An Analysis of Qualitative Article About Medical Errors

Qualitative research methods lead to certain types of studies. With the research reviewed the quality and integrity of qualitative research is determined if the study is trustworthy. The study reviewed explores narratives of nursing students and the experiences with medical error communication. This review seeks to understand how Noland and Carmack selected participants, gathered data, and analyzed the data with as little bias as possible. Determining the effectiveness and importance of this analysis is established based on the criteria to develop a qualitative research study.

In an era where systems are able to assist nursing regarding medical errors whether it be electronic documentation, automated dispensing units, or procedural systems such as a Time Out, the nursing service is a focus of quality to improve and remove medical errors. These systems do not eliminate medical errors but assist in the reduction only with the human component. Recent reports have brought further attention to the human component to the forefront of the issue of addressing the persons responsible for medical errors.

One recent example is of Radonda Vaught of Tennessee. In this case a nurse administered a drug in error causing a fatal consequence. As a result of this the nurse has been recently indicted for reckless homicide (Kelman, 2019). It is not solely system errors cause for the medical errors, but the human factor impacts the response to the nurse making the medical error. In the previous example it was not the withdrawal of the medication that was only examined but also the nurse’s practice of withdrawing the medication that was ordered.

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The electronic systems with the physical systems are also examined as repercussions of medical errors such as checks performed prior to administration to medication – was there barcoding? Finally, the process of reporting was examined which would include identification, reporting and self-discipline regarding such medical errors.

The article to be reviewed here focuses on the response of the nurse during the reporting phase of a medical error. Specifically nursing students and their perceptions on ideal and real actions that should be taking place during near miss and actual medical errors are evaluated. This paper will review the quality and integrity of the research conducted to inquire nursing student perceptions of medical errors and the communication that occurs as a result of the medical error.

Noland and Carmack (2015) in the research “Narrativizing nursing students’ experiences with medical errors during clinicals” sought to understand the communication that played in the role of medical errors. The introduction to this piece of qualitative research utilized research to establish the cause of some errors is communication.

The introduction of the research does provide a background to the topic being studied. In the introduction the authors reviewed several key aspects to establish the importance of the topic. Sited in the introduction are the Institute of Medicine report 2003 regarding patient safety and nursing work environments (IOM, 2003) and the Joint Commission patient safety goal of 2011 of improved communication (The Joint Commission [TJC], 2011). These reports set the stage for the importance of the communication concerning the nursing mission in medical error prevention. Also reviewed was the work of the effects of negative communications within the interpersonal communication or workplace to affect the communication of medical errors.

Establishing what was lacking from their research review the authors identified the scope and focus of their research to be the nursing students “story medical errors and how that helps them determine how to respond to mistakes” (Noland & Carmack, 2015). This search for clarification of answers regarding the nursing students’ perspectives and experiences does lead to the title design by the authors. The title expresses the desire to answer questions regarding nursing student experiences during clinicals and response to medical errors.

Understanding the experience of the nursing student and the learning provided through the school or institution that the nurse attends classes or clinicals provides the background to the nurses understanding of interprofessional and work environment communication. This communication phenomenon is explored in the research here in narrative format to experience the nursing student perspective of medical error communication. Not only are the researchers utilizing the past research such of Kelly and Ahern (2009) but also of others that establish the ways and means to which various professions such as pharmacists, physicians, and new nurse graduates communicate regarding medical errors (Noland & Carmack, 2015).

While the purpose of the study is not clearly stated, it can be inferred from the prior statements of the research questions. In these statements the authors discuss the need for additional evidence regarding the correlation between nursing roles in the health system and how the nursing student handles the medical error communication. The purpose therefore does lead to the clearly identified research questions.

Noland and Carmack clearly does pose two research questions; first how do nursing students describe their medical mistakes, and secondly how do they describe their education on communication and medical errors (2015). The question posed for research does lead to a qualitative study due to the exploration of the experiences of the population being studied. While certain data could be obtained to review the nursing students, to understand and identify the phenomenon that is being studied here (the communication during a medical error) would entail a qualitative data collection and review. With the data collection in qualitative form the researchers would be able to provide the narratives from the students to develop the themes throughout the collection and analysis processes.

The significance of this type of study does lead to determining the design of the research. First the authors determine through the scope that the population to be reviewed would be the nursing students. Secondly the phenomenon studied is the communication during medical errors. The authors identified that the significance of the communication established between providers (nurses and physicians, for example) can begin in the education curricula of the nursing student. The authors explored the communication systems established in nursing systems such as Situation-Background-Assessment-Recommendation (SBAR) or 5 rights of medication administration but somehow nursing students may lack the knowledge or preparedness to communicate effectively and efficiently regarding medical errors (Noland & Carmack, 2015).

The discussion to define the research method and design is clearly discussed by Noland and Carmack. The authors establish the rationale for the design through a thorough review of the process of Narrative stories and evidence of the stories. Narrative stories are utilized to establish the nursing students’ experiences that capture the answers to the research questions presented.

Noland and Carmack utilize narrative theory to develop and design their research method and is clearly stated. Establishing that communication being a backbone of nursing science either between providers or with patients; communication is key for nurses. Through this communication the authors identified that nurses communicate critical data to providers to establish the patient picture for the physicians when they are not physically at the bedside.

With the narrative theory design researchers are able to illustrate the experiences of the phenomenon being studied but also the human factors that impact the phenomenon such as events, perceptions of the events and the meanings from these events. This type of inquiry allows for the value of the experiences expressed from the participants of a study (Green, 2013).

In the research described in Noland and Carmack study, they describe the choice of design in relation to the communication in a time of crisis. In the case of this study is the crisis it is the crisis of a medical error. Noland and Carmack agree that with the narrative theory method the evaluation of story is not of one story but the evaluation of experience that builds a “constellations of experiences” which leads to the interpretation of key themes and concepts through the data analysis of the participants stories expressed (2015).

The authors provide a well described designed based on the chosen method of narrative theory. Noland and Carmack substantiate the design based on the review of literature that establishes the narrative theory chosen allows for the collection of diverse stories but also to use the diversity of the stories to develop a compilation of a story of several experiences with key themes underlying the knowledge that the nursing students gained by living through the experience of medical errors (Noland & Carmack, 2015).

The research methodology conducted by Noland and Carmack is established an appropriate approach to the question proposed for study. Utilizing the narrative theory approach is grounded by the research discussed. Narrative theory also allows the students express their experiences to provide stability in time of a crisis situation such as the communication during a medical error.

After designing the research method, the researchers identified this study as part of a evaluation of larger project. The authors did obtain IRB approval from the university. A selection of 68 students were interviewed from a New England university. The authors did not describe how the rights of the participants were protected. Although through the use of interviews and the descriptions of response in the research no identifiers were discussed in the paper. During review of the of the excerpts of the interviews the only context from the participants that could be identified is their status as a student (year in school and/or clinical rotation) (Noland & Carmack, 2015).

In this review of communication of medical errors, the focus was on nursing students, but the authors focused on specific levels of nursing students. The nursing student would have had one clinical rotation. The sample for participation was selected based on the snowball sampling method. Key components of this type of sampling is that the initial informants are identified from specific contact methods – mail, email, phone, etc. The initial informants then refer additional informants to participate in the study. Chaim Noy stated that the utilization of snowball sampling is widely used in qualitative research but also utilized to access difficult populations. Noy also asserts that control is lost in this type of sampling method due to the recruitment performed by initial participants. However, the method of data collection in which the authors of this study of communication medical errors used which was in depth interviews was a natural progression and relation to the type of sampling method (Noy, 2008). Because of this data sampling method, the participant population and method of sampling are clearly identified by Noland and Carmack in their study (2015).

The authors of the study evaluated the participants on the following prior to interviews: years in school, hospital training/clinical training, training experiences, and specialization considerations. When reviewing this data, it is identified students who are primarily in their third or fourth year, more than two years’ experience in hospital, and specialization preferences in ICU, ED, and pediatrics. As for the training experience, the nursing students had a more uniform dispersion between one to 5 or mores experiences only with one and 4 experiences being the lowest with 8 participants (Noland & Carmack, 2015). Overall there is some weight to the more experience student and those students with desires to specialize in more critical areas, this could create additional pressures when practicing in a higher-pressure work environment in regard to medical errors. The sampling size for this type of study is adequate since using the snowball sampling method used produced 68 participants of various levels of experiences and not of one uniform educational training experiences does add to that varied level of data collection. Participants did provide for an appropriate group to study based on the demographics described by the authors.

The authors described the method of data collection through the utilization of in-depth interviews. Semi-structured interviews were conducted by the first author for 45-90 minutes using 38 questions. This allowed the discussions to explore the topics of education regarding communication, education about medical errors, and experiences between patients, providers, and the students’ role in communication and students’ participation in the medical error. The authors recorded and transcribed the interviews. This extensive data gathering allowed for adequate time for data collection since the collection method was via individual interviews.

Individual interviews also provide several advantages for this study. Individual interviews did provide for the integrity of privacy with the participants with regard to their story and to their participation. Because specific insights are desired regarding the nursing student perspectives the method of collection through interviewing is appropriate. Whereas, should a focus group have been utilized the control regarding the interview would have been lost. Since focus groups are meant to be monitored and facilitated rather than questioned directly, the choice of in-depth individual interviews is appropriate (Gill, Stewart, Treasure, & Chadwick, 2008).

After transcribing the interview recordings, the researchers reviewed the transcriptions several times thoroughly. The authors were reviewing for themes in the transcriptions while not focusing on the specifics of the speech. During the review of the transcription the authors use open coding to identify themes from the participants experiences recorded. During an open coding process, the researcher does not apply their own interpretations of the recorded transcriptions but identifies certain concepts already in the transcriptions. Having a second researcher on this study allowed the process of analyzing the transcribed interviews coded reflectively more than once which can assist in the development and refinement of codes to themes (Blair, 2015).

The research evidence of the study yielded several themes that were presented. One of the first identified was related to the communication education of the nursing students varied from formal to informal training regarding medical errors. Those that reported formal education also reported that they had received orientation at their workplace regarding how to report a medical error. The themes that were developed from the experiences with medical errors which were described as “Save the day”, “Silence”, and “Not always right”. Further explanation of these experiences was discussed with excerpts from the interviews (Noland & Carmack, 2015).

In the first described the students identified an experienced nurse who were able to identify a situation and possibly prevent a medical error by “saving the day”. The experienced nurse would use the identification of the medical error to prevent, interrupt, or rectify mistakes and allowed the experienced nurses the opportunity to discuss the and communicate their learning from the medical mistakes to demonstrate all nurses are capable of making an error (Noland & Carmack, 2015).

The second theme described could have been the scariest of them all. The theme of “silence” is defined as the lack reporting an error, whether to the patient, provider, or to the workplace. Noland and Carmack did explain that the students perception when not reporting a mistake but to stay silent was related to the student’s perception of how they would be perceived and the feelings of lack of comfortability in certain situations (2015).

The final theme discussed was related to the “not always right” concept. This concept was relayed to the researchers through the interviews when the students observed experienced nurses making mistakes and nursing students need to “save the day” to prevent or interrupt a medical error. The students described the experienced nurse observed making mistakes and who and how to approach the individual. This does present challenges for the nursing student and even for new nursing graduates. The authors also explored the nursing students’ dependence on technology to “catch” their errors (Noland & Carmack, 2015).

Based on the review of the evidence from this study and the excerpts documented in the research are trustworthy. Several strategies were employed to ensure the quality of the research inquiry. First the use of the of the data collection of in-depth interviews allowed for a more semi-structured and consistent interviewing process but also the recording and documentation allowed for the dependability of the results as well as the criticality of the results. Again, the use of audio recording and transcription itself leads to the credibility of data generation for the research. The utilization of the two researchers reviewing the transcriptions ensures the coding with the use of open coding allows for confirmability between the two researchers. It is also noted the researchers presented the research at Annual Convention of the National Communication Association in 2014 which would have allowed the opportunity for peer review. The presentation of the results and findings are indicative of integrity through the utilization of reflexive review of the transcripts and documentation of excerpts from the interview transcripts (Noland & Carmack, 2015).

A thorough summary of the research is documented. The discussion section of the study does review the importance of the narratives in use of the answering the questions posed in the study. Use of narratives allowed the students to explore their experiences the developed into the three key themes that were identified – “Saving the day”, “Silence”, and “Not always right”. While there were some interview questions that did not produce an underlying theme, such as the negative communication experiences, the students did describe mistakes as human and a moment to learn.

The research conducted here does leave the nursing education community opportunities for exploration of communication curricula for medical errors. The authors described how the students became experts when identifying errors and correcting superiors either preceptors or instructors. From this perspective students are also able to be a more objective observer because of the inexperience and able to identify lack of continuity or logic in a systems approach to nursing processes and procedures. This is especially challenging those with nursing students who are more acclimated to technology and expect to use technology to provide the system check for their processes that may cause medical errors (Noland & Carmack, 2015).

Several limitations were clearly identified. Beginning with the population that was selected to study. The population was selected from the New England area and limits the scope of study and while beneficial for this study as a pilot study but to be more explorative to other areas of the geographical locations would entail a larger research team. To be able to conduct interviews such as Noland and Carmack performed would need to be multiplied by multiple teams, but the application of the process of data collection method chosen through recorded semi-structured interviews is one that lends to replicating easily. The data analysis through open coding could also be performed through multiple researchers to apply this study to a larger population of review.

The limitation of experiences of solely the nursing students also lends an opportunity to explore those of others in the student’s interaction including instructors, preceptors, and supervisors. The authors found the relationships between the students and these individuals did play an important role in the communication of medical errors.

The research provided by Noland and Carmack regarding medical error communication provides for an effective method to study qualitatively. The exploration of the nursing student experiences does offer the researchers to utilize the narrative theory to base the study. With the narrative theory the researchers are able to develop a quality study with several strategies to establish integrity such as the use of data collection through use of recorded and transcribed in depth interviews one to one with the nursing students selected in a snowball sampling method. Finally, the researchers also recognized the limitations and prospects that their research would allow including new research questions and expansion for study of different geographical areas of the population studied here.