Mohebi et al.

BMC Nursing (2024) 23:13 BMC Nursing

https://doi.org/10.1186/s12912-023-01684-0

RESEARCH Open Access

Investigating safe nursing care

and medication safety competence in nursing
students: a multicenter cross-sectional study
in Iran
Zahra Mohebi1, Mostafa Bijani2* and Azizallah Dehghan3

Abstract
Background Medication safety competence is very important as one of the clinical skills among nursing students
to provide safe nursing care. The lack of medication safety competence in nursing students leads to occurrence of
medication errors subsequently jeopardizing patient safety. Thus, the present study was conducted to investigate safe
nursing care and medication safety competence among nursing students in the south of Iran.
Methods A descriptive cross-sectional multicenter study was conducted from September to December 2022. The
research population included nursing students of three universities of medical sciences in Fars Province, Southern
Iran. A total of 310 nursing students who were selected through convenience sampling participated in the study. The
data collection instruments consisted of a demographics survey, Medication Safety Competence Scale (MSCS), and
a Safe Nursing Care Scale (SNCS). The collected data were analyzed using descriptive statistics (absolute and relative
frequency, mean and standard deviation) and inferential statistics (Independent t-test, Analysis of variance and
Pearson correlation coefficient). The data were analyzed in SPSS 23 and the level of significance was considered 0.05.
Results The mean age of the participants was 22.53 ± 1.69 years. The total mean scores for medication safety
competence and safe nursing care were found to be 111.97 ± 11.85 and 105.12 ± 11.64, respectively. There was a
statistically significant positive correlation between safe nursing care and medication safety competence (r = 0.084,
P < 0.001).
Conclusion The mean scores of nursing students’ medication safety competence and safe nursing care were at an
average level. To maintain patient safety, nursing instructors and managers are recommended to employ appropriate
strategies to improve medication safety competence and safe nursing care in nursing students.
Keywords Clinical competence, Patient safety, Nursing care, Nursing, Students, Medication

*Correspondence:
Mostafa Bijani
bizhani_mostafa@yahoo.com
1
Student Research Committee, School of Nursing, Fasa University of
Medical Sciences, Fasa, Iran
2
Department of Medical Surgical Nursing, School of Nursing, Fasa
University of Medical Sciences, 81936-13119 Fasa, Iran
3
Noncommunicable Diseases Research Center (NCDRC), Fasa University
of Medical Sciences, Fasa, Iran

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Mohebi et al. BMC Nursing (2024) 23:13 Page 2 of 7

Introduction drug events are due to medication errors [12], with nega-
The high risk of physical injuries and financial burden tive consequences for patients, nurses, and other mem-
on patients have turned patient safety into a global con- bers of the healthcare team, and decline in the quality of
cern [1]. According to the National Institutes of Health, care [13].
safety in healthcare environments includes preventing Despite system-based technological advances, nearly
errors and the side effects of treatments as well as not 100 thousand patients are harmed because of prevent-
harming patients in the course of medical procedures able medication administration errors in healthcare cen-
[1–2]. Preservation of patient safety was underscored inf ters every year [14]. According to a report on medication
a report by the American National Institutes of Health in safety released by Federal University of São Paulo, medi-
1999. Entitled “To Err is Human,” the report addressed cation errors or the side effects of medications account
the rate of medical errors in the U.S. and drew the atten- for 7% of hospitalizations in the healthcare system, and
tion of researchers and healthcare experts to the subject every year 44 to 98 thousand deaths are caused by medi-
of patient safety more than ever [2]. One of the primary cation errors in the U.S., which costs the healthcare sys-
objectives of a medical center is to provide safe and effec- tem 17 to 29 billion dollars [15]. Medication errors can
tive care to patients, where nurses, as the frontline work- endanger the patients’ safety, which is the main concern
ers in caregiving, are a major group in fulfilling this goal of healthcare systems worldwide and could lead to mor-
[3]. Healthcare services are provided in environments tality, morbidity, complications, and prolonged length of
which are influenced by a variety of factors, including stay in health care [16].
patients, caregivers, patients’ families, equipment, and The results of the study by Dehvan et al. (2021), which
managers’ policies. When these factors interfere, the con- was conducted as a systematic review and meta-analysis,
sequences are dangerous and unpredictable [4]. Every revealed that the prevalence of medication errors in nurs-
year, millions of patients in the world suffer disabling ing students in different countries varies within 10–80%.
injuries or death due to unsafe healthcare, and at least According to the results of the same study, the prevalence
one out of ten patients is injured despite receiving care in of medication errors in nursing students in Iran has been
a high-tech hospital [5]. Nevertheless, approximately 50% reported as 39.68% [17]. Perhaps, one of the reasons for
of the national running costs are claimed by healthcare these medication errors is the lack of medication safety
services in hospitals [6]. competence in nursing students. Nursing students in the
In addition to the above-mentioned physical harms, the clinical education environment are exposed to a range of
financial burden of caregivers’ failure to comply with the medical errors, especially medication errors [18]. Medi-
principles of patient safety is another issue in healthcare cation safety competence is very important as one of the
systems. World Health Organization (WHO) reports clinical competencies in nursing students to provide safe
that unsafe care augments medical costs by increasing nursing care. The lack of medication safety competence
the length of stay, lowering incomes, causing disabilities, in nursing students leads to the occurrence of medica-
and imposing legal expenses; in some countries, these tion errors thereby jeopardizing patient safety; in some
expenses approach billions of dollars [5]. cases, it can lead to the death of the patients [19]. The
So far, many studies have addressed different aspects goal of assessing safe nursing care and medication safety
of safe nursing care and the associated factors, e.g. medi- competence is to pave the way for improving them, pro-
cal errors, inaccurate reporting, and the culture of safety. vide safer care, and protect the society from preventable
Another important factor in safe nursing care is medica- harms and unwanted complications [20]. Evidence shows
tion safety. Adherence to medication instructions is an that nursing students are still making medication errors
essential part of treatment as well as patient safety and while working in clinical settings. Medication dosage
care [7]. The goal of safe medication therapy is to pro- calculation errors and administration errors continue to
vide comprehensive medical services to patients and occur even with new guidelines, technology, polices, and
ensure the logic of prescribed medication plus improve- education [21–22].
ment in the patients’ health status [8]. Medication safety For investigating the medicine safety competence in
also means protecting patients from accidental inju- nursing students as well as identifying the strengths and
ries, avoiding any preventable complications and side weaknesses of the nursing students’ performance in med-
effects, along with fulfilling maximum medication effect icine safety and in turn safe nursing care, it is necessary
[9]. Medication safety involves accurate evaluation of to use a standard instrument which specifically evalu-
patients, selection, and administration of medication in ates Medication Safety Competence Scale (MSCS). Given
the right dose and at the right time, attention to cases the importance of the subject, and that few studies have
contraindications, side effects, and drug interactions [10]. been conducted in this area, the present study is also sug-
Medication errors are among the most common type of gested to be carried out in different countries to develop
clinical errors [11]. Approximately, one third of adverse the nursing knowledge. Also, nursing instructors and
Mohebi et al. BMC Nursing (2024) 23:13 Page 3 of 7

managers can utilize the results of this study to improve consists of six factors, namely medication management
the medication safety competence and safe care in nurs- and patient assessment, improvement of safety problems
ing students. Accordingly, the present study was con- in the medication process, management of effecting fac-
ducted to investigate safe nursing care and medication tors, management of safety risks, multidisciplinary col-
safety competence in nursing students. laboration, and responsibility as a professional nurse. The
Cronbach’s alpha of the scale was reported to be 0.96 as
Methods well as between 0.77 and 0.91 for its different factors [24].
Study design, setting, and participants The MSCS was translated and validated by Moham-
This descriptive cross-sectional multicenter study was madi et al. in Iran (2023). Exploratory factor analy-
conducted from September to December 2022 based on sis (EFA) results revealed that the factor loading of the
the STROBE Statement (Strengthening the Reporting of 36 items ranged from 0.72 to 0.87 and that all of them
Observational Studies in Epidemiology) [23]. (Supple- were significant. Confirmatory factor analysis (CFA)
mentary file 1: STROBE checklist). The research popula- results indicated goodness of fit of the data (χ2/df = 7,
tion included nursing students with bachelor’s degree in RMSEA = 0.01, CFI = 0.96, NFI = 0.95, and TLI = 0.97). To
three universities of medical sciences in Fars Province, test the reliability of the scale, the researchers measured
Southern Iran (n = 310). its internal homogeneity and found the Cronbach’s alpha
The inclusion criteria were a bachelor’s degree nurs- of the whole instrument to be 0.96. Thus, the Persian ver-
ing students, having passed a course on theoretical and sion of MSCS for nurses is adequately valid and reliable
practical pharmacology, and willingness to participate in [25].
the study. The exclusion criteria included the unwilling-
ness to continue participating in the study for any reason. Safe nursing care scale (SNCS)
For sampling, the first author (ZM) attended the school The SNCS was developed by Rashvand et al. The reliabil-
of nursing affiliated with a university of medical sciences ity of the scale was validated with a Cronbach’s alpha of
in the Fars Province, Southern Iran, and asked the nurs- 0.97. This instrument consists of 32 items which fall into
ing students who met the inclusion criteria to fill out the four parts: part 1 (16 items) assesses nursing skills, part 2
questionnaires. (4 items) addresses evaluation of the psychological safety
The participants were selected using convenience sam- of the patient, part 3 (7 items) deals with evaluation of
pling. The sample size was determined using the results the physical safety of the patient, and part 4 (5 items)
of a study by Khalili et al. [7]. and the following formula. evaluates the nurse respondent’s teamwork performance.
In this formula, Z represents confidence level, which was All items are scored on a 5-point Likert scale: never = 1,
set at 95% in this study, while d represents acceptable rarely = 2, sometimes = 3, usually = 4, and always = 5. This
degree of difference, which was set at 5%. In the afore- scale also determines the loading of each item: items 14,
mentioned study, the extent of drug interaction errors 18, 19, 20, and 32 have a loading of 1; items 2, 3, 4, 5, 7,
was reported to be 9%; thus, the minimum sample size 10, 11, 12, 13, 15, 16, 17, 21, 26, and 30 have a loading of
was calculated to be 126. To boost the credibility of the 2; items 1, 6, 8, 9, 23, 24, 25, 27, 29, and 31 have a loading
findings, the researchers enrolled 310 subjects. of 3; and items 22 and 28 have a loading of 4. Thus, the
score for each item was multiplied by its loading, and the
Z 2.P (1−P ) result was used for analysis. A score of 73 to 170 indicates
n= d2
(1)
poor, 171 to 267 average, and 268 to 365 satisfactory per-
formance [26].

Evaluation tool and data collection Statistical analysis

Demographic features The collected data were analyzed using descriptive statis-
The demographic survey captured the participants’ age, tics (absolute and relative frequency, mean and standard
gender, marital status, and academic semester. deviation) plus inferential statistics (Independent t-test,
Analysis of variance and Pearson correlation coefficient).
Medication safety competence scale (MSCS) The data were analyzed using SPSS 23, and the level of
Developed and validated by Seomun and Park in South significance was set at 0.05.
Korea, the MSCS consists of 36 items which are scored
on a 5-point Likert scale (ranging from never to always). Ethical considerations
The score range of the scale is 36–180, with scores of All participants gave written informed consent to par-
36–90 indicating poor medication safety competence, ticipate in the study. The present study was conducted
91–150 average medication safety competence, and 151– based on the principles of the revised Declaration of
180 satisfactory medication safety competence. This scale Helsinki, which is a statement of ethical principles that
Mohebi et al. BMC Nursing (2024) 23:13 Page 4 of 7

Table 1 Frequency distribution of the nursing students’ Table 4 Frequency distribution of the nursing students’
demographics medication safety competence and safe nursing care
Variable Number Percentage Variable Number Percentage
Gender Male 89 28.70 Medication safety Poor 0 0
Female 221 71.30 competence Average 297 95.80
Academic Semester 4 63 20.32 Satisfactory 13 4.20
5 88 28.37 Total 310 100
6 90 29.03 Safe nursing care Poor 12 3.88
7 29 9.35 Average 298 96.12
8 40 12.90 Satisfactory 0 0
Marital status Single 261 84.20 Total 310 100
Married 33 10.64
Other 16 5.16
105.12 ± 11.64; the lowest mean score (13.08 ± 2.38) was
related to the domain of psychological safety and the
Table 2 Mean and standard deviation of the nursing students’
highest mean score (50.74 ± 6.97) to the domain of nurs-
medication safety competence scores
ing skills (Table 3).
Scale and dimension mean SD
As outlined by Tables 4 and 95.80% and 96.12% of the
Medication management and patient assessment 24.86 5.60
Elimination of safety problems in the medication 18.05 3.73
surveyed students had average medication safety com-
process petence and safe nursing care scores, respectively. The
Management of effecting factors 27.89 3.50 results indicated that none of the students’ score of safe
Management of safety risks 19.06 3.44 nursing care was satisfactory, and only 13 (4.20%) stu-
Multidisciplinary collaboration 12.54 2.23 dents’ scores in medication safety competence were at a
Responsibility as a professional nurse 9.54 1.85 satisfactory level. The results also revealed a statistically
Total medication safety score 111.97 11.85 significant direct correlation between safe nursing care
and medication safety competence as well as across all
Table 3 Mean and standard deviation of the nursing students’ their dimensions (P < 0.05) (Table 5).
safe nursing care scores
Scale and dimension mean SD Discussion
Nursing skills 50.74 6.97 The present study was conducted to explore safe nursing
Psychological safety 13.08 2.38 care and medication safety competence in nursing stu-
Physical safety 23.56 4.72 dents in 2022 to reduce medication errors, and in turn,
Teamwork 17.73 3.30 improve the quality as well as safety of the care provided
Total safe nursing care score 105.12 11.64 to patients.
In this study, the findings revealed that there was a sig-
directs physicians and other participants in medical nificant relationship between safe nursing care and medi-
research involving human subjects. The participants were cation safety competence in nursing students. In other
assured of their anonymity and confidentiality of their words, the ability of nursing students to administer drugs
information. The study was also approved by the Insti- safely determines the quality of services and supports the
tutional Research Ethics Committee of Fasa University patient safety. In our study, most nursing students were at
of Medical Sciences, Fasa, Iran (Ethical code: (IR.FUMS. an average level in terms of safe nursing care and medica-
REC.1401.109) tion safety competence, which indicates a relatively high
level of knowledge and skill in nursing students; more
Results learning experiences are required during the academic
Among the 310 bachelor’s degree nursing students who courses, since providing safe nursing care and maintain-
participated in the study, the youngest was 20, while the ing the safety of patients are very important points stu-
oldest was 30 years old. The mean age of the partici- dents should learn from the very beginning.
pants was 22.53 ± 1.69. Table 1 reports the other demo- The findings of the present study indicated that mul-
graphic characteristics of the students. The participants’ tidisciplinary cooperation and teamwork, as important
total mean score of medication safety competence dimensions of medication safety competence, directly
was 111.97 ± 11.85; the lowest mean score (9.54 ± 1.85) correlate with safe nursing care. Similarly, a study by
belonged to the domain of responsibility as a profes- Franklin et al. showed that providing nursing care as
sional nurse and the highest mean score (27.89 ± 3.50) a team and collective understanding would improve
to the management of influential factors (Table 2). The the patient’s safety and bring about other valuable
participants’ total mean score of safe nursing care was results [27]. Also, according to a study by Ginsberg et
Mohebi et al. BMC Nursing (2024) 23:13 Page 5 of 7

Table 5 The correlation between the nursing students’ scores for medication safety competence and safe nursing care according to
their dimensions
Medication safety competence and its Safe nursing care and its dimensions
dimensions nursing skills psychological physical safety teamwork Total safe
safety nursing
care score
medication management and patient r = 0.249 r = 0.008 r = 0.356 r = 0.395 r = 0.168
assessment P < 0.001 P = 0.898 P < 0.001 P < 0.001 P = 0.008
improvement of safety problems in the r = 0.143 r = 0.124 r = 0.296 r = 0.263 r = 0.195
medication process P = 0.029 P = 0.051 P < 0.001 P < 0.001 P = 0.002
management of effecting factors r = 0.004 r = 0.135 r = 0.048 r = 0.015 r = 0.043
P = 0.095 P = 0.033 P = 0.051 P = 0.0815 P = 0.0498
management of safety risks r = 0.201 r = 0.112 r = 0.061 r = 0.163 r = 0.204
P < 0.001 P = 0.076 P = 0.034 P < 0.001 P < 0.001
multidisciplinary collaboration r = 0.123 r = 0.150 r = 0.197 r = 0.185 r = 0.228
P = 0.053 P = 0.018 P = 0.002 P = 0.003 P < 0.001
responsibility as a professional nurse r = 0.207 r = 0.164 r = 0.028 r = 0.138 r = 0.203
P < 0.001 P = 0.009 P = 0.660 P = 0.029 P < 0.001
Total medication safety score r = 0.028 r = 0.077 r= -0.286 r=-0.210 r = 0.084
P < 0.001 P = 0.022 P < 0.001 P = 0.001 P < 0.001
r: Pearson’s correlation coefficient

al., caregivers’ skills for management of group activities reported that a better patient safety culture correlated
facilitate safer and more effective care of patients, pro- with fewer medication errors and better preservation
mote patient-centered care, and encourage the person- of patient safety. Thus, healthcare and hospital authori-
nel to have a more positive attitude [28]. The findings of ties should set up training programs and workshops to
the present study also demonstrated that there was a sig- improve the patient safety culture [32].
nificant direct correlation between nursing skills on the The present study also found that having a sense of
one hand and medication management and evaluation of responsibility in nurses improved all aspects of safe nurs-
patients on the other. The results of a study by Smeulers ing care. Nurses form the foundation of improvement in
et al. are in the same line with these findings; further, safe healthcare services; therefore, their performance deter-
provision and administration of medication, clinical rea- mines achievement of organizational objectives; nurses’
soning and nurses’ experiences are essential to medica- sense of responsibility plays a crucial role in accomplish-
tion safety. In addition, awareness of their work hazards ment of the goals of the healthcare system and nurs-
and conditions would impact the nurses’ ability to work ing. According to a study by Ghorbani et al., there is a
safely [29]. Also, according to a study by Rohde, nurses significant direct correlation between the nurses’ sense
play a key role in safe medication administration; nurses of responsibility and the quality of care provided in hos-
should use their knowledge, experience, and skills to sup- pitals; thus, educating the personnel in responsibility-
port medication safety according to patients’ conditions related areas, responsiveness, and communication skills
and organizational procedures [30]. is beneficial and is an effective way to improving the
In the current study, it was also found that there was quality of services [33]. Similarly, in their study, Moham-
a statistically significant direct correlation between elimi- madi et al. found a direct correlation between the qual-
nation of safety problems in the medication process ity of education and sense of responsibility in nurses.
and patients’ physical plus psychological safety. In other Increasing the quality of education in nursing schools
words, elimination of safety problems in the medication and raising responsible nursing students can enhance the
process contributes to patient physical and psychological students’ efficiency in clinical environments and promote
safety. Maintaining patient safety is one of the primary safe nursing care [34].
professional and ethical responsibilities of all care pro- The findings of this study also revealed that manage-
viders. Obviously, although nothing is more discordant ment of the influential factors in medication safety had
to healthcare principles like harming a patient, medi- a positive impact on all the dimensions of safe nursing
cal interventions and procedures are not always com- care, i.e. nursing skills, psychological safety of the patient,
pletely safe and occurrence of medical errors and other physical safety of the patient, and teamwork. Likewise,
events which put patient safety at risk is a real possibil- the results of a study carried out by Huang and Chen
ity. Critical conditions would promote the incidence of demonstrated that nursing safety management can sig-
medication errors, which in turn undermine the patient nificantly enhance the quality of nursing and prevent
physical and psychological safety [31]. A study by Kazemi unwanted hazards [35]. As to safe nursing care, most
Mohebi et al. BMC Nursing (2024) 23:13 Page 6 of 7

nursing students were found to be at an average level, nursing care mean scores were at an average level. To
and none of them obtained a satisfactory score. Provid- maintain the patient safety, nursing instructors and man-
ing safe care lies at the core of high-quality nursing care. agers are recommended to employ appropriate strategies
In the present study, the nursing students’ highest safe to improve medication safety competence and safe nurs-
care score belonged to nursing skills, followed by physical ing care in nursing students. It appears that employment
safety of the patient, teamwork, and finally psychological of better learning and teaching approaches to medication
safety of the patient. However, in studies by Kalantari [36] prescription and administration can improve the nursing
and Fotoohi [37], the best aspect of the nurses’ perfor- students’ professional performance as well as contribute
mance in terms of safety was related to physical safety of to the safety and quality of care.
the patient, followed by psychological safety, teamwork,
Abbreviations
and finally nursing skills, which is not consistent with the MSCS Medication Safety Competence Scale
findings of the present study. SNCS Safe Nursing Care Scale
As with safe nursing care, medication safety compe-
Acknowledgements
tence was found to be at an average level in many of the The authors would like to appreciate Fasa University of Medical Sciences &
nursing students and only a few (5.2%) obtained satis- Clinical Research Development Unit of Fasa Valiasr hospital for financially
factory scores. Pharmacotherapy, which is known as the supporting this research.

most common form of treatment, is a domain where Author contributions

most medical errors occur. Thus, medication safety com- MB was involved in the conception and organization of the study. ZM, AD,
petence should be stressed in nursing requirements. The and MB, were involved in the execution and data collection of the study; MB
and ZM participated in statistical analysis design and/or execution. All authors
results of a study by Fernandeze et al. are in line with contributed to the preparation, critical review and all of them approved the
these findings and verify that nursing students are prone final manuscript.
to medication errors in field training programs, which
Funding
poses a threat to patients’ safety. Therefore, it is essen- This research did not receive any specific grant from funding agencies in the
tial that measures should be taken to manage and reduce public, commercial, or not for profit sectors.
such errors [38].
Data availability
The datasets generated and/or analysed during the current study are not
Limitations publicly available due to the necessity to ensure participant confidentiality
In the present study, only undergraduate nursing stu- policies and laws of the country but are available from the corresponding
author on reasonable request.
dents participated; it is recommended that the study be
conducted on nursing graduate students as well. Also,
Declarations
this study was conducted in the south of Iran; it is also
suggested that research be carried out in other regions Ethics approval and consent to participate
of Iran and other countries as well. Also, given that few All participants gave written informed consent to participate in the study.
The present study was conducted based on the principles of the revised
studies have been conducted in the field of medica- Declaration of Helsinki, which is a statement of ethical principles that directs
tion safety competence and safe nursing care in nursing physicians and other participants in medical research involving human
students, the authors had limitations in comparing the subjects. The participants were assured of their anonymity and confidentiality
of their information. The study was also approved by the Institutional Research
results of this study with those of other investigations. Ethics Committee of Fasa University of Medical Sciences, Fasa, Iran (Ethical
code: (IR.FUMS.REC.1401.109)
Strengths
Consent to publish
This is the first study in Iran conducted to investigate safe Not applicable.
nursing care and medication safety competence in nurs-
ing students, which is a novelty. Also, one of the strengths Competing interests
The authors declare that they have no competing interests.
of this study has been the use of a comprehensive and
specific questionnaire (Medication Safety Competence Received: 30 July 2023 / Accepted: 21 December 2023
Scale) for assessing the competence of pharmaceutical
safety, which has been translated and validated in Iran.

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