Educational background of nurse prescribing students
Of the nurse prescribing students entering the course at the University of Nottingham (n = 100) 95% were female and had had a mean of 20.8 ± 0.7 years of nursing experience, ranging from 4 years through to 34 years. These students also exhibited a huge variation in formal biological science qualifications ranging from none all the way up to Master's level. The wide range in academic ability within cohorts has been previously noted by nurse prescribing lecturers in the West Midlands [14
] and according to a recent study by Courtenay et al is reflected nationally [23
]. Perhaps the most important difference between our data and that of previous studies is that we have specifically obtained students' highest biological science qualification rather than their highest academic qualification, which for many nurses is social science based. It can be seen from our data that almost half of students attending the nurse prescribing course had no more than a GCSE in a biological science subject (Figure ). While 25% of students stated that they had a diploma in a biological science a number of students classified their nursing diploma in this category, the shift in the pre-registration nursing curriculum away from a biological science model suggests that the biological science component of these courses may be limited. Overall then the majority of students had little in the way of formal biological science qualifications making the delivery of what should be degree level pharmacology to these students a very challenging process.
Highest Biological Science Qualifications. Highest Biological Science qualifications of students on Nurse Prescribing Course. Combined data from September 03 and January 04 cohorts (70 students).
While 100% of students from cohorts 1 and 2 completed the study only 47% of students from cohort 3 completed the study although this was likely the result of timing, with final questionnaires being handed out on the last taught day of the course. While a number of students took the questionnaire home with them to complete these were not returned to the University for inclusion in the analysis.
Evaluation of pharmacology RLOs
Student feedback indicated that students spent between 8 and 15 minutes working through each RLO with 'First Pass Metabolism' taking the shortest time to work through (8 ± 3 minutes) while 'Half Life' took the longest time to work through (15 ± 6 minutes). In terms of the usability and media attributes of the RLOs the majority of students either agreed or strongly agreed with statements relating to the ease of use of the RLOs and the value of the different components which make up the RLO, although 25% of students did comment that the RLO took longer than expected to complete (Tables and ).
Student ratings of usability of RLOs.
Student ratings of media attributes and size of RLOs.
With respect to educational value and learning support students were overwhelmingly positive about the value of RLOs with 90% agreeing or strongly agreeing with the statement 'The RLO has aided my understanding and I feel I have achieved the learning objective' and 92% agreeing or strongly agreeing with the statement 'I am confident that I will be able to use the knowledge gained from this RLO in future practice' (Table ). Comments made in the open questions backed up this positive view of RLOs;
Student ratings of educational value and learning support of RLOs.
'Liked the visual analogues, fantastic way of learning and remembering'
'It is a useful tool for revision, particularly being able to pace it and return to material to verify understanding'
There were some negative comments but these were based almost exclusively around issues of access;
'Would like to use the computer assisted, thought session was informative – but didn't know how to access from home computer'.
Previous investigations of the effectiveness of e-learning technologies for health professionals identified a number of barriers to its success among them cost, poorly designed packages, lack of skills, need for a component of face-to-face teaching, time intensive nature of e-learning and computer anxiety [21
]. The value of these pharmacology RLOs may be partly because they are by their very nature different to traditional e-learning tools. Our data suggest that individual RLOs do not require more than around 15 minutes to complete thus they do not require a time-intensive input making them more flexible for students to use at work or home. Similarly the visual, audio and interactive nature of these RLOs means that they have an appeal for visual, auditory and kinesthetic learners an important issue bearing in mind data which suggests that learning style is important in web-based e-learning [25
Learners' Perceptions of Pharmacology Understanding
The overall distribution of students' perception of their understanding of pharmacological concepts shifted to the right (towards the 'well' and 'very well' pole) for cohorts 2 and 3 who had had access to RLOs. Indeed when RLOs supported the concept no student rated their understanding as 'bad' or 'very bad'. Statistical analysis comparing the responses of the three cohorts was carried out using a Kruskal Wallis test and demonstrated a significant difference between mean ranks of the 3 cohorts in all but 2 RLOs and these data including 'p' values are shown in Table . The use of these two RLOs did suggest an increase in student understanding of the pharmacological understanding of the concept. However these RLOs were only available to cohort 3 which had the lowest number of student responders and it may be that the lack of statistical significance is a direct result of this reduced 'n' number. Histograms of the change in students' perceptions of three separate pharmacology concepts are shown in Figure .
Comparison of ratings of understanding of pharmacology concepts.
Figure 2 Perceived understanding of pharmacology concepts from 3 cohorts of students. Students from three consecutive cohorts of the nurse prescribing course were asked to rate their understanding of pharmacology concepts on a five point scale (very well to very (more ...)
As can be seen from Table students from cohorts 2 and 3 ranked RLOs third behind lecture notes and text books in terms of the learning resources which they felt had supported their learning best throughout the course. The RLOs were however rated substantially higher than journals, CAL packages and other web resources.
Ranking of RLOs against other learning resources.
It should be remembered that these RLOs were used within the nurse prescribing course to support and supplement, rather than replace, face-to-face teaching. This ensured that students maintained a relationship with a pharmacology lecturer who they saw on a regular basis and with whom they could discuss issues arising out of either lectures or RLO use. The ability to access the RLOs any number of times was also important, one student who had difficulty understanding what a synapse was said about the 'Exploring the Synapse' RLO:
"This one was good to go over and over again until I got it right and for revision"
The main problem associated with RLO use was focussed around computer anxiety and accessibility. The majority of these issues were tackled in the computer lab session however since the completion of this study we have moved to using a web-based environment (WebCT) for learning resources related to the prescribing course and have embedded all relevant RLOs within this environment thus making student access to these tools easier. In addition we utilise an IT expert to provide an introduction to using WebCT session on the first day, and to provide technical support throughout the course.
Students' perceptions of the impact of RLO learning following completion of the course
Ten students (7 female and 3 male) agreed to complete a telephone interview about the pharmacology RLOs used in the prescribing course. These 10 students represented approximately 15% of the total students in cohorts 2 and 3 and included students with a range of biological science qualifications.
When asked to recall the RLOs that supported the course all interviewees remembered using these learning tools;
'Recall vividly, really brilliant, absolutely brilliant' Participant 83 (male)
'I just thought they were very good' Participant 44 (female)
All 10 interviewees valued the RLO approach to teaching pharmacology (question 5) and would like to see more developed (question 8) while 50% of the interviewees had continued to access the RLOs since completing the course (question 3).
Two themes were apparent from the interview data one being the usefulness of the multimedia and reusability of the RLOs in terms of promoting learning in general;
'Quite useful for myself because I need a mental picture of what is going on to be able to understand it' Participant 81 (female)
'For me it was the visual aspect, actually seeing the concept visually was a huge bonus for me because it just made things click. We'd had key lectures and I'd read about things, but I think for me just to see how things worked visually was what I needed to put the whole picture together' Participant 82 (male)
'It probably helped with my exam. To pass the exam yes. It kind of changes the slant, sometimes reading a book is difficult and listening to a person is sometimes difficult, it kind of gives a third opportunity to take information in in a slightly different way' Participant 43 (male)
'Sometimes I found the application of the pharmacology in understanding I found quite difficult. The RLOs when I used them several times, it clarified a great deal of information for me.' Participant 83 (male)
and the value of RLOs in promoting pharmacology understanding;
'In our group we found the pharmacology lectures pretty intense and that (the RLOs) did actually simplify it a lot, yes it was definitely really useful' Participant 41 (female)
'Invaluable. For me as a mental health nurse practitioner the whole concept of pharmacology, pharmacodynamics, pharmacokinetics was a new concept so I would have really liked some RLOs for each area' Participant 82 (male)
'Because you are able to go at your own pace because pharmacology is the toughest part of the course from what I found and talking to other people. Studying it in that sort of fashion enables you to go at your own pace and go over again and again if you need which I certainly did' Participant 44 (female)
Students were also asked in the 12 month follow-up if they were confident in their understanding of the pharmacology of the drugs they were prescribing. Of the 9 prescribers who answered this question six said they were confident, with two of them attributing at least part of this confidence to the RLOs. Perhaps just as importantly, one prescriber interpreted this question to be a measure of 'safety of practice';
'7/10, feel safe enough but wouldn't say I know everything there is to know' Participant 44 (female)
The links between prescribing confidence, safety and pharmacology knowledge were also highlighted by students in the questionnaire;
'For me the underlying knowledge and understanding given by the pharmacology input is very important in giving me confidence to prescribe'
'The more I revise the subject [pharmacology] the more the concepts fit together. It has had a great impact on my clinical decision making........ I feel I have a much greater understanding which has made me a safer practitioner'
Students' perceptions of the impact of RLO learning on clinical practice
Students were asked whether the RLOs had had an impact on their clinical practice, and if so to provide examples, as part of the questionnaire and again during the 12 month follow up. On telephone interview 3 of the 8 prescribers who answered this question agreed that their practice had changed as a result of the knowledge gained through use of the RLOs.
With respect to the application of pharmacology to clinical practice students from cohorts 2 and 3, who had access to pharmacology RLOs, suggested that they valued the use of these learning tools in terms of constructing pharmacological understanding and integrating this into practice;
'Reinforced need to take drugs regularly due to my understanding of half-lives eg paracetamol' Cohort 2
'I feel the increase in RLOs will be very useful, I have used these a lot as part of my revision programme – as they help to visualise and interpret different concepts' Cohort 2
'I have been less impulsive in prescribing decisions, I am more likely to try alternative measures first, rather than just advising medication as I would have done in the past, particularly in the elderly' Cohort 3
This suggests that the use of RLOs as a learning tool did impact on student understanding of pharmacological concepts enough for them to utilise this knowledge within their clinical practice.
It can be seen from Table that the biology qualifications possessed by the interviewed students ranged from none to 'A' level and that those students who continued to access the RLOs post-qualification were at the lower end of these qualifications. The RLOs utilised in this study seemed to be of particular value in supporting students with less underlying understanding of biological concepts, although this is likely to be a function of the level at which these particular RLOs were pitched rather than a function of RLOs themselves.
Summary of responses from students post-qualification.
There are a number of limitations of this study one of which is the lack of reliability data in relation to the pharmacology questionnaire used. The questionnaire was only distributed to students on a single occasion so test-retest reliability was not possible. Similarly in order to keep the questionnaire at a manageable length for students who are already asked to complete both module and teaching evaluations, the questions were limited in number and a measure of internal consistency was not possible. A further limitation is the fact that the study was based in a single institution and as such we are only able to assess the value of this educational intervention in our own setting. It remains to be seen whether this educational intervention retains its value in other institutional settings where pharmacology may be provided by staff from different professional backgrounds. This issue is however countered to some degree by comments received through the on-line evaluation of these open access RLOs from students at other institutions nationally and internationally.
'I wish there were more of these. A great way to bring pharmacology to LIFE'
'Thank you for this excellent website! I am currently coming to the end of my second year in Nursing (mental health) at the University of Surrey'
'I will be glad if you provide me other tutorials regarding pharmacology (MPhilPharmacol)'
We have also received specific requests from a prescribing course in New Zealand and from a Health Trust in Wales to embed these RLOs into their courses.
In terms of nurse prescribing education a recent study by Latter and colleagues suggested that only 22% of prescribing students felt that the education programme met their needs completely, 84% identified pharmacology as the area which was most commonly studied during private study and 39% felt that pharmacology was an area of knowledge which was needed for practice but not adequately covered by the education programme [27
]. This correlates well with a study of mental health nurse prescribing students which reported a lack of confidence in pharmacology knowledge to the extent that students felt it insufficient to support their prescribing practice [28
]. Moreover a recent study of nurse prescribers' conducted in the West Midlands reported that 26% of nurses had not prescribed since qualifying [29
] suggesting a possible lack of confidence in their prescribing knowledge. These data appear to be reflected across the country with not as many nurses implementing their prescribing qualification as anticipated [30
]. Initially these data seem to be in direct contrast to the recent national study of independent extended supplementary nurse prescribers conducted by Courtenay and colleagues [23
] which indicated that 89% of nurses were confident in their prescribing practice. Whilst this survey collated responses from 868 nurses it should be borne in mind that only 73% of the initial sample responded and of these 87% had prescribed as an extended nurse prescriber (allowing them to prescribe independently from the extended nurse prescribing formulary) and 35% as a supplementary prescriber (allowing them to prescribe anything from the British National Formulary within an agreed client-specific clinical management plan drawn up in conjunction with a doctor) since qualifying. There are undoubtedly a large number of issues involved in determining whether nurses actually prescribe following qualification with pharmacology confidence being only one of these. It does seem irrefutable; however, that pharmacology is an area where nurses feel they need significant support even following qualification [23
Perhaps one of the most important issues to arise from this study then is the level of confidence that students have post-qualification and the relationship between this and the pharmacology RLOs. The ability of nurses to continue to freely access this growing collection of pharmacology RLOs even following qualification, may act to expand their pharmacological understanding in terms of continuing professional development and to maintain their confidence levels.