Factors Relating to Changes in Practice

Both bivariate and multivariate analyses were used to examine how predictor variables were related to reported changes in practice (constructive and defensive changes in practice).

Pearson's product correlations were used to assess whether there was a significant relationship between a number of predictor variables and constructive and defensive changes in practice. The results are displayed in table 6.5. Inexperience (i.e. lack of knowledge and not having the relevant information) and work overload were significantly associated with constructive changes in practice.

Errors which were caused by faulty judgement, work overload and stressful atmosphere were significantly associated with defensive change 1 (i.e. loss of confidence and increased anxiety). Lack of support jfrom senior staff and insensitiveness of senior staff were significantly associated with defensive change! (i.e. more likely to keep the error to oneself). Severity of error was found to be significantly correlated with constructive changes in practice, defensive change 2 and defensive change 3.

The types of emotional responses (internal and external responses) to the error as well as the coping strategies used in the aftermath of the error were found to be significantly related to reported changes in practice. The time span for the occurrence of these two types of psychological reactions to the error may be different, with emotional reactions occurring immediately after the error and coping responses in the hours and days in the aftermath of the error.

Chapter 6: Types o f nursing errors and their perceived causes

TABLE 6.5. Correlation of causes of error, circumstances of error, severity of error, coping strategies, and responses to error with constructive and defensive changes in practice.

Factors Constructive changes 1 @ Defensive changel@ Defensive change! @ Defensive change3@ Causes. Inexperience. .26* .05 .16 .15 Work overload .20* .30** .16 .24* F aulty judgement. .16 .26* .09 .34** Circumstances Stressful atmosphere. -.20* .19* -.06 .17 Insensitive staff. .26* .17 .19* .26*

Unsafe work practices. .12 .12 .32** .19

Severity of error. .21 ** .18* 22** .26**

Coping strategies.

Accepting responsibility. .43** 42** .18 32**

Distancing. .20* .04 .41** .17

Self-controlling. .32** .42** .38** 40**

Seeking social support. .45** .23* .14 .36** Planful problem solving. .31** .06 -.01 .34**

Escape avoidance. .30** .58** .18 44**

Emotional responses.

Internal responses(feeling angry at

self, guilty, inadequate). _.36** .34** .04 .14

External responses(feeling angry at

others, fearful of repercussions) _{.18 .28** .09 .32**}

Senior staff responses.

Supporting. .29* -.08 -.29** -.15

Treat unfairly. .31* .38** .21* .41**

Cause loss of self-esteem. .23* .27** .23* .33**

2.

p < . 0 5 * * p < .0 1

N.B.: The problem o f type I error must be taken into account, especially when multiple comparisons are made. In type I error, we reject the null hypothesis when it is true. The probability o f making a type I error can be reduced if a more stringent level o f significance is used (e.g. 1 % rather than 5 %). In table 6.5, a large number of the p values are less than 0.01, but there are still a number of p< 0.05. It is also important to be aware that by reducing the chances o f type I error, we increase the likelihood of making a type II error (i.e. when no difference is found between the groups when there is one).

Table. 6.5 shows that internal responses (i.e. feeling angry at self, guilty and inadequate) as well as accepting responsibility were significantly related to constructive changes in practice. There was no relationship between external responses (i.e. feeling angry at others and fearful of repercussions) and constructive changes, but both internal and external responses were significantly related to being less confident and more anxious in one's work (p <.01). It can also be seen from table 6.S that nurses used more than one coping strategies in response to an error. With a few exception, these strategies were significantly associated with both constructive and defensive changes. Accepting responsibility and planful problem solving strategies were positively related to constructive changes whereas "distancing" and " self- controlling" strategies were more related to defensive change 2 (i.e. more likely to keep an error to oneself).

6.3.8.I. Multiple regression analysis.

In the bivariate analysis, many variables were found to be related to constructive and defensive changes in practice. In order to determine what factors contribute the most to explaining changes in practice, multi-variate analysis was used.

As accepting responsibility for one's error was positively correlated to constructive changes in practice and defensive change 1, it was important to determine whether this applied to the total sample of nurses in this study, the reason being 43 of the 129 nurses reported that the error was made by someone else under their supervision and was technically not physically responsible for making the error. These nurses might not accept personal responsibility for the error. Therefore, a preliminary regression analysis was carried out using only the group (N= 43) which did not personally maKe the error. The results of this analysis revealed that accepting responsibility was no longer a significant factor in predicting changes in practice, but stressful ward atmosphere w6^ & significant

Chapter 6: Types o f nursing errors and their perceived causes

predictor . They were therefore deemed to belong to a separate group. The results are shown in table 6.6.

Table 6.6 Predictors of constructive changes in practice (in the group that did not personally make the error).

Predictors of constructive changes Beta _R2 Antecedents of errors. Years in nursing Lack of knowledge/information Stressful atmosphere Job overload .14 .35* .59** .007 .48 Error severity .28* .55 Coping strategies used

Accepting responsibility Distancing

Planful problem solving

.025 -.11* 29** .58 Emotional responses Internal responses External responses .05 .008 .60 p < .05 p<.01

Therefore, 1 the analysis reported below applies only to those who were personally responsible for the error (N= 86).

Hierarchical regression was employed to determine if addition of information regarding error severity, coping mechanisms and emotional responses improve prediction of constructive changes in practice beyond that afforded by the background factors (i.e. inexperience, job overload and ward atmosphere). Table 6.7 displays the results of the regression analysis at various steps.

TABLE 6.7 Predictors of constructive changes in practice.

Predictors of constructive changes Beta _R2 Antecedents of error. Stressful atmosphere. Years in nursing Lack of knowledge/information. Job overload. .08 -05 .33** .12 .11 E rro r severity. Patient unaffected. .24 .13 Coping strategies used.

Accepting responsibility. Planful problem solving. Seeking social support. Self-control. .39* .26* .19* -.06 .43 Emotional responses.

Internal responses(i.e. angry at self, guilty, feel inadequate).

External responses (i.e. angry at others, fearful of repercussions)

.17

-.05

.45

* p < .05 ** p < .01

Background factors such as inexperience (lack of knowledge/information), job overload and ward atmosphere were entered first, but only inexperience proved a significant predictor. Severity of the error was then entered, followed by coping strategies and emotional responses. Coping strategies at step 3 are significant predictors of constructive changes.

The same technique was used to assess the influence of selected variables on defensive changes 1 and 2 , the selection being based on variables which were found to be significant in the Pearson's correlation analysis. The results of the

Chapter 6: Types o f nursing errors and their perceived causes

multiple regression analyses of defensive changes 1, 2 and 3 are summarised in tables 6.8 , 6.9 and 6.10.

TABLE 6.8 Predictors of defensive change 1 (more anxious and less confident at work)

Predictors of defensive change 1 Beta _R2 Antecedents of error.

Faulty judgement. stressful atmosphere.

Lack of knowledge and information.

.23* .27* .02 .12 Severity of error. .12 .13 Coping strategies used.

Planful problem solving Accepting responsibility. Seeking social support.

.002 .36** .15

.29 Emotional responses.

External responses (angry at others, fearful of repercussions).

Internal responses (angry at self, guilty, inadequate).

.23*

.15

.35

Table 6.9 Predictors of defensive change 2 (more likely to keep an error to myself).

Predictors of defensive change 2. Beta _R2 Antecedents of error.

Unsupportive staff.

Lack of knowledge/information. Unsafe working practices

.19 .03 .27* .15 Severity of error. .11 .16 Coping strategies used.

Distancing self-controlling. .32* .22 .35 Emotional responses.

Internal (angry at self, guilty, inadequate). External responses (angry at others, fearful of repercussions)

-.13 -.18

.39

p < .05 ** p < .01

Table 6.10. Predictors of defensive change 3 (less trusting of others) Predictors of defensive change 3 Beta _R2

Antecedent of error.

Years of experience in nursing -.09

Lack of supervision .031

Job overload .13

Unsupportive senior staff .23 Someone else made the error -.09

.10

Error severity .32**

.20 Accepting responsibility .008

Self-controlling .23

Planful problem solving .08

Escape-avoidance -.03

Seeking social support .20

31

Internal responses -.06

External responses -.02

.31

Chapter 6: Types o f nursing errors and their perceived causes

Of the background factors (antecedents of error), stressfiil atmosphere proved a and faulty judgement proved significant predictors of defensive change 1 (more anxious and less confident in one's work). At step 2, error severity was not significant predictor of defensive change 1 and at step 3, accepting responsibility proved a significant predictor. Addition of emotional responses at step 4 did not significantly improve R2.

With defensive change 2 (more likely to keep an error to myself), background factors (antecedents of error) and error severity contributed only minimally to the equation, but the use of distancing strategy proved to be a significant predictor

Emotional responses did not add further to the equation at step 4.

In defensive change 3 (less trusting of others), background factors did not contribute to the equation. However, error severity explained 20 % of the variance of the dependent variable. When coping factors were added at step 3, the R2 increased to 31. Emotional responses did not add further to the equation at

step 4.