Work Environment, Workload, Job Satisfaction, and Error Reporting

Work Environment, Workload, Job Satisfaction, and Error Reporting

Hui-Ying Chiang, PhD, RN; Ya-Chu Hsiao, EdD, RN; Huan-Fang Lee, PhD, RN

Nurses’ safety practices of medication administration, prevention of falls and unplanned extuba-tions, and handover are essentials to patient safety. This study explored the prediction between such safety practices and work environment factors, workload, job satisfaction, and error-reporting culture of 1429 Taiwanese nurses. Nurses’ job satisfaction, error-reporting culture, and one en-vironmental factor of nursing quality were found to be major predictors of safety practices. The other environment factors related to professional development and participation in hospital affairs and nurses’ workload had limited predictive effects on the safety practices. Increasing nurses’ attention to patient safety by improving these predictors is recommended. Key words: error reporting, handover, nurses’ safety practices, patient safety, work environment, workload

DURING the past 2 decades, health care professionals have concentrated on the patient safety movement by participating in human factor education programs, standard-

Author Affiliations: Nursing Department, Chi Mei Medical Center, Yung-kang Dist, Tainan, Taiwan (Dr Chiang); Chang Jung Christian University, Kway-Jen Dist, Tainan, Taiwan (Dr Chiang); Chang-Gung Institute of Technology, Kwei-Shan, Tao-Yau, Taiwan (Dr Hsiao); and Department of Nursing, National Cheng-Kung University Hospital, Tainan, Taiwan (Dr Lee).

This study was funded by Chi Mei Medical Center (CMFHR10364 and CMFHR10111).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.jncqjournal.com).

Correspondence: Hui-Ying Chiang, PhD, RN, Nurs-ing Department, Chi Mei Medical Center, 901, Chung Hwa Rd, Yung-kang Dist, Tainan 710, Taiwan (300020@mail.chimei.org.tw).

Accepted for publication: October 2, 2016

Published ahead of print: November 21, 2016

DOI: 10.1097/NCQ.0000000000000240

izing practices and processes, and developing a culture of learning from errors.^1,2 Their practical efforts combined with work envi-ronment enhancement and organizational system rebuilding have made substantial con-tributions to patient and nurse outcomes.^3,4 Prevention of risks and errors in patient safety often relies on frontline nurses, who struggle to ration nursing care to patients because of restricted health care reimbursements, en-vironmental barriers, and personal burdens, especially in highly demanding and acuity-focused hospitals. Understanding the safety practices of nurses and their relevant factors is critical to patient safety improvement.

Nurses, the largest population of the health care workforce, provide a set of implementations for patient safety such as medication administration practices and in-terventions to prevent patient falls. More-over, effective and standardized handover communication among nurses can sustain these implementations to be applied con-sistently, updated when needed, and docu-mented correctly. Strategies of standardized handover communication have been widely introduced such as face-to-face handover

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• JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2017

and SBAR (Situation-Background-Assessment-Recommendations).⁵ In the recent years, nurse-initiated quality improvements target-ing effective handover, medication safety pro-cedures, fall prevention, and tube safety have been prioritized to advance patient safety both in the West⁶ and in Taiwan.⁷ Since nurses are responsible for these priorities in clinical settings, it is important to explore to what extent nurse safety practices related to medication administration, fall prevention, unplanned extubations, and nursing handover can provide evidence of nurses’ contributions to the patient safety in hospitals.

A nurse’s work environment is one in-dicator of nursing quality that has an im-pact on patient safety and care quality. Ex-isting evidence suggests that a favorable work environment can assist nurses in un-derstanding their roles and responsibilities in providing safety and quality of nursing practices.^8,9 To nurses, workplace conditions including staffing resources, physical environ-ment, leadership and management, workflow design, and workload are associated with the process of nursing care and nurse behaviors.¹⁰ Studies have shown that higher workload and lower job satisfaction weaken nurses’ involve-ment and engagement with care quality.^11,12 The favorable features of a nurse’s work envi-ronment are identified as sufficient administra-tive support, adequate staffing and resources, professional development opportunities, and teamwork collaboration. These have been shown to have positive effects on the prac-tice of nursing.^13-15

All these features are recognized as essen-tials of Magnet hospitals, which have substan-tially contributed to nurses’ behaviors result-ing in high care quality and patient safety.^16,17 Although Magnet hospital recognition is not used in Taiwan, optimizing the nurse work-ing environment by introducing Magnet-like traits, initiating workload management, and increasing job satisfaction have been widely recognized as major strategies in nurse man-power stabilization and nursing quality im-provement in Taiwanese health care organi-zations since 2007.¹⁸ With that knowledge,

the connection between work environment and nursing practices is emphasized as an el-ement of safety and quality improvement in the health care service.¹⁰ Yet, empirical explo-rations of this connection focusing on nurse safety practices including medication adminis-tration, fall prevention, unplanned extubation prevention, and handover communication are limited. Therefore, the factors of nursing work environment that influence safety practices should be examined.

As stated in the Institute of Medicine report, a safety culture of reporting error is a strength to influence care professionals to have open, constructive, and voluntary attitudes toward patient safety engagement.¹⁹ There are still problems related to frontline nurses’ underre-porting errors.^20,21 Because of their proxim-ity to patients and their surveillance of safety risks, nurses’ perceptions of error reporting are directly reflected in the patient safety cul-ture in the workplace. Whether these percep-tions have effects on their practices in de-livering nursing care is worthy of investiga-tion. The purposes of this study were to (1) explore the extent of hospital nurses’ safety practices related to medication administra-tion, prevention of patient falls and unplanned extubations, and nursing handover, (2) exam-ine the associations between nursing safety practices and work environment factors in-cluding workload and job satisfaction, and

• examine the association between nurs-ing safety practices and nurses’ perceptions of medical error reporting. Finally, the deter-mining factors of each nursing safety practice were analyzed.

METHODS

Design and samples

This survey study was conducted using a self-administered questionnaire to collect data in 6 teaching hospitals in Taiwan. The study was initially approved by the ethical committee at the Chi Mei Medical Center in Taiwan, and Human Subjects Research permission was obtained from each study

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hospital before collecting data. By using computer statistics programs, eligible partic-ipants were randomly selected, constituting 30% of the total nurses directly provid-ing nursing services in each study hospital. Newly hired nurses who had worked less than 3 months were excluded because they usually work under preceptors’ supervision and not independently. Survey packages (n = 1800) including introductory letters, question-naires, and return envelopes were delivered to the eligible nurses. Of those surveys sent to nurses, 1429 were returned, with an average response rate of 79.38% (range, 74.32%-89.01% of study hospitals). Forty-nine surveys were excluded because of having more than 10% of the questionnaire items unanswered. Finally, 1380 surveys were analyzed.

Instruments

There are several well-known instruments of patient safety culture in the West,²² but only 2 instruments of measuring global safety culture applied to all care professionals have been translated and tested their psy-chometric properties at a national level in Taiwan.^23,24 These translated instruments have limited items related to nursing safety practices and need further modification to improve subscale reliabilities and to solve cultural differences in patient safety. Thus, a self-developed questionnaire, the Nursing Safety Practice Scale (NSPS), was used to investigate the frequency of applying safety practices concerning medication administra-tion safety, prevention of falls and unplanned extubations, continuity of nursing care plans, accuracy of nursing documentation, and nurs-ing handover. A panel of nursing experts who were shift leaders, senior nurses, and nursing quality board committee members were invited to generate questionnaire items fol-lowing 2 group discussions based on the study purposes, literature review, and conformity with nursing practices related to safety risks.

A 5-point Likert-type scale format (from 1 = a little of the time to 5 = all the time) was em-ployed to explore the nurses’ engagements with safety practices. The higher the total

score, the more safety practices the nurses engaged in. Its construct validity using ex-planatory factor analysis and reliability were examined in this study. The 15-item NSPS had 3 factors, with a total explained variance of 62.82% and satisfactory reliabilities (Cronbach

• s: 0.90, 0.82, and 0.71; Table 1). These fac-tors were labeled as medication administra-tion safety, prevention of falls and unplanned extubations, and handover safety (Table 1).

Second, the nurses’ work environment was measured by the Nursing Practice Environ-ment Scale (NPES, Chinese), which is derived and translated from Lake’s PES-NWI.²⁵ The PES-NWI, which has been widely applied to evaluate nurses’ practice environment in acute care hospitals, comprises 31 items in 5 factors.²⁶ The 31-item NPES, with acceptable reliability, criterion-related validity, and construct validity, contains 5 comparable factors: management and leadership (ML), nursing professional development (NP), nursing quality (NQ), staffing and resource adequacy (ST), and participation in hospital affairs (PH).²⁵ The ML factor reflects nurs-ing supervisors’ and managers’ leadership, management, support, and concern for staff nurses. The NP factor is mainly related to nurses’ opportunities of in-service education, ladder programs, teamwork with physicians, and clinical preceptor training track. The NQ factor reflects quality of patient care, application of a nursing model, continuity of care, nurse-physician collaboration, and an up-to-date nursing care plan. The ST factor re-flects sufficient staffing, patient consultation time, nurse-physician working relationships, and collegial discussions about patient care. Opportunities for participating in policy making, involvement in internal governance, and service on hospital and nursing commit-tees are considered to be the focus of the PH factor.

Similar to the studies of nursing perfor-

mance and practice using the Lake’s scale in the West,^8,27 the NPES has been used to explore nurses’ working conditions, care quality, and safety culture in Taiwan.^25,28 These environmental factors were treated

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• JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2017

Table 1. Results of Exploratory Factor Analysis, Reliability Indices, and Item Means of the Nursing Safety Practice Scale^a

Factor^c

Abbreviation: I-SBAR, Identification-Situation-Background-Assessment-Recommendations.

• Bold values indicate that items having factor loadings above 0.40 were extracted into one factor.

• Measured by a 5-point Likert scale from 1 = a little bit of the time to 5 = all the time.
• Principal component analysis with varimax rotation and factor loading of more than 0.40.

• Scale responses of “4” and “5” were recoded as high involvement.

• Score range: 7-35.

• Score range: 4-20.

as independent variables with satisfactory reliabilities (Cronbach αs range from 0.90 to 0.75) in this study. In addition, the other independent variables were workload and job satisfaction. A 9-item workload subscale of the Copenhagen Burnout Inventory (Chi-nese version) was chosen because of sound psychometric properties and field testing.²⁹

It has been widely administered to measure Taiwanese workers’ job demand burdens in physical, cognitive, manpower, and work pat-terns. The higher the total score, the higher the workload burden nurses perceived. For this study, the Cronbach α reliability coefficient was found to be 0.91. The overall job satisfaction of nurses was measured by

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1 item with a 5-point Likert-type scale (from

1 = strongly disagree to 5 = strongly agree).

Finally, the survey also asked for demo-graphic information such as age, education, tenure of current work, unit specialty, and agreement on fully reporting medical errors at the workplace. The agreement response is a 5-point Likert-type scale.

Data analysis

Statistical methods included descriptive statistics, bivariate correlation, and multiple linear regression analyses. For each NSPS item, scale responses of 4 (most of the time) and 5 (all the time) were categorized as high involvement and presented in percentages. Scores for the NSPS factors were calculated separately and treated as 3 dependent vari-ables. As to the agreement on reporting med-ical errors, scale responses of 4 (agree) and 5 (strongly agree) were recoded as “agree” prior to data analysis. Correlation and mul-tiple linear regression analyses on each de-pendent variable were performed with the work environment factors, workload, job sat-isfaction, and agreement on fully reporting medical errors. Data management and anal-ysis were conducted using SPSS (version 17; SPSS Inc, Chicago, Illinois).

RESULTS

Nurse demographics are listed in the Sup-plemental Digital Content Table (available at: http://links.lww.com/JNCQ/A310). The mean age of the nurses was 29.93 (SD = 5.48), with an average of 5.94 years (SD =

5.06) at their current positions. Most of them had bachelor’s degrees (n = 1139; 82.5%). Almost half (n = 593; 43.1%) worked at medical-surgical units. Nearly half (48.5%) of the participants disagreed that medical errors were fully reported in their wards. They re-ported that their workload was above moder-ate (mean = 27.74) and their work satisfac-tion was between medium and high (mean = 3.44).

As indicated in Table 1, the nurses re-ported that they were highly involved in med-

ication administration safety practices such as recognizing medication purposes (S11), double-checking for high-alert drugs (S13), clarifying medication orders (S12), monitor-ing drug effects (S10), utilizing drug informa-tion tools (S15), and ensuring the patient’s ed-ucation about medication (S14). These nurs-ing practices were conducted intensively, with more than 80.0% stating high involve-ment. The NSPS items related to prevention of falls (S1) and unplanned extubations (S2) showed 73.6% and 78% of high involvement, respectively.

As to the handover safety factor, the nurses indicated less engagement on avoiding inter-ruption in the handover process (S6, 47.8%) and using I-SBAR (Identification-Situation-Background-Assessment-Recommendations) to communicate with care professionals (S9, 61.2%). The other 2 items indicated that the nurses were fairly involved in reviewing med-ical records prior to handover (S8, 68.8%) and in updating and sharing medical information to the upcoming nurse (S7, 73.9%). The safety practices of face-to-face handover (S5, factor 1) and read-back technique (S4, factor

• also showed higher levels of nurse involve-ment. In brief, the hospital nurses engaged substantially in safety practices to ensure medication administration safety, prevention of falls and unplanned extubations, and han-dover safety. Interruptions in the handover process and application of the I-SBAR tech-nique in team communication had the lowest levels of involvement in the clinical setting.

As indicated in Table 2, correlation anal-yses showed that the 3 NSPS factors were positively associated with the environmental factors (LM, NP, NQ, ST, and PH) of work environment (rs: 0.047-0.308; P < .001), job satisfaction (r = 0.053; P < .001), and agree-ment on fully reporting medical errors (t = 6.601; P < .001). The 3 NSPS factors were neg-atively associated with workload (r = −0.124; P < .001). Nurses who perceived better work environments, were more satisfied with their jobs, and expressed more agreement on fully reporting medical errors were more inclined to engage in the safety practices of medication

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• JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2017

Table 2. Correlation and Regression Analyses for Nursing Safety Practices With Work Environ-ment Factors and Agreement on Reporting Medical Errors^a

Abbreviations: LM, leadership-management; NP, nursing professional development; NQ, nursing quality; PH, participa-tion in hospital affairs; ST, staffing and resource adequacy.

• Bivariate correlation coefficient, standardized beta coefficient, and value of the t test were reported as r, β, and t.

• Agreement on fully reporting errors.

• P < .01.

• P < .05.

administration safety, prevention of falls and unplanned extubations, and handover safety. In contrast, a heavy workload decreased their engagement in the safety practices.

The results of regression analyses showed that nursing quality, job satisfaction, and agreement on fully reporting errors had the best predictions of the safety prac-tices (Table 2). The other environment fac-tors and workload had limited predictive effects on the safety practices. The envi-ronment factor of leadership and manage-ment did not significantly predict the safety practices. The regression model 1 showed that the 3 work environment variables of NP (β = .241; P < .001), NQ (β =

.182; P < .001), and PH (β = .138; P < .001); job satisfaction (β = .024; P < .001); and agreement on reporting errors (β = .109; P

• .001) significantly accounted for 13.1% of the variance (adjusted R² =131) in medica-tion administration safety. Second, NQ (β =

.288; P < .001), ST (β = −.142; P < .001), job satisfaction (β = .075; P < .001), and agree-ment on fully reporting errors (β = .146; P <

.001) accounted for 16.2% of the variance (ad-

justed R² = 0.162) in prevention of falls and unplanned extubations (regression model 2). Finally, regression model 3 of handover safety showed that NQ (β = .222; P < .001), PH (β = .101; P < .001), workload (β = −.059; P <

.05), job satisfaction (β = .064; P < .05), and agreement on fully reporting errors (β = .106; P < .001) accounted for 15.7% of the variance (adjusted R² = 0.157). Clearly, the highest predictive variables of safety practices were nursing quality, job satisfaction, and agree-ment on fully reporting medical errors.

DISCUSSION

Medication administration

Overall, the nurses’ engagements with the safety practices were satisfactory because of high involvement in each NSPS item except avoiding interruption in handover (S6) and using I-SBAR for team communica-tion (S9). Their involvements in medication administration safety especially in high-alert medications (S13), recognition of medication purposes (S11), and clarification questionable

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medication orders (S12) were highest. Stud-ies have shown that most nurses have appropriate knowledge of medication safety, medication error causes, and high-alert med-ication administration.^30,31 Moreover, the Taiwanese hospital accreditation standards of medication safety have a stronger force in guiding the medication administration of frontline nurses.⁷ Of this study, the nurses were committed to using medication information tools, monitoring drug effects and side effects, and teaching patients about their medications. As expected, this study’s results demonstrate nurses’ efforts and engagement with medication administration safety.

Our regression analyses showed that the medication administration safety practice was supported by the 3 work environment fac-tors, job satisfaction, and agreement on fully reporting medical errors. Similar results of other studies found that nursing workload, job satisfaction, and patient safety culture were linked to negative patient outcomes and inad-equate nursing practices.^8,12,32 As addressed in the International Council of Nurses doc-ument, a trust and learning-based error re-porting system is the first step to medication safety.³³ In fact, Taiwanese nurses have con-tinued to advance their professional knowl-edge and care quality through nursing career ladder programs, quality management initia-tives, and positive reporting cultures, which are advantageous to patient safety assurance and awareness in hospitals.²⁰

However, 2 environmental variables (ie, LM and ST) and workload did not signifi-cantly predict the medication administration safety practices in this study. This is incon-gruent with other studies^11,12,32 and with pa-tient safety literature^10,34 and was probably caused by variable competition in the regres-sion analysis.³⁵ The competition implies a mediator or moderator effect among these environmental variables that exists concur-rently in the workplace. An additional plausi-ble reason is the complexity of nurse work-load measurement.³⁶ Work overtime, shift scheduling, nurse-patient ratios, and burnout

are commonly treated as indicators of nurses’ workloads in patient safety research and quality improvement activities. In this study, workload was measured as nurses’ percep-tions of job-related demands in physical, cog-nitive, manpower, and work pattern, which might suppress the predication to the medi-cation administration safety, although a weak and significant correlation was shown to ex-ist (Table 2). Using highly sensitive mea-sures of nurse workload and exploring the interaction effects among the work environ-ment factors are recommended for further research.

Prevention of falls and unplanned extubations

Most of the nurses were highly involved in the prevention of patient falls and un-planned extubations through intensive risk factor assessment, care planning, and read-back techniques for critical information confirmation. The environment factors of NQ (nursing quality) and ST (staffing and resource adequacy), job satisfaction, and agreement on fully reporting medical errors predicted the prevention of patient falls and unplanned extubations. This result is similar to other studies in which nurses who have positive perceptions of quality improvement, a culture of error reporting, and job satisfac-tion are likely to perform these behaviors in their work.^12,16,20 In addition, the ST factor had a negative prediction in the prevention of patient falls and unplanned extubations. As stated in the literature, frontline nurses may tend to decrease their mindfulness and awareness if they judge the work conditions as highly reliable and safe.³⁷ As to the work-load, it was excluded in the regression model 2, although it had a significant correlation (Table 2). As discussed earlier, variable com-petitions among these environmental factors and the diverse aspects of workload measure-ment also interfered in regression model 2. Whether the nurse workload is considered as an inhibitor or a moderator to the prevention of patient falls and unplanned extubations, it should be examined in the future.

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• JOURNAL OF NURSING CARE QUALITY/OCTOBER–DECEMBER 2017

Handover safety

The study results showed that avoiding interruptions in the nursing handover pro-cess had the lowest level of involvement among the nurses. This is expected and con-sistent with other studies.^5,38,39 Researchers have addressed the fact that nurses had sub-stantial concerns with interruptions in the handover process and application of I-SBAR communication.^5,38 One study reported that assertive communication with care teams is still a challenge to Taiwanese nurses, although patient safety improvement and teamwork culture development have been assigned as high priorities in hospitals.³⁹

Handover depends mainly on nurses’ indi-vidual behaviors involving mutual cognition, understanding, and communication with the information of patient care.⁴⁰ In this study, there were significant effects on handover safety from job satisfaction, workload, and agreement on fully reporting errors. It is un-derstandable that nurses who have less satis-faction with their jobs, workload, and error reporting tend to decrease their engagement in patient safety. In addition, practices such as reviewing medical and nursing records and updating them with the latest patient infor-mation may add extra effort for nurses before shift handovers, resulting in shortening or sim-plifying the handover process. Although hu-man factors (eg, knowledge, attitude, and be-havior) play a partial role in adverse events, there are inherent system factors that impact care professionals and their clinical practices, resulting in unintended harm to care quality and patient safety.³³

This study’s results provide evidence that nursing quality, job satisfaction, and culture of error reporting are key contributors to nurses’ practices in maintaining medication administration safety, prevention of falls and unplanned extubations, and handover safety. The workload and environmental factors of nursing professional development and partic-ipation in hospital affairs show modest influ-ence on nursing safety practices, whereas the environment factor of leadership and manage-ment did not predict safety practices. This

study reveals that nurses’ work environment is consistent with varying aspects, which sep-arately contribute to nursing safety practices. Hospitals and nursing departments can im-prove nurses’ work environments, increase their job satisfaction, and optimize the re-porting culture, leading to higher engagement in nursing safety practices and patient safety achievements. Benchmarking national mea-sures of nurse work environments and nurse-specific quality indices focusing on patient safety is recommended.

Limitations

Several limitations are addressed in this study. First, the findings are limited by the selection samples from the 6 study hospitals. All participating nurses were a part of the nurse population in Taiwan, which may have caused a sampling bias because of insufficient representativeness. Second, the study results of nurse safety practices of medication admin-istration, prevention of falls and unplanned extubations, and handover safety might be overestimated by the use of self-reported questionnaires. Without comparisons with nursing records and documentations, the generalization of study findings is conserva-tive. Third, there are differences in nursing delivery systems and administration policies related to patient safety among the study hospitals, which could limit and influence the nurse safety practices conducted. Thus, this difference should be considered in this study’s results.

CONCLUSIONS

Patient safety as a result of nurses’ be-haviors, work environments, workload, job satisfaction, and error reporting appears to be a key organizational factor that underlies their safety practices in hospitals. Within a complex working environment of delivering health care, seeking and managing the most influential factors are cost-effective to patient safety improvement. This study provides evi-dence that one environmental factor of nurs-ing quality, nurses’ job satisfaction, and the

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error reporting culture influence nurses’ en-gagement in medication safety, prevention of patient falls and unplanned extubations, and handover safety. Hospital and nurse ad-

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