Eitan Naveh, DSc Technion – Israel Institute of Technology Zvi Stern, MD

1. The influence of learning-orientation, autonomy and voice on error making: The case of resident physicians Eitan Naveh, DSc Technion – Israel Institute of Technology Zvi Stern, MD Hadassah Hebrew University Medical Center Tal Katz-Navon, PhD The Interdisciplinary Center, Herzeliya

2. Study Aims To explore the influence of situational learning orientation on error making and the moderating effects of level of autonomy and employee voice

3. Situational Learning-Orientation • A setting in which an employee perceives that there is an emphasize on • acquiring new knowledge • improvement • striving to understand new things • actively searching for additional knowledge and feedback • increasing one’s level of competence (Ames & Archer, 1988; Button, Mathieu, & Zajac, 1996; Dragoni, 2005)

4. Medical Treatment Errors & Resident Physicians • Frontline providers of the majority of patient care • Work long hours • Stressful and overwhelming period • Given tremendous responsibility but are novice practitioners in the process of learning • Hence, at increased risk of performance errors • Literature on residents focuses onsleep deprivation(e.g., Gaba & Howard, 2002; Landrigan et. al., 2004; Volpp & Grande, 2003; Thomas, 2004).

5. Level of Analysis • Individual perceptions of the organizational structures, processes, and events may differ among individuals in the same unit or organization (James & Jones, 1974; Kahn, 1990; Parker et al., 2003; Reichers & Schneider, 1990; Rousseau, 1988) • Individual perceptions are critical determinant of individual behavior and performance • Nested structure, residents within departments within hospitals

6. Hypothesis 1. Situational Learning- Orientation Number of Medical Treatment Errors (-)

7. Moderator 1.Perceived Level of Autonomy • The extent to which an employee perceives that s/he has the freedom and discretion to plan, schedule, and carry out their jobs • Has a positive effect on performance because “decision-making power should be in the hands of the individuals with the most information about the task” (Hackman, 1990) • In practice, the positive effects of autonomy on performance have shown themselves to be more elusive than existing theoretical models have suggested (Langfred & Moye, 2004)

8. Perceived Level of Autonomy • Low levels of autonomy may be perceived as inhibiting employee discretion in situations that require immediate adaptation to changing conditions • High levels of autonomy may be perceived as providing insufficient guidance on how to behave

9. Hypothesis 2. Number of Medical Treatment Errors Perceived Level of Autonomy

10. Learning-Orientation and Autonomy • Low level of learning-orientation: results in poor understanding of work processes and lack of knowledge about how to successfully perform the task If, in addition, this is combined with a high level of autonomy in which the employee has to cope with situations on his/her own, it could result in many errors • High level of learning-orientation: a resident will have more of the necessary knowledge and feedback to make the required decisions

11. Hypothesis 3. Level of autonomy moderates the relationship between the situational learning orientation and number of treatment errors, such that: - There is a u-shape relationship between autonomy and the number of errors when learning-orientation is low - There is a decrease in treatment errors as the level of autonomy increases when the learning orientation is high

12. Moderator 2. Employee Voice • An employee’s perception that speaking up the organization is wise • Voice describes feedback up the organizational hierarchy, employees able to discuss problems with supervisors or coworkers, suggesting solutions, and seeking help from an outside agency (Morrison & Milliken, 2000)

13. Hypothesis 4. Employee Voice Number of Medical Treatment Errors (-)

14. Learning-Orientation andEmployee Voice In order to avoid errors there is a need for two-way communication: speaking up and down the organization

15. Hypothesis 5. Employee voice moderates the relationship between learning-orientation and treatment errors in such a way that a high level of learning orientation is associated with fewer errors when employee voice is high rather than low

16. Methods • 2 hospitals • 126 medical residents Measures - IVs: 1 to 5 item Likert scale questionnaires for learning-orientation, autonomy, and voice - DV: Checklist of 14 potential treatment errors; tallied by nurses during a 3-month period - Controls: year of residency (1-5), resident’s department, total number of night shifts during last 3 months

17. ResultsNumber of Treatment Errors as a Function of Perceptions of Learning-Orientation and Autonomy* *Results of a Glimmix Poisson Model

18. ResultsNumber of Treatment Errors as a Function of Perceptions of Learning-Orientation and Voice* *Results of a Glimmix Poisson Model

19. Conclusions • Individual perceptions of situational learning orientation, autonomy, and voice were significantly associated with the number of medical treatment errors • Learning orientation by itself, without taking into consideration its interactions with autonomy and voice, was positively associated with treatment errors. Learning-orientation might encourage experimentation—testing unique, new, high risk approaches that may increase the number of errors

20. Conclusions • The finding that autonomy can be harmful to performance is counterintuitive in that autonomy has traditionally been regarded as an advantage • Only when voice was high, did a higher learning orientation lead to fewer treatment errors