



Mathematical skills of the nursing and midwifery students of Sakarya University school of healht sciences^{1}
Habilidades matemáticas dos estudantes de enfermagem e obstetrícia da escola de ciências da saúde da Universidade de Sakarya
Habilidades matemáticas de los estudiantes de enfermería y obstetricia de la escuela de ciencias de la salud de la Univeridad de Sakaya
Nursan Çinar^{I}; Funda Akuduran^{II}; Aysegül Dogan^{III} ^{I}PhD, Asist . Prof., Sakarya University School of Health Sciences. Correspondence Address: Sakarya Üniversitesi Saglik Yüksekokulu. 54187 Esentepe Kampüs. Sakarya, Turkey. ndede@sakarya.edu.tr ^{II}Research Fellow, Sakarya University Schoof of Health Sciences, Sakarya,Turkey ^{III}Nursing Student, Sakarya University School of Health Sciences, Sakarya, Turkey
ABSTRACT This study was carried out with the purpose of determining the Nursing and Midwifery students’ interest and skills in mathematics, and their skills in calculating the medication dosages. In the study, a survey form comprising 16 questions having the purpose of determining the students’ demographical characteristics and interest in mathematics, and the Medication Skill Test (MCS Test), which had been also prepared by the researchers, were used. The Medication Skill Test (MCS Test) were developed, by the researchers, by means of reviewing the relevant literature, particularly the studies carried out by GrandellNeime et al. and the pharmacology test books. The MCS Test consisted of 25 questions, of which eleven were about general mathematics and fourteen were about the calculation of the medication dosages. The answers the students gave to the questions were evaluated as correct or incorrect. The sampling of the research comprised totally 73 students from the 2^{nd}, 3^{rd} and 4^{th} grades of the midwifery classes, and totally 142 students from the 1^{st}, 2^{nd}, 3^{rd} and 4^{th} grades of the nursing classes. The survey form were applied to the students by providing the examination conditions and giving 20 minutes time. The data collected was evaluated in computer. It was determined that 96.5 % of the nursing students (n: 137) and 90.4 % of the midwifery students (n: 66) liked the mathematics. 90.1 % of the nursing students (n: 128) and 83.6 % of the midwifery students (n: 61) stated that they found mathematics enjoyable, and likewise, 35.2 % of the nursing students (n: 50) and 34.2 % of the midwifery students (n: 25) stated that they deemed the mathematics as necessary in nursing. 66.9 % of the nursing students (n: 95) and 63.0 % of the midwifery students (n: 46) stated that they had good mathematical skills. 60.6 % of the nursing students (n: 86) and 75.3 % of the midwifery students (n: 55) stated that they didn’t deem themselves as adequate in calculating the medication dosages. 65.5 % of the nursing students (n: 93) and 74.0 % of the midwifery students (n: 54) stated that they experienced occasional problems in the mathematical calculations relating to the medication administrations. According to the MCS Test results, it was seen that the lowest correct answering rate was 26.9 % for the nursing students and 5.5 % for the midwifery students, while the highest correct answering rate was 98.6 % for the nursing students and 94.5 % for the midwifery students. Medication administration is an essential skill for nurses and midwives. Any mistake in calculation can lead to medication error and life threatening situations for patients. In the study, it was found that the mathematical skills of the nursing and midwifery students were weak and they didn’t feel adequate in the calculation of the medication dosages. Determining and overcoming this inadequacy of the students during their education would prevent the problems they possibly face in their profession after their graduation. Key words: Nursing students; Medication error; Administration & dosage. RESUMO Este estudo foi realizado com a finalidade de determinar interesse e habilidades dos estudantes de Enfermagem e Obstetrícia na matemática, e suas habilidades em calcular os dosages do medication. No estudo, um formulário contendo 16 questões com o propósito de determinar as características demográficas dos estudantes, o interesse em matemática, e um teste de habilidades em medicação (Medication Skill Test– MCS Test), desenvolvido pelos pesquisadores conforme revisão da literatura, em particular os estudos desenvolvidos por GrandellNeime et al. e um livro de testes farmacologicos. O MCS Test consiste de 25 questões, das quais onze sobre matemática geral e quatorze sobre cálculo de dosagens em medicação. As respostas dos estudantes às questões foram avaliadas como correta ou incorreta. A amostra da pesquisa compreendeu um total de 73 estudantes dos segundo, terceiro e quarto ano de Obstetrícia, e um total de 142 alunos do primeiro, segundo, terceiro e quarto anos de Enfermagem. O formulário de pesquisa foi aplicado aos estudantes fornecendo as condições necessárias para aplicação do teste em 20 minutos. Os dados coletados foram analisados em computador. Foi identificado que 96,5% dos estudantes de enfermagem (n: 137) e 90,4% de obstetrícia (n: 66)gostam de matemática. 90.1 % dos estudantes de enfermagem (n: 128)e 83.6 % dos estudantes de obstetrícia (n: 61)acham a matemática agradável, e do mesmo modo, 35.2 % dos estudantes de enfermagem (n: 50) e 34.2% dos estudantes de obstetrícia (n: 25) julgaram a matemática como necessária aos cuidados. 66.9 % dos estudantes de enfermagem (n: 95) e 63.0 % dos estudantes de obstetrícia (n: 46) indicam que tiveram boa habilidade matemática. 60.6 % dos estudantes de enfermagem (n: 86) e 75.3 % dos estudantes de obstetrícia (n: 55) não se julgaram capazes para calcular as dosagens da medicação. 65.5 % dos estudantes de enfermagem (n: 93) e 74.0 % dos estudantes de obstetrícia (n: 54) indicam que experimentaram problemas ocasionais nos cálculos matemáticos no que se relaciona às administrações de medicamentos. De acordo com os resultados de Teste MCS, viuse que a menor taxa de resposta correta foi de 26.9 % para os estudantes de enfermagem e 5.5 % para os estudantes de obstetrícia, enquanto a maior taxa de resposta correta foi de 98.6 % para os estudantes de enfermagem e 94.5 % para os estudantes de obstetrícia. A administração de medicação é uma habilidade essencial para enfermeiros e obstetrizes. Qualquer falha no cálculo pode conduzir ao erro na medicação que pode provocar situações que ameaçam a vida dos pacientes. No estudo, encontrouse que as habilidades matemáticas dos estudantes de enfermagem e de obstetrícia eram fracas e não estes não se sentiam capacitados para o cálculo das dosagens da medicação. Determinar e superar este despreparo dos estudantes durante sua formação impedirão os problemas que possivelmente enfrentarão em sua profissão após sua graduação. Palavras chave: Estudantes de enfermagem; Erros de medicação; Administração & dosagem. RESUMEN Este estudio fue realizado con el propósito de determinar el interés y las habilidades matemáticas de los estudiantes de enfermería y de la obstetricia', y sus habilidades en calcular las dosificaciones de la medicación. En el estudio, un formulario de 16 preguntas con el propósito de determinar las características demográficas y el interés de los estudiantes en la matemática, y un teste de habilidad en medicación (Medication Skill Test – MCS Test), que también fuera preparado por los investigadores por medio de la literatura relevante, en especial los estudios realizados por GrandellNeime et al. y uno libro de testes farmacológicos. El teste MCS consistió en 25 preguntas, de las cuales once sobre matemática general y catorce sobre el cálculo de las dosificaciones de la medicación. Las respuestas que los estudiantes dieron a las preguntas fueron evaluadas como correctas o incorrectas. La populación de la investigación abarcó 73 estudiantes de los 2dos, 3ro y 4tos grados del curso de la obstetricia, y 142 estudiantes de los 1ros, 2dos, 3ro y 4tos grados del curso de enfermería. El formulario fue aplicado a los estudiantes proporcionando las condiciones de examinación realizado en 20 minutos. Los datos recogidos fueron evaluados en computadora. Fue identificado que 96.5% de los estudiantes de enfermería (n: 137) y el 90.4% de los estudiantes de obstetricia (n: 66) tienen gusto a la matemática. 90.1% de los estudiantes de enfermería (n: 128) y 83.6% de los estudiantes de obstetricia (n: 61) indican la matemática como agradable, y además, 35.2% de los estudiantes de enfermería (n: 50) y 34.2% de los estudiantes de obstetricia (n: 25) juzgan la matemáticas necesaria en el cuidado en enfermería. 66.9% de los estudiantes de enfermería (n: 95) y 63.0% de los estudiantes de obstetricia (n: 46) indican que tenían buenas habilidades matemáticas. 60.6% de los estudiantes de enfermería (n: 86) y 75.3% de los estudiantes de la obstetricia (n: 55) no se juzgan capases en calcular las dosificaciones de la medicación. 65.5% de los estudiantes de enfermería (n: 93) y 74.0% de los estudiantes de obstetricia (n: 54) indican que experimentaron problemas ocasionales en los cálculos matemáticos referentes a las administraciones de la medicación. Según los resultados del teste del MCS, fue visto el menor índice de despostas correcta en 26.9% para los estudiantes de enfermería y 5.5% para los estudiantes de obstetricia, mientras que el índice de desposta correcta más alta era 98.6% para los estudiantes del oficio de enfermería y 94.5% para los estudiantes de obstetricia. La administración de medicación es una habilidad esencial para los enfermeros y parteras. Cualquier problema en el cálculo puede conducir al error de la medicación y a las situaciones peligrosas para la vida para los pacientes. En el estudio, fue encontrado que las habilidades matemáticas de los estudiantes de enfermería y de obstetricia eran débiles y no se sentían capases en el cálculo de las dosificaciones de la medicación. La determinación y la superación de esta insuficiencia de los estudiantes durante su formación prevendrían los problemas que hacen frente posiblemente en su profesión después de su graduación. Palabras clave: Estudiantes de enfermería; Errores en la medicación; Administración & dosage.
INTRODUCTION Medication administration is a nursing function. As such nurses and midwives are expected to remain fully responsible and competent in the knowledge of medication administration, which includes proficient mathematical, dosage calculation skills and also pharmacological skills (GRANDELLNIEMI et al 2006; BAYNE & BINDLER 1988; KAPBORG & ROSANDER 2001). These skills are needed to safely and correctly administer medicines to patients in clinical practice, to provide advice and information to patients about their treatments and to evaluate adverse drug effects. Even though nurses need mathematics in fulfilling their duties in medication administration they find mathematics difficult and have problems in coping with dosage calculations. The same difficulties are also faced by nursing and midwifery students for student nurses and midwifes therefore learning how to calculate drug dosages is an important skill that they need to be taught during their training. For decades studies have found the mathematical skills of nurses and nursing students insufficient. The mathematical skills of nurses and students have been studied by using calculation tests, mostly developed by the researchers (GRANDELLNIEMI et al 2006; KAPBORG 1995). No study on the evaluation of mathematical skills of the nursing and midwifery students was encountered in the literature in Turkey about nursing and midwifery. This study thus designed in order to draw attention to this important subject and to make an evaluation of the current situation. The Turkish public school system comprises compulsory education schools and various types of private schools. The 8year compulsory primary education is for all children between the ages of 7 and 15. Almost all of the pupils attending compulsory education schools continue directly to the voluntary high school education, and almost all of them complete their high schooling within 3 years. High school confers general eligibility for further studies in higher education. In Turkey, mathematics classes are compulsory both during the compulsory primary education and during the high school education. In Turkey, the nursing and midwifery education is given as a 4year vocational education after the 3year high school education. Many subsequent investigations have demonstrated a lack of mathematical and / or calculation abilities in nurses. ROSANDER (1989) has shown that these errors can sometimes be explained by stress, but are often a result of insufficient arithmetic understanding and training. (KAPBORG & ROSANDER 2001; ELLIOTT & JOYCE 2005). This study was carried out with the purpose of determining the Nursing and Midwifery students’ interest and skills in mathematics, and their skills in calculating the medication dosages.
METHODS In the study, a survey form comprising 16 questions having the purpose of determining the students’ demographical characteristics and interest in mathematics, and the Medication Skill Test (MCS Test), which had been also prepared by the researchers, were used. The Medication Skill Test (MCS Test) were developed, by the researchers, by means of reviewing the relevant literature, particularly the studies carried out by GRANDELLNIEMI et al. (2006) and the pharmacology test books. The MCS Test consisted of 25 questions, of which eleven were about general mathematics and fourteen were about the calculation of the medication dosages. The answers the students gave to the questions were evaluated as correct or incorrect. The sampling of the research comprised totally 73 students from the 2^{nd}, 3^{rd} and 4^{th} grades of the midwifery classes, and totally 142 students from the 1^{st}, 2^{nd}, 3^{rd} and 4^{th} grades of the nursing classes. The survey form were applied to the students by providing the examination conditions and giving 20 minutes time. The data collected was evaluated in computer.
RESULTS It was determined that 96.5 % of the nursing students (n: 137) and 90.4 % of the midwifery students (n: 66) liked the mathematics. 90.1 % of the nursing students (n: 128) and 83.6 % of the midwifery students (n: 61) stated that they found mathematics enjoyable, and likewise, 35.2 % of the nursing students (n: 50) and 34.2 % of the midwifery students (n: 25) stated that they deemed the mathematics as necessary in nursing. 66.9 % of the nursing students (n: 95) and 63.0 % of the midwifery students (n: 46) stated that they had good mathematical skills. 60.6 % of the nursing students (n: 86) and 75.3 % of the midwifery students (n: 55) stated that they didn’t deem themselves as adequate in calculating the medication dosages. 65.5 % of the nursing students (n: 93) and 74.0 % of the midwifery students (n: 54) stated that they experienced occasional problems in the mathematical calculations relating to the medication administrations (Table 1, 2 ).
It was determined that the actual mathematical skills differed depending on the grade the nursing students are attending. In some of the items of the test evaluating the actual mathematical skills of the nursing students, meaningful differences were determined between the 1^{st}, 2^{nd}, 3^{rd} and 4^{th} grade students (for p values, see Table 3). Though the correct answering rate of the 1^{st} grade students was found to be higher than the students of the other grades in most of the questions, the differences were not statistically meaningful (p>0.005). It was found out that, the lowest “correct answering rate” of the students was for the questions on the Roman Numerals. It was found out that the correct answering rate of the 1^{st} grade students for these questions was higher, and that the difference between the grades was meaningful (p<0.05). In the calculation of the oral and parenteral medication doses, it was found out that the 2^{nd}, 3^{rd} and 4^{th} grade students were more successful than the 1^{st} grade students (p<0.05, p<0.01). It was also found out that the 2^{nd} and 3^{rd} grade students were more successful than the 1^{st} and 4^{th} grade students in the calculation of the amounts of the liquid to be sent intravenously, and the difference was determined to be statistically meaningful (p<0.001). It was determined that the actual mathematical skills differed depending on the grade the midwifery students are attending. In some of the items of the test evaluating the actual mathematical skills of the midwifery students, meaningful differences were determined between the 2^{nd}, 3^{rd} and 4^{th} grade students (for p values, see Table 4). The correct answering rate of the 2^{nd} grade students was found to be higher than the 3^{rd} grade students grades in some of the questions measuring the basic mathematical skills, and the differences were statistically meaningful (p<0.005). It was found out that, the lowest “correct answering rate” of the midwifery students, likewise the nursing students, was for the questions on the Roman Numerals. In the calculation of the oral and parenteral medication doses, it was found out that there was no meaningful difference between the 2^{nd}, 3^{rd} and 4^{th} grade midwifery students. And the rate of incorrect answering was found to be high for these questions. It was also found out that the 2^{nd} and 3^{rd} grade students were more successful than the 4^{th} grade students in the calculation of the amounts of the liquid to be sent intravenously, and the difference was determined to be statistically meaningful (p<0.05).
DISCUSSION Nursing and midwife students need mathematics to perform medication administration safely in clinical practice. Though a great number of the students taking part in the study considered the mathematics enjoyable and necessary in the nursing and midwifery profession, most of them stated that they found themselves inadequate in calculating the medication doses. NIEMI et al. (2005) also have found out that the nurses and the nursing students found the mathematics difficult and felt inadequate in it. Students, in general, did not perform well on the test, the results showing a lack of mathematical skills (GRANDELLNIEMI et al 2006). This results are worrying especially for the last grade students who will be graduated a few months later. The finding is similar to the ones of the other studies (WEEKS, 2001; WEEKS et al.2000). It was found out that, among the nursing students, the 1^{st} grade student’s answering rate was higher than the students of the other grades. In Turkey, a university entrance exam including difficult mathematical questions has to be passed before entering the universities. In order to succeed this exam, students take extra mathematics lessons or attend to the private university preparation courses. The fact that the 1^{st} grade students were more successful can be attributed to this. We can interpret the findings that since they don’t take any mathematics lessons during their nursing education their mathematical skills weaken in higher grades. There were some questions in the MCS test that proved difficult. Estimation of a sensible amount was founded difficult. It is very important that everyone dealing with medications has an idea beforehand of what might be a sensible amount. Roman Figures and solid and dilute solutions were difficult. These skills are taught within medication calculation, but less commonly used in every day practice, so low belong to critical skills which are needed when readymade doses are not available (WRIGHT 2005; KAWASHIMA & PETRINI 2004). That the 2^{nd}, 3^{rd} and 4^{th} grade students were more successful than the 1^{st} grade students can be attributed to the fact that though the 1^{st} grade students take this lessons theoretically they have little clinical experience. It is possible to infer from these results that the rate of correct calculation of the medication doses increases proportionally to the increased clinical experience of the students. The 1^{st} grade midwifery students were not included into the study since they hadn’t taken yet the theoretical lessons regarding to medication doses. Between the 2^{nd}, 3^{rd} and 4^{th} grade midwifery students, no difference were found in the success obtained in the calculation of the oral and parenteral medication doses. 2^{nd} and 3^{rd} grade nursing and midwifery students were found to be much more successful than the last grade nursing and midwifery students in flow rate calculations. This result which is contrary to the expectation that the last grade students should be more successful is worrying. The fact that the 2^{nd} and 3^{rd} grade students employ these processes more frequently in their clinical practices and that the last grade students, taking Public Health and Psychiatry lessons, employ this processes rarely can account for this result. It is apparent that the unused knowledge is forgotten. Limitations of this study should be acknowledged. Firstly, the rate of the questions not answered by the students was found to be high. In order to decrease this rate, it could have been emphasized more strongly that the students should have answered the test completely. Attention should also be paid to MCS test. Firstly, there were some calculation problems which were difficult and might need refinement. Secondly, written tests have been criticized as a predictors of mathematical competence in clinical practice. This test assessed nursing and midwifery students’ actual mathematical skills in theory but did not monitor their skills and performance in every day practice (GRANDELLNIEMI et al 2006; ADAMS 1991; MURRAY 1996; CARTWRIGHT 1996). Testing skill levels at the beginning, before starting clinical practice and periodically during nursing programs would reveal those students who need extra help with mathematics. Remedial teaching can be directed towards those students who consider their skills in sufficient (GRANDELLNIEMI et al 2006; KAPBORG 1995). Every nurse and student should primarily be responsible for the development of their own mathematical skills needed in clinical practice and, not only rely on occasionally testing.
CONCLUSION Medication administration is an essential skill for nurses and midwives. Any mistake in calculation can lead to medication error and life threatening situations for patients. In the study, it was found that the mathematical skills of the nursing and midwifery students were weak and they didn’t feel adequate in the calculation of the medication dosages. This study showed that few respondents attained 100 % correct in MCS test. Determining and overcoming this inadequacy of the students during their education would prevent the problems they possibly face in their profession after their graduation. Moreover, the connection with learning environment in clinical practice and mathematical skills should be studied.
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Texto recebido em 01.10.2006 Publicação Aprovada em 10.10.2006
1 This study has been presented as a poster in, "I. European Nursing Students Congress" between May 2526,2006 in IzmirTürkiye. 

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