Purpose - Quality of Work Life among Nurses who had Patient Safety Incidents;Mixed Methods Desi

The purpose of this study was to identify factors affecting the quality of work life of nurses who have experienced patient safety incidents. The specific aims of this study were as follows;

(1) To describe the effect of just culture, resonant leadership, organizational support, employee health, and organizational health on the quality of life of nurses who experienced patient safety incidents.

(2) To understand the significance of physical and psychological symptoms, support, and quality of work life after patient safety incidents through in-depth interview

(3) To develop a comprehensive understanding of the quality of work life of nurses who have experienced patient safety incidents through comparative analyses of qualitative and quantitative results.

C. Definition of Terms

1. Patient Safety Incidents

Patient safety is defined as an absence of preventable harm to a patient during the process of patient care (WHO, 2009). The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) has developed categories for classifying medication errors. The NCC MERP index considers factors such as whether the error reached the patient and, if the patient was harmed, to what degree. In this study, patient safety incidents refer to events that fall within the categories C(stage2) through I (stage8) among the 9 Categories of Medication Error Classification, which have been taken from the NCC MERP index and modified according to the Korea Patient Safety Reporting &learning System (KOPs). Table 1 below explains the modified categories of medication error classification.

Table 1. Categories of Medication Error Classification Category(Stage) Description

A(0) No error, capacity to cause error B(1) Error that did not reach the patient

C(2) Error that reached patient but unlikely to cause harm (omissions considered to reach patient

D(3) Error that reached the patient and could have necessitated observation or monitoring

E(4) Error that could have caused temporary harm and could have necessitated laboratory or X-Ray or medical /surgical intervention F(5) Error that could have caused temporary harm requiring initial or

prolonged hospitalization

G(6) Error that could have resulted in permanent harm

H(7) Error that could have necessitated intervention to sustain life I (8) Error that could have resulted in death

2. Just Culture

Just culture defined as organizational culture based on trust. In a just culture environment, all parties involved in a patient safety incident trust that they are entitled to just and fair treatment (Reason, 1998). In this study, just culture was measured by scores provided according to the Just Culture Assessment Tool (JCAT) developed by Petschonek et al. (2013). A high score indicates a high level of just culture in the responder’s organization.

3. Resonant Leadership

Resonant leadership is supervisors’ ability to effectively manage emotions of their own and others in the workplace. It is a measure of leaders’ emotional intelligence and their ability to build strong relationships of trust with employees and create a climate of optimism (Squires, Tourangeau, & Doran, 2010). In this study, resonant leadership was measured by the Resonant Leadership Scale developed by Cummings et al. (2010). A high score indicates a high level of resonant leadership.

4. Organizational Support

Organizational support indicates a level of trust that employees have toward their organization. Employees’ perception of organizational support is based on the level of care, attention, and recognition, and compensation given to them by their organization (Wayne, Shore, & Liden, 1997). In this study, organizational support was measured by

scores provided on colleague support, supervisor support, and institutional support according to the Second Victim Experience and Support Tool. A high score indicates a high level of organizational support perceived by the responder.

5. Employee Health

Employee health refers to conditions of physical and mental sickness, absenteeism, and fatigue found in employees (Peterson & Wilson, 2002). In this study, employee health was defined as psychological and physical distress and reduced professional self-efficacy after patient safety incidents. Employee health was measured by scores provided on 4 items regarding psychological distress, 4 regarding physical distress, and 4 regarding reduced professional self-efficacy from SVEST. A high score indicates a low level of employee health.

6. Organizational Health

Organizational health refers to the well-being of the corporate whole (Peterson

& Wilson, 2002). In this study, organizational health was measured by scores provided on 3 items - 2 regarding turnover intention and 1 regarding absenteeism - from the Second Victim Experience and Support Tool (SVEST). A high score indicates a low level of organizational health.

7. Quality of Work Life

Quality of work life is defined as the emotions and feelings that employees have toward their work (Abo-Znadh, 1998). In this study, quality of work life was measured according to the Work-Related Quality of Life scale developed by Van Laar et al. (2007).

A high score indicates a high quality of work life.

II. Literature Review

The purpose of this literature review is as follows: first, explore the experienced symptoms after patient safety incidents; second, present factors affecting quality of work life; and third, identify the relationship among key variables based on prior studies of the effect of patient safety incidents on the quality of work life of nurses.

A. Nurse`s experience and Patient Safety Incidents

Although hospitals focus on improving patient safety and the quality of their healthcare services, witnessing a patient harm or death due to an unforeseen patient safety incident is an unavoidable reality for health care providers at many medical sites (Quillivan et al., 2016).

According to the WHO (2016), inpatients have an 8-12% chance of experiencing adverse events in the hospital, and De Vriese et al. (2008) report that the adverse event rate is 9.2%, meaning one in nearly 10 inpatients experience a patient safety incident.

Although Korea does not have accurate statistics on the occurrence of patient safety incidents, the cumulative number of patient safety incidents reported in the Korea Patient Safety Reporting & Learning System (KOPs) is 19,360 since the implementation of the Patient Safety Act on July 29, 2016 (Annual Patient Safety Statistics, 2018).

Experiencing a patient harm or death associated with patient safety incidents

also leads to many difficulties for health care providers. Especially incidents caused by unforeseen events or medical errors can cause psychological trauma and personal, emotional, and professional problems (Scott et al., 2009; Rassin et al., 2005; Waterman et al., 2007).

Every health care provider has the potential to fall victim to adverse events or medical errors. 14-30% of health care providers reported in a study that they had experienced patient safety incidents within the last year (Scott et al., 2009). 30% of health care providers in the U.S., 40% in Canada, and 69% of nurses and 77% of doctors in Spain mentioned in a different study that they experienced physical and psychological distress after being involved in patient safety incidents within the past five years (Mira et al., 2017). Another study found that about 50% of health care providers suffer patient safety incidents at least once during their career ( Edrees et al., 2011).

Responses and symptoms they experience following patient safety incidents include sleep disorder (Scott et al., 2009; Rassin et al., 2005; Waterman et al., 2007), burnout (Prins et al., 2009; West et al., 2015), reduced job satisfaction ( Scott et al., 2009;

Waterman et al., 2007), feelings of guilt, anger, and shame (Rassin et al., 2005;

Waterman et al., 2007; Harrison et al., 2015), and fear of punitive actions, job loss, and litigation (Scott et al., 2009; Rassin et al., 2005). Involvement in a serious near-miss patient safety incident or witnessing a patient harm can decrease job confidence and job satisfaction and cause anxiety, sleep disorder, and work-related stress in health care providers (Edrees, 2014; Waterman et al., 2007).

Burlison et al. (2016) stated that the physical and psychological distress experienced after patient safety incidents affect the well-being of nurses, their turnover intention and absenteeism, which are in turn likely causes of subsequent medical errors and pose threats to patient safety.

Chan et al. (2017) and Burlison et al. (2016) showed that forming a strong patient safety culture and providing sufficient support are important elements in alleviating the trauma caused by patient safety incidents and helping recovery. However, research on symptoms and reactions after patient safety incidents is still minimal in the korea setting. Only a handful of existing literature includes a study of operating room nurses who suffer from depression, guilt, and high emotional stress due to nursing and medical errors (Jeon & Lee, 2014), a phenomenological study of nurses’ experiences of patient safety incidents (Lee, Kim, & Kim, 2014), and a study of the effect of second victim experiences on the third victim. (Kim et al., 2017). Nurses are important caregivers directly responsible for patient safety at the forefront of medical practice, so studying their experiences is crucial in preparing for appropriate organizational management after patient safety incidents.

B. Quality of Work Life

Over the past two decades, health-related studies have examined the quality of life of patients as a predictor of their treatment results (Kowitlawkul et al., 2018).

However, the result of patient treatment is dependent on not only clinical care and intervention, but also the quality of work life of nurses and their work-life balance (Lee, Dai, Park, & McCreary, 2013).

Since nurses are a major human resource that accounts for more than half of the workforce in medical institutions, their quality of work life will directly or indirectly affect patient safety and quality of care (Kowitlawkul et al., 2018). Also, since nurses spend a significant portion of their time at work, their quality of life is significantly affected by their quality of work life (Kim & Sung ,2010).

Improving quality of work life is an important prerequisite for recruiting and retaining competent nurses and ensuring patient safety (Sadat, Aboutalebi, & Alavi, 2017).

There is a growing consensus that it is essential to improve the quality of work life of nurses and create and maintain the right working conditions for them to provide quality patient care (Brooks et al., 2007).

The term quality of work life was first introduced in 1930 and broadly used to refer to the quality of life within work environments. However, there was no clear agreement on how to define the term exactly (Easton & Van Laar, 2013). In one of many studies that presented models for understanding quality of work life, Hackman and Oldham (1974) suggested that improving quality of work life involves providing

conditions for employees to experience psychological growth, and called attention to factors such as the nature of work, job autonomy, and feedback. Easton & Van Laar (2013) showed that quality of work life is affected by the nature of work and external factors such as wages, working hours, and working conditions.

Quality of work life is defined as the emotions or feelings that employees have toward their work (Abo-Znadh,1998). Mosadeghrad (2011) defined quality of work life as employees’ overall satisfaction with their work life, which can be reduced by factors such as lack of recognition and emotional exhaustion. Prior studies of the quality of work life of nurses have explored relationships between quality of work life and organizational culture (Gifford et al., 2002; Korner, Wirtz, Bengel, & Goritz, 2015; Thakre et al., 2017), job performance (Abbasi et al., 2017), exhaustion and quality of work life (Hsu, 2016), organizational productivity (Dehghan Nayeri, Salehi, & Ali Asadi Noghabi, 2011), turnover intention (Faraji, Salehnejad, Gahramani, & Valiee, 2017; Kaddourah, Abu-Shaheen, & Al-Tannir, 2018), and social support (Fu et al., 2018; Ghouligaleh et al., 2018). Factors affecting the quality of work life of nurses include leadership and management style, decision-making, shift working, salaries and benefits, relationships with colleagues, demographic variables, workload, and work strain (Vagharseyyedin, Vanaki, & Mohammadi, 2011). Brookes & Anderson (2004) showed that excessive workload and time pressure greatly lower the quality of work life.

On a personal level, quality of work life is related to job satisfaction, work-life balance, safety, health, and well-being. On an organizational level, quality of work life is

related to absenteeism, professional difficulties, employee commitment, and turnover intention (Mitchell, 2012). Another study presented social support and integration as predictors of the quality of life of nurses, as many of them reported that these factors have helped them cope with the stress caused by patient safety incidents (Kowitlawkul et al., 2018).

Although Korea research of the quality of work life of nurses has been minimal, An and Yom (2011) reported significant correlations among the organizational culture of Korean nurses, their quality of work life, and the effectiveness of their organization.

Another study of clinical nurses reported that organizational culture, social support, and organization and employee health affect the quality of work life (Kim & Ryu, 2015).

Several tools for measuring quality of work life have been developed, and the Work-Related Quality of Life (WRQoL) Scale developed by Van Laar, Edwards, & Easton (2007) in specific measures the quality of work life of health care providers, including nurses. The tool was developed under the guidance of the U.K. NHS (National Health Service) for the purpose of securing advanced personnel and measuring quality improvements in work life.

This measurement tool has been translated into six languages and is widely used in more than 30 countries (Easton & Van Laar, 2013). However, it has never been introduced in Korea. The tool is structured in three dimensions—organizational level, department level, and individual level—and takes into account six key factors—job and career satisfaction (JCS), general well-being (GWB), stress at work (SAW), control at

work (CAW), home-work interface (HWI), and working conditions (WCS). The WRQoL Scale is a reliable tool for measuring the quality of work life of nurses and health care providers, and reflects their stress levels, job satisfaction, work environment, and organizational culture. The tool was deemed suitable in this study for measuring the quality of life of nurses who have experienced patient safety incidents.

The results of the literature review show that the prior studies of the quality of work life of nurses have focused primarily on their work environment and organization culture. Hence the need for an integrated study of the relationships among organizational safety culture, leadership, employee health, organizational health, and quality of work life, and how these factors affect nurses who are coping with the aftermaths of patient safety incidents.

C. Quality of Work Life among Nurses who had Patient Safety Incidents

1. Just Culture

Organizational culture is defined as the beliefs, values, behavioral patterns and norms shared by organization members (Cooke & Rousseau, 1998). It influences all organizational activities and vice versa (Reiman & Oedewald, 2004). Patient safety is the practice of eliminating, mitigating, and preventing a patient harm caused by medical errors in the course of providing care (National Patient Safety Foundation, 2003). Patient safety culture—i.e. an organizational culture for patient safety—refers to the beliefs, values, and behavioral patterns (Kizer,1999) of an organization as a whole that prevent possible medical errors in the course of providing medical services. A strong patient safety culture is an important precursor of patient safety. Quillivan et al. (2016) found that within a strong patient safety culture, second victim symptoms experienced by health care providers after patient safety incidents are lessened.

A just culture describes a work environment in which individuals believe they will receive fair and just treatment when involved in patient safety incidents (Marx, 2001).

Compared to the patient safety culture, perceptions of just culture are focused on reactions to specific adverse events, so that when working to improve just culture, it is helpful to have specific data on staff experiences (Petschonek et al., 2013).

Just culture is a sub-concept of safety culture in which employees are encouraged to report all important events regarding safety without the fear of punitive

actions or blame. It is an organizational culture in which employees trust their organization to fairly evaluate their actions in the event of a patient safety incident. The formation of a just culture must be preceded by a well-established safety culture (Reason, 1998). Within a just culture, employees learn from their errors in a non-punitive work environment through open discussions, sharing their experiences with colleagues, and constructive feedback (Seys et al., 2013).

Lewis et al. (2013) found in an integrated study that nurses who experienced patient safety incidents due to medical errors were either positively or negatively influenced by their work environment and the leadership of their nurse managers. Also, experienced nurses were more attuned to adopting a constructive change in their nursing practice after experiencing patient safety incidents. Sirriyeh et al. (2010) said that an environment in which co-workers and supervisors can be freely consulted reduces the stress experienced by health care providers after patient safety incidents. This means that forming a just patient safety culture must be a priority for medical institutions. However, while much emphasis is laid on the importance of forming a just culture in the process of handling patient safety incidents (Beyea, 2004), there are still few Korea studies examining the relationship between just culture and patient safety incidents.

2. Resonant Leadership

Leadership is an act of influencing people to work toward common goals (Kim, Sung-eun, 2010). Resonant leaders demonstrate a high level of emotional intelligence (EI), i.e. manage the emotions of their own and others effectively; build strong and trusting relationships with employees; and create a climate of optimism that inspires commitment (Squires, Tourangeau, & Doran, 2010). Resonant leadership is a newly emerging concept. This positive relationship-oriented leadership allows nurses to feel respected, recognized, and supported; enhances their effective work performance; and increases their job satisfaction (Cummings, Hayduk, & Estabrooks, 2005). In another study, resonant leadership and interactional justice were associated with the quality of the leader–nurse relationship, which affects safety climate and quality of work life. The study associated resonant leadership directly with a decrease in reported medication errors, turnover intention, and emotional exhaustion (Squires et al., 2010).

In addition, resonant leadership positively affects conflict management among nurses, their job safety, employee health, and job satisfaction, and alleviates anxiety, emotional exhaustion, and stress (Cowden, Cummings, & mcgrath, 2011). Squires et al.

(2010) related resonant leadership to healthier leader-nurse relationships, improved safety culture, supportive practice environments, less emotional exhaustion, and lower turnover intention. Wagner et al. (2013) reported the positive relationship between resonant leadership and job satisfaction after examining the effect of resonant leadership, empowerment, and work ethic on job satisfaction and organizational commitment.

Korea research on resonant leadership is still lacking and existing studies only address the relationship between resonant leadership and job satisfaction, turnover intention, and organizational commitment. Therefore, meaningful effort can be made to examine the role of resonant leadership in improving the quality of work life of nurses and helping them cope with second victim symptoms caused by patient safety incidents.

3. Organizational Support

Organizational support refers to a degree to which organization members trust their organization to provide care and recognition (Wayne, Shore, & Liden, 1997). In a workplace setting, organizational support can be provided by institutions, colleagues, and supervisors (Quillivan et al., 2016). Organizational support affects the quality of care, job satisfaction, and psychological well-being (Sharif, Ahadzadeh, & Nia, 2018). Therefore, establishing a supportive work environment for nurses is a crucial step in giving appropriate attention to their psychological well-being.

Lee et al. (2012) observed that nurses who received better support from their organizations, supervisors, and co-workers tended to provide better care to patients.

Another study revealed that organizational support from colleagues and supervisors plays an important role in helping nurses recover from their medical errors (Lewis, Baernholdt,

& Hamric, 2013). Burlison et al. (2016) also showed that organizational support mitigates second victim symptoms caused by patient safety incidents, helps recovery, and reduces turnover intention and absenteeism. In addition, a study observed that the most desired

organizational support option for nurses was a respected co-worker willing to discuss the details of patient safety incidents with them (Burlison, Scott, Browne, Thompson, &

Hoffman, 2014).

Sirriyeh et al. (2010) suggested that health care providers should be encouraged to consult colleagues or supervisors during the coping process after adverse events.

Another study reported that a supportive organizational culture greatly affects the quality of work life of health care providers (Dolan, García, Cabezas, & Tzafrir, 2008).

4. Employee Health

In the culture-work-health-model, employee health is determined by conditions such as physical and psychological sickness, absenteeism, and fatigue (Peterson & Wilson, 2002). In this study, employee health was measured by physical and psychological distress and the decline in professional self-efficacy resulting from second victim symptoms after patient safety incidents. After patient safety incidents, nurses experience physical symptoms such as sleep disorder and burnout and psychological symptoms such as feelings of guilt, anger, fear, and shame; depression; loss of self-confidence; and reduced job satisfaction (Burlison et al., 2014). Such physical, psychological, and

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