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Factors Influencing Military Nurses' Reporting of Patient Safety Events in South Korea: A Structural Equation Modeling Approach

  • Sookhee Yoon
    Affiliations
    Department of Nursing, Semyung University, 65 Semyung-ro, Jecheon-si, Chungbuk, 27136, South Korea
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  • Taewha Lee
    Correspondence
    Correspondence to: Taewha Lee, Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
    Affiliations
    Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
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Open AccessPublished:June 06, 2022DOI:https://doi.org/10.1016/j.anr.2022.05.006

      Summary

      Purpose

      This study explored how just culture, authentic leadership, safety climate, patient safety knowledge, and safety motivation all affect military nurses' reporting of patient safety events.

      Methods

      This study adopted a cross-sectional and descriptive correlational design. Data were collected from 303 nurses working across eight military hospitals under the jurisdiction of the Armed Forces Medical Command in South Korea, from June 17 to July 25, 2020. The hypothesized model was then validated using structural equation modeling.

      Results

      The participating military nurses did not show any proactive attitudes toward reporting near misses when compared with their responses to adverse or no-harm events. The final model exhibited goodness of fit. Herein, both safety climate (β = 0.35, p = .009) and patient safety knowledge (β = 0.17, p = .025) directly influence patient safety event reporting. Moreover, just culture indirectly influences patient safety event reporting (β = 0.31, p = .002). The discovered influencing factors account for 22.9% of the variance in explaining patient safety event reporting.

      Conclusions

      Our findings indicate that just culture, safety climate, and patient safety knowledge either directly or indirectly affected patient safety event reporting among military nurses. These findings then serve to provide a theoretical basis for developing more effective strategies that would then improve military nurses' patient safety behaviors.

      Keywords

      Introduction

      Internationally, patient safety is one of the most important goals in healthcare institutions. The occurrence of any adverse events caused by unsafe care is one of the top ten causes of death and disability worldwide [
      • Jha A.
      Patient safety—a grand challenge for healthcare professionals and policymakers alike.
      ]. In South Korea (hereafter, Korea), the number of adverse events voluntarily reported by medical institutions has more than doubled from 2586 in 2017 to 6932 in 2020 [
      Ministry of Health and Welfare, Korea Institute for Healthcare Accreditation
      Korean patient safety incident report 2020.
      ]. Patient safety event reporting plays an important role in preventing the recurrence of any adverse events through the initiation of investigations and analyses, which then result in improvements in patient safety, awareness, and the institution's internal and external systems [
      • Soydemir D.
      • Seren Intepeler S.
      • Mert H.
      Barriers to medical error reporting for physicians and nurses.
      ]. It has been found that sentinel and adverse events are often eventually disclosed, but that near misses may go underreported if the organizational culture favors concealing or downplaying said events [
      • Lee W.
      • Kim S.Y.
      • Lee S.I.
      • Lee S.G.
      • Kim H.C.
      • Kim I.
      Barriers to reporting of patient safety incidents in tertiary hospitals: a qualitative study of nurses and resident physicians in South Korea.
      ].
      Nurses comprise the largest proportion of the workforce in medical institutions and are at the frontline of patient care, which then facilitates their ability to identify medical errors [
      • Chen L.C.
      • Wang L.H.
      • Redley B.
      • Hsieh Y.H.
      • Chu T.L.
      • Han C.Y.
      A study on the reporting intention of medical incidents: a nursing perspective.
      ]. The study by Lee indicated that Korean nurses feel more comfortable reporting events directly rather than filing event reports, as well as the fact that their rate of medication error reporting was 6.3%–29.9% regardless of hospital type [
      • Lee E.
      Reporting of medication administration errors by nurses in South Korean hospitals.
      ]. In Taiwan, Chiang et al. found that nearly 60% of nurses demonstrate a non-proactive attitude toward reporting errors or near-miss events [
      • Chiang H.Y.
      • Lee H.F.
      • Lin S.Y.
      • Ma S.C.
      Factors contributing to voluntariness of incident reporting among hospital nurses.
      ]. Underreporting then reduces opportunities for shared learning and hinders stakeholders' ability to generate effective changes within the healthcare system that are aimed at preventing the recurrence of errors and improving patient safety [
      • Richter J.P.
      • McAlearney A.S.
      • Pennell M.L.
      Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives.
      ]. Research has shown that patient safety event reporting is associated with both organizational (e.g., culture, safety climate, and leadership) and individual factors (e.g., safety knowledge and motivation) [
      • Agustian I.
      • Lubis A.N.
      • Siregar F.L.S.
      Individual and organization affects perceptions of reporting patient safety incidents in Medan City Hospital.
      ,
      • Archer S.
      • Hull L.
      • Soukup T.
      • Mayer E.
      • Athanasiou T.
      • Sevdalis N.
      • et al.
      Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
      ,
      • Woo M.W.J.
      • Avery M.J.
      Nurses' experiences in voluntary error reporting: an integrative literature review.
      ,
      • Hamed M.M.M.
      • Konstantinidis S.
      Barriers to incident reporting among nurses: a qualitative systematic review.
      ,
      • Wong C.A.
      • Spence Laschinger H.K.
      • Cummings G.G.
      Authentic leadership and nurses' voice behaviour and perceptions of care quality.
      ].
      A just culture refers to an organizational climate in which individuals feel that they are treated fairly when issues like patient safety events occur, which then creates a balance between the organizational system and individual accountability [
      • Marx D.
      Patient safety and the just culture.
      ]. Woo and Avery outlined the fact that nurses often have insufficient experience with voluntary error reporting, with them also pointing out the limitations of organizations in advocating a just and open safety culture to help support error reporting [
      • Woo M.W.J.
      • Avery M.J.
      Nurses' experiences in voluntary error reporting: an integrative literature review.
      ]. Furthermore, Lee et al., in a qualitative study of tertiary hospital doctors and nurses, reported themes like fear of blame, inappropriate responses, and the possibility of potential blame as factors that hinder safety event reporting in Korea [
      • Lee W.
      • Kim S.Y.
      • Lee S.I.
      • Lee S.G.
      • Kim H.C.
      • Kim I.
      Barriers to reporting of patient safety incidents in tertiary hospitals: a qualitative study of nurses and resident physicians in South Korea.
      ]. Other studies have noted that an open and just culture increases nurses' patient safety activity and has a positive influence on their error reporting experiences [
      • Woo M.W.J.
      • Avery M.J.
      Nurses' experiences in voluntary error reporting: an integrative literature review.
      ,
      • Kim B.B.
      • Yu S.
      Effects of just culture and empowerment on patient safety activities of hospital nurses.
      ]. Furthermore, others have reported that, within a just culture, authentic leadership has a positive impact on nurses' trust in their managers, which then provides them with a supportive practice environment, encourages them to speak up, and is able to accurately predict patient safety and quality of care [
      • Wong C.A.
      • Spence Laschinger H.K.
      • Cummings G.G.
      Authentic leadership and nurses' voice behaviour and perceptions of care quality.
      ]. Walumbwa et al. posited that authentic leadership implies a positive leadership style that focuses on ethics, an understanding of oneself and others, the prioritizing of individual growth, the embracing of a transparent relationship between leaders and followers, and the promoting of a positive ethical climate [
      • Walumbwa F.O.
      • Avolio B.J.
      • Gardner W.L.
      • Wernsing T.S.
      • Peterson S.J.
      Authentic leadership: development and validation of a theory-based measure.
      ]. Further, Dirik and Intepeler found that managers' authentic leadership is an important predictor of safety climate among nurses [
      • Dirik H.F.
      • Intepeler S.S.
      The influence of authentic leadership on safety climate in nursing.
      ].
      Specifically, safety climate refers to a shared perception of the importance and value of safety-related procedures and practices within an organization [
      • Neal A.
      • Griffin M.A.
      • Hart P.M.
      The impact of organizational climate on safety climate and individual behavior.
      ]. Safety climate influences individual factors, such as safety knowledge and safety motivation [
      • Christian M.S.
      • Bradley J.C.
      • Wallace J.C.
      • Burke M.J.
      Workplace safety: a meta-analysis of the roles of person and situation factors.
      ]. Previous research has reported a significant correlation between safety climate and error reporting, with it being established that a positive safety climate fosters better safety event reporting [
      • Hong S.
      • Li Q.
      The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.
      ].
      The knowledge underlying patient safety practices, as outlined in the extant literature, is reported to be a facilitating factor for patient safety event reporting [
      • Archer S.
      • Hull L.
      • Soukup T.
      • Mayer E.
      • Athanasiou T.
      • Sevdalis N.
      • et al.
      Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
      ,
      • Woo M.W.J.
      • Avery M.J.
      Nurses' experiences in voluntary error reporting: an integrative literature review.
      ]. Brasaite et al. found that one of the main requirements in ensuring patient safety is the development and maintenance of medical professional safety knowledge. Moreover, undesirable patient outcomes can be avoided by ensuring knowledge sharing and facilitating error reporting among staff [
      • Brasaite I.
      • Kaunonen M.
      • Suominen T.
      Healthcare professionals' knowledge, attitudes and skills regarding patient safety: a systematic literature review.
      ]. Safety motivation refers to an individual's willingness to enact safety behaviors according to their own interests and beliefs [
      • Neal A.
      • Griffin M.A.
      A study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels.
      ]. Prior research has shown that nurses' lack of motivation acts as a barrier in their reporting of patient safety events [
      • Hamed M.M.M.
      • Konstantinidis S.
      Barriers to incident reporting among nurses: a qualitative systematic review.
      ]. Moreover, it has been demonstrated that safety motivation and knowledge influence corresponding safety behaviors [
      • Christian M.S.
      • Bradley J.C.
      • Wallace J.C.
      • Burke M.J.
      Workplace safety: a meta-analysis of the roles of person and situation factors.
      ].
      Nursing staff at military hospitals, specifically, have a clear understanding of the hierarchical relationships therein because of the uniform command system that exists within the class-oriented climate, which is a distinguishing characteristic of military culture [
      • Oh H.
      • Cho Y.
      Effects of organizational culture, transformational leadership and transactional leadership on organizational effectiveness - comparing military hospitals with civil hospitals.
      ]. The characteristics of military hospitals (wherein healthcare providers regularly rotate every one or two years through various network hospitals or departments) require nurses to function consistently in new work environments, with them then being exposed to an increased risk of patient safety issues [
      • Choi Y.J.
      • Lee M.S.
      • Kang M.S.
      • Kim J.H.
      • Kim J.E.
      • Kim S.Y.
      Military nursing staff's perception and satisfaction on communication with other healthcare professionals and their job satisfaction in Korean military hospitals.
      ,
      • Yoon S.
      • Lee T.
      • Maeng S.
      • Kwon J.-E.
      The Influence of nurses' communication competency, critical thinking disposition, and perception of patient safety culture on patient safety competency in armed forces hospitals.
      ]. Therefore, identifying the factors that affect military nurses' reporting of patient safety events is critical for improving patient safety in military hospitals. Except for studies that focus on the relationships between patient safety culture, safety management activities and competency, and communication with other healthcare professionals [
      • Choi Y.J.
      • Lee M.S.
      • Kang M.S.
      • Kim J.H.
      • Kim J.E.
      • Kim S.Y.
      Military nursing staff's perception and satisfaction on communication with other healthcare professionals and their job satisfaction in Korean military hospitals.
      ,
      • Yoon S.
      • Lee T.
      • Maeng S.
      • Kwon J.-E.
      The Influence of nurses' communication competency, critical thinking disposition, and perception of patient safety culture on patient safety competency in armed forces hospitals.
      ,
      • Hwang J.
      • Lee S.
      • Jeon Y.
      • Lee H.
      • Kwak Y.
      • Lee J.
      A descriptive study of military nurses' perception on patient safety culture and their performance on patient safety nursing.
      ], few have comprehensively investigated the factors that influence military nurses' safety behaviors at both the organizational and individual levels. Thus, this study examined the organizational (including just culture, authentic leadership, and safety climate) and individual (including patient safety knowledge and safety motivation) factors that influence military nurses' patient safety event reporting, while also verifying factors that have a mediating effect on this relationship. This study's findings then provide evidence to facilitate the development of effective intervention strategies to ensure patient safety in military hospitals.

      Hypothesized model

      The hypothesized model for this study was derived from both a literature review [
      • Agustian I.
      • Lubis A.N.
      • Siregar F.L.S.
      Individual and organization affects perceptions of reporting patient safety incidents in Medan City Hospital.
      ,
      • Archer S.
      • Hull L.
      • Soukup T.
      • Mayer E.
      • Athanasiou T.
      • Sevdalis N.
      • et al.
      Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
      ,
      • Woo M.W.J.
      • Avery M.J.
      Nurses' experiences in voluntary error reporting: an integrative literature review.
      ,
      • Hamed M.M.M.
      • Konstantinidis S.
      Barriers to incident reporting among nurses: a qualitative systematic review.
      ,
      • Wong C.A.
      • Spence Laschinger H.K.
      • Cummings G.G.
      Authentic leadership and nurses' voice behaviour and perceptions of care quality.
      ,
      • Kim B.B.
      • Yu S.
      Effects of just culture and empowerment on patient safety activities of hospital nurses.
      ,
      • Dirik H.F.
      • Intepeler S.S.
      The influence of authentic leadership on safety climate in nursing.
      ,
      • Christian M.S.
      • Bradley J.C.
      • Wallace J.C.
      • Burke M.J.
      Workplace safety: a meta-analysis of the roles of person and situation factors.
      ,
      • Hong S.
      • Li Q.
      The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.
      ] and the safety model developed by Neal et al. [
      • Neal A.
      • Griffin M.A.
      • Hart P.M.
      The impact of organizational climate on safety climate and individual behavior.
      ]. Their model assumes that organizational climate (which encompasses leadership, work roles, and communication) significantly impacts the overall safety climate, while this climate then influences safety behaviors through its impact on staff members' relevant safety knowledge and motivation. Thus, the hypothesized model of this study (Supplementary Figure S1) is as follows: (1) just culture and authentic leadership have a direct effect on safety climate and patient safety event reporting; (2) just culture and authentic leadership indirectly affect patient safety event reporting through the impact of safety climate, patient safety knowledge, and safety motivation; (3) safety climate has a direct effect on patient safety event reporting; (4) safety climate indirectly affects patient safety event reporting through patient safety knowledge and safety motivation; and (5) patient safety knowledge and safety motivation are individual factors that directly influence patient safety event reporting.

      Methods

      Study design

      This was a cross-sectional, descriptive-correlational study conducted in eight military hospitals under the jurisdiction of the Armed Forces Medical Command in Korea.

      Setting and sample

      The sample included 396 nurses working at eight military hospitals across Korea who gave their informed consent to participate in this study. The inclusion criteria were as follows: (1) nurses who had been working for at least six months in the same department and (2) nurses who delivered care directly to patients. Nursing managers that worked as head nurses or had an equivalent position were excluded. This study's sample size was found to be adequate because the minimum sample required for the maximum likelihood method (which is commonly used in structural equation modeling) was found to be 200 [
      • Bae B.-R.
      Structural equation modeling with Amos 24.
      ]. Of the 396 candidates, 378 responded (95.4% response rate). Of these 378 responses, 75 were excluded due to incomplete or incorrect responses. Thus, 303 responses were included in our final analysis.

      Measurements

      Participants were provided with a self-administered questionnaire (specifically developed for this study) that collected data about their general characteristics, patient safety event reporting, the overall just culture, authentic leadership, safety climate, patient safety knowledge, and safety motivation. The general characteristics included their age, sex, educational level, clinical experience in their current department, clinical career, and patient safety education experience.

      Patient safety event reporting

      Patient safety event reporting was assessed using nurses' perceived levels of their own reporting rates on adverse, no-harm, and near-miss events. These factors were measured using three questions from the translated [
      • Kim J.-E.
      • Kang M.-A.
      • An K.-E.
      • Sung Y.-H.
      A survey of nurses' perception of patient safety related to hospital culture and reports of medical errors.
      ] and modified versions [
      • Kim S.A.
      • Kim E.-M.
      • Lee J.-R.
      • Oh E.G.
      Effect of nurses' perception of patient safety culture on reporting of patient safety events.
      ] of the Hospital Survey on Patient Safety Culture (HSOPSC) [
      • Rockville W.
      • Sorra J.
      • Gray L.
      • Streagle S.
      • Famolaro T.
      • Yount N.
      • et al.
      AHRQ hospital survey on patient safety culture: user's guide.
      ], including: (1) “If a patient safety event that causes harm to a patient occurs, how frequently is it reported?” (adverse event report); (2) “If a patient safety event occurs but the patient is unharmed, how often is this reported?” (no-harm event report); and (3) “If a patient safety event is detected and corrected before it affects the patient, how often is this reported?” (near-miss report). The participating nurses responded to the HSOPSC's items on a 5-point Likert scale ranging from 1 (“never”) to 5 (“always”). In this study, the Cronbach's α of this scale was found to be 0.71.

      Just culture

      Just culture was measured using the translated Korean version [
      • Kim S.A.
      Quality of work life among nurses who had patient safety incidents; mixed methods design.
      ] of the Just Culture Assessment Tool (JCAT) [
      • Petschonek S.
      • Burlison J.
      • Cross C.
      • Martin K.
      • Laver J.
      • Landis R.S.
      • et al.
      Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals.
      ]. The JCAT comprises 27 items across six subdomains, including: trust, continuous improvement, quality of the event reporting process, balance, openness of communication, feedback, and communication. The participating nurses responded to the JCAT's items on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). At the time of development, the Cronbach's α for all of its sections was higher than 0.7, except for the quality of the event-reporting process (≥ 0.63). In this study, the Cronbach's α of this scale ranged from 0.83 to 0.86.

      Authentic leadership

      Authentic leadership was measured using the translated Korean and modified versions [
      • Kim D.
      • Bae E.
      • Han M.
      Mediating effects of teacher's self-directed learning ability on the relationship between principal's authentic leadership and teacher's organizational commitment in early childhood educational institutes.
      ,
      • Song B.
      • Seomun G.
      The influential factors related to organizational citizenship behavior of nurses: with focus on authentic leadership and organizational justice.
      ] of the Authentic Leadership Questionnaire (ALQ) [
      • Walumbwa F.O.
      • Avolio B.J.
      • Gardner W.L.
      • Wernsing T.S.
      • Peterson S.J.
      Authentic leadership: development and validation of a theory-based measure.
      ]. The ALQ has 16 items across four subdomains: self-awareness, rational transparency, internalized moral perspective, and balanced processing sections. Nurses responded to the ALQ's items on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The instrument's original Cronbach's α was 0.79 [
      • Walumbwa F.O.
      • Avolio B.J.
      • Gardner W.L.
      • Wernsing T.S.
      • Peterson S.J.
      Authentic leadership: development and validation of a theory-based measure.
      ], whereas it was found to be 0.95 in this study.

      Safety climate

      Safety climate was measured using the translated Korean version [
      • Kim K.J.
      • Han J.S.
      • Seo M.S.
      • Jang B.H.
      • Park M.M.
      • Ham H.M.
      • et al.
      Relationship between intra-organizational communication satisfaction and safety attitude of nurses.
      ] of the Safety Attitudes Questionnaire Short Form [
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • Rowan K.
      • Vella K.
      • Boyden J.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      ]. This tool includes 31 items measuring teamwork climate, safety climate, job satisfaction, stress recognition, perception of management, and working conditions. Again, nurses responded to this instrument's items on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The stress recognition domain was eliminated due to it having a factor loading lower than 0.1 in this study (p > 0.05). The instrument's original Cronbach's α was 0.90 [
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • Rowan K.
      • Vella K.
      • Boyden J.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      ] and was 0.90 in this study.

      Patient safety knowledge

      Patient safety knowledge was measured using the patient safety knowledge domain from the Patient Safety Competency Tool [
      • Jang H.-N.
      Evaluation and application of patient safety competence assessment tool-survey for nurses.
      ]. This tool has six items, with the nurses then rating these on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Cronbach's α was 0.89 in the study by Jang [
      • Jang H.-N.
      Evaluation and application of patient safety competence assessment tool-survey for nurses.
      ] and was found to be 0.87 in this study.

      Safety motivation

      Safety motivation was measured using the translated Korean version [
      • Moon D.-H.
      The effects of new nurses' patient safety motivation, patient safety management attitude on patient safety management behavior [Korean].
      ] of the Safety Motivation Tool [
      • Vinodkumar M.N.
      • Bhasi M.
      Safety management practices and safety behaviour: assessing the mediating role of safety knowledge and motivation.
      ]. This tool includes five items that were each rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The instrument's original Cronbach's α was 0.93 [
      • Vinodkumar M.N.
      • Bhasi M.
      Safety management practices and safety behaviour: assessing the mediating role of safety knowledge and motivation.
      ]. In this study, specifically, its Cronbach's α was 0.93.

      Data collection

      Eight military hospitals in Korea were visited by the researchers to brief potential candidates on the objectives of this study and to obtain their consent for data collection. Nurses who wished to participate were provided with survey packets that included information on the study, the questionnaire, an informed consent form, and a return envelope. Participants were then asked to complete the questionnaire and return it to a sealed box placed in each ward. In addition, they were also informed that they could withdraw from the study at any time. Each participant was provided with a gift certificate of $5 (USD). Research data were collected from June 17 to July 25, 2020.

      Statistical analyses

      All collected data were analyzed using SPSS 26.0 and AMOS 26.0 software. A descriptive statistical analysis method and Pearson's correlation coefficient were used to analyze participants' characteristics, the mean and standard deviations of the data, the skewness, the kurtosis, and any correlations between variables. Structural equation modeling was then used to test the hypothesized model. First, a confirmatory factor analysis (CFA) was performed to identify the validity of the latent variables [
      • Kim S.Y.
      Fundamental and extention of structural equation modeling with MPLUS examples.
      ]. Then, a model estimation and an examination into the effects between variables were performed using the maximum likelihood estimation method. The bootstrapping method was then used to determine the significance of the indirect effects among the study variables. The model's goodness of fit was evaluated using the following indices: the X2/df ratio index < 3 [
      • Bae B.-R.
      Structural equation modeling with Amos 24.
      ], the comparative fit index (CFI) ≥ .90 [
      • Hooper D.
      • Coughlan J.
      • Mullen M.
      Evaluating model fit: a synthesis of the structural equation modelling literature.
      ], the standardized root mean square residual (SRMR) ≤ .08 [
      • Hooper D.
      • Coughlan J.
      • Mullen M.
      Evaluating model fit: a synthesis of the structural equation modelling literature.
      ], and the root mean square error of approximation (RMSEA) ≤ .08 [
      • Bae B.-R.
      Structural equation modeling with Amos 24.
      ].
      The RMSEA was reported using the AMOS software with a 90% confidence interval. If the RMSEA is 0, the confidence interval becomes one-sided, wherein the upper bound estimate is greater than the RMSEA. Hence, the 90% confidence level was used in this study instead of the more common 95%, which is more conventional for use within two-sided confidence intervals [
      • Kline R.B.
      Principles and practice of structural equation modeling.
      ].

      Ethical considerations

      This study received ethical approval from the institutional review board of the Armed Forces Medical Command (approval no: AFMC-20102-IRB-20-102).

      Results

      Participants' characteristics

      As shown in Table 1, the mean age of the participants was 29.46 years (SD = 5.91). Women constituted 76.6% of the total number of participants and 83.8% held a bachelor's degree in nursing. Only 11.2% of the nurses had worked in their current department for more than three years. Additionally, the participating nurses had worked for an average of 6.08 years (SD = 5.22). Finally, 85.5% of the nurses had participated in patient safety training at least once in the past year.
      Table 1Participants' Characteristics (N = 303).
      Characteristicn%Mean (SD)
      Sex
       Male7123.4
       Female23276.6
      Age29.46 (± 5.91)
       ≤ 258528.1
       26–< 3011136.6
       ≥ 3010735.3
      Education level
       College degree299.6
       Bachelor's degree25483.8
       ≥ Master's degree206.6
      Clinical experience in the current department (years)1.79 (± 1.69)
       < 18026.4
       1–< 318962.4
       3–< 5216.9
       ≥ 5134.3
      Clinical career (years)6.08 (± 5.22)
       < 1134.3
       1–< 38528.1
       3–< 56521.5
       ≥ 514046.2
      Patient safety education experience (in the previous year)
       04414.5
       115651.5
       27725.4
       ≥ 3268.6
      Note. SD = standard deviation.

      Descriptive statistics and factor loading of the confirmatory factor analysis

      As shown in Table 2, the reporting level of near misses (mean = 3.84 ± 0.84, range 1–5) was lower than that of adverse (mean = 4.50 ± 0.80, range 1–5) and no-harm events (mean = 4.11 ± 0.87, range 1–5). Furthermore, participants reported moderate levels of just culture (mean = 3.70 ± 0.50, range 2–5). Additionally, the quality of the event reporting process domain scored the highest, whereas that of trust scored the lowest. Nurses perceived their managers' authentic leadership (mean = 3.64 ± 0.50; range 1–5) and safety climate (mean = 3.61 ± 0.47; range 2–5) as being moderate. Among the individual factors, although nurses did not exhibit high levels of patient safety knowledge (mean = 3.71 ± 0.68; range 1–5), they did report high levels of safety motivation (mean = 4.59 ± 0.51; range, 3–5). The absolute values of all measures of skewness were less than 2 and the absolute value of the measure of kurtosis was less than 7. Thus, the measured variables were normally distributed. Based on the CFA, the criteria for convergent validity (factor loading ≥ 0.5, AVE ≥ 0.5, and CR ≥ 0.7) were satisfied; however, an AVE value was not greater than the square of the correlation coefficient, therefore, the discriminant validity was only partially satisfied (see the diagonal line in Supplementary Table S1) [
      • Bae B.-R.
      Structural equation modeling with Amos 24.
      ].
      Table 2Descriptive Statistics and Factor Loadings of Confirmatory Factor Analysis (N = 303).
      VariablesMean ± SDRangeSkewnessKurtosisFactor loading (p)CRAVE
      Just culture3.70 ± 0.502–5−0.250.060.87.52
       Trust3.44 ± 0.631–5−0.090.350.72 (< .001)
       Continuous improvement3.83 ± 0.651–5−0.520.990.78 (< .001)
       Quality of event reporting process3.92 ± 0.522–5−0.080.000.73 (< .001)
       Balance3.53 ± 0.651–5−0.220.180.68 (< .001)
       Openness of communication3.67 ± 0.701–5−0.751.190.79 (< .001)
       Feedback and communication3.89 ± 0.681–5−0.600.570.62 (< .001)
      Authentic leadership3.64 ± 0.501–5−0.360.540.93.76
       Self-awareness3.55 ± 0.821–5−0.30−0.090.91 (< .001)
       Transparency3.73 ± 0.671–5−0.270.600.88 (< .001)
       Balanced processing3.56 ± 0.861–5−0.550.180.90 (< .001)
       Moral/Ethical3.67 ± 0.671–5−0.581.390.78 (< .001)
      Safety climate3.61 ± 0.472–50.040.100.89.62
       Teamwork climate3.59 ± 0.572–5−0.220.270.79 (< .001)
       Safety climate3.80 ± 0.572–5−0.08−0.030.89 (< .001)
       Job satisfaction3.68 ± 0.731–5−0.380.050.80 (< .001)
       Perception of management3.44 ± 0.681–50.01−0.190.70 (< .001)
       Working condition3.48 ± 0.661–5−0.120.500.76 (< .001)
      Patient safety knowledge3.71 ± 0.681–5−0.180.160.87.53
      Safety motivation4.59 ± 0.513–5−1.020.220.94.75
      Patient safety event reporting0.75.51
       Near miss3.84 ± 0.841–5−0.630.330.55 (< .001)
       No-harm event4.11 ± 0.871–5−1.061.290.92 (< .001)
       Adverse event4.50 ± 0.801–5−1.863.600.62 (< .001)
      Note. AVE = average variance extracted; CR = construct reliability.

      Correlations of study variables

      Table 3 shows the relationships between the study variables. Patient safety event reporting was found to be significantly and positively associated with just culture (r = .32, p < .001), authentic leadership (r = .18, p = .002), safety climate (r = .40, p < .001), patient safety knowledge (r = .33, p < .001), and safety motivation (r = .19, p = .001).
      Table 3Correlations Among the Study Variables (N = 303).
      Variables1

      r (p)
      2

      r (p)
      3

      r (p)
      4

      r (p)
      5

      r (p)
      6

      r (p)
      1. Just culture1
      2. Authentic leadership.60 (< .001)1
      3. Safety climate.69 (< .001).57 (< .001)1
      4. Patient safety knowledge.36 (< .001).27 (< .001).48 (< .001)1
      5. Safety motivation.34 (< .001).17 (.003).35 (< .001).31 (< .001)1
      6. Patient safety event reporting.32 (< .001).18 (.002).40 (< .001).33 (< .001).19 (.001)1

      Testing the hypothesized model

      The hypothesized model fit the data well (X2/df = 2.468, CFI = .908, RMSEA = .070 [90% CI: .064–.075], and SRMR = .068). The model was tested by including all the participants' general characteristics as control variables. The results were consistent with those of the model without control variables (Figure 1).
      Figure 1
      Figure 1Path diagram of the final model.
      Note. CFI = comparative fit index; RMSEA = root mean square error of approximation; SRMR = standardized root mean-square residual.
      The dashed lines with arrows represent non-significant relationships.
      As shown in Table 4, just culture indirectly but significantly influences patient safety event reporting (β = 0.31, p = .002). Regarding the specific indirect effect, just culture indirectly influences patient safety event reporting via the safety climate (β = 0.25, 95% CI: .080–.153) as well as via both safety climate and patient safety knowledge, serially (β = 0.06, 95% CI: .003–.513) (Supplementary Table S2). Furthermore, safety climate directly influences patient safety event reporting (β = 0.35, p = .009), with patient safety knowledge affecting safety event reporting (β = 0.17, p = .025). Additionally, authentic leadership and safety motivation had no significant direct or indirect effects on patient safety event reporting. These influencing factors accounted for 22.9% of the variance in explaining patient safety event reporting.
      Table 4Standardized Direct, Indirect, and Total Effects of Variables in the Final Model (N = 303).
      Endogenous variablesExogenous variablesDirect effect (p)Indirect effect (p)Total effect (p)SMC
      Safety climateJust culture.71 (< .001).71 (< .001).633
      Authentic leadership.12 (.061).12 (.061)
      Patient safety knowledgeSafety climate.53 (< .001).53 (< .001).283
      Safety motivationSafety climate.41 (< .001).41 (< .001).166
      Patient safety event reportingJust culture.10 (.494).31 (.002).41 (.001).229
      Authentic leadership−.11 (.201).05 (.147)−.06 (.472)
      Safety climate.35 (.009).08 (.089).43 (.002)
      Patient safety knowledge.17 (.025).17 (.025)
      Safety motivation−.01 (.844)−.01 (.844)
      Note. SMC = squared multiple correlation.

      Discussion

      The findings of this study partially support our hypothesized model. The patient safety event reporting of military nurses was found to be both directly and indirectly affected by organizational factors, such as safety climate and just culture, as well as by more individual factors, such as patient safety knowledge. Our finding that organizational factors are greater contributors to nurses' patient safety event reporting than are individual ones confirms the importance of enhancing patient safety in hospital settings through the use of more holistic organizational efforts. Although these results possess an explanatory power similar to those in a previous study [
      • Farag A.
      • Vogelsmeier A.
      • Knox K.
      • Perkhounkova Y.
      • Burant C.
      Predictors of nursing home nurses' willingness to report medication near-misses.
      ], it would have been higher if authentic leadership and safety motivation had a significant relationship with patient safety event reporting. Further research is thus needed to examine other factors related to patient safety event reporting given the non-significant effects of the examined variables in our study.
      Our study also reveals that military nurses perceive the need to report adverse events and no-harm events more often than near misses, which is consistent with the results of Kim et al. [
      • Kim S.A.
      • Kim E.-M.
      • Lee J.-R.
      • Oh E.G.
      Effect of nurses' perception of patient safety culture on reporting of patient safety events.
      ]. Chen et al. stated that a high proportion of nurses in Taiwan had limited experience with medical incident reporting [
      • Chen L.C.
      • Wang L.H.
      • Redley B.
      • Hsieh Y.H.
      • Chu T.L.
      • Han C.Y.
      A study on the reporting intention of medical incidents: a nursing perspective.
      ]. Patient safety event reporting is an important tool for the timely detection and correction of adverse events in order to create a safe medical environment [
      • Lee W.
      • Kim S.Y.
      • Lee S.I.
      • Lee S.G.
      • Kim H.C.
      • Kim I.
      Barriers to reporting of patient safety incidents in tertiary hospitals: a qualitative study of nurses and resident physicians in South Korea.
      ]. However, mistakes considered as having a lower severity are not reported as often as more serious errors. Employees often do not feel the need to report errors they perceive as acceptable, being likely that this behavior results in the underreporting of patient safety events [
      • Soydemir D.
      • Seren Intepeler S.
      • Mert H.
      Barriers to medical error reporting for physicians and nurses.
      ,
      • Chiang H.Y.
      • Lee H.F.
      • Lin S.Y.
      • Ma S.C.
      Factors contributing to voluntariness of incident reporting among hospital nurses.
      ]. Furthermore, military nurses did not show a proactive attitude toward reporting near misses, as compared to adverse events or no-harm events.
      Among all the variables, safety climate had the most significant effect on patient safety event reporting. This study found that, specifically, safety climate positively correlates with nurses' safety behavior [
      • Manapragada A.
      • Bruk-Lee V.
      • Thompson A.H.
      • Heron L.M.
      When safety climate is not enough: examining the moderating effects of psychosocial hazards on nurse safety performance.
      ]. Lee et al. reported that a positive safety climate reduces barriers for nurses to report errors [
      • Lee Y.S.
      • Ryu S.Y.
      • Park J.
      • Choi S.W.
      The association of safety climate and transformational leadership of head nurse with barrier to medication error reporting among nurses in a hospital.
      ]. This is important to note as military nurses must constantly adapt to new working environments due to their profession's rotational policy [
      • Oh H.
      • Cho Y.
      Effects of organizational culture, transformational leadership and transactional leadership on organizational effectiveness - comparing military hospitals with civil hospitals.
      ,
      • Choi Y.J.
      • Lee M.S.
      • Kang M.S.
      • Kim J.H.
      • Kim J.E.
      • Kim S.Y.
      Military nursing staff's perception and satisfaction on communication with other healthcare professionals and their job satisfaction in Korean military hospitals.
      ]. Thus, to improve their safety climate, nursing managers should promote unit-based patient safety programs that contain resources that would help staff nurses understand the patient safety mechanisms while improving their patient safety communication and teamwork [
      • Morello R.T.
      • Lowthian J.A.
      • Barker A.L.
      • McGinnes R.
      • Dunt D.
      • Brand C.
      Strategies for improving patient safety culture in hospitals: a systematic review.
      ]. It is also necessary to conduct periodic leadership walks to ensure that staff nurses trust their managers and are able to communicate with them proactively about patient safety [
      • Manapragada A.
      • Bruk-Lee V.
      • Thompson A.H.
      • Heron L.M.
      When safety climate is not enough: examining the moderating effects of psychosocial hazards on nurse safety performance.
      ,
      • Morello R.T.
      • Lowthian J.A.
      • Barker A.L.
      • McGinnes R.
      • Dunt D.
      • Brand C.
      Strategies for improving patient safety culture in hospitals: a systematic review.
      ].
      In this study, patient safety knowledge was found to directly affect patient safety event reporting; this finding is supported by those of previous studies [
      • Agustian I.
      • Lubis A.N.
      • Siregar F.L.S.
      Individual and organization affects perceptions of reporting patient safety incidents in Medan City Hospital.
      ,
      • Kim M.Y.
      • Eun Y.
      Perceptions of patient safety culture, safety care knowledge and activity among nurses at an orthopedic hospital.
      ]. For example, Agustian et al. reported that, between organizational and individual factors, patient safety knowledge is the variable with the most significant effect on Indonesian nurses' patient safety event reporting [
      • Agustian I.
      • Lubis A.N.
      • Siregar F.L.S.
      Individual and organization affects perceptions of reporting patient safety incidents in Medan City Hospital.
      ]. Additionally, Kim and Eun reported that patient safety knowledge is a predictor of nurses' safety activity. They emphasized the importance of training and education on nurses' patient safety knowledge in increasing their safety-based behaviors [
      • Kim M.Y.
      • Eun Y.
      Perceptions of patient safety culture, safety care knowledge and activity among nurses at an orthopedic hospital.
      ]. The development of a standardized patient safety education program for nurses in military hospitals is thus necessary to reduce the relevant knowledge gaps among them. In addition, the implementation of objective measurements and differential patient safety training programs according to individual knowledge levels are both required [
      • Hong S.
      • Li Q.
      The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.
      ].
      This research also found that just culture indirectly influences patient safety event reporting via safety climate. This finding is supported by the results of previous studies, which found that organizational factors, such as incident-reporting cultures, just cultures, and safety climates, have a significant effect on safety event reporting [
      • Chiang H.Y.
      • Lee H.F.
      • Lin S.Y.
      • Ma S.C.
      Factors contributing to voluntariness of incident reporting among hospital nurses.
      ,
      • Kim B.B.
      • Yu S.
      Effects of just culture and empowerment on patient safety activities of hospital nurses.
      ,
      • Lee Y.S.
      • Ryu S.Y.
      • Park J.
      • Choi S.W.
      The association of safety climate and transformational leadership of head nurse with barrier to medication error reporting among nurses in a hospital.
      ]. Our study also found that just culture has a direct effect on safety climate. Thus, it is important to create a just culture in military hospitals to improve patient safety behaviors among nurses. Military hospitals are characterized by a one-sided command system culture and discourage open communication [
      • Oh H.
      • Cho Y.
      Effects of organizational culture, transformational leadership and transactional leadership on organizational effectiveness - comparing military hospitals with civil hospitals.
      ,
      • Choi Y.J.
      • Lee M.S.
      • Kang M.S.
      • Kim J.H.
      • Kim J.E.
      • Kim S.Y.
      Military nursing staff's perception and satisfaction on communication with other healthcare professionals and their job satisfaction in Korean military hospitals.
      ]. Considering these organizational characteristics and this system's rotational position policy, military nurses are influenced more by the climate of their specific unit rather than by any widescale organizational culture. Therefore, continuous education should be conducted to disseminate the conception and awareness of a widescale just culture among nursing managers and frontline nurses in military hospitals in order to create a positive safety climate for each unit [
      • Richter J.P.
      • McAlearney A.S.
      • Pennell M.L.
      Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives.
      ]. In addition, just culture was found to have a indirect effect on patient safety event reporting through both safety climate and patient safety knowledge serially. This finding is supported by those of previous studies that outline the fact that organizational factors and safety knowledge are both significant factors within the process of safety event reporting [
      • Archer S.
      • Hull L.
      • Soukup T.
      • Mayer E.
      • Athanasiou T.
      • Sevdalis N.
      • et al.
      Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
      ,
      • Lee Y.S.
      • Ryu S.Y.
      • Park J.
      • Choi S.W.
      The association of safety climate and transformational leadership of head nurse with barrier to medication error reporting among nurses in a hospital.
      ,
      • Kim M.Y.
      • Eun Y.
      Perceptions of patient safety culture, safety care knowledge and activity among nurses at an orthopedic hospital.
      ]. This research also found that a positive safety climate enhances safety knowledge through the resulting generation of an environment of training or discussion in which safety information is communicated, either formally or informally [
      • Christian M.S.
      • Bradley J.C.
      • Wallace J.C.
      • Burke M.J.
      Workplace safety: a meta-analysis of the roles of person and situation factors.
      ]. Therefore, in order to improve patient safety reporting by military hospital nurses, efforts to improve the overall system, create a safety culture, and to form a positive working environment should be conducted. Contrary to our expectations, as well as in contradiction to previous studies, just culture did not directly affect patient safety event reporting [
      • Chiang H.Y.
      • Lee H.F.
      • Lin S.Y.
      • Ma S.C.
      Factors contributing to voluntariness of incident reporting among hospital nurses.
      ,
      • Kim B.B.
      • Yu S.
      Effects of just culture and empowerment on patient safety activities of hospital nurses.
      ]. This study found that military nurses did not positively perceive the organization's just culture, which is consistent with previous studies on clinical nurses [
      • Kim B.B.
      • Yu S.
      Effects of just culture and empowerment on patient safety activities of hospital nurses.
      ,
      • Lee G.-S.
      • Park J.-Y.
      Impact of nursing work environment on nurses' perception of just culture.
      ]. Levine, Carmody, and Silk mentioned that current hospital organization cultures do not facilitate the reporting of medical errors because nurses do not associate organizational culture with patient safety [
      • Levine K.J.
      • Carmody M.
      • Silk K.J.
      The influence of organizational culture, climate and commitment on speaking up about medical errors.
      ]. Patient safety education should thus be provided to frontline nurses so that they can recognize the overall just culture and patient safety in connection with clinical practice [
      • Marx D.
      Patient safety and the just culture.
      ].
      Interestingly, nursing managers' authentic leadership did not influence the safety climate or directly influence patient safety event reporting, which is a significant difference from the findings of previous studies [
      • Dirik H.F.
      • Intepeler S.S.
      The influence of authentic leadership on safety climate in nursing.
      ,
      • Labrague L.J.
      • Al Sabei S.D.
      • AbuAlRub R.F.
      • Burney I.A.
      • Al Rawajfah O.
      Authentic leadership, nurse-assessed adverse patient events and quality of care: the mediating role of nurses' safety actions.
      ]. Labrague et al. stated that nursing managers' authentic leadership significantly affects nurses' safety actions and their quality of care [
      • Labrague L.J.
      • Al Sabei S.D.
      • AbuAlRub R.F.
      • Burney I.A.
      • Al Rawajfah O.
      Authentic leadership, nurse-assessed adverse patient events and quality of care: the mediating role of nurses' safety actions.
      ]. Nursing managers in military hospitals are mainly active-duty officers, with military nurses being trained to obey the instructions of their superiors. These organizational characteristics encourage frontline nurses to familiarize themselves with managers who have a clear vision, charisma, and the capability to motivate them [
      • Oh H.
      • Cho Y.
      Effects of organizational culture, transformational leadership and transactional leadership on organizational effectiveness - comparing military hospitals with civil hospitals.
      ]. Ma et al. reported that military nurse managers need to develop a team leadership ability, set a clear vision, motivate their team personnel, manage conflict and stress, be adaptable, and be able to manage change [
      • Ma H.
      • Chihava T.N.
      • Fu J.
      • Zhang S.
      • Lei L.
      • Tan J.
      • et al.
      Competencies of military nurse managers: a scoping review and unifying framework.
      ]. Although authentic leadership did not have a significant effect on military nurses' safety event reporting level, to promote their safety behavior, studies need to explore the leadership type most appropriate for nursing managers in military hospitals.
      Moreover, safety motivation had no direct effect on patient safety event reporting, which again represents a significant difference from previous studies that posited the influence of safety motivation on safety behavior [
      • Christian M.S.
      • Bradley J.C.
      • Wallace J.C.
      • Burke M.J.
      Workplace safety: a meta-analysis of the roles of person and situation factors.
      ,
      • Vinodkumar M.N.
      • Bhasi M.
      Safety management practices and safety behaviour: assessing the mediating role of safety knowledge and motivation.
      ]. For example, Toren et al. stated that most nurses (80%) demonstrated an intention to report medical errors and near misses, although 53% of them had not reported near misses in the past year [
      • Toren O.
      • Dokhi M.
      • Dekeyser Ganz F.
      Hospital nurses' intention to report near misses, patient safety culture and professional seniority.
      ]. Thus, there was a difference found between participants' reported intentions and their actual near-miss reporting. Another prior study showed that 58.0% of nurses did not report adverse events in the preceding 12-month period [
      • Hong S.
      • Li Q.
      The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.
      ]. For military nurses within a distinct hierarchical relationship, organizational factors and patient safety knowledge (rather than safety motivation that is comprised of a more voluntary nature) have a significant impact on patient safety event reporting [
      • Agustian I.
      • Lubis A.N.
      • Siregar F.L.S.
      Individual and organization affects perceptions of reporting patient safety incidents in Medan City Hospital.
      ,
      • Archer S.
      • Hull L.
      • Soukup T.
      • Mayer E.
      • Athanasiou T.
      • Sevdalis N.
      • et al.
      Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature.
      ,
      • Hong S.
      • Li Q.
      The reasons for Chinese nursing staff to report adverse events: a questionnaire survey.
      ,
      • Neal A.
      • Griffin M.A.
      A study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels.
      ]. However, few studies have explored the relationship between safety motivation and patient safety event reporting. Further studies on the individual factors of this relationship are thus required.

      Strengths and limitations

      Our study is the first to identify the organizational and individual factors that affect military nurses' patient safety event reporting, based on Neal et al.'s safety model [
      • Neal A.
      • Griffin M.A.
      • Hart P.M.
      The impact of organizational climate on safety climate and individual behavior.
      ]. This study verified that safety climate and patient safety knowledge directly affect patient safety event reporting. Another notable finding is our confirmation that just culture indirectly influences patient safety event reporting.
      Our study contributes to nursing research by comprehensively exploring factors affecting the safety activities of military nurses in ensuring patient safety in military medical institutions. Further, it elucidates a rationale for developing effective strategies and programs to create a just culture and safety climate, as well as for improving military nurses' safety knowledge, in a way that takes into account the unique characteristics of military nursing personnel.
      This study does possess several limitations. First, patient safety event reporting was measured through nurses' subjective responses, rather than through their actual reporting rate, meaning that our results should be interpreted with care. Second, because closed questions and direct surveys have inherent limitations in revealing participants' honest answers, other data collection methods (e.g., online surveys and in-depth interviews) should be used in future studies in consideration of the vertical hierarchical structure of the military nursing organization.

      Conclusions

      This study confirms that safety climate (an organizational factor) and patient safety knowledge (an individual factor) significantly influence military nurses' reporting of patient safety events. Further, this study found that just culture has an indirect effect on patient safety event reporting. However, authentic leadership and safety motivation are not statistically significant factors for patient safety event reporting. This study emphasizes the fact that leaders and nursing managers in military hospitals should create a just culture and a safety climate that fosters nurses' safety activities, keeping in mind the unique characteristics of this organization. Further, nurses should be provided with adequate training that then improves their knowledge of patient safety and the importance of reporting errors so as to enhance the quality of care in military medical organizations.

      Funding

      This research received no funding.

      Data availability

      The data generated and analyzed during the current study is confidential; however, they can be made available from the corresponding author upon reasonable request.

      Conflict of interest

      All authors declare that there are no conflicts of interest.

      Acknowledgments

      We sincerely thank all the military hospitals and military nurses who participated in the study.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

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