A Qualitative Study of Nurses’ Experience of Clinical Incident & Error Reporting Fiona Donaldson-Myles MSc RGN RM Supervisor of Midwives SSAFA Forces Help

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

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

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

The second victim - cost of clinical incidents to carers Doctors –Inability to share feelings –Feelings of guilt, remorse, helplessness –Lack of institutional mechanisms for support –Defensive changes

The second victim - cost of clinical incidents to carers Nurses –Similar emotions to doctor –Better informal support –Fearful of arbitrary disciplinary action –Mainly medication errors studied

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

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

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

Six key themes revealed Nurses’ expectations of management Motivation to report Effects on nurses’ feelings & emotions The need for support Learning from mistakes Views on patient involvement

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

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

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

Motivation to Report “I think it is important to find out why things happen” “It needed to be addressed to prevent the same thing happening again” “It’s happened on many occasions since, but it doesn’t seem to be taken seriously” “I knew it was a mistake. I was comfortable to report it, but I wanted it written down the way it really happened”

Effects on Nurses’ Feelings and Emotions Thirteen out of fifteen nurses described personal impact in very strong terms Used phrases such as: –“feeling sick” –“panic stricken” –“never feeling the same again”

Effects on Nurses’ Feelings and Emotions Strong negative feelings regardless of outcome Primary incidents - blamed themselves Secondary incidents - feelings of powerlessness Negative feelings related to: –type of incident –how much early support received –Whether still felt trusted by colleagues

Effects on Nurses’ Feelings and Emotions “I was absolutely gutted about the thought that I had hurt him. He was quite poorly and didn’t really know, but it still upsets me” “The patient was not adversely affected, but the nurse was absolutely devastated”

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

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

Suggestions for providing immediate support 24 hour availability of senior nurse / risk manager Telephone helpline Protected time for clinical supervision

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

Learning from Mistakes “we all make mistakes, we learn, get through them and move on” “I check, check, double check, triple check, I’m obsessive really now”

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

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

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

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

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

SUPPORT AND COMMUNICATION