Nurses are inculcated with the importance of patient safety from the first day of nursing school. First-semester nursing students typically learn the theoretical rationales for safety measures but do not have the opportunity to apply that knowledge until the following semester in clinical courses. This theory-practice gap can be difficult to bridge once established. Innovative strategies are required to help students make connections between standards of care learned in an academic environment and implications in the clinical setting.
Nursing pharmacology is traditionally taught in the first semester of nursing school with successful completion as a prerequisite for participation in clinical courses. Because of the nature of creative nursing programs (e.g., accelerated, second-degree, and hybrid), students bring a broad range of clinical context to their courses. For students who lack clinical context, this context needs to be created as an orienting stimulus for understanding the high-stakes nature of medication management and core course competencies. Nursing students often approach pharmacology as a course to be endured rather than mastered, resulting in a lack of understanding of the importance of basic and crucial competencies associated with safe and effective pharmacological care (Yazdan Parast et al., 2018). It is imperative that students comprehend the reasons behind performing the three checks and clearly communicating the rights of medication administration every time a drug is given to a patient.
Pharmacology is a didactic course administered prior to clinical experience, and clinical applications can be perceived as abstract and futuristic. Therefore, bringing clinical significance into the classroom early in the semester and the nursing curriculum may be effective in bridging the existing theory-practice gap. Introducing clinical significance may also serve as a catalyst for a change in thinking, from personal performance to mastery goals and from student learning to patient outcomes. This article describes a complex assignment designed using the tenets of the Slavich and Zimbardo (2012) transformational learning theory. The assignment introduced students to the Durstenfeld et al. (2019) Swiss cheese model (SCM).
THEORETICAL FRAMEWORKS
Transformational learning theory describes how adult learners modify their frames of reference, which include patterns of thinking, feeling, and behaving, as well as personal viewpoints (Slavich & Zimbardo, 2012). Frames of reference can be altered by the process of problem-solving, discussing problems with others, and reflecting on assumptions upon which viewpoints are based. Transformational learning theory suggests that identifying and challenging assumptions is done by engaging in active learning activities in which participation is encouraged and robust discourse is facilitated. Some of these learning activities are group projects, engaging with case studies, and simulation exercises (Slavich & Zimbardo, 2012). Students' learning about how errors occur can further enhance context.
Catastrophic errors are rarely committed in isolation by one individual; rather, they are the result of multiple, smaller errors that are compounded by serious, underlying system errors operating in the background (Durstenfeld et al., 2019). The flaws are exposed when the individual and the system align, bringing about bad outcomes. In the SCM, the holes in Swiss cheese (errors) line up with holes within the system. The SCM not only explains how negative outcomes occur but also assists those charged with root cause analysis to proffer solutions to shrink the holes and prevent the holes from lining up in the future. Distinguishing individual and system errors, the SCM labels active errors as those involving frontline personnel at the point of care and latent errors as those at an organizational design level that allows the active errors to occur (Naunton et al., 2016).
PRESENTATION AND IMPACT OF THE CASE STUDY
The assignment required students to problem-solve, discuss perceived problems with peers, and submit a personal reflection about the exercise. Use of a case study to impact clinical context rather than course content is how this exercise was transformational in innovation and motivated student learning. Students were presented with a PowerPoint(R) presentation regarding the role of a nurse as a professional. The presentation introduced the SCM as a method for understanding how errors, both human and systemic, can align with catastrophic results. Students then viewed a video from a medical provider; it provided information about how a nurse was described as responsible for the agonizing death of a vulnerable patient (Damania, 2018; Matheson, 2019). The nurse was shown to override system fail-safes, giving the patient vecuronium instead of prescribed Versed(R). The class then engaged in discussion regarding their thoughts, feelings, and points of view about the situation and the nurse's role in the death of the patient. Most students expressed horror at how the nurse could have acted so recklessly and committed so many consecutive errors.
The students then viewed a video from the same provider three months later. It included the name of the nurse, who was being charged criminally with reckless homicide and abuse of an impaired adult (Damania, 2019). The ensuing discussion was more sympathetic to the nurse, who was largely perceived as a scapegoat for larger systemic gaps and a means to avoid profound penalties to the organization - financial, criminal, and reputational. The discussion enabled a detailed delineation of the differences between negligence, malpractice, and criminality. At the time of the video, the nurse did not have her nursing license in danger of being revoked. The governing body had sent a letter informing her that her license was not in jeopardy (Matheson, 2019).
The discussions were lively and respectful. Students were instructed to write a reflection answering the following questions: 1) Should the nurse be charged criminally for her actions/inactions? Why or why not? 2) Should the nurse lose her license for her actions/inactions? Why or why not? 3) If the nurse has her license suspended, do you think that she should have a pathway to have it reinstated? Why or why not? 4) Did this case change your thinking about nursing pharmacology and patient safety? If so, how? The reflection, due at midnight the day of the discussion to facilitate a continuous flow of ideation, was designed to contextualize the clinical learning regarding pharmacology and safe medication management principles. The learning assignment introduced the professional aspect of nursing and emphasized the direct line between the meticulous aspects of medication management (beyond administration) and patient outcomes. Importantly, this reflection activity helped students recognize the relevance of course materials to their chosen profession.
Students reported a variety of feelings, observations, and opinions. The consensus was that the series of errors committed by the nurse was disturbing and unsettling, especially because she had likely been engaging in workarounds over time and, on this one day, the errors aligned with tragic consequences. Many students expressed their horror at the nurse's seemingly cavalier attitude toward patient safety as well as the systemic problems of the organization. They expressed that nurses should be held to higher standards than other professionals and their concern that multiple mistakes can progress to negligence. Most students felt that the nurse should have a hearing regarding retaining her licensure, but that criminality would have a negative and chilling effect on all health care professionals. Many students expressed compassion for the patient and her family.
RESULTS AND RECOMMENDATIONS
Traditional measures of nursing pharmacology success should be augmented by a clinically contextual impetus to spark a transformation in thinking, from pedagogical learning to patient-focused learning. One strategy to create relevance is presenting a real-life scenario and fostering critical thinking around its outcomes through class discussion and personal reflection. This shift in context may result in an earnest alteration in the motivation and meaning early in the curriculum of what it is to be a safe nurse. Establishing a clinical context may alter students' trajectory in their nursing education and beyond.
This transformational learning shift from didactic memorization and regurgitation to a clinical framework of understanding may have utility beyond nursing education. It may also benefit pharmacy, medicine, and midlevel provider education. When clinical context is introduced early in the professional curriculum, it may have the effect of transforming students' motivation and momentum to learn and have a positive effect on future patient interactions and practice.
CONCLUSION
Nursing pharmacology is a didactic core course requiring successful completion prior to advancement to more clinically complex education. It requires both memorization of facts and understanding of applications to a clinical situation. To bridge a potential theory-practice gap, educators may provide, by intentional design of assignments, a clinical context that students can use to transform frames of reference and personal viewpoints regarding the importance of mastering pharmacology principles, affecting motivation and attitude to learning. This may result in students being more adequately prepared for the next level of education while providing a solid basis for safe and effective patient care. Pharmacology principles are used every day by every nurse. Therefore, traditional learning can no longer be the standard for pharmacology education.
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