A CONCEPT ANALYSIS (ORIGINAL STUDY I)

Walker and Avant’s (2019) eight-step concept analysis method was used to describe the concept of communication contributing to medication

incidents. The method included a systematised literature review and a deductive-inductive content analysis (Elo & Kyngäs, 2008). Enhancing the Quality and Transparency of Health Research’s (EQUATOR) Prisma criteria

and Standards for Reporting Qualitative Research (SRQR) checklists were used for study reporting (O’Brien et al., 2014).

4.2.1 Literature search

The literature search was conducted in August 2016, February 2019, and November 2020 using seven scientific databases: Medline Ovid, PubMed, PsycINFO, Scopus, EBSCO’s CINAHL, Cochrane Library, and Web of Science.

The search phrase used was: ‘Medication’ AND (error OR ‘adverse effect’ OR

‘adverse event’ OR ‘near misses’ OR ‘omission’) AND (‘precursor factors’ OR

‘contributing factors’ OR ‘antecedent’ OR ‘etiology’) AND (‘communication’

OR ‘flow of information’).

The search period was set to 2010–2020. Boolean phrases and inclusion and exclusion criteria were used. The inclusion criteria were: (1) the title included the words ’medication’ and ’communication’ or referred to medication incidents, and (2) the abstract contained information about communication related to medication incidents. The exclusion criteria were: (1) a non-hospital context; (2) focused narrowly on one medicine or disease from a medical perspective with no discussion on communication;

(3) conducted in a single ward or unit with a narrow sample; and (4) grey literature, such as conference articles, discussion articles, and editorials, or when the publisher’s academic quality was suspect.

The search identified 645 articles. Articles were selected based on their title, abstract reading, and inclusion and exclusion criteria. The final selection stage was based on reading the articles’ full texts. The first and fifth authors discussed selections at each stage. The total number of articles (2010–2020) before the Joanna Briggs Institute (JBI) evaluation was 24.

4.2.2 Study quality

The JBI (2020) criteria for systematic reviews (two articles), qualitative studies (eight articles), analytical cross-sectional studies (11 articles), case series (two articles), and quasi-experimental studies (one article) were

evaluated. Finally, twenty-three of the appraised articles were included, spanning 2010–2020.

4.2.3 Content analysis of included studies and concept analyses Walker and Avant’s (2019) concept analysis method is described in Table 7.

The reason for choosing this method was that it is widely used for concept analyses in the nursing science research field (Walker & Avant, 2019).

Deductive-inductive content analyses of the 23 articles and two

purposefully selected WHO guidelines (2014 and 2017) were performed to identify all existing related concepts and communication word use relating to medication incidents (Walker & Avant, 2019).

One systematic literature search of articles published between 1988 and 2009 included the medication and communication terms (Manias, 2010).

However, its scope concerns successful communication. Manias’ study was reviewed to determine whether it contained communication issues

contributing to medication incidents. Suitable issues were included in to the current analysis. Since no existing concept description describing the concept of communication contributing to medication incidents in

hospitals was found, a formative concept framework, ’Medication Incidents and Communication in Hospital’ (MIComHos), was created based on the theoretical structures in the literature. However, the theory-based

framework could not be finalised in that phase. Therefore, the framework was further developed with an inductive content analysis of the articles (Walker & Avant, 2019). The word communication was searched in the context of medication incidents. The term’s use was analysed, classified, and added to the theory-based framework based on the first author’s decision but discussed with all five authors. The practical themes were combined towards a more abstract level to describe the concept’s main themes.

Table 7. Application of Walker & Avant’s (2019) method in this thesis.

Phase Task Subtask Application in this study I Selecting the

concept.

Based on literature evidence of medication incidents in hospitals, communication was

a common contributing factor.

II

Determining the analysis’s

aims and purposes.

The aim was a concept description for tool development to measure

communication factors.

The following steps may occur simultaneously or consecutively:

III

Identifying all discovered uses of the concept provides the broadest view of the concept.

Searching for the use of the concept

or related theoretical structures.

Deductive phase: theory- based framework creation.

Searching for all instances of the

word

‘communication’

relating to medication

incidents.

Inductive phase: adding detailed communication items to the framework.

IV

Determining the defining attributes.

Refining the attributes to the fewest possible.

Grouping the communication issues into main categories

and subcategories.

VI

Prerequisites.

Antecedents (i.e.

existing prior to the concept’s occurrence).

Describing antecedents and stakeholders.

Consequences.

The concept’s consequences lead to outcomes (Walker

& Avant, 2019).

The consequence is either increasing or decreasing

medication incidents.

V

Presenting a model case, including all attributes.

The model case might be real or theoretical (Walker &

Avant, 2019).

Constructing a theoretical case, including all concept

items.

VII

Describing additional cases (A-D).

One or more of the following can be presented (Walker &

Avant, 2019).

A) Related case (close terms).

Case description demonstrating Manias’ (2010)

concept of medication communication.

B) Borderline case (i.e. covers some but

not all attributes). – C) Contrary case (i.e.

does not include any of the main attribute

categories)

Describing a case that has no possibility for a medication

incident D) Illegitimate case

(i.e. the concept is used improperly).

Not applicable since a concept was not defined

previously.

VIII Measuring outcomes

Measurable items and categories are described for tool development (i.e.

operationalisation).

Describing communication indicator phrases related to

medication incidents, the concept’s measurable items.

Empirical referents are the concept’s

measurable consequences (Xyrichis & Ream,

2008; Walker &

Avant, 2019).

Occurrence frequencies of communication-related medication incidents or near-

misses are presented as empirical referents.

Outcome measures. The concept’s outcome is the medication safety level.

Measurable indicator phrases were created as the communication concept’s defining empirical referents. When a communication issue, represented as an indicator phrase, causes a communication challenge, it might cause a medication incident. However, when the communication issue promotes communication, its consequence may be a near-miss.

Communication issues can be searched for in free texts using indicator phrases, and the findings can be quantified for statistical analysis.

The concept’s relevancy was planned to be assessed by searching for indicator phrases in incident reports in Original Study II. Consequences from indicator phrases provide a medication safety level as an outcome.

Therefore, the medication safety level depends on the type of actual communication issues existing at a particular time point.

An example of the concept was described based on Walker and Avant’s analysis model. Here, the imaginary model case was to meet all of the concept’s antecedents and present examples of all of the concept’s main attributes. Additional cases that contradict or violate the concept could also be presented. However, these were not found in the literature since this was the first time the concept had been described. Instead, a related model case was described for this concept. It was close to the concept but did not include all its attributes or antecedents and had its own concept name.

4.3 ANALYSIS OF MEDICATION INCIDENT REPORTS (ORIGINAL