Study of Nurses' Malpractice Tendencies and Burnout Levels

ABSTRACT

Malpractice, which occurs when a reasonable standard of service cannot be provided, is a critical situation in nursing care and interventions. Nurses' tendency toward medical errors and burnout levels are important due to their impact on patient safety and the quality of care. This study was conducted to investigate nurses’ malpractice tendencies and burnout levels and the relationship between the two. The data of this descriptive, cross‐sectional, and correlational study were collected from 292 nurses working in a training and research hospital in Istanbul province between January and February 2021. A Descriptive Information Form, the Malpractice Trend Scale in Nursing (MTSN), and the Maslach Burnout Inventory (MBI) were used to collect data. In data analysis, internal consistency coefficient, descriptive, non‐parametric comparisons, and correlation analyses were performed. The mean age of the nurses participating in the research was 31.13 ± 7.87 years; 79.8% were women, 50.7% were single, and 68.5% had an undergraduate degree. When nurses’ opinions about malpractice were examined, it was determined that 88.7% had not committed malpractice before and 53.4% had witnessed someone who committed malpractice. Nurses' overall MTSN score was 233.48 ± 15.32. Their Maslach Burnout Inventory score was 18.20 ± 8.83 on the emotional exhaustion subscale, 8.07 ± 3.86 on the depersonalization subscale, and 21.31 ± 4.00 on the personal accomplishment subscale. The reliability coefficients of the scales and subscales ranged between 0.61 and 0.95. There was a significant difference between the MTSN scale and MBI subscales according to nurses’ positions and satisfaction with the environment (p < 0.05). A negative correlation was found between the mean scores on the total MTSN and the MBI emotional exhaustion (r = −0.314) and depersonalization (r = −0.293) subscales, and a positive and statistically significant relationship (p < 0.001) existed between the MTSN total scale and the personal accomplishment (r = 0.359) subscale. The level of burnout is associated with a tendency to malpractice. Taking measures to prevent nurses from experiencing burnout may be important for reducing medical errors. These measures will be reflected in better care service and quality.

1. Introduction

Despite rapidly developing technology, medical errors, which have been defined as failure to complete a planned action as intended or use of an incorrect plan to achieve a goal, are a serious public health problem that poses a threat to patient safety (Rodziewicz et al. 2024). These errors threaten patient safety and highlight the urgent need to identify the factors contributing to malpractice, detect errors, and develop effective procedures to enhance patient safety (Flotta et al. 2012). Preventing medical errors is a top priority in healthcare delivery and quality care (Bademli and Lök 2021). Nurses, as vital members of the healthcare team, have direct contact with hospitalized individuals. However, negative working conditions, such as high work intensity, inconvenient shift hours, heavy workloads, and inadequate staffing, can adversely impact the quality of care (Park and Hwang 2021) and increase the risk of malpractice (Şahin and Özdemir 2015). Undoubtedly, patients are the ones affected by medical errors firsthand. However, malpractice also has adverse effects on the individual who commits them.

Burnout is one significant negative consequence of malpractice (Robertson and Long 2018). Healthcare workers who commit medical errors may feel guilty and morally distressed, which are compounded by stress and exhaustion stemming from challenging working conditions. These factors can lead to burnout (Maslach and Leiter 2016; Ryu and Shim 2021; Søvold et al. 2021). Moreover, individuals experiencing burnout may be more prone to committing medical errors themselves (De Hert 2020).

Given the potentially reciprocal relationship between malpractice and burnout, it is crucial to explore the perspectives of nurses who work under challenging conditions and are at risk for burnout and malpractice. Understanding their experiences is essential for preventing potential problems and improving the healthcare environment. This study addresses this gap by focusing on the relationship between nurses’ malpractice tendencies and burnout levels, as well as their associations with various factors. Notably, there is limited research into these two concepts together, making this study particularly significant.

2. Background

Medical errors are defined as situations where the planned treatment or standard procedure by a healthcare professional is not completed as intended due to some reasons, such as insufficient knowledge or experience in professional practices, negligence, lack of attention, etc. This can result in injury, harm, serious physical or psychological damage, or even death due to improper intervention in the patient (Demir Dikmen et al. 2014; Mankan et al. 2017; Kırşan et al. 2019). Rodziewicz et al. (2022) defined malpractice as the failure to complete the intended action or the implementation of the wrong plan to achieve a goal, as well as negligence that contributes or may contribute to an undesirable outcome while planning or performing a procedure. This includes deviations from the care process that may or may not result in harm (Rodziewicz et al. 2022). Many people are adversely affected and unfortunately lose their lives due to medical errors, which is an extremely critical issue for human life. Systems that document, reduce, or prevent errors from occurring are crucial for preventing them (Mauti and Githae 2019). Reporting these errors is of great importance in detecting patient safety problems (Björkstén et al. 2016). To limit errors and increase patient safety (Savva et al. 2022), a safe reporting environment for documenting existing errors needs to be created, and employees should be encouraged to report malpractice (Zarea et al. 2018).

The most common type of malpractice is medication errors (Kırşan et al. 2019). Although medication errors can be made by any member of the healthcare team, those made by nurses, who constitute the majority of this team, are the most frequent (Zarea et al. 2018). According to the Turkish Ministry of Health 2017 Safety Reporting System statistics, the majority of medication errors were reported by nurses, most resulting from incorrect dosing. The examination of the distribution of malpractice by the time of occurrence indicated that errors most commonly occurred during the busiest hours of patient care and intense work (Ministry of Health 2018).

Another factor that increases the risk of medication errors is the shift system. Shift work disrupts nurses’ sleep patterns and leads to exhaustion (Ryu and Shim 2021). It has been reported that fatigue can lead to malpractice that may harm patients’ health (Caruso 2014) and reduce the effectiveness of nursing services (Ryu and Shim 2021).

Malpractice results in a loss of efficiency and motivation among healthcare professionals (Yiğitbaş et al. 2016), leading to stress and moral conflicts. These practices also diminish patients’ trust and satisfaction with healthcare professionals (Zarea et al. 2018). Nurses, who play a key role in healthcare delivery and are responsible for individual care, directly participate in medical practices. Their mistakes in these practices can pose a significant danger to patients. Factors such as work intensity, overtime hours, increasing number of patients per nurse, inadequate staffing, and excessive workload contribute to poor nursing care. This situation negatively affects patient safety and quality of care (Park and Hwang 2021) and increases the likelihood of medical errors (Şahin and Özdemir 2015).

Additionally, nurses exposed to poor working conditions, such as increased workload, inadequate staffing, and long shifts, may experience mental health problems such as burnout (Kwon et al. 2021). It is extremely important to prevent malpractice and ensure patient safety in hospitals, as well as to protect employees from experiencing burnout, which can have negative physical and psychological effects (Melnyk 2020; Ryu and Shim 2021).

Burnout is described as a state of “wearing out, lack of effort, depletion, and powerlessness” (Karakaş et al. 2017). The concept of burnout was first introduced by Freudenberger in 1974 (Waddill‐Goad 2019). The most common and widely accepted definition of burnout today was proposed by Christina Maslach, who also developed the Maslach Burnout Inventory (MBI), named after her (Dall'Ora et al. 2020). Maslach and Jackson (1981) described three components of burnout: emotional exhaustion, depersonalization, and reduced personal accomplishment (Maslach and Jackson 1981). Emotional exhaustion is characterized by fatigue, tiredness, and a lack of energy. Depersonalization occurs when employees display indifference, apathy toward people, and exhibit negative behavior. Reduced personal accomplishment refers to a decrease in productivity, capabilities, morale, and coping skills (Edú‐Valsania et al. 2022).

Healthcare workers are considered one of the most at‐risk groups for burnout, given the emotional strain of providing care for patients and the stressful work environments (Shah et al. 2021). Burnout, characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment, has been reported to affect approximately half of healthcare workers (Melnyk 2020). Nurses who engage in direct communication with patients, work on the front lines under all conditions, and operate in challenging circumstances, are particularly at risk for burnout (Cañadas‐De la Fuente et al. 2015; Waddill‐Goad 2019). The literature supports this statement through some reports that negative job characteristics, such as heavy workload, inadequate staffing, long shifts, and poor team communication, are associated with burnout in nurses (Dall'Ora et al. 2020; Shah et al. 2021).

As mentioned earlier, a decrease in motivation (Yiğitbaş et al. 2016) and unfavorable working conditions (such as heavy workload, inadequate staffing, and shift work) increase the tendency toward malpractice in nurses (Demir Dikmen et al. 2014; Melnyk et al. 2018). The resulting exhaustion, work intensity, overwork, and high stress levels lead to burnout in healthcare workers (Şenturan et al. 2009; Cañadas‐De la Fuente et al. 2015; Ryu and Shim 2021). Increased levels of burnout impede the delivery of healthcare at the desired level, negatively affect the services provided by nurses in close contact with patients, decrease patient satisfaction, and worsen patient safety outcomes such as medical errors (Garcia et al. 2019; Melnyk 2019; Kwon et al. 2021). In this regard, this study was conducted to evaluate the burnout levels and malpractice tendencies of nurses, who hold a significant position in healthcare, identify variables related to both concepts, and examine the relationship between them.

3. Methods

3.1. Design and Participants

This descriptive, cross‐sectional, and correlational study was conducted between January and February 2021. The population of the study consisted of nurses (N = 490) working at a hospital located in XXXX and providing services under the Ministry of Health. The sample selection was based on the sampling of the known population method. The minimum sample size was calculated as 175, with a sampling error of ± 5%, a confidence interval of 90% (α = 0.05), and an effect size of 0.2. The study was completed with 292 nurses who volunteered to participate and answered all questions completely.

3.2. Data Collection

Research data were collected using the online survey method. The survey link was conveyed to the nurses working at the hospital through the nurse manager. In the first part of the questionnaire, information about the purpose and scope of the study was provided. Nurses who agreed to participate in the study had access to the data collection tools after approving the consent form.

3.3. Measurements

A Descriptive Information Form, the Malpractice Trend Scale in Nursing (MTSN), and the Maslach Burnout Inventory (MBI) were used in data collection.

3.3.1. The Descriptive Information Form

This form consisted of fourteen questions regarding the personal and occupational characteristics of the nurses participating in the study (age, gender, department, satisfaction with the work environment, willingness to remain in the profession, cases where nurses committed or encountered malpractice, etc.).

3.3.2. The Malpractice Trend Scale in Nursing (MTSN)

The scale, developed by Özata and Altunkan (2010), comprises 49 items and five subscales, namely “medicine and transfusion practices” (eighteen items), “prevention of infections” (twelve items), “patient monitoring and equipment safety” (nine items), “prevention of falls” (five items), and “communication” (5 items). The scale stem reads “Please indicate the option that best applies to you for each item”. An example item is “I pay attention to the rules of asepsis in invasive interventions applied to the patient “. Each item is scored on a scale ranging from ‘never’ (1 point) to ‘always’ (5 points) (Özata and Altunkan 2010). The lowest possible score on the scale is 49, and the highest is 245. An increase in total scores is interpreted as a decrease in nurses’ tendency to make medical errors. The internal consistency coefficient for the overall scale score was reported as 0.95 (Özata and Altunkan 2010). In this study sample, this coefficient ranged from 0.81 to 0.88 across the subscales and was α = 0.95 for the total scale.

3.3.3. The Maslach Burnout Inventory (MBI)

This scale was developed by Maslach and Jackson (1981) and adapted into Turkish by Çam (2001). It consists of 22 items and three subscales: “emotional exhaustion” (nine items), “depersonalization” (five items), and “personal accomplishment” (eight items). The scale stem reads, “Please indicate how often you experience each item of the scale consisting of sentences expressing your feelings, thoughts and attitudes about your job and mark the appropriate one for you”. An example item is “I feel burned out from my work”. Each item is scored on a scale ranging from ‘never’ (0 points) to ‘always’ (four points). The Turkish adaptation differs from the original MBI, in which items are scored on a seven‐point scale (from never—0 points to every day—six points) (Maslach et al. 1997). Therefore, the values of the Turkish version are not comparable to those of studies utilizing the original MBI, nor are coefficients from analyses utilizing these scores. The cutoff values for the scores obtained from the scale adapted into Turkish by Çam (2001) have not been reported. However, for individuals experiencing burnout, high scores are expected from the emotional exhaustion (0‐36 points) and depersonalization (0‐20 points) subscales, while low scores are presumed from the personal accomplishment subscale (0‐32 points). Scores are calculated separately for each subscale. “Emotional exhaustion” is described as feeling drained by one's job and experiencing increased hopelessness, tension, and restlessness, while “depersonalization” is characterized by indifference and apathy toward the work, doing the job with the body rather than the soul, and treating the service recipients as objects. “Personal accomplishment” is expressed as a decrease in achievements and self‐confidence, accompanied by a feeling of regression at work. In the Turkish version, the internal consistency coefficients were reported as 0.81 for emotional exhaustion, 0.70 for depersonalization, and 0.77 for personal accomplishment (Çam 2001). In the measurements obtained from this study sample, the internal consistency coefficients were calculated as 0.91, 0.62, and 0.72 for these subscales, respectively.

3.4. Ethical Considerations

The approval of the Non‐Interventional Research Ethics Committee of XXX University (Approval no: XXX/XX‐XX) and the necessary institutional permissions were obtained. Informed consent forms were taken from nurses who agreed to voluntarily participate in the study.

3.5. Data Analysis

The data were analyzed on the IBM SPSS Statistics 23 software, based on a confidence interval of 95% and a significance level of p < 0.05. The internal consistency coefficient (Cronbach's Alpha) was used to test the reliability of the measurements obtained from the scales, and descriptive analysis (number, percentage, minimum and maximum values, mean, and standard deviation) was employed to present nurses’ descriptive characteristics and scale scores. Normal distribution was evaluated using the Kolmogorov‐Smirnov and Shapiro‐Wilk tests. Non‐parametric comparative analyses (Mann‐Whitney U test, Kruskal‐Wallis H test) were used for the comparison of the measurements, and correlational analyses (Spearman's) were utilized to assess the relationships between them.

4. Results

4.1. Nurses' Demographic Characteristics

The mean age of the nurses involved in the study was 31.13 ± 7.87 years. Of the participants, 79.8% were women, 50.7% were single, and 68.5% had an undergraduate degree. The results indicated that 85.6% of the nurses worked as staff nurses, and the remainder were charge nurses; 33.9% were employed in the intensive care unit, 58.2% worked day and night shifts, and 34.9% provided care for 1‐5 patients a day. It was found that 75.3% of the nurses wanted to work in their unit, 55.1% were satisfied with their work environment, and that 67.1% wanted to change their profession (Table 1).

Table 1.

Occupational and Demographic Characteristics of Nurses (N = 292).

	M ± SD
Age	31.13 ± 7.87
Occupational Experience	8.61 ± 7.94
Institution Experience	5.17 ± 4.99
		n	%
Gender	Female	233	79.8
	Male	59	20.2
Marital status	Married	144	49.3
	Single	148	50.7
Educational Status	VHS	24	8.2
	Associate Degree	34	11.6
	Undergraduate Degree	200	68.5
	Postgraduate	34	11.6
Position	Charge	40	13.7
	Nurse	250	85.6
Unit	Emergency	54	18.5
	ICU	99	33.9
	Clinic	86	29.5
	Operating Room	53	18.2
Working Shift	Only night shift	24	8.2
	Only day time	98	33.6
	Night and day in shifts	170	58.2
Number of Patients Cared Daily (Average)	1‐5	102	34.9
	6‐10	34	11.6
	11‐15	25	8.6
	15 and over	93	31.8
	Executive	38	13.0
Want to Work in the Unit	Yes	220	75.3
	No	72	24.7
Satisfied with the Work Environment	Yes	161	55.1
	No	31	10.6
	Somewhat	100	34.2
Want to Change the Profession	Yes	196	67.1
	No	96	32.9

Note: Highest percentage values are shown in bold.

4.2. Committing and Encountering Malpractice in Nurses

When the cases where nurses committed or encountered malpractice were examined, it was found that 88.7% had not committed it before, 53.4% had encountered someone doing it, and 62.8% of the nurses who had encountered malpractice had reported it. Additionally, 87.5% of the participants who had not encountered anyone committing malpractice stated that they would report any future malpractice incidents (Table 2).

Table 2.

Committing and Encountering Malpractice in Nurses (N = 292).

		n	%
Committing medical errors/malpractice	Yes	33	11.3
	No	259	88.7
Encountering someone who committed medical error/malpractice	No	136	46.6
	Yes	156	53.4
When witnessing a medical error/malpractice (n = 156)	I ignored it	6	3.8
	I didn't report it, but I warned the person	52	33.4
	I reported it	98	62.8
For the possibility of encountering a medical error/malpractice (n = 136)	I will ignore it	17	12.5
	I will report it	119	87.5

Note: Highest percentage values are shown in bold.

4.3. Comparison of Nurses According to Their MTSN and MBI Scores

Participants’ mean score on the total MTSN scale was 233.48 ± 15.32, indicating very low malpractice tendencies. Their subscale scores were 86.41 ± 4.87 on the medicine and transfusion practices subscale, 57.41 ± 4.25 on the hospital infections subscale, 41.78 ± 4.03 on the patient monitoring and equipment safety subscale, 23.84 ± 2.25 on the falls subscale, and 24.03 ± 2.04 on the communication subscale. The mean scores of the participants on the subscales of the MBI were 18.20 ± 8.83 on the emotional exhaustion, 8.07 ± 3.86 on the depersonalization, and 21.31 ± 4.00 on the personal accomplishment (Table 3), all reflecting relatively low burnout.

Table 3.

Nurses’ MTSN and MBI Mean Scores (N = 292).

Scales		Min.	Max.	M ± SD
MTSN	Total	156.00	245.00	233.48 ± 15.32
	Medicine and Transfusion Practices	64.00	90.00	86.41 ± 4.87
	Hospital Infections	35.00	60.00	57.41 ± 4.25
	Patient Monitoring and Equipment Safety	24.00	45.00	41.78 ± 4.03
	Falls	11.00	25.00	23.84 ± 2.25
	Communication	13.00	25.00	24.03 ± 2.04
MBI	Emotional Exhaustion	0.00	36.00	18.20 ± 8.83
	Depersonalization	1.00	20.00	8.07 ± 3.86
	Personal Accomplishment	9.00	28.00	21.31 ± 4.00

As shown in Table 4, no statistically significant difference was found between nurses’ MTSN scores and their gender, marital status, educational status, shift schedule, daily number of patients provided with care, and malpractice (p > 0.05).

Table 4.

Distribution and Comparison of MTSN and MBI Mean Scores by Nurses’ Demographic and Occupational Characteristics (N = 292).

Nurses’ demographic and occupational characteristics		n	MTSN						MBI
			Total (M ± SD)	Medicine and transfusion practices	Hospital infections	Patient monitoring and equipment safety	Falls	Communication	Emotional exhaustion	Depersonalization	Personal accomplishment
Gender f	Female	233	233.96 ± 14.92	86.49 ± 4.83	57.51 ± 4.18	41.89 ± 3.92	23.89 ± 2.27	24.15 ± 1.93	18.13 ± 8.42	7.72 ± 3.52	21.05 ± 3.86
	Male	59	231.62 ± 16.80	86.10 ± 5.07	56.98 ± 4.53	41.35 ± 4.45	23.66 ± 2.20	23.52 ± 2.40	18.47 ± 10.36	9.45 ± 4.77	22.32 ± 4.40
p			0.558	0.631	0.576	0.684	0.404	0.025	0.954	0.014	0.023
Marital status f	Married	144	234.79 ± 14.00	86.92 ± 4.31	57.69 ± 4.00	42.09 ± 3.73	23.90 ± 2.08	24.17 ± 1.67	18.04 ± 8.42	7.73 ± 3.55	21.35 ± 4.05
	Single	148	232.21 ± 16.45	85.91 ± 5.33	57.13 ± 4.47	41.47 ± 4.29	23.79 ± 2.42	23.89 ± 2.35	18.36 ± 9.24	8.41 ± 4.12	21.27 ± 3.96
p			0.095	0.122	0.193	0.198	0.392	0.621	0.883	0.178	0.727
Educational Status g	VHS	24	236.75 ± 11.97	87.00 ± 3.87	58.25 ± 3.27	42.33 ± 3.67	24.62 ± 1.24	24.5 ± 1.71	16.37 ± 10.84	8.08 ± 5.11	21.58 ± 4.19
	Associate Degree	34	234.73 ± 12.55	86.82 ± 4.06	57.73 ± 3.22	42.52 ± 3.55	24.05 ± 1.66	23.58 ± 2.28	16.05 ± 7.37	8.20 ± 3.69	21.82 ± 3.34
	Undergraduate Degree	200	232.33 ± 16.58	86.05 ± 5.22	57.14 ± 4.67	41.45 ± 4.25	23.67 ± 2.50	24.02 ± 2.12	18.59 ± 8.81	7.97 ± 3.76	21.02 ± 4.03
	Postgraduate	34	236.73 ± 11.26	87.73 ± 3.91	58.05 ± 2.88	42.61 ± 3.20	24.14 ± 1.55	24.17 ± 1.44	19.38 ± 8.60	8.58 ± 3.71	22.32 ± 4.22
p			0.251	0.184	0.459	0.159	0.176	0.094	0.347	0.778	0.418
Position f	Charge Nurse	40	238.11 ± 12.07	87.38 ± 4.73	58.54 ± 2.98	43.69 ± 2.33	24.11 ± 1.92	24.38 ± 1.32	13.76 ± 7.13	6.26 ± 2.43	23.23 ± 2.79
	Nurse	250	232.71 ± 15.69	86.25 ± 4.89	57.22 ± 4.40	41.46 ± 4.17	23.80 ± 2.31	23.97 ± 2.14	18.95 ± 8.88	8.38 ± 3.97	20.98 ± 4.08
p			0.003	0.056	0.023	<0.001	0.196	0.416	<0.001	0.001	0.001
Unit g	Emergency a	54	229.09 ± 21.42	85.05 ± 5.92	56.18 ± 6.30	41.35 ± 5.32	22.88 ± 3.52	23.61 ± 2.98	18.90 ± 9.97	9.25 ± 4.02	21.20 ± 4.52
	ICU b	99	231.98 ± 15.04	85.93 ± 5.13	56.86 ± 4.10	41.16 ± 3.96	23.96 ± 1.87	24.05 ± 1.85	17.58 ± 8.78	7.00 ± 3.51	20.76 ± 3.73
	Clinic c	86	234.93 ± 12.75	87.05 ± 4.37	58.06 ± 3.33	41.91 ± 3.64	23.96 ± 1.88	23.91 ± 1.92	19.72 ± 7.89	8.86 ± 4.09	21.32 ± 3.85
	Operating Room c	53	238.43 ± 10.05	87.64 ± 3.43	58.60 ± 2.56	43.16 ± 2.83	24.41 ± 1.44	24.60 ± 1.13	16.18 ± 8.88	7.62 ± 3.39	22.41 ± 4.04
p			0.016 a < c	0.052	0.081	0.012 b < c	0.027 a < b, c	0.022 a < b	0.160	0.001 a > b, b < c	0.073
Working Shift g	Only night shift a	24	229.45 ± 17.45	85.12 ± 5.93	55.83 ± 5.71	40.50 ± 4.37	24.20 ± 1.47	23.79 ± 2.16	19.00 ± 7.25	9.16 ± 4.16	21.20 ± 3.50
	Only day time b	98	236.76 ± 11.75	86.87 ± 4.11	58.48 ± 3.21	42.84 ± 3.14	24.19 ± 1.66	24.35 ± 1.50	16.67 ± 7.94	7.48 ± 3.18	21.90 ± 3.59
	Night and day in shifts c	170	232.17 ± 16.53	86.32 ± 5.11	57.01 ± 4.42	41.35 ± 4.32	23.60 ± 2.60	23.87 ± 2.27	18.97 ± 9.43	8.26 ± 4.13	20.98 ± 4.26
p			0.066	0.346	0.001 b > a, c	0.004 a < b, c	0.154	0.242	0.081	0.145	0.193
Number of Patients Cared Daily (Average) g	0 a	38	237.50 ± 11.74	87.31 ± 4.39	58.57 ± 2.81	43.13 ± 2.67	24.23 ± 1.53	24.23 ± 1.49	13.50 ± 7.23	6.34 ± 3.06	22.81 ± 3.16
	1‐5 b	102	231.94 ± 15.02	86.23 ± 4.74	56.78 ± 4.24	40.98 ± 4.06	23.95 ± 1.90	23.99 ± 1.93	17.95 ± 8.86	7.19 ± 3.60	20.78 ± 3.90
	6‐10 c	34	232.73 ± 13.88	85.70 ± 4.97	57.76 ± 3.61	41.61 ± 4.05	23.94 ± 2.11	23.70 ± 2.44	18.73 ± 8.75	9.08 ± 4.15	20.91 ± 3.93
	11‐15  d	25	237.00 ± 10.06	87.40 ± 3.71	58.16 ± 2.70	42.44 ± 2.94	24.44 ± 1.29	24.56 ± 1.15	17.56 ± 8.10	9.12 ± 4.70	22.08 ± 3.37
	15 and over e	93	232.88 ± 18.18	86.23 ± 5.42	57.29 ± 5.14	42.00 ± 4.55	23.38 ± 2.96	23.96 ± 2.37	20.38 ± 8.98	9.10 ± 3.65	21.24 ± 4.46
p			0.110	0.268	0.117	0.019 a > b	0.330	0.790	0.001 e > a	<0.001c,d,e > a	0.061
Want to Work in the Unit f	Yes	220	233.84 ± 15.93	86.46 ± 5.15	57.34 ± 4.54	41.95 ± 4.08	23.95 ± 2.14	24.11 ± 1.95	17.02 ± 8.55	7.67 ± 3.65	21.51 ± 4.09
	No	72	232.41 ± 13.32	86.25 ± 3.92	57.61 ± 3.22	41.26 ± 3.87	23.51 ± 2.57	23.77 ± 2.29	21.80 ± 8.75	9.30 ± 4.24	20.68 ± 3.64
p			0.024	0.031	0.253	0.045	0.271	0.235	<0.001	0.002	0.144
Satisfied with the Environment g	Yes a	161	234.86 ± 15.57	86.77 ± 4.92	57.61 ± 4.46	42.19 ± 4.04	24.05 ± 2.12	24.22 ± 1.91	15.06 ± 9.02	7.26 ± 3.95	21.95 ± 3.93
	No b	31	232.48 ± 11.02	85.22 ± 5.67	57.67 ± 2.49	41.54 ± 3.03	24.09 ± 1.86	23.93 ± 1.84	25.93 ± 5.57	9.96 ± 3.61	19.93 ± 3.78
	Somewhat c	100	231.59 ± 15.94	86.20 ± 4.51	57.00 ± 4.34	41.20 ± 4.24	23.44 ± 2.52	23.75 ± 2.28	20.86 ± 6.81	8.81 ± 3.44	20.71 ± 4.01
p			0.002 c < a,b	0.006 b < c	0.026	0.014 a > c	0.115	0.064	<0.001 a < b, c	<0.001a < b, c	0.002 b < a, c
Want to Change the Profession f	Yes	196	231.51 ± 16.14	86.08 ± 4.75	56.93 ± 4.56	41.05 ± 4.30	23.56 ± 2.57	23.88 ± 2.17	21.20 ± 7.54	8.81 ± 3.75	20.58 ± 3.84
	No	96	237.52 ± 12.64	87.09 ± 5.08	58.38 ± 3.33	43.27 ± 2.91	34.43 ± 1.24	24.33 ± 1.79	12.08 ± 8.11	6.58 ± 3.66	22.79 ± 3.93
p			<0.001	<0.001	<0.001	<0.001	0.002	0.010	<0.001	<0.001	<0.001
Committing Malpractice a	Yes	33	232.42 ± 13.68	86.00 ± 4.93	56.84 ± 3.78	41.45 ± 3.68	23.96 ± 1.97	24.15 ± 1.39	20.87 ± 9.06	9.30 ± 4.29	21.57 ± 4.68
	No	259	233.62 ± 15.53	86.46 ± 4.87	57.48 ± 4.31	41.82 ± 4.08	23.83 ± 2.29	24.01 ± 2.11	17.86 ± 8.76	7.92 ± 3.78	21.27 ± 3.91
p			0.106	0.382	0.087	0.201	0.919	0.611	0.098	0.075	0.614
Encountering Malpractice f	Yes	136	231.88 ± 16.16	86.05 ± 4.66	57.07 ± 4.35	41.30 ± 4.30	23.67 ± 2.57	23.78 ± 2.28	20.37 ± 8.09	8.97 ± 3.85	21.41 ± 3.83
	No	156	235.33 ± 14.13	86.83 ± 5.09	57.79 ± 4.12	42.33 ± 3.63	24.05 ± 1.82	24.31 ± 1.69	15.72 ± 9.02	7.05 ± 3.62	21.19 ± 4.19
p			0.001	0.003	0.003	0.008	0.348	0.013	<0.001	<0.001	0.719

Note: Personal and occupational characteristics with a significant difference are shown in bold. The subgroups of the independent variables that caused significant differences are encoded with superscript letters (a, b, c, d and e).

^f Mann‐Whitney U test,

^g Kruskal‐Wallis H test (Bonferroni correction for significant parameters)

There was a statistically significant difference between nurses’ MTSN scale scores according to their position, the unit they worked in, willingness to work in their unit, satisfaction with their work environment, willingness to change their profession, and witnessing malpractice incidents. In this regard, The MTSN score was found to be significantly higher (lower malpractice tendency) in nurses who were charge nurses, worked in the operating room, wanted to work in the unit, were satisfied with the environment, did not want to change their profession, and did not encounter malpractice (Table 4).

There was no statistically significant difference between nurses’ MBI subscale scores and their marital status, educational status, shift schedule, and malpractice (p > 0.05; Table 4). A statistically significant difference was found in nurses’ emotional exhaustion and depersonalization subscale scores according to their position, the number of patients they look after daily, willingness to work in the unit, satisfaction with the environment, willingness to remain in their profession, and witnessing malpractice (p < 0.01). The emotional exhaustion and depersonalization subscale scores of nurses who worked as nurses, provided care for ≥ 15 or between 11 and 15 patients, did not want to work in their unit, were unsatisfied with their environment, wanted to change their profession, and witnessed malpractice were significantly higher. In addition, male nurses had significantly higher depersonalization subscale scores compared to females. Similarly, nurses working in the emergency department had significantly higher depersonalization subscale scores compared to those working in other units (p < 0.05). The comparison of the MBI personal accomplishment subscale indicated a statistically significant difference in terms of gender, position, satisfaction with the work environment, and willingness to change the profession (p < 0.01; p < 0.05). Accordingly, the personal accomplishment score was significantly higher in male nurses, charge nurses, nurses who were satisfied with their environment, and those who did not want to change their profession (Table 4).

4.4. The Relationship between Nurses' Age, Occupational and Institutional Experiences, and Their Tendency to Medical Errors and Burnout

The results of Spearman's correlation analysis conducted to determine the relationship between nurses’ mean MTSN and MBI scores are shown in Table 5. A statistically significant negative correlation was found between the MTSN scale and the MBI emotional exhaustion (r = −0.314) and depersonalization (r = −0.293) subscales. Additionally, a statistically significant positive relationship existed between the MTSN scale and the personal accomplishment (r = 0.359) subscale (Table 5).

Table 5.

The Relationship Between Nurses’ Age, Occupational and Institutional Experiences and MTSN and MBI Mean Scores (N = 292).

		Total (M ± SD)	Medicine and transfusion practices	Hospital infections	Patient monitoring and equipment safety	Falls	Communication	Emotional exhaustion	Depersonalization	Personal accomplishment
Age	r	0.162	0.132	0.084	0.164	0.090	0.036	−0.082	−0.191	0.146
	p	0.005	0.024	0.151	0.005	0.126	0.544	0.161	0.001	0.012
Occupational Experience	r	0.200	0.153	0.145	0.202	0.125	0.103	−0.102	‐0.227	0.171
	p	0.001	0.009	0.013	0.001	0.033	0.080	0.081	<0.001	0.003
Institutional Experience	r	0.194	0.169	0.145	0.196	0.069	0.034	−0.077	−0.087	0.141
	p	0.001	0.004	0.013	0.001	0.240	0.566	0.188	0.140	0.016
Emotional Exhaustion	r	−0.314	−0.234	−0.263	−0.271	−0.176	−0.128
	p	<0.001	<0.001	<0.001	<0.001	0.003	0.028
Depersonalization	r	−0.293	−0.271	−0.213	−0.257	−0.158	−0.231
	p	<0.001	<0.001	<0.001	<0.001	0.007	<0.001
Personal Accomplishment	r	0.359	0.314	0.317	0.356	0.329	0.288
	p	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

Note: r: Spearman's correlation coefficient.

Table 5 also illustrates the relationship between nurses’ age, occupational experience, institutional experience, and scale scores. Accordingly, a significant and positive relationship was found between the MTSN scale score and nurses’ age (r = 0.162; p = 0.005), occupational experience (r = 0.200; p = 0.001), and institutional experience (r = 0.194; p = 0.001).

In the analyses of the MBI subscales, no significant relationship was found in terms of age, occupational experience, and institutional experience, while a statistically significant negative relationship (p < 0.01) existed between the depersonalization subscale score and age (r = −0.191) and occupational experience (r = −0.227). The analyses for the personal accomplishment subscale score revealed a significant positive relationship (p < 0.05) in terms of age (r = 0.146), occupational experience (r = 0.171), and institutional experience (r = 0.141) (Table 5).

5. Discussion

In this study, the concepts of burnout and medical error were examined in nursing, and related variables were determined. In this context, first, comparisons were made according to nurses’ demographic and professional characteristics in terms of both concepts. Then, the relationships of both concepts with each other and with age, occupational experience, and experience in the institution were tested.

5.1. Comparison of Nurses' Characteristics and Scale Scores

The MTSN scores of the nurses in the study indicated a low malpractice tendency. This result was consistent with the studies in the literature conducted with nurse samples (İşci and Altuntaş 2019; Özen et al. 2019; Savci et al. 2020; Cerit et al. 2022). Professional ethical standards reinforce nurses’ ethical comportment. Regular in‐service training for nurses and protocols aimed at preventing malpractice may also contribute to the low likelihood of medical errors (Savci et al. 2020). Additionally, the fact that most participants held an undergraduate degree, worked in their preferred units, and were satisfied with their work environment could be considered factors contributing to their low malpractice tendency. Furthermore, the finding that 88.7% of nurses reported never having made a medical error supported the conclusion of a low malpractice tendency. This low‐level malpractice tendency may reflect social desirability response, but the extent is not known.

Burnout is defined as a response to workplace stress factors experienced by employees (Maslach and Jackson 1981). This response comprises three key dimensions: exhaustion, a sense of detachment from the job, and a sense of failure (Maslach and Jackson 1981). Individuals’ burnout levels can be assessed by using the Maslach Burnout Inventory (MBI), which is used to measure these dimensions (Karakaş et al. 2017; Yılmaz and Arslan 2017; Nantsupawat et al. 2017; Adam et al. 2018). Considering that individuals experiencing burnout tend to have high emotional exhaustion and depersonalization scores and low personal accomplishment scores, it was observed that nurses in this study exhibited above‐average emotional exhaustion, below‐average depersonalization, and above‐average personal accomplishment. Our findings indicated that nurses in the sample experienced burnout primarily in the emotional exhaustion dimension. This result was consistent with previous studies (Can and Hisar 2019; Uzun and Mayda 2020). The below‐average depersonalization score, albeit not zero, may reflect the nurses’ professional commitment to providing compassionate care. Additionally, the above‐average personal accomplishment score may be attributed to the majority of the sample holding an undergraduate degree and having a strong sense of self‐confidence.

Whether nurses’ personal and occupational characteristics significantly influenced their tendency toward malpractice was investigated in this study. It was found that factors such as nurses’ positions, the unit they worked in, willingness to work in the current unit, satisfaction with the work environment, intention to change profession, and previous encounters with malpractice had a significant impact on the total score. Nurses who held the position of charge nurse, worked in the operating room, were employed in a unit of their choice, were satisfied with their work environment, did not wish to change their profession, and had not committed malpractice demonstrated a lower tendency toward medical errors. The reduced or lack of a patient assignment for which medical errors could occur, the leadership tendencies of charge nurses, along with their skills and occupational experience, may explain their lower tendency toward medical errors.

By its nature, nursing is a profession that requires working in shifts, both day and night. Sleep disorders resulting from irregular work schedules can lead to physical and mental exhaustion. Consequently, irregular working hours may increase nurses’ tendency toward malpractice and pose a risk to patient safety (Ryu and Shim 2021; Veal et al. 2021; Cheng et al. 2023; Dall'Ora et al. 2023). In this context, it is expected that nurses who work only during the day would exhibit a lower tendency to make medical errors. Consistent with our findings, Kiymaz and Koç (2018) found that nurses who were satisfied with their jobs and worked during the day had a lower tendency toward malpractice. However, in contrast to our findings, a study by Kwon et al. (2021) found no significant relationship between nurses working in undesired departments and medical errors.

Although operating rooms are considered high‐risk areas for medical errors (Ugur et al. 2016; Güven and Özalp 2022) and surgical errors are reported to occur most frequently in this setting (Çakmak et al. 2018), it is encouraging that this study showed a low malpractice tendency among nurses working in surgical units. The use of safe surgical checklists, in‐service training, and other safety protocols in the operating room may have contributed to the reduced tendency to medical errors. Similarly, Kandemir and Yüksel (2020) reported that nurses working in surgical clinics and intensive care units exhibited lower rates of malpractice. Although some dated studies have contrasting results (Güneş et al. 2014; Demir Dikmen et al. 2014), more recent research has reflected a decrease in medical errors due to the increasing emphasis on patient safety and quality improvement initiatives.

Nurses who provided care for ≥ 11 patients, expressed dissatisfaction with their unit, and experienced malpractice reported higher levels of emotional exhaustion and depersonalization compared to their peers (Edú‐Valsania et al. 2022). Employees experiencing emotional exhaustion often lack the emotional energy needed to manage job tasks effectively, making adaptation to the work environment challenging. This aligned with findings from Galletta et al. (2016) and Zhou et al. (2015), which indicated that excessive workload and high patient‐nurse ratios were linked to emotional exhaustion. Furthermore, inconvenient working conditions contribute to increased burnout among nurses (Nantsupawat et al. 2017). To mitigate these issues, adequate nurse staffing should be ensured, and managers should implement strategies that reduce workload. Failure to address these factors may lead to detrimental consequences for care quality and patient safety (Clari et al. 2022). Additionally, Alharbi et al. (2020) reported that nurses who perceived their work environments and their contributions to organizational decisions as supportive were less emotionally exhausted, more satisfied with their jobs, and less likely to consider leaving their positions within the following year.

Depersonalization, characterized by a loss of interest and compassion, is another phenomenon associated with burnout (Li et al. 2018). In our study, male nurses and those working in the emergency department exhibited higher scores on the Depersonalization subscale. These findings were consistent with the existing literature (Alqahtani et al. 2019). Similar results were reported in studies focused on emergency nurses (O'Mahony 2011; Stathopoulou et al. 2011; Pires et al. 2020). Additionally, research involving physician samples (Adam et al. 2018) and hemodialysis nurses (Kavurmacı et al. 2014) also indicated a higher level of depersonalization among males. However, another study found that nurses who chose to work in emergency departments experienced lower levels of emotional exhaustion and depersonalization (Kavlu and Pınar 2009).

In this study, male nurses, charge nurses, and those satisfied with their work environment and not willing to change their profession had significantly higher personal accomplishment scores. This contrasts with findings from Kavurmacı et al. (2014), which indicated that female nurses had significantly higher personal accomplishment scores than their male counterparts. Similarly, Adam et al. (2018) found that while male physicians had lower scores in personal accomplishment, this difference was not statistically significant. Conversely, Uzun and Mayda (2020) reported higher levels of perceived personal success among men, suggesting that workplace practices and gender dynamics may impact personal accomplishment levels. Adekola (2020) noted that disparities in treatment between genders in the workplace, as well as the emotional experiences of female staff, could lead to decreased Personal Accomplishment. Personal Accomplishment serves as an indicator of employees’ competence and success in their roles (Uzun and Mayda 2020). The elevated levels of personal accomplishment observed in charge nurses may be attributed to their managerial roles, increased decision‐making authority, and heightened self‐confidence. Additionally, our research indicated that participants’ personal accomplishment levels were influenced by their satisfaction with the work environment and their willingness to remain in their profession. Yılmaz and Arslan (2017) found similar results, with mean personal accomplishment scores being higher among satisfied nurses. Furthermore, Fındık et al. (2011) demonstrated that nurses who practiced their profession willingly reported significantly higher personal accomplishment scores.

This study showed a relationship between nurses’ MTSN scale and MBI subscales. It was observed that as the tendency for malpractice decreased, emotional exhaustion and depersonalization also decreased, while personal accomplishment increased. However, most of these significant relationships were of low level (Téllez et al. 2015). Recent literature has questioned the significance of such low correlation values (Wasserstein et al. 2019). Similarly, there was a study supporting this result. Kwon et al. (2021) reported that there was a positive correlation between job‐related burnout and medical errors, but according to the regression analysis results, job‐related burnout did not significantly affect the occurrence of medical errors. This showed that independent improvement strategies were required for the two concepts (Kwon et al. 2021). Increased burnout can affect the malpractice tendency, and at the same time, the occurrence of medical errors can lead to burnout. In existing studies, concepts of burnout (Zhou et al. 2015; Cañadas‐De la Fuente et al. 2015; Can and Hisar 2019) and malpractice (Ugur et al. 2016; Isci et al. 2019; Mauti and Githae 2019) were examined separately, however, studies on their examination together in a nurse sample were limited (Betsiou et al. 2022; Kwon et al. 2021). Evaluating these concepts together is important for understanding the current situation and taking measures for existing problems.

The results of the current study indicated that as nurses’ age and both occupational and institutional experiences increased, their tendency to malpractice decreased. Similarly, Özen et al. (2019) found that the rate of medical errors decreased with increasing age and years of professional experience. It has been suggested in the literature that nurses with less occupational experience exhibit higher levels of malpractice tendency (Demir Dikmen et al. 2014). However, several studies have shown that the tendency toward medical errors does not differ significantly by age, years of work, and occupational experience (Fahimi et al. 2015; Dığın and Özkan 2020).

Age is related to work experience. It was assumed that younger employees had less work experience and that this could lead to higher levels of occupational stress and subsequently burnout (Adam et al. 2018). The results of this study indicated that as participants’ age and occupational experience increased, depersonalization decreased and personal accomplishment increased. Kavlu and Pınar (2009) concluded that depersonalization decreased as age increased. In a study conducted by Alqahtani et al. (2019), it was found that younger workers had lower personal accomplishment compared to older ones. It was stated that this might have been because younger workers were exposed to more pressure and stress while improving skills and knowledge through practice and they did not have enough experience (Alqahtani et al. 2019).

5.2. Limitations

Our study has several limitations. Perhaps the most significant one of these is the issues caused by the anxiety surrounding the term malpractice. This concern hindered more detailed questioning related to this topic in the research. The scores on the Turkish MBI do not correspond to those of the original MBI, as described in the measurements section. The burnout values identified herein are therefore, not comparable to those in the broader MBI literature. The cutoff points published for the original MBI do not apply to this sample. Another issue is the lack of studies on the investigation of the relationship between the two concepts, which hindered the discussion of their relationship with other studies. In addition, testing multiple variables may have increased the Type I error rate.

5.3. Practical Implications

Preventing medical errors is crucial for ensuring patient safety (Flotta et al. 2012). To mitigate malpractice, effective reporting systems should be established, and employees must be encouraged to report errors. In this context, nurse managers play a significant role in fostering a culture of safety. Additionally, increasing in‐service training and raising employee awareness could be beneficial in preventing errors.

Improving working conditions may reduce errors and prevent psychological problems that nurses may experience. These two concepts are mutually related, as the risk of malpractice and burnout can be reduced by developing effective strategies and implementing improvement procedures. By taking initiatives to boost employee motivation and enacting supportive measures, healthcare institutions and managers can make a positive contribution to the quality of care and patient safety.

6. Conclusion

This study was conducted to evaluate nurses’ malpractice tendencies and burnout levels, examine the relationship between these two concepts, and determine their associations with various variables.

As a result of the study, it was found that the highest score (lowest malpractice tendency) was obtained from the medication and transfusion practices sub‐dimension and the lowest score from the falls sub‐dimension. In addition, the majority of the nurses stated that they had not made medical errors before. This is a desirable result and supports the low tendency of nurses toward making medical errors. This low‐level tendency among nurses toward making medical errors may be a positive result of in‐service training and protocols to prevent malpractice (Savci et al. 2020). To reduce the tendency to medical errors, institutions should review their regulatory preventive activities, take necessary measures, and support the development of a patient safety culture by planning training on patient safety practices (Rodziewicz et al. 2024).

Considering the sub‐dimension scores of the MBI scale, the highest score was obtained from the personal achievement sub‐dimension, while the lowest was obtained from the depersonalization sub‐dimension. Accordingly, it was determined that nurses experienced above‐average emotional exhaustion and low‐level depersonalization and that their personal accomplishment was above average.

The findings of the study revealed that nurses’ malpractice tendencies and burnout levels varied depending on demographic characteristics, working conditions, and job satisfaction.

While nurses’ scores on the MTSN scale and MBI subscales did not differ by marital status, educational status, shift schedule, and malpractice, a significant difference was found according to their positions and satisfaction with the environment.

According to the research findings, factors such as nurses’ positions, the units they worked in, their satisfaction with the work environment, and their willingness to change the profession were found to be associated with malpractice tendencies.

As an expected result, it was determined that the total scores and personal accomplishment sub‐dimension scores of the charge nurses and the nurses who were satisfied with the environment where they worked were higher in this study. On the other hand, nurses who were not satisfied with their working environment had significantly higher depersonalization and emotional exhaustion scores.

As a result of the study, it was determined that the tendency to medical errors decreased as the nurses’ age, professional experience, and experience in the institution increased. Nurses with lower emotional exhaustion and depersonalization had lower levels of tendency toward malpractice.

Additionally, a significant relationship was found between burnout and malpractice tendencies. It was observed that nurses with increased levels of emotional exhaustion and depersonalization also showed higher malpractice tendencies. This highlights the impact of workload and unfavorable working conditions on both nurses’ psychological well‐being and patient safety.

In conclusion, this study revealed the relationship between nurses’ malpractice tendencies and burnout levels and indicated that improving working conditions was critical for both patient safety and the well‐being of healthcare workers. To prevent malpractice in healthcare delivery and reduce nurses’ burnout, it is essential to regulate the work environment and conditions and provide support for nurses.

Author Contributions

Leman Şenturan: Study conception and design, Data collection, Data analysis and interpretation, Drafting of the article, Critical review of the article. Gizem Kaya: Study conception and design, Data collection, Data analysis and interpretation, Drafting of the article, Critical review of the article. Tuba Emirtaş: Study conception and design, Data collection, Critical review of the article.

Ethics Statement

This study was approved by the Non‐Interventional Research Ethics Committee of Biruni University (Approval no. 2020/37‐06).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.