The medication administration process (MAP) is a complex and multistage practice in hospital settings. MAP plays a central role in nursing and is mostly managed by nurses, except prescribing that is conducted by the physicians. However, nurses are in some way involved in each stage of the MAP, including prescribing, documenting (transcribing), dispensing, administering, and monitoring. MAP is a time-consuming task, taking an estimated up to 40% of nurses’ work time [
In this paper, by nurse we mean registered nurses (RNs) that do not have the prescription authority. However, nurses have an essential role in prescribing. By “RNs’ role in prescribing” we mean the work that nurses conduct in interpreting and understanding the prescriptions. Nurses’ role in prescribing might also include suggesting medication and asking the physician to check patient’s medication or to do medication changes. In addition, nurses have a responsibility to prevent, evaluate, and report drug effects, side effects, and adverse drug events. In the participating hospital nurses also program the drug administration times and document them into to the medicine software.
The complexity of the MAP exposes risks to medication errors that are surprisingly common and costly [
Medication errors occur in all stages of the MAP in hospital settings, most frequently at administration, prescribing, or dispensing [
Medication administration is not simply a part of nurses’ work but rather constitutes most of their daily work. In hospital settings, one patient may require multiple scheduled and unscheduled medication doses per day. Unscheduled doses, for example, PRN (
The MAP is well recognized in previous studies. They have focused, for example, on nurses’ requisite knowledge of the MAP, such as clinical reasoning and practices [
The aim of this study was to describe the MAP from the registered nurses’ (RNs’) perspective. Both the problems confronted and support desired in the MAP are presented, thus providing new empirical knowledge of RNs implementing the MAP on a daily basis and an insight of the possible developmental areas in the MAP. This study is part of the “
A qualitative descriptive research design including thematic individual interviews and questions in a paper form was conducted.
Participants were chosen using a purposive sampling method from the population of RNs in two medical units. The inclusion criteria were participation in the MAP on the data collection day and RN willing to give a written informed consent. The eligible sample size was estimated to be 20 participants, large enough for data saturation. Saturation was reached when new data confirmed previous data without really adding new insights [
The settings for data collection were from two different fields of medical units in one university hospital in Finland. Both units have patients with high daily consumption of medication. Patients in these units are often elderly with chronic diseases and they come to specialized care with a need for painkillers and antiemetics in addition to the treatment medication and their regular medication. The description of the MAP in the units is shown in Figure
Medication administration process on the units according to the hospital policies.
The data was collected in January 2013, within a two-week period, using semistructured theme interviews and questions which were filled by the participants in a paper format. Both interviews and questions were employed as a single measure in Finnish and, thus, the citations used are translations. As no validated interviews or questionnaires relevant to the topic of interest were available, the themes of the interview and the questions were developed by the research group, based on previous scientific literature. The methods of this study were founded on the following stages of the MAP: prescribing, documenting, dispensing (filling the medication trays), and administering (to patients). The researchers visited both units prior to the data collection to present the study and inform the staff about the study. Subsequently, the staff had an opportunity to ask questions and receive answers concerning the study.
The interviews (Table
The themes and questions of the theme interview.
Themes | Questions |
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Prescribing and documenting | How do you experience your role as a nurse in prescribing and documentation of the medicine? |
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Dispensing and administering | How do you experience dispensing (filling the medication trays)? |
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Medication administration process | What sort of help would you like to have to facilitate the medication administration process? |
The questions in a paper form were handed out to the participants at the beginning of their shift and they were asked to complete, after the medication administration, and return them to the researcher. The completed answers were kept safe from other participants. The questions surveyed the RNs’ actions during the MAP. The questions were as follows: (1) how often do you need help in finding the wanted drug from the medicine cabinet?, (2) from what source do you check the generic substance or the changed brands of the medicines?, and (3) how often do you need to use
We used both methods (questions in a paper form and in-person interviews) to enrich the data and to get more realistic descriptions of the actions during the MAP without the interviewer bias [
The qualitative data was analyzed using deductive content analysis, where the themes and questions (the phases of MAP) guided the analysis. The analysis progressed with the following stages: preparation, organizing, and reporting. Preparation included making sense of the entire data set, selecting the unit of analysis as a unit of meaning, and analyzing the manifest content. Organizing entailed both searching relevant expressions relative to study questions and reduction of the expressions. Subsequently, grouping and abstraction of the data followed [
The study was licensed and approved by the authorities of the Hospital District of Southwest Finland. The study complied with a good scientific practice [
The results of the theme interviews show that RNs confront various problems, in each stage of the MAP, which interfere with their work, and have several areas they desire support in (Figure
Nurses experienced problems and support desired in different stages of the medication administration process.
RNs had different types of experienced roles in prescribing events and in documenting medications (Table
The nurses’ roles in prescribing and documenting medication.
Stage | Role | Specification |
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Prescribing events | An advocate of patients | Informing patient of medications |
An active attendee | Monitoring physician orders | |
A passive attendee | Executing orders | |
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Documenting prescriptions | A programmer | Programming administration times to the software |
A person responsible/in charge | Responsible for the entire documenting process |
The problems RNs experienced in prescribing were related to prescriptions, admissions, or discharges. Prescription-related problems included equivocal and erroneous prescriptions, nonprescribed orders, crucial factors not taken into account, and lack of information.
The support desired in prescribing was that the prescriptions were at accurate times and an updated printout was placed in the medicine rooms. Furthermore, RNs desired that the software would enable more precautions (e.g., notification of erroneous dosing) and getting collective directions for physicians when entering in prescriptions (e.g., complying with unit policies).
In documenting, RNs experienced problems related to programming, software, and environment. Programming was problematic due to
The supports RNs desired in documenting were clarity for the medicine charts and the opportunity to do documenting ubiquitously, regardless of time and place (e.g., during the medicine rounds). RNs urge that software would include all the important information needed (e.g., medicine software, patient records, medication history, prescribing and last expiration dates, and PRN medicines) in the MAP.
With the medicine software, RNs use drug databases (
In both units, each RN dispenses medicines to the patients they are in charge of over their shift. Although dispensing was experienced as laborious, difficult, time consuming, restless, and the most problematic stage of the MAP, RNs experienced it positively as a demanding task, requiring a lot of headwork, accuracy, concentration, and knowledge in order to evaluate if the medicines in the medicine and tray charts are valid. Moreover, dispensing was experienced positively as developing, educating, and maintaining skills and also as a way of gaining more patient information.
The problems experienced in dispensing were related to
RNs desired the most support in the dispensing stage. First, RNs desired assistance with finding, identifying, and verifying medicines or generic substances easier and faster as the following citation shows:
The problems RNs experienced in administering were related to
The desired support in administering was uniform: RNs desired to be able to check and verify medicines ubiquitously (e.g., in patients’ rooms). RNs desired to identify and verify medicines and check their purpose of use if a patient desires to look through them and also to be able to check patients’ MARs, regardless of time or place:
The aim of this study was to describe the MAP from the RNs’ perspective, by describing the RNs experienced problems and desired support in the MAP. This study shows that RNs have various roles in the MAP and RNs confront numerous obstacles impeding their work, making the MAP problematic. Yet, medication administration was experienced mostly as a positive task.
Problems in the MAP were experienced throughout the process. Problems related to RNs’ role in prescribing events, such as interpreting
The problems RNs experienced in documenting were mostly related to the dysfunction of the software. The results suggest that the current IT does not adequately support RNs’ work in the MAP. The software is prone for human error and its usability is inflexible. RNs desired new IT to be applied for the MAP that would enable ubiquitous documenting and clarity for the printed medicine charts, where one solution could be the use of electronic charts only. Dispensing was found as the most problematic stage in the MAP. Unavailability of medicines was experienced as problematic in dispensing. Similarly, Vogelsmeier et al. [
Finally, problems and support desired in administering medicines were discovered. Patient-related problems in this study are similar to Dilles et al. [
Operational environment-related problems were experienced as problematic in each stage of the MAP, excluding prescribing. Previous studies [
The two methods used for data collection and two persons analyzing the data (data and researcher triangulation) strengthen the validity of the results. Additionally, motivation and enthusiasm of the participants can be considered as strength. However, this study has some limitations. The data was collected using interviews and questions in a paper form developed for this study on the basis of previous research but not validated in earlier studies. This research is limited to one hospital and two units only; thus, the results are not generalizable. However, they are mainly in line with results in several previous studies. The study provided new insights precisely from the RNs perspective of MAP and their actions during MAP and put together previous research, hence creating a comprehensive whole of the MAP.
The study is valuable in that it describes RNs’ personal experiences with the MAP. This study identified both a number of problems confronted and the support desired in the process, hence aiding the development of a more safe and flowing process. Furthermore, this study provides a framework for nurse managers to utilize the results of this study when planning the safety of the MAP in a hospital care setting.
Recognizing RNs’ concerns and recognizing desired support in the MAP are important first steps in improving the MAP. The problems recognized in this study are in line with both the support RNs desire and previous studies considering the causes of medicine errors. The results of this study show that there are improvements required in the MAP for RNs to be able to conduct safe medication administration and maintain patient safety. RNs have plenty of ideas of how the MAP could be developed, and their views should be taken into account when developing the process. Further research is needed when developing and applying new technology solutions to assist medication management in order to be the most convenient from users’ perspectives.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Hanna Pirinen, Lotta Kauhanen, Riitta Danielsson-Ojala, Johan Lilius, Ilona Tuominen, Natalia Díaz Rodríguez, and Sanna Salanterä designed the paper. Hanna Pirinen, Lotta Kauhanen, and Riitta Danielsson-Ojala collected the data. Hanna Pirinen and Lotta Kauhanen analyzed the data. Hanna Pirinen and Lotta Kauhanen helped in writing the original paper. Riitta Danielsson-Ojala, Johan Lilius, Ilona Tuominen, Natalia Díaz Rodríguez, and Sanna Salanterä helped in paper review and comments. All authors have read and approved the final paper.
The study was supported by Special State Grant EVO (no. 13190, Turku University Hospital) funding. The authors thank all the RNs from the two units who participated in this study.