I need help with the following questions below for a article analysis. See below article for reference.

1 - What are the independent and dependent variables and type of data for the variables?

2 -Descriptive Statistics(Mean, Median, Mode; Standard Deviation) - Identify examples of descriptive statistics in the article.

3 - Inferential Statistics- Identify examples of inferential statistics in the article.

4 - Sample Size and Sample Method

Article Title: Knowledge about the use of potentially dangerous drugs among hospital health care nurses.

cite: Santos GO, Farre AGMC, Santana ITS, Rocha HMN, Carvalho AA, Santos GKBB, et al. Knowledge about the use of potentially dangerous drugs

among hospital health care nurses. Rev Rene. 2020;21:e44466. DOI: https://doi.org/10.15253/2175-6783.20202144466

ABSTRACT

Objective: to characterize the knowledge about the use of potentially dangerous drugs among hospital health care nurses.

Methods: quantitative, descriptive-exploratory research, with the application of a validated questionnaire, translated and adapted in Brazil, on potentially dangerous medications, with 26 nursing assistants in a university hospital. Univariate and bivariate descriptive statistical analysis of the data was performed using the Statistical Package for Social Science, version 20. Scores 70% were considered as sufficient knowledge and insufficient knowledge scores <70%.

Results: in the first domain of the questionnaire, called Medication Administration, the average percentage of correct answers was 64.6%. In the second domain, Clinical procedures, an average of 53.7% of correct answers was found. The use of electrolytes, chemotherapy and insulin were the main weaknesses in the knowledge of professionals.

Conclusion: insufficient knowledge about the administration and clinical procedures of potentially dangerous drugs was identified among hospital care nurses in this scenario. [ABSTRACT FROM AUTHOR]

Introduction

Medicationadministrationisacomplexprocessinthedailypracticeofnursing professionals, whichrequiresadequateknowledgeaboutpharmacology and technical skills for execution.In the hospitalenvironment, drug therapy is widely used as a therapeutic approach to health recovery, the practice of which is associated with potential and real risks to patient safety.

Research has shown significant rates of medicationerrorsinahospitalenvironment. Medicationerrorsarepreventableadverseeventsthatcancauseharmtothepatientand,incriticalsituations,resultindeath.Theoccurrenceofthistypeoffailure canbeassociatedwithfactorssuchasfailuresintheprescription and dispensing of drugs, lack of communicationamongprofessionals,pharmaceuticalprocedures,workoverload,professionalknowledge and attitude, inadequate identification and similar names

of the drugs.

Drugs associated with a higher risk of injuring thepatient,duetofailuresinuse,areknownaspotentiallydangerousorhighlysurveillancedrugsandincludetherapeuticclasses,such as neuromuscular blockers, and specific drugs, such as injectable concentrated potassium chloride.

Nursing professionals are an important barrier inpreventingerrorsintheadministration ofpotentially dangerous drugs, as they can act in anticipation, identification and prevention of occurrence. Despite this, errors continue to happen, and the insufficient knowledgeofthenursingteam on the subject has been reported as the main triggering factor.

Specifically, nurses have a relevant decision makingroleinthemanagementofpotentiallydangerousmedications,eitherbyworkingdirectlywithpatientsorintheguidance/supervisionofnursingteams.Therefore,itisimportanttoidentifynurses'

knowledgeaboutthesedrugs,inordertocontributeto making positive and critical decisions in the stages of error prevention. Thus, this study aimed to characterize the knowledge about the use of potentially dangerous drugs among nurses in hospital health care.

Methods

Quantitative,descriptive-exploratoryresearch,carriedoutwithnursingassistantsfromaBrazilianuniversity hospital, with urgent and emergency services, located in the Northeast Region, in the countryside of Sergipe, Brazil. The hospital had 112 operational beds, 32 of which were for adult medical clinic, 12 for pediatricclinic,20forsurgicalclinic,10foradultintensivecare,41foremergencycare(23observationbeds,15semi-intensivebedsandthreeforintensivecare)andtwooperatingroomswithpost-anesthetic

recovery.

Thenursingworkforceconsistedof202professionals, 162 (80.2%) of whom were technical and/or auxiliary and 40 (19.8%) of higher education. This hospitalwasinatransitionperiodfromthestatetothe federal public administration, during the data collection of the present research, from December 2016 to February 2017. Most employees were still linked to temporaryemploymentcontractsand/orredistribution plans to other hospitals.

The sample plan included the assistance nurses oftheinstitution,whowerecontactedpersonallybytheresearcher,atmomentsconsideredmorerelaxedduring the shift or when desired/planned by the professional, in a reserved place. The final sample consisted of 26 nurses, considering the reasons for exclusion: legalleave(n=5),didnotanswerthequestionnaire,afterthreeattemptstocontact(n=5),andrefusaltoparticipate (n=4). Because the questionnaire was developed for the exclusive measurement of knowledge about potentially dangerous drugs by nurses, nursingtechniciansandassistantswerenotincludedinthe sample. This questionnaire was developed and validatedbytheChinese,withface,contentandconstructvalidations;internalconsistencywasevaluatedusingtheKuder-Richardsonformula20reliabilitycoefficient (KR-20), obtaining a satisfactory value, with =0.74. ForapplicationinBrazil,theinstrumentwas translated, culturally adapted, evaluated and validated,throughthefaceandcontentvaliditiesoftheinstrument, with subsequent pre-test. It is a self-administered instrument, with 20 statements (17 false and 3 true), "true", "false", "I don't know" answer options and a final score of 100 points, divided into two domains: the first, on medication administration, addressesstorage,prescription,dispensingandadministration particularities; and the second, about clinical

proceduresrelatedtoadministration,particularitiessuch as routes of administration and dosages.

The data were tabulated in Microsoft Office ExcelandanalyzedintheStatisticalPackagefortheSocialSciences,version20forWindows.Descriptivestatisticalanalysiswasperformedusingunivariate and bivariate techniques to obtain the distribution of absolute and relative frequencies, considering the significance level of 5%. For classification of knowledge, scores 70% were considered as good knowledge and scores <70%, as low knowledge. The data are presented in tables.

EthicalandlegalaspectsinresearchinvolvinghumanbeingswererespectedandtheprojectwasapprovedbytheResearchEthicsCommittee,withPresentationCertificateforEthical Appreciation No. 62175516.0.0000.5546 and opinion No. 1,875,657/2016.

Results

Thestudydatashowedapredominanceoffemales (65.4%) among the 26 participating nurses, withanaverageageof35.5years,aminimumageof26andamaximumageof50years.Mostprofessionals had a time of training and experience 10 years

(73.0%), with an average of 8.6 years of training, a minimum of four and a maximum of 20 years. The averagelengthofprofessionalexperiencewaseightyears,with a minimum of three and a maximum of 20 years. Among the participants, 23 (88.5%) of the nurses had

postgraduate degrees, with a predominance of specialization, 22 (95.6%). Regarding the sector of activity in the university hospital, 12 (46.2%) worked in the emergencyroom,followedbythesectorsofmedical clinic, 4 (15.4%); intensive care unit; 4 (15.4%); surgical clinic, 3 (11.5%); pediatrics, 2 (7.7%); and surgical center, 1 (3.8%).

Information about nurses' employment relationships showed that 14 (53.8%) of the participants had two or more bonds, compared to 12 (46.2%) who worked only in the investigated hospital. It should be notedthat,amongtheprofessionalswhohadtwoor

morebonds,sevenworkedintheemergencyroomandoneintheintensivecareunit.Dataontheapplicationofthequestionnaireonpotentiallydangerous

drugs with hospital assisting nurses, with a percentageofcorrectanswersanderrorsintheresponsesofthe participants to the first (medication administration)andthesecond(clinicalprocedures)domains of the questionnaire, with ranking of correct answers,are described in Tables 1 and 2, respectively.

In the first domain of the questionnaire, the average percentage of correct answers was 64.6%. Dataonmedicationadministrationbyprofessionals showed that the highest error rate (80.8%) was found initem1.4,referringtomultipleconcentrationsfor

the same medication. Item 1.10, on the differentiation inlabelsformedicineswithsimilarnames,wastheone with the highest rate of correct answers (96.2%). Item 1.3, on the storage of insulin and heparin, obtained 92.3% of correct answers; in turn, item 1.6,

aboutthecorrectstorageofpotassiumchloride(KCl 19.1%), represented the second item with the highest error rate (46.2%). The highest percentage of "don't know" responses was 27.0%, being found in item 1.8, which dealt with the transdermal patch of fentanyl as

a medication for controlled use. The storage of neuromuscular blockers, such as atracurium, also acquired a 15.4% "don't know" response, in addition to an error rate of 30.8% among nurses.

Theaverageofcorrectanswersintheseconddomain of the questionnaire was 57.3%. According to theanswers,theitemwiththehighestpercentageofcorrect answers (88.5%) was 2.4, which addressed the unit of insulin dose in ml or cc; in turn, the item with the highest error rate (65.4%) was 2.8, which discussed thereplacementoftheinsulinsyringe,witharateof26.9%, in correct answers among professionals. The approach on the use of 10.0% calcium Gluconate in emergency presented a percentage of correct answers

and errors in 30.8%, representing the second item with thehighestpercentageoferrorsbytheparticipants. Theresponserate"doesnotknow"withahigherpercentage (46.1%) was found in item 2.5, which dealt with the dosage of chemotherapy for adults and children, presenting a rate of 46.2% in correct answers andconstitutingthethirdquestionwithlesshits.No statistically significant relationships were found between the participants' sociodemographic data and knowledge about potentially dangerous drugs.

Discussion

The main difficulties encountered in conductingthestudywererelatedtotheapplicationofthe questionnaire, as the professionals were afraid to respondtoaninstrumentthatcouldassesstheirknowledgeaserroneous.Thus,theresearcherreinforcedthe ethics and benefits of research, and even in the face of some refusals, he was accessible and available to wait patiently during the professional's shift, since he could not be taken home.

The study limitation was related to the development in a single hospital, with a relatively small sampleofnursesandadescriptiveapproachtothedata.

Therefore, it points out the need to conduct multicentric research, with comparative analyzes, and evaluations of the type before and after training on the subject, even with control groups.

The strength of the study was to reveal a profile that can serve as a comparison to other Brazilian studies, as well as to similar hospitals. Despite being a local context, the data highlighted the need to reinforce nurses' knowledge, which may reflect on safer nursing practice and better guidance of work teams. Nursing teaching institutions can pay attention to the areas of greatest knowledge deficiency, presented in the study, and thus develop specific teaching programs. For health institutions, the need to adopt permanent educationstrategieswithprofessionalsisreinforcedtocontribute to patient safety.

Thelength of experience andthe continuous encouragementoftheinstitutioncanrepresentimportant factors for the involvement of professionals in health care and in continuing education activities for the necessary improvement of the profession, directly

influencing patient safety.

In Brazil, there is a greater performance of nursing professionals between 26 and 50 years old, with atendencyforadecreaseintheworkforceofnursesup to 60 years old. In addition, the average salary of nurses,whichisintherangeofR$2,000,whichcan

influence the performance in other bonds, without observing,inmostcases,theincreaseinsubstantialincome;furthermore,theexhaustiveroutinecancompromisethe professional'sbiopsychosocialhealth and, consequently, influence the assistance provided.

Continuingeducationstrategiesareessentialforimprovingnurses'knowledgeandpractice. Withregardtoknowledgeaboutpotentiallydangerousdrugs,theaveragenumberofcorrectanswersfound,inthepresentstudy,onimportantaspectsintheir administration (64.6%), was close to the finding in a study carried out with nurses in Palestine, in which an average of correct answers in 58.9%, which may

be related to the greater number of nurses participating in the study (n=301).

In medication administration, the highest numberofconcentrationsandmultipledosagescanrepresentariskfactorfortheoccurrenceoferrors.

Thus, data that revealed the belief in the existence of multiple concentrations of potentially dangerous drugsamongthenursesinthestudyevidencedthelack of knowledge about important aspects that may favor medication errors in patient care, reinforcing the importance of the immediate adoption of measures that prevent this occurrence.

Methodstoavoidmedicationerrors,accordingtosafepracticesintheuseofhigh-riskdrugs,includereducingthenumberofpharmaceuticalpresentations;standardizationofpresentations;use,wheneverpossible,ofthelowestconcentrationpresentation/formulation;limitationofthenumberofpresentations and concentrations available, as well as the elaboration of educational materials easily accessible to professionals.

Thereductionofmedicationerrorsisassociatedwiththeadoptionofeducationalstrategies,suchas the production of educational materials; organizational,suchastheelaborationofinstitutionalprotocols;andtechnological,suchastheimplementation

ofcomputerizedsystems.Thus,theimportanceofcare with medicines with similar names and commonly used in the institution is highlighted, and the parts of the names that differentiate them should be highlighted, and preferably stored in separate locations.

Waysofstoringneuromuscularblockersandusingandstoringpotassiumchloridealsoshowedhigh error rates among nurses. Neuromuscular blockerspresentparticularitiesinuseandstorage,andmustbestoredseparatelyandlabeledwithanalertidentification for the risk of inappropriate use, mainly due to the erroneous administration being associated with significant damage or the death of the patient; similar packaging and labeling, lack of knowledge about improper use and storage are among the main reasons

for lethal adverse events involving these drugs.

In the administration of medications, intravenous infusions can occur continuously or intermittently, quickly between 3 and 5 minutes, in 30 minutes, or in periods of 1 to 3 hours, considering factors such as patient conditions and possible complications. The concentration of the substance is an important factor to be considered. Knowledge about potassium chloride,forexample,isfundamentalintherapy,sincepotassiumimbalancescanbringseriousconsequencesto patients' lives and require immediate action in health,whichcancausearrhythmias,paralysisandweakness; in intravenous administration, the potassium concentration should not exceed 20 mEq/h (100-150 mEq/day).

Thedataonclinicalprocedureswithpotentially dangerous drugs investigated in the present study showed a correct rate (57.3%), close to that found in a study carried out in Palestine, in which a 60.9% correct rate was identified. The main deficiency foundamongparticipatingnursesregardingclinicalprocedureswasrelatedtothereplacementoftheinsulin syringe with the 1 ml or the tuberculin.

Insulin is a drug that requires precision in the dosageadministered,errorsrelatedtoitsusecancauseseriousdamage,suchasprolongedexposuretohypoglycemiaandconsequentconfusion,faintingorconvulsion,periodofexacerbatedhyperglycemiaor even death of the patient; these events are mainly associated with preparation and infusion. Thus, the replacementoftheunitsyringewiththeoneformLortuberculincancontributetotheerrorinthepreparationandadministrationofinsulin,resultingin

hypoglycemia and hyperglycemia that will bring consequences to the patient.

Aspectsaboutthespeedofadministrationof10% calcium gluconate should also be addressed by health institutions with professionals, due to the limitedknowledgeshowninthestudy.Thespeedofinfusion of calcium gluconate should be slow, since the rapid infusion is associated with bradycardia or asystole; in symptomatic cases of hypocalcemia, the administration of 1 to 2 g of calcium gluconate is allowed in 10 to 20 minutes.

Thelackofknowledgeaboutchemotherapycalculations, evidenced among the study participants, demonstratedthatnursesmaynotbeusedtousingchemotherapy drugs, which is probably due to the lack ofchemotherapytreatmentintheinstitutionwhere

the collection was performed. However, as most nursingprofessionalscanworkinmorethanonehealth institution, knowledge of this information is essential to avoid the occurrence of errors associated with the administration of chemotherapy drugs.

In addition, the gradual increase in the role of nursesinpalliativecareassistancetopatientswithcancerandotherchronicdiseases,mainlyrelatedtoaging, has demonstrated the importance of knowledgeandpracticeofprocedures,suchashypodermoclysisformedicationadministration,duetosubcutaneous route is being well supported by these patients. However, the use of this action can be associated with

complications that, although they are mostly easily reversible and with low potential to cause damage, reinforce the relevance of care with the administration of

medications by professionals.

Datafoundinthisstudypointedtoanurgentneedforpermanenteducationwithhealthcareprofessionals.Nursingandhealthinstitutionsarecoresponsibleforthepermanenteducationofprofessionals, as a way to guarantee safe and risk-free health

care, due to the importance of patient safety.

Conclusion

Insufficient knowledge about the administrationandclinicalproceduresofpotentiallydangerous drugs was identified among hospital assisting nurses, mainly related to the use of electrolytes, chemotherapy and insulin. Therefore, it is essential to adopt professional, institutional and educational actions, with a priority focus on these drugs, to improve safety in the use of medicines.