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. 2022 Apr 26;32(5-6):789–798. doi: 10.1111/jocn.16330

Predicting behavioural intentions towards medication safety among student and new graduate nurses across four countries

Ritin Fernandez 1,2,3,✉, Wilma tenHam‐Baloyi 4, Elsheba Mathew 5,6, Selda Secginli 7, Zuhal Bahar 8, Carley Jans 3, Nursen Nahcivan Professor (Retired) 7, Gizemnur Torun 9, Samuel Lapkin 3, Heidi Green 1,2
PMCID: PMC10083919  PMID: 35475307

Abstract

Aims and objectives

To identify final‐year undergraduate students and new graduate nurses’ behavioural intentions towards medication safety across four countries.

Background

Medication errors are a common and avoidable occurrence, being costly for not only patients but also for health systems and society.

Design

A multi‐site cross‐sectional study.

Methods

A self‐administered survey was distributed to students and new graduate nurses in South Africa, India, Turkey and Australia. Descriptive statistics were calculated for all survey items. Multiple linear regressions were performed to predict behavioural intentions using the three Theory of Planned Behaviour constructs: attitudes, behavioural control and subjective norms. This study adheres to the STROBE guidelines.

Results

Data were analysed for 432 students and 576 new graduate nurses. Across all countries, new graduate nurses reported significantly higher scores on all the TPB variables compared with student nurses. Attitudes towards medication management were found significantly and positively related to intention to practice safe medication management for both student and new graduate nurses. Total perceived behavioural control was significantly and negatively related to intention to practice safe medication management for students.

Conclusion

Student and new graduate nurses showed favourable attitude, subjective norm, perceived behaviour control and intention in practising medication safety. However, differences in countries require further exploration on the factors influencing attitudes towards medication safety among student nurses and new nurse graduates.

Relevance to clinical practice

Understanding student and new graduate nurses’ medication administration practices is important to inform strategies aimed at improving patient safety. The findings of this study highlight the need for an internationally coordinated approach to ensure safe medication administration by student and new graduate nurses.

Keywords: attitudes, behavioural intentions, intention to practice, medication safety, new graduate nurses, student nurses

What does this Paper Contribute to the Wider Global Community?

  • This study demonstrated that across all countries new graduate nurses reported significantly higher behavioural intention towards medication safety than final‐year student nurses.

  • Developing effective medication training programmes, including the use simulation in undergraduate nursing programmes would enhance knowledge and skills, address attitudes towards medication safety and improve confidence in student nurses to practice safe medication management.

  • There are differences in countries that requires further exploration on the factors influencing attitudes towards medication safety among student and new nurse graduates.

1. INTRODUCTION

Within a hospital setting, medication is a common treatment for ill health and, when used appropriately, can make significant improvements in the lives of patients (Acheampong et al., 2014; Kim et al., 2020). Patient safety relies on the safe administration of medications, which is potentially a complex process performed by nurses and carries high risks including the liability for medication administration errors (Mulac et al., 2021). Medication errors are a common and avoidable occurrence, being costly for not only patients but also for health systems and society. The global financial burden of medication errors costs approximately USD 42 billion dollars annually, accounting for a total of 1% of all health expenditure globally (Donaldson et al., 2017). According to the World Health Organization (WHO), medication errors globally account for 20% of all medical errors (World Health Organization, 2017). In Australia, medication administration errors in hospital settings are reported as 5%–10%, with medication‐related admissions to hospitals accounting for 2%–3% of all hospital admissions (Khalil & Roughead, 2017; Roughead et al., 2013). Similarly, a study conducted in Turkey demonstrated that reported medication errors were 4.6%, with medication errors indicated to account for 10%–18% of all reported hospital injuries (Kiymaz & Koç, 2018; Küçük Alemdar & Yaman Aktaş, 2013). According to the Turkey Ministry of Health, National Safety Reporting System nurses are mostly responsible for medication errors (Çakmak et al., 2018). In South Africa, currently no real data on medication errors exist as there is no standardised medication error database to identify and quantify medication errors in hospitals except for voluntary reporting systems, as part of pharmacovigilance programmes (Schellack et al., 2020), but some research studies indicate medication errors to be high with multiple medication errors per patient, where administration errors and prescribing errors seem to be the highest (Blignaut et al., 2017; Gokhul et al., 2016; Truter et al., 2017), single medication error has the potential to increase hospital length of stay or even cause mortality.

2. BACKGROUND

Medication errors are a global issue and in 2017, WHO established the Global Patient Safety Challenge initiative, one of the goals within this initiative being a medication safety theme of ‘Medication without Harm’. To strengthen medication safety and reduce medication errors, this initiative has a goal of achieving a 50% reduction in severe and avoidable harm caused by medication errors globally within 5 years (World Health Organization, 2017). To achieve this, WHO has developed a strategic framework that focuses on four key areas: health care professionals; medicines; systems and practices of medication; and patients and the public (Donaldson et al., 2017).

Medication safety refers to the protection of patients from accidental harm and abstention from any preventable adverse event during medication administration, maximising the beneficial effects and minimising any adverse reactions (Maxwell & Webb, 2019; Sheikh et al., 2019). Administration of medications is multifaceted, requiring nurses to have specific knowledge and precision skills to prevent errors. However, medication errors can occur because of ineffective medication management systems, environmental conditions such as noise, staff shortages and other human‐related factors such as medication knowledge, inadequate attention and focus on the task, and fatigue (Isaacs et al., 2021). Improving medication errors relies on full disclosure, comprehensive reporting and investigation of the incident. Medication‐error reporting is strongly influenced by an individual's behaviour, pungently persuaded by their intention and ultimately predicted by their actual reporting behaviour (Gleeson et al., 2020). The theoretical framework, Theory of Planned Behaviour (TPB), developed by Ajzen (1985, 2011), is often used to explain and understand behaviours and attitudes of individuals, and has been used by many to comprehend medication safety practices (Secginli et al., 2021). According to the TPB, behaviour intention can be postulated through three social behaviours: attitudes, perceived behavioural control (PBC) and subjective norms (SN) (Ajzen, 1985, 2011). Attitudes refer to an individual's positive or negative personality when presenting a certain behaviour, whereas perceived behavioural control indicates the self‐assessment of an individual's skill to perform the desired behaviour (Ajzen, 2011; Omura et al., 2018). While subjective norms refer to how an individual perceives, they will be judged by another person when they perform a particular behaviour (Ajzen, 1985; Conner & Sparks, 2005). In the context of medication safety, subjective norm is a measure of how nurses perceive the opinions of other health professionals, patients, and family members or friends.

An instrument developed based on the TPB, the Theory of Planned Behaviour Medication Safety Questionnaire (TPB‐MSQ) is a valid and reliable tool used to evaluate health professionals’ behavioural intentions towards medication safety (Lapkin et al., 2015). Some studies have used the TPB‐MSQ to explore medication safety behavioural intentions. A study conducted by Natan et al. (2017) among nursing students in Israel identified that 78% expressed a high behavioural intention to report a medication error. Similarly, a study conducted by Williams et al. (2015) on hospital pharmacists in England found that they held strong intentions to report a medication error, with senior pharmacists more likely to report the error. While these studies provide significant insight into the behaviours of health professionals related to medication safety, TPB has not been extensively applied in the health field (Dionisi et al., 2020) and little research has been conducted across multiple countries or on recently graduated nurses using the TPB‐MSQ. Therefore, the aim of this study was to identify student and new graduate nurses’ behavioural intentions towards medication safety across four countries. The research questions were (1) what are the behavioural intentions of nursing students and new graduate nurses towards medication safety across four countries and (2) what are the predictors of intention to practice safe medication management among nursing students and new graduate nurses?

3. METHODS

3.1. Design

This study was undertaken using a cross‐sectional design in four universities and one teaching hospital in four countries: Australia, India, Turkey and South Africa. This study adheres to the STROBE guidelines for cross‐sectional studies (Appendix).

3.2. Participants

Participants were included in the study if they were final‐year undergraduate bachelor degree nursing students or new graduate nurses. For the purpose of this study, new graduate nurses were nurses who had less than one year of experience following graduating from a nursing school or college. Nursing students and new graduate nurses were excluded if they were on leave or unavailable during the study period. Students not in the final year of their study were excluded. Using convenience sampling, undergraduate nursing students were recruited from two universities each in Turkey and South Africa and one university in India, and new graduate nurses were recruited from the alumni register of one university in Turkey and a large tertiary teaching hospital in Australia.

3.3. Sample size calculation

The number of eligible students from the participating Universities in South Africa, Turkey and India was 150, 500 and 50, respectively. Similarly, the number of new graduate nurses from the participating hospitals in Turkey and Australia was 300 and 350, respectively. The sample size per group was calculated using the Qualtrics software and using 95% confidence level with a 5% margin of error. Hence, the sample sizes for the students were 108, 218 and 45 for South Africa, Turkey and India, respectively. For new graduate nurses, the sample sizes were 169 and 184 for Turkey and Australia, respectively.

3.4. Data collection

Support for the study was obtained from principals, heads of school and Directors of Nursing of the participating Universities and the hospital. Data collection was undertaken between February 2017–June 2018 in all countries and were coincided with students nearing the completion of the degree or new graduates commencing their career as a nurse. For all undergraduate students, a suitable timeslot was selected with the permission of the lecturer to approach the final‐year nursing students during one of their theoretical lectures and provide information about the research study. Students were given time in the class to complete the anonymous questionnaire. New graduate nurses were provided information about the study at their hospital orientation programme and offered opportunities to ask any questions and seek clarification. Participants were also informed that completion of the survey implied their consent for participation. Questionnaires were distributed following the provision of information about the study. Both students and new graduate nurses were requested to complete the questionnaire and place it in an allocated survey return box, which could be accessed only by the researchers.

Data collected included socio‐demographics including gender, age, and if they did or did not have previous experience in administering medications. For nursing students, experience in medication administration was measured based on previous experience during their clinical placements, or while employed in other nursing roles, such as enrolled nursing or assistant in nursing during their study. Participants’ behavioural intentions of the participants about medication safety were measured using the Theory of Planned Behaviour—Medication safety questionnaire (TPB‐MSQ) (Lapkin et al., 2015). The TPB‐MSQ comprises of four scenarios, focussing on behaviours relating to (1) managing medication errors, (2) open disclosure, (3) managing interruptions during prescribing and administration and (4) person centred care related to patient education. The TPB domains of attitudes (14 questions), behavioural control (14 questions), subjective norms (12 questions) and behavioural intentions (four questions) about medication safety and collaborative practice were assessed within the scenarios. The scoring of each question on the TPB‐MSQ is on a 1–7 scale where 1 represents strongly disagree and 7 strongly agree. The TPB‐MSQ has been validated in English and Turkish. The English version of the instrument has high internal reliability with a Cronbach's alpha 0.854. The reliability of the subscales within the TPB‐MSQ has Cronbach's alpha coefficients of 0.602 for attitude, 0.761 for perceived behaviour control and 0.580 for subjective norm. The Turkish version of the TPB‐MSQ has high internal consistency with a Cronbach's alpha of 0.88, and each of the subscales also indicating high reliability with a Cronbach's alpha of 0.72 for attitude, 0.76 for perceived behavioural control and 0.69 for subjective norm.

3.5. Data analysis

Data were analysed using IBM SPSS version 25.0 (SPSS, Inc.). Participants who had more than 50% of the data missing in the constructs were removed from the analysis. Items in each construct were reverse coded according to author guidelines. Summated scores were calculated for the four TPB constructs, namely attitude, SN, PBC and intention. Descriptive statistics including frequency, means and standard deviation were calculated. Differences in construct scores between the various countries were compared using t‐test and one‐way ANOVA adjusted for unequal sample sizes. Multiple linear regression analyses were used to regress the three independent variables of attitude, SN, PBC on the dependable variable, intention towards medication safety. A p‐value of <.05 was considered as statistically significant.

3.6. Ethical approval

Ethical approval was obtained from Human Research Ethics Committees of all the participating universities and hospitals in all four countries. South Africa: H17‐HEA‐NUR‐009, Turkey (Koc University Hospital): 2017.238.IRB3.132; Istanbul University Social Sciences and Humanities Ethics Committee (IRB number: 2017/118); Australia: (LNR/17/059 and 2017/506) and India: (IRB/01/2019).

4. RESULTS

4.1. Response rates

The overall response rate was 68%. The response rate per country for students was as follows: South Africa: 90% (135 from 150 students); Turkey: 50% (248 from 500 students); and India: 98% (49 from 50 students). The response rates per country for new graduates were Turkey: 52% (155 from 300 new graduate nurses) and Australia: 95% (331 from 350 new graduate nurses).

4.2. Demographic characteristics

Data were obtained from 456 students and 593 new graduate nurses from the four countries However, more than 50% of data relating to medication management were missing from 24 student and 17 new graduate nurses, and therefore, these participants were deleted from the analysis. The final data were analysed for 432 student nurses (South Africa n = 135, Turkey n = 248 and India n = 49) and 576 new graduate nurses (Australia n = 331; Turkey n = 245). Respondents in this study were predominantly females (90% student, 85.1% new graduate nurses). The South African students were significantly older than the Turkish and the Indian students (p < .0001), and there was no difference in age between the Australian and Turkish new graduate nurses (Table 1).

TABLE 1.

Demographic characteristics of participants

Students (n = 432) New graduate nurses (n = 576)
South Africa (n = 135) Turkey (n = 248) India (n = 49) Total (n = 432) Australia (n = 331) Turkey (n = 245) Total (n = 576)
n(%) n(%) n(%) n(%) n(%) n(%) n(%)
Gender a
Female 111 (84.1) 216 (91.1) 49 (100) 376 (90) 253 (81.1) 211 (90.6) 464 (85.1)
Male 21 (15.9) 21 (8.9) 0 42 (10) 59 (18.9) 22 (9.4) 81 (14.9)
Previous medication experience (yes) 89 (67.9) 214 (91.0) 43 (91.5) 346 (83.8) 132 (62.9) 216 (93.1) 348 (78.7)
Age (mean ± SD) 26.7 ± 6.5 22.3 ± 1.9 21.3 ± 0.6 23.6 ± 4.5 26 ± 6.8 25.6 ± 3.1 25.8 ± 5.5
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a

Missing data.

4.3. TPB model constructs

Overall, across all countries, new graduate nurses reported significantly higher scores on all the TPB variables compared to student nurses (Table 2).

TABLE 2.

TPB construct summary statistics

Constructs Students (n = 432) New graduate nurses (n = 576) p‐Value
Mean SD Mean SD
Total attitude 4.63 0.57 5.07 0.66 .00
Total PBC 4.97 0.69 5.36 0.66 .00
Total SN 4.77 0.63 5.18 0.76 .00
Total decision difficulty 5.36 1.03 5.65 0.92 .00
Total intention 2.63 0.74 2.97 0.72 .00
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4.4. Students TPB constructs

Turkish students (Mean 2.65, SD 0.72) reported a greater intention to behave in a manner that promoted medication safety compared to South African (Mean 2.59, SD 0.72) and Indian students (Mean 2.63, SD 0.88); however, these results were not statistically significant. South African students had significantly higher scores (Mean 4.73, SD 0.57) for attitudes towards medication management compared to students in Turkey (Mean 4.63, SD 0.54) and India (Mean 4.37, SD 0.68). South African (Mean 5.09, SD 0.71) and Turkish students (Mean 4.96, SD 0.66) also reported significantly greater perceived behavioural control scores compared to students in India (Mean 4.68, SD 0.69). South African students (Mean 4.90, SD 0.66) also reported significantly greater subjective norms scores compared to students in Turkey (Mean 4.71, SD 0.59) but not compared to Indian students (Table 3).

TABLE 3.

Students and new graduate nurses’ TPB construct according to country

Constructs Students New graduate nurses
South Africa (n = 135) Turkey (n = 248) India (n = 49) F Australia (n = 331) Turkey (n = 245) p
Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Total attitude 4.73 (0.57) 4.63 (0.54) 4.37 (0.68) 0.001 5.38 (0.48) 4.64 (0.62) .000
Total PBC 5.09 (0.71) 4.96 (0.66) 4.69 (0.69) 0.002 5.42 (0.66) 5.28 (0.67) .009
Total SN 4.90 (0.66) 4.71 (0.59) 4.74 (0.74) 0.019 5.52 (0.63) 4.71 (0.67) .000
Total intention 2.59 (0.72) 2.65 (0.72) 2.63 (0.88) 0.748 3.23 (0.61) 2.62 (0.71) .000
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4.5. Students’ predictors of intention to practice safe medication management

The multiple regression model to predict all students’ intention to practice safe medication management among students was significant and accounted for 14.1% of the variance, RAdj2 = .135, F (3,428) = 23.41, p = .000. For all students, attitudes towards medication management (β: 0.379; p < .0001) were found significantly and positively related and total PBC was found significantly and negatively related to intention to practice safe medication management (β: −0.190; p = .001) (Table 4).

TABLE 4.

Multiple regression analysis of students’ predictors of intention to practice safe medication management

Independent variables B‐coefficients Standardised beta t Sig. 95.0% Confidence interval for B Model statistics
Lower Upper
South Africa
(Constant) −0.71 −1.261 0.209 −1.822 0.403 R 2 = .230, F (3,131) = 13.05, p < .001
Total attitude 0.53 0.422 5.123 0.000** 0.326 0.736
Total PBC 0.05 0.045 0.468 0.641 −0.146 0.236
Total SN 0.11 0.105 1.141 0.256 −0.083 0.308
Turkey
(Constant) 1.16 2.765 0.006 0.335 1.991 R 2 = .162, F (3,244) = 15.8, p < .001
Total attitude 0.57 0.421 5.913 0.000** 0.377 0.754
Total PBC −0.30 −0.273 −3.83 0.000** −0.451 −0.145
Total SN 0.07 0.059 0.776 0.439 −0.112 0.256
India
(Constant) 2.20 2.133 0.038 0.123 4.279 R 2 = .133, F (3,45) = 2.3, p = .090
Total attitude 0.33 0.255 1.537 0.131 −0.102 0.76
Total PBC −0.42 −0.326 −2.093 0.042* −0.818 −0.016
Total SN 0.20 0.167 1.016 0.315 −0.196 0.596
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Abbreviations: PBC, perceived behaviour control; SN, subjective norms.

*p < .05; **p < .001.

For South African (β = 0.422; p < .0001) and Turkish students (β = 0.421; p < .0001), attitudes towards medication management were found significantly and positively related to intention to practice safe medication management. For Turkish (β = −0.273, p < .0001) and Indian students (β = −0.255, p = .042), PBC was found to be significantly and negatively related to intention to practice safe medication management (Table 4).

4.6. New graduate nurses TPB constructs

Australian new graduate nurses reported significantly greater intention to behave in a manner that promoted medication safety (Mean 3.23, SD 0.61), better attitudes towards medication management (Mean 5.38, SD 0.48), greater perceived behavioural control (Mean 5.42, SD 0.66) and higher subjective norms scores (Mean 5.52, SD 0.63) compared to Turkish nurses (Table 3).

4.7. New graduate nurses’ predictors of intention to practice safe medication management

The multiple regression model to predict all new graduate nurses’ intention to practice safe medication management was significant and accounted for 17.7% of the variance, RAdj2 = .173, F (3,572) = 49.144, p < .0001. Attitudes towards medication management were found to be significantly and positively related to intention to practice safe medication management (β = 0.376, p < .0001) (Table 5).

TABLE 5.

Multiple regression analysis of new graduate nurses’ predictors of intention to practice safe medication management

B‐coefficients Standardised beta t Sig. 95.0% Confidence interval for B Model statistics
Upper Lower
Turkey
(Constant) 0.88 2.231 0.027 0.103 1.653 R 2 = .115, F (3, 241) = 10.4, p = .000
Total attitude 0.41 0.36 4.714 0.000** 0.237 0.577
Total PBC 0.03 0.02 0.304 0.761 −0.136 0.186
Total SN −0.06 −0.06 −0.713 0.476 −0.226 0.106
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Abbreviations: PBC, perceived behaviour control; SN, subjective norms.

**p < .001.

For Australian nurses, the regression model was not significant. However, for Turkish nurses’ attitudes towards medication management were found significantly and positively related to intention to practice safe medication management (β = 0.407, p < .0001; Table 5).

5. DISCUSSION

This study described behavioural intentions towards medication safety among final‐year nursing students and new graduate nurses’ across four countries: Australia, India, Turkey, and South Africa. The study results show that when comparing both groups of participants; overall, across all countries new graduate nurses reported significantly higher scores on all the TPB variables compared to student nurses. This finding could be explained as graduate nurses are independent practitioners who have to carry full responsibility and accountability towards medication safety and have to take on a critical role to prevent medication errors as opposed to student nurses who are still being regarded as learners (Durham, 2015). Further, graduate nurses have more clinical experience regarding prescribing, transcribing, dispensing, administering and monitoring of medication as compared to final‐year student nurses. Increased medication errors by student nurses have been attributed to lack of clinical experience, knowledge and skills (Musharyanti et al., 2019; Selig, 2020; Ulku Gunes et al., 2020).

Furthermore, our study found that student participants from some countries showed greater intention to behave in a manner that promoted medication safety than participants from other countries, which was reflected in significantly higher scores in terms of attitudes towards medication management, as well as behavioural control. For example, South African students had significantly higher scores for attitudes towards medication management compared to students in Turkey and India, and both South African and Turkish students had higher perceived behavioural control scores compared to students in India. The difference in scores could be attributed to the emphasis that is placed on practising as a safe practitioner in the South African nursing curriculum along with the vast amount of clinical exposure these students have with a compulsory minimum of 4000 clinical hours over a 4‐year period (South African Nursing Council, 2005). By contrast, Indian students have limited experience in administering medications, as they mainly experience observational knowledge (Fusco et al., 2021), with students feeling that reporting medication errors may not be completely within their control. In Turkey, students give medications under the supervision of a registered nurse. Empowering students through role playing and role modelling a clinical scenario may improve their attitudes (Cebeci et al., 2015). A strategy for students can be simulation‐based nursing education that gives students opportunities to gain real‐life situational experience, which can improve their attitudes (Lapkin et al., 2015). A study conducted in the United States examined stimulation‐based medication learning in combination with a theoretical based course for nursing students compared to theoretical learning only. The findings showed that nursing students using the simulation‐based medication learning had more confidence and competence compared with nursing students who had theoretical learning only. Nursing students who participated in the theoretical learning only reported more medication errors (Lee & Quinn, 2019).

Developing effective medication training programmes, including the use of high‐fidelity simulation in undergraduate nursing programmes, would thus be recommended, as these have been found to not only enhance knowledge and skills but also address attitudes towards medication safety and confidence in student nurses to practice safe medication management (Bull et al., 2017; Musharyanti et al., 2021). The use of innovative approaches such as multimedia resources and e‐learning activities for teaching may also improve attitudes (Omura et al., 2018). Further, previous studies have suggested interprofessional education (IPE) as a method for influencing the attitudes of health professional students to promote communication, collaboration and medication safety (Lapkin et al., 2015). IPE could be used to enhance students’ attitudes towards medication management and perceived behavioural control as these have been found to be related to the intention to practice safe medication management in our study. Implementing IPE programmes seems particularly vital as medication errors among student nurses remain high, although under‐reported (Asensi‐Vicente et al., 2018; Salami, 2018).

Similarly, nurse participants in our study reported differences in medication safety attitudes per country. For example, Australian nurses reported significantly greater intention to behave in a manner that promoted medication safety and had better attitudes towards medication management, greater perceived behavioural control and higher subjective norms scores compared to Turkish nurses. These findings may be attributed to the education provided at the undergraduate level. In Australia, safe medication administration is introduced in the first year of the degree and subsequently reinforced throughout the following two years, with a focus on both the theoretical, as well as practical, application of safe medication administration. A range of pedagogical approaches have been employed, including the use of simulated learning experiences, Med + Safe, a programme aimed at improving fundamental medication safety skills and assessment of safe medication administration using Objective Structured Clinical Assessments (OSCAs). Use of multiple methods of teaching enhances students’ success in safe medication administration (Sparacino & Vecchia, 2013) and the use of these approaches improve nursing students’ competence in this essential skill (Bowling, 2015; Jarvill et al., 2018; Meechan et al., 2011). Similarly, other studies have demonstrated that engaging nursing students in a variety of simulation, technology assistance, online learning, clinical environments and virtual reality methods of learning and teaching prepare nursing students for the real‐world experience enabling them to cope with a range of varying scenarios (Lee & Quinn, 2019; Miller et al., 2016). Additionally, Australian nursing education is scaffolded, and students are introduced to medication administration incrementally, increasing in complexity as students’ progress through the degree (Coyne et al., 2013). Principles of safe medication administration remain the same and can be applied as the knowledge and complexity of medications increase and these same principles are applied throughout a registered nurse's career, further increasing the importance of safe medication administration practices (Coyne et al., 2013). Providing comprehensive education may, therefore, enhance new graduate nurses’ intention for medication safety, provide greater perceived behavioural control and result in the development of a positive attitude towards medication safety given these pedagogical approaches demonstrate improved medication administration competency.

These findings could also be contributed to the different organisational and professional cultures among the different institutions in the countries as a scoping review found that organisational and professional cultures, such as professional identity, hierarchy and pressure to adapt to a traditional culture, influence attitudes towards medication safety (Machen et al., 2019). Exploring the role these cultures play can assist in developing interventions, which consider the impact of these cultures on medication safety (Machen et al., 2019). Further, nurse medication safety training can enhance medication safety attitudes among nurses (Bull et al., 2017). Availability of clear and updated evidence‐based guidelines for medication administration and safety, and ongoing in‐service training and educational programmes based on these guidelines are required as lack of such guidelines, training and deficiency in knowledge have been found to be related to medication administration errors and poor attitudes of nurses towards medication safety (Abd Elmageed et al., 2020; Bakhshi et al., 2021; Di Muzio et al., 2016). Finally, identifying the factors that influence medication safety attitudes and intention to practice safe medication management is important as our study found these variables to be significantly and positively related.

6. RELEVANCE TO CLINICAL PRACTICE

Safe medication practices are a key focus of the global strategy to improve patient safety. Understanding student and new graduate nurses’ medication administration practices is important to inform strategies aimed at improving patient safety. While accurately determining the magnitude of medication errors remains difficult, the use of empirically validated theories such at the TPB provide new insights into cognitive, behavioural and other factors that influence medication safety. The findings highlight the need for an internationally coordinated approach to ensure safe medication administration by student and new graduate nurses. Such efforts should include scoping the range of initiatives in place to enhance medication safety and observing students and new graduate nurses’ actual medication administration practices whilst on clinical placements and during their first year of practice.

6.1. Limitations

Although this study has provided valuable information into attitudes of students and new graduate nurses regarding medication safety, some limitations inherent with undertaking such a study should be acknowledged. First, this study relied on a voluntary survey design. As some student and new graduate nurses may have participated in multiple research projects, this may have affected the response rate. It would have been helpful to report on attitudes of both student and new graduate nurses of all four countries, but due to small number of available potential participants in some countries, this was not possible. For both student and new graduate nurses, reporting self‐perceived attitudes towards medication safety may have invited bias, as few participants want to admit to unsafe attitudes that affect their practice. Varying cultures and experiences limit generalisability of the findings as knowledge levels and clinical experience between participants and countries may be different; therefore, this should be interpreted with caution. Additionally, using a convenience sample means that participants are not representative of the country; however, they are representative of the curriculum. Further research is warranted exploring the various teaching methods on students’ intention to practice safe medication administration. In addition, longitudinal studies are needed to follow these students and nurses over a minimum of five years to examine whether their attitudes have changed with experience. It is also important to associate the rates of medications errors associated with nurses’ attitudes towards medications using a blame free culture approach.

7. CONCLUSION

Student and new graduate nurses showed favourable attitude, subjective norm, perceived behaviour control and intention in practising medication safety. However, differences in countries requires further exploration on the factors influencing attitudes towards medication safety among student and new nurse graduates.

CONFLICT OF INTEREST

The authors have no conflict of interest.

AUTHOR CONTRIBUTIONS

Conceptualisation, data curation, supervision, methodology, investigation, formal analysis, writing—original draft, writing—reviewing and editing: Ritin Fernandez; conceptualisation, investigation, writing—original draft, writing—reviewing and editing: Wilma tenHam‐Baloyi, Elsheba Mathew, Selda Secginli, Zuhal Bahar, Carely Jans, Nursen Nahcivan, Gizemnur Torun, and Sam Lapkin; Methodology, data curation, formal analysis, writing—original draft, writing—reviewing and editing: Heidi Green.

Supporting information

Appendix S1

Click here for additional data file. (31.9KB, docx)

ACKNOWLEDGEMENT

Open access publishing facilitated by University of Wollongong, as part of the Wiley ‐ University of Wollongong agreement via the Council of Australian University Librarians. [Correction added on 14‐May‐22, after first online publication: CAUL funding statement has been added.]

Fernandez, R. , tenHam‐Baloyi, W. , Mathew, E. , Secginli, S. , Bahar, Z. , Jans, C. , Nahcivan, N. , Torun, G. , Lapkin, S. , & Green, H. (2023). Predicting behavioural intentions towards medication safety among student and new graduate nurses across four countries. Journal of Clinical Nursing, 32, 789–798. 10.1111/jocn.16330

Funding information

None.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix S1

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Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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