Part A
Rationale for Research Area
Medication error is serious problem that is affecting. Patients are at great health danger because of medication error. Studies have revealed that 59 percent of the Australian population use prescription medications and this increases to about 86 percent for those over 65 years of age. This entails that many Australians in healthcare facilities require medication in some form or another and may be at risk of harm as a result of a medication error made by a healthcare professional.
The Institute of Medicine (IOM) defines an error as a failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim. There are different types of errors according to the IOM – these are errors of omission and errors of commission. An error of omission is something that was supposed to happen but did not. An error of commission means a patient gets something that he or she was not supposed to receive. The Institute of Medicine further defines an active error as an error that occurs at the level of the frontline operator and whose effects are felt almost immediately and a latent error as an error in design, organization, training, or maintenance that lead(s) to operator errors and whose effects typically lie dormant in the systems for lengthy period of time (Janine 2004).
Medication errors made unintentionally by nurses continue to be a major concern in hospitals, medical centers and aged care facilities in Australia. Numerous researches and studies aid in identifying the factors that contribute to nurses making errors. On the other hand, there is a scarcity in studies that focus on the factors that may contribute to errors made by nursing students. The Australian Council for Safety and Quality in Healthcare developed safety strategies to prevent medication errors involving collaboration between different professional groups as mishaps occur at all stages of medication administration process. This collaboration includes the medical practitioner who has the responsibility in prescribing safely, the pharmacist in dispensing and finally the nurse in administering the medication to the patient. Reports have shown that undergraduate nursing students in health care setting can be involved in medication error. These students are trained both on-campus and off campus in medication administration. In the on-campus setting, the students are taught the skills and knowledge in medication administration. In the off-campus setting however, students face real patients using real medications. A study conducted by Wolf et al (2006) in the United States reported 1305 medication errors by nursing students over a five-year period.
The paper aims to explore the process of medication administration for nursing students when in the off-campus clinical setting. The training and experience that undergraduate nurses get from the off-campus clinical setting are very significant in equipping them with the knowledge, skills and abilities in medication administration. It is therefore important to identify the process of medication administration in the off-campus clinical setting and determine the factors that lead to medication error by undergraduate nursing students. The research on this subject will add to the scarce literature on medication error by undergraduate students and will provide significant information for educational institutions, healthcare organizations, regulating bodies and ultimately students regarding medication error.
Methodological Approach
There are two kinds of research methodologies used in social sciences: quantitative and qualitative. The quantitative paradigm is based on positivism which takes scientific explanation to be nomethetic (i.e. based on universal laws). Its main aims are to measure the social world. To test hypotheses and to predict and control human behavior (Newman and Benz 1998). Quantitative research is based on the assumption that the world can be investigated using scientific method and that there is an independent reality. Quantitative research is based on the belief that measurable influences (independent variables) affect measurable outcomes (dependent variables) in a cause-effect manner. Quantitative research is generally conducted in a controlled environment, such as laboratories, or using anonymous data such as statistics collected through surveys, questionnaires, structured interviews or tests. Quantitative studies are studies in which the data can be analyzed using conventional statistical methods (Peat 2001). As its name implies, quantitative research is concerned with quantities – how to measure phenomena and how to express those measurement. A researcher who takes a quantitative approach to investigating a topic aims to learn more about it. Taking a quantitative approach to research implies asking questions about the phenomena that can be counted. Researchers who take a quantitative approach often work within positivism, as this paradigm frames the world as a collection of apparently independent phenomena to be counted, measured and otherwise catalogued as the prelude to deducing the rules or laws underlying them and giving them coherence (MacNaughton et al 2001).
On the other hand, the qualitative paradigm stems from antipisitivistic, interpretative approach, is idiographic, thus holistic in nature, and the main aim is to understand social life and the meaning that people attach to everyday life (Peat 2001; Darlington and Scott 2002; Hansen 2006). According to Newman and Benz (1998) a qualitative research involves an interpretative, naturalistic approach of the subject matter. Qualitative research is about studying things in their natural settings. A researcher conducting qualitative research attempts to make sense of, or interpret, phenomena in terms of the meaning people bring to them. Qualitative research involves different methods of gathering and collecting of empirical materials such as case study personal experience, introspective, life story, interview, observational, historical, interactions, and visual texts. Qualitative methods in health research are now becoming popular among researchers. One reason for this is because qualitative research methods are well suited for investigating the meanings, interpretations, social and cultural norms and perceptions that impact on health-related behaviors, medical practice and health outcomes (Jordens and Little 2004; Sayre 2000). Qualitative research methods also allow researchers to explore issues from the perspectives of the individuals directly involved in the experiences. In qualitative research, behaviors, understandings, actions and experiences are not measured using statistical analysis as in quantitative research (Devers 1999; Sofaer 1999). Instead, detailed written descriptions and explanations of the phenomena under investigation are produced. Qualitative methods are those that collect data in the form of talk, words, observations, visual images and documents.
The article “Shifting supervision: Implications for safe administration of medication by nursing students” is an example of a qualitative research. The researcher made use of in-depth interview as a mode of collecting data. The article is a qualitative research because it focuses on the experiences of undergraduate nursing students in medication administration in healthcare settings. Qualitative research is described by Hardey and Mulhall (1994) as people-centered and frequently provides rich descriptions of an area of human behavior. Because of its people-centeredness, qualitative research was chosen as the mode of conducting the research because it allows the participants to give their opinions without a high degree of prestructured prompting. Individual in-depth interviews using semi-structured approach were chosen as the primary means of data collections. The researchers made use of open-ended questions as they allow issues to be discussed more freely than would occur with closed or structured questions (Adler and Rodman 1997). The research uses ‘grounded theory’ as a research strategy. It has been suggested that grounded theory makes its greatest contribution when used to investigate areas where little research has occurred. As such, this strategy is very appropriate as it allows the study to be well placed to generate theory grounded in data.
Part B
Problem Definition
The statement of the problem according to Mauch and Park (2003) is a short section of a research, but perhaps the most important. The statement of the problem section lays down a guide to follow in all that comes after. A problem according to Creswell (1994) might be defined as the issue that exists in the literature, theory, or practice that leads to a need for the study.
In the article, although the researchers do not present a statement of the problem, the beginning of the article and the succeeding discussion emphasizes the issues in medication administration concerning undergraduate nursing students. The researchers opened the discussion with the problem of medication error that led to the pointing out of the scarcity of literature regarding medication administration by undergraduate students in off-campus settings. The researchers are able to make the problem stand out and make the readers recognize it. From reading the context of the research one is able to recognize the problem. The problem is presented within the context, which is provided and briefly explained. The researchers are successful in presenting the problem to the readers. Through the discussion of the research context, the researchers are able to answer the question “Why does this research need to be conducted?”
The purpose of the research is evident in the summary at the beginning of the articles. The readers will also get what the researchers want to find out just by reading the title. As stated by the researchers, there is a lack of previous researches regarding the topic. The researchers decided to use grounded theory in order to come up with a research that will focus on medication administration by undergraduate students in off-campus settings.
Literature Review
The literature review is one of the longest sections in research which aims to analyze and evaluate what other researchers have done in the past. By reviewing the works of others in the chosen topic or field, the researcher is able to present to the readers the current state of knowledge and justify the research being conducted by showing what has not yet been done. Through the literature review, the researcher is able to identify the gap in knowledge.
The researchers, at the beginning of the paper state that there is limited information on the subject of medication administration by undergraduate nursing students in off-campus settings. The researchers assert that the present work will give way to new knowledge which focuses on medication administration by undergraduate nursing students and the different issues such as medication error. In this regard, the paper serves as a new stream of research.
The research is structured as a grounded theory research and as such there is no review of the literature in the area of the study before data collection. The rationale for this argument is to avoid biasing the researchers’ attempts to develop concepts and ideas from the data that actually fit. In grounded theory studies, researchers typically collect data in the field before reviewing the literature. As the data are analyzed, the grounded theory begins to take shape, researchers the turn to the literature, seeking to relate prior findings to the theory. Grounded theory researchers defer the literature review, but then determine how previous research fits with or extends the emerging theory (Pollit and Beck 2004).
In the case of the paper entitled ‘Shifting Supervision: Implications for Safe Administration of Medication by Nursing Students’, the researchers did not present a literature review before the data are collected. However, the readers will be aware that in the ‘discussion’ section, the researchers compared their findings with the existing research on the topic.
Research Design
The research design according to Mauch and Park (2003) is a total plan for carrying put an investigation. A completed research design shows the step-by-step sequence of actions in carrying out an investigation essential to obtaining objective, reliable, and valid information. The completed design also indicates how the resultant objective information is to be used to determine conclusions about the accuracy of a hypothesis, a theory, or the correct answer to a question (Dillman 2000 cited in Mauch and Park 2003, p. 123).
In the article of Reid-Searl et al, the grounded theory approach was used. The researchers argued that this approach is appropriate in their research as there is little research on the investigated area. This research design originated with Glaser and Straus. The main feature of the grounded theory research design is the development of new theory through the collection and analysis of data about a phenomenon. The researchers were successful in their use of the grounded theory research design. They were guided by their chosen research design in conducting their research. The grounded theory research design helped the researchers in coming up with a new theory regarding a topic that has little attention.
Sampling
The researchers used the theoretical sampling approach. The researchers used this sampling approach to in order to decide what data to collect and which people to include in the research.
The aim of the research is to explore the process of medication administration for nursing students when in the off-campus clinical setting. It is evident that from this aim, the researchers need to look for undergraduate nursing students who have experiences in medication administration in the off-campus clinical setting. The researchers started with a target population which was the final-year undergraduate nursing students from a university in Queensland, Australia. The reason for selecting this population is because these students were about to experience their final clinical placement before becoming registered nurses. This group of people will receive supervision from registered nurses. The researchers were also aware that these students can contribute to the research as they will be gaining experiences in medication administration in off-campus settings. Following conformation of ethical clearance from the university human research ethics committee (HREC), which function in accordance with the National Health and Medical Research Council (NHMRC) guidelines, approval was sought from the Dean of the Faculty to access student names. A package was then sent to 135 final-year university students enrolled in a Bachelor of Nursing programme inviting them to participate in the study.
Using the theoretical approach, the researchers were able to identify the 28 students who will be included in the research. The theoretical approach according to Glaser (1978) is the process of data collection for generating theory whereby the analyst jointly collects, codes and analyzes the data and decides what data to collect next and where to find it, in order to develop the theory as it emerges.
Data Collection
As mentioned, the researchers sought the approval of the Dean to access the names of the fourth year nursing students in a university in Queensland. After the names have been accessed, the researchers sent a package to 135 final-year students inviting them to participate in the study. The researchers made use of individual in-depth interviews using a semi-structured approach as the primary means of data collection for the study. Open-ended questions allow issues to discussed more freely. The researchers also stated that interviews were audio-taped with permission of the participants. In the grounded theory approach, it is important that the researcher, follow a systematic procedure in data collection and data analysis. In the data collection procedure, the researchers collected information through in-depth interview. The individual participant’s responses (including all explanations, discussions, and clarifications) to every question are transcribed by the researchers. The researchers also recorded every interview in an audio-tape. This is important as grounded theory relies heavily on the data that is collected by the researchers as the foundation of developing a new theory. Re-reading and listening to the recorded interviews are important.
The investigator believes that the data collection method employed by the researchers was appropriate for the study. In order to make sure that the respondents are free to answer and discuss their experiences in medication administration, the researchers used open-ended questions. The answers of the respondents were transcribed and audio-taped making the data collection method more effective and allowing the researchers to fully understand and to identify the emerging theory.
Data Analysis
The grounded theory approach used by the researchers compels the researchers to conduct thematic analysis. Grounded theory according to Glaser and Straus is an approach designed to allow researchers to generate or discover theory.
In the article, the researchers used systematic coding procedures known as open coding, axial coding and selective coding. Open coding is the first stage of coding. It involves breaking the data into identifiable properties, categories and dimensions. The researcher searches for differences and similarities between events, actions and interactions and applies labels to them. The next stage in the analysis is axial coding. This type of coding is about making connections between categories. During the selective coding, the analyst attempts to integrate and order their analysis, using core headings (Hansen 2006).
In the research, the researchers used the grounded theory approach to develop a theory regarding the process of medication administration by undergraduate nursing students in off-campus clinical setting. The data were collected through in-depth interview with final-year nursing students because they are the ones who have experienced supervision from registered nurses in off-campus clinical setting. Open coding began after the first interview was transcribed and continued with consecutive interview transcripts until no further categories could be identified and saturation of categories was achieved. Axial coding involved the identification of connections between the categories and sub-categories observed during the open-coding stage by examining the context and conditions in the occurrence of incident and events within the data and identifying connections between them. In the selective coding stage, the researchers were able to identify the central category which is “Supervision”.
Interpretation of Findings, Conclusions and Recommendations
The researchers identified ‘supervision’ as a central category. The central category was used by the researchers to identify a problem that students encounter in administering medications. The researchers were able to come up with a central problem ‘shifting levels of supervision’. This means that the level of supervision the students encountered from registered nurses when administering medications moved from being close to no super vision at all. The levels were labeled as ‘being with’, ‘being over’, ‘being near’ and ‘being absent’. Being with is defined as a level of supervision where the registered nurse is with the student during the process of medication administration. Being over is defined as level of supervision where the registered nurse was in close contact but stood ‘over’ the students. Being near is the level of supervision described most commonly where the registered nurse was within visual range when administering medication but not beside the students. Being absent is when the registered nurse provided no supervision.
The interpretation stage is very critical in the grounded theory as it is where the researcher lays down the results of the research and their interpretation of it. In the case of the research done by Reid-Searl et al, the interpretation stage made the whole research clear and it pointed the investigators attention to the new theory that the researchers developed. In the interpretation stage, the investigator became aware of the path that the grounded theory research has taken. It became clear that ‘supervision’ from registered nurses in the off-campus clinical setting causes problem for undergraduate nursing students in medication administration. The researchers were successful in pointing the effect of level of supervision that the students get when administering medication to the occurrence of medication error.
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