A Qualitative Study of Nurses

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A Qualitative Study of Nurses Experience of
Clinical Incident Error Reporting

• Fiona Donaldson-Myles MSc RGN RM
• Supervisor of Midwives
• SSAFA Forces Help

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• It is a key organisational aim to ensure clinical
  incidents are reported, lessons learned and
  findings disseminated to improve patient care

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• A better understanding of how staff feel when
  they have been involved in reporting an error
  will help develop an effective reporting and
  learning culture

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• A clinical incident reporting system should
• Capture adverse incidents and near misses
• Give staff support and have their confidence.
• Encourage learning and improve patient safety

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The second victim - cost of clinical incidents to
carers

• Doctors
• Inability to share feelings
• Feelings of guilt, remorse, helplessness
• Lack of institutional mechanisms for support
• Defensive changes

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The second victim - cost of clinical incidents to
carers

• Nurses
• Similar emotions to doctor
• Better informal support
• Fearful of arbitrary disciplinary action
• Mainly medication errors studied

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Study Aim

• To obtain and analyse rich data on the experience
  of nurses involved in reporting clinical
  incidents
• To gain insight into how the process was managed
• To identify factors that foster a reflective
  environment and give staff confidence to report
  adverse events

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Methodology

• Qualitative phenomenological study
• Participants identified from anonymised first
  person incident reports
• Informed consent, written information, 3rd party
  introduction
• Semi-structured interview tool
• Taped interviews
• Grounded theory approach

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Demographic Data of Respondents

• Number invited to participate 35
• Number who agreed to participate 18
• Number of actual participants 15
• Average age (years) 42
  (range 32 50)
• Nursing grades
  I -1, H -2, G -3, F -2, E -6, D-1
• Average years in practice 20
  (range 2 31)
• Clinical area
  Acute medicine 5
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  Care of elderly 3
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  Community hospital 2
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  Oncology/palliative 2
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  Nurse practitioner 2
• 
  Specialist nurse 1

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Six key themes revealed

• Nurses expectations of management
• Motivation to report
• Effects on nurses feelings emotions
• The need for support
• Learning from mistakes
• Views on patient involvement

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Expectations of Management

• Nurses felt managerial feedback insufficient
• Nurses wanted to know if any further action was
  being taken involving them or to prevent
  recurrence
• Copy of report inadequate
• Needed closure on episode
• Did not want copy of report freely available to
  others

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Expectations of Management

• They dealt with it at ward level. I am happy
  with that and they said it was the end of the
  matter.
• I have got a very supportive ward manager, we
  discussed it, I had to write a report to the
  people who deal with risk management and the ward
  manager told me it was the end of the matter.
• I am hoping that that is it now, and that it is
  finished. I do not know for certain how far
  management are taking it.
• I suppose no news is good news.

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Motivation to Report

• Nurses want to do their best for patients
• Want to prevent same mistakes happening again
• Not convinced enough being done in response to
  report
• Not involved enough in rectifying situation
• Report can clarify what actually happened

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Motivation to Report

• I think it is important to find out why things
  happen
• It needed to be addressed to prevent the same
  thing happening again
• Its happened on many occasions since, but it
  doesnt seem to be taken seriously
• I knew it was a mistake. I was comfortable to
  report it, but I wanted it written down the way
  it really happened

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Effects on Nurses Feelings and Emotions

• Thirteen out of fifteen nurses described personal
  impact in very strong terms
• Used phrases such as
• feeling sick
• panic stricken
• never feeling the same again

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Effects on Nurses Feelings and Emotions

• Strong negative feelings regardless of outcome
• Primary incidents - blamed themselves
• Secondary incidents - feelings of powerlessness
• Negative feelings related to
• type of incident
• how much early support received
• Whether still felt trusted by colleagues

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Effects on Nurses Feelings and Emotions

• I was absolutely gutted about the thought that I
  had hurt him. He was quite poorly and didnt
  really know, but it still upsets me
• The patient was not adversely affected, but the
  nurse was absolutely devastated

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Need for Support

• Need to talk to someone knowledgeable
• Explore issues and relieve feelings
• Face-to-face preferable but telephone and written
  response helped keep feelings in perspective
• Only nursing / medical family members helpful
• Inadequate support led to unresolved feelings of
  distress

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Need for Support

• I have got a very supportive ward manager. We
  discussed it with her and that was very good.
• There was nobody I could talk to. My manager
  was not available and everyone was busy. There
  was nobody to give me any reassurance or an
  explanation.
• I did not have that much support. I mean,
  people realised I wasnt happy, you know, but
  they did not sit me down and say, look, we need
  to talk this over.

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Suggestions for providing immediate support

• 24 hour availability of senior nurse / risk
  manager
• Telephone helpline
• Protected time for clinical supervision

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Learning from Mistakes

• Despite negative feelings, viewed reporting
  process as a learning episode
• Reassessment / training helped regain confidence
  and trust
• Became more cautious about tasks taken for
  granted
• Became more assertive
• Wanted information regarding tracking trends and
  corporate lessons learned

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Learning from Mistakes

• we all make mistakes, we learn, get through them
  and move on
• I check, check, double check, triple check, Im
  obsessive really now

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Views on Patient Involvement

• Nurses felt
• Errors should be disclosed to patients more
  frequently
• Patients coped well with open dialogue
• Less likely to take further action
• Could contribute to more realistic patient
  expectations

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Views on Patient Involvement

• I think it would be nice if the patient got some
  formal feedback. I think an apology or an
  explanation would have been helpful and help
  acknowledge the discomfort and distress he was
  put through.
• I think I should have told her. Once they know
  the truth and you say you are sorry, on the whole
  they are happy

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Conclusions

• Motivation to report was to prevent similar
  occurrence
• Frustrated by inadequate managerial feedback
• Supported at ward level, but not higher
• Strong personal and professional impact
• Immediate support, clear communication and
  feedback facilitated movement to learning phase
• Consensus that incidents should be discussed more
  with patients
• Overwhelmingly rejected system of incident book
  stored on ward

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Limitations

• Small study / discrete setting
• Findings could reflect organisational, regional,
  national characteristics
• May not be generalisable
• Participants relatively old and experienced

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Recommendations

• More should be done to reduce negative
  psychological and professional impact on nurses
• Devise a system which gives vital early support
• 24 hour helpline
• 24 hour availability of senior nurse/risk manager
• Extension of clinical supervision
• Keep nurses informed of organisational action
• Discontinue incident book system
• Widen debate on extent to which information on
  errors should be shared with patients

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SUPPORT AND COMMUNICATION
SUPPORT AND COMMUNICATION

• SUPPORT AND COMMUNICATION

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