www.sciedu.ca/jnep Journal of Nursing Education and Practice, February 2012, Vol. 2, No.

ORIGINAL RESEARCH

Assessments of safe medication administration

in nursing education
Kelly J. Gonzales

UNMC College of Nursing, 985330 Nebraska Medical Center, Omaha, Nebraska

Correspondence: Kelly J. Gonzales. Address: UNMC College of Nursing 985330 Nebraska Medical Center, Omaha,
Nebraska. Zip Code: 68198-5330 402-968-1258 (cell), 402-559-4111 (office). Email: kelly.gonzales@unmc.edu

Received: October 14, 2011 Accepted: November 29, 2011 Published: February 1, 2012
DOI: 10.5430/jnep.v2n1p39 URL: http://dx.doi.org/10.5430/jnep.v2n1p39

Abstract
Background: QSEN has a variety of suggested strategies for teaching safe medication administration. However, they do
not have a recommendation for how to assess it. The purpose of this study was to gain information on how safe medication
administration is assessed in nursing education.
Methods: A survey was developed to identify methods used by nursing faculty members to assess nursing students’
knowledge and skills of safe medication administration. The specific research questions addressed in the survey were: 1)
How is safe medication administration assessed prior to students entering the clinical area; 2) How is safe medication
administration assessed during clinical; 3) How is knowledge of “right drug” assessed in the classroom and 4) How is
knowledge of “right dose” assessed in the classroom setting.
Results: The results of the survey indicated no standardized method for assessing safe medication administration in
nursing education.
Conclusions: There is much variation in how and when safe medication administration is assessed in the education
setting. There is a need for a valid and reliable comprehensive assessment of safe medication administration in order to
evaluate whether nursing students have the knowledge, skills and attitude to safely administrate medications.

Key words
Education safety, Safe medication administration, Nursing education, Assessments

1 Introduction
Medication errors are the most common error that occurs in hospital settings [1]. It has been estimated that 7000 deaths
occur annually due to medication errors [2]. Quality and Safety Education for Nurses (QSEN) was formed to identify gaps
in nursing education and implement a curriculum to include quality and safety [3]. While QSEN has a variety of suggested
strategies for teaching safe medication administration, they do not have a recommendation for how to assess it [4]. The
purpose of this study was to gain information on how safe medication administration is assessed in nursing education by
presenting the results of a survey (see Table 1) developed to identify methods used by nursing faculty members to assess
nursing students’ knowledge and skills of safe medication administration.

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Table 1. Survey for Nursing Education Programs on Safe Medication Administration

Questions

1. Type of school the nursing program is a part of:

______ Independent (private) institution
______ Public institution
2. What nursing degrees does your college or school offer? Mark all that apply.
______ Bachelor of Science in Nursing (BSN)
______ Bachelor of Arts with a major in Nursing
______ Master of Science / Arts in Nursing
______ Doctorate in Nursing Practice (DNP)
______ PhD in Nursing
______ Other (please describe)
______________________________________________________________________________________________
3. What are the number of BSN students that your program typically graduates each year
______
4. Please identify which of the following methods are used in your nursing program to assess the baccalaureate students’
ability to administer medications safely prior to administering medications in the clinical setting. Mark all that apply.
______ Successful completion of a stand-alone pharmacology course
______ Successful completion of nursing course(s) that integrate Pharmacology content
______ Computer-assisted safe medication administration module and exam
______ Examinations that include questions on safe medication administration
______ Medication calculation / mathematical exam
______ Performance assessment in skills laboratory on medication administration
______ Performance assessment prior to clinical
______ Unsure
______Other (Please describe)
________________________________________________________________________________________________
5. Please identify which of the following methods are used in your nursing program to assess the baccalaureate students’
ability to administer medications safely while in the clinical setting. Mark all that apply.
______ Oral review with clinical instructor
______ Written assignment
______ Performance assessment during clinical
______ Unsure
______ Other (Please describe) ____________________________________________________________
6. Who teaches the pharmacology course content in your nursing program to baccalaureate nursing students? Mark all that
apply.
______Nursing faculty with nursing degree
______Nursing faculty without nursing degree
______Non-nursing faculty
______Unsure
7. How frequently do the BSN nursing students take a medication calculation exam in your nursing program?
______Once during the entire program
______ Annually
______Each semester
______ Integrated into every nursing exam
______ Unsure
______ Other (Please describe)
______________________________________________________

(Table 1 continued on page 41)

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Table 1. (Continued.)

Questions

8. Did you or members of your faculty develop the medication calculation exam used in your nursing program?
_____ Yes
_____ No
_____ Unsure
9. What is a passing percentage grade on the medication calculation exam in your nursing program?
_____
10. If the student is not successful on the medication calculation exam, what type of remediation, if any, is the student
expected to complete in your nursing program?
______________________________________________________
______________________________________________________
11. Is there any additional information you can provide to clarify how your nursing program ensures competency in
medication calculations?
______________________________________________________
______________________________________________________
12. Is a specific “performance checklist” for safe medication administration used in the skills laboratory, clinical or both in
your nursing program?
_______ Yes
_______ No
13. Is there anything else you would like to include to better describe how your nursing program assesses its baccalaureate
students for safe medication administration?
______________________________________________________
______________________________________________________
14. Would you be comfortable sharing any of your assessments with the researcher (such as the performance checklist, exams,
etc)? If so, please copy the document into the space below, email or send via postal service to the researcher.

1.1 Review of the literature

Medication administration has been defined from the Nursing Intervention Classification (NIC) as preparing, giving, and
evaluating effectiveness of prescription and nonprescription medications [5]. In 1995, the United States Pharmacopeia
(USP) formed The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) [6]. The
NCC MERP is an independent body comprised of many national organizations (e.g. American Nurses Association, The
Joint Commission, National Council of State Boards of Nursing, and Institute for Safe Medication Practices) that
addresses the causes of medication errors and promotes the safe use of medications. In 1999, they issued recommendations
to enhance the accuracy of medication administration in the inpatient setting [7]. Included in these recommendations is a
series of checks that has come to be known as the “five rights.” While initially five checks were recommended, this has
since expanded to include: clarify orders that cause concern; check to ensure the right medication, in the right dose, to the
right person, by the right route using the right dosage form, at the right time, with the right documentation immediately
prior to administration; ensure adequate training and competency with medication administration devices; use technology
to reduce transcription errors; ensure patient information is available as close to the point of care as possible; ensure
medications are labeled properly and check the label a total of three times; discuss the purpose and effects of the
medication with the patient/family; monitor for therapeutic and/or adverse effects; consider the environment and its role
on patient safety; collect and analyze data with regards to medication errors and near misses; ensure ongoing training of
standards of practice related to accurate medication administration; establish policies and procedures for the medication
administration process.

A literature review was conducted to locate instruments and other methods for assessing either an individual’s
performance on any element of safe medication administration or on all elements of safe medication administration within

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the literature. The instruments identified in the articles had varying levels of evidence of validity and reliability, and some
of the instruments’ psychometric properties included just validity or reliability but not both. Instruments were categorized
and the resulting categories including assessing right dose, right drug or else were comprehensive of safe medication
administration. No other categories of instruments were found. A discussion of the instruments follows.

1.2 Medication calculation instruments: Right dose

Ten of the articles found were specific for assessing the performance of medication calculation [8-17]. Medication
calculation is an important skill as it assures one of the five rights of safe medication administration: right dose. The most
commonly used instrument to assess medication calculation was the Bayne-Bindler Medication Calculation Test, although
a total of six instruments were found within the ten articles that assess right dose.

The Bayne-Bindler Medication Calculation Test was initially found to have evidence of content validity and an odd-even
split half test of reliability of 0.82 [9]. In their 1997 study, the authors found an internal consistency reliability using
Cronbach’s alpha was 0.72 for the pretest and 0.74 for the posttest [10]. Serembus provided additional evidence of validity
and reliability on the Bayne-Bindler Medication Calculation test [17]. She found evidence of content validity, and internal
consistency reliability using the Kuder-Richardson formula was 0.70 for the pretest and 0.83 for the posttest. Ashby used
the Bayne-Bindler Medication Calculation test in her study, but did not provide additional evidence of validity or
reliability [8].

A second instrument including two forms for assessing medication calculation abilities was described by Bliss-Holtz [13].
The two forms were reported to have content validity. Internal consistency reliability was calculated with alpha = 0.83 for
Form I and alpha = 0.71 for Form II when piloting the instrument on 39 nurses, and the other results in a study of 51 nurses
were alpha =0.81 for Form I and alpha =0.79 for Form II. Reliability was obtained by giving both tests in a random order
to a convenience sample of 49 nurses, and a Pearson correlation of 0.94 was obtained.

Flynn and Moore developed a 20-item examination consisting of metric-English conversions and medication and
intravenous calculations [14]. Content validity was established through two separate pilot studies. When 46 subjects
participated, the alpha for internal consistency reliability was 0.83, and was 0.82 in a study with 64 nursing students.

Kohtz and Gowda described a 24-item tool that involved calculating the number of tablets to administer, calculating the
number of milliliters to administer, calculating milliliters per hour, and calculating drops per minute [15]. The authors state
that content validity was established, but no additional information on the psychometric properties of the instrument was
provided.

Rainboth and DeMasi described two different instruments in their article [16]. The first instrument was a 14-item
multiple-choice test, which they established content validity on and the internal consistency reliability was documented as
alpha = 0.674. The second instrument was a 10-item fill-in-the-blank test, which they established content validity on and
internal consistency reliability was documented as alpha = 0.135. The authors conclude the low reliability score for the
second instrument could be explained by the large percentage of students who received 100% on the exam. No further
information was included or could be located regarding validity or reliability of either of these instruments.

In summary, six instruments were discussed in the ten articles that were specific to assessing students’ or nurses’ ability to
correctly calculate medication dosage, or assure right dose. The medication calculation test that has been used the most is
the Bayne-Bindler Medication Calculation Test. In addition, this instrument had the most reported evidence of established
validity and reliability for assessing individual’s abilities for correctly calculating medication dosage, which is one aspect
of safe medication administration. This is the only instrument identified that was used to assess the preparation of students
prior to the administration of medications.

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1.3 Pharmacology knowledge instrument: Right drug

Knowledge of pharmacology, or right drug, is an important component of safe medication administration. Ndosi and
Newell developed an instrument to assess nurses’ knowledge of pharmacology for medications commonly administered
on surgical units [18]. The authors report the instrument had evidence of face validity and content validity. Reliability
assessment for the pharmacology questionnaire was limited to inter-rater reliability and was determined by calculating the
intra-class correlation coefficient (ICC). The average ICC for the study was 0.726 with p = 0.001, indicating the strength of
agreement among raters was good. No further evidence of validity or reliability was reported.

1.4 Comprehensive instruments for safe medication administration

Hsaio and colleagues developed and validated a questionnaire to measure nurses’ knowledge of administering high-alert
medications from eight categories: cardiovascular medications, chemotherapeutic agents, narcotics, opiates, anticoagul-
ants, benzodiazepines, neuromuscular blocking agents and electrolytes [19]. Face validity and content validity were estab-
lished. Construct validity was established through the contrasted groups approach using registered nurses and nursing
students. Results demonstrated a statistically significant difference in the knowledge scores of participants, and the
authors concluded the questionnaire had construct validity. Internal consistency reliability was established for the pilot
with an alpha=0.66 (N=50) and for the study with 305 subjects, the alpha=0.74.

In a separate article, Werab and colleagues discussed two instruments that assess medication administration [20]. The first
instrument was a 24-question pretest and the second instrument was a 45-question posttest. The posttest had a higher level
of difficulty than the pretest. After 27 nurses had completed the instruments, an item analysis of the pretest and posttest
was completed. Questions on the pretest frequently missed were reworded or discarded; questions never missed were
revised with different distracters. In addition, the pretest was expanded to include questions to assess judgment, critical
thinking skills and on the common types of errors at the hospital. After evaluation, the post-test was eliminated entirely
and an alternate format was used to assess knowledge retention. No further information regarding the pretest or posttest
was provided including overall validity and reliability of the final pretest after changes were made or the rationale for the
elimination of the posttest.

The last instrument to be presented, the Safe Administration of Medication (SAM) Scale, was developed to objectively
measure performance of the safe administration of medication [21]. The SAM Scale was constructed to be administered to
associate degree and baccalaureate degree nursing students. This instrument was the most comprehensive instrument
found. It assessed the broad concept of safe medication administration, and included a detailed description of development
and establishment of validity and reliability using Rasch measurement. Ryan reported evidence of content validity, fit
validity and reliability of separation.

1.5 Summary of instruments presented

Based on this review, there is a paucity of instruments in the printed literature to assess safe medication administration.
One concern is that the majority of the instruments found in the articles only assessed one aspect of safe medication
administration. Another concern is the varying levels of evidence of validity and reliability mentioned in the articles.

2 Study methods
A survey was conducted to identify strategies or instruments used by faculty to elicit information on how safe medication
administration was assessed in pre-licensure nursing education. The specific research questions addressed in the survey
were: 1) How is safe medication administration assessed prior to students entering the clinical area; 2) How is safe
medication administration assessed during clinical; 3) How is knowledge of “right drug” assessed in the classroom and 4)
How is knowledge of “right dose”assessed in the classroom setting.

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2.1 Survey instrument development

A survey instrument was developed for this study based upon the results of the literature review and the five rights of safe
medication administration (see Appendix for survey instrument). The survey is comprised of 14 questions that address the
four research questions; the majority of the questions were closed-ended questions requiring the participants to mark all
that apply. A few questions allowed the respondents to simply answer the question. A summary of the relationship
between the four research questions and the 14 survey questions is found in Table 2.

Table 2. Development of Survey Questionnaire Based on Research Questions

Research Question Survey Question

1. How is safe 4. Please identify which of the following methods are used in your nursing program to assess the
medication baccalaureate students’ ability to administer medications safely prior to administering medications in the
administration assessed clinical setting. Mark all that apply.
prior to students
12. Is a specific “performance checklist” for safe medication administration used in the skills laboratory,
entering the clinical area
clinical or both in your nursing program?

13. Is there anything else you would like to include to better describe how your nursing program assesses
its baccalaureate students for safe medication administration?

14. Would you be comfortable sharing any of your assessments with the researcher (such as the
performance checklist, exams, etc)? If so, please copy the document into the space below, email or send
via postal service to the researcher.
2. How is safe 5. Please identify which of the following methods are used in your nursing program to assess the
medication baccalaureate students’ ability to administer medications safely while in the clinical setting. Mark all
administration assessed that apply.
during clinical
12. Is a specific “performance checklist” for safe medication administration used in the skills laboratory,
clinical or both in your nursing program?
13. Is there anything else you would like to include to better describe how your nursing program assesses
its baccalaureate students for safe medication administration?
14. Would you be comfortable sharing any of your assessments with the researcher (such as the
performance checklist, exams, etc.)? If so, please copy the document into the space below, email or send
via postal service to the researcher.
3. How is knowledge of 4. Please identify which of the following methods are used in your nursing program to assess the
“right drug” assessed in baccalaureate students’ ability to administer medications safely prior to administering medications in the
the classroom clinical setting. Mark all that apply.
6. Who teaches the pharmacology course content in your nursing program to baccalaureate nursing
students? Mark all that apply.
13. Is there anything else you would like to include to better describe how your nursing program assesses
its baccalaureate students for safe medication administration?

The content validity of the survey was evaluated initially by a total of seven faculty at one public and two independent
nursing education programs. Content reviewers were sent the survey and asked to review it for clarity of questions and
answer options. In addition, they were asked to consider whether the survey captured how the competency of safe
medication administration was assessed in nursing education. The experts were also asked to provide suggestions on
whether additional questions were needed in the survey. Following review by the content experts, the survey was refined
slightly by rewriting selected questions and by the addition of answer options for selected questions. The final version of
the survey was completed by both the Dean and Associate Dean of Nursing at an independent university prior to

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distributing the questionnaire to the entire sample. Due to their involvement in development of the survey, this program
was eliminated from participating in the study.

2.2 Sampling methods

The Dean or Program Director of every American Association of Colleges of Nursing (AACN) member schools that offers
a BSN was invited to participate in the study. AACN membership includes programs from all 50 states, Washington D.C.,
Puerto Rico, online programs and international programs, totaling over 640 programs [22]. The sample was obtained
through an e-mail list and included over 600 email addresses.

2.3 Procedure
Following Institution Review Board approval, the survey was placed online on a secured survey system, WebSurveyor.
The Deans or Directors of the AACN BSN schools were emailed three separate times at designated intervals over the
course of a semester. Participation was voluntary; consent was indicated by completion of the survey.

2.4 Data analysis

Data analysis was completed using an appropriate statistical software package, SPSS. The fourteen questions in the survey
yielded nominal, frequency and ordinal data. Descriptive statistics are presented for each item of the survey.

3 Results
Over 100 emails were returned as undeliverable after the first email was sent; the researcher then went to the program’s
website to verify the correct email address for the Dean or Director. Following the second email, many emails were still
returned as undeliverable indicating that the program’s website did not list the correct email address for their
Dean/Director.

Over 80 programs sent a reply email indicating their program was a BSN completion program (also known as RN to BSN
program) and did not assess safe medication administration, thus the survey was not applicable to their education program;
and they were removed from the email list. One program sent a reply email that their program was new and they did not
have any nursing students beyond freshmen standing, thus the survey was not applicable to them as they had yet to assess
safe medication administration in their nursing students. Five programs sent a reply email and requested to be removed
from the email list and stated they would not be participating; some offered an explanation that they simply didn’t have the
time to respond to all the survey requests they receive each year. Ten programs responded to the emails asking if the
researcher had obtained IRB approval at their institution and stated they would not be able to participate unless this was
done. The researcher elected not to request IRB approval at each program’s institution and offered to email the letter
indicating IRB approval had been obtained at the researcher’s institution.

The third email was sent to 457 email addresses; the final sample reflects data gathered from 239 programs that agreed to
participate and submitted survey responses. It is estimated that there were ~450 applicable programs for this study; the
participation rate for this study was 53%. After reviewing the responses, none were deemed ineligible for any reason and
all were included in the data analysis. However, some participants left questions blank on the survey rather than select the
“unsure” option.

The first three questions of the survey collected demographic information. Of the 239 programs that participated, 47.3%
(N=112) identified their program as being a part of an independent institution and 52.7% (N=125) identified their program
as being a part of a public institution. Two participants chose not to provide this information. Ninety-six percent indicated
they offered a BSN; a few offered a BA with a major in nursing. Over 63% of the programs (N=152) also offered a
graduate nursing degree including a Master’s in nursing, Doctorate in Nursing Practice or a Doctorate in Nursing. The

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pprograms varied in size with h the smallest graduating 12 2 BSN studentts annually annd the largest ggraduating 8000 BSN
students; the mean
m number of
o BSN studentts that graduatted annually frrom the prograams that particiipated was 1111. Data
ffrom the 2010 0-2011 AACN N report on bacccalaureate enrrollment indiccates that theree were 51,039 graduates from 608
ggeneric (entry--level) baccalauureate nursing program from m August 1, 20009 to July 31, 22010; each proogram had an aaverage
[23]
oof 84 graduates . The Repo ort did not prov
vide a range forr the number off graduates. Whhile the reporteed average nummber of
bbaccalaureate graduates
g is sm
maller than thaat reported by the
t sample, thiis may be due tto recent enrolllment increasees. The
pparticipants weere instructed to report the average number ofo baccalaureat
ate students theyy graduate eachh year; this maay have
bbeen based up pon their curreent enrollment,, rather than actual
a number they most recently graduateed. This suppoorts the
ggeneralizability
y of the data fo
ound in the preesent study as th
he average sizee of the samplee is representattive of the popuulation
oof AACN BSN N programs.

3.1 Research que

estion one
e
TThe first research question assked how safe medication ad dministration wwas assessed prrior to studentss entering the cclinical
aarea and the paarticipants could select as maany answers as applied. Basedd on the indiviidual item respponses for this survey
qquestion, 60% % (N=144) useed the successfful completion n of a stand-alalone pharmacoology course, 36.8% (N=888) used
successful commpletion of nurrsing course(s)) that integratee pharmacologyy content, 29.33% (N=70) useed computer-aassisted
safe medicatioon administratiion module an nd exam, 85.4% % (N=204) useed examinatioons that included questions oon safe
mmedication ad dministration, 96.2% percen nt of the prog grams (N=230)) indicated thhey used mediication calculaation /
mmathematical exams, 95% (N=227)
( used performance assessment in skills laborattory on medicaation administtration,
54.8% (N=131 1) used performmance assessmeent prior to clinnical, and 5.4%
% (N=13) indicaated “other” (seee Figure 1). Sppecific
ccomments in th he “other” respponse option inncluded: concuurrent enrollmeent in pharmacoology (N=4) annd simulation (N=6).
TThe most com mmonly used assessment straategy prior to students
s enterinng the clinicall area was the use of a mediication
ccalculation / mathematical
m ex
xam.

3.2 Research que

estion two
o
TThe second research questio on asked how safe
s medicationn administratioon is assessed in the clinicall setting; particcipants
ccould select ass many answerss as applied. Ninety-three
N perrcent (N=223) used oral revieew with the cliinical instructor, 90%
((N=215) used performance assessment du uring clinical, 49.8% (N=1199) used a writtten assignmennt, 1.3% (N=3) were
uunsure, and 4.2% (N=10) ind dicated “other”” (see Figure 2).
2 Specific coomments in thee “other” respoonse option inccluded:
simulation (N= =2), PDA/iTou uch (N=2), annd preceptor (N N=4). The mosst commonly uused assessmeent strategy waas oral
rreview with thhe clinical instru
uctor.

Figure 1. Daata for Research

h Question One

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Figure 2. Data for Reseearch Question Two

3.3 Research question three

t
The third research
r questiion was about assessment off “right drug” iin the classrooom, specificallyy asking who taught the
pharmacolo ogy course and a many answeers as applied.. Of those thatt responded, eighty-nine
d participants could select as
percent (N=213) used nu ursing faculty with
w a nursing g degree, 16.3%
% of the particcipants (N=39)) indicated thatt a faculty
member wh ho was not a nu urse taught the pharmacology
p content. As staated in the resuults of research question one, a variation
was eviden nt with regards to the placemeent of pharmacology content w with respect too whether it is pprior to studentts entering
the clinicall setting.

3.4 Research question four

f
The fourth research question was about assessment
a of “right
“ dose” in the classroom.. One item for tthis question assked about
the use of a medication caalculation or mathematical
m ex
xam including hhow frequentlyy it is administtered to nursingg students;
participantss could selectt only one answer. Of thosse that respondded, fifty perccent (N=116) indicated a m medication
calculation
n or mathematiccal exam was done
d each semeester, 20.7% (NN=48) indicatedd this was integgrated into eveery nursing
exam, 7.3%% (N=17) indicated this is donne annually, 6.55% (N=15) inddicated this is oonly done once during the entiire nursing
program, 13.4% (N=31) responded witth “other,” 2.2% % (N=5) were unsure, and 22.9% (N=7) didd not provide a response
(Figure 3). None of the paarticipants cho
ose to completee the “other” opption for this qquestion.

Figure 3. Data
D for Researrch Question Four
F

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The second component of this question was open-ended and asked the participants to provide the “passing” percentage
grade to be achieved on the examination. Of those participants that chose to respond the breakdown was as follows:
passing percentage grade varied between 70-100%. The individual responses were: 4.5% (N=10) required between
70-79%, 21.9% (N=49) required between 80-89%, 43.8% (N=98) required between 90-99% and 29.5% (N=66) required
100% on the medication calculation exam in order to “pass.” Sixteen participants did not answer this item. Two
respondents provided narrative information indicating that the passing percentage grade varied based upon the nursing
students academic level in the program.

The third item for this question was open-ended and asked what type of remediation was required for non-passing
performance. Remediation for non-passing grades varied greatly with the most common type of remediation included
meeting with faculty, lab coordinator, or math tutor (N=48). The second most common type of remediation included the
use of computers, including Evolve and Elsevier textbook websites, ATI review, Kaplan review or other computer
modules (N=34). Most programs indicated that students who did not pass the exam retook it at least once (N=105). Three
programs specified that if the student did not pass it after three retakes then there was an automatic course failure or
program dismissal. One program indicated the student could retake the exam as many times as needed in order to achieve
a passing grade.

The last item for this question asked if the medication calculation exam was developed by faculty of the nursing education
program. Of those who responded, 90.6% (N=213) indicated yes, 6.4% (N=15) indicated no, and 3% (N=7) were unsure.

4 Discussion
To summarize the results of the survey, it was found that there was no standardized method for assessing safe medication
administration. The data for the first research question demonstrated the most frequently used assessment strategy by the
nursing programs was the medication calculation / mathematical exam, which assesses knowledge and performance of
right dose. This echoes the findings of the literature search in that most of the instruments found in the literature related to
safe medication administration were medication calculation or mathematical exams and focused on the calculation of right
dosage. The other two most common forms of assessing safe medication administration prior to clinical were a
“performance assessment” with one specifically stating it occurred in the skills laboratory. It is unclear if this is a
comprehensive assessment of all aspects of safe medication administration, or if it is an assessment of just some of the
parts of safe medication administration, such as correctly drawing up a medication from a vial into a syringe.

The data for the second research question demonstrated that the vast majority of nursing education programs required the
instructor’s presence when assessing safe medication administration in the clinical setting. This is concerning because of
increased demands on the instructor during clinical, increasing size of clinical groups, and the increasing acuity of patients,
all of which impact the quality of the educational experience for the nursing students. It is recommended students are
allowed sufficient opportunities to practice and have their skill performance assessed prior to entering the clinical setting.
This is beneficial to the nursing students, and it is also beneficial to the patient that the student has already practiced and
been assessed prior to providing patient care.

The data for the third research question for the programs that responded indicated a variation in who teaches the
pharmacology course and when it is placed in the program. If non-nurses are solely teaching the pharmacology course,
there may be some question as to whether the course includes the nursing implications of pharmacology and safe
medication administration. One respondent provided narrative information at the end of the survey stating that placement
of the pharmacology course is a current area of debate, and it is presently placed concurrently with the first clinical course,
and that students are administering medications in clinical prior to successful completion of the pharmacology course.
Another respondent provided narrative information indicating that the pharmacology course is placed concurrently with
“Fundamentals” during the nursing student’s sophomore year. It is clear that not all programs require successful
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completion of a pharmacology course prior to entering the clinical setting. Therefore, nursing students may be
administrating medications without sufficient assessment of their knowledge of “right drug.”

The data for the fourth research question demonstrated much variation in the frequency of the medication calculation /
mathematical exam being administered in the nursing programs, what constituted a passing percentage grade for the
examinations, and what type of remediation was required for non-passing grades. In addition, the vast majority indicated
that the medication calculation exam was developed by the nursing program’s faculty. This practice raises the question
whether the medication calculation exam have been psychometrically evaluated, although the survey did not directly pose
this question.

One limitation of the present study is related to the newness of the survey. Meaningful responses came out of the “other”
answer response in which participants were able to add additional comments, such as how many times students were
allowed to retake a medication calculation exam or whether a program would ever dismiss students due to their inability to
successfully pass the medication calculation exam. As this information was not specifically asked in the survey, it is
difficult to interpret the data in the context of descriptive study. The survey should be further refined to add additional
answer options that were provided in the “other” answer option in order to obtain additional descriptive data that could be
analyzed for frequency trends.

Another limitation was the uncertainty as to how many nursing education programs were eligible to participate and the
lack of complete or accurate e-mails addresses to enable the researcher to directly contact every BSN program. It is
impossible to determine survey response rate without knowing how many nursing education programs were eligible.
Also, despite the multiple attempts to contact all BSN Deans and Directors, some programs may not have received their
invitation to participate in the study. In addition, some nursing education programs websites were difficult to navigate and
were time-intensive in order to discover who the Dean or Director was, and to find their email address. If the study were to
be repeated, the researcher may want to incorporate phone calls with the solicitation of surveys via e-mail. This approach
may enable the researcher to have a more accurate list of emails.

5 Conclusions and recommendations

The call has been made by QSEN for all nursing education programs to integrate safety into the curriculum. While the
knowledge, skill, and attitude (KSA’s) for safety have been outlined by QSEN, assessments for this competency and more
specifically, safe medication administration are lacking. Further comprehensive assessments of safe medication
administration are needed in order to evaluate whether nursing students have the KSA’s and to evaluate various teaching
strategies. Assessments should be all-inclusive to safe medication administration and not just focus on assessment of one
of the five rights. Lastly, assessments of safe medication administration should have evidence of validity and reliability.

There is an overwhelming need for a comprehensive assessment of safe medication administration that can be used prior to
the clinical setting, as it is vital to ensure nursing students are prepared to provide safe care. In addition, a comprehensive
assessment of safe medication administration could be used to evaluate various teaching strategies.

Acknowledgement
I would like to acknowledge Dr. Elizabeth Swanson from the University of Iowa, College of Nursing for her support and
continued assistance with the manuscript. I would also like to acknowledge faculty from my Writing Circle at the
University of Nebraska, Medical Center College of Nursing who assisted with critical revision of the manuscript.

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