1. Questioning Culture in Nursing Education: Critical Care Nurses' Perspectives
Dr Mansour Mansour
Senior Lecturer
Acute Care Department
Faculty of Health and Social Care
Anglia Ruskin University

2. Objective
Highlight the findings from a recently completed study on the critical care nurses’ perspective on the organisational contributions toward the safety of medication administration.
Discussing the finding of questioning attitude in adult critical care setting in the context of other literature.
Discuss implication for future research and practice.

3. Critical care Nurses Views on Medication Administration: An Organisational Perspective
To explore nurses’ views on the organizational issue which influence safe medication administration in adult critical care settings.
Semi- structured interviews with 33 adult critical care nurses in two-campus NHS Trust, using Purposive sampling and snowball sampling
Thematic analysis of the participants views

5. Selective questioning: Doctor
Because we are the one who is giving it [medication] at the end of the day and if we are uncertain we would question the doctor and query it: Is this the right dose? Is this written up and prescribed correctly? I think we have got the power to do so, because they are our patients at the end of the day, and we are the patients’ advocates.
[Akua, senior staff nurse, level 3 critical care, the Beech Hospital].
It is noteworthy that some participants’ views suggest that they feel able to question
the doctors, particularly the junior ones, but in contrast, they exhibit different attitudes
toward questioning other member of health care professionals, such as the
pharmacists, but also among themselves, particularly the senior nurses

6. Selective questioning: Pharmacist
“ I think the nurses would usually say “woohoo, I don’t
have to look at it [medication chart] now, because it
has been checked by the pharmacist”, so there is an
awful lot of trust really between us and the Pharmacists”.
[Tom, senior staff nurse, level 2 critical care, the Beech Hospital]
“ Obviously, we [critical care nurses] know the area and
we know what medicines we use, but we don’t have the
broader knowledge of how things will interact with each
other. I don’t think we always know one hundred percent
percent how clear things are … whether to give them or
not … and this is where the pharmacist’s job comes in”.
[Lily, ward manager, level 2 critical care, the Oak Hospital].

7. Selective questioning: Nurses
If you are a junior member of staff, when you first come here, you will
be scared to death from the person who is gonna come after you. Are
they senior members of staff? Or band six members of staff? And
they might say to you: “why have you done that? Why this is like this?
That is wrong, why didn’t you add up your fluid chart?” All this, and
You just feel about that big [gesturing to indicate being extremely
small]. Once I wasn’t quite sure that what I was told by my senior
colleague, it wasn’t very clear, but sometimes if you ask a question,
you will be in trouble. They may think that you are picking up on
them. It seemed to be the case any way. I’ve had this happen to me,
and I think it happens for everybody.
[Martin, staff nurse, level 3 critical care, the Beech Hospital].

8. Selective questioning: Nurses Cont.
“ Also there is a lot of interplay between the two checkers; they
are not often from the same rank. If I have asked a staff
nurse to check something, he or she knows that I’m a charge
nurse and he or she might not check it ... they may say I’m
not going to argue with them, and I had that as act of mistakes
that happened to me.
[John, ward manager, level 3 critical care, the Oak Hospital].

9. Selective questioning: Pharmacology education
You have some sessions [on medication related issues]
in the School of Nursing towards the end of your training
in your last month or so before you finish the course. But
to be honest, it [the information taught to the student
nurses] will just get out one way or another, because they
[School of Nursing’ staff] do it [medication teaching
sessions] a month or two months before you leave,
and you just forget about it, and then you come to your
place of work and you can then remember parts, but you
can’t fully remember everything.
[Randa, staff nurse, level 2 critical care, the Beech Hospital].
When they were asked why they felt their pharmacological knowledge was
inadequate, many participants pointed to the poor pharmacological education they received during their pre-registration nursing training, but also to the lack of the continuous learning for nurses in post-registration in the ward:

10. Selective questioning: Pre –reg nursing training
I think that we need to change people’s philosophy and their sort
of attitude towards giving medications, and take people back
down to basics that we are all human, and we make mistakes.
As far as the safety things are concerned, I do wonder
sometimes whether how much input students get from their
training as far as the medications is concern, and giving
medications as an extended role with other thing. I do wonder
whether there could be more input as a student nurse to
being prone for error as part of their training and being fit for
Purpose if you would like. It does concern me that, and whether
they are properly or adequately prepared enough for what the
expectations are really at the end of the day.
[Jenny, ward manager, level 3 critical care, the Beech Hospital]

11. Selective questioning: The cultural context
I think in critical care, we’ve been taught to
question, and I think any doctor who work with
us understand that. They understand how we
work ... often we get new SHO’s [Senior House
Officers] that aren’t used to that …but they will
get use to it ... you know it is just about
learning about how we work as nurses.
[Hannah, staff nurse, level 2 critical care, the Oak Hospital].
Questioning culture seem to be instigated by nurses blending themselves in the culture of critical care, yet

12. It appears that the working culture, as well as the nature of nursing education, whether it is pre or post-registration education, can be influential in nurturing such “questioning attitude” among the participants

13. The context of other literature
being able to question any aspect of medication safety is a fundamental pre-requisite for a resilient medication administration practice (ref)

14. In particular, on issues surrounding establishing of questioning culture, and the lack of skills and understanding related to the human factors and the possibility of error which underpins the issue of technical competency in medication administration, often called the “non-technical skills” of medication administration (Glavin and Maran 2003).

15. data analysis showed that this issue does
not seem to be adequately addressed at the hospital level, for example, during the hospital induction programme when the participants first joined the critical care settings. Some participants’ views suggest that the working culture in some critical care settings appears to reflect a better understanding for the need to shift the focus from the individual to the system when it comes to investigating unsafe medication administration. However, it fell short of achieving a formal recognition of such
matters via soliciting formal in-hospital training.

16. Effective nursing education is likely to enhance patient safety when nurses are taught to question and challenge what they perceive as contradictory with principles of ensuring the safety of medication administration. It is imperative that any educational plan should encourage nurses, as
well as other healthcare professionals, to speak up about their concerns in any aspects of medication safety, and where anyone involved not only in medication administration, but also in patient care, is expected to be challenged and is receptive to being questioned, as long as the aim is to safeguard the patient.

17. There is lack of addressing “ non-technical skills in nursing education”. Crew Resource Management in pre and post registration nursing education.
many participants suggested that the critical care doctors in this study appear to adjust themselves to the new culture of
critical care settings, and feel positive toward the fact that nurses may challenge their prescribing decisions, or indeed any medical decisions related to patient care

18. What is next ?
Patient Safety Education Study at ARU ( finalising draft report- first paper submitted for publication)
Patient Safety, Peer Reporting and organisational learning at ARU (finalising draft report)
World Health Organisation (WHO) Agreement with ARU to act as Complementary Test Sites of the Multi-professional Patient Safety Curriculum Guide.

19. References: