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Nurses’ Thought Processes During Medication Administration

Nurses have a complex, many-faceted role in administering medications and are the last link in the safety net to prevent errors. The medication administration procedure is focused on the five rights: the right patient, drug, dose, route and time.

While the procedure of administering medications can appear simple and straightforward – the physician prescribes, the pharmacist dispenses, and the nurse administers the medication – the thought processes nurses use during medication administration to prevent errors, to prevent harm, or promote therapeutic responses are not well known.

By documenting nurses’ reported thought processes during medication administration before and after implementation of point-of-care technology, content analysis identified ten descriptive categories: communication, dose-time, checking, assessment, evaluation, teaching, side effects, workarounds, anticipating problem solving, and drug administration.

HOW WAS THE STUDY CONDUCTED?
For the study, 40 regional nurses (RNs) were interviewed. The units where the nurses worked were scheduled to convert to barcode/eMAR in 2004/2005. Nurse managers identified participants they thought to be “good informants,” meaning nurses who were experienced in medication administration and could articulate their experiences.

During the start of each interview one question was asked: “From the time a medication is ordered, would you please take me through exactly what you do when you administer routinely scheduled medications.” Following this, nurses were asked another set of questions by the interviewer and probes were used for clarification and to elicit additional information.

Alongside the interviews, nurses were asked to record their thought processes in real-time before and immediately after administering medication.

WHAT DID THE STUDY FIND?
Ten descriptive categories of nurses’ thinking were identified from the content analysis:

Communication. Nurses and others sharing patient data and their interpretation to ensure that a drug was safe or if a change in medication or dose was indicated.

“Sometimes we have to go back and say, ‘Wait a minute, this is not going to work just like you think it does.’ So then I will just go to them and explain my case. They will either agree with me or not or we have a discussion about it.”

Dose-time. Nurses’ judgments about the timing of PRN medication (e.g., analgesics, antiemetics, drugs for sedation) or about the amount of medication to give within prescribed parameters (e.g., blood pressure medications, insulin).

“I realized when I had looked back, that her medications had [been] tapered off during that time. And the doctors agreed because I said, ‘Look at when all her blood pressure medications have been given.’ They were all scheduled for 9 am and 2 pm so by the time 6 am came around, her blood pressure was high. Then we just went back and I rescheduled them.”

Checking. Nurses verifying the correctness and appropriateness of a component of the medication administration process.

“I had a patient who was on high blood pressure medication. The dose seemed high to me, but it was in the computer for that dose. I asked her [the patient] and she said, ‘Yes, that’s the dose that I take,’ but on further discussion with her, it turns out she takes the extended release form of that dose, so that wasn’t in the record. The physician ordered the dose incorrectly. The pharmacist filled the dose incorrectly, thinking that she was on a non-extended release form.”

Assessment. Nurses’ reasoning related to detection and interpretation of patients’ signs and symptoms potentially related to patients’ needs for medication.

“If I think that the patient would do better with a drug other than morphine but if morphine is the only PRN, I would page the physician and say this patient may be ready for p.o. Oxycodone 5 milligrams, what do you think?”

Evaluation. Nurses’ judgment related to whether the medication was achieving the desired therapeutic effects.

“I’ll have to take steps to get different pain medicine or more pain medicine for that patient. Very often it does work, but there are times when it doesn’t work, so you may end up giving them some- thing else that they’ve got ordered.”

Teaching. Nurses providing the patient or family with information about medications based on medication information needs of patient or family, appropriateness of the teaching moment, and capacity to understand.

“I do not rush into giving people medication before people feel comfortable. If you have any questions, have I answered your questions first, so that people really feel that they are comfortable getting this new medication?”

Side effects. Nurses monitoring for, preventing, or acting to mitigate adverse effects of medications.

“Someone may have some renal dysfunction and they ordered some potassium replacement, but maybe they need to think twice about getting that much potassium. Because of their renal dysfunction, they really shouldn’t get so much.”

Work arounds. Nurses not following standard procedures either for the benefit of the patient or for the convenience of the nurse.

“If somebody’s K [potassium] is extremely low, I might start hanging the IV. Sometimes we take it out of somebody else’s drawer. If it’s between them doing really well and them all of a sudden going into V Tach, you are going to hang it. I call the doctor right after and I say, ‘Please put in the IV order’ because IV is much quicker than p.o.”

Anticipatory Problem Solving. Nurses’ consideration of the future course of events based on patients’ patterns of response, or scheduling of diagnostic tests or therapeutic procedures.

“The finger sticks are about 126, she’s NPO, and I’m not giving her insulin just yet. I’m trying to find out if she can eat. The other thing is she is on Decadron. But still 126 is fairly low; I don’t want her to drop through the night.”

Drug administration. Nurses giving a medication to the patient.

“If it’s intravenous and it’s peripheral, I look at the IV site to make sure that it’s not swollen, red, inflamed, hot, tender, draining, any of those observations. Then I’ll go ahead and time the pump and then identify the medication through the pump and then give the medication. I make sure that the guidelines to give these medications have not changed since I last gave them as far as the concentration of the mix, how many milligrams per cc are acceptable and based on the route that you’re giving it, whether it’s central or peripheral and make sure it’s adequately diluted, and find out whether it needs to be on a filter or not.”

WHAT CAN WE CONCLUDE FROM THE STUDY?
This study shows that the actual act of administering a medication is only a small part of the professional role in the medication administration process. Situations requiring judgment in dosage, timing, or selection of specific medications indicated the most explicit data about participants’ use of critical thinking and clinical decision making.

These ten categories of nurses’ thinking during medication administration indicate the intellectual complexity of the process of medication administration. The results of this study make explicit the constant vigilance of nurses in protecting and advocating for their patients as direct caregivers and members of the interdisciplinary health team.

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References
Adapted from: Eisenhauer L.A., Hurley A.C. & Dolan N. (2007) Nurses’ reported thinking during mediation administration. Journal of Nursing Scholarship 39:1, 82-87. . [WWW document]. URL http://onlinelibrary.wiley.com/doi/10.1111/j.1547-5069.2007.00148.x/abstract [accessed on 24 June 2014]

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