Examining the Relationship Among Ambulatory Surgical Settings Work Environment, Nurses’ Characteristics, and Medication Errors Reporting

Examining the Relationship Among Ambulatory Surgical Settings Work Environment, Nurses’ Characteristics, and Medication Errors Reporting Amany A. Farag, PhD, MSN, RN, Mary K. Anthony, PhD, RN, CS Purpose: To describe work environment characteristics (leadership style

and safety climate) of ambulatory surgical settings and to examine the relationship between work environment and nurses’ willingness to report medication errors in ambulatory surgical settings. Design: Descriptive correlational design using survey methodology. Methods: The sample of this study consisted of 40 unit-based registered nurses, working as full time, part time, or as needed in four ambulatory surgical settings affiliated with one health care system located in Northeast Ohio. Findings: The results of two separate regression analyses, one with three nurse manager’s leadership styles and another with five safety climate dimensions as independent variables, explained 44% and 50%, respectively, on variance of nurses’ willingness to report medication errors. Conclusion: To increase nurses’ willingness to report medication errors, ambulatory surgical settings administrators should invest in nurse manager leadership training programs and focus on enhancing safety climate aspects, particularly errors feedback and organizational learning. Keywords: medication error reporting, safety climate, ambulatory surgical settings. Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses

PUBLICATION OF THE INSTITUTE OF MEDICINE (IOM) report ‘‘To Err is Human’’ was a turning point in the health care safety arena, particularly medication safety research.1 Figures presented by two IOM reports were a clear demonstration that our medication safety practices are Amany A. Farag, PhD, MSN, RN, is an Assistant Professor, College of Nursing, The University of Iowa, 50 N Road, Room 486 CNB, Iowa City, IA; and Mary K. Anthony, PhD, RN, CS, is a Professor, Associate Dean for Research, and Director of PhD Program, College of Nursing, Kent State University, Kent, OH. Address correspondence to Amany Farag, College of Nursing, The University of Iowa, 50 Newton Road, Room 486 CNB, Iowa City, IA 52242; e-mail address: [email protected]. Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.11.014

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less than acceptable.1,2 It is estimated that more than 1.5 million patients are subjected to medication errors during their hospitalization, and 800,000 die of preventable drug events.2 In reaction to the IOM reports, a plethora of research was conducted in acute care settings to assess causes of medication errors and measures for prevention. In contrast to acute care settings, there is little research regarding safety and safety issues in ambulatory surgical settings. However, Hicks et al3 in a US Pharmacopeia (USP) report documented that 422 ambulatory surgical facilities reported a total of 3,427 medication errors that occurred between September 1, 1998 and August 31, 2005; 3.3% of these errors resulted in patients harm. Ambulatory surgical settings, sometimes called ‘‘same-day surgical centers,’’ are settings where

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patients are admitted for surgery and discharged in the same day; therefore. it is uniquely different from acute care facilities where postoperative patients have a longer length of stay needed for postoperative care. Nurses and health care providers working in ambulatory surgical settings are under significant pressure to work with surgical patients, stabilize their conditions, provide the required health education, and discharge them home safely within 24 hours or less.4 Currently, it is estimated that 6 of 10 surgeries are performed in ambulatory settings, about 35 million same-day surgeries are performed annually in the United States5; these numbers are expected to increase with the advancement in ambulatory surgical technology and cost containment pressures. Goeckner et al6 argued that because most of the published medication errors statistics are based on acute care settings, these numbers may not be helpful to inform organizational intervention especially for nurses working in perioperative and ambulatory settings.6 Therefore, addressing medication errors in ambulatory surgical settings where perioperative and perianesthesia nurses work is a major necessity. In efforts to contain medication errors, health care organizations recently began to investigate the processes used by High Reliability Organizations (HROs), such as aviation and nuclear power, to increase their safety levels. Reviewing the HRO literature shows that these complex and high-risk industries managed to achieve optimum safety levels by adapting several measures. One of these measures is creating a safety culture that encourages and praises error reporting; in safety culture, all errors and near misses are reported.7 Reporting, reviewing, and analyzing errors provide opportunities for understanding their root causes, based on this understanding measures to prevent subsequent errors can be developed.8,9 In health care settings, under-reporting of medication errors masks the extent of the actual problem and delays the implementation of corrective actions.10,11 Nurses by virtue of their role are at the ‘‘sharp end’’ for intercepting errors12 and assume a major role in error reporting11; serious life-threatening and fatal errors are usually reported, but minor errors and near misses are not.13 Medication error reporting is a voluntary process;14 hence, creating a good reporting system

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may not be the initial solution to medication errors under-reporting. It is important to first investigate factors that could increase nurses’ willingness to report errors. The IOM, as well as health system scholars, proposed that having work environment that is characterized by supportive leadership and safety culture could enhance staff commitment to safety practices15–17 such as medication errors reporting. This conceptualization for work environment was adopted in our study. In acute care settings, some studies were conducted to examine the relationship between either safety culture or climate and nurses’ practices.18–20 Safety culture reflects the shared values, norms, and beliefs pertinent to safety at a work setting.21,22 Safety climate, on the other hand, is a multidimensional concept that presents individuals’ perceptions of safety practices in their hospitals/units.21,22 Measurement of safety climate provides information about how well an organization has created a culture that facilitates safe practices.21–23 Therefore, this study measured safety climate as a proxy of the overall safety culture. In ambulatory surgical settings, there are limited attempts to examine safety climate as related to safety practices particularly medication errors reporting. Furthermore, in both acute care settings and ambulatory surgical centers, the relationship between leadership style and safety practices is yet to be examined. Therefore, the purposes of this study were as follows: (1) to describe work environment characteristics of leadership style and safety climate in ambulatory surgical settings, (2) to examine the relationship among nurse managers’ leadership style, safety climate, and nurses’ willingness to report medication errors, and (3) to examine whether nurses’ work and demographic characteristics influence their willingness to report medication errors. Study conceptual model is presented in Figure 1. Nurse Manager’s Leadership Style The significant impact of nurse manager’s leadership style on various organizational and nursing outcomes cannot be understated. Leadership styles of transformational, transactional, and passive avoidant are among the contemporary classification of leadership styles; this classification was used in this study. Managers using transformational

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Nurse manager’s leadership style Transformational Transactional Passive-avoidant*

Work Environment

Nurses’ willingness to report medication errors

Safety climate Manager’s actions Organizational learning* Communication openness Teamwork Error Feedback* Non-punitive environment

Figure 1. Conceptual model. *Variable with highest beta weights. This figure is available in color online at www.jopan.org.

leadership style are charismatic leaders who have the ability to articulate organizational goals and vision into the daily practices.24,25 Transformational leaders focus on achieving the desired tasks through inspiring, stimulating, and motivating staff to invest their best abilities in their work.24,25 Transactional leadership is similar to the traditional democratic leader who focuses on achieving goals, engages the staff in decision making, but believes that rewards and incentives should be equated with good performance.24,25 Passive avoidant leadership style is the least desirable style. Managers using this style are mostly absent when needed, do not contribute to staff advancement, and do not have a shared vision with his/her staff,24,25 therefore, can negatively impact the day-to-day work processes. An integrated literature review by Germain and Cummings26 and a more recent one by Wong et al27 clearly highlighted the pivotal role of nurse managers’ leadership style on various outcomes such as job satisfaction, intent to leave, empowerment, and commitment. None of the reviewed studies, however, examined the relationship between nurse managers’ leadership style and medication error reporting or any safety practices. Safety Climate Creating a safety climate is a vital component to contain the problem of medication error and its

reporting. Safety climate is a nebulous multifaceted construct that used sometimes interchangeably with safety culture. The two concepts are related, but each one has its distinct attributes. Given the abstract nature of safety climate, several measures were proposed to measure it. One of the frequently used and well-validated measures is Nieva and Sorra28 instrument that was used in this study. The authors proposed 12 dimensions relevant to measuring safety climate at both hospital and unit level.28 For the purposes of this study, we used only six dimensions that are relevant to nurses’ perception about their unit safety climate and included organizational learning, teamwork, communication openness, feedback and communication about errors, and nonpunitive response to errors. Definitions for the six dimensions29 are presented in Table 1. Studies have been conducted in acute care settings to examine the relationship between safety climate and outcomes such as needlestick injuries, urinary tract infection (UTI) and back injuries.20,30–32 Results of these studies showed that settings with better safety climate had fewer negative outcomes. Regarding climate and medication errors reporting, Throckmorton and Etchegaray33 examined the relationship among one safety climate dimension of nonpunitive environment, nurses’ knowledge about Texas nursing practice act, and nurses’ demographics as related

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Table 1. Definitions of Safety Climate Dimensions29 Dimension Communication openness Feedback and communication about error Nonpunitive response to errors Organizational learning Managers’ actions promoting safety Team work within the unit

Definition: The Extent to Which Staff have the freedom to ‘‘speak up’’ and question authority figures if they see any threat to their patients Staff receive information about errors and about hospital efforts to prevent subsequent errors Staff perceive that their errors or incidents reports will not result in any threat or punitive/disciplinary action. Staff feel that their hospital is using the errors as a learning opportunity and always implementing interventions to prevent further errors. Staff perceive that their managers are listening to their quality and safety improvement activities, appreciate staff efforts to maintain patients’ safety Staff feel that they are working as a team within their unit and there a prevailing sense of coherence, trust, and respect.

to nurses’ intent to report medication error.33 The study results demonstrated that nurses were willing to report harmful errors; their perception to nonpunitive environment was not a strong predictor to errors reporting. However, years since initial licensing was negatively related to their willingness to report medical errors.33 Wakefield et al34 examined the relationship between nurses’ perceptions of their organizational culture and implementation of contentious quality improvement programs as related to medication errors reporting. Wakefield et al did not report a significant relationship between nurses’ perceptions of their work environment and nurses’ intent to report medication errors.34 Unlike our study, the previous studies did not aim to examine the role of safety climate. Medication Error Reporting Solving any problem starts with identifying its causes; therefore, managing medication errors requires identifying and analyzing error root causes. Once causes are identified, intervention strategies can be developed. Medication error reporting is an essential tool to identify causes for medication errors. Currently, in addition to high medication error rates, most of the US health care systems suffer from significant under-reporting of medication errors. In a nationwide study that surveyed 1,105 nurses working in 25 acute care settings, the study participants indicated that 47% of medication errors are reported; only 36% of nurses felt that near misses should be reported.35 In another study with a sample of ICU nurses, the study participants

reported that they are willing to report errors, but they might choose formal or informal reporting (reporting to the treating physician or nurse manager) based on the seriousness of the error.36 Reasons for errors under-reporting are plentiful, some of the reported reasons are as follows: fear from punishment, peer retaliation, personal image, time required to complete error report, unfamiliarity with the error reporting system, and absence of a clear definition to what constitute a medication error.37–39 Furthermore, some nurses perceived that they are not responsible for reporting medication errors that are not within their scope of practice.40 These causes can be grouped as either system or individual related. Given the proposed influence of safety climate and leadership on safety practices (eg, medication errors reporting), this study aimed at examining the following hypotheses: Hypothesis 1: There is a significant relationship between nurse managers’ leadership style and nurses’ willingness to report medication errors. Hypothesis 1-A: Transformational leadership style is the strongest predictor of nurses’ willingness to report medication errors. Hypothesis 2: At least one safety climate dimension will predict nurses’ willingness to report medication errors. Hypothesis 2-A: Nonpunitive response to error is the strongest predictor of nurses’ willingness to report medication errors. Hypothesis 3: There is a relationship between nurses’ work and demographic characteristics and willingness to report medication errors.

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Hypothesis 4: Nurses are more likely to report errors with high potential to cause patient harm as compared with less harmful errors.

Methods Design/Setting/Sample The sample of this pilot descriptive correlational study consisted of 40 unit-based registered nurses (RNs), representing a 59.7% response rate. All the study participants worked as full time, part time, or as needed in four ambulatory surgical settings affiliated with one tertiary health care system located in Northeast Ohio. All the participating settings shared a similar open physical design, with curtains separating the patients’ beds. Instruments Nurses’ perception of their unit nurse manager’s leadership style was measured using Multifactorial Leadership Questionnaire by Avolio and Bass.25 Nurses responded to this questionnaire by completing 36 items under nine subscales, covering behaviors related to the three main leadership styles of transformational (five subscales), transactional (two subscales), and passive avoidant (two subscales).25 In completing the Multifactorial Leadership Questionnaire, nurses used five-point Likert scale ranging from not at all (0) to frequently if not always (4).25 Higher score displays the leadership style that used frequently by the nurse manager. The reported Cronbach alpha in this study was 0.95, 0.62, and 0.81 for transformational, trans-

actional, and passive-avoidant leadership styles, respectively. Nurses’ perception of their unit safety climate was measured using Patient Safety Climate in Health care Organizations tool by Nieva and Sorra.28 This survey consists of 12 subscales; for the purpose of this study, only six subscales related to unit safety climate were used. The used subscales were manager’s safety actions (four items), organizational learning (three items), teamwork (four items), communication openness (three items), feedback and communication about errors (three items), and nonpunitive response to errors (three items).28 Nurses responded to the survey using five-point Likert scale, ranging from strongly agree (4) to strongly disagree (0), higher score indicates better safety climate.28 The reported Cronbach alpha for each subscale in this study ranged from 0.62 to 0.94, detailed presentation for the Cronbach alpha for each subscale is presented in Table 2. Nurses’ willingness to report medication errors was measured by using one outcome scale of Patient Safety Climate in Healthcare Organizations tool.28 The response format was modified to reflect nurses’ willingness to report errors instead of frequency of errors. In completing this subscale, nurses used four-point Likert scale ranging from not at all (0) to very likely (3). Cronbach alpha for the three-item scale was 0.80. In addition to the previous variables, work and demographic variables such as, nurses’ age, education, years of RN

Table 2. Descriptive Statistics and Reliability Coefficient for the Study Variables Measures Characteristics Leadership styles (0-4) Transformational Transactional Passive avoidant Safety climate (0-4) Manager’s actions Organizational learning Communication openness Team work Errors feedback Nonpunitive environment Nurses’ willingness to report medication errors (0-3) SD, standard deviation. Bold entries are reflective of the total scale score.

Number of Items

Mean

SD

Cronbach Alpha

36 20 8 8 20 4 3 4 3 3 3 3

2.59 2.57 1.18 2.9 2.9 3.0 2.8 3.3 2.9 2.4 2.5

0.79 0.55 0.74 0.60 0.77 0.73 0.77 0.76 0.70 0.99 0.67

0.95 0.62 0.81 0.93 0.81 0.86 0.94 0.62 0.71 0.89 0.80

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experience, years of experience in the ambulatory setting, years of experience with the nurse manager, shift work, employment status (full time, part time, or as needed), and working hours per week were collected as well. Procedure After obtaining the required institutional review board approval, the principal investigator (PI) approached the nurse managers of four freestanding ambulatory surgical settings and explained the study and its aims. All the managers agreed to have their staff participate in the study. The PI coordinated with the managers a convenient time to present the study to the nursing staff. After introducing the study, the PI placed the study package which contained study cover letter, study survey, and prestamped and self-addressed return envelope in the nurses’ mail boxes. One week later, the PI placed reminder cards in the nurses’ mail boxes. On the third and fourth weeks, the PI placed reminder flyers and last call flyers, respectively, in the nurses’ meeting room and lounge and station. Each nurse received a $10 gift card after mailing the completed survey. Nurses’ addresses as appeared on the study return envelope were used to mail the gift card. The return envelopes were shredded immediately after mailing the gift card. Data analysis Before conducting the analysis, data were screened for outliers and inaccurate entry and tested for regression assumptions. Two separate regressions to test the effect of leadership style and safety climate on nurses’ willingness to report medication errors were conducted. Given the small sample size, variables with no significant relationship with the outcome variable were excluded from the regression analysis. Only one safety climate dimension of teamwork was not significantly related to nurses’ willingness to report medication errors. Regression analysis was used to address the first two hypotheses, correlation analysis, and descriptive statistics were used to address the last two hypotheses, respectively.

Findings Descriptive Most of the study participants (82.5%) were females with almost equal number of nurses

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(n 5 20 and n 5 19) distributed in the two age categories of Baby Boomer (49 to 65 years) and Generation X (29 to 48 years), respectively. More than half of the participants (60%) had a Bachelor of Science in Nursing degree. Regarding the work characteristics, nurses in this study worked for an average of 20.8 years (standard deviation [SD] 5 11.1), have been working in their current ambulatory surgical setting for an average of 6.4 years (SD 5 4.5), and have been working with their current nurse manager for an average of 4.9 years (SD 5 2.9). Finally, the study participants worked for an average of 30 h/wk (Tables 3 and 4). Nurses in this study perceived that their nurse managers displayed transformational (mean [M] 5 2.5, SD 5 0.79) and transactional (M 5 2.5, SD 5 0.55) leadership styles behaviors almost equally and displayed passive avoidant behaviors less (M 5 1.1, SD 5 0.74). Nurses also perceived their unit climate to be characterized by an overall acceptable safety climate (M 5 2.9, SD 5 0.60). Safety climate dimensions of team work (M 5 3.3, SD 5 0.76) and organizational learning (M 5 3.0, SD 5 0.73) had the highest mean scores, and non-punitive response to errors (M 5 2.4, SD 5 0.99) had the lowest mean score (Table 2). WILLINGNESS TO REPORT ERRORS. In an effort to gain more understanding about nurses’ willingness to report medication errors, the three errors reporting questions were analyzed as a total score and as three separate questions, where each one Table 3. Study Sample Personal Characteristics Characteristics Gender Female Male Age category Baby Boomer (49-65) Generation X (29-48) Education Diploma Associate BSN MSN/DNP

N

%

33 7

82.5 17.5

20 19

50.0 47.5

8 6 24 2

20.0 15.0 60.0 5.0

BSN 5 Bachelor of Science in Nursing; DNP 5 Doctorate of Nursing Practice; MSN 5 Masters of Science in Nursing.

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Table 4. Study Sample Work Characteristics Characteristics Years of RN experience Years of unit experience Years of experience with nurse manager Working hours per week

Mean

Median

SD

20.8 6.4 4.9

20.0 5.5 5.0

11.1 4.5 2.9

30.4

33.5

11.0

SD, standard deviation; RN, registered nurse.

of the questions reflected a degree of error severity. As a total scale, on a scale ranging from 0 to 3, nurses mean score was 2.5 (SD 5 0.67) indicting that the study participants were very likely to report medication errors. As individual questions, the study results showed that nurses in this sample had a slightly higher tendency (M 5 2.80, SD 5 .60) to report errors with high potential to hurt patient, even if it did not. This result provides initial support to the fourth hypothesis. Inferential statistics, however, is required to provide a further support to this hypothesis, given the small sample size inferential statistics was not performed (Table 5). NURSES’ CHARACTERISTICS AND WILLINGNESS TO REPORT MEDICATION ERRORS. There was no statistical significant difference among nurses regarding their willingness to report medication errors based on their demographic and work characteristics as nurses’ years of experience, experience in the ambulatory setting, experience with the nurse manager, and working hours per week. None of the correlation values were significant (Table 6); therefore, the third hypothesis was not supported. Table 5. Willingness to Report Medication Errors Individual Items Statistics Items If a mistake is made, but caught and corrected before affecting patient, how likely you are going to report this error If a mistake is made, but has no potential harm to the patient, how likely you are going to report this error If a mistake is made and could harm the patient, but does not, how likely you are going to report this error SD, standard deviation.

Mean

SD

2.03

1.16

2.70

2.80

.64

.60

LEADERSHIP AND WILLINGNESS TO REPORT ERRORS. The first regression model with the three leadership styles of transformational, transactional, and passive avoidant as predictors to nurses’ willingness to report medication errors explained 44% of the variance on nurses’ willingness in reporting medication errors (R2 5 44, F 5 8.35, P , .000) (Table 7). This result supports the first hypothesis. Although passive avoidant had the lowest mean score, surprisingly in the regression analysis passive avoidant had the highest and the only significant negative effect (b 5 20.45, t 5 22.72, P 5 .01) (Table 7). With this result, we failed to support hypothesis 1-A. SAFETY CLIMATE AND NURSES’ WILLINGNESS TO REPORT MEDICATION ERRORS. The second regression model with the five safety climate dimensions as the independent study variables significantly explained 50% of variance on nurses’ willingness to report medication errors (R2 5 .50, F 5 5.45, P , .000) (Table 7). Organizational learning had the highest and the only significant predictive effect (b 5 0.38, t 5 1.97, P 5 .05) (Table 7). This result supports the second hypothesis. Nonpunitive response to errors was not a significant predictor of nurses willingness to report medication errors (b 5 0.24, t 5 1.13, P 5 .0.26) (Table 7); with this result, we failed to support hypothesis 2-A. Feedback and communication about error, however, had the second highest beta weight but did not reach significance level (b 5 0.24, t 5 1.13, P 5 .0.26) (Table 7). Failure to achieve significance levels should be interpreted with caution given the small sample size. Reviewing the correlation table (Table 8) shows promising medium to large effect size. This result

Table 6. Relationship Between Participants Work Characteristics and Nurses’ Willingness to Report Medication Errors Demographic Variables Years of RN experience Years of experience in the current unit Years of experience with the current nurse manager Working hours per week RN, registered nurse.

RNs Willingness to Report Errors, r (P) 20.00 (.96) 20.09 (.55) 20.17 (.28) 20.22 (.16)

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Table 7. Regression Results and Beta Weights for the Two Regression Models Variables

B

Standard Error

Leadership style Transformational 0.18 Transactional 0.19 Passive avoidant 20.42 R2 5 0.44, Adj. R2 5 0.38, df 5 3, F 5 8.35, P , .000 Safety climate Manager’s actions 0.08 Organizational learning 0.37 Communication openness 0.10 Error feedback 0.20 Nonpunitive environment 0.02 R2 5 0.50, Adj. R2 5 0.42, df 5 5, F 5 6.67, P , .000

supports replicating the study with larger sample which may show more promising findings.

Discussion This study investigated the predictive role of nurse manager’s leadership style and safety climate on nurses’ willingness to report medication errors. In addition, the relationship between nurses’ characteristics and willingness to report medication errors was examined as well. Nurses in the study settings perceived that their nurse managers displayed almost equally both transformational and transactional leadership behaviors. Nurses also perceived their unit climate to be characterized as safe. Correlation analysis showed a significant Table 8. Relationship Between Study Independent Variables (Leadership Style and Safety Climate) and Outcome Variable of Nurses’ Willingness to Report Medication Errors Variables Leadership styles Transformational Transactional Passive avoidant Safety climate Manager’s actions Organizational learning Communication openness Team work Error feedback Nonpunitive environment RN, registered nurse.

RNs Willingness to Report Errors, r (P) 0.54 (.001) 0.34 (.034) 20.61 (.000) 0.56 (.000) 0.65 (.000) 0.43 (.005) 0.28 (.071) 0.61 (.000) 0.44 (.004)

Beta

t

Significance

0.15 0.19 0.15

0.21 0.15 20.45

1.16 1.04 22.72

.26 .30 .01

0.17 0.17 0.13 0.19 0.11

0.09 0.40 0.10 0.21 0.03

0.48 2.18 0.62 1.10 0.20

.63 .03 .54 .28 .85

relationship among nurse managers’ leadership style, safety climate, and nurses’ willingness to report medication errors. All the correlation values ranged between high to medium, having such values with small sample size signify the strength of the relationship among the study variables. Regression analysis showed that both leadership style and safety climate explained significant amount of variance on nurses’ willingness to report medication errors. Willingness to Report Medication Errors Nurses working in the study settings were willing to report medication errors especially errors with greater likelihood to harm patients; this result is consistent with prior research.11,33,41–43 Do no harm is one of the core nursing values; nurses learn about this fundamental value while socializing into the nursing profession. Hence, it is logical that nurses are more willing to report harmful errors. From another perspective, serious errors are more obvious and more likely to be discovered by the system, and/or other health care providers, so reporting is a must action. Whereas several researchers39,43,44 argued that lack of errors reporting is attributed to lack of consensus on the definition of error, serious lifethreatening errors are so evident and are not arguable, so it is clear that such errors must be reported. Nurses Characteristics and Willingness to Report Medication Errors Contrary to Throckmorton and Etchegaray30,33 findings where years of RN experience were

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related to nurses’ willingness to report errors, our study did not support any relationship between years of experience or any work characteristics and nurses’ willingness to report errors. The only variable that had a small inverse and not significant correlation (not reaching significance level can be due to sample size) with nurses’ willingness to report errors was weekly working hours. Nurses who worked more weekly hours were less likely to report errors. A plausible interpretation that nurses with more working hours are more exhausted and overwhelmed, so they are not reporting errors due to work overload or time required to complete the report. Aligned with the idea of work overload and exhaustion, it could be assumed that nurses with more working hours are committing more errors and therefore not willing to report them. The relationship between the cognitive work overload and errors is supported by the work of Potter et al45 and Ebright et al.46 This result, however, raises concern about the importance of assessing the complexity of error reporting system and examining medication errors for nurses working long hours. Because this study did not collect data about the actually reported errors by the study participants and the ease of use or complexity of error reporting system in the study settings, further studies to examine these areas as related to error reporting are warranted. Leadership Style and Nurses’ Willingness to Report Medication Errors Evidence within the nursing, as well as nonnursing literature, has provided support of the impact of nurse managers’ leadership style on various outcomes. In the current safety arena, according to the IOM reports1,2 as well as HRO literature,7 the role of leadership was emphasized as significant facet for creating safety climate that supports safety practices. This relationship, however, lacks empirical support in ambulatory settings which limits our ability to compare this study results with other results. Although most existing studies linked transformational leadership style to positive outcomes, this study results did not support the significant impact of transformational leadership style on nurses’ willingness to report medication errors. In contrast,

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passive-avoidant leadership style was the only significant predictor that negatively impacted nurses’ willingness to report medication errors. Having the negative impact is not a surprise, but having such a significant effect for a style that was not frequently used, as evident by low mean score, is alarming and highlights the seriousness of passive leadership styles. Nurses working in ambulatory surgical centers with its complexity and time pressure want a nurse manager who is present and actively engaged in their activities. This result, however, should be interpreted with caution given the small sample size. On the other hand, with such a small sample having the three leadership styles, significantly predicating 44% of variance in nurses’ willingness to report medication errors speaks to the significance of nurse managers’ leadership style. Safety Climate and Nurses’ Willingness to Report Errors Our study result is consistent with Throckmorton and Etchegaray30 who reported the absence of significant relationship between nonpunitive environment and nurses’ willingness to report medication errors.33 The previous study, however, examined only nonpunitive environment, our study examined five safety climate dimensions with nonpunitive response to errors as one of the dimensions. The relatively low mean score for nonpunitive environment is consistent with a national data survey where nonpunitive environment received the lowest percent (44%).29 Having consistency between our results and national AHRQ data results shows that despite the national movement for communicating the support of nonpunitive and just culture, nurses are still not trusting and not perceiving that their hospital climate as nonpunitive. Although assuming that a nonpunitive environment will lead to increased error reporting, apparently having nonpunitive environment by itself may not be sufficient. Mayo and Duncan10,11 reported in their study that although nurses perceived their environment to be nonpunitive and nurses were comfortable that error reporting will not result in any disciplinary actions, nurses were not feeling comfortable reporting errors. The study participants communicated that they were afraid of possible peer and managers’ retaliation.11 Hence, it could be argued that other

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variables as trust in managers and peers could be an intervening variable between nurses’ perception to the nonpunitive environment or safety climate in general and willingness to report medication errors. Organizational trust was not examined among the examined variables. Organizational learning was the only significant predictor to nurses’ willingness to report medication errors. Organizational learning is an important concept that has surfaced in the safety literature; it reflects the extent to which an organization is considering errors as a learning opportunity.47–49 Communication about errors encourages individuals to explore and learn from them50 and, therefore, contain subsequent errors. Hence, the evidence from our study about the significant relationship between organizational learning and nurses’ willingness to report errors is consistent with the conceptual underpinnings. When nurses perceive that their hospital will use their error report as a mechanism for system improvement rather than performance appraisal tool, they will be more willing to report errors. Humans are error prone, learning from errors and using the incident reporting as learning opportunity is a effective error management strategy.50,51 Chang and Mark50 argued that organizational learning climate can be a moderating variable that could aggravate or contain errors. Given the valuable role of organizational learning, further studies investigating factors contributing to the development of organizational learning are warranted. Error feedback is a safety climate dimension that worth investigating in further studies with larger sample size. Nurses in the study by Elder et al 46,52 reported that not receiving sufficient feedback after reporting an error is very frustrating; nurses felt that their report vanished in a ‘‘black hole.’’ Failure to provide feedback to nurses after error reporting transmits a message that change will not happen. Therefore, even if nurses do believe that their environment is nonpunitive and error reporting will be used as a learning opportunity, absence of any feedback or subsequent system change could steer nurses away from reporting. This explanation is supported by having organizational learning as the only significant predictor to nurses’ willingness to report medication errors. HROs

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have preoccupation with failure as one of their pivotal attributes,7 these organizations managed to create strong blame free culture where error reporting is not only always welcomed but also treated as a golden opportunity for detailed system analysis and search for areas for learning and improvement.

Limitations Although we achieved an acceptable response rate, and the data were collected from more than one setting covering almost all the freestanding ambulatory surgical settings in one midwest city, the study findings cannot be generalized given the small sample size. The absence of studies that were conducted in ambulatory surgical centers limited our ability to compare the study findings with similar studies.

Conclusions and Practice Implications Despite the main limitation of having a small sample size, this study is one of the few studies that examined leadership style, safety climate, and nurses’ willingness to report medication errors in ambulatory surgical settings. Consistent with other studies, nurses were more willing to report harmful errors. Nurses in the study settings perceived their safety climate to be acceptable, although, error feedback and organizational learning were the main safety climate factors that related to increase nurses’ willingness to report medication errors. Therefore, it is important for ambulatory surgical settings managers to provide nurses with a timely feedback after completing error report. Furthermore, nurses should be more involved in error learning activities because this could enhance their willingness to report medication errors. The significant impact of organizational learning and error feedback refutes the frequently proposed assumption that nonpunitive environment is the main key to increase nurses’ willingness to report errors. It directs our attention to other variables that could be equally important. Further Research Based on these study findings, further research should replicate the study using a larger sample size to allow for more advanced and comparative

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analysis and inclusion of ambulatory surgical settings affiliated with more than one health care system to examine the effect of the health system in shaping the safety climate.

Acknowledgments The study was funded by the American Society of PeriAnesthesia Nursing (ASPAN).

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