Three years ago I began teaching a drug-calculation course to third-year nursing students. After more than 20 years at the bedside, I had arrived in academia confident in my expertise and eager to share my clinical perspective with students. But I soon discovered a clash in our points of view.
In revising the course, I designed it to be forgiving of slow starters but demanding at the end. Students would have to earn at least 90% on the final exam in order to pass-admittedly a high bar. Considering the consequences of error once students reach the bedside, however, I regarded the requirement as well justified.
Faculty support was unanimous, but many students were incredulous. You would have thought I'd asked them to compete in the Olympics. Not a week went by in which I wasn't vigorously defending the "90 or better to pass" standard. Even when a note on the syllabus reminded students that "beyond this course there is no permissible level of error," rationalizations were many. "I'm not good at math; I just want to help people." "I can do it. I just need more time." My favorite: "There's a nursing shortage. Why is it so hard?"
Initially, I was surprised to find the students so daunted. After all, they were juniors who had already passed prerequisite math and chemistry courses. As my surprise turned to disappointment, I wondered if perhaps they were just naive about the real-world consequences of anything less than mastery at drug calculation. So last year I expanded my short syllabus note. I gave them an essay titled "Read Me First," translating my 90% requirement into the clinical realm. Among its points:
* If only four in 100 drug dosage errors are fatal, more than 70 deaths could result from the collective dosage errors of those passing this course.
* The volume of drug calculations performed on the job can be 10 times greater than the number assigned each term to students.
* If as RNs you were allowed the error rate this course permits you could end up collectively responsible for the deaths of 700 mothers, fathers, husbands, wives, sons, daughters, brothers, and sisters in the first three months of practice.
* Even if that's a hundredfold exaggeration, one in 10 new RNs could kill someone by medication error within three months of graduation.
I now rarely hear complaints from students. Recently I picked up a whining buzz from a source I didn't expect: RNs indignant about having to take drug-calculation competency exams. Again, the rationalizations: "I can do it on the floor." "I'm just not good at tests." Even more troubling: "You mean I can't work if I fail this stupid exam?"
This has led me to believe that my cautionary tale to students has wider applicability. Facilities have recently begun giving drug-calculation competency exams to new hires, but what if the results weren't used solely to determine employment eligibility? Suppose they also were used in assessing the quality of patient care? Might that serve as a not-so-gentle reminder of the consequences to patients of nurses' reluctance to confront issues of competence? Do nurses resist the idea of periodic testing because it's too frightening to consider the harm we may have done or will do?
Sure, it's frightening to acknowledge that our actions-and failures-have life-and-death consequences. But fear can incapacitate or motivate. I believe that our profession's character demands that we summon the courage to address the consequences of incompetence. And address them we must-for our patients' sake as well as our own.