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What is a synthesis? A synthesis is the combination of multiple sources or ideas into one
framework or theme, to understand the shared qualities of the individual sources. It is
organized in such a way that readers can immediately see where the information from the
sources overlaps.
A few steps that may help you synthesize:
➢ Analyze the articles first! Skim the articles to get an overview of each one.
– Take detailed notes on each article.
– Look for explicit definitions of key terms in the literature. Note whether
different authors use different definitions.
– Look for key statistics that you might use in your synthesis discussion.
– Identify short notable quotations that might be used (sparingly) in your review
because they make a point very succinctly.
– Look for methodological strengths and weaknesses.
– Distinguish between an author’s assertions and evidence in support of the
assertions.
– Identify gaps in the literature.
– Identify relationships among studies.
➢ Synthesize
– Create an outline that puts your topics (and subtopics) in a logical order.
– For each subtopic you identified during your analysis, determine what the
articles in that group have in common.
– For each subtopic you identified during your analysis, determine how the
articles in that group differ.
– If there are contradictory findings, you may be able to identify methodological
differences that could account for the contradiction (e.g., differences in
measurement or participant demographics).
– Determine what general conclusions you can report about a subtopic, given
the entire group of studies related to it.
➢ What would you like to know about this topic? Are your questions answered in
these articles? These items could be identified as ‘gaps’ in the literature.
SOCIAL BEHAVIOR AND PERSONALITY, 2014, 42(7), 1133-1146
© Society for Personality Research
http://dx.doi.org/10.2224/sbp.2014.42.7.1133
NURSES’ WILLINGNESS TO REPORT NEAR MISSES:
A MULTILEVEL ANALYSIS OF CONTRIBUTING FACTORS
MIN YOUNG KIM
Jeju National University
SEUNGWAN KANG
Korea University
YOUNG MEE KIM
Seoul National University Hospital
MYOUNGSOON YOU
Seoul National University
Although potential future medical errors can best be prevented through reporting near misses,
on-site error reporting is not being achieved to a satisfactory level. We surveyed 489 nurses
working in 34 wards at a university hospital in Korea in regard to their understanding of
factors related to error reporting. Survey items included willingness to report near misses,
defensive silence, leader-member exchange, role clarity, and knowledge-sharing climate.
Results indicated that defensive silence in the workplace and unclearly defined roles reduced
nurses’ willingness to report errors, whereas trust-based leader-member exchange (LMX)
increased the intention. Knowledge-sharing climates contributed to increasing nurses’
intention to report errors, even among those of a silent disposition and in settings where the
quality of LMX between the nurses and head nurse was not high.
Keywords: medical error, near miss, error reporting, patient safety, hospitals, trust.
Min Young Kim, College of Nursing, Jeju National University; Seungwan Kang, School of Business
Administration, Korea University; Young Mee Kim, Department of Nursing, Seoul National
University Hospital; Myoungsoon You, Graduate School of Public Health, Seoul National University.
This research was funded by Jeju National University under grant 2012-0386.
Correspondence concerning this article should be addressed to: Myoungsoon You, Graduate School
of Public Health, Seoul National University, 1 Gwanak-ro Gwanak Gu, Seoul 151-742, Republic of
Korea. Email: msyou@snu.ac.kr
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NURSES’ REPORTING OF NEAR MISSES
Safety, quality, and efficiency are goals that all organizations in the healthcare
sector must pursue (Agency for Healthcare Research and Quality, 2008.
Accomplishing these goals in reality is a great challenge for hospital managers,
thus, the evidence-based approach, which highlights the importance of systematic
understanding of the factors that expedite or hinder organizational efforts to
pursue these goals, has been emphasized (Pfeffer & Sutton, 2006).
There has been a concern that patient safety is being increasingly threatened
despite medical improvements brought about by continuous innovations in
the medical world (The Joint Commission on Accreditation of Health Care
Organizations, 2007). Henriksen and Dayton (2006) clarified the conditions
necessary to reduce errors in organizations and explored the relationships
among these conditions, while examining the quality of health care and
patient safety. Weiner, Shortell, and Alexander (1997) focused not only on
errors that gave rise to actual hazards but also on near misses that did not
cause any immediate harm. The occurrence of near misses clearly signals the
need for organizational improvement and creates a significant opportunity for
strengthening the organization’s systematic capabilities, in terms of revealing the
type of management and method of resource allocation that the organization must
adopt in order to prevent future errors (Ginsburg et al., 2010).
However, hospital errors and near misses remain unreported or underreported
in many nations, with the exception of several advanced countries (Council
of Europe, 2006). Mandatory reporting is uncommon and, because of the
large variety of reporting mechanisms and indicators, it is difficult to conduct
a systematic comparison (McLoughlin et al., 2006). Furthermore, given the
difficulty in acquiring a robust dataset, there are few quantitative empirical
studies on errors, compared with literature reviews and articles exploring the
concept of errors (Kopp, Erstad, Allen, Theodorou, & Priestley, 2006). This,
in turn, leads to a lack of understanding regarding the current status of error
reporting (Covell & Ritchie, 2009; Lawton et al., 2012). In addition, prior studies
are limited to the individual level (Chang, Schyve, Croteau, O’Leary, & Loeb,
2005; Laschinger, Finegan, & Wilk, 2011) and few attempts have been made to
conduct multidimensional analyses (Tangirala & Ramanujam, 2008).
Literature Review
On the basis of a critical review of the research on behavior in health service
organizations, we developed a framework for analyzing the influence of
individual and group factors on nurses’ willingness to report errors (see Figure 1).
Figure 1. Analytical framework.
Role clarity
Leader-member exchange
Defensive silence
Willingness to report near misses
Level 1. Individual: registered nursess
Level 2. Group: Wards
Knowledge-sharing climate
NURSES’ REPORTING OF NEAR MISSES
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NURSES’ REPORTING OF NEAR MISSES
Willingness to Report Errors
Error reporting is the best and most fundamental means of preventing
medical errors (Wolf & Hughes, 2008). On-site error reporting, however, is not
consistently achieved in practice (Kohn, Corrigan, & Donaldson, 2000). For
example, despite the high risk of error when administering injections, a task
considered extremely important among nurses, the actual error-reporting rate is
low (Ulanimo, O’Leary-Kelley, & Connolly, 2007; Joolaee, Hajibabaee, Peyrovi,
Haghani, & Bahrani, 2011). In particular, it is extremely rare for nurses to report
minor errors or near misses that do not trigger serious side effects (Covell &
Ritchie, 2009; Mayo & Duncan, 2004; Osborne, Blais, & Hayes, 1999).
When asking the question, “Why are medical errors unreported or underreported
by health care workers?” it is necessary to consider various matters related to
the reporting method. For example, are reporting and disclosure mandatory
or voluntary and can health care workers engage in private and anonymous
reporting or are they forced to carry out formal reporting? In addition, other
important aspects of hospital organizational behavior must be taken into account
and are described below.
Defensive Silence
Making an error often equates to humiliation. In particular, acknowledgement
of errors has repercussions for the professional credibility of medical experts and
is accompanied by feelings of guilt or fear. For these reasons, the occurrence
of a minor error or near miss is usually followed by connivance or silence
rather than reporting (Chiang, Lin, Hsu, & Ma, 2010). Silence refers to a state
of defensive quiet by which, because of fear, a person withholds information
about problems (Van Dyne, Ang, & Botero 2003). Unlike silence linked to
resignation or weakness of mind, defensive silence is a conscious, progressive
attitude adopted to protect oneself from possible disadvantages. This defensive
mechanism becomes stronger as situations trigger greater fears regarding the
expected consequences of reporting, and this, in turn, reinforces defensive
silence. Defensive silence can be transmitted to other team members, who may
be encouraged to remain silent about problems. In this regard, defensive silence
is considered an important problem for both individuals and organizations
(Bowen & Blackmon, 2003).
Leader-Member Exchange
Nurses carry out their duties as team members. Thus, the quality and characteristics of their relationships within the team, and particularly factors related
to their relationships with superiors, directly and indirectly influence their
organizational behavior. In studies on the quality of leader-member exchange
(LMX) relationships marked by low trust and support have been labeled as low
NURSES’ REPORTING OF NEAR MISSES
1137
LMX. High LMX relationships, by contrast, are characterized by factors such as
mutual trust, respect, and favorable impressions (Fairhurst & Chandler, 1989).
Researchers have indicated that self-efficacy, voluntariness, and job commitment
are significantly affected by the quality of LMX between frontline staff and
superiors (Hoff, Jameson, Hannan, & Flink, 2004; Liden & Maslyn, 1998;
Maslyn & Uhl-Bien, 2001). In particular, loyalty, defined as the belief that the
supervisor will support and defend the subordinate in difficult situations, serves
to enable nurses to overcome their reluctance to speak out about their errors or
near misses. Therefore, when nurses have faith in a supportive relationship with
a colleague to whom they can turn for consultation or help when they make
errors, they are encouraged to speak out and the occurrence of preventable harm
is decreased (Frankel, Leonard, & Denham, 2006). Further, in their qualitative
study Hashemi, Nasrabadi, and Asghari (2012) reported that nurses who do not
report errors show a greater tendency to fear the responses of their superiors
or coworkers. They also found that that nurses’ willingness to report errors is
hindered by having received negative feedback from superiors in relation to past
errors.
Role Clarity
Hospitals are organizations in which risk plays a particularly large role because
critical and serious consequences are triggered by organizational error (Agency
for Healthcare Research and Quality, 2008). In addition, hospital organizations
require particular attention because of their complex structures and tight coupling
of various jobs and tasks that must be undertaken cooperatively to achieve patient
safety (Tamuz & Harrison, 2006). In fact, since the Institute of Medicine released
a report called To Err is Human in 2000, greater emphasis has been placed on the
risk of hospital errors arising from human factors rather than problems related
to equipment or facilities. Human factors include not only individual quality and
competence, but also various organizational and environmental variables, such as
interpersonal relationships and communication.
Some scholars view errors as resulting from organizational communication
failure (Sutcliffe, Lewton, & Rosenthal, 2004). They stress that poor
communication must be seen not only as a problem of information exchange,
but as a phenomenon arising from overlapping conflicts and stress generated by
ambiguous or conflicting roles in task hierarchies.
Role conflict, role ambiguity, and role overload have been identified as the
main sources of job stress among nurses, such that failure to manage these
problems appropriately will harm the quality of work life and negatively affect
performance (Tunc & Kutanis, 2009). Recently, O’Brien-Pallas, Murphy,
Shamian, Li, and Hayes (2010) reported that role ambiguity contributes to an
increased risk of medical error.
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NURSES’ REPORTING OF NEAR MISSES
Knowledge-Sharing Climate
Patient safety is difficult to achieve solely through the efforts of an individual
nurse. Thus, the participation and cooperation of the nursing team are essential.
In this regard, it is important to form an organizational climate that promotes
creation of value and sharing of knowledge in relation to patient safety and error
reporting (Nonaka, 1994; Senge, 1990).
Researchers have demonstrated that having a successful experience of speaking
out about an error makes it easier to carry out similar tasks in the future (Attree,
2007; Frankel et al., 2006; Garon, 2012; Kohn et al., 2000). The environment
that promotes such experience ultimately functions as a method of enhancing
the quality of healthcare service, helping individuals and team/organizational
members to develop as a learning organization through the exchange of
knowledge, information, and experience (Kohn et al., 2000).
Occupational boundaries, regulations, and social pressure have been presented
as obstacles to the formation of a knowledge-sharing culture. In particular,
scholars have reported that the existence of a professional hierarchy has had
adverse effects on nursing teams, such as restricted sharing of knowledge and
silence of organizational members (Currie & Suhomlinova, 2006).
Method
Design and Participants
This is a multilevel study in which our aim was to uncover the factors that
affect registered nurses’ (RNs) willingness to report near misses. Data were
collected from RNs in a large university hospital located in the Republic of
Korea. The study sample comprised 547 individuals, 498 of whom (99.4%
female, 0.6% male) returned valid responses and were included in the data
analysis. The average age of the participants was 28.8 years old (ranging from
22 to 53). Most of the RNs had obtained a four-year bachelor’s college degree
(77.5%), 5.2% held a master’s degree or higher, and 17.3% had no college
education. The average number of RNs per unit at their current hospital ward was
14.6 (ranging from 10 to 24), and the RNs’ average unit tenure was 25.1 months.
The mean length of time that the participants had been working as an RN was 5.8
years (ranging from 1 month to 33 years).
Instruments
The surveys were initially written in English and then translated into Korean
using the back-translation procedure to ensure consistency of meaning. All the
survey items were rated using a 7-point Likert-type scale (1 = strongly disagree
and 7 = strongly agree). All measured variables showed a Cronbach’s alpha
level of .70 or greater, satisfying the cut-off requirement of internal reliability
(Nunnally & Bernstein, 1994).
NURSES’ REPORTING OF NEAR MISSES
1139
Willingness to report near misses. To assess the RNs’ willingness to report
near misses, we adopted three items of Mayer and Gavin’s (2005) Willingness to
be Vulnerable to a Particular Trustee Scale ( = .85).
Defensive silence. To assess the RNs’ attitudes toward employee silence, we
used five items of the Defensive Silence Scale developed by Van Dyne et al.
(2003) ( = .87).
Leader-member exchange. To assess the quality of the relationship between
head nurse and RN, we used three items of Liden and Maslyn’s (1998)
LMX-loyalty measurements ( = .95).
Role clarity. To assess the RNs’ perception of role clarity, we used five items of
the Role Ambiguity Scale developed by Peterson et al. (1995) ( = .89).
Knowledge-sharing climate. To assess the units’ knowledge-sharing climate,
we adopted three items from Faraj and Sproull’s (2000) measures that were
individual perceptions of the extent of knowledge shared by team members ( =
.90). We aggregated the individual responses to compute unit-level knowledgesharing climate.
Control variables. We included several control variables in our analyses.
First, at the individual level, we controlled age, education level, and tenure
with unit as demographic variables. Second, at the unit level, we controlled the
number of RNs per unit and tenure diversity of a unit to distribute their potential
influence on the results. We used the standard deviation of the individual RNs’
organizational tenure within each unit to assess the tenure diversity of a unit.
Data Analysis
Prior to data analysis, we performed exploratory factor analysis (EFA) to verify
validities for each key variable in the research (i.e., willingness to report near
misses, defensive silence, LMX, role clarity, and knowledge-sharing climate).
We determined that the validity of the constructs was being established through
the results of EFA (Fornell & Larcker, 1981). We used multilevel modeling to
verify the relationships among our research variables, and STATA version 11.2 to
conduct the statistical analyses including multilevel modeling.
Results
Descriptive Statistics
Table 1 shows the means, standard deviations, reliabilities, and correlations of
the variables used in this research.
Results of Multilevel Model Analyses
We first tested null models in which only the dependent variable (i.e., willingness
to report near misses) pertained, and found a significant between-group variability
Reports of near misses
Defensive silence
Leader-member exchange
Role clarity
Age
Education level
Tenure with unit (months)
Knowledge-sharing climate
Unit size
Tenure diversity of a unit
5.28
3.02
4.65
5.62
28.80
1.88
25.14
5.35
18.16
21.37
1.06
0.86
1.40
0.76
5.38
0.46
22.83
0.33
4.48
8.29
SD
(.85)
-.25***
.25***
.31***
.11*
-.02
.04
.08
.06
.12**
1
(.87)
-.20***
-.27***
-.22***
.03
-.06
-.12**
.00
-.09*
2
(.95)
.24***
.04
.02
-.03
.07
-.15***
.10*
3
(.89)
.23***
.01
.10*
.10*
.09*
.10*
4
-.02
.42***
.05
.10*
.29***
5
-.04
.02
.07
.00
6
.04
-.02
.24***
7
-.24***
.17***
8
-.15***
9
Note. n = 498 for level 1 variables and n = 34 for level 2 variables. Where relevant, internal reliabilities (Cronbach’s alpha coefficients) for the overall
constructs are given in parentheses in the diagonal. * p < .05, ** p < .01, *** p < .001.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
M
Table 1. Descriptive Statistics, Correlations, and Reliabilities
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NURSES’ REPORTING OF NEAR MISSES
86.48
-692.35
5.35***
-.16***
.17***
.25***
.00
-.03
.00
Model 1
Note. n = 498 for level 1 variables and n = 34 for level 2 variables; B = coefficient.
† p < .10, * p < .05, ** p < .01, *** p < .001, all two-tailed.
Level 1
Intercept
Defensive silence
Leader-member exchange
Role clarity
Age
Education level
Tenure with unit
Level 2
Knowledge-sharing climate
Number of RNs per unit
Tenure diversity of a unit
Cr oss-level (Level 1 x Level 2)
Defensive silence × Knowledge sharing climate
Leader-member exchange × Knowledge sharing climate
Role clarity x Knowledge sharing climate
Wald 2
Log likelihood
B
.32
.05
.05
.05
.01
.09
.00
SE
Table 2. Results of Multilevel Analysis on the Willingness to Report Near Misses
.16
.01
.01
.14
.15
.14
.16
.02†
.01
.28*
-.27†
.04
101.92
-686.05
SE
.99
.75
.81
.73
.01
.09
.00
Model 2
4.04***
-1.67*
1.60*
.02
-.01
-.05
.00
B
NURSES’ REPORTING OF NEAR MISSES
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NURSES’ REPORTING OF NEAR MISSES
(00 = .05, p < .001). Calculating intraclass correlation value indicated that 5% of
the variance in RNs’ willingness to report near misses was between units.
The results from multilevel modeling analyses are shown in Table 2, in which
Model 1 shows results from regressing willingness to report near misses only on
individual-lev ...
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