NurrcEdtuatwn T&q (1991) II, 215219 0 Longman Croup UK Ltd I!391

WORK The value drills numeracy skills in

in developing maintaining an undergraduate nursing

Anne and Christine Duffield

The purpose of this study was to determine whether mathematical drills enhanced the ability of students of nursing to calculate drug dosages accurately. First year students were drilled and then tested over the next 2 years in drug calculations. It was found that repeated drilling improved students’ ability to calculate drug doses but that this skill level diminished over time, in some instances to predrill levels of accuracy. An increase in the number of correct calculations was noticed in the two semesters in which students had a clinical placement leading the authors to conclude that, contrary to previous findings, work experiences do enhance the ability to calculate medication dosages. As safety and competency are essential in those areas of nursing practice which depend on mathematical ability, educational strategies which develop and retain mathematical skills are needed.

The historic decision in November 1983 to transfer all pre-registration nursing education in

New South Wales to the higher education sector had important implications for the education

bodies offering programmes and provided

opportunities to reconsider the approaches taken previously to skill acquisition. The transfer

necessarily implied that courses would have

greater theoretical content and less clinical prac- tice. This would potentially alter previous pat-

terns of learning and exit behaviours. An area of

concern expressed by many nurses was the

Anna Adams RN BA MA FCN(NSW) Senior Lecturer, Chrhtino Mold RN BScN MHP PhD FCN(NSW) Associate Professor, School of Nursing Therapeutics, Faculty of Nursing, St Leonards Campus, University of Technology, Sydney, P.O. Box 123, Broadway, NSW 2007 Australia (Requests for offprints to AA) Manuscript accepted 16 January 1991

potential inability of nursing graduates from the

higher education sector to calculate drug dosages accurately. The reasons for this

apprehension stemmed from the decreased clinical time available in which to acquire skills,

and the lack of repeated practice associated with

full-time student status as opposed to employee status, the latter being a feature of hospital

education programmes.

Nurse academics in the higher education sector were aware of the concerns of nurses in

the workforce and a variety of strategies were

proposed to overcome potential deficits in the students’ ability to calculate drug dosages. An

obvious solution was to introduce the use of drills, firstly to assess the numeracy skills of

students, and secondly, to develop and maintain these skills. ‘Drills’, in this context refers to the

repeated practice of mathematical problems in the form of drug orders which require calcula-

213

2 14 NURSE JXXJCATION TODAY

tion in order to determine correct dosages. However, there was an unfortunate lack of research data on which to evaluate the effectiveness of this strategy. The purpose of this study was to determine whether or not the use of drills for students in nursing had any effect on their ability to calculate drug dosages, since this constitutes one of the most common nursing functions and one which is potentially fraught with danger. If drills were found to be useful in acquiring these skills then their inclusion in the nursing programme was warranted. Further, the use of computer assisted learning strategies using commercial software packages could pro- vide a cost-effective means of drill practice. The use of computer assisted learning programmes would also facilitate computer literacy. The acquisition of this latter skill was seen to be highly advantageous. Clearly the rapid expansion of computers into many health care agencies implies that those in the nursing profession must be computer literate in order to function effectively in such an environment.

REVIEW OF THE LITERATURE

The mathematical skills of students of nursing are of interest to their educators for a number of reasons. These reasons include educational success, professional practice and the safety of patients.

for admission performance was predictive of

The academic ability and ultimate success of students in tertiary nursing programmes are real concerns in a time of public economic constraint and concomitant demands for accountability and increased participation rates in higher edu- cation. In North America, recent trends in baccalaureate nursing programme enrolments have seen reductions in the quantity and quality of applicants (Redem & Pilla 1986; Gothler & Rosenfeld 1986; Aiken & Mullinix 1987). In an effort to identify the predictors for success in the North American programmes, a number of variables have been proposed and tested. Allen et al (1988) attempted to identify students at risk for academic difficulty and found a lower grade

earning a fail grade in nursing and noncom- pletion of the programme. While mathematical abilities were not isolated for testing, the grade point averages for social science and biophysical science subjects, prerequisites for studies in nursing, were found to be significantly corre- lated with nursing gradepoint averages. Yang et al (1987), concerned about baccalaureate students’ performance in the national licensing examination, also examined admission data to identify potentially successful students. In their study, mathematical performance was more likely than English to correlate with success.

Students with good mathematical scores were more likely to gain admission to a nursing programme in Ontario, Canada. Preadmission mathematical test scores were found to be good predictors of success, although the number of pure and applied science courses completed was the best predictor. An analysis of student appli- cations, transcripts, language and arithmetic test scores showed that only the arithmetic test results were significant (Weinstein et al 1980).

The ability of students of nursing to think critically and solve problems was investigated by Tiessen (1987). The study results showed math- ematical ability to be most highly correlated with critical thinking. Tiessen concluded that math- ematical ability must remain a prerequisite for- admission to nursing programmes and math- ematical proficiency should be required at each level throughout the programme and on completion. The relationship between critical thinking, mathematical proficiency and accurate medication dosage calculations was the best for these recommendations.

Safety and competency in practice is a concern of those who administer and teach nursing programmes. Dexter and Applegate (1980) refer to problems encountered by students of nursing in mathematical and drug calculations in a programme at Indiana University. A curri- culum component was developed which required 80% mastery in first semester. A review of the subsequent semesters revealed a loss of mathematical ability unless regular practice was maintained. Further tests over the programme, requiring 90% mastery, were introduced in order to reinforce retention of the orevious 1

NURSE EDUCATION TODAY 15

Increases in scores were 4.4%

in general mathematical ability and in

dosage calculations in beginning students,

though tests had not been for long enough

in later modules

year students

were found to be lacking

and Bayne (1984) for mathematical profi-

ciency and medication calculations. Regular

the nursing programme resulted the tests

over five semesters achieving 70% or higher grade. A pass rate was the minimal

The authors out that mathematical profi-

such as medication calcula- tions, and fluid

intake and output calculations. and performance are

the domain the mathematical abi- lity of qualified nurses becomes

and responsibility for for basic

mathematics and drug calculations in a large

university and Beare (I 988) and asso-

did significantly better

than diploma graduates. The that level of education influences the level

The study also found that length

was related test perform-

that test performance is influ-

and by work experience. An interest the of computer technology

to test the dose calculation abilities

led McColgan (1984) to develop with purposes, practice

and The program pro- with exercises drug dose calcu-

lations and later, the the subject matter. McColgan

that because drug dose calculations are

and only sporadically reinforced over

remainder the course, calculation skills are

well retained. Computer were recommended for the reinforcement and

they be tailored

used at point in education

programme and can be readily accessed.

As little attention had paid the expec- tations of students enrolled in tertiary

and their teachers surveyed for their expectations

and year mathematical course in a degree programme. Students

that mathematical courses them to learn and

some higher aims related the application and

also study sciences,

year level courses, part of nursing programme.

Most tertiary courses demand quantita- tive study. with poor

are more likely to fail the

with mathematical components were tested for

non et al 1979). Results confirmed led authors

and offer a basic mathematical reme-

dial course. the identified

the acquisition the first 4 years of high

school.

With problem

ance in secondary education in mind, year 10 high school students mathematical undera-

chievement and below expectation level per- formances given remedial

and anxiety reducing

The students the study showed cant improvements self esteem

and study habits led researchers

that while a continuation can help underachievers, it is individual

dial tuition the preferred this

situation the can be guided not to experience failure and and if necessary back to elementary mathema-

tics in order to succeed (de1 Pop010

that students need to develop mathematical skills for safe clinical

2 16 NURSE EDUCATION TODAY

practice, some of the educational expectations of learning institutions will also relate to math- ematical abilities. In particular, areas of know- ledge such as the physical and biological sciences frequently draw on mathematical skills. In New South Wales from 1985 onwards, and through- out the other Australian states over the next 5 years or so, students of nursing on entering the tertiary sector are confronted with expectations of mathematical ability at tertiary levels. Math- ematical ability in students of nursing in under- graduate programmes is an educational and professional issue. Mathematical ability can be related to achievement and used as a predictor of success. The relationship between critical think- ing and mathematical skills is a matter for all tertiary students, but holds particular import- ance for nurse education in that problem solving is acknowledged as a fundamental professional activity.

Safety and competency in practice are prime concerns of both educational and employing institutions, and as a result strategies which seek to develop and retain mathematical skills become essential. As stated earlier, the hypothe- sis of this study was that students’ peformance in calculating drug dosages would improve with the use of drills. If this was found to be true then computer technology offers one strategy to achieve and maintain the goal of proficiency.

METHODS

Subjects

The study was conducted in a multi-disciplinary, higher education institution over a 3-year period. All students in a diploma level nursing course were tested throughout 3 years, com- mencing with the first intake in 1985. As the study was completed in 1987, the sample consis- ted of first year students for each of the 3 years (1985 - 1987), second year students for 2 years (1986 - 1987) and third year students for only 1 year (1987). The students were taught drug calculation procedures prior to attempting the first worksheet. Mathematical ability varied.

Although students had gained entry to a higher education institution, there was a diversity of mathematical experience and ability. This diversity was related to the selected level of study and achievement in mathematics and subjects which relied on mathematical ability in second- ary school as well as student age. As the study was concerned with skill acquisition and mainten- ance these factors were not surveyed prior to the study.

The tool

A series of five worksheets was prepared for the drills, each consisting of 10 drug calculation problems in the format below:

Drug required: (Drug name and dosage) Drug on hand: (Drug name and dosage)

The students were required to provide the correct answer on the worksheet in the space provided. Each question was of a similar complexity and required an answer indicating the amount of drug to be administered and the correct measure in milligrams or millilitres. Each paper was scored out of 10. A correct answer was one in which both the dosage and measure were right.

The worksheets had two purposes. Firstly, they provided the practice (or drill) in the mathematical calculation of drug dosages. Secondly, on completion, they provided the data for student performance.

Procedure

The papers were handed out in a tutorial session to each student and completed under super- vision at the time. The series of five papers was distributed at approximately 1 week intervals, commencing in the second semester of the first year when the calculation of drug dosages had been taught. As completion of the drills was left to individual tutorial leaders' judgment accord- ing to the time available, not all students attemp- ted the total five papers which accounts for some variation in student numbers. The correct ans- wers were given to students on completion of the drill sheet.

The researchers were also interested in investigating whether the long-term effects of repeated drills diminished with time. In order to investigate this effect the students were tested throughout the remaining 2 years of the pro- gramme. A further five papers were developed giving a combined total of 10 papers. There- after, one of these 10 papers was randomly chosen to be administered to students each semester in second and third year (twice a year).

RESULTS

Table 1 indicates that the number of correct answers for first year students improved from a mean of 7.55 correct per student to 9.10 throughout the semester in which the five drills were completed. This high mean score of 9.10 correct per student was never again attained. Table 2 indicates that the positive effects of drills noted in Table 1 dimished from a high of 9.10 correct per student at the end of first year to below predrill levels at the beginning of the second and third years of the programme. Results improved in the second half of each academic year for both second and third year students.

DISCUSSION

It can be concluded that drills did improve the students’ ability to calculate correctly drug dosages since the mean score of correct responses per student rose from 7.55 on the first paper to 9.10 by the fifth. While the mode remained constant at 10, the lowest number of

Table 2 Results of follow-up testing in sacond and third year students

NURSE EDUCATION TODAY 2 17

Table 1 Results of drills for first year students

No. Mean of students (maximum=lO) Range Mode

Paper 1 436 7.55 O-10 10 Paper 2 361 7.90 O-10 10 Paper3 365 8.30 l-10 10 Paper 4 309 8.53 2-10 10 Paper 5 277 9.10 2-10 10

correct responses achieved rose from none correct to two over the five papers. Bindler and Bayne (1984) expected 70% mastery in each of five semesters for mathematics and drug calcula- tions. If this level of mastery was accepted as a baseline in this programme then the students as a group would have achieved satisfactorily throughout the period of the study (see Tables 1 and 2). However it must be questioned why a 100% level of mastery is not expected when the implications of calculating drug dosages incor- rectly on 30% of occasions are considered.

The mean score attained on the first paper was higher than anticipated (7.55). An explanation for this may relate to the fact that all first year students are enrolled in a chemistry course in which calculations are an integral part of the experiments conducted. However, despite prac- tice in arithmetic and calculations in this course, students did not achieve the 90% preadmission mastery level required by Dexter and Applegate (1980). In fact, it was not until the fifth paper that most students were successful at this level of mastery (90%). It is impossible to determine the effects of the chemistry course on the acquisition of mathematical skills, but consideration must be given to the level of skill possessed by students in programmes in which science is not included.

No. Means of students (Maximum=lO) Range Mode

Year 2, Semester 1 242 7.52 2-10 10 Year 2, Semester 2 206 8.80 4-10 8 Year 3, Semester 1 107 7.34 2-10 8 Year 3, Semester 2 106 8.85 5-10 8

N.E.T D

2 18 NURSE EDUCATION TODAY

Students in these programmes may not possess the same degree of numeracy skills as was found in this study. Such a possibility bears further study as there may be significant implications for curriculum development. As discussed earlier, the safe and accurate calculation of drug dosages relies very heavily on numeracy skills (Tiessen 1987) and those involved in the development of curricula should ensure that there is adequate theoretical input to facilitate the development of these skills.

The researchers were also interested in the long-term effects of drills. When students were tested throughout the second and third years of the programme, the mean number of correct drug calculations per student failed to reach the 9.10 correct per student which was achieved on the fifth paper. In fact, at the beginning of both the second and third years the mean number of correct calculations fell to slightly less than predrill levels (7.52 and 7.34 as opposed to 7.55). The mode also dropped from 10 correct responses at the beginning of the students’ second year of study to eight correct responses thereafter. Such a finding implies that the skills acquired through drills diminish over time.

Of interest, however, is that student results improved in the latter half of both the second and third years of testing (the mean number of correct responses rose and the lower end of the range also increased). In both these semesters students are involved in clinical practicum every week where the calculation of drug dosages and the administration of medications are a feature. This could account for the rise in mean score in both semesters. This finding requires further testing as Conti and Beare (1988) found that performance in mathematics and drug caicula- tions was not affected by work experiences.

The conclusion that drills and experience in the clinical area do improve a student’s ability to calculate drug dosages is significant and there are important implications of this research, not only for students, but also for graduates of nursing, Nurses need continuous practice or assessment if they are to maintain their skill in safe drug administration. As a consequence of this, nurses who are not routinely administering medications would need to undertake refresher

courses or assessment at regular intervals. Furthermore, nurses who are not required to administer medications in the course of their usual work day should not be considered safe to do so when transferred to another clinical area to relieve.

There are also implications also for those staff involved in orientating nurses who graduate from the higher education sector. On the commencement of employment, the ability of these graduates to calculate drug dosages must be assessed. This is important since not all programmes may conclude with a clinical component nor may they have provided oppor- tnities for continuous student practice, thus diminishing the chance that new graduates will be competent or safe at calculating medication dosages. Educational institutions also have a responsibility in this regard, and that is to introduce mastery tests throughout their nur- sing programmes. In this way the students’ ability to calculate drug dosages correctly may improve thus facilitating the graduates’ trans- ition to registered nurse status.

McGolgan (1984) believes that computers are useful in reinforcing previously learned skills. As this study has indicated that drills are useful in developing skills in drug calculations, computer assisted learning could be useful for practice, reinforcement and self-evaluation. Hospital inservice departments and institutions of higher education may find this method of assessment relatively inexpensive once hardware and software purchase has been completed. There is also the added benefit of acquiring computer literacy skills. For nursing staff or students who require remedial assistance, tuto- rials or counselling may be a more appropriate avenue of learning than the use of computers (de1 Pop010 8r Shannon 1987).

In conclusion. this study has shown that the use of drills enhances a student’s ability to calculate accurately drug dosages. However, this skill diminishes over time and educational insti- tutions and employing agencies need to develop strategies which will assist with skill mainten- ance. The use of computer technology would seem to offer a cost-effective method of achiev- ing this.

NURSE EDUCATION TODAY 2 19

Acknowledgements

The authorsacknowledge with appreciation the generous assistance of MS A M Butler RN.

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