Nurses play a very important role in managing patients’ medications in hospitals and in the community. Managing medications is complex, particularly for patients who have many coexisting conditions for whom therapeutic benefits and adverse effects are unpredictable and health priorities may be variable. As the main health professionals who spend an enormous amount of time interacting with patients, nurses need to have adequate knowledge in pharmacology to enable them to provide safe and high quality care.
Once registered or licensed to practise, nurses need to be able to assess patients before taking medications, plan goals of care, administer medications safely and effectively, evaluate the effectiveness of medications administered. They also need to counsel patients about their medications, help relatives to fulfil a supportive role, and collaborate effectively with each other, and with doctors and pharmacists in averting potential problems and setting goals of care. To have these attributes, pharmacological preparation needs to begin early—when students embark on an undergraduate course of study in nursing. While a great focus has been placed on preparing nurses for prescribing rights (e.g. Baker et al., 2008, Courtenay et al., 2008, Latter et al., 2007, Offredy et al., 2008) supporting nurses to achieve a comprehensive underpinning of pharmacology knowledge when they begin work as a registered nurse should be a more pressing priority. It appears, however, that there is insufficient content in pharmacology in undergraduate nursing curricula to help newly graduated nurses carry out this important role.
I teach pharmacological concepts and medication management in the university setting, and as an academic, a registered pharmacist and nurse, I can readily appreciate the importance of including pharmacology as a dedicated area of study in the curriculum. Over recent years, however, I have been confronted by students who are frustrated about the amount of pharmacology they receive in their undergraduate programs. Lecturers comment that with so much to fit into the curriculum, it is often difficult to accommodate everything that students want or need. With these tensions in mind, I sought to determine how much specific pharmacology content is actually delivered to undergraduate nursing students in Australia.
In preparing for this editorial, I completed a web-based audit of all undergraduate-nursing curricula across Australia, and located 30 universities that conduct such programs. I was particularly interested to see which of the courses mentioned the words ‘pharmacology’, ‘medication’ or ‘medication management’ in their titles or course descriptions. Out of the 30 undergraduate nursing programs available across Australia, 16 of these had no course of study in pharmacology, either as a stand-alone course or in combination with other courses. For seven university programs, pharmacology content was present in combination with other subject material, such as microbiology or pathophysiology. Only seven university programs had specific, individualised content, where pharmacology existed as a dedicated course.
There is intense debate in the literature about whether pharmacology should be taught as a separate or combined subject in undergraduate programs (Latter et al., 2000, Manias and Bullock, 2002a, Robinson, 1987). In Manias and Bullock (2002a), while lecturers anticipated that an integrated program would help to consolidate knowledge, students largely preferred to have a dedicated pharmacology course. Students perceived that a combined approach could have encouraged them to adopt superficial learning processes, leading to difficulties in making connections between theory and practice. In combined courses, greater attention may be given to teaching students about disease processes or microbiological aspects of care, therefore subsuming pharmacological content. Greater emphasis could be placed on clinical management of medications rather than on scientific pharmacological principles. An effective teaching strategy would therefore encompass elements of a separate as well as an integrated course. In this way, students can learn fundamental scientific principles of pharmacology, and reflect on the dynamic and clinical demands involved with assessing, planning, monitoring and evaluating patient care in managing medications.
While there is a lack of attention to pharmacology content in undergraduate nursing courses, the need for such content is clearly acknowledged by academics who conduct postgraduate courses for experienced nurses. Nurses in the United Kingdom can now train as independent prescribers, and for many years, nurses have been undertaking nurse-prescribing activities through nurse practitioner positions in the United States. In Australia, the nurse practitioner movement has gained momentum, with endorsed nurses acquiring the right to prescribe independently. To achieve the right to prescribe, nurses are required to have undertaken comprehensive pharmacology education at Master's level. Indeed, there are many debates worldwide about what is the acceptable amount and content of study at the postgraduate or Master's level.
While it is reasonable to accept that nurses with prescribing rights should be adequately prepared in terms of their knowledge base, there needs to be greater focus on preparing nurses in their understanding of pharmacological principles during their foundational years of nurse education. If nurses enter the workforce with a good understanding of pharmacology, they are likely to be confident in managing patients’ medications, and to practise in a safe and effective manner. If such nurses contemplate undertaking postgraduate courses of study because they wish to have prescribing rights, they will have excellent foundational knowledge from which to build upon. Unfortunately, such preparation does not occur to a large extent at the undergraduate level.
A contributing factor to the lack of pharmacology content in undergraduate programs is that regulating nursing bodies pay insufficient attention to the expected competencies of registered nurses for managing medications. For instance, the Australian Nursing and Midwifery Council, the peak national nursing and midwifery organisation for monitoring regulation, has produced core national standards for safe and competent practice (ANMC, 2005). While the standards are comprehensive, out of 231 competencies listed for registered nurses only one competency relates directly to pharmacology or medication management. This competency refers to the nurse's ability to: ‘describ[e] and adher[e] to legal requirements for medications’ (p. 2). The competencies are grouped into four domains–professional practice, critical thinking and analysis, provision and coordination of care, and collaborative and therapeutic practice. Clearly, the nurse's role in managing medications pertains to all four domains, even though no mention is made of competencies relating to this area. Greater attention should be given in delineating the medication-related competencies to which registered nurses should provide in caring for patients. University coordinators are required to use these competencies as guiding principles in developing and monitoring undergraduate nursing programs. If there is no specific focus of medication-related competencies in national competency standards, then it is less likely that dedicated content will be devoted to these aspects in curricula. Ultimately, specific competences need to be developed to guide university coordinators in their program development.
Evidence exists that demonstrates a lack of pharmacology content in undergraduate courses has an impact on future attributes and level of confidence of registered nurses. Research conducted on comparing graduate nurses’ actual and self-rated pharmacology knowledge in an Australian study (Ives et al., 1996), involved graduate nurses completing a knowledge test on five areas of pharmacology: medication administration, therapeutic effects of drugs, adverse effects of medications, 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-five percent of respondents scored less than 50% for the test. The authors concluded that a structured graduate nurse program would be helpful in addressing knowledge deficits. I would also argue that a comprehensive pharmacology course during an undergraduate program would also assist in rectifying the problem.
More recently, focus groups conducted with experienced clinical nurses about their experiences with newly registered nurses showed that they perceived the overall pharmacology knowledge of graduate nurses was severely lacking (Manias and Bullock, 2002b). Participants perceived newly registered nurses had knowledge deficits about the characteristics of medication family groups, the ability to read medication order charts, understanding of pharmacology terminology and applications of theoretical knowledge to clinical practice. There was also an acknowledgement that experienced nurses also had knowledge deficits in pharmacology because of a lack of sufficient grounding in undergraduate education (Manias and Bullock, 2002b).
The teaching and learning of pharmacology for undergraduate students is a very important issue that warrants immediate attention. We need to encourage nurse-regulating bodies to include clear and specific competencies in national standards for practice. University coordinators should be persuaded and supported to include dedicated course content in pharmacology. Only then, will nurses feel confident in delivering safe and high quality care to patients in managing medications.
Conflict of interest
None.
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