INTRODUCTION
Neonatal intensive care units (NICUs) are high-risk environments providing life-sustaining care to premature and critically ill neonates who are highly vulnerable to healthcare-associated infections (HAIs) due to immature immune systems and underdeveloped anatomical barriers [1,2]. This vulnerability is further compounded by the routine use of continuous invasive procedures, including continuous infusion therapies and vascular access devices [1-3]. These essential interventions pose a significant risk of HAIs, such as late-onset sepsis and bloodstream infections, which remain major causes of neonatal morbidity and mortality [3,4]. In this context, NICU nurses, who maintain sustained direct contact with patients, serve as the primary safeguards against infectious complications. Consequently, their strict adherence to safe injection practices and aseptic techniques is a critical determinant of neonatal safety and clinical outcomes [1,5].
Safe injection practices constitute a core component of Standard Precautions. The Centers for Disease Control and Prevention (CDC) emphasizes strict adherence to aseptic techniques, the single-use principle for syringes and needles, and the appropriate management of medication vials [6]. While national guidelines have been established and periodically updated in South Korea, a significant discrepancy remains between these recommended standards and actual clinical performance [7,8]. Previous studies indicate that actual compliance rates for safe injection practices vary significantly depending on the complexity of neonatal medication regimens. This suggests that in the specialized and high-pressure environment of the NICU, the mere dissemination of clinical guidelines is insufficient to guarantee safety [6,9]. The gap between existing protocols and actual bedside performance implies that successful adherence is not determined by the availability of information alone, but rather by how nurses integrate their knowledge and professional values into practice under complex clinical conditions. Therefore, a systematic examination of individual and professional factors—such as specialized knowledge, safety-oriented attitudes, and nursing professionalism—is warranted to identify the mechanisms that bridge this performance gap.
Safe injection practice knowledge serves as the fundamental cognitive prerequisite for ensuring patient safety. Previous studies have demonstrated that a lack of specialized knowledge regarding infection control and drug administration is directly linked to increased medication errors and HAIs [10]. In the NICU, where the vulnerability of neonates necessitates extreme precision, high-level clinical knowledge provides the psychological foundation that enables nurses to execute complex protocols with confidence and accuracy [11]. Therefore, assessing the specific knowledge levels of NICU nurses is essential to identify potential gaps in procedural adherence.
However, while clinical knowledge provides the necessary framework, it does not always guarantee behavioral adherence. In high-pressure environments like the NICU, a nurse's internal predisposition and evaluative stance toward safety protocols—namely, their attitude—often act as the decisive catalyst for transforming knowledge into consistent action. Within the context of this study, a positive attitude toward safe injection practices is operationally defined as a favorable and receptive internal belief system regarding the critical necessity and clinical efficacy of following standardized protocols to protect vulnerable neonates [12,13]. These safety-oriented attitudes reflect a nurse's internalized commitment to patient protection. Previous literature suggests that while positive attitudes facilitate adherence, negative or indifferent attitudes may hinder, or act as barriers to, the consistent execution of preventive behaviors [12,14].
Furthermore, the high technical demands of neonatal care, coupled with its emotional complexity—character-ized by the psychological pressure of caring for extremely fragile infants and the intense communication required with anxious guardians—necessitate a deeper focus on the internal value system of nurses. Nursing professionalism, which encompasses professional responsibility and ethical identity, functions as an internal regulatory mechanism that guides nursing behaviors [15,16]. Nurses with higher levels of professionalism may be more likely to adhere to safety principles as a reflection of their professional accountability. Although several studies have investigated the factors influencing infection control among general hospital nurses [8,17], research specifically targeting NICU nurses remains scarce. There is a critical lack of integrated research exploring how internal regulators—spe-cifically, safe injection-specific attitudes and nursing professionalism—individually influence and collectively contribute to voluntary adherence to safety standards in the specialized NICU environment. This study aims to fill this empirical gap by identifying the distinct impact of these internalized values and beliefs on clinical performance.
Consequently, this study aimed to examine the relationships between safe injection practice knowledge, safe injection practice attitude, nursing professionalism, and safe injection practice performance among NICU nurses, reflecting the most recent safe injection guidelines in Korea. By identifying the determinants of safe injection practice performance, this study seeks to provide foundational evidence for developing strategies to enhance safe injection practices.
METHODS
1. Study Design
This study employed a cross-sectional, descriptive research design to investigate the factors influencing safe injection practice performance among NICU nurses and to examine the relationships among safe injection practice knowledge, attitudes, and nursing professionalism.
2. Participants
The participants were nurses working in the NICUs at six general or tertiary hospitals located in regions C and D. Only nurses who understood the purpose of the study and voluntarily agreed to participate were included. The inclusion criteria were nurses who had worked in NICUs for at least six months and provided direct patient care. This minimum period was established to ensure that the participants had moved beyond the initial professional adaptation phase and achieved the capacity for independent clinical nursing and infection control practices [15]. Head nurses or charge nurses who did not provide direct patient care were excluded. The sample size was calculated using G*Power 3.1.9.4 software. Based on multiple regression analysis with a medium effect size of 0.15, a significance level of 0.05, a power of 0.80, and eight predictor variables, the minimum required sample size was 109. To account for a potential attrition rate of approximately 10% due to incomplete or unreliable responses [16], 120 questionnaires were distributed. All 120 questionnaires were retrieved (response rate: 100%) and included in the final analysis.
3. Measurements
The researchers obtained permission to use all the instruments from the original authors.
1) Participants’ characteristics
Participants characteristics included age, education, clinical experience in the NICU, safe injection practice training, and barriers to safe injection practices. Barriers to safe injection practices were assessed using a single-choice question: "What do you consider the primary reason for not adhering to safe injection practices?" Response options included a lack of time for injection tasks, inadequate environmental facilities (e.g., sinks, supplies), heavy workload, and others.
2) Safe injection practice performance
To assess safe injection practice performance, we used a tool developed by Kim et al. [20] comprising 27 items rated on a 5-point Likert scale (1=never, 2=rarely, 3=sometimes, 4=frequently, and 5=always). An option for “not applicable” was included, and these responses were treated as missing data for analysis. Higher scores reflected a higher level of safe injection practices. Although the original developers primarily focused on content validity—achieving a Content Validity Index (CVI) of 0.80 or higher through a 10-expert panel—and did not report an internal consistency coefficient, the psychometric stability of the tool was confirmed in the present study. For this sample, the instrument demonstrated high reliability, with a Cronbach's ⍺ was 0.88.
3) Safe injection practice knowledge
We assessed safe injection practice knowledge by using a tool developed by Kim et al.[20] This 27-item instrument employs a response format of “yes,” “no,” and “don't know.” Correct responses were scored as 1, whereas incorrect or “don't know” responses were scored as 0. Possible scores ranged from 0 to 27, with a higher score reflecting greater knowledge of safe injection practices. While the original study did not provide internal consistency reliability, the instrument's content validity was established by a panel of 10 experts who only retained items with a CVI of 0.80 or higher. In the current study, the internal consistency of the knowledge scale evaluated using the Kuder-Richardson Formula 20 (KR-20) for the knowledge scale was 0.40., Prior to its application, the instrument's content validity had been rigorously established with a content validity index (CVI) ≥0.80 by 10 experts.
4) Safe injection practice attitude
Attitudes toward safe injection practices were assessed using a tool originally developed by Kim et al. [21] and subsequently modified by the researcher to enhance its clinical relevance for the NICU environment. The modification involved updating terminology and clinical scenarios to align with the latest safe injection guidelines [8,9]. The original 27-item structure and conceptual framework were strictly maintained. Content validity was verified by a panel of four experts—comprising three nursing professors and one infection control specialist—resulting in a Content Validity Index (CVI) of 0.80 or higher for all items. Each item was rated on a 5-point Likert scale ranging from 1 (not at all important) to 5 (very important), with higher total scores reflecting a more positive attitude. Although internal consistency was not originally reported by Kim et al. [21], the tool demonstrated strong reliability in the present study, with a Cronbach's ⍺ of 0.89.
5) Nursing professionalism
Nursing professionalism was assessed using the modified Korean Nursing Professional scale. The original instrument by Yeun et al. [15] was refined and condensed to 18 items by Han et al. [19] based on construct validity testing. It comprises five subscales: self-concept of the profession (6 items), social awareness (5 items), nursing professionalism (3 items), roles of nursing service (2 items), and originality of nursing (2 items). Responses were rated on a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5=strongly agree). Higher scores reflected a higher degree of nursing professionalism. The instrument demonstrated high reliability, with a Cronbach's ⍺ of 0.91 in Han et al.[19] and 0.89 in the current study.
4. Data Collection
Data were collected from August 1, 2023, to January 30, 2024. For participant recruitment, the researcher initially contacted the nursing departments of the six targeted hospitals and submitted formal applications for data collection. Upon receiving administrative approval, the study's purpose was explained, and the questionnaires were distributed to the NICU nurses through the respective nursing departments. A dual-mode approach involving offline and online methods was employed to ensure sample representativeness and accessibility. For on-site collection, the researcher explained the study's purpose, confidentiality, and right to withdraw to the nurses. After providing written informed consent, participants completed a self-report questionnaire in approximately 15 minutes. The completed surveys were placed in sealed envelopes to ensure anonymity. For units that were difficult to access physically, a Google Forms URL was used. Participants provided electronic consent after reviewing the study information. Ultimately, a total of 120 questionnaires were collected and included in the final analysis. Of these, 111 (92.5%) were collected offline, and 9 (7.5%) were collected online. To minimize any potential mode effects, identical instruments and instructions were provided for both groups. Statistical analysis was performed to verify the homogeneity of the data collected through the two modes; no significant differences were found in the primary variables, justifying the integration of the data. All data were processed anonymously. Participants were informed that the contact information collected to provide a token of appreciation would be deleted immediately after distribution.
5. Data Analysis
All statistical analyses were performed using IBM SPSS Statistics (version 26.0; IBM Corp., Armonk, NY, USA). Participants’ characteristics and study variables were summarized using descriptive statistics (frequency, percentage, mean, and standard deviation). Differences in safe injection practice performance according to participants’ characteristics were analyzed using independent t-tests or one-way analysis of variance (ANOVA), as appropriate. When the assumption of homogeneity of variance was violated, the Brown-Forsythe test was applied instead of one-way ANOVA. Post hoc comparisons were performed using Scheffé test when the assumption of equal variances was met and Tamhane's T2 test when equal variances were not assumed. Pearson's correlation coefficients were calculated to determine the relationships among major variables. Multiple regression analysis (enter method) was performed to identify the factors affecting safe injection practice performance.
6. Ethical Considerations
This study was conducted in strict accordance with the ethical principles of the Declaration of Helsinki. Before the commencement of data collection, the study protocol was reviewed and approved by the Institutional Review Board of C University Hospital (IRB No. 2023-06-020-002). Written informed consent was obtained from all participants. The information sheet clarified that participation was voluntary, anonymity was strictly maintained, no risks were involved, and participants could withdraw from the study at any stage without consequences. To protect personal information, hard-copy questionnaires were collected in sealed envelopes, and online data were retrieved using Google Forms. All data were de-identified using a coding system and stored on a password-protected personal computer managed exclusively by the researcher. In accordance with the Personal Information Protection Act [22], all data will be retained for three years and subsequently permanently destroyed under the researcher's supervision.
RESULTS
1. Differences in Performance of Safe Injection Practices According to Participants’ Characteristics
Table 1 presents the participants’ characteristics and differences in safe injection practice performance. The participants’ mean age was 30.02±5.44 years, and average NICU experience was 5.89±4.33 years. Most participants (n=105, 87.5%) reported receiving training in safe injection practices. Overall, 78 participants (65.0%) identified heavy workload as the primary barrier to safe injection practice performance.
Table 1.
Differences in Performance of Safe Injection Practices According to Participants’ Characteristics (N=120)
Safe injection practice performance differed significantly based on clinical experience (F=5.48, p=.005) and safety education experience (F=1.99, p =.049). In the post-hoc analysis, participants with more than 6 years of experience (4.87±0.15) demonstrated significantly higher scores compared to those with 3 years or less (4.70±0.29).
2. Descriptive Statistics for Study Variables
The participants’ mean safe injection practice knowledge score was 26.54±0.84 out of a maximum of 27. Regarding the variables measured on a 5-point scale, the mean scores for safe injection practice attitude and performance were 4.85±0.22 and 4.79±0.15, respectively. Nursing professionalism yielded a mean score of 3.84±0.45 (Table 2).
Table 2.
Descriptive Statistics for Study Variables (N=120)
3. Correlations among Study Variables
Safe injection practice performance was significantly and positively correlated with safe injection practice attitude (r=.58, p<.001) and nursing professionalism (r=.21, p=.022). Furthermore, safe injection practice attitude was significantly and positively associated with nursing professionalism (r=.29, p=.002) and safe injection practice knowledge (r=.22, p=.017) (Table 3).
Table 3.
Correlations between Study Variables (N=120)
4. Factors Influencing Safe Injection Practice Performance
Multiple regression analysis determined the predictors of safe injection practice performance. The independent variables included clinical experience and safe injection practice training, which were significant in the univariate analysis, along with safe injection practice attitude and nursing professionalism, which were correlated with the dependent variable. Categorical variables (clinical experience and safe injection practice training) were dummy-coded for analysis. Diagnostic tests confirmed that the regression assumptions were met. The Durbin-Watson statistic was 1.69, indicating the independence of the residuals (no autocorrelation). Furthermore, there was no evidence of multicollinearity, with tolerance values ranging from 0.81 to 0.91 (>0.1) and Variance Inflation Factors ranging from 1.10 to 1.26 (< 10).
The regression analysis resulted in a statistically significant model (F=13.90, p<.001). Safe injection practice attitude (β=.54, p<.001) and NICU experience of more than 6 years (β=.20, p=.009) were significant predictors of safe injection practice performance. The model accounted for 35.0% of the total variance in performance, and safe injection practice attitude emerged as the most influential predictor (Table 4).
Table 4.
Factors Influencing the Performance of Safe Injection Practices (N=120)
DISCUSSION
This study primarily aimed to examine safe injection practice knowledge, safe injection practice attitudes, and professionalism among NICU nurses, and to determine the predictors of safe injection practice performance. The key findings revealed that safe injection practice attitudes and clinical experience in the NICU (6 years or more) were significant predictors, collectively accounting for 35.0% of the total variance in performance.
First, safe injection practice attitudes were identified as the most significant predictor of performance. This suggests that while knowledge provides the necessary technical foundation, a positive attitude functions as a critical internal regulator that translates theoretical understanding into actual clinical behavior, especially within high-pressure environments like the NICU. Nurses with favorable attitudes toward infection control are more likely to internalize safety protocols, viewing them as essential components of patient protection rather than mere administrative tasks. This finding aligns with the study by Mamashli and Varaei [13], which demonstrated that a positive attitude directly drives better clinical performance.
To cultivate and enhance these critical safety attitudes among NICU nurses, structured and targeted educational interventions are paramount. Previous literature underscores that past training experience in safe injection practices is a powerful driver of enhanced clinical performance, primarily because systematic education does not merely convey technical information but reinforces an internal "safety belief system" [13]. This implies that pedagogical strategies must transition from simple information delivery to continuous, repetitive interventions capable of shaping nurses’ mindset and affective attributes. In this regard, implementing simulation-based training can bridge the gap between knowledge and practice by boosting clinical comprehension and confidence, thereby facilitating a positive restructuring of attitudes [9,20]. Furthermore, incorporating environmental cues, such as visual reminders at the point of care, can serve as immediate behavioral primers that sustain these positive attitudes and foster habitual, voluntary compliance in daily NICU routines [9].
Second, a key finding was that NICU clinical experience of 6 years or more was the second most influential predictor of safe injection practice performance (β=.20, p= .009). This is consistent with previous findings indicating that as nurses accumulate clinical experience, they develop greater proficiency and adaptability [9]. In the highly specialized environment of the NICU, which involves the care of high-risk neonates, advanced expertise is essential for effective infection control [9]. Experienced nurses likely possess the "cognitive efficiency" and internalized professional routines necessary to prioritize safety principles even under demanding workloads [9,11]. Therefore, we contend that the retention of experienced nursing staff is not merely an administrative goal but a direct clinical requirement for optimizing neonatal safety. To prevent the loss of unit-level expertise, healthcare organizations should implement long-term retention strategies and career development programs specifically tailored for proficient NICU nurses [9,23].
Third, in this study, safe injection practice knowledge and nursing professionalism did not demonstrate statistically significant effects on performance. This suggests that procedural performance is not directly determined by knowledge level or broad professional values alone. Previous research similarly reported that among nurses with a certain baseline of infection control knowledge, the association between knowledge and performance was weak [8,11]. In our study, a potential ceiling effect—where most participants demonstrated high knowledge scores—may have limited the variable's discriminatory power. Regarding nursing professionalism, while it reflects a nurse's professional identity and ethical orientation, its influence may be more "distal," shaping general competence rather than specific task-oriented behaviors like safe injection [16,19]. Safe injection practice is a highly protocol-driven activity, making it more sensitive to "proximal" factors such as immediate attitudes and the clinical environment [8,9,11]. This insight highlights the need for multifaceted interventions that bridge the "knowledge-action gap" by focusing on shaping specific safety attitudes and providing robust organizational support.
This study has several limitations. First, the cross-sectional design and convenience sampling from specific regions limit the generalizability of the results and preclude the establishment of causal relationships. Second, the reliance on self-reported data may have introduced response bias. Future research should incorporate objective assessment methods, such as clinical audits or direct observation, to enhance validity. Third, the internal consistency of the safe injection practice knowledge tool was relatively low (KR-20=0.40). This low reliability likely stems from a potential ceiling effect, given the high baseline knowledge of the participants, as well as the heterogeneity of the items. Importantly, while the introduction highlights the high complexity of neonatal medication regimens, the instrument used in this study measured general safe injection practices rather than the specific, high-risk knowledge required in the NICU environment. This lack of clinical specificity may have limited the tool's discriminatory power among highly experienced nurses. Consequently, future research should focus on developing and validating a highly specialized psychometric tool that captures the clinical nuances and complexities of neonatal medication administration to better differentiate knowledge levels among NICU nurses. Fourth, although this study provides foundational baseline data, the specific instruments used for measuring nursing professionalism and safety practices in this specialized population have not been extensively replicated in international literature. This constraint limits our ability to evaluate the cultural and contextual stability of the instruments across different healthcare systems, underscoring the need for cross-cultural validation and multi-center replication studies. Despite these limitations, this study holds significant academic and clinical strength as it is the first to empirically investigate the comprehensive relationships among safe injection knowledge, safe injection attitudes, nursing professionalism, and safe injection performance specifically targeting NICU nurses. By identifying safe injection practice attitudes as the most critical predictor, this study provides pivotal, foundational evidence for designing targeted behavioral interventions and educational programs to enhance patient safety in highly specialized neonatal care settings.
CONCLUSION
This study identified the critical predictors of safe injection practice performance among NICU nurses, providing a robust empirical foundation for enhancing infection control for vulnerable neonates. The findings demonstrate that safe injection practice attitude is the most powerful predictor of performance, followed by NICU clinical experience of 6 years or more. These results imply that fostering a positive "safety-oriented mindset" is more decisive than the simple acquisition of knowledge for ensuring procedural compliance in high-stakes clinical environments. Therefore, a paradigm shift in nursing education is required—transitioning from traditional knowledge-based instruction to multifaceted interventions that cultivate safety attitudes as an internal regulator. Furthermore, this study underscores the vital importance of workforce stability. Since expertise gained through long-term clinical experience is a prerequisite for high-quality safe injection practice performance, healthcare organizations must prioritize policy interventions and supportive environments that promote the retention of proficient NICU nurses.
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