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
report
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report
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report
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report
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report
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report
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report
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report
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report
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report
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report
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report
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report
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report
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report
Should
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report
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report
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report
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report
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report
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report
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report
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report
Should
report
Do
report
Should
report
Do
report
Should
report
Do
report
Should
report
Do
report
Should
report
Do
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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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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