Innovation Center

Seeing Through Google Glass: Using an Innovative

Technology to Improve Medication Safety Behaviors in
Undergraduate Nursing Students
Tonya Schneidereith
doi: 10.5480/15-1653

Abstract
Addressing safe medication administration skills and behaviors is integrated throughout many nursing curricula using
high-fidelity simulation. Simulation allows students to practice on electronic manikins in a safe environment, allowing for
independent, critical thinking as medications are administered. However, the restricted physical environment, often behind a
one-way mirror, inhibits faculty from observing the processes students use to calculate or reference medication dosages. This
article describes the errors in medication administration identified through use of Google Glass, an innovative technology that
allows video recording from the students perspective.
Incorrect medication administration is a well-documented problem
in the United States. Medication errors harm more than 1.5 million
people annually, leading to extra medical expenses of more than $3.5
million (Kim & Bates, 2013). To minimize such errors, nursing education integrates medication competency throughout the curriculum,
including concepts of pharmacology, systematic approaches to medication administration, and medication calculation skills.
Pharmacology concepts are taught in courses that educate students about medication classifications, interactions, indications, and
safe dose ranges to prepare them for appropriate decision-making and
patient education. The systematic approach for safe medication administration traditionally includes the 5 Rights Method. This approach
safeguards that the right patient gets the right medication at the right
dose via the right route at the right time.
Medication calculation skills build on the students mathematical foundations. A review of the literature by Sulosaari and colleagues
found that dosage calculation not only requires higher level mathematical skills, but also that a statistically significant relationship exists
between success on medication calculation tests and high grades in
mathematics courses (Sulosaari, Kajander, Hupli, Huupponen, &
Leino-Kilpi, 2012; Sulosaari, Suhonen, & Leino-Kilpi, 2011). Their
findings suggest that nursing students who are not successful in mathematics may have greater difficulty calculating medication dosages.
While opportunities for medication administration exist in
the clinical setting, student experiences may be limited (Ironside,
McNelis, & Ebright, 2014; Reid-Searl & Happell, 2012; Reid-Searl,
Moxham, & Happell, 2010; Reid-Searl, Moxham, Walker, & Happell,
2010). Depending upon the clinical unit, clinical faculty, and available
opportunities, students have varied experiences with the hands-on
administration of medications. An option to improve the inconsistency in experience is through the use of high-fidelity simulation.
Well-designed high-fidelity patient simulations can offer similar,

standardized experiences for medication administration on a simulated patient in a safe environment (Richardson, Goldsamt, Simmons,
Gilmartin, & Jeffries, 2014).
THE PROBLEM/THE INNOVATION

In many nursing programs, students involved in simulation scenarios

are observed by faculty behind a one-way mirror. That practice allows
students the opportunity to display independent clinical judgment
while faculty observe their behaviors. However, the physical limitations and restricted sightlines of observing simulation from a distance
and behind a one-way mirror can interfere with the ability of faculty
to see exactly what students are doing. Although the technology of
simulation is constantly improving, our ability to discern the practical
aspects of students judgment is still limited.
In 2013, Google launched its Glass Explorers Program to beta test
a new, wearable computer technology. Glass is a head-mounted, handsfree apparatus worn like eyeglasses that can, among other things, record
high-definition (HD) video from the wearers perspective. The Google
Glass (GG) technology was used in high-fidelity simulation with senior
students in an undergraduate nursing program at a small, mid-Atlantic
university to address a gap in published research. Previously, a longitudinal decrease in safe medication administration behaviors was identified
in undergraduate nursing students (Schneidereith, 2014). However, that
study could not discern the reasons behind failure to verify right dose.
In this simulation study, students who were randomized to the
primary nurse role were informed of the study and, after volunteering
to participate, signed consent and wore Google Glass with the video
camera recording. The simulation scenario involved care of a pediatric patient with respiratory syncytial virus and required the student to
administer an intravenous (IV) medication over 15 minutes. The GG
video camera recorded the perspectives of 10 different students during
each of the 15-minute pediatric simulations.

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IMPACT ON STUDENT LEARNING

This study was conducted by a single investigator who was also responsible for reviewing each of the 10 GG videos. The videos revealed students remedial mathematical problems, including infusion rate and
dosage miscalculations. Thirty percent of the students could not correctly calculate the rate of infusion for a 10-milliliter (ml) medication
to infuse over 15 minutes. As the pump could only be programmed
for milliliters per hour (hr), the programmed rate should have been 40
milliliters per hour.
In previous simulations, it was not possible for the faculty
observer to read the pump from a distance, and stationary video cameras were unable to focus well enough to see the pumps face screen.
However, in three different simulations in the current study, videos recorded by the GG revealed that three different students programmed the pump for 0.44 ml/hr, 0.66 ml/hr, and 10 ml/hr.
Three of 10 senior students set up an incorrect dosage equation. Using a paper chart and medication administration record, they
attempted to verify that the dosage ordered for the IV medication
was safe for the pediatric patient. Although the weight was written
in kilograms and the dose was written in the pediatric standard of
milligrams per kilogram, GG video revealed that all three tried to
divide the kilogram weight by 2.2. If the patients weight had been
written in pounds, that conversion would have been appropriate, but
it was already recorded in kilograms. Without the view provided by
the GGs video-recording device, the students miscalculations would
have been missed.
TECHNOLOGY PROBLEMS/DEBRIEFING LIMITATIONS

The recently published INACSL Standards of Best Practice for

Simulation offer educators a framework for simulation (RutherfordHemming, Lioce, & Durham, 2015). While Standards I-V address
aspects of the actual simulation scenario, Standard VI addresses the
importance of learning during debriefing a crucial step that was
not completed immediately after the simulations in this study due to
technology problems.
The initial plan for postsimulation debriefing included review
of the GG videos with the students. However, slow download speeds
and poor campus Internet connections made the video review impossible. Because the calculation errors could not be identified until the
videos were reviewed, postsimulation debriefing did not address the
students discreet behaviors. Instead, the videos were reviewed alone
by the investigator and then with the students in class, where both
positive behaviors and those requiring changes were identified and
discussed. At that time, dosage calculations were reviewed step by
step. The students who made the errors expressed understanding of
the miscalculation and the changes necessary for correct calculations.
Given this experience, faculty interested in using Google Glass
or similar video recording technologies should ensure an appropriate
wireless infrastructure and test the technology in the space where it
will be used. Despite recording and seamlessly downloading videos
in other locations, the investigator did not attempt downloading and

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playback in real time in the real space using the simulation labs wireless system. Learning opportunities were subsequently limited, and
important medication administration lessons could not be addressed
during debriefing discussions.
IMPLICATIONS FOR NURSING EDUCATION

Use of high-fidelity simulation identified many positive medication

competency behaviors and reasoning skills in the senior undergraduate students. Similar to the clinical judgment findings of Ashley and
Stamp (2014), students in this study used appropriate clinical judgment
to question medical orders or seek guidance from the preceptor in
the scenario. However, when the simulation videos were shared with
nurse faculty and staff, most were aghast at the mathematical errors.
As part of this baccalaureate nursing curriculum, students are
required to complete a basic statistics course during the freshman year
and a dosage course during the first semester of the junior year. In
addition, students must pass a written dosage exam with 100 percent
accuracy prior to each of the last three semesters of the nursing program; they are allowed three attempts and are provided immediate
remediation prior to the next attempt. For faculty, the combination of
the math course, dosage course, and dosage exam created a false sense
that students were mathematically proficient.
Even though students in the previous, longitudinal study were
unable to verify the Rights Method in simulation, there was never a
clear explanation for their lapses (Schneidereith, 2014). Students have
consistently shown an inability to calculate doses correctly during simulation and, along with poor performance on dosage questions embedded in course examinations, the problem appears to be a growing
trend. It wasnt until the GG videos showed the miscalculations that
faculty were better able to appreciate the students thought processes
and deficient math skills. The findings from this unique, observational
pilot study suggest that students lack the mathematical foundations to
calculate dosages correctly.
DISCUSSION AND RECOMMENDATIONS

Although the Google Glass Explorers beta program has ended,

Google reported earlier this year that GG will be rereleased after its
design is modified (Google Glass, 2015). HD video recorded by the
GG wearable technology allowed the faculty investigator to view practical aspects of students judgment that would not have otherwise been
identified. The information gained through GG simulation videos is
already being used to guide faculty toward improving students abilities to use higher level arithmetic skills in real time.
Future recommendations include combining teaching modalities for different learning styles through hands-on application in simulation alongside classroom lecture. While paper-and-pencil dosage
exams are traditionally used to evaluate dosage competency, this study
suggests that students are not competent with the calculations needed
at the point of care. Multiple simulations should be used to provide
additional application of dosage calculation, medication administration experiences, and opportunities to remediate inadequate skills and

Innovation Center

reinforce appropriate behaviors for safe medication administration. It

is anticipated that, with changes in teaching methods and increased
simulation experiences, future GG videos will show correct dosage
calculations and an overall improvement in safe medication administration behaviors.
ABOUT THE AUTHOR

Tonya Schneidereith, PhD, CRNP, assistant professor, Stevenson

University Nursing Program, Stevenson, Maryland, participated in the
2015 National League for Nursing Leadership Development Program
for Simulation Educators. Write to tschneidereith@stevenson.edu.
KEY WORDS

Google Glass Patient Simulation Medication Errors Nursing

Education Nursing Students
REFERENCES
Ashley, J., & Stamp, K. (2014). Learning to think like a nurse: The development of clinical judgment in nursing students. Journal of Nursing
Education, 53(9), 519-525. doi:10.3928/01484834-20140821-14
Google Glass. (2015, January 15). Were graduating from Google[x]
labs. Retrieved from https://plus.google.com/+GoogleGlass/
posts/9uiwXY42tvc
Ironside, P. M., McNelis, A. M., & Ebright, P. (2014). Clinical education in
nursing: Re-thinking learning in practice settings. Nursing Outlook,
62(3), 185-191. doi:10.1016/j.outlook.2013.12.004

Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses:

Adherence to guidelines. Journal of Clinical Nursing 22(3-4), 590-598.
doi:10.1111/j.1365-2702.2012.04344.x
Reid-Searl, K., & Happell, B. (2012). Supervising nursing students administering medication: A perspective from registered nurses. Journal of Clinical
Nursing, 21(13-14), 1998-2005. doi:10.1111/j.1365-2702.2011.03976.x
Reid-Searl, K., Moxham, L., & Happell, B. (2010). Enhancing patient safety:
The importance of direct supervision for avoiding medication errors and
near misses by undergraduate nursing students. International Journal of
Nursing Practice 16(3), 225-232. doi:10.1111/j.1440-172X.2010.01820.x
Reid-Searl, K., Moxham, L., Walker, S., & Happell, B. (2010). Supervising
medication administration by undergraduate nursing students:
Influencing factors. Journal of Clinical Nursing, 19(5-6), 775-784.
doi:10.1111/j.1365-2702.2009.03074.x
Richardson, H., Goldsamt, L. A., Simmons, J., Gilmartin, M., & Jeffries, P.
R. (2014). Increasing faculty capacity: Findings from an evaluation of
simulation clinical teaching. Nursing Education Perspectives, 35(5),
308-314. doi:10.5480/14-1384
Rutherford-Hemming, T., Lioce, L., & Durham, C. F. (2015). Implementing
the standards of best practice for simulation. Nurse Educator, 40(2),
96-100. doi:10.1097/NNE.0000000000000115
Schneidereith, T. (2014). Using simulations to identify nursing student behaviors: A longitudinal study of medication administration. Journal of
Nursing Education 53(2), 89-92. doi:10.3928/01484834-20140122-07
Sulosaari, V., Kajander, S., Hupli, M., Huupponen, R., & Leino-Kilpi, H.
(2012). Nurse students medication competence: An integrative review
of the associated factors. Nurse Education Today, 32(4), 399-405.
doi:10.1016/j.nedt.2011.05.016
Sulosaari, V., Suhonen, R., & Leino-Kilpi, H. (2011). An integrative review of
the literature on registered nurses medication competence. Journal of
Clinical Nursing, 20(3-4), 464-478. doi:10.1111/j.1365-2702.2010.03228.x

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