Awareness of reporting practices and barriers to incident reporting among nurses

The persistence of clinical incident, errors, preventable adverse events, and hazards threatens patient safety and increases the burden of care, costs of care, and length of stay for patients which may lead to increased mortality of patients [1]. Indeed, more than 15% of healthcare organizations’ budget is spent on extra hospitalization costs, litigations, and other consequences of errors [2]. One in 10 hospitalized patients faces an adverse event during their hospitalization [3, 4], and nurses account for most errors, according to studies [5, 6].

As members of multidisciplinary teams, nurses play an essential role in providing a variety of care practices to patients in hospitals [7]. Nursing is considered a demanding job because it requires multitasking and poses a heavy workload, in addition to the need to provide specialized care to seriously ill and dependent patients can be intimidating for nurses [8]. Incident highly affect the safety of patients, their families, the staff, and the success of the whole organization. Incident reporting practices comprise how often nurses promptly and adequately report clinical incident, errors, preventable adverse events, and hazards [9]. However, many clinical incidents are underreported [10‐12]. According to an Egyptian study, nurses need improvement in knowledge, attitude, and practices related to incident reporting [5].

Incident reporting practices of nurses and safety practices are highly related to nurses’ perceptions of their organizational culture, including values, behaviors, ways of communication, spreading myths and gossip, attitudes, and commitment to safety, which impacts the patient care quality [13, 14]. However, adequate incident reporting practices for clinical incident among nurses, and even all healthcare providers in clinical practice settings, is crucial to enhance patient safety and improve the quality of care delivery [6].

To achieve high care quality, managers need to have sufficient information on incident rates and types. Therefore, it is essential to encourage adequate reporting practices among nurses. Gathering all necessary information on patient safety reported by healthcare practitioners can assist healthcare managers in understanding system errors and create changes to decrease the probability of incident reoccurrence [6, 15]. Thus, adequate reporting for all types of incident by healthcare practitioners is paramount for patients’ safety as well as organizational success.

Several factors are associated with the under-reporting of incident reporting, such as lack of knowledge, time, workload, personal fear, and embarrassment from the manager and colleagues [15]. Addressing the correct incident reporting practices, identifying factors that contribute to the under-reporting of an incident, and assessing the preventive measures can ultimately help minimize the occurrence of incident and enhance reporting practices. In Jordan and other countries, few studies have discussed nurses’ and other health professionals’ awareness about reporting incident and evaluating reporting barriers [12, 13, 16]. Mrayyan et al. stated that during a nurse’s career, an average of 2.2 errors per a Jordanian nurse were reported with 42.1% as the rate of reported medication errors [12]. The aims of this study were to investigate the level of awareness of incident reporting practices and identify the barriers that impact incident reporting among Jordanian nurses, followed with research questions:

The current study results showed that registered nurses had high level of awareness of incident reporting. These results were consistent with Chen et al., who found that the nurses’ perceptions toward incident reporting practices were high [18]. In addition, the vast majority of the registered nurses participating in the current study (94.8%) declared that they were aware of the existence of incident reporting systems in their healthcare institutions. These results align with the results of AbuAlRub et al., which revealed that almost all the surveyed nurses were aware that their healthcare institutions had an incident reporting system [19]. These results could be due to the efforts and activities of the accrediting bodies and the awareness campaigns held in Jordanian hospitals to increase healthcare providers’ awareness about the incident reporting system.

The results of the current study revealed that around 60% of the surveyed participants had filled in an incident report at least once in their practice, which is consistent with the results of Farzi, et al., who reported that around two-thirds of staff nurses had ever filled in an incident report [20]. However, the results of the current study are to some extent consistent with the results of Agegnehu et al., which found that 80% of the surveyed healthcare professionals had ever filled an incident report [21].

Although most participants had a high level of awareness of the incident reporting, only 32% of the surveyed nurses had filled in an incident report in the last month of the time of data collection. This result is slightly different from the findings of AbuAlRub et al. in which they found that 42.2% of the surveyed nurses had filled in an incident report in the last month at the time of data collection [19]. Many factors could have impacted this result, such as a low volume of near misses or adverse events at that time because it concerns a limited period which is one month.

The participants in the current study knew that the incident reporting system existed, but there was some uncertainty regarding how to locate or access the form, as just 69.3% of the participants knew how to locate or access the incident form. The current results align with Evans et al., which revealed that around two-thirds of the surveyed participants knew how to locate or access the incident form once needed [17]. Moreover, these results align with Alboliteeh and Almughim, who found that nearly 62% of the participants reported no confusion regarding access to the occurrence variance report (OVR) System [22]. However, the current results are considered to some extent consistent with AbuAlRub et al., in which they found that 80.8% of the surveyed nurses had reported that they knew how to locate or access an incident form in their hospitals [19]. These differences might be attributed to the inattention of some nurses to the general orientation programs at the beginning of their practical lives, wherein the incident reporting system and safety issues are discussed thoroughly [22].

Regarding the question of what to do with the completed incident form 63.7% of the participants knew what to do with the completed incident report once it was done. This result is consistent with Agalu et al., which showed that nearly two-thirds of the surveyed participants knew what to do after completing the incident form [23]. On the other hand, these results are in line with AbuAlRub et al., who found that nearly 70% of the surveyed nurses knew what to do with the completed incident form [19]. However, in Alboliteeh and Almughim’s study, almost all the surveyed participants (94.3%) had good knowledge about what to do with the completed incident report [24]. This incongruence might be because some nurses believe in-charge nurses and safety managers are responsible for proceeding with a completed incident form.

The results of the current study revealed that registered nurses perceived their reporting practices at the medium level, with a mean score of 2.23 out of 4. The results of the current study are consistent with the results of Kusumawati et al., in which they found that nurses’ perceptions toward incident reporting practices in Indonesian hospitals were above the average [25]. Many factors influence the behaviors of nurses regarding incident reporting. These factors include the clarity of reporting system, the existence of patient safety culture, workload such as staffing-related problems and heavy assignments, severity of the incident or error [26‐28], and colleague support among the different units and floors [29]. Differences also might be attributed to the difference in the perception of the importance of incident reporting for quality healthcare among health professionals in different countries.

Concerning the incident that participants in the current study reported, only 26.2% of the registered nurses always reported an incident of “patient received wrong treatment or procedure.” This was the highest percentage among all incident, meaning that nurses perceived an incident of wrong treatment or procedure as important always to report. This result is consistent with the results which revealed that the wrong procedure or wrong treatment was among the top most frequently reported incident among health workers [30]. Additionally, this result was consistent with Fathi et al., who found that the wrong treatment or medication time was among the most reported incident among the surveyed nurses [31]. In contrast, the current results are paradoxical to the results conducted at Jordanian hospitals, which revealed that the surveyed nurses most often reported equipment fault resulting in patient harm, not for any other incident type [19].

Incongruencies in general might be because variables such as organizational culture, climate, perceived severity of the incident, gender of the victim, type of the ward, and perceived consequences of reporting in different healthcare systems create differences. It also might be attributed to differences in the perception of the importance of incident reporting for quality healthcare among nurses [32]. In addition, previous research may have used different instruments, study designs, or study settings than the current study which can affect the interpretations of the findings.

The current results revealed that only 14.8% of registered nurses reported an incident of “breach in confidentiality such as information given without authority” all the time, which is the lowest percentage among all incident. These current results are consistent with the results of Sakuma, who found that student nurses did not always report a breach of confidentiality of patients [33]. Wondmieneh, et al. stated that the unit type affects confidentiality reporting issues among nurses [32]. This congruence might be because some healthcare workers believe that confidentiality of patient information is not a severe event that can affect a patient’s health status and safety.

The current study showed that more than a quarter of participant’s nerve reported incident for patient sustained a DVT post-operatively due to inadequate prophylaxis. This result contradicts AbuAlRub et al. in which around 24.9% of the surveyed nurses reported “post-operative DVT due to inadequate prophylaxis [19]. Also, the recent studies nurses reported inadequate prophylaxis of DVT [34‐36].

The current study revealed that 53.2% of the registered nurses did think that they should report an incident of “patient sustained a pressure sore whilst in hospital” all the time, which is the highest percentage among all incident. This result aligns with retrospective review study which showed the high incidence of pressure ulcer which might be related under-reported [37]. In another retrospective study, demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance [38, 39]. Half of the participant’s think that they report the injury due to a fall in hospital. This result does not align with Jordanian study, which revealed that 80% of the surveyed nurses thought that they should report an incident of “patient injury due to fall” all the times, which was the highest percentage [19]. The current results are highly congruent with the results of Heslop and Lu, that pressure ulcers and falls were the two most frequent outcome measures that are nursing-sensitive indicators [40].

The results of the current study revealed that 39.4% of the nurses thought that they should report an incident of “breach in confidentiality such as given information without authority” all the times, which is the lowest percentage among all incident. The current results might be explained by the fact that bedside nurses believe that pressure ulcers incident should be reported all the times (regardless its degree) because it is a frequent and common issue in all clinical settings all over the world that is given higher priority in hospital education programs than confidentiality problems. Plus, many nurses perceive a pressure ulcer incident as an indicator of poor quality of care rather than a system failure, which requires the nurses to make quick decision-making [41, 42]. Moreover, this result is slightly consistent with the results of AbuAlRub et al., in which they found that around 45% of the surveyed nurses believed that they should report an incident of “breach in confidentiality” at all times [19].

Regarding barriers of reporting that registered nurses conveyed in the current study, the results revealed that the highest frequency among all barriers was for worrying about disciplinary actions. This result aligns with study in Saudi Arabia, where “Nursing administrative response to the error” had the highest frequency among all barriers to incident reporting [43]. Taylor et al., claimed that this barrier can be reduced by the implementation of an anonymous reporting system [44].

The participants feared being blamed mostly by junior staff (46.5%). These studies also ascertain that blamed is a major barrier [45, 46], the current results could be because human beings generally do not prefer to be punished by their supervisors and managers and do not want to be fired or have their careers derailed. Few participants strongly agree that they will not get feedback of report something (11.6%), this result was agreed with recent study [47]. This negative tendency can seriously affect and distort nurses’ sense of accountability and moral obligation in the future. Therefore, active communication between nurses and the supervisors contribute for quality and assuring patients’ safety [3, 8].

Nurses working in accredited hospitals demonstrated showed higher awareness of incident reporting and self-perceived reporting practices than non-working in non-accredited hospitals. This result was similar with a systematic review that nurses in the accredited hospitals found positive safety culture, patient satisfaction and experience, and employee satisfaction [48]. However, awareness campaigns, leadership support, and better design of accreditation standards and processes are vital remedies to consider [49].

The participants with postgraduate degrees and having 11 years of experience or more showed higher awareness than other groups, the results agreed with study conducted among Jordanian nurses [50]. Studies described that when experience and education increases, hospital quality of service also increase [14, 26]. Possibly inexperienced and newly graduated healthcare givers suffer from stress regarding practice, which makes them vulnerable to an increased incidence of errors [39]. Huge numbers of staff with inadequate experience and insufficient concerns for incident reporting are a risk to patient care.

Variations exist in the perceived barriers that hinder nurses from reporting incident due to several factors such as differences in perceptions of the barriers, personal factors such as seniority and experience, organizational culture, and work circumstances. The current results provide empirical results about perceived incident reporting practices and perceived barriers to reporting frequently, which urge nursing policymakers and legislators to provide solutions for these barriers, such as staffing issues, nursing shortage, nurses’ empowerment, and fear of disciplinary actions by front-line nurse managers.