Internal conflict: Undergraduate nursing students’ response to inadequate supervision during the administration of medication
Article Outline
Summary
Current legislation in Queensland requires that undergraduate nursing students are personally supervised when administering restricted medication in the clinical setting. Previous research suggests this is not always the case. Exploration of the experiences of undergraduate nursing students was undertaken using grounded theory as the methodological framework. In-depth, semi-structured interviews were conducted with 28 students during their final year clinical placements. Data were analysed using a constant comparative approach. The focus of this paper is to examine the emergent theme of internal conflict, which is experienced by the participants as a consequence of the theory–practice gap. This conflict is reflected by the divergent requirements and expectations between the university and the registered nurses providing supervision in light of the role both play in student assessment. In addition, the participants voiced concerns about patient safety due to the potential for medication error. Internal conflict was identified by participants as the cause of considerable fear and anxiety about passing the course, getting a job and avoiding harm to patients. These findings raise serious concerns about the adequacy of the supervision for nursing students and highlighted the need for a more concerted approach to the theoretical and clinical education of students in relation to medication administration.
Keywords: Clinical education, Medication administration, Undergraduate nursing students, Medication safety, Supervision
Introduction
The theory–practice gap has concerned the nursing profession for many years (Corlett, Palfreyman, Staines, & Marr, 2003). There is widespread agreement within classical and contemporary literature that this gap relates to the distancing of theoretical knowledge from its practical application in the world of clinical practice (Gallagher, 2004, Goode, 1998). Stuart (2003) suggests that educationally it is unrealistic to teach theory in one setting and expect it to be applied automatically in another. When inconsistencies are apparent students become torn between doing what they are guided to do by the university to that expected in the clinical setting (Cooper, Taft, & Thelen, 2005; Evans & Kelly, 2004; Kitchener, Caronna, & Shortell, 2005; Maben, Latter, & Clark, 2006). Ultimately the theory–practice gap can impact on the professional practice of newly graduated nurses (Maben et al., 2006).
The findings from Maben et al. (2006) study suggested that newly graduated nurses had a strong set of values, but organizational and professional barriers made it difficult for those values to be realised in practice. Having to obey covert rules, experiencing lack of support and poor nursing role models, time pressures, role constraints, staff shortages and work overload represent powerful examples of these barriers.
In the midst of this conflict, getting through the clinical placement becomes the priority (Chapman & Orb, 2001). Students are pressured to conform to the expectations of the clinical environment by conforming to the prevailing culture and expectations. This is further compounded by the role registered nurses play in assessing students (Holland, 2002, Nolan, 1998), particularly so in the final year of study (Kim, 2003).
Given that the administration of medication has potential for harm to patients in the event that a medication error is made, it is somewhat surprising the student role receives so little attention in the nursing literature. The theory–practice gap in general is clearly an important issue impacting the effectiveness of nursing education. Ensuring patient safety means there are specific considerations for the administration of medication.
A review of the literature reveals student concerns about making a medication error. Anxiety and fear was reported in several studies (Kim, 2003; Lopez-Medina & Sanchez-Criado, 2005). Kim (2003) identified the administration of medication as one of the most stressful situations for first and second year nursing students.
The paucity of research concerning medication management by registered nurses was noted by Aitken, Manias, and Dunning (2006). These authors researched registered nurses’ documentation of medication management. They found that nurses focused primarily on the actual medication itself, with considerably less focus on patient response to medications or to the educational role of the nurse.
The administration of medication is tightly controlled by legislation in Australia. Each State and Territory has an Act of Parliament and set of regulations that controls the usage, prescription and administration of medication. In all Australian jurisdictions, registered nurses have the legal authority to administer medication that has been prescribed by an authorized medical practitioner (Bullock, Manias, & Galbraith, 2007). This means by definition that nursing students have no legal authority to administer medication other than under the personal supervision of a registered nurse.
The registered nurse remains ultimately accountable for patient care and it is they who are responsible for delegating care from a patient's care plan to others such as unregulated care providers (Bullock et al., 2007, Queensland Nursing Council, 2005). This would include delegating the responsibility of medication administration to a student. It might seem reasonable to assume therefore that with appropriate supervision, students should feel more confident and less anxious. As a key strategy to ensure safety and promote skill development in students, the concept of supervision is notably absent in the literature.
Research undertaken by the first author (name withheld to maintain anonymous review) identified that direct and personal supervision was not always apparent for nursing students administering medication. Shifting levels of supervision was identified as the central theme of the study which explored final year undergraduate nursing students’ experience of medication administration in the clinical setting. Nursing students experienced internal conflict in response to three specific levels of supervision (being over, being near and being absent). This paper presents an overview of this internal conflict and its consequences for nursing students.
Methods
Design
A grounded theory design was used to explore nursing students’ experiences of administering medication. Grounded theory is particularly appropriate as an exploratory approach because it facilitates the development of theoretical explanations for phenomena that are not well understood (Burns & Grove, 1995; Chenitz & Swanson, 1986; DeLaine, 1997).
Sample and setting
Final year undergraduate nursing students from a Queensland university constituted the target population for this study. These students were embarking on their final year clinical experiences before qualifying as registered nurses. The final placements involved supervision by registered nurses employed by the clinical organizations rather than university employed educators or facilitators. Clinical placements were to be of six weeks duration and it was expected that students would have ample opportunities to gain experience in administering medication.
Letters of invitation were sent to all 135 final year students. Those interested in participating were asked to return the signed consent form to the researcher. A total of 57 students consented to participate. Theoretical sampling was then used to select 28 participants according to the process outlined by Strauss and Corbin (1990). Through the process of open sampling, five participants were selected initially to reflect diversity in demographic data. Preliminary data analysis on these five interviews led to the identification of emerging concepts. On the basis of these concepts a further 17 participants were selected reflecting a range and variability to the data that had emerged in the open sample. The remaining six participants were selected during the discriminate sampling stage. Specific demographic data was used for the selection to maximize opportunities for comparative analysis (Strauss & Corbin, 1998). The demographic data revealed a diversity in participant characteristics range (20–41) and prior nursing experience (39% as assistants in nursing, 14% as enrolled nurses and 7% as carers). While the majority (n
=20) were female, this is consistent with the student cohort. The participants had undertaken clinical experience in 41 different organizations in their final year placements, meaning they could draw on experiences from a variety of different clinical contexts ranging from aged, community and acute care areas.
Procedure
Semi-structured individual interviews provided the opportunity for the research topic to be explored in detail (Adler & Rodman, 1997). At the outset of all interviews, the following question was posed to participants:
“Tell me about your experiences with medication administration as a final year student when in the off campus clinical setting?”
In the initial open sample the following questions served as a framework:
“From your experiences tell me what promotes your ability to administer medications safely?”
“From your experiences tell me what impacts on your ability to administer medications safely?”
In subsequent interviews the questions changed based on the emergence of labels and categories. Examples of these questions includes:
“Tell me about your experiences with registered nurses in administering medications?”
“Tell me about your experiences with attitudes of staff with regards to medication administration?”
“Tell me about your experiences with supervision when administering medications in the off campus clinical setting?”
Two questions used to finish each interview were structured in a similar manner to that proposed by Schrieber (2001). The aim was to elicit any information that may have been missed. These included:
“What advice would you have for final year undergraduate nursing students administering medications in the off campus clinical setting?”
“Is there anything else that I should know about undergraduate nursing students experiences in administering medication when in the off campus clinical setting that I have not already asked?”
In some interviews few questions were posed after the initial opening question because participants spoke openly about their experiences and in doing so covered topics relevant to the labels and categories that had emerged from previous interviews. Interviews were audiotaped with permission from the participants.
Ethical issues
Ethics approval was obtained from the relevant university committee. Prospective participants were informed about the voluntary nature of their participation. Furthermore they were reassured that they could withdraw from the research at any time without impacting their academic progress. Privacy and confidentially were assured.
The interviews were conducted by an academic staff member of the university where the students’ were studying. This staff member was not teaching the students at the time and was not involved in their assessments. Nevertheless, the students were assured that their decision either to participate or not participate would not influence their status as a student. Furthermore, as described above, students were asked to contact the researcher if interested in participation in the study, therefore it was not necessary to decline involvement directly.
Data analysis
The data analysis approach articulated by Glaser and Strauss (1967) and Strauss and Corbin, 1990, Strauss and Corbin, 1998 known as constant comparative analysis was undertaken. Firstly open coding was used to familiarize the researchers with the participants’ opinions, ideas and meanings. This led to the development of categories. Further categories were identified through open coding of the interview transcripts, a process which continued until no further categories were identified.
Connections between categories were made through the process of axial coding. Finally, selective coding involved the integration and refinement of the categories around a central explanatory concept, namely supervision. Dealing with internal conflict was one category found to be highly influenced by the levels of supervision provided. This category is the focus of discussion for this paper.
Trustworthiness
Confidence in the trustworthiness of the data was achieved through ensuring the credibility, auditability and transferability of the data. Several methods were employed to ensure credibility. This included allowing participants to guide the inquiry process (Chiovitti & Piran, 2003) through the use of semi-structured interviews. Data analysis included the use of excerpts from the transcripts, this ensured that the categories reflected what participants were saying and ultimately resulted in the use of participants’ actual words in the substantive theory (Chiovitti & Piran, 2003).
A final method to ensure credibility was articulating the researcher's views and insights regarding the phenomenon explored (Chiovitti & Piran, 2003). To achieve this, notes were made after each interview. This was important in identifying any aspects which could have impacted on the interview thus influencing the results. This information was accessed during the analysis period. The final strategy to ensure credibility was member checking, whereby the larger theoretical scheme was checked against the participants meaning of the phenomenon (Chiovitti & Piran, 2003).
Auditability is described by Roberts and Taylor (2002) as a decision trail which is able to be scrutinized by other researchers to see if the study has been consistent with its methods and processes. Auditability was specified by articulating how and why the participants were selected (Chiovitti & Piran, 2003) through the process of theoretical sampling.
Transferability is concerned with the generalisability of the findings whereby results of the findings, such as the emerging substantive theory, may have meaning to others in similar situations. In this study, two methods were used to promote transferability of the findings. The first was describing the scope of the research in terms of the sample, the setting and the level of theory generated (Chiovitti & Piran, 2003). The second method to promote transferability was using the literature to connect the substantive theory developed.
Findings
Internal conflict
Internal conflict emerged as a consequence of the theory–practice gap. The theory–practice gap represented opposing expectations. Participants recognised requirements and expectations from the university and the health care settings. When conflict emerged between these requirements, participants became worried about compromising their assessment, and either being caught by the University for administering without the required direct supervision or displeasing the registered nurse for not doing what they required or expected. Further, compromised assessment also concerned risking patient safety and its associated consequences.
The theme internal conflict included four sub-themes: the theory–practice gap; meeting the university requirements; meeting the requirements of registered nurses; and compromised patient safety. Each of the properties of internal conflict will now be discussed and illustrated with quotes from participants.
The theory–practice gap
The theory–practice gap was a concept that participants described as in terms of opposing expectations, in other words the difference between what they were taught at university and what really happened for them in clinical setting. They felt the requirements from the university were often opposed to the expectations of the registered nurses. The gap that they spoke about was in relation to being supervised, performing the five rights and conducting the appropriate checks. For example:
I don’t think that the RNs who were supervising me understood … the way that we’ve been taught at university about the importance of having someone to supervise us. And I also think that they didn’t understand the implications of what would happen if we did make a mistake … I think the RNs who are supervising us need to understand …, the consequences of and how important it is to us to be supervised with all medications (P22).
And:
… at uni, you learn the technique, but it's absolutely nothing compared to what you do on the ward (P6).
Participants also spoke about the variation in policies. They knew what was expected but this often differed to what occurred in the clinical area. Participants described having to do what the registered nurse expected because they were in a subordinate position and therefore believed they could not question the registered nurse:
… as a student you’re in a … subordinate position, you’re not in a real position to say ‘well, this is the right way to do it, this is what we’re taught [if] you do say ‘this is what … we’re taught’ … the response is almost always ‘well, here we do it blah, blah, blah’ (P15).
Being in a subordinate position was also described by some participants as ‘lacking power’ to question shortcuts in supervision with medications. They felt that this was actually escalated by the university not being aware of the true culture of the ward setting, as stated:
You need to ensure the students feel they have some power over their situation on the prac. Give them a real idea of ward culture…comments such as “you’re the people that will change things” may be relevant once students are actually RN's, but when in the student/RN situation, these comments only serve to alienate the student from the uni, and the RN's. These comments only serve to make the student feel as though the uni has no idea of the ward culture and student experience, and reduce the power students have in the situation, because if the uni is saying that, then the uni either has no idea of what is really going on or the uni doesn’t care … If students have no power, then they are not going to argue with RN's re shortcuts (P28).
Participants also spoke about how their internal conflict with the theory–practice gap was very strong because they just wanted to fit in. For example:
… you’re trying to fit in, which is a big thing with nursing (P2).
The desire to fit in could result in adopting bad habits as the following quote illustrates:
If you’ve got a very careless nurse … you think if they’ve done it I can do it, you’re misled from their example. But if you’ve got a very proactive nurse in the way that they do things, you’ll actually find that you’ll pick up those traits and use them next time you go to do something. … if you … do have a careless nurse, you will definitely, in your practice, pick up their bad habits. And especially if they don’t have time to show you the right way, they’ll show you every shortcut, and it's not necessarily the best way to do it (P9).
Meeting the university requirements
As a consequence of the theory–practice gap, participants spoke about the need to meet university requirements regarding supervision for medication administration or risking failing the clinical placement. They spoke of their concern about being found administering medications without personal supervision by someone from the university. Avoiding being in trouble was their number one priority. For example:
I don’t want to get into trouble … that's … my number one priority” (P23).
And:
… I’m just not going to take chances with my future. … I want it too much and I just can’t compromise by … having a mark against me saying that I’ve gone beyond that level and getting in trouble for doing so …the consequences to me of doing the wrong thing, it's just not worth it, and I’m, I’m nearly registered, I’m not going to mess with that … I do remember one person who said to me ‘it's only a rule, that, you know they’re there to be broken’, I said ‘well… actually not by me’, … I just couldn’t go down that path of being in trouble (P16).
While the fear of being caught by the university and being in trouble caused them internal conflict, even greater levels of conflict were experienced with regards to what it would mean for their clinical assessment if they did not please the registered nurse as described in the next section.
Meeting the expectations of the registered nurse
While participants were conscious of the need to meet university requirements, internal conflict often arose because registered nurses were the ones who would give them their grade and getting them off side could result in failure:
…students would just do as they were told for fear of failure. Because if they didn’t, they could be failed .…Even though they knew … that it's wrong, they would still do as they were told because … no one wants to fail at anything (P7).
Participants spoke about the risk in not accepting whatever supervision the registered nurse provided. For example:
You’re out there to impress the nurse you’re with, nothing else matters … if you do stand up to them then they see you in a different way and then you are treated unfairly (P19).
Similarly:
…and the thing is like, you just try to make them happy… ultimately these people who grade you and the last thing your going to do is to piss them off to get failed. (P4).
The need to please would cause varying levels of conflict depending on the level of supervision that the registered nurse presented and/or provided. The following participant provides an example of internal conflict when the registered nurse did not provide supervision:
…I felt really unsure about giving the medication without the supervision… they [RNs] say … if you’re not confident enough to give medication by yourself, what are you competent at doing? And you’re doubting yourself, … I should just do it.…Keep them happy and that way, you know, I’ll get my assessment done, …but then I don’t want to be going outside … at uni you get told all the way through ‘you must be supervised (P20).
Compromised patient safety
A further property of the theme internal conflict was compromised patient safety. Participants feared making a medication error and harming the patient because of the lack of adequate supervision. For example:
… it's scary because what if I give them the wrong thing, or what if I miss something that I shouldn’t have missed. … That scares the crap out of me (P5).
And:
I’m very scared of making medication errors…the medications will make my patients sick and then they’ll get sick and I’ll be trouble and they’ll die…I’d be scared of telling the uni because they would fail me (P12).
One participant emphasised the magnitude of the consequences for making mistakes with medication:
You’re… just frightened that you’re going to hurt someone or, or kill someone or, by frightened of making mistakes because the mistakes are just so severe (P23).
The fear of compromising patient safety was heightened for many because of stories that they had heard from other students or from what they described as those told by lecturers at the university.
Discussion
The findings of this research clearly indicate the existence and consequences of the theory–practice gap. Participants described differing expectations between the university and the registered nurses employed within the clinical setting. The participants experienced internal conflict as a direct result of the theory–practice gap. More specifically, the participants described a tension between their desire to meet the expectations of the university and of the clinical setting in order that they are successfully assessed and able to proceed through the nursing program.
Discourse around the theory–practice gap has dominated nursing literature for many years (Corlett et al., 2003, Gallagher, 2004). However, the current study addressed it specifically in relation to the medication administration experiences of nursing students in their final year of study.
Internal conflict featured in the work of Cooper et al. (2005). The researchers explored the cognitive and emotional responses of baccalaureate nursing students during their final clinical experience. ‘Facing reality versus expectations’ was one of seven themes identified. Students noted incongruence in two areas. These included the behaviour of professional registered nurses (and other health care personnel) and policies, procedures, and practices within the health care system (Cooper et al., 2005). While medication administration practices were not specifically mentioned, the incongruence noted by students is similar to the experience of internal conflict that emerged in this study.
Within the literature further support is evident for the emergence of conflict generally for nurses as a result of the theory–practice gap (Evans & Kelly, 2004; Kitchener et al., 2005, Maben et al., 2006). The Maben et al. (2006) study examined the extent to which the ideals and values developed by students in their pre registration nursing courses were adopted by them as graduate registered nurses. The findings suggested that although graduates emerged from the pre registration programs with a strong set of values, organizational and professional factors made their implementation difficult. Having to obey covert rules, lack of support, poor nursing role models, time pressures, role constraints, staff shortages and work overload were identified as contributing to this difficulty. Maben et al. (2006) describe this phenomenon as professional–bureaucratic work conflict, referring to the divergence between the ideals of professional practice and those of the employing institutions.
The work of Maben et al. (2006) affirms the significance of this study. The medication administration practices students adopt as undergraduates may readily transfer to their practice as graduates. Their exposure to inadequate supervision of medication administration could readily result in them taking shortcuts with the supervision of future undergraduate nursing students.
The current study provided important insights into how the participants dealt with this internal conflict. Their motivations were influenced by the desire to get through, by passing their clinical placement. Chapman and Orb (2001) identified strategies adopted by students to get through and meet the demands of the clinical placement. Playing the game and not rocking the boat were commonly used. These strategies are similar to the sentiments expressed by the participants in this study.
For the participants in this study, the internal conflict was also influenced by the potential consequences of being censured by the university and compromising patient safety. For these participants, registered nurses complete the clinical evaluation with the university course coordinator as the ultimate overseer. Essentially this meant they could be failed by the university if found to be administering medication without appropriate supervision or by the registered nurse if not meeting his or her expectations.
The anxiety and stress associated with these conflicting expectations has been described in the literature. Nolan (1998) identified that anxiety amongst nursing students resulted from constant observation by nursing staff and being formally assessed, which constrains confidence and learning. A point substantiated by Kim (2003) and Holland (2002). The current study also identified that getting a job intensified the experience of internal conflict. Participants described what was written on their clinical assessment tool, might affect their chances of employment with the specific health service. Andre (2000) reported that clinical assessment tools are indeed used in the appointment process of graduates. This is likely to be a particular issue for students from rural and regional areas who do not have the same range of options for securing future employment. There is a high probability they will apply for a job in the clinical organization where their final placement is being completed thus increasing the pressure to conform to the expectations of the registered nurses within that setting.
Internal conflict was not only about compromised assessment; the fear of making a mistake because of inadequate supervision was paramount. This fear was connected to concern for patient safety as well as the fear of failure. This point was also identified by Kim (2003) and Lopez-Medina and Sanchez-Criado (2005), however previous work did not make any associations between this fear and the level of supervision provided when administering medication. This is somewhat surprising given the greater potential for serious consequences arising from medication errors. The fear of participants was also based on their past experiences with near misses or actual errors. When medication administration is fraught with the possibility of making errors, strategies need to be implemented to ensure that students are supervised at all times while administering medication.
In summary the theory–practice gap, the central property to internal conflict, created challenges for undergraduate nursing students when having to deal with shifting levels of supervision from registered nurses. Maben et al. (2006) suggest that the nursing profession should not lose sight of individual nurses, such as students, who struggle with opposing forces because to neglect this issue and leave them without support will contribute to retention difficulties and the already heightened global shortage of nurses. Adding to the tension of the theory–practice gap is the compounding pressures that undergraduate nursing students experience with assessment in the clinical context.
Limitations
The major limitation arises from the exploratory nature of this research. The research was conducted with participants from the one university, undertaking clinical experience in a relatively small number of settings. These factors limit the extent to which these findings can be generalized to a broader population.
Conclusion
The results of this exploratory research suggest that undergraduate nursing students experience internal conflict when faced with inadequate supervision provided to them while administering medication in the clinical setting. This conflict resulted from the divergence between the requirements of the university and the expectations of the registered nurses they worked with. While the theory–practice gap has been extensively described in the nursing literature, these findings suggest that it becomes more pronounced in relation to the administration of medication. The fear of medication errors was identified as the source of fear and anxiety for the participants.
The identification of the theory–practice gap to medication administration is important for patient safety and consequently has important considerations for health policy. The findings from this research should provide impetus for lobbying at the State Regulatory Authority level for the development of guiding principles for registered nurses supervising students in medication administration. Lobbying should also address the need for a role description of the undergraduate nursing student during their clinical placement. The position statement should articulate student accountability and responsibility in undertaking the administration of medications.
The reality of practice and what undergraduate students encounter in the laboratories of the university setting need closer examination. While universities should not move away from having students adhere to what is legal, it is clear that the realities of the clinical arena do not allow for such supervision to always be apparent. This study raises questions and suggests further research into different approaches to clinical supervision and assessment of students during medication administration episodes that take into account the need for students to methodically move through the process whilst at the same time considering the realities of the clinical environment.
Acknowledgments
The authors gratefully acknowledge the research participants for giving up their valuable time and expressing their experiences and opinions so openly.
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PII: S1322-7696(08)00069-3
doi:10.1016/j.colegn.2008.11.002
© 2008 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
