NURSING ARTICLE CRITIQUE

Separate groups: NURS328 Students (tinaa)

Assignment 3: Critique of a Research Report (30%)

Select either a quantitative or qualitative research study that is of interest to you. Search terms such as \\\"research\\\" and \\\"nursing\\\" (or another discipline if not a nurse) will help you to narrow your search to an article written by researchers from within your specific discipline. Ensure that the study you select is a research study (avoid literature reviews or summaries of research articles). You should approve your choice of article with your tutor prior to proceeding with the critique. It is important to select an online article from a journal database from the Athabasca University Library so that your tutor has access to the article that you will critique. Please include the persistent link URL with your paper so that the tutor can access the article or send as a .pdf attachment. Submit using the links in the Assessment section on the course home page. Resend your approved article to your tutor when you submit your assignment.



Read the chapter in your course textbook about Critiquing Research Reports (Chapter 17) before proceeding with this assignment. You should pay particular attention to the information on General Guidelines for Conducting a Written Research Critique located in Box 17-3 and the Guides to an Overall Critique in Tables 17.1 and 17.2. To help you collect and organize your comments you could use the Five Dimensions of a Research Critique outlined in your textbook or alternately, the Reader's Companion Worksheet in your Davies and Logan (2003) textbook. Note: there are two worksheets, one for qualitative research studies and one for quantitative research studies.



Your paper will be restricted to a maximum length of 8-10 typed, double-spaced pages, excluding the title and reference pages, and should adhere to APA format. Assignment 3 is due after you have completed Unit 14.



Please include the following content in your critique:



1. Substantive and Theoretical Dimensions



relevance of research problem and significance

appropriateness of the conceptual framework

congruence between research question and methods used

literature review

2. Methodological Dimensions



research design

population and sample

collection of data

validity

3. Ethical Dimensions



confidentiality or anonymity

informed consent

vulnerability of study subjects/participants

research ethics board approval

4. Interpretive Dimensions



discussion section

conclusion section

implications section

5. Presentation and Stylistic Dimensions



any missing information

clear, grammatically correct writing

well organized

enough detail, no jargon

Also include a discussion of the strengths and limitations of the study. Use examples to illustrate points. Make sure your content is accurate and \\\"critique-like\\\" demonstrating evidence of critical thinking. Suggest realistic alternatives to improve/enhance the quality of the research.



Presentation of your paper will also be graded. Make sure you include a title page as per APA (12 pt font, running head etc.), introduction (no subheading) that includes a brief overview of what will be included in your paper, headings and subheadings, scholarly objective language, appropriate grammar and spelling, APA referencing in the body of your paper and on your reference page, and a conclusion (with this subheading).



Submitting Your Assignment

When you have completed this assignment, send it to your tutor for marking. Always retain a copy of your assignment for your files.



Click the \\\"Browse\\\" button to find your assignment and then \\\"Upload\\\" to move it into Moodle. If you make a mistake, you can delete the uploaded file by clicking the red X next to the file name.



Then, add a note if needed and click the \\\"Submit for Marking\\\" button to send it to your instructor.

Submitting your assignments



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I have chosen the qualitative article attitudes and barriers to incident reporting: a collaborative hospital study.

--------------------------------------------------------------------------Attitudes and barriers to incident reporting: a collaborative

hospital study

S M Evans, J G Berry, B J Smith, A Esterman, P Selim, J O'Shaughnessy, M DeWit

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article for

authors' affiliations

. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:

Ms S Evans, Department of

Epidemiology and

Preventive Medicine,

Monash University, Alfred

Hospital, Prahran,

Victoria, Australia;


edu.au

Accepted for publication

22 November 2005

. . . . . . . . . . . . . . . . . . . . . . .

Qual Saf Health Care 2006;15:39–43. doi: 10.1136/qshc.2004.012559

Objectives: To assess awareness and use of the current incident reporting system and to identify factors

inhibiting reporting of incidents in hospitals.

Design, setting and participants: Anonymous survey of 186 doctors and 587 nurses from diverse clinical

settings in six South Australian hospitals (response rate = 70.7% and 73.6%, respectively).

Main outcome measures: Knowledge and use of the current reporting system; barriers to incident

reporting.

Results: Most doctors and nurses (98.3%) were aware that their hospital had an incident reporting system.

Nurses were more likely than doctors to know how to access a report (88.3% v 43.0%; relative risk (RR)

2.05, 95% CI 1.61 to 2.63), to have ever completed a report (89.2% v 64.4%; RR 1.38, 95% CI 1.19 to

1.61), and to know what to do with the completed report (81.9% v 49.7%; RR 1.65, 95% CI 1.27 to 2.13).

Staff were more likely to report incidents which are habitually reported, often witnessed, and usually

associated with immediate outcomes such as patient falls and medication errors requiring corrective

treatment. Near misses and incidents which occur over time such as pressure ulcers and DVT due to

inadequate prophylaxis were least likely to be reported. The most frequently stated barrier to reporting for

doctors and nurses was lack of feedback (57.7% and 61.8% agreeing, respectively).

Conclusions: Both doctors and nurses believe they should report most incidents, but nurses do so more

frequently than doctors. To improve incident reporting, especially among doctors, clarification is needed of

which incidents should be reported, the process needs to be simplified, and feedback given to reporters.

It is a decade since Leape1 highlighted the need to gather

information and redesign hospital systems to minimise

errors in health care. Since then, many strategies and tools

have been developed to identify and reduce errors.2 More

than 90% of consumers believe that healthcare workers

should report errors,3 and peak quality and safety organisations

4–6 recommend incident reporting to better understand

errors and their contributing factors.

Incidents occurring infrequently, or those not easily coded

through limitations in the existing classification system,7 can

miss detection through medical record review. Incident

reporting captures more contextual information about

incidents8 and, when actively promoted within the clinical

setting, it can detect more preventable adverse events than

medical record review9 at a fraction of the cost.10 Near misses

are rarely documented in medical records,11 yet occur more

frequently than adverse events12 and provide valuable lessons

in recovery mechanisms without the detrimental consequences

of an adverse event.5 6 The subjective data provided

by incident reporting enable hypothesis building and

preventative strategies to be developed and tested.

Despite its strengths, many incidents are not reported

probably for the same reasons they are omitted from medical

records; they are simply not recognised, and those that are

detected after the event are often not dealt with effectively.13

Outside the discipline of anaesthesiology, incident reporting

is used predominantly by nurses.14 15 The subjective nature of

reports, the lack of consistency and validation of incident

data classification, and underreporting constrain incident

reporting from being used as a reliable epidemiological tool to

measure the frequency of events and whether interventions

are effective in improving patient safety.2 14 Studies which

have successfully improved incident reporting have often

done so through intense facilitation, either through ward

rounds9 or staff reminders,10 16 and have questionable

sustainability.

For incident reporting to be more reliable, both doctors and

nurses must provide a representative account of errors

occurring in hospitals. The objectives of this study were

therefore to investigate by profession: (1) awareness and use

of the current incident reporting system; (2) the types of

incidents staff were more likely to report and believe should

be reported; and (3) the barriers to reporting.

METHODS

Study design

A cross sectional survey of doctors and nurses was undertaken

between November 2001 and June 2003. Hospitals

sampled included three principal referral hospitals (each with

.300 acute inpatient beds), one major referral hospital

(,200 acute inpatient beds), and two major rural base

hospitals (each with ,120 acute inpatient beds) in South

Australia. Rostered doctors and nurses, and casual agency

nurses working in one or more of the four intensive care

units (two metropolitan and two rural), four emergency

departments (two metropolitan and two rural), five surgical

units (three metropolitan and two rural), and seven medical

units (five metropolitan and two rural) were invited to

participate.

Project officers either personally distributed questionnaires

to rostered staff and outlined the purpose of the study or,

where this was not possible, posted the questionnaire. All

doctors were contacted by telephone to encourage participation.

To facilitate frank comment without fear of disclosure,

the questionnaire was anonymous and self-administered.

Ethics committee approval was obtained from each hospital's

relevant body.

39

www(dot)qshc(dot)com

Questionnaire

The questionnaire was modified from one used in an

obstetrics unit by Vincent et al17 to make it generalisable to

a wider population. Following review by a panel of clinicians

to assess content validity, the questionnaire was piloted on 14

doctors and 10 nurses. Test-retest reliability was determined

using a kappa statistic, and only questions for which there

was at least moderate reproducibility (kappa >0.4) or a

consistent endorsement of one option were included.

Content

Staff were asked if they knew whether their hospital had an

incident reporting system. Those answering in the affirmative

were asked whether they knew which form to use, how to

access it, and what to do with a completed form.

To measure reporting practice, staff were asked to estimate

how often they reported 11 patient incidents representing a

diverse range of common iatrogenic injuries,18 and how often

they believed each should be reported using a 4-point Likert

scale (never, ,50% of occasions, >50% of occasions, always).

To determine barriers to reporting, staff were provided with

19 potential reasons for not reporting incidents and asked to

rate on a 5-point Likert scale (1=strongly agree, 5=strongly

disagree) the degree to which these acted as a deterrent.

Analysis of data

Comparisons were made for doctors and nurses by profession,

level of qualification, years post entry level qualification

spent in the acute health sector, and rural/metropolitan

location. For knowledge and use of reporting systems and

reporting practices, log binomial generalised linear models

adjusting for clustering by hospital were used. Likert scales

were dichotomised into agree or not agree for reporting

barriers and analysed using Fisher's exact test. The conventional

level of p(0.05 was taken to represent statistical

significance. Concordance between views on current reporting

behaviour and necessity of reporting was determined

using an intraclass correlation coefficient (ICC). Data were

analysed using Stata statistical software Version 7.0 (Stata

Corporation, College Station, TX, USA).

RESULTS

The overall response rate was 72.8%, and was similar for both

doctors and nurses (fig 1). As the questionnaire was

anonymous, we were unable to ascertain the demographic

features of non-respondents.

Knowledge and use of the incident reporting system

Nurses had a greater awareness of and used the incident

reporting system more than doctors (table 1). Senior doctors

(registrars and consultants) were significantly less likely than

junior doctors (interns and residents) to have ever completed

an incident form (58.4% v 85.4%; relative risk (RR) 0.58, 95%

CI 0.46 to 0.73). Doctors with .5 years experience post entry

level were less likely to have ever completed an incident

report than those with less experience (58.1% v 79.2%; RR

0.73, 95% CI 0.59 to 0.92). There were no significant

differences between rural and metropolitan doctors in

knowledge or use of the incident reporting system.

Senior nurses (nurse managers and clinical nurses) were

more likely than junior nurses to know how to access a form

(100.0% v 88.0%; RR 1.14, 95% CI 1.09 to 1.18), to know what

to do with it (100.0% v 80.9%; RR 1.24, 95% CI 1.13 to 1.35),

and to have ever filled one out (100.0% v 89.0%; RR 1.12, 95%

CI 1.10 to 1.15). Permanently employed nurses were

significantly more likely than contract nurses to know how

to locate/access an incident form (89.1% v 57.1%; RR 1.56,

95% CI 1.25 to 1.95), to know what to do with it once

completed (82.7% v 50.0%; RR 1.65, 95% CI 1.12 to 2.45), and

to have ever filled one out (90.0% v 57.1%; RR 1.57, 95% CI

1.21 to 2.06). Nurses with .5 years post entry level

experience were more likely to know how to locate a form

(91.5% v 83.8%; RR 1.09, 95% CI 1.04 to 1.14), to know what

to do with it once completed (85.5% v 76.7%; RR 1.12, 95% CI

1.06 to 1.17), and to have ever filled out an incident form

(94.0% v 82.5%; RR 1.14, 95% CI 1.06 to 1.23) than those with

less experience. Rural and metropolitan nurses did not differ

in their knowledge or use of the incident reporting system.

Staff reporting practices

Figure 2 shows, for 11 patient incidents, the percentages of

doctors and nurses who perceive they report the incident

always, on 50% or more of occasions, less than 50% of

occasions, or never, and their views on the necessity of

reporting these incidents.

Doctors reported that they completed incident reports most

often for patient falls and least often for pressure sores.

Doctors' views ranged from 75.8% who believed that patient

falls should always be reported to only 42.1% for drug error

‘‘near misses''. Agreement between what doctors did

compared with what they thought they should report was

low, ranging from an ICC of 0.44 for incidents where a

patient received the wrong treatment or procedure to an ICC

of 0.17 for pressure sores. Senior doctors were less likely than

junior doctors to always report patient falls (38.1% v 74.4%;

RR 0.51, 95% CI 0.30 to 0.87) and patients receiving the

wrong treatment or procedure (39.5% v 54.1%; RR 0.73, 95%

CI 0.63 to 0.84). There were no significant differences in

reporting practices among doctors according to rural/metropolitan

location.

Nurses reported that they completed incident reports most

often for patient falls and least often for pressure sores.

Nurses regarded falls as the most important incidents to

always report and drug error ‘‘near misses'' as the least

important (97.0% and 41.9%, respectively). The correlation

between what nurses did compared with what they thought

they should report ranged from an ICC of 0.78 for patient

falls to an ICC of 0.27 for deep vein thrombosis (DVT)

through inadequate prophylaxis. Nurses with ,5 years

experience were more likely to always report DVT (23.0% v

14.4%; RR 1.60, 95% CI 1.46 to 1.74). There were no

significant differences in reporting practices among nurses

according to rural/metropolitan location.

Staff views on barriers to reporting

Table 2 shows that major barriers to reporting for doctors

were lack of feedback (57.7%), the incident form taking too

long to complete (54.2%), and a belief that the incident was

too trivial (51.2%). There were no significant differences for

Metropolitan

482 (76.0%) nurses

41 clinical nurse

managers

353 clinical nurses

74 enrolled nurses

14 agency nurses

Rural

105 (63.6%) nurses

12 clinical nurse

managers

68 clinical nurses

25 enrolled nurses

Metropolitan

165 (71.1%) doctors

75 consultants

50 registrars

21 residents

19 interns

Rural

21 (67.7%) doctors

19 consultants

2 residents

186 doctors completed the questionnaire

(response rate = 70.7%)

587 nurses completed the questionnaire

(response rate = 73.5%)

263 doctors invited to participate

(232 metropolitan: 31 rural)

799 nurses invited to participate

(634 metropolitan: 165 rural)

Figure 1 Sampling frame.

40 Evans, Berry, Smith, et al

www(dot)qshc(dot)com

any barriers according to level of qualification, experience,

and rural/metropolitan location.

Major barriers to reporting for nurses were lack of feedback

(61.8%), a belief that there was no point in reporting near

misses (49.0%), and forgetting to make a report when the

ward is busy (48.1%, table 2). Nurses with .5 years

experience were more likely to believe there was no point

reporting near misses (52.5% v 44.0%; RR 1.19, 95% CI 1.06 to

1.34) than nurses with less experience. There were no

significant differences for any barriers according to level of

qualification and rural/metropolitan location.

DISCUSSION

With adverse event rates estimated to be in the range of

2.9%19 to 16.6%18 of acute care hospital admissions, most

doctors and nurses working in hospitals will be familiar with

a range of adverse events. Despite most staff knowing that an

incident reporting system existed, almost a quarter of staff

did not know how to access an incident form or what to do

with it once completed, and over 40% of consultants and

registrars had never completed a report. Nurses were more

aware of the reporting system than doctors, although casually

employed nurses were significantly less likely than permanent

hospital nurses to know how to access a report, and

were a third less likely to have ever completed a report.

At the time of the survey the AIMS reporting system had

been used in each hospital for at least 5 years. The reporting

system, which offers statutory immunity to reporters, collects

data which are entered retrospectively into a stand alone

database within each hospital and is managed by only

authorised hospital personnel.

In most cases reporting practices were consistent with staff

views on the necessity of reporting incidents. Incidents which

are immediate, often witnessed, and habitually reported

(such as patient falls and medication errors requiring

corrective treatment) were better reported than incidents

which occurred gradually and were often not attributable to a

single event, or were commonly regarded as complications of

prolonged hospitalisation (such as pressure ulcers, hospital

acquired infections, and postoperative DVT due to inadequate

prophylaxis). Only 42.0% of the staff surveyed believed that

medication near misses should always be reported, indicating

that literature emphasising the importance of reporting near

misses12 is not translating to changes in attitude or clinical

Table 1 Awareness and use of the incident reporting system

Doctors (%) Nurses (%) p value* Relative risk 95% CI

Yes N Yes N

Awareness of hospital incident reporting

system

93.6% 174 99.8% 586 0.195 1.01 0.99 to 1.03

Ever completed an incident report 64.6% 115 89.2% 520 ,0.001 1.38 1.19 to 1.61

Know how to locate/access an incident

form

43.0% 77 88.3% 515 ,0.001 2.05 1.61 to 2.63

Know what to do with a completed

incident form

49.7% 89 81.9% 476 ,0.001 1.65 1.27 to 2.13

*Log binomial generalised linear models adjusting for clustering by hospital.

Should

report

Do

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report

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report

Nurses Doctors

100% 80% 60% 40% 20% 0% 20% 40% 60% 80% 100%

Patient injury

due to a fall

Drug error requiring

corrective treatment

Patient received wrong

treatment or procedure

Equipment fault resulting

in patient harm

Drug error not requiring

corrective treatment

Patient did not receive

necessary treatment

Breach in

confidentiality

Hospital acquired

infection

Post-operative DVT due to

inadequate prophylaxis

Drug error made,

not given to patient

Pressure sore

0%

Never

Should/Do report

<50% of occasions >50% of occasions Always

Figure 2 Staff self-perception of reporting of incidents.

Attitudes and barriers to incident reporting 41

www(dot)qshc(dot)com

behaviour. The finding that 80.9% of doctors thought they

should always report when a patient gets the wrong

treatment—yet only 57.3% believed they should always

report when a patient does not receive necessary treatment—

is important, given that acts of omission have been

implicated in twice as many adverse events as acts of

comission.18

Almost two thirds of respondents believed lack of feedback

was the greatest deterrent to reporting. Organisational factors

relating to structures and processes for reporting,20 such as

inadequate feedback, long forms and insufficient time to

report, were identified as the major barriers.

Many of our results support those obtained internationally,

including the finding that only a small percentage of doctors

formally report incidents,20 21 and unfamiliarity with the

reporting process results in a poorer reporting culture.22

Whereas other studies identified cultural issues such as fear

of disciplinary action,17 23 legal ramifications, and workplace

discrimination24 as barriers to reporting, our study, like that

of Uribe et al,20 did not identify these issues to be major

reporting obstacles. Poor reporting practices by doctors and

the fact that they did not identify cultural barriers so much as

organisational barriers to reporting probably reflects the

prevailing deeply entrenched belief in medicine that only bad

doctors make mistakes.

There were a number of limitations to this study. This

survey formed baseline data for a matched controlled study

in which purposive sampling was undertaken to reduce

contamination between intervention and control units and to

ensure a variety of areas were represented. Despite nonprobability

sampling being less ideal than random selection,25

our findings were similar to those determined by Vincent et

al17 in a distant healthcare setting, which suggests that the

results are representative. Non-responder bias cannot be

excluded as we were unable to collect information on nonresponders

due to the anonymous design of the survey. There

may be potentially important variables and barriers not

included in the questionnaire because we needed to limit

questionnaire burden. Despite being anonymous, respondents

may have provided more socially acceptable responses

for fear of identification, which might explain why cultural

barriers were not reported as significant deterrents to

reporting. We did not investigate why staff reported certain

incidents more frequently than others. Perhaps staff did not

view them as incidents, or believed tools exist to detect/

monitor them or that, in the case of senior medical staff, they

delegate reporting to junior staff.

Further research is required to explore why senior medical

staff do not support reporting and why iatrogenic injuries

with potentially disastrous consequences such as DVT and

hospital acquired infections are poorly reported. Our data

suggest that the move towards more casual nurses26 could

result in a further decline in the number and types of reports

submitted, which requires action if incident reporting is to be

valued as an important component of each hospital's risk

management framework.

Balancing the requirement to receive adequate information

on an incident report to enable meaningful analysis and

follow up with the clinician's desire to make it less

time consuming is an ongoing concern. Faster reporting

systems, combined with adequate resources and infrastructure

to enable responsive action and feedback, need to be

adopted. The use of personal digital assistants,27 call centres

to collect information,28 and techniques such as root

cause analysis29 to investigate incidents offers possibilities

to enable safer health care to be delivered. Perhaps the most

challenging task is ensuring that practice improvements

resulting from reports are disseminated to clinicians, because

only then will incident reporting be seen as worthwhile and

relevant.

ACKNOWLEDGEMENTS

The authors thank Rhonda Bills, Clinical Epidemiology Unit for

administrative support; Dr Deborah Turnball, Department of General

Practice, University of Adelaide and Lora DalGrande, Centre for

Population Studies in Epidemiology, SA Department of Human

Services for valuable advice on questionnaire construct and format;

and the staff of the participating hospitals for completing the

questionnaire.

Authors' affiliations

. . . . . . . . . . . . . . . . . . . . .

S M Evans, Department of Medicine, University of Adelaide, South

Australia, 5005

J G Berry, Research Centre for Injury Studies, Flinders University, South

Australia, 5001

B J Smith, P Selim, J O'Shaughnessy, M DeWit, Clinical Epidemiology

and Health Outcomes Unit, The Queen Elizabeth Hospital, South

Australia, 5011

A Esterman, School of Nursing and Midwifery, University of South

Australia, South Australia, 5000

Table 2 Self-perceived barriers to reporting (percentage who agree with the statement)

Incident

Doctors (%) Nurses (%)

p value*

Agree N Agree N (doctors v nurses)

I never get any feedback on what action is taken 57.7 170 61.8 570 0.371

The incident form takes too long to fill out and I just don't have the time 54.2 168 44.1 571 0.022

The incident was too trivial 51.2 170 41.2 565 0.027

When the ward is busy I forget to make a report 47.3 167 48.1 574 0.930

I don't know whose responsibility it is to make a report 37.9 169 10.8 573 ,0.001

When it is a near miss, I don't see any point in reporting it 36.0 172 49.0 569 0.003

The AIMS+ form is too complicated and requires too much detail 31.9 163 35.0 565 0.512

Junior staff are often blamed unfairly for adverse incidents 31.0 171 25.6 571 0.169

Adverse incident reporting is unlikely to lead to system changes 28.6 171 29.9 568 0.775

I wonder about who else is privy to the information that I disclose 27.1 170 33.8 568 0.112

If I discuss the case with the person involved nothing else needs to be done 24.9 169 11.5 566 ,0.001

I don't feel confident the form is kept anonymous 22.6 168 30.0 574 0.065

I am worried about litigation 20.7 169 20.6 574 1.000

It's not my responsibility to report somebody else's mistakes 17.2 169 16.4 567 0.814

My co-workers may be unsupportive 13.8 167 20.8 573 0.045

I don't want to get into trouble 10.6 169 18.6 570 0.014

Even if I don't give my details, I'm sure that they'll track me down 8.4 167 17.0 564 0.006

I am worried about disciplinary action 8.3 168 18.1 570 0.002

I don't want the case discussed in meetings 7.2 167 15.5 574 0.005

*Fisher's exact test.

42 Evans, Berry, Smith, et al

www(dot)qshc(dot)com

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6 Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer

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7 Runciman WB, Moller J. Iatrogenic injury in Australia, A report prepared by

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9 Beckmann U, Bohringer C, Carless R, et al. Evaluation of two methods for

quality improvement in intensive care: facilitated incident monitoring and

retrospective medical chart review. Crit Care Med 2003;31:1006–11.

10 O'Neil AC, Petersen LA, Cook EF, et al. Physician reporting compared with

medical record review to identify adverse medical events. Ann Intern Med

1993;119:370–6.

11 Neale G, Woloshynowych M. Retrospective case record review: a blunt

instrument that needs sharpening. Qual Saf Health Care 2003;12:2–3.

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www----

the text book is canadian essentials of nursing research third edition by carmen g loiselle, joanne profetto-mcgrath, and polit & beck-

please email me the paper-do not submit it!!



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