International Journal of Nursing Studies 39 (2002) 773784

The educational preparation of undergraduate nursing students in pharmacology: clinical nurses perceptions and experiences of graduate nurses medication knowledge
Elizabeth Maniasa,*, Shane Bullockb,1
a

Faculty of Medicine, Dentistry and Health Sciences, School of Postgraduate Nursing, University of Melbourne, Level 1, 723 Swanston Street, Carlton, Victoria 3053, Australia b School of Arts and Sciences, Australian Catholic University, Locked Bag 4115, Fitzroy MDC, Victoria, Australia Received 17 August 2001; received in revised form 29 November 2001; accepted 21 December 2001

Abstract This paper explores clinical nurses perceptions and experiences of graduate nurses pharmacology knowledge. Six focus group interviews were conducted with clinical nurses of various appointment levels at two metropolitan public and two regional public hospitals in Victoria, Australia. Four major themes emerged from the study. First, participants indicated that graduate nurses had an overall lack of depth of pharmacology knowledge. While clinical nurses indicated that graduate nurses had enormous decits in their pharmacology education, these decits were not conned to graduate nursesall nurses experienced difculties in understanding and demonstrating pharmacological concepts in the clinical practice setting. Second, there was an unstructured approach to addressing the continuing education needs of graduate nurses. Third, theoretical and clinical principles of pharmacology knowledge were perceived to be important for practice. Fourth, improvements for nursing education involved the need for undergraduate students to take greater responsibility in monitoring and administering medications and the need for more structured learning experiences. The ultimate goal of consolidating pharmacology knowledge for graduate nurses is to optimise medication use, thereby improving the health outcomes of patients. Current teaching and learning opportunities appear to be inadequate in their efforts to enhance and improve graduate nurses pharmacology knowledge. These inadequacies need to be addressed if the ultimate goal is to become a reality. r 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Pharmacology knowledge; Graduate nurses; Nursing education

1. Introduction The roles of clinical nurses in medication management are complex and multifaceted. These roles include: administering medication safely and efciently, assessing and monitoring for desirable and unwanted effects,
*Corresponding author. Tel.: +61-3-8344-0778; fax: +61-39347-4172. E-mail address: e.manias@nursing.unimelb.edu.au (E. Manias). 1 Present address: School of Biomedical Science, James Cook University, Townsville, Queensland 4811, Australia.

discharge planning, and providing patient education (Baker and Napthine, 1994; Manias, 1997). For nurses to carry out these roles effectively, they must possess comprehensive pharmacology knowledge, which involves an understanding of the scientic principles underpinning medications as well as the ability to contextualise medication management to the complex and changing needs of patients. Newly graduated clinical nurses, in particular, experience enormous difculties in comprehending pharmacology and applying it to practice. For this reason, the paper focuses on clinical nurses perceptions and experiences of graduate nurses pharmacology knowledge and whether this

0020-7489/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 0 8 - 1

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knowledge prepares them adequately for practice as a newly registered nurse.

2. Literature review The specic needs of graduate nurses in preparing them to understand and apply pharmacology knowledge in clinical practice have rarely been addressed in the literature. Also lacking is clinical nurses perceptions and experiences about the pharmacology needs of graduate nurses. Research relating to the pharmacology knowledge of nurses has focused primarily on four areas. The rst area concerns nurses perceptions of their ability to comprehend pharmacology principles. The second area relates to testing nurses actual knowledge of pharmacology. The third area addresses comparisons between nurses actual knowledge and their perceptions about their knowledge. The fourth area relates to identifying and evaluating the medication education roles of nurses. Traditionally, nurses experience difculties in understanding pharmacology and are unable to apply pharmacological concepts to clinical practice. Studies have indicated a lack in the breadth and depth of pharmacology being taught to students in undergraduate nursing programs, and students feel inadequately prepared in their learning of this area (Akinsanya, 1987; Caon and Treagust, 1993; Courtenay, 1991). Courtenay (1991) found that only 10% of her sample comprising students and lecturers (n 87 and n 29; respectively) believed that their pharmacology knowledge was adequate. In Akinsanyas study, nursing students anxieties centred upon what they perceived to be ineffective teaching, the apparent difculty of the concepts they had to learn, and an inability to apply these concepts to clinical practice. Nursing students have also indicated that they memorise isolated and numerous facts about specic medications without understanding the important concepts (Manias et al., 1999, 2000). This supercial approach provides little opportunity for expanding and applying knowledge in a systematic manner. Studies examining nurses educational needs in pharmacology have also focused on testing their actual knowledge about medications. Markowitz et al. (1981) reported that nurses had signicantly less pharmacology knowledge than physicians and pharmacists, and that nurses knowledge was inadequate. Nurses who worked day shifts were found to have signicantly better scores than nurses working night duty. On the other hand, no differences were found between the test score and nurses years of experience or between the test score and nurses qualications. In a similar study (Boggs et al., 1988), when nurses were tested in their knowledge of three commonly used medications, their scores ranged from 8% to 75%. Investigators examining nurses under-

standing about the medications they were taking personally found that they lacked knowledge about side effects and precautions (Bray and Ghose, 1993). Based on these ndings, Bray and Ghose raised concerns about nurses having responsibility for, and offering advice about, patients medications. Research has also been conducted on comparing nurses actual and self-rated pharmacology knowledge. In an Australian study (Ives et al., 1996) graduate nurses were asked to complete one multiple choice and one short answer question for each of ve areas of knowledge that included: medication administration, therapeutic effects of drugs, adverse effects of drugs, patient education, and legal aspects of medication administration. The test scores of 363 respondents ranged from 16% to 92%, with a mean score of 56%. Thirty-ve percent of respondents scored o50% for the test. The number of months worked as a qualied nurse and participation in a graduate year program were positively correlated with test scores. More than half (60%) of the nurses indicated that they had not undertaken any pharmacology education since graduating. Only 29% had received this education in a graduate year program or through in-service programs. The study demonstrated signicant correlation between the respondents overall self-rating of their knowledge and their total test scores. More recently extensive research has been completed on the medication education roles of nurses, and their medication-related interactions with patients (Latter et al., 2000a, b; Martens, 1998; Rycroft-Malone et al., 2000). A variety of data collection methods was used for this work including focus group discussions with nursing students, lecturers and practitioner groups, observations of teaching sessions and a survey of educational institutions in the United Kingdom. The investigators identied the following themes with a specic emphasis on preparing nurses for a medication education role: the insufcient amount of taught pharmacology in preregistration nursing courses, the divided opinion about who should teach pharmacology, the importance of applying knowledge to practice, a lack of opportunity for integrating knowledge and skills, the limited opportunities for practice-based learning, a lack of evidencebased teaching, and a lack of consistency across programs. While this comprehensive study examined important issues about pharmacology knowledge, the specic needs of graduate nurses were not addressed. The focus of the research centred on the nurses role in medication education for patients. In summary, previous research on pharmacology knowledge has tended to concentrate on testing nurses actual pharmacology knowledge or on exploring nursing students perceptions of their knowledge. Aside from the Ives et al. (1996) study there is little research on the pharmacology preparation of graduate nurses or about the perceptions and experiences of nurses who work

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with graduate nurses. Most studies also tend to involve surveys that seek students and lecturers opinions about pharmacology education. Such surveys, which have tended to request information about task-based activities, are decontextualised from the complexities affecting clinical practice (Casey, 1996). If graduate nurses are to meet patients needs and full their medication roles efciently and effectively, it is important that comprehensive information is obtained about their educational preparation in pharmacology (Jordan and Potter, 1999; Schwertz et al., 1997). It is also important to seek the perceptions and experiences of clinical nurses who work with graduate nurses. The purpose of this paper is to provide insights into clinical nurses perceptions and experiences about the preparation of graduate nurses in pharmacology. The specic aims of this paper are to:
*

describe clinical nurses perceptions and experiences about the pharmacology knowledge base of graduate nurses; explore the expectations of clinical nurses about graduate nurses education in pharmacology.

For the purpose of the study, a graduate nurse is dened as a nurse who is in the rst year of clinical practice following completion of a 3-yr undergraduate nursing degree. A clinical nurse is dened as any nurse working in the hospital setting who has completed a 3-yr undergraduate nursing degree.

3. Methods The study was conducted as part of a larger project, which sought to evaluate the educational preparation of graduate nurses in pharmacology. A total of six focus group interviews was conducted with nursing staff at metropolitan and regional hospitals in Victoria, Australia (Table 1). Subsequent to ethics approval from the hospital ethics committees, expressions of interest for participation were sought from clinical nurses who were employed in various capacities including nurse unit managers, clinical nurse consultants, bedside nurses and

Table 1 Hospitals included in the study Hospital A B C D Type of hospital Metropolitan, public Metropolitan, public Regional, public Regional, public Number of focus group interviews 1 2 1 2

recently employed graduates. Focus groups comprised generally between four and 12 participants to allow individuals to contribute while still eliciting a range of responses (Grbich, 1999). Participation was voluntary and condentiality was assured. Since the work is qualitative it does not claim to represent the views of clinical nurses as a whole, or of clinical nurses employed in a particular hospital. The interviews were conducted in a quiet room within the hospital from where participants were recruited. All interviews were tape-recorded to enable the interviewer to concentrate on responses and to strategically guide the progress of the interview. Interviews were B60 90 min in duration. The interviewer acted as a facilitator of the group, by encouraging the expression of different views, helping participants to be more specic with their responses, and exploring reasons underlying particular views. Demographic information about each participant was obtained at the commencement of the interview (Table 2). During the interview, the interviewer took brief notes as a validation of taped comments. At the conclusion of the session, the interviewer also recorded key insights and summary comments. All interviews were transcribed verbatim and subjected to the framework method of analysis described by Ritchie and Spencer (1994), which comprised the following ve key stages: familiarisation, identication of a thematic framework, indexing, charting, and nally, mapping and interpretation. Familiarisation involved gaining an overview of the interview transcripts. In identifying a thematic framework, data were examined in order to derive key issues and themes. Indexing was the process of labelling the data into manageable units for subsequent retrieval and exploration. Charting involved the process of abstraction and synthesis whereby each passage of transcript data, which had been annotated with a particular issue or theme, was examined and a summary of the participants perceptions and experiences was entered onto a chart. The mapping and interpreting stage involved comparing and contrasting participants comments, and searching for patterns, connections and explanations for the data set as a whole. Various strategies were implemented to ensure that validity and reliability issues (rigour) were addressed (Holloway and Wheeler, 1996). Inter-rater reliability was achieved in the following two ways. First, considerable time was spent training a research assistant to ensure that data collected during interviews occurred in an accurate and appropriate manner. This training allowed for consistency of information obtained. Second, the investigators examined independently the interview transcripts to determine the emerging patterns of analyses. The results of these analyses were then compared and scrutinised. Credibility of the data was

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Table 2 Participants demographic information (n 38) Demographic data Age 2024 yr 2529 yr 3034 yr 3539 yr 4044 yr >44 yr Gender Female Male Appointment level Grade 1 nurse Grade 2 nurse Clinical nurse specialist Associate nurse unit manager Nurse unit manager Nurse educator Years of nursing experience as a registered nurse o1 yr 13 yr 46 yr 79 yr 1012 yr 1315 yr >15 yr Years of nursing experience in the area currently employed o1 yr 13 yr 46 yr 79 yr 1012 yr Hours worked per week 916 h 1724 h 2532 h 3340 h Number Percent 6 11 10 8 1 2 36 2 5 14 3 2 12 2 15.8 29.0 26.3 21.1 2.6 5.2 94.8 5.2 13.2 36.8 7.9 5.2 31.7 5.2

assured as the investigators have experience in conducting research into pharmacology education and evaluation, and in qualitative methods of research. The investigators were also present for initial interviews to ensure the research assistant used appropriate skills for this process. Experts in the teaching of pharmacology were sought for a process of peer review of the emerging themes. Finally, member checks were carried out with participating nurses to ensure that the interview transcripts were accurate and true to their experiences.

4. Results As shown in Table 3, four major themes emerged from interviews regarding the preparation of graduate nurses in pharmacology. These themes are presented below, incorporating examples from the data. 4.1. Knowledge base of graduate nurses

5 7 5 7 4 4 6

13.2 18.4 13.2 18.4 10.5 10.5 15.8

6 14 11 4 3 3 1 7 27

15.8 36.8 29.0 10.5 7.9 7.9 2.6 18.4 71.1 100.0 29.0 7.9 7.9 31.7 34.4 7.9 2.6 2.6 5.2 5.2 5.2 5.2

Throughout the six focus group discussions, participants indicated that the overall pharmacology knowledge of graduate nurses was severely lacking. Participants perceived there were knowledge decits relating to understanding of medication family groups, the ability to read medication order charts, and understanding of pharmacology terminology. According to participants, graduate nurses lacked knowledge about specic groups of medications that were commonly used in the clinical area. While it was recognised that a wide variety of medication groups exist, participants identied particular groups that they perceived were pivotal for clinical practice, for example: Nurse: On the medical ward where I work, the graduate nurses dont know the antibiotics for chest infections. They dont know most of their cardiac drugs. They dont know the respiratory drugs. I guess they are coming in at a base level, which is fairly low. In addition, concerns were raised about graduate nurses ability to read a medication order chart. One nurse commented about this concern in the following way: Nurse: I had a recent occurrence where a graduate nurse came and said to me, What does this mean on the drug sheet?y I just said, You should know this stuff before you come here. And she said, No, they [the lecturers at the university] didnt teach us. So I think it is pretty patheticy They [graduate nurses] should at least know how to read a drug chart before they come out. Apart from the ability to read a medication order chart, participants were concerned about graduate

Completed educational qualicationsa Bachelor/Diploma/Certicate of Nursing 38 Graduate or Postgraduate 11 Diploma of Nursing Master of Nursing 3 Otherb 3 Area of nursing currently employed Medical Surgical Intensive care Coronary care Oncology Paediatrics Midwifery Orthopaedics Renal
a b

12 13 3 1 1 2 2 2 2

Some participants completed more than one qualication. One participant had completed Bachelor of Education, and two participants had completed Graduate Diploma of Education.

E. Manias, S. Bullock / International Journal of Nursing Studies 39 (2002) 773784 Table 3 Emergent themes regarding the preparation of graduate nurses in pharmacology (1) Knowledge base of graduate nurses Lack of understanding of medication family groups Lack of ability to read medication order charts Lack of understanding about terminology Stressors experienced by graduate nurses All clinical nurses have knowledge decits (2) Continuing education development of graduate nurses in pharmacology knowledge Access to a graduate nurse program Formalised education sessions on particular areas Single- and double-checking procedures Responsibilities of various health professionals (3) Aspects of pharmacology knowledge that are perceived important for nursing practice Medication actions Therapeutic and adverse effects Allergic tendencies Ability to understand common medication family groups Relation of medication effects to patient symptoms Ability to look up information Possession of competent medication administration skills (4) Improvements required of undergraduate pharmacology education Need to impart a sense of responsibility and accountability by graduate nurses More structured organisation of clinical experiences Conduct of pharmacology as a separate subject

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available, mistaking one antibiotic drug for another. One participant responded to this concern in the following way: Nurse: I learned that ranitidine was a H2 receptor antagonist and these graduates would go, It is for ulcers, isnt it? I think their terminology is just shocking. With metoclopromide they would say, This one stops vomiting, and whats the term for it? They dont know it is an anti-emetic. Despite these concerns, participants were empathic about the stressors experienced by graduate nurses, and the importance of allowing time for them to consolidate their pharmacology knowledge in the clinical area. As one nurse commented: Nurse: Graduate nurses see a drug chart and they go, I am expected to know all of this.y Many times you have to reinforce that it is okay if they dont know everything and to go and look it up in a reference book. Every experienced nurse in my clinical area knows antibiotics. And they [graduate nurses] go, I am expected to know all this stuff too. And I say, No, slow down, you are not expected to know this. As long as you know where to go and nd the information. However, there was also a general perception that all clinical nurses had some decits in their knowledge of pharmacology, and that graduate nurses were not any different. In particular, participants commented that because new medications were being developed continuously, it was enormously difcult for all nurses to keep pace with change. This difculty manifested also if nurses moved to a different clinical setting, for example: Nurse: I suppose when they [graduate nurses] are starting pharmacology in their course by the time they come out, there are always new drugs around. There is a changeover of their function from student to nurse, and I suppose they are like other nurses. To keep up we all have to acknowledge our decits. It is the [clinical] area in which you work that you have the most knowledge. And if you move to another area, then you got to start all over again. 4.2. Continuing education needs of graduate nurses in pharmacology knowledge Another theme to emerge from participants comments concerned the continuing education needs of graduate nurses in pharmacology. There were four key aspects to this theme. First, while all hospitals conducted a structured graduate nurse program where graduate nurses received theoretical input as well as clinical support, not all graduate nurses were guaranteed a place in the program. Second, formalised educational means

nurses lack of understanding about common terminology used in pharmacology. One participant commented: Nurse: The graduates are able to look up information and read about the drugs, but they sometimes dont understand the terms that are there. You have to say to them, What does that mean? And the drug may be a diuretic, and they dont know that it reduces uid and it works on a particular part of the kidney and has an action on a specic chemical. In examining the data, it seems as though graduate nurses difculties with terminology could easily lead to medication errors and possible patient harm. For instance, one participant indicated that graduate nurses did not know the difference between Panadol, a type of pain preparation, and propanolol, an antihypertensive drug. Another participant commented that graduate nurses were confused about the preparations, Panadol, a pain preparation containing paracetamol only, and Panadeine, a pain preparation containing paracetamol and codeine. Participants also believed that graduate nurses were frequently confused between different types of antibiotics that were commercially

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by which graduate nurses pharmacology knowledge could be addressed included the completion of medication calculation tests and the conduct of in-service education sessions. Third, in the clinical arena, participants also identied specic ways by which the educational needs of graduate nurses could be served, including single- and double-checking procedures of medications. Fourth, various health care professionals were identied as having the responsibility of addressing the continuing educational needs of graduate nurses, including nurse educators, preceptors and pharmacists. While only a nite number of places existed in graduate nurse programs, some graduate nurses missed out a place during their graduate year. According to participants, as graduate nurses were relatively inexperienced, they were often considered less attractive to clinical areas as permanent employees and were often forced to consider casual positions. One participant commented on the difculty encountered by graduates whose only option was to consider casual work after failing to enter a graduate nurse program: Nurse: If you fail to get into a graduate program, then you work on casual bank. And if you come across a drug you dont know, then you have to look it up in a reference book like the rest of us. But unless you are keen and you go to in-service training, or pay attention to what conferences are around and you pay for these yourself, you are really unsupported in that rst year. Furthermore, while all hospitals conducted graduate nurse programs for a 12-month period, the theoretical content of such programs had little emphasis on pharmacological issues. As one participant commented: Nurse: We have a one-week study block and then one day every month for 12 monthsy Mainly documentation and disease processes are covered in these sessions. There is nothing specic on medications or anything like that. Formalised education programs, through medication calculation sessions and in-service seminars, were also available to graduate nurses. Within two hospitals, all graduate nurses were required to undertake medication calculation tests by following a structured program. Participants acknowledged the importance and benet of such a program because it addressed safe practice and prevented litigation. At the same time, however, they also recognised the need for other areas of pharmacology to be addressed in the program. As one graduate nurse indicated: Nurse: We [the graduate nurses] do a drug calculation test, but it doesnt really involve a question and answer on what does this drug do and that drug do. I suppose it is hard because there are so many drugs

but we concentrate mostly on drug calculations, as they are so important. And what motivates me to keep my personal standard up is the fact that I have to know what I am doing. And I take my job seriously and I guess a fear of litigation scares the hell out of me. In-service educational seminars were held in the ward settings of all hospitals and were directed at all clinical nurses in order to address a variety of professional issues. Commitments within the graduate nurse program and work schedules may have affected access of some graduate nurses to in-service seminars. As one participant commented: Nurse: It is actually up to our ward to come up with what topics are covered. You have to consider though that these seminars are every Wednesday afternoony So it takes a while for staff members to actually get onto an afternoon shift to do in-service and there may be something already planned for the graduate nurses by the education department. Aside from educational programs, participants acknowledged clinical endeavours including single- and double-checking procedures of medications as ways in which graduate nurses needs could be addressed. All hospitals were involved in a method of single-checking oral medications, whereby the nurse who administered a medication was the one who checked it. However, certain medications required a double-checking procedure, including the administration of some oral medications, such as digoxin or warfarin, as well as intravenous or intramuscular medications, and narcotic analgesics. In two hospitals, moves were being made to incorporate single-checking procedures for all medications, except for narcotic analgesics. Participants had varied opinions about whether single- or double-checking procedures hampered or helped graduate nurses. There was a perception that single-checking may encourage a nurse to be more accountable with medication administration: Nurse: With single-checking you have to be fully responsible for giving the drug. Nobody will tell you how you will give ity I think it is good as it helps graduate nurses to gain more concentration. On the other hand, participants also believed that single-checking also prevented medication errors from being detected: Nurse: You are only going to get drug errors when someone actually tells you that they have made an error. So it comes down to the honesty of the nurses who are giving the medications and they are the ones who are getting chastisedy I think you will nd there are a lot of errors that occur that are never ever reported during single-checking.

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Some participants acknowledged that the doublechecking process was time-consuming and promoted a nonchalant attitude, for example: Nurse: You cant get staff to check with you because everyone is really busy. Youve got no time to checky In the whole ward you cant nd anybody so you just wait for somebody to check. I think it is just a waste of time. Other participants recognised the value of the doublechecking process, as indicated by the following participant: Nurse: The advantage of double-checking is that they [graduate nurses] have to check with a registered nurse when they give IVs [intravenous], IMs [intramuscular], and narcoticsy So to a certain extent, they are not going in there and thinking for themselves. They have got someone who is checking and helping them. Nurse educators and preceptors in the clinical area supported graduate nurses who were fortunate enough to gain entry into a graduate nurse program. However, this support was provided for a limited period over the graduate year and determined by the varying needs of all graduates. In view of the support provided, some participants abrogated responsibility in this area: Nurse: They [graduate nurses] are getting a fair bit of support from preceptors. They have their education days. They have an educator, so we probably feel that it is more their role in teaching the graduates. Participants comments also highlighted the difculty in nding time to spend with graduates in addressing their continuing education needs, for example: Nurse: Basically, we as workers on the ward are getting more to do, and time does not permit us to do everything that is requiredy It is an ongoing thing and Im sure if you pulled off all the staff from the ward and started asking questions about specic medications, even their education would be pretty sub-standard because it is up to nurses to educate themselvesy We should be educating them [graduate nurses] but we dont have the staff. Another participant commented: Nurse: If graduate nurses had a chance to debrief properly we would know they want pharmacological help. I dont think graduate nurses get a proper debrieng. Everyone is exhausted by the end of the eight-hour shift and everyone just wants to go home.

4.3. Aspects of pharmacology knowledge that are perceived important for nursing practice Participants commented frequently about aspects of pharmacology knowledge they perceived to be important for nursing practice. Two key principles were evident in participants discussions: rst, the theoretical principles of pharmacology knowledge, and second, the clinical principles. Theoretical principles perceived to be important included the actions, therapeutic and adverse effects, and the allergic tendencies of the medications administered. One participant commented: Nurse: I think nurses should know what the drug does, what are the outcomes we want from this drug rather than being able to say that something is a beta2 blocker or a calcium channel blockery It is my belief that a graduate nurse should be able to say that glyceryl trinitrate is a coronary artery vasodilator that improves circulation of the myocardium. Another nurse indicated the following: Nurse: I think nurses should know about the allergy status of a drugy Real crucial side effects about a drug, such as cardiovascular collapse or anaphylaxis, are important. For example, gentamicin causes toxicity to the ear and the kidney. Interestingly, participants rarely acknowledged the importance of graduates understanding fundamental, theoretical principles of pharmacology, which include pharmacokinetics, pharmacodynamics, the structural makeup of medication groups, and common drug interactions. Part of the reason may have been because participants themselves had inadequate preparation of fundamental principles in their pharmacology education. One participant commented: Nurse: There should be a theoretical component in thereit is important. The focus on my training was on administration of drugs. I dont know, I think some of that other stuff [theory] has gone by the waysidey I think that theory such as structural makeup is important. I guess my own theory of pharmacology is poor, and I have to do my own work to get my pharmacology knowledge up-to-date. In addition to theoretical principles, participants identied a number of clinical principles that were important for nursing practice. Several participants expressed the value of understanding the characteristics of common medication groups, relating the medications effects to the patients symptoms, possessing the ability to look up information in medication resource materials, and having adept medication administration skills. With all clinical principles identied, participants emphasised

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their signicance in contextualising pharmacological knowledge for practice. Despite the diverse areas in which the participants practised, they acknowledged the importance of knowing the characteristics of specic groups of medications. These medication groups encompassed the respiratory, cardiac and emergency groups. An understanding of these groups was perceived to be vital for competent practice, for example: Nurse: Cardiac drugs like frusemide, digoxin and coronary vasodilators are important. Respiratory drugs like the bronchodilators are also commonly given. They [graduate nurses] should also know the arrest-type drugs, such as adrenaline and the antiarrhythmics. Furthermore, participants commented that understanding how the mechanism of action of a medication affected the patients symptoms enabled effective clinical reasoning about its therapeutic or unwanted effects, for example: Nurse: There are a large number of elderly patients on our ward who are on digoxin, so it is a matter of what is the implication of a low pulse. You need to know that you dont give it to someone with a low pulse. And with antihypertensive medication, what are the expectations relating to blood pressure?y We get patients who have vascular bypass surgery so they are on antihypertensives. We also have a lot of epidurals so being hypotensive is an issue. Another participant expressed this view in the following way: Nurse: I personally think they [the graduates] dont think about the symptoms and they shouldy It is not as if they are reasoning, This is an antihypertensive, and the patients blood pressure is only 90 systolic. I wont give it. Participants highlighted also the importance of accessing information as a means of maintaining safe practice. For many nurses, the ability to access information could not be overestimated. Some participants referred to their medication reference manuals as their bibles because nurses used them frequently. As one participant commented: Nurse: As long as they [graduate nurses] know to go and look and read, thats the important thing. I dont know every drug so I am not going to know it, and my choice isyto look the drug up and make sure it is safey We have our book, our bible of drug administration, so if in doubt we get that out. Aside from using written resource material, participants also referred to the importance of knowing how to

access information from other health care professionals and hospital departments: Nurse: It is knowing where to access information. For cytotoxic drugs, if you have a query, you would ring the oncology department. If you have another query you would ring up pharmacy. I suppose as nurses you are not expected to know everything but it is knowing where to get that information, whether from a senior nurse or from a reference text or whatever. As a major portion of nurses medication role involves the preparation and administration of parenteral therapy, participants believed that graduate nurses should demonstrate dexterity with these tasks. Preceptors in the clinical area supported graduates who were undertaking a graduate nurse program, and part of that role involved the supervision of graduates preparation and administration of injections. However, participants were also involved in this supervisory role, and as one clinical nurse commented: Nurse: It is a bit of a worry in that their practical basic skills such as subcutaneous and intramuscular injections are not therey I dont know how much opportunity they have to play with these skills during their course, but I would suggest not a lot. 4.4. Improvements required of undergraduate pharmacology education A number of areas were identied that focused on how undergraduate pharmacology education could be improved because it affected the future aptitude of graduate nurses. Areas of improvement, which tended to target clinical principles rather than theoretical principles of pharmacology, included the need for undergraduate students to take greater responsibility for monitoring and administering medications and the need for more structured learning during clinical practice. Participants indicated the need for undergraduates to develop a greater sense of responsibility and accountability in their monitoring and administering of medications. This need was related to the importance of safety and the legal ramications involved in not assuming these roles, for example: Nurse: I really think students themselves are not taking the responsibility of administering and monitoring medications seriously, especially in the third year, and this view continues onto their graduate year. They have this notion that they will be righty If I was a teacher, I would remind them that this is serious and they need to be accountable and responsible for each and every pill they dish out.

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They should know the name and the acceptable dosage for common drugs. Another participant voiced this concern in the following way: Nurse: They need to be taught that the focus is on them. They are going to end up in a court of law if they give this drug wrongy If they are going to kill the patient, no one is going to be there to protect themy A student often thinks that the doctor knows everything and you think about some of these medical interns, and it is a worry. I think it all ties back to safety. You need to know the drugs you are giving. Participants also indicated that clinical practice experience for undergraduate students could be organised in a more structured manner, for example: Nurse: Part of the students time in clinical practice should involve checking their medications and looking them up in the reference books. They do have moments during their clinical experience when they basically are twiddling their thumbs and dont know what to doy They should be looking up their medications that they have recorded on the medication chart and reporting the information back to their tutor at the end of the day. Finally, participants referred to the need to provide pharmacology as a separate undergraduate subject rather than incorporating it into other subjects, such as nursing or bioscience. This notion was held partly because graduate nurses had indicated to their colleagues about their desire for a segregated pharmacology subject, for example: Nurse: I think that students should have pharmacology as a separate subject. The ones [graduate nurses] I have just had in my ward say, We didnt have pharmacology as a subject on its own, and we are supposed to do it in our nursing subjects but it doesnt get covered.y And you need to consider that a lot of them didnt do pharmacology at university, and if they didnt do it, they dont know it.

5. Discussion The comments raised by participants in focus group discussions provide an interesting insight into the experiences of clinical nurses and the perceptions of the pharmacology knowledge of graduate nurses. A number of themes were raised that reveal insights into understanding the unique concerns surrounding graduate nurses knowledge of pharmacology. Participants identied that graduate nurses were not adequately

prepared in pharmacology education. Graduate nurse programs were acknowledged as being important for helping graduates to consolidate their knowledge although the focus of such programs tended to be on practical issues. Furthermore, as experienced nurses lacked adequate knowledge of pharmacology themselves, they seemed reluctant to adopt a teaching role with graduate nurses. Single- and double-checking procedures were used to address the learning needs of graduate nurses in the clinical area although the participants debated heavily the relative importance of such procedures. Aspects of pharmacology that participants tended to value involved clinical rather than theoretical principles. Finally, participants believed that graduate nurses preparation in pharmacology could be greatly improved by a reorganisation of the undergraduate nursing curriculum. Overall, participants embraced the perception that the pharmacology knowledge base of graduate nurses was severely lacking. This perception supported the ndings of other studies, which indicated that nurses were not adequately prepared for their responsibility in monitoring the effects of medications (Boggs et al., 1988; Ives et al., 1996; Markowitz et al., 1981). While participants were concerned about the pharmacology knowledge of graduate nurses, they also empathised that experienced nurses had some decits. In fact, previous studies have consistently demonstrated no correlation between years of experience and medication knowledge (Boggs et al., 1988; Fothergill-Bourbonnais and Wilson-Barnett, 1992; Markowitz et al., 1981). On the other hand, Ives et al. (1996) demonstrated a positive correlation between months of working as a graduate nurse and test scores in pharmacology. It is possible that once in the workplace, nurses learning in pharmacology is greatest during their graduate year when they rst take responsibility for administering medications. Participants acknowledged continuing education through a structured graduate nurse program as an important means by which graduate nurses developed further their pharmacology knowledge. Ives et al. (1996) found that participation in a graduate nurse program improved nurses pharmacology knowledge. However, in the current study, participants indicated that such programs focused on safe administration practice, litigation issues and medication calculations. Other pharmacological areas of concern such as the mechanisms of action of medications, adverse effects and drug interactions were severely lacking in these programs. Furthermore, as nurse educators and preceptors provided various levels of clinical support for graduate nurses during graduate nurse programs, participants tended to abrogate their responsibility in this area. This abrogation is of particular concern because nurse educators and preceptors did not usually support graduates for the entire duration of their program. It

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was also acknowledged that the perceived inadequate knowledge of experienced nurses prevented them from accepting a teaching role for graduate nurses. To address this concern, participants indicated the need for self-directed learning as a favoured way to improve current pharmacology knowledge, which was also supported by Ives et al.s study. In Fothergill-Bourbonnais and Wilson-Barnetts (1992) study, of the total sample who indicated they needed more education on pharmacological aspects of pain, 64% of nurses stated this education should come from in-service seminars while 34% stated it should come from the ward nursing manager. In addition, Ives et al. (1996) found that only 9% of graduate nurses obtained their continuing education from senior nurses. Senior nurses, such as nursing managers and clinical nurse specialists, are often espoused as professional role models and educators for other nurses (Street, 1995). However, as indicated in this study, it is debatable whether they have been adequately prepared for this role or if they have the time to focus on medication administration sufciently due to their heavy managerial responsibilities. Double- and single-checking procedures were also important means by which graduate nurses addressed their continuing learning needs. Participants were divided in their opinion about the benets of these procedures. Single-checking was viewed as a means of self-determinationgraduates could be more accountable and responsible for their administration activities. On the other hand, double-checking provided opportunities for nurses to collaborate and learn from each other. An Australian study revealed the error rate per 1000 medications administered by a single nurse was 2.98, which was statistically signicantly higher than the 2.12 per 1000 medications for two nurses (Kruse et al., 1992). The investigators stated that the clinical benets of this reduction were small because the errors identied were of a relatively minor nature (p. 82). After disclosing the economic savings of having one nurse administering medications, they concluded the use of two nurses to check medications did not improve safety and was demanding on nurses time. Although in the current study participants had varying opinions about the benets of single- and double-checking procedures, a commonly held view was that the double-checking procedure provided a regular forum of supportive communication for graduate nurses. This forum facilitated the provision of valuable medication information that perhaps may not have otherwise occurred because of clinical nurses busy work schedules. Such a benet probably transcends any concerns about economic savings or time constraints. Another signicant theme raised by participants related to the principles of pharmacology knowledge perceived to be important for nursing practice. There was no acknowledgement of the signicance of funda-

mental theoretical principles such as pharmacokinetics, pharmacodynamics and drug interactions. This nding is not surprising because nurses have traditionally demonstrated low levels of knowledge in these areas (Boggs et al., 1988; Markowitz et al., 1981). Since nurses nd these principles difcult to grasp, it is reasonable to assume that the participants underestimated their importance. The participants identied valuable clinical principles that were considered important; however, they represent only a small portion of the clinical judgements that a nurse is required to make (White, 1994). On the other hand, an understanding of pharmacokinetics will enable a nurse to predict when therapeutic and toxic effects are most likely to appear. It also determines the route of administration, the timing of administration and when a medication is given in relation to the consumption of food. Similarly, knowledge about pharmacodynamics will enable a nurse to analyse the effects of a particular medication on physiological processes in the body. Furthermore, demographic shifts in the hospital population to more chronically ill and increasingly aged patients make it crucial for nurses to know about potential drug interactions (Galbraith et al., 2001). Finally, another important theme to emerge was participants perception about improvements required in undergraduate pharmacology education. Participants believed that the clinical component of the undergraduate program could be organised in a more structured manner. They also acknowledged the need to have pharmacology as a separate undergraduate subject. These ndings, which concurred with the results of previous studies, may indicate deciencies in curriculum design and teaching methods (Courtenay, 1991; Ives et al., 1996; Latter et al., 2000a; Manias, 1997). The value of emphasising pharmacology theory in the undergraduate curriculum has also been consistently promoted in the literature (Courtenay, 1991; Jordan and Hughes, 1998; Jordan and Potter, 1999; Manias, 1997; White, 1994). While there may be a need to increase or restructure the undergraduate pharmacology content, any change should be complemented by self-directed initiatives and lifelong learning practices, as indicated by some participants in this study. Ultimately, a balance is needed between the ability to impart pharmacology knowledge and the ability to provide opportunity for continuing professional development in pharmacology (Latter et al., 2000a, b; Manias, 1997). The limitations of this study relate to the small number of focus group interviews conducted in the clinical arena. Due to the voluntary nature of participation, it is possible that discussions reected the views of individuals who had an interest in the area of pharmacological preparation of graduate nurses. It is also likely that the participants clinical and hospital environments may have various contextual inuences

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that impact on this area of research. Despite the small number of focus groups, the ndings represent the views of 38 nurses whose demographic backgrounds were varied. Subsequently, these ndings are likely to resonate with other nurses perceptions and experiences. It is timely that the nursing profession needs to reect the changing and dynamic nature on the graduate nurse in the monitoring and administering of medications. A balance should be created between the need to impart knowledge about medications and the need to provide space for professional development in pharmacology knowledge. Whether this education is provided in the university or health care setting, graduate nurses must be given a solid foundation upon which they can further build their knowledge.

ates knowledge of pharmacology could also be investigated. The ultimate goal of consolidating pharmacology knowledge of graduate nurses is to optimise medication use, thereby improving the health outcomes of patients. Current teaching and learning opportunities for graduate nurses appear to be inadequate in their pursuit of enhancing and improving their knowledge. These inadequacies have been described and now they need to be addressed if the ultimate goal is to become a reality. Acknowledgements This study was supported by the Commonwealth Government of Australia through the Australian Research Council (ARC) Small Grant Scheme. We are grateful to Ms. Mamanne Moran and Ms. Roberta Stead for their assistance in completing this study.

6. Conclusions and implications This paper has explored clinical nurses perceptions and experiences of graduate nurses pharmacology knowledge. Clinical nurses expressed that graduate nurses experienced enormous decits in their pharmacology education, which resulted in a lack of understanding about medication family groups, an inability to read medication order charts, and a lack of insight about pharmacology terminology. In addition, clinical nurses indicated that these decits were not conned to graduate nursesall nurses experienced difculties in understanding and demonstrating pharmacological concepts in the clinical practice setting. A number of implications relating to the development of future policy and educational initiatives can be drawn from the study. It is important to acknowledge the value of graduate nurse programs in improving nurses pharmacology knowledge. Graduate nurses should be prepared for ongoing continuing pharmacology education following the completion of an undergraduate nursing program to consolidate learning and to help contextualise theory with clinical practice. Experienced clinical nurses may be offered structured education sessions on pharmacological issues to assist in improving their knowledge. They will then be in a better position to help graduate nurses to address decits in their pharmacology knowledge. Future researchers could investigate the specic learning needs of graduate nurses employed in specialised practice settings, such as critical care, orthopaedics, and oncology nursing. While this study examined the perspectives of nurses employed in a variety of areas, their demographic dispersion in focus group interviews did not allow for particular conclusions to be drawn about a specic practice area. The specic learning needs of a particular practice area can be delineated and evaluated through education sessions. In addition, the ability of graduate nurse programs to improve gradu-

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