The daily relationships between staffing, safety perceptions and personality in hospital nursing: A longitudinal on-line diary study

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Abstract

Background

The association between poor staffing conditions and negative patient safety consequences is well established within hospital nursing. However, many studies have been limited to nurse population level associations, and have used routine data to examine relationships. As a result, it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis. Furthermore, personality may have direct and moderating roles in terms of work environment and patient safety associations, but limited research has explored personality in this context.

Objective

To further our understanding of these associations, this paper takes a within-person approach to examine nurses’ daily perceptions of staffing and patient safety. In addition, we explore the potential role of personality factors as moderators of daily level associations.

Method

We recruited eighty-three hospital nurses from three acute NHS Trusts in the UK between March and July 2013. Nurses completed online end-of-shift diaries over three–five shifts which collected information on perceptions of staffing, patient–nurse ratio and patient safety (perceptions of patient safety, ability to act as a safe practitioner, and workplace cognitive failure). Personality was also assessed within a baseline questionnaire. Data were analysed using hierarchical linear modelling, and moderation effects of personality factors were examined using simple slopes analyses, which decomposed relationships at high and low levels of the moderator.

Results

On days when lower patient–nurse ratios were indicated, nurses reported being more able to act as a safe practitioner (p = .011) and more favourable perceptions of patient safety (p = <.001). Additionally, when staffing was perceived more favourably, nurses reported being more able to act as a safe practitioner (p = <.001), more favourable perceptions of patient safety (p = <.001) and experienced less workplace cognitive failure (p = <.001). Conscientiousness and emotional stability emerged as key moderators of daily level associations between staffing and patient safety variables, with many relationships differing at high and low levels of these personality factors.

Conclusion

The findings elucidate the potential mechanisms by which patient safety risks arise within hospital nursing, and suggest that nurses may not respond to staffing conditions in the same way, dependent upon personality. Further understanding of these relationships will enable staff to be supported in terms of work environment conditions on an individual basis.

Introduction

The association between a poor work environment and negative patient safety consequences is well established within hospital nursing (Alenius et al., 2014, Duffield et al., 2011, Hughes and Clancy, 2005, Lin and Liang, 1997). Great emphasis has been placed on nurse staffing for patient safety and quality outcomes from a research (Aiken et al., 2002, Berdot et al., 2012, Pronovost et al., 1999, Trinkoff et al., 2011) and a policy perspective (Berwick, 2013, RCN, 2010, RCN, 2012). However, many studies have been limited to cross-sectional methods (e.g., Aiken et al., 2002, Liu et al., 2012, Rafferty et al., 2007). As a result, the majority of existing findings are based on group level associations and often use routine data to examine relationships (e.g., nurse reported staffing levels linked with mortality data), so it is less clear how these relationships might be manifested at the individual nurse level on a day-to-day basis.

Relationships established at a between-person level may differ from associations established at the individual daily level (Affleck et al., 1999). Research representing relationships based on nurse group level associations do not tell us how work environment factors impact on any individual nurse on a day-to-day basis, bearing in mind that nurses may react differently to similar pressures. Research that furthers our understanding of relationships at the individual daily level is paramount, as in theory interventions based on studies reporting nurse group level associations, might actually make things worse for some nurses. Given that many of the usual approaches of measuring staffing and patient safety would be inappropriate at an individual daily level, we focused on “perceptions” of both staffing and patient safety in this study.

There is also a distinct lack of research involving European or UK nurses which attempts to understand associations between features of the hospital work environment and patient outcomes, with many studies limited to nursing samples in the United States (US) (Aiken et al., 2012). Indeed, it is recognised that the research available to guide policy and practice for safe nurse staffing is lacking in Europe (Aiken et al., 2014). Recent findings from the RN4CAST study (Sermeus et al., 2011), one of the largest nursing workforce studies ever conducted in the European Union, demonstrate the importance of a better nurse work environment (e.g., in terms of managerial support, doctor–nurse relations) for nurse reported care quality and patient safety, and patient reported satisfaction (Aiken et al., 2012), and report an increase in nurses’ workload to be associated with the likelihood of inpatient hospital death (Aiken et al., 2014).

Another potentially important gap in the literature is the study of individual differences (e.g., personality). Whilst this has been neglected in the literature to date, it is intuitive that personality factors may have both direct and moderating roles in terms of associations between the work environment and patient safety within hospital nursing. The five-factor model of personality encompasses dimensions of personality: extraversion, agreeableness, conscientiousness, neuroticism (emotional stability), and openness to experience (intellect/imagination) (McCrae and John, 1992). Evidence from outside a healthcare context demonstrates associations between conscientiousness and job performance (Barrick et al., 2001, Hurtz and Donovan, 2000, Salgado, 1997), team performance (Barrick et al., 1998, Morgeson et al., 2005) and accident involvement (Clarke and Robertson, 2005). Emotional stability has been highlighted as a predictor of job performance (Judge and Bono, 2001, Salgado, 1998, Tett et al., 1991), and agreeableness established as a predictor of work accidents (Clarke, 2006) and job performance (Tett et al., 1991). There is also some cross-sectional evidence in support of an association between emotional stability and quality and safety (Teng et al., 2009), and patient perceptions of care quality (Teng et al., 2007).

This literature reinforces the need to consider personality in terms of patient safety within a healthcare context. Cross-sectional associations with patient safety have been demonstrated for specific personality factors i.e., emotional stability (Teng et al., 2009), but to our knowledge, no research has investigated all five personality factors in the same study using a comprehensive measure of personality, nor have personality factors been explored as potential moderators of daily work environment and patient safety relationships. If we are able to understand the role of personality, this may enable health service providers to support nurses more effectively, and better manage patient safety.

This study is not grounded within a single theory, due in part to this being an emergent area of research. A dominant theoretical perspective within patient safety research is the systems approach to human error (Reason, 2000), which provides the theoretical basis for the variables included in this study. The basic tenet of the systems approach is that changes in one part of the system will have repercussions on another part of the system, and defences, barriers, and safeguards are key components of this approach. The systems approach proposes that errors can be understood as an interaction between active failures – conceptualised as unsafe acts committed by people who are in direct contact with the patient or system – and more system based organisational weaknesses, referred to as latent conditions. Error is said to occur as a result of the interaction between these components. This system-wide view of causation has meant that system-based patient safety research has traditionally focused on latent conditions (e.g., management of staffing) and local conditions (e.g., staff–patient ratios, skill-mix), rather than active failures (e.g., slips, lapses, mistakes). Therefore, focusing on factors at the individual nurse level affords us the opportunity to capture potential proxies of active failures. Measuring cognitive failure, which relates to failures in perception, memory, and motor function (Broadbent et al., 1982), may prove useful here, with associations between job characteristics and workplace cognitive failure (Elfering et al., 2011), and workplace cognitive failure and rate of patient safety incidents (Park and Kim, 2013) previously established in nursing. Thus, in addition to perceptions of safety, daily workplace cognitive failure experienced was also included as an outcome variable in this study. Moreover, it is less clear how individual differences fit into the systems approach. Therefore, we have attempted to extend theory by exploring personality in the context of nurse staffing and patient safety.

Evidently, important questions remain unanswered, including (i) how are staffing and patient safety outcomes associated for individual nurses on a daily basis? and (ii) are these associations variable at the individual nurse level as a function of personality? Methodological designs termed “within-person approaches” are relatively new to nursing research (Johnston et al., 2013, Jones and Johnston, 2013) and may be beneficial to address these questions as they enable comparisons in terms of how individuals respond to contextual factors, by collecting data repeatedly within the natural environment using daily diary methods (Bolger et al., 2003). There are many advantages of a within-person diary approach, for example, exploring relationships at the daily level aims to reduce the amount of retrospective bias (Affleck et al., 1999, Ferguson, 2005) compared to single reports where participants recall their experiences (e.g., cross-sectional survey). Consequently, ecological validity may be increased, as recollection is temporally close to the experience (Iida et al., 2012).

Another advantage of this approach is the associated analyses (multi-level modelling) which enables the investigation of within-person variability together with between-person factors (Griffin, 1997, Hofmann, 1997). Analyses that focus on differences between group-level averages do not consider the hierarchical structure of the data and may obscure, or even contradict, the nature and direction of relationships between variables at an individual level (Affleck et al., 1999). If we are to be able to develop robust interventions to support nurses and improve the safety and quality of care, we need to better understand how the work environment impacts on individuals, not just the average impact on groups of individuals.

To summarise, this study adopted a within-person diary approach to examine associations between daily staffing and safety perceptions at the individual level, within a sample of hospital nurses over a three–five shift period. In addition, the study explored the potential moderating role of personality in relation to these associations. It is hypothesised that these daily relationships will differ dependent upon personality factors.

  • (1)

    Are nurses’ daily perceptions of staffing associated with daily safety perceptions?

  • (2)

    Do personality factors moderate relationships between nurses’ daily perceptions of staffing and daily safety perceptions?

Section snippets

Participants

Hospital nurses from three acute NHS Trusts in the UK were recruited to the study between March and July 2013. Ninety-five participants completed baseline measures, 77 participants completed three or more end-of-shift diaries, 83 participants completed two end-of-shift diaries, and 89 participants completed one end-of-shift diary. A MANOVA conducted with age, gender, length of time qualified and the five personality factors as dependent variables, and completion as the independent variable, was

Descriptive statistics

The descriptive statistics for all study variables are presented in Table 2. A total of 324 diary days were completed for 83 participants, the mean number of diaries completed was 3.9, and the mean shift end time across the study period was 17:24 (median 19:00).

Perceptions of staffing, patient–nurse ratio and safety perception relationships

The findings for the level 1 models (See online Appendix 2: Table 3), demonstrated significant associations between patient–nurse ratio, perceptions of staffing, and the safety perception outcomes (β10). On shifts when participants

Discussion

This paper presents findings from a study which administered a daily diary to hospital nursing staff from multiple clinical areas, across three acute NHS Trusts in the UK. The findings add to the existing literature in three important ways – first, by establishing daily level associations between nurse staffing perceptions and perceptions of safety; second, by highlighting the relevance of personality; and, third we have contributed to theory by exploring individual differences in this context.

Conclusion

Reinforcing the importance of nurse staffing for safety, on shifts where staffing was perceived more positively, patient safety was perceived more favourably, nurses reported being more able to act as a safe practitioner, and experienced less workplace cognitive failure. On shifts where lower patient–nurse ratios were indicated, nurses reported higher perceptions of patient safety as well as being more able to act as a safe practitioner. The findings highlight the relevance of personality in

Acknowledgements

We would like to thank the nurses who took the time to complete the questionnaires and made this study possible, and the nurses who took part in the feasibility focus group. We would also like to thank the Editor and three anonymous reviewers for their helpful comments on earlier drafts of the manuscript.
Conflict of interest: None.
Funding: PhD Studentship – funded by School of Psychology, University of Leeds and Bradford Institute for Health Research.
Ethical approval: The Ethics Committee at

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