Triangle technique: An effective tool for improving nursing students’ ability to calculate safe pediatric medication dosages

Abstract

Calculating the correct medication dosage for pediatric patients can be difficult for nurses to determine, as the pediatric dose is typically a small fraction of the adult dosage. This study aims to examine the impact of the Triangle Technique on the ability of nursing students to calculate low and high safe dosage ranges in children. To evaluate how this educational tool could improve a nurse’s skill in this area, a quasi-experimental pre-/post-test research design was employed including one hundred fifty-eight third-year nursing students. The Pediatric Medication Administration Form and Pediatric Safe Dosage Calculations Quiz (PSDCQ) were used to measure the effectiveness of the Triangle Technique. While <50% (n < 79) of students gave correct answers to each question in PSDCQ before this intervention, all of the participants (N = 158, 100%) gave a correct answer to one question, and >89.2% (n > 141) of the students correctly answered the other four questions of PSDCQ. The change in scores (pre-PSDCQ median score = 0, IQR = 60; post-PSDCQ median score = 100, IQR = 0) post-intervention was statistically significant (z = 10.633, p ≤ .001), indicating that this teaching technique was effective for improving students’ ability to calculate pediatric safe dose ranges. Nursing students (n = 144, 91.1%) were satisfied with using Triangle Technique. Using the Triangle Technique can increase nursing students’ understanding of how they calculate safe pediatric medication dosages.

Graphical Abstract

Keywords

Drug dosage calculations nursing students-teaching methods nursing education drug administration

Introduction

Drug dosage calculation skills for nurses and student nurses are the most critical function for ensuring patient safety (Cheragi et al., 2013; Wright, 2012). Errors in drug dosage calculation are the most common medication mistake in pediatric and neonatal units (Cheragi et al., 2013), and this type of mistake plays a key role in threatening patient safety, and can cause drug administration error rates, overdose, toxic reaction, and even death (Westin et al., 2015). Calculating correct dosage can be difficult in pediatric patients, as they may require only a fraction of the adult dosage (Aneja et al., 1992; Lesar, 1998, 2003; Tisdale, 1986). Unlike adult patients, distribution of medication may be altered in infants and young children due to several reasons, including: higher gastric pH relatively during the neonatal period, increased gastric emptying and shorter intestinal transit time in neonates and young infants, decreased plasma protein in newborns and early infancy, a higher percentage of body water than adults, faster extracellular fluid exchange, decreased body fat, decreased amount of plasma proteins for drug binding, and undeveloped blood-brain barrier, allowing permeation by medications, increased hepatic blood flow due to larger liver relative to body mass which cause highly metabolized drugs, and delayed maturation of glomerular filtration rate which cause reduced renal clearance (Stucky ER, 2003; Hodges, 2018; Woo, 2004). Thus, children respond to pharmacodynamics and handle pharmacokinetics medicines differently and they are more sensitive and prone to possible medication errors (Wright, 2006).

Correct pediatric dosage calculation is a major component of medication administration, and a systematic literature review found that median rate of medication administration errors in children was 14.6 per 100 medication orders and between 6.4 and 9.1 per 1000 patient-days (Ameer et al., 2015). To calculate the correct dosages for pediatric patients, two methods are used: the more common one is based on the unit of drug per kilogram of body weight, while the other uses body surface area (Wong et al., 2019). Using body weight method alone increases the risk of drug miscalculations, leading to subsequent medication administration errors. This shortcoming of the method has been documented (Lesar, 2003), suggesting that nurses should be trained to calculate the low and high safe dosage range.

Literature

Mathematical competence and accurate drug dosage calculations are essential to providing a safe healthcare environment, which includes preventing medication errors (Simonsen et al., 2014). In literature, there are various studies focused on nursing students’ drug calculation skills and different strategies for developing them.

Although there are studies on pediatric safe drug dose calculations in the literature, there are few studies on techniques used in teaching this subject to students. There is a need for studies in which teaching techniques that will provide effective learning are tested. Most of the studies indicate that nursing students’ drug dosage calculation skills are generally poor (Brown, 2002; Caboral-Stevens et al., 2020; Mansouri et al., 2013; Özyazıcıoğlu et al., 2018; Ramjan et al., 2014; Westin et al., 2015; Wright, 2006). In a study by Brown, whose sample was composed of 118 nursing students, student math skills were inadequate (Brown, 2002), and in a study by Grandell-Niemi et al., which included 282 nursing students, the results showed that instructions for drug dosage calculation were insufficient (Grandell-Niemi et al., 2006). Harvey et al. found that only 19% of 304 incoming nursing students passed a competency test that assessed basic math abilities, including arithmetic, decimals, units, and fractions (Harvey et al., 2010). A study by Özyazıcıoğlu et al. (2018) found that most failed areas have found out to be related to the problems of safe dose, drug dosage calculations, and four operations. In the same study, 30.4% of the students failed to calculate the safe dose range. Mansouri et al. (2013) stated that nursing students make errors in dosage calculations (17.4%–37.7%).

There are published studies looking at the techniques for teaching dosage and calculation to nursing students (Coben and Weeks, 2014; Middleton, 2008). Nurses need to graduate with adequate medication competence, so to improve this skill, it is necessary to find effective teaching techniques, and to assess them as appropriate for nurse education programmes (Dilles et al., 2011; Grandell-Niemi et al., 2006; Ramjan et al., 2014). Wright (2005) has outlined in a study a spiral method that has explored the most effective strategies for teaching drug calculation skills to student nurses. The stages of Wright’s study are represented as a spiral, which includes the importance of practice and establishes—the need to research, collect, and analyse data; and search for significant patterns and insights to develop hypotheses, followed by gathering more data to—further build on your hypotheses, introduce change in practice, and continuing to gather more data. (Bruner, 1960). A study by Özyazıcıoğlu (2018), was conducted to evaluate the students’ knowledge of pediatric dosage calculations in which they were given open-ended questions, known as classic method. In the same study in which classic method was used, direct expression technique and ratio-proportionality were used in dose calculation.

Sredl’s study evaluated the effectiveness of the “Triangular Technique,” in which nursing students were required to use symbolic imagery, where they were asked to enter patient weight at the pinnacle of the mountain, imagine the base of the triangle as a river flowing from west to east (left to right), write the normal therapeutic range on the right and left bases of the triangle, calculate the normal therapeutic range for the child’ weight, and place both values at each end of the line. In this technique, if the value landed on the left side of the river, the students knew that the dose is subtherapeutic; if it landed on the right side of the river, they knew that it is potentially toxic (Sredl, 2006). The study included 30 nursing students; all of which were evaluated before and after the training on their ability to calculate safe pediatric drug dosage intervals. This study showed that students’ ability significantly improved following training in that method (Sredl, 2006).

The Triangle Technique for the computation of safe therapeutic-range medication dose estimates for pediatrics was developed as a response to student concerns about math anxiety and problems performing accurate computations prior to medication administrations (Sredl, 2006). The technique was developed according to evidence-based process by applying the results of research into the nursing student’s learning milieu, learning styles, and learning strategies (Sredl, 2006). Within the learning milieu, educators—especially educators of nursing students—must be sensitive to the learning styles of their students (Wright, 2004). A learning milieu promoting student empowerment by acknowledging competency is likely to lead to greater retention and application of the material.

Individuals interpret their environment by filtering information through three main sensory systems: visual, auditory, and kinesthetic (Fleming and Mills, 1992). The instructional design of the Triangle Technique, using visual analogy and imagery in explaining how to solve a mathematics problem while performing the mathematical computation on the blackboard, includes all three learning styles (Sredl, 2006).

Aim

To evaluate the effects of using the Triangle Technique as an educational tool for nursing students, in order to improve the calculation of pediatric dosages.

Research questions asked

• Do nursing students’ correct answers on the PSDCQ increase after teaching the Triangle Technique as an educational tool for calculating pediatric safe therapeutic-range medication dosages?

• Is there a correlation between sociodemographics and correct answers on the PSDCQ?

• What do nursing students think about the Triangle Technique as an educational tool for calculating pediatric safe therapeutic-range medication dosages?

Materials and methods

Research design and sample

A quasi-experimental single group pre-/post-test research design was employed.

Population/setting/sample size

This quasi-experimental study was conducted between November 2018 and June 2019. The current study employed pre-training and post-training evaluation in .........................The target population included third-year students enrolled in Bachelor of Science in Nursing (BSN) program. Inclusion criteria included students who were able to give consent and/or had pediatric drug calculation lessons to determine the pediatric safe dosage range formula. Exclusion criteria included students who were unable to give consent and/or had already taken the Pediatric Nursing Course and could not speak and understand Turkish very well.

Measures/instruments

The outcome measurements were evaluated using the Pediatric Medication Administration Form (PMAF), Pediatric Safe Dosage Calculations Quiz (PSDCQ), and Satisfaction Form with the Triangle Technique (SFTT), developed by researchers following literature review.

Pediatric Medication Administration Form (PMAF): This form consisted of 11 questions in total, including two sections prepared by the researchers. They structured the form based on a review of relevant literature to determine students’ views on pediatric medication administration (Cheragi et al., 2013; Ramjan et al., 2014; Wright, 2010, 2012). The form was then reviewed by three experts affiliated with the Department of Pediatric Nursing for assessment of content validity and measurement properties of the questions. One of the experts was a professor of nursing, the other was an associate professor of nursing, and the last one was a lecturer in the assessment and evaluation field. (The final form of the questioner version is available in the supplementary file). The form was composed of two parts: the first three questions were to highlight certain demographic characteristics of the nursing students, such as age, gender, type of high school; and the second part contained eight items, including knowledge (five items), and attitudes (three items) toward pediatric medication administration. Scoring was performed using a 3-point Likert scale from 0 (disagree) to 2 (agree).

Pediatric Safe Dosage Calculations Quiz (PSDCQ): This quiz consisted of five pediatric dosages questions that were created from the researchers’ literature review; with the aim to test students’ knowledge and skill related to pediatric safe dosage calculations. These calculation questions were based on the child’s weight and pediatric safe therapeutic-range medication dosage (PSDCQ is available in the supplementary file). Five pediatric dosages questions were included, and participants needed to answer by drawing a triangle and calculating the minimum and maximum drug dosages on the triangle. Each correct answer was given a score of “20,” and each incorrect answer was given a score of “0.” The total scale score was 0–100. When students selected not to answer certain questions, they are marked as “null” and received “0” points. In order to determine whether the questions in PSDCQ are suitable for the purpose of the study, a professor of nursing, an associate professor of nursing, and a registered nurse who worked in the pediatric ward in the hospital in which participants have been for Pediatric Nursing Course rotation; were consulted and questions of the PSDCQ were not changed by the consultants.

Satisfaction Form with the Triangle Technique (SFTT): The form included seven items, which were based on findings from the researchers’ literature review. Items were scored using a 3-point Likert scale from 0 (disagree) to 2 (agree) to gauge the nurses’ satisfaction with the intervention of Triangle Technique.

Procedure

We used a three-phase process: pre-education; education; post-education.

Pre-education phase (T1): One month prior to the current study, participants were taught the principles of safe medication administration and pediatric safe dosage range formulas as part of the Pediatric Nursing Course content in the first semester of their third-year studies. Determining safe dosage range formulas included calculating recommended safe low and high doses. The safe low dose entailed computing the ordered dosed X weight of the child/times in a 24 h period. The safe high dose involved multiplying the ordered dose by the weight of the child times number of doses in a 24 h period. Following a theoretical pediatric nursing course, the students took a practical pediatric nursing course, which resulted in 48 h of experience in a pediatric service. Before clinical practice, written consent was obtained from the participants in a seminar room used for pediatric service. Then, the researcher administrated PMAF and PSDCQ. Students were allowed 10 minutes to complete PMAF, and 50 min for PSDCQ.

Education phase: Education of all participants was provided by the same researcher in the same seminar room, and lasted approximately 4 hours on the same day following the pre-education phase. Teaching session of pediatric drug administration included four topics; (i) drug labels and drug order, (ii) safe medication principles in pediatric patients, (iii) conversion of units, and (iv) pediatric safe therapeutic-range medication dosage calculations, using the Triangle Technique. Interactive teaching methods such as PowerPoint presentation, flipchart, a discussion with the students about medication orders commonly used in pediatric services, and demonstration comprised the educational sessions. During the sessions, the students had ten practice questions to complete so that they can better understand drug dose calculations.

How triangle technique works—an example

A child weighing 22 lb (10 kg) is to receive cefuroxime (Ceftin) 250 mg every 8 hours. The normal therapeutic range is 50–100 mg per kg of body weight for children. Write “50 mg” on the line indicating the base of the mountain on the left (B), and “100 mg” on the same line to the right (C). Then draw a line with arrows at both ends just below the base of the mountain. Calculate the normal therapeutic range for a 10 kg child: 10 × 50 mg = 500 mg and 10 × 100 mg = 1000 mg. Place these values at each end of the line. To calculate how much your patient should receive in 24 h, multiply the ordered dosage (250 mg) by the number of times it is to be administered—in this case, three times a day. Three dosages x 250 mg = 750 mg. Apply the result of the calculation (750 mg) to the river at the base of the mountain to see where it fits. It fits between the 500 mg on the left and the 1000 mg on the right. From a quick visual assessment, it is apparent that the dosage is within pharmaceutically accepted parameters and therefore, is safe (Application of Triangle Technique appears in the supplementary material).

Post-education phase (T2): Starting the day after the education session, nursing students participated in a total of 48 h of pediatric clinical training, taught consecutively over 2 weeks (24 h/week) by the same researcher who taught the Triangle Technique. During clinical practice, nursing students had a chance to observe and implement drug dosage calculation. Same researcher guided and monitored the students throughout the clinical practice. At the end of the clinical practice, the nursing students repeated the PMAF, PSDCQ, and SFTT in the seminar room of the pediatric service. Students were allowed 15 min to complete the PMAF and SFTT, and 50 min for PSDCQ. Evaluation of the PSDCQ was performed by the same researcher who worked as a nurse in pediatric service for 8 years, and taught the Triangle Technique to the participants.

Ethical considerations

Official permission for the study was obtained from Gulhane Faculty of Nursing, and ethical approval was obtained from the ethics committee (18/294-46418926).

The participating students received written and verbal information about the study. They were informed that all data would be treated confidentially, and to protect participant identity, pseudonyms would be used. Further, because participation or nonparticipation was both voluntary and anonymous, students were assured their course grades would not be affected and were guaranteed that they could withdraw their participation whenever they wanted. The students signed consent forms.

Data analysis

Data were analyzed using the IBM SPSS (Version 23.0, IBM Corporation, Armonk, NY, USA). Median, the Interquartile Range (IQR), mean, standard deviation (SD), percentage, and frequency were used for descriptive statistics. Changes in each of the eight items in the pre- and post-PMAF were evaluated with the McNemar–Bowker Test. Normality for the scores of PSDCQ was checked by using the Kolmogorov–Smirnov test. Answers to individual questions on PSDCQ were coded in SPSS as correct (20 points) or incorrect (0 points). To compare scores of those who had attended traditional high schools versus science-based high schools was calculated using the Wilcoxon Signed Ranks test and Mann–Whitney U test. The level of statistical significance was set at p < .05.

Results

The study population consisted of third-year nursing students who took pediatric nursing course. One hundred fifty-eight third-year nursing students who met the inclusion criteria were the sample of this study, which took place between November 2018 and June 2019. All third-year nursing students were included. The mean age of the students was 21.5 years (Standard Deviation [SD] = 0.7 years). All of the students (n = 158, 100%) were female. As shown in Table 1, when pre-education PSDCQ median scores (median [IQR] = 0[60]) and post-education (median [IQR] = 100[0]) PSDCQ median scores were compared across all participants, the change in scores was found to be statistically significant (z = −10.633, p < .001). While <50% (n < 79) of students gave the correct answers to each question of quiz before the intervention, almost all of the participants gave the correct answer to one question of the PSDCQ (Q2), and ≥89.2% (n ≥ 141) of the students answered the four PSDCQ questions correctly.

Table 1.

Comparison of correct answers by nursing students pre- and post-PSDCQ (n = 158).

	Pre-test	Post-test	Test statistics^a	p
Median (IQR)	0 (60)	100 (0)	−10.633	<0.001

Note: IQR: The Interquartile Range.

^aWilcoxon test.

Knowledge and attitudes of students related to pediatric medication administration are presented in Figure 1. Pre-education, 63.3% (n = 100) of students agreed with this statement, “Pediatric drug dosage in children is calculated based on body weight”; 50.6% (n = 80) of them disagreed with “I know how to convert units of measurement”; and 56.3% (n = 89) of them partially agreed with “I know that when calculating the pediatric drug dosage, it should be prepared by taking into account the dry powder volume.” After education, 42.4% (n = 67) of students partially agreed with this last statement, and 29.1% (n = 46) disagreed with it. Moreover, post-education, 93.7% (n = 148) of respondents agreed with “Drug dosage in newborn babies is calculated based on body weight” (Figure 1).

Figure 1.

Knowledge and attitudes related pediatric medication administration for nursing students (n = 158).

In Table 2, the pre- and post-PSDCQ scores have been compared with regards to the type of high school attended by nursing students in the study. Within the same regular high school, it has been found that the post-PSDCQ score (median: 100; IQR = 0) is significantly higher than the pre-PSDCQ score (median: 0; IQR = 60) (z = 7.344, p < .001). In the same way, within the same science-based high school, the post-PSDCQ score (median: 100; IQR = 0) has been once again found to be significantly above the pre-PSDCQ score (median: 0; IQR = 60) (z = 7.768, p < .001).

Table 2.

The distribution of quiz’ score across the participant variable and attitude to pediatric dosage calculation ability of the nursing students (n = 158).

Variable		T1	T2	Test statistics^a
High school type
Regular high school (n = 76)	Median (IQR)	0 (60)	100 (0)	−7.344
Science high school (n = 82)	Median (IQR)	0 (60)	100 (0)	−7.768
	Test statistics^b	2894.50	3038.00

Note: T1: Pre-education phase, T2: Post-education phase, IQR: The Interquartile Range.

^aWilcoxon test.

^bMann–Whitney U test.

As shown in Figure 2, nursing students mostly expressed positive views on the Triangle Technique. More than 80% (n = 126) reported that they agreed with six of the seven statements that evaluated their opinions. Only the third item—“This approach enhanced my motivation”—had a lower score, with 75.9% (n = 120) of participants agreeing with the statement (Figure 2).

Figure 2.

Distribution of satisfaction with using Triangle Technique for pediatric safe dosage calculations (n = 158).

Discussion

This study aimed to evaluate the effect of using the Triangle Technique as an educational tool for nursing students to learn to accurately calculate pediatric dosages. Using the Triangle Technique, students’ ability to calculate pediatric safe dose ranges was improved aligning with the outcomes of the study by Sredl’s study which also used this technique (Sredl, 2006).

The theme and slogan of the 2017 World Health Organizations’s Global Patient Safety Challenge was entitled “Medication Without Harm” (Donaldson et al., 2017). This campaign focused on the fact that unsafe medication practices and medication errors are a major cause of avoidable injury across the globe. Nurses play a key role in ensuring medication safety, so pediatric nurses need to graduate from nursing programs having acquired drug dosage calculation skills for children, including babies (Guy et al., 2003). Differences in the organ development of children (hepatic enzyme systems and renal systems, delays in gastric emptying, decrease in bowel movements) may affect the metabolizing and discharge of the drug, especially in overdose medication. Therefore, it is critical to prevent medication errors.

Pre- and Post-PSDCQ

Nursing care involves not only accurate medication administration, but also knowledge and skill competency in calculating medications (Kohtz and Gowda, 2010). A number of studies illustrated that nursing students often have a poor ability to solve drug calculation tests (McMullan et al., 2010). McMullan et al., in their study with 229 second-year nursing students, found that 92% of students failed the drug calculation test (McMullan et al., 2010). Jukes and Gilchrist’s study with 37 second-year nursing students showed similar outcomes, with only three of them able to score 90% and above, suggesting that generally, students were unable to achieve 90% mastery (Jukes and Gilchrist 2006). Blais and Bath, in their study with 66 first-year nursing students, found that 89% failed drug calculation tests. They also showed that 68% of the errors made were related to conceptual errors (Blais and Bath, 1992).

Özyazıcıoğlu et al. (2018) showed that an exam question on the dosage calculation was based on child’s age, which is the most common method in pediatrics, and which ensures right dosages and drug dilution was answered wrong by 30.4% (n = 45) of nursing students. Wright (2005) found out that 36.7% of the students were not able to answer even half of the questions correctly; Simonsen et al. (2014) pointed that in questions on the administration of medication, error ratio of the students was 25%; and Stratton et al. (2004) revealed that incorrect dosage calculation ratio in the pediatric clinics is 31.4%. Macdonald et al. (2013) reported students answered 67% of the questions as “true” and 6% as “don’t know”; which is consistent with our findings. In their study, Mansouri et al. (2013) stated that nursing students make errors in preparing medicine for injection (11.5%–28.7%), and dosage calculations (17.4%–37.7%). The findings of our study align with these results, which show that prior to training, most of our students’ pediatric safe dosage calculation ability was inadequate.

As described in the literature, many studies have been conducted to develop effective teaching methods for setting up the problem. These methods include Triangle Technique, problem solving approaches, dimensional analysis, didactic methods of teaching, active learning, group activities with instantaneous feedback, PowerPoint, CDs, video instructions, online multimedia learning, and integrative approaches, such as the use of technology, computerized-learning, and in person activities to teach math (Ellis-Monaghan, 2010; Kelly and Colby, 2003; Sredl, 2006). To facilitate learning of pediatric safe dosage calculations and set up the calculation problem as something that could be visualized by nursing students, we used “the Triangle Technique.”

In our study, nursing students had higher PSDCQ scores after the intervention. This finding aligns with Sredl’s work on this technique, which she developed and reported as showing marked improvement in students’ post-test scores (Sredl, 2006). This would suggest that using effective teaching methods can improve pediatric safe therapeutic-range medication dosage calculations in nursing students. As in Sredl’s study, it was determined that the use of the Triangle technique is a valid and reliable method that allows students to get high scores in calculating safe pediatric drug dose ranges.

Acquiring the skill to calculate pediatric safe dosage calculations is vital for nursing students to bridge the gap between theory and practice (Chan, 2002). Wright, who wrote about the national debate on nurses’ drug calculation skills, has suggested that clinical practice should be integrated into theoretical curricula because these skills are best taught in the clinical arena (Wright, 2009). Similarly, Allen and Pappas (Allen and Pappas, 1999), and Wilson (Wilson, 2003) emphasized the link between clinical practice and math competency. In our study, the reasons for improvement stemmed from using the Triangle Technique for calculating pediatric safe dosage. As shown in Figure 2, 86.7% (n = 137) of participants reported satisfaction with using this technique for making these calculations.

Knowledge and attitudes

Teaching methods on this subject affect nursing students’ self-confidence and self-esteem (Pauly-O'Neill and Prion, 2013; Kapborg and Rosander, 2001). Likewise, in the current study, we found that after the training, most nursing students considered their drug dosage calculation skills to be sufficient. As complex concepts are more easily understood when simplified by using a symbol that fits the problem (Hunter Recell and McCurry, 2013), it is clear as to why learning the Triangle Technique led to greater self-confidence in the majority of our study sample.

Correlation between demographics and outcome variables

Nursing students’ ability for solving drug calculation test is related to various factors, such as pre-college math experiences, teaching methods, clinic educators acting as mentors, and using a calculator (Costello, 2011). There is a limited study by Costello showing the relationship between pre-college math experiences and the ability to solve drug calculation tests. As shown in her study with 44 first-year nursing students, a high math score on the scholastic achievement test, the number of high school math courses, and high school algebra grade were statistically positively correlated with a higher score on the medication calculation test (Costello, 2011). In a similar study, Grandell-Niemi et al. found that among 282 graduating nursing students in Finland, students who performed better in mathematics in high school were more successful in drug calculation tests (Grandell-Niemi et al., 2006). Unlike these studies (Costello, 2011; Grandell-Niemi et al., 2006), in our research, we found no correlation between high school type and success on a drug calculation quiz. It is possible that this result may reflect the fact that pediatric safe dosage calculation does not require complex math ability, such as solving intravenous drug dosage calculations with dry powder volume.

Limitation

There are a number of limitations associated with our study. First, was the lack of a control group and lack of a randomized sample, so there is the possibility of sampling bias due to purposive sampling. As a result, further studies are necessary to compare the outcomes of nursing students receiving training against a control group. The second limitation of the study is that the Satisfaction Form with the Triangle Technique was developed by researchers and was not tested at a pilot group. The third limitation of the study stems from the fact that teaching methods are not compared with one another in our study. Consequently, there is a need to evaluate which teaching methods are in fact most effective: PowerPoint presentation, web-based education, or Triangle Technique for solving pediatric safe dosage calculation for nursing students. The fourth limitation of the study, the fact that all the participants were women; may have limited the study findings. Hence, it would be very interesting to examine effects of Triangle Technique on both female and male nursing students’ ability to calculate pediatric safe dose ranges. Also, the study was limited to a specific institution, and a restricted group of students, which may have been a limitation as well. Hence, the findings of this study should be interpreted with these limitations in mind.

Implications for practice

For pediatrics, incorrect dosing is the most commonly reported medication error (Stucky, 2003). Since medication administration errors are common in children, student nurses should receive a comprehensive training regarding calculation of safe pediatric medication dosages. Nurse educators should use teaching techniques which include visual graphic such as triangle technique for students to learn accurate drug dose calculation. The symbol of an isosceles triangle provided the visual graphic for the conceptual framework. Considering that visualization increases learning, it is recommended to use the triangle technique in drug dose calculations in pediatric nursing.

Conclusion

The findings indicate that nursing students showed a low score on PSDCQ prior to educational intervention. Students’ low scores should be taken seriously as therapeutic-range medication dosage miscalculations could cause subtherapeutic dosage or potentially toxic dosage in children, or even deaths. However, the outcomes post-PSDCQ proved to be statistically significant regarding the TriangleTechnique; as effective in improving the pediatric safe therapeutic-range medication dosage calculations skill among nursing students. Outcomes from the current study highlighted that following the Triangle Technique training, only 17.7% (n = 28) of students claimed that their pediatric safe therapeutic-range medication dosage calculations ability was insufficient. Also, a large majority, 82.3% (n = 130), believed that pediatric safe therapeutic-range medication dosage calculations were not difficult. Overall, the findings indicate that Triangle Technique is effective for improving students’ ability to calculate pediatric safe dose ranges and has a high level satisfaction rate among nursing students.

Supplemental Material

Supplemental Material - Triangle technique: An effective tool for improving nursing students’ ability to calculate safe pediatric medication dosages

Supplemental Material for Triangle technique: An effective tool for improving nursing students’ ability to calculate safe pediatric medication dosages by Derya Suluhan, Dilek Yildiz and Berna Eren Fidanci in ournal of Child Health Care

Supplemental Material

Supplemental Material - Triangle technique: An effective tool for improving nursing students’ ability to calculate safe pediatric medication dosages

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Derya Suluhan

Supplemental Material

Supplemental material for this article is available online.

References

Allen

Pappas

(1999) Enhancing math competency of baccalaureate students. Journal of Professional Nursing15(2): 123–129.

Aneja

Bajaj

Mehandiratta

(1992) Errors in medication in a pediatric ward. Indian Pediatrics 29: 727–730.

Ameer

Dhillon

Peters

, et al. (2015) Systematic literature review of hospital medication administration errors in children. Integrated Pharmacy Research & Practice 4: 153–165.

Blais

Bath

(1992) Drug Calculation errors of baccalaureate nursing students. Nurse Educator 17(1): 12–15.

Brown

(2002) Does 1 + 1 still equal 2?: A study of the mathematic competencies of associate degree nursing students. Nurse Educator 27(3): 132–135.

Bruner

(1960) The Process of Education. Cambridge, MA: Harvard University Press.

Caboral-Stevens

Ignacio

Newberry

(2020) Undergraduate nursing students' pharmacology knowledge and risk of error estimate. Nurse Education Today 93: 104540.

Chan

(2002) Development of the clinical learning environment inventory: using the theoretical framework of learning environment studies to assess nursing students’ perceptions of the hospital as a learning environment. Journal of Nursing Education 41(2): 69–75.

Cheragi

Manoocheri

Mohammadnejad

, et al. (2013) Types and causes of medication errors from nurse’s viewpoint. Iranian Journal of Nursing and Midwifery Research 18(3): 228–231.

10.

Coben

Weeks

(2014) Meeting the mathematical demands of the safety-critical workplace: medication dosage calculation problem-solving for nursing. Educational Studies in Mathematics 86(2): 253–270.

11.

Costello

(2011) Predictors of success on medication calculation tests. Nurse Educator 36(1): 11–12.

12.

Dilles

Vander Stichele

Van Bortel

, et al. (2011) Nursing students’ pharmacological knowledge and calculation skills: ready for practice? Nurse Education Today 31(5): 499–505.

13.

Donaldson

Kelley

Dhingra-Kumar

, et al. (2017) Medication without harm: WHO’s third global patient safety challenge. Lancet 389(10080): 1680–1681.

14.

Ellis-Monaghan

(2010) Considering the chalkless classroom. Problems, Resources, and Issues in Mathematics Undergraduate Studies 20(4): 332–343.

15.

Fleming

Mills

(1992) Not another inventory, rather a catalyst for reflection. To Improve the Academy 11: 137.

16.

Grandell-Niemi

Hupli

Puukka

, et al. (2006) Finnish nurses’ and nursing students’ mathematical skills. Nurse Education Today 26(2): 151–161.

17.

Guy

Persaud

Davies

, et al. (2003) Drug errors: what role do nurses and pharmacists have in minimizing the risk? Journal of Child Health Care 7(4): 277–290.

18.

Harvey

Murphy

Lake

, et al. (2010) Diagnosing the problem: Using a tool to identify pre-registration nursing students’ mathematical ability. Nurse Education in Practice 10(3): 119–125.

19.

Hunter Revell

McCurry

(2013) Effective pedagogies for teaching math to nursing students: a literature review. Nurse Education Today 33(11): 1352–1356.

20.

Hodges

(2018) Pharmacology and the Nursing Process. New Orleans, LA: White Press Academics.

21.

Jukes

Gilchrist

(2006) Concerns about numeracy skills of nursing students. Nurse Education in Practice 6(4): 192–198.

22.

Kapborg

Rosander

(2001) Swedish student nurses solving mathematical items with or without help of a hand-held calculator - a comparison of results. Nurse Education in Practice 1(2): 80–84.

23.

Kelly

Colby

(2003) Teaching medication calculation for conceptual understanding. Journal of Nursing Education 42: 468–471.

24.

Kohtz

Gowda

(2010) Teaching drug calculation in nursing education: a comparison study. Nurse Educator 35(2): 83–86.

25.

Lesar

(1998) Errors in the use of medication dosage equations. Archives of Pediatrics & Adolescent Medicine 152: 340–344.

26.

Lesar

(2003) Tenfold medication dose prescribing errors. The Annals of Pharmacotherapy 36: 1833–1839.

27.

Middleton

(2008) A Standardized nursing mathematics competency program. Nurse Educator 33(3): 122–124.

28.

Özyazıcıoğlu

Aydın

Aİ

Sürenler

, et. al. (2018) Evaluation of students’ knowledge about paediatric dosage calculations. Nurse Education in Practice 28: 34–39.

29.

Macdonald

Weeks

Moseley

(2013) Safety in numbers 6: Tracking pre-registration nursing students’ cognitive and functional competence development in medication dosage calculation problem-solving: the role of authentic learning and diagnostic assessment environments. Nurse Education in Practice 13(2): 66–77.

30.

Mansouri

Ahmadvand

Hadjibabaie

, et al. (2013) Types and severity of medication errors in Iran; a review of the current literature. DARU Journal of Pharmaceutical Sciences 21(49): 1–10.

31.

McMullan

Jones

Lea

(2010) Patient safety: numerical skills and drug calculation abilities of nursing students and Registered Nurses. Journal of Advanced Nursing 66(4): 891–899.

32.

Pauly-O'Neill

Prion

(2013) Using integrated simulation in a nursing program to improve medication administration skills in the pediatric population. Nursing Education Perspectives 34(3): 148–153.

33.

Ramjan

Stewart

Salamonson

, et al. (2014) Identifying strategies to assist final semester nursing students to develop numeracy skills: A mixed methods study. Nurse Education Today 34(3): 405–412.

34.

Simonsen

Daehlin

Johansson

, et al. (2014) Differences in medication knowledge and risk of errors between graduating nursing students and working registered nurses: comparative study. BMC Health Services Research 14: 580.

35.

Sredl

(2006) The triangle technique: a new evidence-based educational tool for pediatric medication calculations. Nursing Education Perspectives 27(2): 84–88.

36.

Stratton

Blegen

Pepper

, et al. (2004) Reporting of medication errors by pediatric nurses. Journal of Pediatric Nursing 19(6): 385–392.

37.

Stucky

(2003) American academy of pediatrics committee on drugs, & American academy of pediatrics committee on hospital careprevention of medication errors in the pediatric inpatient setting. Pediatrics 112(2): 431–436.

38.

Tisdale

(1986) Justifying a pediatric critical-care satellite pharmacy by medication-error reporting. American Journal of Hospital Pharmacy 43: 368–371.

39.

Westin

Sundler

Berglund

(2015) Students’ experiences of learning in relation to didactic strategies during the first year of a nursing programme: a qualitative study. BMC Medical Education 15(1): 49.

40.

Wilson

(2003) Nurses’ maths: researching a practical approach. Nursing Standard (Royal College of Nursing) 17(47): 33–36.

41.

Wong

Ghaleb

Franklin

, et al. (2019) Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review. Drug Safety 42(12): 1423–1436.

42.

Woo

(2004) Pediatric pharmacology update. Essential concepts for prescribing. Advance for Nurse Practitioners 12: 22–27.

43.

Wright

(2004) An investigation to find strate-gies to improve student nurses’ math skills. British Journal of Nursing 13(21): 1280–1287.

44.

Wright

(2005) An exploration into the most effective way to teach drug calculation skills to nursing students. Nurse Education Today 25(6): 430–436.

45.

Wright

(2006) Barriers to accurate drug calculations. Nursing Standard (Royal College of Nursing) 20(28): 41–45.

46.

Wright

(2009) The assessment and development of drug calculation skills in nurse education - a critical debate. Nurse Education Today 29(5): 544–548.

47.

Wright

(2010) Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Education Today 30(1): 85–97.

48.

Wright

(2012) The assessment of drug calculation skills - Time to rethink the whole process. Nurse Education Today 32(4): 341–344.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.06 MB

0.23 MB