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. 2024 Jun 30;11(7):e2226. doi: 10.1002/nop2.2226

Assessing numeracy and medication calculations within undergraduate nursing education: A qualitative study

Christine Minty‐Walker 1,✉, Nathan J Wilson 1, Leanne Rylands 2, Jim Pettigrew 3, Leanne Hunt 1
PMCID: PMC11214913  PMID: 38946052

Abstract

Aim

To explore how undergraduate nursing students are assessed on nursing numeracy and medication calculations from the perspective of Australian nurse education leaders.

Design

A qualitative study.

Methods

Semi‐structured interviews were conducted with 17 nurse education leaders between November 2022 and January 2023. Braun and Clarke's six phases of thematic analysis were used to analyse the data.

Results

Five key themes were identified: (i) high expectations to keep the public safe, (ii) diverse assessment formats, (iii) different ways of managing assessment integrity, (iv) assessment conditions incongruent to the clinical setting and (v) supporting struggling students.

Conclusion

Nurse education leaders set high standards requiring students to achieve 100% in numeracy and medication calculation assessments, thus maintaining the reputation of nursing and patient safety. However, students struggled to meet this expectation. Diverse assessment formats were implemented, with some examination conditions contrary to clinical practice. Currently, there is no benchmark or independent point of registration examination in Australia, hence the problem is each university had a different standard to judge students' competence. Gaining insight into how these assessments are conducted provides an opportunity to work towards an evidence‐based model or benchmark for the assessment of numeracy.

Implications for the Profession

Dosage errors in clinical practice threaten patient safety and the reputation of the nursing profession. The accuracy rate of calculations by undergraduate and registered nurses is deficient worldwide. This research highlights a major educational issue, that being the wide variation in how numeracy assessments are conducted with no clear pedagogical rationale for a standardised method. Such assessments would establish a national standard, contributing to quality assurance, the development of the nursing profession and improve patient safety.

Keywords: assessment, dosage competency, medication calculations, nursing numeracy, patient safety, undergraduate education, undergraduate nursing students

1. INTRODUCTION AND BACKGROUND

Undergraduate nursing students must be equipped with the skills to be numerically competent. Weaknesses in numerical ability contribute to poor medication calculation skills, resulting in dosage calculation errors, which are potentially life threatening for patients. The international literature reports widely that undergraduate students struggle to pass basic mathematics and medication calculation tests (Eastwood et al., 2011; McMullan et al., 2010; Wennberg‐Capellades et al., 2022), especially those “involving multiple operations and a higher level of conceptual understanding” (Elonen et al., 2022, p. 548). Dosage errors also occurred within controlled simulated teaching environments (Schroers et al., 2022) and during clinical placement (Gunes et al., 2020).

Weaknesses in medication calculation skills start within undergraduate nursing education and continue post‐tertiary education within the clinical practice setting. The literature reveals that dosage calculation errors were common among Registered Nurses (RN) (Brabcová et al., 2023; Cavell & Mandaliya, 2021; Jessurun et al., 2023), involving the incorrect conversion of units, proportional errors, and conceptual errors related to volumes and formulas (Mulac et al., 2022) resulting in an underdose or overdose (Eastwood et al., 2011).

Developing students' numeracy and medication calculation skills is a challenge for the leaders of undergraduate nursing degrees (Minty‐Walker et al., 2023). Students often enter university ill‐equipped to pass basic numeracy tests, with mathematics assumed knowledge upon admission (Minty‐Walker et al., 2021). Numeracy teaching for undergraduate nursing students is also problematic, with a plethora of approaches taught to students and limited studies on the most effective teaching method (Minty‐Walker et al., 2024).

Similar to the diverse range of teaching methods are the wide variations in how nursing numeracy and medication calculations are assessed. For instance, some assessments are paper‐based (Pettigrew et al., 2020; van de Mortel et al., 2014), others online (Sabin et al., 2013), a combination of the two (Karabağ Aydin & Dinç, 2017) or a clinically simulated scenario (Sabin et al., 2013). Clinically contextualised questions are reportedly preferred by students as they add realism (Ramjan, 2011) and reflect authentic real‐world practice (Weeks et al., 2013). Online assessments have been compared with practical assessments in Objective Structured Clinical Examinations (OSCE) revealing a high level of congruence between both methods (Sabin et al., 2013).

When designing numeracy and medication calculation assessments, consideration should be given to the use of an underpinning learning theory. The constructivist learning theory provides evidence to suggest the need for a realistic environment based on real‐world examples where learners build knowledge through actively engaging with artefacts used in clinical practice (Mosca, 2017; Newton et al., 2013; Weeks et al., 2013). The cognitive load theory uses a step‐by‐step approach to learning, moving from simple to complex tasks to reduce the load on the working memory (McMullan et al., 2011).

Assessing undergraduate numeracy competency is usually determined by passing medication calculation assessments. The requirement to reach 100% is reportedly common internationally (van de Mortel et al., 2014), and in the United Kingdom, the regulator of pre‐registration nurse education programmes mandates a 100% pass mark (Nursing & Midwifery Council, 2018). By contrast, in countries such as Australia the accreditation council offers no such benchmark (Australian Nursing & Midwifery Accreditation Council [ANMAC], 2019). Furthermore, variations in the number of attempts students are offered vary widely (Karabağ Aydin & Dinç, 2017; Mosca, 2017; van de Mortel et al., 2014).

The varied use of examination aids such as calculators, written medication formulas or equivalency tables are also reported. Calculators were not permitted in some examinations (Basak & Yildiz, 2014; Karabağ Aydin & Dinç, 2017), yet were permitted in others (Coyne et al., 2013; Rainboth & DeMasi, 2006). Grugnetti et al. (2017) compared cohorts with and without a calculator and reported that mathematical deficiencies occurred despite the use of a calculator. In a study by Rainboth and DeMasi (2006), an equivalency table was provided to students to use in a medication examination to assist with metric system conversions. Furthermore, in a study by Coyne et al. (2013), students could take written medication calculation formulas into the examination, yet the incorrect formula was still used by some students.

Research into the effectiveness of the different approaches to assessing numeracy and medication calculations is lacking. In the Australian context, there is no standardised national nursing curriculum (Hall, 2014); therefore, each university conducts assessments differently leading to ‘widely different standards held by different institutions’ (Schwartz, 2019, p. 42). This is coupled with the absence of an a‐priori numeracy requirement for entry to most Australian nursing degrees, and no guidance for nurse academics provided by the Australian RN Accreditation Standards (Minty‐Walker et al., 2021). It is timely to gain an insight into how these assessments are conducted to work towards an evidence‐based model or benchmark for the assessment of numeracy. This research provides insight from Australian nurse education leaders of undergraduate nursing degrees into how numeracy and medication calculations are assessed in the tertiary environment.

2. AIM OF THE STUDY AND RESEARCH QUESTIONS

The aim of this study was to explore how undergraduate nursing students are assessed on nursing numeracy and medication calculations from the perspective of Australian nurse education leaders. The research questions for this study were: (1) to explore how numeracy and medication calculations are assessed within undergraduate nursing education, and (2) to understand how the national accreditation standards influence numeracy assessment requirements.

3. METHODS

3.1. Design and setting

A qualitative study design was conducted, involving the thematic analysis of semi‐structured interviews. The setting was Australian universities delivering an accredited undergraduate nursing degree.

3.2. Participant recruitment, sampling and data collection

Sampling for this study was purposive, and eligibility criteria were the nurse education leader of an undergraduate nursing degree in Australia. This person had the responsibility of leading the development, implementation and accreditation process of the undergraduate curricula at their school/faculty. Postgraduate pre‐registration nursing degrees were excluded. The recruitment procedure was as follows: the chief researcher contacted all Australian Schools of Nursing (n = 42) by phone or email, to establish who held the position of nurse education leader or equivalent. The identified nurse education leader was contacted via email inviting them to participate, with a mutually agreed time arranged for an online interview.

In total, (n = 42), participants were approached and invited to participate, and (n = 17) accepted. There were four participants who refused to participate due to heavy work commitments and annual leave. Another participant did not attend the interview despite multiple interview times being scheduled, 15 participants did not respond to the email invitation and reminder, one university ceased their undergraduate nursing degree, and four universities had a campus presence nationwide with one nurse education leader representing all locations during the interview.

The dataset size of this research was determined using information power which ‘indicates that the more information the sample holds, relevant for the actual study, the lower number of participants is needed’ (Malterud et al., 2016, p. 1759). Information power is considered appropriate for qualitative nursing research, as opposed to data saturation which is appropriate for grounded theory studies (Thorne, 2020). To obtain sufficient information power, the richness of the information was determined by having a narrow study aim and purposive sampling to recruit participants that held characteristics specific to the study aim; the quality and richness of the interview dialogue were strong as the participants were articulate and well‐informed on the topic; the length of the interviews (40–80 min) allowed for depth and breadth of information, and an in‐depth analysis of the narratives offered sufficient information.

Data were collected through individual, semi‐structured online interviews between November 2022 and January 2023, with the duration between 40 and 80 min. To ensure a consistent interview process, the chief researcher undertook all interviews and followed the same interview schedule for each participant. Interviews commenced by asking for consent to participate and be audio recorded, clarifying understanding of the participant information sheet, the time involved, and that withdrawal could occur at any time. The interview questions were created by the authors, which included three academic Registered Nurses and two mathematicians. The context of the questions was developed and informed based on the findings of previous research (Minty‐Walker et al., 2024). A pre‐test was conducted, and as suggested by Grove et al. (2013), this should be ‘on subjects similar to the individuals who will be included in the study’ (p. 424). The interview guide was pre‐tested with a previous nurse education leader from the chief researcher's university. The results of the pre‐test concluded that the questions were clear, sequential, encouraged an open dialogue and in‐depth conversation; hence, no changes were made to the interview guide.

The semi‐structured interview schedule included broad questions on the participant's experiences with numeracy content development and accreditation requirements, how numeracy assessments were designed and delivered including when and in what context, the types of numeracy aids permitted during assessments, the expected pass mark required and questions on what an ideal learning and assessment context for numeracy might look like. In this research, member checks were carried out as data was being collected, as suggested by Polit and Beck (2018). This was done through probing to ensure that the interviewer properly interpreted the participant's meaning. Panopto® was used to transcribe the interview recordings verbatim, with cross‐checking by the research team.

Participants were from the following Australian states: Queensland (n = 3), New South Wales (n = 8), Victoria (n = 4), South Australia (n = 1) and Tasmania (n = 1). The mean age of the participants was 51.8 years (SD = 8.2, range 37–66), with 82% identified as female. The highest level of education was PhD (53%), masters (41%) and graduate diploma (6%). The mean number of years as a RN was 28.9 (SD = 8.6, range 11–42 years). The mean number of years working in a tertiary education setting teaching undergraduate nurses was 13.2 (SD = 6.9, range 3–32 years), the mean number of years of experience in their current role was 3.9 (SD = 3.7, range 1–12), and the mean size of the undergraduate cohort was 2281.2 (SD = 1372.5, range 631–5000).

3.3. Data analysis

Thematic analysis was guided by Braun and Clarke's (2006) six phases. In phase 1, researchers immersed themselves in the data, listening repeatedly to the audio recordings and reading the transcriptions multiple times. Phase 2 involved a fine‐grained analysis of the data, extracting and generating 100 relevant codes using NVivo©; and in phase 3, codes were further refined to 20 codes and then grouped together to develop themes. In phase 4, the themes were refined by the authors during team meetings to verify whether the data presented a consistent and clear presentation. In the fifth phase, each theme was given an informative name. Finally, in phase 6, the findings were written up using a logical process with supporting quotes, providing a coherent story. See Table 1 for an example of the thematic analysis and coding.

TABLE 1.

Thematic analysis: An example of coding and development of themes, linked with selected verbatim interview data quotes.

Verbatim interview data quote and participant (P) identifier number Coding in NVivo® Final theme title Number of participants (n = 17) mentioning this theme (%) Total number of quotes for this theme throughout the 17 interviews
‘… our maths exams are threshold assessments … 100% passing rate and to pass the subject’ (P8)

Pass rate

Assessment attempts

ANMAC

High stakes

Level of stress

Patient safety

Curriculum

Reputation of nursing

Set up to fail

 4.1 High expectations to keep the public safe 16 (94) 46
‘ANMAC are very much about safe medication calculation administration … you know that we have 100%’ (P7)
‘We stipulated the three attempts’ (P14)
‘every semester, every year, unlimited attempts until they got to get 100%’ (P17)
‘I think the fact that it was a hurdle creates anxiety because they know they can't pass the unit without passing it’ (P11)
‘Besides the whole patient safety aspect and medication administration competency aspect, is our reputation, we are a profession and we're very well respected amongst, you know, not only the medical community, the health and community, but also amongst the general public’ (P8)
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3.4. Ethical considerations

This research was approved by Western Sydney University, Human Research Ethics Committee (HREC Approval Number: H15179 on 20 October 2022). A minor amendment to the demographic questionnaire was approved on 7 November 2022.

3.5. Rigour and reflexivity

Dependability was established by using a consistent interview approach with all participants. Credibility was maintained using audio recordings, interview notes, verbatim transcripts and coding of the data through the six phases of analysis. Confirmability was achieved by a logical and auditable trail of the data. Regular team meetings helped to establish a clear pathway for the development of the themes, with documentary evidence in NVivo© and Excel. Individual participants were assigned a code from P1 to P17, which are linked to the direct quotations, demonstrating the authenticity of the data. Transferability was enhanced by providing the details of the research context, setting and participants' demographic details. The research team minimised bias by employing reflexivity. Theoretical triangulation was achieved through the diversity of the research team, which consisted of three RNs and two mathematicians. The chief researcher is a Registered Nurse of 30 years, who has been lecturing undergraduate nursing students for 14 years.

4. FINDINGS

Five themes were generated from the data analysis: (i) high expectations to keep the public safe, (ii) diverse assessment formats, (iii) different ways of managing assessment integrity, (iv) assessment conditions incongruent to the clinical setting and (v) supporting struggling students.

4.1. High expectations to keep the public safe

The assessment was described as a threshold, gatekeeper or a hurdle, meaning that if students did not pass, they would fail the subject. Participants highlighted that they see numeracy as important: ‘… our maths exams are threshold assessments … 100% passing rate and to pass the subject’ (P8). A 100% pass rate was not a requirement in the national accreditation standards; however, participants believed it was something ANMAC would expect: ‘ANMAC are very much about safe medication calculation administration … you know that we have 100%’ (P7).However, there was inconsistency in the number of attempts students had to achieve a 100% pass mark: ‘We stipulated the three attempts’ (P14), ‘every semester, every year, unlimited attempts until they got to get 100%’ (P17). Some students found the assessment stressful, and participants noted that: ‘I think the fact that it was a hurdle creates anxiety because they know they can't pass the unit without passing it’. (P11).

Patient safety and maintaining the reputation of nursing were the rationales for universities setting a high standard for the numeracy and medication calculation assessments: ‘Besides the whole patient safety aspect and medication administration competency aspect, is our reputation, we are a profession and we're very well respected amongst, you know, not only the medical community, the health and community, but also amongst the general public’ (P8).

4.2. Diverse assessment formats

Assessment questions often commenced with basic numerical concepts, followed by clinically contextualised questions. Students were initially assessed on: ‘Addition, subtraction, multiplication, division, rounding and conversions’ (P14). Contextualised questions were considered beneficial: ‘We've got images of medication packages, and you know IV fluids and students are asked to interpret information from those as well’ (P13).

Extra information used to set the context of the questions caused confusion: ‘We've recently reviewed all of our questions and we've pulled out all the clinical fodder … you just don't need all the crap about like why the person's come in and all that type of stuff. Because students tell us that that confuses them … they spend so much time just reading the question’ (P14). Another participant mentioned how non‐contextualised questions were not relevant to nursing: ‘… we asked questions if we gave you a bag of chips and it weighed 70 grams and you ate 30 grams, how many grams were left? … you know, when we're so big on contextualising and making it relevant to nursing and then we're talking about eating chips’ (P8).

Paper‐based or online assessments were used to test student understanding of numeracy and medication calculations. A participant said: ‘Paper and pen is probably for us quicker. We have a great many disadvantaged students who we couldn't expect to bring a laptop into a classroom … we don't think that's fair’ (P16). Another participant shared how they moved from paper examinations to online examinations: ‘But since we have integrated Med+Safe® [self‐directed learning and assessment program], we aren't getting any noise [student complaints] we used to have when we would have the face‐to‐face assessments [paper‐based], which would be ten questions, really basic questions, and the students would absolutely meltdown’ (P17).

Clinically simulated assessments were also conducted to test numerical and medication calculation competency: ‘We have an Observed Structured Clinical Assessment (OSCA) … they are required to carry out maths, some kind of calculation in most of those OSCAs’ (P8). Another approach was ‘a v‐sim, an online clinical scenario system’ (P11), a ‘scenario based clinical exam the VIVA [viva voce] they have to talk through the process of calculating and administering medication’ (P13).

4.3. Different ways of managing assessment integrity

Maintaining academic integrity during the assessments was important, with invigilated examinations preferred: ‘We've gone back to paper assessments because we just feel that we have a much higher level of confidence that the individual has done the work and that they've demonstrated their capacity’ (P16). ‘We invigilate it … the students come in the computer lab and we observe them undertake the assessment’ (P11).

One participant considered a practical assessment the securest way to prevent cheating: ‘Then we do an injectable in second year, second semester, so their required to do maths to calculate how much medication to give in that OSCA. So it is, that is probably our best, safest, most secure assessment that we have … there is absolutely no opportunity to cheat’ (P8).

An unsupervised online mathematics examination was preferred by one university: ‘… they can do it at home … the university decided to not have centrally scheduled exams anymore. So, everything was moved online … the university carries the responsibility for determining for deciding how those exams are going to be invigilated … but for what they consider to be a small exam, just 1 h, 30 questions, they don't provide any support for that’ (P13).

4.4. Assessment conditions incongruent to the clinical setting

The use of phones, calculators or written medication formulas in the examination was a contentious issue. Some participants agreed that allowing this was consistent with the clinical environment: ‘We do allow calculators … Registered nurses are all carrying calculators in their pockets’ (P11). Students who used a calculator were encouraged to work out an estimated answer: ‘So, if you're going to use a calculator, you need to do a guesstimate … because the calculator is not going to tell you that you pressed the wrong button’ (P11).

One participant described how their school only permitted calculators in third‐year examinations: ‘There's a lot of argument in our school. There's a black and a white team and the black team said no calculators at all, the white team … think … calculators could be used … so, we've allowed calculators in third year only for that test’ (P6).

Another participant described how phones were permitted in the examination: ‘We've debated the issue till the cows come home! And boy isn't it a divided perspective, our landing point was eventually that all students could use a calculator … a non‐programmable calculator … many students just use their phone, which of course doesn't meet the requirements of a non‐programmable calculator, but it also represents reality’ (P16).

To remain consistent with the clinical environment, students were permitted to bring nursing medication formulas into the examination: ‘… when you're working on a ward doing medication calculations, there's nothing to stop you having your formulas on a card, on your lanyards and a calculator in your hand … it's not about you must be able to remember these things otherwise you fail … this is about making sure our patients are safe’ (P15).

4.5. Supporting struggling students

Participants had various thoughts on why students struggled to pass numeracy and medication calculation assessments: ‘I think it's because they're not taught basic maths in high school, so they've done a little bit in primary school and then they haven't used it for years’ (P6). Self‐efficacy was another reason: ‘They go I'm hopeless at maths … I can't do maths and then they come and start doing nursing and go, oh my gosh. I'm really struggling here help’ (P7).

Numerical competence is mandatory in the nursing profession yet is a struggle for many: ‘… they are not often coming into the profession because they're good at maths, but more because they have extremely good emotional intelligence and they're very frightened of numeracy’ (P4).

Therefore, ‘It's a matter of identifying the students that you think are going to struggle and giving them a safe space to come and tell you that they're not coping’ (P11). ‘It is about trying to provide that supportive environment’ (P17). It is about: ‘Caring for our students … making sure they have this knowledge … to prepare them for, not difficult exams, but high‐risk exams because it is 100%’ (P13).

5. DISCUSSION

This study has illustrated the diversity in how numeracy and medication calculation assessments are conducted across Australian undergraduate nursing degrees. What did not vary was the reality that public safety is paramount, and a 100% pass mark is required. The high expectation to reach 100% competency in numeracy and medication calculation assessments can cause students to experience high levels of anxiety and stress (O'Reilly et al., 2020), and students struggled to reach this expectation; however, the nurse education leaders felt a clear sense of responsibility towards identifying struggling students and providing a supportive environment. The diversity in assessment methods across Australian universities is unsurprising as each university has the autonomy to design their own assessment format. The design of the questions varied from contextualised to non‐contextualised, paper‐based or online formats, and clinically simulated approaches. The issue of maintaining academic integrity varied greatly depending on resource support. Some assessments were invigilated, with practical assessments described as the securest approach; however, unsupervised assessments also occurred due to resource constraints. Furthermore, some assessment conditions were incongruent to the clinical setting, with the use of numeracy aids such as calculators, phones or formulas a contentious issue, and hence, variability occurred at each university.

The variability in assessment methods at each university can arguably compromise the validity and reliability of numeracy and medication calculation assessments. In studies by Karabağ Aydin and Dinç (2017) and Sabin et al. (2013), their nursing numeracy and medication calculation assessments were reported to be valid and reliable; however, validity and reliability were not reported in Ramjan (2011), and interrater variability was questioned by Daly et al. (2017). What we do know from this research is that the nurse leaders recognised that de‐contextualised questions could cause confusion, as can adding too much detail to the question. Although contextualised questions are reportedly preferred by students (Ramjan, 2011; Weeks et al., 2013), they can also cause incorrect problem‐solving if the semantic structure of written questions is presented in nursing language that the students cannot understand. Regardless of the method of assessment, test formats should contain sensible answers that reflect doses administered in clinical practice.

The findings revealed divergent views on the use of examination aids such as calculators, phones or allowing written medication formulas to be brought into the assessment. This diversity is echoed in the literature where some authors support the use of aids (Coyne et al., 2013; Rainboth & DeMasi, 2006), and others do not (Basak & Yildiz, 2014; Karabağ Aydin & Dinç, 2017). Nurses do have access to and use a calculator in clinical practice, yet these are not a substitute for sound numeracy knowledge and understanding, as conceptual errors can still occur (Grugnetti et al., 2017).

These findings raise a critical issue, as in the Australian context there is an absence of a regulated standard or benchmark for the assessment of numeracy and medication calculations. Hence, each nursing school chooses how to measure the competencies of their students and to what standards. We are not suggesting a one‐size‐fits‐all approach, but a national benchmark or point of registration assessment would provide an ‘independent definition of what it means to say a nurse is safe to practice’ (Schwartz, 2019, p. 41). RNs must demonstrate proficiency in the English language prior to registration which is legislated under the National Law (ANMAC, 2019), yet numeracy is not, despite poor numeracy skills being a major risk to public safety. A review into future nurse education has argued the requirement for ‘all candidates for registration to undergo an independent assessment to demonstrate they have the literacy and numeracy skills required to practise safely’ (Schwartz, 2019, p. 31).

Elsewhere, an independent assessment at the point of registration is required. Since 1995, in China, the National Nursing Licensure Examination (NNLE) is undertaken prior to registration, and in the United States, the National Council Licensure Examination for Registered Nurses (NCLEX‐RN) is mandatory (Hou et al., 2019). In New Zealand, candidates for registration must pass the Nursing Council State Final Examination (The Nursing Council of New Zealand, 2023). Such assessments establish a national standard, contributing to quality assurance and development of the nursing profession. Coben et al. (2010) have proposed the establishment of a benchmark at entry to practice, as this is the point at which undergraduate nurses transition to being RNs and are required to accept accountability for their actions. Setting a numeracy standard and requiring students to undertake an external examination to ensure that the benchmark has been met, would also make universities accountable for ensuring their graduates possess suitable levels of numeracy (Schwartz, 2019).

To integrate the results into an overarching context to assist nurse leaders with the development of numeracy and medication calculation, assessment consideration should be given to the following areas. Numeracy and medication calculation assessments should be designed based on an underpinning learning theory. The constructivist learning theory suggests the need for a realistic environment based on real‐world examples where learners build knowledge through actively engaging with equipment used in clinical practice (Mosca, 2017; Weeks et al., 2013). The use of simulated medication charts and medical equipment is beneficial (Grugnetti et al., 2014), as it provokes problem‐solving and critical thinking skills and this combination makes it easier to identify errors. The use of a simulated environment is helpful for first‐year students who have limited clinical experience and exposure to ‘tools of the trade’ (Latimer et al., 2017).

The validity and reliability of the assessment must be considered. Wright (2009) states that ‘written drug assessments do not represent the reality of practice and are therefore not a valid measure of drug calculation skills in practice’ (p. 545). Students can become confused when the questions do not represent reality, or when nursing terms such as ‘drawing up’ are used which are unfamiliar to students who have not attended clinical placement. Furthermore, too much detail within questions that contextualise the patient history can be problematic for students, as ‘reading and interpreting a word problem is a skill in itself’ (Wright, 2009, p. 546). Another difficulty for students is when they are not permitted to use examination aids such as a calculator. Within the clinical setting, calculators are commonly used by nurses, and hence, Wright (2009) suggests that the assessment is invalid and unreal if calculators are not permitted. Calculators are a valid instrument that support students; however, it does not replace the need for students to conceptually understand how to perform medication calculations (Grugnetti et al., 2017). Medication calculation assessments are high stakes assessment undertaken by students who struggle with numeracy; hence, academic integrity can be an issue. This could be combated by educating students on the expectations of the nursing profession, the professional codes of conduct and the consequences of professional misconduct, which could ultimately compromise patient safety (Bloomfield et al., 2021).

Supporting students to become safe and successful practitioners requires upfront support using various teaching and learning approaches. Flexibility in teaching that reinforces individual learning styles can help with problem‐solving (Weeks et al., 2013). A blended learning approach (face‐to‐face and online) increased confidence and reduced anxiety in a study by (O'Reilly et al., 2020). Bridging the theory practice gap and ensuring congruence with the clinical setting is vital. Using contextualised, realistic and authentic assessments that recreate real‐world practice will help students relate to real‐life patient situations (Pettigrew et al., 2020; Ramjan, 2011; Weeks et al., 2013). The inclusion of system factors such as interruptions, noise and time pressures also prepares students for the reality of the clinical environment (Schroers et al., 2022). Overall, approaches that mimic the clinical environment that are aligned with meaning and context are suggested as strategies that foster undergraduate nursing education (Mulac et al., 2022) .

6. STRENGTHS AND LIMITATIONS

This study exhibits notable strengths including being the first to elicit the viewpoints of nurse education leaders regarding the assessment of numeracy and medication calculations in undergraduate nursing degrees in Australia. Another strength was the response rate of 40%. A limitation is that only one person was interviewed from each university. Their roles were not identical, and some had only been in the position for a short time with limited knowledge on the assessment of numeracy and medication calculations in the curriculum.

7. IMPLICATIONS FOR PRACTICE

Dosage errors in clinical practice threaten patient safety and the reputation of the nursing profession. The accuracy rate of calculations by undergraduate and Registered Nurses is deficient worldwide. This research shows the variance in assessments and standards when measuring nursing numeracy competence. This prompts consideration into adopting a national/standardised approach supported by pedagogical evidence. The literature and results from this study highlight that education strategies used to write assessments need to be contextualised, questions and answers must represent reality, and the use of examination aids should promote consistency with clinical practice. Drawing this evidence together into an independent external national assessment would establish a national standard, promote consistency, set a benchmark for all students, and contribute to quality assurance and the development of the nursing profession. By identifying the types of dosage calculation errors in the tertiary or clinical environment, teaching and assessment approaches can be targeted to enhance competency. Therefore, if teaching and assessment methods can be enhanced within the tertiary education setting, students and RNs will become more competent and the risk to patient safety due to dosage calculation errors will be reduced.

8. CONCLUSION

The findings of this study have prompted consideration of how undergraduate nursing students are assessed on numeracy and medication calculations. Each university designs their own assessments and measures proficiency according to their standards. How the determination of competency is achieved and standardised across the curriculum is an issue for further research. However, having an independent external assessment of numeracy would require universities to be accountable and improve education. It also ensures that candidates have all achieved the required benchmark to practise safely.

AUTHOR CONTRIBUTIONS

Christine Minty‐Walker: Conceptualisation; data curation; formal analysis; investigation; methodology; project administration; software; validation; visualisation, writing—original draft; writing—review and editing. Nathan J. Wilson: Conceptualisation; formal analysis; methodology; project administration; supervision, validation; visualisation; roles/writing—original draft; writing—review and editing. Leanne Rylands, Jim Pettigrew and Leanne Hunt: Conceptualisation; formal analysis; methodology; supervision; validation; visualisation; roles/writing—original draft; writing—review and editing. All authors contributed to the preparation, critical review and approval of the final manuscript.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICAL APPROVAL

This study was approved by Western Sydney University, Human Research Ethics Committee (HREC Approval Number: H15179 on 20 October 2022). A minor amendment to the demographic questionnaire was approved on 7 November 2022.

PATIENT CONSENT STATEMENT

Patient consent was not required, as no patients were interviewed.

ACKNOWLEDGEMENTS

We would like to thank the 17 participants who generously gave their time to share their knowledge on nursing numeracy, and their care and concern for ensuring that all undergraduate nursing students are provided with a supportive and caring environment.

Contributions: Mandy Salas, Professional Communication and Academic Literacy Support for proofreading. Open access publishing facilitated by Western Sydney University, as part of the Wiley ‐ Western Sydney University agreement via the Council of Australian University Librarians.

Minty‐Walker, C. , Wilson, N. J. , Rylands, L. , Pettigrew, J. , & Hunt, L. (2024). Assessing numeracy and medication calculations within undergraduate nursing education: A qualitative study. Nursing Open, 11, e2226. 10.1002/nop2.2226

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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