Investigation of the Attitudes of Nurses Working in Paediatrics Departments Towards Malpractice

INTRODUCTION

Malpractice is frequently observed in the healthcare field, with negative consequences both professionally and personally. It is essential to assess the attitudes of nurses working in paediatric services regarding malpractice-related situations that affect the quality of care for children, a vulnerable group. Within the framework of understanding the law, all health professionals must perform practices within the framework of the concept of “permissible risk” (complication). Accordingly, the health professional is obliged to take possible precautions before the practice, except in emergencies. Even if adverse consequences occur due to the action within the permissible risk framework, this situation does not impose an obligation on the employee. Because the person has complied with the duty of care and attention.^[1] Failure to exercise caution and care is medically recognized as “medical malpractice”.^[1] Malpractice includes a wide range of conditions ranging from delayed recovery to the patient’s death as a result of the recommendations and/or practices of healthcare professionals^[2] and is defined as the act and situation that causes harm to the person caused by the negligence of the healthcare personnel not performing standard medical practice, applying the wrong treatment or not giving the treatment to the patient.^[3] Causes of malpractice; human factors (fatigue, inadequate training, lack of care, lack of precautions, carelessness, lack of communication, power/control, lack of time, wrong decision, error of logic, argumentative personality), institutional factors (workplace structure, policies, administrative/financial structure, leadership, inadequacy in feedback issues, misallocation of personnel) and technical factors (inadequate automation, inadequate devices, missing devices, lack of decision-making support, lack of integration).^[4] Malpractice practices lead to a decline in morale and motivation among healthcare professionals, increased distrust of healthcare personnel among patients, and dissatisfaction with the healthcare system within society.^[5] In the “Ethical Principles and Responsibilities for Nurses” published by the Turkish Nurses Association in 2009, section I, subparagraph a is based on the “principle of nonmaleficence/beneficence” and in summary, it is stated that the nurse should both comply with this situation and advocate-protect the patient from possible harm.^[6] However, nurses face a higher risk of medical errors more frequently compared to other professional groups due to the multiplicity and diversity of their dependent and independent functions, as well as the continuity of their patient care. In a retrospective study conducted by Ertem et al. in Turkey, which evaluated newspaper news over seven years, the rate of malpractice among nurses was reported to be 12.2%.^[7] In particular, it was stated that these rates and errors were higher in nurses working in paediatric services. The aim of this study is to examine the attitudes of nurses working in paediatric services about malpractice.

MATERIAL AND METHODS

This study is descriptive in nature. The research population consisted of nurses working in the paediatric service in Turkey who voluntarily participated in the study and completed the informed consent form. Their data were collected between February 9, 2024, and April 6, 2024. However, since it is almost impossible to reach all nurses in Turkey, the study was created online. Nurses with internet access were included in the research. A survey was used as a data collection technique in the research, and an online survey form (Google Forms) was distributed through social networks and social media. Missing data, surveys, and scales were sent to nurses working in the paediatric ward via Google Form, and approximately 3 weeks later, participants were reminded via social media to ensure their participation in the study, and the deficiencies were eliminated. The sample size for the study was determined based on the number of variables used in multivariate data analyses. In this regard, since the survey included 16 statements, the goal was to reach 350 people. In this context, the study sample was selected from nurses working in the paediatric ward in Turkey using the convenience sampling method, a non-probability sampling method. The study was conducted with 325 nurses working in paediatric wards who met the conditions for participation in the research.

Research data were collected through the following data collection forms: Socio-demographic questionnaire and questions to measure the prevalence of malpractice, attitude scale on medical errors

Socio-Demographic questionnaire form and questions to measure of the malpractice: This form to be filled out by nurses working in the paediatric ward consists of a total of 12 questions about age, sex, marital status, educational status, position, total years in the profession, number of paediatric patients cared for per day, having heard of malpractice, malpractice experience, reason for malpractice, having experienced malpractice, knowing that your teammates or others have committed malpractice.

Attitude scale on medical errors: The scale developed by Güleç and Intepeler in 2013^[8] consists of 16 items and 3 sub-dimensions. The validity and reliability of the scale were established. The scale aims to examine the attitudes of healthcare professionals towards medical errors. As stated, the Medical Attitude Scale consists of three components: cognitive, emotional, and behavioural. The subheadings are 3: medical error perception (2 items), medical error approach (7 items), and reasons for medical errors (7 items). The scale is a five-point Likert scale. The scores for the answers to the items range from 1 (strongly disagree) to 5 (strongly agree). Questions 10 and 13 under the ‘Medical Error Approach’ subheading are reverse-scored. The cut-off point of the scale was determined as 3. In the scale calculation, the scale score is obtained by dividing the total scale score by the number of scale items. In the sub-dimension calculation, the total score of the sub-dimension is divided by the number of related sub-dimension items. The score obtained ranges from 1 to 5. A mean score below 3 indicates that the participants’ attitude is negative, while a mean score above 3 indicates that their attitude is positive. A negative attitude means that employees have an insufficient understanding of the importance of medical errors and medical error reporting, which is a primary condition for preventing medical errors. On the other hand, a positive attitude indicates that employees have a better understanding of the importance of medical errors and error reporting. The data were analysed using frequency, chi-square test, Mann-Whitney U, and Kruskal-Wallis tests, as implemented in the SPSS 26.0 package program. Permission to use the Attitude Scale on Medical Errors was obtained from Güleç and Intepeler in 2013 via email. Permission for the study was obtained from Hakkari University Scientific Research and Publication Ethics Committee (IRB: 2024/19-1).

RESULTS

According to Supplementary Table S1, 88.7% of the nurses included in the study were female, and 11.3% were male. Considering the age findings, it was found that 32.3% of the majority (81 people) fell within the age range of 26-33. Malpractice was reported by 92% (310 participants) of the nurses, and the number of those who experienced malpractice was 115 (37.9%).

According to Table 1, the opinions of nurses working in the paediatric service regarding the causes of malpractice are presented. According to the participants, the causes of malpractice are stress (81 people), fatigue (79 people), inexperience (73 people), insufficient professional experience (63 people), long working hours (59 people), unfavourable environment (53 people), lack of communication (29 people), and lack of error prevention system (47 people). According to Table 2, it was determined that the mean score of the medical error attitude scale for nurses working in the paediatric service was above the mean score of the scale.

According to Table 3, the analysis of the distribution of total scores and subgroup mean scores of the medical error attitude scale among nurses working in paediatric services revealed significant differences in terms of sex and whether they had heard of malpractice before (p < 0.05). Post hoc analyses (Mann-Whitney U) were performed to investigate the origin of the difference between the results of the question of having heard of malpractice before and the medical error attitude scale score. As shown in Table 3, the mean scores of the medical error attitude scale, as well as the cognitive, emotional, and behavioural scores, for women are higher than those for men (p < 0.05). It was determined that the level of education did not affect malpractice (p > 0.05). According to the level of education, the mean scores of the medical error attitude scale and cognitive, emotional, and behavioural scores are higher. The reporting status of the participants, as well as their malpractice status and the reporting status of their teammates’ malpractice, also affect it.

DISCUSSION

Errors made in nursing practices can result in both material and moral damages for the nurse, as well as harm to the patient and their family. Nurses need to be aware of the mistakes they make, recognize the situations that increase the likelihood of erroneous practices, and take the necessary precautions to prevent harm to patients and their families, as well as protect themselves against legal repercussions.^[9] According to the results of sociodemographic characteristics from our research findings, the evidence^[10] that nurses should participate in diagnosis: Lessons learned from malpractice claims and^[11] Concept analysis: malpractice and contemporary nursing practice. The results of^[12] medication errors as malpractice, a qualitative content analysis of 585 medication errors made by nurses in Sweden, are also similar.

Our research findings, which present the causes of malpractice, are shown in Table 1. Our findings^[13] concluded that stress and fatigue, especially long working hours, were among the causes of malpractice in their study on nursing students’ awareness of nursing malpractice.^[14] According to a study titled “Malpractice in nurses: error tendency and causes,” it was concluded that inexperience, frequent change of doctors, and long working hours are among the causes of malpractice. The results of the study^[15] on the malpractices of student nurses in clinical practice in Turkey and the study^[16] on malpractice/negligence and responsibility in nursing are similar. In a study^[17] on nursing errors and their causes among nursing students, it was concluded that inexperience and lack of knowledge were the most common causes of errors. In this study, as seen in Table 2, the mean score of the Medical Error Attitude Scale of nurses working in the paediatric ward was found to be 4.65, which is close to the studies of Odabaşoğulu (4.63), Seren İntepeler and Soydemir (4.61), Öztürk and Özata (4.71), (4.70), but different from the studies (2.70).^[18-22]

In our research findings, according to age variables, as illustrated in Table 3, there was no significant difference (p >0.05) between age groups in terms of educational status, marital status, job, working time, average number of patients seen per day, and scores on the medical error attitude scale and its sub-dimensions.^[23,24] Similar to this study, in some studies in the literature, no difference was found between the variables of age, education level, and working time and the mean scores of the medical error attitude scale and subgroups.^[25,26] It was observed that there was a difference between genders in the distribution of mean scores on the medical error attitude scale and subgroup scores, with a tendency for female nurses to make more errors. A similar result was reported in a study indicating a higher error tendency in women.^[22] Although no difference in this direction was found in the studies of Altunkan, Pekuslu et al., it was reported that male nurses were more prone to medical errors.^[5,27,28] Our research findings are presented in Table 4, among the other characteristics: Have you heard of malpractice before? The results of this study^[29] on the status and contributing factors of negligence-related adverse events in nursing care and the results of a study by Myers et al., (2020)^[30] on lessons learned from medical malpractice claims involving intensive care nurses are in parallel^[31]. A study on the tendency for malpractice among nurses in Turkey found that the results of expressing malpractice and the involvement of any of their coworkers in the malpractice process are similar. Similarly,^[32] the causes and management of nursing malpractice: A questionnaire survey of hospital nurses in Iran and^[33] allegations of malpractice related to calls to Swedish telephone counselling nursing: What went wrong and why. This study does not represent the general population of nurses working in the paediatric ward and is limited to nurses who voluntarily participated in the study and provided their consent. This research will be useful in guiding studies aimed at reducing malpractice, which is frequently observed in the field of health, particularly in addressing situations that prevent nurses from working professionally in the paediatric service.

CONCLUSION

According to the participants in this study, the reasons for malpractice include fatigue, excessive workload, stress, off-duty workload, a low number of nurses, long working hours, inexperience, and dissatisfaction with managers. Improvements in the working conditions, service quality, and compensation of nurses may be effective in reducing malpractice. It is recommended that nurses working in the paediatric service be encouraged to participate in training on reducing malpractice, and research should be conducted to inform this area of practice.