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 FULFILLMENT OF 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

ii ABSTRACT Patient 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

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.

iv TABLE OF CONTENTS Abstract ..........................................................................................................................................ii Table of Contents ..........................................................................................................................iv List of Tables ................................................................................................................................vii Acknowledgments .......................................................................................................................viii 1. Chapter One: Problem Identification and Purpose ...............................................................1 1.1. Introduction .....................................................................................................................1 1.2. Significance .....................................................................................................................3 1.3. Problem Identification .....................................................................................................4 1.4. Statement of Purpose .......................................................................................................5 1.5. Research Questions .........................................................................................................5 1.6. Chapter Summary ............................................................................................................5 Chapter Two: Literature Review ..........................................................................................6 2.1. Introduction .....................................................................................................................6 2.2. Review of Current Evidence ...........................................................................................6 2.2.1. Reporting Practices ..............................................................................................10 2.2.1.1. Factors Affecting Reporting Practices........................................................11 2.2.1.1.1. Relationships .....................................................................................12 2.2.1.1.2. Nurse Characteristics ........................................................................12 2.2.2. Barriers to Reporting............................................................................................14 2.2.3. Facilitating Factors to Reporting .........................................................................16 2.2.4. Workplace Culture ...............................................................................................17 2.2.5. Interdisciplinary Team Dynamics ........................................................................18 2.3. Chapter Summary ..........................................................................................................20 Chapter Three: Research Methods......................................................................................22 3.1. Introduction ...................................................................................................................22 3.2. The Research Design .....................................................................................................22 3.3. Sample/Population/Participants.....................................................................................23 3.3.1. Procedures ............................................................................................................24 3.3.2. Inclusion Criteria .................................................................................................25 3.4. Ethical Considerations...................................................................................................26 3.4.1. Protection of Human Subjects .............................................................................26 3.5. Recruitment ...................................................................................................................29 3.6. Data Collection ..............................................................................................................31 3.7. Data Analysis ................................................................................................................35 3.8. Rigor and Quality ..........................................................................................................37 3.9. Chapter Summary ..........................................................................................................39 Chapter Four: The Findings ................................................................................................40 4.1. Introduction ...................................................................................................................40

2.

3.

4.

v 4.2. 4.3. Description of the Sample .............................................................................................40 Qualitative Themes........................................................................................................42 4.3.1. Nature of Incidents...............................................................................................43 4.3.1.1. Descriptions ................................................................................................44 4.3.1.2. Determining What Qualifies as an Incident ...............................................48 4.3.1.3. Litigation ....................................................................................................51 4.3.2. How Incidents Happen.........................................................................................53 4.3.2.1. Decision Making ........................................................................................53 4.3.2.2. Dynamics ....................................................................................................54 4.3.3. Barriers to Incident Reporting .............................................................................55 4.3.3.1. Fatigue ........................................................................................................56 4.3.3.2. Time to Report............................................................................................56 4.3.3.3. Reporting Tools ..........................................................................................57 4.3.3.4. Unit Culture ................................................................................................59 4.3.3.4.1. How Incident Reporting is Viewed...................................................59 4.3.3.4.2. Reactions/Responses .........................................................................60 4.3.4. Facilitating Factors to Incident Reporting ...........................................................65 4.3.4.1. Learning......................................................................................................66 4.3.4.2. Practice Improvement.................................................................................67 4.3.4.3. Professional Responsibility ........................................................................69 4.4. Chapter Summary ..........................................................................................................71

5.

Chapter Five: Discussion of Findings, Nursing Implications, Summary and Conclusion ..............................................................................................................................72 5.1. Introduction ...................................................................................................................72 5.2. Discussion of Findings ..................................................................................................73 5.2.1. Comparing the Sample to the Canadian Population of Perinatal Nurses.............73 5.2.2. Comparison of Findings to the Literature ............................................................74 5.2.2.1. Perinatal Practice Setting............................................................................74 5.2.2.1.1. Medication Incidents .........................................................................75 5.2.2.1.2. Workload...........................................................................................77 5.2.2.2. Factors Affecting Incident Reporting .........................................................78 5.2.2.2.1. Judgment and Experience ................................................................78 5.2.2.2.2. Reporting Based on Criteria..............................................................79 5.2.2.2.3. Litigation ...........................................................................................80 5.2.2.3. Barriers to Incident Reporting ....................................................................82 5.2.2.3.1. Organizational Barriers .....................................................................82 5.2.2.3.2. Personal Barriers ...............................................................................85 5.2.2.4. Facilitating Factors .....................................................................................85 5.2.2.5. Team Dynamics and Organizational Culture .............................................87 5.2.2.5.1. Informal Reporting............................................................................88 5.2.2.5.2. Determining What Qualifies as an Incident ......................................91 5.2.2.6. Feedback and Follow-up to Incident Reports ............................................91 5.3. Study Limitations ..........................................................................................................92 5.4. Nursing Implications .....................................................................................................94 5.4.1. Recommendation for Administration, Education and Practice............................94

vi 5.4.1.1. Implications for Nursing Administration...................................................94 5.4.1.2. Implications for Nursing Education ...........................................................99 5.4.1.3. Implications for Nursing Practice.............................................................101 5.4.2. Recommendation for Further Research .............................................................102 5.5. Communication of Findings ........................................................................................103 5.6. Chapter Summary ........................................................................................................104 5.7. Summary and Conclusion ...........................................................................................104 References... .............................................................................................................................106 Appendices...................................................................................................................................117 Appendix A: Research Ethics Board Approval Certificates ..................................................117 Appendix B: Information Letter Sent to Managers ...............................................................121 Appendix C: Participant Information Letter ..........................................................................123 Appendix D: Informed Consent Document ...........................................................................125 Appendix E: Recruitment Poster ...........................................................................................130 Appendix F: Demographic Questionnaire .............................................................................131 Appendix G: Focus Group Interview Guide ..........................................................................132

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

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.

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

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.

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

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

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.

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 &

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

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 semistructured 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

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

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).

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

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,

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,

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

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

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).

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 grouporiented 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.

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.

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.

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

21 reported in the literature. Workplace culture and team culture have also influenced reporting rates (Espin et al., 2007; Uribe et al.; Vogus & Sutcliffe, 2007). Group-oriented cultures were found to have higher reporting rates than hierarchical cultures where a fear of repercussions from reporting may act as a deterrent (Wakefield, 2001). Team dynamics can also influence reporting rates with nurses not feeling comfortable reporting incidents that involved another discipline (Espin et al., 2007). An understanding of the factors influencing reporting rates that are specific to perinatal nurses would be beneficial because it would allow systems to be developed that could reduce incidents. Studying perinatal nurses perceptions can provide more understanding of factors specific to their workplace cultures that both encourage and act as barriers towards incident reporting.

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).

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.

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).

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

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). 3.4.1 Protection 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

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,

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.

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

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

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.

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

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.

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).

35 I treated each of the hospitals as a separate site with focus groups conducted that were composed of nurses from each hospital. I had originally planned to conduct a focus group with participants from each of the hospitals with a goal of 6 to 12 participants in each focus group. I expected my total sample size to be between 18 and 24 participants. As previously indicated, my sample size of 16 participants was smaller than I had anticipated. At two hospitals, there were two groups of five perinatal nurses. At the third hospital, there was one group of four perinatal nurses and one group with two perinatal nurses. I found I was more comfortable moderating the larger groups, which I believe was due to the group synergy that was present. I also found there was greater depth to the discussion in the groups with larger numbers of participants. 3.7 Data Analysis I used content analysis to analyze the data from the focus groups. Content analysis is defined as the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns (Hsieh & Shannon, 2005, p. 1278). Benefits to using content analysis include its flexibility in terms of research design and its content-sensitivity (Elo & Kyngs, 2008). There are two different approaches to content analysis: inductive or deductive. Because there was no reported research on the topic of perinatal nurses and incident reporting, it was appropriate to use an inductive approach to content analysis (Elo & Kyngs). When inductive content analysis is used preconceived categories are not used; instead the categories and names from the categories are created from the data (Elo & Kyngs; Hsieh & Shannon). This approach to analysis allowed the identification of prominent themes and patterns among the themes (Polit & Beck, 2008). The process of data analysis began with the first focus group. I used constant comparative analysis and concurrent data collection and analysis (Polit & Beck, 2008). Data from each focus

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 while reading it in order to describe all aspects of the content that were relevant to the research questions (Burnard; Elo & Kyngs, 2008; Hsieh & Shannon). Examples of codes generated at this stage included having a record, near misses & incidents and incident reporting amongst ourselves. Once I had read and reread the transcripts and generated no further codes, I recorded the codes on index cards (Pope et al., 2000). I sorted the codes and those that shared similar characteristics were grouped into categories (Milne & Oberle, 2005). Computer files were also created and the codes were placed into a word table to allow searching amongst codes (Polit & Beck, 2008; Pope et al.). Examples of categories included self learning, specific incidents and experience. I repeated the process for each focus group transcript. I used constant comparison to compare data within and between focus groups to develop themes (Pope et al., 2000). The lists of categories were grouped under higher order headings such as teams reasons for incidents and learning from incidents (Elo & Kyngs, 2008). This reduced the numbers of categories as those that were similar or dissimilar were collapsed into the higher order headings. I worked with my thesis supervisor to refine the themes and subthemes. We clustered the higher order headings from all data into subthemes and themes. I copied quotations that illustrated the various themes

37 and subthemes from the transcripts and placed into the word tables along with the related code. We developed 4 themes and corresponding sub-themes from the focus group interviews. I explain the themes and subthemes in further detail in the following chapter. 3.8 Rigor and Quality I employed various strategies throughout data collection and analysis to enhance the rigor and quality of this qualitative descriptive study. There are many frameworks for assessing quality in qualitative research suggested in the literature (Milne & Oberle, 2005; Nelson, 2008; Polit & Beck, 2008; Whittemore, Chase, & Mandle, 2001). I chose to use Lincoln and Gubas (1985) framework. Lincoln and Guba proposed four criteria for developing the trustworthiness or rigor of a qualitative study. These four criteria included credibility, dependability, confirmability and transferability of the findings (Lincoln & Guba). In the framework, credibility is viewed as an overriding goal. It is defined as confidence in the truth of the data as well as in the interpretations made from the data (Polit & Beck, 2008). I undertook a number of measures to meet this criterion. Member checking, defined as confidence in the truth of the data, was an ongoing process throughout the study (Milne & Oberle, 2005; Polit & Beck). As moderator, I probed during focus group interviews to ensure understanding of the participants meanings (Nelson, 2008; Polit & Beck). I transcribed transcripts verbatim and field notes were taken to ensure accurate accounts of what the participants said in the focus group interviews. I reviewed audio recordings of the interviews while reading the transcription to ensure no errors or assumptions were made in the transcription process. I refined the codes through meetings with my supervisor and reviewed codes and categories I was developing with a member of my thesis committee and my thesis supervisor throughout the analysis (Milne & Oberle, 2005).

38 The second criterion of dependability is defined as the stability of data over time and conditions (Polit & Beck, 2008). To achieve dependability, I kept a clear account of the methods of data collection and analysis throughout the study. I explicitly documented all procedures by using an audit trail of how conclusions were drawn (Mays & Pope, 2000). I kept all records including interview transcripts, process notes, and theoretical notes and working hypotheses (Polit & Beck). The audit trail includes clear documentation of how coding evolved and how the categories and themes were developed (Mays & Pope). Confirmability refers to objectivity. Confirmability implies the findings are reflective of the participants perceptions and conditions of the inquiry, rather than the biases or perceptions of the researcher (Nelson, 2008; Polit & Beck, 2008). I used direct quotations whenever possible in the descriptions of the themes so readers are able to judge for themselves whether the findings are reflective of the participants perceptions. I engaged in reflexivity by maintaining a research journal. Journaling allows the researcher to carefully analyze and document any presuppositions, biases, and ongoing emotions throughout the study (Nelson, 2008). This process allowed me to reflect on my own biases as a perinatal nurse who has had past experiences with incident reporting. I was also able to reflect on my reactions to events that occurred during the data collection process (Mays & Pope, 2000; Polit & Beck, 2008). Writing the journal helped me to clarify any contributions of my perceptions to the process of data collection and analysis. Transferability, or the extent to which the findings are applicable to other settings or groups, is the final criterion proposed by Lincoln and Guba. (1985). I attended to transferability through the inclusion of rich descriptions of the participants and the settings where they practice. A demographic questionnaire was used in order to describe the sample of perinatal nurses who participated in the study. Information was also included on the levels of service provided at each

39 of the hospitals where the participants practiced. These processes allow others to asses the applicability of these results to other settings (Polit & Beck). 3.9 Chapter Summary A descriptive qualitative research design was used to answer the research question: what are the perceptions of perinatal nurses towards incident reporting? A purposive sampling method was used to select participants who could provide in-depth information on the research question. I determined, for the purposes of this study, perinatal nurses who worked in labour and delivery or single room maternity care units were the best able to provide data to answer the research question. Perinatal nurses were recruited from three different hospitals within one health authority in the Province of B.C. Data were collected using focus groups. The data obtained from the focus groups were analyzed using inductive content analysis. Various measures were undertaken throughout the research process to enhance the rigor of this study. The next chapter will discuss the findings from this study.

40 4. CHAPTER FOUR: FINDINGS 4.1 Introduction In this chapter, I present the findings from my study of nurses perceptions of incidents in labour and delivery settings. I begin by providing a description of the sample participating in the study. I then describe the themes that were generated using inductive analysis. The four main themes were: nature of incidents, how incidents happen, barriers, and facilitating factors to incident reporting. 4.2 Description of the Sample The sample consisted of 16 perinatal registered nurses from three acute care hospitals in one health authority in the Province of British Columbia. The hospitals were chosen because they were all within one health authority and serving similar patient populations. They differed in the level of perinatal services they provided as classified by the BC Perinatal Health Program (BCPHP) and this was considered in the selection of sites in order to obtain information from nurses working with patients at different levels of acuity. BCPHP defines three levels of perinatal care, which were previously described in Chapter Three. One hospital was classified as a level three centre. Level three centres have the capability to manage the care of moderate to high, high, and very high risk mothers, fetuses, and newborns (BC Perinatal Health Program, 2005). The other two sites were classified as level two centres, meaning patients who required a higher level of care would be transferred to a centre that could provide theses services (BCPHP, 2005). All sites provided services at level one in addition to the level specified. Level one service is provided to healthy pregnant women with singleton pregnancies at greater than or equal to 36 weeks gestation and infants greater than 2500 grams (BCPHP, 2005).

41 The hospitals provided intrapartum care to patients either in a separate labour and delivery unit or in a single room maternity care model. All of the perinatal nurses who participated in the study worked on labour and delivery or single room maternity care units. Four focus groups were conducted from the three sites. A second focus group had to be conducted at one of the sites because a number of the potential participants who had agreed to participate did not attend the first arranged interview. All of the nurses who participated in the study were female. The average age of the 16 participants was 39.6 years, ranging from 24-58 years (one participant did not respond to this question in the demographic survey). Eleven of the nurses identified their ethnicity as Caucasian, two as East Indian, one as Chinese, one as Italian/French Canadian and one participant did not provide a response. The perinatal nurses years of experience as registered nurses ranged from one to 35 years with a mean of 17.5 years (See Table 4.1) Table 4.1 Number of Perinatal Nurses by Years of Experience

The nurses also indicated their length of experience as a perinatal nurse. This was defined as experience working with maternity patients, rather than obtaining advanced specialty

42 certification or training. The nurses years of experience as a perinatal nurse ranged from one to 33 years with a mean of 12.5 years (see Table 4.2). Table 4.2 Number of Perinatal Nurses by Years of Experience as a Perinatal Nurse

The highest level of education achieved also varied among the participants. Of the 16 perinatal nurses, five had obtained a diploma as the highest level of education; four had an undergraduate degree and seven held post-graduate specialty certification. None of the participants had obtained a Masters or Doctoral Degree. 4.3 Qualitative Themes Using data from the nurses descriptions of their experiences with perinatal incidents, four themes were developed. These were: nature of incidents, how incidents happened, barriers to incident reporting, and facilitating factors to incident reporting. Each theme is composed of sub- themes, which further developed the theme. In the next section, I describe each theme, subtheme and category using direct quotations from the focus groups as necessary. The quotations will not be linked to either a specific focus group or hospital in order to maintain the confidentiality of the participants. Participant numbers will remain in the quotations, as they do not reflect the group membership of the participants. The themes and sub-themes are summarized in the following table:

43 Table 4.3 Summary of Themes Perinatal Nurses Perceptions of Incident Reporting Sub-Themes Descriptions Determining What Qualifies as an Incident Litigation How Incidents Happen Decision Making Dynamics Barriers to Incident Reporting Fatigue Time Reporting Tool Unit Culture Facilitating Factors for Incident Reporting Learning Practice Improvement Professional Identity

Themes Nature of Incidents

4.3.1

Nature of Incidents

The first theme I developed was the nature of incidents. The perinatal nurses used different words to describe what an incident was, as well as providing specific examples of events they would classify as an incident. Some of these examples were related to area of practice while others were related to outcomes. The sub-theme of descriptions captures the various ways that nurses classified incidents. There appeared to be a wide variety of events that could be described as an incident, in addition to the work that went into deciding whether or not to report a particular event.

44 The way that the nurses defined incidents was influenced by both their area of practice and the types of patients for whom they cared. They regarded their practice areas as unique. They were dealing with healthy adults in a situation that could be considered normal. One nurse stated: I dont know how to describe it but there is something about being in labour and delivery that (...) just feels so different compared to a medical floor and, I dont know, it seems to go across everything. They described the types of incidents occurring in their practice areas as different from other practice areas. The different types of incidents affected how they viewed incident reporting, as well as how they reported incidents. The process by which nurses decided which events qualified as incidents represented a second sub-theme: determining what qualifies as an incident. The nurses described how errors unfolded and how errors were recognized. They related this process to how they determined what qualified as an incident that required reporting. Litigation is the final sub-theme under nature of incidents. The nurses described how litigation was on their mind when they initially decided to report an incident and how it influenced the reporting process. 4.3.1.1 Descriptions Perinatal nurses provided a number of descriptions of what they would call an incident. When asked to describe what an incident was the perinatal nurses provided terms to broadly describe what constituted an incident. Some of the ways in which incidents were described alluded to someone making a mistake in their practice. An example of this was the term error, which was commonly used to describe incidents in the groups. Other ways that incidents were described included major mistake, miscommunication, and failing to follow policies and procedures. The participants also spoke of system breakdown, as well as unusual occurrence and unsafe equipment. These latter terms do not reflect individual involvement as

45 much as systemic factors in an incident. Near misses was another term used to describe incidents and was explained as you can recognize that there could have been something that happened. These types of incidents had the potential to cause harm but were caught prior to affecting patients and provided opportunities for learning. The nurses also provided specific examples of events for which they would fill out an incident report. The nurses indicated any time someone was injured an incident report should be filled out. Terms used to describe this included injury, harm, falls, and safety. The affected individual could be a nurse, an interdisciplinary team member, a patient, or a visitor. Examples of specific types of errors nurses regarded as warranting an incident report included: medication errors anything to do with medication, giving the wrong dose or giving the wrong medication (...) or adverse reactions to medications, unintentional intravenous boluses, and charting errors or omissions in charting. Perinatal nurses also described how their area of practice influenced the way they defined an incident. They described incidents on their units as mostly related to outcomes as opposed to other practice areas where there might be greater focus on incidents involving medication administration. The perinatal nurses believed medication errors were less of a concern to them than to nurses in other areas. The nurses not only administered fewer medications, but also administered mostly prophylactically prescribed medication. They viewed those differences in their practice as reducing the likelihood they would have a medication error. The perinatal nurses described incidents that occurred in their practice areas as different and more complex than in other areas of nursing. Their incidents occurred over long time frames and involved many separate events that culminated in an incident. They regarded incident reporting in their area as distinct from other areas of nursing because they perceived defining an

46 incident as more subjective. They viewed other areas of nursing as having incidents related to a single event, for example an error in medication administration. P1: Because when you fill it out its (...) not like when somethings happened when somebodys fallen or youve done a medication. You are looking back at the whole labour process you have been involved in. Say its a baby that came out flat or whatever. Somethings going on and you are trying to think back, like where did this start? You are just reviewing everything because it is a long process. Its not like a one time incident usually its a process of labour and pushing and delivery and resuscitation

The nurses indicated incidents in perinatal nursing were, to some degree, out of their control because they were not always able to prevent the event from occurring. Nurses described events, such as a baby born with a low cord pH or low APGARS (scores assigned for neonatal well-being at birth), as incidents that needed to be reported, even though those events might be attributable to a patients labour process and birth rather than a specific nursing action. One group of nurses went further to describe perinatal events as obstetrical emergencies and regarded such complications as arising from the patients clinical history. Examples of obstetrical emergencies they provided included a prolapsed umbilical cord or a postpartum hemorrhage, which they described as out of the control of the nurses. Nonetheless, the nurses indicated such incidents required a report. P1: [Obstetric emergencies] that could be a prolapsed cord, it could be a massive PPH (...). You are documenting in the chart but at the time when something happens (...) there are lots of little things that get missed especially when you are documenting in a hurry and you dont know who was who so I think there needs to be an incident report written up and they need to be followed up with risk management. Another group explained that, if the patient outcome was unexpected, an incident report needed to be completed even if the nurse had followed hospital policies and there were not any errors in care.

47 The nurses also spoke about incidents affecting not only one patient but two, the mother and her baby. Having a baby compromised as a result of an incident was upsetting to the nurses and cast a shadow on the entire incident reporting process. P1: It just means that somethings happened thats not... In perinatal when somethings happened its a baby [that] is compromised. () Whether its fine afterwards or whether long term its not so fine. Whether its something that would have happened no matter what you did, if you did everything right, somethings happened to a baby. Thats what it all comes down to. The perinatal nurses described incidents occurring in their practice as stressful and upsetting. When an incident occurred they commented nurses would have a different reaction than if an incident had occurred in another area. They attributed that difference to the types of incidents and perceived effects an incident could have on their patients health. They described their patient population as generally healthy and experiencing a normal event; therefore, they perceived an incident would have greater impact on their patients. P2: its possible that its different in maternity or in labour and delivery because youre for the most part dealing with a healthy patient who isnt ill. Therefore, if it was an accident on your part it may be perceived as having a greater impact on the persons health. Not only were the types of incidents considered stressful for the nurses but also the situations leading to the incidents. The perinatal nurses found this affected their incident reporting. Their stress over being upset with the incident was increased when the incident reporting process had to occur. One of the perinatal nurses explained: I find it stressful because you are already pretty upset with the thing that happened and then on top of that you have to deal with your incident report as well 4.3.1.2 Determining What Qualifies as an Incident

48 The perinatal nurses indicated determining what qualified as an incident was a complex process that required nurses individual judgment, as well as consideration of the effects of the event for the patient. They did not always regard deciding what constituted an incident as a clear process because making this determination required consideration of many factors as explained in the quotation below: P4: For instances when we get a patient up and, if they faint, I dont know anyone really that fills in an incident report. P1: no, no P4: because its almost like quite common occurrence, they might be faint, and you just do what you do P3: exactly it, you just kind of accept it even though they have been trying to push us not to do so much physical work with the patients whether it be with the delivery or after the delivery but (...) there is just so much physical stuff that its like... P5: or maybe certain doctors.... P3: a you know, whatever, shes fine, Im fine and you just go on P4: you just go on and you dont fill out the form P3: and then you just dont think about it P4: and then there is the question should we be filling them out P3: exactly P4: for someone that was faint or has fainted? P1: or where is the borderline, Like did she faint and did you ease her gently to the ground or did she hit herself, like I dont know? P3: do you wait for the injury? P1: well, do you only incident report if they like hit their head and you didnt get enough help to help her down or if she eases herself down and just gently sits herself down and went on you then you know P3: or if you hurt yourself P5: (...) you know, theres no cut and dried, how can you go report somebody that P1: if she had a fourth degree tear is that an incident report? Like I dont know, you dont really know, P5: its very vague its not really cut and dried There were differences of opinion within groups about what constituted an incident, which was partly driven by nurses differing views on the purpose of incident reports. One group described two different views within their unit in terms of the purpose of incident reports. One view was incident reports were reserved for life threatening crises; the alternative view was

49 incident reports were for a wider range of events, such as when things were missed or not done correctly or when harm had been caused. Such differences reflected both the different descriptions of incidents nurses provided and individual judgment used by perinatal nurses when determining if an event qualified as an incident. Nurses in some of the groups explained judgment and experience were used when deciding to report and what to report because they regarded perinatal incidents as a grey area. Nurses would use the characteristics of the individual event when making a judgment about whether or not to report it. This was a process that required a certain level of experience to make the decision. As one group explained: P2: how do you decide whats incident reportable and what isnt? P1: well I mean things like I have already outlined. Safety issues you definitely have to report. I think obstetrical emergencies you would have to report. I mean obviously in an obstetrical emergency I wouldnt say ok P5 youre not going to fill out our chart about that we are just going to review it, I wouldnt do that P5: no P1: your judgment comes into and your experience and... P2: right - experience P1: experience thats what I was going to say P5: I think there is a grey area P1: experience and judgment comes into it. I mean have to take that into experience P2: because somebody who has less experience is not going to be maybe seeing something as having an outcome... P1: right P2: or possibly having an outcome that someone with more experience might see. P1: mmhm, right The perinatal nurses related the types of incidents occurring in their practice to more difficulty in identifying personal errors. They argued this had a negative effect on the incident reporting process in terms of completing reports and identifying errors. They were not always able to pinpoint exactly when or how an incident occurred. Two perinatal nurses explained this way:

50 P3: Different, perhaps and its not so easy perhaps to explain. It is very easy and is objective you just say you know you missed that medication or you gave a wrong medication to the wrong patient. In labour and delivery other issues may take more time to put on a report and its probably even harder to identify that you actually P5: made an error P3: Made a nursing error, (...) sometimes is not so clear and you know to say yes definitely that was definitely an error [that] should be reported

When nurses were unable to identify why something had happened or the root cause of an incident, some questioned whether an incident had occurred. Unexpected outcomes they could not explain made it difficult for them to determine if an incident had occurred and to describe how the incident developed. The chain of events led to uncertainty about whether or not an incident report should be completed. The perinatal nurses also spoke of the influence of timing when determining if an incident occurred. The nurses linked the nature of incidents occurring in perinatal nursing practice with patient outcomes because they made up a large number of the incidents. The nurses regarded incidents as not being obvious immediately. They explained sometimes they would need to wait to see if there was an adverse outcome to the affected person before classifying the event as an incident. Some of the nurses stated they would then be prompted to fill out the incident report after the fact, which the nurses described as a retroactive incident There were also types of events nurses indicated should always be reported. All groups agreed safety events, for example a nurse falling or being harmed by a patient, should be reported because of the potential for long-term consequences from the event. It was also agreed medication errors needed to be reported because of the potential harm that could be caused. Medication errors were described as being related to timing, dosage, adverse reactions to medications, or giving the wrong medication altogether.

51 Nurses also identified certain events requiring reporting in response to pre-defined criteria. Obstetrical emergencies and low cord gases or APGARS, as well as readmission for infection, were events that required reporting in response to pre-defined criteria as described in the quotation below: I: So why do you as perinatal nurses decide to report an incident then (....) P2: because you have to, because there are criteria P1: theres criteria based on our APGARS, based on cord gases, there is very specific criteria. If somebody delivers at home, readmission for infection post c-section, meconium aspiration. If any of these five things happen then you need to fill out an incident report I: so thats mainly what guides it? P1: pretty much

The perinatal nurses believed they were asked to document particular patient outcomes because of the possibility of legal action in the future. 4.3.1.3 Litigation The perinatal nurses indicated they were at high risk for litigation as an outcome to an incident due to the nature of the incidents that occurred in their practice area. The nurses stated litigation was of more concern in their area of practice because lawsuits involving babies could occur up to the time the child reached the age of majority. This risk of litigation was something that was on their minds when initially making the decision to report; it seemed to influence the entire incident reporting process but in a subtle way. P1: And I think also too that in labour and delivery.... litigation is a big thing P2: Thats true P1: and with litigation there its a quite an involved process and its very.... demoralising. And its very time consuming (...) I: Right so does that impact incident reporting? P1: I dont think impacts it but I think its in the back of your mind that when you need to report things because of the fact that litigation, it is one of the highest areas for litigation

52

More experienced perinatal nurses indicated they expected at some time in their practice to meet with one of the hospital lawyers about an incident in which they were involved. They described past meetings with lawyers being a negative experience; however, they perceived there was currently greater support during such processes. Fear of litigation did not prevent nurses from reporting because they believed the opportunity to review incidents soon after they occurred was beneficial. Reviewing incidents increased their learning and enabled them to share their stories to help others learn. One nurse also believed this experience caused her to be more proactive in reporting incidents to prevent certain incidents from happening again. In summary, the nature of incidents was composed of descriptions and determining what qualified as an incident. The nurses used many terms to describe incidents. These terms referred to individual or team mistakes in practice and systemic factors that contributed to errors. The nurses also described specific events that required reporting, such as falls or medication errors. The way in which perinatal nurses described incidents was influenced by their area of practice and by the types of patients for whom they cared. They felt incidents in their practice settings were more related to birth outcomes and were to some degree out of their control. The types of incidents that occurred in perinatal practice were more complex and affected patients with different characteristics than those in other practice areas. The complexity influenced nurses abilities to identify incidents and the underlying causes. There were many factors that influenced the process by which nurses determined if an incident had occurred. These included the individual judgment of the nurse and their personal views about the purpose of incident reports. Other factors considered were the types of events that had occurred as well as the outcome for the affected person. The nature of the incidents that

53 occurred in perinatal nursing meant there was a higher risk for litigation. Nurses thought litigation influenced the entire incident reporting process in subtle ways. 4.3.2 How Incidents Happen How incidents happen was the second theme I developed. The nurses described incidents happening for many reasons and the various ways specific factors contributed to an incident occurring. The reasons and factors included decision-making by the nurse or health care team as a whole, as well as team or personal dynamics that influenced care. The nurses identified structural features in the workplace that influenced whether or not an incident was deemed to occur. This theme illustrates nurses perceptions of contributing factors to incidents. 4.3.2.1 Decision Making Perinatal nurses felt incidents occurred in practice as a result of the ways decisions were made. The decision-making process could include only nurses or nurses and other team members. Incidents occurring in care resulted from multiple decisions. Because different team members contributed to the care of one patient and decisions made by one team member could influence the outcome, as one nurse described quite often there are different people involved in the event and something may have been missed by one person and everyone is affected in the end. The nurses indicated incidents were often the result of a long process, which created difficulty determining exactly when the incident occurred or the decision resulting in the incident. Perinatal nurses regarded this as an important factor that made incident reporting difficult for them: P1: because sometimes its not a nursing error that caused the problem P3: sometimes is like a compound... P1: sometimes its a variable of what the situation P3: Exactly

54 P1: thats caused the problem......and its a matter having to recite the entire incident. P3: Yes P1: rather then just saying it was a nursing error, I gave the wrong med I mean you are anecdotally going along but this is what happened and on and on The perinatal nurses also regarded their decision making as possibly preventing certain incidents from occurring because they tended to anticipate problems before they happened. If the nurses were able to properly anticipate and plan for any possible complications, they felt they could avoid an incident. For example, if they recognized a patient may be more at risk for a certain complication, such as a shoulder dystocia, they would plan to have additional team members present to help if required. As one perinatal nurse explained: (...) when a patient presents themselves it should be in the back of your mind if they have certain variables going on in their labour that might trigger you to think I better be prepared for everything... 4.3.2.2 Dynamics The perinatal nurses indicated not only could decisions made by different team members contribute to an incident, but also the dynamics between team members could contribute. They suggested it was not the fault of any single team member that dynamics were poor. They viewed improving dynamics as leading to a reduction in incidents and improved patient outcomes in the future. The nurses also linked poor communication amongst team members to incidents and identified more formal and effective communication processes as one strategy for reducing incidents. They spoke of when communication amongst team members was incomplete, the greater possibility of incorrect decisions being made in care. The nurses suggested formal communication processes would permit less information to be missed leading to fewer incidents. Another way the nurses regarded dynamics as influencing how incidents happened was through workload. Having a heavy workload and doing too many things at once contributed to

55 errors, as did fatigue associated with heavy workload. The perinatal nurses stated often incidents were discovered when workload was high. One perinatal nurse explained: usually the unit is super busy when the error is found right, because when people are tired (...), then they make the error. In summary, how incidents happen provided information about what the perinatal nurses felt were contributing factors to incidents. They felt the way in which decisions were made, either by nurses or interdisciplinary team members, could contribute to an incident. They spoke of incidents being the result of many different decisions throughout the labour process, which they perceived had an effect on how incidents were deemed to have occurred. Team dynamics within the work place were also thought to be contributing factors to incidents. These included personal and team factors, as well as structural features such as workload. 4.3.3 Barriers to Incident Reporting The third theme I identified was barriers to incident reporting. When I asked nurses about their reaction to the terms incident reporting all groups stated their reaction was negative. One perinatal nurse stated: its actually seen as a negative experience all the way around from beginning to the end. Although the negative view of incident reporting likely acts a barrier in itself, there were a number of other barriers identified to incident reporting by perinatal nurses. The sub-themes, including personal factors, reporting tools, and unit culture explained how barriers towards incident reporting operated. Personal factors included fatigue and the time it takes to report an incident. Some nurses also indicated reporting tools themselves acted as a barrier to reporting. Unit culture could promote or inhibit reporting. It was clear that most of the perinatal nurses believed their unit culture or climate inhibited incident reporting. I identified two

56 categories that made up the larger theme of unit culture. These were: how incident reporting was viewed and reactions/responses. 4.3.3.1 Fatigue The perinatal nurses stressed the importance of fatigue as a barrier. When incidents occurred or were discovered in practice perinatal nurses found an incident was usually associated with an already stressful assignment and busy shift. The events leading up to an incident or discovery of an incident were stressful for nurses, which compounded the fatigue that they were feeling from their workload. Fatigue could act solely as a barrier or, if the incident occurred during a busy shift or, near the end of a shift, it could combine with timing to decrease the likelihood of reporting an incident. In those conditions, they viewed incident reporting as an additional hassle in addition to nurses already busy assignments. As a result, they often described not completing the incident report. P3: (...) usually by the time it comes to filling out the incident report P1: youre done (...) youre tired P3: because the majority of the time, its busy, busy, busy and you dont have time to do it till the end, and then at the end youre scrambling around 4.3.3.2 Time toReport Time was another barrier to incident reporting. When nurses took time to report an incident it negatively affected workload or patient care and added time to already busy shifts. Because nurses indicated incidents occurred when units were busy with heavy workloads, they indicated if an incident occurred they would do what was necessary to correct the situation but an incident report was not consistently completed. Nurses regarded the time it took to complete the incident report as an additional burden for their workload, which further negatively affected their patient care. One perinatal nurse explained why incident reports were not always completed:

57 P5: we dont get extra time to do paperwork and (...) I have to do this on top of my regular assignment (...). So most of the nurses say oh no, I dont have time to do this. And quite often it means its not reported because its something additional demanded on the nurse which means she has to stay overtime (...). Taking the time to report an incident often meant nurses had to stay after their shifts ended to complete the incident report form. The perinatal nurses linked staying after their shifts to being less likely to report. Nurses related the nature of events leading up to the incident to lack of time to report the incident during their work hours. One nurse explained this as being penalized twice. She was referring to not only finding the incident but having to stay after the shift to complete the incident report form. Extra time was compounded by the nature of incidents in perinatal nursing practice because incidents usually took more than a single sentence to explain. Filling out the form required a lot of time to go through all the events that led up to the incident. These factors made the experience of incident reporting more difficult for the nurses. P3: (...) I remember one particular time I stayed until twenty to nine in the evening and I have other things in my life waiting for me at home. For me to stay all that time, not even mentioning the energy and all that, after being there for twelve hours, you put in one hour and a half more on top of it...its not easy... 4.3.3.3 Reporting Tools Perinatal nurses described options for reporting incidents in practice. They spoke of an older paper reporting system and a newer computer-based system. Although the majority of the participants described the new computer system as more efficient, they reported barriers associated with both systems, resulting from using a form common to all areas of the hospital. Perinatal nurses perceived the majority of the incidents occurring in their practice area as unique. The nurses found the hospital-wide incident report forms were not able to capture the

58 unique features of perinatal care. They indicated the forms were more applicable to practice settings such as medical or surgical units. P1: (...) I think the forms that we had are hospital wide forms and they were much more applicable to surgical and medical floors for the reasons that you usually have every incident report that we have had on the floor that I know of has been related to outcomes cause the APGARS, because of this and that right? Its not because somebody fell or somebody did this...Its just doesnt seem to really be perinatal-focused so you have to try and fill in these little dots you know what happened, medication error well ok, well thats not it, its not a fall and no its not this I: its something totally different? P1: exactly The nurses described being unable to find adequate options to capture exact incidents in their area, which led some of the nurses to question whether what they planned to report was actually an incident. Questioning the relevance of potential incidents was linked to nurses possibly not reporting incidents. P1: (...) I found the major thing about the paper one is that in obstetrics sometimes some of them arent even applicable. Like if you are doing a delivery then there is nowhere to click and they dont give you options to put in certain spots and online at least it gives you some options.... Oh ok its this area or its this area but with the delivery ones too, its just, I find the sheet does not really apply. You dont know where you are supposed to write anything that is what makes us question whether or not its actually an incident, cause its, typical

The nurses also described elements of the reporting tool that could act as barriers to incident reporting. Not only was the form focused on other practice areas, but also they also found the amount of time it took to complete the form acted as a barrier. Filling out the form correctly involved gathering many different pieces of information. If writing up an incident was combined with a heavy workload, nurses reported finding they were scrambling around trying to find all the necessary information. Nurses perceived other ways of reporting

59 incidents to be more efficient because they took less time and they were still doing what was necessary to alert management about an incident. 4.3.3.4 Unit Culture It was clear that the perinatal nurses believed their unit culture or climate affected incident reporting. Unit culture negatively affected the incident reporting process according to most of the nurses, because negative reactions from team members or management to incidents affected how nurses viewed incident reporting and the process of reporting. There are two categories comprising the sub-theme of unit culture: how incident reporting was viewed and reactions/responses. 4.3.3.4.1. How incident reporting is viewed. There were two different views on incident reporting described by the perinatal nurses. The first framed incident reporting as not placing any fault, but an opportunity for learning. Those nurses looked at incident reporting as a means of being proactive in response to incidents where no harm had been caused to patients. Incident reporting was a way of improving various aspects of care through learning. The second more commonly held view, among perinatal nurses in this study, was incident reporting caused people to feel as if they were being blamed. They found the process of incident reporting stressful and negative for all involved. Even if they were not directly involved in the incident or could not have changed the outcome, they viewed the process negatively because they perceived they were to blame or had done something wrong. This was usually the case if an incident occurred to a patient while the nurses were assigned to them. P1: I think people feel like they did (...) something wrong, so if you end up doing an incident report then people feel like they are ( ...) to blame for whatever happened and it may not even be your mistake. You maybe just caught it or find out (...) there is something wrong. Or an incident

60 with a patient falling, or whatever it may be, but it doesnt have to mean that if you are the one doing it up you are at fault and you are going to be traced back and punished The nurses viewpoints were affected not only by their personal reactions to incident reporting but also by reactions of other team members. 4.3.3.4.2 Reactions/Responses. The nurses described different personal reactions to incident reporting. Their reactions included finding the process of reporting and the follow-up after an incident stressful. They also expressed anger with themselves when an incident happened to a patient in their care. Because perinatal nurses perceived they had done something wrong if they were involved in an incident, they had concerns about how it affected colleagues views of them. They associated the stigma attached to incident reporting to being judged by their colleagues for their involvement in an incident. P2: to expand on that a little bit (...).... is that going to be something that they remember me by that I made this mistake or that they record someone under my care had this incident occur or P5: yes P2: like is it related to me and will people - will that be on my record that kind of an idea. Therefore people are sometimes scared to act or and possibly want to just brush it over or brush it under the carpet The perinatal nurses valued being part of the team on the unit. Teamwork was valued in their clinical area and an important part of the way that their unit functioned. The nurses sense of team work influenced their incident reporting because they sought input from their team members about whether or not an event was an incident and should be reported. P1: I dont know of anyone that has found an incident and hasnt mentioned it to other people just to verify that we should actually do an incident. You know I found this and am I right or am I just overlooking something or whatever. I dont know of someone that hasnt spoken to someone and actually filled out a form. I think at least a CRN and some team members do know about it before it happens. Because you might

61 see, somebody else might see things differently or might interpret an order maybe the same way the person that had done an incident interpreted it and then maybe its the order thats an incident that it wasnt clarified or, you just cant know sometimes. You cant assume. When nurses sought advice from team members, team members reactions to the incident or incident reporting affected their incident reporting process. Some of the nurses spoke about sensing a defensive reaction from their colleagues when incident reports had to be completed. Although the nature of colleagues reactions was described as changing - most felt that it was now improving - the perinatal nurses reported this reaction occurred because incidents were thought to reflect badly on the entire team. One nurse stated: It was like a black spot on everybody if we had reported what happened. The fear of being viewed as separate from the team seemed to be especially important for new nurses in the group. These nurses regarded their lack of experience in the practice area as leading more experienced nurses to judge them if an incident occurred. They believed there was a perception, if they completed an incident report they made lots of mistakes, which, in turn, would make them more hesitant to report. Nurses with more experience agreed with this perception and described their tendencies in the beginning to want to be accepted by the group of nurses. They indicated that desire may have negatively affected their incident reporting. P1: Thats what you go through P3: takes time P1: With the learning curve P3: just see whats going on too, because you want to be accepted in the group. P2: you keep things closer to your chest I think P3: Yes, (...). In the beginning you really want to be accepted by the group and you dont know if reporting.... the others may think oh... not good, right?

62 Another factor that appeared to affect incident reporting was whether the nurses felt comfortable enough with their team members to disclose an incident. The nurses comfort with the group enabled them to speak openly to their colleagues about incidents. Although the nurses acknowledged the importance of disclosing incidents to other team members, disclosing incidents did not always lead them to fill out an incident report. The nurses stated, in an ideal world they would report all incidents, regardless of the issue, and support their team members through the process; however, they indicated an ideal world was not typical. In fact, they indicated being part of a team could detract from their reporting. Some of the perinatal nurses linked the sense of camaraderie amongst the team members to making them less likely to report incidents involving other team members. P2: (...) I feel like possibly because perinatal, (...) or labour and delivery, as nurses we work together its kind of more like a team P5: very much so P2: and you would be less willing or likely to... P5: to report somebody P2: to report something on something someone else did I think P5: and I feel there is much more sense of camaraderie and team and partnership in labour and delivery then anywhere else I have worked.

Some of the nurses suggested the team spirit was something unique to their practice area. They spoke of how the team would work together to remedy a situation but would not always take the step of making a formal incident report. The perinatal nurses spoke of how they would debrief amongst team members when an incident occurred, which one of the groups called verbal incident reporting. This involved speaking to other team members about an incident to obtain advice or help or simply to debrief. The nurses reported feeling safe discussing incidents with their colleagues because they felt there was a certain degree of protection within the group.

63 If the nurses discovered an incident in the course of care, they would attempt to speak to whoever was involved to notify them there was something missed or not done correctly but they did not always complete an incident report form. The exception to this was, if the nurses felt the incident was likely to cause harm to the patient. If that was the case, they would report but would also notify their colleagues about completing an incident report. As one nurse explained when responding to whether or not she would report a medication error she had discovered: I follow up with the people but (...) not necessarily report. Unless it is a wrong medication that was given, that is going to cause harm. Then you would for sure. This was similar to how another nurse described how the team would respond to incidents in practice sometimes you work through things and some things you just cant overlook. It is such a major mistake you just have to do an incident report on it. Follow-up to an incident report also appeared to have an effect on the reporting process. The nurses indicated follow-up was already on their minds when reporting an incident because of the increased workload they believed would arise. Follow-up required communicating with many people and was perceived to create more work for both the nurse reporting and for the nurse leaders who were involved in follow-up P1: I find its not the filling out thats the hassle its the fact that its probably going to come back and you are going to have to go over everything again because we have chart reviews P3: well yes that, you are already thinking about that P1: thats more of a hassle then actually filling out. You are already thinking about chart reviews and what have I done that...... P3: your mind isnt focused on filling out the form

The nurses indicated nurse leaders or management involved in follow-ups to incident reports had an effect on reporting. The perinatal nurses spoke of leaders responding to incidents and incident reports in different ways. They discussed not always receiving feedback after an

64 incident report was written. Failing to provide feedback led them to question what, if anything, was done with the report. Nurses linked lack of feedback to feeling as if there was no point to incident reporting. The failure to provide feedback would discourage them from reporting again because they did not feel they were being heard. One nurse stated: I hope the managers look at them. Otherwise, sometimes you just feel like whats the point if nothing is going to change and nothing is going to happen? I dont think anyone is going to do them. Not receiving feedback appeared to be a common experience amongst the nurses P1: I dont think I have ever received feedback. I think the only feedback I ever got was (...) did you do it? (...) and then I dont hear anything about it. P3: I think my only ones (...) it was just pretty much oh did you remember to fill that out. And I know a copy goes to the charge nurse that was on that day and a copy goes to the manager, so P1: I think the only feedback I got was to say that yes I got it and that was it P4: so some feedback would be nice to actually encourage people to do them Nurses indicated lack of knowledge about what happened after the incident report was written led them to wonder about the result of reporting. They were unsure if they would be blamed for the incident or the nature of the final outcome. Those that had received feedback felt as if it was not always given in a supportive way and their care was being evaluated and judged. P1: Im thinking about a risk management meeting I had to go to last year. (...) Little comments during the meeting can sometimes just.... well everything is pulled out and its across the table and everybody is giving their comments about it. Afterwards you think to yourself, wow! I mean they are virtually saying that you missed a huge big one rather than approaching it from a supportive or educational point of view Prior experiences, such as the one described above, were on the nurses minds the next time they needed to fill out an incident report. One nurse stated: You dont know whats going to be done with the information if you go to management.

65 In summary, factors operating as personal barriers towards incident reporting were time and fatigue. Fatigue as a result of heavy workloads or stressful situations leading up to an incident could solely act as a barrier. Time operated as a barrier to incident reporting in conjunction with fatigue in relation to the timing of incidents, and the amount of time it took to report an incident. Reporting tools acted as barriers because the nurses found they were not focused on perinatal problems and were cumbersome to use. Unit culture operated as a barrier towards incident reporting through how incident reporting was viewed and reactions/responses by individual nurses, team members and management. The majority of the nurses felt that incident reporting caused people to feel as if they were being blamed. This detracted from reporting. Nurses feelings of stress and blame could detract from incident reporting. Teamwork influenced the reporting process because the team would work together to correct the error rather than reporting it. Follow-up to incident reports, particularly the amount of work created by following up, detracted from reporting. Negative reactions from management involved in the follow-up process also detracted from reporting. 4.3.4 Facilitating Factors for Incident Reporting In addition to barriers to incident reporting, the perinatal nurses described factors that motivated them to report. Perinatal nurses viewed incident reporting as an opportunity for learning, both for themselves and for others. Incident reporting was also viewed as leading to practice improvement because it would show where changes could be made in order to create both better work environments and care for patients. The final sub-theme related to facilitating factors was professional responsibility. The perinatal nurses understood their roles as

66 registered nurses required accountability for any incidents in which they were involved and being responsible for reporting incidents. 4.3.4.1 Learning The perinatal nurses indicated every time an incident occurred in practice a learning opportunity was created. After recognising an error was made, they took time to sit down and review what they believed had contributed to the incident. They described this as being a positive experience and one that allowed them to review the day and think about what they could personally change in the future to prevent the error from recurring. One perinatal nurse stated: P1: every time you make a mistake you learn leaps and bounds about yourself, about everything, right? In that way its not negative, I mean, Im happy to say that every mistake that I have made in my mind has been minor and simple, things have gone on that I have realized, ok, and (...), I have learned from it Even the process of writing up an incident report or completing the form on the computer was regarded by nurses as being a learning experience because they felt that this would remind them in the future not to repeat the same error. Reporting the error meant admitting they had made a mistake, which they viewed as learning, because they had recognized the error. They believed recognition would teach ways to avoid making the same mistake again. P3: (...) if I sit down to write something that I think I was a mistake going over it will hopefully will remind me later not to do it again (...).Cause its not like you are excusing yourself, you are forcing yourself to admit that that was a mistake. I: So its almost like P2: Youre acknowledging it Another way the perinatal nurses believed learning occurred with incident reporting was through teaching others. They used the knowledge they had gained from their errors to teach other nurses how to avoid making the same mistake. One nurse referred to this as acting as a

67 change agent. The learning that occurred with incidents was also incorporated into training new staff or students by perinatal nurses as an example of how to improve or how to attempt to avoid making similar errors that the more experienced nurses had encountered in practice. P2: I was just thinking of a specific incident (...) that happened to me when I was a new person on the unit and every time I have a student now as a preceptor I mention to them, ok this happened to me dont ever let it happen to you Change arising from an incident also motivated nurses to report incidents. They recognised, without reporting incidents, change and follow-up would not occur; they were motivated to report. As one nurse stated my experience has been if its written down on an incident report form there is certainly a lot more action then if you just pass along this happened and we need to do something about it. Its like it just goes into a big vacuum. When they had reported an incident and observed new policies being implemented or there was communication from management to staff about the issue they felt this also encouraged reporting because their report had facilitated communication and learning on the unit. P1: for instance, there is a fairly recent memo and there have actually been quite a few nurses that have been injured fairly recently from that so I have noticed that as a change, she sent out a memo and she is trying to change the practice to reduce people getting injured 4.3.4.2 Practice Improvement The nurses indicated seeing change in their practice environments, as a result of incident reporting, facilitated incident reporting. When asked why nurses chose to report incidents in practice one of the main reasons given were to improve care for their patients. Although they acknowledged incident reporting had a negative connotation, practice improvement was viewed as a positive result. Incident reporting prevented a recurrence of an incident because it showed

68 where change was needed. Nurses anticipated the change taking place on the unit would protect other patients. P4: (...) sometimes its seen as a negative connotation (....), reporting an incident, but theyre for trial and error to learn from P2: so we can make future plans out of it like if the worst outcome is today then we can make a plan so that it can be prevented next time

The nurses spoke about ways incident reporting allowed them to track certain errors to do with medications or pre-printed orders. If the same errors were occurring repetitively, they believed reporting them would give management, or others, the information they needed to make changes so the errors could be prevented. They likened incident reporting to quality control on their units and felt that this was an important means of being proactive to prevent future incidents. P1: well I think if its a nursing error then we can all learn from that and I think that we can be proactive in that it could change the day-to-day activity on the unit and (...) if its something thats repetitively happening then that could be, for lack of a better word, proof or ammunition to show management that we may need more staff or need a change somewhere in the unit

The perinatal nurses also regarded incident reporting as an effective way of improving their work environments. They linked reporting incidents to the safety of the nurses. The nurses wanted to report events to ensure there was appropriate documentation for the purpose of follow-up. Because unsafe equipment or practices on the unit led to nurses being injured, both were viewed by nurses as important concerns. For example, when a staff member was injured during work, incident reporting allowed these types of incidents to be tracked so improvements could be made to prevent future injuries. They were also motivated to report incidents to show whether their work environment was a safe place to practice. They indicated

69 reports allowed management to uncover reasons underlying errors, which would show if systemic factors in their practice environments, such as patient acuity or workload, were contributing to common errors. P1: I think it is for our safety too, like I think that if you are reporting you are hoping that there is going to be change that happens but you also hope that it just shows whether our work environment is safe, too,. You know, if you are finding that there are a lot of medication errors and the sole reason is you know acuity, not enough staff or whatever it may be, it those things that we should be looking at and examining and changing

4.3.4.3 Professional Responsibility Professional responsibility was a reason many of the nurses provided when asked why they would choose to report an incident in practice. They felt reporting incidents brought to their awareness or in which they had been involved was indicative of prudent nursing practice. It was their obligation as registered nurses. They regarded acknowledging they made an error as important for their practice; reporting the incident allowed them to demonstrate the steps that they had taken after they had become aware of the error. P4: that you are doing your part like if you missed a medication or something that you are aware of it, that you are reporting it and you are not just ignoring it, sliding it under the table, this is what happened, it can be changed, taking responsibility for your actions

Perinatal nurses also felt a responsibility to their patients to report incidents occurring during their care. If the patient was injured from the incident or there was the possibility that an injury could result, the nurses felt obligated to document the incident for the benefit of their patients.

70 Another reason the nurses gave as a facilitating factor for incident reporting was to cover them if something were to happen in the future. They spoke of incident reporting as creating a record in case care was questioned at a later date. P3: I always think of incident reporting as covering yourself P4: covering your own liability P1: thats true P3: acknowledging yes, that this shouldnt have happened this way but it did and to make sure the appropriate people are aware of it whether that be the physicians, the charge nurse, manager, etcetera According to the nurses, reporting could be in response to an incident in which they had been directly involved or one they unearthed in practice. If it was in response to the latter event, nurses stated they would report so that they would not be blamed for another nurses error. Incident reporting was also regarded as a method of communicating with management about events nurses were accountable to report. P3: Well like you were just saying to just also a way to communicate with the manager. You know there is only so much they absorb from when they come on in the morning or you know after the weekend to hear oh this delivery happened or this incident happened but then this way it is a record for them as well Using incidents as a way of communicating with management motivated nurses to report certain events, not only to meet their obligations, but also to create an opportunity to review the incident with leadership while it was still fresh in their memories. While this was a part of the nurse covering herself, it was necessary to create an opportunity for the nurse to review the incident with management soon after the event. Nurses noted this need to review the incident as a separate reason for reporting because they could learn more from what had happened. In summary, facilitating factors towards incident reporting comprised three sub-themes. Incident reporting was viewed as a learning opportunity, both for the nurses directly involved

71 in the incident and the rest of the unit. Self-initiated learning or learning from others motivated nurses to report. Practice improvement that occurred as a result of incident reporting was a facilitating factor for reporting. Nurses likened incident reporting to quality control that would show the safety of their work environments and where there were opportunities for improvements. The final factor that was identified as a motivator to reporting was professional responsibility. Nurses were obligated as registered nurses to report incidents in practice but also accountable as staff members to report incidents. 4.4 Chapter Summary In this chapter, I presented the findings from the qualitative, descriptive study. I generated four major themes. The first theme was the nature of incidents, which was comprised of the sub-themes of descriptions of incidents, determining what qualifies as an incident and litigation. The second theme - how incidents happen - incorporated decision making and dynamics. The third theme, entitled barriers to incident reporting, included sub-themes of fatigue, time to report, and reporting tools. The final theme, entitled facilitating factors to incident reporting, was supported by sub-themes of learning, practice improvement, and professional identity. In the next chapter, the findings will be discussed in the context of current literature. As well, a discussion of the implications for nursing practice, research, education, administration, and policy development will be presented.

72 5. CHAPTER 5: DISCUSSION OF FINDINGS, NURSING IMPLICATIONS, SUMMARY, AND CONCLUSIONS In this chapter I present a summary of the research and a discussion of the findings in the context of existing literature. The implications for nursing practice, education, administration, and policy based on my discussion of the findings are presented, as well as conclusions drawn from the study. 5.1 Introduction I conducted a qualitative descriptive study to gain a better understanding of the perceptions of perinatal nurses about incident reporting. The sample consisted of 16 perinatal registered nurses working on labour and delivery or single room maternity care units at three hospitals within one health authority in the province of British Columbia. I purposively selected the hospitals because they differed in the level of perinatal services provided. I wanted to obtain a sample of perinatal nurses working with patients at different levels of acuity. The perinatal nurses varied in their years of experience both as a registered nurse and as a perinatal nurse. Years of experience as a registered nurse ranged from one to 35 years while years of experience as a perinatal nurse had a similar range, from one to 33 years. I collected data using focus groups with a semi-structured interview guide. I audio-taped the focus group interviews and transcribed them verbatim. I arranged for field notes to be kept. The groups were homogenous because all the perinatal nurses worked with patients in the intrapartum stage of pregnancy on either labour and delivery or single room maternity care units. I used the criteria proposed by Lincoln and Guba (1985) to develop trustworthiness in a qualitative study to contribute to the rigor and quality of my research study.

73 I used inductive content analysis to analyze data from the focus groups. I developed codes from the data by reading and rereading transcripts and going line-by-line through each transcript making notes in the margins. I used constant comparison to analyze data within and between groups. I grouped codes into categories across groups and combined them into themes. I developed four themes and 12 sub-themes through this process. The four main themes were: nature of incidents, how incidents happen, barriers, and facilitating factors to incident reporting. 5.2 Discussion of Findings 5.2.1 Comparing the Sample to the Canadian Population of Perinatal Nurses I collected information on the demographic characteristics of my sample using a short survey. Information obtained included age, gender, self-described ethnicity, length of experience as a registered nurse, length of experience as a perinatal nurse, and highest level of education achieved. The sample characteristics varied from those of the general population of nurses practicing in maternal/newborn areas of practice according to the Canadian Nurses Association (Canadian Nurses Association: Department of Public Policy, 2008). The sample was similar in terms of gender to the Canadian population of nurses practicing in maternity/newborn areas of practice. All of the participants in my study (100%) were female; 99.8% of nurses practicing in maternity/newborn areas across Canada are also female (CNA). The average age of the participants, 39.6 years, was slightly younger than the national average of 43.5 years. Across Canada most of the nurses practicing in this area have achieved a diploma as the highest level of education, which differed from my sample of perinatal nurses. In my sample, 31% had achieved a diploma as the highest level of education, and 44% held postgraduate specialty certification. Twenty five percent held an undergraduate degree as opposed to a national average for nurses practicing in maternal/newborn areas of practice of 38.1% (CNA).

74 Ethnicity has been described as having an influence on incident reporting in the literature. Participants were therefore asked for their self-described ethnicity as part of the demographic questionnaire. Fifteen of the 16 participants provided their ethnicity. The majority of the nurses in the sample were Caucasian. Other ethnicities represented included Chinese, East Indian and Italian/French Canadian. It was not apparent from analysis of focus group data whether ethnicity had any influence on incident reporting for this sample of perinatal nurses. None of the nurses described the influence of ethnicity their experiences with incident reporting. 5.2.2 Comparison of Findings to the Literature Key findings from my study will be discussed in the context of the literature including: the influence of the perinatal practice setting on how incidents are described, how certain incidents are unique to the perinatal practice setting, factors affecting incident reporting by perinatal nurses specifically, barriers to incident reporting, facilitating factors, team dynamics, and team culture. I will also discuss how team dynamics can influence how incidents happen in perinatal settings. The influence of team dynamics on communication processes in perinatal settings, including incident reporting, will also be discussed. Finally, I will discuss the impact of feedback and follow up to incident reports on the incident reporting process. 5.2.2.1. Perinatal Practice Setting The nurses used many terms to describe incidents. The ways in which they described incidents was influenced by their area of practice and by their specific patient population. The perinatal nurses described how they believed incidents occurring in their practice setting were unique to their practice setting. Other studies concur with my findings regarding the unique nature of incidents occurring in perinatal practice settings (Forster et al., 2006; Mann et al., 2006). The nurses in my study felt that incidents in their practice setting were more complex and

75 related mostly to birth outcomes. The perinatal nurses described how incidents in their practice setting were to some degree out of their control. An example of an incident provided by the perinatal nurses was a prolapsed umbilical cord. This type of event is likely to result in an unexpected operative delivery for the mother and could also result in the infant suffering from the consequences of decreased oxygenation from the prolapsed cord. Incidents such as these are outcome-related, and usually the result of a patients labour and birth process, which to some degree is out of the control of the nurses. There were no other studies identified that discussed perinatal nurses views on the nature of incidents in this practice context. My study findings add new information to the literature on incident reporting and registered nurses. Examples of incidents provided by the perinatal nurses included obstetrical emergencies, low APGARS, low cord pH, a prolapsed umbilical cord, and postpartum hemorrhages. These incidents are similar to those found by Stanhope et al. (1999) in their review of adverse events occurring in two obstetric units in the United Kingdom. They are also similar to the obstetrical adverse outcome index created by Mann et al. (2006). This list is composed of items such as maternal death, uterine rupture, birth trauma, return to labour and delivery, APGARS less than 7 at 5 minutes and third or fourth degree perineal tears, as well as others (Mann et al., 2006). The majority of these criteria are related to a patients labour and birth process rather than an error by an individual team member. Therefore the literature supports perceptions of the perinatal nurses in this study on the nature of incidents that occur in their practice area. 5.2.2.1.1 Medication incidents. The perinatal nurses discussed how the decreased frequency of incidents involving medications made the nature of incidents unique to their practice context. They believed incidents involving medication administration were less of a concern to them than nurses in other

76 practice contexts. This was because they administered fewer medications and those that were administered were mostly prophylactic medications. They felt these differences in their practice made it less likely that they would make an error involving medication. In contrast to the findings of my study, other researchers have argued high-risk medications, such as oxytocin, magnesium sulphate, hydromorphone and fentanyl are routinely administered in labour and delivery units and have the potential to cause serious patient injury, or even death (Beyea, Kobokovich, Becker, & Hicks, 2004; Mahlmeister, 2007; Pennsylvania Patient Safety Advisory (PPSA), 2009). Although some of these medications may be prescribed prophylactically, if administered incorrectly they have the potential to result in serious patient harm (PPSA, 2009). The Pennsylvania Patient Safety Authority conducted a review of over 2600 medication event reports submitted by Pennsylvania Health Authorities from 2004 to 2009. Of the 2600 event reports, 68.7% of the events resulted in the patient either receiving an incorrect dose of the correct medication or the incorrect medication but patients were not generally harmed by the error, with only 1% of the events resulted in patient harm. The majority of the medication errors reported were dose omission errors; the patient did not receive the intended medication, followed by wrong drug errors. Beyea et al. (2004) conducted a review of medication errors reported by labour and delivery, obstetrical recovery, and postpartum units to a national medication reporting system in the United States. From this review, they found more than half of the errors reported occurred in labour and delivery and although 65.8 % did not result in patient harm 3.23 % of errors did result in patient harm, including one fatality (Beyea et al.). The literature does not support the claims of nurses in my study that medication errors were unlikely to be a problem for them.

77 Although the nurses believed medication errors were not as much of an issue in their practice area and they were less likely to make a medication error than nurses in other practice contexts, the majority of the nurses in my study stated they would report any medication errors discovered in practice. This was because they recognized the potential harm that could result from medication errors and therefore appreciated the importance of recognizing and reporting these incidents. Similar to the findings of my study, medication errors are recognized by nurses in various practice areas as being important patient safety measures because of the potential risk to patients created by medication errors (Antonow et al., 2000; Stratton et al., 1999). The perinatal nurses in my study also discussed how it was important to report any errors involving medications because they acknowledged the importance of learning from these types of errors. As in my study, other studies have found increased awareness about medication errors or positive changes occurring in practice as a result of medication errors had a positive influence on nurses decision to report medication errors (Covell & Ritchie, 2009; Walker & Lowe, 1998). 5.2.2.1.2 Workload. The perinatal nurses described how workload could contribute to errors in their practice area. They perceived incidents often happened and were discovered when workload was high. Their view is partially supported in the literature. A study of the relationship between patient-tonurse ratios and patient mortality among surgical patients found that the odds of patient mortality increased by seven percent for every additional patient in the average nurses workload (Aikens, Clarke, Sloane, Sochalski, & Silber, 2002). Another study sought to determine if the likelihood of adverse events would increase as workload increases (Weissman et al., 2007). Workload was measured at the level of the unit of the hospital rather than at the level of individual units, by assessing occupancy rates, turnover, and the complexity or severity of illness of patients

78 receiving care. This study did not find a significant relationship between workload and the rates of adverse events. Although they did not find a significant relationship between hospital workload and adverse events, as measured by assessing the previously mentioned criterion, they did find a 10% increase in occupancy increased the risk of adverse events by 15% in a busy hospital (Weissman et al.). The perinatal nurses in my study did not define what they meant by a heavy workload. Therefore, it is unclear whether a similar effect would be seen in perinatal practice settings. 5.2.2.2 Factors Affecting Incident Reporting The perinatal nurses described factors influencing their incident reporting. These included their judgment and experience, the level of harm of the incident, whether or not they were asked to report based on pre-defined criteria, and a perceived higher risk of litigation compared to other practice areas. 5.2.2.2.1 Judgment and experience. The perinatal nurses described how they would determine if an error or event was an incident that required a report. They viewed determining what qualified as an incident as a complex process, which required the nurses individual judgment and was influenced by level of experience. The use of nurses individual judgments and experience to determine if an incident had occurred is supported in the literature. Other studies have also found nurses use their clinical judgment, experience, and knowledge to determine if an incident has occurred and if it requires reporting (Covell & Ritchie, 2009; Vincent, Stanhope et al., 1999; Walker & Lowe, 1998). The perinatal nurses in my study described how certain incidents, such as falls, which have the potential for harm and long-term consequences from the event, were important to report. Similar to the findings of my study, Vincent et al. (1999) found incidents associated with a greater

79 degree of harm, such as maternal death or stillbirth/neonatal death were much more likely to be reported compared to other incidents, such as unexpected admissions to the special care nursery or a patient requiring a blood transfusion. Although the perinatal nurses in my study explained why it was important to report incidents associated with a greater degree of harm, they also acknowledged the importance of reporting near misses or events that did not result in patient harm. They felt it was important to report near misses because there was learning that could be gained from these events. In contrast to the findings of my study, other studies have found nurses would not fill out an incident report for near misses, events where no harm was caused, or events posing minimal risk to the patient (Elder, Brungs, Nagy, Kudel, & Render, 2008; Jeffe et al., 2004) The findings from my study do not support the view of Knox, Simpson, and Garite (1999) who argued perinatal units are especially vulnerable to normalizing deviance from accepted practice. Knox et al. stated this was due to the low numbers of adverse outcomes in this practice context. In contrast, the perinatal nurses in my study reported they would fill out incident reports on near misses as well as incidents where harm had been caused because they recognized it was important to learn from incidents at all levels of harm. 5.2.2.2.2 Reporting based on criteria. Although the perinatal nurses described how they would use their judgment and experience to determine if an incident had occurred, some of the perinatal nurses indicated they reported incidents in response to pre-defined criteria. They spoke of a list of adverse outcomes, which included events such as low APGARS, low cord pH, readmission for infection or meconium aspiration. They were asked to report these particular events to management. Some of the perinatal nurses discussed how they would only report events meeting this list of criteria. In support of my findings, Vincent et al. (1999) also found their study participants, staff

80 members of an obstetric unit in the UK, reported events in response to a list of predefined criteria. The perinatal nurses in my study indicated they would report incidents based on predefined criteria regardless of circumstances or even if the care was appropriate. In contrast to the findings of my study, Vincent et al found their study participants would not report all adverse events on the list of predefined criteria if they felt the circumstances made it unnecessary. Circumstances that made their staff members feel the event did require reporting included: the incident was not preventable, care was of good standard, or there was no possibility of a complaint or claim. Although it is important to gather information on designated incidents in order to detect potential claims it is also important that all events are reported in order to monitor the quality of care on the unit (Vincent et al). My findings suggest reporting events on the basis of predefined criteria could result in incomplete data on near miss events or incidents occurring in a practice setting, which would preclude a true picture of the types of incidents occurring in a particular practice setting. 5.2.2.2.3 Litigation. The perinatal nurses in my study spoke of how the risk of litigation in their practice area influenced the entire incident reporting process in a subtle way. It influenced the types of events they would report and also influenced how they determined what qualified as an incident. They explained certain incidents required reporting because of the potential for litigation. This finding is supported by the views of others who agree that perinatal nurses are at higher risk for involvement in malpractice suits than nurses in other specialties (Greenwald & Mondor, 2003; Miller, 2003). Similar to the findings of my study, a study by Vincent et al. (1999) found the possibility of a certain incident resulting in a claim or complaint influenced reporting; staff members were more likely to report an incident if they felt it would result in a claim or

81 complaint. This finding was also supported by another study where the participants reported a benefit of reporting was the prevention of potential lawsuits (Jeffe et al., 2004). Greenwald and Mondor agreed incident reports should be completed for incidents that have a high potential for litigation and reports should be given to management. This ensures management is advised of the event and also provides the nurse with an opportunity to detail the steps taken to attempt to prevent the outcome. The perinatal nurses described how they believed they were asked to report certain events because of the potential risk of litigation associated with these events. Similar to the findings of my study, Waring (2004) found obstetricians had the highest levels of reporting and enthusiasm for incident reporting compared with physicians who practiced on other units (Waring, 2004). The obstetricians gave two reasons: they recognized the value of incident reporting because of changes made in response to reported incidents and they had received professional education and guidance about incident reporting because of increased litigation pressure in their practice setting (Waring). The perinatal nurses in my study believed completing an incident report would offer them a form of protection because it would ensure their care was documented. Documenting the incident created an opportunity for the nurses to review their documentation in the patients health record with management to ensure it was accurate and complete. Similar to the findings of my study, Dunn et al. (2005) stated complete and accurate documentation in the patients health record would assist the nurse in recalling details or specifics of the case at a later date and be integral to the nurses protecting himself or herself in the event of a future lawsuit. The perinatal nurses spoke of how at some point in their practice, they expected to meet with the hospital lawyer. Those who had already met with lawyers explained how litigation was in the back of their mind when they needed to report certain incidents. The influence of litigation

82 did not prevent nurses from reporting incidents, in fact, they believed reviewing the incident with the hospital lawyer was to their benefit and could help them to be more proactive in reporting incidents in the future. In contrast to the findings of my study, other studies found fear of lawsuits acted as a barrier to reporting incidents in practice for nurses in other practice areas (Chiang & Pepper, 2006; Uribe et al., 2002). 5.2.2.3 Barriers to Incident Reporting All of the nurses in this study identified barriers to incident reporting in practice. They identified both organizational and personal factors that operated as barriers to incident reporting. My study findings concur with findings of other studies identifying a significant number of barriers to incident reporting for registered nurses in a variety of practice contexts (Blegen et al., 2004; Evans et al., 2006; Jeffe et al., 2004; Kim, An, Kim, & Yoon, 2007; Kingston, et al., 2004; Uribe et al., 2002; Walker & Lowe, 1998). The perinatal nurses in my study linked unit culture to inhibiting incident reporting by how incident reporting was viewed, by the negative reactions/responses of the other nurses with whom they worked, and by negative reactions of management. All of the nurses in my study reported having a negative reaction to the terms incident reporting. Covell and Ritchie (2009) also found when they probed the participants of their study about using incident reports participants responded negatively. The participants felt the words incident and report actually deterred nurses from using forms to report incidents. 5.2.2.3.1 Organizational barriers. The perinatal nurses in my study identified time to report as a barrier to incident reporting. Consistent with my findings, other studies have found time to report was one of the top barriers to incident reporting for registered nurses (Covell & Ritchie, 2009; Evans et al., 2006; Jeffe et al., 2004; Ulanimo, O'Leary-Kelley, & Connolly, 2007; Uribe et al., 2002; Walker

83 & Lowe, 1998). The perinatal nurses in my study also described how taking the time to report an incident had a negative impact on their workload and patient care and added additional strain on to an already busy assignment. In support of my findings, other studies also linked time to preventing incident reporting by the amount of time it took to document an incident, insufficient time available during a shift to report and by other demands competing for time, resulting in incident reports not always being filled out (Evans et al., 2006; Jeffe et al., 2004; Uribe et al., 2002). The perinatal nurses in my study associated lack of time available during their working hours to complete incident reports with staying after the completion of their shifts to report. This meant they were less likely to report the incident. Nurses in other studies have also reported they were unsure if they would take the time to fill out incident reports because it often meant time was taken away from direct patient care and required them to stay past their shifts (Covell & Ritchie, 2009). The perinatal nurses in my study reported fatigue could operate solely as a barrier to incident reporting. The perinatal nurses reported fatigue was usually associated with an already busy, stressful assignment. This is a new finding because no other studies identified fatigue acting as a barrier to incident reporting. Similar to the findings of my study, other studies have found workload combined with fatigue can operate as a barrier to incident reporting (Jeffe et al., 2004; Ulanimo et al., 2007). Researchers reported units that were chronically understaffed were less likely to have incident reports completed as compared to units with appropriate staffing levels. Reporting tools operated as barriers to incident reporting for some of the perinatal nurses in my study. They indicated they found the hospital-wide incident report forms were unable to capture the unique features of incidents in their area of practice. This would cause some of the

84 nurses to question whether what they planned to report was actually an incident and in some cases would result in the nurses not reporting. No other studies were located that described how hospital-wide reporting tools could act as barriers to incident reporting in this way. Reporting tools could also act as a barrier for the perinatal nurses in my study due to the amount of time it took to fill out the form, which included the amount of time it took to gather all the necessary pieces of information required to complete the form. This could result in the nurses relying on informal reporting mechanisms rather than accessing the hospital incident reporting system in order to be more efficient. Similar to the findings of my study, other studies also found reporting tools operated as barriers because the forms were long and therefore were cumbersome and time consuming to fill out (Evans et al., 2006; Jeffe et al., 2004). The availability of different options to advise management of adverse events in practice also could act as a barrier to incident reporting for the perinatal nurses in my study. If other options were available, such as an ability to provide a verbal report to management, nurses would often avoid the formal incident report. Although the nurses discussed how they would sometimes follow their verbal report with a formal incident report, this was not always done. As in my study, Espin et al. (2007) found the presence of multiple methods for reporting incidents in an organisation could act as a barrier to reporting. In contrast to the findings of my study, Espin et al. indicated the presence of multiple methods created confusion. The nurses in my study did not link multiple reporting methods to creating confusion, which prevented them from reporting. Instead, the perinatal nurses in my study discussed how it was sometimes more efficient to alert management verbally to an incident rather than writing out the entire incident on the formal incident report form. They argued informal methods, such as a verbal report to management, allowed them to satisfy their obligations to alert management about incidents that had occurred

85 while not taking time away from patient care. However, if the verbal report was not followed up by a formal incident report, system wide learning would not be likely to occur as it would with a formal incident report. 5.2.2.3.2 Personal barriers. The perinatal nurses in my study reported personal barriers to incident reporting in practice. These included the stigma associated with reporting and fear their colleagues would judge them for their involvement in an incident. New nurses appeared to be particularly concerned about being stigmatized by incident reporting. Other studies concur with the findings of my study in regard to personal barriers towards incident reporting. Personal fear as a result of embarrassment, concern about reputation, and fear of reprimand appear to be the strongest personal barriers towards incident reporting for registered nurses in the literature (Blegen et al., 2004; Espin et al., 2010; Evans et al., 2006; Jeffe et al., 2004; Kingston et al., 2004; Walker & Lowe, 1998). Negative reactions from their peers about incidents in which they were personally involved could also influence whether or not perinatal nurses of all levels of experience would formally report an incident. Similar to the findings of my study, Ulanimo et al. (2007) found over half of the nurses in their sample believed some medication errors were not reported because nurses feared the reactions of their peers.

5.2.2.4. Facilitating Factors Because most perinatal nurses in my study did not receive feedback after incident reports, receiving feedback was not a motivating factor for reporting. The perinatal nurses regarded practice improvement as one of the main facilitators for incident reporting. Practice improvement would be facilitated by preventing similar incidents and protecting other patients from the same

86 error. The perinatal nurses in my study discussed how they viewed the patient as being at the centre of care and this motivated them to report incidents. They reported feeling obligated to report incidents for the benefit of their patients. My findings concur with a study by Rathert and May (2007) who found nurses who viewed their units as patient-centred were more satisfied with their jobs, perceived that medication errors occurred less frequently on their units, and felt more comfortable reporting errors and near misses. The perinatal nurses in my study felt obligated to report due to their professional responsibility as registered nurses. Similar to the findings of my study, Walker and Lowe (1998) also identified professional responsibility as having a positive influence on reporting. Their study participants stated they recognised they had a legal obligation to report as a registered nurse (Walker & Lowe, 1998). The perinatal nurses in my study not only felt obligated to report as registered nurses but they also felt incident reporting allowed them to cover themselves. Incident reporting created a record in case their care was questioned at a later date and also allowed them to fulfil their obligations to report certain events to their manager. Similar to the results of my study, Jeffe et al. (2004) found registered nurses were motivated to report incidents in practice because they felt incident reporting offered a form of self-protection. The perinatal nurses in my study reported they were motivated to fill out incident reports because they believed incident reporting created a learning opportunity for themselves and for other nurses. They would be reminded not to make the same mistake again and they could share their learning with their colleagues so they would be less likely to make the same mistake. My findings concur with those of Jeffe et al. (2004) who found educational purpose was a motivating factor for incident reporting for the participants of their study.

87 5.2.2.5 Team Dynamics and Organizational Culture The nurses in my study identified team dynamics as having an important influence on the safety of perinatal units. The perinatal nurses associated poor team dynamics with negative patient outcomes. The nurses discussed how improved team dynamics would likely lead to a reduction in incidents and improved patient outcomes. Similar to the findings of my study, FirthCozens (2001) found teams play an important role in safer patient care and safety cultures. My findings also concur with others who found that teamwork performance is directly correlated with organisational culture (DuPree et al., 2009; Mann, Marcus, & Sachs, 2006). Miller (2003) claimed team dynamics influenced patient outcomes in perinatal practice contexts. She stated perinatal nursing and medicine are both highly complex and strongly influenced by technology. She argued the successful operation of perinatal units is dependent upon teamwork (Miller). High reliability industries such as aviation and nuclear power plants have recognized teamwork as crucial to the avoidance of accidents and errors (Knox et al., 1999; Miller). Such organizations operate highly complex and hazardous technological systems, essentially without mistakes, over long periods of time (Knox et al., 1999). The perinatal nurses in my study also felt team dynamics influenced how incidents occurred in their practice area as a result of the way decisions were made. They felt incidents resulted from multiple decisions, made by multiple team members and were the result of a long process. The nurses described having to review their patients entire labour and delivery history to determine when decisions were made that might have contributed to a poor outcome at the end of a long labour. The process made it difficult to determine when an incident occurred or what decision had resulted in the incident. The nurses also felt the long process made incident reporting difficult for them as it took them longer to report incidents. These findings add new

88 information to the literature on incident reporting as no other studies were located that described incidents occurring as a result of the way decisions were made in care. 5.2.2.5.1 Informal reporting. The perinatal nurses in my study valued team relationships in their practice area and found this influenced incident reporting. They believed being part of a team could detract from incident reporting. Lyndons (2008) findings concurred with those of my study because she described staff of perinatal units withholding reporting of incidents for fear of damaging relationships. The perinatal nurses in my study reported high value for team relationships so they considered the effect on team relationships when making the decision to report. A study exploring nurses error reporting and communication in ICU settings also supports the findings of my study (Elder et al., 2008) where discovering errors made by others created anxiety for the nurses as they were concerned that reporting errors made by their team members would cause them to make enemies and lose friends. One of the ways team relationships specifically influenced incident reporting in my study was through the practice of informal incident reporting. The perinatal nurses stated they would report errors informally to seek clarification from other team members about whether or not an incident had occurred. They would do so to save time and because they perceived informal reporting to be more efficient in some circumstances. Similar to the findings of my study, other studies have found the decision to report formally or informally was influenced by the type of error and the workload of the nurse (Espin et al., 2007). Covell and Ritchie (2009) indicated incidents would sometimes be reported informally to seek clarification from colleagues about whether an incident had occurred and it required reporting. As in my study, Espin et al. (2007) found the decision to formally or informally report an incident was influenced by the knowledge

89 and experience of the nurse, the relationships with colleagues, physicians and managers, the type of error and the workload of the nurse. The perinatal nurses in my study also reported how informal incident reporting was sometimes used to avoid filling out incident reports on incidents involving other team members. They reported, if they discovered an incident involving their colleagues, they would always attempt to speak directly with their colleague about the incident to notify them they had discovered an incident, as a professional courtesy. To a degree, my study findings concur with those of others who reported registered nurses in a wide range of practice areas are less likely to report incidents involving their colleagues if they are able to speak to their colleagues directly (Blegen et al., 2004; Elder et al., 2008; Evans et al., 2006; Kingston et al., 2004; Walker & Lowe, 1998). The perinatal nurses in my study discussed how using this form of informal reporting did not mean that an incident report would not be completed. The nurses indicated, if they felt that the incident was likely to result in patient harm, they would fill out a formal incident report. Other studies did not comment on whether the degree of harm involved affected whether or not verbal reports to colleagues were followed up with formal reports (Blegen, et al., Elder et al., Evans et al., Kingston et al., Walker& Lowe). My study findings add new information to the literature on informal and formal methods of incident reporting The perinatal nurses in my study viewed informal reporting positively as it allowed them to address their fear about reporting the incident and obtain emotional support from their colleagues. In support of my findings, Covell and Ritchie (2009) also indicated nurses in their study viewed informal reporting positively. In addition, studies have indicated nurses use informal reporting mechanisms to protect their colleagues from being blamed for an incident and to preserve and maintain positive team relationships (Covell & Ritchie; Elder et al., 2008; Jeffe

90 et al., 2004). The perinatal nurses in my study felt the sense of camaraderie amongst team members of their unit made them less likely to formally report incidents involving other team members. Covell and Ritchie (2009) also found the strength of relationships amongst team members influenced informal reporting by the nurses in their study. The nurses in Covell and Ritchies study explained, if they perceived there were strong relationships amongst team members, they would not report errors formally. Instead, the nurses would use informal mechanisms, such as speaking to their colleague directly, to report the error (Covell & Ritchie). A novel finding in my study is informing colleagues and debriefing with them did not consistently prevent the perinatal nurses from reporting the incident. The perinatal nurses in my study discussed how they would debrief amongst team members after an incident, which they called verbal incident reporting. They felt discussing incidents within the group offered a certain level of protection and would use this form of informal reporting to obtain advice, clarify with their colleagues that an incident had occurred or simply to debrief. If they were using informal reporting to clarify with their colleagues that an error had occurred then once they had confirmed an incident report needed to be filled out, they would also formally report the error. My findings concur with those of one other recent study. Espin et al. (2010) indicated nurses would use informal reporting to clarify or validate whether an incident report needed to be filled out prior to filling out the formal incident report. The perinatal nurses in my study linked more formal communication processes amongst team members to missing less information and fewer incidents. Their perceptions are supported in general by the literature. Communication is highly valued in high reliability organizations. All team members are encouraged to use open and extensive communication to plan, update, and adjust to unexpected outcomes (Knox et al., 1999). Perinatal nurses in my study related

91 incomplete communication amongst team member to incorrect decisions being made in care. Other information sources about errors support this finding. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) noted in a Sentinel Alert in 2004 communication issues were the factors cited most frequently as contributing to infant death and injury during delivery. In support of my findings, White et al. (2005) conducted a retrospective analysis of consecutive risk management records from a single institution and found communication failures were associated with 31% of adverse events. In 21% of these cases communication failures appeared to contribute directly to the patients medical outcome. 5.2.2.5.2 Determining what qualifies as an incident. In my study, the nurses would seek input from their peers to determine whether or not a specific incident needed to be reported. They tended to concur with the opinion of the group, which often meant incidents were not reported. They recognised working in perinatal units involved a steep learning curve and they were concerned that reporting a more junior colleague would negatively affect their learning. Therefore, they would prefer to discuss incidents with junior colleagues and then report them. Although this finding resonates with Vincent et al.s (1999) participants view that failing to report incidents would prevent junior staff members being blamed, the perinatal nurses in my study reported they would not desist from reporting errors involving more junior colleagues in all circumstances. If an incident involved a patient being harmed or an obstetrical emergency, they would report after reviewing the incident.

5.2.2.6. Feedback and Follow-up to Incident Reports Although the perinatal nurses in my study reported following up with their colleagues about incidents they identified, they did not always receive follow-up from their managers after

92 reporting an incident. The participants of my study described how failure to receive feedback served as a barrier to incident reporting. Lack of feedback made the nurses question the point of filling out incident reports as they were unsure what happened to reports once they were completed. Other studies have supported this finding by indicating lack of feedback after an incident report served as a significant barrier to incident reporting (Elder et al., 2008; Evans et al., 2006; Jeffe et al., 2004; Uribe et al., 2002). Failure to receive feedback after an incident report was completed led some of the perinatal nurses in my study to question whether there was any point to filling out the incident report. This was because they were unsure about what happened to the report or if any changes were made in response to their report. Lack of feedback discouraged them from reporting in future because they did not feel as if they were being heard. Nurses in other studies have also reported not receiving feedback after incident reports were written, or if they did receive feedback it was not direct, instead general messages would be posted advising staff to avoid certain practices (Elder et al., 2008; Evans et al., 2006; Jeffe et al., 2004). In those studies, managers who participated in discussions with their staff members about incidents, including providing feedback, were more highly trusted by their staff members (Elder et al., 2008; Evans et al., 2006; Jeffe et al., 2004) 5.3 Study Limitations This study contributes to research regarding incident reporting by registered nurses. It provides new information about perceptions of perinatal nurses towards incident reporting, a topic that had not been studied. Although rich data were obtained through focus group interviews there were limitations to this research design. Data were collected using focus groups. There are known disadvantages to this method of data collection, such as focus groups are contextualized within a specific social situation, with a

93 risk that focus group interviews will produce situated accounts influenced by the focus group interaction (Sim, 1998). This can affect the applicability of results as the information obtained may be less relevant to nurses who are located in differing contexts for perinatal nursing (Stewart et al., 2007). The particular research design and method of data analysis used in this study addressed this issue, as more than one focus group interview was conducted which increases the reliability of the data. Similar responses and codes were noted across groups during the process of inductive coding and constant comparative content analysis, which increased confidence that the findings were not explicit to a particular group context. A second issue with focus group data is, in group settings, alternate views from the majority may not be expressed (Polit & Beck, 2008) and individual expression inhibited (Polit & Beck; Sim, 1998). These problems can lead to the findings representing particular perceptions of some focus group participants towards incident reporting (Sim; Stewart et al., 2007). In the case of my study, during the focus group interview participants vigorously discussed alternative views to particular topics. When I moderated the focus groups all participants were encouraged to contribute to the discussion and most contributed equally to the discussion. There are issues with the sampling method used that may have had an effect on the findings. Because most of the nurses, during their initial contact with me, reported minimal experience with incident reporting, their comments may have been limited by their lack of experience. Nurses who participated with a long experience with incident reporting may have affected the responses of nurses with minimal experience. Their responses might have been based on what they believed would be their experience rather than their actual experience. Although it is never appropriate to generalize the results of qualitative research, the small numbers of participants in each focus group may have limited the richness of the data generated

94 through the discussion. It would be inappropriate to generalize these results beyond the participants of this study. This study provides insights about perceptions of perinatal nurses towards incident reporting at the selected hospitals, which may not be transferable to other perinatal nurses in different settings (Stewart et al., 2007). Multiple hospitals were used as study sites to attempt to reduce this limitation. Common themes and similar responses to focus group questions were found across hospitals. It is therefore likely that these themes are relevant and transferable to perinatal nurses in other settings (Mays & Pope, 2000). 5.4 Nursing Implications I have developed implications for practice, education, and administration. I will first discuss implications for administration, education, and practice and then in a separate section I will discuss recommendations for future research. 5.4.1 Recommendations for Administration, Education, and Practice There are a number of nursing implications for nursing administration, education and practice that arise from this study. 5.4.1.1. Implications for Nursing Administration The perinatal nurses in my study identified a number of barriers to incident reporting. They discussed how unit culture inhibited incident reporting through how incident reporting was viewed and the negative reactions and responses of their peers and by management in response to reported incidents. Nurses were concerned that filling out incident reports would result in junior nurses being blamed, team relationships being compromised, and that they would be judged for their involvement in an incident. The perinatal nurses discussed how they would advise their colleagues of incidents to debrief and obtain feedback but would not report all

95 incidents to the hospital incident reporting system because they were so concerned about jeopardizing team relationships. From the discussions of the perinatal nurses it appears that incident reporting on their units was associated with naming and blaming culture rather than a safety culture where the focus is on learning (DuPree et al., 2009). Various strategies have been suggested to foster cultures of safety within perinatal units. One of the strategies proposed in the literature for fostering a safety culture is patient safety walk-arounds (Jeffs, Law & Baker, 2007). This strategy involves leadership walking through the unit and engaging in discussions with staff about patient safety concerns. New concerns are discussed and leadership also has the opportunity to share changes that have been implemented in response to previously identified patient safety issues (Jeffs et al.). All patient safety issues are discussed and considered regardless of level of harm. This allows nurses an opportunity to discuss patient safety issues generally in a safe and supportive forum, which allows nurses to be reassured and supported in their practice of reporting incidents. If it is demonstrated to nurses that their concerns will be addressed in a respectful, non-punitive way with a focus on learning rather than blaming it is likely that this will have a positive effect on the stigma associated with incident reporting. This will hopefully also alleviate concerns of the nurses about incident reporting negatively affecting team relationships because they will be reassured that follow-up to patient safety issues is not punitive in nature. In addition to unit culture operating as a barrier to reporting, the amount of time it took to report incidents using the formal incident reporting system also acted as a barrier to incident reporting for the perinatal nurses. This often resulted in perinatal nurses using informal reporting mechanisms because they allowed them to satisfy their obligations to notify management about certain incidents in a more efficient manner than reporting through the formal incident reporting

96 system. One of the reasons that incident reporting was so time consuming for the perinatal nurse was that the hospital wide incident report forms did not accurately capture the nature of incidents that occurred in their practice context. This caused nurses to question whether or not the incident actually needed to be reported but also led to the nurses having to spend long periods of time writing out the incident. Therefore, it is recommended that nursing administrators modify formal incident report forms so that they are more applicable to the nature of incidents that occur in this practice setting taking into account specific unit requirements. This will allow reporters to document incidents in a more efficient way and will hopefully result in increased reporting rates. Incidents reported through informal avenues, such as discussion with colleagues or management, may not be entered into the formal incident reporting system; such omissions limit systemic learning and change (Espin et al., 2007). Although it is unlikely that an accurate estimate of systemic problems will be developed through formal reporting, informal reporting may result in other perinatal nurses making the same error and avoidable harm to patients. To increase formal reporting rates, nurse administrators need to demonstrate to staff that reported incidents are handled with discretion in a non-punitive way. One of the main barriers to incident reporting for the perinatal nurses in my study was lack of feedback. Not receiving feedback after a report led them to question what happened to the report and whether there was any point in reporting future incidents. The nurses were then discouraged from reporting future incidents. Nursing leadership plays a key role in encouraging reporting through the provision of timely, actionable feedback in response to reported incidents in practice (Benn et al., 2009). Benn et al. found when managers provided their staff with actionable feedback, visibly resulting in changes to systems staff members were encouraged to report future incidents.

97 Crucial to the establishment of a reporting culture is to assure staff that incident reporting is linked to a responsive system where change is made in response to incident reports (DuPree et al., 2009; Mann et al., 2006). The perinatal nurses in my study discussed how seeing change in their practice environments motivated them to report. Nurses need to be informed about changes made in response to reported incidents. Feedback should be informative and timely and followup to incidents needs to be non-punitive and focused on learning from the event rather than blaming those involved. Therefore it is recommended that nursing leaders ensure they provide feedback and follow-up to all staff members that have completed incident reports. When leaders demonstrate to staff that reported incidents are handled in a non-punitive way and that they will receive feedback on their reports staff are more likely to report incidents in the future. Feedback to staff about changes made in response to reported incidents can occur through staff newsletters or through documentation in a unit communication book. It is also important that leaders provide direct feedback to those that have completed incident reports. In order to ensure that feedback reaches all staff it is important that nursing leaders make themselves available to provide feedback in person to staff members who work alternate shifts, including weekends and nights. Alternatively, they can establish a other means to ensure that feedback and information on changes made in response to reported incidents is provided to staff members, such as a unit communication book. It is recognized perinatal units are unique from other units due to their practice areas and the types of patients for whom they care. Perinatal practice areas are highly complex and the successful operation of perinatal units is largely dependent on effective teamwork (Miller, 2003). In addition to strategies focused on fostering safety cultures, interventions focused directly on improving team dynamics and communication amongst team members in perinatal units are

98 integral to improving the safety of these units (Forster et al., 2006). Crew resource management (CRM), a teamwork training initiative, has been suggested as a strategy to improve dynamics between team members in labour and delivery units (Mann, Marcus & Sachs., 2006). CRM focuses on improving interprofessional communication and teamwork through developing strong teamwork skills and introducing concepts such as team meetings and situation monitoring based on concepts from aviation (Mann, Marcus & Sachs.). Physicians, nurses, and other team members are trained as a team in a formalized manner in order to deliver timely, effective and coordinated care (DuPree et al., 2009). Therefore it is recommended for perinatal nurses to receive education in teamwork training initiatives, such as crew resource management, along with other multidisciplinary team members (Mann, Marcus & Sachs). The unique nature of incidents in perinatal nursing has created additional implications for nursing administration and leadership. Currently, it appears perinatal nursing units collect different information on the types of incidents occurring in their practice contexts. Some of the nurses in this study discussed how they reported incidents based on lists of pre-defined criteria while others reported based on their own judgment and experience. To reduce commonly occurring incidents in perinatal nursing practice, a better understanding of the types of incidents occurring in this practice area is needed. To achieve this, decisions must be made about the types of incidents that should be reported by area to hospital incident reporting systems. Perinatal nurses need to be provided with information on what should be reported and how to identify an incident to increase reporting rates. Examples of incidents and contributing factors to incidents can be discussed during patient safety walk-arounds and other appropriate venues so that nurses are provided with information on triggers that will assist them in determining if an incident has occurred.

99 The perinatal nurses in my study identified a number of reasons why incidents were not reported to the formal incident reporting system. From the discussions of the perinatal nurses, it is evident not all incidents are reported to the formal hospital incident reporting system. This leads to inaccurate information on the types and numbers of incidents that are occurring in perinatal practice contexts. Tools such as the Institute for Healthcare Improvement (2006) Perinatal Trigger Tool use a list of triggers to identify adverse events during manual chart reviews. To obtain information on incidents occurring on perinatal units it is recommended, in addition to using information from reported incidents, methods such as chart audits using triggers tools are adopted. 5.4.1.2 Implications for Nursing Education In order for perinatal nurses to appreciate the importance of reporting all incidents regardless of type of incident or level of harm it is necessary for nurses to be educated in the importance of reporting all incidents and how this can contribute to safer perinatal units. Nurse educators and leaders play an important role in reinforcing incidents as representing important opportunities to learn and improve. In addition to interventions focused on fostering safety cultures, continued education on these topics is likely to result in front line nurses being more willing to report incidents. It also has the potential to result in a better understanding of human error management and a greater acceptance of the importance of reporting incidents in practice (Reason, 2000). It is important nursing educators continue to reinforce the importance of reporting all medication errors. The majority of nurses in this study stated that they would report any incidents involving medications; however, the perinatal nurses also indicated incidents involving medications were not as much of an issue in their practice area - a view not supported by the

100 literature. It is therefore possible certain incidents involving medications may not be reported as the nurses may not appreciate the potential harm that could result from errors involving medications, even those prescribed prophylactically. It is important all medication errors are reported due to the potential serious complications that can result. Therefore it is recommended that nursing educators and nursing leaders continue to reinforce the importance of reporting any and all incidents involving medication regardless of the level of harm. In order to educate perinatal nurses on the potential consequences of medication errors in their practice context it is recommended that perinatal units establish journal clubs where this topic is discussed. Publications can be brought in that describe outcomes of medication errors in perinatal settings, which will provide perinatal nurses with a greater understanding of the potential consequences of these errors. Although some of the perinatal nurses in my study did say they felt it was important to report near misses and any and all incidents involving medications, this was not the case for all of the perinatal nurses. Instead some reported they would only report incidents based on a set list of incidents developed from pre-defined criteria. Leape (2002) stated the primary purpose of reporting incidents in practice is to learn from events that have already occurred. To gain an understanding of the contributing factors to incidents, it is therefore necessary that all incidents and near misses are reported, regardless of outcome or level of harm. The identification of trends and contributing factors to incidents will hopefully prevent similar incidents from reoccurring (Leape, 2002). It is, therefore, recommended perinatal nurses continue to report all incidents regardless of the outcome or level of harm associated with the event. Reporting incidents in response to lists of events appeared to operate as a barrier to reporting all incidents because some nurses discussed how they would only report incidents on the list of reportable events. To

101 encourage reporting of all incidents, regardless of level of harm, it is recommended nursing administrators and educators avoid providing nurses with lists of possible incidents. Instead nurses should be provided with education about the purpose of incident reporting and basic patient safety principles, so that nurses appreciate the importance of reporting all incidents. 5.4.1.1 Implications for Nursing Practice The perinatal nurses in my study discussed how they believed that a certain level of experience was required to identify incidents in practice. They described incidents in perinatal practice contexts as complex and therefore argued junior staff may not be able to identify all incidents in practice without assistance from more experienced staff. Experienced nursing staff members have an important role in mentoring and training new nurses in their clinical areas. The perinatal nurses in my study explained how they would use examples of incidents they have been involved in as part of the training that they provided to new staff. It is recommended that senior nursing staff continue to incorporate information on incidents, including the importance of reporting incidents, in the education and mentoring they provide to new staff. The perinatal nurses in my study were motivated to report incidents they felt had a potential for future litigation. They viewed incident reporting in these circumstances as important because it gave them the opportunity to review their documentation with management to ensure it was complete and to potentially prevent suits against them. Complete and accurate documentation is important to the nurses defense should she or he become involved in a lawsuit (Dunn et al. 2005). It is recommended nurses continue to report incidents for these purposes and that management continue to conduct chart reviews with nurses when reporting for this reason.

102 5.4.2 Recommendations for Further Research Because this is the first study examining perinatal nurses perceptions of incident reporting further research is needed on this topic. Due to the small sample size, it is recommended that this study be repeated with a larger sample size to ensure that information is obtained covering the perceptions of a varied group of perinatal nurses about incident reporting. To obtain the perceptions of a large number of perinatal nurses it is recommended that a quantitative survey be developed based on the results of this initial study. The survey could then be sent out to a large group of perinatal nurses. Other studies have found scope of practice and interdisciplinary relationships can influence the reporting process. The nurses in my study did not comment on interdisciplinary relationships or scope of practice in the focus group interviews. Therefore, further research could illuminate ways interdisciplinary relationships and scope of practice in perinatal settings influence incident reporting. This study sought to obtain an understanding of the perceptions of perinatal nurses towards incident reporting. It was not a goal of this study to identify commonly occurring incidents in perinatal practice settings or their underlying causes. It is recognized that many types of incidents occurring in perinatal practice are unique and there is limited knowledge about types of incidents occurring in this practice area for the perinatal patient population (Forster et al., 2006; Mann et al., 2006). Forster et al. proposed several challenges to conducting adverse event research in the perinatal practice context. Challenges to conducting adverse event research in perinatal practice settings include the rarity of events that occur in this practice setting and that the majority of adverse event research to date has been focused on poor outcomes, of which there are few.

103 Integral to the reduction of incidents in this practice area is a greater understanding of the types of incidents that commonly occur in perinatal practice areas. In the literature, nurses have been the profession most likely to report incidents in practice (Kim et al., 2007). Therefore, it is recommended research be conducted on the types of incidents commonly reported, both formally and informally, by perinatal nurses to gain knowledge about types of events and their underlying causes in perinatal practice areas. Reporting tools were found to operate as barriers to incident reporting for the perinatal nurses in my study. The nurses found that hospital wide forms were not applicable to the majority of the incidents in their practice setting. This made some of the nurses question whether or not the incident should be reported. The nurses also reported lack of feedback to completed reports discouraged them from reporting again. In response to these findings, it is recommended that nurse managers or others involved with the incident report process be interviewed to determine barriers they perceive to incident reporting and potential strategies for disseminating information about report outcomes more widely. This information could be used to develop more sensitive and responsive systems and reporting tools to encourage reporting amongst this population of nurses. 5.5 Communication of Findings I plan to communicate the findings of my research study by publishing this study in a peer-reviewed journal to widely communicate the results of this study. I also plan to communicate the results of my study to those involved in the research process. I will offer to present the findings of my study to the staff of the units where recruitment took place. The Quality Committee of the Health Authority where recruitment took place has made a request for the results to be communicated at a future meeting where I will present the findings of my study.

104 5.6 Chapter Summary In this chapter, I compared and contrasted the study results with extant literature. I presented nursing implications generated from the discussion and made recommendations for nursing practice, education, administration, and research. The implications addressed the importance of fostering safety cultures on perinatal units to address many of the barriers to incident reporting in perinatal practice contexts. To encourage reporting, nurses need to be reassured that they are able to report incidents in a confidential manner without fear of being stigmatized or damaging team relationships. Nurses also need to receive timely and actionable feedback to reported incidents and see change on their units in response to their reports. Because this is the first study exploring the perceptions of perinatal nurses about incident reporting further research is needed on this topic. Research can explore the influence of interdisciplinary team relationships and scope of practice on incident reporting in perinatal settings, the types of incidents that occur in this practice area, and nurse leaders perceptions of barriers to incident reporting. I plan to communicate the results of this study by seeking publication in a peerreviewed journal, through presentations to the units where recruitment occurred, and by presenting a summary of findings to the Quality Committee of the Health Authority involved in the research. 5.7 Summary and Conclusion This study used a qualitative, descriptive design to explore the perceptions of perinatal nurses towards incident reporting. This was accomplished through conducting focus group interviews comprised of perinatal nurses employed in labour and delivery or single room maternity care units within one health authority in the province of British Columbia. I conducted four focus groups with perinatal nurses from three separate hospitals. I analyzed data using

105 inductive content analysis and concurrent comparative analysis. Four major themes were developed from the analysis: Nature of incidents, how incidents happen, barriers, and facilitating factors to incident reporting. I compared the findings of this study with extant literature on the topic and made nursing recommendations. In conclusion, this study was the first to explore the perceptions of perinatal nurses towards incident reporting. There are factors that make incident reporting in this area of practice unique and special considerations are required to meet the needs of this population related to incident reporting to encourage and increase incident reporting rates. With the exception of medication incidents, most of incidents discussed by the perinatal nurses appear to be unique to this practice context. The way in which care is organized in perinatal practice contexts appears to influence how incidents occur and how they are recognized. Further research is needed on the influence of interdisciplinary team relationships and scope of practice on incident reporting in this practice context.

106

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116 White, A. A., Pichert, J. W., Bledsoe, S. H., Irwin, C., & Entman, S. S. (2005). Cause and effect analysis of closed claims in obstetrics and gynecology. Obstetrics & Gynecology, 105(5 part 1), 1031-1038. Whittemore, R., Chase, S. K., & Mandle, C. L. (2001). Validity in qualitative research Qualitative Health Research, 11, 538-552.

117 APPENDICES Appendix A

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121 Appendix B: Information Letter sent to Managers

THE

UNIVERSITY OF BRITISH

COLUMBIA School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel: (604) 822-7417 Fax: (604) 822-7466

Exploring Perceptions of Perinatal Nurses towards Incident Reporting: A Qualitative Study Principal Investigator: Wendy Hall, PhD, Professor, University of British Columbia School of Nursing 604-822-7447 Co-Investigator(s): Norna Waters, RN, BSN, Masters of Science in Nursing Student University of British Columbia, School of Nursing 604-831-5781 February 20, 2009 Dear: __________________(Manager of Labour and Delivery or SRMC unit) We are writing to you as the manager of the birthing unit at ____________(Name of Organization) to request your assistance with a study we are conducting.. The aim of our study is to describe views of nurses working on labour and delivery or single room maternity units about incident reporting. Data collection for the study will occur in focus groups run by a Masters of Science in Nursing graduate student who is conducting this research as part of a masters thesis. The registered nurses in the focus group will be asked a series of questions designed to capture their thoughts about and experiences with incidents. The groups will consist of nurses employed at the same hospital either in a room at the hospital or a room in a community setting. The meeting will be approximately 90 minutes long.

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Participants will be provided with light refreshments during the focus group meetings. A small honorarium of $20.00 will also be offered to all participants for their time. We are also offering a contribution to the unit education fund of $200.00 to express our appreciation for unit participation in the study.

We have obtained research ethics board approval from the University of British Columbia Behavioral Research Ethics Board and are now seeking your support as we prepare an application to the Fraser Health Research Ethics Board. Attached is a copy of the approval from UBC. We request your agreement to distribute a participant information sheet to your staff members who work a minimum of a 0.5 FTE in the labour and delivery or single room maternity care units at your organizations. Attached is a copy of the participant information sheet that has been approved by the UBC Behavioral Research Ethics Board. Adjustments to this form will be made in accordance with the Fraser Health Research Ethics Board. We are also hoping to offer a 30 minute information session about to study for any of thestaff members in your facility who may be interested in participating. We would appreciate your assistance with notifying staff about the session. Please inform us if you are willing to assist us. Once we have obtained your response we will proceed with obtaining approval from the Fraser Health Research Ethics Board. Following approval from the Fraser Health Ethics Board we will provide you with a copy of the approval certificate. If you have any questions or require further clarification please contact Norna Waters at nbwaters@telus.net or 604-831-5781

123 Appendix C: Participant Information Letter

THE

UNIVERSITY OF BRITISH

COLUMBIA School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T2B5 Tel: (604) 822-7417 Fax: (604) 822-7466

Participant Information Sheet

Exploring Perceptions of Perinatal Nurses towards Incident Reporting: A Qualitative Study Principal Investigator: Wendy Hall, PhD, Professor, University of British Columbia School of Nursing 604-822-7447 Co-Investigator(s): Norna Waters, RN, BSN, Masters of Science in Nursing Student University of British Columbia, School of Nursing 604-831-5781 Thank you very much for your interest in this Study. The aim of this Study is to explore the experiences of perinatal nurses with incident reporting. In particular, this study seeks to discover the views of nurses who work on labour and delivery or single room maternity care units. Data collection for the study will occur in focus groups run by a Masters of Science in Nursing Graduate Student who is conducting this research as part of a Masters Thesis. The Registered Nurses in the focus group will be asked a series of questions designed to obtain information about their thoughts and experiences with incidents. The groups will consist of nurses employed at the same hospital and the meeting will be approximately 90 minutes long.

124 Participants will be provided with light refreshments during the focus group meetings. A small honorarium of $20.00 will also be offered to all participants for their time and input. A two hundred dollar donation to the education fund for each unit that participates will serve as an acknowledgment of appreciation of unit involvement in the study. The focus groups will be audio-taped. Tapes will be transcribed into computer files, and then stored in a locked file cabinet. All tapes will be kept for five years and then destroyed. Participants will be encouraged not to use names during the focus groups and if names are used they will be removed during transcription. Participants will not be identified by name in any reports of the completed study. All participants will be requested to keep focus group discussions confidential; however we cannot control what other participants do with the information discussed. Confidentiality of information discussed in the focus groups would not be maintained by the researcher if incidents of intentional harm and neglect are disclosed. The Child, Family and Community Services Act requires such incidents be reported. Therefore should any participant disclose information of this nature they will be advised by the researcher that this information would need to be formally reported to the Health Authority, The Ministry of Child and Family Development and the College of Registered Nurses of British Columbia. A potential risk associated with your participation in the study is that you may feel uncomfortable discussing your experiences with incident reporting. Participants have the right to refuse to participate in any part of the focus group and to refuse to answer any questions at any time.
If you have any concerns or complaints about your rights as a research subject and/or your experiences while participating in this study, please contact Dr. Marc Foulkes and/or Dr. Allan Belzberg, Research Ethics Board [REB] co-Chairs by calling 604-587-4681. You may discuss these rights with the co-chairmen of the Fraser Health REB.

You may also contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail to RSIL@ors.ubc.ca Thank you for your interest. If you have any questions regarding the study please contact Norna Waters at 604-831-5781.

125 Appendix D: Informed Consent Document

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130 Appendix E: Recruitment Poster

THE

UNIVERSITY OF BRITISH

COLUMBIA School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T2B5

Tel: (604) 822-7417 Fax: (604) 822-7466 Research Study: Exploring Perceptions of Perinatal Nurses towards Incident Reporting: A Qualitative Study
We are conducting a qualitative research study on Perinatal Nurses and incident reporting in order to learn more about the perceptions of Perinatal Nurses towards incident reporting. In particular, this study seeks to discover the views of nurses who work on labour and delivery or single room maternity care units. If you are a registered Perinatal Nurse working at least 0.5 FTE on a labour and delivery or single room maternity care unit within the Fraser Health Authority then you are eligible to participate. Participation in the study will take approximately 90 minutes and will involve participating in one focus group interview composed of your peers. Nurses who choose to participate in the study will receive a light meal and refreshments and will also receive a small honorarium for their time. Focus Groups will be planned for August - October 2009 at an exact date and time to be determined. If you are interested in learning more about this opportunity, or have any questions please contact Norna Waters at the contact information below. Thank you for your interest! Principal Investigator: Wendy Hall, PhD, Professor, University of British Columbia School of Nursing Co-Investigator: Norna Waters, RN, BSN, Masters of Science in Nursing Student UBC, School of Nursing

604-822-7447

604-831-5781
nbwaters@telus.net

131 Appendix F: Demographic Questionnaire

THE

UNIVERSITY OF BRITISH

COLUMBIA

School of Nursing T201- 2211 Wesbrook Mall Vancouver, B.C. Canada V6T2B5 Tel: (604) 822-7417 Fax: (604) 822-7466 Demographic Questionnaire Please fill out the following questions. This information will not be linked to individual participants responses and will be used only for the purposes of describing the sample as a group Participant Identification Number (as assigned during the focus group interview e.g., P1, P2) _______ 1. Age: 2. Sex: 3. Ethnicity __________ Male_________ Female__________

__________________________________

4. Highest Level of Education: Diploma Undergraduate Degree Post Graduate Specialty Certification Masters 5. Length of Nursing Experience (years) __________ __________ __________ __________ __________

6. Length of Experience as a Perinatal Nurse (yrs)________

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Appendix G: Focus Group Interview Guide Perinatal Incident Reporting Focus Group Interview Guide Facilitator A. Thank the Participants for attending 1. Introduce yourself and provide some background B. Objective of the focus group 1. Why the research is being conducted 2. What the goals are of the research C. Explanations 1. Length of time of the focus group and a promise to end on time 2. Confidentiality of participants: The discussions that occur within the focus group interviews are confidential and should not be discussed outside of the focus group interview. Participants names and any other identifying information will be removed from the data during the transcription process. 3. Participants may leave at any time 4. There are no wrong answers; everyones input is welcome and encouraged 5. Guidelines for conduct in terms of respectful treatment of all participants and avoiding interruptions or speaking over other participants. 6. Any questions or comments? D. Interview Questions Question One: What comes to mind when you hear the word incident reporting? Question Two: What reactions do you think have occurred? Question Three: Why do nurses report an incident? Question Four: What sorts of incidents should be reported? Question Five: Why might you decide to report an incident? Question Six: Is there anything else that we should have discussed that has not already been mentioned? E. Conclusion 1. Thank you all for coming, 2. Collect demographic information on participants 3. Provide contact information