The Nurses’ Experience of Barriers to Safe Practice in the Neonatal Intensive Care Unit in Thailand

Objective:  To describe barriers nurses experienced in providing safe practice in the neonatal intensive care unit and to investigate area of errors commonly affected when nurses confronted the barriers.Design:  Qualitative descriptive

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  746    JOGNN    © 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses  Objective : To describe barriers nurses experi-enced in providing safe practice in the neonatal intensive care unit and to investigate area of errors commonly affected when nurses confronted the barriers. Design : Qualitative descriptive method. Setting : Randomly selected 4 large neonatal intensive care units in Thailand. Participants : Twenty-seven neonatal intensive care unit nurses. Main Outcome Measures : A semistructured in-terview of the nurses ’ experience of neonatal intensive care unit error, factors forming barriers to safe prac-tice, and neonatal outcome. Results : Of 245 error events, neonates were identified to suffer 126 (55.5%) adverse events. Five themes emerged as common factors obstructing nurses from incorporating safety processes into their caring roles: human susceptibility to error, system op-erating care weakness , problematic medical devices, poor team communication, and situational provoca-tion. Multiple barriers were largely associated with understaffing, a sudden increase in patient acuity, multiple assignments, and an inadequate knowledge of safety in neonatal critical care, which often inter-acted and influenced their performance when pro-cessed to a single error occurrence. Conclusion : A focus on management of the po-tential barriers in a system-related human error ap-proach could prevent and intercept future errors in this vulnerable population.  JOGNN,   35,  746-754; 2006. DOI: 10.1111/J.1552-6909.2006.00100.x Keywords : Error event —  NICU —  Nursing prac-tice —  Performance obstacle —  Safety Accepted: August 2006 Nursing practice in neonatal intensive care units (NICUs) requires extreme vigilance and a structured approach to preventing practice errors, as neonates have a limited ability to buffer such mistakes and are vulnerable to adverse sequelae of practice errors ( Gray & Goldmann, 2004; Lefrak & Lund, 2001 ). Previous studies have reported that neonates admitted to NICUs have had multiple preventable complications associ-ated with practice procedures and the use of equip-ment. These have included adverse drug events, nosocomial infections, sepsis, blindness, deafness, chronic lung diseases, and neurosensory sequelae, and they have undermined parental trust in the health care system ( Chang, Lin, & Lin, 2001; Hack et al., 2000; Lee et al., 2000; Mahieu, De Muynck, et al., 2001; Mangurten, Angst, See, Boyle, & Beckman, 2000; Petdachi, 2000; Prot et al., 2005; Sohn et al., 2001 ). The adverse outcomes have resulted in a longer length of hospital stay and a higher cost of medical care ( Mahieu, Buitenweg, Beutels, & De Dooy, 2001 ). Any effort to improve safety practice in the NICU depends on learning how safety emerges from the context of the care delivered. Recent studies have de-scribed the error phenomena in the NICU setting from the medical view ( Kanter, Turenne, & Slonim, 2004; Mangurten et al., 2000; Nagata, Brito, & Matsuo, 2002; Simpson, Lynch, Grant, & Alroomi, 2003 ). These studies used incident reports and all but two conducted a retrospective medical record review. The approach limited a detailed analysis of the inci-dents and the reliability of the causal attribution of incidents as it relied on implicit judgments by experts  ( Parker & Lawton, 2003 ). Moreover, it restricted opportunities to disclose the error types and the un-derlying causes of the nonreporting incidents. Kozer et al. (2002) and Leape et al. (1991) stated that their CLINICAL RESEARCH The Nurses ’  Experience of Barriers to Safe  Practice in the Neonatal Intensive Care Unit in Thailand Veena Jirapaet  , Kriangsak Jirapaet  , and Chompunut Sopajaree  November/December 2006  JOGNN    747  studies of record review had tapped only a fraction of the actual errors made and might not provide insight into the specific causes of an adverse event. Nurses comprise the largest component of the NICU health care team and are involved with the day-to-day complex care environment where neonatal patient safety is often compromised through errors. An examination of the barriers that nurses experience in trying to deliver quality care can provide insight into safety practice in the NICU that might be improved resulting in a better out-come for this vulnerable population. However, error inci-dents in the NICU nursing care context have not been fully described, and the barriers associated with the incidents have not been elucidated. T his study describes nurses ’ experiences of safety incidents and the barriers they experienced in trying to provide safe practice in NICUs. To better understand the nature of barriers to safe prac-tice from the nursing perspective, we conducted a qualita-tive study to learn the way in which the barrier was defined by the primary person involved in the events. In this way, insight into specific barriers and links between the interac-tive components in each incident could be fully explored. In addition, this approach would give rise to nonreported events as a means of promoting voluntary self-reporting and creating a climate whereby nurses feel free to discuss and analyze their errors. Definition The following terms and definitions adopted by the Insti-tution of Medicine ( Kohn, Corrigan, & Donaldson, 2000 ) were used to ensure a clear understanding of the terms and a consensus interpretation of the safety phenomena in NICUs. The errors were defined as the failure of a planned action being completed as intended or the use of a wrong plan to achieve an aim. Error outcomes were classified based on events associated with harm or injury that led to the neonate ’ s suffering, disability, or death due to nursing practices rather than the neonate ’ s underlying disease or condition. An adverse event was defined as an unintended incident in care that resulted in an adverse outcome and required additional care effort. Near misses were events in which unwanted consequences were prevented. Barriers to safety were identified when they were commonly present for practice situations that entailed error events. n % Age (years; mean [SD])32.5 (7.6)NICU working experience (years; mean [SD])9.7 (7.3)Level of education Bachelor’s degree24.089 Master’s degree3.011 NICU beds (no.; mean [range] for four NICUs)11.5 (8-18)Nursing staff  a  ratio (sick neonates per staff) Day shift (no.; mean [range] for four NICUs)2.1 (1.3-3.6) Evening shift (no.; mean [range] for four NICUs)3.6 (1.7-6) Night shift (no.; mean [range] for four NICUs4.5 (2-6)   Note . NICU = neonatal intensive care unit.  a RN and licensed vocational or practical nurse.   TABLE 1  Characteristics of the Study Participants (  N  = 27) Methods A qualitative descriptive methodology was utilized. Sample The participants were 27 Thai RNs who experienced er-rors in their practices while working in three teaching and one nonteaching hospital NICUs in Bangkok, Thailand (see Table 1). Sampling began with a random selection of hospi-tals representing the military, public health, an academic medical center, and metropolitan administrations. This sam-ple was representative of the entire unit ’ s population in terms of the common hospital organizational climate in Thailand. The sample size was determined when persistent themes of error type and barriers to safe practice in NICUs began occurring after interviewing 22 participants. However, the researchers continued to increase the number of participants to represent each hospital organization climate. Sites used for this study were equivalent to level IIIB NICUs as classified by the American Academy of Pediat-rics (2004) . The units had the capability of providing care to critically ill neonates with gestational age of 28 weeks or less and a birthweight of 1,000 g or less with advanced respiratory support, such as high-frequency ventilation and synchronized ventilation. NICU nurses had the capa-bility of providing complex care to mechanically ventilated neonates in collaboration with the attending neonatologists but without respiratory therapists or neonatal pharmacists.  748    JOGNN    Volume 35, Number 6 Medications were provided to NICUs by pharmacists and dispensed to neonates by nurses. Residents were available only in teaching hospitals. The units were organized on the values of family-centered care and the Baby-Friendly Hospital Initiative.  Procedure After receiving institutional review board approval, the nurse manager of each NICU identified the potential pool of participants based on a nurse ’ s NICU working experience for at least 2 years in an effort to increase the chance of lo-cating nurses with error experiences. The researcher con-tacted potential nurses to explain the study ’ s purpose and informed them that participation was voluntary and anony-mous. Their verbal consent was indicative of consent to participate in this study. None of the staff nurses declined to participate and all had experienced errors in their practice. An individual audiotaped interview, lasting 60 to 90 minutes, was conducted in a private room. Each interview began by asking general questions, for example, how do you feel about taking care of a baby in the NICU? Then the interview was gradually moved to the main questions, such as “ Have you had any experiences with the safety incidents? ” and “ What were the barriers to safe practice underlying that incident? ” Additional questions flowing from the immediate context were asked concerning the nurse ’ s life experiences of issues regarding error in their practices, factors forming the barriers to providing safe practice in NICU, and the neonate ’ s outcome. The re-searcher avoided the word error to prevent the study from appearing threatening to nurses. The interview data were validated with the participant at the end.  Data Analysis and the Rigor of the Study Data were generated and analyzed using Colaizzi ’ s method ( 1978 ). After collecting the participants ’ descrip- tion of the phenomena, the interview tapes were tran-scribed and then verified for accuracy. No tapes had any identification of the participants and all were destroyed after the verbatim transcription was completed. Tran-scripts were read and reread independently by each researcher to examine the language for common meanings and for the range of human responses to the stories described. Significant statements relating to the error events and factors constituting barriers to the event were extracted. Patterns and themes as well as exemplars were then identified as part of a search that reflected the collec-tive experience. Data authenticity and trustworthiness were enhanced by participants reviewing the final exhaus-tive description to verify that it was representative and true to their life experience. Conformability was achieved through the use of an audit trail and a review of the raw data by a second researcher. Results The in-depth content analyses showed 245 error events. Of these, participants indicated 126 adverse events and 119 near misses in their nursing practices. Only 39% (95) of all events were reported to the institution, and safety solutions to prevent harm implemented. Learning from these events through nurses ’ self-critical analyses revealed the unique nature of the types of error in nursing practice, the outcome for the neonates, and the barriers that im-peded nurses from delivering safe practice in NICUs. Types of Error and Neonates ’  Outcomes The participants ’ descriptions of errors in NICU nurs-ing practices were classified into six categories and 23 spe-cific types of error. Table 2 presents the common types of error in each category with the incident outcomes for the neonates. Exemplars of specific error types are detailed in Table 3. All participants reported having experiences in three categories including medication error, an unsafe pa-tient environment, and inattentiveness. A high occurrence of adverse events in the neonates was noted in circum-stance associated with an unsafe patient environment, in-attentiveness, and technical error. The adverse events ranged from correctable physiological abnormalities to fa-tal adverse/catastrophic events. Near misses were experi-enced in cases of early detection either by the individual or by other multidisciplinary team members. N eonates face a higher potential hazard for an unsafe patient environment due to their developmental limitation for self-preservation.  Barriers to Safe Practice in NICUs Five essential theme clusters with 19 subthemes were identified in the nurses ’ descriptions of factors obstructing them from safe practice and leading to NICU error events. Analysis of the error patterns demonstrated that there were commonality factors in all types of error. Certain factors can combine their effects and create greater oppor-tunities for error events. These interactive factors forming barriers were mainly involved in care operating under sys-tem weakness, situational provocation, and characteristics of human susceptibility to error. Human Susceptibility to Error.  These barriers consti-tuted both the characteristics of the nurse provider and the sick neonate. The main characteristics of nurses that led to errors involved knowledge deficit and inexperience. The knowledge base plays an important part in most  November/December 2006  JOGNN    749  Neonatal Outcomes Categories and Specific Types of Error EventsAEsNear- Misses Medication error73 (29.8)19 (7.8)54 (22.0) Wrong dose401624 Wrong patient14—14 Wrong time and continued with expired order13—13 Wrong drug/solvent413 Incorrect administration technique (bolus dose injected instead of infused)22—Unsafe patient environment65 (26.5)45 (18.3)20 (8.2) Failure to provide neutral thermal environment20182 Failure to prevent accidents incurred by use of hot water bottle/  electrical blanket, scalp shaving, and unlocked incubator window1367 Failure to prevent nosocomial infection12111 Inappropriate response to clinical alert alarm monitor1082 Failure to maintain the neonate’s identification6—6 Failure to readjust indicated oxygen level after procedure422Inattentiveness38 (15.5)33 (13.5)5 (2.0) Failure to detect IV leakage21201 Failure to detect a dislodgment of three-way stopcock1082 Inattention to over filling sterile water into the ventilator humidifier752Technical error34 (13.9)26 (10.6)8 (3.3) Dislodged, inadvertent removal of endotracheal tube1616— Traumatic section725 Error in ventilator circuit assemble and equipment setup853 Adhesive removal incurred epidermal trauma33—Avoidable delay and omission20 (8.2)1 (0.4)19 (7.8) Nursing care on suctioning, feeding, starting IV line, changing position, monitoring vital signs, and recording of fluid balance13112 Medical service on endotracheal intubation/administered blood product/oxygen weaning7—7Failure to adhere to guideline/protocol15 (6.1)12 (4.9)3 (1.2) Overinflated bagging from lack of pressure gauage/experience66— Too tight attachment/nonrelocation of the pulse oximeter probe position541 Failure to follow protocols of orogastric bolus feeding, umbilical cord care, and time constraint422   Note.  AEs = adverse events. Values are numbers (percentages) of errors in 245 self-reported events.  TABLE 2 Categories and Specific Types of Error in NICUs and Outcomes error occurrences particularly when nurses do not advo-cate for the best interests of the patient. As one partici-pant failed to question an incorrect physician order, “ The doctor ordered 1:1000 epinephrine. This didn ’ t sound correct for such a small baby [the correct concentration is 1:10,000], but I didn ’ t question it because I wasn ’ t 100% sure. I administered it as ordered … ” However, a nurse ’ s attitude that is incongruent with the professional practice protocol can build up false confidence and propel her into successful error behavior in spite of knowledge. “ I knew  750    JOGNN    Volume 35, Number 6 about it … wasn ’ t lazy in changing the pulse-oximeter sensor site [recommended to relocate q3-4 h] … But I didn ’ t believe that it could really burn the skin until I had experienced it. ” In addition, lack of knowledge from in-adequate in-service training on complex equipment and nursing procedures was described as a nursing perfor-mance obstacle. Most participants identified that they rarely received the training and time to become skilled with complex task, thus putting them at risk for making errors. “ Our unit seldom used this sophisticated oscilla-tor. It was complicated to set-up. We incorrectly con-nected the circuit … ” Another barrier was poor decision making, which hap-pened in two practice conditions. First, when the nurse had imperfect rationale resulting from having inadequate knowledge or skill in managing a troubleshooting situa-tion. It limited the application of good logical reasoning, thus bending the facts to fit a hasty conclusion. Later, the nurse became emotionally disturbed by the situation and avoided acknowledgment. As one participant stated, “ I was inexperienced … The cardiac monitor kept on sounding the alarm, but I found nothing wrong [making the illogical assumption as a false alarm] … I felt annoyed and permanently switched off the sound alarm … ” Sec-ond, when the nurse had complete confidence in a task that was repeated often enough for it to be done auto-matically, particularly when under time pressure. This was illustrated by one nurse who failed to recheck venti-lator circuit assembly before using the ventilator on a baby. “ I [accidentally] connected the wrong side of the ventilator circuit … I thought it was correctly connected ‘ cause I had done it for … I was in a hurry to complete it for the arrested baby. ” The characteristics of the neonates also increase the risk of an error event. Errors that are tolerated well by normal neonates can be lethal in sick neonates who are weakened by disease or who are immature. This was reflected in a participant ’ s statement, “ I couldn ’ t identify the [IV] leak early. It was hard to tell because the baby had generalized edema. ” Significant StatementsFormulated Meanings Sample of specific types of medication error “I prepared 2 mLs of Furosemide (10 mg/mL) instead of 2 mg ...”Wrong dose “I gave antibiotics to a baby who had same name.”Wrong patient “I gave a bolus push of Vancomycin … supposed to be infused for at least 60 minutes.”Incorrect administration techniqueSample of specific types of unsafe patient environment “I performed a venepuncture without using a radiant warmer properly … baby developed hypothermia.”Failure to provide neutral thermal environment temperature “I sent a baby out of the unit for ultrasonography, without checking that she didn’t have an identification band. I thought another nurse in my team already did ...”Failure to maintain the neonate’s identitySample of specific types of lack of attentiveness “The i.v. site was covered with cloth.... leaked for a long time, skin area was inflamed and edematous like popeye’s arm.”Failure to detect the IV leakage earlySample of specific types of avoidable delay and omission “The order was to record gastric content q2h for an NEC baby but I was tied up with an arrested baby and .... I recalled that at a shift change.”Omit to observe the neonate’s conditionSample of specific types of technical error “It was about my care during changing the position ... the baby’s neck was overextended and endotracheal tube was dislodged”Failure to prevent endotracheal tube inadvertent removalSample of specific types of inadherance protocol “I skipped using pressure gauge while bagging because it was not in place and the baby required immediate ... without realizing that the baby’s lungs were hyperinflated ....”Nonconformity with bagging protocols  TABLE 3 Selected Examples of Significant Statements and Corresponding Formulated Meanings Toward Specific Types of Error in Each Category
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