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Abstract

Introduction

Medication safety competence is a critical factor in enhancing patient safety. Safe nursing care is also a fundamental component of nursing service quality and a key indicator in clinical governance and risk management programs.

Objective

This survey-based study, conducted for the first time in Iran, aimed to determine medication safety competence and its relationship with safe nursing care among nurses.

Methods

This cross-sectional study used questionnaires to collect data. The study population consisted of all nurses working in clinical departments across eight hospitals in North Khorasan Province, northeastern Iran. The total number of nurses in these eight hospitals was 1,025. Given the number of hospitals and the proportion of nurses in each, a proportional sampling method was first employed, followed by convenience sampling within each hospital based on inclusion criteria. The data collection tools included the electronic version of the Medication Safety Competence Scale, Assessment of Safe Nursing Care Questionnaire, and a demographic characteristics section. One-sample t-test was used to compare the mean of the samples with the mean score criterion. The Pearson correlation test was used to assess the relationship between medication safety competence and safe nursing care. To predict safe nursing care based on medication safety competency, multiple linear regression analysis was performed using the simultaneously (Enter) method. To analyze medication safety competence and safe nursing care based on participants’ demographic characteristics, independent t-tests and analysis of variance (ANOVA) were conducted. Data analysis was performed using SPSS software version 28, with a significance level set at p ≤ .05.

Results

Out of the 500 nurses who received the questionnaire link, 429 completed the questionnaire. The mean medication safety competence of the participants was 148.85 ± 19.21, indicating a moderate level. The mean safe nursing care score was 314.71 ± 36.82, indicating a desirable level. A significant direct relationship was observed between medication safety competence and safe nursing care. The role of medication safety competence and department type in predicting safe nursing care was confirmed. Working in the emergency department was negatively associated with safe nursing care compared to other departments.

Conclusion

The participants’ medication safety competence was at a moderate level, while their safe nursing care was at a desirable level. It is recommended that nursing managers develop plans to enhance medication safety competence, with a particular emphasis on the components of safe nursing care.

Keywords

patient safety nursing care medication clinical competence medication safety competence cross-sectional study

Introduction

Safe nursing care is fundamental to nursing service quality (Austin et al., 2014). It refers to the application of knowledge and skills by nurses to provide high-quality care while minimizing the likelihood of harm to patients. In other words, safe nursing care aims to ensure patient safety across all dimensions of care. It is regarded as one of the key indicators in clinical governance and risk management programs (Rashvand et al., 2017). Safe nursing care is described as the prevention of harm that may result from clinical and medical errors (Tourani et al., 2016).

Medical errors are events that occur during the provision of medical care and are recognized as a global issue across all countries, potentially leading to patient harm or even death (Carver et al., 2023). As such, medical errors are among the critical challenges threatening patient safety worldwide. Medication errors, identified as the most common type of medical error both in Iran and globally, are particularly concerning due to their high prevalence, frequent occurrence, and the potential risks they pose to patients. Consequently, they are used as an indicator to assess the level of patient safety in hospitals.

Review of Literature

A systematic review conducted in 2020 reported that preventable medication harm occurs in 3% of patients across medical care settings and that at least a quarter of preventable medication harm is severe or potentially life threatening (Hodkinson et al., 2020). According to the results of the study by Ezeldin et al. (2024), the prevalence of medication errors is reported to be 27.5% (Ezeldin et al., 2024).

Similarly, a meta-analysis published in 2021 reported the prevalence of medication errors among nurses to be between 16% and 44.4% (Almalki et al., 2021). In Iran, the medical error rate is reported to be 53%, with 22% to 44% of these errors resulting in patient death. The most common types of medical errors include, in order, medication errors, preventive measures, and therapeutic and managerial actions (Shamsaii et al., 2012). A 2019 meta-analysis conducted in Iran found that 66.7% of nurses working in intensive care units had committed medication errors, and 40.6% of nurses had reported at least one medication error (Vaziri et al., 2019). A medication error were defined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer” (NCCMERP, 2017). The preparation and administration of medication is a complex process that involves multiple steps, including disease diagnosis, drug selection, dose calculation, accurate preparation by the nurse, providing explanations to the patient, administering the medication, monitoring, and evaluation by both the physician and nurse and precise documentation of the information (Llapa-Rodriguez et al., 2017).

The preparation and administration of medication (delivering medication to the patient) are among the key responsibilities of nurses. The quality and quantity of these activities directly influence the quality and safety of patient care (Hewitt, 2010). Moreover, nurses play a critical role in the process of medication safety management, which extends beyond their responsibilities in preparing and administering medications. Nurses coordinate care delivery and, due to their close interaction with patients, are in a unique position to assess patients’ conditions about prescribed medications by utilizing their knowledge, critical thinking, and clinical reasoning skills (Smeulers et al., 2014). Additionally, nurses play a crucial role in educating and supporting patients’ adherence and compliance with their medication regimens (Hewitt, 2010). Consequently, nurses must possess sufficient competence and proficiency to safely and effectively administer medications (Sulosaari et al., 2011a, 2011b). In this regard, defining, assessing, and enhancing medication safety and, subsequently, the medication safety competencies of nurses, have become essential and critically important.

Medication safety refers to the protection from any avoidable harm during medication use. It also encompasses activities aimed at avoiding and preventing the causes of medication errors, as well as improving and addressing adverse drug reactions that may result from medication use. In contrast, medication safety competence refers to the knowledge, attitudes, and skills related to medication safety that are applied by nurses in practice. This competence includes theoretical and cognitive knowledge, practical skills, and decision-making abilities. Medication safety competence is demonstrated throughout the medication administration process, which involves multiple steps: assessing the patient's need for medication, evaluating the patient's health status, preparing the medication, distributing and administering the medication to the patient, providing medication-related education to the patient, and monitoring and evaluating the medication's effectiveness. This process also includes tasks related to medication storage, transportation, and the safe disposal of medications. Medication safety competence is always interconnected with the nurse's professional values, workplace attitudes, and the individual situations of the patient (Park & Seomun, 2021).

Although research has been conducted on nurses’ patient safety competence, there has been limited investigation into nurses’ medication safety competence in practice. This is even though many nurses and nursing students demonstrate inadequate medication safety competence, particularly in medication calculation (Grandell-Niemi et al., 2005; Mohebi et al., 2024). Medication safety, as one of the key factors in patient safety, plays a critical role in healthcare delivery. Ensuring patient safety and preventing harm, particularly in pharmacotherapy, is considered one of the most important pillars of care and treatment services (Mekonnen et al., 2018).

Accordingly, evaluating nurses’ level of medication safety competence is essential to minimize medication errors and enhance medication safety. Such evaluations allow for the identification of areas that may require further education or improvement, ultimately leading to increased safety and the overall quality of nursing care and performance. In other words, to prevent adverse outcomes, reduce mortality, avoid imposing significant financial burdens on healthcare institutions, enhance the safety of care services, and improve patient satisfaction, it is necessary to plan and implement measures aimed at improving nurses’ medication safety competence. To this end, it is crucial to first assess and identify the level of medication safety competence, the level of safe nursing care, and the relationship between the two. This will provide the basis for developing strategies to enhance these aspects. Evaluating medication safety competence in nurses requires the use of a comprehensive, standardized, and specialized tool. Considering that no study in Iran has yet been conducted using a standardized and specific tool to assess medication safety competence and its relationship with safe nursing care among nurses, the present study was conducted for the first time in Iran to address this research gap and contribute to the advancement of knowledge in this area. The survey-based study aimed to determine medication safety competency and its relationship with safe nursing care among nurses.

Methods

Study Design

The present study is cross-sectional, research conducted from June to September 2024.

Setting and Participants

The study population included all nurses working in clinical departments (emergency, internal medicine, surgery, pediatrics, neurology, infectious diseases, psychiatry, as well as critical care unit (ICU), cardiac care unit (CCU), and dialysis) across eight hospitals in North Khorasan Province (the cities of Bojnurd, Shirvan, Faruj, and Jajarm), northeastern Iran.

The total number of nurses in these eight hospitals was 1,025. The following formula was utilized to determine the minimum sample size. Based on the results of Mohebi et al. (2024), and considering, α = .05 margin of error with p and q values set at .5, the minimum required sample size was calculated to be 280. Given the potential for non-cooperation from some nurses in fully completing the questionnaire and the possibility of sample attrition, a minimum sample size of 500 was determined to enhance the study's accuracy and ensure data adequacy. $n = \frac{\frac{Z^{2} p q}{d^{2}}}{1 + \frac{1}{N} [\frac{Z^{2} p q}{d^{2}} - 1]}$

The inclusion criteria were: having at least a bachelor's degree in nursing, a minimum of one year of clinical work experience, and a willingness and consent to participate in the study.

Evaluation Tool

Data were collected using the Medication Safety Competence Scale, Assessment of Safe Nursing Care Questionnaire, and the section on demographic characteristics.

A. Demographic Characteristics Section

The demographic questionnaire developed by the research team encompasses several key variables, including, age, gender, level of education, marital status, clinical nursing experience, city of employment, hospital name, department name, type of shift, employment status, and history of participation in medication safety courses and workshops.

B. Medication Safety Competence Scale (MSCS)

This scale was developed and psychometrically evaluated by Park and Seomun (2021) in South Korea (Park & Seomun, 2021). The internal consistency of the scale was initially confirmed by Park and Seomun, with a Cronbach's alpha coefficient of .96 for the overall tool and .77 to .91 for its dimensions. The MSCS was translated and validated by Mohammadi, et al. in Iran (Mohammadi et al., 2023). In the study by Mohammadi et al. (2023), internal consistency for the overall tool was reported as .96. In the present study, the scale was also evaluated using internal consistency (Cronbach's alpha), yielding a coefficient of .95 for the overall scale. The scale comprises 36 items across 6 dimensions: Patient-centered medication management (9 items), improvement of safety problems (8 items), management of effecting factors (6 items), safety risk management (6 items), multidisciplinary collaboration (4 items) and responsibility in the nursing profession (3 items). Each item is scored on a 5-point Likert scale: never (1), rarely (2), sometimes (3), often (4), and always (5). The total score is calculated by summing the responses, with higher scores indicating greater medication safety competency. Based on the scoring range of the scale (36–180), scores between 36 and 90 are categorized as poor medication safety competency, 91 to 150 as moderate competency, and 151 to 180 as desirable competency.

C. Assessment of Safe Nursing Care Questionnaire (ASNC)

This questionnaire was developed and psychometrically validated by Rashvand et al. (2017) in Iran. It consists of 32 items across four dimensions: evaluation of nursing skills (16 items), assessing the patient's psychological needs (4 items), assessing the patient's physical needs (7 items), and assessing nurses’ teamwork (5 items).

Each item is rated on a 5-point Likert scale ranging from 1 (never) to 5 (always). The item weights vary across the questionnaire dimensions: items (14, 18, 19, 20, and 32) weight 1; items (2, 3, 4, 5, 7, 10, 11, 12, 13, 15, 16, 17, 21, 26, and 30) weight 2; items (1, 6, 8, 9, 23, 24, 25, 27, 29, and 31) weight 3; and items (22 and 28) weight 4. Accordingly, each item's score is multiplied by its respective weight. Given the variation in item weights, the minimum possible score is 73, and the maximum is 365. Scores between 73 and 170 indicate poor performance, 171 to 267 indicate moderate performance and 268 to 365 indicate desirable performance. The reliability of the tool was assessed using internal consistency (Cronbach's alpha) and intra-class correlation coefficient (ICC). Cronbach's alpha for the overall tool was reported as .92, and the ICC was .72 (Rashvand et al., 2017). In the present study, internal consistency, with a Cronbach's alpha of .94 for the overall questionnaire.

Data Collection

After receiving approval from the university ethics committee and obtaining the necessary permissions to access the research setting, data collection commenced. Considering the large number of counties and hospitals involved, an electronic version of the questionnaire was utilized via the Persian platform Porsline (http;//survey.porsline.ir/s/kfshkO04). Initially, the electronic version of the questionnaire was designed, including details about the study's title, objectives, and methodology. At the beginning of the electronic questionnaire, an explanation regarding consent and agreement to participate in the study was provided. All participants gave informed consent by confirming the following statement, displayed on the first page of the electronic questionnaire: “If you wish to participate in the study, click the ‘Start’ button.” Completing the electronic questionnaire was also considered as consent to participate in the study. The questionnaire link was then distributed to eligible nurses through hospital liaisons using text messages and social media platforms such as WhatsApp^®. Nurses who were willing to participate in the study completed and submitted the electronic questionnaire. The questionnaire link remained active for four months, from June to September 2024, during which data collection was conducted.

Data Analysis

Data were analyzed using both descriptive and inferential statistical methods. First, the demographic characteristics of the participants, medication safety competence, and safe nursing care were examined and described using means and standard deviations. According to Kolmogorov-Smirnov normality test research variables had a normal distribution. Consequently, parametric tests were employed. One-sample t-test was used to compare the mean of the samples with the mean score criterion. The Pearson correlation test was used to assess the relationship between medication safety competence and safe nursing care. To predict safe nursing care based on medication safety competency, multiple linear regression analysis was performed using the simultaneously (Enter) method. To analyze medication safety competence and safe nursing care based on participants’ demographic characteristics, independent t-tests and analysis of variance (ANOVA) were conducted. Data analysis was performed using SPSS software version 28, with a significance level set at p ≤ .05.

Results

In the present study, out of 500 nurses who received the questionnaire link, 429 nurses completed the questionnaire. Among them, 302 (70.4%) were female, 314 (73.2%) were married, and 193 (45%) had previously participated in medication safety courses and workshops. Regarding department distribution, 134 nurses (31.2%) worked in the emergency department, 125 (29.1%) in the critical care units (intensive care unit (ICU), cardiac care unit (CCU), and dialysis), and 170 (39.7%) in other departments (internal medicine, surgery, pediatrics, neurology, infectious diseases, and psychiatry). The mean age of participants was 33.36 years (SD = 6.53), ranging from 23 to 53 years. The mean work experience was 8.58 years (SD = 5.61), with a range of 1 to 25 years (Table 1).

Table 1.

Demographic Characteristics of Nurses Participating in the Study (n = 429).

Variable	N	%
Sex
Female	302	70.4
Male	127	29.6
Marital status
Single	115	26.8
Married	314	73.2
Level of education
BSc in Nursing	406	94.6
MSc in Nursing	23	5.4
Age (years)
20–29	122	28.4
30–39	229	53.4
40–49	65	15.2
50–59	13	3
Clinical nursing experience (years)
1–5	150	35
6–10	155	36.1
11–15	69	16.1
16–20	38	8.9
21–25	17	4
Type of shift
Morning	31	7.2
Evening and night	18	4.2
Morning and evening	26	6.1
Rotating	354	82.5
City of employment
Bojnourd	334	77.8
Shirvan	38	8.9
Farouj	21	4.8
Jajarm	36	8.8
Department name
Emergency	134	31.2
Critical care units (ICU, CCU, dialysis)	125	29.1
Other departments (internal medicine, surgery, pediatrics, neurology, infection diseases, psychiatry)	170	39.7
History of participation in medication safety courses and workshops
Yes	193	45
No	236	55

ICU = intensive care unit; CCU = cardiac care unit.

The mean medication safety competence score among participants was 148.85 ± 19.21. None of the participants had a poor level of medication safety competence. Medication safety competence was moderate in 51% of participants and desirable in 49% (Table 2). As shown in Table 2, the mean safe nursing care score among participants was 314.71 ± 36.82. Similarly, none of the participants reported a poor level of safe nursing care, and the majority (87.6%) reported a desirable level of safe nursing care. Based on the results of the One sample t-test, none of the dimensions of medication safety competency are at a weak level. The lowest level among the dimensions of medication safety competence is also related to the dimensions of multidisciplinary collaboration and responsibility in the nursing profession, which are at moderate level (Table2). Also, all dimensions of safe nursing care were in the desirable range with an average score higher than the standard score (Table2).

Table 2.

Medication Safety Competence and Safe Nursing Care in Nurses Participating in the Study.

Medication Safety Competence	Mean ± SD	Range (Min–Max)^a	Mean Difference	t	p-Value^b	Interpretation
Patient-centered medication management	38.66 ± 4.92	9–45	1.16	37.5	<.001	Good
Improvement of safety problems	33.91 ± 4.62	8–40	0.41	33.5	.064	Fairly good
Management of effecting factors	25.24 ± 3.02	6–30	0.24	25	.107	Fairly good
Safety risk management	25.24 ± 3.97	6–30	0.24	25	.220	Fairly good
Multidisciplinary collaboration	14.27 ± 4.08	4–20	−2.23	16.5	<.001	Moderate
Responsibility in the nursing profession	11.53 ± 2.36	3–15	−0.97	12.5	<.001	Moderate
Total	148.85 ± 19.21	36–180	1.65	150.5	.076	Moderate

Qualitative Description	Score Range	n (%)
Poor	36–90	0 (0)
Moderate	91–150	219 (51)
Desirable	151–180	210 (49)

Safe Nursing Care	Mean ± SD	Range (Min–Max)^a	Mean Difference	t	**p-Value	Interpretation
Evaluation of nursing skills	145.22 ± 19.85	35–175	16.72	128.5	<.001	Good
Assessing the patient's psychological needs	21.86 ± 3.29	5–25	3.36	18.5	<.001	Good
Assessing the patient's physical needs	89.73 ± 9.79	20–100	16.23	73.5	<.001	Good
Assessing nurses’ teamwork	57.90 ± 7.42	13–65	10.40	47.5	<.001	Good
Total	314.71 ± 36.82	73–365	47.21	267.5	<.001	Good

Qualitative Description	Score Range	n (%)
Poor	73–170	0 (0)
Moderate	171–267	53 (12.4)
Desirable	268–365	376 (87.6)

SD: standard deviation.

Minimum–maximum.

One sample t-test.

Based on the results of the Pearson correlation test, a significant and direct relationship was observed between medication safety competence and safe nursing care across all dimensions (p < .05) (Table 3).

Table 3.

Correlation Between Medication Safety Competence and Safe Nursing Care in Nurses Participating in the Study.

Variables	Evaluation of Nursing Skills		Assessing the Patient'S Psychological Needs		Assessing the Patient'S Physical Needs		Assessing Nurses’ Teamwork		Safe Nursing Care (Total)
Variables	r	p	r	p	r	p	r	p	r	p
Patient-centered medication management	.737	<.001	.719	<.001	.732	<.001	.652	<.001	.788	<.001
Improvement of safety problems	.718	<.001	.698	<.001	.695	<.001	.661	<.001	.767	<.001
Management of effecting factors	.698	<.001	.599	<.001	.646	<.001	.568	<.001	.716	<.001
Safety risk management	.704	<.001	.599	<.001	.656	<.001	.590	<.001	.726	<.001
Multidisciplinary collaboration	.641	<.001	.454	<.001	.472	<.001	.445	<.001	.601	<.001
Responsibility in the nursing profession	.692	<.001	.564	<.001	.614	<.001	.523	<.001	.692	<.001
Medication safety competence (Total)	.838	<.001	.736	<.001	.767	<.001	.696	<.001	.862	<.001

r = Pearson's correlation coefficient.

In the present study, the predictive role of medication safety competence and demographic variables (work experience, marital status, history of participation in medication safety courses and workshops, and department type) in predicting safe nursing care was examined using multiple linear regression analysis, employing the enter method. The predictor variables in the model accounted for 75% of the variance in safe nursing care (Adj R² = .750). As shown in Table 4, there was a significant relationship between medication safety competence and department type with safe nursing care (p < .001), and these two factors were able to significantly predict safe nursing care. The strongest correlation with safe nursing care was found for medication safety competence, with a standardized coefficient of .856. On the other hand, working in the emergency department was negatively correlated with safe nursing care, compared to other departments (Table 4).

Table 4.

Prediction of Safe Nursing Care According to Medication Safety Competence Using Multiple Linear Regression Analysis.

Predictor Variables	B	SE	ß	t	Sig.	95% CI for B	Collinearity Statistics
Predictor Variables	B	SE	ß	t	Sig.	95% CI for B	Tolerancee	VIF
Constant (c)	56.93	9.20	-	6.19	<.001	38.84 to 75.02	-	-
Medication safety competence	1.64	0.050	.856	33.06	<.001	1.54 to 1.74	0.87	1.15
Work experience as clinical nurse	0.16	0.172	.024	0.93	.355	−0.50 to 0.18	0.85	1.18
Married	1.02	2.132	.012	0.48	.63	−5.21 to 3.17	0.88	1.13
Attending drug safety training courses and workshops	2.32	1.868	.031	1.24	.214	−1.35 to 5.60	0.92	1.09
Emergency ward	−7.40	−1.956	−.093	3.79	<.001	3.56 to 11.25	0.96	1.04

Note. Multiple linear regression (simultaneous [enter] method); VIF = variance inflation factor; B = unstandardized coefficients; SE = standard error; ß = standardized coefficients; coefficient of determination (R²: .753); Adj R²: .750; F: 257.86; Durbin-Watson (DW: 1.82); p ≤ .05.

Discussion

The present study aimed to determine medication safety competence and its relationship with safe nursing care among nurses. Among the dimensions of medication safety competence, the highest mean was found in the patient-centered medication management dimension, while the lowest means were observed in the dimensions of responsibility in the nursing profession and multidisciplinary collaboration. Accordingly, nurses performed better in the patient-centered medication management dimension, while the dimensions of responsibility in the nursing profession and multidisciplinary collaboration required improvement and enhancement. In line with this, a study by Kim and Lee (2022) involving 140 nurses from four hospitals in Busan metropolitan city, South Korea, also found that nurses reported a moderate level of medication safety competence. Regarding the dimensions of medication safety competence, nurses in that study had a high mean score for patient-centered medication management, but a lower score for multidisciplinary collaboration (Kim & Lee, 2022).

The results of the study by Yang et al. (2021), which involved 894 nurses in China, also showed that nurses reported a moderate level of medication safety competence. When examining the dimensions of medication safety competence, the average scores for patient-centered medication management and improvement of safety problems were high, while multidisciplinary collaboration scores were low (Yang et al., 2021).

These findings suggest that nurses tend to be somewhat passive in collaborating with other healthcare team members. Therefore, to maintain and enhance patient safety and, consequently, improve safe nursing care, it is essential to improve communication and collaboration between nurses and other members of the healthcare team and departments (Kim & Lee, 2022).

Teamwork and interdisciplinary collaboration are crucial competencies for nurses to improve care quality and reduce caregiving errors. Effective teamwork requires the ability to anticipate the needs of others, adapt to each other's roles, adjust to environmental changes, and maintain a shared understanding of how activities should be carried out for optimal outcomes (Hwang & Ahn, 2015). Given the importance of team-based care and the emphasis on teamwork and interdisciplinary collaboration, there is an increasing need to focus on inter-professional competencies among healthcare workers. Teamwork can lead to improvements and enhancements in clinical quality. It is essential for nursing managers to foster this critical skill among their staff. The lack of such skills can result in increased medical and caregiving errors, wasted time and resources during response efforts, and negatively impact the quality of nursing care (Gagnon & Roberge, 2012). Additionally, a collaborative approach, emphasizing accurate medication reconciliation, precise prescriptions, and standardized protocols, enhances safety by sharing information and resolving conflicts (Weaver et al., 2014). Training strategies such as simulation-based learning and inter-professional workshops improve decision making, teamwork, and communication, reducing medication errors (Likic & Maxwell, 2009).

According to the results of the study by Mohebi et al. (2024), which was conducted among nursing students, the majority of nursing students reported a moderate level of medication safety competence. The safety risk management and responsibility in the nursing profession dimensions had the highest and lowest means, respectively, among the dimensions of medication safety competence (Mohebi et al., 2024).

Medication safety is influenced by various factors, including nurse characteristics (knowledge, experience), skills and competencies (self-awareness and alertness), clinical processes (adherence to standard drug administration practices/following the five medication rights, adherence to protocols, patient involvement and education), and the clinical environment (such as ward design and treatment room layout, which can impact the nurse's focus and accuracy in drug administration). The results of a review study conducted by Athanasakis (2021) emphasize the importance of implementing safety measures for patients, stating that safe clinical practices are at the heart of all medical actions. Positive nurse involvement in improving safety culture, along with the practicality, simplicity, and effectiveness of safety interventions, is emphasized. Each safety measure is significant and contributes to patient safety in its unique way. Nurses can promote medication safety at various levels (clinical performance and management policies in clinical settings) (Athanasakis, 2021). On the other hand, medication safety competence is always linked to the nurse's values and attitudes in the work environment and the individual patient's situation (Park & Seomun, 2021). A review study aimed at exploring the role of organizational and professional cultures in medication safety also showed that organizational and professional cultures influence various aspects of medication safety. Understanding the role of these cultures can assist in the development of local governance arrangements and interventions that consider the impact of these cultural aspects (Machen et al., 2019).

Nurses constitute the largest group within the healthcare delivery system, and many care outcomes result from their activities. Care, as the essence and core of nursing, is the central concept that distinguishes nursing from other health professions (DalPezzo, 2009). Nurses’ activities at all levels of healthcare, ranging from primary to advanced care, play a critical role in improving patients’ health and well-being (Ortega-Lapiedra et al., 2023). Among these, the provision of safe nursing care is a crucial component in ensuring the quality of care within the healthcare system (Tourani et al., 2016). Safe nursing care aligns with ensuring patient safety across all dimensions of care and is regarded as one of the key indicators in clinical governance and risk management programs (Rashvand et al., 2017). Safe nursing care is described as the prevention of harm that may arise from various errors, including medication errors (Tourani et al., 2016). Therefore, the second objective of this study was to determine the level of safe nursing care. Based on the results, none of the nurses participating in this study demonstrated a poor level of safe nursing care, and most reported a desirable level of safe nursing care. This finding aligns with previous studies, highlighting the importance of prioritizing safe nursing care (Mohebi et al., 2024).

Among the dimensions of safe nursing care, the highest mean pertained to the evaluation of nursing skills and assessing the patient's physical needs, while the lowest mean was related to assessing the patient's psychological needs and assessing nurses’ teamwork.

Various factors, including clinical skill practice, professional experiences, continuous education, and regular assessments, can enhance the quality and safety of nursing care. Practicing clinical skills and conducting regular evaluations contribute to increasing nurses’ confidence in providing safe care. Additionally, using tools for assessing and measuring clinical skills improves the quality of care delivered and reduces medical errors. These evaluations enhance precision in nursing practice. Assessments of patient's physical and psychological needs positively impact the overall quality of nursing care (Rashvand et al., 2017).

On the other hand, the low mean in the dimensions of assessing the patient's psychological needs and assessing nurses’ teamwork highlights the need for particular attention to these aspects to improve safe care. Based on these findings, it can be concluded that in addition to maintaining physical safety, addressing the dimensions required for enhancing psychological safety and teamwork should also be integrated into nursing education and management programs. Consequently, creating a supportive environment where nurses can work based on interpersonal skills and teamwork would significantly contribute to improving the quality and safety of nursing care. In this regard, the findings of the study by Dillon-Bleich et al. (2023), conducted on 163 nurses in the western United States to examine the impact of environmental and personal factors on nurses’ ability to provide safe care, revealed that structural empowerment assessments demonstrated a moderate level of empowerment, whereas systems thinking was at a high level. Structural empowerment and systems thinking showed a significant correlation with the knowledge component of safety competence; however, neither was significantly correlated with the attitude component of safety competence. The researchers suggested that to enhance safety in nursing, professional support in the workplace and the integration of systems thinking into nursing curricula are essential. They also emphasized that healthcare organizations should support the development of safety competence and provide ongoing education (Dillon-Bleich et al., 2023).

Since safe nursing care is a fundamental component of the quality of nursing services and a key indicator in clinical governance and risk management programs, and since medication safety competence is an influential factor in improving patient safety, the third objective of this study was to determine the relationship between medication safety competence and safe nursing care among nurses.

The results demonstrated a direct, strong, and significant relationship between medication safety competence and safe nursing care across all dimensions. As this was the only study conducted within the nursing community to examine the relationship between medication safety competence and safe nursing care, no similar studies were found for comparison. However, the findings of Mohebi et al. (2024), conducted among nursing students, support this result.

Among the dimensions of safe nursing care, the strongest relationships with medication safety competence were observed in the evaluation of nursing skills and assessing the patient's physical needs. This strong correlation underscores the necessity of nurses’ proficiency in medication management to reduce medication errors and improve patient outcomes. By focusing on continuous education in these areas, healthcare institutions can create environments that prioritize patient safety.

Additionally, among the dimensions of medication safety competence, patient-centered medication management exhibited the strongest correlation with safe nursing care. This finding aligns with the principles of patient-centered care, which emphasize the importance of involving patients in the management of their medications (McCormack, 2003; Santana et al., 2018).

By empowering patients and ensuring effective communication, nurses can significantly reduce the risk of medication errors. Furthermore, the results of the multiple regression analysis confirmed the role of medication safety competence and the department type in predicting safe nursing care. Working in the emergency department was negatively associated with safe nursing care compared to other departments. This negative association highlights concerns about the unique challenges faced in emergency departments. The high-paced nature of emergency care may hinder the precise implementation of medication management practices, potentially leading to safety risks. Addressing these challenges through additional training and support for emergency department nurses is crucial for improving medication safety. This finding underscores the need for healthcare organizations to implement targeted educational programs tailored to the specific needs of their departments, particularly high-risk areas such as emergency departments (Di Simone et al., 2018).

According to the results of the study by Petrino et al. (2023), most health professionals identify emergency departments as an environment with specific safety issues. The main factors appeared to be a shortage of personnel during busy periods, overcrowding due to boarding, and a perceived lack of support from hospital management (Petrino et al., 2023). According to the findings of Soola et al., The patient safety competency of emergency department nurses was primarily related to the structure and leadership of the team and secondary to psychological safety and experience in patient safety activity. The results demonstrated that policymakers and hospital managers should improve and enhance team structure and leadership via supervision and cooperation with the nursing staff. The development of training programs in patient safety activities, improvement, and increase of psychological safety at the levels of the nursing units is essential to increase patient safety competencies in the emergency nursing program.

According to the findings of Kim and Lee (2022), who investigated the impact of job stress, critical thinking disposition, and clinical decision-making ability on the medication safety competence of clinical nurses in South Korea, medication safety competence showed a significant correlation with job stress, critical thinking disposition, and clinical decision-making ability. Among these, critical thinking disposition and job stress were the strongest predictors of medication safety competence. The study emphasized the necessity of systematic efforts in clinical settings to enhance nurses’ medication safety competence by planning and implementing interventions aimed at managing job stress and fostering critical thinking disposition (Kim & Lee, 2022).

Study Limitations

First, while this research was the first multi-center study of its kind conducted in Iran, the study population was limited to nurses in North Khorasan Province, northeastern Iran. Therefore, it is recommended that larger, multi-center studies be designed and conducted in other regions of Iran and internationally to compare data and assess the relationship between the main variables of the study—medication safety competence and safe nursing care. Second, this study was cross-sectional, with data collection conducted over four months. Due to the descriptive and cross-sectional nature of the study, causal relationships between the variables could not be determined. Additionally, attitudes and behaviors may change over time, which could influence the results. Future research should consider interventional, longitudinal, and cohort studies with larger sample sizes and incorporate psychological, social, and cultural variables to enhance our understanding of the studied variables. Third, given the self-reported nature of data collection for medication safety competence and safe nursing care, the participants’ responses may not have been truthful, so social desirability bias or acquiescence bias could have been present. To address this, it is recommended that future studies include qualitative research and designs that utilize external evaluators to assess these two variables. Fourth, as this study was the first to evaluate medication safety competence and its relationship with safe nursing care among nurses, the research team faced some limitations in comparing the findings with prior studies.

Strengths

This is the first study in Iran and other countries, that was conducted on medication safety competence and its relationship with safe nursing care among nurses, which is a novelty. Also, one of the strengths of this study is the use of a comprehensive and specific questionnaire (Medication Safety Competence Scale) for assessing the competence of medication safety.

Conclusion

The participants’ medication safety competence was at a moderate level, while their safe nursing care was at a desirable level. A significant direct relationship was observed between medication safety competence and safe nursing care. The role of medication safety competence and department type in predicting safe nursing care was confirmed. Based on the findings of this study, it is recommended that nursing managers develop plans to enhance medication safety competence, with a focus on the components of safe nursing care. Additionally, it is suggested that nursing education curricula place greater emphasis on the components of medication safety competence and safe nursing care. Efforts should be made to professionally empower nursing students in these areas through targeted interventions and educational initiatives.

Footnotes

Acknowledgments

We sincerely thank all the participants who contributed to this study. This research is based on a Master's thesis in Emergency Nursing,approved by the School of Nursing at Alborz University of Medical Sciences,Karaj,Iran. We also extend our gratitude to Alborz University of Medical Sciences for supporting and approving this study (Research Code: 6930).

ORCID iDs

Mostafa Bijani

Maryam Aghabarary

Ethical Considerations

This study was conducted in full compliance with the principles outlined in the revised Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.REC.1402.335). All ethical considerations were adhered to in this study. The research participants,who were clinical nurses working in clinical departments,voluntarily participated in the study. Before the study began,participants were informed about the study's methods and objectives. At the beginning of the electronic questionnaire,an explanation regarding consent and agreement to participate in the study was provided. All participants gave informed consent by confirming the following statement,displayed on the first page of the electronic questionnaire: “If you wish to participate in the study,click the ‘Start’ button.” Completing the electronic questionnaire was also considered as consent to participate in the study. The questionnaires were completed anonymously,and all participant information was kept strictly confidential.

Consent for Publication

All authors have read and approved the final article.

Author Contributions

MA: writing–review and editing,writing–original draft,visualization,validation,supervision,project administration,methodology,data curation,and conceptualization. FK: writing–original draft,data curation,and conceptualization. MB: writing–review and editing,methodology,and conceptualization.

Funding

The authors received no financial support for the research,authorship,and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

Informed Consent

Written informed consent was obtained from all subjects before the study

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A Survey-Based Study of Medication Safety Competence and Its Relationship with Safe Nursing Care among Nurses

Abstract

Introduction

Objective

Methods

Results

Conclusion

Keywords

Introduction

Review of Literature

Methods

Study Design

Setting and Participants

Evaluation Tool

A. Demographic Characteristics Section

B. Medication Safety Competence Scale (MSCS)

C. Assessment of Safe Nursing Care Questionnaire (ASNC)

Data Collection

Data Analysis

Results

Discussion

Study Limitations

Strengths

Conclusion

Footnotes

Acknowledgments

ORCID iDs

Ethical Considerations

Consent for Publication

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

Informed Consent

References