Adaptive Web-Based Technology Aiming at Improving Learning of Medication Calculation Skills for Nursing Students

Abstract

Medication calculation skills are in great demand among registered nurses. However, miscalculations are a common medication error performed by registered nurses in the clinical setting. Medication calculation errors are common causes of unintended harm to patients of all ages. Mastery of medication calculation skills is one of the tasks nursing students should achieve during their education. Outcome measures, however, indicate that for many students, accurate medication calculations are challenging to both learn and master. This justifies the need for effective learning and teaching approaches in medication calculation skills for nursing students. In recent years, interactive and dynamic learning resources in the form of technological devices and interventions have been developed and implemented to improve nursing students’ learning opportunities in medication calculation skills. Research suggests that web-based technologies can enhance learning opportunities in medication calculations. However, for students who have inadequate knowledge, opportunities, and abilities in learning, progression slows down, and more time must be spent on learning. Adaptive web-based learning technology is an emerging technology that have additional learning benefits than traditional interactive web-based learning technologies. This chapter describes the potential of adaptive web-based learning technologies to support learning of medication calculation skills.

1. Introduction

1.1 Learning and development of professional competence in medication calculation skills

Professional competence is considered as an essential ingredient to provide effective nursing care and to ensure patient safety [1, 2]. Professional competence is defined as the ability to use a set of knowledge, skills, attitudes, clinical reasoning, and behaviors to successfully perform jobs, roles, or responsibilities [3]. Medication calculation skills are in great demand among registered nurses [4]. To provide high-quality and safe care to patients, registered nurses need to be competent in medication calculations [5]. However, miscalculations are a common medication error performed by registered nurses in the clinical setting [5, 6, 7]. Medication calculation errors are common causes of unintended harm, such as injury and death, to patients of all ages [7, 8]. Miscalculations also affect patients’ length of stay and the financial cost of healthcare services [9]. Miscalculations have to be avoided to protect patients against undesirable consequences such as injury and death [9, 10].

Nursing students go through extensive education, in both the academic and the clinical setting, to develop professional competence so that they are prepared to meet the patients’ needs and to provide care with high quality [11, 12]. Mastery of medication calculation skills is one of the tasks nursing students should achieve during their education [12]. Outcome measures, however, indicate that for many students, accurate medication calculations are challenging to both learn and master [13, 14, 15]. For example, in a European study including six countries, the authors found that even simple calculation tasks were challenging to master correctly for nursing students [15]. Medication calculation skills should be acknowledged as a well-defined competency in nursing education curricula and continuing education programs [6, 12, 16].

Improving the medication calculation skills of nursing students has been an ongoing challenge for nursing educators [9, 15, 17]. The issue lies in designing pedagogical, monitoring, and tutoring scenarios to support students to learn medication calculation skills appropriately [13, 17]. Currently, there are several global educational initiatives to enhance learning and thereby prevent medication calculation errors. Most common are textbooks that aim to provide students with theoretical and practical knowledge in calculation skills [18]. Other resources that have been developed to facilitate student learning include audio files, pictures, animations, simulations, workshops, blended learning, and simple tests [19, 20, 21, 22]. In an attempt to respond to the demands of patient safety, many web-based learning resources have also been developed over several years to assist students and professionals in the learning of medication calculations [23, 24, 25, 26, 27, 28, 29, 30].

1.1.1 Web-based learning

Web-based learning is increasing from the extensively available and easily accessible connection to the Web [31, 32]. In web-based learning, a computer, such as for example a laptop or mobile phone, is used for instructional processes and is a key component of the educational intervention [33]. Web-based learning allows students to acquire knowledge in risk-free environments without involving real patients, in addition to allowing the learning intervention to be used at a time and place convenient for the students [32, 34]. This means that students can access web-based learning in real time or according to their own schedules, meaning a synchronous and an asynchronous approach to learning. Such flexibility is reported to be a core benefit with web-based learning [34, 35].

Web-based learning that only is based on a network of static hypertext pages provides students with passive and inadequate learning experiences [33]. However, in the recent years of web-based development, several web-based learning developers have implemented different kinds of interactive web-based learning interventions, providing students with opportunities to make their own choices from the various options available based on their understanding of a task or situation [17, 32]. In this lens, students are given a hands-on approach to web-based learning, working with questions or quizzes and assessment activities when learning a task. This active learning approach engages students with the learning material [34]. Students are required to participate in the learning process actively, rather than simply be passive receivers of information [35].

Since the advent of web-based learning, various web-based learning resources have been developed to improve learning in medication calculation skills [23, 24, 27, 36, 37, 38]. However, technological learning interventions do not necessarily provide benefits in medication calculation skills for all students. Kim and Park [27], for example, studied the effectiveness of an interactive smartphone-based dosage calculation training app in a Korean context and revealed that the app improved nursing students’ calculation skills but only for students with higher prior knowledge. The smartphone-based training program had an inadequate effect on knowledge building in students with lower prior knowledge. In a Norwegian context, Foss et al. [24] developed the interactive web-based learning resource ‘The Medication Game.’ Nursing students experienced the web-based learning resource to be fun to use, but the authors concluded that the learning resource did not significantly improve the students’ test results in medication calculations. Both students and professionals continue to struggle with the learning and mastering of medication calculation skills [5, 6, 13, 26, 27]. This brings to the fact that even interactive web-based learning resources do not ensure learning and competence development in medication calculations for all learners.

Students progress at different paces; while some individuals learn fast, others learn more slowly [27]. It is imperative to design and develop web-based learning resources that provide appropriate learning opportunities in medication calculation skills for meeting knowledge requirements of all learners [15, 27]. The learning of medication calculation skills should be based on the individual student’s learning needs and abilities in learning, an adaptive approach to learning, and not in a system that ‘fits all’ [39]. By adaptive technology, we mean an algorithm that can determine what knowledge the individual student lacks, what kind of feedback the individual student needs, and what challenges the student should face [40, 41, 42].

1.1.2 Adaptive web-based learning

Adaptive means adaptation, and adaptive learning is the same as adapted training. Adaptive learning is an educational method that uses web-based learning resources to specially adapt learning materials and assignments to the individual’s prior knowledge and skill level [40, 41, 42, 43]. In adaptive web-based learning, the software observes one or more aspects of learning, most often whether if the student has answered correctly or has errors in tasks, and then analyzes the observations in order to personalize the learning materials offered by the web-based learning resource [41, 42]. This means that the software does an analysis of what the student has mastered and not and the need the individual has for learning to achieve progression in their understanding and mastery. In such an approach to learning, the adaptive web-based learning resource will help a student obtain information in a form that fits the individual’s characteristics and fulfills the student’s real learning needs automatically, as well as help the student to avoid the challenges of information overload [40, 41, 42]. Many students do not understand themselves as learners in order to understand their learning needs and abilities in learning [44]. Consequently, students do not understand their strength and limitations, making it challenging for students to select what tasks they need to learn and practice. Moreover, they make inappropriate choices in both learning objectives and approaches to studying, for example, surface and deep approaches to studying and learning [45].

Development of adaptive web-based learning resources in the field of healthcare education is in its infancy [39, 40, 43, 46]. Fontaine et al. [40] have conducted a systematic review including 21 articles, enrolling 3684 health professionals and students. Clinical topics were in particular related to diagnostic testing, and no studies were related to medication calculation skills. In a recent scoping literature review by Andersen et al. [43], aiming to explore characteristics with adaptive learning technologies blended into nursing education, none of the six studies included in the review concerned medication calculation skills. Andresen [39] has in a Norwegian context developed an adaptive web-based learning resource related to medication calculation skills, and the learning resource is revised and adjusted until June 2022. This emerging web-based learning resource could hold promise for enhanced learning and development of competence in medication calculation skills. It is challenging to develop a web-based learning resource combining pedagogical rules with adaptive web-based technology in order to give students more personalized learning experiences [42, 47]. First, we describe the emerging web-based learning resource, and then, we suggest how the web-based learning resource can contribute to learning. Following this, we define research to be conducted to evaluate and test the adaptive web-based learning resource.

2. Description of emerging technology, an adaptive web-based learning resource

A big challenge in developing an educational web-based learning resource is the intelligent and personalized resource recommendation for learners, how to implement personalized facilities by understanding the learner’s personal characteristics such as learning needs and abilities in learning [42, 47]. The adaptive web-based learning resource designed by Andresen [39] provides a personalized approach to learning of medication calculation skills, implying the individual student’s level of calculations to be considered.

A key point was the use of the Technological, Pedagogical, and Content Knowledge (TPACK) model [48] (Figure 1) to design and develop the adaptive technological learning resource for medication calculations. Such knowledge is important to possess in order to realize the potential benefits from the web-based learning technology [43, 48]. Using the TPACK model contributed to a learning resource, shifting the accent from simple information transmission to a constructivist way of learning [46].

Figure 1.

The TPACK model [48].

Figure 1 illustrates that the TPACK model consists of three types of knowledge (technological, pedagogical, and content knowledge) and further that the TPACK model’s three types of knowledge are mutually dependent for innovative teaching and learning. By differentiating among these types of knowledge, the TPACK model outlines how content and pedagogy form the foundation of effective education, while the technology used should communicate the content and support the pedagogy to enhance students’ learning experience. Content knowledge is domain-specific knowledge and, in this case, related to medication calculations, for example, what formulas (dose–quantity–strength) to be used when calculating medicines in different categories (tablets, injections, drops etc.).

Pedagogical knowledge describes theoretical learning approaches, lesson planning, and assessments. The adaptive web-based learning technology in medication calculations is proposed as a person-centered long-term strategy for learning and developing essential medication calculation skills. A cognitive perspective on learning is underpinned by the idea that individual learning is a result of a re-construction of knowledge, implying that new knowledge builds on previous knowledge [49]. The adaptive web-based learning resource was also developed based on the theoretical understanding of scaffolding, a process in which a more knowledgeable ‘other’ demonstrates how to perform a specific task, then allows the learner to work independently, offering support as needed [50]. Vygotsky [50] related this to the zone of proximal development (ZPD), which describes the difference between what a learner can do independently and what he/she can do with support or guidance from the more knowledgeable ‘other.’ The adaptive web-based learning technology is the more knowledgeable ‘other,’ supporting the learner to be in a flow zone, which is the balance between what is too challenging and what is too easy to be mastered independently. In such a way, learning is adapted to the individual student’s learning needs and abilities in learning. Students will be kept continuously motivated for learning and development when a computer guides them into their personal flow zone [43]. Additionally, the learning and teaching principle ‘constructive alignment’ has been taken into consideration, as learning goals, learning activities, and assessment methods have been appropriately aligned [51]. The adaptive web-based learning resource was developed in line with these theoretical approaches, as it is based on how students learn and develop knowledge in order to achieve understanding and competence. Theoretical approaches are commonly applied to inform development of web-based learning resources [46].

Technological knowledge concerns understanding the function of a web-based learning resource and exploring its possibilities for assisting or impeding learning in a specific subject area [48]. Adaptivity is implemented into the web-based learning resource via content adaption and link adaption: the former is how the learning outcomes/tasks are presented, and the latter is how the student navigates between the content adaption [40, 47]. In this way, the student is provided with feedback and assessments that are the most appropriate for the student’s medication calculation level, learning needs, and abilities in learning [41].

In summary, the TPACK model is implemented into the adaptive web-based learning resource via content and link adaption. The student’s medication calculation level anticipates the types of medication calculations and learning support (content knowledge) that best address the student’s learning needs and thereby increase learning efficacy. The student’s correct and incorrect medication calculations are stored in the adaptive web-based learning resource to build the individual student’s profile (knowledge, learning needs, ability in learning) and thereby adapt the presentation of education material according to learners’ profile. In this way, computer algorithms coordinate the interactions and learning support to address the content, knowledge, learning needs, and ability in learning of each individual student in medication calculations (technological knowledge). Students are given opportunities to engage in repetitive learning and further be engaged in less challenging medication calculations before being engaged in more challenging medication calculations, which highlights the learning of medication calculation skills as a developmental trajectory (pedagogical knowledge). The adaptive web-based learning resource is in line with a complex learning resource, providing meaningful and constructive feedback around learning and motivating and stimulating reflection within the learning situation [52].

2.1 Reflections and expectations of the adaptive web-based learning resource in medication calculations

To ensure that nursing students are competent in medication calculation skills, nursing education must bear the responsibility for the development and implementation of pedagogical strategies for teaching, learning, and assessing medication calculations [15]. Including any web-based learning resources does not necessarily guarantee better learning outcomes in medication calculation skills [27]. Students may fail to effectively grasp important information and learning opportunities due to having total freedom in browsing the web-based learning objectives/tasks. Self-directed learning (known as learning independently) can be challenging even in higher education, even for the brightest and most motivated students [53]. The fact that students can decide which tasks they want to learn and what tasks to solve by quizzes is not to be understood as being adaptive but only an interactive non-adaptive function that stimulates an active approach to learning [40, 41].

We suggest that an adaptive web-based learning resource will facilitate acquisition of medication calculation skills so that students become competent in medication calculations. An adaptive web-based learning resource will enable students to learn more comprehensively through independent learning with individual accountability and mastery of learning [40, 42]. The existing literature is limited to the development of web-based learning resources in medication calculations without taking into consideration the individual’s learning needs and abilities in learning. The adaptive web-based learning resource developed by Andresen (2018), however, tailors learning to each individual student instead of providing the same traditional educational material to all students in a one-size-fits-all model. The adaptive element of the web-based learning resource is considered to be a person-centered approach to learning, by providing students with personalized learning even in a large group or clinical setting and thus avoiding cognitive overload [49] when learning medication calculations. Furthermore, students are enabled to be active and engaged learners, with individualized feedback based on their ZPD [50], important for optimal learning and development of their medication calculation skills.

The adaptive web-based learning resource is expected to allow educators teaching medication calculation skills to monitor nursing students’ learning processes, to determine which aspects of medication calculation skills students find easy or difficult to master, and, in such a lens, to identify common challenges suitable for whole-class teaching. In this way, the adaptive web-based learning resource will function as a formative assessment resource to guide teachers as to what they should focus on when teaching in a group. In such an approach to teaching and learning in medication calculations, students’ learning will become more visible and useful, to both teachers and nursing students. Teachers need to be aware of students’ learning and development of knowledge to provide appropriate learning experiences for students [54]. Moreover, the adaptive web-based learning resource is assumed to be transferable to other healthcare professionals, for example, students in social work, paramedics, and medicine, who also are reported to have challenges in learning and developing knowledge and competence in medication calculation skills [55, 56, 57].

3. Conclusion

This chapter has proposed an adaptive recommendation approach of educational resources in learning medication calculation skills in nursing education. The aim of this recommendation was to provide better learning opportunities in medication calculations for students according to the individual student’s learning needs and abilities in learning. We have shown how to combine pedagogical rules with an adaptive web-based learning resource in order to give students more personalized learning experiences. We believe that nursing students will appropriately learn and develop medication calculation skills that are necessary to practice proper and safe nursing when they engage in using the adaptive web-based learning resource. How web-based learning resources are shaping learning in higher education is, however, less explored [42]. Due to the promising benefits of adaptive web-based learning [39, 42], we argue that directions for future research should be guided by the voices of the learners who will use the adaptive web-based learning resource when learning and developing medication calculation skills.

This complex adaptive web-based learning resource needs to be evaluated and tested to obtain knowledge of the consequences of implementing the resource in terms of its benefits and drawbacks in areas such as learning outcomes, learning experiences, user friendliness, motivation for learning outside the classroom, lightening the burden on the teaching staff when instructing large numbers of students, improved patient safety due to less miscalculations, and cost effectiveness due to accurate calculations in the clinical setting. Kabudi et al. [42] have emphasized the importance of evaluating adaptive web-based learning resources, because they can offer significant benefit for the individual learner.

Funding

This book chapter did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials

Given the nature of this work, there is no dataset used and/or analyzed.