Clinical nurses’ work-life balance prediction due to patient safety incidents using classification and regression tree analysis: a secondary data analysis

When healthcare workers provide medical care to patients, physical and mental injuries or side effects can occur [1] and cause patient safety incidents (PSIs), where patients unintentionally become the first victims in unavoidable circumstances [2]. Furthermore, the nurses become second-victims as they are traumatized by the unexpected PSIs, which negatively impacts their daily lives. These cascading effects cause harm and losses in healthcare facilities, resulting in third-victim experiences [3].

Experiencing patients’ pain and deaths resulting from PSI causes personal, emotional, and professional difficulties for nurses who provide care, thereby leading to additional problems, such as second-victimization [4‐7]. Negative emotions, such as fatigue, anxiety, depression, and low self-confidence caused by patient safety events directly affect organizations’ productivity losses through turnover intentions and absenteeism, which could continue as a vicious cycle that threatens patient safety [8]. Furthermore, the continuous workload of nurses, without any improvements in their working environments, such as manpower and salaries, and the resultant shortage of nurses increases third-victims’ experiences, such as turnover intentions and absenteeism [5, 9‐11].

Work-life balance (WLB) is a state of harmony between work, family, and social activities outside work according to one’s life priorities [12]. Failure to maintain WLB not only causes deterioration of physical and mental health, but also decreases the quality of life of individuals and their families, reduces job satisfaction and organizational commitment, and increases employee turnover [13]. As the degree of second and third victims’ experiences is an important variable in predicting clinical nurses’ WLB, it is necessary to understand its relationship with each variable. Exploring the relationship between nurses' Patient Safety Incidents (PSIs), second and third-victim experiences, and achieving Work-Life Balance (WLB) is crucial. Understanding how PSIs impact nurses emotionally, professionally, and personally is crucial, as it significantly influences patient care quality, organizational dynamics, and the well-being of healthcare workers. Addressing this link presents an opportunity to introduce focused support strategies, potentially decreasing turnover rates, enhancing job satisfaction, and cultivating a safer patient care environment within healthcare organizations [14]. Understanding how nurses are emotionally, professionally, and personally impacted provides an opportunity to bolster their support and enhance the organizational environment. These efforts ultimately contribute to improving patient safety, treatment outcomes, and the overall quality of healthcare services [15].

To improve the quality of care and maintain a culture of patient safety, second-victims should be supported, and research and support strategies should be initiated and evaluated as the patient safety movement progresses [7]. A strategy to prevent third damage by reducing second damage will also be an effective strategy for not only improving organizational medical service quality and productivity but also for improving job satisfaction, engagement, and patient safety [16]. Additionally, supporting one’s WLB—one of the driving forces supporting joy in the job process—should be prioritized as a strategy to achieve workforce development and health goals [10]. Therefore, the link between second-victims’ experiences and support, and third-victims’ experiences need to be examined to establish strategies for improving nurses’ performance and appropriately managing patient safety issues.

Most previous studies on nurses’ second-victim experiences from PSIs examined the causality of the impact of nurses’ perceived second-victim experiences on third-victim experiences [3, 17]. Although these studies tried to establish the relationship between variables through causality, their research results had limitations, which explains the complex patterns inherent in the relationship between second- and third-victims, and WLB for healthcare workers, especially nurses. Therefore, it is necessary to develop a model that can accurately evaluate the impact of factors such as PSI second-victims’ experiences, second-victims’ support, and third-victims’ experiences on nurses’ WLB, and closely examine the influence of these variables.

The target variables in this study were selected to predict WLB using the Least absolute shrinkage and selection operator (Lasso) regression model and the results were derived using the algorithm of classification and regression tree (CART) analysis. The lasso model is to handle collinearity and variable selection to find an accurate model among the predictor variables. The CART analysis is a valuable tool to provide an insightful understanding of complex and hierarchical relations and guide nurses to reduce gaps in the application of evidence to practice [18]. In order to find an easy-to-interpret and accurate model for the relationship between WLB and predictor variables in data with collinearity and missingness, Lasso and CART analyses are applied.

This study aimed to 1) analyze the relationship between second and third-victim experiences caused by PSIs, and the WLB of clinical nurses were predicted using classification and regression tree analysis techniques; and 2) present effective supportive measures to reduce second- and third-victimization, improve nurses’ work conditions, and ultimately enhance their WLB by identifying the factors involved in this relationship.

Studies have confirmed that various factors can influence WLB in nurses [12, 13]. In this study, the factors affecting WLB of nurses’ second-victim experiences, second-victim support, and third-victim experiences were analyzed in-depth, and a predictive model was identified. The degree of experiences of second- and third-victims after PSI was an important variable in predicting clinical nurses’ WLB, and among them, seven variables—education level, physical distress, turnover intentions, marital status, position, second-victim support, and absenteeism—were considered as the main explanatory variables. From among these, in the final model, the main variables affecting the effective WLB of clinical nurses were turnover intentions, physical distress, and second-victim support. Based on this study's findings, we were able to identify the key variables influencing work-life balance aligned with the research objectives. Consequently, we could delineate the pathways of factors negatively impacting work-life balance and propose suitable strategies considering risk factors.

Seven explanatory variables affecting WLB were derived based on the Lasso regression. Particularly, education levels, physical distress, and turnover intentions were found to have a negative effect on WLB. This suggests that the higher the education level, the more it could support confidence and responsibility in performing nursing tasks, based on one’s knowledge and experience, but getting frustrated in the situation of the second-victim was more likely. Moreover, experiencing an adverse event related to patient safety is a strong stressor, thus, resulting in job stress among clinical nurses [27]. These stresses include physical changes, such as tachycardia, sleep disturbance, and loss of appetite [28], that inevitably affect nurses’ health. As turnover intentions due to burnout and stress eventually lead to a shortage of manpower owing to nurse turnover, which affects patient outcomes [28]; it is important to first manage the stress and job performance of individual nurses [29] that facilitate managing second damage and avoiding progression to third damage.

This study’s results revealed that marital status, position, second-victim support, and absenteeism had a positive effect on WLB. Faced with heavy workloads and shift work, married nurses with children were constantly attempting work-family balance in the hope that they would be able to take good care of their families and raise their children [30]. This suggests that family life can affect married nurses’ WLB and absenteeism rates, as compared to unmarried nurses, who may not have family responsibilities. Therefore, it is necessary to consider granting leave effectively to improve work efficiency, reduce absenteeism, strengthen the competitiveness of hospitals, and enhance the image of organizations. Depending on the nurses’ job positions, there are differences in work that affect their individual lives. Newly qualified RNs are at increased risk of absenteeism because of illnesses related to work commitments and psychological demands. To prevent this, nursing managers must monitor nurses’ mental and physical functioning [31]. Additionally, strategies for reducing absenteeism and retaining newly graduated RN teams require input and organizational commitments from nursing managers [32]. In particular, nurses with second-victim experience were significantly more resilient than nurses who did not use peer support and support programs [33]. Peer support helps to reduce the emotional burden and provides an understanding of the error situation, thus enabling accessing the post-error event [34]. For clinical nurses who were involved in PSIs, support from colleagues, supervisors, family, and organizations reduces various difficulties caused by second-victim experiences and helps them to return to their normal daily lives and work [17].

In the decision tree, this study’s results showed the predicted WLB (target value) of four types based on three predictor variables (turnover intentions, physical distress, and second-victim support). The high value of WLB was 3.972 in the group where turnover intentions were less than 4.250, physical distress was less than 2.875, and second victim support was less than 2.345. Therefore, it can be concluded that turnover intentions, physical distress, and second-victim support are key factors influencing WLB, in that order.

Nurses’ WLB is important for nurse retention, and building organizational stability is essential for increasing job satisfaction and lowering turnover intentions [35]. Nurses’ turnover intentions have been presented as a recurring problem that can be reduced by improving their working conditions [4]. As physical afflictions such as insomnia, appetite problems, and tension-related pains are more severe in rigid work situations, a flexible time policy may solve this problem [36], but the method has not yet been fully established. It is expected that accepting such a system will take time owing to the temperament of the nurses who work in shifts. However, research related to providing an attractive work schedule and work environment is continuously being undertaken in an attempt to provide a solution [37].

While hospital-led support and mentorship opportunities are important for clinical nurses to recover from their second-victim experiences, it is also important to understand and support nurses’ needs, motivate them to become determined to recover from their wounds, and give them opportunities to develop further [29]. Organizations can implement several strategies to enhance work-life balance, nurse retention, and organizational stability. Introducing support programs for work-life balance, managing nursing workloads effectively, providing psychological support, offering appropriate rewards and incentives, enhancing learning and professionalism, and improving organizational culture and leadership can collectively contribute to achieving these objectives. These strategies aim to foster a conducive environment that promotes well-being, reduces turnover, and ensures stability within healthcare settings. Previous studies on nurses’ perceived second-victim experiences have investigated the status of these experiences, and discussions are emerging to devise strategies and programs [38, 39]. Therefore, it is necessary to improve the existing procedures and work environment by reviewing the work environment and work performance management of second-victims.

Accurate assessment of WLB based on second- and third-victims’ experiences using various methods to assess PSIs may provide better evidence for managing risk factors and remedial outcomes. Objective methods, such as health care providers’ electronic monitoring for patient safety, and modifying and developing safety protocols, are ideal for reducing second- and third-victim experiences resulting from PSI but may be costly or have no evidence of effectiveness on outcomes. Representing a predictive model by deriving variables in this way, based on the data obtained from the self-report questionnaire raises concerns about reporting bias, but since it is applicable in any environment and cost-effective, it can be an efficient way to provide additional information about one’s concerns.

In conclusion, this study provided a forward-thinking perspective on the interconnectedness of individual well-being and organizational resilience in healthcare. The effects of relevant factors in WLB are based on second- and third-victim experiences following a PSI and identified the optimal factor pathways for WLB using Lasso regression and regression tree methods. PSIs not only bring about difficulties for patients and their families but also cause physical and psychological difficulties for the clinical nurses involved. Further, healthcare facilities become the third victim because of negative work-related outcomes. Clinical nurses who have more second-victim experiences were found to have more third-victim experiences and work-life imbalances.

Managing individual nurses’ stress and job outcomes is important to prevent PSIs. The findings of this study can be used to develop interventions that strengthen support from colleagues and organizations to reduce clinical nurses’ second-victim experiences, thus preventing third-victim outcomes for hospitals. By advocating for strategic interventions aimed at the secondary connector experience, this research contributes to the ongoing discourse on improving healthcare outcomes and fostering resilient healthcare institutions. The proposed recommendations have practical implications for healthcare practitioners, administrators, and policymakers seeking to fortify the fabric of healthcare delivery systems.