Assessing self-perceptions related to safe medication management among nursing students: an analytical cross-sectional study in Iran

What is the level of self-perceived competence among nursing students in safe medication management?

How do socio-demographic factors influence their perceptions?

An analytical cross-sectional study was conducted on nursing students at Ardabil University of Medical Sciences, northwest Iran, from June to August 2023.

This study focused on nursing students from three nursing schools—Ardabil, Meshgin, and Germi—affiliated with Ardabil University of Medical Sciences in Iran. These three centers were selected based on the Ardabil University of Medical Sciences having three nursing schools with the names mentioned. To participate in the study, candidates must meet specific criteria: they must have completed at least one clinical internship (excluding practical and laboratory units), possess theoretical knowledge of drug management, have practical experience in a healthcare setting, and provide voluntary consent to participate. First-year nursing students were excluded from the study as they had not yet completed the hospital internship and lacked familiarity with self-perceptions related to safe medication management. Additionally, students were excluded if they did not complete the questionnaire or indicated they did not wish to participate.

After obtaining the necessary permissions from the Research Deputy, responsible for overseeing all research activities at Ardabil University of Medical Sciences, a list of eligible students was compiled from the relevant centers. In total, 350 students were identified as meeting the criteria. Using Epi Info StatCalc version 7 (with a confidence interval of 95%, a margin of error of 0.05, and a total population of 523), a sample size of 221 was calculated. Considering an anticipated non-response rate of 20%, the sample size for the study was increased to 265 participants. This adjustment ensures that the final data remains statistically valid and accurately reflects the target population.

The number of participants from each nursing institution was allocated based on the proportion of students enrolled across different academic years. Specifically, Ardabil Nursing and Midwifery School, with its larger student population, contributed 215 students to the sample. Germi Nursing School, which has a smaller academic cohort, provided 30 students, while Meshgin Nursing School contributed 25 students to the overall sample. This proportional distribution of participants is essential for achieving a representative sample from each institution involved in the study. Data collection primarily took place after classes or during students’ free time to minimize disruptions to their academic schedules. Participants were randomly selected from each academic year, resulting in a final sample size 253. Throughout the data collection process, potential challenges faced by participants, such as time constraints or discomfort in answering questions, were closely monitored. Additionally, significant efforts were made to mitigate researcher bias by ensuring neutrality in data collection, thereby preserving the integrity of the study and instilling confidence in its objectivity.

We collected data from a demographic information form and the Nursing Students’ Self-Perceptions about Safe Medication Management (NURSPeM) questionnaire [10]. NURSPeM is designed to assess nursing students’ self-perceptions about safe medication management. It is a self-report instrument comprising two questionnaires: self-perceptions about safe medication management and the frequency and practice of drug dose calculation questionnaire. Participants completed the questionnaires on their own.

Based on our study, the average self-perception score for safe medication management was 57.65, with scores ranging from 31 to 96. The creators of the questionnaire provided only psychometric results and did not include descriptive statistics (such as means and standard deviations) for the dimensions of the questionnaire. Consequently, we were unable to make direct comparisons with their findings. Instead, we compared our results with those obtained from other assessment tools in the field. For instance, Fernandez et al. utilized a different assessment tool to measure students’ behavioral attitudes toward safe drug management, revealing moderate levels of awareness [7]. Conversely, Fusco et al. employed a competency-based assessment, which indicated that students demonstrated acceptable medication safety skills [9]. Similarly, Rezaie et al. used another instrument that showed students exhibited average skills in certain aspects of medication management while demonstrating weaknesses in others [21].

Our study indicates that nursing students in Iran may need to assume full responsibility for drug safety, which could result in a lower level of competence in safe medication management compared to newly graduated nurses [7, 22]. There is an urgent need for new educational programs that emphasize safe medication management, specifically focusing on the responsibilities of nursing students to ensure drug safety and protect patient health. Furthermore, it is crucial to acknowledge that the tool developed by Fuster-Linares et al. has not been implemented in other countries, which limits the generalizability of our findings and complicates international comparisons. Future research should seek to employ standardized tools across different contexts to facilitate more meaningful comparisons of nursing students’ competencies in safe medication management.

According to our study, the score for safety in drug prescription is 9.06 (with a score range of 0 to 16). This score reflects familiarity with drug doses, injection methods, and related concepts. A study by Sabzevari et al. [23] found that students’ knowledge of drug therapy was moderate. The study also highlighted that medication errors often occur during the drug-prescribing stage. Our findings differ from the Rezaie et al. study [21]. In a study of nursing students in Taiwan, 71% had prior experience with drug prescribing but reported low competence and high stress. Disagreement with drug prescribing responsibilities was linked to perceived competence. The study recommended implementing educational programs and guidelines at the university level to increase competence and reduce stress in drug prescription [24]. Nursing is a scientific profession that prioritizes patient care based on evidence. Nursing students must stay updated on new evidence, recommendations, and practices related to medication and management [25]. They should be familiar with medication management goals and safe practices.

The “familiarity with pharmacological concepts” was 8.65 (with a score range of 2 to 16). In the study by Caboral-Stevens et al. [26], 60% of nursing students were familiar with pharmacological concepts. However, in the survey by Hosseini et al. [27], students who underwent pharmacology simulation training had a higher level of knowledge. Insufficient pharmacological knowledge is recognized as one of the human factors related to medication errors. In addition, lack of knowledge and skills, poor experience, excessive fatigue, disregard for hospital protocols, and lack of time can lead to medication errors [4]. Our study suggests that nursing students may need more exposure to pharmacological concepts due to inadequate skill acquisition and experience. Pharmacology simulation training can help students gain the necessary knowledge and skills, ultimately reducing medication errors.

Our study indicates that the “relevance of professional practice” is 2.24 (with a score of 0.6 to 4). Nursing is crucial in this area, as nurses manage and monitor drug therapy. Specialists need to have more knowledge and commitment, particularly when it comes to administering drugs to children. The lack of quality in this process leads to instability and subsequent occurrence of undesirable events that can be avoided with preventive management interventions such as proper training [28]. Interprofessional education is proposed to influence nursing students’ attitudes and strengthen communication, collaboration, and drug safety. Implementing interprofessional education programs can play an essential role in improving the attitudes of students toward drug management and their perceived behavioral control related to safe drug management [7]. Professional practice can enhance nursing students’ attitudes toward medication management and their perceived ability to control behavior and improve communication, collaboration, and medication safety.

The factors linked with the “risk of making an error” were 8.20 (with a score range of 3 to 12). Factors such as drug reconciliation at admission and discharge, computerized physician order entry, identification of patient medications with barcodes, and reduction of nursing hours are among the factors that can effectively reduce medication errors [29]. Medication administration is complex and requires nurses to have precise knowledge and skills to prevent mistakes [7]. However, medication errors can occur due to inefficient medication management systems, environmental conditions such as noise, staff shortages, and other human-related factors such as drug knowledge, attention, lack of focus on work, and fatigue [30]. Hospitals can implement medication reconciliation, computerized provider order entry, and barcode scanning for patient medications to reduce medication errors.

The “importance of administering medication according to the prescription” was 11.88 (with a score range of 4 to 16). It is crucial to ensure the safety of patients when prescribing and receiving medication by nursing students. It must be confirmed that the prescribed medication matches the name of the medication managed by the physician [31]. Brand and generic terms may have similar prefixes, suffixes, initial letters, spellings, or similar sounds. Therefore, it is essential to differentiate between medications with similar names, as they may have different mechanisms of action or indications for prescribing [32]. Nursing students must accurately and promptly manage patients’ medications to ensure patient safety. Proper education on medication management is crucial for improving healthcare quality.

The “Verifications before drug administration” was reported at 6.48 (with a score of 1 to 12). Medication management is the nurse’s responsibility, which takes up about 40% of their time. Nurses perform the final safety check in the medication chain and are the last line of patient safety [24, 33]. Medical literature states that about one-third of all medical errors that harm hospitalized patients occur primarily in nursing activities, during the preparation and prescribing of medication [34]. Therefore, nursing students should have the necessary skills to reduce medication errors by examining the management of the clinical environment in which they work [31].

The “thinking process about medication management” was 11.13 (with a score range of 4 to 20). The thinking process includes stages such as drug preparation, drug administration, monitoring the drug’s effect, considering the patient’s condition, collecting and transferring information to the patient, reading the physician’s orders, following the drug dosage plan, and educating patients about treatment. This process requires sufficient knowledge and experience in medicine and pharmacy, and failure to adhere to it may lead to serious side effects for the patient [10]. It is said that safe drug management and prescription require more than five rights and drug management to prevent costly mistakes. Literature gradually shows more evidence that new efforts to maintain safety should highlight nurses’ clinical reasoning as an element that shapes nurses into highly skilled professionals [31]. Also, understanding students’ thinking processes during drug prescriptions is very important for preventing medication errors. Nursing education programs should correct any misconceptions or errors in students’ thinking before prescribing drugs to patients [31].

The average score for the second questionnaire, “Frequency and learning of drug dose calculation,” was 31.62 (with a range of 12–52). In the Hosseini et al. [27] study, students had an average level of medication calculations before undergoing simulation-based training. However, their medication calculation skills improved significantly after the simulation-based training course. In the Rezaie et al. [21] study, most students needed better skills in accurate medication calculation. Many medication errors occur due to a need for an understanding of drug concentrations, particularly when drugs are calculated in different ways. Errors can also arise from miscalculating the required medication dosage, students’ difficulty with mathematical calculations involving decimals and fractions, or their inability to extract conceptual information from medication dosage calculations. These issues can be influenced by insufficient education. Increasing awareness can increase accuracy in medication dosage calculation and improve safe drug management. Utilizing necessary education and awareness in medication calculations at the beginning of nursing education is of great importance so that students can benefit from it until the end of their professional careers. Therefore, nursing instructors should pay more attention to educating students about accurate medication dosage calculations.

The results of multiple regression revealed that among nursing students, an increase in overall GPA and having work experience in a hospital were associated with improved Self-perception in safe drug management and increased ability in drug dosage calculation and repetition. Additionally, an increase in age was related to improved Self-perception in safe drug management. In other words, younger nursing students with a higher overall GPA and work experience in a hospital as a student likely have better skills in safe drug management and drug dosage calculation and repetition. Previous studies have identified factors such as students’ age and previous academic success (such as high GPA) as individual factors related to nursing students’ drug calculation competence [11]. According to Gunes et al., graduate nurses have more clinical experience in prescribing, rewriting, distributing, prescribing, and monitoring drugs than final-year nursing students [35]. Therefore, the increase in medication errors by nursing students has been attributed to a need for clinical experience, knowledge, and skills [7]. Wendimeneh et al. conducted a study that found that nurses with more experience exhibited better medication management practices. These findings are consistent with our research. As individuals gain more work experience, they develop additional skills for safe drug management and become more knowledgeable about a broader range of medications, as reflected in our study’s findings [33]. Therefore, to enhance the skills of nursing students in safe drug management, they need to gain more work experience to improve their knowledge and expertise in this area.

The academic year in our study showed a positive correlation with self-perception of safe drug management and increased ability in drug dosage calculation, which was consistent with the study by Sulosaari et al. [36]. Therefore, the significant and positive relationship between academic year and Self-perception of safe drug management in nursing students indicates that students develop better abilities in safe drug management and properly implement related methods over time and progression in their education. However, the results of studies may vary based on different conditions and factors and should be further examined with greater scrutiny.