Iranian Paediatric Nurses Experience of Nursing Error: A Content Analysis
Nursing error has complex and vague dimensions and paediatric nurses' experience is different from the other nurses. Therefore, this study was conducted to illuminate Iranian paediatric nurses' perception of nursing error. Our study designed is qualitative content analysis. Semi-structured interviews were performed with 8 paediatric nurses in three hospitals. Filed notes were documented. Data were analysed using manifest qualitative content analysis by Bernard's theory. Five themes were obtained from interviews and field notes: 1) damage; 2) careless; 3) wrong thinking/action; 4) relative/absolute situation; 5) Compulsory/Optional Situation. Iranian paediatric nurses perceive nursing error as situations attributed in wide spectrums that damage is heart of them. Two new aspects of nursing error presented in this study was wrong thinking and normalisation of errors (in Compulsory/Optional Situation). Our results show the need of more research and education attention to this issue.
Keyword : Content analysis; Error; Medical errors; Nursing
Nursing is an ethical profession,1 and assistance to people in a vulnerable situation is one of the main tasks of nurses;2 however, errors endanger this task. Patient safety is a serious global public health issue. In 2002, WHO member states agreed on a World Health Assembly resolution on patient safety.3 So any health system tries to decrease error to reach patient safety. The cost of nursing errors is imposed on nurses, patients and their families, the health system, and professionals who are involved;4 nursing error has to be considered as a phenomenon with irreparable damage for patients. These injuries are variable, from a minimum of wasted time and efficacy to discomfort, injury, or death.5
Error statistics in health systems are high5 and these statistics are also affected by environmental situations and error definition. Paediatric wards have more challenges due to nursing errors. The nature of paediatric care differs from adult care and the care process is more complex in children.2 Therefore, some errors are more common in paediatric units. They have high rate of error incidence.6 Caring in these wards is more specifically and medical and nursing errors are more incident.7 Thus paediatric nurses' perception about nursing error is different by other health care providers and nurses.
A key component for examining and improving patient safety is error reporting3,8 but like other medical errors, nursing errors tend to be underreported.9 One issue to disclosure of errors is ambiguity in error definitions and perception of nurses about it.10 Error is a complex concept by vague dimensions and nurses involvement in error need to clarification.11 National standards for the profession in each country are different, and this introduces nursing error as a contextual concept.12 Paediatric nurses work in different socio-cultural context and perception of them about nursing error is different by other nurses and need to explore.
Paediatric nurses due to paediatric wards characteristics involve by nursing error more than other nurses. Children are more vulnerable to medical errors.13 For example, due to children's low weight, drug dosage errors result in more severe poisoning in children. Due to issues such as poor communication skills, greater fear, and lower ability to understand their circumstances in children compared to adults, paediatric nurses' experience of nursing errors is distinct and unique. Therefore their experiences are valuable to nursing error definition.
Nurses perception of nursing error can affect their practice.14,15 Nurses do and repeat practice they percept it correct. Individual interpretation of error occurrence is an important component to reaction of nurses to errors16 and learning from errors at work.17 Also nurses perception about nursing error is dependent on norm definition and standard indicators in each context.12,17
Previous studies on perception of health care provider about error generally focused on medical errors not nursing error as an independent concept18 or didn't focus on Iranian paediatrics nurses perception of nursing error.15,19-21 Due to importance of nursing error as an independent concept and lack of information and context bound characteristics of it, this study aims to answer this question:
What is perception of Iranian paediatrics nurses about nursing errors?
Qualitative approach is the best to explore experience and perception of participants about context bound concepts.22 Therefore, to answer this question qualitative content analysis chose as study research methodology.
This study conducted as a qualitative content analysis.
Setting and Participants
Iran is a country in Western Asia. With 75.14 million inhabitants, Iran is the world's 17th most populous nation. 99.4% of peoples are Muslims23 and Iran is home to one of the world's oldest civilizations. Nurses usually are employed in hospitals in the Iranian context.24 Therefore paediatric wards in three governmental hospitals were chosen as a field of study. Nursing error is a nursing concept; therefore, paediatrics nurses as persons most affected by nursing error were selected as participants to purposeful sampling. Interviews were conducted with nurses who had the experience of committing an error, at least one year of clinical experience in the paediatric ward, were performing clinical work at the time of the study, were Iranian, and had at least a bachelor degree in nursing (Table1).
Researcher referred to paediatric clinical departments. The importance of research described for nurses. Semi-structured interviews in prior synchronised time were conducted to data collection. Researcher explains the ethical considerations and participants fill informed consent form.
Participants were asked to mention one example for nursing error based on his/her experiences and express attributes distinguishing it from other situations. Scheduled open ended questions such as these used in interviews: Did you make a nursing error? Please talk about it. If needed follow up questions asked: Why did you name it nursing error? Overall, the researcher found 20 shifts in line with emerging data in clinical departments. Field notes were documented. Data collection and data analysis were performed simultaneously. Excessive workload of nurses led to problems in their participation. For this reason, the interviews, organised in predefined and limited duration. Researchers to solve this problem attempted to analyse each interview accurately and then did another interview to reduce interviews duration. All participants preferred that the interviews be conducted on one period of time. Duration of each interview has mentioned in Table 1. The interviews were audio recorded with the permission of the participants. The audio recordings were coded and preserved in order to maintain confidentiality and transcribed immediately. All interviews conducted and transcribed verbatim by one researcher. Researcher, who did interviews, participated in data analysis and peer check and member check of finding. Interviews continued (approximately 6 months July till December 2014) until data saturation. Finally 8 nurses participated in individual interviews.
Data Analysis and Trustworthiness
Data was analysed using manifest qualitative content analysis by Bernard's theory.25 Rules of coding were determined. Coding was based on the main question. Research team divided in two teams. The interviews were reviewed to find meaning units and coded separately by two individuals (the interviewer and another researcher). The codes were discussed, and consensus was reached through obtaining the opinion of the supervisor. The aim was to reach a common understanding of codes and classifications. Each interview was separately analysed in each group, and then, coding scheme was evaluated and discussed. Coding scheme was used to achieve comprehensive themes. The codes were classified on the basis of conceptual similarity in the categories, and 5 abstract themes were obtained from categories. The categories were also reviewed repeatedly to make sure that the results show the manifest content of the data. Lincoln and Guba (1986) criteria for trustworthiness used to evaluate data.26 Audit trial and member check and peer check was done in each and in end of analysis process.
"All authors declare that 'written informed consent' was obtained from the nurses. A copy of the written consent is available for review by the Editorial office/Chief Editor/Editorial Board members of this journal."
"All authors hereby declare that all experiments have been examined and approved by Medical Ethics Committee of University of Social Welfare and Rehabilitation Sciences (number: USWR.REC.1392.61) and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki."
The findings were expressed as five themes: 1) damage (with two categories: irreparable/negligible damage, and imminent/probable damage); 2) careless; 3) wrong thinking/action; 4) relative/absolute situation; 5) Compulsory/Optional Situation (with two categories: unconscious/conscious and normalisation).
This theme has been proposed as the main focus of study participants. In fact, damage is the heart of all themes, and the most distinctive feature of the nursing error that participants expressed.
"Well, environmental conditions will lose focus. Sometimes, a series of all other factors affect accuracy. Well, these impacts. Ultimately, it comes down to your attention and care. Generally, the accuracy is the main issue."
The nurses had no justification for its negligence, and entirely consider their culpability. Another participant said:
"I should use the right scissors. The wrong is wrong.
If I were highly accurate I would not do wrong."
"In short, she did not accept that she also might be wrong. This idea itself is nursing error!"
"I say using the wrong device in the wrong situation is nursing error! If it has an adverse affect or if it does not, it may or may not have the possibility of damage, In general, wrong is wrong!"
At the same time, the relative perceptions of nursing error were presented. Some participants believed anything that is in conflict with their beliefs initially were introduced as an error. These beliefs are the result of scientific principles or practice experiences. This is not necessarily limited to very complex procedures and even may include a simple practice. Any action which is not based on prior nurse knowledge and is aimed to change them will be considered nursing error. A participant stated:
"I think my own way is the right way. Now another person does other methods. I say it is not true!?Yeah, I think this is a mistake. Someone coming and bringing a new belief is error in my view."
Some participants felt the effects of time, working conditions, the philosophy and emphases of organisation on the error perception. A participant stated:
"According to the conditions of work, crowded wards, or ?I didn't have enough time then if I didn't do mouthwash is not error."
It is important point in this study that nursing error is addressed in the nursing profession and in this respect, paediatric nurses. Nurses are a large group of health care providers and provide direct care for patients and have unique perception about each situation. Paediatrics nurses also work in different socio-cultural condition. All participants were familiar with the concept and had no conflict about the importance and usefulness of the concept. Participants spoke with some confusion on the definition of this concept.
The participants expressed damage as the most prominent feature of nursing error. Nursing students perception of error in previous study presented it as conditions lead to life threaten to patients10 and the first definitions of nursing error in the literatures were definitions based on outcome.27-29 In the literatures some definitions mention actual or potential damages11,30 but declaration of irreparable damages in opposite of negligible damage is new finding that presented in this study by participants.
Wrong thinking as a nursing error was not presented directly in the literature. Literatures mentioned error as a behaviour or action.7,15,17 They focused on commission or omission of care plan.7,11,17,31 This theme was noted as a first new aspect of nursing error that Iranian nurses independently expressed. They expressed regardless of the damage, wrong thinking (e.g., believed to be immune from error) also considered a nursing error. This aspect of nursing error is supported by Islamic believe of "Actions are but by intensions and every man shall have but that which he intended" [Prophetic Hadith].32
Reason's human error model based on cognitive faults11 and supports careless theme. Literatures mentioned goal oriented definitions of nursing error17 or considered it as cognitive fault33,34 point to careless theme in present study.
Absolute/relative aspect of nursing error comprehensively is consistent whit critical care nurses viewpoints in Kurdistan. They explained nursing error as an unavoidable issue, lack of congruence with standards, doing extra-nursing tasks and giving care against the agreed-upon routines.15 All of them are absolute or relative issues. As well as this theme has covered by some medical/nursing errors definitions that based on aim or context and standards.17,33
In the literature error is defined as unintended behaviour.11,29 Second new aspect of nursing error presented in this study was the category of normalisation in this theme. This sub-category refers to errors that are common to perform. In other words, over the long term these errors wear the cover of OK, even they were not judged again. This type of nursing error (that we termed it "nested errors") requires further investigation and research. Research about types, causes and dimension of nested errors is necessary to decrease and eliminate them. Nurse practitioners and students must be aware of this kind of errors and should attempt to avoid them.
This article presented Iranian paediatrics nurses' perception of nursing error and emphasized new aspects of it. The essential point in the participant's perception is damage, and it is a threat to the patient's life. All of themes are considered along a spectrum that at the heart of all is damage. In fact, as seen in filed notes, Iranian nurses by their experiences define nursing error by pay attention to damage and consider it thinking or action and as a concept that is absolute or relative, mandatory or optional. "Nested errors" and wrong thinking is new aspects of nursing error in paediatrics nurses in Iran. Importance of nursing error concept and some result of this study as normalisation of nursing error in practice shows necessity of health care system attention to this issue.
Declaration of Interest
The authors have no conflict of interests to declare.
We appreciate all the participants and all those who helped us in this study.
1. Borhani F, Abbaszadeh A, Mohsenpour M. Nursing students' understanding of factors influencing ethical sensitivity:
A qualitative study. Iran J Nurs Midwifery Res 2013;18:310-5.
2. Borhani F, Abbaszadeh A, Mohsenpour M, Asadi N. Lived experiences of pediatric oncology nurses in Iran. Iran J Nurs Midwifery Res 2013;18:349-54.
3. 10 facts on patient safety. World Health Organization (WHO), 2015 [updated June 2014; cited 2015 7/22/2015]. http://www.who.int/features/factfiles/patient_safety/en/
4. Benner P, Sheets V, Uris P, Malloch K, Schwed K, Jamison D. Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Adm 2002;32:509-23.
5. Benner P, Malloch K, Sheets V, et al. TERCAP: Creating a national database on nursing errors. Harvard Health Policy Review 2006;7:48-63.
6. Sharek PJ, Classen D. The incidence of adverse events and medical error in pediatrics. Pediatr Clin North Am 2006;53:1067-77.
7. Garrouste-Orgeas M, Philippart F, Bruel C, Max A, Lau N, Misset B. Overview of medical errors and adverse events. Ann Intensive Care 2012;2:2.
8. Kim CH, Kim M. Defining Reported Errors on Web-based Reporting System Using ICPS From Nine Units in a Korean University Hospital. Asian Nurs Res (Korean Soc Nurs Sci) 2009;3:167-76.
9. Johnstone MJ, Kanitsaki O. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. Int J Nurs Stud 2006;43:367-76.
10. Sanagoo A, Majnoni M, Jouybari L, Ghana S, Kalantari S. Studying the nursing students experiences of clinical errors and dealing with them. Nursing Research 2012;25:45-53.
11. Crigger NJ. Always having to say your's story: an ethical respose to making mistakes in professional practice. Nurs Ethics 2004;11:568-76.
12. Bauer J, Mulder RH. Conceptualisation of learning through errors at work: a literature review. Emerging perspectives of workplace learning / edited by Stephen Billett, Christian Harteis and Anneli Etelapelto. Rotterdam, Netherlands: Sense Publishers; 2008.
13. Stratton KM, Blegen MA, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. J Pediatr Nurs 2004;19:385-92.
14. Borhani F, Hosseini S, Abbaszadeh A. Commitment to care: a qualitative study of intensive care nurses' perspectives of end of life care in an Islamic context. Int Nurs Rev 2014;61:140-7.
15. Valiee S, Peyrovi H, Nasrabadi AN. Critical care nurses' perception of nursing error and its causes: a qualitative study. Contemp Nurse 2014;46:206-13.
16. Crigger NJ, Meek VL. Toward a theory of self-reconciliation following mistakes in nursing practice. J Nurs Scholarsh 2007;39:177-83.
17. Bauer J. Learning from errors at work. Studies on nurses' engagement in error-related learning activities. Regensburg: University at Regensburg; 2008.
18. Lewis EJ, Baernholdt M, Hamric AB. Nurses' Experience of Medical Errors An Integrative Literature Review. J Nurs Care Qual 2013;28:153-61.
19. Martinez W, Lo B. Medical students' experiences with medical errors: an analysis of medical student essays. Med Educ 2008;42:733-41.
20. Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN J 2010;91:132-45.
21. Collins SE. Knowing Nursing Error: Understanding Nursing Error Through Nurses' Error Experiences: University of South Florida; 2001.
22. Creswell JW. Qualitative inquiry & research design choosing among five approaches. Third ed. Los Angeles: SAGE; 2013.
23. Implementation of the 2011 Iranian Population and Housing Census In Autumn (24 October-13 November 2011). In: Presidency of the IRI MaPO, editor.: Statistical Center of Iran; 2011.
24. Nursing statistics [database on the Internet]. Ministry of Health and Medical Education, 2014 [cited 9/29/2015].
25. Burnard P. A method of analysis interview transcripts in qualitative research. Nurse Educ Today 1991;11:461-6.
26. Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Directions for Program Evaluation 1986;30:73-84.
27. Sutcliffe K. Defining and classifying medical error: lessons for learning. Qual Saf Health Care 2004;13:8-9.
28. Tamuz M, Thomas E, Franchois KE. Defining and classifying medical error: lessons for patient safety reporting systems. Qual Saf Health Care 2004;13:13-20.
29. Grober ED, Bohnen JM. Defining medical error. Can J Surg 2005;48:39-44.
30. Eslamian J, Taheri F, Bahrami M, Mojdeh S. Assessing the nursing error rate and related factors from the view of nursing staff. Iran J Nurs Midwifery Res 2010;15(Suppl 1):272-7.
31. Reason J. Human error: Cambridge University Press; 1990.
32. Golshahi H. Disscusion about "Enama al-a,mal be-niyat / Actions are but by intensions". Rasekhoon, 2011 [cited 2015 8/23/2015]. http://rasekhoon.net/article/show/161728.
33. Armitage G. Human error theory: relevance to nurse management. J Nurs Manag 2009;17:193-202.
34. Duthie EA. Application of human error theory in case analysis of wrong procedures. J Patient Saf 2010;6:108-14.
This web site is sponsored by Johnson & Johnson (HK) Ltd.