Finnish nurses and nursing students pharmacological skills

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1 ISSUES IN CLINICAL NURSING Finnish nurses and nursing students pharmacological skills Heidi Grandell-Niemi MNSc, RN Doctoral Candidate, Department of Nursing Science, University of Turku, Turku, Finland Maija Hupli PhD, RN Senior Lecturer, Department of Nursing Science, University of Turku, Turku, Finland Helena Leino-Kilpi PhD, RN Professor, Department of Nursing Science, University of Turku, Turku, Finland Pauli Puukka MPolSc Senior Research Statistician, National Public Health Institute, Turku, Finland Submitted for publication: 19 April 2004 Accepted for publication: 2 November 2004 Correspondence: Heidi Grandell-Niemi Doctoral Candidate University of Turku Department of Nursing Science Hiidenkatu 4 FIN Turku Finland Telephone: þ heidi.grandell-niemi@postikaista.net GRANDELL-NIEMI H, HUPLI M, LEINO-KILPI H & PUUKKA P (2005) Journal of Clinical Nursing 14, Finnish nurses and nursing students pharmacological skills Purposes and objectives. The purposes of this study were to investigate the pharmacological skills of Finnish nurses and graduating nursing students, to determine how pharmacological skills are related to background factors and to identify differences between nurses and students and, finally, to examine how the instrument used, the Medication Calculation Skills Test, works. Background. Pharmacology is a relevant and topical subject. In several studies, however, pharmacological skills of nurses and nursing students have been found insufficient. In addition, pharmacology as a subject is found to be difficult for both nursing students and nurses. Design and methods. The study was evaluative in nature; the data were collected using the Medication Calculation Skills Test, developed for the purposes of this study. The instrument was used to gather information on background factors and self-rated pharmacological and mathematical skills and to test actual skills in these areas. Results. Results concerning pharmacological skills are reported in this paper. The maximum Medication Calculation Skills Test score was 24 points. The mean score for nurses was 18.6 and that for students Half of (50%) the students attained a score of 67% and 57% of nurses attained a score of 79%. Conclusions. Nurses and students had some deficiencies in their pharmacological skills. Nurses had better pharmacological skills than students according to both selfratings and actual performance on the test. Relevance to clinical practice. It is vitally important that nurses have adequate pharmacological skills to administer medicines correctly. This study showed that the Medication Calculation Skills Test seems to work well in measuring pharmacological skills, even though it needs further evaluation. Findings from this study can be used when planning the nursing curriculum and further education for Registered Nurses. Key words: education, nurse, nursing intervention, pharmacological skills, student Ó 2005 Blackwell Publishing Ltd 685

2 H Grandell-Niemi et al. Introduction Medication administration is one of the fundamental tasks performed by nurses in everyday clinical practice. Nurses need pharmacological skills to contribute effectively to medication administration, to advise patients on issues related to their treatments, to administer appropriate medicines correctly and to identify and make a preliminary evaluation of adverse drug effects (Perry & Potter 1990, Gee et al. 1998, Leathard 2001a). Pharmacology as a subject has been found to be difficult for nursing students and nurses (Courtenay 1991, Clarke 1995, Jordan et al. 1999) and doubts have been expressed concerning the adequacy of the pharmacological knowledge base of nurses and their understanding of the actions of drugs on patients (Ashurst 1993). Evidence-based information about pharmacological knowledge and skills of Registered Nurses and nursing students in Europe is available for the UK only (Clancy et al. 2000, Latter et al. 2000, Sodha et al. 2002). To extend this knowledge base, the present study was conducted to evaluate Finnish nurses and nursing students pharmacological skills. This paper deals with self-rated and actual pharmacological skills of Registered Nurses and graduating nursing students in Finland and also examines how the instrument used, the Medication Calculation Skills Test (MCS test), works. In this study, the term basic level (BL) pharmacological skills was used to refer to the terminology used in pharmacology (e.g. tolerance), commonly used abbreviations (e.g. ad), dosage forms (e.g. tablets) and routes of administration (e.g. per os, i.v.). Higher level (HL) skills refer to pharmacokinetics, pharmacodynamics, notes used in prescriptions and administering doses to patients. Findings from this study provide information that can be used for developing nursing education and reinforcing the skills of practising nurses. Literature review To review the relevant literature studies of nurses and nursing students actual pharmacological knowledge base and evaluations of pharmacology education were searched for, using the Medline and CINAHL databases. Keywords used were pharmacology knowledge, pharmacological skills, pharmacology learning, teaching and education. The search was limited to actual knowledge and skills in pharmacology and to the issues of nursing journals. The main features of the review are summarized below. Several studies have found that the actual pharmacological knowledge of nurses (Boggs et al. 1988, Ives et al. 1996, Sodha et al. 2002) and students is insufficient (Courtenay 1991, Clancy et al. 2000, Latter et al. 2000, Manias & Bullock 2002b). Boggs et al. (1988) studied nurses actual pharmacology knowledge by testing their knowledge of three commonly prescribed drugs (n ¼ 182) by use of a multiplechoice test. The categories of pharmacology information were: dosage range, mechanism of action, drug interactions, side-effects and pharmacokinetic parameters. The mean score achieved was only 46% (range 8 75). There was lack of knowledge of dosages, mechanism of action/interaction and pharmacokinetics. The highest knowledge levels were found for clinical indications for the drugs and side-effects. The results suggested that drug knowledge tends to increase with educational level but is not related to experiential background. Later, Ives et al. (1996) examined actual and selfrated pharmacology knowledge of nurses (n ¼ 363) by conducting a questionnaire survey. The participants were asked to rate their knowledge in five areas related to pharmacology and to answer questions which tested their knowledge in these same areas. The five areas were: overall knowledge of pharmacology, knowledge of drug administration, therapeutic and adverse effects of drugs, client education and legal responsibilities concerning drug administration. The nurses estimated their overall knowledge of pharmacology accurately, but overestimated their knowledge of drug administration and legal aspects related to medication use. The average test score was 56% (range 16 92). The most difficult area was adverse effects. There was an association between the test scores and the number of years of practice. The respondents who had worked longest achieved the highest test scores. Cason et al. (1999) tested nurses knowledge of pain management by use of a questionnaire (n ¼ 217) and found knowledge deficits related to pharmacotherapeutics. Also in this study, general pharmacology was the best known area. The level of education was associated with a high level of performance on the test. Selfratings were not correlated with the total test scores. Veräjänkorva (2003) also used a questionnaire to test nurses (n ¼ 365) theoretical and practical medication skills. These were found to be quite sufficient. The mean score for pharmacological skills was 3.78 (max. 5). Nurses who were handling medicines daily or who found medication administration easy had better skills in pharmacology. Pharmacological knowledge of nurse prescribers has also been studied. While and Rees (1993) investigated the knowledge base of health visitors (n ¼ 26) and district nurses (n ¼ 28) regarding products in the formulary for nurse prescription. The knowledge base of the nurses was found limited and unacceptably low for prescribing purposes. Similar results were obtained later by Sodha et al. (2002), 686 Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

3 Issues in clinical nursing who conducted a postal survey to examine actual and selfrated knowledge of community nurses (n ¼ 110) and their confidence in the prescribing role. The results indicated that nurse prescribers had an inadequate pharmacological knowledge base although their self-ratings showed high levels of confidence. Working experience was not linked with the level of confidence. More recently, research has focused on pharmacology education and results of several studies lend support to the finding that nurses lack adequate pharmacological skills for the role they are expected to fulfil (Clancy et al. 2000, Latter et al. 2000, Manias & Bullock 2002b, Morrison-Griffiths et al. 2002). Nursing students also have inadequacies in their pharmacology knowledge base. In the study of Courtenay (1991) nursing students (n ¼ 140) felt inadequately prepared in pharmacology and regarded the subject as the most difficult. In Clancy et al. (2000) questionnaire study, students (n ¼ 153) working in adult or child branches were asked whether they had a good understanding of the biological basis of drug actions. According to the results, they were unsure of their knowledge of drug actions. However, pharmacological terms were known very well by 332 newly qualified nurses tested by Murtola (1999). Several evaluations of pharmacology education reveal that students skills in pharmacology are unsatisfactory. This might be due to difficulty of teaching pharmacology, lack of hours devoted to the subject, lack of clarity in the curriculum, debates about who should teach pharmacology and about linking nursing practice and theoretical pharmacology (Latter et al. 2000, 2001, Bullock & Manias 2002, Manias & Bullock 2002a,b, Morrison-Griffiths et al. 2002, Veräjänkorva & Leino-Kilpi 2003). Purposes The purpose of this study was to investigate self-rated and actual pharmacological skills of Registered Nurses and graduating nursing students in Finland. A second purpose was to determine whether nurses and students pharmacological skills are associated with background factors. A third purpose was to identify differences between the two groups (nurses, students). Another important goal was to find out how the MCS test works. Methods In this evaluative study, we made use of a questionnaire of the MCS test, which was developed for the purposes of this study, to find out the pharmacological skills of nurses and nursing students. The MCS test includes parallel questions for nurses and students. There are differences only in sociodemographic and professional/educational questions. The MCS test comprises structured questions and computations and was designed based on the research literature and pharmacology textbooks (Bayne & Bindler 1988, Shockley et al. 1989, Perry & Potter 1990, Blais & Bath 1992, White 1994, Kapborg 1995, Lilley & Aucker 1999, Latter et al. 2000, Morrill 2000, Pharmaca Fennica 2001, 2000, Grandell- Niemi et al. 2001, Leathard 2001a,b, Rycroft-Malone et al. 2001, Grandell-Niemi et al. 2003). The MCS test consists of three sections: section 1 is concerned with sociodemographic (nurses eight items, students 10) and professional/educational characteristics (12/15 items); in section 2 participants are asked to assess their BL (4/4 items) and HL (4/4 items) pharmacological skills, mathematical skills (4/4 items) and their interest in pharmacology (3/3 items), in mathematics (3/3 items) and in dosage calculation (3/3 items); section 3 tests actual BL (12/12 items) and HL (12/12 items) pharmacological and mathematical skills (29/29 calculation problems). The statements used in the self-ratings were arranged on a 5-point Likert-type scale (1 ¼ strongly disagree, 5 ¼ strongly agree); in the section testing actual pharmacological skills the items were right wrong statements and in that testing mathematical skills there were mathematical problems. The content validity of the instrument was established by review of the previous research literature and pharmacology textbooks and through a pilot study, carried out on a group of nurses (n ¼ 69) and graduating nursing students (n ¼ 59). The Cronbach alpha for the pilot test was adequate ( ) (Litwin 1995, Burns & Grove 2001). The participants of the pilot study were specially asked to comment on every statement and question. All the comments were supportive and encouraging, not suggesting any corrections. Also two of the first author s colleagues checked the relevance of the statements. Sample Pharmacological skills of nurses and nursing students There are five university hospitals and 25 polytechnics providing preregistration nursing education in Finland. One of the five university hospitals was already studied using an earlier version of the MCS test (Grandell-Niemi et al. 2003) and was excluded from the present study. Two of the remaining four hospitals were selected, one from the southern and one from the northern part of the country. Medical wards were then selected based on the complexity and expensiveness of medication administration. To obtain a representative sample size, hospitals located near the university hospitals were also included. Polytechnics which were Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

4 H Grandell-Niemi et al. situated near the hospitals and used these hospitals for students clinical training were selected for the study. The final sample consisted of 364 Registered Nurses and 282 graduating nursing students from a total of seven hospitals and five polytechnics in southern and northern Finland. The response rate was 68% for nurses and 70% for students. Data collection process In 2002 the MCS test questionnaires were distributed to the study hospitals and polytechnics, all of which had consented to participation. Approval was obtained according to the ethical standards of every organization. On the wards the head nurses distributed the questionnaires to all nurses working in the unit, who returned them in sealed envelopes to a specific box in the nurses station. At the polytechnics the students completed the questionnaires during class and returned them in sealed envelopes to a specific box. After the scheduled time of three to four weeks the boxes were sent to the principal investigator. Ethical questions Participation was voluntary and the participants could respond anonymously (Leino-Kilpi & Tuomaala 1989, Rogers 1996, Burns & Grove 2001). All information was processed confidentially. Each MCS test included a covering letter, which explained the purpose of the study, the voluntary nature of the study and the anonymity of responses. The covering letter also included instructions for the participants, contact details of the information about how to reach the researcher and a description of how the results were to be used (Rogers 1996). Data analysis The results concerning the pharmacological section of the MCS test are reported in this paper. Those concerning the mathematical section will be analysed and reported later. Descriptive statistics, mean values, standard deviations, ranges and frequencies were calculated for the MCS test variables. In the frequency tables the responses to the statements using a 5-point Likert scale were combined so as to form three categories: disagree (strongly disagree and disagree combined), do not disagree/agree and agree (strongly agree and agree combined). A statement was originally for example I know pharmacological terminology (e.g. tolerance) well and the response alternatives were strongly disagree, disagree, do not disagree/ agree, agree and strongly agree. The items concerning interest in pharmacology (three items), self-rated BL (four items) and self-rated HL (four items) pharmacological skills were combined to obtain three sum variables. A mean score was calculated for each sum variable, retaining the same 5-point scale as in the original items. The internal consistency of the instrument was evaluated using Cronbach alpha, which showed adequate reliability (nurses , students ). The answers to the test of actual pharmacological skills were coded as either right or wrong before the analysis. Two sum variables were formed, one combining the items on actual BL skills (12 questions) and the other combining those on actual HL skills (12). Finally, a sum score was calculated for all 24 test items, reflecting the total number of correct answers. Due to the non-normal distribution of most variables nonparametric statistical methods were chosen. The differences between nurses and students were analysed using the chisquare test or the Wilcoxon two-sample test (if the prerequisites for the chi-square test were not met). The differences between the categories of background variables were tested with the Wilcoxon two-sample test (comparing two groups) or the Kruskal Wallis test (comparing more than two groups). The associations between self-rated and actual skills were examined using the Spearman rank correlation. The data were analysed using SAS for Windows 8.2 software (SAS Institute, Cary, NC, USA). Results The mean age of the nurses was 38.7 years (SD 9.7, range 22 60) and that of the students 26.0 years (SD 5.5, range 21 54). The nurses had worked on the present ward for an average of 9.3 years (SD 8.1, range 0 37). Characteristics of the two groups are shown in Table 1. Most participants were female and had completed upper secondary school. Most of the students were qualifying as Registered Nurses (66%), public health nurses (24.5%) or midwives (9.5%). A total of 42% of the students had had a previous occupation in health care. On wards both nurses and students delivered medicines and calculated dosages frequently, some of them often using ready-made doses. MCS were seldom tested on wards, but quite often participants let someone else check their calculations. Practising to maintain calculation skills was not regular among nurses and students. The students were dissatisfied with the amount of instruction in medication calculation. Self-rated pharmacological skills Nurses and students found pharmacology interesting, but not easy; a minority of both groups regarded their own pharmacological skills as sufficient. The best-known areas were dosage forms (such as tablets, injections), administration 688 Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

5 Issues in clinical nursing Table 1 Characteristics of samples Characteristic Nurses (%) Students (%) Gender Female Male 5 7 Age (years) Basic education Lower secondary school (9 years of basic education) Upper secondary school (12 13 years) Working experience on medical ward (years) Studying to be Nurse (140 credits) 66 Midwife (180 credits) 10 Public health nurse (160 credits) 24 Previous occupation in health care Yes 42 No 58 Delivering medicines Often Seldom 13 9 Not often not seldom 4 12 Delivering ready-made doses Often 47 25* Seldom 40 32* Not often not seldom 13 15* Calculating dosages at work Often Seldom Not often not seldom Calculation skills are regularly tested (at work) Often 1 15 Seldom Not often not seldom 8 15 Let someone else check one s computations Often Seldom Not often not seldom Maintaining calculation skills Often Seldom Not often not seldom Satisfied with amount of instruction in medication calculation Yes 34 No 66 *The total percentage does not add up to 100% due to missing values. Nurses, n ¼ 364; students, n ¼ 282. Pharmacological skills of nurses and nursing students routes, notes used in prescriptions and searching information on the medicine packages. Knowledge of pharmacological terminology and commonly used abbreviations was rated by participants as average. Pharmacokinetics and pharmacodynamics were rated as least well known by both groups. Selfrated skills are illustrated in Fig. 1. Actual pharmacological skills and differences between the groups The MCS test included 12 questions about BL and 12 questions about HL pharmacological skills; the maximum score was 24 (100% correct). Both groups had considerable difficulty answering the questions. The mean score for nurses was 18.6 (77.5%) (SD 2.9, range 2 24) and for students 16.3 (67.9%) (SD 3.4, range 1 23). In BL skills nurses scored 8.9 (74.2%) (SD 1.8, range 2 12) and students 7.4 (61.7%) (SD 2.1, range 1 12), while in HL skills nurses scored 9.7 (80.8%) (SD 1.5, range 6 12) and students 9 (75%) (SD 1.7 range 3 12). The mean scores for the skill categories and the test as a whole are shown in Table 2. None of the students scored 24 (100% correct); 50% attained a score of 67%. Six nurses (1.6%) answered all 24 questions correctly and 57% of nurses attained a score of 79%. There were two problematic questions in the BL skills section. Firstly, the question concerning the abbreviation for a drug with mainly central nerve system action was most often answered Do not know. Secondly, the question about whether administration of the insulin injections is parenteral (the Latin word parenteral means outside the intestine) was often answered incorrectly. In the HL skills section questions concerning pharmacodynamics and pharmacokinetics were difficult for participants. Well-known BL topics included the pharmacological terminology and a word meaning a certain kind of enema. In the HL skills section the best-known topics were prescription notes and medicine package information. There were differences between nurses and students in terms of sum variable mean values for self-rated and actual pharmacological skills, as shown in Table 2. Distributions concerning single test items are presented in Table 3. Pharmacology was considered more interesting by nurses than by students. The sum variable mean values for self-rated BL and HL skills were higher for nurses than for students. Also in actual BL and HL skills and the test as a whole nurses scored higher than students. Pharmacological skills in relation to background factors The results are described here in terms of the sum variables and statistically significant background factors; P values are shown in Table 4. There were differences between students in Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

6 H Grandell-Niemi et al. Percentage Pharmacology easy Pharmacodynamics familiar HL Terminology familiar BL Own skills sufficient Pharmacokinetics familiar HL Abbreviations familiar BL Pharmacology interesting Description notes familiar HL 72 Information in package familiar HL Forms of medicines BL Routes of administration BL Nurses Students Figure 1 Self-rated BL and HL pharmacological skills of nurses (n ¼ ) and students (n ¼ ). Categories agree and strongly agree combined (Likert scale 1 5) (%). Sum variable Mean for nurses (n ¼ 364) SD Mean for students (n ¼ 282) SD P-value Table 2 Differences in skills between nurses and students Interest in pharmacology (3 items) < Self-rated BL skills (4 items) < Self-rated HL skills (4 items) Actual BL skills (12 items) < Actual HL skills (12 items) < Total score for actual skills (24 items) < self-rated pharmacological skills. Those over 30 years of age found their BL and HL skills adequate. Those who had had a previous occupation in health care reported better skills compared with those with no previous training in health care. Students who responded often to the question about maintaining MCS found pharmacology interesting and assessed their BL and HL skills as adequate. Those satisfied with the amount of instruction in medication calculation found pharmacology interesting and assessed their BL and HL skills as sufficient. Differences were also found between nurses. Those who reported often maintaining their MCS found pharmacology interesting and assessed their HL skills as adequate. There were also differences between student and nurse groups in actual pharmacological skills (for P values see Table 5). Midwife students scored higher in BL skills, while general nursing students had the highest total score. Students with an excellent mark (9 10) in mathematics (upper secondary school) performed better than others in terms of total test scores. Students whose calculation skills were often tested on the ward performed best on the test. Nurses who had completed upper secondary school scored higher than others in BL skills and also had higher total scores. Those nurses who had worked over 20 years on the present ward performed well on the whole test. There were differences between the polytechnics the one located in the most southern area scoring highest (Table 6). Differences were not found between the hospitals. In students self-rated BL skills correlated significantly with actual BL skills (rho ¼ 0.31, P < ) and with the total score for actual skills (rho ¼ 0.28, P < ). Similarly, self-rated HL skills correlated significantly with actual HL skills (rho ¼ 0.17, P ¼ 0.004) and with the total score (rho ¼ 0.20 P ¼ ). Also in the nurses group there were similar, but mainly lower, significant correlations (Table 7). Discussion Medication administration is a daily nursing task, also verified by this study. According to the results, four out of five nurses and students delivered medicines frequently. Participants did not, however find pharmacology an easy subject and considered their own skills insufficient. Similar 690 Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

7 Issues in clinical nursing Pharmacological skills of nurses and nursing students Table 3 Actual pharmacological skills of nurses and students: percentages of correct and incorrect answers and difference between the two groups Questions concerning Distribution of answers (%) n Correct Incorrect Do not know P-value BL skills Meaning of acquired tolerance Nurses Students Abbreviation for drug with mainly central nerve system action Nurses < Students Special Finnish term for medicated enema Nurses < Students Meaning of parenteral with reference to insulin injection Nurses < Students HL skills Drug distribution Nurses Students Drug excretion Nurses < Students Role of cell receptors in drug action Nurses Students Antagonist as an activator Nurses Students Antihistamine as an antagonist Nurses Students Prescription notes Nurses < Students Medicine package information Nurses Students results have been obtained in several studies (Courtenay 1991, Clancy et al. 2000, Manias & Bullock 2002a,b). The areas experienced as the most difficult were pharmacokinetics and pharmacodynamics, while dosage forms, routes of administration and medicine package information were the most familiar topics. Despite the uneasiness, over half of participants found pharmacology interesting. This might suggest that they were motivated to study pharmacology in spite of finding it hard. Nurses performed better than students on the MCS test. Differences between the two groups were significant. The maximum score for actual skills was attained by only a few nurses. However, over half of nurses obtained a score of 79% correct, which can be considered quite adequate (Boggs et al. 1988, Ives et al. 1996). Students, in general, did not perform well on the test, the results showing inadequate levels of knowledge. This might indicate that learning pharmacology actually takes place in clinical practice, as concluded also by Morrison-Griffiths et al. (2002). Students in the study by Bullock and Manias (2002), however, disagreed with the view that most learning occurred in clinical placement. Because of this discrepancy in study results further research on the pharmacological learning environment in nursing practice is needed. Information about how pharmacological knowledge of nurses and students is constructed and develops would be valuable in planning education. There were two questions in the MCS test BL pharmacological skills section that proved difficult. The first concerned the abbreviation for drugs with mainly central nervous system action, commonly used in books like the Finnish pharmacopoeia (Pharmaca Fennica). The reason for its unfamiliarity might be that such abbreviations are not used in clinical practice on medical wards. The second question, asking whether administration of insulin injection is parenteral, was often answered incorrectly by both groups. This was surprising, because the word has been used in the instruction of pharmacology and in text books for decades. Table 4 Self-rated pharmacological skills in relation to background factors and levels of significance (P-values) Sum variables Pharmacology interesting BL skills HL skills Nurses (n ) Students (n ) Nurses Students Nurses Students Nurses Students Age >30 years n.s. n.s. n.s n.s Previous occupation in health care 117 n.s Maintaining calculation skills n.s Satisfied with amount of instruction Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

8 H Grandell-Niemi et al. Table 5 Actual pharmacological skills in relation to background factors and levels of significance (P-values) Sum variables BL skills HL skills Total score Nurses (n) Students (n) Nurses Students Nurses Students Nurses Students Midwife students n.s. n.s. Nurse students 186 n.s. n.s Excellent mark in mathematics 50 n.s. n.s Upper secondary school completed n.s. n.s. n.s n.s. Calculations tested on ward 5 41 n.s. n.s. n.s. n.s. n.s Working experience of over 20 years 34 n.s. n.s Table 6 Actual pharmacological skills according to polytechnic and significance levels (P-values) Sum variable n Mean SD P-value BL skills Polytechnic A south Polytechnic B south Polytechnic C north Polytechnic D north Polytechnic E north HL skills Polytechnic A south Polytechnic B south Polytechnic C north Polytechnic D north Polytechnic E north Total scores Polytechnic A south Polytechnic B south Polytechnic C north Polytechnic D north Polytechnic E north Table 7 Spearman correlation coefficients describing the relationship between actual skills scores and the self-rated skills Score for actual BL skills Score for actual HL skills Total score Nurses (n ¼ ) Self-rated BL skills 0.12* 0.19*** 0.19*** Self-rated HL skills *** 0.13* Students (n ¼ ) Self-rated BL skills 0.31*** 0.17** 0.28*** Self-rated HL skills 0.18** 0.17** 0.20*** *P < 0.05, ** P < 0.01, ***P < 0.001, other coefficients not significant. The questions concerning pharmacodynamics and pharmacokinetics were also difficult for participants; similar results have been obtained in other studies (Boggs et al. 1988, Ives et al. 1996, Clancy et al. 2000). Pharmacological terminology was familiar to both groups. The finding is parallel with results obtained by Murtola (1999) but differs from those of Manias and Bullock (2002b). Prescription notes and medicine package information were known very well by present participants. The oldest group of students, and also students with a previous occupation in health care, reported higher levels of BL and HL skills, compared with other students. Age or a previous occupation were not associated with actual performance on the MCS test. Nurses and students who maintained their MCS assessed their skills as sufficient more often than others. This finding is confirmed by studies of both Latter et al. (2000, 2001) and Ives et al. (1996), who concluded that the depth and dynamic nature of pharmacology needs self-directed and continuous lifelong learning. The level of actual skills was higher in nurses with completed upper secondary school than in other nurses. The level of education has been found also by Boggs et al. (1988) and Cason et al. (1999) to be associated with nurses level of knowledge. Working experience of over 20 years was related to a better actual performance on the MCS test. The finding is consistent with the studies by Ives et al. (1996) and Manias and Bullock (2002b) but differs from those by Boggs et al. (1988) and Sodha et al. (2002). Limitations of the present study are concerned with the data collection procedure. Firstly, the nurses answered without supervision; their response rate was not very high; and they might also have been more highly motivated to answer and more knowledgeable than the non-respondents. During the research process some nurses said that they dared not answer because they were afraid of revealing their skill level even to themselves. Secondly, there is a possibility that nurses cooperated in answering the MCS test questions. However, this suspicion was not confirmed by the results, which showed no consistent patterns indicating cooperation. Finally, the characteristics and knowledge levels of non-respondents remained unknown. The MCS test was 692 Ó 2005 Blackwell Publishing Ltd, Journal of Clinical Nursing, 14,

9 Issues in clinical nursing developed for this study because we wanted to use one instrument, measuring both self-rated and actual pharmacological and also self-rated and actual mathematical skills. Ives et al. (1996) and Cason et al. (1999), for example, used instruments which measured only pharmacological skills. The MCS test has also some limitations. Firstly, the test needs some refinement concerning the two problematic questions so that they are understood properly by respondents. Secondly, the reliability of the MCS test needs to be confirmed, especially the stability of the test. The test retest was not used to evaluate the stability of our instrument due to lack of resources (e.g. difficulty in recruiting participants). Thirdly, even though the construct validity may be evaluated by use of the results of self-rated assessments, the reliability and construct validity of the MCS test will be further evaluated in the future. A good mark in mathematics and testing students MCS in nursing practice were associated with a better actual performance on the MCS test in the student group. Keeping up one s calculation skills often was associated with a good performance on the MCS test in both groups. Practising, testing of the skills and good mathematical skills predict a better performance. Pharmacology is integrated within medication calculation instruction, the amount of which was regarded by students as inadequate. These findings should be taken into consideration when planning pharmacology education. The amount and level of pharmacology teaching could depend on the level of the student s knowledge. Nurses and students could also measure their own skills, as described in earlier studies (Bayne & Bindler 1988, Grandell-Niemi et al. 2001, 2003). Despite the limitations the MCS test seems to be a reliable instrument for testing one s own skills and a useful tool that can be used for both constructing the nursing curriculum and measuring the knowledge level of students before they start clinical practice. It could also be used on wards to test the pharmacological skills of nurses, to evaluate the needs for additional education and to further improve the quality of nursing care. While the MCS test seems to work well as an operative tool, nurses and students are, however, themselves responsible for the development of their own knowledge in pharmacology (Latter et al. 2001, Morrison-Griffiths et al. 2002). The sample was representative and the results can be generalized to all Finnish nurses and nurse students, as there were no differences between the hospitals and the polytechnics differed only in terms of actual skills. The study results concerning the differences between nurses and students skills deserve special attention. Firstly, there are no recent studies which test actual pharmacological skills of both nurses and nursing students and compare their knowledge levels. Secondly, despite its limitations, the MCS test seemed to work well, was able to identify differences in skills and proved a useful tool for measuring one s own skills. Thirdly, pharmacological skills were found to be poorer at the time of graduation than later, during actual clinical practice. Further development and reinforcement of the skills seemed to take place during clinical practice. These findings could be used in assessing the effectiveness of Finnish nursing education. Nursing education should provide a sufficient pharmacological knowledge base for nursing practice; according to this study, however, there are deficiencies in students skills. Further research is needed to determine the elements in the nursing curriculum and in the clinical learning environment which influence the development of pharmacological skills. Findings of this study also indicate the areas in which there is a need to reconsider the instruction in pharmacology and arrange supplementary education for Registered Nurses. Acknowledgements This study was supported by grants from the Foundation for Nursing Education, the Finnish Association of Caring Sciences and the Finnish Cultural Foundation. Contributions Study design: HG-N, MH, HL-K, PP; data analysis: PP, HG- N, MH, HL-K; manuscript preparations: HG-N, MH, HL-K, PP. References Pharmacological skills of nurses and nursing students Ashurst S (1993) Nurses must improve their knowledge of pharmacology. British Journal of Nursing 2, 608. Bayne T & Bindler R (1988) Medication calculation skills of registered nurses. The Journal of Continuing Education in Nursing 19, Blais K & Bath JB (1992) Drug calculation errors of baccalaureate nursing students. Nurse Educator 17, Boggs P, Brown-Molnar CS & DeLapp TD (1988) Nurses drug knowledge. 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