EMPIRICAL STUDIES
12712
Nurses’ self-assessments of adherence to guidelines on safe
medication preparation and administration in long-term
elderly care
Markus Karttunen RN, MNSc, PhDc (Senior Lecturer, Team Manager)1 , Sami Sneck PhD, RN (Medication
Education and Safety Coordinator)2, Jari Jokelainen MSc (Biostatistician)3,4 and Satu Elo PhD (Adjunct Professor,
Consultant)1,5,6
1
Oulu University of Applied Sciences, Oulu, Finland, 2Oulu University Hospital, Oulu, Finland, 3Unit of General Practice, Oulu University
Hospital, Oulu, Finland, 4Center for Life Course Epidemiology and Systems Medicine, University of Oulu, Oulu, Finland, 5Research Unit of
Nursing Science and Health Management, University of Oulu, Oulu, Finland and 6Medical Research Center MRC, Oulu University Hospital,
Oulu, Finland
Scand J Caring Sci; 2019
Nurses’ self-assessments of adherence to guidelines
on safe medication preparation and administration in
long-term elderly care
Background: Medication-related errors are common in
elderly care. Most are detected during the preparation
and administration stages of the medication process.
Nursing staff have a key role in preventing errors, and it
is based on adherence to guidelines.
Aim: The aim was to determine nursing staff’s self-assess-
ments of how they adherence to guidelines on safe medi-
cation preparation, administration and asepsis in the
medication process in long-term elderly care and to iden-
tify factors affecting this adherence.
Method: Cross-sectional study was conducted by total
sampling at the communal long-term elderly care wards
of one healthcare district in Finland in November 2016.
Data were collected from nursing staff by using a previ-
ously developed web-based questionnaire. The response
rate was 39.4% (n = 492).
Results: One-third of the nurses stated that they do not
always follow guidelines when preparing medication, and
around a half deviate from them occasionally, when
Background
Medication plays a big role in long-term elderly care. Accord-
ing to WHO statistics, life expectancy is increasing steadily
around the world. However, longer lives are associated with
increased morbidity: hypertension, osteoarthritis, dementia,
Correspondence to:
Markus Karttunen, Oulu University of Applied Sciences, PL 222,
90101 Oulu, Finland.
E-mail: markus.karttunen@oamk.fi
© 2019 Nordic College of Caring Science
doi: 10.1111/scs.
administering medication. The most serious deviation on
preparation stage was crushing of sustained release and
enteric-coated tablets and mixing of crushed tablets
together. On administration stage, the deviation of guide-
lines of giving medicine in recommended time or in rela-
tion to food was common. Associations were detected
between the adherence to guidelines and the nurses’
experience about the adequacy of their knowledge of
pharmacology and infection control, and their skill at
performing medication calculations.
Conclusion: Deviation from guidelines often causes an
error. There is a need to review the teaching of phar-
macology, infection control and medication calculations
during undergraduate and continuing education. In
addition, nursing staff must be reminded about the eth-
ical aspects of safe medication processes and the appro-
priate attitudes to these processes. Nurses must
understand why it is important to follow guidelines
when preparing and administering medications, in
order to avoid errors.
Keywords: medication management, nursing home care,
elderly care.
Submitted 20 October 2018, Accepted 15 April 2019
cardiovascular diseases, COPD, thyroid dysfunction and
Parkinson’s disease are very common in geriatric patients (1,
2). Consequently, elderly people often use several different
medicines. The purpose of medication is to treat diseases and
alleviate symptoms such that the patient receives more bene-
fit than discomfort. However, polypharmacy increases the
risk of side and adverse effects, as well as the risk of being
prescribed inappropriate medication (3–5). Moreover, elderly
people will not necessarily remember to take their medica-
tion or to take it at the recommended time. Consequently,
their adherence to medication may be poor (6).
1
2 M. Karttunen et al.

Most errors in health care are associated with medica- identify factors affecting this adherence. There were two
tion (7, 8). A medication error is defined as any error in research questions:
the prescription, dispensation or administration of medi-
1 How do nursing staff self-assess their adherence to
cine, irrespective of whether the error causes any harm
guidelines on medication preparation, administration
to a patient (9). Medication errors have been studied in
and asepsis in long-term elderly care?
several nursing environments and contexts (10–18),
2 What factors influence the adherence to guidelines on
revealing that they occur most commonly during the
safe medication preparation, administration and asepsis
process of administering medication (8, 10, 12, 15).
in long-term elderly care?
Medicines must be prepared and modified in appropriate
ways to be safe and effective (19, 20). However, many
elderly people suffer from dysphagia (18) and thus find it Study design
difficult to swallow intact pills or capsules, so nurses
This was a cross-sectional study conducted by total sampling
commonly crush pills and tablets or open capsules to
at the communal long-term elderly care wards of one
help patients ingest them more easily even though the
healthcare district in Finland during November 2016. Data
medicine may be unsuitable for crushing or opening. (13,
were collected using a web-based questionnaire (Webropol
21–23). This constitutes an error in the preparation of
3.0). A link to the questionnaire was sent to the superiors of
medication. Moreover, splitting or crushing pills causes
all 79 wards within the studied district; the superiors were
drug loss (24–26). Other common errors include omission
asked to forward the link to the nurses they oversee. The
of medication, consumption of incorrect medication,
link was accompanied by a covering letter that explained
incorrect dosing and administration of medication to the
the study’s purpose and how to complete the questionnaire,
wrong patient (8, 15, 27, 28). Timing is an important
and which stated that participation in the study was volun-
aspect of the medication process: medicines must be pre-
tary. There were 1249 nurses working on the studied wards
pared and administered at the right time or taken before
during the data collection period. The main occupational
or with meals. However, it is very common for medica-
groups within this population were registered nurses and
tion to be administered at inappropriate times (10, 13,
practical nurses. In Finland, registered nurses hold bache-
18), giving rise to a time error. Finally, asepsis is an
lor’s degrees in nursing and have the right to administer oral
essential part of medication administration process, and
and intravenous medication and to give injections to
hand hygiene guidelines must be followed in any situa-
patients; they are responsible for the overall implementation
tion in which health care is delivered (29).
of medication prescribed by medical doctors or specially edu-
Nursing staff have a key role in preventing medication
cated registered nurses. Practical nurses hold a vocational
errors because medication is typically administered by
upper secondary qualification in nursing and are mainly
nurses. There are many different barriers to the mainte-
allowed to prepare and administer enteral medication and
nance of safe medication management (30), but accord-
limited parenteral medication. The minor occupational
ing to nurses, one effective way to prevent errors is to
groups were bachelors of social services and nursing assis-
promote attention and caution. Medication competence
tants. Both these occupational groups take part in medica-
spans multiple practical and theoretical domains (31)
tion administration under supervision after further training.
including pharmacology knowledge (32–34) and medica-
The participants were sent reminders about the question-
tion calculation skills. Various incident reporting systems
naire four times over the data collection period, and the
have been created to detect medication errors and near
questionnaire was closed four weeks after the link had first
misses, but not all medication errors are recorded in
been sent to the prospective participants. The response rate
these incident reporting systems (35) or even necessarily
was 39.4% (n = 492). The work reported here is a part of
recognized when they occur (36). Medication errors have
our ongoing study on Safe Medication Management in
been studied by observation and by analysing medication
Long-Term Elderly Care, which is divided into three phases:
records, interviews and incident reporting systems. How-
(I) Development of the Safe Medication Management Scale,
ever, there have been no studies on nurses’ self-assess-
(II) Safe Medication Preparation and Administration in
ments about their own adherence to (and potentially,
Long-Term Elderly Care, and (III) Safety Checks, Monitoring
knowing deviation of) guidelines during the medication
and Documentation during the Medication Management
process and the possibility of conscious medication error.
Process in Long-Term Elderly Care. This study reports on
Phase II. The results of Phase I are presented elsewhere (37).
Aim
The study’s aim was to determine nursing staff’s self-
Scale
assessments of how they adherence to guidelines on safe
medication preparation, administration and asepsis in the The Safe Medication Management Scale (SMMS) was
medication process in long-term elderly care and to developed according to the scale development process of

© 2019 Nordic College of Caring Science


DeVellis (38). A scoping literature review was conducted,
and a qualitative content analysis was performed. As a
result, eleven distinct aspects of safe medication manage-
ment were identified (Right Action, Right Medication,
Right Dose, Right Route, Right Patient, Right Prepara-
tion, Right Time, Right Counselling, Right Response,
Right Documentation and Right Asepsis) and eleven sets
of items were created to assess adherence to guidelines
with respect to each one. Items on the scale were scored
using a Likert scale, but in each eleven set, there was an
open question for free text for the participants to justify
their choice. A panel of experts (n = 7) determined the
scale’s content and the structure of its items. After modi-
fication based on the panel’s assessment, the scale’s con-
tent validity scores (I-CVI and CVI/Ave) were excellent
(>0.90). In the next phase of the scale development pro-
cess, a pilot study was conducted. Material for this pilot
study was collected from the staff (N = 294) of the com-
munal long-term elderly care wards in one town in
northern Finland using a web-based questionnaire. The
response rate was 24% (n = 69). The scale’s reliability
was estimated using Tarkkonen’s rho. Details of the pro-
cess are available elsewhere, in Finnish (37).
Prior to analysis, the items in the 11 categories
described above were re-categorized into seven new
categories: medication preparation (16 items), medication
administration (15 items), asepsis in medication (11
items), safety checks during the medication administra-
tion process (15 items), monitoring (eight items), docu-
mentation (six items) and patient involvement (14
items). The re-categorization grouped all items relating to
the same stage of the medication process together,
enabling process-based analysis. The re-categorization
was done by applying the medication process described
by American Society of Health-System Pharmacists
(ASHP): (i) ordering/prescribing, (ii) transcribing and ver-
ifying, (iii) dispensing and delivering, (iv) administering,
and (v) monitoring and reporting (39). Nurses are pri-
marily involved in the administering stage, which also
includes preparation of medicine, but they also partici-
pate in the dispensing, delivering, monitoring and report-
ing stages. Asepsis in medication process and safety
checks was formed separate categories in order to detect
information on how the nurses perform asepsis and
safety checks during the medication process. After the re-
categorizing based on the content of the items, hierarchi-
cal cluster analysis was used to confirm the relationship
between the items (40). Based on the analysis, six items
were discarded from the medication preparation category,
seven items from the medication administration category
and four items from the asepsis in medication process
category. Cronbach’s alpha and Tarkkonen’s Rho were
then calculated for each of these new categories
(Table 1). Cronbach’s alpha is low in asepsis in medica-
tion process category (41). Because of the content of the
© 2019 Nordic College of Caring Science
Nurses’ self-assessments of adherence 3
items, no additional items were discarded to maximize
alpha. After the process, medication preparation category
covered 10 items, medication administration eight items
and asepsis in medication process seven items. In addi-
tion to the demographic information, the scale included
the background variables presented in Table 2.
Ethical considerations
This study did not require an ethical statement from the
ethical committee because it did not violate the subjects’
physical integrity; did not use data without informant
consent such as register or archive data; did not involve
children under 15 years old; did not involve harmful psy-
chological or physical effects upon the participants; and
did not involve a security threat towards participants
(Medical Research Act 488/1999, 295/2004, 794/2010,
143/2015 Declaration of Helsinki 2013). A research per-
mit was obtained from the director of elderly care of each
municipality involved in the study. Participation was vol-
untary, and participants were informed of the study’s
objectives and methods. The return of a completed ques-
tionnaire by a participant was interpreted as a grant of
informed consent. The responses were returned anony-
mously, and all information regarding the participants
was processed confidentially. No participant could be
identified at any stage.
Analysis
The data were analysed using statistical methods as
implemented in the Statistical Package for the Social
Sciences (SPSS) version 24. To begin with, the distribu-
tions of the variables were described. Age group quartiles
(< 39 years, 39–48 years, 49–55 years, and > 55 years)
were defined based on the participants’ reported ages. In
addition, three categories describing the participants’
level of education were defined (registered nurses, practi-
cal nurses and others). Finally, working experience quar-
tiles were defined based on the length of the participants’
careers in health care (<8 years of experience, 8–14 years
of experience, 15–24 years of experience and > 24 years
of experience).
Most items on the scale were scored using a Likert
scale ranging from 0 to 5, where 0 means that the partic-
ipant ‘always follows the recommendations’, 1 means
‘often follows the recommendations’, 2 ‘sometimes fol-
lows the recommendations’, 3 ‘rarely follows the recom-
mendation’, 4 ‘never follows the recommendation’ and 5
means ‘Does not concern me’. Scores of 5 were treated
as missing values. As all the seven categories are sum o
variables, the results appear in decimals anywhere
between the scores 0 and 5. For all items, the closer a
participant’s score was to zero, the better that participant
implemented safe medication.
4 M. Karttunen et al.

Table 1 The sum variables of the medication preparation, medication administration and asepsis in medication process categories, the values of
Tarkkonen’s rho and Cronbach’s alpha for each category, and the mean (M) and standard deviation (SD) of the participants’ scores for each
category

Category Items Tarkkonen’s rho Cronbach’s a Ma SD

Medication preparation 10 0.891 0.776 0.58 0.51

Medication administration 8 0.799 0.737 0.56 0.42
Asepsis in medication process 7 0.631 0.470 0.11 0.17
a
Ranging from 0.0 indicating maximal adherence to 4.0 indicating minimal adherence.

Table 2 Additional background variables in the SMMS scale

At least 3 times
Item Daily a week Rarely Never

I prepare medicine for patients 45.1% 16.5% 29.3% 9.1%

222 (n) 81 (n) 144 (n) 45 (n)
I administer medicine for patients 91.1% 5.7% 3.0% 0.2%
448 (n) 28 (n) 15 (n) 1 (n)

Always Often Sometimes Rarely or never

I have adequate knowledge base of pharmacology as it 33.5% 53.7% 11.2% 1.6%

relates to the medication process 165 (n) 264 (n) 55 (n) 8 (n)
I have adequate knowledge base of infection control as it 68.3% 28.0% 3.0% 0.6%
relates to the medication process 336 (n) 138 (n) 15 (n) 3 (n)
I have adequate knowledge base of medication 72.8% 24.2% 2.6% 0.4%
calculations as it relates to the medication process 358 (n) 119 (n) 13 (n) 2 (n)
I adhere to all the guidelines of safe medication 82.3% 17.3% 0.4% -
administration during the medication administration 405 (n) 85 (n) 2 (n)
process.
In our ward, all the medication errors are reported in 58.1% 32.9% 7.1% 1.9%
incident reporting system. 286 (n) 162 (n) 35 (n) 9 (n)

10 9 8 <8

How well are the safe medication principles (rights) 13.6% 53.9% 25.8% 6.7%
implemented in your own work? (1–10 scale) 67 (n) 265 (n) 127 (n) 33 (n)
How well are the safe medication principles (rights) 11.6% 41.9% 35.0% 11.6%
implemented at the ward in general? (1–10 scale) 57 (n) 206 (n) 172 (n) 57 (n)

Cross-tabulation and the chi-squared test were used to
investigate associations between categorical variables.
Variation between group means was analysed by one-
way ANOVA if their variances were equal. If the vari-
ances were not equal, the Kruskal–Wallis test was used.
The equality of the variances was evaluated using
Levene’s test. When a statistically significant difference
was indicated by ANOVA, the Bonferroni correction was
used to identify categories exhibiting statistically signifi-
cant differences. When a statistically significant difference
was indicated by the Kruskal–Wallis test, the relevant
categories were identified using the Mann–Whitney U-
test. The results were described using means (M) and
standard deviations (SD). Standard threshold values were
used to define statistical significance: differences were
considered significant at p < 0.05 and very significant at
p < 0.001.
Results
A minority (18.7%) of the participants were registered
nurses while 73.5% were practical nurses. The other par-
ticipants (7.7%) had job titles such as bachelors of social
services or nursing assistant. Most (98%) of the partici-
pants were female; their ages ranged between 18 and
64 years (mean, 46  11.094 years). Their working
experience in nursing ranged from 0.5 to 42 years
(mean, 15.9  10.487 years) (Table 3).
Most of the nursing staff administered medication to
patients daily (91%). Almost half (45%) of the

© 2019 Nordic College of Caring Science

 Nurses’ self-assessments of adherence 5

Table 3 Demographic profile of the participants (N = 492) There were no significant differences between the
scores for participants with different educational levels
Variable n % on the medication preparation items. There was also no
association between the length of the participants’ work-
Sex
Male 9 1.8 ing experience and their responses. However, there were
Female 483 98.2 significant differences between the scores for participants
Age (years) in different age groups (p < 0.01): nurses in the oldest
<39 123 25 age group (mean, 0.46  0.456) adhere to medication
39–48 122 24.8 guidelines more closely than those in youngest age group
49–55 132 26.8 (mean, 0.7  0.575).
>55 115 23.4 There was no detectable association between medica-
Nursing education tion preparation practices and the frequency with which
Registered nurse 92 18.7
nurses prepared medication. However, there were
Practical nurse 362 73.5
significant differences between the medication prepara-
Other 38 7.7
tion practices of participants reporting different levels of
Working experience (years)
<8 131 26.6 knowledge of pharmacology and infection control
8–14 118 24 (p < 0.001), and different levels of skill at performing
15–24 125 25.4 medication calculations (p < 0.05). The most significant
>24 118 24 differences related to knowledge of pharmacology and
infection control: the better the participant considered
their knowledge in this area, the more closely they fol-
participants prepared medication daily, while the rest lowed guidelines when preparing medication. The partici-
(55%) did it <3 times per week. Most of the participants pants with the highest average scores on the medication
(82 %) reported the dispensation of medication to be preparation items (mean, <0.2) also assessed that they
among their duties. Also most of the participants (82.3%) follow the safe medication principles more thoroughly
self-assessed that they always adhere to all the guidelines (mean, 9.04) than those getting lower scores (p < 0.001).
of safe medication administration during the medication
administration process. However, almost one-fifth
Medication administration
(17.7%) assessed that they occasionally violet them.
Additionally, around one-third of the participants Over half the participants (56%) claimed to administer
(32.5%) awarded themselves a score of 8 or lower (on a medication to patients in accordance with the provided
scale ranging from 1 to 10) when asked to rate how clo- guidelines. However, almost half of the participants
sely they adhere to medication principles during the claimed to deviate from the guidelines if necessary.
medication process. Participants were also asked to evalu- Registered nurses (mean, 0.65  0.448) adhered more
ate how consistently the nursing staff around them consistently to safe medication administration guidelines
adhered to safe medication principles using a scale rang- than participants with other levels of education (mean,
ing from 1 to 10, where 10 corresponds to adherence at 0.42  0.033). Adherence to safe administration guideli-
all times and 1 corresponds to complete nonadherence. nes was unaffected by length of working experience but
As shown in Table 2, registered nurses rated their adher- did differ significantly between age groups (p < 0.01).
ence significantly (p < 0.01) lower (mean, 8.17  0.945) The most significant difference occurred between the old-
than practical nurses (mean, 8.54  1.052). est age group (mean, 0.46  0.42) and the two youngest
age groups (mean, 0.63  0.443, p < 0.001).
Nurses who administer medication to patients fewer
Medication preparation
than three times per week followed recommended
Most participants (70%) claimed to always prepare medi- administration guidelines more consistently (mean,
cation according to the relevant guidelines (Table 4). How- 0.27  0.24) than those who administer medication
ever, a third of the participants said that they deviate from three times per week or more (mean, 0.58  0.39,
the guidelines when preparing medication (mean, p < 0.01). There were significant differences in adherence
0.61  0.689). For example, participants quite commonly to recommended administration guidelines between par-
crush sustained release and enteric-coated tablets even ticipants with different reported levels of knowledge of
when the summary of the product’s characteristics does pharmacology, infection control and medication calcula-
not recommend doing so, and mix powders from different tions (p < 0.01). That is, the better a nurse’s self-assessed
medications together after crushing. In addition, several knowledge of pharmacology, the more closely he or she
participants commonly split pills without using a pill split- adhered to recommended administration guidelines. The
ter and open capsules even when it is not recommended. same was observed for nurses with higher self-assessed

© 2019 Nordic College of Caring Science

6 M. Karttunen et al.

Table 4 Participants’ scores for items in the medication preparation category

Percentage who
always follow
Item guidelines n Ma SD

When splitting a tablet, I do it with tablet splitter. 43.7% 215 0.76 0.821
I always use a spoon/pincers when dispensing medication. 54.5% 268 0.62 0.811
I clean the crusher carefully before crushing another tablet. 56.1% 276 0.71 1.000
If I plan to crush a tablet, I first check the recommendations given in the summary 58.5% 288 0.70 1.015
of the product’s characteristics or another information source.
I do not mix two or more crushed tablets together. 60.0% 295 0.67 0.987
I administer crushed tablets to patients separately with a small portion of cool food. 61.2% 301 0.67 1.035
I do not crush enteric-coated tablets if the summary of product characteristics does 65.9% 324 0.53 0.851
not recommend doing so.
If a patient cannot swallow a capsule, I open it only if the summary of product 67.7% 333 0.57 0.979
characteristics recommends doing so.
I do not crush sustained release tablets if the summary of product characteristics 67.3% 331 0.52 0.868
does not recommend doing so.
I prepare medication for one patient at a time. 94.5% 465 0.05 0.255
a
Ranging from 0.0 indicating maximal adherence to 4.0 indicating minimal adherence.

knowledge of infection control and higher self-assessed

skill at performing medication calculations. There was a
clear association between nurses’ self-assessment of how
well the safe medication principles are implemented in
their work and their mean score over all items belonging
to the medication administration category (p < 0.001)
(Tables 2 and 5).
Asepsis in medication
In the asepsis in medication category, majority of the
respondents (90%) assessed that they always follow
recommended guidelines. (mean, 0.11  0.00). However,
the proportion of participants who claimed to always use
hand disinfectant before and after administering medica-
tion was substantially lower (69%). There were no signif-
icant differences between occupational groups or
participants with different numbers of years’ working
experience with respect to asepsis scores. There were sta-
tistically significant differences between the asepsis scores
of nurses in different age groups (p < 0.01): older partici-
pants (> 48 years) claimed to maintain higher standards
of asepsis than younger ones (< 49 years). However, the
difference in the mean scores of the older and younger
participants was fairly small (mean, 0.14  0.204/mean,
0.069  0.123). There was no significant difference
between the asepsis scores of nurses who perform medi-
cation actions daily and those who perform them less
frequently. In addition, the asepsis scores did not differ
significantly between participants with different self-
assessed levels of pharmacology knowledge, infection
control knowledge or skill at performing medication cal-
culations (Table 6).
Discussion
The results of this study indicate that most nurses main-
tain good practices and follow guidelines when adminis-
tering medication. However, improvement is needed to
confirm medication safety. The medication preparation
items on the scale used in this study are all relevant to
types of medication that are common in long-term
elderly care and mainly relate to the handling of the
medication after removing it from the packaging. For
example, there are items asking about whether the
respondent ever opens capsules and crushes or splits
tablets, how they administer the resulting pulverized
medicine to the patient and how they use tools when
preparing medicine for a patient. Crushing pills and
opening capsules are very common procedures in elderly
care, and powder from several different tablets is com-
monly mixed before being administered to a patient.
There are no earlier reports on nurses’ perceptions of the
handling of these issues, but the findings presented here
are similar to those obtained in earlier observational
studies (12, 23), interviews (21) and medication register
analyses (23). Sustained release and enteric-coated pills
are often crushed even when the summary of the pro-
duct’s characteristics recommends against this (12, 22).
Several nurses participating in this study noted that in
some wards, even the doctors recommend crushing sus-
tained release and enteric-coated products, or that the
doctors do not prescribe alternative medications, which
obliges nurses to crush the pills so they can be ingested
by patients who have difficulty swallowing. The partici-
pants in this study also reported that it is common for
several tablets to be crushed together in the same vessel,

© 2019 Nordic College of Caring Science

 Nurses’ self-assessments of adherence 7

Table 5 Participants’ scores for items in the medication administration category

Percentage who always

Item follow guidelines n Ma SD

If a medication must be taken three times a day, I administer it every eight 42.9% 211 0.80 0.933
hours.
I ensure that the patient does not chew entero-coated tablets or capsules, depot 44.7% 220 0.83 0.939
tablets or capsules, sucking tablets, dispersible tablets, or resoriblets.
If the summary of product characteristics recommends that the medicine has “to 47.4% 233 0.67 0.758
be taken on an empty stomach” I strictly follow the recommendation.
If the medicine is recommended to be given 30 min prior to meal I strictly follow 51.0% 251 0.63 0.787
the recommendations.
If the soporific must be administered just before bedtime, I ensure the patient 56.7% 279 0.47 0.624
takes it on time.
If the medicine must be given at 8 o’clock, I give it within one hour of the 64.4% 317 0.53 0.913
scheduled time.
I ensure that the patient takes his/her medication on time. 71.3% 351 0.29 0.461
If the summary of product characteristics recommends that the medicine “be 71.3% 351 0.30 0.511
given with food” I strictly follow the recommendation.
a
Ranging from 0.0 indicating maximal adherence to 4.0 indicating minimal adherence.

Table 6 Participants’ scores for items in the asepsis in medication process category

Percentage who always

Items follow guidelines n Ma SD

I always disinfect my hands for 30 seconds 68.9% 339 0.38 0.641

before and after any action related to
medication processes.
I take care of the skin condition of my hands. 83.9% 413 0.17 0.409
I do not use nail polish or artificial nails on duty. 92.5% 455 0.09 0.349
I use protective gloves if the skin of my hands is cracked. 94.3% 464 0.06 0.264
I do not use rings on duty. 96.1% 473 0.05 0.247
I wash my hands with soap and water if they are visibly dirty. 97.4% 479 0.03 0.178
I dispose of needles and other sharp 98.6% 485 0.01 0.135
instruments in the sharps container after the use.
a
Ranging from 0.0 indicating maximal adherence to 4.0 indicating minimal adherence.

and for pills to be split by hand. According to Verrue
et al. (24), this practice of splitting pills by hand can
cause dose deviation due to mass loss. This may also
occur when tablets are crushed (25, 26). Because these
practices are often hazardous, alternative solutions such
as the use of different forms of medication or administra-
tion via different routes should be considered, and the
possibility of adverse events should be assessed (20).
The medication administration section of the scale used
in this study focused on whether the participants admin-
istered medication on the prescribed schedule and at the
right time in relation to meals (i.e. before or with a
meal), whether soporifics were administered at the right
time based on the patient’s needs, and whether nurses
ensure that patients do not chew pills that are harmful to
the teeth or mucous membranes of the mouth, or they
are depot or enteric-coated products. The challenge of
administering medication on a prescribed schedule has
been considered also in several other studies (13, 18).
The daily rhythm in long-term elderly care wards often
makes it difficult to ensure that medication is consistently
administered at the right time; evening medication is
commonly administered very early, and there may be
extended gaps between the administration of evening
and morning doses. Conversely, there is often insufficient
time between successive administrations of medicine in
the morning, during the day and in the evening. Teunis-
sen et al. (18) found that medicine is often given
1–2 hours after the prescribed time. Another study (13)
showed that scheduling errors often occur because nurses
must complete long morning rounds lasting up to
2–3 hours. This can make it impossible for nurses to
administer medicine within an hour of the prescribed
time. When answering open questions using free text,

© 2019 Nordic College of Caring Science

8 M. Karttunen et al.
some of the study’s participants noted that it can also be
challenging for nurses to ensure that patients receive
their medication on an ‘empty stomach’ (i.e. before
meals) because most wards use automated dispensing
systems and the nurses feel that separating a particular
medicine from a patient’s prescription and administering
it at a separate time to the other tablets would take up
too much time in their daily routine. Therefore, some
medications are given with meals even when the sum-
mary of product characteristics recommends against
doing so. This problem was also identified in an earlier
study (12) and commonly gives rise to clinically relevant
errors. For medication to be effective and safe for the
patient, it must be prepared in the right way and admin-
istered at the right time.
According to the nurses’ self-assessments, the most
well-actualized of the three categories in this study was
asepsis. The asepsis items included in this study related
primarily to hand hygiene and were based on the WHO
Guidelines on Hand Hygiene in Health Care (29). The
asepsis item for which the participants achieved the low-
est score in this work related to the use of hand disinfec-
tant: one-third of the participants do not use disinfectant
at all before administering medication, or use it in a way
that is ineffective. Some of the participants claimed to be
too busy for hand disinfection, and a few considered it
unnecessary if they do not touch the tablets with their
bare hands. In their answers to open questions, some
participants mentioned other challenges, such as that
encountered when a pill falls on the floor in a ward that
uses an automated dispensing system, making it impossi-
ble to obtain extra medication to replace the contami-
nated pill. In such cases, the nurses explained that they
had no choice but to give the pill to the patient despite
its contamination.
Surprisingly, there was no detectable association
between the scores on any item and the participants’
working experience. This finding is consistent with an
earlier study in which nurses assessed their own compe-
tence at intravenous infusion and drug therapy (42).
M€akipeura et al. (43) also observed no significant associ-
ation between nurses’ working experience and compe-
tence. There were no significant differences between any
of the occupational groups with respect to the scores for
items in the preparing medication category. However,
registered nurses achieved better scores than other occu-
pation groups on items in the medication administration
category.
The most significant differences in scores were
observed between different age groups: the oldest partici-
pants followed guidelines more closely than younger
ones. Interestingly, nurses who administer medication
three times or fewer per week followed guidelines more
closely than those who administered medicine daily. In
addition, there was a clear association between the
participants’ scores on medication preparation/adminis-
tration items and the adequacy of their theoretical
knowledge of pharmacology and infection control: nurses
with more adequate knowledge base of these subjects fol-
lowed guidelines more strictly. Dilles et al. (34) found
that nursing students had limited pharmacological
knowledge and calculation skills shortly before graduat-
ing, but another study (33) indicated that nurses’ knowl-
edge and skills in pharmacology and medication
increased after an educational intervention. Surprisingly,
there was no detectable association between knowledge
of infection control and the participants’ scores on items
relating to asepsis during medication. However, the par-
ticipating nurses perceived asepsis to be well managed in
their wards, so this conclusion may not be meaningful.
Limitations
Data were gathered using a web-based questionnaire, for
which the response rate was 39.4%. While this value is
low, it is good for a tool of this sort. The response rates
for some wards were above 90% while those for others
were below 30%. In total, 492 nurses completed the
questionnaire, giving sufficient responses for meaningful
statistical analysis. Four reminders were sent to the
wards’ superiors during the data collection period, so all
eligible nurses had the same opportunity to participate.
However, there was no way to confirm that the ward
superiors forwarded links to the questionnaire to their
staff, or to determine what measures they took to
encourage staff participation. There were also occasional
problems with the web-based data collection tool, such
as disconnections, which may have affected participants’
motivation. The participants were ‘forced’ to complete all
items on the questionnaire to avoid missing data, which
facilitated analysis. Feedback from some nurses suggested
that completing the questionnaire took too long, and
they had no time to participate on busy days. The open
questions were answered surprisingly thoroughly, which
may be why it took participants so long to complete the
questionnaire.
Conclusion
Nurses’ self-assessments show that the guidelines on
medication preparation, administration and asepsis in
long-terms elderly care are often deviated. One-third of
the participants gave themselves a rating of eight or less
when self-assessing how well they implemented safe
medication principles in their work, and there was an
association between these self-assessments and partici-
pants’ responses to items in the preparation and adminis-
tration categories. This means that deviation of the
guidelines is often a conscious choice. The participants
explained that nurses may choose to deviate from the
© 2019 Nordic College of Caring Science
 Nurses’ self-assessments of adherence 9

guidelines because of their constant workload, daily Conflict of interest

rhythm, routine and a lack of alternative solutions. How-
None.
ever, many deviations of these kinds resulted in medica-
tion errors. These findings suggest that attention should
be paid in development of undergraduate and continuing Author contributions
education in order to improve the knowledge base of
Markus Karttunen performed planning, data collection,
pharmacology and infection control. More effort should
analysis and writing the report. Satu Elo involved in
also be used in developing nurses’ medication calculation
planning, writing the report and supervision. Sami Sneck
skills. Nursing students and nurses must be reminded of
involved in writing the report and comments. Jari Joke-
the ethical aspects of safe medication and the necessary
lainen involved in analysis and comments.
attitude towards them. Nurses must understand why it is
important to follow the recommended guidelines when
preparing and administering medications. Finally, systems Ethical approval
should be established in long-term elderly care wards to
None.
enable and ensure safe medication management.

Funding
Acknowledgement
None.
None.

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