Iranian nurses’ experience of “being a wrongdoer”: A phenomenological study

Abstract

Background:

Patient safety, which is a patient’s right, can be threatened by nursing errors. Furthermore, nurses’ feeling of “being a wrongdoer” in response to nursing errors can influence the quality of care they deliver.

Research objectives:

To explore the meaning of Iranian nurses’ experience of “being a wrongdoer.”

Research design:

A phenomenological approach was used to explore nurses’ lived experiences. Nurses were recruited purposively to take part in semistructured interviews, and the data collected from these interviews were analyzed using Van Manen’s thematic analysis.

Participants and research context:

Eight nurses working in three private or governmental hospitals in Tehran, Iran.

Ethical consideration:

The research design was approved in each participating hospital, and all interviews were carried out at a predetermined time in a private place.

Findings:

Five themes were extracted from the data: “wandering in unpleasant feelings” (with two subthemes: “unpleasant physical feelings” and “unpleasant emotions”), “wandering in the conscience court” (with three subthemes: “being the accused,” “being the victim,” and “being the judge”), “being arrested in time,” “time for change” (with three subthemes: “promoting accountability,” “promoting learning,” and “strengthening supportive relationships”), and “spiritual exercise.”

Discussion:

Some of our results are supported by the model of self-reconciliation and the recovery trajectory of “second victims” theory.

Conclusion:

The meaning of “being a wrongdoer” has positive and negative aspects. Feelings of wandering provide nurses the opportunity to reflect on and re-embrace the professional and moral responsibility of nursing. Nursing managers can convert their “defeats” into a prelude to learning, increase their accountability, and improve the quality of nursing care.

Keywords

Experiences medical errors nurses patient safety phenomenology

Introduction

Patient safety is a patient’s right.¹ Furthermore, as a major component of quality of care,² it is a primary concern of the health system.³ However, a major threat to patient safety is medical errors, which are highly prevalent among any healthcare system.^2,4,5 On average, 1 in 10 hospitalized patients are subject to medical errors,⁶ and approximately 7% of such errors are harmful or deadly.⁶ Worse still, medical errors often go unreported.³ Every nurse engaged in clinical practice faces at least one nursing error during his or her career.³ As in other countries, Iran has a high rate of nursing errors,^7,8 although there are no official statistics as yet. Nevertheless, the growing number of error complaints in legal organizations suggests the need for increasing attention to this matter.⁴

Nursing errors have a considerable negative impact on health systems, patients, and nurses.⁷ Patients who experience errors may come to distrust the health system; for this reason, most health organizations are sensitive to errors and try to hold the perceived wrongdoer accountable.⁹ Although blame for medical errors has traditionally fallen on staff, the work environment may be the main cause, even more so than nurses’ work experience or skills.^7,9 This new perspective has highlighted how the professionals involved in nursing errors are “second victims.”^9,10

Nurses involved in errors face a number of legal and ethical dilemmas,¹¹ which can lead to work absence, turnover, or leaving the profession altogether.^9,12 Similarly, the stress caused by such dilemmas can promote job dissatisfaction and intention to leave.^13
–15 Nurses’ emotional reactions to being involved in an error can also increase their likelihood of further error, which in turn leads to poorer care quality, a higher likelihood of adverse events, and even greater endangerment to patient safety.^13,16 Given the global nursing shortage and the need for high care quality and qualified caregivers, understanding nurses’ experience of error involvement is important, particularly concerning the effect of these experiences on the healthcare system, patients, and nurses themselves. This understanding would help to alleviate nurses’ concerns, thereby maintaining the workforce and improving care quality and patient safety.^14,17

Phenomenology is appropriate for in-depth study of phenomena that needs to explore and interpret.¹⁸ As researchers involved in clinical practice and teaching practical nursing courses, we have frequently observed nurses involved in errors. Thus far, however, there have been no studies on the lived experiences of Iranian nurses involved in errors. Iranian nurses may have different experiences of errors (or “wrongdoing”), given their culture, religion, sociodemographic characteristics, and style of service delivery. We aimed to explore “what is the meaning of being a wrongdoer nurse?” among Iranian nurses. Thus, we conducted this study to hear the voices of these second victims and in-depth understand their stories and structures of their lived experiences by phenomenological approach.

Methods

This study was a phenomenological study of Iranian nurses’ experience of “being a wrongdoer.” Phenomenology is a systematic research of human experience that aims at gaining a deeper understanding of the nature or meaning of our everyday experiences. It brings us in more direct contact with the world by researching the structures of nurses’ lived experience of “being a wrongdoer” as a component of being in the world.

Setting and participants

Iran is a country in Western Asia with a population of 75 million. Of the total population, 99.4% are Muslim.¹⁹ Tehran is the capital. Nursing is a university discipline in Iran, and most nurses are employed in hospitals and medical offices; however, compared to other countries, there are fewer nurses in the health sector overall.²⁰

We purposively selected nurses with clinical experience and experience with nursing errors from four public or private and general or specialist hospitals in Tehran to participate. Participants’ demographic characteristics are shown in Table 1.

Table 1.

Demographic characteristics of participants.

No.	Age (years)	Sex	Ward	Work experience (years)	Marriage	Education	Interview length (min)
1	50	Female	Oncology	24	Married	Bachelor’s	36
2	40	Female	ICU	14	Married	Bachelor’s	40
3	48	Female	Chemotherapy	23	Married	Bachelor’s	20
4	30	Male	ICU	7	Single	Bachelor’s	25
5	40	Male	Operation room	13	Married	Bachelor’s	42
6	32	Female	Internal	7	Married	Bachelor’s	16
7	29	Female	Surgical	3	Single	Bachelor’s	45
8	31	Female	Emergency	1	Single	Master’s	40

ICU: intensive care unit.

Data generation

Data were obtained through semistructured interviews. Participants were recruited in two ways. Some were recruited via the hospital manager, who explained the ethical considerations and participant rights to nurses with legally documented nursing errors. Nurses who agreed to participate were then introduced to the researcher by the manager. The researcher then arranged a time and place for the interview. Other participants were recruited directly by the researcher at the hospital; the time and place of the interviews were arranged after receiving nurses’ agreement to participate. After each interview, the analysis was performed. The next interview was scheduled as needed. This continued until data saturation. Ultimately, eight interviews were conducted. Most interviews were conducted in the nursing manager’s office or the nurses’ break room, although one interview was conducted outside of the hospital. All interviews were conducted in private and involved only the researcher and participant.

Interviews

The interviews relied on an interview guide. Questions were reviewed and revised before each interview based on what was already known on the topic. We began with open-ended questions (e.g. “If possible, please talk me about your story”); as the interview progressed, we asked more probing follow-up questions based on participants’ earlier answers (e.g. “What did you think about it?” and “Had you ever experienced this feeling previously?”).

Thematic analysis

After transcribing the audio recordings of each interview verbatim, we used Van Manen’s¹⁸ thematic analysis to analyze the data. Phenomenological themes are the structures of experiences. When we analyze “being a wrongdoer nurse,” we are trying to determine what the themes are, the experiential structures that make up this experience. After that, it is lived experience that we are attempting to describe. The first step of Van Manen’s thematic analysis is uncovering the thematic aspects by identifying “thematic phrases,” which serve to allude to an aspect of the phenomenon of interest. Such phrases were identified through repeated reading of transcribed text. Interviews were the unit of analysis, and for each, we wrote a theme and an interpretative summary. The implicit aspects of each theme were then identified, and thematic statements were isolated using a threefold approach. First, we identified thematic aspects using a holistic approach. Second, we used a selective approach to increase the reliability of the findings, which involved isolating the parts of the text referring to each theme. Finally, we identified all of the thematic aspects in the text using a line-by-line approach. We then performed linguistic transformations, wherein we changed various words and phrases in the text to phenomenological language. The stereotypical sentences and artistic statements that expressed participants’ identities were identified and excluded, whereas quotations that represented the study results were isolated. During collaborative analysis among our team, we attempted to maintain a strong and oriented relation to the phenomenon at all steps of the analysis and balanced the research context by considering both the parts and whole—namely, by maintaining oriented with the phenomenon in the clinical wards and collaborative data analysis. During the study process, the researcher carefully matched each step with the previous ones as well as the whole process to maintain the integrity of the research.

Trustworthiness

To ensure the trustworthiness of the results, we used the four criteria of Lincoln and Guba:^21,22 credibility, dependability, confirmability, and transferability.

We ensured the credibility and the dependability of the findings through prolonged engagement and communication with participants. Specifically, we presented in clinical wards and frequently visited hospitals, the Medical Council, the Nursing Organization, legal centers, and nursing ethics congresses and organized frequent meetings of the research team to perform the data analysis. Peer and member checks were performed. To ensure the confirmability, we identified and recorded all research assumptions. Furthermore, all rules for decision making in the analysis and data collection processes were determined, and any important tips identified during the investigation were recorded and constantly reviewed by the research team and independent observers. For transferability, the demographic characteristics of the participants were described, and the context of the research was explained. This would allow future researchers to freely decide whether the results can transfer into their context.

Ethical consideration

The medical ethics committees of the participating hospitals approved the research design. All participants signed an informed consent form. All interviews were conducted in private in a precoordinated time and place. All recorded files were password protected, and the to-be-reported findings were anonymized. Research ethics were also considered in writing this article.

Results

Five themes were extracted from the analysis, describing Iranian nurses’ lived experiences of “being a wrongdoer”: “wandering in unpleasant feeling” (with two subthemes: “unpleasant physical feelings” and “unpleasant emotions”), “wandering in the conscience court” (with three subthemes: “being the accused,” “being the victim,” and “being the judge”), “being arrested in time,” “time for change” (with three subthemes: “promoting accountability,” “promoting learning,” and “strengthening supportive relationships”), and “spiritual exercise.”

Wandering in unpleasant feeling

Wandering in unpleasant physical feelings

Nurses reported experiencing physical symptoms when involved in errors. These symptoms were widespread throughout the body, such as feelings of being in hot or cold water, exhaustion in the extremities, and loss of consciousness. The symptoms often impaired nurses’ thinking and reactions in the acute period following the error occurrence. One participant said, “It seemed that I was dead at the same time as the patient. My whole body was numb. I was pale and confounded.”

Wandering in unpleasant emotions

Nurses saw themselves as immersed in a pool of unpleasant emotions; when one emotion faded, another arose in its place.

After the error, nurses felt a strong sense of anxiety for the patient’s future. Although the patient’s future was often ambiguous before the error, it became more so after, particularly because nurses could not often guess the effect of the error. Another aspect of nurses’ anxiety was about what would happen to themselves. They felt that they were in a “world of worry.” They had no idea of what would happen to the patient or themselves. They worried about the reactions of the patient, his or her relatives, the nurse managers, and even their own families: “My colleague was very stressed. She walked in the ward until morning. She constantly walked and every minute said something like ‘what will happen now?’”

Nurses expressed feelings of guilt because they felt that they had oppressed or betrayed someone who had needed them and had trusted them with his or her life. Nurses compared being involved in a nursing error with a car accident, which was accompanied by feeling that they had failed to perform a duty or had disobeyed God’s commandments:

Just think [about if] I suddenly had an accident and harmed my baby. This is similar to a patient in the hospital, as the patient is entrusted to a nurse that he believes is like an angel. Well, I’m responsible for this task. He’s reliant on me. I have to answer to God! The patient! [His/her] Family! Me!

After making an error, many nurses also experienced regret and remorse; most participants blamed themselves for the error, believing that if they had acted differently for that one moment, there would have been no complications for the patient or others. One participant said, “I said: Look! If I had done a little more, if I had used the right scissors, perhaps this would not have happened to the newborn.”

Within this vortex of unpleasant emotions, many nurses felt alone. For most, this feeling of loneliness derived from their self-imposed isolation after making the error, however undesirable this feeling was to them; this isolation often arose when nurses did not have sufficient support from others (e.g. colleagues, managers, and family):

[A] wrong injection was my first mistake. My second mistake was that I told it my colleague. Later, if I made a nursing error, I did not tell anyone. After a long time, maybe I would tell the head nurse. When something [like an error] is told, everything gets worse …

Wandering in the conscience court

When Iranian nurses realized their error, they found themselves in the court of conscience, wherein they represented all three pillars (accused, judge, and victim). They wandered throughout the court, seeking out their actual role. Nurses considered themselves the prime suspect at one moment, while in the next, they were the victim. At every point, nurses were the judge. They suffered considerable distress in determining whether they were the accused or victim.

Being the accused

Nurses’ unpleasant experience of “being the accused” in the eyes of colleagues and themselves perhaps most exemplified the feeling of “being a wrongdoer.” The blame and compassion offered by colleagues, patients, judges, and others induced an even greater sense of “being the accused” for nurses, even when they were unsure of their charges. One nurse said,

The patient was photographing all of the documents. She was saying: “maybe you’ve changed the documents.” My colleagues said “whatever the judge says, you must accept it.” The judge was saying “Lady! Accept your mistake!”

Following the error, the initial reaction of colleagues and even nurses themselves is finding culprit. Nurse who has completed the chain of nursing error is most focused of this.

Being the victim

Nurses involved in an error, regardless of whether they believed in their guilt, often saw themselves as victims. In fact, despite the complications of the nursing error for patients, the error was ultimately costly for nurses too. Nurses reported numerous administrative, professional, legal, and emotional conflicts. These plights formed their experience of “being the victim.” Nurses stressed how there were intrinsic differences between committing an error in the nursing profession and committing an error in other professions, such as the fact that their errors had a direct and possibly permanent impact on individuals’ lives:

All people go to work. They get their salaries and live. Sometimes they do something wrong. No matter. We make a mistake and this affects every aspect of our lives. It is actually a bad situation. I feel pity for us.

Being the judge

Nurses who had committed an error were constantly preoccupied with judging their own culpability—namely, they were never sure if they were the accused or the victim. As judges of the court of conscience, nurses sometimes fully considered themselves the culprits; at other times, they fully believed that they should be acquitted. This conflict often continued for years after the error. Indeed, although most nurses talked about errors that had happened a long time before the interview, their search for the culprit was ongoing: “Who knows? Maybe the culpability was mine, maybe it was the crowded ward. Maybe, it was my colleague, who didn’t say the patient’s name! Well, I have to ask …”

Many nurses found this experience too difficult; indeed, they often preferred to be punished, as they could relax and restore their lives afterward. In other words, they would prefer to accept the maximum punishment than to stay in the court. One participant said, “My colleague who made a wrong injection said that ‘I can’t do nursing’ and then left. He opened a shop to sell baby clothes. He doesn’t even give injections to friends or acquaintances. Some are calm this way …”

Being arrested in time

Regardless of how much time had passed since their error, nurses were constantly dwelling in their memories of it. When talking about their error, they spoke in considerable detail and with high accuracy, as if it had just occurred. Nurses themselves were fully aware of this and insisted that the memory was tangible for them; they could express even the tiniest details: “It was exactly 21 years ago. But it was exactly like the same ward and the same moment … I think as if it had happened right now. I never forget either.”

The nurses reported that the error was important to them and that it had created an obsession in them. They felt that the impressions of it were “undying” and would never be fully erased from their minds:

This happened years ago. I read books [about it] again and again. I was talking to different people about it. All of them say that a wrong injection of that sort does no harm to the foetus. But I always think about whether the child was born with a handicap. Thinking about it drives me mad. Constantly if! If! If …

Time for change

Promoting accountability

Nurses considered making an error to be an opportunity to improve their accountability. Specifically, they considered themselves more sensitive about their profession after making an error and more concerned than ever about their responsibility: “Although it was a very bad thing, it also had the effect that I’m much more careful. I am very careful with drugs. I read more and check drug cards.”

They expressed that their feeling of “being a wrongdoer” made them think about nursing errors in general. Errors led to a collapse in false confidence about their knowledge and power: “The possibility of this error was written in a book. After [the error], I believed other things that have been written would happen too.”

One aspect of responsibility nurses mentioned was deciding whether to disclose the error. Although serious errors had to be reported immediately to reduce their effects, nurses knew that most errors did not have a clear effect on patients’ condition, which made disclosing the error a test of responsibility, as doing so would help their colleagues from repeating the error: “When you are a wrongdoer it’s related to your responsibility. I believe [errors] must be reported. I am responsible if this error is repeated. I say, tell your story to make things better.”

Promoting learning

Nurses perceived making an error as an opportunity to learn. They believed that their feelings were difficult for others to understand—namely, the notion of learning from errors was different for the wrongdoer than for others who might learn from that same error. Although errors ostensibly provide a learning opportunity for everyone involved, the nurse who actually made the error experiences a different type of learning, one that transforms his or her viewpoint about himself or herself, related phenomena, people in general, and the nursing profession:

I learned to not judge other people and that it’s easier to forgive them. I always thought that the one who had done the wrong was a thoughtless person, but now! I know! No! Not always. I forgive them and myself more readily [now].

Making an error provides nurses with the opportunity to show their skills in the management of complex and unexpected situations. Nurses involved in an error are instantly forced to make many consecutive difficult decisions. Furthermore, they must detect the error and minimize its potential side effects for the patient as quickly as possible. This is registered as an exceptional moment in their lives. Thus, “being a wrongdoer” is both a dilemma and an examination to nurses. This turbulence in the immediate aftermath of an error tests nurses’ performance and reveals their weaknesses, which in turn helps them to reconstruct a new sense of their abilities:

I had a tablet, and so when any error occurred in my ward, I made a file about it. I evaluated the error and learned and taught [what I learned] to my colleagues. I even presented some of my findings at a nursing congress. Sometimes, I achieve a feeling of satisfaction and power after controlling the error effects.

Strengthening supportive relationships

Nurses saw the experience of “being a wrongdoer” as an opportunity to strengthen their relationships with others. Nurses reported that they received sympathy and attention from colleagues after making an error. Such supportive relationships were rather particular to this situation; they were rarely seen otherwise. One nurse said of this relationship: “Everyone took a job. One talked with the surgeon and gave the information. One checked the patient’s outcomes … Everyone tried to help.”

This support was not limited to nurses—other health team members also tried to support the nurse who had made the error as much as they could. In this way, nurses perceived that making an error was an opportunity to strengthen their supportive relationships and ability to consult and collaborate with other healthcare team members. These opportunities helped them learn more about their team members, as well:

I did not know how great Dr. M was. He was the patient’s doctor. [After making the error], I ran to him and told him [what I had done]. He came with me [back to the ward]. He said “the dose you gave will not affect the patient.” After that, every time I had a question, I asked Dr. M. We actually manage two wards together. Finally, these events have some beauty!

Spiritual exercise

The interviewed Iranian nurses believed that “being a wrongdoer” was an opportunity to rebuild their relationship with God. They mentioned that being a wrongdoer was a position that challenged their relationship with God while simultaneously making them seek out God and His help. The challenge to this relationship was raised in several ways.

First, nurses often feared God’s retaliation or chastisement for the wrongdoing in their personal lives. One participant said, “Today [the retaliation] is for this patient and tomorrow [its] for me. I think God just acts on the result of our own doing …”

However, sometimes nurses blamed God, asking Him why He had allowed the error to occur: “I was angry at everyone … even at God. Why did it have to be like this? Doesn’t God say that he always pays attention to us? I was very bad …”

Along with this fear and anger, nurses hoped for God’s forgiveness and aid in passing through their difficulties: “I vowed that it would end well … I made a promise to God and asked for help.”

These challenges to their relationship with God ultimately led to a feeling of certainty. In other words, making an error meant an opportunity to know that God was interested in them and supported them:

[For this error] it was [only] dexamethasone. What would we have done if it were another dangerous drug? I thank God. So many times! God helps us. [He] doesn’t let things that are too bad happen. We say that “Allah covers our shifts!” [i.e., God supported their work].

They believed that the differences between nursing and other professions led God to pay particular attention to nurses and that this attention was a form of protection for the problems they would encounter in the future. Indeed, some nurses believed that had made the side effects of the error less unpleasant on the day it had occurred: “It could have been much worse. Today was that day. The day God was attentive to me because of the patients’ prayers.”

Furthermore, nurses’ sense of wrongdoing made them believe that they had defied the divine, which led them to repent and thereby develop a closer relationship with God:

After a few days where I felt so bad, I went to the shrine and cried a lot. I asked God to forgive me. Methinks He did. I felt better. Now I will take care to ensure that it isn’t repeated. If it is repeated, then God … No, God will always forgive, but that doesn’t mean it has to repeat.

Discussion

Overall, our results showed that for Iranian nurses, the meaning of “being a wrongdoer” is wandering in unpleasant feelings and the conscience court, which leads to a sense that time has been arrested. However, it also signifies a time for change and can be considered a spiritual exercise.

Regarding wandering in unpleasant feelings, each stressful situation brings with it emotional and physical symptoms. Because nursing is so involved in caring for human life, making an error in this profession can be exceedingly stressful. Numerous previous studies on the experiences of health workers of medical errors have found the same.^5,9,23,24 Being a wrongdoer is a devastating experience for nurses that produces strong feelings of remorse, guilt, and regret.⁵ Grober and Bohnen²⁵ reported that health staff are likely to experience feelings of guilt, anger, inadequacy, and depression following medical errors, while Crigger and Meek,²³ in devising a model of self-reconciliation after a nursing error, refer to how errors produce strong emotional reactions. Lewis et al.⁹ noted that making errors often leads to feelings of burnout (i.e. a condition characterized by emotional exhaustion, depersonalization, low personal accomplishment, and feelings of anger) and the intention to leave their current position. Despite these previous findings on unpleasant emotions, our finding that nurses “wander” in them is novel. Wandering highlights how these nurses experience a wide spectrum of unpleasant emotions with synergic effects. Scott et al.²⁴ described the recovery trajectory of second victims in terms of six stages, with the first stage being “chaos and accident response” and the second stage being intrusive reflections. The “chaos” of this first stage is reminiscent of the “wandering” we found.

A second kind of wandering for Iranian nurses was wandering in conscience court. Previous literature has noted how health providers who have made errors feel like perpetrators or the accused.^{4,11,24
–26} For instance, in the perfectibility model, blame for errors is placed squarely on healthcare providers,²³ which accords with Iranian nurses’ experience of “being the accused.” The term “bad apple,” which refers to individual who make medical errors, has this connotation as well.²⁵ Another subtheme of “wandering in the conscience court” was “being the victim,” which has also been considered in the literature.^9,27 In the organizational approach to medical errors, nurses who are involved in nursing errors are called “second victims,” as noted before.⁹ This term was first coined by Wu¹⁰ in describing the effects of medical errors on professionals. Since then, this term has become increasingly widespread in the literature. Finally, the “being the judge” subtheme also accords with previous literature. There is some research, for instance, on the moral distress resulting from making a nursing error.^9,28 Furthermore, one study on conscience noted that deciding the culpability of wrongdoing and later conflicts⁹ is called “being a judge,” as in our study.

Being arrested in time is new aspect of the experience of nurses involved in errors. It has been reported that nurses consider being notified of their wrongdoing as among the darkest hours of their professional lives.²⁴ Furthermore, medical errors appear to have nigh-permanent effects on healthcare providers.^9,24 However, most previous studies did not emphasize that these feelings were long-lasting, making our participants’ report of being “arrested” in that dark period and feeling that it will extend throughout their professional life a relatively new experience.

The time for change theme was considered a positive aspect of being a wrongdoer among Iranian nurses, which accords with some previous studies. However, attention to the positive effects of wrongdoing has so far been limited to learning from one’s errors at work.^29

–33 The recovery trajectory model proposes that nurses seek resources and support in order to liberate themselves of the harm done by their error.²⁴ Furthermore, better individual performance, greater attention to detail, and learning from the experience are considered positive achievements of nursing errors,⁹ while the self-reconciliation model proposes that making a mistake in nursing practice ultimately leads to greater learning.²³ Considering the positive effects of errors can be an effective way of changing approaches to nursing errors. Errors may be considered “beacons” of patient safety—namely, they should be viewed as opportunities for education and to enact positive changes in health systems. A key aspect of improving from errors is sufficient support from others, which strengthen certain aspects of nurses’ experience and decrease the negative effects of the error on nurses’ professional lives, ultimately improving patient safety as a patient’s right.

The spiritual exercise theme referred to how nursing errors challenged nurses’ relationship with God and helped to rebuild it. This theme doubtlessly derives from our study’s Islamic context. Divine providence is always considered by Muslims, and each event—good or bad—is interpreted from this perspective. For Muslims, discovering the meaning of being in the world involves a relationship with God. An experience of wrongdoing is no exception for Muslim Iranian nurses. In Islamic belief, any event in the world is an act of God, whereas the authority to act in response to such events and attention to the results of human actions is given to humans.³⁴ Belief in God as the protector of all humans (both the nurse who made the error and the patient involved) and as a supervisor for nurses (both when making an error and when conducting their normal duties) helps nurses to balance the positive and negative aspects of being a wrongdoer. Indeed, it can help nurses to better cope with mishaps often deemed as the darkest events of nurses’ professional lives. We did not find study that refers to the spiritual experiences of Muslim or other nurses who made error. Further studies in other context are useful in knowing about religious beliefs’ effects on spiritual experience of wrongdoer nurses.

The negative aspects of wrongdoing lived experience force nurses to change in their behavior on their future care providing to prevent errors and positive system changes that improve patient safety as a key patient’s right. It also emphasized in promoting accountability. Also, nurse who made error, if overwhelmed in unpleasant feeling may be considered as a danger for patient’s safety. It may prevent nurse from responding positively and quickly to a problem which is time sensitive. So, positive and negative aspects of this experience must be considered as a potential risk and strength for patient safety in nursing management and education.

According to Van Manen,¹⁸ discovering the meaning of “being in the world” has four components: the lived space (spatiality), lived body (corporeality), lived time (temporality), and lived other (relationality). “Wandering in the conscience court” is consistent with the component of spatiality: Nurses actually see themselves behind the judge’s bench, wherein they are consciously or unconsciously forced to decide on their own or others’ culpability. Wandering in unpleasant physical feelings refers to corporeality, as nurses involved in an error “live” their wrongdoing as an unpleasant experience. Temporality was a part of most themes but was a major aspect of the theme of “being arrested in time,” particularly in how the error becomes a part of the individual nurse’s whole life (or at least their professional life). The time for change can also be considered as lived time, as it represents the evolution of the nurse’s life. In contrast, the wandering themes suggest a loss of time and lack of nurses’ proficiency in managing time as a component of “being in the world.” Both the “time for change” (particularly regarding individual communications with other people involved in the error) and “spiritual exercise” (regarding nurses’ relationship with God) represent relationality. Being a wrongdoer provides nurses with an opportunity to review how others think of them and to attempt to improve these views and in this way manipulate their sense of “being in the world.” Indeed, the beings of others (both people and God) can change or confirm the meaning of “being in the world” for the wrongdoer.

A study limitation is that it was conducted only with nurses working in hospitals. Because nursing roles can differ substantially among other healthcare positions, future studies must attempt to develop the meaning of “being in the world” for other nurses who have made errors.

Conclusion

We examined the positive and negative aspects of “being a wrongdoer” among Iranian nurses. The negative aspects included the themes of wandering in unpleasant feelings and in the conscience court and being arrested in time, whereas positive aspects were the themes of time for change and spirituality exercise. Maintaining a balance between both aspects of this experience can help nurses manage adverse events and thereby improve patient safety as a primary patient’s right.

Footnotes

Acknowledgements

The authors appreciate the nurses who participated in this study and everyone who helped us to conduct it.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Barach

Moss

. Delivering safe health care: safety is a patient’s right and the obligation of all health professionals. BMJ 2001; 323: 585–586.

Garrouste-Orgeas

Philippart

Bruel

. Overview of medical errors and adverse events. Ann Intensive Care 2012; 2: 1–9.

Johnstone

M-J

Kanitsaki

. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. Int J Nurs Stud 2006; 43: 367–376.

Hashemi

Nikbakht Nasrabadi

Asghari

. Nurses perceived worries from error disclosure: a qualitative study. Iran J Nurs Res 2011; 20: 30–43.

Crigger

. Always having to say you’re sorry: an ethical response to making mistakes in professional practice. Nurs Ethics 2004; 11: 568–576.

De Vries

Ramrattan

Smorenburg

. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008; 3: 216–223.

Joolaee

Hajibabaee

Peyravi

. Nursing medication errors and its relationship with work condition in Iran University of Medical Sciences. Iran J Med Ethics Hist Med 2009; 3(1): 65–76.

Hajibabaee

Joolaee

Peyravi

. The relationship of medication errors among nurses with some organizational and demographic characteristics. Iran J Nurs Res 2011; 20: 83–92.

Lewis

Baernholdt

Hamric

. Nurses’ experience of medical errors: an integrative literature review. J Nurs Care Qual 2013; 28: 153–161.

10.

. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320: 726–727.

11.

Hashemi

Nikbakht Nasrabadi

Asghari

. Factors associated with reporting nursing errors in Iran: a qualitative study. BMC Nurs 2012; 20: 1–15.

12.

Borhani

Abbaszadeh

Nakhaee

. The relationship between moral distress, professional stress, and intent to stay in the nursing profession. J Med Ethics Hist Med 2014; 7: 3.

13.

Teng

Chang

Hsu

. Emotional stability of nurses: impact on patient safety. J Adv Nurs 2009; 65: 2088–2096.

14.

Ulrich

Taylor

Soeken

. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs 2010; 66(11): 2510–2519.

15.

Borhani

Jalali

Abbaszadeh

. Nurses’ perception of ethical climate and job satisfaction. J Med Ethics Hist Med 2012; 5: 1–6.

16.

Schwappach

Boluarte

. The emotional impact of medical error involvement on physicians: a call for leadership and organisational accountability. Swiss Med Wkly 2009; 139: 9–15.

17.

Borhani

Jalali

Abbaszadeh

. Nurses’ perception of ethical climate and organizational commitment. Nurs Ethics 2013; 21: 278–288.

18.

Van Manen

. Researching lived experience: human science for an action sensitive pedagogy. 2nd ed. Cobourg, ON, Canada: Transcontinental Printing, Inc., 2001.

19.

Implementation of the 2011 Iranian population and housing census in autumn (24 October–13 November 2011; ed Presidency of the IRI MaPO). Statistical Center of Iran, 2011.

20.

Nursing statistics . Ministry of Health and Medical Education, 2014.

21.

Lincoln

Guba

. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir Program Eval 1986; 1986: 73–84.

22.

Streubert

Carpenter

. Qualitative research in nursing: advancing the humanistic imperative. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2011.

23.

Crigger

Meek

. Toward a theory of self-reconciliation following mistakes in nursing practice. J Nurs Scholarsh 2007; 39: 177–183.

24.

Scott

Hirschinger

Cox

. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009; 18: 325–330.

25.

Grober

Bohnen

JMA

. Defining medical error. Can J Surg 2005; 48: 39–44.

26.

Armitage

. Human error theory: relevance to nurse management. J Nurs Manag 2009; 17: 193–202.

27.

Wolf

Serembus

Smetzer

. Responses and concerns of healthcare providers to medication errors. Clin Nurse Spec 2000; 14: 278–290.

28.

Schelbred

Nord

. Nurses’ experiences of drug administration errors. J Adv Nurs 2007; 60: 317–324.

29.

Meurier

Vincent

Parmar

. Learning from errors in nursing practice. J Adv Nurs 1997; 26: 111–119.

30.

Bauer

Mulder

. Conceptualisation of learning through errors at work: a literature review. In: Billett

Harteis

Etelapelto

(eds) Emerging perspectives of workplace learning. Rotterdam: Sense Publishers, 2008, pp. 115–130.

31.

Sutcliffe

. Defining and classifying medical error: lessons for learning. Qual Saf Health Care 2004; 13: 8–9.

32.

Chuang

Y-T

Ginsburg

Berta

. Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions. Health Care Manage Rev 2007; 32: 330–340.

33.

Bauer

. Learning from errors at work: studies on nurses’ engagement in error-related learning activities (Psychologie, Padagogik und Sportwissenschaft). Regensburg: University of Regensburg, 2008.

34.

Holy Quran, Sureh Yasin, Verse 82. Sureh Raad, Verse 11.