, particularly in consideration of the nurse’s role and amount of hours

spent in clinical practice for medication management. In addition to inadequate time,

lack of clinical opportunities, integration of pharmacology, information overload,

superficial learning strategies, ineffective teaching methods, and the clinical

environment are all cited as factors that negatively influence pharmacology

knowledge acquisition. Students consistently identify that greater opportunities are

needed for medication management during clinical experiences. (Banning, 2003;

Bullock & Manias, 2002; Honey & Lim, 2008; Latter et al., 2001; Page & McKinney,

2007; Sulosaari et. al., 2011). The length of clinical practice experience for nurses

and clinical opportunities for medication decision-making are also frequently noted as

significant factors that impact pharmacology knowledge acquisition.

In addition to the desire for more pharmacology hours, students universally

insist that pharmacology should be taught as a separate course. They also believe that

an excessive emphasis on the behavioral sciences in nursing education contributes to

the lack of a solid foundation in the biological sciences. Other recommendations from

students include the need for more effective teaching strategies, a greater focus on

polypharmacy and drug interactions, and more clinical opportunities for medication

decision-making and application of pharmacology knowledge. The complexity and

pace of the clinical setting, lack of preceptor role modeling, and lack of time are cited

as barriers to clinical application.


Many nurse educators agree that inadequate time has been allocated for

pharmacology, yet most faculty believe that students have sufficient pharmacology

knowledge for safe practice (Bullock & Manias, 2002). Faculty further identify that

existing content-laden curricula typically preclude additional time for pharmacology.

Educators emphasize the need for clinical application of pharmacology and therefore,

favor integration as opposed to pharmacology taught as a separate course. Study

investigators suggest, however, that basic pharmacological principles are not being

addressed when pharmacology is integrated, and emphasize the significance of these

principles to promote future consolidation and application of pharmacology

knowledge. Several studies also underscore the need to focus on drug groups or

medication classifications as a means to manage the scope of pharmacological

content and address the issue of information overload.

There is consensus among educators that faculty who teach pharmacology

content should be able to apply the theory component to clinical practice. Teaching

methodologies are cited as factors influencing pharmacology knowledge although to a

lesser degree than other issues that have been described. Educators continue to utilize

lecture as the primary format for teaching, but a variety of teaching strategies have

been described in the literature as a means to promote knowledge and retention of

pharmacology. A final key point in the literature focuses on the need for professional

accountability and self-directed lifelong learning in order for nurses to maintain

adequate knowledge in the wide-ranging and dynamic area of pharmacological

therapies.


Researchers frequently conclude that nurses have inadequate pharmacology

knowledge, and the findings of almost all studies have important educational

implications. Studies examining pharmacology curricula identify wide variations in

curriculum design, content, dedicated hours, faculty, teaching strategies, and

assessment of learning. Several authors underscore the lack of clarity regarding

prerequisite pharmacology knowledge for beginning practitioners, and assert the need

for specific outcomes and competencies for pharmacology knowledge. Although

nurse prescribing is not relevant to this study, the literature also highlights the need

for adequate pharmacology knowledge and supplemental education in relation to the

expanding role of nurses in prescribing medications.

Strategies to Enhance Pharmacology Knowledge Acquisition

The need for improved pharmacology education is noted throughout the

literature. Managing the depth and breadth of pharmacology content is challenging,

and even more so in the current fast-paced clinical environment. In a review of

nursing student medication errors, Harding and Petrick (2008) assert, “There is a

paucity of literature specific to nursing education that identifies teaching strategies to

address the complex dynamic system in which students are learning to administer

medications” (p. 44). A number of studies were reviewed that examined general

elements of a nursing program that are believed to enhance pharmacology knowledge,

while other articles offered specific strategies for teaching pharmacology to promote

application and retention of content. The previous section of this chapter discussed

several components of pharmacology education that have been identified as


approaches to enhance pharmacology knowledge. This next discussion summarizes

some of the specific strategies for teaching pharmacology that have been used online

or in the classroom.

In evaluating the effectiveness of teaching strategies, it is worthwhile to

discuss an integrative review of the literature completed in 2011 addressing registered

nurses’ medication competence (Sulosaari et al.). The objective of the study was to

describe medication competence, document the need for future studies, and utilize the

results for instrument development. The established areas for medication competence

served as a guideline for content and curricular development in nursing pharmacology

courses. The integrative review followed five stages, and twenty-one studies met the

selection criteria. See Table 2 for eleven competency areas that were determined to

constitute medication competence, and three major categories that integrated these

competencies. The authors concluded that medication competence requires a solid

knowledge base for pharmacology and the ability to apply that knowledge in complex

and dynamic real-life situations (Sulosaari et al., 2011). Furthermore, decision-

making ability was found to be an integral component of both theoretical and practice

competence.

Changes in educational standards in the United Kingdom created the need for

a greater emphasis on theoretical principles of medication management and skills for

clinical reasoning. Banning (2003) developed a generic framework in applied

pharmacology and therapeutics with the intention of providing students with basic

principles and a concrete foundation. She also identified teaching and learning


strategies recommending that self-directed teaching strategies be avoided as students

require considerable guidance to comprehend applied pharmacology. A variety of

teaching methods were encouraged including role play, small group discussion,

video-taped vignettes, problem-solving exercises, patient simulation, and review of

clinical scenarios. Banning emphasized the need for a clinical environment that

fosters inquiry, trust, and openness. Furthermore, the environment should eliminate

threat, fear of mistakes, and judgment on performance.

Table 2

Categories and Competency Areas that Establish Medication Competence

Categories of Medication

Competence

Competency Areas for Medication Competence

1. Theoretical Competence

2. Practical Competence

3. Decision-Making

Competence

1. Anatomy and Physiology

2. Pharmacology

3. Communication

4. Interdisciplinary Collaboration

5. Information Seeking

6. Mathematical and Medication

Calculation

7. Medication Administration

8. Medication Education

9. Assessment and Evaluation

10. Documentation

11. Promoting Medication Safety

(Source: Sulosaari, V., Suhonen, R., & Leino-Kilpi, H. (2011). An integrative review

of the literature on registered nurses' medication competence. Journal of Clinical

Nursing, 20 (3-4), 464-478. )

Barry, O’Sullivan, and McCarthy (2015) implemented structured periodic

class review sessions for 89 multidisciplinary students in an undergraduate




pharmacology course, and evaluated the efficacy of these sessions through a pre- and

post-review, multiple choice examination. The review sessions were based on various

classroom assessment techniques, where students were asked to identify topics of

difficulty following a lecture. There was a significant increase in student learning

across all disciplines following three review sessions, and 99% of the students

indicated that learning was enhanced.

Eight studies in the literature from 2007 to 2015 were reviewed that described

educational strategies for teaching pharmacology through various technological

innovations. Three studies discussed the use of mobile technologies including

personal digital assistants, mobile phones with text messaging, and smartphones

(Cibulka & Crane-Wilder, 2011; Yeu-Hui & Chiung-Wen, 2013; Wittman-Price,

Kennedy, & Goodwin, 2012). Four studies presented web-based educational

programs or software for basic pharmacology and medication safety (Fidalgo-Neto et

al., 2014; Hewitt, Tower, & Latimer, 2015; Tse & Lo, 2008; Vana & Silva, 2014).

One study evaluated the effectiveness of an audience response system for teaching

pharmacology to baccalaureate students (Vana, Silva, Muzyka, & Hirani, 2011). Of

the eight studies, four were qualitative descriptive studies, two were quasi-

experimental studies, one was experimental, and one was a mixed methods pilot

study. Pre-licensure nursing students comprised the population for seven of the

studies with sample sizes ranging from 8 to 119 students. The one experimental study

included 60 students from various biological and health-related fields. All studies

incorporating pre- and post-testing of pharmacology content identified improved


performance in the post-test following implementation of a selected intervention.

Students completing survey questionnaires also provided positive feedback regarding

the technological innovations, and acknowledged enhanced learning of pharmacology

content.

A number of other strategies described by educators to teach pharmacology

include the use of faculty-generated videotapes, high-fidelity simulation, a

collaborative graphic organizer, interprofessional teaching, case studies, interactive

microsimulation, computer-assisted instruction, and a conceptual approach for

teaching psychopharmacology (Bonniver & Magateaux, 2012; Collins, Graves,

Gullette, & Edwards, 2010; Gee, Peterson, Martin, & Reeve, 1998; Jordan, 1997;

Manias, Bullock, & Bennett, 1999; Montenery, 2013; Powell, Canterbury, & McCoy,

1998; Sears, Goldsworthy, & Goodman, 2010; Thompson & Bonnel, 2008). Authors

of these articles indicated effectiveness of the teaching strategy based on qualitative

feedback from students or performance improvement in medication testing.

Summary of Strategies to Enhance Pharmacology Knowledge Acquisition

The literature acknowledges the challenges in teaching pharmacology as a

result of the extent of content and limited time allocated in most curricula. Educators

continuously strive for new and innovative teaching methodologies. Advances in

technology have offered various innovative electronic instruments to facilitate

learning; however, some of these devices are cost-prohibitive, and technology support

for the student is required.


The need to supplement traditional lecture with interactive learning strategies

has been emphasized in education as a means to improve student learning, increase

knowledge retention, and apply science to practice. A variety of active learning

strategies for pharmacology have been presented that are similar to strategies utilized

in other areas of nursing education; these include role play, case studies, group

activities, videotaped vignettes, problem-based learning, and simulation. Researchers

and educators agree that even more effective and efficient methodologies are needed.

Current trends emphasize innovative techniques that will promote a more integrated

and efficient curriculum, as well as improve the quality of teaching and student

learning.

Gaps in the Literature

There is an abundance of articles in the literature that document an inadequate

level of pharmacology knowledge for nurses, and the lack of this knowledge as a

factor for medication errors. Several studies also identify the wide variation in

pharmacology curricula across nursing programs, and the fact that the level of

knowledge required by nurses to administer medications safely and monitor their

effects is not well-defined. Numerous authors have also identified various factors that

influence pharmacology knowledge acquisition as perceived by students, nurses, and

faculty. However, only one study was found in the literature that directly evaluated

the relationship between selected variables and pharmacology knowledge acquisition.

Numerous factors are involved in the context of medical errors. While many

medication errors involve novice nurses or a lack of practice experience, distractions


and the complex dynamic nature of the clinical environment contribute significantly

to the incidence of errors. At the same time, the literature acknowledges the scarcity

of teaching strategies to address the complex clinical environment in which students

administer medications.

Several studies have presented qualitative descriptive data identifying

perceived problems in nursing education with respect to how pharmacology is taught.

Issues relate to lack of a dedicated pharmacology course, inadequate time devoted to

the subject, lack of clinical opportunities, information overload, and ineffective

teaching strategies. Some research has been completed to compare integrated versus

separate course approaches; however, few studies have addressed information

overload and the lack of clinical opportunities for medication management.

The extent of scientific information students must learn has increased

considerably with advancements in technology and drug discovery; however,

teaching all of the pharmacological facts for each drug is impossible. The

complexities of teaching and learning pharmacology are increasingly significant for

empirical study. Interestingly, several studies have specifically linked pharmacology

course grades or performance on pharmacology standard assessments to NCLEX-RN

success (Emory, 2012; Paraszczuk, 2011; Silvestri, 2010; Ukpabi, 2008). This

information is valuable for identifying students at risk academically. Nevertheless, the

literature research is limited with respect to specific factors that influence

pharmacology knowledge acquisition.


Chapter 3: Methodology


academic and non-academic variables to pharmacology knowledge acquisition by

undergraduate nursing students as demonstrated by performance on a final

standardized pharmacology assessment. A second purpose of the study was to

evaluate the medication administration and decision-making experience as self-

reported by students, and determine if there is any correlation between student

perceptions of opportunities for medication management during clinical experiences,

and performance on the final standardized pharmacology assessment. This chapter

describes the methodology for the research study.

Design

This study was a descriptive correlational design examining relationships

between selected variables and the final pharmacology assessment. Correlational

statistical analyses were used to explore any relationships between the selected

variables and performance on the standardized pharmacology assessment.

Setting

The study was conducted at a private, not-for-profit institution of higher

education located in the Midwestern area of the United States. The institution is a

subsidiary of a teaching hospital and large integrated health care delivery system, and

serves the Tri-State region of Southwestern Ohio, Northern Kentucky, and

Southeastern Indiana. The history of the institution dates to 1896 when the School of

Nursing was originally established; diplomas were granted to the first graduates of the


program in 1899. The College transitioned from a diploma program to an associate

degree program, and was re-founded as an independent college in 2001. Three degree

programs were offered at the time of the study, including two nursing programs and

one non-nursing program.

The College admits students twice a year in January and August. Total student

enrollment in the institution averages in the range of 400-450 students. At the time of

the study, there were 332 students in the pre-licensure AASN nursing program; the

remaining students were enrolled in the BSN completion program or the non-nursing

program. Of the 332 students in the pre-licensure AASN nursing program, 232

students were registered in nursing courses; the remaining 100 students were taking

general education courses at the time. The age profile for AASN students during the

spring 2016 semester revealed an average age of 19.3 years and a range of 17-56

years. The College is approved by the Ohio Board of Nursing and Ohio Board of

Regents, and is accredited by the Higher Learning Commission North Central

Association. In 2010, the AASN program was accredited by the National League for

Nursing Accrediting Commission (NLNAC), now the Accreditation Commission for

Education in Nursing (ACEN). The BSN program is accredited by ACEN.

Study Population

The AASN nursing program encompassed four major nursing courses that

included theory and clinical hours, and one non-clinical nursing course focusing on

professional issues. Each clinical nursing course was a pre-requisite for the next

higher level course. Completion of the Nursing IV course (NUR 202) signified the


culmination of all clinical experiences in the AASN program. The study required a

sample of students who had finished all of their clinical nursing courses with the

exception of role transition. Role transition clinical hours were excluded because the

ATI Pharmacology Assessment was conducted prior to the role transition rotation.

Therefore, the projected sixty-five students that were enrolled in the ten credit hour

Nursing IV course during the spring 2016 semester comprised the target population

from which the sample was drawn. The majority of these students were taking

Nursing V as a co-requisite, and were within five weeks of graduating from the

program at the time of the pharmacology assessment. Table 3 provides an overview

of the curriculum for the AASN program. While the General Chemistry II course

incorporated basic pharmacological principles and some drug classifications, it should

be noted that a separate pharmacology course did not exist in the curriculum.

All students in the Nursing IV course were required to complete the ATI

standardized pharmacology assessment during week ten of the semester. Five percent

of the course grade was allocated to ATI proctored and non-proctored testing.

Students who met the benchmark of a Level 2 proficiency in the ATI Pharmacology

Assessment received one point of the five potential points. Students who did not meet

the Level 2 proficiency were expected to remediate in the lower performing content

areas. The ATI pharmacology assessment was intentionally scheduled during week

ten rather than at the end of the semester in order for students to identify weak areas

in pharmacology. Students were then able to focus on these areas to prepare for the


Nursing IV final course examination conducted at week eleven, and for the ATI RN

Comprehensive Predictor assessment during week thirteen.

Table 3

Associate Degree Nursing Program Curriculum

Course Description

Credits

Required General Education Courses - (37 Credits)

CSP 100 First Semester Experience

BIO 201 Human Anatomy and Physiology I

BIO 202 Human Anatomy and Physiology II

BIO 215 General Microbiology

CHE 101 General Chemistry I

CHE 102 General Chemistry II

ENG 101 English Composition

ETH 212 Health Care Ethics

MTH 103 Pharmacological Mathematics

PSY 103 Introduction to Psychology

PSY 205 Lifespan Development

SOC 103 An Introduction to Sociology

Required Nursing Courses - (36 Credits)

NUR 101 Nursing I - Fundamentals

NUR 102 Nursing II - Adult MS (Chronic Care)

NUR 201 Nursing III - Pediatrics, OB, Community, MS

NUR 202 Nursing IV - Adult MS (Acute Care)

NUR 260 Nursing V - Trends and Professional Issues

1

4

4

4

4

4

3

3

1

3

3

3

6

8

10

10

2

Recruitment

The study investigator reviewed the study with the course faculty and

determined a convenient day and time during class to meet with students. The

investigator introduced the study to all students enrolled in the Nursing IV course

during the tenth week of the semester. A notice for the study was distributed one


week in advance to allow students time to contemplate participation and ask

questions. See Appendix A for a copy of the notice distributed to students via e mail

by the course faculty. To encourage participation in the study, time was allotted

during scheduled class hours for students to complete the questionnaires. The purpose

of the study, significance, data collection procedure, time commitment, informed

consent, and expectations of the participants were explained. The study investigator

emphasized that participation in the study was voluntary, and that declining to

participate would not affect any aspect of the remaining semester nor the students’

course grades. The study investigator was explicit that student records would be

reviewed, but that individual names would be removed from all documents.

Furthermore, study findings would be reported only as aggregate data. See Appendix

B for a copy of the script that was used to introduce and describe the study.

It was expected that students would be able to complete the demographic

questions and survey questionnaire within approximately ten minutes. As an

inducement for students to remain for the duration of the class and participate in the

study, refreshments were also provided. Students who did not wish to participate had

the option to leave the class, but were still able to partake of refreshments if desired.

All students who provided informed consent and completed the survey questionnaire

comprised the study sample. It was estimated that 85-90% of the class would

participate in the study since time was allotted to complete the questionnaire during

the regular class session, and minimal time was required. The investigator also

believed that students would be motivated to participate in the study as a result of


personal interest in the focus of the research. Considering the magnitude of

pharmacology content, implications for safe practice, and numerous challenges

associated with pharmacology education, the nature of the research topic was highly

relevant for both faculty and students.

Inclusion and Exclusion Criteria.

Inclusion criteria for participants in the study were 1) students enrolled in the

Nursing IV course at week ten of the spring 2016 semester, and 2) students

completing all regular clinical rotations prior to role transition. Students meeting

these criteria were eligible members of the target population for the study sample.

The only exclusion criterion was a student who withdrew from the course prior to

completing the Nursing IV clinical rotation. However, it was not expected that such a

student would be present for the class unless special permission was granted to audit

the remaining semester.

Sample Size Determination.

There are several factors that influence sample size of a study including the

type of study, effect size, the number of variables, the sensitivity of the measurement

methods, and the data analysis techniques. The deciding factor in determining an

adequate sample size for a correlational study is power, and power is the ability to

detect differences or relationships that actually exist in the sample population (Burns

& Grove, 2009). Field (2013) defines power as “the ability of a test to detect an effect

of a particular size, with a value of .8 as a good level to aim for” (p. 881). A power of

.8 means that there is an 80% chance of detecting an effect if one does actually exist


(Field, 2013). Effect size may be described as small, medium, or large; a large sample

size is needed for a small effect size or to detect small differences. Small sample sizes

may be used to detect large differences between groups.

Pearson’s product-moment correlation coefficient was utilized to explore

relationships between the selected variables and performance on the standardized

pharmacology assessment. When using Pearson’s correlation coefficient, the values

for the effect sizes are .10 for a small effect, .30 for a medium effect, and .50 for a

large effect (Field, 2013). Although other statistical analyses were also used in the

study, Pearson’s correlation analysis took priority as a parametric test. Parametric

testing is more sensitive to violations of statistical assumptions and therefore,

provides more robust data.

A power analysis allows the determination of a sample size needed to obtain

sufficient power and determination of the risk of a type II error. The investigator ran a

priori power analysis in G*Power with a medium effect size, alpha of .05, and beta of

.20 for a power of .80; this was based on using Pearson’s correlation two-tailed power

analysis. In order to arrive at .80 power and a medium effect size of .30 with an alpha

of .05 and beta of .20, the minimum sample size needed is 82 participants. A target

population of 65 pre-licensure nursing students was anticipated, and the investigator

expected 85-90% participation in the study. Participation by 85-90% of the class

would provide a sample of 55-59 students; even with 100% participation of the class,

the desired sample size cannot be met since the target population is limited.

Therefore, the investigator re-ran the power analysis based on the actual number of


students who participated in the study, and then reported the effect size that could be

obtained. When solving for effect size rather than sample size, there was power to

detect up to an effect size of .35 with a sample of 60 participants, and up to .36 with a

sample of 58 participants; these were both slightly larger than a medium effect size.

Measurements

ATI RN Pharmacology Assessment.

The comprehensive assessment and review program offered by ATI provides

remediation and assessment activities to assist students throughout a nursing program.

ATI acknowledges a relationship with 2100 colleges and universities nationwide that

utilize the company’s products (Emory, 2012). The outcome and dependent variable

for the study was pharmacology knowledge acquisition as measured by the ATI 2013

RN Proctored Pharmacology Assessment. This assessment is incorporated in the ATI

2013 RN Content Mastery Series (CMS), and is a 70-item examination, which

provides an appraisal of a student’s basic comprehension and mastery of

pharmacologic principles (ATI, 2015a). Ten of the seventy items in the examination

are pilot questions and are not considered when calculating the test score.

Consequently, there are a total of sixty questions which determine the final test score

and resulting level proficiency. Students are allotted 70 minutes to complete the

examination. Table 4 provides a listing of concepts and content areas evaluated in the

ATI RN Proctored Pharmacology Assessment.


Table 4

ATI RN 2013 Proctored Pharmacology Assessment Concepts and Content Areas

Concepts Assessed

Specific Content Areas

Basic Pharmacological

Principles

Knowledge related to the Safe

Administration and Monitoring

of Prototype Medications

Medications for Pain and

Inflammation

Medications that Affect

Immunity

Medications for Infection

Pharmacodynamics and Pharmacokinetics

Safe medication administration

Medication error prevention

Age-specific considerations

Dosage calculations

Medications that affect the nervous, respiratory,

cardiovascular, hematological, gastrointestinal,

reproductive, and endocrine systems

Non-opioid analgesics, opioid agonists and

antagonists, and adjuvant pain medications

Immunizations and chemotherapy agents

(Source: Assessment Technologies Institute, LLC. (2015a). ATI Nursing Education,

Integration, Resources, Assessment Information, RN Assessment, RN Content

Mastery Series Proctored 2013, Test Descriptions)

The ATI 2013 series is the fourth version of the CMS, and comprises nine

Assessments including Fundamentals, Maternal Newborn, Nursing Care of Children,

Adult Medical-Surgical, Mental Health, Pharmacology, Nutrition, Leadership, and

Community Health. The CMS provides assessment information regarding a student’s

mastery of specific concepts consistent with the NCLEX-RN test plan (ATI, 2015a).

The assessments in the CMS are criterion referenced, and are designed as a formative

evaluation to determine NCLEX-RN readiness in the specific content areas (ATI,

2015a). ATI emphasizes that the assessments are not intended to be a direct predictor


of NCLEX-RN performance or future success in nursing, but rather determine the

level of proficiency the student has attained. In relation to Bloom’s taxonomy of the

cognitive domain, questions in the content-specific assessments and comprehensive

predictor tests are written at the application level or above. The intended testing

population for the RN CMS 2013 are students who are at or near completion of a

course in a selected content area (ATI, 2015a). The ATI content-specific assessments

are also designed to guide remediation efforts based on exam performance. A variety

of tools to measure academic performance enable educators to identify problem areas

early and intervene to promote student success.

ATI developed a set of recommended cut scores based on standards

established by the National Council on Measurement in Education (NCME); nursing

schools could choose to adopt these scores as benchmarks for student performance on

each of the nine RN CMS 2013 assessments (ATI, 2015a). Content expert judges

were selected to participate in a study to determine the criterion-referenced cut scores;

these judges were nurse educators from various RN programs across the United

States, typically with at least ten years of experience in teaching the content area. The

cut scores were established through a formal study in accordance with the

recommendations of the NCME standards (ATI, 2015a).

The college in the study setting utilized the recommended Level 2 proficiency

as a benchmark for all proctored ATI assessments. The recommended cut score by

ATI for the Pharmacology Assessment for a Level 2 proficiency is 71.7%-83.3%

(ATI, 2015a). The faculty rounded the low end of the range value from 71.7% to 72%


for consistency with all ATI assessments in the Nursing IV course. It should be noted

that gaps in percentage values between the level scores reflect only a one-item

difference, and values between these percentages for each cut score are not possible

(ATI, 2015a). ATI defines the Level 2 proficiency as a performance level whereby

the student is expected to readily meet NCLEX-RN standards in the content area. ATI

clarifies that the definitions for the CMS proficiency levels are based on the expertise

of nurse educators participating in the cut score study, rather than on any empirical

research relating NCLEX-RN performance to performance on the CMS or to actual

job performance (ATI, 2015b). Table 5 identifies the ATI recommended cut score

ranges for the Pharmacology Assessment, and describes the levels of proficiency.

The ATI RN Content Mastery Series 2013 Technical Manual (2015b) presents

a comprehensive report which analyzes data from the pilot study including the first

attempt scores of examinees who completed any CMS 2013 assessment between

September 17, 2013 and April 19, 2014 (ATI, 2015b). There were 7,066 examinees

who completed the Pharmacology Assessment from October 18, 2013 through April

19, 2014 (ATI, 2015b). The findings in the technical manual report provide evidence

to support the reliability and validity of the RN CMS 2013 scores. Validity evidence

is discussed in the report, including research to support content validity and measures

to investigate construct-irrelevant variance (ATI, 2015b). In particular, analyses were

conducted to verify that test “speededness” was not a significant source of construct-

irrelevant variance. Test speededness involves the examination of the degree to which

scores include a speed component for a test that has a time limit (ATI, 2015b).


Evaluation of the appropriateness of that speed component on the basis of the domain

that the test is designed to measure is also a component of test speededness (ATI,

2015b). Construct-irrelevant variance refers to extraneous, uncontrolled variables that

potentially affect assessment outcomes, and therefore reduce validity.

Table 5

ATI 2013 Pharmacology Assessment Cut Scores and Proficiency Level Definitions

Level of

Proficiency

Recommended

Cut Score

Definition of Proficiency

Level 1

Level 2

Level 3

56.7% – 70.0%

71.7% – 83.3%

85.0% – 100.0%

A student achieving Proficiency Level 1:

- is expected to just meet NCLEX-RN standards in this

content area.

- should demonstrate the minimum level of knowledge in

this content area required to support academic readiness for

subsequent curricular content.

- should meet the absolute minimum expectations for

performance in this content area.


- is expected to readily meet NCLEX-RN standards in this

content area.

- should demonstrate a level of knowledge in this content

area that more than adequately supports academic readiness

for subsequent curricular content.

- should exceed minimum expectations for performance in

this content area.


- is expected to exceed NCLEX-RN standards in this

content area.

- should demonstrate a high level of knowledge in this

content area that confidently supports academic readiness

for subsequent curricular content.

- should exceed most expectations for performance in this

content area.

(Source: Assessment Technologies Institute, LLC. (2015a). ATI Nursing Education,

Integration, Resources, Assessment Information, RN Assessment, RN Content

Mastery Series Proctored 2013, Test Descriptions)


Standard 4.10 of the ATI RN Content Mastery Series 2013 Technical Manual

(2015b) specifically addresses the reliability and validity of the ATI tests. Following

the release of an assessment for use, ATI conducted additional analyses of the test

data with students taking the assessments for the first time. Table 6 presents the test

statistics, including the reliability coefficient, for scores on the pharmacology

assessments. The distribution of item difficulty (p-value) and discrimination (point

biserial correlation) were also presented in the report. The mean p values for the nine

RN CMS 2013 assessments ranged from 0.62 to 0.72, and the mean discrimination

values ranged from 0.22 to 0.28; ATI indicates that these values fall within ranges

which contribute to the overall range of scores and delineate between low and high

ability examinees (ATI, 2015b). Test items were evaluated by expert nurses and

scored according to established criteria, and cultural bias was addressed by ethnic and

gender experts. Reports presented by the scientists and psychometricians at ATI

conclude that reliability and validity of the content-specific assessments has been

established with respect to the intended use and purpose of the test.

Following administration of any content-specific assessment, students receive

a report which provides an overall raw percentage of correct items and a norm-

referenced percentile ranking. This percentile compares each student’s score to the

scores of all students in registered nursing programs nationally, and to all students

completing the assessment who are enrolled in a comparable program.


Table 6

RN CMS 2013 Test Statistics for the Pharmacology Assessment

Test Statistics (Date range of October 18, 2013 to April 19, 2014)

N (items) 60 Minimum 18

N (examinees) 7,066 Maximum 59

Mean 65.27% Median 40

Variance 54.32 Reliability (alpha) .796

Std. Dev. 7.37 SEM 3.33

Skew -.466 Mean P .65

Kurtosis -.153 Mean Biserial .281

(Source: Assessment Technologies Institute, LLC. (2015b). ATI RN Content Mastery

Series (CMS) 2013 Technical Manual. Leawood, KS: ATI)

Clinical Experience Survey Questionnaire.

A second tool in the study was utilized to obtain data regarding students’

perceptions of clinical experience opportunities for medication administration and

medication management. The investigator developed a survey questionnaire of six

items addressing various components of medication administration and management.

A Likert scale was utilized to establish the level to which a student agrees or

disagrees with each statement in the survey. “The Likert scale is the most commonly

used of the scaling techniques, and the original version of the scale included five

response categories” (Burns & Grove, 2009, p. 410). Similar to the original Likert

scale, the survey questionnaire on clinical experience opportunities provided five

response categories with an assigned value of “1” for the most negative response and

“5” for the most positive response. To establish content validity, the questionnaire


was distributed to six graduate nurses and six faculty members in the college.

Graduate nurses were defined as nurses with less than one year experience. None of

the individuals participating in the review of the survey tool were involved with the

study. Reviewers were asked to answer specific questions, as well as rate the

importance of each survey statement to the purpose of the study and the survey tool.

See Appendix C for a copy of the original tool and questions completed by the

reviewers.

The survey evaluations were returned by three graduate nurses and five

faculty members. Suggestions for change were identified, as well as

recommendations for additional statements. One hundred percent of the survey

statements were perceived as moderately essential or highly essential to the study.

The survey questionnaire was revised based upon feedback from the reviewers, and

was then distributed to three individuals a second time for re-evaluation of content

and terminology. See Appendix D for the final revised survey questionnaire.

Demographic Information Form

Selected variables and demographic data in the study were collected through

admission and academic records; however, three variables required direct feedback

from participants in addition to the clinical experience survey questionnaire. These

non-academic variables included previous health care experience, working hours per

week, and family responsibilities. A third form was utilized to collect this data, and

each variable was explained on the form in accordance with its conceptual definition.

See Appendix E for the demographic information form.


Data Collection Procedure

The study investigator discussed and secured permission for the study from

the President of the College, the Dean of Academic Affairs, and the Dean of

Enrollment Management. The data collection process was initiated upon approval by

the Institutional Review Board (IRB) of both the integrated health care organization

affiliated with the college and Case Western Reserve University. Three sets of

individual data were collected. The first set of data was obtained through college

admission and registration records following IRB approval and consent by individual

students. SONISWEB was the data administration system of the college, which

allowed faculty access to grade point averages, admissions, registration, financial aid,

billing, alumni, and fundraising information.

The study investigator met with the Dean of Enrollment Management and the

Registrar who confirmed access to reports that provided data for demographics and

for the selected variables of the study. The demographic information obtained from

these reports included age, gender, and race or ethnicity. Gender is defined as male or

female, and age was presented as specific age in years. School districts and states are

required to follow federal standards for categorizing race and ethnicity for students

and staff; these standards are commonly used for data collection. Race and ethnicity

were defined according to the following federal categories: American Indian or

Alaska Native, Asian, Black or African American, Native Hawaiian, Hispanic or

Latino, and White (U.S. Office of Management and Budget, 1997). Additional data

retrieved from college records for other selected variables included nursing GPA,


science GPA, and previous college credit or degrees. The study investigator obtained

the reports from the Registrar upon IRB approval and student consent to participate.

A second set of data was collected directly from the participants. This data

included the non-academic variables of previous health care experience, working

hours per week, family responsibilities, and student self-perceived opportunities for

medication management during clinical experiences. Participants in the study were

asked to complete the investigator-developed survey questionnaire and the

demographic information form following introduction of the study. A third set of data

was collected from the computerized testing report generated by ATI for the

proctored pharmacology assessment; this data only included the one dependent

variable of the student’s pharmacology test score.

The study investigator prepared and distributed a packet which included a

consent form, the demographic information form, and the clinical experience survey

questionnaire. Each packet and set of documents was assigned a code number. A

student identification number assigned by the registrar’s office upon entry to the

program was recorded by the student on the survey questionnaire and demographic

information form. Although specific student names would not be identified on any

documents, it was, in fact, possible to connect data to a specific student. The college-

generated identification number was necessary, however, in order to match

demographic and survey information with the corresponding ATI standardized

pharmacology assessment. Therefore, students also needed to provide informed


consent. The written consent form was developed in accordance with IRB guidelines

and requirements of the institution.

Data Management

When all students completed the informed consent and survey questionnaire,

the documents were collected by the study investigator and maintained in a locked

file cabinet in the investigator’s office. After data was collected from academic

records, the survey questionnaire, and the assessment report from the testing

company’s password-protected electronic database, a study enrollment log was

created using Microsoft Excel. This log included the study code number, student

names, the college identification number, and demographic information.

The data was prepared for computer entry by first examining all demographic and

survey questionnaires for missing data or inaccurately recorded responses. A

computerized database was created to collect demographic information, information

for the six independent study variables, and performance on the ATI Pharmacology

Assessment. Data entry was completed using Statistical Package for the Social

Sciences (SPSS), Version 23. Both the study enrollment log and the data file in SPSS

were secured in an electronic password-protected and encrypted computer database

by the investigator.

Once the data file was created and score reports matched with the participants,

student identification numbers were removed from the data file prior to analysis. In

this way, it was not possible to connect specific data results to any participants in the

study. Only the code number assigned by the investigator was identified in order to


maintain confidentiality, and study results were reported as aggregate data. All study

documents were boxed and submitted to the Research Council liaison to be

maintained in an IRB-designated storage area for a period of ten years. This was a

requirement of the institutional IRB.

A systematic plan for data entry was established, which served to reduce

errors and minimize interruptions during the data entry process (Burns & Grove,

2009). The labeling and organization of fields for data entry or development of a

codebook in SPSS was constructed prior to the data entry. The codebook identified

the range of possible numerical values entered in the entire computer file, and defined

each variable. Once data was entered, the data file was printed and crosschecked for

accuracy with the original data documents. An exploratory analysis was conducted to

identify any missing values and outliers, and to determine if the data was skewed or

normally distributed. There were no missing fields for essential data points and

therefore, no participants were excluded from the study.

Upon completion of data entry and cleaning, the original data was returned to

a locked cabinet in the investigators office. The data file was backed up automatically

by the institutional network on a daily basis. Computer printouts of the statistical

analysis were systematically stored by time sequence to facilitate easy access at a

later time.

Statistical Analysis

The sample population was comprised of pre-licensure nursing students in an

Associate Degree program who were enrolled in Nursing IV (NUR 202), the terminal


clinical nursing course of the curriculum. Approximately 65 students were enrolled in

the Nursing IV course during the spring 2016 semester, and the anticipated sample

size was 55-59 participants. The demographics of the sample population were

analyzed using descriptive statistics; these variables included age, gender, and

ethnicity. Age, a continuous variable, was described by three measures of central

tendency (mean, median and mode), two measures of dispersion (range and standard

deviation), and one measure of distribution (skewness). Gender and ethnicity

reflected categorical data and were presented with frequencies. The data analysis plan

was presented for each individual research question in the study.

Research Question 1: What is the level of performance for the study group on

the final ATI standardized pharmacology assessment? The data analyzed for this

question were the specific scores that students achieved on the ATI Pharmacology

Assessment and therefore, were continuous data. Continuous variables are variables

that provide a score for each individual and can take on any value on the

measurement scale that is being used (Field, 2013). Specifically, the scores on the

ATI Pharmacology Assessment reflected interval data because there were equal

distances or differences between intervals on the scale of test scores. As continuous

data, a descriptive analysis was completed for measures of centrality and measures of

dispersion. The mean, median, mode, standard deviation, variance, and range were

reported for the test scores for the sample. A second analysis was completed by

categorizing the scores into two groups, students who met the benchmark and

students who did not meet the benchmark, using the level 2 proficiency score of 72%


as the cutoff. This secondary analysis was done in the event that the statistical

assumptions of Pearson’s correlation coefficient could not be met. For example, the

data may not have been normally distributed, or the data may have been skewed to

one end or another. Burns and Grove (2009) identify the assumptions of Pearson’s

correlation are as follows: (a) interval measurement of both the independent and

dependent variables, (b) normal distribution of at least one variable, (c) independence

of observational pairs, and (d) homoscedasticity which is defined as data that “are

evenly dispersed above and below the regression line, which indicates a linear

relationship on a scatter diagram (plot)” (p. 479). If the assumptions of Pearson’s

correlation coefficient could not be met, non-parametric testing would have been used

to analyze the data. Non-parametric tests do not rely on the restrictive assumptions of

parametric tests; in particular, it is not assumed that the sample is normally distributed

(Field, 2013). As categorical data, the level of performance was presented by

frequencies.

Research Question 2: What is the bivariate relationship between certain

academic variables (nursing grade point average and science grade point average)

and non-academic variables (previous college credit or degree, previous health care

experience, working hours per week, and family responsibilities) and performance on

the final ATI standardized pharmacology assessment? The academic variables of

nursing GPA, science GPA, and working hours per week were continuous data, and

presented by the measures of centrality. The non-academic variables of previous

college credit, health care experience, and family responsibilities were dichotomous


variables defined by a “Yes” or “No” answer; this data was described with

frequencies. For example, participants were asked to answer “Yes” or “No” if they

had received any credit for college courses prior to acceptance to the college. Health

care experience was defined as any current or previous work experience related to

direct patient care in a health care setting to which respondents also answered either

“Yes” or “No. When exploring family responsibilities, participants answered “Yes” if

they have assumed financial responsibility as head of household, responsibility for

dependent children, or responsibility as a caregiver during their enrollment in the

Associate Degree program.

Bivariate correlation analyses determine the direction and strength of the

relationship between two variables in a single sample, and a correlation is used when

two variables are continuous (Burns & Grove, 2009). Pearson’s correlation

coefficient examines interval data, which requires that data has equal intervals,

mutually exclusive categories, and exhaustive categories. The academic variables of

nursing GPA, science GPA, and working hours per week were continuous interval

data. The outcome variable of the ATI Pharmacology Assessment test score also

reflected continuous interval data. Therefore, Pearson’s correlation coefficient was

used to evaluate for any relationships between these independent continuous variables

and test performance.

The Chi square test is used when the independent predictor variable is

categorical or dichotomous and the dependent outcome variable is also categorical. If

performance on the ATI Pharmacology Assessment was required to be analyzed as


categorical data, meaning that the student either met the 72% benchmark or did not

meet the benchmark, the Chi square test was to be utilized. There were three non-

academic dichotomous variables and therefore, three 2 x 2 contingency tables would

be presented showing the relationship between each of the three independent

variables and the one outcome variable. The three non-academic dichotomous

variables could also be treated as continuous variables because each of them has a

meaningful mean. For example, if the sample size is 60 and 30 participants answer

“Yes” to family responsibilities, 50% of participants have family responsibilities and

the mean for family responsibilities is .50. Therefore, Pearson’s biserial correlation

coefficient would also be used to analyze the three dichotomous variables if scores on

the ATI Pharmacology Assessment were presented as continuous data.

Research Question 3: What is the bivariate relationship between students’

self-reported perceived clinical experiences in medication management and

performance on the final ATI standardized pharmacology assessment? Students’ self-

reported perceived clinical experiences for medication management presented

continuous ordinal data that was obtained through a survey questionnaire. Students

were required to respond to specific statements about clinical experience

opportunities that were evaluated with a Likert scale. The scale ranged from

“Strongly Disagree” (a value of 1) to “Strongly Agree” (a value of 5). A positive

evaluation of clinical experiences was reflected by a higher score number for each of

the survey statements. The data was ordinal because the intervals between the ranked

categories were not equal; however, since there were more than four items in the


questionnaire, the data was able to be powered up to interval data. Interval data

allows the magnitude of an attribute to be identified more precisely and therefore, is

considered to be more useful than ordinal data (Burns & Grove, 2009; Field, 2013).

Additionally, many statistical tests rely on having data measured at the interval level

including Pearson’s product-moment correlation; this correlational analysis was used

to answer the Research Question 3. The average score for each statement in the

survey was reported, and each statement was analyzed for any significant relationship

to performance on the ATI Pharmacology Assessment.

The study encompassed an item-level survey analysis and statistical analyses

requiring multiple correlations. Both of these circumstances may compound the error

factor or increase the probability of making a Type I error. This is sometimes referred

to as a “galloping alpha”, whereby statistically significant results simply occur by

accident when multiple correlations are performed. In order to compensate for the

number of tests that were run on the same data, the alpha was adjusted to a 0.04 level.

Trends were established at the .05 level, but statistical significance was only reported

at the .04 level.

Protection of Human Subjects

Researchers have an ethical responsibility to protect the rights of human

research subjects. The human rights that require protection include the right to self-

determination, the right to privacy, the right to anonymity and confidentiality, the

right to fair treatment, and the right to protection from discomfort and harm

(American Nurses Association and American Psychological Association as cited in


Burns & Grove, 2009). The right to self-determination is based on respect for human

subjects and freedom to participate or not participate in research.

A number of steps were taken to ensure the protection of human subjects. First

and foremost, approval for the research study was obtained through the institutional

review boards of the health care organization affiliated with the college, and Case

Western Reserve University. These approvals were acquired prior to introducing the

study or any data collection. Second, no coercion was employed to achieve

participation. As identified previously, the study investigator emphasized that

participation in the study was voluntary, and that declining to participate carried no

consequences for the student. The investigator clarified that student grades,

progression to role transition, and graduation from the program would not be affected

in any way. The study investigator was not involved in teaching the Nursing IV

course during the spring 2016 semester, and therefore, did not know the students nor

was affiliated with the course in any way. Consequently, any student concerns

regarding a negative relationship with course faculty as a result of not participating

was avoided. Furthermore, there were no excessive rewards being offered that would

constitute undue influence for participation in the study. Finally, the investigator for

the study completed the Collaborative Institutional Training Initiative (CITI)

education as a requirement for the NUND 541 course, Practice-Focused Research II;

this certification was a requirement for human subjects’ research and was also

mandated by the affiliated health care organization’s IRB. The CITI Program mission

statement reads: "To promote the public's trust in the research enterprise by


providing high quality, peer reviewed, web based, research education materials to

enhance the integrity and professionalism of investigators and staff conducting

research” (CITI, 2015).

A student identification number assigned by the registrar’s office was utilized

to determine demographic information and relationships between selected variables

and performance on the ATI RN Proctored Pharmacology Assessment.

Confidentiality was maintained as all data collected in the study were analyzed and

reported in aggregate form. Furthermore, all survey questionnaires, data collection

records, statistical analyses, and study results were maintained in a secure locked

cabinet in the investigator’s office, and any document with student identification

numbers was destroyed once the data file was created.

All students in the Nursing IV course were at least 18 years of age and were

informed regarding the research study and their rights as a participant. The

completion of a survey questionnaire presented no risk of harm to participants;

however, informed consent was obtained since student records were reviewed, and it

would be possible to link data to individual students through the college-generated

identification number.

All students in the Nursing IV course were eligible to participate, thereby

supporting fair selection. No potential participants in the study were considered to

have diminished autonomy. The nature of the study precluded concern regarding

freedom from discomfort or harm for human subjects as students were only

completing a demographic form and survey questionnaire. No treatment or


intervention was implemented, and there were no physical, emotional, or social risks

involved for participants in the study. However, it was possible that some students

would be uncomfortable with a faculty member outside of the course reviewing

personal grades and test scores. Exposure to the research process might have been

considered a benefit to those students participating in the study, but any benefits with

respect to changes in the curriculum to improve pharmacology education would only

be applicable to future students in the program.


Chapter 4: Data Analysis

This study was conducted to examine the relationship of selected academic

and non-academic variables in undergraduate nursing students’ acquisition of

pharmacology knowledge as demonstrated by performance on a final standardized

pharmacology assessment. The study also sought to evaluate the medication

administration and decision-making experience as self-reported by students, and

determine any correlation between student perceptions of clinical experience

opportunities for medication management, and performance on the final

pharmacology assessment. Chapter four presents the demographics of participants,

the descriptive statistics for seven independent study variables, the descriptive

statistics for one dependent outcome variable, and the results of the correlational

analyses conducted in the study.

Sample Demographics

Pre-licensure nursing students enrolled in the final clinical nursing course of

an AASN program during the spring 2016 semester comprised the target population

from which the sample for the study was drawn. Fifty-six students were present for

class when the research study was introduced; of these 56 students, 54 students

(96.4%) participated in the study. The demographic information for the study sample

was collected through school admission and registration records in SONISWEB, the

data administration system of the college. Reports from SONISWEB for demographic

data and selected variables were generated by the college Registrar. A data file was

created using SPSS software, and all information was entered by the study


investigator. The specific demographic data collected for the study included age,

gender and ethnicity. Analysis of the data file for descriptive statistics will present

dichotomous variables by frequencies, and continuous variables by measures of

central tendency, dispersion, and/or distribution.

The average age for the study population was 25.7 years (SD = 4.49) with a

range of 21-46 years. Eighty-three percent of participants were less than 30 years of

age (n = 45), and 44% of participants were in the age range of 22-24 years (n = 24).

The vast majority of participants were female at 96.3% (n = 52), while only 3.7% of

the study population was male (n = 2). On the basis of federal standards for

categorizing race and ethnicity for data collection, participants fell into three of the

six defined categories with 83.3% as Caucasian or White (n = 45). See Table 7 for

additional analysis of the demographics.

Table 7

Study Participants’ Age, Gender, Ethnicity

_____________________________________________________________________

Demographic n % M Mdn Mode Range SD Skew SE

_____________________________________________________________________

Age 25.74 24.00 * 21-46 4.47 2.04 .325

Gender

Male 2 3.7%

Female 52 96.3%

Ethnicity

Hispanic 1 1.9%

African American 8 14.8%

Caucasian 45 83.3%

* Multimodal age: 22, 23, 24

(N = 54)

_____________________________________________________________________


Analyses of Research Questions

Analysis of the study data for each research question was also completed

through Statistical Package for the Social Sciences (SPSS), version 23. Pearson’s

product-moment correlation coefficient and Pearson’s biserial correlation were

utilized to explore the relationships between the selected variables and test scores on

the pharmacology assessment. The significance level for the correlational analyses in

the study was adjusted to 0.04 as previously identified in order to compensate for the

use of an item-level survey, and for the series of bivariate correlations required for the

analysis.

The assumptions of Pearson’s correlation were met as demonstrated by the

normal distribution of data and no evidence of nonlinearity. The Scatter Plots in

Figure 2 indicate a linear relationship between the continuous independent variables

and ATI pharmacology assessment scores. While the linear relationship is less

obvious in Scatter Plots b and c as a result of the weak correlation for these variables,

none of the Scatter plots revealed a curvilinear presentation, which would be a

concern with Pearson’s correlation.

Research Question 1. What is the level of performance for the study group on

the final ATI standardized pharmacology assessment? Since the assumptions of

Pearson’s correlation were met, the analysis for performance on the ATI

pharmacology assessment was completed using the ATI scores as continuous data.

Therefore, it was not necessary to categorize the scores into two groups, students who

met the benchmark and students who did not meet the benchmark, in order to


generate the categorical data required for non-parametric testing. Figure 3 presents a

histogram of the ATI scores demonstrating a bell-shaped curve or normal distribution.

Figure 2

Scatter Plots for Continuous Variables

Scatter Plot a Scatter Plot b

Relationship between Nursing Relationship between Science

GPA and ATI scores, (r = .416) GPA and ATI scores, (r = .355)

Scatter Plot c Scatter Plot d

Relationship between Average Hours Relationship between Clinical

Experience Worked and ATI scores, (r = -.030) Survey and ATI scores, (r = .081)


The mean score on the ATI pharmacology assessment was 65.53 (SD =

8.605), and the range of scores was 45.00 - 80.00. Both the median score and mode

for the assessment was 66.70. On the basis of the recommended Level 2 proficiency

(scores ranging 71.7 - 83.3%), 13 students (24.1%) met the benchmark, and 41

students (75.9%) did not meet the benchmark. See Table 8 for the descriptive

statistics of the ATI pharmacology assessment scores.

Figure 3

Histogram of ATI Pharmacology Assessment Scores

Research Question 2. What is the bivariate relationship between certain

academic variables (nursing grade point average, science grade point average, and

previous college credit or degree) and non-academic variables (previous health care

experience, working hours per week, and family responsibilities) and performance on

the final ATI standardized pharmacology assessment? Again, Pearson’s product-

moment correlation coefficient was utilized to explore relationships between


continuous variables (nursing GPA, science GPA, and work hours per week) and the

ATI pharmacology assessment scores. Pearson’s biserial correlation was utilized to

determine any correlation between the dichotomous variables (previous college

credit, previous health care experience, family responsibilities) and ATI test scores.

Table 8

Descriptive Statistics for ATI Pharmacology Assessment Scores

_____________________________________________________________________

Score n % Level M Mdn Mode Range SD Variance

_____________________________________________________________________

65.53 66.70 66.70 45-80 8.60 74.04

45.00 1 1.9% < Level 1

46.70 3 5.6% < Level 1

48.30 1 1.9% < Level 1

51.70 1 1.9% < Level 1

55.00 3 5.6% < Level 1

56.70 1 1.9% < Level 1

58.30 1 1.9% Level 1

60.00 1 1.9% Level 1

61.70 1 1.9% Level 1

63.30 2 3.7% Level 1

65.00 6 11.1% Level 1

66.70 9 16.7% Level 1

68.30 4 7.4% Level 1

70.00 7 13.0% Level 1

71.70 6 11.1% Level 2

73.30 1 1.9% Level 2

75.00 1 1.9% Level 2

76.70 1 1.9% Level 2

78.30 2 3.7% Level 2

80.00 2 3.7% Level 2

Level 0 0 Level 3 (scores 85.0 - 100%)

Proficiencies 13 24.1% Level 2 (scores 71.7 - 83.3%)

31 57.4% Level 1 (scores 56.7 - 70.0%)

10 8.5% < Level 1 (scores < 56%)

(N = 54)

____________________________________________________________________


Description of Independent Variables. The study encompassed data

collection for seven independent variables for each participant. These academic and

non-academic variables included nursing GPA, science GPA, previous college credit

or degree, previous health care experience, average work hours per week, family

responsibilities, and average score for the student clinical experience survey. This

section will describe all independent variables with the exception of the clinical

experience survey, which is addressed in the analysis of the third research question.

The academic variables were collected from college admission and registration

records, and the non-academic variables were obtained through direct participant

feedback on a demographic information form.

Academic variables. The cumulative nursing GPA was based on three clinical

nursing courses in the program and ranged from 1.33 to 3.33 with a mean value of

2.27 (SD = .526). It should be noted that nursing GPA was based on first-time

performance in a course; therefore, the GPA for students failing a nursing course does

not reflect the revised cumulative average based on successful completion of the

course a second time.

The cumulative science GPA was calculated based on three biological science

courses; this GPA was based on science courses conducted at the college, as well as

science credits transferred in for equivalent courses. The mean science GPA for study

participants was 2.68 (SD = .656) and ranged from 1.33 to 4.00. The number of

participants who received transfer credit for external science courses, and the specific

number of credit hours accepted were additional variables collected in order to


determine science GPA. Seventy percent of participants (n = 38) received transfer

credit ranging from 4 to 12 credits for the three biological science courses being

evaluated in the study.

Eighty-seven percent of the study population (n = 47) accrued college credit

prior to admission to the AASN program, and 20% of participants (n = 11) had

earned a previous college degree. Table 9 provides additional descriptive statistics for

the academic variables.

Table 9

Descriptive Statistics for Academic Variables

_____________________________________________________________________

Variable n % M Mdn Mode Range SD Variance

_____________________________________________________________________

Nursing GPA 2.27 2.00 2.00 1.33-3.33 .526 .277

Science GPA 2.68 2.66 2.33 1.33-4.00 .656 .430

Science Credits Transferred

4 credits 9 16.7%

8 credits 23 42.6%

12 credits 6 11.1%

Previous College Credit or Degree

Yes 47 87.04%

No 7 12.96%

College Degree

Yes 11 20.4%

No 43 79.6%

(N = 54)

___________________________________________________________________

Non-academic variables. The non-academic variables were also analyzed to

be presented by measures of central tendency and frequencies. Eighty-five percent of

the participants (n = 46) were employed; of those employed, participants worked an


average of 4 - 37.5 hours per week. When participants identified a range of hours

worked instead of a whole number, working hours per week were averaged between

the two numbers. For example, if participants identified the average number of work

hours as 8-12 hours, a value of 10 was entered for this field in the data file. The

average number of working hours per week for all employed participants was 18.89

hours (SD = 9.161).

Approximately 80% of the study population (n = 43) acknowledged previous

or current health care experience involving direct patient care other than that acquired

during nursing school. Forty-four percent of participants (n = 24) identified existing

family responsibilities; these responsibilities were further categorized by financial

responsibility as head of household (29.6%, n = 16), responsibility for dependent

children (27.8%, n = 15), and responsibility as a caregiver (13%, n = 7). Ten

participants (18.5%) answered “Yes” to more than one category of family

responsibilities, and four participants (7.4%) answered “Yes” to all three categories of

family responsibilities. See Table 10 for statistics describing the remaining non-

academic variables analyzed in the second research question.

Correlational Analysis. Pearson’s product moment correlation was used to

evaluate relationships between nursing GPA, science GPA or average work hours and

ATI test scores. The correlation between nursing GPA and ATI pharmacology

assessment scores was significant (r = .416, p = .002), and the size of the correlation

was moderate (r2 = .173). This suggests that nursing GPA explains 17.3% of the

variability of the ATI score. The correlation between science GPA and ATI


assessment scores was also significant (r = .355, p = .008), and the size of the

correlation, again was moderate (r2 = .126). In this correlation, 12.6% of the variance

is explained by the science GPA. The correlation between average work hours and

ATI test scores was not significant (r = -.030, p = .844).

Table 10

Descriptive Statistics for Non-Academic Variables

_____________________________________________________________________

Variable n % M Mdn Mode Range SD Variance

_____________________________________________________________________

Average Work Hours 18.89 20.00 20.00 4.00-37.50 9.162 83.932

(N = 46)*

Previous Health Care Experience

Yes 43 79.6%

No 11 20.4%

Family Responsibilities (any)

Yes 24 44.4%

No 30 55.6%

>1 10 18.5%

>2 4 7.4%

Financial

Yes 16 29.6%

No 38 70.4%

Children

Yes 15 27.8%

No 39 72.2%

Caregiver

Yes 7 13.0%

No 47 87.0%

(N = 54)

_____________________________________________________________________

*Descriptive statistics for work hours is reported for the 46 participants employed.


Pearson’s biserial correlation was used to determine any relationship between

previous college credit degree, previous health care experience, or family

responsibilities, and pharmacology assessment scores. None of the correlations for

these variables and ATI performance were significant. Table 11 summarizes the

correlational analyses for the second research question.

Table 11

Correlations for Selected Variables and ATI Pharmacology Assessment Score

_____________________________________________________________________

Independent Variable N r p

(2-tailed)

_____________________________________________________________________

Cumulative Nursing GPA 54 .416** .002

Cumulative Science GPA 54 .355** .008

Previous College Credit or Degree 54 -.024 .863

Previous Health Care Experience 54 -.059 .674

Average Hours Worked per Week 46 -.030 .844

Family Responsibilities 54 .179 .196

_____________________________________________________________________

**Correlation is significant at the 0.01 level (2-tailed)

Research Question 3. What is the bivariate relationship between students’

self-reported perceived clinical experiences in medication management and

performance on the final ATI standardized pharmacology assessment? Pearson’s

correlation coefficient was used again to analyze for any correlation between student

perceptions of clinical experience opportunities for medication management, and


performance on the final pharmacology assessment. When evaluating the distribution

of data, the histograms for three variables presented values outside of the normal

distribution. These outliers were noted on the histograms for age, the average score

on the clinical experience survey questionnaire, and the total score on the survey.

Participant age was not to be utilized in any correlation but rather only for the

descriptive statistics. Therefore, the outlier for age did not need to be removed since

there was no potential influence on the results of the study analysis. However, the

clinical experience survey was a variable being examined in the analysis for the third

research question. The clinical experience survey was analyzed by average score and

total score, but only the average score was utilized in the correlational analysis. In

order to evaluate for any distortion of significance as a result of extreme values or

values outside of the normal distribution, the correlational analyses were run before

and after removal of the outliers. The histograms in Figure 4 show the distribution of

survey scores with and without the outliers.

Description of the Clinical Experience Survey Questionnaire. The clinical

experience survey questionnaire was an investigator-developed survey comprised of

six statements, and participants responded to each item using a Likert scale. The

survey was analyzed using both the average score for each statement and the total

score for all survey items. There were no missing values for any of the survey items.

The average score of survey responses was selected for analysis to enhance clarity for

interpreting results. Prior to analyzing the overall scores of the survey, reliability of

the six-item scale was evaluated by Cronbach’s alpha statistic. Cronbach’s alpha was


.892 demonstrating that the six survey items were internally consistent and reliable as

a scale. This reliability then supported use of either the overall average or total score

of the survey questionnaire in the analysis.

Figure 4

Histograms of Clinical Experience Survey Average Scores

Survey responses showing outliers Survey responses with outliers removed

Responses on the survey ranged from 1 (“Strongly Disagree”) to 5 (“Strongly

Agree”). The average score for each survey statement was 3.92 (SD .814) with a

range of 1.00 – 5.00, and the mean total score of the survey questionnaire was 23.54

(SD 4.882) with a range of 6.00 - 30.00. Table 12 provides descriptive statistics for

the average score and total score on the clinical experience survey prior to and after

the outliers were removed. Table 12 also demonstrates how the values for skew and

kurtosis were corrected following removal of the outliers.

Of the six survey items, the statement with the greatest number of positive

responses (“Agree” or “Strongly Agree”) was noted for clinical experience

opportunities in medication administration (n = 50). The survey item with the greatest


number of negative responses (“Disagree” or “Strongly Disagree”) was identified for

clinical experience opportunities in patient teaching (n = 11), as well as medication

management and decision-making (n = 11). The greatest number of neutral responses

was observed for clinical experience opportunities in patient teaching (n = 12). Table

13 presents additional information describing the results of each item on the clinical

experience survey questionnaire.

Table 12

Descriptive Statistics for Clinical Experience Survey

_____________________________________________________________________

Statistic Average Total Average Total

Score Score Score* Score*

_____________________________________________________________________

N 54 54 51 51

M 3.92 23.54 4.07 24.43

Mdn 4.00 24.00 4.00 24.00

Mode 3.83 23.00 3.83 23.00

Range 1.00-5.00 6.00-30.00 2.67-5.00 16.00-30.00

SD .814 4.882 .525 3.151

Variance .662 23.838 .276 9.930

Skew -1.789 -1.786 -.010 -.012

SE of Skew .325 .325 .333 .333

Kurtosis 4.876 4.875 -.289 -.281

SE of Kurtosis .639 .639 .656 .656

_____________________________________________________________________

*Descriptive statistics with outliers removed.


Table 13

Frequency Distribution for Clinical Experience Survey Responses

_____________________________________________________________________

Survey Responses Frequency and Percent

Likert Scale Item 1* Item 2 Item 3 Item 4 Item 5 Item 6

Response n (%) n (%) n (%) n (%) n (%) n (%)

_____________________________________________________________________

Strongly Disagree 2 3 2 3 2 2

(3.7%) (5.6%) (3.7%) (5.6%) (3.7%) (3.7%)

Disagree - 2 - 8 9 4

(3.7%) (14.8%) (16.7%) (7.4%)

Neither Agree nor 2 5 5 11 12 4

Disagree (3.7%) (9.3%) (9.3%) (20.4%) (22.2%) (7.4%)

Agree 20 23 30 23 19 31

(37%) (42.6%) (55.6%) (42.6%) (35.2%) (57.4%)

Strongly Agree 30 21 17 9 12 13

(55.6%) (38.9%) (31.5%) (16.7%) (22.2%) (24.1%)

(N = 54)

_____________________________________________________________________

*Survey Items Defined:

Item 1 = Opportunities for medication administration

Item 2 = Opportunities for varied medication administration routes

Item 3 = Opportunities for different drug classifications

Item 4 = Opportunities for medication management/decision-making

Item 5 = Opportunities for patient teaching

Item 6 = Confidence to safely manage medication therapies

Correlational Analysis. Pearson’s product moment correlation coefficient was

used to examine relationships between the responses on the clinical experience survey

questionnaire and ATI pharmacology assessment scores. The correlation between the

survey and ATI performance for all 54 participants was not significant (r = .148, p =

.286). The correlation between the survey and ATI performance was re-analyzed


following removal of the outliers. This correlation was then evaluated for 51

participants and was also not significant (r = .081, p = .570).

The investigator conducted additional correlational analyses on the two survey

items with the greatest number of negative responses; the fourth and fifth survey

items both received an equal number of “Disagree” and “Strongly Disagree”

responses (n = 11). The correlation between these two survey items and the

pharmacology assessment was not significant. Table 14 provides the statistics for all

of the correlations conducted on the clinical experience survey questionnaire and the

ATI pharmacology assessment.

Table 14

Correlational Statistics for Clinical Survey Questionnaire

_____________________________________________________________________

Independent Variable N r p

(2-tailed)

_____________________________________________________________________

Average Score Clinical Experience Survey 51 .081 .570

Item 4 – Medication Management 51 .106 .445

Item 5 – Patient Teaching 51 .177 .201

_____________________________________________________________________

In the methodology chapter of the study, it was identified that the desired

sample size could not be met since the target population was limited. The investigator

was to re-run the power analysis based on the actual number of students who

participated in the study, and then report the effect size that could be obtained. A


revised power analysis was conducted for the sample size of 54 participants based on

Pearson’s correlation two-tailed power analysis. A sample size of 54 with an alpha of

.04 and beta of .20, for a power of .80 yields an effect size of .37. This is slightly

larger than a medium effect size but relatively close to the .30 correlation size initially

desired.

Summary

In summary, a total of seven academic and non-academic variables were

evaluated in this study for any relationship to pharmacology knowledge acquisition as

demonstrated by performance on a final standardized ATI pharmacology assessment.

Descriptive analysis of the variables was completed and reported using SPSS

statistical procedures. In addition to the descriptive statistics, Pearson’s product

moment correlation coefficient and Pearson’s biserial correlation were utilized to

complete a series of bivariate correlations. The assumptions for Pearson’s correlation

were met as demonstrated by the normal distribution of data and linearity of the

Scatter Plots. The correlational analysis for the variables was completed with and

without the outliers to evaluate for any misrepresentation of statistical significance.

Cronbach’s alpha coefficient revealed internal consistency of the clinical experience

survey items, thereby establishing reliability of the survey questionnaire as a scale.

The analysis of the study showed statistically significant correlations for

nursing GPA and ATI pharmacology assessment scores, and science GPA and ATI

pharmacology assessment scores. The strength of the correlation was moderate for

both variables. The correlation between clinical experience opportunities for


medication administration and management as self-reported by students and

pharmacology test scores was not statistically significant, nor were any of the other

academic and non-academic variables in the study.


Chapter 5: Discussion

The purpose of this study was to determine any correlation between selected

academic and non-academic variables and pharmacology knowledge acquisition as

demonstrated by performance on a cumulative pharmacology assessment. A total of

seven academic and non-academic variables were evaluated for undergraduate

nursing students. The analysis of the medication administration and decision-making

experience as self-reported by students was of particular interest to the investigator;

this variable reflected any relationship between student perceptions of clinical

experience opportunities for medication management, and performance on the final

pharmacology assessment. Chapter five provides a discussion of the major findings of

the study, limitations, and implications for nursing, nursing education, and future

research.

Discussion

Of the seven variables analyzed in the study, the analysis only showed

statistically significant correlations for nursing GPA and ATI pharmacology

assessment scores, and science GPA and ATI pharmacology assessment scores.

Pearson’s product moment correlation was used to evaluate for these relationships. A

correlation coefficient of positive or negative .1 reflects a small effect compared to .3,

which is considered a moderate effect, or .5 a large effect (Field, 2013, p. 270).

Therefore, the strength of the correlation was moderate for both of the GPA variables.

The following discussion will focus on the findings of the study for each research

question and compare these findings to the literature.


Level of performance on the ATI pharmacology assessment. The overall

level of performance of the study group was below the established Level II

benchmark; this benchmark demonstrates the ability to readily achieve NCLEX-RN

standards and exceed expectations for performance in the content area of

pharmacological therapies. Level 1 proficiency suggests that the student has minimal

knowledge and meets the absolute minimum expectations for performance. Fifty-

seven percent of the study population achieved a Level 1 proficiency, and 18% fell

below the Level 1 proficiency. These findings are concerning for students nearing

completion of an undergraduate program. Nevertheless, they are consistent with the

literature suggesting that nurses do not have sufficient knowledge and are

inadequately prepared in pharmacology (Adhikari et al., 2014; Dilles et al., 2011;

Honey & Lim, 2008; King, 2004; Latter, et al., 2000, 2001; Morrison-Griffiths et al.,

2002; Ndosi & Newell, 2008; Simonsen et al., 2014). The literature also identified

that nursing students, novice nurses and new graduates have difficulty

comprehending pharmacology (Adhikari et al., 2014; Manias & Bullock, 2002;

Simonsen et al., 2014). The level of participant performance on the ATI

pharmacology assessment correlates with these findings in the literature.

It is possible that the timing and consequences of the ATI pharmacology

assessment influenced the level of performance. The theory content of the Nursing IV

course is front-loaded within the first ten weeks of the course resulting in eight hours

of theory content per week. The pharmacology assessment was conducted during the

tenth week of the semester and within less than one week of the final course


examination. Although points were allocated for achieving the benchmark, the

pharmacology assessment was only worth 1% of the course grade. Fatigue during the

tenth week of the semester and minimal consequences tied to the assessment are

potential factors negatively impacting motivation for students to do well on the test.

Participants may also have been more focused on the upcoming comprehensive

examination, which was worth 30% of the course grade and therefore, significantly

influences passing or failing the course.

The computerized report generated by ATI for the pharmacology assessment

demonstrated a group score mean of 65.4% for all students in the class. The national

mean for the test was 63.2% and the program group mean was 64.1%. The program

mean reflects the average score of groups within the same program type category. It

should be noted that the group score mean was based on the entire class of 63

students who took the examination, as opposed to the 54 participants who agreed to

participate in the study. Although only 24% of the study population met the Level 2

benchmark, almost 80% of participants exceeded the national mean, and 72%

exceeded the program type mean. While it may appear that the study population

performed well in comparison to students in other programs, there are several factors

that are unknown in the group performance calculations by ATI. For example, it is

not clear whether students from the study population are compared to other students

who are at the same progression point in their respective programs. It is also uncertain

as to whether the testing for other programs was proctored or non-proctored, if the


assessment comprised a portion of a course grade, or whether any other consequences

were tied to the examination.

Relationship between selected variables and ATI performance. Of the six

variables analyzed in the second research question, two factors correlated positively

with performance on the pharmacology assessment. A higher nursing GPA and

science GPA was associated with a higher score on the ATI assessment. These

findings were not unexpected as a number of studies have demonstrated science GPA

as a predictor for success in nursing, nursing GPA as a predictor for NCLEX-RN

success, and science GPA as a predictor of NCLEX-RN success. The literature also

presents several studies that have linked pharmacology course grades or performance

on pharmacology standardized assessments to NCLEX-RN success (Emory, 2012;

Paraszczuk, 2011; Silvestri, 2010; Ukpabi, 2008).

The study did not show any correlation between the academic variable of

previous college credit or degree and performance on the ATI assessment. This

finding was inconsistent with assertions of the theoretical framework that past

experiences serve as a rich resource for learning, or that adults tend to draw on

previous experience for learning. Eighty-seven percent of participants had completed

previous college courses. This finding is not surprising considering the increasing

number of nontraditional students who enter undergraduate nursing programs or the

number of students who are pursuing nursing as a second career. However, the

overall high percentage of students who accrued previous college credit contributes to


the homogeneity of the sample. The lack of variability in the study population

potentially explains the lack of any impact on ATI performance.

While student admission records identify the specific courses taken or degrees

acquired prior to entry in the program, the study investigator did not collect or

analyze this information. However, when calculating the science GPA, the

investigator did ascertain that 70% of participants transferred 4-12 credits in the

biological sciences. While transferred credit was not a variable in the study, several

questions are raised in relation to the impact on science GPA, nursing GPA or

pharmacology knowledge acquisition. Theoretical competence and proficiency in

anatomy and physiology is identified as a competency area for pharmacology

knowledge and medication competence (Sulosaari et al., 2011). The rigor and

expectations of science courses completed outside of the college is not known. In

consideration of science GPA as a predictor for academic success in nursing, one

implication is that outside courses may not be comparable to those offered internally.

Conversely, another implication is that outside courses are actually more rigorous

accounting for the average science GPA of 2.68 and low range of 1.33. The teaching

methods for outside courses may be inconsistent with the conceptual approach of the

college, or the application of theory to practice may have been limited. The interval

of time that has transpired since completion of an external science course is also

unclear. The retention of basic principles of anatomy and physiology as a foundation

for nursing is a concern when large gaps of time exist between science and nursing

courses. The relationship between performance in the biological sciences and nursing


GPA has been well documented in the literature, and therefore, the quality of

education in the biological sciences warrants close attention.

The non-academic variables of previous health care experience, working

hours per week, and family responsibilities did not reveal any significant correlations

with ATI performance. Nearly 80% of participants in the study identified previous

health care experience for direct patient care outside of clinical experiences. Similar

to college credit, this high percentage suggests a homogenous group, thereby lending

little variability to the study population. Again, the discussion of andragogy as a

theoretical framework for the study noted that adult learners perform well when they

use prior experience (Pappas, 2014, Billings & Halstead, 2012). On this principle,

prior experience such as health care experience, or prior knowledge as a result of

earning another degree or college credit would be expected to enhance learning.

Therefore, the lack of correlation for previous health care experience is inconsistent

with the literature. The fact that some schools of nursing require nursing assistant

certificates as an admission requirement had piqued interest by the investigator in the

relevance of previous health care experience; however, any previous health care

experience that may have been associated with nursing assistant certification did not

reveal any impact on test performance.

As non-licensed personnel, it is possible that previous health care experience

had little relevance for the knowledge needed to comprehend pharmacological

principles and apply them to practice. Another consideration is the age of the study

population and the length of experience in health care. Although the college has a


high percentage of nontraditional students, the mean age of participants was 26 years

and the mode ranged from 22 to 24; students in the age range of 24 years and younger

accounted for 54% of the study population. Even though the student population is

considered nontraditional and beyond adolescent years, the average age of

participants was still fairly young. Consequently, some of the principles of andragogy

may not be as applicable in this study population as they would be to an older student

population. The study also did not analyze the length of health care experience nor

the specific type of health care setting where experience had been obtained. Students

may also have failed to recognize the aspect of the question that emphasized

experience in direct patient care. All of these are additional factors that may have

impacted the lack of correlation to ATI performance.

Eighty-five percent of study participants were employed, and worked an

average of 18-20 hours per week. Forty-four percent of participants indicated family

or financial responsibilities, and ten participants identified responsibility in two or all

three categories. It is logical to expect that as work hours or family responsibilities

increase, time available for studying decreases; decreased study time is typically

associated with decreased academic performance. Therefore, a negative correlation

was anticipated between working hours and ATI test scores, but no correlation

existed between these variables. Furthermore, even though a high percentage of

students in the college fall into one or more of the characteristics that define

nontraditional students (AACRAO, 2015), and studies have shown that nontraditional


students may be at risk for failure, there was no correlation between this variable and

ATI test performance.

The study findings for the nonacademic variables of working hours per week

and family responsibilities were inconsistent with the literature. The study by Strayer

and Beitz (2010) evaluated pharmacology knowledge acquisition between traditional

and nontraditional students, and indicated that students with responsibilities such as

family dependence and the need to work to support themselves do not perform as well

academically. Lack of time and the use of superficial learning strategies as a result of

time constraints and information overload have also been identified as factors

influencing pharmacology knowledge (Honey & Lim, 2008; King, 2004; Manias &

Bullock, 2002a, 2002b). As with several other variables, the high percentage of

working students, and the significant number of participants with family

responsibilities resulted in a more homogenous sample. The overall performance by

the study group on the pharmacology assessment was also similar, which further

contributes to the homogeneity of the study population. The degree to which

participants were very similar is, again, a leading factor in the lack of correlation with

ATI performance.

Relationship between clinical experiences and ATI performance. There

was no correlation between student perceived clinical experience opportunities for

medication administration and management and performance on the pharmacology

assessment. The investigator further analyzed those items in the survey where

opportunities were perceived lowest; however, no correlation was noted between


those survey items and ATI scores. These findings are not consistent with the

literature in terms of factors that have been found to influence pharmacology

knowledge acquisition. Numerous studies have identified that additional clinical

experience opportunities are needed for medication administration and decision-

making, and that undergraduate clinical experience is one of the most important

factors promoting pharmacology knowledge acquisition (Adhikari et al., 2014; Honey

& Lim, 2008; Manias & Bullock, 2002a, 2002b; Bullock & Manias, 2002; Ives et al.,

1996). The importance of clinical experience opportunities has been emphasized in

the literature by both graduate nurses and seasoned nurses, as well as undergraduate

students in nursing.

When analyzing the total clinical experience survey score and the average

survey score, the mean values are relatively high, and the majority of responses to

each survey item were positive. Of the potential 324 responses by 54 participants, 248

responses (77%) were identified as “Agree” or “Strongly Agree”. This finding

indicates that a high number of participants found the clinical experience

opportunities in the program to be sufficient. The positive evaluation of clinical

experiences may be associated with the long-time clinical emphasis of the

undergraduate program. The degree of positive responses by the vast majority of the

group is a factor for the absence of any correlation between the clinical experience

survey and ATI performance.

Other explanations for the lack of correlation with clinical experience

opportunities include survey-related issues. Students may not feel comfortable


answering survey items in an unfavorable manner, or may feel pressured to respond

in a way they believe faculty expect them to respond. Students tend to record

responses that reflect more positively on their abilities, knowledge, or perceptions. It

is possible that survey items were interpreted differently by different participants.

Students were instructed to consider cumulative clinical experience opportunities

when responding, but were possibly influenced to a greater extent by their most

recent clinical experiences. Nursing IV clinical experiences involve the most

comprehensive patient care by students, provide multiple patient assignments and

require administration of all medications. Survey responses may have been influenced

by the clinical experiences immediately prior to administration of the survey, or

students may not have been able to recall the quality of experiences in previous

courses. It should be noted, however, that only 12% of all responses were answered

as “Neither Agree nor Disagree” suggesting that participants were confident and clear

in the majority of their answers to the survey items.

Burns and Grove identify that measurement error is inherent in any

measurement strategy and is defined as the “difference between what exists in reality

and what a research instrument measures” (2009, p. 372). Content validity for the

survey was established by the investigator through review by faculty colleagues, as

well as students who recently graduated from the program. Furthermore, the

reliability of the six-item scale was evaluated by Cronbach’s alpha statistic. A statistic

of .7 to .8 is considered an acceptable value for Cronbach’s alpha (Field, 2013). The

internal consistency reliability of the six-item survey scale was supported by a


Cronbach’s alpha of .892. Despite efforts to establish content validity and reliability,

“an instrument that is reliable cannot be assumed to be valid for a particular study or

population” (Burns & Grove, 2009, p. 380). The survey questionnaire has not been

tested as a valid instrument from one sample population to another; therefore, the

extent to which the instrument potentially measures concepts other than what was

intended contributes to systematic error and decreased validity. Measurement error is

a final potential factor affecting the results of the analysis.

Utility of the theoretical framework. As mentioned previously, several

findings in the study were inconsistent with the theoretical framework. These findings

included the lack of correlation of previous college credit or degree and previous

health care experience with performance on the ATI pharmacology assessment. Adult

Learning Theory or Andragogy emphasizes the value of past experiences of the adult

learner as a resource for learning. Factors that may have contributed to this lack of

correlation have been presented. Another issue impacting the usefulness of the

theoretical framework was the average age of the study population. While the

majority of students in the college met criteria for nontraditional status, the mean age

of participants was 26 years, and 54% of the study population was 24 years or

younger. As a result, some of the principles or assertions of Andragogy may be less

relevant to this younger population of students. Andragogy also asserts that adult

learners are self-directed and need to be involved in the learning process or be able to

direct their learning. Pharmacology is traditionally a difficult subject for many

students to learn and encompasses an extensive amount of material; therefore, the


need for greater direction by faculty may be warranted in this content area. Despite

some of the inconsistencies between the study results and the theoretical framework,

components of Andragogy germane to the study population included readiness to

learn, personal relevance of the learning, and employment and family responsibilities

as potential variables interfering with academic performance.

Limitations

A number of methodological limitations of the study exist which restrict the

population to which the findings can be generalized. The first primary limitation is

the use of a convenience sample, the size of the sample, and data collection from a

single setting. The original estimate of 65 students in the Nursing IV class fell to 63 at

the time of enrollment in the study due to withdrawal from the course. Attendance of

the class when the study was introduced dropped even further to 56 students.

Therefore, even though 96% of the target population participated in the study, the

sample size obtained was small. A small sample size affects the power or capacity of

the study to detect differences or relationships that actually exist in the population

(Burns & Grove, 2009, p.357). In addition to sample size, the number of variables to

be examined in the study and effect size are additional factors that impact power. The

need for a larger sample size and greater diversity within the group was a foremost

issue for the study. While the use of multiple sites would have increased the size and

diversity of the sample, differences among programs with respect to admission

standards, curriculum design, faculty, and teaching methods would present other

influencing factors to consider.


Another limitation for the study was the use of an investigator-developed

survey instrument, and the fact that responses to this survey relied on self-reported

data by students. The lack of any tested survey instrument in the literature to evaluate

clinical experience opportunities for medication management can be considered a

limitation as well. Concerns regarding measurement error and validity were addressed

in the discussion of the survey questionnaire. The reliability of self-reported data by

participants is also questionable. Factors that influence how participants might

respond to survey items were also presented in the discussion of the survey results.

All of these elements contribute to measurement error potentially creating bias and

variable error. In turn, bias and variance affect reliability; in this way, self-reported

data is another limitation of the study.

The lack of studies in the literature with which to compare this study

constitutes a final limitation of the study. A number of studies have addressed

variables which influence academic success and performance on the NCLEX-RN

examination, and several studies exist that identified a correlation between

pharmacology grades and NCLEX-RN performance. However, only one study was

found that specifically evaluated factors correlating with pharmacology knowledge

acquisition. Strayer and Beitz (2010) examined variables influencing pharmacology

course grades comparing traditional and nontraditional students. This gap in the

literature provided support for conducting the study, but the lack of similar studies

precludes comparison of findings to revise the methodology or validate results.


Implications for Nursing and Nursing Education

As noted under the limitations of the study, the generalizability of the study is

limited. Even so, valuable information may be garnered from the review of the

literature and study results. The review of the literature provides a comprehensive

analysis of variables influencing pharmacology knowledge acquisition. The areas

identified serve as criteria by which nursing programs can establish curricular

standards for teaching pharmacology. The review of the literature identifies specific

knowledge deficits found in new graduates and novice nurses. This information is

valuable to nursing administrators for designing orientation programs and preventing

medication errors.

The study results have implications for program admission requirements and

processing, and a number of institutional policies. Enrollment management

committees may need to reconsider standards for admission, and revise policies

establishing admission criteria in order to enhance student success. Cumulative GPA

in the biological sciences may need to be considered more carefully, emphasized to a

greater extent, or assigned a higher percentage in comparison to other criteria used for

admission rubrics. Despite educational regulations that facilitate the transfer of

college credits, students who complete the majority of science courses outside of the

admitting institution may require further scrutiny. Cut-off values for grade point

averages that warrant academic probation may need to be raised, or students may

need to be referred for counseling and remediation at an earlier time. Grading policies


should be evaluated and revised to ensure that passing grades reflect the necessary

achievement to facilitate success in subsequent courses and the overall program.

Nontraditional students are perceived as a group potentially at risk for

retention and academic performance issues. Identifying valid predictors of academic

success or failure enables nurse educators to pinpoint high-risk students, provide

needed academic support, and optimize student performance. Evidence of the

relationship between standardized assessments in pharmacology and NCLEX-RN

performance also supports the need to further investigate factors that influence or

predict pharmacology knowledge acquisition.

Even though the variables of work hours and family responsibilities did not

show a significant correlation, these issues compete for time available to devote to

studies. Admission processing should emphasize program rigor and expectations, and

incorporate a self-assessment analysis of personal circumstances. In this way,

potential applicants understand the impact of school on work-life balance and may be

counseled to delay admission until personal situations are less demanding. Institutions

that utilize standardized testing should continue to focus on early identification of

students who are at risk for failure, whether this failure applies to higher level nursing

courses or to the NCLEX-RN examination. Remediation efforts may need to begin

earlier in the program particularly for content-specific assessments that rely heavily

on a solid foundation of the biological sciences.


Future Research

Curricular factors that influence pharmacology knowledge acquisition and

overall student success in nursing need to be explored further. In consideration of the

limitations of the study, the principal indication for future research is to repeat the

study for additional Nursing IV groups to obtain a larger sample size and a more

diverse study population. Future research might evaluate pharmacology knowledge

upon completion of the course rather than during week ten so as to minimize some of

the influencing factors described during this time of the semester. A pharmacology

assessment at the end of the semester would also account for clinical experiences

during role transition, which often significantly impacts student confidence in clinical

skills and patient care.

Several variables in the study present possible areas for future study as result

of the descriptive analysis. The high number of transferred science credits raises

questions as to the relationship between this variable and pharmacology knowledge

acquisition and academic success in general. A future study could examine any

correlation between the number of science credits transferred and nursing GPA, or the

number of science credits transferred and pharmacology test scores. The non-

academic variables of work hours and family responsibilities could be analyzed to

determine the relationship between combined factors and performance on the

pharmacology assessment. Combined factors might examine those participants who

are working plus have a family responsibility, or participants with two and three

family responsibilities combined.


The emphasis of the literature on clinical experience opportunities as a

significant factor in acquiring pharmacology knowledge warrants further

investigation of this variable. In addition to the number of opportunities for

medication administration and management, the context in which clinical experiences

take place is worthwhile to study as numerous factors associated with the practice

setting have been cited to impact student experiences. The survey questionnaire

regarding clinical experience opportunities could also be revised to include more than

one measure of a concept being evaluated. For example, two or three survey items

could be developed to evaluate the same concept (e.g. medication management or

patient teaching), and the results of each of the items could be compared to enhance

validity. The impact of clinical experience opportunities for medication management

and decision-making on pharmacology knowledge could also be compared among

different nursing programs with varying clinical experience hours and requirements.

The relationship that has been identified between standardized pharmacology

tests and NCLEX-RN performance warrants further investigation of the factors that

influence or predict pharmacology knowledge acquisition. Identification of valid

predictors of academic success and academic risk can enable nurse educators to

devise strategies and interventions to optimize student performance and increase the

probability of passing the NCLEX-RN (Briscoe & Anema, 1999). Determining such

factors for pharmacology knowledge acquisition may assist educators to identify

high-risk students earlier in the program, provide needed academic support, and focus

on more effective teaching methodologies.


The level of performance on the pharmacology assessment was consistent

with studies identifying inadequate knowledge and preparation of new graduates.

Numerous studies indicate that the number of hours allocated to pharmacology

education is unbalanced with the responsibilities and time nurses spend managing

pharmacological therapies. The literature also identifies controversy regarding

separate versus integrated pharmacology education, and some authors have suggested

the need for both. The college does not offer a separate pharmacology course at this

time. Therefore, future research might also focus on the impact of a separate

pharmacology course in the curriculum or compare outcomes between programs that

offer a separate pharmacology course and those that do not. While variables

influencing knowledge assist to identify at-risk students and facilitate early

remediation, future research is also needed to explore more effective teaching

strategies for this highly complex and wide-ranging subject matter.

Conclusion

A discussion of the seven variables analyzed in the study has been presented.

The variables of nursing GPA and science GPA were found to be statistically

significant, and these study results are consistent with the literature. The remaining

five variables did not show any correlation with performance on the ATI

pharmacology assessment. These findings were inconsistent with the literature, and a

number of factors have been suggested as possible reasons for the lack of correlation.

One factor considered was the homogeneity of the study population with respect to

ATI performance, college credit, working hours, and family responsibilities.


Additional significant factors include the size of the sample, the single-site setting,

the use of an investigator-developed survey questionnaire, and the use of student self-

reported data. The issues surrounding each of these factors have been described.

Some of the factors that potentially influenced the outcome of the study were

also recognized as limitations. Again, these elements encompassed the small sample

size, a single setting, measurement errors associated with student self-reported data,

and the use of an instrument that has not been tested. Factors influencing motivation

to perform well on the pharmacology assessment were also recognized, and may be

considered limitations of the study.

The results of this study validate the significance of nursing GPA and science

GPA in determining academic success in nursing programs. Careful scrutiny of GPA

is indicated as a standard for admission and throughout the admission process.

Admission criteria and grading policies may need to be revised to support optimal

performance and successful completion of the program.

The findings in the descriptive analysis of variables raised questions regarding

additional areas to study in future research. Potential themes include further

investigation of the impact of transferred science credits, and working hours

combined with family responsibilities. Clinical experience opportunities need to be

evaluated further for a larger sample, and incorporate aspects of the clinical

environment that influence the experience.

The Institute of Medicine (IOM) has identified a number of recommendations

for the prevention of medication errors in response to alarming statistics for adverse


medical events in health care. These recommendations include the need to improve

patient education regarding the risks, contraindications, and possible side effects of

prescribed medications, as well as the need for additional training in medication

management practices (IOM, 2006). Implicit in the IOM recommendations is the

need for nurses to acquire more comprehensive pharmacology knowledge. The

significance of pharmacology knowledge to safety, quality patient care, and the

prevention of medication errors warrant ongoing investigation of the factors that

influence, predict, or support knowledge acquisition.


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, 34(2), 185-190.

American Association of Collegiate Registrars and Admissions Officers (AACRAO).

(2015). Retrieved from

http://consulting.aacrao.org/publicationsevents/publications/changing-

demographics-why-nontraditional-students-should-matter-to-enrollment-

managers-and-what-they-can-do-to-attract-them

Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: A

literature review. Journal of Nursing Management, 11(2), 130-40.

Assessment Technologies Institute, LLC. (2015a). ATI Nursing Education,

Integration Resources, Assessment Information, RN Assessment, RN Content

Mastery Series Proctored 2013, Test Descriptions. Retrieved from

http://www.atitesting.com/ati_next_gen/Faculty/FacultyLanding.aspx)

Assessment Technologies Institute, LLC. (2015b). ATI RN Content Mastery Series

(CMS) 2013 Technical Manual. Leawood, KS: ATI.

Banning, M. (2003). Pharmacology education: A theoretical framework of applied

pharmacology and therapeutics. Nurse Education Today, 23(6), 459-466.

http://consulting.aacrao.org/publicationsevents/publications/changing-demographics-why-nontraditional-students-should-matter-to-enrollment-managers-and-what-they-can-do-to-attract-them



http://www.atitesting.com/ati_next_gen/Faculty/FacultyLanding.aspx


Barry, O. P., O’Sullivan, E., & McCarthy, M. (2015). Periodic review sessions

contribute to student learning across the disciplines in pharmacology. Journal

of the Scholarship of Teaching and Learning, 15(1), 38 - 56. doi:

10.14434/josotl.v15i1.12984

Billings, D. M., & Halstead, J. A. (2012). Teaching in nursing: A guide for faculty,

(3rd ed.). St. Louis: Saunders Elsevier.

Bonnivier, J. F., & Magoteaux, A. L. (2012). Innovative teaching strategy for

pharmacology in psychiatric-mental health nursing: Moving from content to

concepts. Journal of Psychosocial Nursing, 50(12), 22-29.

Brady, A., Malone, A., & Fleming, S. (2009). A literature review of the individual

and systems factors that contribute to medication errors in nursing practice.

Journal of Nursing Management, 17(6), 679-697.

Briscoe, V. J., & Anema, M. G. (1999). The relationship of academic variables as

predictors of success on the National Council Licensure Examination for

Registered Nurses (NCLEX-RN) in a selected associate degree program.

Journal of the Association of Black Nursing Faculty in Higher Education,

10(4), 80-83.

Bullock, S., & Manias, E. (2002). The educational preparation of undergraduate

nursing students in pharmacology: A survey of lecturers' perceptions and

experiences. Journal of Advanced Nursing, 40(1), 7-16.

Burns, N., & Grove, S. K. (2009). The practice of nursing research: Appraisal,

synthesis and generation of evidence, (6th ed). St. Louis: Saunders Elsevier.


Caon, M., & Treagust, D. (1993). Why do some nursing students find their science

courses difficult? Journal of Nursing Education, 32(6), 255–259.

Cebeci, F., Karazeybek, E., Sucu, G., & Kahveci, R. (2015). Nursing students’

medication errors and their opinions on the reasons of errors: A cross-

sectional survey. Journal of Pakistan Medical Association, 65(5), 457-62.

Chan, S. (2010). Applications of andragogy in multi-disciplined teaching and

learning. Journal of Adult Education, 39(2), 25-35.

Cibulka, N. J., & Crane-Wilder, L. (2011). Introducing personal digital assistants to

enhance nursing education in undergraduate and graduate nursing programs.

Journal of Nursing Education, 50(2), 115-118.

Clancy, J., McVicar, A., & Bird, D. (2000). Getting it right? An exploration of issues

relating to the biological sciences in nurse education and nursing practice.

Journal of Advanced Nursing, 32(6), 1522-1532.

Cohen, M. R. (2006). Medication errors. American Pharmacists Association:

Washington DC. Collaborative Institutional Training Initiative (CITI). (2015).

CITI Program, Retrieved from https://www.citiprogram.org/

Collins, A. S., Graves, B. A., Gullette, D., & Edwards, R. (2010). Developing an

interactive microsimulation method in pharmacology. Journal of Nursing

Education, 49(7), 410-413.

Courtenay, M. (1991). A study of the teaching and learning of the biological sciences

in nurse education. Journal of Advanced Nursing, 16(9), 1110–1116.

https://www.citiprogram.org/


Dilles, T., Vander Stichele, R. R., Van Bortel, L., & Elseviers, M. M. (2011). Nursing

students' pharmacological knowledge and calculation skills: ready for

practice? Nurse Education Today, 31(5), 499-505. doi:

10.1016/j.nedt.2010.08.009.

Eisenhauer, L. A., Hurley, A. C., & Dolan, N. (2007). Nurses’ reported thinking

during medication administration. Journal of Nursing Scholarship, 39(1),

82-87.

Emory, D. J. (2012). Use of standardized mastery content assessments given during

the first year of a baccalaureate nursing program for predicting NCLEX-RN

outcomes. (Doctoral Dissertation) Retrieved from ProQuest, UMI

Dissertations Publishing, 3505834.

Fidalgo-Neto, A. A., Pinto-Alberto, A.V., Calvano-Bonavita, A.G., Soares-Bezerra,

R. J., Berçot, F. F., Lopes, R. M., & Alves, L. A. (2014). PHARMAVIRTUA:

educational software for teaching and learning basic pharmacology. Advanced

Physiology Education, 38, 368-371.

Field, A. (2013). Discovering statistics using IBM SPSS statistics, (4th ed.) Los

Angeles: Sage Publications.

Gee, P. R., Peterson, G.M., Martin, J. L., & Reeve, J. F. (1998). Development and

evaluation of a computer-assisted instruction package in clinical

pharmacology for nursing students. Computers in Nursing, 16(1), 37-44.

Harding, L., & Petrick, T. (2008). Nursing student medication errors: A retrospective

review. Journal of Nursing Education 47(1), 43-47.

http://search.proquest.com/indexinglinkhandler/sng/au/Emory,+DeAnna+Jan/$N?accountid=9920


Henschke J. A., (2011). Considerations regarding the future of andragogy. Adult

Learning, 22(1), 34-37.

Henschke, J. (1998, September). Historical antecedents shaping conceptions of

andragogy: A comparison of sources and roots. Paper presented at the

International Conference on Research in Comparative Andragogy, Radovljica,

Slovenia.

Hewitt, J., Tower, M., & Latimer, S. (2015). An education intervention to improve

nursing students’ understanding of medication safety. Nursing Education in

Practice, 15, 18-22.

Holton, E. F., Swanson, R. A., & Naquin, S. (2001). Andragogy in practice:

Clarifying the andragogical model of adult learning. Performance

Quarterly, 14(1), 118-143.

Honey, M., & Lim, A. G. (2008). Application of pharmacology knowledge in

Medication management by final year undergraduate nursing students.

Contemporary Nurse, 30(1), 12-19.

Institute of Medicine of the National Academies. (1999). To err is human: Building

a safer health system. L. T. Kohn, J. M. Corrigan, M. S. Donaldson, (Eds).

Washington, DC: National Academy Press.

Institute of Medicine of the National Academies (2006). Preventing medication

errors: Quality chasm series. Report Brief July 2006, Retrieved from

http://www.nationalacademies.org/hmd/Reports/2006/Preventing-Medication-

Errors-Quality-Chasm-Series.aspx


Ives, G., Hodge, K., Bullock, S., & Marriott, J. (1996). First year RNs’ actual and

self-rated pharmacology knowledge. Australian Journal of Advanced Nursing,

14(1), 13–19.

James, J. T. (2013). A new, evidence-based estimate of patient harms associated with

hospital care. Journal of Patient Safety, 9(3), 122-128.

Jordan, S. (1997). Teaching pharmacology by case study. Nurse Education Today,

17(5), 386-393.

Keohane, C. A., Bane, A. D., Featherstone, E., Hayes, J., Woolf, S., Hurley, A.,

Bates, D. W., Gandhi, T. K., & Poon, E. G. (2008). Quantifying nursing

workflow in medication administration. Journal of Nursing Administration,

38(1), 19-26.

King, R. L. (2004). Nurses’ perceptions of their pharmacology educational needs.

Journal of Advanced Nursing, 45(4), 392-400.

Latter, S., Rycroft-Malone, J., Yerrell, P., & Shaw, D. (2000). Evaluating educational

preparation for a health education role in practice: The case of medication

education. Journal of Advanced Nursing, 32(5), 1282-1290.

Latter, S., Rycroft-Malone, J., Yerrell P., & Shaw, D. (2001). Nurses' educational

preparation for a medication education role: Findings from a national survey.

Nurse Education Today, 21(2), 143-154.

Lim, A. G., & Honey, M. (2006). Integrated undergraduate nursing curriculum for

pharmacology. Nursing Education Practice, 6(3), 163-168.

http://www.ncbi.nlm.nih.gov/pubmed?term=Latter%20S%5BAuthor%5D&cauthor=true&cauthor_uid=11170801

http://www.ncbi.nlm.nih.gov/pubmed?term=Rycroft-Malone%20J%5BAuthor%5D&cauthor=true&cauthor_uid=11170801

http://www.ncbi.nlm.nih.gov/pubmed?term=Yerrell%20P%5BAuthor%5D&cauthor=true&cauthor_uid=11170801

http://www.ncbi.nlm.nih.gov/pubmed?term=Shaw%20D%5BAuthor%5D&cauthor=true&cauthor_uid=11170801

http://www.ncbi.nlm.nih.gov/pubmed?term=Lim%20AG%5BAuthor%5D&cauthor=true&cauthor_uid=19040872

http://www.ncbi.nlm.nih.gov/pubmed?term=Honey%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19040872


Manias, E., Bullock, S., & Bennett, R. (2000). Formative evaluation of a computer-

Assisted learning program in pharmacology for nursing students. Computers

in Nursing, 18(6), 265-271.

Manias, E., & Bullock, S. (2002a). The educational preparation of undergraduate

nursing students in pharmacology: perceptions and experiences of lecturers

and students. International Journal of Nursing Studies, 39(7), 757-769.

Manias, E., & Bullock, S. (2002b). The educational preparation of undergraduate

Nursing students in pharmacology: clinical nurses' perceptions and

experiences of graduate nurses' medication knowledge. International Journal

of Nursing Studies, 39(8), 773-784. PubMed PMID: 12379295.

McVicar, A., & Clancy, J. (2001). The biosciences and fitness for practice: A time for

review? British Journal of Nursing, 10(21), 1415-1420.

McVicar, A., Clancy, J., & Mayes, N. (2010). An exploratory study of the application

of biosciences in practice, and implications for pre-qualifying education.

Nurse Education Today, 30 (7), 615-622

Meechan, R., Mason, V., & Catling, J. (2011). The impact of an integrated

pharmacology and medicine management curriculum for undergraduate adult

nursing students on the acquisition of applied drug/pharmacology knowledge.

Nursing Education Today, 31(4), 383-389.

Montenery, S. M. (2013). Reinforcing pharmacology content using the medication

mansion. Nurse Educator, 38(3), 96-97.

javascript:__doLinkPostBack('','ss~~AR%20%22McVicar%20A%22%7C%7Csl~~rl','');

javascript:__doLinkPostBack('','ss~~AR%20%22Clancy%20J%22%7C%7Csl~~rl','');

javascript:__doLinkPostBack('','mdb~~rzh%7C%7Cjdb~~rzhjnh%7C%7Css~~JN%20%22British%20Journal%20of%20Nursing%22%7C%7Csl~~jh','');


Morrison-Griffiths, S., Snowden, M., & Pirmohamed, M. (2002). Pre-registration

nurse education in pharmacology: Is it adequate for the roles that nurses are

expected to fulfil? Nurse Education Today, 22(6), 447-456.

National Council of State Boards of Nursing (NCSBN). (2015). NCLEX and

Other Exams, FAQs, Exam Development FAQs. Retrieved from

https://www.ncsbn.org/2324.htm

National League for Nursing. (2013). Annual Survey of Schools of Nursing, Fall

2012. Nursing Student Demographics, Percentage of Students Over Age 30

by Program Type, 2012. Retrieved from

www.nln.org/research/slides/index.htm.

Ndosi, M. E., & Newell, R. (2008). Nurses’ knowledge of pharmacology behind the

drugs they commonly administer. Journal of Clinical Nursing, 18(4), 570-

580.

O’Shea, E. (1999). Factors contributing to medication errors: A literature review.

Journal of Clinical Nursing, 8, 496-504.

Page, K., & McKinney, A. A. (2007). Addressing medication errors - The role of

undergraduate nurse education. Nurse Education Today, 27(3), 219-224.

Pappas, C. (2014, April). The Adult Learning Theory Andragogy of Malcolm

Knowles. Adult Education Infographics, e- Learning Infographics: ELearning

Industry. Retrieved from http://elearninginfographics.com/adult-learning-

theory-andragogy-infographic/

http://elearninginfographics.com/adult-learning-theory-andragogy-infographic/

http://elearninginfographics.com/adult-learning-theory-andragogy-infographic/


Paraszczuk, A. M. (2011). The effect of review classes on performance on

comprehensive assessments and the National Council Licensure Examination

of graduating baccalaureate nursing students. (Doctoral Dissertation)

Retrieved from ProQuest, UMI Dissertations Publishing, AAI3497100.

Peterson, C. M., & Ray, C. M. (2013). Andragogy and metagogy: The evolution of

neologisms. Journal of Adult Education, 42(2), 80-85.

Powell, S. S., Canterbury, M. A., & McCoy, D. (1998). Medication administration:

Does teaching method really matter? Journal of Nursing Education, 37(6),

281-283.

Robinson, J. E. (1987). Separate or integrated pharmacology content? Nursing

Outlook, 35(4), 185–188.

Sears, K., Goldsworthy, S., & Goodman, W. M. (2010). The relationship

between simulation in nursing education and medication safety.

Journal of Nursing Education, 49(1), 52-55.

Silvestri, L. A. (2010). Self-efficacy and the predictors for NCLEX-RN (RTM) success

for baccalaureate nursing students. (Doctoral Dissertation) Retrieved from

ProQuest, UMI Dissertations Publishing, AAI3412401.

Simonsen, B.O., Daehlin, G.K., Johansson, I., & Farup, P. G. (2014). Differences in

medication knowledge and risk of errors between graduating nursing students

and working registered nurses. BioMed Central Health Services, 21(14), 580.

doi: 10.1186/s12913-014-0580-7.


Smith, J., & Crawford, L. (2003). Medication errors and difficulty in first patient

assignments of newly licensed nurses. Journal of Nursing Administration

Healthcare Law, Ethics and Regulation, 5(3), 65–67.

Steunkel, D. (2006). At-risk students: Do theory grades + standardized

examinations = success? Nurse Educator, 31(5), 207–212.

Strayer, R. M., & Beitz, J. M. (2010). Factors influencing pharmacology knowledge

acquisition in traditional versus nontraditional baccalaureate nursing students.

Journal of Professional Nursing, 26(5), 301-308. doi:

10.1016/j.profnurs.2010.02.001.

Sulosaari, V., Suhonen, R., & Leino-Kilpi, H. (2011). An integrative review of the

literature on registered nurses' medication competence. Journal of Clinical

Nursing, 20(3-4), 464-478.

Tang, F., Sheu, S-J., Yu, S., Wei, I-L., & Chen, C-H. (2007). Nurses relate the

contributing factors involved in medication errors. Journal of Clinical

Nursing, 16, 447-57.

Thompson, T. L., & Bonnel, W.B. (2008). Integration of high-fidelity patient

simulation in an undergraduate pharmacology course. Journal of Nursing

Education, 47(11), 518-521.

Thornton, T. (1997). Attitudes towards the relevance of biological, behavioral and

social sciences in nursing education. Journal of Advanced Nursing, 26(1),

180–186.




Trnobranski, P. H. (1993). Biological sciences and the nursing curriculum: A

challenge for educationalists. Journal of Advanced Nursing, 18(3), 493–499.

Tse, M. M., & Lo, L. W. (2008). A web-based e-learning course: Integration of

pathophysiology into pharmacology. Telemedicine and e-Health, 14(9), 919-

924.

Ukpabi, C. (2008). Predictors of successful nursing education outcomes: A study of

the North Carolina Central University's nursing program. Educational

Research Quarterly, 32(2), 30–40.

United States Department of Education, National Center for Education Statistics

(2002). Nontraditional Undergraduates (NCES 2002–012). Retrieved from

http://nces.ed.gov/Pubs2002/2002012.pdf

United States Government, Executive Offices, Office of Management and Budget.

(1997). Revisions to the Standards for the Classification of Federal Data on

Race and Ethnicity (Report). Federal Register Notice. Retrieved from

https://www.whitehouse.gov/omb/fedreg_1997standards

United States Department of Health and Human Services, Food and Drug

Administration (FDA). (2013). Drug Approvals and Databases. Retrieved

from http://www.fda.gov/Drugs/InformationOnDrugs/default.htm.

United States Department of Health and Human Services, Health Resources and

Services Administration. (2010). The Registered Nurse Population, Findings

from the 2008 National Sample Survey of Registered Nurses, Retrieved from

hpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf

http://nces.ed.gov/Pubs2002/2002012.pdf

http://www.fda.gov/Drugs/InformationOnDrugs/default.htm


van den Bemt P. M., Egberts, A. C., & Lenderink A. W. (2000). Risk factors for the

development of adverse drug events in hospitalised patients. Pharmaceutical

World Science 22(2), 62– 66.

Vana, K. D., & Silva, G. E. (2014). Evaluating the use of a simulated electronic

health record and online drug reference in a case study to enhance nursing

students’ understanding of pharmacologic concepts and resources. Nurse

Educator, 39(4), 160-165.

Vana, K. D., Silva, G. E., Muzyka, D., & Hirani, L. M. (2011). Effectiveness of an

audience response system in teaching pharmacology to baccalaureate nursing

students. Computer Informatics Nursing, 29(6), 326-34; quiz 335-336. doi:

10.1097/NCN.0b013e3181f9dd9c.

Wittman-Price, R. A., Kennedy, L. D., & Goodwin, C. (2012). Use of personal

phones by senior nursing students to access health care information during

clinical education: Staff nurses’ and students’ perceptions. Journal of Nursing

Education, 51(11), 642-646.

Wolf, Z. R., Hicks, R., & Serembus, J. F. (2006). Characteristics of medication errors

made by students during the administration phase: A descriptive study.

Journal of Professional Nursing, 22(1), 39-51.

Yeu-Hui, C., & Chiung-Wen, T. (2013). Enhancing nursing students’ medication

knowledge: The effect of learning materials delivered by short message

service. Computers and Education, 61, 168-175.


Zellner, K., Boerst, C., & Semling, K. (2003). Teaching separate versus integrated

pharmacology content. Western Journal of Nursing Research, 25(3), 338-348.


http://www.ncbi.nlm.nih.gov/pubmed/?term=Boerst%20C%5BAuthor%5D&cauthor=true&cauthor_uid=12705115



Appendix A

Notice of Study

NOTICE OF A RESEARCH STUDY AT GOOD SAMARITAN COLLEGE

OF NURSING AND HEALTH SCIENCE

Nursing 202 students are invited to participate in a research study entitled:

The Relationship of Selected Academic, Nonacademic, and Clinical Variables

as Factors Influencing Pharmacy Knowledge Acquisition

in Associate Degree Pre-licensure Nursing Students

This purpose of this study is to examine the following:

What is the relationship between student academic variables and pharmacology knowledge?

What is the relationship between student non-academic variables and pharmacology

knowledge?

What is the relationship between clinical experience opportunities for medication

administration and decision-making and pharmacology knowledge?

When: Thursday, March 17, 2016 (following class)

Where: NUR 202 Classroom 869.7&8

Who: Study Investigator:

Diane M. Stauffer, MSN, RN, CNE

Associate Professor, Good Samaritan College

Please consider participating in this important study - student participation in the study is

voluntary. Completion of study questionnaires will take approximately 10 minutes. For

questions regarding this study, please contact Professor Stauffer at 513-862-3717.

REFRESHMENTS WILL BE PROVIDED


Appendix B

Script for Participant Recruitment

Following introduction of the faculty member/principal investigator…

As a student in the process of completing a doctoral research project, I am very

interested in studying factors that may affect nursing students’ ability to learn pharmacology.

You are invited to participate in a research study entitled, “The Relationship of Selected

Academic, Nonacademic, and Clinical Variables as Factors Influencing Pharmacy

Knowledge Acquisition in Associate Degree Pre-licensure Nursing Students.” The purpose of

this study is to examine the relationship of selected student variables to pharmacology

knowledge acquisition as demonstrated by the ATI pharmacology assessment. A second

purpose of the study is to determine if there is any correlation between student perceptions of

clinical experience opportunities for medication management and scores on the ATI

pharmacology assessment.

As a senior nursing student who has successfully completed all clinical rotations

prior to role transition, you are eligible to participate in the study. Participation in this study

is voluntary and will have no effect on your course grade, progression to role transition or

graduation from the program. All students will be given a packet with three forms to

complete. The first form is an informed consent to participate in the study. The second form is

for demographic information related to selected student variables. The third form is a brief

survey questionnaire regarding your clinical experience opportunities with medication

management. It will take approximately 5-10 minutes for you to complete the forms.

Some data for the study will also be obtained through college records including age,

gender, ethnicity and grade point average. Pharmacology Assessment scores will be obtained

through ATI testing reports. In order to achieve the purpose of the study, student variables

must be matched with corresponding ATI pharmacology scores. This matching will be

completed with the use of your student identification number, but the investigator will not be

able to view any student names. Once the data has been collected and entered, all student

identification numbers will be removed from the study data file, and all study results will be

reported only as aggregate or group data.

If you agree to participate in this study, please complete all the forms in the study

packet, return them to the envelope, and place the envelope in the collection box at the front

of the room. If you do not wish to participate in the study, you may simply return the blank

forms to the envelope, and place the envelope in the same collection box.

Are there any questions about this study?

Thank you very much for your time and consideration to participate in this study.

Please help yourself to refreshments that have been provided. If you have any further

questions or concerns at a later time, this study investigator will be available to answer your

questions.

Appendix C

Original Survey Questionnaire and Summary of Reviewer Feedback

Please answer the statements below regarding your clinical experience opportunities,

pharmacology preparation, and confidence with medication management. Consider your

cumulative or total clinical experience in all four nursing courses prior to role transition

when answering each statement. Skills lab practice sessions and/or simulation experiences

may also be considered when responding to each statement. Each statement should be

evaluated with the following scale:

1 = Strongly Disagree with Statement

2 = Disagree with Statement

3 = Neither Agree nor Disagree with Statement

4 = Agree with Statement

5 = Strongly Agree with Statement

Statement

1

Strongly

Disagree

2

Disagree

3

Neither

Agree

nor

Disagree

4

Agree

5

Strongly

Agree

1. I had sufficient

opportunity to

administer medications

to patients during my

clinical experiences

prior to role transition.

2. I had sufficient

opportunity to

administer different

routes of medications

(routes other than

PO/oral) during my



3. I had sufficient

opportunity to make

decisions about the

administration of

medications during my


prior to role transition

(e.g., withhold a

medication, administer

medication at a later

time, decide which prn


medication to give,

decide on the dosage

when a range is ordered,

question a medication

order, consult with the

RN/MD or Pharmacist

on an issue or concern).

4. I had sufficient

opportunity to teach

patients about their

medications during my



5. I feel confident in my

ability to accurately and

safely administer

medications to patients.

6. I feel confident in my

knowledge of

pharmacology as a

beginning clinician in

terms of how drugs

work, side effects,

nursing implications,

and how to evaluate if a

medication is effective.

ORIGINAL Study Survey Tool

SUMMARY OF FEEDBACK/RESPONSES FROM SURVEY REVIEWERS

GRADUATE STUDENTS AND FACULTY: Please consider the following in your

evaluation of the statements that have been included in the tool:

1. Are the instructions for completing the survey tool well-defined/distinct/clear?

100% of responses indicated that the instructions were clear.

Comment: “Examples that are included make the statements very clear for the

reader. I am able to read these statements and know exactly what aspect of

medication administration it is referring to.”

2. Does each statement relate to the purpose of the study?

100% of responses answered “Yes” to this question

3. Is each statement applicable to current pharmacology practice/expectations during

student clinical experiences? (Consider cumulative experience.)


87.5 % of responses (7/8) answered “yes” to this question. One response did not

give any answer to the question but expressed concern over terminology,

specifically in relation to using the word “sufficient” (See “Other

Recommendations”)

4. Is each statement articulated clearly so that students will easily understand what they

are expected to evaluate?

87.5 % of responses (7/8) answered “yes” to this question. One faculty member

pointed out the need to ensure that each statement is only evaluating one skill or

one ability. Statements #5 and #6 both have two components.

Comment: “Examples that are given are particularly helpful and help to avoid

any misinterpretation of what the statement is referring to.”

5. How essential is each statement/question to the survey tool and purpose of the study?

Please rate each statement/question as “minimally essential”, “moderately essential”

or “highly essential” to include in the questionnaire.

All statements were evaluated as moderately essential or highly essential.

Survey

Statements

Minimally

Essential

Moderately

Essential

Highly

Essential

Total

Statement #1 1 rating in this

category

7 ratings in

this category

8


category

7 ratings in

this category

8

Statement #3 8 ratings in

this category

8

Statement #4 3 ratings in this

category

5 ratings in

this category

8


category

7 ratings in

this category

8

Statement #6 8 ratings in

this category

8


ORIGINAL Study Survey Tool

SUMMARY OF FEEDBACK/RESPONSES FROM SURVEY REVIEWERS

6. Are there statements/questions that you believe to be essential that are NOT included

in the survey tool?

Comments or suggested additional statements:

1) Consider adding a statement regarding experience with different

classifications of medications.

2) Consider asking about the impact of the Chemistry II course which

incorporates basic pharmacological principles and some drug classifications.

3) Consider asking if the student ever experienced a medication error or had

difficulty with skill competencies related to medication administration (e.g.

was required to repeat a return demonstration for a competency).

4) Should there be a statement that asks about how students perceive

consistency (or inconsistency) with faculty expectations of medication

administration? This consistency or lack of consistency may affect the

number of opportunities and confidence.

5) If pharmacology preparation is being assessed (as in the directions and

statement #5 and #6), there should be a question regarding this.

7. Other Recommendations:

1) There are a variety of definitions for the word “sufficient”. Should this be

quantified?

2) Add category of “Unsure” to Likert scale.

3) Change the word, “feel” in statements #5 and #6 to “am”.

4) Change the statement in the directions to three courses since students do not

actually give medications in the clinical area until the second nursing course.

5) Will the student understand the terminology, “sufficient”? Other options

would be “Adequate” or “Satisfactory”. Does this need to be clarified on the

tool?

6) Do you want to assess if the student feels “confident” or “competent”?

Students often feel confident about something but may not be competent.

7) Should statement #3 say RN/Health Care Provider instead of RN/MD?


Appendix D

Final Revised Clinical Experience Survey Questionnaire

Student ID Number ____________________ Study Number ___________

Please answer the statements below regarding your clinical experience opportunities

with medication administration and medication management. Consider your

cumulative experience or total clinical experience prior to role transition when

answering each statement. “Sufficient opportunity” is defined as enough clinical

opportunities to meet the needs of the situation described in the survey statement.

Place a checkmark in the column that best reflects the level to which you agree or

disagree with the statement. Each statement should be evaluated with the following

scale:

1 = Strongly Disagree with Statement

2 = Disagree with Statement

3 = Neither Agree nor Disagree with Statement

4 = Agree with Statement

5 = Strongly Agree with Statement

Statement

1

Strongly

Disagree

2

Disagree

3

Neither

Agree

nor

Disagree

4

Agree

5

Strongly

Agree

1. I had sufficient opportunity

to administer medications to

patients during my clinical

experiences prior to role

transition.


to administer different routes

of medications (routes other

than PO/oral) during my

clinical experiences prior to

role transition.


to administer medications from

a variety of different drug

classifications during my

clinical experience prior to role

transition.


4. I had sufficient opportunity to make decisions about the

management of medications

during my clinical experiences

prior to role transition (e.g.,

withhold a medication,

administer a medication at a

different time, decide which

prn medication to give, decide

on the dosage when a range is

ordered, question a medication

order, consult with the health

care provider or pharmacist on

a concern.


to teach patients about their

medications during my clinical

experiences prior to role

transition.

6. My clinical experience

opportunities were sufficient to

achieve confidence in my

ability to safely manage

medication therapy for

patients.


Appendix E

Demographic Information Form

Student ID Number ____________________ Study Number ___________

Please answer the following questions. Mark an “X” beside the answer that is most

accurate.

1. Do you have any previous or current health care experience involving direct

patient care other than that acquired during nursing school as a student?

YES __________

NO __________

2. Are you currently employed? (includes any type of work for which you are

employed).

YES __________

NO __________

If YES, how many hours per week on average do you work?

__________ hours/week

3. Do you have any of the following family responsibilities?

a. Financial responsibility as head of household

YES __________

NO __________

b. Responsibility for dependent children

YES __________

NO __________

c. Responsibility as a caregiver (e.g., aging parent, family member, friend or

significant other with health care issues)

YES __________

NO _________

PHARMACOLOGY KNOWLEDGE ACQUISITION - OhioLINK ...

Documents

Transcript of PHARMACOLOGY KNOWLEDGE ACQUISITION - OhioLINK ...