Changes to teaching and learning about medication administration within a diploma of nursing course due to the Covid-19 pandemic: A staff and student multi-method evaluation

Abstract

Aim

This project aimed to evaluate student and staff satisfaction with, and perspectives on, changes to delivery and format of the Medication Unit of Competency within a Diploma of Nursing Program.

Background

Medication safety is an integral component of learning for pre-registration nursing students. The COVID-19 pandemic required rapid changes to be made to the medication competency unit being taught to students within a Diploma of Nursing, pre-registration course. Changes to sequencing of theory, mode of education delivery, class sizes, available resources and learning support were required.

Design

A multi-method evaluation process was conducted. The project is reported as per SQUIRE-EDU guidelines.

Methods

Focus groups and survey data were obtained from staff and students in December 2020, to evaluate responses to the changes. Student exam results and the number of learning support consultations accessed were also assessed to identify impact of changes.

Results

Staff and student evaluation identified mixed responses but overall, the change in sequence of theory and mode of delivery was positively received. Crude comparisons of final assessment results revealed improved marks compared to the previous cohort. The addition of an online medication resource was utilised by most students. The agility of staff in responding to the challenges was highlighted in the staff focus group and additional, flexible learning support was favourably received by students.

Conclusions

Despite the need for rapid changes being made to the course, positive responses were received from both staff and students. Some students preferred the traditional sequencing of learning as they felt it matched their learning style. An added online resource and extra learning support supported student self-efficacy development of medication competency; however further research is needed to ascertain any associations. The online resource is still being utilised within course curriculum.

1. Introduction

The onset of the Covid-19 pandemic toward the end of 2020, impacted nursing education in many ways. Nursing staff from non-clinical and/or non-critical areas were rapidly upskilled to return to clinical care (Marks et al., 2021). Furthermore, in some contexts, nursing students were deployed to extended clinical placements (Swift et al., 2020). Health directives on social distancing, restrictions to students’ clinical placement experiences (Dewart et al., 2020) and strict lockdowns were challenges that nursing students and educators had to and continue to manage (Carolan et al., 2020). A need emerged to pivot rapidly and provide flexible education delivery modes to manage challenges effectively. This paper reports on the student and staff experience of rapid changes made to a medication competency unit of teaching, undertaken as part of the pre-registration, Diploma level nursing program in one context.

Within Australia, a Diploma level nursing student graduates after an 18-month full time program and can then apply for registration as an Enrolled Nurse. The level of education is similar to that of a Licenced Practical Nurse in America, or a Nursing Associate role in the UK (Nursing and Midwifery Council, 2022). Diploma level, pre-registration student nurses are often referred to as ‘hands on’ learners with their training usually undertaken in a vocational setting (Akhter et al., 2021). In comparison, a Bachelor of Nursing student is required to successfully complete a minimum of three years full time study to apply for registration as a Registered Nurse and have broader knowledge and skills. Despite these differences, both Enrolled and Registered graduate nurses will have responsibility to prepare and administer different types of medications to patients, within their scope of practice (Nursing and Midwifery Board of Australia, 2022). Therefore, regardless of learning pathway, medication knowledge and skills are critical requirements for all nursing students, especially considering reports on the numbers of medication errors and adverse drug reactions (Roughead et al., 2016).

The original design of the Diploma of Nursing medication unit in our context, acknowledged Diploma-level student learning needs, providing a multi-modal delivery format where students were required to attend lectures, take part in simulation (SIM) activities and attend clinical placements. SIM learning is a mandatory physical learning component with associated assessment and a final learning level requirement is completed in the clinical environment and fully supervised performing applicable skills and knowledge. In response to challenges presented during the COVID-19 pandemic, curriculum changes were needed that not only addressed student needs but also complied with Government and health regulations and directives.

To respond to the challenges faced due to the pandemic, nurse educators within the Diploma level course at our centre adapted alternative methods of curriculum delivery. The original education format delivered theoretical content in a face-to-face, classroom setting first, then provided simulation training, followed by clinical placement. Changes to the program involved reversing the sequence of learning i.e., SIM learning followed by theoretical content delivered in a classroom setting; use of online platforms (via Zoom); addition of an online learning resource and utilising smaller student group sizes for each learning activity.

The new sequencing of learning content for the medication competency unit utilised principles of a flipped classroom approach but also exposed students to digital content to augment their learning and individual self-efficacy for medication management. ‘Flipped learning’ is an educational method that emerged in the early 2000′s, whereby students are responsible for pre-learning educational content prior to actively participating in discussion with their educator in a classroom situation (Betihavas et al., 2016). While flipped classroom strategies appeared to promote learning, (Hamdan et al., 2013) there is mixed results of its effectiveness in undergraduate Bachelor level nursing courses in relation to student satisfaction and academic outcomes (Betihavas et al., 2016). Two studies revealed nursing students had better achievement on exams in pharmacology courses using the flipped versus traditional classroom approach (Munson and Pierce, 2015, Sisk, 2011). However, five studies within a systematic review (including 934 undergraduate and postgraduate nursing students), reported that while some students were satisfied with the flipped approach, there was no confirmation it improved academic performance (Betihavas et al., 2016). This project aims to evaluate and report on staff and student perspectives of learning sequence and other course delivery changes as a response to challenges and restrictions resulting from the Covid-19 pandemic.

2. Aim

More specifically, this project aimed to answer the question, “What was the impact on students and staff, of changes to the Medication unit of competency in response to Covid-19 restrictions.”

3. Methods

3.1. Curriculum outline

The Diploma of Nursing (pre-registration) program is conducted within a nationally accredited, independent, hospital-based Registered Training Organisation in Queensland, Australia. The course facilitates acquisition of skills, knowledge, attitudes and behaviours required to become an Enrolled Nurse within Australia. Students complete their studies within one facility but can undertake placement experiences across local or regional clinical facilities. After successful completion of the 18-month Diploma course, students can apply for National Registration to practice as an Enrolled Nurse through the Nursing and Midwifery Board of Australia (NMBA) (Nursing and Midwifery Board of Australia, 2022) and can pathway into a Bachelor of Nursing course with some advance standing credit. The complete course is comprised of 20 core units and five elective units (or subjects). The unit on administering and monitoring medicines and intravenous therapy, is therefore, one of twenty-five units of competency within the program. Historically, cohort sizes averaged 100 students.

3.2. Changes to course delivery

Due to Covid-19, the full cohort of 80 students enrolled since September 2020, were allocated into smaller groups than previous cohorts and exposed to a different sequence and mode of learning than previous cohorts had followed. The changed sequencing of learning content for the medication competency unit utilised principles of a flipped classroom approach (Betihavas et al., 2016) and incorporated varying modes of content delivery including face-to-face (theory), an online platform (e.g. Zoom); simulation (SIM) activities in the clinical simulation lab as well as learning during clinical placement, when possible. Changes were made throughout the unit, to facilitate meeting social distancing requirements, such as spacing desks and chairs appropriately within the classroom, providing more teaching sessions with smaller class sizes, and consideration of student numbers for scheduling of class and clinical placements. Extra learning support sessions were scheduled for individual students to meet with educators via Zoom or face-to-face if extra explanation or help was required. Mask-wearing was mandated according to Government requirements, for both students and staff. Additionally, a new digital content resource was added to augment student learning. Med+Safe® is an Australian designed software program, endorsed by the Australian College of Nursing, that provides a learner centered comprehensive program for the accrual of knowledge, skills, and confidence for numeracy in nursing. The program is currently used by many universities and hospitals throughout Australia. Table 1 outlines changes to teaching and learning approaches for each of the three student groups.

Table 1.

Structure of diploma of nursing course medication module.

Group 1	Group 2A	Group 2B (Reverse sequence)
34 students enrolled	17 students enrolled	29 students enrolled
Continued scheduled semester 1 clinical placement; continued to Semester 2 as per original timetable. Commenced in week 1 (as planned) of Medication Unit	Original clinical placement cancelled. Alternate placement for 3 weeks. Commenced semester 2 theory early and remained 3 weeks ahead of Group 1 until clinical placement. After clinical placement, re-joined Group 1 and continued semester 2 study	Original placement cancelled. Alternate placement for 3 weeks. Commenced semester 2 theory early and remained 3 weeks ahead of Group 1 until clinical placement. Completed semester 2, term 1 study at the same time as the rest of cohort, and re-joined rest of cohort for term 2 in January 2021 after the Christmas break
•Campus theory Wed •SIM on Thurs •Online theory lessons Fri	•Campus theory Wed •SIM on Thurs •Online theory lessons on Fri - continued this after their delayed semester 1 placement when they continued semester 2 with Group 1	•Campus theory Wed •SIM on Thurs •Online theory lessons on Fri (With group 1, weeks 1–3) From week 4 - online theory on Wed, SIM on Thurs and campus classes on Friday until the end of term 1 (Christmas break)
When Group 1 is in campus class, Group 2 is taught online. When Group 2 is in campus class, Group 1 is taught online. All students attend SIM on the same day but are divided into 3 smaller groups to reduce numbers in each learning space.

3.3. Data collection and analysis methods

As this project was evaluating an existing service and using a convenience sample, no formal sample size calculation was required. Data were collected from students via:

• •Student satisfaction survey – a 13-item anonymous survey developed by the project team to assess student responses to questions about changes in the sequence of content delivery as well as the incorporation of the online resource to augment their usual learning. As this was an evaluation specific to this unit and context, no prior validated survey was available that would have been suitable. Response format for each question was a 5-point Likert scale with responses ranging from Strongly Agree to Strongly Disagree. Quantitative data was analyzed using basic descriptive statistics, including counts, percentages and means. A hard copy of the survey was made available to students as they came to their last theory class for the unit. An administration staff member, who was not involved in any education activities with the students, collected and collated the responses for the project evaluation team.
• •Two semi-structured focus groups were undertaken in December 2020 to gather student perceptions on how the changes in delivery sequence and the introduction of a digital platform impacted their learning of medication administration. The focus groups were scheduled for two days towards the end of the unit, where there were approximately half of the full cohort (80 students) attending each day for other classes. All students were invited to attend, but reminded that participation was voluntary, and lunch was provided. The focus groups took place in a large room where students were able to move their seats to comply with social distancing and were facilitated by the primary author who was the Nurse Researcher at the time and not involved in the education program at all. The discussions were audio-recorded, transcribed verbatim by the facilitator and the text was examined carefully for recurrent phrases or concepts arising from the text.
• •Student marks from online medication calculation and written assessments, undertaken throughout and at the end of the unit (six assessments in total), were recorded. A crude comparison was undertaken, of overall marks against the previous year cohort (pre-Covid-19) who received the traditional education mode and delivery sequence.

Evaluative data were collected from staff via:

• •One staff focus group was conducted at the end of the semester (Jan 2021). An invitation to this focus group was extended to course educators and SIM tutors, learning support staff, and education managers involved in the unit. The focus group was facilitated by the Nurse Researcher and took place in a room within the education facility. The discussions were audio recorded and transcripts of the conversation were analyzed for recurring concepts.

3.4. Ethical considerations

A research protocol and application for ethical exemption was submitted to the hospital Human Research Ethics Committee (HREC). The project was determined to be an improvement/evaluation project and not research therefore an exemption was approved (Project 69657 -EXMT/MML/69657). Participants were reminded that their decision to take part in any aspect of the study was voluntary and that they could withdraw at any time or choose not to participate, without penalty. Confidentiality was maintained as no identifiable participant details were collected.

4. Results

4.1. Survey data

A total of 28 (35.3 % of total cohort) students completed the online survey. Of these responses, 18 students (n = 18; 64.29 %) stated that they had no prior healthcare experience. However, half of the participants (n = 14; 50 %) reported having some nursing experience prior to the course. Students were aged from 19 to 51 years, with most being between 21 and 30 years of age. Most students had completed high school as their highest level of education (n = 16; 27.14 %),with five (17.86 %) having a Diploma level qualification from a field other than nursing, and the remaining students (n = 5; 17.86 %) had other formal education qualifications (e.g., undergraduate degree).

Regarding the changes to sequencing of the unit, a range of responses were received. Overall, 89.2 % (n = 25) of students agreed, strongly agreed or were neutral in response to being comfortable with the change in sequencing supporting their learning. Conversely, three students disagreed with this item, and three more strongly disagreed, identifying 21.4 % (n = 9) of students discontented with the changes. No negative responses were received regarding the addition of an online resources supporting their learning. All but one student (96.4 %; n = 27) felt that the use of the online medication resource increased their confidence in medication administration. Learning support was favourable reported with 25 students (89.2 %) either agreeing or strongly agreeing that the Learning support session were helpful in learning about medication administration. The remaining three response for this item were neutral. Three students (10.7 %) reported that they were not aware of the extra learning support sessions. Full Survey results are presented in Table 2.

Table 2.

Survey responses.

Item	Strongly Agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	N/A
The method of delivery (theory before SIM) supported my learning effectively	n = 14 (50 %)	n = 9 (32.14 %)	n = 4 (14.29 %)	0	n = 1 (3.57 %)	0
I was comfortable with the way the unit was sequenced	n = 8 (28.57 %)	n = 14 (50.0 %)	n = 3 (10.71 %)	n = 3 (10.71 %)	n = 3 (10.71 %)	0
The methods of delivery(Simulation before theory) supported my learning effectively	n = 9 (32.14 %)	n = 5 (17.86 %)	n = 4 (14.29 %)	n = 8 (28.57 %)	n = 1 (3.57 %)	n = 1 (3.57 %)
The Med+Safe® online module helped improve my understanding of medication calculation	n = 12 (42.86 %)	n = 8 (28.57 %)	n = 8 (28.57 %)	0	0	0
The Med+Safe® online module helped improve my understanding of medication administration	n = 11 (32.29 %)	n = 9 (32.14 %)	n = 8 (28.57 %)	0	0	0
The Med+Safe® online module was engaging	n = 12 (42.86 %)	n = 9 (32.14 %)	n = 7 (25.00 %)	0	0	0
The Med+Safe® online modules encouraged me to think critically	n = 12 (42.86 %)	n = 8 (28.57 %)	n = 8 (28.57 %)	0	0	0
My understanding about medication calculation has improved through using the Med+Safe® module	n = 9 (32.14 %)	n = 10 (35.71 %)	n = 9 (32.14 %)	0	0	0
My understanding about medication administration has improved through engaging with the Med+Safe® module*	n = 9 (32.14 %)	n = 8 (28.57 %)	n = 11 (32.29 %)	0	n = 1 (3.57 %)	0
The online module was authentic and ‘real world’	n = 4 (14.29 %)	n = 15 (53.57 %)	n = 8 (28.57 %)	0	n = 1 (3.57 %)	0
I feel more confident about medication administration after completion of this unit	n = 13 (46.43 %)	n = 14 (50.0 %)	0	0	n = 1 (3.57 %)	0
I was aware of the Learning Support Offerings available to assist my learning in medication administration	n = 13 (46.43 %)	n = 14 (50.0 %)	0	0	n = 3 (10.71 %)	0
I believe Learning Support was effective in helping me with my learning in medication administration	n = 17 (60.71 %)	n = 8 (28.57 %)	n = 3 (10.71 %)	0	0	0

*One student responded twice.

4.2. Focus group responses

Each focus group was well attended with approximately 46 (58.9 %) students in total. The demographic consists of male and female students from a range of ethnic backgrounds including Aboriginal and Torres Strait Islander students. No time limit was placed on the focus groups, but each group lasted approximately 25 min which provided time to address required items as well as some engaged and free-flowing discussion from the students. Responses to impact of and satisfaction with course changes and the added medication resource are presented below.

4.3. Impact of changes in learning sequence

Responses to the change in sequence delivery were mixed, but most students seemed to agree that the changes did not impact them negatively. Some students identified that their individual learning style was such that they preferred learning theory first and then doing a practical component. Other students identified that they were ‘hands-on’ learners and therefore it didn’t bother them to be doing a SIM class first prior to their theory. The concept of ‘cementing’ learning was raised by some students who did a SIM class before their theory lessons. Some students were concerned about ‘missing out’ on content by not having a theory lesson first however, this anxiety was relieved by the tutors who reassured students that everyone was exposed to the same content by the end of the unit. Having options such as extra learning support sessions, additional learning resources or the ability to discuss concerns or knowledge gaps with educators were reported by the students as useful to assist them throughout the changes. Examples of responses from the groups supporting these concepts can be seen in Table 3.

Table 3.

Example verbatim student responses to change in sequence of content delivery.

Focus Group 1	Focus Group 2
“I just like the in-class stuff first because I like to plan everything, I like to know what I’m going to learn.”	“Well I was always theory first and then SIM, it’s easier to learn the material first and then practice.”
“It felt like we were learning something new straight away so everyone’s paying more attention and then we go back to theory and it would be more familiar”	“… I personally liked having the prac first, the SIM, and then when I was actually reading and doing my theory. It then made more sense to me. I prefer that.”
“It was much better to do the practical side before the theory”	“It was just a bit weird because you didn’t know what to do and the other people knew what to do.”
“It was just easier to understand what was being spoken about, if they said, you know, syringes or vessel or this gauge needle, you understood”	“…if I’ve read it, I know about it, I go in there and I know what I’m doing. Whereas, and I will say it is exacerbated by other people seeming to know and me not knowing, that also kind of knocks your confidence, because you’re like, oh hang on a minute, what am I not knowing.”
“I think with the change in the learning, to me it didn’t really matter so much because the educators were very knowledgeable and helped us in SIM and provided that pick up where we might have learnt more around theory and they just helped us a bit more on those SIM days so to me it didn’t really matter.”	“I was in a group that got split into two other groups and so originally, we were doing theory first and then SIM, and then we were doing SIM and then theory. Personally, I want theory first and then SIM, …you’ve got two groups where some people seem to know stuff and some people don’t. I found that quite hard.”
“Our first couple of weeks, so we broke up into three sessions, so we did hands-on in the lab and then we did a classroom half an hour … and then we did a third one with someone else, but I liked the SIM being split in half – you know people doing half prac, half hands-on, I thought that was really cool the way those first couple of weeks were run before going out on placement…”	“I didn’t mind either way. Like there was always an opportunity to catch up if you felt you didn’t know the theory or the prac so it kind of didn’t really bother me, it interchanged a bit. I think there was always an opportunity to ask questions or read your theory in your spare time so I think for a few of us it didn’t make much difference which way we did it.”
“I just like the in-class stuff first because I like to plan everything, I like to know what I’m going to learn.”	“I think in the SIMs you were always a little more focused and engaged than going into a classroom as well.”
“So you had your SIM and then your theory which was great because you learnt it that way and then the next week it was kind of cemented.”	“It’s easier, theory first then SIM.”

4.4. Satisfaction with medication online resource

Regarding use of the online program, some students admitted that they did not access the program at all. However, data analytics identified that individual students accessed the program between 1 and 900 times, prior to their exams. Students appreciated that the online exercises were close to practice and allowed for repetition to support mastery of skills. Students reported that the program could easily be integrated with their work, family or personal responsibilities, although some students only used the program in-class. Repeated comments were received that the program helped to build confidence with calculations, and medication safety practices, such as checking expiry dates. Student responses toward utility and impact of the online resource are seen in Table 4.

Table 4.

Example verbatim responses to use of online MedSafe™ program.

Focus group 1	Focus Group 2
“I thought it was great…”	“The videos … and the resource materials teach you step-by-step what to do and how to do it – it was amazing!”
“I really liked how if I didn’t understand something, like the drip rates, you know calculating them, then you had to physically go in there and look at a few examples and do the calculations and it really helped…”	“It was great. With drawing up the syringes and stuff. ‘cause we had heaps of worksheets and stuff and we’d been supplied with that but I feel like it really bridged that gap for me.”
“I feel like it’s a confidence thing too, like I know there were a couple of people who weren’t confident enough to put their hand up and say, “I don’t understand’ in the middle of the class but then later on at home they could go to MedSafe and do it and understand it more … it’s easier for those people who don’t have the confidence to speak up in class.”	“It also gives you a lot of information if you do get it wrong. It tells you this is how you do it, this is where you went wrong, so it’s good feedback.”
“I’m more of a practical learner and when you get home and trying to do stuff … I could just whip out my laptop and … just do a few of those things and do practical learning …”	“It was also extremely convenient [laughs], …I would just go on it during times at work when it wasn’t busy, so it was just really useful for filling in the gaps.”

4.5. Student exam marks

Sixty (n = 60) students sat the final exam at completion of this unit. Of these, 47 (78.3 %) received 100 % on the exam on the first go or after a verbal challenge. Two students did not attend the exam and the remainder (n = 11; 18.3 %) were offered a learning support session prior to resitting their exam. A crude comparison against the previous cohort identified improvement in overall pass marks against the previous cohort and less learning support sessions accessed throughout the semester.

4.6. Staff focus group responses

One focus group lasting 45 min was held with five (n = 5) teaching staff to discuss the impact of the curriculum changes. Additional written feedback was received from one other staff member who was unable to make it to the focus group but was engaged the unit and wanted to express thoughts on the changes. The main concepts that arose for the focus group are presented below.

4.7. Agility and flexibility

A recurrent theme was the agility of staff in responding to the challenges faced by the pandemic for education delivery. As stated, “Covid came along which meant we had to reduce class sizes drastically…” However, staff agreed that offering a variety of resources and learning modes for students was successful in supporting students throughout changes to the unit.

“One group was doing worksheets, two groups were doing hands-on stuff and we would rotate them around…and they would have someone in that space to support them.”

Although this had an impact on staff workload, and there was heightened stress about uncertainties, staff agreed that the changes were necessary to ensure students felt supported throughout the semester. As stated by one staff member, “One thing we worked hard on was educator responses, to be about the student experience.” Additionally, it was noted,

“We had to offer double the workshops to accommodate for the scheduling and the scheduling was a lot more complex than it would usually be, however I think that once we put that effort in, from an administrative point of view, the students didn’t miss out in terms of learning support offerings – it looked the same as it would have for any other semester.”

Maintaining student progress and wellbeing through such a turbulent time was reported as a priority. Staff were also required to deliver/model more skills demonstrations within class time, especially for students who attended the simulation learning prior to the theory. Flexibility was required to be able to work across different learning environments and staff reported this as a positive change, as it helped with maintaining and updating their own clinical and teaching skills. The addition of the online educational program was seen as part of a range of strategies designed to enhance learning opportunities.

“ Collectively, with everything that was offered, this [the online resource] just augmented their learning.”

4.8. Ongoing positive changes

Staff also discussed that although they were nervous about managing all the changes so rapidly and unsure about student impact, on reflection, they agreed that having smaller class sizes and incorporating the online resource were changes that they hoped would continue in the future.

“We went from having 45 in the SIM lab and we immediately reduced it to 20 in the SIM lab and we are unlikely to go back to 45 because Covid showed us the benefit of having the smaller sizes.”

When asked about the overall impact to student engagement and experience following the changes to the unit, the response from staff was that students did not seem to be impacted negatively, as stated,

“They (the students) knew why we were doing what we were doing but usually you would expect a small number of people to come to you and say, ‘I’ve got issues with my group, can you swap me?”, and we’ve had none of that. Which is a clear indication to me that it’s been managed very well by the educators.”

Positive responses and gratitude that had been expressed from the student focus groups, was also conveyed to staff during this session.

5. Discussion

The Covid-19 pandemic resulted in significant changes across nursing and within nursing education, internationally. The changes to learning and teaching in the Diploma of Nursing course at our setting, presented opportunities for re-thinking and re-imagining teaching and learning approaches, which were overall, positively received. Through providing additional workshops and adding in an online resource that students could access at their convenience, students still felt supported in their learning and their final academic results supported the decisions made by the teaching staff. Overall, it appeared that having a variety of learning options was the most positive aspect for students, as this allowed student to select an approach that matched their learning style.

The ability and success of transforming curriculum quickly to meet challenges from Covid-19, was dependent on motivated and flexible staff members and some of the changes made are now embedded within the course. The need to pivot and present alternate and flexible learning and teaching experiences has been reported on in the literature regarding nursing education throughout the pandemic (Leaver et al., 2022). In our context, some staff were reluctant at first to go ahead with the changes so quickly, as there has been no precedent for changing the sequence of learning within this cohort. Being able to adapt to a positive mindset was necessary and on reflection most students and staff felt the changes were handled in a positive and supportive manner. Studies conducted of nursing students during the pandemic identified higher levels of anxiety and stress (Fitzgerald and Konrad, 2021, Majrashi et al., 2021). Concerns about passing their courses amidst all the disruptions along with being separated from usual support networks and social activities have also been reported on (Swift et al., 2020). Increased connections between staff and students, clear communication and being able to provide flexible learning support are strategies which provided reciprocal benefit to both staff and students.

On further reflection, the changes made seemed to contribute toward developing student self-efficacy development for medication administration. An individual’s perceived self-efficacy reflects belief in their capability for a task. Bandura’s self-efficacy construct (Bandura, 1977, Bandura, 1997) promotes four sources for developing individual self-efficacy for a specific behaviour, namely mastery opportunities, timely and constructive feedback, vicarious learning (role modelling) and an awareness of ones’ own reaction to the learning experience. Comments received from students suggest that the delivery of content in this unit supported these sources, regardless of the sequence of delivery. One student stated, “”we weren’t just drawing up one injection a day we were drawing up like five or six injections in a day so you were going from not knowing how to do the skill to knowing how to … so next time you walked in there I…felt comfortable enough to just go and get what I needed and draw up…”, which identifies opportunity for improving mastery. Other students specifically reported a change in their level of self-confidence for preparing and delivering medications before and after the unit. Additionally, staff provided regular feedback which is another way to support self-efficacydevelopment, as adjustments can be made as feedback is provided (Bandura, 1977) . Some students even reported how they felt at the beginning and toward the end of the course which highlighted an awareness of their own reaction to the changes and their individual self-efficacy development. It is feasible that each of these opportunities for developing self-efficacy were influential toward the student’s overall improved academic performances; however further specific research on this is needed to determine any associations.

There are several limitations that must be discussed following this evaluation. The methods of data collection did not capture all the reasons for student performance in the unit. For example, we did not measure student mathematical ability which may have influence over their overall marks. Additionally, other impacts from Covid-19 and coping mechanisms were not examined also which may have impacted student and staff engagement with the unit, positively or negatively. As reported by Moxham et al (Moxham et al., 2022). coping is an individual experience and educational institutions must recognise that although many students might enact strategies to manage additional and unexpected stressors such as with the pandemic, some students will require additional support and understanding.

A further limitation to the evaluation was the low response rate to the student survey. Student survey responses can be variable and it is reported that online surveys are more amenable to higher response rates, however inconsistencies do arise (Nulty, 2008). Closer follow-up of the response rate, offering an online option, sending out reminders or extending the response time frame are all strategies that could be employed to promote higher response rates to future evaluation surveys (Nulty, 2008) Finally, the evaluation was of one unit in a single setting and therefore our experience may not be representative of other centres who may have made similar changes to education delivery due to the impact of Covid-19.

6. Conclusions

The ability to make rapid changes to curriculum that supported students but still met the needs imposed by the pandemic, was challenging. However overall, changes that were made elicited positive responses from both staff and students. Some students preferred the traditional sequencing of learning as it matched their identified learning style. The addition of an online resource and extra learning support sessions were utilised by most students and appeared to support student self-efficacy development of medication competency, however further research is needed to clearly identify any associations. A flexible and motivated teaching team using a student-centred approach was integral to supporting student success in the course.

Finding sources

No external funding was obtained for this project.

CRediT authorship contribution statement

MAR: concept and design, acquisition of data, data analysis, write up and critical revisions, approval of manuscript to be published. KJ: concept and design, interpretation and analysis of data, critical revisions to manuscript, approval of manuscript to be published. SG:, interpretation and analysis of data, critical revisions to manuscript, approval of manuscript to be published.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.