Drug Administration by Nurses - Essay Example

2.0 Literature Review Introduction The following is a literature review of relevant research studies carried out in the past to determine the role played by nurses in drug administration as well as the effects of nurses and how their errors in drug administration affect patients. The literature discussed below draws from studies al over the world and most of the studies reviewed are qualitative although a few quantitative studies will be cited. The management for the administration of patient's medication by nurses requires nurses to make complex decisions to enable them to provide high quality and individual patient care. Managing patients' medications involves more than the task of administering medications (Torrance & Jordan, 1995;Jordan & Reid, 1997;Jordan & Hughes, 1998). It encompasses the assessment of patients' health and well- being, the planning, interventions, discharge planning and to provide patient education; within that administering and monitoring the effects of their medications, and evaluating desired and adverse effects of these medications and then document all finding. Management of drug administration is a very central area of concern as far as medical practitioners are concerned. The above is of particular relevance to nurses especially in light of many drug administration related casualties which have been reported in the UK as well as other countries. The problem of increased 'error' in administration by nurses has therefore become a cause of worry for many researchers as attempts to unearth the root cause of the problem remains a pipe-line dream. The above notwithstanding, authorities in health care have for a very long time strived to understand and perhaps explain in a clear and re-assuring way what causes some of the malpractices which cause health care administrators and especially nurses to result to behaviour and practices which put at risk not only their careers but also their patients' lives. In the sections to follow, the researcher carries out a systematic review on the current knowledge body on the field of drug administration by nurses with an aim of establishing the reasons as to how comes and why it happens that nurses leave medication besides patients' bedside thus ignoring policies and procedures. Of particular importance to the study is to establish whether the above behaviour of the nurses arise due to systematic situations such as lack of other 'means' or 'ways' of doing things or it occurs and eminates from nurses' lack of proper preparation in terms of education and training as well as other causal factors to be discussed below. Although the causes or explanations may seem familiar or straightforward to a layman, an explanation that is key to informing the nursing profession calls for a thorough investigation into the problem. Such requires the analysis of past studies similar or remotely related to this study which has been carried out in various places in the world by professional bodies, government agencies, health authorities, nursing schools as well as nursing students. 2.1 Education & Training for Nurses The appropriateness and effectiveness of training received by nurses plays a very crucial role in determining the type and kind of quality services the nurses are going to offer once in the work stations Jones, and Jack, (1999). A study carried out by Jones, and Jack, (1999) established that 88% of cases involving overdosing by nurses stemmed from lack of proper qualifications on the part of the affected nurses. The study carried out in Malaysia involved 60 nurses who had undergone atleast 2 years of training and had been practicing for between 1 to 6 years. The study which involved gathering data through a random sampling utilized the cross-sectional method and covered several towns. Utilizing surveys, interviews and focus groups, results as were released as to how education and training affected nurses' effectiveness affected nurses' ability to disseminate duties professionally. The study arrived at the conclusion that, indeed the level and type of training nurses received determined how the latter would deliver services in the field. In the study, 60% of those nurses who owned up to committing errors in drug administration at least once in their practices are those who had received training for a minimum period which in that case was 2 years. While this could imply that the less the amount of time of training the more the likelihood of committing mistakes in practice, care must be taken to factor in other variables such as the different abilities people possess as far as learning is concerned. The above study is refuted overwhelmingly by another study conducted by (Cormack, 2000) in South America involving nurses in private and public hospitals. The study involved 75 nurses drawn from private hospitals (35) and another (35) nurses drawn from public hospitals. To ensure uniformity; all nurses participating in the study had same minimum qualifications from almost similar institutions of higher learning and also to qualify for the study, a nurse had to have been in practice for not more than 1 years and for not less than a period of 1 year. The findings radically differed from those of (Cormack, 2000) above in that (Jones, & Jack, 1999) found no significant relationship between a nurse's level of education and accuracy in drug administration. In the study findings, it was established that 82% of the nurses who had received a minimum amount of training time, that is, 1 year certificate, were not more likely to err in drug administration as compared to their counterparts who had received training for extended periods. Rather than level and extent of education and training, accuracy, effectiveness and efficiency in drug administration were found to be influenced by the environment; however 70% of those who served in public hospitals admitted to committing errors atleast once in a while in the course of disseminating their duties. Interestingly, only 37% (almost half the figure) of the nurses from the private hospitals admitted to once in a while committing errors in drug administration although the study did not control for extraneous variables. The difference was significant to warrant a conclusion that in actual fact, education and level of training of the nurses was not all important in determining how nurses were effective in drug administration. Care must be taken while interpreting this particular study because the environment as well as the number of facilities offered to nurses in the public and private hospitals in South Africa differs significantly. In another study carried out in South America by Crookes, & Davis, (1999) it was established that private hospitals were more better equipped than public hospitals and also it was found out that the former were more likely to compensate their nurses and staff in general better than the latter. The above imply that availability or lack of facilities could in overall affect how staff in the two institutions executed their duties. This further points out to the dangers of judging nurses by the virtue of level of education and training only, since as clearly demonstrated in the above study, other factors also do play a crucial role in determining the performance of nurses. To further understand the significance of training the researcher reviewed a study of nurses in Pennsylvania U.S.A. by (Jones, & Jack, 1999). The study which was wide in scale involved a total number of 128 nurses from various racial backgrounds; that is, white Americans were represented by 70 nurses, African, American by 30 nurses, immigrant workers by 20 nurses and Hispanic by 8 nurses. In the study, all the nurses were actually put under observation for a period of 4 months with the researcher recording firsthand any observable mistakes that the nurses did actually commit. This method was adopted due to its effectiveness and accuracy in disseminating reliable results. In the findings it was found out that nurses with higher academic qualifications did actually commit less mistakes in drug administration as compared to nurse with basic nursing education. An astounding 88% of the nurses trained upto degree level but with varied duties from their less educated counterparts recorded the least incidences of errors in drug administration. On the other hand, a significant 46% of the nurses with basic nursing training education committed more errors in drug administration. Some of the errors attributable to low education and training included overdosing, injecting the wrong type of medication, missing to administer drugs or treatment at the prescribed time as well as transfusing the wrong blood type. From the above studies it is worthy concluding that there still exists knowledge gap in terms of whether the training and education of nurses contributes to their effectiveness in drug administration. Care must be taken not to assume that it is an obvious thing that level of education influence results. Further research is necessary to establish the real casual-effect factors, something which will lead to effective service delivery and therefore serve to avoid more sufferings and sometimes deaths which result when due to nurse's ignorance of duties and responsibilities and their lack of proper execution of duties lead to loss of innocent lives and deaths which are otherwise preventable. The importance of education and training offered as well as the quality of it offered to nurses is pointed out by Polit, & Hungler, (1993) who notes that nurses are forced to rely on their colleagues in work stations to be trained some basic skills required in the execution of their duties such as proper use of infusion devices. This reduces the efficiency of nurses as well as increasing their stress at work. This situation is wanting going by the fact that this is a skill which nurses can acquire in colleges but bureaucracy and rigidness in many institutions has barred nurses from receiving such valuable knowledge and skills firsthand (Cormack, 2000). In light of the above, there is a need for more input in form of studies to inform stakeholders on the importance of proper drug administration knowledge to nurses since it is the nurses who are in direct contact with patients and are largely responsible for drug administration and therefore responsible in the event of mistakes or errors in drug administration. As (Cormack, (2000) notes, it is nurses who bear much of the blame when mistakes occur. Therefore why not train them fully 2.2 Lack Of Clear Policies and Guidelines According to (Cormack, (2000) clear policies and guidelines for nursing practice is very crucial. The nursing profession has an obligation to be responsive to the demands of the profession as well as the challenges facing the health care system in the UK and indeed in all over the world. (Cormack, 2000) defines clear policies and guidelines as those basic tenets which guide professionals or other entities in the performance of their duties and execution of responsibilities with an aim of operating by generally acceptable standards. The above is very crucial in nursing due to the fact that nursing involves a sensitive area that is, saving lives as well as offering hope and assistance to human beings at a time when they could be very vulnerable Burns, and Grove, (1999). In a study to establish the relationship between laid-down policies and procedures in relation to drug administration, Benton, and Cormack, (2000) found out that there was a strong positive correlation between the extent of caution exercised by nurses during drug administration and the level and clarity of policies and guidelines. How government, professional nursing bodies as well as individual hospitals adhere to generally spelled out policies, guidelines and procedures influence the amount of errors or cases involving wrong drug administration by nurses. Of significance to this study was a finding by (Hewitt-Taylor, 2001) that the hospitals with strict guidelines on drug administration of drugs by nurses recorded low incidences of nursing giving wrong doses to patients. On top of the above, Hewitt-Taylor, (2001) found out that hospitals whose policies and guidelines were repeatedly posted in strategic locations in the hospitals such as wards, next to patients' bed-sides as well as in nurses offices recorded fewer incidences of drug administration offences by nurses. In one hospital in which the hospital administration had displayed the policies and guidelines in every single entrance to the wards, no single incidence of drug administration error had been committed in one year and only 3 drug administration related errors were recorded over a period of 5 years prior to the year the study was carried out. The above study although not clearly an authority to fully defend availability of policies and guidelines in hospitals as well as clear display of the same clearly points out to the growing importance of clear policies and guidelines. Therefore the researcher hopes to search for more supporting evidence from primary sources to be used in this study in an effort to understand better what causes nurses to make mistakes in drug administration. Research by (Cormack, (2000) carried out in Lyons Hospital is worthy mentioning here. In the study it was found out that, surprisingly, enforcement of the policies and guidelines and not their displaying nor did their availability have an effect on how nurses were likely to exercise caution while administering drugs. To arrive at the above conclusions, the study used two groups of nurses one for control purposes and the other group of nurses as the test group. The control group of nurses was put under constant supervision to ensure that they were following the guidelines as well as the hospital policies to the latter. This was done through holding meetings weekly in which nurses were reminded of the importance the hospital administration attached to its policies and guidelines and therefore how adherence to the same was important. The test group of nurses included entry level (newly recruited nurses) mainly those who were less than a year old in the profession. The above were subjected to the same guidelines and policies by the virtue of the fact that they were required to observe the same guidelines and policies but nevertheless were not highly monitored and therefore it would seem enforcement was not as strong and sustained as far the control group was concerned. It was later observed that, the test group had more incidences of drug administration errors (43%) as compared to the control group which recorded 95% of error-free drug administration period for which the study was being carried. Care should be taken when borrowing from the above study especially due to the effect of extraneous factors in play such as level of training, availability of facilities, type of hospital as well as level of motivation amongst nurses participating in the study. This study in its endevour to find a long-lasting solution to the research problem shall to the extent possible factor in the effect of extraneous factors in order to ensure reliability as well as the generalability of the research findings. 2.3 Motivation Motivation plays a very crucial role in job performance of nurses (Parahoo, 1997). In a study carried out by Pepper, (1995) in USA to determine whether motivation of nurses affected performance in execution of their duties, the results were found to be interesting as well as worth quoting from. In the study, it was found out that an overwhelming 90% of respondents said that motivation at work was the key to how they performed their duties including how they administered drugs to patients. In the study which used focus groups as an instrument of data collection, one nurse was quoted as having noted that she was less careful in how she was handling her patients due to the fact that nurses in their hospital were lowly compensated. Another nurse interviewed in the same study noted that unfair treatment by her superiors as well as unfair promotion system left her disillusioned and made her less committed in her duties. The above two cases point out to the importance of motivation in nursing. Although the above explanations do not particularly point out to an effect of motivation to drug administration, it nonetheless points out to the general fact that, motivation has an effect on nurses' job performance and therefore influence their behaviour in as far as drug administration is concerned. A study by Polit, Beck, and Hungler, (2001) though, did not find any significant positive correlation between nurses' level of motivation and drug administration error incidences. In the study carried out in Minnesota hospitals and which involved respondents from 15 hospitals, it was found out that only 30% of nurses participating in the study owned up to looking at motivation as affecting their accuracy in administering drugs to patients. Compared to over 90% registered in other studies which the researcher reviewed, this particular study was astounding in that major deviations in results were recorded. Although it is possible that the study could have overlooked certain important procedures in the process of research, no weaknesses worth mentioning were noted in the research design for this particular study. Therefore the findings were found to be worth incorporating in this study. Rather than dwelling in disputing the findings, the researcher rather decided to test for motivation and its role in influencing nurses' effectiveness in drug administration. Interestingly, Cormack, (2000) disputes the contention and notion perpetrated by many researchers that nurses are the least compensated in most health care systems and therefore are least motivated. On the contrary Roark, (2004) refutes this claim by arguing that not every nurse is driven into the profession by money related reasons. He points out the fact that there are many nurses out there who treat the profession as a calling and therefore serve wholeheartedly and with full devotion inspite of pay. Barbour, (1999) further adds that the notion that pay is central to nurses orientation in practice is misguided as it is too general. In light of the above it is crucial that any research setting out to answer the question of what causes nurses to err in drug administration first avoids making assumptions which ignore the fact that the nursing profession attracts people for different reasons and an understanding of underlying causes into joining the profession is the very key to coming up with dependable results (Pepper, 1995). While many hospitals are largely to blame for some of the mistakes which happen in as far as drug administration is concerned, much of the blame seems to shift to the nurses (Pepper, 1995). This is improper as some of the measurements which can curb the problem of drug administration do arise from negligence of hospital authorities not necessarily of the nurses themselves. For instance it is beyond a nurse's mandate to propose the use of a simple system like the tag or label system fitted with barcodes to aid accurate blood transfusion leave alone implementing such a noble idea. Therefore, while most research findings have tended to shift blame and lay it squarely on nurses, there is a need for researchers to also refocus on the role hospital administration play contributing to the mistakes or errors that nurses in practice commit. This will be timely since the findings could bring to rest the problem which has for a very long time remained unresolved. 2.4 Perceptions. Dunning, (2005), carried a research to establish graduate nurses' perceptions of their medication management activities. The study utilized a qualitative research design in which semi-structured interviews were used. All the 12 respondents were graduate nurses, in the findings it was established that, "graduate nurses are required to address several facets of the medication management role in their daily practice" (Dunning, 2005.935-944). That suggested that a lot of effort should be applied "to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals" (Dunning, 2005.935-944). The report also highlighted the need for, "graduate nurses to be encouraged to explore the different possibilities when making clinical judgments about monitoring patient medications" (Dunning, 2005.935-944). 2.5 Facilities And Equipment / Automation Process/Information Technology Medical facilities are just as important as the human factor in nursing practice. Almost 70% of all happenings or activities in the line of duty of a nurse require the use of a medical facility. While the facilities would almost be rendered ineffective without proper administration and operation by nurses and hospital technicians, the contribution of automation in the nursing practice can not be ignored. The ever improving process of automation has had impact on other spheres of work environment such as the office. Therefore just as the process of automation has impacted on the office worker for instance a secretary, so has the introduction of automated systems in hospitals introduced a new chapter on the nurse's career. So big is the impact of medical equipment on the duties of a nurse that unless the modern nurse constantly upgrades to match with the advancement of technology, the former may find himself/herself relegated and no longer needed in an hospital setting (Grissinger, & Globus, 2004).The above notwithstanding, there are reports of some trials of robots to take up the role of nurses (Polit, Beck, & Hungler, 2001). The question as to whether it is not the high time some nurses' duties such as drug administration were automated and perhaps taken up by robots is not unbearable. However as (Polit, Beck, & Hungler, 2001) cautions it could be nave to think of ever replacing a human nurse with a dummy leave alone replacing nurses totally and relegating their duties to outside of hospitals situations only. According to (Roark, 2004) nurses play the critical role of comforting those who are in compromised health situations and therefore the few mistakes which have been documented such as for instance errors in drug administration should be viewed as usual human errors. Therefore (Roark, 2004) defends nurses from the blame arguing that many people have developed the tendency of heaping all the blame at the nurses whenever reports of drug administration are reported. As noted by Benton, and Cormack, (2000), some people have even tended to belief and use the some media reports as evidence against nurses while very little is done to authenticate the claims. To date, most of the debate on the relevance and importance of automation of some nursing duties remain inconclusive. There is a knowledge gap and therefore a need for further research to establish the feasibility of automation process as solution of the numerous problems facing the nursing profession. However, Armitage, and Knapman, (2003) disagrees with those who entertain the thought that automation will offer a quick solution to the woes facing the nursing profession. On the contrary he suggests more co-operation and collaboration as a solution to the challenges arising. Rycroft-Malone, et al 2001 carried out a research in the United Kingdom to study consumerism in health care. The research utilized non-participant observation as well as audio-recordings method in which aimed at colleting data on nurse-patient interactions as far as medications administration was concerned. For this study, researchers used as their sample, adults drawn from community health centers and mental health centres.This study aimed at analyzing the quality of service by nurses to patients as well as measuring satisfaction levels from the patients. In the end, the study found out that nurses dominated communication with patients and patients were not given a room for choice over issues affecting them. Conclusion Nursing as a profession is clearly at cross roads as far as drug administration errors are concerned. The public is fast loosing trust and the time for corrective measures is now. It is the high time that, a conclusive study was carried out to suggest solutions to the above mentioned issues with a goal of ensuring that, no patients continue to suffer due to preventable human errors and especially drug administration related errors caused by rogue nurses. The research will inform the stakeholders and hopes to bring to rest the missing links between drug administration errors and the solutions to the problem. There have been numerous studies on errors in drug administration by nurses. However, there are few studies that have focused on the effects on patients, when nurses leave patients' drugs unattended by their bedsides during a drug round. Then to expect the patients to be responsible for taking their own medication regardless of their age, condition or mental state or relay on somebody else to administer the medication. Nurses are totally oblivious as to whether or not the patient has taken their medication even though the nurse has signed the treatment card, which states she or he had dispensed or administered and witnessed the patient taking their drugs, when he or she really have not. Although on a number of occasions the dispensed medication has been found still to be by the patient's bedside on the next drug round. REFERENCES Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: A literature review. Journal of Nursing Management, 11. Barbour, R.S. (1999). The case of combining qualitative and quantitative approaches in health services research. Journal of Health Services Research Policy. Benton, D. and Cormack, D. (2000) The research process in nursing. 4th edition. Oxford: Blackwell publishing. Burns, N. and Grove, K. (1999) Understanding Nursing Research. 4th Edition. New York: W.B Saunders Company. Burnard, P. (1991). 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