Geriatric Nursing 35 (2014) 441e447

Contents lists available at ScienceDirect

Geriatric Nursing journal homepage: www.gnjournal.com

Feature Article

Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes Ida Winsvold Prang, RN, BSc a, Lars-Petter Jelsness-Jørgensen, RN, MSc, PhD b, * a b

Østfold University College, Fredrikstad, Norway Østfold University College/Østfold Hospital Trust, Norway

a r t i c l e i n f o

a b s t r a c t

Article history: Received 19 April 2014 Received in revised form 16 July 2014 Accepted 19 July 2014 Available online 11 October 2014

Adverse events, errors and acts of inadequate care have been shown to occur quite frequently in hospitals, and there is growing evidence that this poor care may also occur in nursing homes. Based on hospital studies, we know that incidents are only reported to a limited extent and that there may be a high number of unrecorded cases. Moreover, little is known about the barriers to incident reporting in nursing homes compared to hospitals. Consequently, the aim of this study was to explore the barriers to incident reporting in nursing homes. Thematic analysis of 13 semi-structured interviews with nurses revealed that unclear outcomes, lack of support and culture, fear of vilification and conflicts, unclear routines, technological knowledge and confidence, time and degree of severity were the main drivers of not reporting incidents. These findings may be important in planning quality and safety improvement interventions in nursing homes. Ó 2014 Elsevier Inc. All rights reserved.

Keywords: Incident reporting Nursing homes Qualitative study Nursing Quality Safety

Introduction Patient safety is a term that has been well-established in recent years. It has been defined as “the prevention of harm to patients”1 and as “the prevention of errors and adverse effects to patients associated with health care.”2 There is little doubt that when patients are treated and cared for within the health care system, they are exposed to an environment consisting of complex interactions. This complexity may lead to an increased risk of unanticipated incidents and adverse events.3 In their groundbreaking report in the late 1990s, “To Err Is Human,”4 the Institute of Medicine (IOM) concluded that thousands of people were injured because of health care treatment each year. In 1999, it was estimated that the total cost of preventable adverse events in the United States (U.S.) was between $17 billion and $29 billion annually.5 Consequently, awareness of quality of care and treatment was increased, not only inside but also outside the health care system.3,4 Emphasis was placed on a care delivery system that “prevents errors, learns from

Conflict of interest: None to declare. The authors declare that the current paper has been submitted solely to Geriatric Nursing. * Corresponding author. K.G. Meldahlsvei 9, 1671 Kråkerøy, Norway. Tel.: þ47 473 35 947. E-mail address: [email protected] (L.-P. Jelsness-Jørgensen). 0197-4572/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.07.003

the errors that do occur, and is built on a culture of safety that involves health care professionals, organizations, and patients.”3 The U.S. Department of Health and Human Services, Office of Inspector General (OIG), defined the term “adverse event” as “harm to a patient that comes as a result of medical care.”6 In a review of eight studies including 74,485 patient records, de Vries et al7 found that nearly one in 10 patients experienced adverse events during hospital admission. The majority of these events were related either to surgery (39.6%) or medications (15.1%). Although the OIG definition of adverse events includes the failure to provide needed care, these events do not always involve “errors, negligence and poor quality of care.”6 However, studies have also shown that nurses frequently report missed care (defined as the omission of any aspect of required patient care)8,9 and that the amount of care that isn’t performed ranges from 26 to 76%. Missed care has been associated with nurse-patient ratios10 and nurses’ perceptions of patient safety.11 In the late 1990s, the IOM found that the lack of awareness of the high number of daily errors “exists because the vast majority of errors are not reported.”12 In recent years, several randomized controlled trials of interventions aimed at improving patient safety across various health care settings have been published.13e17 Additionally, standardized patient safety taxonomies have been developed for hospitals, several U.S. states have laws for reporting adverse events and the U.S. Congress passed the Patient Safety and

442

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447

Quality Improvement Act that includes incident reporting as a significant contributor to improving quality. The latter is known to be essential to improving patient safety.18e23 However, despite research efforts and the implementation of incident reporting systems, underreporting seems to persist as a significant problem.24 The problem of underreporting incidents may stem from a complex mix of factors. Lawton and Parker,25 in a study of 315 doctors, nurses and midwives from three English National Health Service (NHS) Trusts, found that doctors were the most reluctant to report incidents and that the risk of not reporting them increased if the incident did not result in an adverse event or did not constitute a direct violation of protocols. In a study during the mid-1990s that investigated nurses’ perceptions of medication error reporting in hospitals, Wakefield et al26 found, that fear, disagreement over whether an error occurred, administrative responses, and effort required to report were the main drivers of incidents not being reported. Indeed, these results have been supported by several studies showing that nurses avoid error reporting because of prior experiences and personal consequences, such as anxiety, depression and social exclusion.27e32 Lafton et al33 also argue that a lack of knowledge concerning what should be reported constitutes an important driver of underreporting, whereas Ammenwerth et al34 found that a lack of electronic confidence prevented nurses from reporting. Younger age and a higher educational level have also been associated with increased likelihood of reporting incidents.35 Although substantial attention has been paid to patient safety in hospital settings in recent years, far less is known about these issues in nursing home settings.6 Most existing studies have primarily focused on medication-related adverse events.36 The recently published OIG report6 found that 22% of Medicare beneficiaries experienced adverse events during their stay in a skilled nursing facility. This finding included not only events related to medications but also events related to resident care (e.g., the development of pressure ulcers, falls, skin tears) or related to infections. Fifty-nine percent of these cases were likely preventable. In a study in Norway, Malmedal et al37 investigated the prevalence of reporting inadequate care among nursing staff in 16 nursing homes. A total of 91% reported that they had observed at least one act of inadequate care, and 87% reported that they had committed at least one act of inadequate care.37 Negligent and emotional acts were frequently reported.37 Although nurses have a profound role in ensuring patient safety and quality of care, several studies have shown that they may be underreporting incidents.12,30,32 There is currently a paucity of studies that have explored potential barriers of incident reporting in nursing home settings. Consequently, the aim of this study was to explore how nurses who work in long-term wards in nursing homes experience and perceive barriers to incident reporting.

patients admitted to long-term care settings in nursing homes may not always be able (e.g., because of cognitive impairment) to lodge a complaint themselves. Consequently, incidents that are viewed by nurses as having the potential to result in a complaint, damage and harm may be of equal importance. Setting This study was conducted in seven nursing homes in three different municipalities in the county of Østfold in the south eastern part of Norway. The county covers 3889 km2 and consists of 18 municipalities with approximately 300,000 inhabitants. All Norwegian municipalities ensure that there is a 24-hour based service staffed by medical professionals. Nursing homes offer both short-term and long-term residency accommodation. Shortterm accommodation can be arranged if, for example, a recipient needs training (rehabilitation) or extensive professional medical assistance for a limited period. An “own contribution” charge is made for outpatient, overnight short-term and long-term admittances. The cost is stipulated annually in the national budget. The long-term wards are classified into regular units (RUs) and special care units (SCUs) for persons with dementia. Patients who are admitted for long-term stays pay a particular proportion of their income (pension, earnings on interest and so forth). The institution cannot demand payment from capital assets (fixed property, bank deposits, shares, etc.). Participants The 17 nursing homes (the total number of nursing homes in the three municipalities) were identified through official registries and invited to participate in the study. The sites were selected because of their convenient accessibility and proximity to the Østfold University College and the two researchers (IWP/LPJJ). The respondents were recruited in three phases: Phase 1) All nursing homes identified were contacted and given oral and written information about the study; Phase 2) Nurse administrators at the participating sites, informed members of their staff about the proposed study and identified nurses who were willing to participate in an interview; Phase 3) The individual participants identified in phase 2 were contacted by phone. All participants were then given updated oral and written information, and individual interview appointments were scheduled. A total of 24 nurses were approached, and 13 gave their consent to participate. The respondents represented seven nursing homes in all three municipalities. Individual semi-structured interviews were conducted from April 2013 to October 2013. The characteristics of respondents and non-respondents are listed in Table 1.

Methods

Data collection

Because the aim of this study was to obtain information that is based on the values, opinions and social contexts of the population in question, a qualitative approach was the most appropriate method. In reviewing the quality and safety in health care literature, several different terms are used e some narrower than others (e.g., adverse event or near miss).38 We chose to use a broad definition to explore the respondents’ views of incident reporting, although this approach resulted in a wide range of circumstances (e.g., overt errors, errors of omission and poor quality of care). We consequently used the term “incident” as the basis of our study. An incident has previously been described in the literature as an “event or circumstance which could have or did harm to anyone or which resulted in a complaint, loss or damage.”38 However, in our view,

Socio-demographic characteristics (age and time since graduation from nursing school) were collected through self-reports. Semi-structured interviews were conducted face-to-face at the nurses’ workplace during working hours (IWP). All interviews were performed in a closed room, avoiding unnecessary disturbance. To explore the nurses’ perspectives on barriers to incident reporting, an interview guide was developed to direct the individual sessions. The guide included the following topics: 1) previous experiences with incident reporting and their relation to barrier development (questions such as “Can you describe previous experiences with incident reporting?”, “How were these handled?”, “Do you think prior experiences may limit incident reporting?”); 2) Systems and routines (questions such as “Can you describe the routines you have at work when it comes to reporting incidents?”, “Can you describe

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447 Table 1 Characteristics of respondents and non-respondents.

Female (%) Age (years) Age (range) Time since graduationa (years) Time since graduationa (range)

Respondents n ¼ 13

Non-respondents n ¼ 11

84.6 38.5 (10.2) 26e56 10.3 (10.5)

90.9 40.3 (9.8) 25e60

P-value

0.91

1e31

Figures are in means and standard deviations (SD), if not otherwise noted. a Time since graduation from nursing school.

how you perceive the practical procedure of reporting incidents?” [e.g., by paper or computerized programs]?”); 3) Perception of severity (questions such as “In your mind, are there differences in what incidents need to be reported or not?” and “If so, can you describe some of these incidents?”). Each interview lasted between 45 and 60 min (Table 2). Data analysis According to Sandelowski and Barroso,39 research findings in qualitative studies can be placed on a continuum indicating the degree of data transformation, from description to interpretation, during the process of analysis. We used thematic analysis, as described by Braun and Clarke,40 to identify, analyze and report patterns (themes) within our data. This process included the following steps: 1) reading through all the material to obtain an overview, 2) identifying aspects relevant to the aim of the study and coding relevant patterns or themes, 3) sorting the codes into overarching themes (These themes were reviewed and validated in relation to the entire data set) and 4) defining and deciding on final themes. All interviews were audio-recorded (IWP) and transcribed verbatim (IWP/LPJJ). Saturation, indicated by data replication, redundancy and the fact that no new themes emerged, was reached at the end of the 11th interview. However, we chose to undertake two additional interviews to ensure that saturation had been reached. All 13 interviews included all the components of the interview guide. Data collection, transcription, and analysis of interviews were performed in parallel. The latter was performed to

443

allow themes from earlier interviews inform later interviews. Both authors (IWP/LPJJ) read the interview transcripts to familiarize themselves with the data and to identify recurrent themes. Initial coding was used to generate analytical summaries, which were grouped together into the most noteworthy and frequently occurring categories. Blind coding was used to develop reliable and inclusive themes. If there was a lack of consensus, the two authors (IWP/LPJJ) discussed and agreed on the coding framework. Validation of initial coding was performed on one of the first transcripts. The analysis was conducted in ongoing discussions between the two researchers. All respondents were invited to read through the transcripts to ensure accuracy. Moreover, interim research findings were cross-checked with respondents to validate our findings. Ethical considerations All participants were given oral and written information about the project. Necessary approval was sought from the Regional Committee of Medical and Health Research Ethics (REK), as well as the Norwegian Data Protection Agency (NSD). However, they both found the project to be classified as health service research and consequently concluded that no formal approval was necessary according to Norwegian laws and regulations. Findings The interviews revealed that nurses experienced several barriers that restricted them from reporting incidents if they occurred in clinical practice. We identified seven subthemes that related to two main themes. The two main themes were 1) organizational barriers and 2) individual barriers. The subthemes related to organizational barriers were a) lack of support and culture, b) unclear outcomes and c) unclear routines. The subthemes related to individual barriers were a) fear of vilification and conflicts, b) lack of technological confidence and knowledge, c) time and d) degree of severity (Table 2). According to Sandelowski,41 qualitative data may be represented using one of several templates or logics to give structure, two of which are time and prevalence. Time refers to presenting a process as it happened in real time (when themes first occurred during the interviews), whereas prevalence refers to presenting the most prevalent or frequently occurring themes first.41 Because we

Table 2 Participants’ perceptions of barriers of incident reporting in nursing homes. Themes

Subthemes

Representative quotes

Organizational barriers

The leadership support and organizational culture

I asked my head nurse for guidance in reporting a mishap (.). Well, she asked me whether reporting was necessary or not? I felt it was too much for her to cope with and that she didn’t want us to report everything We do not know what actually happens in those cases we report (.). No feedback. Nothing more happened. It was not discussed. Just nothing. We do report (.). Not systematically, but when we judge it to be of importance. It is not clear to me what I am expected to report or not. I believe it is important to report, but I sometimes wonder e is it worth it? (.). I mean it is difficult when it is a colleague. I mean, we are not only colleagues, we are friends. That makes it difficult. We have a computerized reporting system (.). I can’t seem to get my bearing (.). Previously we reported on paper forms. I think it was easier in those days. I find the digital platforms scary. I mean; forgetting one tablet is not that serious. Minor problems, like missed care (e.g., patients not getting a shower, not getting up from bed in the morning), is not reported. When I believe something should be reported I have to wait until the end of my shift because of a heavy workload (.). Sometimes I just forget. I keep reminding myself to report an incident that might have happened during my shift. However, there is always so much to do (.). Sometimes I remember it when I get home.

Outcomes from incident reporting is seldom clear Routines is not clearly established Individual barriers

Fear of vilification, social reprimand and work conflicts Technological confidence and knowledge

Judgment of severity

Time pressure

444

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447

used a semi-structured approach (pre-determined open questions allowing us to explore particular themes), time was chosen as the preferable mode of presenting our findings.

nurses also emphasized that a distant leader contributed to both frustration and the development of poor attitudes among the staff: “I mean, if nobody intervenes and everyone keeps on doing thing in whatever way it suits them, we can still continue to make the same mistakes over and over again (.) Probably even with higher confidence.”

Previous experiences and their relation to barrier development Our first interview theme addressed prior experiences, how they were handled and whether these experiences had contributed to developing barriers to incident reporting. All of the nurses interviewed had prior experience with incident reporting. Although the nurses emphasized that they understood the importance of reporting incidents, several experiences, including unclear outcomes, lack of support and culture, and fear of vilification and conflicts, led them to be more reserved about reporting them. Unclear outcomes According to the respondents, the lack of knowledge about actions for previously reported cases was frustrating. Quality improvement was regarded as an important driver of incident reporting. However, the nurses had, in many cases, found that they did not receive information about the consequences of their report (e.g., improvement in routines or surveillance). This lack of feedback was viewed as an obstacle to quality improvement on the wards, particularly because nurses did not know how they should handle similar cases that might occur in the future. “We do not know if something really happens with the things we report (.). It is quite frustrating. We cannot move on” or “It is difficult to know how to improve quality due to lack of feedback” Lack of support and culture Nurses also identified the role of the administrator (e.g., head nurse) as being very important in the process of incident reporting. Prior negative responses to incident reporting had deleterious effects on whether an incident was reported. Some nurses had observed administrators discussing the necessity of incident reporting. Moreover, nurses had witnessed situations in which administrators encouraged their employees to carefully select what they reported. A nurse stated, “I have always tried to keep focused on reporting the things I deem necessary to improve quality and safety. However, I sometimes wonder if it’s necessary, since some of the feedback I have received has been questioning the relevance of reporting in those cases” Consequently, the respondents believed that the clinical judgment of each employee was less important. Furthermore, the anonymity of employees who reported was not always well protected, leading to increased worry about being identified in public. A nurse described a situation in which she was approached by her head nurse at the nurses’ station in one of the nursing homes: “Some time ago, my head nurse questioned me in public about the necessity of reporting an incident (.). I have been reluctant to report ever since.” Nurses reported that the milieu in which they were working was quite diverse, particularly with respect to incident reporting. Whereas some nurses had been encouraged, other nurses had experienced a limited focus on incident reporting in daily clinical practice. A general negative attitude toward quality and safety reporting systems was also noted at some of the interview sites. The

Fear of vilification and conflicts Most respondents reported that they had experienced conflicts related to reporting incidents. These conflicts were particularly difficult if the incident involved a colleague. Furthermore, prior experiences of exclusion from social settings, verbal bullying and conflicts restrained nurses from reporting incidents that they would have reported in other circumstances. Reporting of matters concerning medical errors was regarded as less sensitive, whereas incidents that involved a failure in nursing or patient care were much more sensitive. “Except for those social events that were arranged by the institution or ward, I was literally excluded from all other happenings (.). I believe, this was due to my reporting a senior colleague” or “I don’t know if it is worth the price (.). I mean, if I report, it will put me in a very difficult situation.” Working in nursing home wards was not only associated with professional work. Most nurses had social relationships with colleagues, and many coworkers were friends. These social ties potentially influenced incident reporting: “I have not yet had to report incidents involving some of my friends. I imagine however, that this would be difficult and that I really would have to think twice” Systems and routines All the nursing homes had systems in place for reporting incidents. The systems had also been changed from manual (paper based) to computer based. Nurses, however, identified areas that could increase the risk of not reporting incidents. These risks were both related to the practical procedure of reporting incidents, either the lack of knowledge and confidence in the system or the lack of time to complete the incident report. Unclear routines Although systems were established at each of the nursing homes, the use of these structures varied. It was concerning that a vast amount of incidents were addressed face-to-face in the wards. Although nurses acknowledged the importance of direct communication, they were afraid that variations in routines might lead to a less systematic approach and consequently diminish quality and safety. “I do not know to what extent we are able to identify a majority of incidents on our ward (.). Based on my experiences, a lot of these cases are handled in the offices without ever being registered in our systems.” Comfort with technology and electronic reporting Confidence in and knowledge of the use of technology was also frequently addressed as a barrier to incident reporting, particularly among older respondents (i.e., how to use the electronic incident reporting system, how to register and how to store). Some found it easier to report incidents if they could record the incident on paper, but nurses stated they reported less incidents after “new”

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447

technology was implemented. A few nurses had failed when trying to register an incident on the computer earlier and regarded their poor computer knowledge and frequency of use as a clear limitation. “Registering an incident only to find out that you have not been able to store it is quite frustrating. I do not look forward with pleasure to the next time I have to try” Time In addition to a lack of technological knowledge and confidence, some nurses found that the reporting systems were quite rigorous and they needed extensive time to complete it. Nurses also conveyed that limited time was itself a significant barrier to incident reporting. Time was regarded as the element that most often resulted in the need to prioritize what was reported, and no specific time was given on the work schedule to engage in these issues. Nurses had to “fit it in” in the middle of additional obligations, and nurses emphasized that they were “always short of staff.” Consequently, some elements were overlooked, and others were forgotten. “How can we be expected to report incidents when we do not have the time to do it!” or “It is quite simple. Just reduce some of my workload or give us more employees and I will have time to report more” Perception of severity All the interviewees had experienced situations in which they had reflected on the necessity of reporting incidents. Mostly, these reflections were associated with the severity of the incidents or in the potential harm toward patients. Degree of severity There were diverse opinions among the nurses as to what sort of incidents needed to be reported and their seriousness. These perspectives were based on common understanding on the wards. Some nurses viewed incidents such as forgetting the administration of a tablet to be categorized as an error but not important enough to report. Missed care (e.g., inability to help patients with a shower) were not viewed as important to report as other types of incidents, such as giving antibiotics to the wrong patient or falls. Consequently, nurses felt that they had to focus on “more important” aspects of quality improvement based on the degree of severity, such as the prevention of falls and infections. Whether the incident had the potential to cause harm to patients was also an important factor in assessing the degree of severity: “Of course I have to consider if the incident may jeopardize the care of the patient or not” or “I think it is unlikely that we will be able to report every potential incident (.). We have to prioritize”

Discussion The study revealed important perspectives on the factors that may restrain nurses from reporting incidents. Although there is an extensive literature on the likelihood of reporting, most of the current evidence is based on hospital studies.25,26,34 The unique feature of this study is that it takes place in a nursing home setting.

445

All of the interviewees had experienced acts they deemed necessary to report. These acts ranged from clear adverse events as defined by the OIG6 (e.g., wrong medication to wrong patients or falls) to events related to suboptimal care. Our main findings indicate that there are many reasons why incidents are not reported by nurses in nursing homes, and the reasons relate to the organization and the individual. This may strengthen the importance of targeting several levels within the context of nursing homes to improve incident reporting (e.g., related to culture, improving routines and feedback). A fundamental aspect in nursing care throughout the decades has been to “do the sick no harm.”42 By being on the front line of patient care, nurses play a profound role, based on their experience, knowledge and skills, in ensuring safe and high-quality care.3 Reducing incidents is essential to improving the quality of care given to patients.43 The recent OIG report emphasized that “staff identification of resident harm is critical to the success of resident safety efforts, giving them the opportunity to correct problems and reduce harm as well as to report problems contributing to events.”6 Consequently, knowing the circumstances that affect nurses’ decisions to report incidents is highly important. An initial theme that emerged in our analysis was related to unknown outcomes or lack of feedback about prior incident reports. Nurses revealed that this uncertainty frustrated them and prevented them from knowing the effects of incident reporting. They were particularly frustrated that the lack of feedback did not enable them to know how to address comparable incidents in the future. The importance of receiving feedback is consistent with findings from other studies, including those by Evans et al,44 Mahajan,24 Handler et al,45 Kingston et al46 and Wagner et al.47 Nurses emphasized that support and patient safety culture on the ward was important with respect to reporting incidents. In accordance with previous studies, lack of support and a culture of blame had deleterious effects on incident reporting. In a study of medical and nursing staff in three public hospitals in Australia, Kingston et al46 found that nurses lacked trust in the organization’s ability to provide support and believed that the organization promoted secrecy to defend itself against litigation. In a cross-sectional survey of 983 registered nurses in Southern California, Mayo and Duncan48 found that the reasons for not reporting errors included fear of manager reaction (76.9%) and coworkers’ reactions (61.4%). Compared to hospitals, patient safety culture has been reported to be lower in nursing homes.45,49 A potential explanation could be that there has been substantial focus on quality and safety issues in hospitals compared to nursing homes in recent years. The nurses in this study associated a lack of support and an impaired culture of incident reporting with leaders that maintained a distance to the clinical problems that the nurses faced. Nurses were frustrated and believed these factors were a potential source of developing “bad attitudes” on the wards. Adelman22 found that leaders that were more available contributed to increased dialog with employees and that this was essential in establishing a milieu that supports incident reporting.22,50,51 Wakefield et al26 also emphasized that changes to improve current practice need to consider the influences of organizational and work group culture. The social context at work was clearly highlighted by the interviewees. The nurses had close relationships with work colleagues both at and outside of work. These relationships often increased their reluctance to report incidents. Some nurses experienced, either themselves or by observing similar situations on their wards, that incident reporting could have deleterious effects on their personal and social life. Previous research has underscored that the relationships among colleagues are factors preventing

446

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447

nurses from reporting.52 Bullying and social exclusion may also occur and negatively impact the psychological health of those reporting.27,30 All of the nursing homes had electronic systems in which incidents could be reported. However, in Norway and the U.S., incident reporting policies and processes vary widely.23 Nurses noted that the routines in the various wards were somewhat unclear and that some incidents were handled “face-to-face” and not registered in any report or systems. Kingston et al46 found that nurses, compared to physicians, were more in favor of a culture consisting of directives and protocols, rather than treating incidents “in-house.” Lack of confidence and knowledge related to the use of technology was also found to be a barrier to incident reporting. Because many senior members of staff reported this barrier, a plausible explanation may be that younger members more frequently use technological solutions on a daily basis. Indeed, the attitudes held by nurses toward health information technology seem to become more positive with increasing computer experience.53 Ammenwerth et al34 also found that an important factor that prevented nurses from reporting incidents electronically was that they did not believe that they did it correctly, findings that concur with the views of several of the nurses in this study. In accordance with prior studies, the nurses tended to have different views concerning the degree of severity of various incidents. This factor led to a wide variety of individual judgments about the necessity of reporting.54 Lafton et al33 argue that lack of knowledge concerning what should be reported constitutes an important driver of underreporting. The severity of the incident has, in many cases, been shown to be crucial to whether incidents are reported.35 In accordance with previous studies, time was viewed as a critical barrier.44,45 The nurses explained the lack of time was related to a heavy workload or the length of time needed to complete the incident reports. Handler et al45 found that a sufficient number of employees to handle the workload was an important contributor to incident reporting. Although there are studies suggesting that the number of available nursing staff can affect patient outcomes,55,56 a recent review by Backhaus et al57 found no relationship between nurse staffing and quality of care in nursing homes. Limitations The current study is not without limitations. The main limitation was the use of a convenience sample instead of a purposeful sample. We are aware that this choice limits the generalizability of our findings. Because the participants were identified by nursing home managers, the sample may not represent the views of all nurses working in the various nursing homes. Based on the sampling method, allowing managers to identify potential participants could have led to selection bias, in which nurses who were perceived as more critical may have been less likely to be chosen. We experienced saturation during our 11th interview; however, it is possible that more themes could have emerged if we had used a purposeful sample. Moreover, there may be structural differences between nursing homes in Norway and various international settings. However, our findings are fairly consistent with several international studies on quality and safety issues. Because we only included nurses from nursing homes in the Southeastern part of Norway, additional themes could have been revealed if nurses from other parts of the country had been included. This result is unlikely because all Norwegian nursing homes are bound by the same national laws and regulations. Additionally, nurses were recruited from three different municipalities in which these differences

should have been evident. Lastly, in one of the nursing homes, only one nurse was interviewed. This circumstance may have limited our findings, particularly related to organizational issues. Conclusion and implications Learning from previous incidents is important to improving safety culture. Improving and promoting incident reporting in nursing homes requires knowledge about the elements that constitute reporting barriers. The themes identified in the current study support the necessity of utilizing a broad perspective to improve incident reporting in nursing homes. Moreover, the majority of the barriers are modifiable. The need to create a psychologically safe reporting culture in nursing homes to lower the threshold of incident reporting is very important. Additionally, establishing a standardized taxonomy of reportable incidents across various care settings is important to reducing the risk of different situational judgments by various nurses. References 1. Aspden P. Patient Safety: Achieving a New Standard for Care. Washington, D.C.: National Academies Press; 2004. 2. WHO. Exploring Patient Participation in Reducing Health-care-related Safety Risks; 2013. 3. Hughes RG. Patient Safety and Quality: An Evidence-based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. 4. Institute of Medicine Committee on Quality of Health Care in A. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001. 5. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999;36:255e264. 6. Office of the Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries; 2014. 7. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17: 216e223. 8. Lucero RJ, Lake ET, Aiken LH. Nursing care quality and adverse events in US hospitals. J Clin Nurs. 2010;19:2185e2195. 9. Wakefield BJ. Facing up to the reality of missed care. BMJ Qual Saf. 2014;23:92e 94. 10. Aiken LH, Cimiotti JP, Sloane DM, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. J Nurs Adm. 2012;42:S10e16. 11. Ball JE, Murrells T, Rafferty AM, et al. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf. 2014;23:116e125. 12. Donaldson MS, Kohn LT, Corrigan J. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 2000. 13. Haugen AS, Softeland E, Eide GE, et al. Impact of the World Health Organization’s Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study. Br J Anaesth. 2013;110: 807e815. 14. Colon-Emeric CS, McConnell E, Pinheiro SO, et al. CONNECT for better fall prevention in nursing homes: results from a pilot intervention study. J Am Geriatr Soc. 2013;61:2150e2159. 15. Milos V, Rekman E, Bondesson A, et al. Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study. Drugs Aging. 2013;30:235e246. 16. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33:533e540. 17. Trivalle C, Cartier T, Verny C, et al. Identifying and preventing adverse drug events in elderly hospitalised patients: a randomised trial of a program to reduce adverse drug effects. J Nutr Health Aging. 2010;14:57e61. 18. Currie L, Watterson L. Challenges in delivering safe patient care: a commentary on a quality improvement initiative. J Nurs Manag. 2007;15:162e168. 19. Harkanen M, Turunen H, Saano S, et al. Medication errors: what hospital reports reveal about staff views. Nurs Manag (Harrow). 2013;19: 32e37. 20. Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21:685e699. 21. Wong CA, Cummings GG, Ducharme L. The relationship between nursing leadership and patient outcomes: a systematic review update. J Nurs Manag. 2013;21:709e724. 22. Adelman K. Promoting employee voice and upward communication in healthcare: the CEO’s influence. J Healthc Manag. 2012;57:133e147. discussion 147e138.

I. Winsvold Prang, L.-P. Jelsness-Jørgensen / Geriatric Nursing 35 (2014) 441e447 23. Wagner LM, Castle NG, Reid KC, et al. U.S. Department of Health adverse event reporting policies for nursing homes. J Healthc Qual. 2013;35:9e14. 24. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105: 69e75. 25. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11:15e18. 26. Wakefield DS, Wakefield BJ, Uden-Holman T, et al. Perceived barriers in reporting medication administration errors. Best Pract Benchmarking Healthc. 1996;1:191e197. 27. Jackson D, Peters K, Andrew S, et al. Trial and retribution: a qualitative study of whistleblowing and workplace relationships in nursing. Contemp Nurse. 2010;36:34e44. 28. Jackson D, Peters K, Andrew S, et al. Understanding whistleblowing: qualitative insights from nurse whistleblowers. J Adv Nurs. 2010;66:2194e 2201. 29. Jackson D, Peters K, Hutchinson M, et al. Exploring confidentiality in the context of nurse whistle blowing: issues for nurse managers. J Nurs Manag. 2011;19:655e663. 30. Peters K, Luck L, Hutchinson M, et al. The emotional sequelae of whistleblowing: findings from a qualitative study. J Clin Nurs. 2011;20: 2907e2914. 31. Brubacher JR, Hunte GS, Hamilton L, et al. Barriers to and incentives for safety event reporting in emergency departments. Healthc Q. 2011;14: 57e65. 32. Moumtzoglou A. Factors impeding nurses from reporting adverse events. J Nurs Manag. 2010;18:542e547. 33. Lafton H, Fagerström L. Implementation of incident reporting systems in Norwegian nursing homes from a management perspective e a pilot study. Vård I Nord. 2011;31:45e47. 34. Ammenwerth E, Mansmann U, Iller C, et al. Factors affecting and affected by user acceptance of computer-based nursing documentation: results of a twoyear study. J Am Med Inform Assoc. 2003;10:69e84. 35. Malmedal W, Hammervold R, Saveman BI. To report or not report? Attitudes held by Norwegian nursing home staff on reporting inadequate care carried out by colleagues. Scand J Public Health. 2009;37:744e750. 36. Handler SM, Wright RM, Ruby CM, et al. Epidemiology of medicationrelated adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4:264e272. 37. Malmedal W, Ingebrigtsen O, Saveman BI. Inadequate care in Norwegian nursing homes e as reported by nursing staff. Scand J Caring Sci. 2009;23: 231e242. 38. Runciman WB. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust. 2006;184:S41e43.

447

39. Sandelowski M, Barroso J. Classifying the findings in qualitative studies. Qual Health Res. 2003;13:905e923. 40. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77e101. 41. Sandelowski M. Writing a good read: strategies for re-presenting qualitative data. Res Nurs Health. 1998;21:375e382. 42. Nightingale F, McDonald L. Collected works of florence nightingale. In: . Florence Nightingale’s Suggestions for thought, vol. 11. Waterloo, ON: Wilfrid Laurier University Press; 2008. 43. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759e763. 44. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39e43. 45. Handler SM, Perera S, Olshansky EF, et al. Identifying modifiable barriers to medication error reporting in the nursing home setting. J Am Med Dir Assoc. 2007;8:568e574. 46. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust. 2004;181:36e39. 47. Wagner LM, Harkness K, Hebert PC, et al. Nurses’ perceptions of error reporting and disclosure in nursing homes. J Nurs Care Qual. 2012;27:63e69. 48. Mayo AM, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004;19:209e217. 49. Castle NG, Wagner LM, Perera S, et al. Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. J Patient Saf. 2010;6:59e67. 50. Conerly C. Strategies to increase reporting of near misses and adverse events. J Nurs Care Qual. 2007;22:102e106. 51. Hashemi F, Nasrabadi AN, Asghari F. Factors associated with reporting nursing errors in Iran: a qualitative study. BMC Nurs. 2012;11:20. 52. Thornlow DK. Nursing patient safety research in rural health care settings. Annu Rev Nurs Res. 2008;26:195e218. 53. Huryk LA. Factors influencing nurses’ attitudes towards healthcare information technology. J Nurs Manag. 2010;18:606e612. 54. Storli M. Medical errors in hospitals e the influence of organizational culture. Vård I Nord. 2008;28:19e23. 55. Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. J Am Med Assoc. 2002;288: 1987e1993. 56. Bostick JE. Relationship of nursing personnel and nursing home care quality. J Nurs Care Qual. 2004;19:130e136. 57. Backhaus R, Verbeek H, van Rossum E, et al. Nurse staffing impact on quality of care in nursing homes: a systematic review of longitudinal studies. J Am Med Dir Assoc. 2014;15(6):383e393.