Medication Calculations Competency among Nurses: A Cross- sectional Study

Kholood E. Al-Nbabteh1, Ayman M. Al-Qaaneh2,3*, Fida'a E. Al-Shatnawi1, Fuad O. Abdullah4,5, Heba N. Hudhud6, Muna S. Al-Kharabsheh6


1Department of Midwifery, Faculty of Nursing, Al-Balqa Applied University (BAU), Al-Salt 19117, Jordan

2Department of Allied Health Sciences, Al-Balqa Applied University (BAU), Al-Salt 19117, Jordan

3Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology (JUST), Irbid 22110, Jordan

4Department of Chemistry, College of Science, Salahaddin University-Erbil, Kurdistan Region, Erbil, Iraq

5Department of Pharmacy, Tishk International University, Erbil, Kurdistan Region, Erbil, Iraq

6Department of Nursing, Faculty of Nursing, Al-Balqa Applied University (BAU), Al-Salt 19117, Jordan

*Corresponding author’s Email: ayman.alqennh@bau.edu.jo; alqunneh@yahoo.com


ABSTRACT


Background: Medication calculation, dispensing, and administration are one of the major tasks of nurses, and medication errors (MEs) are one of the most common errors in the medical field, where some of these errors are fatal. ME can be attributed to many causes, such as medication dosage calculation errors. Accordingly, this study aims to assess Jordanian nurses` competency regarding medication calculation and its associated factors. Methods: A descriptive cross-sectional study design was used to assess the medication calculation skills of 126 registered nurses in Jordan, representing different departments of three governmental hospitals. Nurses’ dosage calculation skills were evaluated using a self-administered Nursing Medication Calculation Competency Tool (NMCCT) prepared by eXperts in nursing practice assessing nurses’ medication calculation competency in oral, parenteral, and intravenous flow rate. Data was collected; data entry was done on a Microsoft Office EXcel sheet and analysed using SPSS 25.0. Results: The study found that 95% of nurses (n = 120) did not receive mathematical education during their nursing program, and 84.9% (n = 107) reported no medication calculation competency programs at their hospitals. Additionally, 79.7% (n = 113) had not attended any such courses post-graduation, and 90.5% reported a lack of medication administration guidelines at their hospitals. Competency was highest for oral medication calculations (65.1%), followed by intravenous flow rates (57.9%) and parenteral/intravenous medications (48.9%). Only 27.8% (n = 35) were competent in all three areas. Significant factors affecting competency were nurse age, availability of programs, and post-graduation courses (p = 0.045, <0.001). Conclusion: Nursing curricula and continuing education programs should recognize pharmaceutical education, including drug calculation skills, as an essential part of their content. Also, the researchers encourage the adoption of a national-wide learning/competency program that is able to assess the level of competency, track gaps in medication calculation skills, and provide a supportive learning program in this aspect as needed.


Keywords: Medication Errors; Medication Calculations; Nursing Competency; Nursing Education; Nursing Skills

INTRODUCTION

Medication calculation, dispensing, and administration are some of the major tasks of nurses. And medication errors (MEs) are one of the most common errors in the medical field, where some of these errors are fatal (Gage & Preuss, 2024; Linden-Lahti et al., 2021). ME is defined as “any error in the prescribing, supply, preparation, administration, or monitoring of a medication, regardless of whether such errors lead to adverse consequence” (Al-Qaaneh et al. 2022 b; Westbrook et al., 2016). ME can be related to various causes such as inappropriate practice, health care products, procedures, and systems, including prescribing, order communication, labeling, packaging, and nomenclature, dispensing, distribution, administration, education, monitoring, and use, and can happen at any of the following stages: prescription, transcription, preparation, dispensing, administration, and/or monitoring (Breuker et al., 2021; Lu et al., 2023). It is estimated that the annual cost of medication harm was €4.5–21.8 billion in Europe, which accounts for more than half of the overall preventable harm in medical care globally (Al-Qaaneh et al., 2022a; Hodkinson et al., 2020). Additionally, one study reported 237 million medication errors over a year in one country; 66 million of those errors are potentially clinically significant, and the estimated costs for the government in avoidable adverse reactions to medication are £98.5 million a year (Al-Qaaneh & Al-Ghamdi, 2021; Elliott et al., 2021).


The Norwegian incident reporting system demonstrated that dosage errors are the most frequently reported medication errors, accounting for 38% of all errors (Mulac, Hagesaether & Granas, 2022). Several studies have reported that dosage errors are common and have eXplored medication dose calculation errors as a subtype of dosage errors (Aronson, 2009; Keers et al., 2013). Mulac, Hagesaether & Granas (2022) analysed 100 incident reports from 2016 to 2017 from the Norwegian reporting system and reported that 77% of calculation errors are associated with the parenteral route, and 20% were associated with the oral route. Most errors (70%) involved intravenous administration route, where 52% were intravenous infusions, 18% were intravenous injections, and 7% were subcutaneous injections. Errors associated with the oral administration route involved tablet/capsule (11%) and liquid oral formulations (9%). The researchers reported that omission of double checks, lack of safety barriers to intercept prescribing errors, and emergency/stress are the most frequent error enablers (Mulac, Hagesaether & Granas, 2022). Medication errors may cause loss of drug efficacy, increased incidence and or severity of side effects to serious side effects, including death (Mulac, Hagesaether & Granas, 2022; Wijaya et al., 2019). On the other hand, in a review conducted by Sherriff, Wallis & Burston (2011), it is demonstrated that a large number of international papers have identified that many nurses lack sufficient skills to calculate drug dosages correctly, raising concern about the mathematical skills and preparedness of nurses and nurses` students to nursing practice.


In Jordan, a systematic review reported that medication prescribing errors were the most common errors in clinical healthcare settings. The prevalence of prescribing errors ranged from 0.1% to 96%, where the prevalence of unintentional discrepancies ranged from 47% to 67.9%, and the prevalence of documentation errors ranged from 33.7% to 65%, which reflects a wide variation in the error prevalence rates in Jordanian healthcare settings (Rababa'h et al., 2022). On the other hand, a recent study conducted in Jordan by Rabadi et. al. reported that nurses who had the lowest experience (0–5 years) were the highest in committing MEs. Otherwise, gender, age, and education were not significantly associated with MEs, and the most common causes of medication error were setting the infusion devices incorrectly, distraction, labeling, and packaging problems (Alrabadi et al., 2020). Another study conducted by Mrayyan, Shishani and AL‐Faouri (2007) in Jordan found that female nurses reported a higher number of medication errors than male nurses. The researchers concluded that gender was the only predictable factor of ME in Jordan (Alrabadi et al., 2020). Most studies that were conducted in Jordan assessed the prevalence and nurses` knowledge, attitude, and perceived causes of medication errors. Calculation-related errors and nurses` competencies are hardly investigated in the literature. To the best of the knowledge, this is the first study conducted in Jordan that assesses the nurses’ competencies in medication calculation and the associated factors. Therefore, the purpose of the current study is to assess Jordanian nurses` competency regarding medication calculation and its associated factors.


METHODOLOGY


Study Design

A descriptive cross-sectional study design was used to assess the medication calculation skills of nurses in Jordan.


Study Setting and Population

This study was conducted in 3 different hospitals located in different governorates in Jordan. Participants were recruited from different departments of the hospitals, mainly medical, surgical, intensive care unit (ICU), cardiac care unit (CCU), neonates, paediatrics, and emergency departments. Forty-two registered nurses were selected from each hospital using a convenient sampling technique, making a total sample of 126 nurses.


Inclusion criteria are: (i) registered nurse with a diploma of three years, bachelor, or postgraduate degree in nursing. (ii) having continuous work eXperience in the specified department for more than three months. The exclusion criteria are (i) any nurse with three or less than three months of continuous experience in the specified department (ii) part-time nurses or (iii) nurse did not complete the distributed questionnaire.


Data Collection Tool

To measure nurses’ competency toward medication dosage calculation, a tool was developed by eXperts in the nursing fields, representing academicians and head nurses with more than 10 years of eXperience in their respective fields. The validity of the tool was assessed by ten eXperts representing different departments of nursing. Pilot testing was conducted to check the reliability of the tool, for which Cronbach’s alpha value was found to be 0.81.


Data Collection

The Nursing Medication Calculation Competency Tool (NMCCT) consists of four sections; section I: 12 items assess nurses’ demographic data, including but not limited to if the nurse received any mathematical education during his/her nursing program education, availability of medication calculation competency program at his/her hospital, if the nurse attended any medication calculation course/program after graduation, availability of medication administration guidelines at the hospital, and how the participating nurse rated himself/herself in medication calculations. Sections II-IV are twelve open-ended medication calculation questions that measure nurses’ competency in different dosage forms. Section II (four questions): access nurses’ competency in oral medication dosage calculation. Section III (four questions): access nurses’ competency in parenteral/intravenous medication dosage calculation. Section IV (four questions): access nurses’ competency in intravenous flow rate calculation. The range of score of Section II-IV is 0-12 (if answered correctly, the nurse will receive 1 grade, but if answered wrong, the nurse will receive zero grade). If the nurse answered all four questions in the selected section correctly, then he/she is considered competent in that section. Otherwise, the nurse is considered incompetent in that section. Furthermore, the nurse is considered competent in medication dosage calculation if he/she is competent in the three domains of the tool.


Data was collected from nurses working in different hospitals in Jordan. Participants were reached at the hospitals and were briefed about the research study by the principal researcher. Those nurses who were ready to participate in the study were asked to read the informed consent thoroughly and give formal consent for participation. Questionnaires were self-administered by the participants and were collected from the respondents after completion. After data collection, data entry was done on a Microsoft Office Excel sheet.


Data Analysis

The categorical variables are presented as absolute numbers and percentages. Continuous variables are presented as mean ± standard deviation (SD). Differences in the numbers of competent nurses and noncompetent nurses in relation to different demographics were assessed by the Chi-square test of independence or Fisher's exact test as appropriate (Obeidat, Qan’ir, & Turaani, 2018). In contrast, the chi-square goodness-of-fit test was used to assess the difference between the studied categorical variables vs. pre-identified value. A post hoc chi-square test using a Bonferroni-corrected p-value was utilized to determine the exact pair responsible for the significance as appropriate. All conducted tests were two-tailed and considered significant when p-value <0.05. No imputations were made for missing data points. All data used in the study were analysed using SPSS 25.0 (IBM SPSS Statistics for Windows, Version 25.0, IBM Corp., Armonk, NY, USA).


Ethical Consideration

Research approval for the current study was obtained from the Ethical Committee of Al-Balqa Applied University, Jordan with reference number 26/03/01/2280 on 21st November, 2023. Also, ethical approvals were obtained from Ministry of Health, Jordan reference number AB/Ethics/20005 on 21st December, 2023 before the questionnaire distribution and data collection process.


RESULTS

Demographical Data of Sample

A total of 152 questionnaires have been distributed in the participating hospitals, and 133 have been retrieved, with retrieval percent equal to 87.5%. Among the retrieved questionnaires, 7 have been eXcluded due to incomplete demographic data, which keeps 126 questionnaires for analysis. Incomplete or missing calculations are considered as wrong answers and were included in the analysis.


Out of 126 nurses who filled out the questionnaire, 53.2% of them were female (n = 59). However, there was no significant difference between males and females in terms of participation. Most of the nurses were younger than 35 years (n = 82, 62.7%), and 86.5% of the participating nurses have a bachelor’s degree in nursing (n = 109). The study showed 94 (75%) nurses reported having an experience of 15 years or less. Regarding the working department, ICU/CCU nurses represented the largest participating nurses (34.9%), followed by ER nurses, medical-surgical, neonates, and paediatrics department nurses. Results showed that 95% of participating nurses (n = 120) did not receive any mathematical education during their university nursing program education, and 84.9% (n = 107) reported absence of a medication calculation competency program at their respective hospitals. 113 nurses (89.7%) did not attend any medication calculation courses or programs after graduation, and 90.5% of the participating nurses reported the unavailability of medication administration guidelines at their hospitals, which can be checked when needed. Detailed demographic data are presented in Table 1.


Table 1: Demographical Data of the Participating Nurses

Parameter

n (%)

X2 (df, N)

p-value

Demographical Data (n = 126)

Gender

Male (n, %)

59 (46.8%)

X2 (1, 126) =

0.508

0.476

Female (n, %)

67 (53.2%)


Age group

≤ 25

31 (24.6%)


X2 (4, 126) =

40.825


<0.001***

26-35

48 (38.1%)

36-45

25 (19.8%)

46-55

17 (13.5%)

≥ 56

5 (4.0%)

Academic level of nursing education

Diploma degree (3 years)

8 (6.3%)

X2 (2, 126) =

160.333


<0.001***

Bachelor’s degree

109 (86.5%)

Postgraduate degree

9 (7.1%)

Total years of eXperience as a nurse

≤ 5 years

47 (37.3%)


X2 (3, 126) =

30.762


<0.001***

6-15 years

47 (37.3%)

16- 25 years

18 (14.3%)

26- 35 years

14 (11.1%)


Main work

department

Emergency department

27 (21.4%)


X2 (4, 126) =

30.587


<0.001***

ICU/ CCU

44 (34.9%)

Medical/ Surgical department

31 (24.6%)

Neonates’ department

16 (12.7%)

Paediatric department

8 (6.3%)

Main patients served

Neonates

42 (33.3%)

X2 (2, 126) =

0.762


0.683

Paediatrics

38 (30.2%)

Adults

46 (36.5%)

Did you receive any mathematical education during your nursing program

education?

Yes

6 (4.8%)


X2 (1,126) =

103.143


<0.001***


No


120 (95.2%)

Do you have a continuous medication calculation competency program

at your hospital?


Yes


19 (15.1%)


X2 (1, 126)

=61.460


<0.001***


No


107 (84.9%)

Did you attend any medication calculation courses/programs

after graduation?

Yes

13 (10.3%)


X2 (1,126) =

79.365


<0.001***

No

113 (89.7%)

At your hospital, do you have medication

administration


Yes


12 (9.5%)

X2 (1,126) =

82.571


<0.001***

guidelines that can be checked/ referred

once needed?


No


114 (90.5%)



How do you rate your medication calculation skills/ Capabilities

Poor

3 (2.4%)


X2 (3,126) =

107.968


<0.001***

Fair

6 (4.8%)

Good

74 (58.7%)

EXcellent

43(34.1%)


Level of Medication Calculations Competency among Nurses


Descriptive statistics revealed that the highest level of medication competency was obtained for oral medications (65.1%), followed by intravenous flow rate calculation (57.9%), then parenteral/intravenous medication calculation (48.9%) and 27.8% (n = 35) reported to be competent in the three aspects described in Table 2 and Figure 1.


Table 2: Level of Medication Calculations Competency among Nurses

Disciplines

Non-competent (n %)

Competent (n %)

Oral medication

44 (34.9%)

82 (65.1%)

Parenteral/intravenous medication

65 (51.6%)

61 (48.4%)

Intravenous flow rate calculations

53 (42.1%)

73 (57.9%)

Overall medication calculation competency

91 (72.2%)

35 (27.8%)


image

Figure 1: Level of Medication Calculation Competency among Nurses (A: Oral Medication; B: Parenteral/Intravenous Medication; C: Intravenous Flow Rate; D: Overall Medication Calculation Competency)


Oral Medication Dosage Calculations Competency


A Bonferroni-adjusted post hoc test revealed that nurses with age groups ≥ 59 years are statistically significant incompetent in oral medication dosage calculation (p =0.0018). Furthermore, nurses who attended a medication calculation course or program after graduation showed a statistically higher level of competency toward oral medication (p = 0.033). On the other hand, there were no statistical differences in oral medication dosage calculation competency in terms of gender, academic level of nursing education, total years of eXperience, main work department, main patients served, receiving mathematical education during nursing program education, availability of continuous medication calculation competency program at participated hospitals, and availability of medication administration guidelines (Table 3).


Parenteral/Intravenous Medication Dosage Calculations Competency

Male nurses who attended medication calculation courses/programs after graduation showed a significantly higher level of competency toward parenteral/intravenous medication dosage calculations (p =0.03 and p<0.001, respectively). However, other factors showed no significant impact on nurses’ parenteral/intravenous medication dosage calculation competency in (Table 3).


Intravenous Flow Rate Calculations Competency

The person chi-square test revealed that the main work department has a significant effect on the nurses’ competency in the intravenous flow rate calculation (p =0.037). However, the Bonferroni adjusted post hoc test couldn’t reveal the reason for this significance. On the other hand, other factors showed no significant impact on intravenous flow rate calculation competency in Table 3.


Table 3: Comparison in Medication Calculation Competency among Nurses Using Different Parameters


Competency

Parameter

Non- competent

(n, %)

Competent (n, %)


X2 (df, N)a


p-value


Oral Medication Dosage Calculation Competency

Gender

Male (n, %)

19 (32.2%)

40 (67.8%)

X2 (1, 126) =

0.360

0.579a

Female (n, %)

25 (37.3%)

42 (62.7%)


Age group

≤ 25

11 (35.5%)

20 (64.5%)


X2 (4, 126)=14.90


0.004**a

26-35

14 (29.2%)

34 (70.8%)

36-45

5 (20.0%)

20 (80.0%)

46-55

9 (52.9%)

8 (47.1%)

≥ 56

5 (100.0%)

0 (0.0%)

Academic level of nursing education

Diploma degree (3

years)

3 (37.5%)

5 (62.5%)



0.780b

Bachelor’s degree

39 (35.8%)

70 (64.2%)

Postgraduate

2 (22.2%)

7 (77.8%)



degree





Total years of eXperience as a nurse

≤ 5 years

16 (34.0%)

31(66.0%)


X2 (3, 126)=6.277


0.102a

6-15 years

14(29.8%)

33 (70.2%)

16- 25 years

5 (27.8%)

13 (72.2%)

26- 35 years

9 (64.3%)

5 (35.7%)


Main work department

Emergency

department

11 (40.7%)

16 (59.3%)


X2 (4, 126)=1.034


0.909a

ICU/ CCU

16 (36.4%)

28(63.6%)

Medical/ Surgical

department

9 (29.0%)

22 (71.0%)

Neonates

department

5 (31.3%)

11 (68.8%)

Paediatric

department

3 (37.5%)

5 (62.5%)

Main patients served

Neonates

19 (45.2%)

23 (54.8%)


X2 (2, 126)=5.267


0.077a

Paediatrics

8 (21.1%)

30 (78.9%)

Adults

17 (37.0%)

29 (63.0%)

Did you receive any

mathematical education during your nursing program

education?

Yes

3 (50.0%)

3 (50.0%)



0.420b


No


41 (34.2%)


79 (65.8%)

Do you have a continuous medication calculation competency program at your

hospital?

Yes

4 (21.1%)

15 (78.9%)


X2 (1, 126)=1.893


0.201a


No


40 (37.4%)


67 (62.6%)

Did you attend any medication calculation courses/programs

after graduation?

Yes

1 (7.7%)

12 (92.3%)



0.033*b


No


43 (38.1%)


70 (61.9%)

At your hospital, do you have medication administration guidelines that can be checked/ referred once

needed?

Yes

6 (50.0%)

6 (50.0%)



0.340b


No


38 (33.3%)


76 (66.7%)

How do you rate your medication calculation skills/ Capabilities

Poor

2 (66.7%)

1 (33.3%)



0.182b

Fair

0 (0.0%)

6 (100.0%)

Good

26 (35.1%)

48 (64.9%)

EXcellent

16 (37.2%)

27 (62.8%)

Parenteral/Intravenous Medication Dosage

Calculation Competency

Gender

Male (n, %)

24 (40.7%)

35 (59.3%)

X2 (1, 126)=

5.287

0.032*a

Female (n, %)

41 (61.2%)

26 (38.8%)


Age group

≤ 25

15 (48.4%)

16 (51.6%)


X2 (4, 126)=2.021


0.751a

26-35

25 (52.1%)

23 (47.9%)

36-45

11 (44.0%)

14 (56.0%)

46-55

11 (64.7%)

6 (35.3%)

≥ 56

3 (60.0%)

2 (40.0%)

Academic level

Diploma degree (3

3 (37.5%)

5 (62.5%)


0.631b


of nursing education

years)





Bachelor’s degree

58 (53.2%)

51 (46.8%)

Postgraduate

degree

4 (44.4%)

5 (55.6%)

Total years of eXperience as a nurse

≤ 5 years

25 (53.2%)

22 (46.8%)


X2 (3, 126)=1.963


0.601a

6-15 years

21 (44.7%)

26 (55.3%)

16- 25 years

10 (55.6%)

8 (44.4%)

26- 35 years

9 (64.3%)

5 (35.7%)


Main work department

Emergency

department

11 (40.7%)

16 (59.3%)


X2 (4, 126)=3.903


0.428a

ICU/ CCU

25 (56.8%)

19 (43.2%)

Medical/ Surgical

department

16 (51.6%)

15 (48.4%)

Neonates

department

7 (43.8%)

9 (56.3%)

Paediatric

department

6 (75.0%)

2 (25.0%)

Main patients served

Neonates

22 (52.4%)

20 (47.6%)

X2 (2, 126)

=3.830


0.151a

Paediatrics

15 (39.5%)

23 (60.5%)

Adults

28 (60.9%)

18 (39.1%)

Did you receive any

mathematical education during your nursing program

education?

Yes

2 (33.3%)

4 (66.7%)



0.429b


No


63 (52.5%)


57 (47.5%)

Do you have a continuous medication calculation competency program at your

hospital?

Yes

7 (36.8%)

12 (63.2%)


X2 (1, 126)

=1.948


0.214a


No


58 (54.2%)


49 (45.8%)

Did you attend any medication calculation courses/programs

after graduation?

Yes

1 (7.7%)

12 (92.3%)


X2 (1, 126)

=11.183


<0.001***a


No


64 (56.6%)


49 (43.4%)

At your hospital, do you have medication administration guidelines that can be checked/ referred once

needed?

Yes

5 (41.7%)

7 (58.3%)


X2 (1, 126)

=0.523


0.552a


No


60 (52.6%)


54 (47.4%)

How do you rate your medication calculation skills/ Capabilities

Poor

1 (33.3%)

2 (66.7%)



0.928b

Fair

3 (50.0%)

3 (50.0%)

Good

38 (51.4%)

36 (48.6%)

EXcellent

23 (53.5%)

20 (46.5%)

Intravenous

Flow Rate Calculation Competenc

y

Gender

Male (n, %)

26 (44.1%)

33 (55.9%)

X2 (1, 126)=

0.183

0.720a

Female (n, %)

27 (40.3%)

40 (59.7%)


Age group

≤ 25

16 (51.6%)

15 (48.4%)


X2 (4, 126)=6.545


0.163a

26-35

24 (50.0%)

24 (50.0%)

36-45

7 (28.0%)

18 (72.0%)



46-55

5 (29.4%)

12 (70.6%)



≥ 56

1 (20.0%)

4 (80.0%)

Academic level of nursing education

Diploma degree (3

years)

2 (25.0%)

6 (75.0%)



0.576b

Bachelor’s degree

48 (44.0%)

61 (56.0%)

Postgraduate

degree

3 (33.3%)

6 (66.7%)

Total years of eXperience as a nurse

≤ 5 years

18 (38.3%)

29 (61.7%)


X2 (3, 126)=5.939


0.116a

6-15 years

17 (36.2%)

30 (63.8%)

16- 25 years

8 (44.4%)

10 (55.6%)

26- 35 years

10 (71.4%)

4 (28.6%)


Main work department

Emergency

department

7 (25.9%)

20 (74.1%)


X2 (4,

126)=10.100


0.037*a

ICU/ CCU

15 (34.1%)

29 (65.9%)

Medical/ Surgical

department

18 (58.1%)

13 (41.9%)

Neonates

department

10 (62.5%)

6 (37.5%)

Paediatric

department

3 (37.5%)

5 (62.5%)

Main patients served

Neonates

18 (42.9%)

24 (57.1%)


X2 (2, 126)=0.153


0.948a

Paediatrics

15 (39.5%)

23 (60.5%)

Adults

20 (43.5%)

26 (56.5%)

Did you receive any

mathematical education during your nursing program

education?

Yes

4 (66.7%)

2 (33.3%)



0.238b


No


49 (40.8%)


71 (59.2%)

Do you have a continuous medication calculation competency program at your

hospital?

Yes

5 (26.3%)

14 (73.7%)


X2 (1, 126)=2.277


0.207a


No


48 (44.9%)


59 (55.1%)

Did you attend any medication calculation courses/programs

after graduation?

Yes

2 (15.4%)

11 (84.6%)


X2 (1, 126)=4.234


0.072a


No


51 (45.1%)


62 (54.9%)

At your hospital, do you have medication administration guidelines that can be checked/ referred once

needed?

Yes

5 (41.7%)

7 (58.3%)


X2

(1, 126)=0.001


1.000a


No


48 (42.1%)


66 (57.9%)

How do you rate your medication calculation skills/ Capabilities

Poor

1 (33.3%)

2 (66.7%)



0.641b

Fair

1 (16.7%)

5 (83.3%)

Good

31 (41.9%)

43 (58.1%)

EXcellent

20 (46.5%)

23 (53.5%)

a Person Chi-Square test; b Fisher’s EXact Test


DISCUSSION

Ozyazicioglu et al. (2018) reported that the ability of nurses to calculate and deliver the medications properly is a highly developed skill. Based on the results of this research, there are many identified factors affecting medication calculation skills among nurses, which is considered one of the challenging issues in safe medication administration practice. Also, the focus is on the factors that can improve nurses' medication calculation accuracy which will have a significant impact on decreasing medication errors (Sherriff, Wallis & Burston, 2011; Wright, 2010). This research highlights the factors that may affect nurses' competency regarding medication calculation skills, whether demographic factors or work-related factors.


The present study revealed that 72.2 % of registered nurses failed the drug calculation ability, and 65.1% of nurses are competent in oral medication dosage calculations, followed by Intravenous flow rate medication calculations (57.9%), and then parenteral/ intravenous medication dosage calculations (48.4%). The results of this study were similar to previous studies found that nurses were more competent in tablet calculations and fluid dosage calculations than they did on drip rates (Cousins et al., 2005; Han, Coombes & Green, 2005). Although the highest level of competence was among nurses in emergency departments and critical care units (67% competency), the significance level couldn’t be determined. The current study showed that only 28% of nurses are competent, which is similar to McMullan et al. who reported that only 11% of registered nurses were competent in drug calculation test (McMullan, Jones & Lea, 2010).


On the other hand, the current study found that the majority of nurses did not receive any mathematical education during their university nursing program education, didn’t attend any medication calculation courses or programs after graduation, and their respective departments didn’t have any specific competencies about medication calculation, which were in alignment with Elliott et al. (2021) studies, who reported that the teaching and evaluation of medication calculation skills with frequent practice and assessment throughout the undergraduate program had shown a significant increase in nurses' calculating skills (Elliott & Joyce, 2005; McMullan, Jones & Lea, 2010). Also, Fleming, Brady and Malone (2014) studied that 4% of nurses achieved a perfect score and 60% of nurses answered correctly, which attributed to the time spent by the nurses in learning these calculations in universities as well as the time spent in hospital training on these skills (Fleming, Brady & Malone, 2014). However, there are still no international or national standards dictating how much or how little medication calculation should be covered in undergraduate nursing programs (McMullan, Jones & Lea, 2010). On the other hand, another study reported that only 45% of registered nurses in a university program did not pass the medication mathematics eXam (McMullan, Jones & Lea, 2010). Accordingly, studies encouraged the nurses to take medication calculation courses/programs before graduation within the nursing curriculum or attend any training courses after graduation, especially when they are at the top of their work in hospitals (Fleming, Brady & Malone, 2014; McMullan, Jones & Lea, 2010). Many studies have shown that nursing curricula and continuing education programs have insufficient teaching content regarding medication calculation skills, and they still focus on pharmacology knowledge rather than actual clinical practice (Dilles et al., 2011; Grandell-Niemi et al., 2005; Koohestani & Baghcheghi, 2010). Another suggested method to enhance medication calculation skills after graduation is by adopting hospital as well as national protocols for maintaining competencies in medication calculations. This suggestion is assessed by Tromp, Natsch & van Achterberg (2009), who reported that applying such a protocol reduced errors in the preparation and administration of intravenous medications significantly. Nowadays, annual medication calculation competency for nurses is part of Joint Commission International Accreditation requirements (Al- Sayedahmed et al., 2023).


The results of this study might help in conducting an orientation program that provides training on medication calculation for the newly employed nurses and a continuous education program for all nurses in all hospital wards, as well as might help in remodelling the nursing curriculum of nursing bachelor programs at Jordanian universities to provide nurses with required medication calculation skills. This eventually may help in improving the level of competency of nurses regarding medication calculations, reducing the incidence of medication errors, and enhancing the quality of healthcare systems and patients’ safety, which is the goal of the healthcare institutions.


Limitations

The study limitations include a small sample size, and the selected sample did not reflect all country regions. Also, the current study did not include nurses working in outpatient settings and clinics.


CONCLUSION

The present study revealed that nurse age, availability of continuous medication calculation competency programs, and attending medication calculation courses/programs after graduation are significantly associated with nurses' skills/competency regarding medication calculation. Accordingly, the study suggests that nursing curricula and continuing education programs should recognize pharmaceutical education, including drug calculation skills, as an essential part of their content. Furthermore, the researchers encourage the adoption of a national-wide learning/competency program that is able to assess the level of competency, track gaps in medication calculation skills, and provide a supportive learning program in this aspect as needed. Further studies are needed to determine the eXact causes of medication calculation incompetency between nurses rather than knowledge insufficiency.


Conflict of Interest

The authors declare no competing interest.


ACKNOWLEDGEMENT

The authors are thankful to the Dean of the Faculty of Nursing, Al-Balqa Applied University, Al-Salt, Jordan for continuous support and encouragement.


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