What is the lived experience of advanced nurse practitioners of managing risk and patient safety in acute settings? A phenomenological perspective

Recruitment of participants

Participants were recruited through purposeful sampling of ANPs who identified themselves as having experience with managing risk and safety in practice (Creswell and Clark, 2011). Purposeful sampling is commonly used in phenomenology to acquire thick descriptions (Hollywood and Hollywood, 2011; Sabo, 2011; Bedwell et al, 2012; Converse, 2012). Between two and 10 participants are considered sufficient in a phenomenological inquiry (Giorgi, 2003). A total of 10 ANPs were selected; this number protected against participant drop out. Recruitment took place across three settings: an urban ED, a suburban UCC and a collection of rural MIUs. Sites were varied in the hope of potentially achieving more variable results and a greater breath of enquiry (Shenton and Hayter, 2004).

Data collection

Data were collected in three phases over 10 months alongside the researcher's journal:

Multiple research stages allowed for the author to build trust with the participants and enhanced the credibility of the gathered data by allowing for a variety of topics to be discussed (Lincoln and Guba, 1985). This form of reflective storytelling allowed participants to discuss their perspectives and lived experiences (Craig and Smyth, 2011). Gibbs' (1988) reflective cycle, which offers a flexible simplistic structure for participant-led interviews and written reflections, was implemented in the data collection.

It is important for qualitative researchers to situate themselves in the research (Ely et al, 1991). As an ANP with pre-understanding of the area being studied, the author can be considered an insider and fulfilling of this criterion (Coghlan and Casey, 2001). Such positionality can have implications for the trustworthiness of the study, as it may lead participants to being more ‘open’ with insiders (Edwards and Talbot, 1999; Asselin, 2003) and provide a greater depth and breadth of data (Kanuha, 2000). Conducting this study required respect, self-awareness of the author's presence and the potential effect on the research on the participant (Bonner and Tolhurst, 2002; Mercer, 2007; Bourne and Robson 2009). The author ensured they remained focused and non-subjective through self-reflection, reflective journaling and regular supervision meetings.

Ethical approval

Ethical approval was sought and gained through the university's research ethics committee on 29 July 2016; informed consent and participant information sheets were provided. Research governance and risk assessment forms were completed.

Data analysis

Van Manen's (1997) step-by-step data analysis afforded clear guidance to the stages of analysis required. This approach has been frequently used in similar studies (Donnelly and Wiechula, 2006; De Witt et al, 2010; Smythe and Spence, 2012; Glenn et al, 2015) and was used to analyse the collected data. NVivo 11 software assisted analysis. Figure 1 demonstrates this process.

In line with Van Manen's (1997) approach, each interview was transcribed verbatim and read in its entirety to grasp overall meaning. Journaling, recording ideas and ongoing comparative analysis enabled iterative continuous analysis. NVivo 11 software assisted reading and re-reading transcripts line by line, and the coding and selective highlighting of relevant quotations. Units of meaning derived were individually interpreted and then clustered to form subthemes and themes for each participant. Participants' lifeworld themes were presented, interpreted and interpretively described (Figure 2). All individual lifeworld themes were collated to form a collective worldhood of the lived experience of all participants. This process involved cross-analysis between the different data sources for each participant, including the cross-tabulation of themes and subthemes of each lifeworld to derive collective subthemes and themes for the collective worldhood of the experience of managing risk and patient safety in practice.

Environment

ANPs work in a time-sensitive environment. They manage and cope through balancing the probabilities of risk and safety with their capacity to cope at any given time. Risk is constantly changing according to place, time and perspective; thus, related decisions must be understood in this context. Judgements are made based on snapshots of time. A participant likened their workplace to a ‘conveyor belt’, which conveyed the relentless flow of patients. This metaphor suggests a constant pressing on of time and an overall lack of control. For these practitioners, risk management, in an environment that values objectivity over subjectivity, leads some to working around protocols/guidelines for the benefit of patients. Blind adherence to guidelines, rather than interpretation for individual patients, can restrict practitioners and could potentially push them down the incorrect treatment pathway and outcomes that are not in the best interests of patients. As one participant said:

Organisational targets and healthcare priorities can muddle risk navigation and cloud clinical judgements. Guidelines being followed defensively to safeguard professional risk can expose patients to new risks, such as unnecessary referrals, tests or hospitalisation.

Patient

Patient assessment involved rapid snapshot judgements based on a dynamic visual assessment. As described by one participant:

Risk is negotiated according to perception, perspective and the risk-tolerance of all stakeholders. This involves care, trust-building, communication and building rapport with patients. Perspectives of risks do not always correlate; some patients can be anxious about issues that appear minor to a practitioner.

Coping

Coping with risk involves having an intuitive awareness, including being aware of the capacity of others (patients and colleagues), and their level of understanding and risk tolerance. Detection of risk provokes feelings of discontent, worry and concern, which then compels action, such as information seeking, safety-netting, sharing the risk and flagging it to others.

Participants described the security of managing risk safely ‘beneath the wings’ of more experienced staff and the clinical support of medical colleagues was described as a ‘safety blanket’. Effectively coping with risk enables the practitioner a sense of safety, resolving to positive feelings of being happy, satisfied, confident and self assured.

One participant described coping with this risk at critical times as:

Mood

Coping with risk is done so through emotive moods, such as being scared, because it sharpens one's awareness. Emotions were illuminated to be both drivers and barriers to practitioners' capabilities of coping with risk. As described by one participant:

Feelings that may benefit practitioners, such as competence and confidence, were mirrored by feelings that may inhibit their capacity to work, such as feeling overly risk adverse or ‘fuelled by fear’. Feelings of exhilaration or being ‘on the edge’ may increase the potential for cavalier risk-taking, and innocuous moods, such as boredom, may lead to a complacent approach and lack of care. As described by one participant:

Knowledge

Risk was found to emerge from a knowledge deficit. This presents as a sense of not knowing, the unknown, something missing or not yet understood; thus, residing outside of the comfort zone of firm knowledge. Indeed, participants' experiences of risk often led to them identifying a learning need and an opportunity to develop and advance their ANP practice. The key to advancement of practice was found to be in embracing and facing fears of what was not known, accepting the inevitability of risk and uncertainty, and taking ‘safe risks’ based on probability by using available resources.

One participant described:

Policy–reality gap

The environment theme illuminated a conflict between clinical guidance and the reality of managing risk in practice. Traditional approaches to managing risk and patient safety in practice are policy-driven, and evidence-based guidelines are typically considered vital for safe, quality, cost-effective and standardised care (Department of Health, 2016; NHS England, 2016; HEE, 2017). Guidelines aim to increase effectiveness, minimise risk, avoid unnecessary testing and provide comfort and safety for practitioners (Snyder and Weinburger, 2014). However, systems aiming to enhance safety can introduce risk of over-investigation, over-admission, increased costs and unnecessary hospital transfers (Ghosh et al, 2012; Carayon, 2016). Conflict between guidelines and clinical context has been highlighted in other studies (Kramer and Schmalenberg, 2008; Benner et al, 2011).

The findings of this study also align with wider literature that reported that nurses use ‘work-arounds’ beyond practice guidelines for their patients' best interests (Stewart et al, 2004; Benner et al, 2011). While rule-breaking for the greater good relates to positive deviance containing elements of innovation, creativity and adaptability, it involves risk for the nurse (Gary, 2013). Naylor et al (2016) referred to an implementation gap between policy-driven strategies to enhance patient safety and the realities of what happens in practice.

Indeed, clinical and educational policies and guidelines must be applicable to the reality of practice, for both patient safety and the wellbeing of practitioners. If defensive practice is a by-product of practitioners finding it difficult to cope with risk safely (Gary, 2013), inadequate risk management could be seen as perpetuating a loss of patient confidence and trust, particularly in the wake of increasing public accountability.

Intuiting risk

Within the ‘mood’ theme, participants described their ‘gut-feel’, ‘intuition’, ‘inner voice’ and ‘instinct’ as tools for assessing risk and safety.

Links have been made between intuition and risk in the literature (Perez and Liberman, 2011). Bowen et al (2014) found that senior clinicians used a high level of intuition to effectively manage clinical risk. Being a risk-taker was identified by Miller (1995) as a characteristic of intuitive nurses, encompassing the willingness to act on intuition, client connection and an interest in the abstract. Sajjanhar (2011) concluded that guidance combined with expert intuition is invaluable and identified novice clinicians' reliance on guidelines and second opinions to achieve ‘safe’ decisions. Aligning with participant experiences, Perez and Liberman (2011) identified that intuition requires supportive networks for mentorship through risk-taking activities.

Resoluteness to pursue the awareness of risk or uncertainty was a key feature in how anticipated risk was managed for these participants. Stolper et al (2011) described an intuitive gut-feeling monitoring process as an effective component in reducing risk. According to Engebretsen et al (2016), dealing with uncertainty in emergency care is unavoidable and rather regrettable if attended to in a systematic and self-conscious way. Aligning with participant experiences, Perez and Liberman (2011) identified that intuition requires supportive networks for mentorship through risk-taking activities.

These findings illuminate non-linear processes in supporting practice involving risk and patient safety. Studies exploring the nature and use of intuition on every level and in every setting are imperative (Robert et al, 2014).

Emotional instinct

These findings also illuminated the use of emotional instinct, which was a thread through both the ‘mood’ and ‘coping’ themes. Clinical decisions are often made in challenging contexts that require clinicians to manage their emotions (Lerner et al, 2015). This study highlighted the benefit of channelling these emotions to enhance the ability to cope with risk on a personal level and ultimately lead to safer care.

Worry, concern and fear appeared to fuel participant responses to incidences of risk and safety. Affective states can have arousing or motivational properties in decision making (Lerner et al, 2015). Emotions can enhance attention, cause conflict, compromise cognitive processing and lead to the overriding of rational processes and decision-making bias (Keltner and Lerner, 2010; Garfinkel et al, 2016). Indeed, participants in this study reported feeling the entire continuum of emotions, from feeling like a maverick risk-taker, to paralysing fear and dread.

Participants also professed to feeling professionally vulnerable. Worry or concern for some participants lead to avoidance. This can be related to cognitive avoidance theory (Ruscio and Borkovec, 2004) and intolerance of uncertainty (Koerner and Dugas, 2006). Indeed, the ‘knowledge’ theme identified that practitioners lack of knowledge in specific aspects may increase the risk to patients. Understanding the role of this knowledge deficit provides an opportunity for practitioners to push themselves to develop a deep understanding of the profession.

According to the findings of this study, dealing with risk and patient safety can be harrowing. Indeed, for the participants, excessive worry or fear could lead to sleepless nights, avoidance, defensive practice and rules being followed blindly, rather than being applied according to individual patients' situations. A greater understanding and support for ANPs in managing and coping with these feelings of concern and worry is crucial to enable risk to be managed effectively and safely. Sharing risk with others was a source of comfort for the participants in this study.