Vicki Shawyer, DipHealthSocialCare, RGN, is ward manager and clinical skills tutorl; Alison Copp, PGCE, DipCOT, CertMHSC, is clinical skills lead tutor, both at Royal Devon and ExeterHospital. Julie Dobrijevic, MA, PGCE, CertEd, DipN, RGN, is learning in practice tutor; Lois Goding, PhD, BEd, CPT, RHV, RGN, is learning in practice lead tutor, both at Heavitree Hospital, Exeter.
VOL: 103, ISSUE: 4, PAGE NO: 32-33
AbstractShawyer, S. et al (2007) Nursing students and the administration of IV drugs. www.nursingtimes.net.
Intravenous drug administration is now regarded as a fundamental rather than an extended role of a nurse. This article describes an initiative to train nursing students at the Royal Devon and Exeter NHS Foundation Trust to give IV drugs after a skills gap was identified in newly qualified nurses. The purpose was to ensure the students were confident and competent in this clinical skill on qualification. Local PCTs are now considering adopting this successful initiative for their third-year nursing students on placement.
Historically, intravenous (IV) drug administration has been seen as an extended nursing role, but this is no longer the case. Since pre-registration training had yet to take account of this, a skills gap was identified in third-year pre-registration nurses appointed to band 5 posts at the Royal Devon and Exeter NHS Foundation Trust.
This put an additional burden on a nursing structure already struggling with recruitment and retention issues. Newly qualified nurses needed to attain IV skills, but there were difficulties in releasing them to attend clinical skills training. As a result, the nurses felt they were a burden to their colleagues because they where unable to fulfil their expected role. It could be argued that effective total patient care was compromised.
Detailed examination of the issues revealed some interesting anomalies. It appeared that some clinical areas of the trust were allowing third-year nursing students to give IV drugs and supporting them in the procedure. This was neither an agreed part of the students’ clinical skills training nor a recognised activity within the trust.
This practice was creating a disparity in the clinical experience of nursing students attached to different areas and was also a litigation risk. Training nursing students in IV administration was not an activity acknowledged by the trust’s clinical governance committee.
The Department of Health’s workforce redesign Agenda for Changehighlighted the need to look at the nursing student and IV drug administration issue. The band 4 nursing role, coupled with the redesign of the band 3 role could have led to a situation where unregistered nurses’ clinical skills were more ‘fit for purpose’ than those of the newly qualified band 5 nurse.Although the university was considering changes to pre-registration training, the trust had an immediate need with regards to IV drug administration and decided to address it. The learning and development service has worked in partnership with the university to gather information on the issue to dispel any myths about NMC and government regulation surrounding IV administration of drugs by nursing students.
Purpose of education
The NMC (2004a) recently revisited standards of proficiency for pre-registration nursing education and requires that ‘pre-registration nursing programmes are prepare students to be able on registration to ‘apply knowledge, understanding and skills when performing to the standards required in employment and to provide the nursing care that patients and clients require, safely and effectively and also assume the responsibilities and accountabilities necessary for public protection’. It adds that ‘educational quality should be achieved through partnership and collaboration involving all stakeholders including service users, educational purchaser’s, service providers and educational institutions and quality assurance agencies’.
Preparing students to be fit for practice and deciding what that constitutes is an ongoing challenge for everyone involved in nurse education, both within the NHS and educational institutions.
The NMC (2006) recently published new standards to support learning and assessment in practice, which must be implemented by September 2007. These emphasise the need for a quality assessment process with a clear line of accountability for mentors assessing a learner’s competency for fitness for practice. The fact that mentors rarely fail students in practice has led to concerns about the quality of assessment. An NMC-commissioned study (Duffy, 2004) concluded that mentors needed to understand their own accountability in supporting and assessing students in practice.
The government has also emphasised that the education of all healthcare workers and professionals should be based around preparing them for their role and maintaining their competencies.Following the implementation of Agenda for Changeand the Knowledge and Skills Framework (KSF: DH, 2004), postholders will be required to provide evidence of competence and continual professional development through annual performance review.
Confidence and competency
Nursing education has moved away from an apprentice style preparation, where students ‘learnt on the job’, towards a university-based model. Methods of delivery and the content of nursing programmes are continually evaluated and changed in order to produce competent, knowledgeable practitioners who have the skills required by service providers.
Gerrish (2000) and Evans (2001) found that newly qualified nurses lack confidence and competence in essential and required skills on registration. Brown et al (2003) concluded that confidence was central to competence when performing clinical skills and Zhang et al (2001) identified personal characteristics as a contributing factor to confidence in performance issues in practice.
Numerous studies have looked at the changing role of the clinical skills tutor, mentor, preceptor, practice facilitator and lecturer practitioner in skill acquisition and the assessment of practice, reinforcing the importance of quality teaching and learning in practice (Evans, 2001; Neary, 2000a, 2000b, 2000c, 1997;). The debate surrounding how and where clinical skills should be taught and who should teach them continues (Kenny, 2004; Hilton and Pollard, 2004; Pfeil, 2001).
Quality placements for learners have been identified as integral to skill acquisition (ENB/DH, 2001a; Edwards et al, 2004), and learning opportunities and support from the mentor are central to this (NMC 2004b; 2004c; ENB/DH, 2001b). It has been shown that the quality of the learning environment for healthcare professionals has a major impact on providing high standards of care.
In response to concerns that nurses were registering without the required skills to practise confidently and competently, the UKCC published two reports: Fitness for Practice (UKCC, 1999) and Fitness for Practice and Purpose(UKCC, 2001). These recommended that nurse education should be practice-driven and that nursing students would be taught and assessed by mentors who were competent practitioners. Mentors were encouraged to have a teaching and assessing qualification and the role of the practice educator was developed to support them. The recommendations resulted in the development of the competency-based curriculum in 2000.
In recent years an equal balance of theory and practice has been delivered locally through the development of a diploma and degree-level competency-based curriculum, initially based on occupational standards. The competencies of graduates and diplomats from UK nursing programmes have been explored (Bartlett et al, 2000; Girot, 2000) and current trends suggest that nurses are required to be graduates on registration.Boxer and Kluge (2000) attempted to identify the essential skills required on registration and Watkins (2000) recommended that these were determined at a national level. The NMC has recently released a consultation paper (NMC, 2006) regarding setting standards on the requirements of the preparation of mentors and teachers in the assessment of learners in practice.
Emphasis on skills acquisition and ongoing maintenance of competencies mapped to the KSF requires that each post within the NHS is integral to providing safe, effective healthcare. Work is currently being undertaken to develop the role of the unregistered practitioner, who it is envisaged in the near future taking on some of the skills traditionally linked to the registered practitioner.
Myths about nursing students and IV drug administration
There was a common belief within the trust that nursing students were not allowed legally to administer IV drugs. Comments made included:
’I do not want to be accountable for someone else’s mistake’;
’It is illegal for nursing students to carry out IV drug administration’;
’They do not have the knowledge or experience to give IV drugs safely and be aware of the complications’;
’The NMC guidelines relating to nursing students prohibit it’.
However, NMC advice was sought and this revealed that nursing students were allowed to administer IV drugs provided they had been trained and assessed appropriately. The NMC guidance said:
Additional skills would complement the whole programme and allow nursing students to develop the fundamental skills of contemporary practice to the necessary high standards;
The supervision will need to be commensurate with the task;
There would be additional issues relating to accountability for mentors and the programme to ensure safe practice;
Clear protocols would be necessary so that implementation could be open to the scrutiny of external quality assurance.
With the clear protocols in place, there was no reason why third-year nursing students could not be given clinical skills training in relation to IV drug administration. This meant students were able to undertake the IV skills course under the jurisdiction of the university and not deemed as a trust employees.
Nursing student training process
In order to ensure that all areas of risk had been addressed and clear protocols were in place, further approval to proceed was sought from the trust. A paper was prepared and presented to the clinical governance board detailing all aspects of the proposed strategy for nursing students and IV drug administration.
The proposal stated that IV drug administration training was to be offered to third-year nursing students who had applied for band 5 posts within the trust. This ensured that the organisation would benefit from providing the training. Nursing students would not be allowed to practise IV administration independently until they received their PIN numbers. It was, however, important to recognise that some nursing students could feel apprehensive about developing this skill, so it was agreed that students should not be coerced into attending the training.
The taught component led on to directly supervised practice to prevent ‘skills fade’ between competency sign-off and registration with the NMC. It was therefore decided that the taught component would take place three months prior to anticipated registration, allowing time for direct supervised practice leading to competency sign-off just before registration.
The trust’s IV drug administration policy and medicine management policy were updated to support the initiative. A record of learning was also compiled to ensure assessors/mentors and students were all aware of the requirements of the programme (Box 1).
Box 1. Record of learning
Introduction to IV drug administration practice
An overview of the educational programme
Maths and theory paper
Performance criteria relating to each technique and device used within the acute trust
Records of assessments completed
Reflective learning templates
Boundaries of competent practice
All eligible students were given information about the IV course by the learning and development service, and 16 applied. The two-day theory and practice training included: accountability and safe practice, risks of IV therapy, practical aspects of IV drug administration, pharmaceutical aspects of IV therapy, anaphylaxis, infection control, adverse events, central line care, and practical aspects of IV therapies. After completing the course, students participated in direct supervised practice in their clinical area until they felt confident enough to undertake a summative assessment to demonstrate competency.
Close collaboration between the clinical skills team, assessors/mentors and practice educators was essential to ensure continuity and understanding. When the university finalises changes to its curriculum to keep pace with changing clinical skills, IV administration will be part of everyday pre-registration nursing education.
Recommendations for future practice
The experience of running the course has demonstrated that nursing students should be taught IV drug administration during their training in order to fulfil the role of the band 5 nurse on qualification. In order to introduce this successfully, standardised documentation is required which students and mentors complete to show a clear record of learning, and mentors need extra support around facilitating IV skills practice. There must be a specified amount of supervised practice, which must include direct observation, quality monitoring and enhancement strategies including regular evaluation and review. Appropriate assessors must be identified and maths and theory papers (adult and paediatric) with competency guidelines developed to support this.
Nursing students can now undertake IV drug administration following local guidelines. Many myths had to be dispelled within the hospital before the students could be trained in the procedure, because the misunderstandings could have impeded practice. Some staff believed it was ‘illegal’ or against NMC guidelines to allow students to administer IV drugs. After consultation with the NMC this assumption was shown to be unfounded. The students had to undertake direct supervised practice and during this period the observing registered nurse has accountability.
IV drug administration historically was seen as an extended role. As medicine has evolved over the years more demands have been put on medical and nursing staff. IV therapy is prescribed to many patients and nurses must be able to able to administer it safely and competently if patients are to receive the best care.
Following the success of this initiative, local PCTs are considering adopting this process for third-year nursing students on placement. The IV drug administration training is also being prepared for use with student radiographers. Emphasis on skills acquisition and ongoing maintenance of competencies is integral to providing safe effective healthcare.
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