Knowledge, Attitude and Barriers of Nurses to Incident Reporting in Al Dhafra Hospitals, Abu Dhabi, United Arab Emirates ()
1. Introduction
Incident reporting in the health care system is crucial to improving patient safety and quality of care. World Health Organization defines an incident as “any deviation from the usual care that poses a risk of harm or causes injury to a patient, it includes errors, preventable adverse events, and hazards”. The objective of incident reporting is to identify and address adverse events, near misses, and other incidents related to the safety of patients and to implement corrective action plans to prevent the future recurrence of the incidents. Developing an atmosphere of safety culture in hospitals will motivate and encourage everyone to point out and report any deviation from normal. A non-punitive culture toward incident reporting in hospitals is essential for promoting patient safety, learning from mistakes, and improving the overall quality of care.
Nurses are the largest component of the hospital workforce and significantly influence patient safety and healthcare outcomes. Reporting errors fosters a culture of safety within healthcare organizations. Patient safety event reporting systems are widespread in healthcare organizations and are the backbone of detecting patient safety events and quality problems (Kapil & Anoopjit, 2020). The significance of reporting systems is situated in the ability to detect errors and risky situations, analyze root causes, and take corrective measures (Kaya et al., 2020). In a study conducted in Ethiopia, 73% of the nurses mentioned that any incident that will not cause harm to the patients will not be reported (Engeda, 2016). Errors can lead to an economic burden on the organization and cause additional costs because of re-hospitalization (World Health Organization, 2020). A non-punitive or just cultural atmosphere in hospitals will encourage the nurses to report any incidents without any hesitation. There should be a lack of blame for motivating people to be more engaged and be a part of the solution instead of fearing for their careers (Dekker, 2018). A well-explained and effectively communicated incident assists everyone in knowing the situations in which that incident occurred, learning the lesson from it, and preventing future occurrences. Nurses refrain from reporting medication errors, even though they detect them (Dirik et al., 2019). Each error offers a chance to learn. Whether it’s an operational mistake or a product defect, understanding what went wrong provides insights into what needs to change or improve. This learning can lead to better practices and procedures in the future. In the context of continuous quality improvement, every error indeed presents an opportunity to improve (Hamed & Konstantinidis, 2022). Lack of time was identified as a main barrier to incident reporting, and the availability of report pathways was the proposed solution (Abeer et al., 2020).
Patient safety will be compromised if the errors are either not reported or underreported (Vrbnjak et al., 2016). Early detection of errors and corrective actions on time will help to prevent recurrences in the future (Heard et al., 2012; Ghorbanpour Diz et al., 2016). There are a lot of factors affecting the nurses to move away from reporting incidents, such as workload, heavy assignments, and lack of clarity about the system of reporting and the incident (Alrabadi et al., 2020; Ali et al., 2021).
Study Objective
The study is conducted to assess the knowledge, attitude, and barriers to reporting incidents among the nurses working in Al Dhafra hospitals.
2. Materials and Methods
2.1. Research Design
A descriptive design was employed to assess the knowledge, attitude, and perceived barriers among nurses to incident reporting.
2.2. Research Settings
The study took place in Al Dhafra Hospitals, Abu Dhabi, United Arab Emirates. The target population refers to the specific group that fits the researcher’s predetermined criteria for inclusion in the study. The research study focused on nurses employed in Al Dhafra Hospitals as the target group.
2.3. Sample Size
The sample consisted of 168 nurses who are employed in Al Dhafra Hospitals. The researchers utilized convenience sampling to get the data from the nurses working in different units in Al Dhafra Hospitals. In the context of this study, the inclusion and exclusion criteria refer to the specific requirements that were used to determine which nurses were eligible to participate. All nurses who were accessible during the data collection period and willing to participate in the study are eligible for inclusion without any exclusion criteria.
The crucial element of doing research is the careful selection and development of tools that will enable the collection of relevant information. These tools are essential for obtaining the required data to address the research questions posed in the study. The tool was developed based on a literature review and with guidance from renowned professionals in the research and nursing domains. Additionally, the relevant areas of the tool were informally observed.
The tool is divided into four parts.
Part A: Demographic outline encompassing gender, age, total working experience, and the workplace in Al Dhafra Hospitals.
Part B: Self-structured questionnaire designed to assess the knowledge of the nurses.
Part C: Utilizing a Likert scale to check the attitude of the nurses.
Part D: Checklist for evaluating the perceived barriers among the nurses.
3. Results
3.1. Descriptive Statistics
Part A: Socio-demographic profile:
The sociodemographic profile of nurses at ADH facilities reveals a significant majority of female employees, comprising 78% of the workforce. This aligns with the prevailing patterns observed in the healthcare sector as a whole. 48.8% of the employees are within the age range of 30 - 39 years, indicating a workforce that has the potential for both long-term retention and expansion. A noteworthy observation is that a considerable percentage (37.5%) of individuals have more than 16 years of professional experience, indicating the presence of a highly experienced and qualified staff group. Ghiathy Hospital functions as the primary workplace for almost half of the participants (43.5%), suggesting that the concentration of workers may have an influence on techniques for distributing resources. Descriptive Statistics of the socio-demographic profile of the study are shown in Table 1.
Table 1. Demographic profile results.
Variables |
Socio-demographic profile |
Frequency |
Percentage |
Gender |
Male |
37 |
22.0 |
Female |
131 |
78.0 |
Age |
20 - 29 years |
15 |
8.9 |
30 - 39 years |
82 |
48.8 |
40 - 49 years |
47 |
28.0 |
50 years and above |
24 |
14.3 |
Total working
experience |
1 - 5 years |
25 |
14.9 |
6 - 10 years |
47 |
28.0 |
11 - 15 years |
33 |
19.6 |
16 years and above |
63 |
37.5 |
The facility of work in ADH (Workplace) |
Madinat Zayed Hospital |
12 |
7.1 |
Ghiathy Hospital |
73 |
43.5 |
Mirfa Hospital |
31 |
18.5 |
Sila Hospital |
11 |
6.5 |
Liwa Hospital |
21 |
12.5 |
DFMC |
4 |
2.4 |
Sir Baniyas Clinic |
1 |
.6 |
Beda Mutawa Clinic |
1 |
.6 |
Abu Al Abyad Clinic |
2 |
1.2 |
Delma Hospital |
12 |
7.1 |
Total |
168 |
100.0 |
Part B: Knowledge of nurses:
The dataset provides a detailed representation of several components of incident reporting as perceived by nurses, indicating comprehensive knowledge and adherence to protocols. Approximately 72.6% of individuals acknowledge that both medication errors and diagnostic delays are considered events, indicating a significant level of awareness regarding common occurrences in hospitals. Moreover, 98.8% of individuals fully comprehend the fundamental concept of incident reporting, which entails documenting atypical occurrences within the hospital environment. The responsibility for preparing the report is widely recognized, with 95.2% giving it to all staff, highlighting a communal approach to incident management. The main objective as determined by 97% of the participants is to enable essential modifications to avoid future occurrences, emphasizing a proactive approach to improving patient safety. Furthermore, the predominant category of occurrence, as indicated by 86.3% of the participants, encompasses both near misses and sentinel events, indicating a sophisticated comprehension of the range of incidents that can take place in healthcare environments. Descriptive Statistics of the knowledge of the nurses are shown in Table 2.
Table 2. Knowledge of the staff nurses.
Knowledge of the staff nurses |
Response Option |
Frequency |
Percentage |
What is considered as an incident? |
Transfer/discharge of patient |
1 |
0.6 |
Fall/Medication error |
39 |
23.2 |
Delay/cancellation in any diagnostic test |
6 |
3.6 |
Both 2 & 3 |
122 |
72.6 |
Following is a type of incident? |
Near miss |
14 |
8.3 |
Sentinel events |
9 |
5.4 |
Both 1 & 2 |
145 |
86.3 |
What is incident reporting? |
Record of details of an unusual event in hospital |
166 |
98.8 |
Record of shift changes of staff nurses |
1 |
0.6 |
Record of previous hospitalization |
1 |
0.6 |
What is included in incident report? |
Date, time and location |
2 |
1.2 |
Detailed documentation of incident |
15 |
8.9 |
Both 1 & 3 |
151 |
89.9 |
Who is responsible for formulation of incident report? |
All employees |
160 |
95.2 |
Supervisor |
3 |
1.8 |
Ward attendant |
1 |
0.6 |
Nurse in-charge |
4 |
2.4 |
What is the intended goal of incident reporting? |
Provide information in the medical report |
1 |
0.6 |
Identify changes needed to prevent
re-occurrence |
163 |
97.0 |
Document actual injury in follow-up action |
4 |
2.4 |
How can you recognize poorly written report? |
Factual |
6 |
3.6 |
Judgmental towards others |
137 |
81.5 |
Short and to the point |
19 |
11.3 |
Location specific |
6 |
3.6 |
What is the need to report an Incident? |
To get appraisal |
2 |
1.2 |
To promote awareness |
148 |
88.1 |
To get others’ opinion on incident |
18 |
10.7 |
What is a “Near Miss”? |
No harm to the patient |
121 |
72.0 |
Events that lead to harm to the patient |
29 |
17.3 |
A planned event that threatens human safety |
11 |
6.5 |
An unpreventable incident |
7 |
4.2 |
What are the questions that must be answered while completing an incident report? |
Where, when, and what happened to cause the incident |
15 |
8.9 |
All of the above |
153 |
91.1 |
What are the key components of effective reporting? |
Short and concise report |
138 |
82.1 |
Medical reports and scene safety |
6 |
3.6 |
Patients’ personal information and type of incident |
21 |
12.5 |
Verbal reporting to the supervisor |
3 |
1.8 |
Part C: Attitude of Nurses:
An examination of the attitudes of nurses about the reporting of adverse incidents demonstrates that the majority strongly advocate for open reporting standards. Specifically, 92.9% of the nurses endorse the reporting of every incident, indicating a robust dedication to enhancing patient safety through transparency. A majority of nurses (73.2%) dismiss the idea that reporting occurrences will harm their reputation, indicating a professional acknowledgment of reporting as an essential safety precaution. Moreover, a substantial proportion of individuals hold the belief that decreasing nurse-patient ratios (58.9%) and enhancing training in clinical processes (91.7%) are crucial for mitigating unpleasant events. There is widespread agreement among nurses regarding the significance of systemic enhancements and professional growth in improving patient care and safety. Descriptive statistics of the attitude of the nurses are shown in Table 3.
Table 3. Attitude of nurses.
Attitude of the Staff Nurses |
Response Option |
Frequency |
Percent |
Every incident should be reported |
Agree |
156 |
92.9% |
Uncertain |
8 |
4.8% |
Disagree |
4 |
2.4% |
Reporting adverse incident will spoil my reputation |
Agree |
16 |
9.5% |
Uncertain |
29 |
17.3% |
Disagree |
123 |
73.2% |
Reducing the nurse-patient ratio will reduce the adverse incidents |
Agree |
99 |
58.9% |
Uncertain |
29 |
17.3% |
Disagree |
40 |
23.8% |
Better training in clinical procedures will reduce adverse incidents |
Agree |
154 |
91.7% |
Uncertain |
9 |
5.4% |
Disagree |
5 |
3.0% |
Only those events should be reported which can be a learning for others |
Agree |
63 |
37.5% |
Uncertain |
35 |
20.8% |
Disagree |
70 |
41.7% |
Reporting adverse incidents will make people accountable for their actions |
Agree |
77 |
45.8% |
Uncertain |
31 |
18.5% |
Disagree |
60 |
35.7% |
Reporting incidents will lead to positive patient outcome |
Agree |
160 |
95.2% |
Uncertain |
7 |
4.2% |
Disagree |
1 |
0.6% |
Reporting adverse incidents will expose your mistakes |
Agree |
38 |
22.6% |
Uncertain |
43 |
25.6% |
Disagree |
87 |
51.8% |
Only serious adverse incident should be reported |
Agree |
19 |
11.3% |
Uncertain |
20 |
11.9% |
Disagree |
129 |
76.8% |
Reporting adverse incidents will lead to punishment/written explanation |
Agree |
24 |
14.3% |
Uncertain |
37 |
22.0% |
Disagree |
107 |
63.7% |
Reporting an incident will lead to analysis of that event by hospital committee |
Agree |
148 |
88.1% |
Uncertain |
17 |
10.1% |
Disagree |
3 |
1.8% |
Reporting adverse incidents will lead to gossip among colleagues |
Agree |
22 |
13.1% |
Uncertain |
41 |
24.4% |
Disagree |
105 |
62.5% |
Reporting an incident will lead to a risk of losing job |
Agree |
14 |
8.3% |
Uncertain |
37 |
22.0% |
Disagree |
117 |
69.6% |
Reporting an incident is not required because we can’t control their occurrence |
Agree |
16 |
9.5% |
Uncertain |
11 |
6.5% |
Disagree |
141 |
83.9% |
Part D: Perceived Barriers among nurses:
The poll “Perceived Barriers” identifies various notable barriers that nurses encounter while reporting unfavourable situations. The primary barrier identified is time constraints, with 69% of nurses stating that they are excessively occupied or lack the time to report incidents competently. Additionally, 56% of respondents indicate a concern about fear of legal repercussions. Confidentiality concerns have a notable impact, affecting 45.8% of nurses. Additional significant obstacles include concerns over the influence on professional advancement and standing (49.4%), uncertainty on which instances should be disclosed (45.2%), and challenges in reporting occurrences involving higher-ranking personnel (44%). Other concerns encompass the disruption caused by the reporting process (32.1%), the overly long reporting documents (41.1%), and the absence of information on activities made in response to reports (25.6%). These barriers indicate specific places where enhancements could improve reporting practices and overall patient safety. Descriptive Statistics of the attitude of the nurses are shown in Table 4.
Table 4. Perceived barriers among nurses.
Perceived Barriers |
Response Option |
Frequency |
Percentage |
Lack of confidentiality |
Yes |
77 |
45.8% |
No |
91 |
54.2% |
Too busy/Lack of time |
Yes |
116 |
69.0% |
No |
52 |
31.0% |
Fear of legal actions |
Yes |
94 |
56.0% |
No |
74 |
44.0% |
Pointless nothing will be done about it |
Yes |
53 |
31.5% |
No |
115 |
68.5% |
Fear of career and personal reputation |
Yes |
83 |
49.4% |
No |
85 |
50.6% |
Lack of clarity about what to report |
Yes |
76 |
45.2% |
No |
92 |
54.8% |
Difficulty in reporting a more senior member of staff |
Yes |
74 |
44.0% |
No |
94 |
56.0% |
Never get any feedback on action taken |
Yes |
43 |
25.6% |
No |
125 |
74.4% |
Reporting interrupts the work process |
Yes |
54 |
32.1% |
No |
114 |
67.9% |
Everyone makes errors |
Yes |
76 |
45.2% |
No |
92 |
54.8% |
Form takes too long to complete |
Yes |
69 |
41.1% |
No |
99 |
58.9% |
3.2. Correlational Analysis of Variables
This analysis investigates the correlations among knowledge, attitudes, and perceived barriers among 168 nurses, who are working in Al Dhafra Hospitals. The analysis indicates a modest inverse connection between knowledge and attitudes (r = −0.128, p = 0.098), suggesting that as knowledge levels rise, attitudes may marginally decline. However, this correlation is not statistically significant. There is also a statistically significant, yet still weak, negative correlation between knowledge and perceived barriers (r = −0.154, p = 0.046), indicating that increased knowledge is associated with fewer perceived barriers. Additionally, there is a weak positive correlation between attitudes and perceived barriers (r = 0.192, p = 0.013), implying that more positive attitudes are linked to the perception of more barriers. The correlation coefficients are displayed in Table 5.
Table 5. Correlations result.
|
Knowledge |
Attitudes |
Perceived Barriers |
Knowledge |
Pearson Correlation |
1 |
−0.128 |
−0.154* |
Sig. (2-tailed) |
|
0.098 |
0.046 |
N |
168 |
168 |
168 |
Attitudes |
Pearson Correlation |
−0.128 |
1 |
0.192* |
Sig. (2-tailed) |
0.098 |
|
0.013 |
N |
168 |
168 |
168 |
Perceived Barriers |
Pearson Correlation |
−0.154* |
0.192* |
1 |
Sig. (2-tailed) |
0.046 |
0.013 |
|
N |
168 |
168 |
168 |
*Correlation is significant at the 0.05 level (2-tailed).
3.3. Hypothesis Testing
Various hypotheses are generated according to the literature search performed at the beginning of this search.
H1: There is a significant relationship between nurses’ knowledge of incident reporting procedures and their attitudes towards incident reporting.
H2: There is a significant relationship between the perceived barriers to incident reporting and nurses’ attitudes towards incident reporting.
The regression model shows a very low R-square value of 0.016, indicating that knowledge explains only 1.6% of the variance in attitudes, suggesting a weak predictive power. The p-value is 0.098, which is above the conventional significance threshold of 0.05. Therefore, Hypothesis H1 is rejected, as the data does not support a significant relationship between nurses’ knowledge and their attitudes towards incident reporting. On the other hand, the regression model for barriers shows a slightly higher, but still low, R-square of 0.037, explaining 3.7% of the variance in attitudes. However, p-value is 0.013, indicating statistical significance at conventional levels. Therefore, Hypothesis H2 is accepted, supporting a significant relationship between perceived barriers and nurses’ attitudes towards incident reporting. This result implies that addressing these barriers could be key to improving attitudes and practices around incident reporting in the hospital setting. The regression results are shown in the following Table 6.
This implies that nurses who identify more barriers may also perceive a higher significance in overcoming these barriers, maybe indicating a resilience or heightened understanding of the consequences of not reporting incidences. Although the model has statistical significance, its practical usefulness is limited. This suggests that other factors, such as organizational culture or support systems, which have not been explored, may have a crucial influence on attitudes toward incident reporting. This highlights the necessity of conducting a more comprehensive inquiry that includes other factors to properly comprehend and enhance incident-reporting methods in healthcare environments.
Table 6. Regression result.
Hypothesis |
R |
Beta |
R Square |
Adjusted R Square |
Std. Error of
the Estimate |
Sig. F Change |
H1 |
0.128a |
−0.271 |
0.016 |
0.011 |
4.75429 |
0.098 |
H2 |
0.192b |
0.289 |
0.037 |
0.031 |
4.70440 |
0.013 |
a. Predictors: (knowledge); b. Predictors: (perceived barriers).
4. Discussion
The current study reveals that the majority of nurses have moderate knowledge about what an incident is, the goal of reporting incidents, the types of incidents, the responsible person, and the key components of effective reporting. These results were consistent with Chen et al., which stated the high perception of nurses about incident reporting practices (Chen et al., 2018). While checking the attitude of nurses in the study, it is evident that 95.2% agree that reporting incidents will lead to positive patient outcomes. 92.9% of nurses reveal that every incident is to be reported and 91.7% state that better training in clinical procedures will reduce adverse incidents. On the other hand, 58.8% of participants think that reducing the nurse-patient ratio will decrease the adverse incidents and 45.8% points reporting adverse events will make people accountable for their actions. The enhancement of workload management by nurse managers and improved job satisfaction of nurses should be continued, which will be favourable to the safety practices that are executed.
In this study, the participants mentioned many barriers to reporting incidents. Lack of time has been claimed by 69% of nurses as the major barrier to reporting incidents. While 56% of nurses report fear of legal action as a barrier, 49.4% of nurses agree that fear of career and personal reputation is the common barrier for incident reporting. It aligns with a study in Saudi Arabia, where it was found that one of the highest barriers to incident reporting is the nursing administrative response to the error (Mohammad, Aljasser, & Sasidhar, 2016). Taylor et al. (2007) claimed that the implementation of an anonymous reporting system could reduce the fear of legal action. Patient safety will be improved through an effective incident reporting system and reassuring the nurses to report an incident in a non-punitive manner, so their learning capacity will be enhanced regarding the causation of the incident, which will prevent it from recurring (Tatum & Kumar, 2021). A key step in improving the quality of care and enhancing the patients’ safety is learning from their mistakes (Ellis & Abbott, 2019). Lack of confidentiality and lack of clarity about what to report have been reported by 45.8% and 45.2% of participants respectively. Musarezaie et al. (2013) proved in their study that fear of the unpleasant effects after reporting an error is the main factor for failure to report an adverse event (Musarezaie et al., 2013). The other barriers expressed by the nurses are fear of being blamed and lack of training about how to report incidents clearly and concisely. Being blamed is a major barrier because no one generally likes to be punished by superiors and does not wish to impede the career (Al-Mugheed et al., 2023). The results of Nouhi et al. (2015) and Amrollahi et al.’s (2017) studies have explored that the lack of support from colleagues can cause fear of being blamed and stigma of inefficiency, resulting in failure to detect and report errors (Nouhi, Mohamadi, & Abbaszadeh, 2015).
A study conducted by Bovis et al. (2018) stated that the nurses did not accept incident reporting as an effective tool to improve patient safety because they experienced that their concerns were not addressed and repeated incidents occurred that had already been reported. Non-punitive incident reporting systems will improve patient safety by assuring and enhancing the nurses’ knowledge regarding the causes of the incident, which will prevent it from recurring. Efficient balancing of workload management and job satisfaction by nursing leadership is advantageous to the safety practices implemented (Chiang et al., 2019). Positive and effective communication between nurses and supervisors bestows for quality and assuring patients’ safety (Al-Mugheed et al., 2023). Al Dhafra Hospitals has an intranet system called UHC Safety Intelligence for reporting incidents.
5. Conclusion
Every healthcare organization should have an efficient incident reporting system to ensure patient safety and assure quality care. The organizational leaders at the workplace should develop a conducive and positive environment so that the nurses will feel free to report any unsafe conditions sincerely without fear and anxiety. On the other hand, the nurses should be provided with adequate education and training on patient safety and incident reporting. Creating a non-punitive culture towards incident reporting by the nursing authorities and organization will provide positive reinforcement for the nurses in reporting adverse events and errors, ultimately leading to improved patient care and outcomes.
Limitations
The study was conducted in six peripheral hospitals under the umbrella of Al Dhafra Hospitals in Abu Dhabi, so the findings can be generalized. However, the sample size was limited. Therefore, we recommend conducting the study in different settings covering private and public sectors to gain a better understanding and get more representative samples from healthcare facilities. Hence, in our study, we have not covered all the factors affecting the nurses’ intention to report incidents at their workplace. The authors highly recommend future research to explore many factors, such as psychological and environmental factors, that may influence the attitude of nurses when reporting incidents.
Ethical Considerations
The approval for the research study was obtained from Al Dhafra Hospitals Research Ethics Committee with unique reference no. ADH-REC-698.
Acknowledgements
The authors would like to thank all nurses who participated in the study and cooperated with the researchers in gathering and analyzing the required data. In addition, we acknowledge Mr. Sharma Kapil, Associate Professor, College of Nursing, DMC & Hospital, and Ludhiana, who had granted permission to use the questionnaire tool selected from his research study.