D. Ethical consideration
7. Factors of influencing Quality of Work Life
A multiple regression analysis of variables including age ,marriage, education, Present hospital experience, Nursing experience(total), marital status, employee health, organizational health, organizational support, just culture, and resonant leadership was conducted to identify influence factors of the work-related quality of life of nurses who experienced patient safety incidents (Table 15). Correlation tolerance, tolerance limits, and variation inflation factors (VIFs) among independent variables were examined in search of multicollinearity. Correlation among independent variables was less than 0.80, so all factors were considered in the analysis. The tolerance limits were .454-.813, less than 1.0. The VIFs for all variables were in the range 1.229-2.204 and less than 10, so no multicollinearity was found. The statistically acceptable regression model for the quality of work life of nurses who experienced patient safety incidents was found at 46%
(Adjusted R2 = .452). Statistically significant influence factors of quality of work life were marital status (β=.070 t=2.106, p< .05), total nursing experience (β=.117 t=2.723, p< .001), resonant leadership (β=.352 t=8.245 p< .001), just culture (β=.202 t=4.578, p< .001), organizational support (β=.124 t=2.981, p < .01), and organizational health (β
=-.114 t=-2.992, p< .01) (Table 15).
Table15. Factors of Influencing quality of work life
(N=622)
Variable B SE β t p
Constant 1.205 .178 6.771
Gender (Ref. Female) -.126 .067 -.057 --1.874 .061
Education (Ref. Bachelor) ..083 .052 .049 1.579 .115
Married (Ref. Unmarried) .080 .038 .070 2.106 .036
Total Nursing experience (Ref. <36m) .145 .053 .117 2.723 .007
Just Culture .222 .048 .202 4.578 .000
Resonant Leadership .263 .032 .352 8.245 .000
Organizational Support .126 .042 .124 2.981 .003
Employee Health -.023 .035 -.025 -.658 .511
Organization Health -.067 .022 -.114 -2.992 .003
R2= .460, Adjusted R2= .452, F=52.122,
B. Qualitative Study
1. Characteristics of participants
The general characteristics of this study participants are as shown in Table16. In this study, a total of 8 nurses who experienced the patient safety incidents within one year participated. The current departments were four internal medicine wards, two surgical wards, one emergency room and one stroke care unit for cerebral apoplexy. Type of hospital was general hospitals 6, tertiary general hospitals 2. the total nursing experience averaged 6.4(±5.5) years, with the longest working period of 18 years and the shortest working period of 1 year and 3 months. The positions of the participants were two charge nurses and six staff nurses, and there were two married and six unmarried. The Participants were composed seven women and one man, and their average age was 29(±4.9). There were five in their 20s, two in their 30s and one in their 40s. The participants had two advanced diploma degrees, five bachelor's degrees and one master's degree. The types of patient safety incidents that participants experienced within the past year included two suicide or attempted suicide, four medication errors, one fall down, one fall and crash. The degree of harm were three stage 3, one stage4, three stage5, one stage
Participant Age/Gender Department Position Total nursing
experiences Type of incident Degree of harm
Participants1 26/F Internal medicine ward staff nurse 2year.8mo fall down Stage5
Participants2 26/F Internal medicine ward staff nurse 3year 8mo medication error Stage5
Participants3 28/F surgical ward Charge nurse 7year.10mo medication error Stage3
Participants4 40/F Internal medicine ward Charge nurse 18year suicide Stage8
Participants5 27/M Internal
medicine ward
staff nurse 1year7mo attempted suicide Stage3
Participants6 30/F Stroke care unit Charge nurse 8year9mo medication error Stage4
Participants7 24/F surgical ward staff nurse 1year3mo medication error Stage3
Participants8 30/F Emergency Room Charge nurse 8year 2mo fall and crash Stage5
2. Results
The data collected from the in-depth interviews with the 8 participants who experienced patient safety incidents within the past year were examined using the content analysis method. As a result, 2 themes—a workplace culture in which blame and trust co-exist and the quality of work life related to patient safety incidents—and 7 categories—
‘closedness of work atmosphere,’ ‘Patient safety incidents report preparation depends on the degree of harm and the unit atmosphere,’ ‘constructive changes after the incidents,’ ‘physical, psychological, and professional distress due to patient safety incidents,’ ‘stress due to the patient safety incident sharing,’ ‘Be concerned about quitting the hospital,’ and ‘need for organizational support’—were identified. The content analysis results for the quality of work life in relation to patient safety incidents are as follows (Table 17).
Table 17. Content Analysis of the Quality of Work Life of Nurses with Patient Safety Incident Experience
2) Patient safety incidents report preparation depends on the degree of harm and the unit atmosphere
3) Constructive changes after the incidents
2. The quality of work life related to patient safety incidents
1) Physical, psychological, and professional distress due to patient safety incidents
2) Stress due to the patient safety incident sharing 3) Be concerned about quitting the hospital 4) Need for organizational support
Theme 1. A Workplace Culture in Which Blame and Trust Co-exist
The participants were exposed to a culture that prevented them from speaking about the incidents and put blame on the individuals directly involved in the incidents, even though they were inclined to share information and discuss with co-workers after experiencing patient safety incidents. Those involved in the incidents felt stigmatized and no longer trusted by their co-workers and organization. Though they were obligated to file reports after patient safety incidents, they suggested that at times the reporting process would be intentionally omitted if the patient involved was in a good condition.
They all shared the pressure of having to work over-time to write incident reports.
However, some aspects of the patient safety system were re-organized and improved after patient safety incidents took place, and the participants witnessed efforts to learn from errors and constructive changes toward continuously improving patient safety.
The participants received most help in reducing the stress experienced after patient safety incidents from communicating with their co-workers, who emphasized with them and provided support. They expressed the need for a support system with professional counseling services accessible around the clock.
Category 1. Closedness of Work Atmosphere
The participants believed that the information regarding a patient safety incident must be disclosed to the patient involved and shared among the unit to find the root cause and ways to make improvements. However, they experienced an atmosphere in which speaking about incidents were strictly prohibited and incident-related information was not shared effectively. Some participants were even held responsible for having disclosed information to a patient.
“Why are you telling the patient all this without talking to us first?” I was about to explain everything, but she kept saying, ‘You're the one who told him everything.
You’re responsible.’ She just got mad at me, and this made me angry as well. Wasn’t I supposed to explain things to the patient?” (Participant1).
“I’m sure I would’ve talked to my colleagues and tried to find a way to help the patient. But doing such thing was prohibited from the get-go. So, I never had these conversations with colleagues. Not once. Not even a conference meeting. She was really against things like that and made it clear to me. So, I never spoke to her about this afterward. In a way, this made me feel sorry and upset” (Participant 4).
The participants received blame from their co-workers for allowing patient safety incidents to happen and were worried that their supervisor would no longer trust them. Also, I felt like I was stigmatized. They stated that the patient safety incidents that they experienced would negatively affect their future hospital work life.
“When the patient or the caregiver a complaint after a patient safety incident, it puts pressure on colleagues (other nurses). I become the sole target of blame. They say things like, ‘Only if you hadn’t messed up’ and ‘This wouldn’t have happened if it were not for you.’ Hearing them say these things is stressful” (Participant 2).
“I thought that nothing I do in the ward would be trusted now. People couldn’t trust me. I even thought that things wouldn’t change even if I did something right. I kept having these thoughts” (Participant 3).
“I felt I was stigmatized. I wanted to move to a new hospital and show them that I’m not the kind of person who only causes trouble”(Participant 4).
“I thought that people might think of me as someone who can’t do basic things. I thought I didn’t stand a chance for a promotion if I stayed here. I was so stressed out by these thoughts. I felt like everyone was judging me” (Participant 5).
Category 2. Patient safety incidents report preparation depends on the degree of harm and the unit atmosphere
The participants perceived the need to report patient safety incidents. However, some senior nurses on duty did not enforce the reporting process if the patient involved was in a good condition or the incident had already been handled. The participants did not have a clear idea of whether their reports reached the unit supervisor, higher management, or the patient safety department after the unit submitted them to the head nurse.
“We all have to write patient safety incident reports. We know how we have to do it.
Write it and submit it to head nurse. But I don1t know how far that1s being reported, whether it`s going to the team leader, or if it`s being reported to the patient safety department. I think there are more cases where they do not. In some cases, we don't write a safety report if no harm was done to the patient or it’s a minor incident”
(Participant 3).
“I didn’t write a report about the incident. I just notified the doctor, left a note in the record, and checked the patient’s vitals. The report? I didn’t write it because the charge nurse said not to. She told me not to write the report if there is no big problem with the patient” (Participant 4).
“We know it when a senior nurse causes a medication error. We know that. But it never gets shared at the group handover. They just keep things to themselves. In many cases, incidents involving senior nurses are not followed up with reports. If more than two people knew about it at the handover, they would have a conversation and then write up the report after one of them said, ‘Hey, you should write a report”(Participant 7).
“I sometimes wonder if I have to write up a full report when I’ve already concluded the incident and notified the doctor. I think in some cases, reports are not written if the patient is fine or there is no harm” (Participant 8).
Participants are found to experience the stress and burden of having to write reports after work when a patient safety incident occurs, and sometimes their superiors who worked with them instead of themselves write reports on behalf of them, according to the department.
“It’s a little stressful. I mean, I can’t write the report when I’m on a shift. There is just no time. It’s stressful because I have to stay after work to write the report”(Participant 2).
“When there is a safety incident, I’m too busy during shifts dealing with the situation and doing other work. I don’t have the time. I can’t just set everything aside to write reports about one incident. I usually just stay after work to write it. That’s overwhelming”(Participant 3).
“When there’s a safety incident, my first reaction is “Okay, I’ll be working late tonight” because I have to stay late to write the report. The charge nurse writes reports. Even when a junior nurse causes an incident, it’s the charge nurse that writes the report. That’s a burden. On the wits, that`s what our department has been doing”
(Participant 6).
Category 3. Constructive Changes After the Incidents
The participants had a chance to consider ways to prevent further incidents and improve upon current procedures after experiencing patient safety incidents. They noted that the patient safety team and the nursing department made efforts to generate feedbacks, assess root causes, and prepare responses. Some improvements were implemented in the system.
“I keep thinking, ‘I shouldn't cause a safety incident. I should prevent incidents. I should keep my eyes on my patients. I should take good care of my patients. I should improve the process to help my colleagues prevent incidents earlier.’ Things have actually improved a lot. We implemented new procedures to screen high-risk patients after assessing their suicide susceptibility, and pain management process. We did remodel the restrooms” (Participant 4).
“When a patient safety officer called me to give feedback, I thought it was just another call asking why you did it again. But the officer said, ‘I don't think it's your fault, either. I know that things don’t change easily when it comes to carelessness in a patient or a guardian.’ After hearing that, I knew that things I said actually made a difference. Getting feedback calls meant that supervisors were actually interested.
Before then, I never knew what happened to our reports once we handed them in”(Participant 3).
“Things improve after there is an incident. Both the hospital and department pay attention so that incidents don’t happen again” (Participant 5).
“The team leader comes to us on a rounding and asks us, ‘How do you want us to improve this?’ Then, I know that the last incident was reported and that’s why he’s here. In that sense, things definitely change after an incident” (Participant 6).
The participants experienced increased attentiveness to patient safety after being directly or indirectly involved in patient safety incidents and learned from the incidents that took place in other units.
“There was a medication error recently. Not just in our unit but in another one as well. They reminded us of the safety incident reporting process at the group handover
again. They told us to report everything when there is a safety incident. After the group handovers, there were talks about compartmentalizing medication carts, getting bigger racks so drugs don’t get mixed up, and so on. All this has made us to be more alert not to make medication errors”. (Participant 7)