Background
The health care system in Iran has moved towards implementing clinical governance like other health care systems at the international level since 2009 to ensure that health care is provided to members of the community with the highest possible standards of care and guarantees patient safety [1]. In a system based on clinical governance, patients and, in fact, clients of the health care system are at the heart of the care process, so efforts are made to provide the community with high-quality services according to the desired principles to improve work standards [2]. The health system based on clinical governance has seven important axes (including patient and community participation, information use, education and learning, clinical effectiveness, clinical audit, and risk management). In the field of risk management, medication errors are a major concern and a global issue related to patient care safety [3].
Types of medication errors include prescription errors, drug injection errors, distribution errors, and patient compliance errors, which can occur due to the lack of experience or knowledge about the drug, failure to use the basic rules, misspellings of the drug name, and ignorance of important information such as the patient's allergies [1].
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The National Health Service (NHS) of England estimates that medication errors account for about 20% of drug-related deaths [4]. It can also be claimed that 61% of life-threatening errors are related to intravenous drugs [5, 6]. Studies in the United Kingdom and the United States confirm that nurses make 13% -84% mistakes in the preparation and use of intravenous drugs annually [7]. However, cytotoxic drugs, Total Parenteral Nutrition (TPN), and drugs needed to relieve acute pain are provided separately by pharmacists [8]. However, in many countries, such as Iran, the preparation and injection of intravenous drugs is the responsibility of nurses [9].
In some studies, many medication errors have been associated with the lack of medication knowledge, the lack of appropriate skills in prescribing medication [10, 11]. Besides, other studies have mentioned failure to communicate and follow clinical policies and guidelines as the main causes of medication errors in addition to the lack of knowledge and skills [12, 13]. Low quality and errors in the preparation and administration of intravenous drugs among health professionals are strategic issues that reduce the quality of health care in general [14]. Moreover, it can lead to adverse consequences, such as endangering patients' health, increasing health care costs, and even death. However, children are more at risk of medication errors than adults. Because the ability to communicate is limited in children, especially younger ages. Further, the lack of sufficient information for the preparation and injection of medicine for children by the drug manufacturer can lead to medication errors [15]. Therefore, the quality of this process is crucial in providing safe patient care, and there must be continuous efforts to improve it [16]. Regarding the safe application of intravenous drugs, health care providers need to have sufficient knowledge and skills, while continuous participation in training programs can increase the knowledge and awareness of nurses [17, 18]. There is no comprehensive pediatric study that reflects the current situation to be used for quality improvement planning. Therefore, this study aimed to determine the level of knowledge and performance of nurses in terms of preparation and injection of intravenous drugs in pediatric wards of hospitals affiliated to Isfahan University of Medical Sciences.
Methods
Design and participants
This cross-sectional study was performed over a 6-month period in the pediatric wards of hospitals affiliated to Isfahan University of Medical Sciences. To conduct the study, the hospitals affiliated to Isfahan University of Medical Sciences were referred Sampling was performed by census method among individuals with inclusion criteria. Overall, 300 nurses were working in the study wards, of whom 160 met the inclusion criteria. Inclusion criteria were at least 6 months of work experience in pediatric wards regardless of status or shift, working in pediatric emergency departments, pediatric internal medicine, intensive care and pediatric surgeryExclusion criteria were unwillingness to participate in the study, absence from the hospital during the study period due to annual leave or childbirth, and a distorted and invalid questionnaire.
Data collections
A questionnaire of pharmacological knowledge was distributed among the participants at the beginning of the morning, evening and night shift after obtaining writing consent, by a member of the research team, and the nurses had the opportunity to answer the questionnaires until the end of the shift. Questionnaires were collected at the end of the shift, leading to 156 valid and 4 invalid questionnaires. The performance of nurses was observed using the observation method, which was carried out in three medication situations to complete the observation checklist of performance and the average of three observations as the overall performance score.
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Research tools
The study tool comprised three parts: the first part of the questionnaire included demographic information, such as gender, education, age, ward, work experience, type of employment, job satisfaction and working hours per month, which were completed by self-report by nurses.
In order to prepare the questionnaire, the ward nurses were first asked to raise questions in five areas of documentation, drug preparation, drug injection, drug side effects, and medication error to evaluate their staff drug knowledge. Then, their opinions were collected and questions were reviewed and categorized with scientific sources [19, 20]. Formal and content validity was determined using the opinions of 10 experts (three pediatric nursing professors, one clinical pharmacist, two pediatric medical professors, and four senior nursing experts) (CVI = 0.8 and CVR = 0.8). Cronbach's alpha was performed with 40 samples (0.735) for instrument reliability, while HTMT was also calculated for divergent validity of the structure (0.4).
The pharmacological Knowledge Questionnaire consisted of 20 questions classified into five areas of preparation and injection (nine statements), family empowerment (four statements), documentation (two statements), drug side effects (three statements), and medication error (two statements). The answers to the questions were in the form of a four-point Likert scale (correct, I do not know, and 2 false answers). The scores ranged from 0 to100 for ease of data analysis. The total score of the questionnaire was defined as good, acceptable, poor, and unacceptable for scores of > 90, 75–90, 50–75, and < 50, respectively. These statements had quantitative nature.
A 20-item checklist was used to evaluate pharmacological performance. This checklist consists of five areas of preparation and injection (nine statements), family empowerment (four statements), documentation (two statements), drug side effects (three statements), and medication error (two statements). The performance was observed by a research team member and completed the three-point Likert scale (It is done right, it is done in completely, it is done wrong). The checklist reliability was measured by the agreement coefficient of two observers in 10 drug positions (r = 0.8). The performance of each nurse was observed in three situations and the average of three observations was recorded as the performance of each person. The scores ranged from 0 to100 for ease of data analysis, respectively.
Statistical analyze
The collected data were statistically analyzed by SPSS VER 16 software by using KS, independent t-test, Chi-square, One-Way ANOVA, Pearson and Spearman. Furthermore, the open-ended questions were considered to gain a general understanding of the nurses' point of view. After summarizing the descriptive answers, they were examined for accuracy and analyzed using content analysis.
Results
A total of 160 questionnaires were distributed among nurses, 156 of which were accepted for the study. Women made up 96% of study participants. The mean age of nurses participating in the study was 32.29 + 4.09 years old, and the average work experience of staff was 12.6 + 3.12. Regarding the level of education, 88% of the participants had a bachelor's degree, and 12% had a master's degree in nursing. Job satisfaction among nurses was on average 68.5%, but no significant difference was observed between nurses working in pediatric wards.
The mean and standard deviation of total nurses' knowledge scores were 58.31 + 10.1, respectively. Additionally, the mean and standard deviation of nurses' knowledge scores were 63.55 + 14.3 for documentation, 46.1 + 7.9 for preparation and injection, 73.9 + 12.3 for drug side effects, 58.4 + 10.2 for medication error, and 69.4 + 9.4 for family empowerment. The mean score of pharmacological knowledge of different pediatric wards examined in this study included pediatric surgery ward (62.31 + 7.52), pediatric internal ward (57.31 + 3.31), pediatric emergency department (60.97 + 4.74), and pediatric intensive care unit (56.67 + 3.62). There was a significant difference in the analysis of the results (p < 0.05). Table 1 shows the results of the statistical analysis of data in different areas of pharmacological knowledge.
Table 1
Comparison of the average score of nurses' pharmacological knowledge in different areas of pharmacological knowledge
Scope of pharmacological knowledge | Internal | Surgery | Emergency | PICU | ||
|---|---|---|---|---|---|---|
P* | ||||||
Mean (SD) | ||||||
Preparation and injection | Drug compatibility | 43.6(6.9) | 40.1(8.2) | 53.8(8.6) | 48.8(9.2) | .079 |
Storage of prepared drugs | 50.0(7.9) | 35.2(7.3) | 32.3(8.2) | 24.4(8.2) | .000 | |
dilution of drugs | 53.8(5.8) | 40.7(6.9) | 48.4(8.8) | 52.9(9.1) | .115 | |
Duration of injection | 44.9(6.4) | 51.8(9.5) | 69.9(8.7) | 48.9(7.2) | .000 | |
Medication Error Knowledge | Medication error report | 44.5(12.3) | 38.4(8.1) | 50.0(8.6) | 41.1(11.6) | 0.196 |
Medication error detection | 80.1(10.2) | 76.2(11.6) | 64.9(9.2) | 72.2(10.3) | 0.006 | |
Knowledge of drug side effects | Identification of drug side effects | 76.9(11.2) | 75.8(12.6) | 82.7(13.2) | 72.8(12.4) | .275 |
Report of drug side effects | 78.9(12) | 70.8(11.3) | 60.8(11.6) | 72.2(14.3) | .275 | |
Family empowerment | Knowledge of home care | 77.9(9) | 79.6(8.2) | 64.5(10.8) | 55.6(9.4) | .013 |
Documentation | 60.1(12.2) | 66.1(18) | 65(15.3) | 63(11.7) | 0.23 | |
Mean of total knowledge | 61.1(9.4) | 57.5(10.2) | 59.3(10.3) | 55.2(10.3) | 0.000 | |
Accordingly, as shown in Table 2, only 16.1% of emergency department nurses, 34.6% of pediatric surgical nurses, 6.7% of intensive care unit nurses and 13% of pediatric intensive care unit nurses were within an acceptable range, and the rest of them (84.5%) got a lower-than-expected knowledge score (poor and unacceptable) (Table 2).
Table 2
Comparison of knowledge levels in different pediatric wards
Knowledge levels | ||||||
|---|---|---|---|---|---|---|
Unacceptable (< 50) | Poor (50–75) | Acceptable (75 -90) | Good (> 90) | |||
Pediatric surgery | Frequency | 9 | 8 | 8 | 1 | p* |
% | 34.6% | 30.8% | 30.8% | 3.8% | .000 | |
Pediatrics internal | Frequency | 11 | 36 | 6 | 1 | |
% | 20.4% | 66.7% | 11.1% | 1.9% | ||
Pediatric Emergency | Frequency | 3 | 23 | 5 | 0 | |
% | 9.7% | 74.2% | 16.1% | 0.0% | ||
PICU | Frequency | 11 | 31 | 3 | 0 | |
% | 24.4% | 68.9% | 6.7% | 0.0% | ||
Total | Frequency | 34 | 98 | 22 | 2 | |
% | 21.7% | 62.8% | 14.1% | 1.2% | ||
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The mean and standard deviation of total nurses' performance scores was 66.1 + 14.4, respectively. In addition, the mean performance was 69.1 + 17.6 for documentation, 61.3 ± 9.9 for preparation and injection, 78.21 + 12 for drug side effects, 58.6 + 15 for medication error, and 65.4 + 17.7 for family empowerment. Analysis of statistical results showed that the performance of nurses in different areas of drug administration was significantly different (P > 0.001). The best performance among nurses in the pediatric internal ward had a mean (SD) of 71 (14.3), and the worst performance was related to the pediatric surgical ward with a mean (SD) of 62 (12.9) (Table 3).
Table 3
Comparison of the average performance of nurses in different areas of medicine in different clinical wards
Scope of pharmacological performance | Internal pediatrics | Pediatric surgery | Emergency | PICU | ||
|---|---|---|---|---|---|---|
P* | ||||||
Mean (SD) | ||||||
Preparation and injection | Drug compatibility | 62(11.7) | 49.3(13.9) | 61.3(14.3) | 48.8(12.9) | .003 |
Storage of prepared drugs | 54.1(16.5) | 35.2(12.3) | 42.3(16.2) | 53.4(12.6) | 0.004 | |
dilution of drugs | 72.2(15.6) | 61.5(11.1) | 77.2(13.9) | 64.4(18.1) | .0160 | |
Duration of injection | 79.6(12.8) | 69.3(11.1) | 67.4(17.9) | 82.3(8.5) | .0820 | |
Medication Error | Prevention of drug microbial resistance | 48.2(16.1) | 45.9(13.1) | 80.81(18.6) | 42.2(13.2) | .0050 |
Medication error prevention | 79.6(11.9) | 75.9(12.8) | 83.8(17.9) | 82.2(18.6) | .4080 | |
Drug preparation | 41.3(16.9) | 38.2(13.9) | 48.6(14.6) | 36.3(12.3) | .2900 | |
Drug side effects | Identification of drug side effects | 86.9(10.1) | 78.78(2.6) | 75.28(9.6) | 86.6(16.2) | .3330 |
Report of drug side effects | 33.9(12.3) | 30.7(16.1) | 48.8(15.3) | 32.2(13.9) | 0.001 | |
Family empowerment | Education and family empowerment | 74.1(7.4) | 62(29.4) | 58(25.5) | 67.6(8.6) | .340 |
Documentation | 78(26.1) | 73(15.1) | 61.3(13.1) | 64.1(16.2) | 0.001 | |
Mean of total performance | 71(14.3) | 62(12.9) | 66.3(16.1) | 65(8.1) | 0.001 | |
Analysis of the findings showed a weak and direct correlation between drug knowledge and performance (p < 0.05, r = 0.128). Besides, there was a significant correlation between shift work and knowledge (r = 0.325) and drug performance (r = 0.248). Moreover, there was a weak correlation between job satisfaction and drug knowledge (r = 0.163). Contrary to expectations, the observations showed an inverse correlation between work experience and knowledge (r = -0.306) and drug performance (r = -0.232) (Table 4).
Table 4
Assessing the relationship between nurses' mean performance score and medication knowledge score, job satisfaction, working hours per month, education, work experience
Work Experience | Job Satisfaction | Working hours per month | Mean pharmacological Knowledge Score | ||
|---|---|---|---|---|---|
Job satisfaction | Correlation | .074 | 1 | ||
p | .217 | ||||
N | 156 | 156 | |||
Working hours per month | Correlation | -.788** | -.029 | 1 | |
p | .000 | .635 | |||
N | 156 | 156 | 156 | ||
Mean pharmacological knowledge Score | Correlation | -.306** | .163** | .325** | 1 |
p | .000 | .007 | .000 | ||
N | 156 | 156 | 156 | 156 | |
Mean performance score | Correlation | -.232** | .055 | .248** | .128* |
p | .000 | .361 | .000 | .027 | |
N | 156 | 156 | 156 | 156 | |
Discussion
The aim of this study was to determine the knowledge and performance of nurses regarding the preparation and injection of intravenous drugs. According to the results of the present study, 84.5% of the participants in the study had a lower-than-expected knowledge (poor and unacceptable) in this test, indicating insufficient knowledge. Ashtiani et al. examined the pharmacological knowledge of heart hospital nurses using a questionnaire of nurses 'pharmacological knowledge in the fields of drug mechanism, drug side effects and nursing care. The results showed that nurses' knowledge was at an average level [21]. Unlike the present study, which examined only the pharmacological knowledge of pediatric public hospital nurses, they also examined the pharmacological knowledge between public and private nurses, which, although did not show a significant difference, in future studies, it seems that more attention will be paid to private sector nurses in this field.
Moreover, Salehifar et al. surveyed nurses in the field of knowledge, attitude and practice about the side effects of drugs and their reporting with a standard questionnaire of the Pharmacovigilance Research Group in Europe. The results of their study showed that most participants do not have sufficient knowledge in the field of drug monitoring and often provide incomplete definitions. Therefore, it seems that nurses' pharmacological knowledge in various fields suffers from several shortcomings [22]. Therefore, it can be acknowledged that measures to improve nurses' knowledge should be one of the important goals in healthcare because the results of several studies in different geographical locations in the country show weak to moderate medical knowledge of nurses.
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Another study conducted in South India to examine the knowledge, attitude and practice of nurses' pharmacovigilance towards the reporting of drug side effects showed that most participants showed good knowledge and knowledge in this field. However, the transfer of knowledge to practice was not enough [23].
A study conducted at a university hospital in Rome to assess the knowledge, educational needs, behavior and attitudes of nurses about medication errors and the steps of intravenous drug administration showed that the samples had good knowledge, positive attitude and correct behavior related to the preparation and administration of intravenous drugs [24].
The study of studies abroad and at the home of the study of pharmacological knowledge of nurses at different levels showed that it seems that in order to improve the quality of health care and ensure the safety of patients, more investment should be made in training programs for nurses and promoting their knowledge and adequate knowledge of medical errors and prevention of special tools.
In addition to the above, only 7% of the participants had good pharmacological knowledge. In the study conducted by Arshadi et al., the level of knowledge of nurses was moderate. The reason for the difference in the results of these two studies could be the sampling context because Arshadi et al. studied the neonatal intensive care unit. The results of the study conducted by Khajeh Ali et al. showed that approximately 50% of nurses working in intensive care units and 33% of nurses in general wards were good at recognizing and using drugs and medication computing skills, which is not consistent with the present study probably due to the number of nurses participating in that study, the questionnaire used, etc.
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The results of the present study showed that only 16.1% of emergency department nurses, 34.6% of pediatric surgical nurses, 6.7% of intensive care unit nurses, and 13% of pediatric intensive care unit nurses had an acceptable and good response, and the rest had lower knowledge scores (weak and unacceptable). Contrary to the present study, Ashtiani et al. and Khajeh Ali et al. reported higher drug knowledge scores for the nurses in the intensive care unit compared to those in general wards [21, 25]. This difference in the results may be due to the different number or work experience of nurses in these two studies.
According to the results, the nurses had weak or even unacceptable knowledge about the preparation and injection of drugs in all wards. Ashtiani et al. showed that nurses had moderate knowledge about drug side effects and nurse care in the field of pharmacological mechanisms; however, they had good knowledge about the preparation and injection of drugs. Therefore, there is a need to train nurses in the field of pharmacological retraining and especially how to prepare and inject drugs.
In addition, the findings of this study demonstrated a significant relationship between job satisfaction and the number of shifts and a significant inverse relationship between work experience and performance and medication knowledge. The results of studies conducted by Ashtiani regarding experience and shift work and drug knowledge of nurses and the study performed by Haji Babaei showed no significant differences between age and medication errors [21, 26]. Studies by Ito et al. and Sheu et al. have revealed that work experience further reduces medication errors [27, 28].
This indicates that the accuracy of medication calculations and drug knowledge decreases with the increase in nurses' experience, which is probably because newly graduated nurses remember much information while this is not true about experienced nurses, necessitating in-service training [25].
Considering that medication errors have become one of the most significant problems affecting patient safety in hospitals today, and given the large percentage of people with low drug knowledge in pediatric wards as shown in the present study, those involved in education in hospitals and the officials of the relevant committees are expected to provide continuous training courses and familiarize clinical staff with pharmacovigilance. Further, it is necessary to provide the necessary facilities for nurses to access information about drug complications and interactions while providing access to clinical pharmacologists in pediatric wards as well. Besides, based on the findings and the high sensitivity of working with children, it is recommended to use nurses with the necessary pharmacological knowledge in the workforce to prevent the occurrence of drug side effects in pediatric wards.
Conclution
Overall, the nurses in this study had a moderate and below-average level of knowledge in the preparation and administration of intravenous drugs. Besides, their performance in different areas of medicine was at an average and below-average level. In addition, this study showed that the experience of nurses had no effects on the level of knowledge of these nurses in the preparation and injection of drugs and was only helpful in identifying the side effects of drugs.
Nurses' training should place more emphasis on these skills, and nursing education programs should provide more hours to calculate and understand the various areas of intravenous methods and drug safety issues. The participation of clinical pharmacists in nursing education programs in various areas related to intravenous drugs will be beneficial.
Limitation
This study had some limitations, and the results may not necessarily reflect the knowledge status of all nurses working in pediatric wards. Knowledge measurement questions (only 20 items in the questionnaire) were very few and did not cover different aspects of injectable drugs such as drug interactions, pre-, intra-, and post-injection care and drug reaction treatment.The presence of an observer in the research field and observing the behavior of nurses could lead to the Hawthorne effect, which was tried to reduce with a long-term presence.
Acknowledgements
The researchers would like to thank the Research Center of the School of Nursing and Midwifery of Isfahan University of Medical Sciences, as well as the esteemed nursing colleagues, the head nurses, and nursing managers who collaborated in conducting this research
Declarations
Ethics approval and consent to participate
All the methodes of this research were carried out in accordance with the relevant guidelines and regulations and were approved by the ethics committee of Isfahan University of Medical Sciences with the code of ethics (IR.MUI.RESEARCH.REC.1398.731). The knowledge questionnaire that was filled by the nurses was anonymous, all of them knew that their performance was being observe and participated with verbal and written informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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