Analysis

Maths anxiety: how to conquer your fears and calculate with confidence

Reduce your risk of medications errors by becoming comfortable with numbers

Nurses use numeracy every day, when calculating drugs doses, fluid balance or in other essential tasks, but many worry about their competence when it comes to doing the maths

  • Numeracy is a safety-critical nursing skill, yet nurses and nursing students often lack confidence in it
  • 66 million medication errors a year are classed as clinically significant in England alone
  • Test yourself with our quick drug calculations quiz and read expert advice for keeping your practice safe

Rachel Game loves maths. But like many other nurses, the University of Central Lancashire (UCLAN) principal lecturer wasnt always keen. She used to hate the subject and it caused her

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Nurses use numeracy every day, when calculating drugs doses, fluid balance or in other essential tasks, but many worry about their competence when it comes to doing the maths

  • Numeracy is a safety-critical nursing skill, yet nurses and nursing students often lack confidence in it
  • 66 million medication errors a year are classed as clinically significant in England alone
  • Test yourself with our quick drug calculations quiz – and read expert advice for keeping your practice safe
Numbers are ever-present in nursing practice Picture: iStock

Rachel Game loves maths. But like many other nurses, the University of Central Lancashire (UCLAN) principal lecturer wasn’t always keen. She used to hate the subject and it caused her a great deal of anxiety. When she went into nurse education and was asked to teach drug calculations, all that anxiety came flooding back.

‘I thought, how do I do it? How can I overcome this fear I’ve got?’ says Ms Game, interim deputy head of school business development and partnerships in UCLAN’s school of nursing.

Rachel Game

The answer, it turned out, was to practise – a lot.

‘Now I’m absolutely passionate about maths. I love it and I love to teach it.’

In fact, Ms Game is so keen on maths that her master’s dissertation was devoted to it – specifically, how to enhance nurses’ confidence in their mathematical skills.

Why there’s no need to be spooked

In most cases, the calculations are not especially complicated. As Ms Game points out, you don’t need to know algebra or Pythagoras’ theorem. If you can add, subtract, divide and multiply, you are part way there. And if you can brush up on percentages and fractions, you should have little to fear, even in children’s nursing where the calculations can be more convoluted.

‘Students qualify, go into practice and are never tested again, which is a bizarre thing’

Rachel Game, principal lecturer, University of Central Lancashire school of nursing

Undoubtedly, nurses need maths. Drug administration, fluid balance, weight and dietary calculations – so many aspects of nursing care require a fundamental ability to crunch the numbers and arrive at an accurate total.

And yet experts agree that nurses’ belief in their mathematical skills is often lacking.

Nurses often lack confidence in their calculation skills

£30 million

Estimated annual global cost of medication errors

(Source: World Health Organization)

Confidence is ‘generally not fantastic’, says Queen’s University Belfast school of nursing and midwifery senior lecturer Katherine Rogers.

‘People are a bit nervous even though a lot of it comes down to fairly straightforward mathematical manipulation.’

All nursing students will have studied maths at school but for many it will be a while since they took their GCSE exam. And the requirement during undergraduate nurse training to pass numeracy assessments with a score of 100% adds to the pressure many experience, says Dr Rogers, author of Nurses! Test Yourself in Essential Calculation Skills.

Failure in those assessments can be life-changing. If, after repeated attempts, students cannot meet the required pass, they are unable to join the nursing profession. The stakes for the individual are therefore high.

Fundamental to patient safety

Katherine Rogers

But they are higher still for patient safety. A nurse who is unable to complete accurate drug calculations poses obvious risks.

‘How would you feel about someone who was that challenged in their numeracy skills administering medicine to your loved one?’ says Dr Rogers.

The World Health Organization (WHO) estimates the annual global cost of medication errors, in money terms alone, is $42 million US dollars, or close to £30 million.

Clearly, not all those mistakes can be attributed to healthcare staff getting their calculations wrong. But the WHO says errors occur when factors such as fatigue, workflow interruptions and staff shortages ‘affect prescribing, transcribing, dispensing, administration and monitoring practices’. Severe harm, disability and even death can result.

‘From a patient safety point of view, drug calculations are absolutely paramount,’ says Birmingham City University visiting professor and independent nurse consultant Matt Griffiths.

‘Practising your skills on your own is all right if you have some confidence, but if you don’t, you need support’

Katherine Rogers, senior lecturer, Queen’s University Belfast school of nursing and midwifery

He quotes 2018 research commissioned by the Department of Health and Social Care that found an estimated 237 million medication errors every year in the NHS in England.

Most of these have little or no potential for harm but 66 million are thought to be clinically significant.

‘In relation to these medication errors, we can’t put them all down to calculations,’ says Professor Griffiths. ‘But it’s estimated that in England alone there are around 1,700 deaths a year from adverse drug reactions at a cost of £98 million to the NHS. So it’s a big thing.’

Test your calculation skills

Questions set by Rachel Game, University of Central Lancashire
For answers, see box at end of this article

1. Morphine 1500mcg is prescribed. The ampoule contains 10mg in 1ml.
What amount in ml is required?

2. A patient is prescribed a seven-day course of amoxycillin 500mg TDS. The tablets available are 500mg.
How many tablets should be administered as a take-home for her to complete the course?

3. Your patient requires IV paracetamol. He weighs 12kg and is prescribed 15mg/kg. Paracetamol is available as 100mg in 10ml.
How many ml will you administer?

Lack of evidence on efficacy of numeracy assessments

However, establishing a direct link between improving nurses’ confidence and skills in mathematics and a subsequent reduction in medication errors is not straightforward.

For a start, says Professor Griffiths, there is little data on the efficacy of numeracy assessments in reducing calculation mistakes.

237 million

medication errors every year in the NHS in England

(Source: Policy Research Unit in Economic Evaluation of Health and Care Interventions)

‘We need more evidence about whether numeracy assessments work. We need to find out whether they actually do help reduce errors.’

And, as Ms Game points out, at present it is usually only nursing students who are subject to numeracy assessment.

‘Students qualify, go into practice and are never tested again, which is a bizarre thing,’ she says.

Post-registration numeracy testing – why it’s far from straightforward

Even if all registered nurses were subject to an annual test of their numeracy skills, the results could give rise to additional challenges.

‘If somebody fails, do we stop them doing medicines?’ asks Ms Game. Professor Griffiths questions what an acceptable pass rate for such a test would be.

‘If it’s 40%, is it acceptable to get 60% wrong? That’s an awful lot of potential errors and potential patient harm. And for people who do fail, do we offer them extra coaching and reassessment, and at what stage?’

So although a UK-wide, mandatory approach may be the solution to ensuring nurses’ numeracy is up to scratch, regular classroom testing is not necessarily the best way to achieve that.

‘If I was doing a calculation with a student, are they going to question my maths, because I’m a professor and they are a student? Probably not’

Matt Griffiths, independent nurse consultant and visiting professor, Birmingham City University

As Professor Griffiths points out, the data is lacking. And, says Ms Game, where there is evidence, it sometimes confounds expectations.

For example, nursing students who do a maths test, and fail to attain the required score but eventually succeed – may be expected to make more medication errors once they become registered nurses.

‘But it doesn’t actually work out like that,’ Ms Game says.

Identifiers such as this red tabard are effective in discouraging interruptions during drugs rounds Picture: Ashley Coombes/Epicscotland

Testing under exam conditions can spook competent candidates

Exam conditions, maths anxiety, a 100% pass mark – these are all factors that can contribute to nursing students’ failure in numeracy assessments.

‘When you bring them into the university and it becomes “a maths test”, that changes the dynamic,’ Ms Game says.

In clinical practice, however, those same students may not consider drug calculations or working out fluid balance to be ‘maths’. Instead, she suggests, they think, ‘This is the nurse’s role, this is part of my job’ and the pressure is, to some extent, off.

Similarly, in a practice setting, potential errors may be easier to detect before harm is done.

‘I’ve had students who would write on a maths paper that they would administer, say, 50ml of paracetamol to a child, which is a huge overdose.

‘But I think if they had a medicine pot and they poured that amount out, they would think, “Hang on, that’s far too much. What have I done wrong?”.’

RCNiLearning module: Drug calculations for oral medications

A test undertaken in a classroom may therefore be seen as a blunt instrument for assessing a nursing student’s competence in arithmetic, especially if it is never repeated once they are qualified.

So what can be done to help nurses improve their maths skills and build their confidence?

As Ms Game demonstrates with her acquired passion for maths, practice is key. Support is also valuable, Dr Rogers suggests. ‘Find someone to help you – some one-to-one tuition.’

How to improve your maths skills for safe nursing practice

  • Practise As well as books for nurses on calculations, there are lots of online resources designed to test and enhance your numeracy. Start with the basics – addition, subtraction, multiplication and division – and work up to percentages and fractions
  • Seek support If you lack confidence in your skills, get help. ‘Where you have students repeatedly getting different things wrong, you see there is a problem in how they’re computing when they’re doing a calculation,’ says Queen’s University Belfast senior lecturer Katherine Rogers. ‘Practising on your own is all right if you have some confidence, but if you don’t, you need support.’ One-to-one tuition can be a game-changer, she says
  • Stick with what works Dr Rogers suggests that if you have a calculation method that works for you, use it, and don’t be tempted to adopt a different, unfamiliar approach
  • Estimate an answer Do a rough calculation using figures that are rounded up or down to give an indication of the correct answer. ‘Estimation is always very good practice in my book,’ Dr Rogers says
  • Play games Rachel Game, of the school of nursing at the University of Central Lancashire, recommends phone apps that use gaming to develop numeracy. ‘I say to students, find something you’re interested in to help build those skills’
  • Know your drugs Birmingham City University visiting professor Matt Griffiths says familiarity with dose ranges for the medicines you administer frequently can help alert you to calculations that appear wrong
RCNiLearning: How to perform drug calculations for IV medications

Minimising errors in drugs calculations through confident, independent checking

Independent checking is effective only if the checker has the confidence to query their colleague’s calculations Picture: iStock

In clinical practice, systemic approaches may help minimise the risk of drug errors caused by incorrect calculations. Interruptions during medicine administration are frequent and can disrupt concentration. One study at an Australian hospital in 2018 found that for every 100 administrations, nurses were interrupted 57 times.

57 interruptions

per 100 drug administrations, according to a 2018 hospital study

(Source: BMJ Quality and Safety)

Measures such as the wearing of a colour-coded sash or tabard have been shown to reduce interruptions and may be helpful in reducing calculation mistakes.

Double-checking drug calculations can also help prevent errors – but there are provisos, says Professor Griffiths.

‘True independent checking is vital,’ he says. And that means two nurses doing the maths entirely separately.

‘I don’t stand next to you and just agree with you,’ he says. ‘Although that does very often happen.’

And he cautions against an incorrect calculation being rubber-stamped simply because the nurse whose calculations are being verified is more senior than the checker.

‘If I was doing the calculation with a student nurse, are they going to question my maths because I’m a professor and they’re a student nurse?

‘Probably not, but actually we need them to. We need them to do the calculation on their own and then come together with me and I put down my results, they put down theirs, and we see if the two tally.’

Second-checking can compound mistakes, so nurses’ confidence to speak up is key

Ms Game agrees that having a second nurse acting as ‘checker’ is not necessarily the safety net it might appear.

‘What we’re finding is that the second checker can lead to more mistakes.

‘If you’re working with a second checker who’s very confident with maths and who says this child needs 7.5mls but you’re not confident, you may just agree with them because you think they’re not going to be wrong, “they’re amazing at maths, so it must be me”.’

Safe practice is therefore also about nurses having the self-assurance to speak up when the checker’s calculations don’t tally.

‘Don’t just assume it’s you who is wrong,’ Ms Game advises.

Answers to calculation skills test

1. 0.15ml

2. 21 tablets

3. 12 x 15 = 180mg so 180 ÷ 100 x 10 = 18ml

Further reading


Related articles

RCNiLearning modules to help you develop your maths skills


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