Having introduced the research the thesis will now be outlined. Each of the following chapters contains further detail regarding this research.
Chapter 2 is presented in two parts. Part I provides the background to the research including the importance of error management and error disclosure. The context of the research is also introduced, including the non-static nature of the health care system. An overview of health services in Tasmania, the location of this research, is provided.
The second part of Chapter 2 explores the literature in relation to error reporting, error disclosure and safety climate. Areas of difference that have been noted in previous studies are outlined, including differences between rates of error reporting and disclosure as well as differences in relation to workplace setting, work role and various other factors. Research related to safety climate and teamwork is also presented, again noting differences relating to workplace setting and work role. Literature relating to the relationship between safety climate and error reporting and disclosure is also examined in this chapter
Chapter 2 concludes with the development of the aim and main research question that is explored in this research. The first three research sub-questions informing the main research question and aim are also presented.
In Chapter 3 the contrast between evidence based medicine (EBM) and complexity science is presented. This contrast is then explored within a framework of health care as a complex system, thereby forming the theoretical framework for this
13 research. Knowledge is discussed in terms of an absolute truth as compared with an
understanding which is mirrored in the framework as knowledge generation based on evidence and sense-making. Configurational comparative methods (CCM) are introduced as a means of researching the complexity of health care. Two further research sub-questions are presented at the conclusion of this chapter.
The method is outlined in Chapter 4. This includes the research design for use of CCM. This design is based upon the funnel of complexity which consists of the three phases of before, during and after the analytic moment.
The first phase consists of using existing theoretical knowledge to inform this design, including data collection and data analysis. This is outlined in detail in Chapter 4 in relation to the development of a questionnaire based upon existing available tools.
A variable-based approach to analysis (inferential statistics) has been used alongside the case-based analysis of fuzzy set qualitative comparative analysis
(fsQCA). The first is undertaken in the before the analytic moment phase as some results inform the analysis using fsQCA. Details of the variable-based analysis are outlined in detail.
This is followed by details of the analysis using fsQCA. The analysis proper is the second phase, termed during the analytic moment. Once this has been outlined an overview of how the fsQCA results are presented is provided.
Chapter 5 provides the results in two separate parts. Variable-based results are presented in Part I and the case-based results are included in Part II.
Variable results include frequency data relating to the demographic data allowing for an overview of the sample to be provided. This includes, where possible, assessment of sample representativeness.
14 Other results include those relating to safety climate and the identification of
factors of teamwork and safety climate through principal components analysis. These form the basis of the conditions for analysis with fsQCA.
The final chapter, Chapter 6, interprets the results. This represents the final phase of the funnel of complexity or the after the analytic moment. This phase requires results to be interpreted in respect to the theoretical knowledge that underpinned the research design.
Both variable and case-based results are interpreted in this fashion, with consideration also given to each of the research sub-questions as well as to the overall main research question and the research aim.
The limitations of the research are also discussed in Chapter 6. These are outlined in relation to research design, analysis and generalisability of the results. The chapter concludes with a discussion of the implications of the research findings upon future practice along with suggestions for future research.
The need for improvements in patient safety and health systems reform have been referred to as a “quality chasm” (Institute of Medicine, 2001). The following
chapters outline research that has been undertaken with the aim to describe the complexity of safety climate of nurses working in rural clinical settings. In doing so it makes a contribution to narrowing the quality chasm.
15
2
The complex nature of health care
error
Patient harm resulting from human error remains an ongoing challenge for health care. The issue is important to consumers, clinicians, managers and government. Despite almost a quarter of a century of work aimed at improvement, patient safety remains an ongoing matter of both public and professional debate.
Health care services form a complex system. Understanding and managing error within that complex system is important for providing safe patient care. This, along with the impact of safety culture, is the subject of this research.
The key role of this chapter is to provide an overview of both the context and
literature and outline how each of these informed the development of the research. The chapter is divided into two parts with the first of these providing an overview of the background of patient safety and provides the context for the research. The second part discusses how the available literature has informed the research aim and research question.
The complex nature of health care is outlined in Part I. The global context of patient safety is presented followed by background in relation to the Australian context. Information about health services and recent developments in Tasmania is then provided.
Following this the complexities that evolve from defining error are discussed with specific consideration given to error and the disclosure of error in health care settings. Some background is also provided about current law and policy in relation to these matters in the Australian context.
Approaches to patient safety and error management are then presented
16 care is outlined including discussion of the differences found when comparing health care compared to other industries. Part I concludes with an overview of medication error within the Australian context.
Part II provides detail of current knowledge of error reporting and error disclosure. It commences with an examination of the publications available from a recent search of the literature relating to error reporting and disclosure. This is followed by a summary of the literature relating to error reporting and disclosure and the differences that exist based upon workplace setting, work role and other factors. At the end of Part II is a discussion of safety climate that focuses on how differences have been found in these same areas in relation to variations in safety climate. The chapter concludes with an explanation of how the literature has informed the research. From this discussion the development of the research aim and research question are outlined. Three research sub-questions, necessary for informing the overall research question, will also be presented. A constant theme throughout both parts of the chapter is that health care delivery, error reporting and disclosure and safety climate are areas that are extremely complex.
17