Tonya Schneidereith, PhD, CRNP, PPCNP-BC, CPNP-AC, CNE, CHSE-A
University of Maryland School of Nursing, Baltimore, MD
Adverse drug events (ADEs) continue to impact patient safety. Described as harm that results from medication use, ADEs are responsible for more than 1.3 million visits to the Emergency Department and cost in excess of $3.5 billion annually (Centers for Disease Control and Prevention, 2018 ). Due to the rapid development of new medications, discovery of new uses for old medications, and increases in medications used for disease treatment and prevention, ADEs are likely to continue to rise.
Nurses, on the front line in the war against medication errors, spend more than 40% of shift time engaged in transcribing, dispensing, and administering medications (Asensi-Vicente, Jimenez-Ruiz, & Vizcaya-Moreno, 2018). Since over 82% of Americans take one medication and 29% take five or more (Centers for Disease Control and Prevention, 2018), the percentage of time dedicated to safe medication administration is likely to grow.
However, we have made significant strides to improve safety measures and interrupt medication errors by utilizing Computerized Provider Order Entry programs, smart pumps, and barcode scanners. All of this technology relies on Wi-Fi and internet systems. This reliance puts the system at risk during power outages, Wi-Fi disconnects, and most troubling of all…to hacking. A simple Google search will show the many stories of hospital systems under attack from hackers, including those in the states of New York, Massachusetts, and Rhode Island. So, while these systems are improving safe care, we must also learn how to work when that technology is unsafe or unavailable.
Additionally, hospitals and academia have recognized the role of human factors in error prevention. There are safe zones around medication carts to minimize interruptions. Students continue to learn standardized processes for safety checks, such as the “rights” of medication safety. This method ensures that you have the right patient, right medication, right dose, right time, and right route. We encourage students and staff to calculate medication doses to ensure that the orders fall within the safe dose range, but what happens when they find an error? In my simulation research, I found that students take one of three paths: 1) they do not check the dose and assume that it is correct, 2) they calculate the dose, notice that it is incorrect, and call the pharmacist to have the order changed, or 3) they calculate the dose, notice that it is incorrect, and administer the medication anyway (Schneidereith, 2017).
I assert that these observations are due to behaviors that I have placed in three categories: “Just Following”, Generation, and Gender.
Historically, nurses have been trained to follow “orders”, placing them in a position of need. I needed an order to get a patient out-of-bed, to eat a certain diet at mealtime, or to give medications. This military connotation and perceived power differential can inhibit the dialog and interdisciplinary collaboration that is often required for patient care. It has been suggested that those who perceive themselves as low in the hierarchy do not want to appear incompetent, so they are less likely to question when an error is found (Reese, Simmons, & Barnard, 2016). When I asked my students why they didn’t question the order in simulation, the response was repeatedly, “I didn’t think about it”. That makes me wonder…are we continuing to train—or model-- that orders are meant to be followed and not questioned or challenged? Or is it that our students doubt their abilities and don’t want to appear incompetent? What are we doing to help students practice questioning?
The second category is generation. Today’s students, born between 1995 and 2012, are part of Generation Z (Chicca & Shellenbarger, 2018). As you may recall, the importance of defining a generation is that it provides a contextual frame for the shared experiences that shape a similarly-aged group of people. What technology was part of their childhood? What was the economic state of our country? What were the parenting norms? What media messages were heard? Did everyone get a trophy for just showing up?
For Generation Z, they grew-up with technology and are very comfortable interacting with a digital world. Remember when we were first introduced to online shopping and the fear we shared of placing an order that required our credit card number? How about linking an app like PayPal to our bank account? What a crazy idea! Now it is commonplace. Generation Z has grown up in a world where they are more likely than not to trust electronics. So why would they question an electronic medication order? It’s not inherent.
This generation has underdeveloped social and relationship skills. Remember, they interact digitally and are not accustomed to having conversations. They are at increased risk for isolation, anxiety, and depression. They take fewer risks in life. They respect authority and adhere to hierarchies.
Millennials and Generation Z will make-up the majority of the work-force in the next 5 years. They aren’t talking, they adhere to hierarchies, and they inherently trust electronics. What impact will this combination have on medication safety?
My third cog in the wheel of medication safety is Gender. According to the Bureau of Labor Statistics, 90% of Registered Nurses are female. What impact does this have on medication safety? According to the Pew Research Center (Walker, Bialik, & van Kessel, 2018), who conducted a study on words used to describe men and women, men were described as “strong” and “powerful”, while women were described as “kind” and “compassionate”. In addition, men were more positively identified with the words “leadership”, “strong”, and “powerful”, yet those terms were more negatively associated with women. So, while men and women may have their own thoughts on what gender means to them, the results of this survey show that women are viewed as less powerful and strong.
Except for Reshma Saujani. Her TED talk was brought to my attention by my daughter’s 7th grade teacher (TED, 2016). The class was going to discuss her TED talk and the teacher wanted parents to be able to continue the conversation at home. As I watched the video, I couldn’t help but wonder about the relationship between her message and what I was seeing in medication safety. Reshma is a strong woman who ran for Congress when she was 33 years-old. She was repeatedly told how brave she was for taking on an incumbent and she wondered why brave would be used to describe what she thought was an act of leadership. Over time, the reasons became clear. Not long after losing the election, she founded a company, “Girls Who Code” and was struck by the differences between girls and boys. Boys learn early in life to be risk-takers, but girls are raised to be overly-cautious, aimed at perfection. She learned when teaching girls to code that, instead of showing code that was imperfect, they would rather show nothing at all. Girls would doubt themselves. Girls would think “something is wrong with me” before thinking that something was wrong with their work. She said that we need to teach our girls bravery, not perfection.
So, adding to the layer of following orders and the effects of Generation Z is the role of Gender—both actual and perceived—on medication safety. What are we doing to help students learn to be brave and speak-up for safety?
According to Merriam-Webster, brave is defined as “having or showing mental or moral strength to face danger, fear, or difficulty” (Brave). When I think of brave individuals, I think of Todd Beamer who helped derail the hijackers on Flight 93 during the attacks on 9/11. Or of Malala Yousafzai, the Pakistani pupil who was so outspoken for women’s rights to education that she was shot in the head by a Taliban gunman. Or of Rosa Parks, the unknowing civil rights advocate who refused to relinquish her seat in the “colored only” section of the bus to a white passenger. These individuals took a stance for something that required mental and moral strength to face danger or difficulty.
But, I also think of Chesley “Sully” Sullenberger who landed his passenger plane on the Hudson River and saved everyone aboard. Or of Anthony Sadler, Spencer Stone, and Alek Skarlatos who thwarted a terrorist on the train to Paris. Or Matt Holladay, a Florida firefighter who, at the end of a very long shift, saved a 70-year old woman from her burning home. What these individuals have in common is intense preparation for unforeseen circumstances. Sully spent time in the flight simulator running through emergency scenarios. Spencer and Alek were part of the US military and were trained in combat. Matt spent his shift on that fateful day reviewing pictures with other firefighters and discussing “what would you do if faced with this situation?” Ironically, the call at the end of the day was one of the scenarios that they had discussed.
So, like this last group of people, who were trained to be brave because of their chosen careers, we have a responsibility to train our nursing students to be brave. Many of us teach elements of leadership in practicum courses, but leadership is theoretical. How are we practicing the words and the feelings of difficult conversations? How are we socializing for bravery?
Fortunately, simulation can help. Create immersive opportunities to bring students into simulated environments where they are in the role of the nurse. Allow them to practice social interactions, body language, tone of voice. Have embedded medication errors that require conversations with the Provider. Maybe you can create simulations where nurses witness incivility and need to speak-up. How about a scenario where nurses are expected to provide discharge instructions to a patient who isn’t really ready to go home? Another suggestion for simulation can incorporate the need to provide care to a patient after a medication error has occurred. You can work with your local hospitals and design scenarios to address underlying issues that resulted in sentinel events.
To paraphrase Reshma, we cannot wait to teach bravery after errors have occurred. We have to teach our students now to avoid errors. To learn the verbal and non-verbal skills for speaking-up. We are obligated to provide safe care to our patients and therefore we must help our future nurses learn how to be brave.