ubc 2010 fall waters norna

8/13/2019 Ubc 2010 Fall Waters Norna

1/140

EXPLORING PERCEPTIONS OF PERINATAL NURSES TOWARDS INCIDENT

REPORTING: A QUALITATIVE STUDY

by

Norna Foxcroft Waters

BSN, The University of British Columbia, 2002

A THESIS SUBMITTED IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SCIENCE IN NURSING

in

The Faculty of Graduate Studies

(Nursing)

THE UNIVERITY OF BRITISH COLUMBIA(Vancouver)

August 2010

Norna Foxcroft Waters 2010


2/140

ii

ABSTRACTPatient safety has received greater attention in response to the release of reports

estimating a significant number of incidents (adverse events or near misses) occur during

inpatient hospital stays. Improving the safety of our health care system requires a greater

understanding of the types of incidents and their underlying causes. Nurses are recognized as the

discipline most likely to report incidents in practice due to their front line role in patient care.

Perinatal nurses are of specific interest as they are well recognized as playing an active role in

the identification and reporting of incidents that occur in inpatient perinatal settings.

This descriptive qualitative study explored perinatal nurses perceptions about reporting

incidents in practice and also identified factors that facilitate or act as barriers towards incident

reporting. Data were collected in focus groups (n=16) consisting of perinatal nurses employed on

labour and delivery units within one Health Authority in the province of BC. Audiotaped data

were transcribed and analyzed using constant comparison. Four main themes and 12 subthemes

were identified. The main themes were: nature of incidents, how incidents happen, barriers to

incident reporting, and facilitating factors for incident reporting. The subthemes included:

descriptions of incidents, determining what qualifies as an incidents, litigation, decision making,

dynamics, fatigue, time, reporting tools, unit culture, learning, practice improvement, and

professional identity.

The perinatal nurses indicated the types of incidents that occurred in their practice area

were unique to their practice setting. They felt these incidents were mostly related to outcomes

and were to some degree out of their control. They did not view incidents involving medications

as an issue They identified team dynamics as influencing the safety of perinatal units, because

poor team dynamics were often associated with negative patient outcomes. Fatigue, lack of time

to report incidents, reporting tools and the negative reactions/responses of team members were


3/140

iii

identified as barriers to incident reporting. Facilitating factors to incident reporting were

professional responsibility, learning opportunities created by incident reports, and observing

change on their units in response to incident reports. The themes had implications for nursing

practice, administration, education, and research.


4/140

iv

TABLE OF CONTENTSAbstract ..........................................................................................................................................ii

Table of Contents ..........................................................................................................................iv

List of Tables ................................................................................................................................vii

Acknowledgments .......................................................................................................................viii

1. Chapter One: Problem Identification and Purpose ...............................................................11.1. Introduction .....................................................................................................................11.2. Significance .....................................................................................................................31.3. Problem Identification .....................................................................................................41.4. Statement of Purpose .......................................................................................................51.5. Research Questions .........................................................................................................51.6. Chapter Summary ............................................................................................................5

2. Chapter Two: Literature Review ..........................................................................................62.1. Introduction .....................................................................................................................62.2. Review of Current Evidence ...........................................................................................6

2.2.1. Reporting Practices ..............................................................................................102.2.1.1. Factors Affecting Reporting Practices........................................................11

2.2.1.1.1. Relationships .....................................................................................122.2.1.1.2. Nurse Characteristics ........................................................................12

2.2.2. Barriers to Reporting............................................................................................142.2.3. Facilitating Factors to Reporting .........................................................................162.2.4. Workplace Culture ...............................................................................................172.2.5. Interdisciplinary Team Dynamics ........................................................................18

2.3. Chapter Summary ..........................................................................................................203. Chapter Three: Research Methods ......................................................................................22

3.1. Introduction ...................................................................................................................223.2. The Research Design .....................................................................................................223.3. Sample/Population/Participants.....................................................................................23

3.3.1. Procedures ............................................................................................................243.3.2. Inclusion Criteria .................................................................................................25

3.4. Ethical Considerations ...................................................................................................263.4.1. Protection of Human Subjects .............................................................................26

3.5. Recruitment ...................................................................................................................293.6. Data Collection ..............................................................................................................313.7. Data Analysis ................................................................................................................353.8. Rigor and Quality ..........................................................................................................373.9. Chapter Summary ..........................................................................................................39

4. Chapter Four: The Findings ................................................................................................404.1. Introduction ...................................................................................................................40


5/140

v

4.2. Description of the Sample .............................................................................................404.3. Qualitative Themes........................................................................................................42

4.3.1. Nature of Incidents ...............................................................................................434.3.1.1. Descriptions ................................................................................................444.3.1.2. Determining What Qualifies as an Incident ...............................................484.3.1.3.

Litigation ....................................................................................................514.3.2. How Incidents Happen .........................................................................................53

4.3.2.1. Decision Making ........................................................................................534.3.2.2. Dynamics ....................................................................................................54

4.3.3. Barriers to Incident Reporting .............................................................................554.3.3.1. Fatigue ........................................................................................................564.3.3.2. Time to Report ............................................................................................564.3.3.3. Reporting Tools ..........................................................................................574.3.3.4. Unit Culture ................................................................................................59

4.3.3.4.1. How Incident Reporting is Viewed ...................................................594.3.3.4.2. Reactions/Responses .........................................................................60

4.3.4.

Facilitating Factors to Incident Reporting ...........................................................654.3.4.1. Learning ......................................................................................................664.3.4.2. Practice Improvement .................................................................................674.3.4.3. Professional Responsibility ........................................................................69

4.4. Chapter Summary ..........................................................................................................715. Chapter Five: Discussion of Findings, Nursing Implications, Summary and

Conclusion ..............................................................................................................................725.1. Introduction ...................................................................................................................725.2. Discussion of Findings ..................................................................................................73

5.2.1. Comparing the Sample to the Canadian Population of Perinatal Nurses.............735.2.2. Comparison of Findings to the Literature ............................................................74

5.2.2.1. Perinatal Practice Setting ............................................................................745.2.2.1.1. Medication Incidents .........................................................................755.2.2.1.2. Workload ...........................................................................................77

5.2.2.2. Factors Affecting Incident Reporting .........................................................785.2.2.2.1. Judgment and Experience ................................................................785.2.2.2.2. Reporting Based on Criteria ..............................................................795.2.2.2.3. Litigation ...........................................................................................80

5.2.2.3. Barriers to Incident Reporting ....................................................................825.2.2.3.1. Organizational Barriers .....................................................................825.2.2.3.2. Personal Barriers ...............................................................................85

5.2.2.4. Facilitating Factors .....................................................................................855.2.2.5. Team Dynamics and Organizational Culture .............................................87

5.2.2.5.1. Informal Reporting ............................................................................885.2.2.5.2. Determining What Qualifies as an Incident ......................................91

5.2.2.6. Feedback and Follow-up to Incident Reports ............................................915.3. Study Limitations ..........................................................................................................925.4. Nursing Implications .....................................................................................................94

5.4.1. Recommendation for Administration, Education and Practice............................94


6/140

vi

5.4.1.1. Implications for Nursing Administration...................................................945.4.1.2. Implications for Nursing Education ...........................................................995.4.1.3. Implications for Nursing Practice.......... ...................................................101

5.4.2. Recommendation for Further Research .............................................................1025.5. Communication of Findings ........................................................................................1035.6.

Chapter Summary ........................................................................................................1045.7. Summary and Conclusion ...........................................................................................104

References... .............................................................................................................................106

Appendices ...................................................................................................................................117Appendix A: Research Ethics Board Approval Certificates ..................................................117Appendix B: Information Letter Sent to Managers ...............................................................121Appendix C: Participant Information Letter ..........................................................................123Appendix D: Informed Consent Document ...........................................................................125Appendix E: Recruitment Poster ...........................................................................................130

Appendix F: Demographic Questionnaire .............................................................................131Appendix G: Focus Group Interview Guide ..........................................................................132


7/140

vii

LIST OF TABLES

Table 4.1 Number of Perinatal Nurses by Years of Experience...41Table 4.2 Number of Perinatal Nurses by Years of Experience as a Perinatal Nurse..42Table 4.3 Summary of Themes.43


8/140

viii

ACKNOWLEDGEMENTS

I would like to acknowledge and thank my thesis committee for all of your help and

support throughout this process. I have gained an amazing amount of knowledge from working

with all of you. I am very fortunate to have had you guide me through this challenging process. I

would also like to thank all of the perinatal nurses who participated in my study. Thank you for

sharing your insights with me, I have learned so much from all of you. I would also like to thank

all of the managers, educators and nurse clinicians from the Health Authority who supported my

study and assisted me throughout the recruitment process.

Finally, I would like to express my sincere gratitude and appreciation to my family who

has supported me throughout my masters program. Thank you for reading countless drafts of

papers and chapters, listening to my concerns and always encouraging me. I could not have

completed this without your help and support.


9/140

1

1. CHAPTER ONE: PROBLEM IDENTIFICATION AND PURPOSE

1.1 Introduction

Patient safety, defined as the reduction and mitigation of unsafe acts within health care

systems (Davies, Hebert, & Hoffman, 2003), has received growing attention in both Canada and

around the world due to the release of various reports estimating that a significant number of

adverse events occur during inpatient hospital stays. These reports estimated that 10-20 percent

of patients experienced one or more adverse events during their hospital stay (Baker et al., 2004;

Davies et al.; Fraser & Rubin, 2007). The Adverse Events Study by Baker et al. was the first

Canadian Study to provide a national estimate of the incidence of adverse events across a range

of hospitals. This study found 185,000 patients (7.5% of admissions) in acute care hospitals in

Canada in fiscal year 2000 were affected by one or more adverse events. Of these events, 70,000

(36.9%) were thought to be preventable (Baker et al.).

Adverse events, defined as unexpected or undesirable incidents directly associated with

care or services provided to patients, can result in increased length of hospital stay and can be

stressful to both patients and health care providers (Davies et al., 2003; Rathert & May, 2007).

Incidents are events, processes, practices or outcomes occurring during patient care and may be

large or small events (Davies et al., 2003). Incidents are noteworthy because of the hazards they

can create for or the harms they can cause patients (Davies et al.). There are various terms used

in the literature and in practice to refer to incidents. These include the terms: error, events

(adverse, or sentinel), patient safety event, near miss, occurrence or unusual occurrence. The

terms currently accepted by experts in the area of patient safety for these concepts are adverse

events or near misses; near misses refer to events that did not cause patient injury but only

because of chance (Agency for Health Care Research and Quality, 2009). For the purposes of


10/140

2

this study the terms used will be incident and incident reporting. These terms will be used as they

are most widely recognized among health care providers, including registered nurses, who will

be participating in this study.

Integral to the improvement of patient safety is the reporting of incidents by health care

professionals (Canadian Nurses Association & University of Toronto Faculty of Nursing, 2004;

Weiner, Hobgood, & Lewis, 2008). Incident reporting systems in hospitals are meant to capture

any and all incidents worthy of reporting, although they often fail to do so due to numerous

factors (Davies et al., 2003). The analysis of reported incidents and their root causes can generate

useful information on system problems while also increasing front line staff awareness of safety

issues in the delivery of care (Benn et al., 2009; Evans et al., 2007; Weiner et al.). An effective

incident reporting system is dependent on front line staff submitting reports of incidents that

occur within their practice. It is also critical that incident reporting systems meet the needs of

those expected to use them (Evans et al.).

Studies have found nurses habitually report incidents and are more likely to access formal

incident reporting systems than physicians, which reflects the different approaches the

disciplines take towards incident reporting (Jeffe et al., 2004; Kingston et al., 2004). Nurses, as

hospital employees, are required to follow various protocols including those requiring reporting

of adverse events through the incident reporting system. Nurses are also the discipline primarily

responsible for administering medications to patients, a common source of error in health care,

and are, therefore, more likely to be involved in a greater number of incidents than other

disciplines (Mrayyan, Shishani, & Al-Faouri, 2007; Stratton, Blegen, Pepper, & Vaughn, 2004).

Nurses have been studied in the literature on incident reporting yet little is known about incident

reporting in various practice contexts.


11/140

3

There is limited knowledge about incident reporting within the specific practice context

of perinatal nursing. Perinatal nurses are those nurses who provide care to women during the

antepartum, intrapartum and postpartum periods. Perinatal nurses practice in hospital nursing

units, ambulatory care settings and community health units. In Canada, there are 13,824

registered nurses employed in Maternity/Newborn areas of practice; the majority (91.9%) work

in acute care hospitals (Canadian Nurses Association, 2008). The average age of perinatal nurses

is 43.5 years and 99.8% are female. Over 90% of perinatal nurses are employed in hospitals as

staff nurses (CNA). Most perinatal nurses (68.5%) have achieved a diploma as the highest level

of education, while 38.1% hold a baccalaureate degree, with the remaining 1.4% holding

Masters or Doctoral degrees (CNA). Because 91.9% of perinatal nurses work in acute care

hospitals, those are the locations where the majority of patient safety events occur (Forster, et al.,

2006). Although obstetric or labour and delivery units, where perinatal nurses commonly

practice, have been studied in the literature on incident reporting, perinatal nurses were not

included in those studies. In order to improve the safety of perinatal patients through improved

incident reporting it is important to gain an understanding of the perceptions of perinatal nurses

about the factors affecting incident reporting.

1.2 Significance

It is well recognized in the literature that a greater understanding of the types of incidents

and their underlying causes is necessary to improve the safety of our health care system (Leape,

2002); however, it is also recognized that the majority of incidents that occur in health care are

not detected because they are not reported (Uribe, Schweikhart, Pathak, Dow, & Marsh, 2002).

Gaining an understanding of the types of incidents that occur and their causes is essential to

reduce future incidents (Baker et al., 2004). Estimates of the numbers of incidents not reported


12/140

4

range from 50% to 96% (Kagan & Barnoy, 2008). The failure to report leads to a lack of

accurate data on the number of incidents that have occurred and the contributing factors to

incidents (Uribe, et al., 2002). Many different types of practice units have been studied in regards

to incident reporting practices, including obstetric units in the United Kingdom, which are

similar to perinatal nursing units. Such units employ midwives rather than perinatal nurses;

therefore, there is paucity of literature about the perceptions of perinatal nurses about the specific

factors affecting incident reporting in a perinatal context (Stanhope, Crowley-Murphy, Vincent,

O'Connor, & Taylor-Adams, 1999; Vincent, Stanhope, & Crowley-Murphy, 1999).

Perinatal nurses are of particular interest, because perinatal units account for most of the

claims involving patient injury and death as evidenced by the high costs of litigation in this area

of practice (Forster et al., 2006; Simpson, 2000). Gaining an understanding of perinatal nurses

perceptions of reporting incidents in practice, including the identification of facilitating factors

and barriers to reporting incidents, at both organizational and personal levels, is important to

determine factors that affect incident reporting for this population of nurses (Fraser & Rubin,

2007; Leape, 2002; Miller, 2003). Increased knowledge will be beneficial in the development of

processes and systems that will encourage reporting of incidents and in increasing understanding

of how and why various incidents occur in perinatal nursing practice (Lawton & Parker, 2002).

A greater understanding will ultimately lead to the development of safer perinatal nursing units,

which will benefit both the care of patients and the practice of perinatal nursing.

1.3 Problem Identification

Perinatal nurses have not yet been studied in relation to incident reporting. There is a lack

of information about factors that are pertinent in regards to incident reporting for this population.

Knowledge is also needed about incident reporting in unique practice contexts because it has


13/140

5

been shown in the literature that contextual factors do impact incident reporting. The purpose of

this study is to gain a greater understanding of perinatal nurses perceptions of incident reporting

and to determine factors shaping reporting practices. Understanding their perspective is

important to improve reporting rates and ultimately improve the safety of perinatal care. In

addition, the findings will add to the literature on incident reporting by health care professionals

by providing new information about a population that has yet to be studied.

1.4 Statement of Purpose

The purpose of the study is to explore perceptions of perinatal nurses about reporting

incidents in practice. A secondary purpose of the study is to identify factors that facilitate or act

as barriers towards incident reporting.

1.5 Research Questions

1. What are the perceptions of perinatal nurses towards incident reporting?2. What do perinatal nurses perceive to be facilitating factors to incident reporting?3. What are the barriers to incident reporting perceived by perinatal nurses?

1.6 Chapter Summary

In this chapter, I have explained the background and significance for my research study. I

have explained the problem statement and presented the research questions guiding my study. In

the following chapter a synthesis of the current literature on incident reporting and registered

nurses will be presented.


14/140

6

2. CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

In this chapter, I present a review and synthesize relevant literature to outline the context

for my research study. Relevant articles were identified by conducting a search of five major

databases, CINAHL, Web of Science, Medline, PubMed, and Psycinfo. Key words initially used

in the search included reporting, adverse events, and nurses. Additional search terms were used

after exploring MESH headings and these included risk management, medication errors, safety,

and medication error (prevention and control). The literature review includes an analysis and

synthesis of the current literature conducted on incident reporting and registered nurses,

reporting practices, facilitators and barriers to incident reporting identified in the literature, and

the influence of team dynamics and the organizational context on incident reporting.

2.2. Review of Current Evidence

Quantitative, qualitative and mixed methods studies have been conducted to date on

incident reporting by nurses. Most quantitative studies have been exploratory and descriptive in

nature and have examined relationships between organizational characteristics and incident

reporting (Antonow, Smith, & Silver, 2000; Blegen et al., 2004; Chiang & Pepper, 2006; Evans

et al., 2006; Kagan & Barnoy, 2008; Kim, An, Kim, & Yoon, 2007; Stratton, et. al, 2004; Uribe,

et a;., 2002; Walker & Lowe, 1998). The studies cited above focused on nurses perceptions of

the causes of medication errors, factors affecting reporting of these errors and the influence of

various cultural factors on reporting rates (Blegen et al.; Chiang & Pepper; Kagan & Barnoy;

Mrayyan et al., 2007; Stratton et al.). One quantitative study evaluated the process of incident

reporting in a surgical setting including both physicians and nurses in the sample, although

results were reported separately for physicians and nurses (Kreckler, Catchpole, McCulloch &


15/140

7

Handa, 2009). This study focused on the influence of event outcome on reporting behaviour, as

well as staff members perceptions of surgical complications as reportable events (Kreckler et

al.).

Nurses sampled in studies to date have worked with both adult and pediatric populations

in acute care settings (Antonow et al., 2000; Blegen et al., 2004; Chiang & Pepper, 2006;

Edmondson, 1996; Evans et al., 2006; Jeffe et al., 2004; Kingston et al., 2004; Kreckler et al.,

2009; Mrayyan et al., 2007; Stratton et al., 2004). Stratton et al. found, in their study of pediatric

and adult hospital nurses, pediatric nurses were more likely to report medication administration

errors than nurses working on adult units. The authors hypothesized that this was due to pediatric

nurses knowledge of risks to the pediatric population from medication errors, which led to an

increased awareness of the need to report these incidents (Stratton et al.). This information

demonstrates how a specific practice context can influence incident reporting practices, thereby

justifying the importance of developing knowledge of under-studied nursing practice areas, such

as perinatal nursing contexts.

Qualitative studies have also been used to explore incident reporting. Most qualitative

studies have used focus groups to examine registered nurses attitudes and perspectives on

incident reporting in hospitals (Elder, Brungs, Nagy, Kudel, & Render, 2008; Jeffe et al., 2004;

Kingston, Evans, Smith, & Berry, 2004). Two of these studies included both registered nurses

and physicians in their samples, although the focus groups conducted were discipline specific

(Jeffe et al.; Kingston et al.). The third study sampled registered nurses from intensive care units

at four different hospitals (Elder et al.). One of the qualitative studies used a descriptive

methodology and semi-structured interviews to explore emergent factors influencing nurses


16/140

8

error reporting preferences in intensive care units (Espin, Wickson-Griffiths, Wilson, & Lingard,

2010). No qualitative studies conducted to date have included perinatal nurses.

One mixed-method study has been conducted on registered nurses incident reporting

(Covell & Ritchie, 2009). The study used a cross-sectional design, which included semi-

structured interviews and questionnaires. It sought to explain nurses responses to medication

errors and to identify nurses beliefs about ways to improve reporting of errors. A convenience

sample of registered nurses who were employed as staff nurses in a variety of clinical settings

within one health center was used in this study (Covell & Ritchie).

The majority of research on this subject has occurred in the United States (Antonow et

al., 2000; Blegen et al., 2004; Edmondson, 1996; Elder, et al., 2008; Jeffe et al., 2004; Rathert &

May, 2007; Stratton et al., 2004; Throckmorton & Etchegaray, 2007; Uribe et al., 2002; Vogus &

Sutcliffe, 2007; Wakefield et al., 1999) and Australia (Evans et al., 2006; Kingston et al., 2004;

Walker & Lowe, 1998). Three studies have been conducted in Canada (Covell & Ritchie, 2009;

Espin et. al., 2010; Espin, Regehr, Levinson, Baker, Biancucci, & Lingard, 2007). Two studies

have been conducted in Israel (Kagan & Barnoy, 2008; Naveh, Katz-Navon, & Stern, 2006) and

single studies have been conducted in Korea (Kim et al., 2007), Taiwan (Chiang & Pepper,

2006), Jordan (Mrayyan et al., 2007), and the United Kingdom (Kreckler et al., 2009). One

cross-national study has been conducted which surveyed physicians and nurses in the United

States, Israel, Germany, Switzerland, and Italy (Sexton, Thomas, & Helmreich, 2000). Hospitals

that served as study sites were located in both rural and urban areas, although the majority were

in urban areas.

Types of practice areas included in research have been medical wards, surgical wards,

emergency departments, telemetry/step-down units, intensive care units, and operating rooms


17/140

9

(Elder, et al., 2008; Espin et al., 2007; Jeffe et al., 2004; Kingston et al., 2004; Vogus &

Sutcliffe, 2007; Walker & Lowe, 1998). Research conducted to date has found that contextual

factors do impact incident reporting; therefore, it is important to consider the influence of

different practice contexts, such as labour and delivery units, on incident reporting practices to

improve patient safety in different practice areas.

There have been two studies conducted with staff members from two obstetric units in

the United Kingdom (UK) (Stanhope et al., 1999; Vincent et al., 1999). The first study examined

adverse event reporting rates through screening patients health records, and incident reports on

the units, and found that over half of all incidents were not reported through the hospitals

incident reporting system. The second surveyed staff to obtain their views on which incidents

would be reported, and the factors affecting reporting rates. Midwives and physicians who

worked on the selected units were surveyed (Stanhope et al.; Vincent et al.). This study found

that staff exercise a considerable degree of judgment in determining what incidents to report.

Incidents with a greater degree of harm, such as a maternal death, were more likely to be

reported as were incidents that were likely to result in a claim or complaint.

Although the UK studies targeted obstetric or labour and delivery units for incident

reporting practices, perinatal nurses were not sampled. This is because the UK has a different

care delivery model then those used in North America; nurses are not primary caregivers for

women during pregnancy or following birth. In the UK, pregnant women will be referred to an

antenatal care facility from their general practitioner (GP). Most births take place in hospital, and

midwives are the professionals who provide care for normal pregnancy, birth, and the postnatal

period. Women with complicated or high risk pregnancies receive care from medical staff and

midwives in partnership (Kateman & Herschderfer, 2005). In most parts of Canada, primary care


18/140

10

professionals such as family physicians or midwives provide maternity care for women with low

risk pregnancies. Obstetricians are the main caregivers for women with high risk pregnancies,

although they may also provide care for women with low risk pregnancies (Kateman &

Herschderfer). Perinatal nurses provide care for women who are hospitalized, although they do

not take on the role as the lead professional. This is a key distinction between perinatal nurses

and UK midwives.

Although there are likely similarities between perinatal nurses and midwives in the

factors that affect incident reporting, there may also be significant differences. Midwives have

more autonomous roles than registered nurses; they often provide care to women without

consulting a physician. Increased levels of autonomy in practice experienced by midwives would

likely affect incident reporting practices creating differences between perinatal nurses and

midwives. On the other hand, there may be similarities because both groups are employees of

organizations. It is important to determine perceptions of perinatal nurses about incident

reporting to explore similarities and differences with midwives.

2.2.1. Reporting Practices

Direct involvement in patient care and in the majority of incidents, as well as

predominantly reporting incidents, places nurses in a position to play an integral role in the

reduction of incidents that occur in health care (Kim et al., 2007). Although it is important to

understand factors affecting all health care professionals in regards to incident reporting, it is

especially important to understand the factors affecting the reporting of incidents by registered

nurses, in particular, in settings that have not yet been studied, such as perinatal nurses (Kim, et

al.; Mrayyan et al., 2007; Stratton et al., 2004; Chiang & Pepper, 2006).


19/140

11

2.2.1.1 Factors Affecting Reporting Practices

Nurses appear to exercise considerable judgment in deciding whether or not to formally

report an incident (Antonow et al., 2000; Covell et al. 2009; Jeffe et al., 2004; Kingston et al.,

2004; Walker & Lowe, 1998). Estimated rates of nurses incident reporting, as self-reported by

nurses, vary across studies ranging from 30.5 to 90 percent of incidents; those incidents were

reported to formal incident reporting systems (Antonw et. al.; Blegen et al., 2004; Covell et al.;

Kim et al., 2007; Stratton et al., 2004; Walker & Lowe). One study of 886 nurses found while

two-thirds of nurses stated they would always report incidents that resulted in patient harm,

nurses would report near miss events that did not harm the patient only one-fifth of the time

(Kim et al., 2007). Nurses were more likely to report incidents where patient safety had been

compromised and the patient had been harmed (Antonow et al.; Elder et al., 2008; Espin et al.,

2010; Kim et al.; Kreckler et al., 2009; Walker & Lowe). Incidents that are more likely to be

discovered, such as falls, pressure ulcers, and those that are sudden and attributable to a single

event are also more likely to be reported (Blegen et al.; Walker & Lowe). On the other hand,

errors not resulting in patient harm and near misses were least likely to be reported (Antonow

et al.; Blegen et al.; Espin et al.; Evans et al., 2006; Jeffe et al., 2004; Kreckler et al.).

Notwithstanding, one study found registered nurses were three times more likely than physicians

to always report incidents that do not cause patient harm (Kreckler et al.).

A few studies found nurses would also report errors informally (Covell & Ritchie, 2009;

Espin et al., 2010; & Espin et al., 2007). Informal reporting could include communicating the

error to a nursing colleague, a manager, a senior staff member, or an interdisciplinary team

member (Espin et al., 2010; & Espin et al., 2007). If the error was determined not to have

harmed the patient or if nurses were unsure if errors would result in harm, they would informally


20/140

12

report incidents to clarify or validate their concerns (Covell & Ritchie; Espin et al., 2010). In one

study, the decision to report informally or formally was influenced by the knowledge and

experience of the nurse, relationships with colleagues, physicians, and managers, the type of

error, and workload (Covell & Ritchie).

2.2.1.1.1 Relationships.

The quality of relationships appeared to exert a strong influence on the decision to report

informally or formally with one nurse explaining if we have good relationships, we prefer not to

do incident reports (Covell & Ritchie, 2009 p. 290). Nurses viewed informal reporting

mechanisms as positive because they allowed them to address their fear with reporting and

obtain emotional support from their colleagues (Covell & Ritchie; Espin et al., 2010). Errors that

were reported informally were not always formally reported to the hospital incident reporting

system. This is of concern because informal reporting does not allow systemic learning to occur

in relation to the error; therefore others may be at risk of making the same error (Espin et al.,

2007). These relationship dynamics and the need to allow for systemic learning are relevant in all

nursing contexts: intrapartum and postpartum perinatal practice contexts are as likely as other

practice contexts to experience near misses and discoverable incidents, such as medication

administration errors and patient injuries related to the labour and birth process; therefore,

incident reporting rates in perinatal areas might be influenced by similar factors.

2.2.1.1.2 Nurse characteristics.

Nurses characteristics have also been found to influence reporting practices. Nurses are

more likely to report incidents if they have more years of nursing experience, a longer length of

employment at their hospital, or occupy a management position (Blegen et al., 2004; Evans et al.,

2006; Kim et al., 2007). Two studies have found junior nurses are less likely to report incidents,


21/140

13

due to concerns about being blamed and punished for their part in an incident (Jeffe et al., 2004;

Kingston et al., 2004). The lack of willingness to report may indicate the hierarchical structure of

hospitals impacts nurses comfort in reporting incidents, as those with less experience generally

have less seniority within the institution; lack of willingness may also be a reflection of the

workplace culture that exists in the majority of health care institutions (Blegen et al., 2004;

Edmondson, 1996; Rathert & May, 2007).

Seniority was also found to influence reporting practices in a study of labour and delivery

units in the UK. A study by Vincent and colleagues (1999) found senior midwives indicated they

may not report an incident if they felt that a junior midwife would be blamed. Perinatal nurses

consist of both junior and senior nurses; therefore, their incident reporting rates may be affected

by similar factors. Alternatively, there may be discipline-specific differences between perinatal

nurses and UK midwives. It is important to understand how seniority impacts nurses reporting

practices so appropriate measures can be put in place to encourage incident reporting. To

understand the influence of seniority on incident reporting rates, it is necessary to study perinatal

nurses with varying lengths of experience.

Lyndon (2006) conducted a review of the literature to identify evidence on the role of

assertiveness and teamwork and the application of aviation safety techniques, in inpatient

perinatal units. Lyndon proposed perinatal nurses are the discipline primarily responsible for

identifying any incidents that occur throughout patient care in the inpatient perinatal settings.

This is because perinatal nurses are often responsible for the management of a patients labour

and the gatekeeper of patient observations, interventions, and treatments (Lyndon). Nurses are

recognized as being the professional group most likely to be involved in reporting (Kim et al.,

2007); although perinatal nurses have not yet been studied in the literature on error reporting,


22/140

14

perinatal nurses are likely to be the professional group most involved in incident reporting in

their practice context.

To improve patient safety in this practice area, it is therefore important for incidents to be

reported by perinatal nurses. Various patient safety issues affecting perinatal nurses have been

explored in the literature. These include avoidance of lawsuits through documentation and rapid

recognition by perinatal nurses of risk factors for poor outcomes (Dunn, Gies, & Peters, 2005;

Greenwald & Mondor, 2003; Miller, 2003). Perinatal nurses are more likely to be involved in

lawsuits than nurses in other practice areas due to the nature of their area of practice (Greenwald

& Mondor). These factors may affect incident reporting practices by perinatal nurses as they may

fear disclosure of incidents due to the risk of litigation or may feel it is not their responsibility to

report incidents that involve multiple disciplines, which is often the case in inpatient perinatal

settings. A study of obstetric units in the UK demonstrated the possibility of a specific incident

becoming a complaint or claim influenced whether or not staff chose to report the incident

(Vincent et al., 1999). It is therefore important to understand what, if any, influence the increased

threat of claims and litigation recognized in the perinatal practice area has on incident reporting

practices of perinatal nurses.

2.2.2 Barriers to Reporting

There are significantly more barriers than facilitating factors to incident reporting

mentioned in the literature. Administrative response, personal fear, and organizational factors are

reported as barriers to incident reporting (Blegen et al., 2004; Evans et al., 2006; Jeffe et al.,

2004; Kim et al., 2007; Kingston et al., 2004; Stratton et al., 2004; Uribe et al., 2002; Walker &

Lowe, 1998). Organizational factors that influence incident reporting include the amount of time

it takes to complete an incident report form, confusion created by multiple methods present in an


23/140

15

organization for reporting incidents, and the inability to report anonymously in some institutions

(Espin et al., 2010; Evans et al.; Jeffe et al; Kim et al.; Uribe et al.; Walker & Lowe). Peer

relationships amongst health care providers within and between disciplines have also been

recognized as having the potential to act as barriers towards incident reporting (Blegen et al.;

Uribe et al.; Wakefield et al., 2001).

Barriers to incident reporting affect both physicians and nurses; however, there appear to

be significant differences in how nurses and physicians approach incident reporting due to their

different professional cultures and values (Espin et al., 2007). Nurses are more likely to cite fear

of organizational response as a barrier to reporting, which may be a reflection of the culture of

nursing to follow protocols and directives as organizational employees (Kingston, et al., 2004;

Uribe et al., 2002). In contrast, the culture of medicine emphasizes physician autonomy and self

regulation (Kingston et al.). Physicians were less likely than nurses to know what should be

reported, how to report errors, and to believe that reporting contributed to quality improvement

efforts (Jeffe, 2004; Uribe et al.). They were also more likely to cite forces external to the

organization, such as litigation or coroners inquests, as barriers to incident reporting (Kingston

et al.).

Personal fear arising from embarrassment, concern about reputation, and fear of

reprimand appear to be the strongest personal barriers to reporting for nurses (Blegen et al.,

2004; Espin et al., 2010; Evans et al., 2006; Jeffe et al., 2004; Kingston et al., 2004; Walker &

Lowe, 1998). Personal fear affects psychological safety; there has been an association found

between an employees sense of psychological safety and rates of reporting near miss events

(Edmondson, 1996). Psychological safety occurs when employees do not fear retribution for

expressing their thoughts and opinions and is created through empowering employees; it is


24/140

16

strongly influenced by leadership and management (Naveh et al., 2006; Wakefield et al., 2001).

In one study, unit managers who encouraged discussions about incidents were found to be more

highly trusted by staff members (Vogus & Sutcliffe, 2007). If greater trust in unit managers

exists, there may be more discussion about incidents, and this in turn means staff members will

be more likely to report incidents when they occur.

Organizational factors that negatively influence incident reporting have included a focus

on personal rather than systemic factors when investigating incidents and management response

too severe for the nature of the error made (Kingston et al., 2004; Stratton et al., 2004). A

significant barrier to reporting mentioned in multiple studies is the lack of feedback that occurs

when an incident is reported (Elder et al., 2008; Evans et al., 2006; Jeffe et al., 2004; Uribe et al.,

2002). Therefore, multiple and complex dynamics create the organization context within which

barriers and facilitators to incident reporting arise. In fact, based on studies reported here, it is

reasonable to propose a reporting culture exists within different nursing workplaces. Therefore,

investigating how organizational factors shape nurses perceptions of barriers and facilitators for

incident reporting is necessary for improving reporting rates and patient safety.

2.2.3 Facilitating Factors to Reporting

Although the literature reports significantly more barriers than facilitating factors towards

incident reporting, two studies identified facilitating factors to incident reporting. Walker and

Lowe (1998) studied nurses reports of factors positively influencing their decision to report.

Facilitating factors included reporting out of concern for their patient, raising awareness of their

colleagues about errors that were occurring, and targeting an individual or professional group

with the aim of improving practice. The final facilitating factor mentioned was nurses

motivation to report to meet their legal obligations as a registered nurse (Walker & Lowe).


25/140

17

Educational purposes were identified by another study as a facilitating factor to reporting (Jeffe

et al., 2004). Self-protection was also identified as a facilitating factor in the study by Jeffe et al.

Self-protection was created by incident reporting because nurses felt incident reporting was

integral to preventing potential lawsuits (Jeffe et al.). An understanding of the factors that

facilitate perintatal nurses formal reports of incidents is crucial to increasing incident reporting

in this population of nurses.

2.2.4 Workplace Culture

Workplace culture, both at the organizational and unit level, has been shown to influence

incident reporting rates (Uribe et al., 2002; Vogus & Sutcliffe, 2007). An exploratory study of

relationships between organizational culture, continuous quality improvement, and medication

administration error reporting rates found smaller institutions were more likely to have group-

oriented cultures, where the focus is affiliation and trust, and to have higher perceived reporting

rates (Wakefield et al., 2001). Wakefield et al. found that two culture types: hierarchical (cultures

that are controlling and focused on rules and stability) and rational (cultures focused on

achievement, productivity and efficiency), were negatively associated with reported errors. The

study supports other findings where a fear of repercussion from superiors had a negative

influence on reporting (Uribe et al.; & Vogus & Sutcliffe). Because perinatal nursing practice has

been shaped by the drive for economic efficiency to the same extent as other settings, as

evidenced by the ongoing trend towards early postpartum discharge rates that began in the

1990s (Cusack, Hall, Scruby, & Wong, 2008), it is necessary to examine how fiscal reform

impacts incident reporting practices.


26/140

18

2.2.5 Interdisciplinary Team Dynamics

Many clinical areas operate with individuals functioning as members of multidisciplinary

teams. These include operating rooms, intensive care units, and labour and delivery units (Espin,

et al., 2007). The dynamics of the health care team may influence whether incidents are or are

not reported. Generally, nurses indicated they were less likely to report errors made by

colleagues if they were able to speak to their colleagues directly about an error to avoid someone

being blamed for the incident (Blegen et al., 2004; Elder et al., 2008; Evans et al., 2006;

Kingston et al., 2004; Walker & Lowe, 1998).

A study examining factors influencing the reporting practices of perioperative nurses

used semi-structured interviews and case studies to determine whether scope of practice

influenced incident reporting practices (Espin et al., 2007) found Nurses were interviewed after

reviewing four error scenarios involving interdisciplinary team members. The error scenarios

included events that were varied in terms of whether or how the error fell within the nurses

scope of practice. This study found that scope of practice did influence reporting practices for the

participants in the study (Espin et al.). For example, if an incident occurred during a surgery,

nurses felt it was outside of their scope of practice to report the incident and would defer to the

physician to make the decision about whether or not to report; the nurses felt this was outside of

the boundaries of their nursing knowledge and expertise (Espin et al.). A similar finding was

reported in a qualitative study of factors affecting incident reporting; nurses would decide

whether or not to report an incident based on location and would not report incidents that

occurred in the operating room, as this was felt to be the responsibility of the surgeon (Kingston

et al., 2004). Therefore, how nurses interpret their roles and responsibilities impacts their

participation in interdisciplinary interactions and both are relevant factors for incident reporting.


27/140

19

How nurses understand their scope of practice in team environments also influences

whether or not nurses would use formal incident reporting systems (Espin et al., 2007). If the

main discipline involved in the incident was a discipline other than nursing, nurses were more

likely to rely on informal reporting mechanisms, such as alerting nurse managers or other

colleagues (Espin et al.). A similar result was found in a study examining attitudes towards

communication and teamwork among perioperative nurses, surgeons, and anesthesiologists

(Sexton et al., 2000). Steep hierarchies within organizations and low levels of teamwork as

reported by staff resulted in nurses not feeling free to voice their opinion and to take part in team

discussions (Sexton et al., 2000).

Perinatal nurses working in labour and delivery units function as members of

multidisciplinary teams in a highly complex environment. These units are also prone to steep

hierarchies, similar to operating rooms, with the obstetrician at the head of the team. There may

be similarities between the factors affecting perinatal nurses incident reporting practices and

those studied to date in operating rooms and intensive care units (Espin, et al., 2007; Sexton et

al., 2000). Perinatal nurses may not feel comfortable reporting incidents, without the permission

of the obstetrician or other care providers, or may feel that it is not their place to report through

formal incident reporting systems when another discipline was primarily involved. Therefore, it

is important to determine whether teamwork and hierarchical cultures affect incident reporting

by perinatal nurses, because they are most likely to discover incidents in practice. If nurses do

not feel free to speak up when they feel situations are unsafe or need attention by other team

members, nurses may not feel comfortable or able to report incidents when they occur.


28/140

20

2.3 Chapter Summary

In this chapter, I have presented a review and synthesis of the current literature on

registered nurses and incident reporting. A thorough review of the literature identified

qualitative, quantitative, and mixed-methods studies on incident reporting by registered nurses in

acute care hospitals. Studies have been conducted in different countries and practice areas. There

have been no studies conducted to date on perintatal nurses and incident reporting.

Registered nurses play a key role in incident reporting, as the professionals most likely to

access hospital incident reporting systems (Kim et al., 2007). Registered nurses exercise

judgment in determining what to report and whether to report using formal incident reporting

systems or informal reporting mechanisms (Antonow et al., 2000; Covell, et al., 2009; Jeffe et

al., 2004; Kingston, et al.; 2004). These decisions are made based on the type of event that

occurred and the effects of the incident (Antonow; Blegen et al., 2004; Elder et al., 2008; Espin

et al., 2007; Kim et al.; Kreckler et al., 2009; Walker & Lowe, 1998). Nurses characteristics

have also influenced reporting practices with nurses with greater experience and longer length of

employment being more likely to report incidents (Blegen et al. Evans, 2006; Kim et al.).

Perinatal nurses may be affected by such factors, as well as factors specific to their area of

practice. Therefore it is important to gain a greater understanding of the perceptions of perinatal

nurses towards incident reporting.

There are both barriers and facilitating factors towards incident reporting mentioned in

the literature. Barriers can be organizational factors, administrative responses, or personal

reasons, while facilitating factors include protection and learning (Blegen et al., 2004; Evans,

2006; Jeffe et al., 2004; Kim et al., 2007; Kingston et al., 2004; Stratton et al., 2004; Uribe et al.,

2002; Walker & Lowe, 1998). There are significantly more barriers than facilitating factors


29/140


30/140

22

3. CHAPTER THREE: RESEARCH METHOD

3.1 Introduction

In this chapter, I describe the method used for the study. The purpose of my study was to

understand the perceptions of perinatal nurses towards incident reporting. I chose to use a

descriptive qualitative design to answer my research question. I will begin by describing the

research design used followed by an explanation of the population of interest, my sampling

strategy, the sample and the inclusion criteria used. I will then discuss ethical considerations for

this study followed by a discussion of the challenges encountered during recruitment for the

focus groups. I will then explain methods used for data collection. Finally, I will explain the

methods used for data analysis and discuss the various strategies used to ensure rigor and quality

in the research process.

3.2 The Research Design

A descriptive qualitative research design was used for the study. Qualitative approaches

seek to discover meaning and to arrive at an understanding of a particular phenomenon from the

perspectives of those involved (Polit & Beck, 2008). Qualitative research accomplishes this by

describing social experiences, including how these experiences are created and what meaning the

phenomena has for those involved (Burns & Grove, 2001; Speziale & Carpenter, 2003). Many

qualitative approaches can be used to accomplish understanding; therefore, it is important to look

to the research question to determine which method to employ (Speziale & Carpenter). Because I

was seeking to understand perinatal nurses experiences with incident reporting, I chose a

qualitative descriptive design, which can guide the construction of a comprehensive description

of participants perceptions and understandings presented in everyday language (Polit & Beck;

Sandelowski, 2000).


31/140

23

The qualitative descriptive design is distinct from other qualitative methods, such as

phenomenology or grounded theory, in that it involves understanding that is low inference

(Sandelowski, 2000). Qualitative description is based on the general premises of naturalistic

inquiry, which rests on premises of multiple interpretations of reality; qualitative description an

underlying goal of studying the phenomenon of interest in its natural state (Polit & Beck, 2008;

Sandelowski). Qualitative description can comprehensively capture participants perceptions and

understandings (Sandelowski); therefore, it is an appropriate fit for my purpose to obtain

perinatal nurses perceptions of incident reporting as understood by perinatal nurses.

3.3 Sample/Population/Participants

Discovering meaning and gaining a rich understanding about a topic is the aim of most

qualitative studies. Therefore, generalizability is not a concern when choosing a sampling

strategy (Polit & Beck, 2008). In order to achieve a rich understanding, participants are chosen

through a number of strategies based on their first hand experience with the topic being studied

(Speziale & Carpenter, 2003). One of these strategies is purposive sampling where researchers

use their judgment to select participants that they believe will best benefit the study. In other

words, they consider participants selected to be the most knowledgeable about the phenomena

(Polit & Beck; Sandelowski, 2000).

Perinatal nurses are registered nurses who provide care to women and their infants in the

antepartum, intrapartum and postpartum periods in both acute care hospitals and community

settings. For the purposes of my study, the population of interest was perinatal nurses who

practiced in labour and delivery or single room maternity care (SRMC) units. This population

represented the most knowledgeable individuals to best answer the research question.


32/140

24

I recruited participants for my study from the population of perinatal nurses who were

employed at three different acute care hospitals within one Health Authority in the Province of

British Columbia. Perinatal nursing care takes place in the context of many different units and

settings, which I assumed would exert some influence over their experience with incident

reporting. To reduce variation and allow for a more focused inquiry, I decided to use

homogenous sampling, a type of purposive sampling, to only include perinatal nurses who

currently worked in labour and delivery or single room maternity care (SRMC) units as staff

nurses (McLafferty, 2004; Polit & Beck, 2008). To maximize the breadth and diversity of the

perceptions of perinatal nurses towards incident reporting there were no restrictions placed on

level of experience or background for those participating in the study (Polit & Beck).

3.3.1Procedures

I purposefully chose the Health Authority and relevant hospitals after consultation with

my thesis committee and review of the services provided at the different hospitals. Several

hospitals within the Health Authority provided maternity care services, which allowed

recruitment to occur at multiple sites. The three hospitals chosen were similar in that they all had

labour and delivery suites or single room maternity care (SRMC) units. The hospitals differed

slightly in the way perinatal care was delivered at each site and also provided different levels of

perinatal care (BC Perinatal Health Program (BCPHP), 2005). They also differed because one of

the sites had implemented the MORE OB program. MORE OB is a professional development

and performance improvement program for caregivers and administrators in hospital perinatal

units. The program is based on the principles of effective communication, teamwork, decreased

levels of hierarchy and safety as a priority (Salus Global Corporation, 2010).


33/140

25

Levels of perinatal care have been established in British Columbia to identify standards

for the provision of specified levels of care, as well as the creation of common understandings of

the capabilities of each centre (BCPHP, 2005). The levels range from one to three, with level one

centers providing care to healthy women and their newborns while level two centers have all of

the functional capabilities of a level one centre but also offer support from specialists and are

capable of managing the care of women and infants at low to moderate risk (BCPHP). Level

three centers have all the functional capabilities of level one and two centers and, in addition,

have the capability to manage the care of moderate to high, high and very high risk mothers,

fetuses and newborns (BCPHP). Hospitals with different levels of perinatal care were

purposefully selected to vary the nature of the contexts for levels of acuity in practice. The intent

was to explore their influence on incident reporting practices in perinatal settings.

The first hospital selected had 1500-2499 births per year and provided care to intrapartum

patients on a separate labour and delivery unit. This centre was classified as level two, according

to the classification set out by the BCPHP (2005). The second hospital is a larger centre with

2500-4999 births per year. It was also classified as a level two centre. At the second site all care

was provided to intrapartum patients in a single room maternity care unit with patients receiving

care including the labour and delivery and postpartum periods. The third hospital had between

2500-4999 births per year and was classified as a level three centre. Care was delivered to

patients on separate labour and delivery and postpartum units and most of the perinatal nurses

were cross-trained to work on both units.

3.3.2 Inclusion Criteria

The inclusion criteria for the study incorporated: working as a perinatal staff nurse, being

employed at one of the three designated hospitals, having an ability to read and speak English


34/140

26

and working greater than or equal to a 0.5 full time equivalent (FTE). It was assumed the

perinatal nurses who participated would have different levels of experience and expertise in their

practice, which would contribute to the richness of the discussion in the focus groups. It was not

a requirement to have past experience with incident reporting, although it was assumed that most

perinatal nurses would have had some past exposure to incident reporting.

3.4 Ethical Considerations

The study was conducted following Tri-Council Ethical Guidelines (Canadian Institutes

of Health Research, Natural Sciences and Engineering Research Council of Canada, Social

Sciences and Humanities Research Council of Canada, 2005).

3.4.1Protection of Human Subjects

Approval for this study was obtained from the University of British Columbia (UBC)

Behavioral Research Ethics Review Board (BREB) and the Health Authority Research Ethics

Board (HA REB). Copies of the approval certificates as well as the letter of authorization to

conduct research can be found in Appendix A. I also obtained approval from the managers of

each of the three maternity units for participation in the study after obtaining consent from UBC

BREB but prior to obtaining consent from the HA REB. I sent each of the managers an

information letter on the study (Appendix B) as well as copies of the approval certificates from

the Research Ethics Boards.

When first contacted by a potential participant I provided them with a copy of the

participant information letter (see Appendix C) that fully explained the nature of the study, a

persons right to refuse participation, the responsibilities of the researcher and the likely risks

and benefits to participating in the study. I also provided each participant with a copy of the

informed consent document (Appendix D) and reviewed it briefly with him or her during our


35/140

27

initial contact. The participants were asked to review the documents. If they were still interested

in participating they provided me with information so that I could contact them when I was

arranging a time for the focus group interview. Each participant had several days to a few weeks

from the time they expressed interest in participating in the study to the focus group interview to

decide whether to participate. This time frame was never less than twenty-four hours required by

both UBC BREB and HA REB. As practicing registered nurses, all potential participants were

competent to give full informed consent for their participation in the study.

At the beginning of each focus group interview, I reviewed the purpose of the study, the

consent form, the voluntary nature of their participation in the study and issues with

confidentiality. All participants fully consented to their participation in the study by signing an

informed consent document prior to the interview. I advised participants they were able to leave

the focus group interview at any time.

I reassured participants about the confidentiality of their responses in regards to

gathering, storing, and handling of data (McLafferty, 2004). I made efforts to protect

confidentiality of the participants throughout the research process. Focus group members were

asked to adhere to the confidentiality of any information revealed in the group context. I also

explained to the group, although the researchers would keep all information confidential, I could

not guarantee that other participants would do so. I also advised participants that no identifying

information from the interview would be released without their prior consent.

One exception to confidentiality would have been if participants had discussed any

incidents where a child was intentionally harmed or neglected. Anyone who has reason to

believe a child has been intentionally harmed or neglected is legally required to report this

information under the British Columbia Child, Family and Community Services Act (Child,


36/140

28

Family & Community Services Act, 1996). I advised participants of the regulation at the

beginning of the focus group. I explained, if any participants disclosed incidents that were

reportable to the Health Authority, a Ministry of Children and Family Development Office and

the College of Registered Nurses of British Columbia, I would report the incidents. Incidents of

this nature were not disclosed during any of the focus group interviews.

Data collected during the focus group interviews were managed in keeping with ethical

principles. I recorded focus groups using audio-tapes and had colleagues take field notes. I

transcribed the audio-tapes verbatim following the focus groups (Sim, 1998). Colleagues took

field notes during the interview to record information on setting, non-verbal information and

other participant interactions not captured through audio-tapes (Sim). I moderated the focus

group and had a member of my thesis committee assist me with taking field notes at two of the

focus groups; a friend who signed a pledge of confidentiality assisted me at one other interview.

I removed any names used during focus group interviews during transcription, as well as any

identifying place or institutional names. I coded participants on the transcripts as Participant 1

(P1), Participant 2 (P2) etc.

I have stored all interview tapes, identifying data, and transcribed notes, as well as field

notes, in locked cabinets, in a locked room where there is no public access. I have stored all

computer files on password protected hard drives and all files are password protected and

encrypted. Written data will be stored in a locked cabinet in a locked room as noted above for at

least five years. After this point all data and audiotapes will be destroyed as per UBC BREB

guidelines.


37/140

29

3.5. Recruitment

Recruitment occurred at the three different hospitals over a period of six months.

MacDougall and Fudge (2001) argued recruitment can be especially challenging when the topic

is sensitive, such as discussing incidents that may have occurred in practice. Other issues that can

make recruitment difficult are when gatekeepers withhold access or when recruitment does not

build on an existing relationship. Because I was an outsider to the health authority and my topic

was potentially a sensitive one for the perinatal nurses, I anticipated recruitment would be

challenging. I used a number of recruitment strategies to overcome some of the challenges and

obtain sufficient numbers for the focus groups.

I contacted the managers of the maternity units at each of the three hospitals and provided

information about the study. Once I obtained approval from the managers and from the Health

Authority Research Ethics Board (HA REB), I distributed informational posters (Appendix E) at

each of the three sites inviting perinatal nurses to participate in the focus group. I had a contact

member at each site, either the manager or an educator, who provided assistance with gaining

access to the perinatal nurses at the site.

In addition to posters on the units, I distributed information about the study to the

perinatal nurses through presentations at professional practice meetings on each unit. My

presentations at these meetings included information on the background of the study, the purpose

of the research, and what would be required from those who chose to participate. Specifically, I

explained that I intended to add to the literature on incident reporting because nurses

perceptions of incidents are under-studied. I distributed copies of the participant information

letter (Appendix C) and the consent form (Appendix D) at the professional practice meetings. I

also left copies at each site with the manager or educator who had been provided with


38/140

30

information on the study. I provided electronic copies of the information letter and consent form

to the managers and educators and, at two of the sites, these were sent by e-mail to the perinatal

nurses who met the inclusion criteria by the manager or educator.

After the information was distributed to the different sites, I waited to be contacted by

nurses who were interested in participating. I planned to wait until I had been contacted by a

minimum of six nurses from each site to arrange an interview time that would be convenient for

the majority. I responded to any potential participants who contacted me as soon as possible, by

phone or email, depending on the contact information provided. I also followed up with potential

participants to update them on the status of arranging focus group interviews and to prompt and

confirm participation (MacDougall & Fudge, 2001). I contacted all potential participants the day

before the agreed upon interview time to confirm participation.

Despite implementing the measures I have described, I encountered a number of

challenges during recruitment. My recruitment at two sites was slower than anticipated. I had

been contacted by six nurses at the second site and arranged an interview time with those that

contacted me. Unfortunately, only two participants attended at the agreed upon time. I chose to

go forward with the interview as I was in my fourth month of recruitment with what appeared to

be minimal interest from the nurses in participating.

I continued to have difficulty recruiting at the third site. I had no responses to the posters

that were distributed on the unit or by email and my presentation at the professional practice

meeting. I discussed my difficulties with my thesis committee supervisor and the educator on the

unit. From the educator, I understood the unit had undergone many changes and it was difficult

to find staff willing to participate outside of their work hours. I decided to arrange an interview

after an education session that was scheduled at the hospital. The nurses planning to attend the


39/140

31

education session were given information about the study and my contact information. Four

nurses contacted me and participated in a focus group interview.

In a site that facilitated recruitment of nurses, I was contacted shortly after my

presentation to the professional practice group by a group of nurses who wished to participate. I

set an interview date at a time and location that was convenient for them. There were five

participants attending this group; one was unable to participate in the interview due to illness.

3.6 Data Collection

I collected data using focus group interviews with perinatal nurses from three different

acute care hospitals in one health authority in the Province of British Columbia. The interviews

took place at a time and location chosen by the participants, outside of their work hours. Each

focus group was composed of perinatal nurses from the same hospital and was approximately an

hour in length. I provided participants with a light meal and refreshments and a twenty-dollar

honorarium for their time and participation in the study to offset costs associated with

participation such as parking and child care. I also made a two hundred dollar donation to the

nursing education fund of each unit to thank the units for their participation in the study and their

assistance in distributing materials and providing and arranging meeting space, if necessary, at

the hospital.

I collected basic demographic data at the beginning of each focus group from the

participants using a demographic questionnaire (Appendix F). Specifically, information collected

included age, sex, gender, ethnicity, highest level of education achieved, and length of

experience as both a registered nurse and in perinatal nursing. This information was collected to

describe the sample and to determine how to sample compared to the general population of

perinatal nurses in Canada.


40/140

32

Focus groups are a useful form of data collection for qualitative descriptive studies

because they allow the researcher to obtain a broad range of information about a topic

(Sandelowski, 2000). Focus groups are carefully planned discussions that take advantage of

group dynamics for accessing rich information in an efficient manner (Polit & Beck, 2008, p.

395). Group norms and values are revealed through discussion, which can provide major insights

into attitudes, beliefs, and opinions of the group studied, as well as information about the social

realities unique to the particular group (McLafferty, 2004).

Focus groups are also particularly useful for studying workplace cultures (Kitzinger,

1995). Naturally occurring groups, such as those that work together, are particularly suited for

focus groups as co-participants can provide mutual support in expressing feelings common to the

group (Pope & Mays, 2006) and feel supported and empowered by a sense of group membership

(Sim, 1998). This is useful when studying a sensitive topic, where participants may feel

vulnerable discussing their personal experiences, such as incidents that have occurred through

the course of employment (Kitzinger; Pope & Mays). Homogenous groups are also thought to be

particularly suited for focus groups as they provide participants with the freedom to express their

thoughts, feelings and behaviors candidly (Burns & Grove, 2001).

Focus groups facilitate the expression of ideas and experiences that may be

underdeveloped in an interview setting, because participants will be stimulated through the ideas

and discussions of others present (Kitzinger, 1995; Nyamathi & Shuler, 1990; Pope & Mays,

2006; Stewart, Shamdasani, & Rook, 2007). Focus group interviews allow researchers to interact

directly with participants, observing non-verbal responses and clarifying responses (Stewart et

al., 2007). They are an economical way of collecting large amounts of data (Kidd & Parshall,

2000; Sim, 1998). This is particularly important in qualitative research where the researcher


41/140

33

strives to collect as much data as possible in order to capture all elements of a particular

phenomenon (Sandelowski, 2000). Based on the advantages, I decided focus group interviews

were an appropriate form of data collection for gaining understanding of perinatal nurses

perceptions of incident reporting in practice.

The disadvantages to focus groups must be considered during data collection and

analysis. Participants may not answer questions in the same manner they would in other settings

due to the influence of group dynamics (Kidd & Parshall, 2000). Conversation in focus group

interviews can be monopolized by more dominant members of the group biasing the responses as

more reserved group members may not contribute as much to the discussion (Stewart et al.,

2007).

Because the quality and nature of the data collected are dependent on the process of

interaction that takes place as moderated by the researcher (Sim, 1998), the moderator plays an

important role in overcoming some of the disadvantages associated with focus group interviews

(Stewart et al., 2007). The moderators role is to create a non-threatening environment that

encourages all participants to share their views (McLafferty, 2004). I acted as moderator at all of

the focus group interviews. At the beginning of each focus group I introduced myself to the

participants and explained my background and the purpose of the research. Because all of the

perinatal nurses in each group worked with each other regularly, it was not necessary to

introduce the participants to each other. I explained ground rules for the focus group interviews

to the participants. This included not speaking over other participants and exercising the ability

to leave the interview at any time. I reminded the participants the groups would be recorded

using audio-taping and through the collection of field notes.


42/140

34

The focus groups were conducted using a semi-structured interview guide (see Appendix

G) containing open-ended questions in order to stimulate discussion among the participants and

gather data relevant to the study purpose. The purpose of the interview guide is to stimulate

conversation among the participants about the research topic (McLafferty, 2004). The questions

in my interview guide progressed from general to more specific and included general questions

such as what comes to your mind when you hear the word incident reporting? and more

specific questions such as why might you decide to report an incident. I used the questions

only as a guide. I asked other questions to obtain further clarification or to stimulate and focus

discussions, as needed (McLafferty).

The setting of the interviews is also acknowledged as an important part of developing an

atmosphere where participants feel comfortable enough to express their thoughts and ideas

(McLafferty, 2004). I asked each nurse contacting me if they preferred to meet at the hospital or

at a room in the community and followed the wishes of the majority. I sought participants input

about the location to provide an environment that was comfortable to the participants. Three of

the groups preferred to meet at the hospital where they worked so a room was booked at the

hospital away from the unit. The fourth group preferred to meet in the community so a room was

booked at a local community centre.

Authors vary on the ideal group size for focus groups. If groups are too large it is felt that

the group may be hard to manage (McLafferty, 2004; Stewart et al., 2007). Smaller groups raise

concerns that they may not generate as many ideas as larger groups (McLafferty; Stewart et al.).

Some authors recommend 6-12 participants (Sim, 1998; Stewart et al.); while others state that the

ideal group size is between 4 and 8 people (Kitzinger, 1995).


43/140


44/140

36

group were analyzed as soon as possible following the focus group by reviewing field notes and

transcripts. Performing the transcription allowed me to become immersed in the data. Once the

interviews were transcribed, I read and reread the transcripts to achieve further immersion in the

data (Burnard, 1991; Hsieh & Shannon, 2005; Pope, Ziebland, & Mays, 2000). I began the

process of coding with open coding; I coded data according to the information that they

represented (Polit & Beck; Pope et al., 2000). This could include phrases, incidents or types of

behaviors (Polit & Beck; Pope et al.). I wrote notes and headings in the text whil

ubc 2010 fall waters norna

Documents