Pharmacology education for nurse prescribing students – a lesson in reusable learning objects

Background The shift away from a biological science to a social science model of nursing care has resulted in a reduction in pharmacology knowledge and understanding in pre-registration nursing students. This has a significant impact on nurse prescribing training where pharmacology is a critical component of the course from a patient safety perspective. Methods Reusable learning objects (RLOs) are electronic resources based on a single learning objective which use high quality graphics and audio to help engagement with the material and to facilitate learning. This study used questionnaire data from three successive cohorts of nurse prescribing students (n = 84) to evaluate the use of RLOs focussed around pharmacology concepts to promote the understanding of these concepts in students. A small number of students (n = 10) were followed up by telephone interview one year after qualification to gain further insight into students' perceptions of the value of RLOs as an educational tool. Results Students' perceptions of their own understanding of pharmacology concepts increased substantially following the introduction of RLOs to supplement the pharmacology component of the course. Student evaluation of the RLOs themselves was extremely positive with a number of students continuing to access these tools post-qualification. Conclusion The use of RLOs to support the pharmacology component of nurse prescribing courses successfully resulted in a perceived increase in pharmacology understanding, with some students directly implicating these educational tools in developing confidence in their own prescribing abilities.


Background
As part of the government's commitment to a more modern National Health Service (NHS) which allows patients quicker and more efficient access to medicines, prescribing powers have been extended to include not just doctors and dentists but also nurses who have undertaken a postregistration prescribing qualification [1]. Over the past few years we have seen both the implementation of supplementary prescribing for nurses [2] and the gradual expansion of the independent formulary for nurses [3,4] such that nurse prescribers are, in effect, able to prescribe the same drugs as doctors. The implications for patient safety following this expansion of nurse prescribing rights clearly signals the need for robust teaching strategies to promote understanding of new concepts and development of competency.
While the prescribing rights of qualified nurse prescribers in the UK are not dissimilar to those of advanced nurse practitioners with prescriptive authority in both Australia and USA there are some considerable differences in how these nurses are educated to perform this role. Currently the requirements for undertaking a prescribing course in the UK are that nurses should be able to study at degree level and must have been qualified for a minimum of 3 years [5]. In the UK there is however no requirement for nurses to show that they have previously studied at degree level nor is there any requirement for them to demonstrate a background level of understanding of basic biological sciences, a concern that has been previously raised by Tyler and Hicks [6]. This contrasts with the USA and Australia where, following research into nurse practitioner education, these programmes are taught at master's level as a minimum [7,8].
With the shift in pre-registration nurse training away from a medical model to a social model of care the level of biological science knowledge and understanding gained by pre-registration nurses has significantly reduced [9]. Indeed a number of studies have identified pharmacology education as an area of significant weakness both in the UK and elsewhere [10][11][12]. The implications of this for nurse prescribing education are profound [13] with a number of studies suggesting that both nurse prescribing students and educators recognise the problems associated with providing an adequate level of pharmacology input into these courses. [14,15] While pharmacology is only one of eight areas of indicative content for nurse prescribing courses (Table 1) it impacts on the majority of the remaining areas of indicative content and as such is important to ensure the safety of nurse prescribing, as it is with medical prescribing [16]. Pharmacology knowledge is examined as a separate assessment, by means of multiple choice and short answer questions, at the end of the nurse prescribing course and there is no compensation across assessments so students need to pass this exam to obtain the professional qualification. In order to promote safe prescribing we should be encouraging nurses not just to memorise enough pharmacology to pass the exam but to assimilate this knowledge and be able to integrate it (both vertically and horizontally) into their clinical practice. In this sense vertical integration can be defined as the integration of fundamental pharmacology principles into clinical therapeutics while horizontal integration refers to the integration of these principles into a comprehensive and holistic view of patient care [17].
Unfortunately teaching basic pharmacological concepts is a dry business and many students find it difficult to relate these concepts to clinical experience. Teaching these types of concepts is made more complex by the different academic levels and capabilities of nurses accessing nurse prescribing courses [14]. If we include the lack of classroom time available for nurse prescribing courses (only 26 days) coupled with the variety of clinical backgrounds and expertise of nurses attending these courses we can see that developing pharmacological understanding in students is a difficult task. Indeed in the study by Bradley and colleagues a number of lecturers involved in nurse prescribing training commented that their students had particular concerns with pharmacology and would benefit from preparatory material covering basic principles to develop familiarity with pharmacological terminology [14].
Perhaps part of the problem lies with the nature of pharmacology education for nurses which appears to utilise traditional teaching methodologies almost exclusively [15]. While lectures result in delivery of information they do not necessarily engender learning and understanding which may be better supported by blended or more applied teaching methodologies.
Consequently in order to promote the required understanding of pharmacology concepts, and taking into account the developments in e-learning technology, we have developed a number of flexible learning tools known as reusable learning objects (RLOs). Reusable learning objects (RLOs) are discrete units of learning that can be integrated into a formal lecture or used individually to aid revision or background knowledge. These learning objects use high quality graphics and audio to help engagement with the material and to facilitate learning. The concept of RLOs has already been identified as an important issue for new medical curricula abroad [18,19] and they have even been identified as improving learning performance of students studying clinical laboratory sciences [20]. Clinical pharmacology including the effects of co-morbidity. 5 Evidence-based practice and clinical governance in relation to nurse prescribing. 6 Legal, policy and ethical aspects. 7 Professional accountability and responsibility. 8 Prescribing in the public health context.
This Each of our reusable learning objects deals with a single pharmacological concept, is designed to take no more than 30 minutes to work through, and includes short interactive assessments to test developing knowledge. The subject of each RLO was specifically chosen as it represents a fundamental principle, an understanding of which is important not just for the pharmacology assessment but also as a building block for clinical therapeutics. These RLOs are freely available through the School of Nursing website and can therefore be accessed by students from home or work as well as from within the University, thus allowing students' greater flexibility in their learning (All the RLOs used in this project are open access with their web addresses being detailed in Table 2). This flexibility is particularly important for post-registration nursing students who may have both work and family responsibilities in addition to being a student. Indeed web-based open and flexible learning modules have previously been used with some success for post-registration nurse education including prescribing [21].
This paper describes the evaluation of these pharmacology RLOs and their value in promoting the understanding of pharmacological concepts between different cohorts of nurse prescribing students at the University of Nottingham between January 2004 and September 2005.

Methods
All students entering the nurse prescribing course at Nottingham University between January 2004 and September 2005 were invited to take part in this study. The study protocol was explained to all students and all students were given the opportunity to opt out of the study. Participation or lack of participation did not impact on the way in which students were taught and did not influence progress on the course.
As an evaluation of the value of an educational tool conducted mainly within class time ethical approval from the University research committee was not required. Experimental design and analysis was however performed following the British Educational Research Association's revised ethical guidelines (2004) and all data were anonymised before publication.
RLOs were developed using the Universities Collaboration in Elearning (UCel) framework [22] and comprised a multistage process including expert review at two different stages of development and formative student evaluation prior to use with student groups.
Cohort 1 (34 students) -This cohort of students followed the standard course module with pharmacology being delivered by didactic lecture format. Students were provided with book lists, weblinks and some general CAL materials but no RLOs were provided to supplement the pharmacology teaching.
Cohort 2 (36 students) -This cohort of students followed the same course and had access to the same resources as Cohort 1 but with the addition of RLOs 1-4 ( Table 2) that could be accessed by the student at any time in the course. RLOs were not used in lectures but were introduced to students in a separate session. Students were also advised on the timetable about RLOs which might be suitable supportive learning tools for specific lectures. Cohort 3 (14 students) -This cohort of students again followed the same course but had access to all eight pharmacology RLOs (Table 2) and introductory RLOs on the anatomy and physiology of both the liver and kidney.
Questionnaires were distributed to students at the end of the pharmacology component of the course and students who did not attend class on that occasion were asked to complete the questionnaire at the following session.

Value of RLOs in promoting pharmacology understanding
This study involved the collection of questionnaire data from three successive cohorts of nurse prescribing students regarding their perception of their own understanding of pharmacological concepts and whether they have been able to apply this to clinical practice. This questionnaire consisted of 26 items and was a mixture of both fixed response and open response questions. Students rated their perceived understanding of 10 specific pharmacological concepts (including, but not exclusively, concepts represented by RLOs) on a five point scale ranging from 'very badly' to 'very well'. Students were also asked to rate their own confidence in understanding pharmacology on a four point scale ranging from 'very confident' to 'not confident'. The questionnaire also contained 3 open response text boxes asking 'What was the most valuable resource that you used to clarify your understanding of pharmacological processes', 'In relation to your nurse prescribing practice please comment on any elements of the pharmacology component you found to be particularly beneficial' and 'Please give a specific example where you have used the knowledge of pharmacology you acquired during the course in your nurse prescribing practice'. Cohorts of students who had access to RLOs were also asked to rate the value of the RLOs for pharmacology teaching against other resources such as course notes and textbooks with 1 being the most useful and 6 being the least useful.
The questionnaire was designed following discussion between the authors and was checked for content validity by the module leader for the nurse prescribing course. Following distribution to cohort 1 no issues regarding face validity arose so there were no subsequent changes in the questionnaire for cohorts 2 and 3.

Evaluation of individual RLOs
Cohorts 2 and 3 were also asked to evaluate the RLOs using a questionnaire which comprised 29 fixed response questions using a 6 point scale using the descriptors 'Not applicable', 'Strongly agree' 'agree', 'neutral', 'disagree' and 'strongly disagree'. The questions were arranged into sections concerning access to computers, usability, look and feel, content and reuse. The questionnaire also included 3 open response text boxes asking 'What did you like about this RLO?', 'How could the RLO be improved?' and 'Any further comments?' Students were introduced to the concept of RLOs and provided with evaluation forms for individual RLOs in a computer lab session. This ensured that all students were aware of the available RLOs and where to find them. An information technologist was on hand in this session to deal with technical and navigational problems issues which arose through using the university system. There was no pharmacological input from a lecturer in this session. All evaluation forms were completed anonymously and placed into a box by students at the end of the session As these RLOs were freely accessible from the School of Nursing website these evaluation questionnaires were also completed by other students, such as those studying for a Masters in Nursing Science, who had accessed them.

Impact of RLOs for pharmacology on Clinical practice
An independent researcher was employed specifically to conduct telephone interviews with students one year after successful completion of the nurse prescribing course in order to gain an insight into the impact of the pharmacology RLOs on their continuing clinical practice. The independent researcher randomly selected students from among those who had attended the course as part of cohorts 2 and 3 for interview by telephone. 10 students were interviewed representing 15% of the total students from these cohorts, were interviewed by telephone. The interview was semi-structured and was piloted on two prescribers before being utilised in this study. Student responses to the questions shown in Table 3 were noted This researcher had had no previous involvement in the nurse prescribing course, was not known to any of the interviewees and is not an author of this paper.

Results and Discussion
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 1). 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.
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 4 and 5).
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 6)  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 [21,24]. 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 [25,26].

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 Percentage of students (cohort 2 and cohort 3) rating the pharmacology RLOs in terms of statements relating to their educational and learning support value. Percentage of students (cohort 2 and cohort 3) rating the pharmacology RLOs in terms of statements relating to their media attributes and size 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 7. 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 2.
As can be seen from Table 8 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.
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 Perceived understanding of pharmacology concepts from 3 cohorts of students   Kruskal Wallis test to compare the ratings of perceived understanding of each pharmacology concept between the 3 cohorts of students (2 degrees of freedom).
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; 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 deci- 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 9 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.
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' 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 [23,27,28].
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 con-tinue 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.

Conclusion
The introduction of RLOs dealing with specific pharmacological concepts significantly improved nurse prescribing students perceived understanding of the majority of these concepts. All RLOs were evaluated extremely positively by the students and telephone interviews with a small sample of students suggested that the RLOs were continuing to be used to support learning post-qualification and that a number of students felt their prescribing confidence was due, at least in part, to these educational tools. Developing an understanding of pharmacological concepts will allow nurse prescribing students to apply these fundamental concepts to their specific areas of clinical practice. This in turn will hopefully lead to increased confidence in their prescribing abilities thus ensuring that patients have a better access to medicines without compromising safety. This increase in confidence is perhaps even more important following the recent changes in government policy to discontinue the extended formulary for nurses and allow them independent access to the BNF.
Data from other institutions internationally which plan to utilise these RLOs will also be extremely valuable in determining the global value of pharmacology RLOs in improving understanding among prescribing students.