Medication administration evaluation tool design: an expert panel review

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Contents lists available atScienceDirect

Collegian

j o u r n a l h o m e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / c o l l

Medication

administration

evaluation

tool

design:

An

expert

panel

review

Karen

M. Davies

a,b,c,∗,1

_,

_Ian

_D.

_Coombes

c,d,2

_,

_Samantha

_Keogh

e,f,g,3,4

_,

Karen

M. Whitﬁeld

c,d,5,6

a_Department_of_Clinical_{Pharmacology,}_Royal_Brisbane_and_Women’s_Hospital,_Brisbane,_Queensland,_Australia b_Faculty_of_Medicine,_University_of_Queensland,_Brisbane,_Queensland,_Australia

c_School_of_Pharmacy,_University_of_Queensland,_Brisbane,_Queensland,_Australia

d_Pharmacy_Department,_Royal_Brisbane_and_Women’s_Hospital,_Brisbane,_Queensland,_Australia

e_School_of_Nursing,_Institute_of_Health_and_Biomedical_Innovation,_Queensland_University_of_Technology,_Brisbane,_Queensland,_Australia f_Centre_for_Clinical_Nursing,_Royal_Brisbane_and_Women’s_Hospital,_Brisbane,_Queensland,_Australia

g_Alliance_for_Vascular_Access_Teaching_and_Research_Group,_Grifﬁth_University,_Brisbane,_Queensland,_Australia

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received26September2017 Receivedinrevisedform17April2018 Accepted9May2018 Availableonlinexxx Keywords: Nurses Medicationadministration Self-assessment Feedback Evaluationtool

a

b

s

t

r

a

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Background:Toolscurrentlyavailabletoevaluatenursemedicationadministrationpracticeshave limi-tationsandareeithernotvalidatedorhavepoorreliability.

Aim:Toidentifycriteriaandcontentforinclusioninatooltoevaluatemedicationadministrationby nursesintheclinicalsetting,usinganexpertpanel.

Methods:Apeerreviewprocessusinganexpertmultidisciplinarypanelratedtherelevanceofthecontent onthreetools;MedicationAdministrationSafetyAssessmentTool,MedicationwithRespectTooland ClinicalSkillsAssessmentTool,usingafour-pointratingscale.Expertopinionwasprovidedonrelevance ofcontent,ratingscalesandfrequencyofnurseevaluation.Thelevelofagreementwasanalysedby itemcontentvalidityindex,meanitemcontentvalidityindex,meanexpertproportion,scalecontent validityindexwithuniversalagreement,probabilityofchanceagreementandamodiﬁedkapparating. Qualitativethemeswerealsoreviewed.

Findings:TheitemandscalecontentvalidityindexandthekappaindexbothratedtheMedication Admin-istrationSafetyAssessmentToolandClinicalSkillsAssessmentToolasexcellent.FortheMedicationwith RespectToollessthanhalfoftheitemcontentvalidityindexratingsratedasgoodandthekappaindex ratedasexcellent,thereforethescalecontentvaliditydidnotachieveagoodrating.

Conclusions:Theexpertpanelreviewidentiﬁeditemsofhighlevelofagreementforrelevanceand deter-minedthatcontentneededtobeclear,concise,observable,genericandpracticaltobeusefulforallnurses. Self-evaluation,feedbackandadevelopmentalplanwerealsokeycriteria.

∗_{Corresponding}_author_at:_Department_of_Clinical_{Pharmacology,}_Royal_Brisbane

andWomen’sHospital,Brisbane,Queensland,Australia.

E-mailaddresses:[email protected](K.M.Davies),

[email protected](I.D.Coombes),[email protected](S.Keogh), karen.whitﬁ[email protected](K.M.Whitﬁeld).

1 _Clinical _{Pharmacology,} _Level_1, _Ned _Hanlon _Building, _Royal _Brisbane_and

Women’sHospital,ButterﬁeldSt.,Herston,Brisbane,Queensland4029,Australia.

2 _Pharmacy _Department,_Level _1,_Ned _Hanlon _Building,_Royal _Brisbane_and

Women’sHospitalButterﬁeldSt.,Herston,Brisbane,Queensland4029,Australia.

3 _QUT,_Rm_338,_N_Block,_Kelvin_Grove_Qld_4059,_Australia.

4 _Centre_for_Clinical_Nursing,_Royal_Brisbane_and_Women’s_Hospital,_Level_2,

Build-ing34,Herston,Brisbane,Queensland4029,Australia.

5 _School_of_Pharmacy,_PACE_Precinct,_Building_870,_The_University_of_Queensland

QLD4072,Australia.

Summaryofrelevance Problem:

Therearefewvalidatedandreliablenursemedication admin-istrationevaluationtoolscurrentlyavailableforuseintheclinical setting.

Whatisalreadyknown:

Avoidablemedicationadministrationerrorsarewidelyreported in nursing literature. Compliance to safe medication practice reducesthepotentialforerrorandunintentionalpatientharm.

6_Pharmacy_Department,_Royal_Brisbane_and_Women’s_Hospital,_Level_1,_Ned

Han-lonBuilding,RoyalBrisbaneandWomen’sHospital,ButterﬁeldSt,Herston,Brisbane, Queensland4029,Australia.

https://doi.org/10.1016/j.colegn.2018.05.001

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WhatthisPaperAdds:

Developmentofarelevantandpracticalmedication adminis-trationevaluationtoolthatincorporatesself-evaluation,feedback andadevelopmentalplanaskeycriterion.

1. Introduction

Medicationadministrationisakeycomponentofthe medica-tionmanagementprocessandcomprisesasignificantcomponent ofnursingpatientcare (Jennings etal., 2011; Westbrooket al., 2011). Basic coreclinicalskills are required tounderstand and ensure the safe, effective and efficient administration of med-ications to patients and avoid unintentional harm (Australian CommissiononSafetyandQualityinHealthCare,2012b;Coyne etal.,2013;Härkänenetal.,2016;Sinclairetal.,2014;Stolic,2014). TheWorld HealthOrganisation (WHO) aimstohalve avoidable medication-relatederroroverfiveyearsbyaddressingweaknesses inhealthsystemsandimprovingthewaymedicationsare man-aged(WorldHealth Organisation,2017).Examplesof theWHO strategiestoachievethisare:1)theuseoftoolstohelphealthcare professionals,especiallywhenusingmedicationswithahighrisk ofharmifusedimproperlyandenhancingpatientsunderstanding ofthesemedications,2)tostrengthenleadershipdevelopmentand skill-buildingand,3)topromotepatientsafetyresearchinthisarea. Therearemanystudiesdemonstratingthepotentialfor medi-cationadministrationerrorthatcanleadtopatientharm(Popescu et al., 2011), (Gunningberg et al., 2014). Observational studies undertakeninternationally,andlocallywithinAustraliaandNew Zealandhaveidentified factorsthatareknowntocontributeto increasedpotentialfor errorand harmtopatients. Distractions caused by external environmental factors such as monitoring alarms, interruptions by nurses, doctors, other staff members, patientsandfamilymembershavebeenshowntoincreaseerrors (Daviesetal.,2015;Härkänenetal.,2015;Westbrooketal.,2010). Simulated scenario-based training of 591 nurses has shown a thirdofnursesidentifiedallknownerrors(Coombesetal.,2005). Examplesoftheseerrorswere1)incorrectintravenouspotassium concentration2)re-exposuretoasevereadversedrugreaction3) incorrectformulationofamedication4)nodosedocumentedon theprescription5)incorrectfrequencydocumented6)incorrect medicationssuppliedondischarge.Lackofknowledgeand devia-tionfromnationalstandards,statelegislationandlocalprocedures andpoliciesthatunderpinsafemedicationpracticehavealsobeen showntocontributetoincongruencefromacceptedsafepractice (Westbrooketal.,2011).Thisleadstoperpetuationofpoor med-icationpracticethroughlearnedanddemonstratedbehavioursto newstaff(Popescuetal.,2011).

Whengapsinpracticeareidentiﬁed,feedbackisrequiredto enable the nurse to implement strategies to improve practice (Spector,2014).Forfeedbacktobeeffectivemultiplefactorsneed tobeconsidered; whetherthenurse is willingand engagedto receivefeedback,theenvironmentinwhichfeedbacktakesplace, thetimingoffeedbackand ifthetaskissomethingthenurseis requiredtodoorwantstodo,aswellastherelationshipbetween thenurseandthereviewer.Feedbackneedstobeformative,not summative,withinformationabouttheirperformance communi-catedtothelearnerthatisintendedtomodifytheirthinkingor behaviourforthepurposeofimprovinglearningandpatient out-comes.Summativefeedbackisusuallycumulativefeedbackover timefrommultipleassessmentsandisoftengradedwithamark. Thistypeoffeedbackisoftenlessdescriptiveinprovidingexamples ofindividualperformanceopportunitiesforimprovement(Butler &Winne,1995;Molloy&Boud,2013;Wikander&Bouchoucha, 2018).Localobservationalauditstudieshavedemonstratedthat combiningintermittentnurseobservationofmedication

adminis-trationaswellasprovidingdirectindividualfeedbackcanimprove practice.Examplesinclude:increasedcheckingofpatient identi-ﬁcationandadverse drugreactions,decreased medicationerror selection,decreasedwrongrateadministrations,decreased omis-sionsofmedications,decreasedforgettingtosignmedicationcharts afteradministration,decreasedinterruptions(Daviesetal.,2015). Other professions including Pharmacy have demonstrated improvement in pharmacist’s performance facilitated by an adaptedcompetency-basedgenerallevelframework(GLF).TheGLF isatoolusedtoevaluatepharmacist’sperformanceand incorpo-ratestailoredfeedbackandindividualisedtrainingplantoguide professional development (Coombes et al., 2010; Stacey et al., 2014).However,thereisalackofvalidatedandreliabletoolsto conductself-evaluation,observationandprovideformative

feed-backofnursingmedicationadministrationpracticeintheclinical

setting,suchas:thehospitalinpatientsetting,residentialagedcare facility,communityorgeneralpractice.

2. Literaturereview

Theliteraturereviewofmedicationadministrationassessment toolssynthesisesthe variousmethods and toolsused toassess nursesmedicationadministrationpracticeandhasidentifiedalack ofvalidatedandreliablecompetencymeasuresintheclinical set-ting(Liˇcen&Plazar,2015).Tools identifiedwere either: a)not specifictomedicationadministration,b)developedforstudents, newgraduatesornursingspecialtiesonly,c)medicationcalculation focused,d)lackedself-assessment,e)hadnodevelopmentalplan,f) werenotvalidatedorg)hadpoorreliability(Bulletal.,2017;Coates &Chambers,1992;Fisher&Parolin,2000;Longetal.,2013;Sinclair etal.,2014).Threetoolswereidentifiedthatcontainedmanyof thesecriteriaandwereusedtoassessnursemedication adminis-tration.Therefore,thesethreetoolswerechosentobeincludedin thisstudy.

ThetoolfromtheUnitedKingdomwasamedication adminis-trationcompetencytool,MedicationwithRespectTool(MwRT), adaptedfromanestablishedassessmentframeworkusedto eval-uateorallyadministeredmedicationsin thementalhealth area. (Hemingway etal.,2011;Turneret al.,2007,2008).Theformat usedevidence-basedstructuredcriteriaaimingtominimisethe riskofmedicationerrors bydeﬁning andsettingproceduresfor safe administration. Two assessments were used (1) Observed StructuredClinicalExamination(OSCE)and(2),anassessmentof Administrationof Medicine CompetencyFrameworks(Oral and Intramuscular). Only the Oral tool was reviewed in this study. Thecontentwascomprehensiveincludingadditional environmen-talcomponentssuchascleaning,restockingandsecurelockingof medicationstorage,aswellastheadministrationofthemedication. However,theresearchwasundertakenwithmentalhealthnurses onlyandfurtherworkwouldberequiredtovalidateinother clin-icalareassuchasthegeneralhospitalinpatientsetting,specialty ﬁeldssuchasintensivecareandpaediatric,aswellascommunity andagedcarefacilities.

Themedicationadministrationsafetyassessmenttool(MASAT) from the United States of America (US) is a binomial scale usedtoevaluateaccuratemedicationadministrationperformance (Goodstone&Goodstone,2013).Theresearchersconducteda lit-eraturesearchofthe“6rights”ofmedicationadministrationto develop thecontent and identifyspeciﬁc behavioursrelated to performingthem.Reliabilityofthetoolwasconductedusing sim-ulationscenarios and a simple ﬁve-point anchoredlikertscale. Thecontentwasachecklistformatof8rightsforsafemedication administration.Threewereforcheckingthecorrectpatientandone eachforcheckingtherightdrug,dose,route,timeand documen-tation.TheauthorsconcludedtheMASATchecklistformedication

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administrationassessmentwasreliable(Cronbach’salpha0.90)ina simulatedandclinicalhospitalwardsettingwithanundergraduate nursingstudentcohort.Itwasnothowever,usedwithRegistered Nurses.

TheAustralianClinicalSkillsAssessmentTool(CSAT)was devel-opedbynurseeducatorsforthepurposeofsupportingnewstaff, postinductionaspartofamedicationresourcepackage(O’Brien, 2015).Themaincomponentsidentifykeymedicationprocedures toinformstandards ofpractice,assesses foundationknowledge bycasescenarioexamples,thenobservesthenurseinpracticeto ensurethatthestepsforsafeadministrationareadheredto.The contentincludedcheckingthecorrectrightsofthemedicationas wellasthevalidityoftheprescription,knowledgeofthe medica-tionandassessmentofthepatientpreand postadministration. Formativefeedbackisprovided,andanyknowledgepracticegaps arediscussedforfurtherimprovement.TheCSAThasnothowever beenvalidatedtodeterminereliability,reproducibility,usefulness andefﬁcacy.Thepackagehas5hoursofContinuingProfessional Development(CPD)allocatedtocompletethemoduleknowledge componentandthreeassessments.Importantly,thetimerequired tocompletethepackagelimitsitsbroaderuse,precludingallnurses fromtheopportunitytobeneﬁt.

Thereisaneedforapractical,userfriendlymedication admin-istrationevaluationtoolforallnursesthatallowsself-evaluation, observationinclinicalpractice,provisionofformativefeedbackand developmentofamutuallyagreedplanforimprovingperformance. 3. Methods

3.1. Aim

Toidentifycriteriaandcontentforinclusioninatooltoevaluate safe,effectiveandefﬁcientmedicationadministrationbynurses intheclinicalsettingtoensureallproceduresarebeingfollowed, usinganexpertpanel.

3.2. Studydesign

Apeerreviewprocesswasemployedusinganexpert multidisci-plinarypaneltoreviewthecontentofthreetoolsidentiﬁedinthe literatureusedtoevaluatemedicationadministrationbynurses. Theexpertreviewwasconductedasdescribedby(Polit&Beck, 2008)byinvitedmedicationexpertsaskedtoratethecontentof itemsandoverallscalesforrelevanceinthedevelopmentofa med-icationadministrationevaluationtool.Thisstudyreceivedawaiver ofHumanResearchEthicsCommittee(HREC)reviewfromthe Hos-pitalandHealthServiceHREC(HREC/16/QRBW/351).Thefunder forthestudydidnotcontributetothestudyprotocol,design,data collection,analysisofresultsorthemanuscript.

3.3. Studysettings

The expert panel review was held at a tertiary metropoli-tanhospitalinJuly2016overtwohours.Expertpanelmembers eitherattendedfacetoface,viavideoconferenceorteleconference. Expertsunabletoattendwereofferedtheopportunityforoneon oneinterviewwiththesameagendaquestionsastheexpertpanel meeting.

3.4. Datacollection

Invitationsfor thepanelweresent viaemailto22potential expertsthatmetthecriteria asexpertsinmedication adminis-trationorhadevaluatedmedicationassessmenttoolspreviously. Sixteenofthetwenty-twoinvitedexpertswhowerefromarange ofmultidisciplinary(nursing,pharmacyandmedical)backgrounds

and roles including clinical, academic, research, education and safetyandqualityprofessionsparticipated.Consentwasprovided byacceptanceoftheinvitation.

Theexpertpanelmemberswereprovidedfourquestionnaires viaemailpriortothemeeting.Abriefdemographicquestionnaire included data abouttheir profession,role, years of experience, whethertheymanagedmedicationsorwhetherornottheyhad validated anassessment tool previously. Therewere alsothree structuredquestionnairesofthechosentoolstocompletepriorto thediscussionpanel:

•MwRT(Hemingwayetal.,2011), •MASAT(Goodstone&Goodstone,2013) •CSAT(O’Brien,2015)

Thequestionnairesaskedthepaneltoratetheindividual con-tentforrelevancytosafemedicationadministrationpracticeusing thefollowingscale:

1notrelevant, 2somewhatrelevant, 3quiterelevantto 4highlyrelevant.

Thequestionnairesalsoaskedthepaneltoratetheindividual contentonafour-pointratingscalefrom:

•deleteitem, •reviseitem(major), •reviseitem(minor) •keepitemasis.

(Polit&Beck,2008)

Thefacilitatorwasasenioracademicpharmacistwithover10 years’experienceinfacilitatinglargegroupsofhealth profession-als.Thepanelmeetingwasrunbythefacilitatorusinganagenda toguidethediscussion.Minutesweretakenaswellasanaudio recording tocapturecontentof thediscussion. Thepanel were dividedintothreegroupsoffourparticipantstoallowconstructive discussionaroundtheeightagendaquestions.Thepaneldiscussion focusedonthefollowingareas:

•typeofcontenttobeincludedsuchas:checkingtheright medi-cationandproceduralstepsinmedicationadministration. •theformatofthetool,whetherbinomialorlikertscalesshouldbe

usedforevaluation;whetherallroutesandtypesofmedication suchas:oral,intravenous(IV),intramuscular(IM)andcontrolled schedule8drugs(CD)shouldbeincludedinonetoolorshould therebemultipletools.

•numberofpatientstoadequatelyassesseachnurse. •numberofmedicationstoadequatelyassesseachnurse •numberofroutesofmedicationstoadequatelyassesseachnurse •lengthoftimetoadequatelyassesseachnurseandallowthetool

tobepracticalanduseful •frequencyofobservations

Based onthe resultsof therecommended contentfrom the expertpanelamedicationadministrationtoolwasdesigned.The designedtoolwasthensenttotheexpertpanelforfacevalidity evaluation.

3.5. Dataanalysis

DatawerecollatedusingMicrosoftExcelandtheitemcontent validityindex(I-CVI)wascalculatedbytheproportionofitems ratedrelevantbyeachexpert.ThedescriptionforcalculatingI-CVI

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Fig.1. DataAnalysis. (Polit&Beck,2006)

Table1

DataAnalysisMeasuresofAgreementandAcceptableRatings.

Measure Calculation ValidityRating

I-CVI=Itemcontentvalidityindex Numberofitemsratedrelevant(3or4)/numberofexpert

responders

Good=>0.78; Excellent=>0.90

S-CVI/Ave=Scalecontentvalidityindexaverage AverageofallI-CVI Excellent=>0.90

MeanExpertProportion Averageofexpertproportionratedrelevantbyallexperts Excellent=>0.90

S-CVI/AU=Scalecontentvalidityindexuniversal agreement

Numberofitemsratedrelevant(3or4)byALLexperts /numberofitems

Good=>0.70 Pc=Probabilityofchanceagreementonrelevance N=numberofexpertsandA=numberagreeingon

relevance[N!/A!(N-A)]x0.5N

Good=<0.070

k*=Kappachancecorrectedforagreementonrelevance (I-CVI-Pc)/(1-Pc) Poor=k*<0.40;

Fair=k*0.40-0.59; Good=k*0.60-0.74; Excellent=k*>0.74

isinFig.1.Thevalidityofeachscaleoverall,themeanitem con-tentvalidityindex(S-CVI/Ave),themeanoftheexpertproportion relevantbyallexpertsandthescalecontentvalidityindexwith universalagreement(S-CVI/UA)byallexpertswereallcalculated. Inordertoaccountforthepossibilityofagreementor disagree-mentonrelevancebeingbychancetheProbabilityofChance(Pc) wascalculated.Thenamodiﬁedkappa,forusewithmultipleraters, astatisticalindexadjustingforchanceagreementwascalculated. Dataanalysismeasuresofagreementandacceptableratingsare detailedinTable1.

Fig.1.Itemcontentvalidityindex(I-CVI)forratingrelevance (Polit&Beck,2006)

Thecontentsratedasrelevant(3.quiterelevantand4.highly relevant)andrecommendedtokeepitemasis,wereconsideredfor useinthedesignedtool.Contentsratedasrelevant,andreviseitem wereconsideredformodifying.Contentsratedasnotrelevantwere notconsideredforuseinthetooldesign.Duringtheexpertpanel meetingallresponsestotheagendaquestionsweredocumented andthemajorityresponsewasusedinthedesignofthetool.

Qualitativethematicanalysisofcommentswasconductedby collatingintocommonwordstodeterminethemes.Thesethemes wereusedasreasonstoaltercontentorincludeintheproposed tooldesign.

4. Findings

4.1. Quantitative

Fourteenofthe16expertpanelcompletedthedemographic questionnaire.Theyconsistedof5nurses,6pharmacists,2medical ofﬁcersand1publichealthresearcher.Allhadbetween10and40 years’experienceintheirprofessionalpracticewiththemajority

having20–30years’experience.Overhalfofparticipantscurrently managemedicineseitherprescribing,dispensingoradministering. Justunderhalf(6/14)havingpreviousexperiencewithvalidating acompetencytool,ofwhich67%weremedicationrelated.

Thedataanalysisresultsforrelevanceandcontentvalidityfor eachof thethree medicationadministrationtoolsare shownin Table2.Allcontentitemsratedasexcellentinthethreetoolswere considerforuseintheproposedtooldesign.

4.2. MwRT

TheMwRThad45questionswithlessthanhalf(22)scoringan I-CVIgreaterthan0.78ratingthecontentrelevanceasgood.The S-CVI/Avedidnotmeettherecommended0.9ratingandthe S-CVI/UAratingofagreementbyallexpertswasonly0.27.Therefore, thekappaindexcorrectedforchanceagreementratedonly22/45 itemsforthescaleasexcellent.

4.3. MASAT

TheMASAThadonlyeightquestionsandtheI-CVIratingforall eightquestionswas100%agreeingonrelevance.Therefore,the S-CVI/Ave,meanexpertproportion,S-CVI/UAandkappadesignating agreementonrelevanceallratedthescaleasexcellent.

4.4. CSAT

TheI-CVIforall25questionsintheCSATratedover0.78rating theitemsrelevanceasgood.Thescalecontentvalidityratedas excellentforallcalculationsofS-CVI/Ave,meanexpertproportion, S-CVI/UAandkappa.

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Table2

CombinedSummaryofToolExpertPanelEvaluationofContentValidity.

Tool Number ofItems Numberof Experts Numberof I-CVI>0.78 Meanexpert proportion>0.90 MeanI-CVI (S-CVI/Ave)>0.90 S-CVI/UA >0.70 Pc<0.069 Numberof k*>0.74 KappaEvaluation Rating MwRT 45 10 22 (0.30-1.00) 0.68 (0.21-0.98) 0.73 0.27 0.001-0.273 22 (0.20-1.00) 22/45Excellent MASAT 8 10 8 (1.00) 1.00 (1.00) 1.00 1.00 0.001-0.002 8 (1.00) 8/8Excellent CSAT 25 12 25 (0.89-1.00) 1.00 (1.00) 0.97 0.72 0.00-0.018 25 (0.90-1.00) 25/25Excellent Table3

QualitativeThemesfromToolsReviewed.

Tool Theme Description

MwRT “wordingneedstoberevised”

“clariﬁcation”“notpracticalbecauseitwastoo long”“notrelevanttogeneralnursing medicationsafety”inAustralia

Clariﬁcationrequiredaroundquestionsmeaning.Itwaslongwith45questions. ItwasspeciﬁcallyformentalhealthnursesandnotgeneralnursinginAustralia.

MASAT “student”“allergies”“acronyms”“outcome” Speciﬁctostudentnurses,notgenericforallnurses. Therewasnocheckofpatientallergies.

Acronymsusedwerenotclearorgeneric.

Havingcheckeditwasnotcleariftheoutcomewas“correct”.

CSAT “checking”“correct”“add”“how”“duplication” Patientidentiﬁcationandallergieswerenotseparatequestionstobeabletodetermineifthey werecorrect.

Moredetailneededtobeclearonspeciﬁccomponents. Howisitdonetobeobservable,measurableandconcise. Duplicationofquestionsandcomponentsintool.

4.5. Qualitative

Therewasgeneralagreementbytheexpertpanelthatthere shouldbe“rights” ofmedicationadministration included;right patient,medication,dose,route,time.Commentswerethat word-ingneededtobeclearanddeﬁnedasobservabletasksbysuccinctly describingthesteps.Itwasalsoagreedthatthereareprocedural stepsassociatedwithmedicationadministrationthatneedtobe included.Suchas:

•Appropriatehandhygiene

•Aseptictechniquewhenpreparingmedication

•Conductingassessmentandobservationsofthepatientto deter-mineifitisappropriateandsafetoadministerthemedication. •Engage the patient in the administration to determine their

knowledgeandunderstandingofthemedications.

•Appropriatelydocumentadministrationofthemedicationafterit hasbeenadministered,orifnot,whynot,andwhowasinformed andendorsedthedecision.

Thepanelconcurredthatideallythereshouldbeoneratingscale forbothcomponentsofthetoolandthatabinomialyes/noscale, waspreferableandpractical.Itwasagreedthatonetoolshould coverallroutesandtypesofmedicationadministeredandtherefore somequestionswouldnotbeapplicableinallscenarios.An exam-pleofthiswouldbeoralmedicationwhichrequiresonenurseto administerandwouldnotrequirelabellingofanintravenousline. Thequestionofhowmanyobservationsormedicationswouldbe adequatetoevaluateeach nurses’practiceremainedunclear,as itwouldbedependentontheoutcomeoftheobservation. Rigor-ousdiscussionwasaroundhowthiswouldbedeterminedwithall agreeingthatitwouldbedependentonmanyvariablesi.e.Howsafe thenurse’spracticewas;andwhethertheobserver’sexpertopinion wasthattheyrequiredmoreinformationtodetermineconsistency ofpractice.Mostsaidtheywouldrequireatleastoneobservation, withoneexpertrecommendingmorethantwopatients,andone recommendingﬁvetotenpatients.Butitwasagreedthatsome nursesmayneeda repeatevaluation. Thepanelagreedthatan annualassessmentwouldbebeneﬁcial.Theconsensuswasthata

toolneededtobeameaningfullearningtool,thatincludednurse’s self-assessment to enablereﬂection ontheirown practice.The panelagreed thatarticulated feedback inwhich a plan for any improvementcanbediscussedandagreeduponwasimperative. Overallthetoolandprocessneedtobepracticalandworkable,so itwillbeappliedandbecomepartofthenormalpractice.

Individualqualitativethemesforthethreetoolsreviewedare summarisedinTable3.Thethemeswerepredominantlyaround addingitemsdeemedimportantsuchascheckingpatientallergies andclariﬁcationtoensurecontentwasconciseandnotduplicated. Examplesofquestionsdeemednotrelevantincludedthosethat werelongandusedmultiplecriteriatomakeanevaluation, mak-ingitunclearonwhatwasbeingchecked.TheMwRTcontentwas speciﬁctoUKmentalhealthnurses.Halfofthecontentwasratedas irrelevanttothegeneralnursepopulationandwouldrequiremajor revision.Howitemsweremeasuredwasnotalwaysobservable,and whatwastheoutcomeonceitwaschecked,wasitcorrect?

Usingtheresultsofthefeedbackfromthefacevaliditysurvey thetool wasrevisedfor furtherevaluation withintra-raterand inter-ratertesting(Table4).

5. Discussion

Theaimofthisstudywastoidentifysuitableandrelevant con-tentrequiredforinclusioninanevaluationtoolfornursingstaff undertakingmedicationadministrationintheclinicalsettingby reviewingthecontentofthreeexistingtools.

The MwRT was very long containing 45 questions and was speciﬁctomentalhealthnursesintheUK.Thecontentwas compre-hensiveincludingproceduralstepsforappropriatehandhygiene, considerationofwhetheritisapplicableforthepatientconditionas wellasengagingthepatientinthemedicationadministration.Only halfofthecontentwasratedasrelevantandwouldthereforeneed revisionforuseinthegeneralnursepopulation.Thetool there-forewasdeemednotpracticalorrelevanttothegeneralnursing medicationsafetysetting.

TheMASAThadthefewestquestionsandratedthehighest rele-vanceforallthreetools.Thisensureditwasconciseandeasytouse. Thestudywasdesignedspeciﬁcallyforstudentnurses.Although

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Table4

ExampleofContentinDesignedMAEFT.

RightMedication

1 Checkedthemedicationagainstthemedicationorderandconﬁrmedthe medicationnameandformulationiscorrect.

2 Conﬁrmedthemedicationisindicatedforthepatientdiagnosisandchecked therearenoduplicateordersofthemedicineorofsimilarclassofmedicine. 3 Checkedthemedicationexpiryiswithindate.

RightProcedure

1 Nurseconductspatientobservationspriortoadministeringthemedication asrequired.

2 Nurseconductshandhygieneandusesappropriatepersonalprotective equipmentasrequiredwhenadministeringthemedication.

3 Nurseusesstandardnon-touchoraseptictechniquewhenpreparingand administeringmedication.

4 Nurseconﬁrmsifmedicationrequires2nursestocheck.Ifso,bothnurses performanindependentcheckandcalculation.

thiscouldbeextrapolatedtothegeneralnursepopulation. The expertpanelidentifiedanumberofgaps–suchasnocheckingof thepatient“allergies”whichiscrucialtoavertre-exposureofthe patienttoknownadversedrugreactions(ADR)and preventable harmandakeycomponentinAustralianMedicationSafety Stan-dard4 (AustralianCommissiononSafety andQualityin Health Care,2012b).Inaddition,therewereonlytwopatientidentifiers andinAustralia,Standard5.PatientIdentificationandProcedure Matchingrequiresatleastthreeidentifierstoconfirmthecorrect patient;patientname, dateofbirth anduniquehospital record number(AustralianCommissiononSafetyandQualityinHealth Care,2012a).Thepanelidentifiedthatanumberofthequestions withinthetoolwereunclearandambiguous.

TheCSATratedashavingexcellentcontentvalidity.Thepanel didhighlightsomedisadvantages however.Notallcomponents werewrittenasobservableandmeasurabletasks.Anexamplewas thecheckingofthepatientidentiﬁcationwherethepatientchart label,hospitalrecordnumber,dateofbirthandallergieswereall onequestion.Thesewouldneedtobeseparatecriteriainthetool. Thetoolwasfoundtobecomprehensivebutsomeofthecontent wasduplicatedsuchasrequirementsforsinglenursecheckandtwo nursecheckwhichwerethesame.Onlythetoolfororal, subcuta-neousandintramuscularmedicationadministrationofthepackage wasreviewedhowever,thepackageincludedtwootherseparate toolsfordifferentroutesandtypesofmedicationsthatwerenot reviewed.

Therefore,theliteraturehasidentiﬁedadearthofappropriate toolsforevaluationofallnurses’medicationadministrationclinical practicethatarereliableandvalidated.

Itisimportantthatthedesignofanevaluationtoolisgenericto theadministrationprocesswithgenericterms,soitisnot coun-tryspeciﬁcto make it as universalas possible.Although there aredifferencesininternationalpracticese.g.USApre-madeand automateddispensedmedications,thecorecheckingrequirements shouldremainthesame.Norshouldthedifferencebetweenthe typesofmedicationadministration(e.g.fromtheoriginal pack-age,adoseadministrationaidorautomateddispensingsystem) impacttheuniversalityofamedicationadministrationevaluation tool.Itshouldalsobegenericforanymedicationadministration setting,suchas;inahospitalwardenvironment,proceduralarea, nursinghomeorcommunity.Medicationadministrationstandards ofpracticeshouldremainthesameregardlessofprofessione.g. Nursing,medicalofﬁcersandalliedhealthstaffsuchas

physiother-apists.Hencethereisaneedfordesigningagenericmedication administrationtoolsuitableforusebyallclinicians.

6. Conclusion

The expert panel identified that the content of a medica-tionadministrationself-evaluation,observationandfeedbacktool neededtobeclear,conciseandobservableinordertobeuseful. Specificcriteriawereestablishedbasedonthreetoolsidentified in the literature. Such a tool needed to be generic for use by allnursesregardlessofexperience,specialtyandclinicalsetting. Nursesneededtoself-evaluatefirsttoenablereflectionontheir ownpractice.Formative,notsummative,feedbackbytheobservers wasidentifiedaskey,aswasanagreeddevelopmentalplanforthe tooltobeutilisedasalearningtool.Importantly,self-awareness andfeedbackofclinicalpracticemayprovidemotivationto main-tain and improvestandards of care,potentially reducing errors andprovidingsafermedicationadministrationpracticeandbetter patientoutcomes.Futurestudieswillinvolvevalidatingfor inter-raterandintra-raterreliabilityandfurthertestingintheclinical setting.

Ethicalapprovalstatement

Thisstudydidnotinvolvehumanoranimalresearchandwas grantedan exemptionfromHighRiskEthics bytheRoyal Bris-baneandWomen’sHospitalHumanResearchEthics Committee HREC/16/QRBW/351on11thJuly2016.

ExpertPanelReviewArticle Conﬂictofintereststatement

Therewasnoconﬂictofinterestsinconductingthisstudyfor anyoftheauthors.

Acknowledgments

Theauthorsaregratefultotheexpertpanelwhotookthetime tocompletethequestionnairesandparticipateinthereviewofthe contentanddesignoftheMAEFT.Theauthorswouldliketothank QIMRBerghoferMedicalResearchInstitutestatisticiansfortheir expertiseandadvice.

ThisworkwassupportedandfundedbytheQueenslandHealth, Metro North Hospital and Health Services, Royal Brisbane & Women’sHospital,ResearchPostgraduateScholarships2017for theﬁrstauthorPhDcandidatethroughtheUniversityof Queens-land.

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