Knowledge, attitude, and practice toward azithromycin infusion reactions among pediatric nurses: a cross-sectional study

Abstract

Background

Infusion-related adverse reactions to azithromycin, though uncommon, can pose serious risks in pediatric care, warranting focused attention from nursing professionals. Pediatric nurses are key to early identification and intervention, but their knowledge, attitude, and practice (KAP) regarding such events remain unclear.

Methods

We conducted a cross-sectional survey among 835 pediatric nurses from 53 hospitals in Zhejiang Province, China. A custom-designed, expert-reviewed questionnaire assessed demographic characteristics, azithromycin-related knowledge, attitudes, and practices. Confirmatory factor analysis (CFA) and reliability testing (Cronbach’s alpha) were used to evaluate the instrument’s validity. Mediation analysis was performed to examine the indirect effects of knowledge and job satisfaction on practice, with attitude as a mediator.

Results

The CFA indicated acceptable model fit (RMSEA = 0.043; CFI = 0.892), and internal consistency was moderate to good across domains (α = 0.637–0.84). Nurses demonstrated moderate knowledge (mean score 13.59/20), constructive attitudes (28.43/35), and high levels of self-reported practice (42.30/50). Job satisfaction and 5–8 years of experience were associated with better attitudes and practices. Mediation analysis revealed that knowledge (β = 0.11, P = 0.034) and job satisfaction (β = 0.49, P < 0.001) directly influenced attitude, which in turn mediated their effects on practice. Knowledge had only an indirect effect on practice (β = 0.04, P = 0.042), underscoring the importance of attitudinal reinforcement.

Conclusions

Pediatric nurses possess limited pharmacological knowledge but exhibit safe infusion practices, likely driven by standard protocols and clinical experience. Educational interventions should go beyond factual training to include attitude-shaping strategies. Hospitals should prioritize structured in-service programs, simulation-based learning, and pre-infusion checklists to enhance safety. Future large-scale, multi-center, and longitudinal studies across diverse regions are warranted to validate these findings and enhance their generalizability.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03682-w.

Background

Antibiotics are the cornerstone of pediatric medicine, constituting approximately 21% of all prescriptions in pediatric outpatient facilities and amounting to nearly 44 million prescriptions annually in the United States alone [1, 2]. Among these antibiotics, azithromycin stands out as one of the most widely utilized drugs [3]. It is particularly used for treating both upper and lower respiratory tract infections in outpatient pediatric care, underscoring its clinical relevance [4]. Despite its widespread use, intravenous administration poses distinct safety challenges compared to oral routes, particularly in pediatric patients. While generally well-tolerated by patients, common side effects of azithromycin include upset stomach, diarrhea or loose stools, nausea, vomiting, and abdominal pain. However, there are potential serious adverse effects such as hearing loss and QT prolongation, the latter of which can be fatal under certain conditions [5, 6]. Infusion reactions, unlike those associated with oral azithromycin, can occur rapidly and may involve systemic manifestations such as anaphylaxis or cardiac arrhythmia, thus requiring immediate clinical response. Therefore, for pediatric nursing professionals, a comprehensive understanding of, along with a positive attitude and effective practice toward managing azithromycin infusion reactions, is imperative.

The Knowledge, Attitude, and Practice (KAP) survey method is an organized approach for assessing the knowledge (K), attitude (A), and practice (P) of participants on specific subjects, utilizing questionnaires to gauge these aspects [7]. Its primary objective is to unearth prevailing issues in current practice, offering valuable insights that can guide the enhancement of health education and the management of diseases within various populations [8]. Pediatric nurses, who are at the forefront of administering antibiotics to children, play a critical role in identifying and managing adverse reactions to medications such as azithromycin, a frequently prescribed antibiotic. Their expertise and alertness are crucial in significantly mitigating the risks associated with drug side effects, which can range from mild to severe, including the potentially life-threatening condition known as QT prolongation.

Focusing on pediatric nurses highlights the distinct challenges and responsibilities inherent to healthcare providers working with children, as opposed to those caring for adults, due to the unique physiological and developmental needs of younger patients. However, relevant research is currently lacking. The increasing clinical reliance on intravenous azithromycin, coupled with inconsistent nurse-led monitoring practices, highlights the need to investigate frontline nursing knowledge and actions. In Zhejiang Province, where tertiary pediatric centers administer high volumes of IV azithromycin, understanding nurses’ preparedness is both timely and regionally relevant. In light of these considerations, we conducted this study to explore the KAP of pediatric nurses regarding azithromycin infusion reactions.

Methods

Study design and participants

This cross-sectional study enrolled pediatric nurses from 53 hospitals in Zhejiang Province between July and November 2023. The selection of Zhejiang Province was based on the accessibility and availability of collaborating hospitals within the existing institutional network, rather than on specific regional characteristics. Detailed hospital information is shown in Supplementary Table 1. The inclusion criteria were: (1) possessing a nursing practice certificate issued by the National Health Commission of the People’s Republic of China; (2) actively involved in clinical nursing within pediatrics; (3) having experience administering azithromycin in clinical practice; and (4) consenting to participate by signing an informed consent form. The exclusion criteria were: (1) with incomplete questionnaire responses; or (2) no longer engaged in infusion-related clinical practice. Ethical approval was obtained from the Ethics Committee of our Hospital (2023-IRB-0184-P-01), and informed consent was obtained from all participants. A total of 871 questionnaires were returned. After excluding six responses with a completion time under 90 s, two participants under the age of 18, 26 cases with incorrect trap question answers, and two with unclear responses in the knowledge section, 835 valid questionnaires were included in the final analysis.

Questionnaire introduction

The questionnaire underwent rigorous refinement following input from two senior experts specializing in respiratory care and pediatric intravenous therapy nursing, as well as feedback from three associate senior experts with expertise in pediatric intravenous therapy nursing, pediatric nursing, and pediatric specialties.

The finalized questionnaire in Chinese encompasses four distinct sections: (1) demographic characteristics, such as age, gender, education, professional title, pediatric nursing experience, hospital grade, workload, job satisfaction, and experience in administering azithromycin to pediatric patients; (2) knowledge dimension, consisting of ten questions covering topics such as the classification and indications of azithromycin, common adverse reactions, contraindications, and management strategies for adverse reactions. Each correct response is awarded two points, resulting in a total score of 0–20; (3) attitude dimension, comprising of seven questions employing a five-point Likert scale to gauge perceptions and attitude toward azithromycin safety, recoverability of adverse reactions, treatment discontinuation recommendations, importance of health education, and factors contributing to adverse reactions. Scores range from 7 to 35 based on responses from “never bothered” to “always bothered”; (4) practice dimension, including ten questions assessing respondents’ practice related to patient history inquiry, allergy testing, case review, medication checking, adherence to prescribed protocols, communication with family members and attending physicians, and provision of health education. Responses are rated on a five-point Likert scale, with scores ranging from 10 to 50 points based on the frequency of practice from “never” to “always”. Regarding job satisfaction, it was assessed through a self-reported single-item question: “How satisfied have you been with your work in the past two weeks?”, with five response options ranging from “Very dissatisfied” to “Very satisfied.”

The distribution of questionnaires among study participants was facilitated through multiple channels including WeChat groups, one-to-one messaging, QR code scanning at onsite locations, and direct distribution at clinics. Given the scope of the study encompassing 59 hospitals across 11 prefecture-level cities in Zhejiang Province (namely Hangzhou, Jinhua, Shaoxing, Lishui, Huzhou, Ningbo, Wenzhou, Jiaxing, Taizhou, Zhoushan, and Quzhou) consisting of both secondary and tertiary hospitals, efforts were made to establish contact through phone and WeChat. Consequently, responses were obtained from 53 hospitals. Six hospitals were subsequently excluded from the analysis due to the absence of dedicated pediatric wards, thereby limiting azithromycin exposure among pediatric nurses in clinical practice.

Psychometric evaluation was conducted to assess the reliability and validity of the questionnaire. Confirmatory factor analysis (CFA) showed an acceptable model fit (CMIN/DF = 2.286; RMSEA = 0.043; IFI = 0.893; TLI = 0.880; CFI = 0.892) (Supplementary Table 2). The Kaiser-Meyer-Olkin (KMO) value was 0.729 (P < 0.001), supporting the sampling adequacy. A structural diagram of the latent variables and observed indicators is provided in Supplementary Fig. 1.

Sample size calculation

Sample size was calculated using the formula for cross-sectional studies: α = 0.05, where =1.96 when α = 0.05, the assumed degree of variability of p=0.5 maximizes the required sample size, and δ is admissible error (which was 5% here). The theoretical sample size calculated was 480, inclusive of an additional 20% to accommodate potential subject loss during the course of the study.

Statistical analysis

The statistical analysis was performed using STATA version 14.0 (StataCorp LLC, College Station, TX, USA). The continuous variables were tested for normal distribution using the Kolmogorov-Smirnov test. Continuous data with a normal distribution were described as mean ± standard deviation (SD) and analyzed using Student’s t-test; otherwise, they were presented as medians (interquartile range, IQR) and analyzed using the Wilcoxon rank-sum test. Categorical data were described as n (%) and analyzed using the chi-square test or Fisher’s exact test. Correlations between Knowledge, Attitude and Practice dimensions were analyzed using the Spearman correlation analysis. Mediation analysis was performed to determine the relationships among Knowledge, Attitude and Practice dimensions. A two-sided P-values < 0.05 were considered statistically significant. The mediation model was constructed based on previous literature suggesting associations between knowledge, job satisfaction, attitude, and practice. Pediatric nursing experience was included as a covariate to partially control for potential confounding effects. Job satisfaction was included alongside knowledge because it is a well-established predictor of healthcare professionals’ motivation, clinical engagement, and behavioral intention. Including both cognitive (knowledge) and affective (job satisfaction) variables allowed for a more comprehensive analysis of their direct and indirect influence on safe clinical practice via attitude. Pediatric nursing experience was included as a covariate to partially control for potential confounding effects.

Results

Demographic characteristics

The final analysis included 835 pediatric nurses, with a mean age of 33.84 ± 7.29 years, and the majority were female (813, 97.37%). Among the participants, 761 (91.14%) held a bachelor’s degree, and 510 (61.08%) had more than 8 years of pediatric nursing experience. Most participants (676, 80.96%) were employed in public tertiary hospitals. Despite 472 (56.53%) reporting being very busy in the last two weeks, 405 (48.50%) expressed satisfaction with their job. The mean scores for knowledge, attitude, and practice were 13.59 ± 1.85 (possible range: 0–20), 28.43 ± 2.95 (possible range: 5–35), and 42.30 ± 5.22 (possible range: 10–50), respectively. Participants with 5–8 years of pediatric nursing experience and those who reported higher job satisfaction tended to have better attitude and practice scores. Differences were also noted across professional titles, clinical azithromycin experience, and hospital levels. Nurses with heavier recent workloads showed lower practice scores. These findings suggest that moderate clinical experience and positive work attitudes may enhance nurses’ preparedness and responsiveness in managing azithromycin infusion reactions (Table 1). As shown in Table 1, nurses with moderate experience and higher job satisfaction reported better attitudes and practices, suggesting that both experience and workplace perception play key roles in shaping safe infusion behavior.

Table 1.

Demographic characteristics

Variables	N (%)	Knowledge	P	Attitude	P	Practice	P
Total	835 (100%)	13.59 ± 1.85		28.43 ± 2.95		42.30 ± 5.22
Age	33.84 ± 7.29
Gender			0.361		0.698		0.358
Male	22 (2.63)	14.09 ± 1.77		28.86 ± 3.55		40.27 ± 6.49
Female	813 (97.37)	13.57 ± 1.85		28.41 ± 2.93		42.35 ± 5.17
Education			0.449		0.841		0.276
College and below	64 (7.66)	13.50 ± 1.97		28.50 ± 2.76		43.22 ± 5.01
Bachelor’s degree	761 (91.14)	13.58 ± 1.84		28.43 ± 2.96		42.21 ± 5.24
Master’s degree and above	10 (1.20)	14.40 ± 1.84		27.70 ± 2.95		43.00 ± 4.62
Pediatric nursing experience			0.073		0.025		0.032
≤ 3 years	148 (17.72)	13.40 ± 1.89		27.64 ± 3.18		42.24 ± 5.60
3–5 years	64 (7.66)	13.13 ± 1.96		28.56 ± 2.70		43.19 ± 5.24
5–8 years	113 (13.53)	13.58 ± 1.83		28.70 ± 2.61		43.27 ± 5.01
More than 8 years	510 (61.08)	13.70 ± 1.82		28.57 ± 2.94		41.99 ± 5.12
Professional title			0.086		0.043		0.224
Nurse	102 (12.22)	13.44 ± 2.08		27.81 ± 3.13		41.82 ± 5.77
Senior Nurse	345 (41.32)	13.43 ± 1.78		28.39 ± 2.92		42.52 ± 5.21
Chief Nurse	336 (40.24)	13.73 ± 1.85		28.50 ± 2.83		42.07 ± 5.08
Director Nurse	52 (6.23)	13.98 ± 1.73		29.38 ± 3.28		43.25 ± 4.99
Experience of administering azithromycin			0.364		0.013		0.678
No	37 (4.43)	13.27 ± 1.87		27.32 ± 2.55		41.54 ± 6.48
Yes	798 (95.57)	13.60 ± 1.85		28.48 ± 2.95		42.33 ± 5.15
Hospital grade			0.207		0.040		0.139
Primary hospital	32 (3.83)	13.69 ± 1.79		27.44 ± 3.41		43.34 ± 5.03
Secondary hospital	26 (3.11)	13.85 ± 1.64		28.50 ± 3.02		41.15 ± 6.09
Tertiary hospital	676 (80.96)	13.61 ± 1.85		28.46 ± 2.87		42.40 ± 5.26
Specialist Hospital	74 (8.86)	13.19 ± 1.97		28.03 ± 3.21		41.34 ± 4.55
Private Healthcare Institution	27 (3.23)	13.85 ± 1.70		29.63 ± 3.12		42.33 ± 5.12
Work intensity in the last 2 weeks			0.392		0.791		0.029
Normal	42 (5.03)	13.81 ± 1.66		28.07 ± 3.45		42.10 ± 5.64
Busy	321 (38.44)	13.66 ± 1.88		28.47 ± 2.86		42.90 ± 4.96
Very busy	472 (56.53)	13.52 ± 1.84		28.42 ± 2.96		41.91 ± 5.32
Job Satisfaction in the last 2 weeks			0.989		< 0.001		< 0.001
Very dissatisfied	25 (2.99)	13.48 ± 1.76		28.24 ± 2.63		41.36 ± 5.43
Dissatisfied	45 (5.39)	13.60 ± 1.90		28.16 ± 2.63		40.89 ± 4.50
Moderately satisfied	285 (34.13)	13.59 ± 1.81		27.82 ± 3.01		40.75 ± 5.64
Satisfied	405 (48.50)	13.57 ± 1.88		28.68 ± 2.93		43.17 ± 4.71
Very satisfied	75 (8.98)	13.72 ± 1.89		29.60 ± 2.56		44.64 ± 4.63

Knowledge, attitude, and practice dimensions

Of the ten knowledge items assessed, the lowest accuracy rates were observed for K2 (1.08%, regarding azithromycin’s indication for typical pathogens like Mycoplasma pneumoniae), K8 (4.43%, regarding its use in patients with CCr < 15 mL/min), and K1 (48.50%, regarding its misclassification as a quinolone) (Supplementary Fig. 2). These findings highlight a significant knowledge gap among nursing staff, particularly in understanding azithromycin’s indications, contraindications, and drug classification, which may impact safe clinical use. Attitude dimension showed 72.46% strongly agreed that it is very important to educate parents (guardians) about the adverse reactions during infusion (A6). Also 57.72% strongly agreed that early identification of high-risk groups is effective in avoiding serious adverse events (A5). Meanwhile, 44.55% strongly agreed and 45.99% agreed that adverse effects of azithromycin are usually reversible and recoverable (A1). In addition, 52.93% disagreed that the infusion adverse effects of azithromycin can outweigh its efficacy (A3). Patient practice was generally positive, with 78.20% always strictly following the concentration and flow rate prescribed by the physician (P6), and 78.92% always communicating and educating to reassure the child’s family in case of adverse reactions (P9). On the other hand, 74.25% and 67.19% never forgot to check the expiration date of azithromycin (P4) and concentration ratio (P5), respectively. Intriguingly, in terms of knowing the patient’s history (P2) and case details and indications (P3) prior to infusion, a significant proportion of the participants sometimes, occasionally, or never performed these two practices, indicating that there is still a lot of room for improvement in this area. This gap is concerning, as failure to obtain a thorough patient history and review case indications may lead to preventable infusion-related adverse events. Possible contributing factors include time pressure, high workload, and lack of standardized pre-infusion checklists in some institutions. (Supplementary Table 3).

Spearman correlation analysis

Spearman correlation analysis revealed that attitude and practice were correlated (r = 0.233, P < 0.001) (Table 2). It showed that while knowledge and attitude were weakly correlated, attitude had a significant positive correlation with practice, reinforcing its mediating role in behavior.

Table 2.

Spearman correlation analysis

	Knowledge	Attitude	Practice
Knowledge	1.000
Attitude	0.061 (P = 0.077)	1.000
Practice	0.000 (P = 0.992)	0.233 (P < 0.001)	1.000

Mediation analysis

Mediation analysis indicated that knowledge (β = 0.11, P = 0.034) and job satisfaction (β = 0.49, P < 0.001) had direct effect on attitude. Attitude had a direct effect on practice (β = 0.42, P < 0.001), knowledge had an indirect effect on practice (β = 0.04, P = 0.042). Meanwhile, job satisfaction also had a direct (β = 1.12, P < 0.001) and an indirect (β = 0.21, P < 0.001) effect on practice (Table 3), the final model demonstrated excellent fit (RMSEA = 0.027, SRMR = 0.010, TLI = 0.925, CFI = 0.980), supporting the robustness of the mediation framework (Supplementary Table 4). As illustrated in Fig. 1, knowledge and job satisfaction influenced practice both directly and indirectly through the mediating role of attitude. Specifically, knowledge and job satisfaction improved nurses’ attitudes, which in turn enhanced their clinical practices. This model highlights the importance of not only increasing knowledge but also cultivating positive professional attitudes to improve safe infusion behavior.

Table 3.

Mediation analysis

Model paths		Total effects		Direct effect		Indirect effect
		β (95% CI)	P	β (95% CI)	P	β (95% CI)	P
Asum <-
	Ksum	0.11 (0.01, 0.22)	0.034	0.11 (0.01, 0.22)	0.034	—	—
	Job Satisfaction in the last 2 weeks	0.49 (0.26, 0.73)	< 0.001	0.49 (0.26, 0.73)	< 0.001	—	—
Psum <-
	Asum	0.42 (0.30, 0.53)	< 0.001	0.42 (0.30, 0.53)	< 0.001	—	—
	Ksum	0.02 (-0.16, 0.20)	0.834	-0.02 (-0.21, 0.15)	0.755	0.04 (0.00, 0.09)	0.042
	Job Satisfaction in the last 2 weeks	1.33 (0.92, 1.74)	< 0.001	1.12 (0.72, 1.52)	< 0.001	0.21 (0.09, 0.32)	< 0.001
	Duration of pediatric nursing experience	-0.21 (-0.50, 0.07)	0.148	-0.21 (-0.50, 0.07)	0.148	—	—

Fig. 1.

Mediation analysis

Discussion

Pediatric nurses in Zhejiang Province demonstrated limited pharmacological understanding but exhibited positive attitude and proactive practice toward azithromycin infusion reactions. Educational interventions aimed at improving knowledge levels among pediatric nursing professionals may help augment their vigilant implementation and attitude toward managing azithromycin infusion reactions effectively.

The study reveals a nuanced understanding of pediatric nursing professionals’ knowledge, attitude, and practice regarding azithromycin infusion reactions in Zhejiang Province. This discovery resonates with prior studies underscoring the inadequate knowledge of antimicrobial stewardship among retail private pharmacy personnel, which includes nurses [9]. The identified associations between demographic and professional factors and nurses’ attitude and practice resonate with existing literature. For instance, the positive correlation between nursing experience and attitude and practice scores is consistent with studies highlighting the role of experience in shaping nurses’ clinical judgment and decision-making processes [10]. Similarly, the independent association between job satisfaction and constructive mindset al.igns with previous research emphasizing the impact of organizational factors on nurses’ job attitude and performance [11–13]. Furthermore, the significant influence of job satisfaction on practice scores echoes findings suggesting that satisfied nurses are more likely to engage in patient-centered care behaviors and demonstrate higher levels of clinical competence [14, 15].

The positive correlation between attitude and practice scores underscores the interconnectedness of nurses’ perceptions and behaviors in clinical practice, corroborating previous studies emphasizing the importance of attitude in driving healthcare professionals’ actions [16, 17]. Additionally, the mediation analysis provides insights into the pathways through which knowledge and job satisfaction impact nurses’ attitude and practice, echoing previous research emphasizing the mediating role of attitude in translating knowledge into action [18, 19]. This finding also implies that improving knowledge alone may not be sufficient to directly change nurses’ clinical behavior. Instead, interventions must also focus on shaping positive attitudes in order to translate knowledge into safe infusion practices. This has practical implications for training programs, which should incorporate motivational and attitudinal components alongside factual knowledge.

In terms of Knowledge, the lowest scoring item reveals a notable misconception regarding the classification of azithromycin as a quinolone antibiotic and azithromycin’s indication for non-typical pathogens like Mycoplasma pneumoniae. This finding is concerning as it reflects potential gaps in pharmacological knowledge among pediatric nurses, which could have implications for safe medication administration practice. This knowledge gap may stem from limited coverage of intravenous drug safety in undergraduate nursing curricula, as well as insufficient emphasis on infusion-related adverse events in continuing education programs. Additionally, frontline nurses may lack structured opportunities for regular pharmacology updates, particularly in non-academic hospitals. Notably, a recent Chinese rapid advice guideline has provided evidence-based recommendations on the off-label use of intravenous azithromycin in children, including dosing, indications, administration precautions, and adverse reaction management [20]. Incorporating such standardized guidance into nurse training may help bridge existing pharmacological knowledge gaps. To address these knowledge gaps, targeted educational programs focusing on pharmacology and drug classifications could be implemented within pediatric nursing curricula. Additionally, continuous professional development initiatives, such as workshops and seminars, can reinforce pharmacological knowledge and promote evidence-based practice among pediatric nurses, ultimately enhancing patient safety and quality of care [21, 22].

In terms of Attitude, the highest scoring item reflects a constructive mindset toward preventive measures, with the majority of nurses agreeing on the importance of identifying high-risk groups to mitigate adverse events associated with azithromycin administration. However, the lowest scoring item highlights a concerning perception among some nurses regarding the balance between azithromycin’s therapeutic benefits and adverse reactions. A significant proportion of nurses disagreed or strongly disagreed with the statement, suggesting a potential misconception regarding the risk-benefit profile of azithromycin. To promote constructive mindset toward medication safety and adverse event management, organizational support structures should prioritize open communication channels and interdisciplinary collaboration. Regular case discussions and quality improvement initiatives can provide opportunities for nurses to share experiences, learn from adverse events, and collectively enhance patient care practice [23–25]. Furthermore, a recent study among Chinese nursing students highlighted that the absence of discussions on antimicrobial resistance in school courses was an independent risk factor negatively impacting their knowledge, attitude, and practice regarding antibiotic use and resistance [26]. This underscores the necessity of integrating comprehensive antimicrobial education into nursing curricula to enhance pharmacological knowledge and promote evidence-based practices. The observed mismatch between low knowledge and high practice performance may appear counterintuitive but could reflect institutional reliance on standardized operating procedures and supervision. Nurses may perform well in practice due to procedural training, mentoring, or task repetition, even in the absence of deep pharmacological understanding. However, such a model may fail under unexpected clinical situations where critical thinking is required.

In terms of Practice, the highest scoring item reflects a strong adherence to prescribed concentration and infusion rates, indicating a commitment to safe medication administration practice among pediatric nurses. Conversely, the lowest scoring item reveals a potential area for improvement in patient history-taking practice, with a significant proportion of nurses admitting to occasional lapses in inquiring about allergy history. To enhance patient safety and medication management practice, quality improvement initiatives should focus on streamlining workflow processes and implementing standardized assessment tools. Regular audits and feedback mechanisms can help identify areas for improvement and monitor progress toward achieving practice standards, ultimately optimizing patient care delivery in pediatric healthcare settings [27–29]. From an organizational perspective, hospitals and nursing leadership play a critical role in closing the knowledge-practice gap. Regular in-service training, simulation-based learning, integration of infusion safety modules into mandatory education, and system-level reinforcement through protocols and feedback mechanisms may help sustain both cognitive and behavioral safety performance. A multicenter survey highlighted that pediatric nurses in China often lack sufficient knowledge and decision-making support when administering high-alert medications, emphasizing the necessity for enhanced training and decision-support systems to ensure medication safety in pediatric care [30]. These findings have direct implications for patient safety and parent trust. Inadequate understanding of medication risks may compromise the nurse’ s ability to communicate effectively with families or respond promptly to adverse events, potentially affecting clinical outcomes and parental confidence in care delivery.

Despite the valuable insights gained from this study, several limitations should be acknowledged. Firstly, the cross-sectional design limits our ability to establish causal relationships between variables, warranting caution in interpreting the observed associations. Secondly, relying on self-reported data through questionnaires introduces the possibility of response bias and social desirability bias, potentially influencing the accuracy and reliability of the findings. Lastly, the study was confined to pediatric nursing professionals in Zhejiang Province, as all participating hospitals were located within this region due to practical accessibility and existing institutional collaboration. As a result, the findings may not be generalizable to pediatric nurses in other provinces or healthcare settings with different structural contexts. Further research in diverse populations is necessary to validate the findings and ensure broader applicability.

Conclusions

This study highlights the significant gaps in pharmacological knowledge and the critical role of professional attitude in shaping safe clinical practice among pediatric nurses. To improve azithromycin infusion safety, hospitals should implement structured, recurring in-service training programs that not only deliver pharmacological content but also cultivate positive attitudes toward adverse event prevention. Nursing education departments and hospital leadership should jointly develop standardized protocols, simulation-based training modules, and clinical decision-making tools. At the policy level, health authorities may consider integrating infusion safety training into mandatory continuing education requirements and conducting regular audits to ensure compliance and effectiveness. These steps are essential to reduce infusion-related risks, enhance pediatric patient safety, and strengthen caregiver trust in clinical care.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

KAP

Knowledge attitude and practice

SD

Standard deviation

Author contributions

Linlin Wei and Jianying Xu carried out the studies, participated in collecting data, and drafted the manuscript. Linlin Wei and Jianying Xu performed the statistical analysis and participated in its design. Chaolang Zhang, Cuiying Chen and Jia Chen participated in acquisition, analysis, or interpretation of data and draft the manuscript. All authors read and approved the final manuscript.

Funding

The study was supported by Zhejiang TCM Science and Technology Program (2023ZF123); General Research Project of Education Department of Zhejiang Province (Y202249362); General Research Project of Education Department of Zhejiang Province (Y202045777).

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Committee of Children’s Hospital, Zhejiang University School of Medicine (2023-IRB-0184-P-01), and written informed consent was obtained from all participants. I confirm that all methods were performed in accordance with the relevant guidelines. All procedures were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.