3.1 Design and methodology

A qualitative descriptive phenomenology rooted in the philosophical tradition of Husserl was conducted. Two interviews were carried out with each participant and the research data were generated from a total of sixteen interviews and field notes. Colaizzi’s seven-step methodological guidelines were used for analysis and interpretation of data.

3.2 Participant recruitment and profile

Participants for this study were registered nurses (RNs) employed in facilities and experienced in caring for patients in a variety of healthcare areas. These nurses were currently practicing with a valid RN license for at least six months in the state of New York. A purposive sample of eight RNs with the above inclusion criteria who were directly involved in one or more medication errors were selected. The recruitment of participants was primarily done by snowballing method. The first participant however, was recruited by posting a flyer on the announcement board of a RN- BS completion program. The study sample comprised of seven female and one male participant with ages ranging from 36-55 years. The educational background of one participant was associate degree in nursing; five held a baccalaureate degree and two were masters prepared RNs. Their professional experience of practicing as RNs ranged from 3-22 years. Two participants prior to practicing as RNs also had the opportunity to practice as licensed practical nurses (LPNs). Most of the participants had the opportunity to practice in more than one area of expertise. The work areas of these participants were: medicalsurgical, neurology intensive care unit, emergency department, telemetry, intensive care unit, nursing home and home care. Most of the participants were full time registered nurses in one facility with a second part-time job in another facility. Two participants worked as per diem RNs in their second job and floated to a different unit almost every day. Of the eight participants, three participants worked eighthour day shifts, one worked twelve-hour day shift and one worked both day and night eight-hour shifts. The remaining three participants worked twelve-hour night shifts (table 1 below shows participant demographics).

Table 1: Participant Description by Demographics.

3.3 Data collection

Data collection was done by the principle investigator via two faceto- face interviews. The first interview was an in-depth interview with open-ended questions; the second being a focused interview with probes to clarify information obtained during the first interview. This style of interviewing allowed the researcher to follow the participant’s lead to format clarifying questions for the second interview [14]. The researcher carefully observed participants’ during the interviewing process for any nonverbal expressions and the elements of their environment. The observations were recorded in the field notes. The researcher encouraged each participant to describe his or her lived experience without leading the discussion. Broad open-ended questions were used in the first interview to allow participants to gradually ease into the interviewing process.

Examples of questions included in the first interview were: ‘Describe the incident when you were involved in a medication error’. ‘Describe your feelings when you made the medication error.’ Probes were used in the second interview, examples of these were: ‘What was it like to care for the patient involved in the incident?’ ‘What were the reactions of your colleagues/supervisor after the incident?’ Based on the literature review the interview questions were structured to focus on specific areas like:

• Nurses’ reactions (physical, emotional and psychological) to medication error occurrence immediately after the incident, and later.
• Factors within practice environment that led to medication error occurrences.
• Challenges faced by nurses before during and after medication error occurrence.
• Culture within the work area and /or factors that predisposed to medication error occurrences.
• Coping mechanisms used by nurses when medication error/s occurred.
• Type of support needed by nurses after the medication error occurrence.
• Nurses’ perceptions as to why the medication error occurred.
• Nurses’ reflections about error occurrence and effects on future practice.

Each interview lasted approximately 50-60 minutes. These were conducted in a private area of choice of each participant. The duration of data collection process was about three months. Being that all except the first participant were recruited by snowballing method, the interviews were conducted as participants were recruited. The second interview was scheduled by setting a date approximately one week later immediately after the first interview was completed. The date was scheduled according to the convenience of the participants. All interviews were conducted by the principal investigator and completed as scheduled except participant #3, whose second interview was scheduled after three weeks due to an illness. Even though questions for the two interviews were previously formatted to gain basic information, the researcher (interviewer) reformatted interview questions to make their meanings explicit to respondents as needed.

3.4 Trustworthiness and rigor

Techniques to ensure trustworthiness were employed by engaging participants, member checking, thick descriptions, and audit trail methods for this study. Participant engagement was accomplished by building a relation of trust between the investigator and the participant. The researcher gave relevant explanations and answered any questions the participants had prior to interview, enabling comfort and gradual ease into the interview process. Member checking involved the action of returning of the investigator to each participant after the interview process was complete to ensure correctness of the information given by the participant and to validate the essential structure developed for the preservation of the true meaning of the experiences [15]. The researcher made the participant aware of this at the time of interview sessions. All participants responded via email. Thick descriptions were key to the meaning of research and an important aspect of trustworthiness. The researcher sought permission and verification to use narratives, which was crucial for this study. Finally, audit trail was critical to establishing authenticity and trustworthiness of the data. The researcher documented the research activities over time with clarity and in a systematic way to be followed by others to understand the line of thinking used by researcher at the time of data analysis [16,17]. To ensure methodological rigor the researcher used the processes of phenomenological reduction, bracketing and member checking. The researcher’s attitude was non-judgmental, she practiced the art of openness as the data were revealed, which was carried out before the study began and continued throughout data collection and data analysis [14].

3.5 Ethical considerations

The study was approved by Institutional Review Board, Adelphi University, New York. The researcher obtained a written informed consent from each participant prior to data collection. The participants were assured of confidentiality and the right to withdraw from the study at any time during the research. Anonymity was not completely assured, as the researcher was the interviewer however, the participants’ names were coded to allow for confidentiality when data was examined by experts. Since the study investigated error in the participants’ workplaces, all methods to eliminate and/or avoid coercion were employed always during the research. Permission to tape record the interviews was obtained prior to each interview being conducted. To ensure participant privacy and comfort the interviews were conducted in a private area that allowed for a calm environment [14]. A “cooling-off” period was provided to individual participants before moving the interview forward in case of any emotional upset or distress during the interview process while they reflected upon their experiences of medication errors. Individual participants were also provided the opportunity to reschedule the interview if needed.

3.6 Data analysis

The recorded interviews were transcribed verbatim by the researcher. Transcription of interviews was completed in approximately two months. The data collected from the eight participant’s interviews revealed ten medication errors which were categorized as: unauthorized drug error, wrong route error, wrong dose error, omission error and wrong documentation error (table 2). The interviewer also gathered additional data in the form of field notes for all eight participants. Data were subjected to intense and thorough analysis utilizing Colaizzi’s method, significant statements were extracted and in-depth explanation of the meaning of each statement was achieved after coding the data. This process was valuable in understanding the actual meaning behind each statement made by the participants. Coding and intense analysis of data resulted in two hundred and thirty formulated meanings. All data were coded by hand by the researcher. As the process of coding and recoding continued previously examined codes were re-examined for new codes and repetitions retained for each protocol. The transcripts were reviewed with a doctorally prepared nurse researcher for authenticity and validation of the coding system. Significant statements were subjected to systematic review, formulated meanings were carefully constructed to preserve the context of the protocol as closely as possible to the stated expressions to ensure preservation and significance of their meaning. Formulated meanings were organized into clusters of themes and theme categories. Themes were continuously referred back to the original protocols to ensure validation and commonality of themes.

Table 2: Categories of Medication Errors.

The data were finally organized into nineteen theme clusters and five theme categories. The findings presented are the nurses’ (participants) descriptions of the reality of their lived experiences of making one or more medication errors. The actuality of the meaning was derived from the experiences that these nurses lived through during and after the medication error ocurred. Following are the descriptions derived from the lived experiences of eight registered nurses and are presented under five theme categories.

9.1 Fear and anxiety, self-degradation

Nurses verbalized feelings of extreme emotional and physical nature which resulted from situations after the medication error was committed. Nurses feared for the patient’s wellbeing, but were equally anxious and fearful about being reprimanded, losing their job or professional license. Nurses also expressed thoughts of selfdegradation and remorse with respect to medication error occurrences and blamed themselves for the incidents. These feelings were similar to those expressed by nurses in other related studies [2,3,18].

“I was speechless…I really didn’t know what to do!”

“I feel like I failed my patient that day…”

Nurses, however, also spoke about multiple factors that contributed to these medication errors, particularly, the chaotic demands of the workplace with little or no organizational support. They said that if certain common issues were anticipated and addressed, the medication error/s could have been prevented.

9.2 Being overwhelmed and coping, being a new nurse and facing practice challenges

This study illuminated nurses’ experiences of situations highlighting the complexity of workplace which was exceptionally distressing and overwhelming for nurses as they cared for patients while simultaneously trying to cope with difficult situations. Nurses expressed feelings of frustration and inadequacy when they were unable to complete patient related tasks and were constantly struggling to balance multiple RN responsibilities of patient care along with administering medications.

...when I was in med-surg for three years; it was so stressful…so overwhelming! … you’re dealing with different diagnoses, different treatment plans …antibiotics every 6 hours… you have to draw blood, monitor vital signs… monitor a seizure … patient with infected peg…changing dressings…it’s just heavy task!”

Participants also stated that such experiences were mostly challenging when they were novices striving to familiarize themselves with the intricacies of the profession and simultaneously caring for patients of diverse nature. Nurses spoke about encountering stressful situations with colleagues and nurse leaders and experienced mistreatment and lack of guidance. Previous studies identified similar situations and experiences of nurses that reported inefficiencies, distractions, multiple factors and latent failures significant to error incidents [19-21].

Nurses spoke about altering their own behavior while transitioning from being new to becoming experienced by educating self about routines and policies while managing patient workload with little or no peer or leadership support and explained that these experiences were ‘eye openers’ both personally and professionally in terms of future practice. They described a culture that did not support the new nurses instead, the culture existing within the professionals was to primarily allow the new nurses to succeed or fail on an individual basis and not to offer individual support, acceptance or collaboration. The participants termed it as ‘individual cultural sense’, different but just as destructive as the culture of blame that was generally prevalent in the workplace. Nurses strongly advocated for support systems to be incorporated in workplaces where newcomers should be welcomed and encouraged by senior members of the nursing staff.

9.3 Workplace culture, survival and moving on

Nurses described a common atmosphere of censure and reproach encountered day to day during patient care both in the nursing homes and acute care facilities which was not just limited to medication error incidents. Some nurses described situations where they experienced behaviors of incivility by nurse managers and senior nurses towards them. Nurses emphasized that survival of new nurses in such a challenging work atmosphere is almost impossible and frequently forces new nurses to leave their jobs.

“... as a new nurse there was time management, bullying, that is just there and then, umm…just trying to learn your trade as well as the real-world side of it... and being so unsure of myself...it could happen to anybody...I’ve seen it happen to, you know, experienced nurses as well...”

Nurses were also, greatly concerned that because interruptions and distractions have become so commonplace and such a part of most workplaces in the healthcare arena, that leaders often fail to recognize these as significant factors that may result in most medication errors. Nurses in this study described experiences where they encountered and overcame challenging situations while caring for patients as they moved forward in the practice arena. Nurses also said that they understood the challenges of practice and recognized various barriers present in the current healthcare system and asserted that staff nurses must be included in discussions while addressing common patient issues for safe professional practice. Similar concerns by nurses were reported in previous studies addressing medication errors [22,23,11,24,21].

Nurses strongly expressed that patient care should not be an individual responsibility rather a team effort where members of the healthcare team may be able to depend on each other to deal with critical patient care situations owing to the busy and sensitive workplace environment and explicitly stated the need for change from a toxic environment to one that was just and supportive. Nurses attributed error occurrences to lack of collaboration among healthcare team members in terms of following correct protocol or individual team members following a different protocol or being unaware of the protocol. Nurses in this study stated that most organizational systems currently in place are possibly not very conducive to safe patient care practices, and strongly suggested the utilization of experienced frontline staff nurses in care related discussions to build future safe practices.

9.4 Communication and teamwork, voicing concerns without fear

Nurses in this study expressed concerns about not being able to voice concerns or express their opinions regarding medication errors or other patient care related issues because they were not invited to be a part of discussions vital to their patients.

“…definitely, get their (nurses) input, because they are the ones doing the medication administration, so they have to really be involved in the whole process ... input as far as the policies and procedures and umm…the nurses know the workflow, so you have to go to the nurses!... You have to talk to the nurses because they know what they actually did!”

This markedly draws attention to the fact that nursing is not involved directly in discourses or discussions where patient care concerns are addressed. This aspect is clearly reported by previous medication error studies [3,25].

Participants in this study asserted that nurses’ involvement in patient care and care related decisions should always be a primary focus which is less likely to be successful without effective communication and teamwork. Nurses stated that workplaces that lack communication and teamwork create major barriers for safe and effective patient care which invariably results in medication and other types of errors that compromise patient care. Nurses strongly believed that even though much system improvements have been made, medication errors are still prevalent because nurses are excluded from discussions related to these occurrences. Nurses uniquely and explicitly advocated that having conversations with those nurses who were involved in medication error incidents would be an excellent way to better understand the circumstances that predisposed to the medication error occurrences. Participants felt that nurses’ input is most essential to equip units to reduce such incidents which, going forward would assist organizers and leaders to effectively improve existing work conditions as well as assist nurses to gain back selfconfidence and be able to voice concerns without intimidation from colleagues or supervisors.

9.5 Governance and collegiality

Nurses asserted that staffing decisions are commonly made by nurse leaders where nurses are frequently assigned to different set of patients on the same unit or moved out of the unit to staff another floor which disrupts the continuity of care and work routine. They (staff nurses), on the other hand are not allowed to organize or manage the care of their own patients. This disrupts teamwork and frequently leads to inconsistencies in work routine generating distractions that may promote error occurrences due to unfamiliarity of patients and patient care routines.

“...poor judgment and assigning too many patients with similar names to the same team... you have two nurses a team with 28 or 29 patients, we don’t have a cap in the emergency room.”

“... ‘cause when you have a different nurse, she doesn’t know the patient- she doesn’t know the floor, she doesn’t know the unit or the procedures, what goes on, on that floor, so she tends to be more fidgety and nervous and anxious!”

Literature reviewed reports several studies that have identified disruptions, distractions and interruptions as causes of medication errors and identifies them as the leading cause of medication error. Some studies recommend restructuring nursing and educating staff nurses as well as incorporating specific protocols to reduce medication errors [25-28].

This study highlighted participants’ experiences where nurses explained that because patient care units were constantly busy it was extremely challenging to administer medications safely and simultaneously care for patients especially those that were critically ill with multiple care needs. Nurses expressed distress at the unfair treatment by peers while a few expressed gratitude for being treated fairly and said that support is much needed in times of crisis. Nurses strongly felt that difficult situations warranted coordinated teamwork and collegiality which would help significantly to manage patient care and avoid medication error incidents. Participants suggested involvement of nurses in creating processes for safe medication administration and said that nurses are the persons who understand the medication administration process better than anyone else. Nurses also stated that because they are often the second victims who experience the errors along with patients, they should be the designated change agents to help promote safe medication administration process. Nurses further asserted that adequate staffing as well as a collegial and supportive workplace environment free of intimidation is extremely essential to reduce medication errors.

9.6 Professional security

This study revealed nurses’ concern about the wellbeing of their patients when a medication error/s occurred because they were aware of their responsibility towards the safety of patients. However, nurses were also extremely concerned about their professional security which was mostly generated from a fear of being held accountable if patient was harmed by the error and the culture of blame prevalent in the workplace.

“...people are afraid of losing their jobs, so they’re not gonna say anything or they’ll just be prone to making more errors because the environment is not conducive to one’s learning, for safe practice (blame) and for people to feel comfortable…to say, “ok I made a booboo, don’t, don’t kill me!”

All participants in this study agreed that underreporting of medication errors was largely due to an underlying fear of losing one’s job. These findings were identified by previous medication error studies [20,29,2].

Most participants in this study described a general atmosphere of hostility in the workplace where nurses were against nurses and the workplace culture was that of animosity and antagonism towards each other. Nurses felt that one wrong move may jeopardize their job because they were either new to practice or new to the unit and were constantly made to feel that they needed to prove themselves to their colleagues. Nurses felt that they were being set up for failure which rendered them incapable of handling patient situations professionally. Nurses described feelings of being unwanted and undeserving of the RN position mostly after the medication error incident and felt that senior nurses tried to make them look incompetent in the sight of the nurse manager as if they committed a misdemeanor. Nurse colleagues often tried to implicate them in multiple ways which generated insecurity and a fear of losing their professional status. Participants believed that maintaining a job status was more important than being hired as a RN for the first time. Nurses in this study strongly suggested that healthcare leaders need to strengthen frontline staff nurses by eliminating the culture that exudes constant criticism, reprimand and rebuke and inculcate the workplace environment with collegiality and support.

11.1 Nursing practice and healthcare organizations

It is common knowledge that making errors is part of the human experience therefore; nurses and other healthcare professionals being humans may commit medication errors. According to Reason [30] there are two ways to view causes of human errors. The person approach attributes the errors to individuals (culture of blame) and the system approach assess deficiencies in the existing systems and recognize individuals to be fallible (just culture). Research suggests that perceptions of a safe patient care environment and safety culture in healthcare facilities vary among staff nurses and nurse leaders because of differences in their viewpoints which is a major deterrent to quality patient care and a concern among staff nurses [31,32]. Other medication error studies were found to be linked to lateral violence and bullying [33,34].

Present-day healthcare system has metamorphosed in numerous ways, the most significant of which is the eminence of RN roles and responsibilities of patient care. This transformation calls for frontline nurses to be leaders at the bedside with full dominion and responsibility of patient care. The findings of this study suggest that nursing practice and healthcare organizations consider the following recommendations:

• Provide at all times, adequate staffing on units, not only based on numbers but also consider the acuity and diversity of the patient population to enable prioritization of care and teamwork while providing safe and quality care to all patients.
• Remodel workplace culture to champion collegiality among all members of the nursing team as well as among the interdisciplinary healthcare team members for better and improved patient outcomes.
• Restructure to build a non-toxic, blame free and stress-free culture in workplaces enabling nurses to voice patient related concerns and be change agents for better patient outcomes.
• Organizational and nurse leaders may create and/or incorporate programs that provide staff nurses with learning experiences of high caliber and quality for the continued enhancement their management skills to encourage professional growth and safe quality patient care.

11.2 Nursing education

Being that nursing students have restricted and supervised exposure to patients, it is a common observation that they acquire very limited experience in the care of patients. Therefore, it is vital that new graduate nurses should be guided and supervised by experienced nurses, especially in the first year of nursing practice [35,36]. Participants in this study revealed new realizations with implications for nursing education that underscored the importance of educating student nurses who are about to graduate in a way that they can anticipate and overcome obstacles while entering practice to reduce medication error incidents. The findings of this study recommend and/or suggest that nursing educators may consider the following recommendations:

• Qualitative medication error studies about nurses’ lived experiences may be conducted in other states of the USA, other countries and globally for a varied perspective of medication errors in other healthcare systems currently across the USA and worldwide.
• Quantitative medication error studies to compare and correlate medication errors to staff nurse concerns about patients and nurses across the healthcare systems.
• Research studies to further investigate medication error categories to understand what really constitutes a medication error in the administration process and staff nurse involvement.
• Studies for in-depth investigation of medication errors from the perspective of student concerns to understand challenges of transition into practice. This may assist nurse educators to formulate ways for seamless transition of new nurses into practice.