Our study shows that very positive results were obtained from using simulation as a means of teaching professional skills such as the safe administration of nursing medication, a finding that corroborates previous research in this field [18, 26,27,28,29,30, 43]. In general, better results were obtained for the six rights during the simulation than in the prior questionnaire. This can be explained because the Pre-S questionnaire was carried out individually, while the situation raised in the SBA was resolved from cooperative learning.
Our analysis of this teaching experience coincides with that of Shearer , who reported that the students’ identification of their patients improved substantially after the simulation exercise. However, although more than half of the students correctly identified the patient during the SBA, they did not systematically use the identification bracelet, which is the method normally recommended [10, 32, 40]. In this respect, our findings concur with those of previous research according to which patient identification error can occur in up to 80% of cases . The question of patient identification was commonly raised in the debriefing sessions, when students realised the potential repercussions of such an error, like Avraham . For example, if the patient had been allergic, this mistake could have caused anaphylactic shock and possibly death.
As in other studies [7, 39], notable improvements were observed in terms of achieving the right drug, the right dose, the right route and the right time during the simulation, compared with the situation recorded in the Pre-S questionnaire. Specifically, the students reported that simulation helped them learn dose calculation, which is a major initial source of stress and concern. In this respect, our results coincide with those of Harris et al.  and Dutra . However, in the simulation situation the dose calculation was performed by the group as a whole, and not individually as in the Pre-S questionnaire. As observed in previous research [7, 28], this competency should be assessed in the individual, not the group, as difficulties might not otherwise become apparent.
The right time was the most difficult point to assess in both tests. As explained above, in the questionnaire the students were asked to resolve a situation of work overload and to perform the necessary prioritisation of tasks. This activity may have been complicated by their still incipient knowledge of pharmacology, lack of clinical reasoning skills and continuing need to develop their overall view of the patient and of the clinical unit [11, 31]. Furthermore, they did not ask “what time it was”. On the other hand, we should acknowledge the real difficulty faced by the student in practising a task of this type within a simulated situation. Having a single prescription leads students to assume that this is the medication to administer during the simulation without verifying that the simulated time is the time the drug should be administered. As an improvement strategy for the verification of this right, we could propose that the student have a 24-h prescription of drugs. The 24-h prescription of drugs would force students to check more explicitly the medications to administer at a given time (right time). Furthermore, it’s a way to improve the scenario reliabity.
The only task that was better performed in the questionnaire than in the subsequent simulation was that of the right documentation. This may be because the students were asked directly about the content of the record made, and therefore it was always present as an activity to be performed. It is difficult to compare this principle with its performance in the simulation, because although the first five of the rights arose spontaneously and were necessary in order to simulate the administration of medication, the documentation process was overlooked in most cases. The students’ failure to perform the necessary data documentation shows that while they had mostly assimilated the activities aimed at preventing medication-related errors, they did not realise that the process also involves recording the medication administered and controlling its subsequent effects. These results highlight the need to integrate this action into checklists for safe medication administration, as indicated in previous studies [4, 40].
In line with the INACSL Standards Committee [38, 45] and other research [7, 27, 28], we found debriefing to be of crucial importance to the learning process. This aspect of the SBA facilitated the subsequent application of patient safety culture and provided a space for analysis of the errors committed, highlighting their causes and offering solutions to ensure they were not repeated. The significant advances achieved with the SBA are consistent with one of the principles of improving patient safety: the need to learn from adverse events . The students were made aware of their responsibility to avoid medication errors, in line with Steiner , who observed that simulation allows students to address possible situations of shock without putting anyone – patients or students – in danger, thus protecting students from becoming second victims .
In relation to the second objective regarding the opinion of the students about the activity, the SBA was well received by the students, who appreciated the opportunity to have an initial contact with the reality of healthcare in a controlled environment and to learn relevant skills in an innovative way. Simulation enabled these students to better understand pharmacology concepts and to apply them in a realistic context. Similar opinions have been expressed in previous studies in this field [8, 21, 24, 28, 29].
In our study, the students highlighted the need for more time in which to perform the activity and for the groups to be smaller. In this, they seconded the recommendations of the INACSL . This Teaching Innovation Project is part of the Faculty plan for the implementation of clinical simulation in nursing studies. It is expected that in the future these teaching sessions can be adapted to a greater extent to the simulation standards . Indeed, some studies have examined one-on-one simulation exercises, designed to give the student the opportunity to complete all stages of the medication administration process alone, as is often the case in practice [7, 28]. However, it should be noted that appropriate resources need to be assigned to this type of teaching method  and the Nursing degree curriculum might need to be adjusted appropriately.
This study presents certain limitations, especially the difficulty encountered in comparing the results of project activities. Thus, the Pre-S questionnaire was evaluated individually, while in the SBA a group evaluation was performed. In addition, the techniques used in the two moments to evaluate each of the right ones were different. The lack of validated tools for assessing the competency of safe drug administration during the simulation has limited the generalization of our results. Moreover, the small number of students participating in this study and their recruitment from the same institution limits the generalisability of our findings to other populations and settings.
First, despite the methodological limitations identified, we consider that the results are of interest to the nursing teaching community, given the low number of studies related to simulation as a methodology for teaching safe medication administration in the Spanish context. The incorporation of this teaching methodologies raises the need to make efforts in the teaching curriculum in order to increase its use during the nursing degree. For optimum effectiveness, further resources are needed for simulation, such as appropriate spaces, teachers trained in this methodology, more time for the preparation and design of the scenarios and smaller groups and/or individual evaluation. Second, the development of new teaching methodologies must be accompanied by evaluations through different research designs despite de difficulties of investigating within the classroom and randomizing research without discriminating against students in their learning process . Third, the improvement of competence in the safe medication administration by students will result in clinical practice, improving patient safety and protecting students from becoming second victims.
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