The Relationship between Stress and Nursing Errors: The Moderating Role of Professional Ethics

Chiao Da Managemenl Review 的 1. 32 No. 2, 2012 pp.I-36

壓力與護理失誤之關聯性研究一專業

倫理的調節角色

The Relationship between Stress and Nursing Errors:

The Moderating Role of Professional Ethics

許金田 1 Chin-Tien Hsu

銘傳大學諮商與工商心理學系

Department of Counseling and Industrial/Organizational Psychology, Ming Chuan University. 摘要 :在醫院組織中，護理人員的壓力一直是深受關注的議題 。 本研究主要 探討壓力與護理失誤之間的關餘，並檢視專業倫理在此關條中所扮演的調節 角色 。 本研究透過問卷調查法針對台灣地區醫院之專業護理人員進行研究， 共獲得有效樣本494份 。 研究結果發現，兩種不同之壓力源(攸關工作壓力與 非攸關工作壓力)均會對護理失誤產生正向影響;此外，專業倫理對攸關工作 壓力與護理失誤間的關條具有調節效果，亦即當專業倫理較高峙，悠關工作 壓力與護理失誤之間的正向關你會被減弱，但對於非攸關工作壓力與護理失 誤閉關條、的調節效果則不顯著，此研究結果拓展了目前壓力與護理失誤相關 的文獻 。 最後，討論本研究的研究限制及未來研究方向 。 關鍵詞:壓力;護理失誤;專業倫理

Abstract:The nurses' stress is an important issue in the hospital organizations This study examines the process Jinking the relationship between stress and 1 Corresponding author: Department of Counseling and Indus甘ialOrganizational Psychology,

Ming Chuan Univers耶 TaoyuanCounty, Taiwan..E-mail:cthsu@mail.mcu.edu.tw Financial support from the National Science Council (NSC-98-2410-H-130-057-MY3) is greatly appreciated

2 The Relationshψ between Stress and Nursing Errors The Moderating Role oJ ProJessional Ethics nursing errors by focusing on the moderating role of professional ethics. This study adopts the questionnaire and used 494 hospital-based nursing staff in Taiwan. Results demonstrate that two forms of stress (work related and non-work related) are both positively related to nursing errors. In addition, professional ethics moderates the relationship between work related stress and nursing errors, such that the relationship is weaker when nursing staff with the higher professional ethics. However, professional ethics does not interact with non-work related stress to predict nursing errors. This study contributes to the literature on the relationship among stress, professional ethics, and nursing errors. Finally, the limitations of the research are discussed and suggestions for further research are proposed

Keywords: Stress; Nursing e叮ors;Professional ethics

1.

Introduction

Patient safety has long been an issue of concern in the medical industry (Johnstone, 2007). According report titled: "To err is human, building a safer health system", published by the Institute of Medicine (10M) in 2000, medical errors account for more than 呃，000deaths annually in the U.S.; moreover, 58 % of these deaths could have been avoided (Stock, McFadden, and Gowen, 2006). This data indicates that medical errors present a tremendous threat to patient safety. Research argued that highly complex and variable care environments are the most prone to medical errors (Narumi et al., 1999). In such an environment, professional nursing staff plays a crucial role in monitoring patient safety through their frequent contact with patients (Woods and Doan-Johnson, 2002). Thereby, understanding medical errors and the reasons behind for their occurrence is critical in academic research and the practice ofhealthcare management.

It is important to address the ways by which professional nursing staff produces nursing errors. Previously in clinical practice, medical errors have been attributed to insufficient educational training or violations of discipline. However, senior policy makers Welker-Hood (2006) at the American Nurses Association (ANA) addressed that environmental stress is a prirnary reason of medical errors

Chiao Da Management Reν問你P的1.32No. 2, 2012 3

To further investigate this concept

,

we perforrned a review of past literature, and discovered that the literature attributes nursing errors mainly to the nursing sta缸's lack of knowledge and skills (Leape

,

1994; Pelletier

,

200l). Though some research has been done on the topic of the stress induced by the environment

(Welker-Hood, 2006). Thus the goal of this research is to deepen our

understanding of how stress from extemal environment influences nursing errors produced by professional nursing staff.

In addition

,

previous studies have focused on the relationship between stress on nursing staff and their perforrnance. Lue et al. (2010) indicated that stress, individual character, and emotion directly influence individual bumout. Study targeting Japanese nursing staff also stated that heavy work stress leads to a decline in nursing quality and an elevation in medical risk (Ida et al.

,

2009). In fact, they explained the effects of stress on individual perforrnance; however, they did not consider the other possible influences of situational factors. Moreover,

Baer and Oldham (2006) examined the relationship between stress and perforrnance by focusing individual character and organizational support as moderators. While there is a strong assumption of a link between stress and perforrnance

,

little empirical evidence has been found to establish a direct relationship between stress of professional nursing staff and their nursing errors

Among the various situational variables, it is vital to deterrnine moderating variables that affect stress and nursing errors. Bellizzi (2006) and Chen, Pan, and Pan (2009) believed that an individual sense of morality and ethical beliefs are important moderators. Kelly (2010) also discovered that for rnilitary nurses, professional ethics can moderate the influence of intense battlefield stress on nursing quality. ln other words, in a social environment that emphasizes professionalism, for professional nursing staff that possess special knowledge and skills

,

their level of belief in professional ethics might affect the relationship between the stress they perceive and their behavior.

However

,

studies regarding professional ethics mainly focused on its concep仙al aspects and descriptive explanations of its importance (Huang, 1996; Jiang, Chen

,

and Su, 2006; Wang and Ch凹，2003; Yeh, 2000). Empirical studies rarely discussed the level of belief in

4 The Relationship between Stress and Nursing Errors The Moderating Role 01 Projessional Ethics considers the nursing staff attitude in professional ethics as a moderator to further understand the relationship between stress and nursing errors. 1n short

,

this study hopes to investigate the belief of nursing staff in professional ethics

,

and its moderating effect on the correlation between stress and nursing errors produced.

Based on the above discussion

,

this study sets out to investigate two aspects: fir哎，to discuss the relationship between stress in nursing staff and nursing e汀ors;

and second

,

to examine the moderating effect of nursing staff beliefs in professional ethics on the relationships between stress and nursing errors. This sωdy wishes to produce evidence resulting from empirical research to serve as a direction for the improvement of hospital strategies for reducing nursing errors. In

addition

,

hospitals can also understand the stress perceived by current professional nursing sta仔 and their beliefs in professional ethics. Based on this

,

hospitals will be able provide appropriate assistance and facilitate improvement

,

in turn promoting the nursing quality of professional staff and providing patients with a safer medical environment

2. Literature Review

2.1. Stress

Lyon and Werner (1987) indicated that stress can have various definitions. Stress can be considered as a stimulus, a response, or a transaction. 1n studies related to stress, Lazarus (2000) mentioned that stress is a result of an individual transaction of cognitive appraisal. It is co-initiated by events or thoughts that stimulate stress forrnulation, responses to stress and stimulation, and environmental factors (Benoliel et al.

,

1990). Numerous studies tended to define

stress from a transactional perspective ( Lazarus, 2000; Tsai and Chen, 1996) Stress is a subjective

,

individual psychological feeling that is deterrnined by how an individual interprets hislher relationship with the environment. When employees are asked to handle requests (either work related or non-work related) that exceed their individual capacity, they feel a sense of conf1 i仗， displeasure, or

Chiao Da Managemenl Review Vol. 32 No. 2, 2012 5

physicaVpsychological burden; this in tum leads to stress (Lazarus

,

2000). This is

a long-term accumulative process that may continue to exist (N悶， 2001). Jones et al. (1988) also argued that the stress employees feel not only includes work-related stress

, but

also stress from personal events (non-work related). The

stress that they perceive may derive from a high stress occupation or organization

,

dissatisfaction with job contents or workplaces, and stressful Iife events unrelated to work. Therefore, in practice, the stress that an organization 's members feel is not solely derived 台omwork, but can also result from personal affairs unrelated to work. This stress can affect both an individual's psychological feelings and

extemal behaviors

Moreover, as health care systems change rapidly, advanced equipment and

information result in complex nurse-patient relationships. Nursing staff are

therefore often in environments under high stress. 1n addition

, nurses account for

the m句 ority of staff in a health care system, serving as the main workers in hospitals. Their jobs are wide-ranging and highly complex

,

their working hours

are irregular

,

and they are often required to play altemative roles and make

various decisions when confronting different situations (Anderson, 2002). They

constantly need to cope with sources of stress that are unique to their job

( Benoeil et al., 1990), and need to withstand tremendous loads of stress (Happell, Pinikahana, and Martin, 2003; Peng, Liu, and Chang, 2003; Tsai and Chen, 1996; Welker-Hood, 2006)

It is important to identify the factors that induce stress in professional nursing staff. From stress studies targeting clinical nursing sta缸; the following five sources can be concluded: (1) personal reactions

,

indicating that stress

derives from combined physical, cognitive, and emotional responses; (2) personal

concems, indicating that stress is derived from the feeling of encroachment by

other players (for example, doctors, patients, and patients, doctor members), in

which nursing staff need to emphasize their individual value; (3) work concems, indicating that stress occurs when an individual needs to focus on his/her required

work goals even when facing the influence from others; (4) role competence,

indicating that stress originates with an individual's satisfaction with his/her individual or professional behavior; and (5) work completion concems

,

i

6 The Relationship between Stress and Nursing Errors

The A必derating Role 01 Prolessional Eth叫

that an individual derives stress 台om being requested to fulfill requirements beyond hislher typical work duties (Benoliel et al., 1990).

Professional nursing staff with several years of c1inical experience express agreement with the above explanations, as they quite accurately reflect actual situations in clinical practice (Tsai and Chen, 1996). To further understand the stress felt by current professional nursing sta缸;Tsai and Chen (1996) developed a stress scale designed for Taiwan nurses to test and evaluate the stress that they feel. The results indicated that the four m句 or factors (all resulting from the interaction between an individual and the environment) which influence the formation of stress in th的 target population are: (1) personal reaction, indicating that stress derives from the physical

,

psychological

,

cognitive

,

and emotional responses of nursing staff; (2) work concems

,

indicating that stress is derived 企om communication issues related to the patient, doctor, or patient 企om com members, personal expectations of professionalism, and the evaluation of health care systems when nursing staff were tending to patient care; (3) work competence

,

indicating that stress originates from the requirements of nursing staff to fulfill professional and personal capabilities; and (4) the inability to complete personal tasks

,

indicating that nursing staff derive stress from their personal or household obligations unrelated to work, in addition to their normal work duties. Among these items

,

this study categorizes work concem and work competence into work-related stress, while personal reaction and the inability to complete personal tasks are categorized as non work-related stress.

Some researchers argued that different sources of s甘ess exerted different influences on personal performance. When stress sources are hindrance-oriented (for instance in job ambiguity), it causes negative effects on job performance; when stress sources are challenge-oriented (such as I:ime stress), this possibly results in positive effects on job performance ( LePine, Podsako缸 and LePine

,

2005). Studied indicated that there is a non-linear correlation between stress and performance (Yerkes and Dodson

,

1908; Robbins and Judge

,

2011). Some studies argued the relationship between stress and performance to be constantly inconsistent (Hunter and Thatcher

,

2007). However

,

previous studies re

Chiαo Da Managemenf Reνiew ~台1.32 No. 2. 2012 7

Packard, and Mannig, 1986; Fra凶也叫laeuser， 1991; McGowan, 2001), inducing

u叫leal也 y physical and psychological symptoms (Matheny, Gfroerer, and Harris,

2000; Elangovan, 200 1; Tian and Wang, 2005), leading the individual to feel

Ullsatisfied in their work (Burke, 2001), increasing his/her intentions to quit

CSenol-Durak, Durak, and Gen俏， 2006), reducing work performance

(Senol-Durak et al., 2006; Mohr and Puck, 2007), and so forth. Bourbonr泌的，

Comeau

,

and Vezina C 1999) have also suggested that stress can cause mental illnesses, which can be identified through an individual's behavior and responses;

stress can furthermore cause negative effects on work productivity (Hollen et al.

,

2000). Studies also distinctly indicated that stress among nursing sta仔 isoften the reason for their low work satisfaction and organization commitment

,

and higher

absenteeism and quitting rates (Hollen et al., 2000). These factors can indirectly

affect the nursing quality that they offer. Therefore, in conclusion, stress can cause

both physical and psychological discomfort in an individual, which can in turn

exert negative effects on an individual's behavior at work

,

causing members of an organization to perform below expectations (for instance

,

by committing medical

errors) (Williams et al., 2002; Hollen et al., 2000; Senol-Durak et al., 2006; Mohr

and Puck

,

2007).

2.2.

Nursing Errors

Perrow (1984) indicated that 70% of accidents are the result of human error Moreover

,

the field most prone to these errors is the nursing industry (Narumi et al., 1999). Errors include any type of behaviors that deviate from established,

requested, or expected criteria, which in turn cause Unnecessary or unfavorabl巳 time delays, difficulties, problems, accidents, or failure. According to the definition of an error by the 10M, an error is the result of non-compliance with

planned actions

,

or implementing incorrect plans to achieve expected results

(Dimant, 2001). Therefore, any unexpected behavior and negative resu!ts produced can be defined as an error (Stock et al., 2006). Nursing errors indicate unplanned accidents (for instance

,

incorrect judgments) caused by professional nursing staff and events that may adversely affect patient safety and nursing quality (Johnstone and Kanitsaki, 2006). Therefore, the errors produced by

8 The Re/ationship between Stress and Nursing Errors The Moderating Ro/e 01 Pro.戶口iona/ Elhics professional nursing staff may not only affect patients, their families, other nursmg sta缸~ and the health care system as a whole; but they can also increase medical costs and induce the waste of resources (Blendon et al., 2002), and furthermore jeopardize the quality of a hospital's medical care (Meaney, 2004). Thus

,

preventing or reducing the errors produced by professional nursing staff is a

critical issue for health services management (Woods and Doan-Johnson, 2002)

As for the factors that can lead to nursing errors

,

according to 21 disciplinary cases 仕om 9 national nursing comrnittees in the U.S., there a total of eight categories of nursing errors (which are all produced during systemic operations

and practice) (Woods and Doan-Johnson

,

2002):

(1 )Lack of attentiveness

,

which indicates that patient safety depends on the complet巳 concentrationof nursing staff on the patient's clinical responses and sources of danger during 悅atment; when nursing staff cannot focus at work

,

nursing errors tend to occur. For instance

,

when the number of patients increases, it reduces the ability of nursing staff to treat each patient attentively,

which might result in nursing errors due to negligence.

(2)Lack of agency/fiduciary concem, which indicates that there is a fiduciary

re\ationship between professional nursing staff and patients. When the

professional knowledge, skills, and care of professional nursing staff cannot obtain the trust of patients and their family members, nursing errors tend to occur. For instance, when nurses fail to notifY patients of the inappropriateness of a doctor 's orders, nursing errors due to negligence might occur.

(3)Inappropriate judgrnent

,

which indicates the case in which professional nursing

staff fail to take the patient's actual condition into consideration when making clinical judgments, but instead rely solely on data :from medical equipment, further leading to nursing errors. For instance

,

when a nurse takes notice of an abnormal heart beat in a patient

,

and fails to identify this problem until it is indicated by a doctor, a nursing error is then produced.

(4)Medication errors

,

which refer to any nursing errors produced during the medication treatment process attributed to (preventable) improper use of medication

,

or patient damage that is related to professional medical behavior

,

health care products, processes, and system. This can happen during the

Chiao Da Managemen/ Reνlew 均 1.32 No. 2, 2012 9

transcribing of doctor's orders and in the prescription

,

labeling

,

packaging

,

naming

,

preparation

,

distribution

,

administration

,

patient education

,

monitoring, and usage of medication. For instance, it includes offering the wrong medication to patients, and failing to administer medication according to the scheduled time.

(5)Lack of intervention on the patient's behalf

,

which indicates nursing errors due to negligence of patients' responses. For instance

,

a failure to discover that a patient is still bleeding because of negligence in executing a post-operational examination, resulting in a nursing error.

(6)Lack of prevention, which indicates the lack of preventing, to the extent possible, the occurrence of possible complications, therefore endangering the patient and thus resulting in nursing errors. This includes nursing errors such as letting a patient fall

,

or not offeri月 properassistance

(7)Missed or mistaken physician or health care provider orders, which indicate nursing errors attributed to the execution of improper medical procedures or orders

,

resulting in enorrnous impacts. This category includes the conducting of incorrect procedures, thereby endangering patients and in turn producing nursmg errors.

(8)Documentation errors, which indicate nursing errors due to the incorrect documentation of processes or medication before terrnination of their tasks, For instance, incorrect documentation which causes a patient to miss a scheduled treatment can therefore result in nursing errors

The above eight items are categories of nursing errors that have been utilized in previous studies (Benner et 瓜， 2006). This study also references the above-mentioned cases and situations in questionnaire design, Nursing errors are extensive in scope (lnoue and Koizumi, 2004); however, previous studies on nursing errors either introduce them as a single case (Narumi et al., 1999) or focus more on errors related to medication (Davidhizar and Lonser

,

2003), To investigate the overall concept of nursing errors, this study does not focus on nursing errors of a certain range (a single case or topic), but instead considers all of the eight factors described above

10

2.3.

Professional Ethics

The Relafionship between Sfress and Nursing Errors

The Moderafi咚 Role of Professional Efh叫

Liaschenko and Peter (2004) define "professionals" as those who possess 肌肉ue personal knowledge

,

provide altruistic services to the society

, and have

independent control over their work content and environrnent. Professionals can

also be seen as an exc\usive occupational group fonned by several workers who

uti\ize specialized

,

abstract knowledge when completing tasks (Abbott

,

1983). Therefore

,

professional nursing staffs can be categorized as professionals.

Ethics refers to making judgments on what is right and wrong 企'Om an ethical perspective serving as a set of behavioral criteria on right and wrong that

can be app\ied in interpersonal interactions (Yang

,

2006). Ethics refers to the

excellence of human conduct and behavior, and also serves as a standard for detennining right from wrong in human relations. Ethics consists of morality

,

habits

,

and behavior

,

which are interactive with each other (Wang and Hung

,

2005). Yeh (2000) also viewed ethics as a nonn for individual behavior; it has no specific fonn

,

but exists everywhere. Ethics do not merely exist in fonnal

specification

,

but also has an intangible power that can sculpt a personal sense of value. Robbins and Judge (2011) viewed a sense of value as a fundamental belief that takes the form of a certain behavioral mode or tangible final state, and is

superior to other contrary or opposing modes or states. Its importance is in its ability to inf1uence an individual's perceptions. Previous studies indicated that the way salespeople treat customers is significantly and positively correlated with

their perceptions of ethics (Pettijohn

, Pettijohn

,

and Taylor

,

2008). ln other words

,

if an individual originally possess proper be\iefs as to right and wrong

,

they can affect others during interaction

,

and perfonn ethical behavior that confonns to

those approved by the society

ln an overview of previous studies

,

it can be discovered that professional

ethics has not been c\early defined. White and Wooten (1986) tried to define professional ethics based on theory. They be\ieve that professional ethics inc\udes

five fundamental elements: values

, nonns

,

science

,

laws

,

and ethics. ln addition

,

they indicated that if professional ethics are to be effective, values have form a

Chiao Da Management ReνleW 均 1.32 No. 2, 2012 IJ

part of its core structure, which can in turn affect an individual core in the

surrounding environment. Nelson (2006) indicated that most people see

professional ethics as a standard of professional behavior which professionals

should possess

However, professional ethics should include more than written regulations, but should be a value that can be internalized. Consistent ethical behavior can

only be achieved by integrating professional ethics into the values of professional

workers. ln other words, in practice, it is thought that professionals should

consider the criteria of professional ethics as the essence of their behavior and intentions. These should be complemented with relevant theories for professionals to possess highly independent judgmental capabilities, and combine them with

efficient acts to carry out tasks at work. Therefore, professionals (professional nursmg sta的 should internalize the criteria of professional ethics to forrn their

core values. This induces them to act ethically instead of deviating from ethical

standards, and also helps them deliver better perforrnance at work.

2.4. Stress and Nursing Errors

Benoliel et al. (1990) indicated that stress causes professional nursing staff to

easily commit errors which deteriorate the quality ofmedical care (Meaney

,

2004) Past studies tended to attribute the reason for these nursing e叮orsto education and

training issues, or to behavior which violates regulations, and rarely focus on the

relationship between stress and nursing errors. ln previous studies regarding stress, the homeostatic model indicates that stress is a result of an imbalance between the demands of an environment and response capacity of workers. When this occurs, an individual tends to feel psychological discomfo肘， which is considered to be “stress". From this perspectiv巴， it can be discovered that sources of stress in an

individual's environment can cause damage to hislher resources to respond

effectively.

When individuals face different sources of stress and take different actions

,

their concentration is dispersed or diverted; and when the stress that they face

exceeds their capability, they feel exhausted (Simpson, 2002), which can easily lead to errors and affect their perforrnance (lda et al., 2009). No matter whether

12 The Relalionship between Stress and Nursing Errors The Moderaling Role of Professional Ethics

the response results are good or bad, the individual's resources would be damaged, causing psychological discomfort. Hollen et al. (2000) also indicated that heavy work stress can induce work bumout, restlessness, low ability for adaptation,

dissatisfaction with work

,

and even negligence in patient care and neglectful attitudes or behavior. Previous studies also shown a positive relationship between work stress and bumout (8urke and Richardsen, 2001; Hobfoll and Shirom, 2001;

Pinikahana and Happel, 2004; Sardiwalla, VandenSerg, and Esterhuyse, 2007) The latter causes nursing staff to lapse in focus on the.ir work

,

in turn leading to nursing errors (Williams et 瓜， 2007)

Furtherrnore, Cohen (1980) indicated that stress from the worki月 environment (work-related stress) and personal affairs (non-work-related stress) both exert adverse effects on an individual's physical, psychological, and emotional aspects, wh.ich in tum affects their work perforrnance (Williams et al.,

2001), and even results in cases ofhurnan error. 1n addition, 81endon et al. (2002)

also indicated that the primary reason for medical errors is a heavy work load

,

stress, and feelings of bumout. Welker-Hood (2006) indicated that stress is the main cause of errors produced by nursing staff; and under long-terrn and excessive stress loads, they can easily make blunders in their judgment, decisions, and behavior, and result in errors (Jones et al., 1988). Therefore, the stress that professional nursing sta仔 feel exerts a certain level of influence on the errors that they produce. 1n conclusion, a potential relationship exists between stress and nursing errors. Th.is study therefore deduces that higher levels stress induce professional nursing staff to produce nursing errors. Thus

,

this study proposed the following:

Hl: Work-related stress is positively related to nursing errors. H2: Non work-related stress is positively related to nursing errors.

2.5.

The Moderating Role of Professional Ethics

This study further sets out to understand the role ofprofessional ethics on the relationship between stress (work related and non-work related) and nursing

Chiao Da Managemenl Review 均1. 32 No. 2,2012 13

errors. Thompson (2004) argued that if doctors do not demonstrate appropriate

conduct, they are deviating from their professional ethics. Therefore, the practice of professional ethics serves to increase patient safety and reduce medical errors, allowing professionals to provide behavioral guidance for patients, their family

members, and their coworkers. Professional ethics are thus the core guidelines for

professional nursing staff in perforrning their daily tasks (Erlen

,

2007)

Written codes of professional ethics cannot provide an in-depth impact on

the perforrnance of professionals when they are at work，的 theydo not have these

concepts deeply integrated within them, and thus cannot transforrn them into extemal behavior. For professionals to deliver expected professional behavior at

work

,

they need to intemalize the concepts of professional ethics to forrn their personal values

,

thereby they can inhibit any behavior that deviates from that which is expected. According to cognitive theory, the cognition of individuals to facilitate their development and change their behavior is related to ethics. ln other words

,

an individual's behavior is affected by his/her cognitive differences

Gick (2003) argued that the stronger one's cognition and concept of

professional ethi囚，the more it alters immoral or unethical behavior. Stress coping

theory also states that when an individual faces stress

,

they achieve relief through cognitive evaluation and adaptation. Professional ethics can enhance one's

intemal resources, allowing one to effectively evaluate the various stress events in the nursing environment, and adapt to alleviate the negative effects caused by

stress. In other words

,

stronger individual beliefs in professional ethics indicate better intemalization thereof (Lazarus and Fo\km阻， 1984). This can help reduce a certain amount of incorrect behavior, and thus tbe perforrnance exhibited would

better adbere to expectations in medical care

Ivancevich and Matteson (1980) also mentioned that in an integrated model

of stress and work

,

the cognitive differences of an individual do in fact affect their cognition of stress and their behavior. ln other words, beliefs in professional ethics (an individual's belief also counts as a forrn of cognition) can affect the

stress (work-related and non-work-related) that professional nursing staff feel and

14 The Relationship between Stress and Nursing Errors

The Moderating Ro/e of Professional Ethics

from tbe extemal environment and the responses of the individual (Baer and

0ldham

,

2006). Based on these conclusions

,

when professional nurses possess

stronger beliefs in professional ethics, they can be c1early aware of the expected

criteria of their profession; this can result in a lower incidence of nursing errors

attributed to heavy stress

Tbe above results lead to the understanding that the ethics of professional nursing staff can inhibit the effects of stress (work-related and non-work-related)

on nursing errors. This study therefore deduces that when professional nursing staff possess stronger be\iefs in professional ethics, the positive relationship

between s出ss (work related and non-work related) and nursing errors might be

weakened, and vice versa. Thus, this study proposes the fol\owing:

H3: Pro.你sionalethics moderates the relationship between work叫áted

stress and nursing errors such that professional nursing service sta

fJ

with high proj的'sional ethics

,

the weaker the relationship between work related stress and nursing errors.

H4: Professional ethics moderates the relationship be，仰een

non-work-related stress and nursing errors such that professional nursing service sta

fJ

with high professional ethics

,

the weaker the relationship between non-work related stress and nursing errors.

3. 1\宜ethod 3.1. Participants and Procedures

The goal of this study is to understand the relationship between the stress

faced by professional nursing staff and nursing errors, and examine the moderating effect of professional ethics on this relationship. This study se\ected c1inical nursing staff 企om 12 hospitals in Taiwan and distributed a questionnaire

survey via purposive sampling to col\ect data. Questionnaire distribution was performed in person (by the researchers of this study). For those distributed in

Chiao Da Managemenl Reνiew Vol. 32 No. 2, 2012 15

person, the subject would also be provided with detailed instructions on answering the questionnaire, and also an envelope in which to seal the completed questionnaire. For those that were distributed by representatives, the contact persoo was provided with detailed instructions on answering the questionnaire prior to distribution, and the subjects were also provided with envelopes in which

to seal their completed questionnaires. Completed questionnaires were collected

by contact persons and later sent back by mail. A total of 750 questionnaires were distributed, and 537 were retumed. Among these, 43 were incomplete; therefore, a total of 494 valid questionnaires were collected (a valid retumed rate of 57.3%) As for subject composition, the average age of the subjects was 27.5 years, and the majority of them possessed college/university diplomas (92%). The m貝jority of subjects had 1 to 5 years of working experience (39.5%). Over half of these su句 ects were unmarried (59.5%) or did not have children (64.9%). As for work places, most ofthem worked at medical centers (73.0%), and the majority ofthem

served in general wards (47.2%)

3.2. Measures

3.2.1 Stress

This study refers to stress as the feeling in professional nursing staff caused by an inability to cope with extemal eveots or stimulations in workiog

environments, which io tum induce psychological discomfort. For stress

measurement, this study referred to a stress scale developed by 8enoliel et al.

(1990) which targeted clinical nursing sta缸; and utilized it to design a stress questionnaire. 8ack translation was appLied in the translation of the stress scale the scale was translated into Chinese by a researcher, and then 仕ans1ated back to

English by another researcher fluent in both 1aoguages to exclude any

misinterpretatioos of the original scale (8ris1in, 1980).

The questionnaire consisted of questioos 00 both work related and non-work re1ated stress. The former was divided into "work concem" and "work competence", and consisted of 17 questions; for example, "1 find it hard to

16 The Relationship between SI1臼'sand Nursing Errors The Moderating Role of Professional Ethics

divided into "personal reaction" and "inability to complete personal work"

,

and

consisted of 23 questions; for example

,

"1 often feel stressed." and "A砂 wardrobe often needs cleanin

g."

The entire questionnaire consisted of 40 questions, and applied a 6-point Likert scale (with 1 = Never and 6 = Always) to evaluate the perceptions of stress in professional nursing staff. Higher scores indicated more intense perceptions of stress

,

and vice versa. As for the intemal consistency of the two aspects of this questionnair巴，the Cronbach'sαvalues were respectively 0.90

and 0.93.

3.2.2. N ursing Errors

The definition of nursing errors in this study follows concepts introduced by Johnstone and Kanitsaki (2006)

,

which defmed them as unplanned accidents

produced by professional nursing staff (for instance

,

incorrect judgment) and events that can negatively affect patient safety and care quality. Nursing errors are

di伍cult to measure in practice. Employees may not provide actual information due to fear of being reported or recelvmg punishment. Moreover

,

in an organization

,

the documentation of erroneous behavior and the frequency with which it occurs is based on the information received when employees are reported

or punished; thereby, the actual occu訂閱ceof these errors may be underestimated. ln addition

,

aside from the difficulty in obtaining information

,

different hospitals might also have inconsistent standards regarding their definition of nursing errors

Based on these conditions

,

Burke (2003) argued that the most appropriate method

for accurately evaluating errors produced by nursing staff is to apply an anonymous and self-evaluating form of measurement. This can better reflect

actual situations. Previous studies also applied a self-evaluating method in investigating nursing e汀ors;thus

,

this study has chosen to adopt the same method. In addition, this study utilized the eight categories of nursing errors defined by 9 national nursing committees from 21 disciplinary cases

,

which inc\ude: lack

of attentiveness

,

lack of agency/fiduciary concem

,

inappropriate judgment

,

medication errors

,

lack of intervention on the patient's behalf

,

lack of prevention

,

missed or mistaken physician or health care provider orders

,

and documentation

Chiao Da Managemenl Reνiew Vol. 32 No. 2, 2012 17

references in designing a questionnaire that targets nursing errors. To take cognitive differences caused by different cultural backgrounds into consideration

,

aside from asking three highly-experienced nursing staff (experts) to revise the content of the questionnaire

,

another eight senior nurses with over 10 years experience were asked to evaluate the questionnaire regarding its relevance,

importance, and c1arity, and the content validity index (CVI) was calculated accordingly. After revision based on the experts' opinions

,

questions with importance exceeding 3 and a CVI exceeding 0.8 were retained (Schmitt and No巴，

1983). Expert evaluations ranged 台om 3.5 to 4 points, with an average of 3.76, and the average CVI was 0.96. A total of 16 questions were retained, and a 6 point

Likert scale (with 1 = Strongly disagree and 6 = Strongly agree) was applied for evaluation. Higher scores indicated greater possibilities for nursing errors

,

and vlce versa

Prior to the empirical research, a pretest was conducted with the questionnaire resulting from the revision. A total of 94 valid questionnaires were retumed (16 questions x 5 times), and exploratory factor analysis (EFA) was applied to examine the validity. Principal axis factor analysis was applied to extract common factors, and varimax rotation was applied. After EFA, no questions were deleted, and a dimension of nursing errors was established, with a cumulative explained variance of 50.38% and a Cronbach'sαvalue of 0.86. The example question was "1 o

.f

ten ignore patient signs o

.f

pain.", and during official research

,

the intemal consistency ofthis aspect was assigned a Cronbach'sαvalue ofO.81

3.2.3. Professiona1 Ethics

Professional ethics in this study refers to the princip1es of professional nurses in their field. When designing the questionnaire for this stu旬，this study utilized an ethical scale developed by Fry and Darnrosch (1994) in measuring professional ethics, and focused on the aspects of "patient care" that were c10sely related to the nurse-patient relationship described in this scale. The completed questionnaire consisted of 14 questions. As in the stress scale, back translation was performed from English into Chinese (Brislin, 1980). Sample items included "/ maintain

18 The Relationship between SI月'ssand Nursing Errors The Moderating Role of Professional Elhics absolute the confidentiality of patients ' confidential matters and privacy." and "1 report any abnormal events that violate ethical standards 10 the authorities." A 6-point Likert scale (with 1 = Strongly disagree and 6 = Strongly agree) was applied to evaluate the level of principles in professional ethics. Higher scores

indicated stronger principl間，and vice versa. The intemal consistency of this scale

was assigned a Cronbach'sαvalue of 0.84 3.2.4. Control Variables

To accurately measure the causal relationship between variables, previous studies were carefully reviewed, and the age, educational background, work experience, marital status, number of children, workplace, and work unit of nursing staff were listed as control variables

,

as previous studies have indicated

that these can potentially affect individual performance and nursing errors

(Narumi et al., 1999; Benner et al., 2002; Lee, and Wang, 2002; Stock et al., 2006)

Due to difficulties in collection and the paired sampling of objective data, all variables were tested via a self-reporting scale

,

which could possibly result in

common method biases (CMV), causing the relationship between variables to be

expanded and leading to false relevance (Podsakoff et 111., 2003). In addition, the

evaluation of professional ethics and nursing errors could possibly lose

authenticity due to individual social desirability bias (Peng, Kao, and Lin, 2006) To decrease the effects of common method biases and social desirability bias on the study results, this study not only adopted anonymous, self-sealed methods in answering questionnaires

, but also inc\uded reverse questions

and questions with

hidden meanings (Ha戶，Hayashi, and Stewa此，1989) Moreover, the questionnaire

also included 5 questions related to social desirability bias; for instance, "1 sometimes 的ke advantage of other people". A 6-point Likert scale (with 1 Strongly disagree and 6 = Strongly agree) was applied to evaluate and control the social expectations of professional nursing staff and enhance the validity of the questlOnnarre

Harmans one-factor test proposed by Podsakoff et al. (2003) was applied for

Chiao Da Managemenl Review Vol. 32 No. 2, 2012 19

C恥1V. Concepts of stress and nursing errors obtained after reliability analysis were applied in exploratory factor analysis. Under conditions without rotation, the number of factors extracted could be applied to deterrnine whether the severity of CMV was high. Analysis results indicated that the primary factor explained 24.59% of the variance, and no factors could explain over 50% of the variance

50%. These results indicate that the effects of CMV are not severe

,

and that the

analysis results of this study are reliable. 3.2.5 Exploratory Factor Analysis

Table 1

Model Summary for Confirmatory Factor Analysis (N=494)

典10del

_/

df I:J.f GFI AGFI NFI NNFI CFI RMSEA

Single factor 485.44 43 83 73 74 69 76 11 model Three-factor 268.86 41 99.58'" 90 85 86 83 88 _。8 model Four-factor model 169.28 38 316.16 94 90 91 90 93 06 Single factor model performed all data merged

Three-factor model perform巴:dthe data of work related stress and non-work related stress merged

Four-factor model perfo口nedthe data of work related stress, non-work related stre蹈，professional etbics ,and nursing e叮orsm咕嚕ed

Note: ••• p < .001

Prior to hypothesis veri日cation， this study first applied LISREL 8.72 to perforrn confirrnatory factor analysis (CFA) on all variables (work-reIated stress, non work-related stress

,

professional ethics

,

and nursing e汀ors) to exarnine the validity of the study concepts. The results of CFA showed that

i

(df= 施， N= 519)

=

169.28, indicating that significance was achieved; however, most model moderating indicators verified the four-factor model to be acceptable (GFI = 0.94; AGFI

=

0.90; CFl

=

0.91; NFI

=

0.90; NNFI

=

0.93; RMSEA

=

0.06) (Hu and

20 The Relationship between Stress and Nursing Erγ'ors The A必derating Role of Professional Ethics Bentler, 1995). ln addition, loading t tests of all factors in the four-factor model achieved significance

,

indicating that questions categorized under the same factor reflected the same concept. Furthermore, according to Table 1, the results of Chi-square difference tests indicated that compared to the one-factor model (.ó.X 2

= 316.峙， .ó.df= 5

,

p < .001) and the three-factor model (.ó.X 2= 99.58

,

.ó.df= 3, p

< .001)

,

the preliminary four-factor model provided the best moderation;

indicating that the four concepts could be easily distinguished from each other

,

as shown in Table 1.

4.

Results

4.

1.

Descriptive Statistics

Table 2 shows the mean values, standard deviation, and correlation coe伍 cientmatrix of different variables. The mean value for work related stress was 2.94 (standard deviation = 0.61) and that for non-work related stress was 3.31 (standard deviation = .89), indicating that professional nursing staff felt a certain amount of stress either at work or outside of work; in addition, non-work related stress was more evident than work-related stress. The mean value for professional

ethics was 4.52 (standard deviation = 0.57), indicating that professional nursing

staff commonly possessed principles in professional ethics. The mean value for

nursing errors was 2.84 (standard deviation 0.56), which was quite low

,

indicating mild levels of severity in the errors committed by nursing staff. As for the correlation between variables, both work-related s仕ess(r =兒 ， p

< .01) and non-work related stress (r

= .36, p

< .01) were positively correlated

with nursing erro悶; indicating that when nursing staff perceived stronger stress either at work or outside of work

,

it produced a greater tendency for nursing errors. ln addition, the correlation between work-related stress and nursing errors was higher than for non-work-related stress. These analysis results are consistent with previous hypotheses and results of past studies (Jones et al., 1988). As for

the correlation between ethics and erro悶， a negative correlation existed between

ChiaoDα Management Re叫飢似的1.32 No. 2. 2012 21

nursing staff possess stronger principles in professional ethics, they tend to produce fewer errors. These results were also consistent with those of previous studies (Gick, 2003)

Table 2

Means

,

Standard Deviations

,

Correlations

,

and Reliabilities (N=494)

Variables Mean S.D.a _2.

3. 4. 1. Work related stress

2.94 61 (.90)b

2.Non-work related s甘.ess

3.31 89 54'" (.93)

3.Professional ethics

4.52 57 -.35 -.14 (.84)

4.Nursing errors

2.84 56 58 36'" -.37'" (.81)

Note : ':S.D. = Standard Deviation

b: Intemal consistency values (Cronbach's Alpha) were shown on the across the diagonal parentheses.

p < .05 、刁<.01 、山 p< .001

4.2. The Relationship between Stress and Nursing Errors

This study verified its hypotheses through multiple hierarchical regression analysis. The analysis results are shown in Table 3. In the Ml regression model in Table 3

,

it can be seen that the age and workplace of professional nursing staff had a significant negative relationship with nursing errors 伊 =-.25,p < .01;

ß =

-.09, p < .05), while the number of children of nursing staff had significant positive relationship with nursing errors 伊 = .10

,

p < .05). This indicates that nursing staff of a younger age, with more children, or who worked in hospitals tended to produce more nursing errors. The results proved that it was appropriate to control for these variables in this study

After controlling for demographic variables

,

the M2 regression model in Table 3 indicated that work-reIated stress is positively related with nursing errors 伊= .56

,

p < .001). The M3 regression model in Table 3 also indicated a similar

22 The Relationship between Stress and Nursing Errors The Moderating Role of Professional Ethics

result for non-work related stress (ß = 泊， p < .001). Furtherrnore

,

in the M4 regression model of Table 3, when the two types of stress are combined, they achieve significant predictive results on nursing eπors; work-related stress also

exerts a stronger effect on nursing errors than non-work-related errors 伊 =.52

,

p

< .001;β= .08, p < .5). Combining the above results, it can be conc1uded that the

stronger the stress that nursing staff feel, the higher the possibility of nursing errors. Thus

,

hypotheses 1 and 2 were both proven supported

4.3.

The 恥foderating Effect of Professional Ethics on the

Relationship between Stress and Nursing Errors

To verify the regulatory effects of professional ethics on the relationship between stress and nursing errors

,

this study adopted an analytical process proposed by Baron and Kenny (1986): introducing in sequence independent

variable

,

moderating variable

,

and interactive variables (independent variable x moderating variable) after controlling for demographic variables to predict

outcome variables. If the interactive variables are significant in predicting outcome variables, then the moderating effect is deterrnined to be significant. The

analysis results are shown in Table 3

The M6 regression model in Table 3 shows that professional ethics exerts a weakening effect on the positive relationship between work-related stress and

work perforrnance (ß = -.09, P < .05), but does not exert a significant effect on moderating the relationship between non-work related stress and work perforrnances 伊=船， p > .1). These results indicate that the stronger the principles in professional ethics that nursing staff possess, the lower the possibility ofproducing nursing errors caused by work-related stress. Professional

ethics can therefore effectively inhibit the amount of nursing errors attributed to work-related stress, but does affect those resulting 仕om non-work related stress Analysis results therefore support H3, but not H4

To further verify the moderating effects of professional ethics on the relationship between work-related stress and nursing errors, this study refers to a method suggested by Aiken and West (1991): taking the average values of

Chiao Da Managemenl Reνlew 均1.32 No. 2, 2012 23

work-related stress and professional ethics and adding or subtracting one standard

deviation

,

then applying this value in a regression model and applying it in illustration (as shown in Figure 1). The results indicated that professional ethics

play a moderating role through weakening effects. ln other words, when professional nursing staff possess stronger professional ethical principles, the positive relationship between work-related stress and nursing errors is weakened This corresponds to Hypothesis 3, and therefore verifies to be supported

Table 3

Results of Hierarchical Rezression Analysis (N=494)

Variables Nursing Errors

MI M2 M3 M4 M5 M6

Control variables

I.Age -.25" -.18' -.23" -.18' -.15' -.15'

2.Education Leve1 -.04 _{。 l} -.00 _。2 01 _{。 l}

3.Senioity -.02 -.06 -.06 -.06 -.06 _。5 4.Marita1 status _{。7 。3 。3 。2 。2 。2} 5.No. of chi1dren 10' 11 08 10' 10' 09' 6.Social desirabi1ity _。9 -.09 -.09' 09 -.09 -.10" 7.Work unit 06 -02 _{。4 。2} 01 _{。 l} Independent variables

8. Work related stress (WRS) 56"‘ 52'" 46'" 48'"

9.Non-work related stress 35'" 0日 09' 。8'

(NWRS) Moderator

IO.Professional ethics (PE) -.16'" -.15'"

Interactive effect II.WRS x PE -.09' 12.NWRS x PE ₀₆ R' _。7 38 19 38 40 41 AφlIs1ed R1 06 37 18 37 39 40 llR' _。7''' 31'" 12'" 31'" _。2' 。 1+ F 5.29'" 36.33'" 14.36'" 32.78'" 32.38'" 27.64'" Note: 'p < .05;"p < .01;“'p<.OOI

The Re/ationshψ between Stress and Nursing Errors The Moderating Ro/e of Professional Ethics

24

Figure 1

Interactive Effect ofWork-Related Stress and Professional Ethics on Nursing

- - Low professional ethics - - High professional ethics Errors 5.∞ 4.∞ 2.50 4.50 3.50 3.∞ zzasm 開耳。 a H Work-related L 2.∞

5.

Discussion

5.

1.

Conclusion

This study was perfonned with the following two purposes: (1) to understand the relationship between stress and nursing errors in professional nursing sta缸，

and (2) to investigate the moderating effect of professional ethics on this relationship. Aside from the insignificant moderating effect of professional ethics on the relationship between non-work related stress and nursing erro郎， the study results gave credence to al1 other hypotheses. The results indicate that both types of stress correlated positively with nursing errors. In addition

,

professional ethics

Chiao Da Managemenf Review均 1.32 No. 2, 2012 25

exerts weakening effects on the relationship between work-related stress and nursing errors

,

indicating that professional ethics can effectively inhibit the occurrence of nursing errors as caused by work-related stress. The results of this study not only complement the lack of literature linking stress with nursing e叮0時，

but also provide in-depth analysis of the relationship between stress and nursing errors

,

thereby completing the theory and providing hospitals with an aspect for improvement in reducing nursing errors.

5.2. Theoretical Implications

As for theoretical implications

,

study results indicate that both work-related stress and non work-related stress have a positive relationship with nursing e汀ors. These results indicate that regardless of the source of the stress, it would cause professional nursing staff to easily commit errors. These results are consistent with studies of c1inical nursing sta缸 which mention that stress caused professional staff to commit errors when carrying out their tasks (Benoliel et a/.,

1990). These results also verify the conc1usions from studies on medical errors produced by medical staff which indicate that stress is a main reason for the occurrence of medical erro的 (Blendon et al., 2002). Furthermore, studies on nursing errors are quite scarce, especially empirical studies which target the stress of professional nursing staff and nursing errors. The results of this study can serve as empirical evidence for subsequent studies discussing relevant issues

The results of this study also indicate that professional ethics exert weakening effects on the relationship between work-related stress and nursing errors. In other words, when nursing staff possess strong professional ethical beliefs, they better understand the standards that they should follow in providing medical care

,

and thus the potential for nursing errors because of work stress are reduced. This also indicates that an individual's cognition can affect the relationship between stress and behavioral response. These results are consistent with those of previous studies (Ivancevich and Matteson, 1980; Baer and Oldham,

2006)

In addition, this study also discovers that professional ethics does not exert a moderating e叮ecton the relationship between non-work related stress and nursing

26 The Relationship between Stress and Nursing Errors

The Moderating Role

0/

Pr，。如sional Ethics 巴叮ors. A possible reason for such results might be corre1ated with the implications of professional ethics. Professional ethics are the beticfs of a professional in the

standards related to his/her profession, and are closely linked to their profession,

occupation, and work content. Therefore, it may not play the same role on stress derived from sources external to work

,

and in turn fails to effectively 曲ibit

nursing errors caused by non work-related stress. These results can be further discussed and verified in subsequent studies

5.3.

Practical Implications

As for practical implications

,

the study results indicate that the stress felt by professional nursing staff relates positively with the committing of errors. Therefore

,

this study concludes a possible reason for which nursing staff commit

errors

,

and also provides hospitals with an area for improvement regarding the prevention or reduction of nursing errors. In the futu時， when establishing regulations

,

authorities in hospitals and organizations can introduce more ways of relieving the stress of nursing sta缸 such as petmitting leave, travel, or implementing family-friendly policies to alleviate the stress that nursing staff feel both during and outside work

,

and in turn prevent 01' reduce the occurrence of

nursing errors. Welker-Hood (2006) argued that by effectively reducing the occurrence of nursing erro時， the perforrnance of professional nursing staff can thus be improved. Previous studies indicated that medical errors exert negative

effects on employee work performance (Stock et 叫.2006). Therefore

,

if hospitals

can effectively reduce the feelings of stress among nursing sta缸" the possibility of nursing errors can therefore be reduced, and the quality of care improved

The study results indicate that professional ethics exerts weakening effects on the relationship between work-related stress and nursing errors. In other words,

when professional nursing staff possess stronger principles in terms of professional ethics

,

they tend to produce fewer nursing errors. These results provide hospitals another possible aspect for improvement in regards to reducing the number of nursing errors. In the future, hospitals can enhance professional ethical training, either by including this as a mandatory item in education and training courses

,

or adding it an evaluation item in performance inspections.

Chiao Da Managemenl Reνiew Vol. 32 No. 2, 2012 27

Hospitals should also regularly promote and perform evaluations on

profession ethical criteria to strengthen beliefs in professional ethics among

nursing staff, and in turn achieve the goal of reducing nursing errors. As we move

into an era that values professionalism

,

professionals should be responsible for

their behavior. When a professional provides services by concretely adhering to professional ethical standards, positive benefits are exerted on individuals, orgamzatlOI芯， and society. If professional nursing staff can intemalize

professional ethical principles

,

nursing errors caused by work-related stress can

then be effectively reduced, thereby strengthening the image of nursing staff as

guardian angels and improving the safety of patients 5

.4. Li

mitations

As for the study's Iimitations，的 describedearlier, all evaluation items of the variables in the questionnaire have been answered by professional nursing staff via a self-report method. This could possibly lead to CMV issues. This study has carried out preliminary preventive and subsequent remedial measures based on the suggestions of previous studies (Podsakoff et al., 2003), with the pu中oseof

reducing the effects of CMV on the study results. Moreover

,

researchers have also

indicated that the effects caused by CMV are less severe than expected (Crampton and Wagner, 1994; Klin巴，Sulsky, and Rever-Moriyarr泊， 2000). However, CMV is

derived from applying the same tool in the measurement of all study variables,

causmg 出e interactive levels between variables to be higher than in reality (Podsakoff and Organ, 1986). Therefore, it is recommended that subsequent studies utilize measurement methods from different sources or different points in time, such as by asking the supervisors of professional nursing staff to answer

questions regarding nursing errors, or by inc1uding other objective indicators (for

instance, the documentation of nursing errors) to evaluate cases of nursing errors

and effectively reduce the effects cause by this bias.

Second, in the evaluation of nursing e汀0時， objective data are mainly filed

based on units or hospitals, and scarcely disc10se individual records; moreover,

ob叫 ective data are di伍cult to obtain. This study mainly targets nursing errors produced by individuals; therefore

,

during evaluation

,

only the potential amount

28 The Relationship between Stress and Nursing Errors The Moderating Role of Professional Ethics of nursing errors produced by nursing staff call be disc1osed. These inc1ude accidellts that have already taken place and those that might take place. Future studies can attempt to collect more data to distinguish between these two aspects to allow a stricter questionnaire structure. In addition

,

subsequent studies can also collect 0句 ective data to perform in-depth investigation and analysis t尬。ugh group or organization-Ievel research based on accidents that have already taken place, to better understand the relationship between stress, professional ethics, and nursmg errors.

Third

,

this study is a cross-sectional study that evaluates all variables at the same point in time. The study results under this design can merely explain the relationship between variables, or reflect the subject's overa11 trends of response To further investigate the causal relationship between variables, it is recommended that subsequent studies perform vertical section research at different time points, which can more accurately evaluate the causal relationship between stress and nursing errors

Lastly, during the sampling process, this study adopted purposive sampling due to certain limitations. Study samples illc1ude 494 professional nursing staff members from 12 hospitals in Taipei, Tainan, and Kaohsiung. The study results cannot thus be extrapolated to a11 nursing staff in all regions of Taiwan. The representativeness of the sample is thereby somewhat insufficient. In addition, the moderating effect of professiollal ethics on the relationship between non-work related s甘ess and nursing errors did not achieve significance. Therefore

,

subsequent studies can perform more extensive investigation on professional nursing staff to further elevate the applicability and contribution of the study results in c1inical practice

5.5.

Future Research

This study assumes that there is a linear relationship between stress and nursing errors. However

,

previous studies discovered an illverted-U relationship between stress and performallce

,

indicating that either excessive or insufficient stress is not beneficial to work performance (Yerkes and DodsOIl, 1908; Robbins and Judge

,

2011). Whether the relationship between stress and nursillg errors

Chiao Da Management Review Vol. 32 No. 2, 2012 29

resembles this relationship is an area worth investigating and analyzing

Furthermore

,

the effects of the sources of stress of an individual on his/her responses to stress can be influenced by di佐erences in character or situation (Lue

et al., 2010); for instance, an individual 's character, resistance to stress, emotional

intelligence

,

adaptive capabili旬 environmental uncertain旬 and work characteristics can all interfere with this relationship. Therefore, subsequent studies can attempt to include these variables in an investigation to fully

understand the actual relationship

Finally, previous studies have indicated that sources of stress can cause an

individual to feel emotional effort and exhaustion, eventually leading to work

bumout (Brotheridge and Lee

,

2002). This can weaken an individual's level of concentration and increase the possibility of errors (Hollen et al., 2000). Thus,

仇Jture research may attempt to examine the psychological experience of the relationship between sources of stress and nursing errors to understand the

intermediary mechanisms and further complete the theoretical model

6. References

Abbott, A. (1983),“Professional Ethics," American Journal of Sociology, 88(5),

855-885

Aiken, L. S., and West, S. G. (1991), Multiple Regression: Testing and lnterpreting Interactions, Newbury Park, CA: Sage Publications

Anderson, C. (2002),“Past Victim Future Victim," Nursing Management, 33(3),

26-30

Baer, M., and Oldham, G. R. (2006), “The Curvilinear Relation between

Experienced Creative Time Pressure and Creativity: Moderating Effects of

Openness to Experience and Support for Creativi恥" Journal of Applied Psychology, 91(4), 963-970

Baron, L L., and Kenny, D. (1986), “The Moderator Mediator Variable Distinction in Social Psychological Research: Conceptual, Strategic, and Statistical Considerations," Journal of Personality and Socia/ Psychology,