Evaluating Nursing Students’ Confidence and Accuracy in Drug Calculations to Enhance Medication Safety

Shubhada N. Ponkshe¹*, Ashwini V. Lande²

¹Vice Principal, HOD of Nursing Foundation Department (Retd), Nursing Foundation Department, Maharshi Karve Stree Shikshan Samstha’s Smt. Bakul Tambat Institute of Nursing Education, Pune, Maharashtra, India.

²Nursing Foundation Department, Maharshi Karve Stree Shikshan Samstha’s, Smt. Bakul Tambat Institute of Nursing Education, Pune, Maharashtra, India.

*Corresponding Author E-mail: snponkshe@gmail.com

ABSTRACT:

Background and objective: Drug administration is a critical component of nursing care, and accuracy depends on competence in basic mathematics. This study assessed the relationship between self-rated confidence and actual performance in drug calculations among first-year B.Sc. Nursing students using a criterion-referenced approach. Materials and methods: A one-group post-test correlational design was adopted with 47 consenting students. Teaching sessions on drug calculations were followed by a teacher-made 25-mark test and a 5-point confidence scale. Passing criteria were set at ≥90% performance and ≥4/5 confidence. Students not meeting these thresholds received 8 hours of remedial teaching and retesting. Data were analysed using IBM SPSS version 20 with descriptive statistics and Spearman’s rho correlation (α = 0.05). Results: Baseline scores ranged from 11 to 22 (M = 17.34, SD = 2.91), with a mean confidence of 2.51(SD = 0.83). Confidence correlated significantly with performance at baseline (ρ = 0.525, p<0.01) and post-teaching (ρ = 0.868, p<0.01), but not post-remediation (ρ = 0.348, p = 0.113). Pre-university mathematics background showed no significant association with baseline performance (ρ = 0.051, p = 0.731). At Post-test 1, 25 students (53.2%) achieved the criteria, while 22(46.8%) required remediation. By Post-test 2, all students (100%) met the benchmark. Conclusion: Confidence was a useful predictor of performance when variability existed, but less so once all students attained high scores. Criterion-referenced testing with structured remediation effectively ensured competence and confidence before clinical placement, thereby strengthening patient safety.

KEYWORDS: Clinical competence, Confidence, Criterion-referenced testing, Drug dosage calculations, Nursing education, Medication safety.

INTRODUCTION:

Drug administration is a critical component of nursing care, and accuracy depends on competence in basic mathematics. Errors in drug calculation remain among the most common causes of medication-related harm worldwide, with consequences ranging from prolonged hospital stays to life-threatening outcomes. Several studies have consistently shown that nursing students struggle to achieve competency in drug calculations despite formal teaching^1,2. Reported difficulties include conversion errors, misapplication of formulas, and confusion with fractions and ratios³.

Confidence and competence in pharmacology are closely linked, and targeted interventions have shown measurable improvements in student outcomes^4,5. Simulation-based learning and criterion-referenced testing have been successfully used to enhance medication safety before clinical placement^6,7. Peer tutoring and structured feedback have also emerged as effective strategies to bridge competency gaps^8,9.

These findings highlight the urgent need for educational strategies that integrate confidence-building with rigorous competency checks. The present study, therefore, adopted a criterion-referenced approach requiring ≥90% accuracy and ≥4/5 confidence before clinical posting, aligning with recommendations from AJNER studies on medication safety^10,11.

OBJECTIVES:

1. To describe baseline drug calculation performance and self-rated confidence among first-year B.Sc. Nursing students.

2. To examine the relationship between pre-university mathematics background and baseline drug calculation performance.

3. To describe drug calculation performance and self-rated confidence at two subsequent assessments: Post-test 1 and Post-test 2 (after remediation).

4. To determine the correlation between self-rated confidence and actual performance at three time points: baseline, Post-test 1, and Post-test 2.

5. To determine how many attempts were required for students to achieve the predefined passing criteria (≥90% performance and ≥4/5 confidence).

HYPOTHESES:

1. H₀₁: There is no significant association between pre-university mathematics background and baseline drug calculation performance among student nurses.

2. H₀₂: There is no significant correlation between self-rated confidence and actual performance at each time point (baseline, Post-test 1, and Post-test 2).

3. H₀₃: All students will require only one attempt to meet the predefined passing criteria.

MATERIALS AND METHODS:

Study Design:

This study, entitled “Assessing the Correlation Between Self-Rated Confidence and Actual Performance in Drug Calculations Among Student Nurses,” adopted a one-group post-test correlational design to assess the relationship between self-rated confidence and actual performance in drug calculations. The work was conducted within an action research framework, aimed at improving teaching practice and ensuring competency-based preparation before clinical posting.

Study population and sample:

The study population consisted of all first-year, second-semester B.Sc. Nursing students enrolled in the program (n = 49). A convenience census of the entire cohort was attempted. Of these, 47 students consented to participate in the research component. Two students, while completing the test for academic purposes, chose not to have their results included in the study; their decision was respected in keeping with ethical principles of voluntary participation.

Teaching intervention:

As per the curriculum, 42hours (20hours theory, 22 hours skill lab) were allocated to the unit Administration of Medication. Within this unit, special emphasis was placed on the objective “Calculate conversion of drugs and dosages within and between systems of measurement.” To strengthen competence in drug calculation, the researcher devoted 15 hours to focused teaching and practice using situational problem-solving exercises in dosage calculations.

Assessment tools:

· Drug calculation test: A teacher-made 25-mark test was developed, consisting of situational and numerical problems involving addition, subtraction, multiplication, division, conversions, fractions, ratios, and drug dosage calculations. The test was administered after completion of the teaching intervention and before students’ clinical posting.

· Self-rated confidence scale: Students rated their confidence for each question using a 5-point Likert scale (1 = Not confident at all, 2 = Slightly confident, 3 = Moderately confident, 4 = Confident, 5 = Very confident). An overall self-confidence score was computed for each student.

· Background information sheet: Students reported demographic and academic background details, including whether they had studied mathematics only up to Grade 10 or had continued with mathematics in Grades 11–12.

Criterion-referenced assessment:

The test was conducted as a criterion-referenced test (CRT), with performance judged against a predetermined standard rather than relative to peers. The passing criteria were:

1. A score of ≥90% on the drug calculation test, and

2. A minimum average confidence rating of 4/5.

The 90% threshold was selected instead of 100% to account for practical variability, acknowledging that factors such as question interpretation, minor arithmetic slips, or temporary health issues might influence performance. This ensured the bar for competency was set very high, while still realistic and fair.

Students who did not initially achieve the required criteria were provided with 8 additional hours of remedial teaching, focusing on reinforcing basic mathematical operations, conversions, and applied dosage problem-solving. Once all students reached the defined proficiency level and confidence score, the entire group proceeded together to clinical practice under close supervision. This staged approach ensured that no student was left behind, learning gaps were systematically addressed, and patient safety was safeguarded by confirming competency prior to clinical exposure.

RESULT:

Data were analysed using IBM SPSS Statistics version 20, descriptive statistics, and Spearman’s rho correlation. Statistical significance was set at α = 0.05 (two-tailed). At baseline, students’ drug calculation scores averaged around 69%, with none achieving the ≥90% benchmark. Most clustered between 14–22 marks, while confidence levels were generally low to moderate, with nearly half rating themselves “moderately confident.” These findings confirmed substantial gaps in both competence and confidence before clinical posting (Table 1, Figures 1–2).

Table 1. Descriptive statistics (mean, SD, min, max for baseline score and confidence). N=47

Variable	Mean (SD)	Min	Max
Drug calculation score (out of 25)	17.34 (2.91)	11	22
Self-rated confidence (1–5)	2.51 (0.83)	1	4

Figure 1. Bar graph distribution of drug calculation scores (out of 25) vs. % of students N=47

Figure 2. Distribution study participants on self-rated confidence levels N=47

Table 2. Relationship between pre-university mathematics background and baseline drug calculation performance N- 47

Variables	Pre-university mathematics background		Spearman's rho	Sig. (2-tailed)
	f	%
Pre university mathematics till 10th	19	40.43	0.051	0.731
Pre university mathematics till 12th	28	59.57

Note: ρ = Spearman’s rank correlation coefficient; p = probability value (two-tailed); significance level set at α = 0.05.

Pre-university mathematics background showed no significant association with baseline performance, indicating that prior exposure to mathematics did not influence drug calculation ability (Table 2).

Table 3: Descriptive statistics for drug calculation scores and self-rated confidence at Post-test 1 and Post-test N-47

Variable	Mean (SD)	Min	Max
Drug calculation score (Post test-1)	22 (2.05)	18	25
Self-rated confidence (Post test-1)	3.76 (.75)	3	5
Drug calculation score (Post test- 2)	24 (.82)	23	25
Self-rated confidence (Post test- 2)	4 (.50)	4	5

Following the teaching intervention, performance improved markedly, with mean scores rising to 22/25 and confidence levels shifting upward. While many students achieved the benchmark, nearly half still required remediation (Table 3, Figure 3). After targeted remedial teaching, all students reached ≥90% accuracy and ≥4/5 confidence, demonstrating the effectiveness of structured support (Table 3, Figures 3–4).

Figure 3. Distribution of study participants’ self-rated confidence levels at Post-test 1 and Post-test 2. N-47

The distribution of scores (Figure 4) demonstrated a marked clustering at the highest performance levels, confirming the effectiveness of the remedial intervention in ensuring both competence and confidence before clinical posting.

Table 4. Correlation between drug calculation performance and self-rated confidence at three time points (N = 47)

Time point	Spearman's rho	p-value	Interpretation
Baseline	0.525**	0.001	Moderate positive correlation
Post-test 1	0.868**	0.001	Strong positive correlation
Post-test 2	0.348	0.113	No significant correlation

Note: ρ = Spearman’s rank correlation coefficient; p = probability value (two-tailed); significance level set at α = 0.05.

Note: ρ = ** Spearman’s rho. Correlation is significant at the 0.01 level (2-tailed).

Correlation analysis revealed that confidence was moderately predictive of performance at baseline and strongly predictive after teaching, but lost significance once all students achieved high scores (Table 4). This suggests confidence is most useful as a predictor when variability in performance exists.

At Post-test 1, just over half the students achieved the benchmark, while nearly half required remediation. After targeted support, all students met the criteria by Post-test 2, confirming the effectiveness of structured remedial measures in ensuring competence and confidence before clinical placement.

DISCUSSION:

This study demonstrated that prior mathematics background alone does not predict competence in drug calculations among nursing students, echoing findings from AJNER reports where foundational numeracy skills did not consistently translate into clinical accuracy ¹⁰.Confidence emerged as a useful predictor of performance when variability existed, particularly at baseline and after structured teaching, consistent with earlier studies linking self-efficacy to clinical competence^4,5.

Nearly half of the cohort required remediation before achieving competency, underscoring the importance of structured support. Similar results have been reported where remedial teaching and peer tutoring significantly improved drug calculation accuracy^2,8. Simulation-based learning and criterion-referenced testing have also been shown to strengthen medication safety outcomes ^6,7.

Taken together, these findings highlight that confidence can guide—but not guarantee—competence, and remediation is indispensable for many students. Integrating criterion-referenced testing with structured remediation and formative feedback offers a rigorous and equitable strategy to ensure that all nursing students achieve both competence and confidence before clinical placement, thereby strengthening patient safety ^9,11.

ETHICAL CONSIDERATIONS:

Ethical approval for the study was obtained from the institutional ethics review committee. Participation in the research component was voluntary, and informed consent was obtained from all students. Confidentiality of responses was maintained, and students’ academic progression was not affected by their decision to participate or decline. The approach adhered to the principles of beneficence, non-maleficence, and respect for autonomy.

CONFLICT OF INTEREST:

The authors declare no conflict of interest. The research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest.

LIMITATIONS:

This study was conducted as an action research project with a convenience sample from a single cohort of nursing students. While this approach allowed for in-depth evaluation within the teaching context, the findings may not be generalizable to larger or more diverse populations. Future studies using multi-institutional samples and experimental designs would help strengthen the evidence.

IMPLICATIONS FOR PRACTICE:

Despite these limitations, the findings highlight the value of criterion-referenced testing combined with remedial support in nursing education. Integrating such approaches into routine teaching can help ensure that all students achieve both competence and confidence in drug calculations before clinical placement, ultimately promoting patient safety.

CONCLUSION:

This study demonstrates that prior mathematics background alone does not predict drug calculation competence among nursing students. While self-rated confidence correlates with performance when variability exists, it loses predictive value once all students achieve high scores. Nearly half of the cohort required remediation, underscoring its importance in meeting rigorous competency thresholds.

For nursing education, the implications are clear: criterion-referenced testing, supported by structured remediation and frequent formative feedback, is essential to ensure that all students achieve both competence and confidence before clinical placement. Such an approach provides a systematic safeguard for patient safety.

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Received on 04.12.2025 Revised on 01.01.2026

Accepted on 27.01.2026 Published on 30.04.2026

Available online from May 02, 2026

Int. J. Nursing Education and Research. 2026;14(2):111-115.

DOI: 10.52711/2454-2660.2026.00022

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