ATLAS.ti . The authors recount the new DCCT model’s development, implementation, and subsequent modifications and further discuss student/instructor perceptions of learning types, math confidence, and competency. The paper concludes with a series of seven key recommendations for nursing programs.Mathematical competency in the profession of nursing has increasingly become a central focus as more nursing students appear to struggle with basic concepts of arithmetic, mental estimation, and critical reasoning. This paper highlights how one School of Nursing in Ontario, Canada implemented a Dosage Calculation Competency Test model which involved an online, self-directed, prerequisite approach to improve student mathematical competency and confidence. The purpose of this research case study was to document, through shared participant perceptions, the creation, implementation, and subsequent modifications to a Dosage Calculation Competency Test model in light of student needs and advances in online learning and assessment. The research design combined a quantitative survey of Year 1–4 nursing students, followed by a series of qualitative, semi-structured interviews with nursing students and program instructors. The study took place within a School of Nursing undergraduate program in Ontario, Canada. Forty-four participants, including students from all four years of the nursing program, completed the survey, followed by individual interviews with nine students and six faculty instructors. Survey (the open-response items) and interview data were analyzed thematically using  Over the past few decades, a disturbing phenomenon has emerged within undergraduate nursing education. Nursing students are increasingly demonstrating an overall lack of basic, as well as more advanced, math skills . The abiNurses require a set of mathematical skills in order to safely administer various types of medications  to the patients in their care. Part of this mathematical calculation competency involves basic mathematical knowledge such as working with fractions, ratios, and rates, as well as being proficient with conversions between unit measures  and systems . Nurses are central to medication safety since they are predominantly responsible for the administration of patient medication in a variety of healthcare contexts including acute care settings . The intersection of nursing and mathematical competency has become an increasing concern among nurse educators and health administrators. Nursing students with relatively weak math skills are enrolling in undergraduate programs, and, after several years of study, appear to often still be lacking the mathematical competence and self-confidence required for practice . Math anIn order to address this lack of mathematical competency among students, undergraduate nursing programs have implemented a number of different strategies to address this important issue. Requiring the completion of certain secondary school math/science courses , achievibalanced approach, calling for an amalgam of strategies that include both technology-enhanced and face-to-face components  model was introduced over the period of several years, and this involved an online, self-directed, and prerequisite approach. In the remainder of this paper, we outline the rationale for, and issues relating to, the transition from the previous model to the existing DCCT model; present findings based on a case study involving an online survey and subsequent student/instructor interviews; and offer a series of related recommendations for schools of nursing that may be contemplating similar changes to their program.The researchers framed the investigation around the following two research questions (RQs): RQ1: What was the rationale for the transition from a teacher-directed, on-site, course-embedded DCCT model to a self-directed, online, prerequisite model; how was it implemented; and what modifications were later made to the model?RQ2: According to nurse student and instructor perceptions, to what degree, and in what ways, is the DCCT model adequately preparing students for nursing practice?Qualtrics software . The survey collected answers to 22 direct questions , as well as approximately 5000 words of feedback by way of the final three open-response item questions. The case study was designed and implemented according to qualitative case study standards ,19,20, aAll of the Year 1–4 nursing students in the Collaborative BScN program  were invited to participate in the online survey see . Of the Zoom video-conferencing software , then were transcribed by a graduate student and returned to participants for member checking of the content for accuracy. The interview transcription data, over 70,000 words (140 pages), were then analyzed using ATLAS.ti software.From the 44 survey participants, 9 nursing students agreed to take part in subsequent interviews. Instructors and administrators who had previously been, or currently were, associated with the Dosage Calculation Competency Test (DCCT) model were also invited via email to take part in an interview. Thus, fifteen interviews  were conducted and audio-recorded from December 2019 through April 2020, with each interview lasting approximately 40–60 minutes see . The intATLAS.ti qualitative software and careful thematic analysis using multi-layer coding was conducted. From a large list of original codes, several overarching themes emerged as being key to the narrative of the new DCCT Model adoption history, as well as a second set of themes relating to key issues surrounding nurse perceptions and practice. Limitations of the study included the response rate (11%) which provided adequate data for our purposes but could have been higher; the fact that only single interviews were possible with our participants due to time constraints; and the lack of access to comparable student achievement data from before and after the DCCT model implementation. All of the collected open-response survey data and interview data were entered into In this section, we will address Research Question 1 in light of the collected participant data relating to the following themes: the rationale for making changes to the previous Dosage Calculation Competency Test (DCCT) model; the implementation of the new model; and the various subsequent modifications that were made to the new model.Prior to the transition to the new DCCT model that took place during the years 2012–2014, nursing students in the Collaborative Bachelor of Science in Nursing program would learn about dosage calculations as part of general nursing courses that each involved on-site classroom attendance, simulation labs, and clinical  placements. In the previous model, each clinical course was a pass/fail course requiring an overall Satisfactory completion designation in order for a nursing student to progress through the program. Nursing students who were not successful in obtaining the 90% baseline achievement in their first writing of the DCCT were usually provided with remedial support and then allowed to attempt the DCCT assessment again. As one instructor noted: “If they failed that second test attempt, typically they were at risk for failing out for the semester.... They did let them go into clinical, but they could not administer meds” (P01). Noting the increasing number of students rewriting the math tests, with some also failing the math component of the clinical course, and hence the course and program, the nursing faculty understood that they had a significant and recurring problem on their hands.While the previous model did serve to highlight the importance of mathematical competency for nursing practice by including the math skills content within the clinical courses, and by requiring successful completion of those tests, it also involved a number of problematic aspects that were becoming increasingly evident. For example, in the old model, one difficulty with having the dosage calculation directly linked to clinical courses was that instruction and assessment were quite varied among faculty, often leading to inconsistencies in test content and expectations.Far more serious than the perceived inconsistencies regarding teacher practice was the fact that each year a growing group of nursing students would ultimately be unsuccessful (even after further re-write attempts) in the math/dosage aspects of the clinical courses, and in some cases would eventually be forced out of the program as a result of two such clinical failures, as per program policy. As one participating instructor shared, “We were seeing probably 8–10 students per year, across all four years, that would fail and would do some sort of remediation, or take some sort of action to be able to continue on in clinical” (P03). This perennial situation represented a stressful and costly endeavor for these students, a time-consuming aspect of instructor workload, and a negative reflection on the Collaborative program and the university as a whole. A former Director noted, “If they didn’t pass, they would fail that clinical; if you fail clinical, you don’t pass the year—so that test, that small test, could cost them, you know, a year’s tuition and residence, so maybe $10,000” (P10). Another instructor further shared, “It became problematic, not only for our student population, which we were very concerned about, but our CASN [Canadian Association of Schools of Nursing] accreditation body was not looking at it favourably either” (P02). Departmental discussions began to focus on ways in which the program might consider shifting towards a different type of model, given the student difficulties relating to the math skills assessment.One key aspect of designing the new model was to carefully analyze the four years of the program in terms of the clinical placements and related math skills and to then create a relevant series of math modules that corresponded to these required skills needed in the different placement settings .One instructor who was heavily involved in the development of the new model explained this process, highlighting the importance of tailoring the modules to reflect the context-specific math skills. P15: That is when we began developing key spots in the program throughout the eight semesters where the math testing would be building the skills of the student, and constantly getting them to be repetitively learning and retaining the math skills right up until fourth year. Because when they graduate, they have to be able to determine what the right dosage would be to give to any patient. It’s something you learn but can then easily forget—so you have to maintain the skills throughout.prerequisite component for each subsequent clinical placement. “The decision was made to move to a stand-alone dosage program that is treated like a basic competency, just like having your CPR, or your Non-Violent Crisis Intervention training as requirements for students going into clinical” (P11). An instructor explained: “They would be required to pass each module before they could move on.... If the students didn’t pass any test, they wouldn’t be allowed to go into clinical, however it no longer meant a ‘Fail’ on their transcript” (P01). Another positive result of the new model approach was the overall consistency in the teaching of the math dosage skills: “We are teaching the students the same way to do the math in all four years, as opposed to having different people in different ways each semester, that are covering the same content” (P11). Another vital aspect of the new model was to change the math component  of each clinical course into a separate , required, self-directed activity that would serve as a Not only would the new DCCT model involve a logical progression of nursing math skills and a clinical prerequisite approach, it would also feature an in-depth collaboration with a software company, Elsevier, and the co-creation of a uniquely tailored online learning and assessment system. One instructor recalled the departmental discussions which led to the new model adoption:P02: I remember many faculty meetings where we spoke about the DCCT at length. We talked about what is the best way to implement this into the curriculum. Do you want to make it a stand-alone course? Will it be worth course credits?... We decided through many discussions that we would purchase this DCCT software and implement it as a stand-alone, pre-clinical requirement.In the new DCCT model, students are assigned modules essentially in an online textbook that they work through, learning at their own pace. There are deadlines set, and there is access granted to new content each semester. Once they have completed the online modules, then they go into Blackboard (the Learning Management System) and there are practice tests that have similarly worded questions that they’ll see on their final test. Students can take these practice tests as many times as needed to prepare for the writing of the final test for that term. One of the challenges for students with the self-directed nature of the new model was just planning when one would complete the practice work and then write the final test. As one student noted, “It was basically just fitting in into your schedule, when you weren’t working on your five other courses—so, basically your time management skills” (P13). The new DCCT model was implemented in stages, with P03 piloting the new system first with her Year 1 and 2 nursing students in Fall term of 2012, and then subsequently with Year 3 and 4 students as they worked their way through the program. “It was during that time that [P03] was doing first and second year, so we started out with one group, and then we did it for third and fourth, and she took on all of them as it went along” (P15). One of the main reasons for staggering the implementation of the model was the cost of the software for students, thus the first group of students would have access to the online software for at least three, if not four years.Once the new model had been put in place, the department sought continual feedback from both the instructors involved and from the nursing students by way of anecdotal feedback and informal surveys. The instructor who had been pivotal in collaborating with Elsevier in the creation of the new online package reminisced on how the new model very quickly showed promising effects.P03: When I left three years ago [ca. 2017], we did not have one single student who had to be withdrawn from clinical as a result of dosage calculation. We did have a few students who needed to do multiple re-writes, and so we put a remediation package together for them.... They had to go through the Elsevier program again, and all of the practice tests again, and then when I saw that they had passed those, then they would get a third attempt, and all of them passed.Survey Monkey  to collect feedback from nursing students in the program: “I did some statistics gathering every single year. I would say that about 90 to 95% who would reply on the survey really much preferred the self-directed ability to test and retest” (P03).The same instructor had also used an online survey tool, One of the major ongoing modifications to the new DCCT model is related to how and where the actual testing is performed. Chronologically, the model moved from final dosage tests being written by hand in classrooms, to being written on a computer within a lab proctored by an instructor or designate, to ultimately being written off-site using the Internet and a combination of security programs in order to prohibit or reduce potential cheating. The Faculty Lead compared the previous and current DCCT models.P11: There’s a limitation on campus with the number of computer labs, and number of computers in each lab, and so it was very labour-intensive to have 300 students write tests on-site.... We’ve changed it so that they have the flexibility to write it when they’re ready.... and starting this academic year [2019–20], they test at home.... We use LockDown Browser as sort of the basis, then in first year, second semester they also use Respondus Monitor, a video proctoring software. Students expressed a number of issues that they found stressful regarding the move to the fully online, off-site version of the final testing. First, they felt stressed about having to find an appropriate space to write it, often having to leave their homes or residence spaces to do so. As one student shared, “I live in a very hectic and very busy household, so I actually had to find a space in my community at the local library where I could go to write my test, that had a good internet connection” (P07). The Faculty Lead noted that an attempt was made to help students with this challenge by arranging for library study rooms and vacant former office spaces in the university to be used for potential quiet writing sites. Second, some students missed having a proctor and a technician present during the test writing in case they had questions or experienced technical issues, respectively. Third, the web camera software requirements were felt to be somewhat overly restrictive in terms of non-applicable warnings automatically issued by the software during testing. Fourth, students with special needs and related accommodations initially encountered certain challenges with the move to online, distance evaluation but these access/timing issues were ultimately addressed by the Faculty Lead.LockDown Browser and Respondus Monitor , they ultimately became more at ease with the system. In contrast, many students expressed an appreciation for online, off-site testing, highlighting the reduced amount of travel time as one of the main benefits of the new model. As one such noted, “Personally, since I live outside of [city], it has taken me, due to the weather, upwards of 40 minutes to get to school, and sometimes I didn’t even spend that long writing the test” (P05). One Year 3 student highlighted a perceived parallel with the self-directed module work, “I thought it was less stressful because you’re more independent that way. You’re used to doing your dosage math on your own, and there’s no strict time to come and write it, so I appreciated being able to do it online” (P09). Faculty members were originally hesitant and cautiously reluctant to move towards an Internet-based assessment process for fear of potential student cheating. However, with the advent of better software options, such as In this section, we will address Research Question 2 by exploring further themes that emerged from the case study data dealing with student and instructor perceptions of overall DCCT model effectiveness in terms of mathematical confidence and competency.Based on the survey data and interview transcripts, several different types of learning relating to the new DCCT model became evident. Three of these were arguably part of the planned curriculum, while a fourth seemed to develop in a more informal, spontaneous manner.self-directed learning aspect of both the module-based math content learning and of the assessment experiences. Nursing students were free to work on the content at their own pace each term, and to complete both the practice tests and final test for each clinical course whenever most convenient for them, within the allotted timeframe windows. This theme became evident in the survey open-response item and was further elaborated on by participants during the interview process.Perhaps the most distinctive feature of the new DCCT model was the When asked about what they perceived as the most beneficial aspects of the dosage course experience, many of the 44 survey participants focused on their appreciation of the flexibility surrounding the self-directed, independent nature of the DCCT module learning. For example, one student noted, “Being able to complete at my own pace, and I can focus my studying on places I need extra practice.” Another wrote, “I am glad that we were able to learn this information on our own time and not have to sit in a lecture to learn it.” One first-year student reflected on student procrastination:P13: It’s really based on your time management skills as a student. This program is so time-consuming with clinical, which has the lab, as well as the other four courses. And then going to the hospital or long-term care facility as well, so it’s really hard to fit it all in.... It’s not like it’s super draining or demanding, but it’s just setting it up at the beginning of the semester to do it throughout the year, and not leaving it until the very end.Nurse instructors indicated that they too felt that the self-directed aspect of the new DCCT model was important for their students, in terms of the perceived benefits during both the undergraduate experience and throughout their future nursing careers. One faculty member noted, “I think what is working well is that it allows students who are strong to go ahead and work independently” (P03). Another colleague explained: “I think it’s good. I like the fact that it’s not attached to a clinical. I think for students it’s important for them to develop that skill of doing self-directed learning, because nursing is a life-long learning profession, and I think that they need to be encouraged to do that” (P01). According to Faculty Lead, it also allows for adequate time for study.P11: I think one of the strengths is that it allows the students to take as much time as they need, and sort of adjust their studying to when it’s good for them. I’ve had students who have really, really struggled with their dosage, and who will contact me in January to start working through things, but then also students who are stronger who don’t need to take as much time, and they’ll start reviewing the modules only a few weeks before.personalized learning experience within the Elsevier platform itself. By this, we mean that the software was designed to present dosage calculation questions that featured several different solution methods or strategies. Early on in each module, students were asked to try the various methods and to select the one that they found most easy to follow and replicate when solving similar problems. The software would then proceed to present all subsequent module content and related questions/solutions using only, or predominantly, that selected method for sake of consistency. As one student noted, “There’s like a bunch of different ways you can do it in the online modules, there’s like three different formats for a lot of these questions, so it was finding which one works for you best” (P06). Another likewise explained:Beyond the self-directed aspect of the DCCT model, students were also presented with a P12: It offers you four or five different ways to complete the same question, depending on your learning style.... It’s set up so that it presents ways to approach each of those questions with different math styles, like proportional, or dimensional, or ratio analysis. The idea is that you’re going to go through and you’re going to learn all four different ways first, and then you’re going to decide which one works best for you. Thus, even though the module format was consistent and the content was being presented in a standardized and repetitive way throughout all four years of the program, there was also the ability to personalize the learning.contextual (or embedded) learning. While this aspect had indeed been part of the previous DCCT model with math skills being taught by the clinical instructor in a classroom as part of the overall course delivery, in the new model the clinical lab instructors expected nursing students to have already encountered certain pertinent math skills as part of their self-directed learning progress within the Elsevier/Blackboard system. Of course, the success of such an educational approach requires that (i) students actually take the time to complete the related learning prior to the group session; and (ii) that instructors plan their courses carefully to ensure that students are aware of, and are given adequate time to complete, the new independent learning content prior to each simulation lab session. A third type of learning experienced by students in the new DCCT model was that of When both of these conditions were met, and the lab instructors presented math concepts or skills within the context of a clinical simulation lab activity, participants indicated that the resultant learning was usually very positive as it was seen as directly relating to practice. One student shared, “We learned about calculating primary, secondary, and continuous drip calculations in the lab, and then at the end, we had to get individually tested on it” (P09). A Year 2 student likewise noted, “I found that there was quite a consistency between what we learned in the lab and what we had to do for calculating dosage” (P12). Another participant shared: “For things like basic drug calculations, we did have to do them in clinical class and we also did that in the lab, which is really neat, and we had evaluations based on that” (P13). A final year student reflected back on this form of contextual learning:P07: I liked it when our instructors incorporated it into our labs, because we are learning the skills and so allowing you to integrate the dosage into it was very similar to simulating what you would have to do if you were to encounter that situation on a hospital floor, or when working as a nurse. Faculty mostly agreed with the value of embedding dosage skill teaching within authentic contexts that allowed for the direct application of the new learning. The former Dean noted, for example: P10: I don’t think you can teach anything without context—that’s part of my own teaching philosophy. You know, you can theoretically do this stuff, but you need to use real experiences, or use case studies, which are great and safe contexts. So, I mean, you should be teaching the math skills kind of theoretically, but you have to push it into a practical context because nursing is nothing but, you know, practical knowledge. However, in instances when either one or both of the above-mentioned conditions had not been met, this sometimes led to less than satisfactory results, for a number of reasons. For example, a Year 3 student recollected: “I remember they were saying things like, ‘So, you guys know how to do this, right?!’” (P09). Another stated, “I think it’s important, but I found that when they tried to integrate dosage questions into labs, they would go very fast and skim over it because it was expected that you had already done it by yourself, and so would understand it” (P14). In terms of why this mismatch may have been occurring, students hypothesized that there may have been a lack of communication between the Faculty Lead and the clinical lab instructors in terms of the dosage module content and related deadlines. Given the very busy schedule of a nursing student, participants noted that it was often difficult to find time within one’s school, clinical, and general life event schedules to complete the DCCT modules, practice tests, and final test. Students shared that having opportunities to access the online material earlier  might have made things easier for them in terms of learning the math skills in advance of the corresponding lab simulation or class sessions. A first-year student noted: “I’m pretty sure they’re opening our dosage course up in the summer for next year, so that’s going to be really nice to get it all done in the summer. Definitely beneficial... when you don’t have everything else to do” (P13). A senior student concurred: “I think it would be very helpful, yes, especially for second, third, and fourth years. I know if I had that option available to me, I would have used it in terms of doing it before courses started” (P14).social learning. In other words, although the primary mode of new math skill learning was independent and self-directed using the Elsevier portal and Blackboard LMS, it was not uncommon for students to make their own arrangements to review DCCT material with others, in pairs or small groups. All of our student participants described having experienced or observed this kind of spontaneous and informal social learning behavior while in the program. This would take place on-site, in available classrooms or library study rooms, or off-site using email or social media. A Year 1 student describes this kind of informal social learning phenomenon:A fourth and final type of learning relating to the new DCCT model that was discussed by participants in the interviews was that of informal, P08: If somebody would say, “I’m really struggling with long division,” or something, then we would all start talking about that topic.... It was just whoever had already done the modules, or who understood it the best, would just explain it to everybody else, and if multiple people understood it, then they would just kind of break off into smaller groups and talk one-on-one with somebody. Upper year students (Years 3 and 4) recalled similar experiences as they reflected back on their social learning, “We went to the library and were together every single time. So, definitely a social setting for curriculum review, of working together, and understanding it together, and figuring out what the requirements were” (P06). Another noted:P04: Yes, we would normally go get a room at the library and just study there together.... I think that group learning is probably the best way for nurses to learn. Say you have four people in a group, and you might have one person who feels super confident with the math, like they know what they’re doing; then you have another person who may be as confident, but doesn’t really know how to explain things to others; and then you’ll have one or two other people who have no idea what’s going on, and are just trying to stay above water.Instructors indicated an awareness and general approval of this kind of informal social learning that was happening within the new DCCT model. “It’ll naturally happen, as that’s the way nursing students study, they tend to do a lot in groups, even for their final NCLEX [National Council Licensure Examination-RN] exam. Yeah, I think that’s great, and I have no problems with that” (P10). In summary, nursing students experienced self-directed, personalized, contextual, and social learning—the first three types being directly related to the planned curriculum, and the fourth type developing more spontaneously.Students who took part in the online survey shared mixed responses in terms of their perceptions of the overall effectiveness of the Collaborative program in adequately preparing them for the math realities of nursing practice.In the online survey, when asked about the number of hours that nursing students had spent, on average, in preparing for the final qualifying test each term, the following data were shared . Thirty-one of the forty-four participating students indicated that they spent more than three hours in preparation for this final assessment. Clearly, it was something that was of importance to them, given the required 90% achievement in order to proceed to the next clinical placement the next term.When asked in Q16 if they felt they possessed strong mathematical skills prior to starting the nursing program, students noted a range of responses see . Thirty-When asked if they felt that the dosage program has helped them with their understanding of medication administration, 28/44 (64%) indicated a strong (6) or somewhat (22) agreement; while 10/44 (23%) noted a somewhat (8) or strong (2) disagreement, with 6/44 (14%) being undecided. In Question 18, we asked participants if they believed the dosage program has helped them with overall math skill development. Results here indicated that 21/44 (48%) indicated a strong (4) or somewhat (17) agreement; while 14/44 (32%) noted a somewhat (10) or strong (4) disagreement, with 9/44 (20%) being undecided. In terms of perceived content alignment, Question 20 in the survey presented the following statement, “The mathematical content covered in the dosage course aligns well with the knowledge and skills that I will need in the clinical setting” Results showed that 27/44 (61%) of survey respondents indicated a strong (3) or somewhat (24) agreement; while 11/44 (25%) noted a somewhat (8) and strong (3) disagreement, with 5/44 (11%) undecided. The final two Likert questions in the survey focused on perceived readiness for practice. Question 21 proposed that, “I was able to use the math skills learned in the dosage program in my clinical area in a timely manner ” Feedback from participants indicated that 20/44 (45%) indicated a strong (8) or somewhat (12) agreement; while 9/44 (20%) noted a somewhat (6) or strong (3) disagreement, with 15/44 (34%) undecided. Question 22 stated more specifically that, “The dosage program, in combination with my clinical courses, make me feel confident with my ability to safely give medications in the clinical setting” Here, survey respondents indicated that 24/44 (55%) were in strong (8) or somewhat (16) agreement; while 5/44 (11%) noted a somewhat (5) or strong (0) disagreement, again with 15/44 (34%) undecided. Survey responses regarding perceived benefits of the dosage calculation program included a number of comments regarding positive curricular alignment. One nursing student shared, “Dosage gave me the opportunity to practice a lot of basic math that I had forgotten about, as well as learning and memorizing new and helpful conversion factors” Another noted, “I find that the questions have real world applications, and that I can see how they apply to clinical practice” “Having case scenario questions that model real-life clinical situations” explained one participant. Yet another student noted: “It allows time for students to specifically focus on dosage calculations before the test, rather than having it integrated within a course and potentially seeing it drowned out by other skills” “It was a good insight of what is to come in the nursing profession, when it came to medication” stated another participant. “The number of ways medications can be administered  was covered” noted a fellow student, “helping us learn how we would give medications in the clinical setting” One student highlighted needed skills, even in light of the reality of the pharmacy’s role in drug calculations.It is helpful because it introduces what kind of calculations are needed in dosages. It teaches what to expect in the clinical setting. Although pharmacy does most dosage calculations, nurses need to understand them and be able to calculate I-V rates, especially mg/hr versus ml/hr, on their own, confidently. Students find IV calculations the hardest to understand but they are used in most areas of practice and the nurse is usually responsible for calculating it. why nursing students who feel they were mathematically competent when reflecting on their math skills upon program entry, and who are passing final dosage tests with 90% or greater achievement each term, still do not seem to feel overly confident about their related math dosage skills. Perhaps it has something to do with the high-risk nature of actually administering medications to real patients in healthcare/community contexts? Is it possible that some, perhaps many, students are barely passing the dosage tests via persistent efforts and multiple attempts, and hence still do not feel overly confident about their math dosage competency?So, while a majority of survey participants felt that they were mathematically competent when reflecting back to their point of entry into the program (Q16), and felt that the DCCT model was helping their understanding of medication administration (Q17) as well as featuring a curriculum that was well-aligned with the realities of practice (Q20); less than half of the surveyed group felt confident in their general math skills in clinical (Q21), and only slightly more than half felt confidence in their ability to give medications while on practicum placement (Q22). Keep in mind that this is a relatively small sample size (approximately 10%) of current nursing students and that we have not teased apart the responses by program year. Notwithstanding, we are curious to know Much of today’s medication dosage calculations are carried out by a pharmacist within the hospital, and medication capsules are often prepared and delivered to the nurse through an Automated Dispensing Cabinet (ADC). Furthermore, although much of any remaining calculating work is carried out by the nurse with a calculator, computer, or mobile phone, instructors and their students still understand the importance of critical thinking and the ability to be able to estimate and check answers for reasonableness. A Year 1 student shared her clinical observations:P13: A lot of the healthcare facilities have automated dispensers, where all of the medication is pre-packaged... and they use the barcodes on patients’ wrists, and those on their medications to match up patients with the already prescribed pills. So, the nurse doesn’t really have to calculate.... With experience you’d be exposed to more and more, so you’d know the reasonable ranges without having to calculate it every time, but obviously it is still important to know how to do it.In our previous research, we called for the introduction of mobile smartphones and Internet resource searching to become part of all nursing education programs, given the commonplace reality of these activities in the nursing profession . The useP04: Everyone carries a cell-phone. It’s like it’s essential now to carry your cell-phone as a nurse.... If something comes up and a doctor is talking, and they say something that you’ve never heard of before, you can quickly Google it instead of looking stupid.P06: Every nurse I’ve seen in practice has their cell-phone on them, using it for dosage calculations or to look up medications.... One of the applications that is loaded onto all of the hospital accounts is called UpToDate, where it has all of the information, like medication administration, processes, and common symptoms. P07: I have not ever in my four years seen a nurse calculate with pencil-and-paper—I have always seen them use a calculator.... There’s a calculator at their dosage station, but for emergency situations they might have their phone in their pocket, and so they would just pull that out and use that as a calculator.However, not all participants observed smartphone usage among nurses and students on clinical placements. One student noted, “I know for students it’s not allowed. At my long-term care home placement, they also weren’t allowed to have cell-phones at all on the floor. So, I haven’t seen anybody with any cell-phones or using them—even the staff there weren’t allowed to do it” (P08). Another stated, “You weren’t supposed to have your cell-phone on you. I think some nurses would use it as a calculator, but I think that was it. It was pretty strict... I didn’t really see a lot of use of cell-phones, actually” (P09). Clearly, this is an area requiring further research in terms of curriculum reform.When asked in the interviews about their perceptions of overall preparedness for practice based on their experiences with the new DCCT model, nursing student participants by and large appreciated the program. One Year 3 student shared her thoughts:P09: Being tested yearly, it makes me feel like I’m being kept up-to-date.... I think [university] has a really good reputation for making good nurses, and it’s because of the way that we test here. It holds everybody accountable.... My friend, she hated dosage calculations—but I think, deep down, she does appreciate having to do it each year, because now she’s good at it.Another Year 4 student summarized her undergraduate experience: “I feel well-prepared. I’ve also been able to kind of seek out learning opportunities on my own, outside of the program, like in summer employment, and kind of be exposed to building confidence in those dosage situations” (P07).Like any program structure or model, there is always room for improvement. Student participants in both the survey and the interviews shared a number of criticisms in this regard. First, some noted that there was a mismatch between module practice and final tests. Some students also experienced problems with the software interface itself, or encountered issues relating to internet access or connection stability. Faculty members invariably shared how that they felt mathematical skills were essential for nursing practice, particularly with regard to computational competency (with and without technology), as well as an ability to use critical thinking to estimate answers and to analyze the reasonableness of answers. The former Dean noted as follows:P10: One is just knowing your basic math skills—so, whether or not you know two plus two equals 4, and then being able to check an answer for reasonableness. You also have a legislated responsibility to know how much of a drug should go into a patient, whether you received that from the pharmacy through a dispensing machine or prepared it yourself, and whether or not you use a calculator or not, you have a legal, ethical responsibility to know that it’s the correct drug, going to the correct patient, at the correct time.... Yes, even if you have a calculator, I mean, a human has still got to enter the numbers? So, go ahead and get your phone out, and do 25% of 37, you know, I would do that with a phone too, but I have to at least be able to go, “Yeah, I think that answer is correct because 37 is close to 40, so a quarter of that has to be just less than 10.” They should be able to know that.... And you know the bottom-line consequences, if you don’t know how much, or why, and you give someone the wrong drug, well, you’re legally responsible for that, and you could go to jail.... Human error is huge in the healthcare system.According to another instructor, a nurse must be able to accurately calculate dosages, check answers for reasonableness, and avoid a general over-reliance on technology.P15: Just because a machine says it’s so, doesn’t mean it’s so. You have a 12-lead ECG, and some of those machines interpret what the findings are, but being a Critical Care Nurse and an expert in reading 12-lead ECG’s, I can tell you the ECG machine is wrong all the time.... In terms of the ADS machines, they have not always prevented medication incidents, and in fact, in some cases, they’ve created them.... You still have to open the drawer, check the med cart for what the patient is supposed to be getting at that point and time.... The meds aren’t necessarily going to be in the exact perfect dosage amounts either—they may need to be split, or you’ll have to give two instead of one, because they only come in 25 mg and you have to give 50, three times a day. If you can’t figure that out, then you’re in trouble.When asked if they felt confident that the new DCCT model was graduating nurses who are competent and confident in their dosage administration abilities, one instructor shared the following summary:P15: The new system provides an opportunity to do some self-directed learning, to really take some ownership and accountability for learning, and to be able to do it at their own pace in an environment of their choosing.... I think that this approach has reduced the anxiety overall, and gives them a repetitiveness that’s often required to retain these kinds of things.Participating instructors also provided input on what types of changes would be helpful as the DCCT model continues to be monitored and revisited in the coming years. Similar to the student comments, faculty highlighted the following areas: (i) formalizing contextualized, yet unassessed, dosage teaching in the labs; (ii) updating DCCT questions to reflect any changes in nursing practice; (iii) producing short instructional videos that nursing students could play, pause, or rewind as needed; (iv) reviewing the timing of the module releases ; (v) considering a second designated person to help support the complex work of the Faculty Lead; and (vi) increasing communication with Clinical instructors. Our case study findings, here presented, offer significant insights into student and instructor perceptions, particularly surrounding the delivery of online curriculum  and assessment  methods. These considerations are particularly relevant during the pandemic era since almost all education sectors were required to make sudden transitions to online programming, thereby encountering many of the same challenges, and hence discovering, by virtue of necessity, a number of useful strategies and systems that are worth sharing more widely.Much research was carried out in the area of improving the mathematical literacy of nurses in terms of programs and strategies used in the undergraduate curriculum. Existing in-depth literature reviews in this area provide extensive background information ,23. QualAs we conclude the paper, we would like to suggest some key recommendations for faculty and administrators who may be facing similar challenges surrounding required mathematical/dosage learning. These recommendations are based on the nature of the emergent themes within the case study, and specifically touch on what appear to be priority focal points for both the instructors who were involved in designing and implementing the model and the nursing students who experienced the model first-hand.Focus on Calculation and Critical Thinking: Nursing practice invariably requires both mathematical and dosage calculation skills, as well as critical thinking skills such as mental estimation and the ability to check answers for reasonableness. Instructors were unanimous on this point, all indicating that nurses must possess both hand-written and technology-based dosage calculation competency.Focus on a Mandatory Prerequisite Structure: As opposed to a model wherein the dosage calculation component was a composite and assessed feature of clinical courses, dosage testing/competence is now also a prerequisite for each clinical admission. Instructors felt that insisting on this requirement helped students to understand the critical nature of dosage skills, and to increase their readiness. Focus on Practicum-Relevant Skills and Repetition: The dosage modules, involving content, practice questions, and tests, are purposefully aligned with relevant practicum placement skills, and students complete dosage modules throughout all four years. For example, Year 1 focuses on basic math skills ; Year 2 on Maternal, Child, Mental Health, and Chronic Care; Year 3 on Community and Family Nursing; and final Year 4 on Acute Medicine and Complex Care. The majority of both students and instructors consistently spoke to the importance of repetition, throughout all four years, as being key to learning. Focus on Self-Directed, Personalized, Embedded, and Social Learning: Module learning is self-directed, personalized via selected solution methods, reinforced through demonstrations within the simulation labs, and often supported by informal peer-to-peer tutoring. The majority of participating students emphasized their appreciation of a self-directed program that allowed them to review content as many times as needed, and whenever most convenient to do so. Instructors stressed the importance of connecting the module dosage/math learning to nursing practice by way of the corresponding simulation lab experiences and were also not surprised to find students informally drawn together for purposes of review. LockDown Browser and Respondus Monitor software. Perhaps the most important aspect of the new DCCT model, in light of current trends in online education, was the complete transition, over time, from onsite, computer lab-based assessment to secure, online, assessment practices including final tests. While both instructors and students shared initial reservations about such a transition, the majority of participants indicated that the benefits of such an approach, once established, far outweighed the previous model. Focus on Online Access and Secure Assessment: All dosage module work is completed online through secure access to the Elsevier Evolve portal and Blackboard LMS, including the final test using Focus on a Designated Administrator and Student Supports: A Faculty Lead, through the designated workload, is strategically positioned to oversee the DCCT model, tracking all student progress, addressing technological/content issues, and providing student support. Instructors recounting the planning and implementation of the new DCCT model all stressed the importance of clearly establishing a recognized position in which a faculty member would feel well supported by the department, and from which they could offer student assistance.Focus on Cyclic and Data-Driven Program Evaluation: Ongoing review of the DCCT model is conducted through regular student surveys, student achievement data analysis, and faculty/clinical instructor input that is shared via email and at departmental meetings. All new programs or models need to be revisited and revised according to ongoing and careful review. Instructors in the study relied heavily on both formal (surveys) and informal  feedback from their students, and this information shared in departmental meetings, guided progress.In closing, based on what we perceive as strengths of the examined DCCT model, we would like to share the following seven focal points, or key recommendations, for nursing education programs as they consider the development of similar curricular programming.Mathematical competence and confidence are vital aspects of contemporary nursing practice, even within an era of increased technological advances. Nurses must be able to complete dosage calculations, with and without the use of digital machines, and to be able to judge dosage calculations for reasonableness. In preparing nurses for this complex profession, undergraduate nursing programs must find a way to address these math- and technology-related competencies in a way that is both pedagogically sound and pragmatically sustainable. The online, self-directed, prerequisite DCCT model that was examined herein, arguably provides just such an approach for nurse education programs.Clinical Resources▪Blackboard Learn: An Advanced LMShttps://www.blackboard.com/teaching-learning/learning-management/blackboard-learn (accessed 11 December 2021)▪Elsevier Dosage and Solutions, Online Textbook Resourceshttps://www.elsevier.ca/ca/specialty.jsp?lid=4&sid=636 (accessed 11 December 2021)▪Respondus Monitor & LockDown Browser: Assessment Tools for Learning Systemshttps://web.respondus.com/he/monitor/ (accessed 11 December 2021)▪UpToDate Clinical Decision Support Resource SoftwareWolters Kluwer https://www.uptodate.com/home (accessed 11 December 2021)


Supported self-management for asthma reduces acute attacks and improves control. The internet of things could connect patients to health care providers, community services, and their living environments to provide overarching support for self-management.We aimed to identify patients’ and clinicians’ preferences for a future internet-of-things system and explore their visions of its potential to support holistic self-management.In an exploratory sequential mixed methods study, we recruited patients from volunteer databases and charities’ social media. We purposively sampled participants to interview them about their vision of the design and utility of the internet of things as a future strategy for supporting self-management. Respondents who were not invited to participate in the interviews were invited to complete a web-based questionnaire to prioritize the features suggested by the interviewees. Clinicians were recruited from professional networks. Interviews were transcribed and analyzed thematically using PRISMS self-management taxonomy.We interviewed 12 patients and 12 clinicians in the United Kingdom, and 140 patients completed the web-based questionnaires. Patients expressed mostly wanting a system to log their asthma control status automatically; provide real-time advice to help them learn about their asthma, identify and avoid triggers, and adjust their treatment. Peak flow , environmental  , and asthma symptoms  were the specific data types that patient most wanted. Information about asthma and text or email access to clinical advice provided a feeling of safety for patients. Clinicians wanted automated objective data about the patients’ condition that they could access during consultations. The potential reduction in face-to-face consultations was appreciated by clinicians which they perceived could potentially save patients’ travel time and health service resources. Lifestyle logs of fitness regimes or weight control were valued by some patients but were of less interest to clinicians.An automated internet-of-things system that requires minimal input from the user and provides timely advice in line with an asthma action plan agreed by the patient with their clinician was preferred by most respondents. Links to asthma information and the ability to connect with clinicians by text or email were perceived by patients as features that would provide a sense of safety. Further studies are needed to evaluate the usability and effectiveness of internet-of-things systems in routine clinical practice. Asthma is a chronic disease, affecting 235 million people worldwide . Supportdoor to interact with the system . The IoT health care network has defined an IoT topology [The IoT is a giant system comprising networks linking web-based services and clouds with online sensors and actuators. Sensors are able to communicate with each other to make distributed intelligent decisions in real time -15 An aptopology , which itopology -20, hypetopology ,21, and topology ,22,23. Ttopology . IoT intThere are many asthma-related smart devices in the market  London Fulham Research Ethics committee (ref 19/LO/0703). The study was sponsored by the University of Edinburgh and the NHS Lothian . All participants were fully informed about the study and provided their consent.We used qualitative interviews and a web-based questionnaire to explore patients’ and professionals’ vision for future IoT features. We adopted an exploratory sequential design , using qWe included UK-based adult patients who were actively using treatment for asthma  and exclWe purposively recruited a maximum variation sample of 12 patients to take part in individual interviews. Sampling was based on age ; ownership of an action plan (or not); duration of asthma ; hospital admission in the previous 12 months (or not); confidence with using technology .We recruited health care professionals from primary and secondary care through newsletters and social media . We also approached individual professionals who were actively involved in clinical care or research through personal networks.We adopted a think-aloud approach  to exploWe asked patients to complete 2 tasks in the interview. For task 1, we provided a list of the most wanted app features  identifiAt the end of each task, participants were asked to add any features, data, or smart devices that they thought would be useful but that were not included in the list or images (or were not yet available).Professionals were asked to think about their previous experiences providing care for people with asthma and select the features from the list  that couFinally, we showed participants a prototype app (an interface app which included many wanted features ) to stimThe web-based questionnaire aimed to quantify the features wanted by interviewees and their perceived usefulness enabling us to triangulate the findings. Participants’ feedback in the qualitative interview informed the features listed.The questionnaire  collecteWe used Bristol Online Survey, a secure web-based survey platform that complies with ISO27001 information security standards and the General Data Protection Regulation, to build the web-based questionnaire and collect data. To test content validity and readability, we invited a patient volunteer and an independent researcher to try out the questionnaire independently. Their feedback was incorporated in the questionnaire before it was sent to participants. Potential participants who had not been selected for an interview and who had given permission to be contacted regarding the survey were emailed a participant information sheet and a link to the questionnaire.Interviews were digitally recorded, transcribed, and coded in NVivo . We used PRISMS taxonomy  as a fraWe used descriptive statistics to analyze patients’ preference ratings for the data they would like a future IoT system to collect and in which circumstances the system would be most useful. We used data from the survey to quantify the features wanted by interviewees and their perceived usefulness.The findings, data synthesis, and interpretation were discussed regularly within the multidisciplinary study team, which included a patient representative, technology developer, health care professionals, and researcher. The researcher had an engineering and technology background and clinical research experience with patients and clinicians in asthma app development.thank you page was not closed after completion). There were no instances of missing data.Invitations were sent by email to 572 patients . Advertisements were posted to the Asthma UK’s Facebook and Twitter  and AUKCAR Twitter (1224 followers). Of 362 patients who expressed interest in the study, 297 (82.0%) were from Asthma UK’s social media, email, or website; 42 (11.6%) were from the AUKCAR Twitter; 10 (2.8%) were from SHARE; 3 (0.8%) were from REACH, 2 (0.6%) were recommended by their hospital or a relative, 8 (2.2%) received an e-mail invitation from Asthma UK and others responded to our advertising. Of the 362 patients, 12 were selected for an interview, and the remaining 350 were invited to complete the web-based questionnaire: 3 rejected the invitation , and 29 were undeliverable emails. Thus, 318 were sent the web-based questionnaire link, of whom 140 (44.0%) completed the questionnaire. Of the 140 participants, 139 participants (99.3%) completed the questionnaire within 15 minutes, and 1 person (0.7%) appeared to take 3 hours and 42 minutes to complete the questionnaire (most likely because the Of 152 participants (12 interviewees and 140 web-based questionnaire respondents), most  were 46 years to 65 years of age, 69.1% (105/152) were female, 54.6% (83/152) had an action plan, 75.0% (114/152) had been diagnosed with asthma for more than 10 years, 12.5% (19/152) had been admitted to hospital in the previous 12 months, and 86.2% (131/152) were confident that they could download apps themselves .Twelve professionals were recruited from primary, secondary, and tertiary care in the United Kingdom. All provided care for people with asthma, and some had research experience using digital technology to monitor patients’ medication use and symptoms for respiratory patients .Perceptions of the 12 patients about the potential usefulness of features were mapped to the PRISMS taxonomy . FeaturePatients decided the usefulness of potential IoT features based on their own past asthma self-management experiences , their asthma triggers, their curiosity about what affected their asthma, the severity and control of their asthma condition, and what they considered  was best practice for asthma.Monitoring, supported by feedback advice, was the feature that most patients wanted to see in an IoT system. Information about asthma and an action plan were also priorities. Flexible access to follow-up advice with a general practitioner or asthma nurse by text or email service were “safety net” features that most patients thought would create a sense of “staying connected” with clinicians, although they stated they would only use it when needed. One patient with hearing problems who struggled to communicate during an exacerbation wanted a panic button to automatically text for emergency help. Perceptions on monitoring of control, and feedback are presented in more detail below. Other features were wanted by patients but were lower priority .The responses to the survey are illustrated with a bubble plot . In keepSome patients explained that a peak flow was “useful” and “needed” to help clinicians assess their asthma. Most professional interviewees agreed with this and thought that a log of peak flows, symptom scores, and medication use would engage patients and could inform assessment of control and management strategies.I see particularly important is logging asthma symptoms and medication use. Peak flow, maybe less so, but the symptoms and medication use I think are very important. although peak flow is far from perfect, it just shows that the patient has engaged to some degree, that they’re seeing differences, whether it’s in the morning or evening or when they...after exercise and they’re engaged with that, so I know when I ask them some questions about their symptom experience that they’re thoughtful about it.Health care professional 7, general practitionerHowever, in contrast to the priority attached to logging, most patients acknowledged that in reality they checked their peak flow “rarely” or “only when their asthma was getting worse.” The reasons for not measuring every day were varied. Some “forgot,” while others felt “weird doing it in front of people,” but many suggested it was unnecessary as they knew their asthma and could assess status by how they felt.Not very often. I do sometimes, if I get chest infections or if I get tight chested or if it’s not, if I just feel there’s something wrong, then I test what my peak flow is, just to see what it is.Patient 4, 26-45 years old, maleI’m a big believer in logging things so that if you’ve got a history... I mean to log things, but I forget, so it would be good to have something there.Patient 5, >65 years old, maleSeveral suggestions were made about how an IoT system could help overcome this discrepancy. A word that was used frequently was “automatic.” Most patients wanted an IoT system that could automatically log their asthma condition. They were interested in trying smart devices ; some explicitly mentioned that this would enable them to capture data automatically though they were not clear how the devices could capture their asthma status without some effort on their part. A device with an automated data transfer feature still requires the user to blow the air into the meter, and patients acknowledged that to do this regularly would require motivation such as a request from researchers or their clinician. Patients had different opinions on using voice assistants, smart watches, smart fabrics, smart purifiers, human robots, and robot pets to collect additional data automatically:Smart peak flow would be the way forward I think, it really would, because it’s recording it (my peak flow). If you say to me record it every day, I would record it every day...I very rarely use it . But if this smart peak flow is going to record my peak flow at that particular time each day or twice a day, that’s only going to be good to help me and to help my doctor understand, you know.Patient 2, >65 year old, maleIt would be good to have something that I could just quickly tell it what’s happening. Probably not when I’m having an asthma attack because I can’t talk.Patient 1, 46-65 years old, femaleI don’t have my inhalers with me and my other sensors in the office, so for me, given I’m going in and out of meetings and various other things and travelling about and stuff, it’s probably easier if I just have the watch and any clothing or something with sensors on it that can do it, in an ideal world.Patient 4, 26-45 years old, male(Voice assistant) It’s not very secure, I don’t like that.Patient 5, >65 years old, maleHow the data were used was an important motivator. Most patients said it was “good” or even “essential” that data from smart peak flow meters and inhalers were transferred automatically to the system so these logs could be correlated with other data and displayed graphically on a mobile phone. Some suggested that they would log peak flows if their clinicians asked them to do so.Clinicians were keen to see a record of medication use to enable assessment of adherence. They favored automated logging of this information via a smart inhaler as that was perceived to be more accurate.It would be very useful if the patient is logging their asthma symptoms and peak flow, medication use...because that’s then helping us to adjust on treatment. I would love to know if they were taking it (prescribed medication) every day like they’re telling me they are.Health care professional 4, prescribing support pharmacistPatients in the interviews suggested a broad range of information and advice that could be usefully provided through an IoT system such as a timely alert when their asthma control changed; the amount of medication to be taken according to asthma control to reduce medication side effects; the numbers of doses taken and remaining in the inhaler, ideally with an option to order a repeat prescription when the medication was running low; and correct inhaler technique.The clinician interviewees concurred with these priorities, especially the need for detecting poor inhaler technique and linking to information about correct use of an inhaler. They also saw value in feedback supporting treatment adjustment according to an action plan.Outdoor environmental data such as pollen, humidity, and air temperature were considered “good to know” and “useful” data by many patients. Patients who were newly diagnosed with asthma wanted to learn which environmental factors affected their asthma, whereas those who already knew what triggered their asthma wanted to use daily environmental data to plan their day. could maybe suggest like how likely they are to be actual triggers as opposed to me just thinking. Then if it suggests that I’m really triggered by something then I could put more effort to avoid that.Patient 10, 16-25 years old, femaleThese data were of less interest to clinicians though some suggested that, together with indoor triggers, outdoor pollution, exercise intensity, weight, peak flow, and symptoms, data could provide real-time feedback and help patients understand which factors affected their asthma in order to avoid them.Both patients and clinicians expressed their interest in automated monitoring with real-time feedback within an IoT system that could support a wide range of self-management tasks. In the qualitative interviews, patients mostly wanted the system to log peak flow, asthma symptoms, and environmental triggers ; provide advice on relevant actions or medication adjustment to suit different levels of asthma control; and provide alerts about the number of doses of medication remaining and inhaler technique. The questionnaire responses quantified these preferences with the most wanted features being monitoring peak flow , environmental asthma triggers  , and symptoms . Clinicians wanted automated objective logs about patient condition that they could access during a consultation. Patients considered that easy access to information and clinical advice, such as text or email communication via the system, provided a feeling of safety, while clinicians appreciated the potential reduction in face-to-face consultations because it would reduce patient travel time and the use of health service resources. Lifestyle logs (fitness regimes or weight control) were wanted by some patents but were of less interest to clinicians.Our study identified the preferred IoT features for patients and clinicians and the type of data that they wanted the system to collect; however, there are some limitations. First, due to limited resources and time, we excluded children under 16 years old from patient interviews though we included experienced pediatricians to provide insights on the needs of children with asthma and their carers. Second, we did not manage to interview any patients who were newly diagnosed with asthma (within the previous year) who may well have had specific needs for information and support. Similarly, all our participants were familiar with downloading and using apps, suggesting that our recruitment strategy of using social media reached a technologically experienced population. Although this approach will have resulted in some perspectives being overlooked, the sample included in the study were demographically diverse, with a range of experiences of living with asthma, and could provide a range of perspectives on the potential of technological support. Increasingly, the global population is becoming more familiar with digital communication. However, we reached data saturation ,42 in thThe researchers had engineering and research experience in developing asthma apps. To reduce the influence on the interview findings of the researcher’s background, the coding and interpretation of results were discussed with study team members from different backgrounds and with different experiences, including general practitioners, a patient, and a technology developer. This range of expertise enabled the study to present a balanced interpretation.IoT is an option to support self-management. Asthma action plans, asthma education, and regular consultations with clinicians are core component of effective self-management; which aims to support patients achieve good control by recognizing when their asthma is getting worse and responding promptly and appropriately . The feaThere is, however, an anomaly. Most patients wanted features that enabled regular monitoring of peak flow and symptoms, but the literature suggests that this is rarely, if ever, achieved in real life . For exaMonitoring is also influenced by whether the patients’ clinician is interested in the results. Home monitoring with feedback has shown promise as a self-management strategy for people with hypertension  and diabAn IoT system can encompass the range of components needed to support asthma self-management. Patients and clinicians preferred features that monitor asthma status (preferably using automated silent monitoring), provide timely advice in line with an agreed upon asthma action plan, and allow observation of environmental factors in relation to asthma control. Our technologically literate participants appreciated the ability to connect to asthma information, as well as easy access to clinicians by text or email. Sustained use was acknowledged as a challenge. Large-scale evaluation of usability, health outcomes, and resource implications are needed to realize the potential benefits of silent monitoring connected IoT systems.


General practitioners often act as gatekeeper, authorizing patients’ access to hospital care. This gatekeeping role became even more important during the current COVID-19 crisis as uncertainties regarding COVID-19 made estimating the desirability of hospital referrals  complex, both for COVID and non-COVID suspected patients. This study explored Dutch general practitioners’ experiences and ethical dilemmas faced in decision making about hospital referrals in times of the COVID-19 pandemic.Semi-structured interviews with Dutch general practitioners working in the Netherlands were conducted. Participants were recruited via purposive sampling. Thematic analysis was conducted using content coding.Fifteen interviews were conducted, identifying four themes: one overarching regarding (1) COVID-19 uncertainties, and three themes about experienced ethical dilemmas: (2) the patients’ self-determination vs. the general practitioners’ paternalism, (3) the general practitioners’ duty of care vs. the general practitioners’ autonomy rights, (4) the general practitioners’ duty of care vs. adequate care provision.Lack of knowledge about COVID-19, risks to infect loved ones, scarcity of hospital beds and loneliness of patients during hospital admission were central in dilemmas experienced. When developing guidelines for future crises, this should be taken into account. In many countries, general practitioners (GPs) act as gatekeepers, authorizing patients’ access to hospital care. That is, for a patient to receive specialized hospital care, referral by his or her GP is needed , 2. ThisAs COVID-19 concerns a previously unknown disease, it is difficult to estimate for whom hospital referral would be beneficial or harmful . In sharDuring the COVID-19 crisis, this competency is even more challenged since it concerns a disease about which little is known. These uncertainties bring about several ethical concerns and dilemmas , such asA qualitative research design was chosen, as the goal was to understand experiences and views of GPs, and obtain insights in dilemmas they faced . An inteGPs working in the Netherlands were recruited via the research teams’ networks and by contacting practices of which the email address was available on the internet. Exclusion criterion was not having practiced during the COVID-19 period. GPs working in both “clean” and “COVID-suspected” practices were interviewed. Purposive sampling was employed based on gender, work experience, geographical region of the practice and the number of COVID-19 patients in the practice. Participants were recruited via an invitation letter which was sent by email. One week later, GPs were contacted via telephone to ask if they wanted to participate. Recruitment stopped after data saturation was confirmed in five interviews in a row.A topic guide of open ended questions was used, developed by the research team and based on earlier literature , 30. SeeInterviews were transcribed verbatim with the help of F4 software. Thematic content analysis with an open-coding scheme was performed. Firstly, transcripts were coded line-by-line using Atlas.ti software version 8.4.20. The first five interviews were coded independently by two researchers . After each interview, the coding was discussed until consensus was reached. The existing codebook was used as start for coding each next interview. After the process of initial coding, axial coding took place and codes were combined into categories and themes . These wMethods were carried out in accordance with relevant principles of the GCP guideline.Protocols were checked by the Medical Review Ethics Committee region Arnhem-Nijmegen, which concluded this study was not subject to the Medical Research Involving Human Subjects Act (2020-6669) as participants were not subject to treatment, nor were they required to behave in a particular way. Informed consent was obtained from all subjects involved in the study.Data saturation was reached after ten and confirmed in five additional interviews, resulting in a total of fifteen interviews, including the pilot interviews. Table Interviewees mentioned they had to deal with general uncertainties regarding the new COVID-19 virus as little was known about the virus, its treatment and consequences. Moreover, GPs had to care for patients they did not know, and about whom they were not familiar with the medical and social background.The uncertainties due to COVID-19 came across in all interviews. For example: what do symptoms of COVID-19 look like? When is someone in need of hospital referral? And, what are the benefits of hospital admission? Interviewees did not know what they were dealing with exactly, and what best care was. Furthermore, some of the interviewed GPs experienced difficulties in communication with their patients. They felt impeded to give clear information, as they themselves lacked knowledge due to the uncertainties regarding COVID-19. “What I know today, can be different in two days.” (R10).Moreover, as patients in Dutch GP practices were divided between ‘clean’ COVID-19 free and contaminated practices, GPs had to care for patients they did not know. This introduced extra uncertainties, as they often were unfamiliar with patient’s background. Questions like ‘will he benefit from hospital referral’ or ‘will it harm him? What are his wishes and expectations of life?’ popped up. “Yes,  a lot. You can rely on the past. The relationship is better, people know who you are as a doctor. Perhaps because of that, there is also more trust. (…) So it does make things much easier. You know people better, what they are capable of. And you know a bit about how they live their life.” (R1) Some interviewees mentioned that not having a care history with patients caused complications in decision-making. One interviewee voiced this as follows: “That makes it way more complicated, and then you can get more knotted up with yourself. What does she actually want? Yes or no? And you also have to deal with the medical treatment. Maybe she will be fine, maybe she won’t.. But what does or doesn’t she want? (…) So you are aware of the fact that the chance to make a wrong decision is bigger.” (R4).This ethical dilemma consists of two conflicting moral values: the patients’ self-determination versus GP paternalism. The principle of respect for the patient’s autonomy is associated with enabling her or him to make her own decisions about receiving certain medical care.  PaternalSome interviewed GPs claimed that the principle of self-determination guided decisions regarding hospital referral during COVID-19, regardless of the opinion of the GP. “I have to be absolutely certain before telling someone, you know. ‘it doesn’t make sense to go to the hospital, you simply should not go. And even then: if someone really wants to go, I am willing to support her or him.” (R2) However, because of the uncertainties due to COVID-19 and resulting lack of information on the disease, interviewees found it particularly complicated to interfere with the patients’ choices. “If I am not absolutely certain about whether someone will benefit from it, but I do take away her of his self-determination, I think that is absolutely.. no I think that is a no go. (…) Taking away someone’s self-determination in case of uncertainty? No.” (R2) Apparently, according to some, respecting the patient’s autonomy is increasingly important in times of uncertainties. When interviewees were not absolutely certain about the pros and cons of hospital referral, they felt it was not right to decide for the patient. They felt they had to act with certainty although the situation was uncertain.However, this also depended on the situation. One interviewee explained it as follows: “Then  the patient is the asking party. When I suggest treatment and the patient does not want it, the patient is the refusing party. That is the difference.” (R13) The GPs’ gatekeeping role became critically important with regard to the ‘asking’ side, as the pressure on our hospitals increased. One of the interviewees stated that “I think a part of the fact the amount of IC-beds remained feasible, and the subsequent fact that hospitals were able to manage by pulling out all the stops, is because of the GP. That the GP did not refer patients who did not need to be referred to the hospital.” (R14) In other words: the gatekeeping function was deployed in order to balance against societal pressures.According to the majority of interviewees, the ‘refusing party’ of patients not in favor of hospital referral existed due to fear. They were afraid they would be contaminated with COVID-19 in the hospital. Many interviewees stated they had to convince these patients about the fact they would benefit from hospital care. In certain cases however, interviewees felt they had to override patients refusing this, by acting more paternalistic. “Sometimes you even had to convince people: ‘You really need to go to the hospital!’. Because, people did not want to as they were afraid to pick up COVID in the hospital.” (R6).In both cases, when the patient wants to get a hospital referral when it is not an adequate option and in the case the patient is too afraid to visit the hospital, some GPs felt they had to decide themselves instead of their patient. Moreover, acting more paternalistic was sometimes even seen as part of their job. For example, one GP stated that: “At some point, you just have to say ‘Your child is not that ill, we are not going to do this.’ And yes.. We are also educated to, in such cases, nót do it. Then you explain that a few times, and at a certain moment it suffices.”This ethical dilemma derived from the high contagiousness of COVID-19, and the risk of being infected. This created a conflict between the GPs’ duty to treat and his or her own right to autonomy. The former is the principle that ‘a physician shall be dedicated to provide competent medical care, with compassion and respect for human dignity and rights.’  The physThe feeling of owing a duty came across in the majority of the interviews. “That might sound a bit melodramatic, but I did experience it as a duty. It wasn’t a war, but you are the one who, based on your profession, obliged to be there and to do what you have to do. Because if you all refuse to do so, nothing will happen.” (R13) Some of the GPs even described this duty as a mission: “You also feel it is sort of a ‘vocation’ to be part of it.” (R8) Many GPs stated that this feeling increased during the crisis. However, because of the high contamination hazard of COVID-19, this duty was experienced differently among interviewees. Some argued that “And I think when a GP, in the midst of a crisis, is afraid of COVID her- or himself and because of that does things differently, that’s should simply be called unprofessional.”(R7) Others, especially during the beginning of COVID-19, experienced “I do have my own boundaries, but no-one asked about them.” (R15).This conflict was mostly present when it concerned GPs’ loved ones. One of the interviewees was pregnant and did not know the risks for her baby when she would work with COVID-19 patients. “Yes, absolutely, I thought that  was difficult indeed. But also protecting yourself, that I thought, you know.. I don’t feel like actively pursuing this. (…) Because, I am pregnant at the moment.” (R3) GPs who were part of the group at risk, avoided contact with patients with COVID-19 symptoms. Instead, their colleagues were seeing these patients. On the other hand, some GPs who were at risk decided that their duty to care weighed more heavily than preventing their own risk. “For me personally, yes. I know I am in the risk zone. I am not naïve about the fact I could get seriously ill from it. But I will just accept that and just do whatever I can, and that’s it. And if it goes wrong, despite the fact I am doing what I can, than that’s that.” (R7) And “Look, if you have an outbreak of a contagious disease, if you are a doctor, yes: you still have to. You have to treat. I think every doctor would. Even if it is dangerous sometimes.” (R4) Most of the GPs in this study felt the duty to help as stated by one of them as follows: “I never considered to say: I report sick for the next month, they have to do it without me. It felt too important to be there, because they really need you.” (R8) The duty of care principle thus seemed to have a considerable weight.During the COVID-19 peak, patients were divided over newly composed ‘clean’ and ‘contaminated’ general practices. As a consequence, many interviewees had to care and make decisions for patients they did not know. This created a conflict between their duty of care and adequate care provision. The duty of care is described as: ‘a physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care’.  On the oThe majority of interviewees claimed it was difficult to make decisions for unknown patients, indicating the importance of a trust relationship, but felt the duty to provide medical care. “It of course remains difficult to make decisions about people you don’t know, but refusing it never crossed my mind.” (R13) And “But I would do it , you know. Because, eventually you have to do something. But I am aware of the fact you can more easily make mistakes.” (R4) Most GPs in this study preferred their decisions to be based on the wishes and expectations of their patients. Many interviews felt uncomfortable making decisions regarding patients they did not had an established relationship with, and some of them even refused to decide about hospital referral.In this study, it was explored how Dutch GPs experienced their role as a gatekeeper and which ethical dilemmas they faced when making decisions about hospital referrals in times of the first wave of the COVID-19 pandemic, both for COVID and non-COVID suspected patients. One overarching core theme and three ethical dilemmas were identified. The core theme concerned (1) uncertainties caused by COVID-19. It overarched three themes of ethical dilemmas, which became (more) prominent during the COVID-19 crisis: (2) the patients’ self-determination vs. the GP’s paternalism, (3) the GP’s duty of care vs. the GP’s autonomy rights, and (4) the GP’s duty of care vs. adequate care provision.During the COVID-19 crisis, many GPs experienced decision making as problematic. Instead of SDM, they more often had to choose between conflicting values: self-determination of the patient and their own paternalism, which was experienced as an ethical dilemma. GPs in this study considered paternalism not justified, because of the lack of knowledge about the pros and cons of hospital referral. Many GPs stated that despite these uncertainties, it was expected of them to make clear decisions, to paternalize. Numerous GPs found this difficult: to be obliged to act as if being certain in an uncertain situation. This lack of knowledge also existed when the GP would let the patient decide. Due to these uncertainties, SDM was challenging during the COVID-19 crisis.asked for hospital referral, the GP’s gatekeeper role became enormously important due to the fact the pressure on our healthcare system and hospitals increased. Fair allocation is hugely relevant in the midst of scarcity [refusal of a hospital admission (outpatient or inpatient) in certain cases. This finding is in line with previous research indicating that overriding patients’ wishes might benefit the patient, especially when the patient is the refusing party [Many GPs made a differentiation between the patient being the asking party and the patient as refusing party. If the patient scarcity , and heascarcity . On the ng party , 38.Most GPs interviewed in this study stated they felt a tension between their duty of care as a professional versus their own risk of getting infected with COVID-19. However, their duty of care became more explicit, like a mission, during the pandemic. This value overshadowed the fear for their own health, even when belonging to a risk group themselves. This confirms recent COVID-19 studies , 39–41. The difficulty of grounding the duty of care is consistent with former research, showing it is a social contract with society . HoweverAlthough adequacy of care is difficult to define, i.e. is not a ‘black and white’ issue, interviewees in this study experienced difficulties in making decisions regarding referring patients when it concerned patients they did not yet know. They stated that, because of their duty of care, they would make such decisions, but felt impeded to provide the care they wished to provide. Although GPs are accustomed to make decisions for patients they do not have a care history with when on duty at the out-of-hours service, it was during the COVID-19 period that this became a dilemma. Clearly, a trustful relationship between patient and physician is important when it concerns serious problems and decision making , like duThis is one of the first studies about the COVID-19 crisis that concerned professionals in general practice; most literature focused on hospitals and nursing homes. Despite the lock-down, we managed to interview sufficient GPs in a short period of time. However, GPs who worked in regions with less victims had not always experienced dilemmas in their work; their input was partly based on anticipating on the realistic option of having to deal with such dilemmas in the near future. Moreover, although this would have been valuable information, a comprehensive overview of reasons for non-participation was not systematically collected. Next, the female interviewees were younger and had less working experience than the male ones, which might have influenced our study’s level of generalizability.In conclusion, this study identified three ethical dilemmas experienced by Dutch GPs when making decisions about referring patients to the hospital, in times of the first wave of the COVID-19 pandemic, both for COVID and non-COVID suspected patients. These ethical dilemmas are well-known dilemmas in general practice but became more prominent during the COVID-19 crisis, because of lack of knowledge about the virus, risk for the GP to infect beloved ones, scarcity of hospital beds, and loneliness of the patient during hospital admission. When developing guidelines and protocols for crisis management like this pandemic, these ethical dilemmas should be taken into account.