A psychometric appraisal of a revised preparedness for medication administration questionnaire in final-year undergraduate nursing students: a secondary analysis

Safe Medication administration is a fundamental requirement of nursing practice once a student graduates and is required to practice unsupervised. Medication errors are a global concern as they can result in adverse health events, including death [1]. A systematic review conducted by Anseni-Vicenti and colleagues on medical errors in nursing students reported that medication errors by nursing students were as high as 32% and that errors are underreported [2]. To optimise health outcomes, students must be well-prepared for the important skill of medication administration as a graduate nurse. However, international reports indicate this may not be the case [3]. Education is an important factor in preparedness for medication administration, including error prevention and recognition [3‐5].

In the final year of a nursing course, students must address the forthcoming transition from nursing student to graduate nurse. Students must be prepared for the transference of medication administration (pharmacology knowledge and clinical skills) to clinical practice. Reports indicate that students have mixed feelings about being prepared for their role after graduation [6]. Students may question their knowledge and confidence in meeting the demands of the registered nurse role [7, 8]. These self-perceptions are important to identify and understand students' preparedness for medication administration and to assist in developing educational strategies to address these issues [9]. A sound, reliable instrument that captures and measures these areas of concern is crucial to understanding nursing students' preparedness for medication administration before graduation.

While measures associated with the measurement of medication errors exist, Fuster-Linares et al. established that few instruments measure self-perceptions of competence [10]. One tool used internationally is the 'The Preparedness for Oral Medication Administration Questionnaire'. This tool originated from a 13-item competency-based assessment tool developed by Fisher and Parolin to measure student nurses' clinical performance [11]. Aggar and Dawson modified the questionnaire to 17 items to assess undergraduate nursing students' perception of preparedness for oral administration of medications [12] and the tool has been used in Australia [13] and Ireland [14].

A mixed-method study conducted by Irvine et al. [15] revised the Aggar and Dawson (ref) Preparedness for Oral Medication questionnaire. The revision included three additional questions to reflect changes to the registration requirements for nurses in Australia [16] and New Zealand [17]. Additionally, in line with concerns about the tool's focus on oral medication [10], the tool was revised by Irvine and colleagues [15], to be used for any route of medication administration with the word ‘oral’ removed from the questionnaire titled ‘Preparedness for Medication Administration(Revised)’. The 20-item questionnaire was used to explore undergraduate nursing students in the final unit of the degree and their perceived preparedness to administer medications once they graduate.

The reliability of the Aggar & Dawson questionnaire has consistently demonstrated strong internal reliability and consistency, with Cronbach's alpha coefficient, of 0.70 [11], 0.89 [12], 0.91[18] and as has the revised version 0.96 [15]. Although these studies have reported good internal reliability, no studies could be located examining the factor structure or dimensionality of the questionnaire. Therefore, this study aims to examine the psychometric properties of the Preparedness for Medication Administration (Revised).

This study aimed to examine the psychometric properties of the 20-item Preparedness for Medication Administration (Revised) questionnaire. The questionnaire was constructed based on nursing competency standards [16, 17]. Items were selected and redacted to reflect further the preparedness for administering medications in the competency framework for practising registered nurses across the two countries involved in the primary study [15]. According to Field [27], after the deletion of items, a rerun of the EFA is required to check that the factor structure still holds, and this was the case in this study after the removal of the four items. Interestingly, of the three items added to the revised questionnaire, two were deleted, Q19 I feel confident to safely administer medications, Q20 I am competent to safely administer medications). A possible reason for this may be that students in this study may have perceived Q19 and Q20 as similar. Q18, although retained, was poorly represented. The EFA has captured the relevant information, and although the additional questions were used to reflect the changes to the registration requirements for nurses in Australia and New Zealand, the modified registration requirements are well reflected in the EFA even after the items are deleted. Although the questionnaire was reliable, it emphasises the need for psychometric testing on revised questionnaires to ensure sound construct validity.

Twelve factors loaded onto Factor 1 and were labelled Clinical Reasoning, with loadings ranging from 0.65 to 0. 97 for Items 12, 15, 14, 13, 17, 16, 11, 6, 10, and 9, see Table 1. The highest loading was item 12; I have the ability to communicate effectively with individuals of the healthcare team.

The items loaded in factor 1 require the nurse to integrate knowledge, skills, and judgement, which would, therefore, be visible in the nurses' clinical reasoning [29]. Benner et al. defines clinical reasoning as "the ability to reason about a clinical situation as it unfolds, as well as about patient and family concerns and context" [30] p46. The process of clinical reasoning depends on a critical thinking disposition [31] and a critical cognitive process that nurses engage in to make informed and safe decisions when administering medication [32, 33]. The development of clinical reasoning requires deeper learning whereby students must integrate multiple components involved in the practice, including patient assessment, applying foundational knowledge, planning and administering medications safely, evaluating patients' responses to medications and educating patients about their medications [33, 34].

Students in this study perceived they could integrate knowledge into practice by questioning interventions that appear inappropriate (Q11), clarifying unclear instructions (Q10), and effectively communicating these matters with members of the healthcare team (Q12). These communication-based competencies would enhance patient safety, reduce the risk of adverse events, and contribute to effective healthcare delivery [33]. According to the outcome of an integrative review, there is insufficient evidence of nurses' clinical reasoning in the safe administration of medications [34], highlighting the need to assess the clinical reasoning skills of final-year nursing students when administering medications [34]. This also highlights the need for a reliable and valid questionnaire to ensure students are confident and prepared to administer medications before graduation.

Six factors were loaded into Factor 2 and labelled Confidence to Practice Safely. The loadings ranged between 0.89–0.48 (items 5, 3, 2, 4, 18, 1, see Table 1); with item 5, I am able to provide medication education by integrating theory and practice having the highest loading. Nurses play a crucial role in health literacy, including educating patients about their medications. Effective patient education requires a comprehensive understanding of the medication profile, including its purpose, potential side effects, and how to take it properly [35]. This role includes educating patients and families about medication management [35]. It is essential that students feel prepared and confident about teaching health literacy, as they are expected to undertake this role as graduate nurses [36].

Students perceived they were confident in the areas of practice, indicating that these students may perform well once they graduate because higher confidence is linked positively to performance [37]. Furthermore, items related to pharmacology knowledge (item 5), availability of learning opportunities (item 3) and clinical supervision (item 4) are known to facilitate the development of confidence, including in medication administration [38].

Perceptions do not always align with reality because confidence in student preparedness and knowledge can be displaced. [38], highlighting the need for real-time studies. Given that numerous international reports highlight errors associated with medication administration in student nurses [2, 3, 39], there is an urgent need to review teaching strategies [39]. Furthermore, to ensure comprehensive medication education and assessments are integrated throughout the nursing curriculum [15].

This research provides important information for a psychometrically sound tool to assess undergraduate nursing students' preparedness for medication administration. Knowing the construct validity, dimensionality and reliability of a tool to assess students' preparedness for medication administration is essential for curriculum development, measurement and other research purposes.