Study design and setting

This was a cross-sectional study designed to measure nurses’ knowledge and practices about mixing medications with food. The data were collected between February and April 2019.

Palestine consists of two geographical areas: The West Bank and the Gaza Strip. According to the Palestinian health annual report 2021, there are approximately 5.29 million inhabitants in Palestine, 59.6% in the West Bank and 40.4% in the Gaza Strip [20]. There are three regions in the West Bank:

The North Region is divided into six governorates: Jenin, Tulkarm, Nablus, Qalqilya, and Tubas.

The Middle Region is divided into three governorates: Jerusalem, Ramallah, Salfit, and Jericho.

The South Region is divided into two governorates: Bethlehem and Hebron.

The current study was carried out in the West Bank of Palestine. We chose the West Bank because it is difficult to reach the Gaza Strip due to its boundaries. We collected information from all government secondary and tertiary hospitals in the northern West Bank. A list of government hospitals' names and addresses was obtained from the Ministry of Health (MOH). Based on these lists, we visited the following West Bank governorates: Nablus, Jenin, Qalqilya, Tulkarm, Salfit, and Tubas [21]. These hospitals provide several services and have different disciplines, including pediatric and geriatric units.

Sample size calculation

In 2019, the Palestinian Health Information Centre gathered data indicating that there were a total of 1822 nurses employed in government hospitals located in the West Bank [22]. For the purpose of this study, a specific group of hospitals was selected, and within those hospitals, there were 769 nurses included in our analysis [22]. To ensure the reliability of our findings, we calculated the required sample size using the Raosoft sample size calculator [23], aiming for a 95% confidence level and a 5% error margin. The calculator indicated that a minimum sample size of 257 nurses was necessary.

Sampling procedure

In this study, the population was chosen from nurses in government hospitals in the northern region of the West Bank of Palestine, according to data taken from the Palestinian Health Information Center. Nurses from different hospitals were invited to participate in the study using a convenience sampling technique. We reached the nurses in each department during their morning shift, and they were interviewed face-to-face.

Inclusion and exclusion criteria

In 2019, the total number of registered nurses employed in government hospitals and health care units in the West Bank was 2613 [22]. The population was selected from nurses employed in northern government hospitals. We included all six government hospitals in northern Palestine: Al-Watani Hospital, Martyr Dr. Thabet Governmental Hospital, Rafidia Surgical Hospital, Tubas Turkish Hospital, Darwish Nazzal Hospital, and Jenin Government Hospital.

The inclusion criteria were as follows: a registered nurse in the Palestinian Ministry of Health (MOH), with at least a certificate or higher degree of qualification (master’s degree or PhD) and employed in a government hospital. All working nurses, regardless of their wards, were able to participate. We included nurses with a diploma because there are no restrictions in Palestine that prevent them from preparing medications without assistance.

The exclusion criteria were nurses who refused to participate in our study.

Data collection instrument form

The semistructured questionnaire on the knowledge and practices of healthcare professionals regarding the mixing of medications with food, especially nurses, has been developed in previous studies [1, 7, 12,13,14, 24,25,26,27], which were carried out in different places, including France, the Netherlands, the UK, Iran and Palestine.

Demographics

The questionnaire contains five sections. The first was the demographic section, which included issues relating to age, gender, work years, marital status, region of residence, level of education, place of graduation, year of graduation, experience, and training background or specialty.

Nurses’ practices of mixing medications with foods

The second section is divided into three parts. The first evaluated how frequently the nurses modified the dosage form and how they dealt with this modification by adding crushed tablets or capsules to food or drinks or inversely. This was based on a review of the literature, the experience of researchers and the consultation of clinical experts. This part consisted of seven questions, each answered yes or no. The second part determined how often each kind of food (banana, milk, juice, etc.) was used to mix with crushed medicine. The list contained seven types of foods or drinks, and the nurses could add other kinds. They were asked how frequently food was mixed with medicine (never, rarely, sometimes, often, or very often). The third part was a list of drugs (analgesics, antihypertensives, antiplatelets, antibiotics, corticosteroids, diuretics, antilipidemic, and gastric acid-reducing medications), and the nurses chose from it what medication they commonly crushed and mixed with food before administering to the patients to determine the most common drugs crushed and mixed with food by nurses. The answers to these questions are coded as yes or no.

Reasons for dosage modifications

The third section determined the reasons for the modification of the dosage form of the drug in hospitals and consisted of five potential reasons based on the literature review and clinical expert consultation (never, rarely, sometimes, often, or very often) [1, 7, 12,13,14, 24,25,26,27].

Nurses’ knowledge regarding mixing medications with foods and sources of information.

The fourth section was divided into two parts. The first evaluated nurses’ knowledge about mixing drugs with food, food-drug interactions, and chemical/physical stability of drugs after modification and whether they were sufficiently prepared to carry out this procedure or reported every time they modified the dosage form. It consisted of 18 questions, answer yes, no, or I don’t know. No cut-off point was used to determine knowledge. Instead, the total median score was calculated, with a higher score indicating greater knowledge, and then compared between all variables.

The second part was a multiple-choice question about the nurses’ sources of information about splitting or crushing tablets or capsules; they could choose more than one.

Transparency of the dosage modification process

The fifth section was about the transparency of the modification procedure, asking about receiving permission from patients to mix the medicine with food or if they asked them about their favorite food to use for mixing with medication. It was also asked if the mixing procedure was written on nurses’ notes or mentioned by the prescriber. It consisted of seven questions answered never, rarely, sometimes, often, or always.

At the end of the interview, we provided nurses with an educational orientation on incorrect answers that may harm the patients.

Ethical approval

Before the start of this study, authorisation in all aspects, including access to and use of the information in our study procedure, was obtained from the Institutional Review Board (IRB) of An-Najah National University [approval number: (1) June 2018], MOH, and local health authorities. Before filling out the questionnaire, all parts of the study, including study instruments, objectives, privacy, and confidentiality (all information will be used only for research purposes), were completely explained to the participants, and verbal consent was received from them.

Study rigor

The questionnaire was reviewed by consensus by a panel of three experts in the field drawn from academia for its content validity (one expert in clinical pharmacology and two experts in clinical pharmacy). The questionnaire was originally created in English and subsequently translated into Arabic by two highly skilled healthcare professionals (SHZ and SWA), who possess vast expertise in health survey design and are fluent in both languages. All experts stated that the questions adhered exclusively to the study’s objectives. A pilot study with 25 participants from all included hospitals was conducted to test the instrument of our study to ensure readability, estimate the time and then adjust the data collection form (questionnaire) as needed.

Statistical analysis

Data entry and analysis were performed using the IBM Statistical Kit for Social Sciences version 21 program (IBM-SPSS). Medians (interquartile ranges [IQRs]) were used to present continuous variables, while frequencies (percentages) were used for categorical variables. The normality of each variable was assessed using the Kolmogorov‒Smirnov test. To evaluate median differences between groups, either the Kruskal‒Wallis or Mann‒Whitney tests were employed. Statistical significance was denoted by a p value of less than 0.05.