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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
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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
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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.
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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
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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
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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
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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
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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.
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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
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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.
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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
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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
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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.
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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 &
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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
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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
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(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
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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).
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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
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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,
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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,
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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
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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
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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).
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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.
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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.
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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.
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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
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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).
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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.
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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).
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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
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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
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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,
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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.
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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
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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
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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.
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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
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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.
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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).
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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