Medication Errors and Critical Care Nurses

Moral Distress,
Compassion Fatigue,
and Perceptions About
Medication Errors
in Certified Critical
Care Nurses
Jeanne Maiden, PhD, RN, CNS-BC; Jane M. Georges, PhD, RN;
Cynthia D. Connelly, PhD, RN, FAAN

The primary purpose of this study was to examine the previously

untested relationships between moral distress, compassion fatigue,
perceptions about medication errors, and nurse characteristics in a
national sample of 205 certified critical care nurses. In addition, this study
included a qualitative exploration of the phenomenon of medication
errors in a smaller subset of certified critical care nurses. Results revealed
statistically significant correlations between moral distress, compassion
fatigue, and perceptions about medication errors in this group.
Implications for critical care nurses seeking to create work environments
conducive to the reduction of medication errors are explored.
Keywords: Compassion fatigue, Medication errors, Moral distress
[DIMENS CRIT CARE NURS. 2011;30(6):339/345]

Certified critical care nurses (CCRNs) care for patients in increasingly stressful contexts, it becomes important to
experiencing some of the most challenging illness states study phenomena related to stress, such as moral distress
in which life becomes extremely fragile and tenuous. Pro- (MD), compassion fatigue (CF), and medication errors.
moting optimal patient outcomes requires careful mon- Little is known about the interaction of these phenomena
itoring in this fast-paced and often chaotic environment. in the CCRN population. The primary purpose of this
Caring for patients amid distractions and competing study was to examine the previously untested relation-
priorities becomes a normalized part of nursing practice ships between MD, CF, perceptions about medication
within the critical care environment.1 Stress is a common errors (PMEs), and nurse characteristics (NCs) in a na-
phenomenon for nurses working in critical care settings tional sample of 205 CCRNs. Second, this study qual-
and often results in a variety of spiritual, psychological, itatively explored the phenomenon of medication errors
and functional outcomes. As CCRNs care for patients in a smaller subset of CCRNs. The specific aims of this

DOI: 10.1097/DCC.0b013e31822fab2a November/December 2011 339

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses

study were to (1) describe the levels of MD, CF, PMEs, the critical care environment, CCRNs may be at risk for
and NCs in a national sample of CCRNs; (2) examine the developing CF.
relationships between MD, CF, PMEs, and NCs in this
group; and (3) obtain a deepened understanding of the Medication Errors: An Indicator of Unsafe
CCRN experience of MD, CF, and PME. Practice and Work Environment
Patient safety encompasses a wide variety of patient care
BACKGROUND AND SIGNIFICANCE processes and outcomes, including the safe use of med-
ications.23,24 The Institute of Medicine noted that pre-
The Critical Care Environment: Moral Distress ventable adverse drug events or harmful medication errors,
The critical care environment may create a situation that that is, any error occurring in the medication-use process,
becomes detrimental to the very staff charged with the occur in 1% to 10% of hospital admissions and account
patients’ care.2,3 Frequently, the expectations of patients, for a $3.5 billion cost.25 In 2005, the overall combined
families, physicians, and/or institution are in conflict. reporting of sentinel events (unexpected occurrence in-
Nurses’ proximity and presence at the bedside and inter- volving death or serious physical or psychological injury,
actions with the patient and family regarding care choices or the risk thereof) revealed that almost 10% were due to
and treatments may cause distress, either for the patient/ medication errors.26 Notably, medication errors are a
family or staff.4 Moral distress may be a consequence of major source of overall medical errors and have been
maintaining the nurse-patient relationship. identified as a patient safety priority by state and federal
Jameton5 defined MD as ‘‘knowing the right thing regulatory and funding agencies.25,27,28 This study
to do, but institutional constraints make it impossible to sought to explore nurses’ PMEs, specifically the reasons
pursue or carry out the right course of action.’’ As de- that medication errors occur and the reasons that such
scribed by Elpern and Balk,6 ‘‘moral distress involves the errors are not reported.
perception that core personal values and ethical obliga-
tions are violated’’ that can result in psychological dis-
equilibrium. Research on MD conducted with CCRNs7-16
has found unit staffing patterns, carrying out orders for
Patient safety encompasses a
unnecessary tests on terminally ill patients, deception wide variety of patient care
through failure to take an action, and failure to tell the processes and outcomes, including
truth regarding actions not in the best interest of the pa- the safe use of medications.
tient contribute to nurses’ MD. Notably there is evidence
that MD may be manifested in avoidance or withdrawal
behaviors, resulting in compromised patient care.15,16
Summary
The Critical Care Environment: Given the enhanced potential for MD and CF among
Compassion Fatigue CCRNs, it can be posited that these factors may play a
Compassion fatigue describes a state of emotional, phys- role in the detection or nonreporting of medication er-
ical, social, and spiritual exhaustion leaving the indi- rors. This study was undertaken to provide an exami-
vidual fatigued, overwhelmed, helpless, and hopeless nation of the relationships between these variables, with
about one’s situation or life, causing a pervasive decline the ultimate goal providing a knowledge base for decreas-
in the person’s desire, ability, and energy to feel and ing medication errors in the critical care environment.
care for others.17,18 The majority of research on CF has
been conducted with emergency response personnel in- METHODS
cluding police officers, firefighters, psychology, and
select nursing specialties17-22 and is documented as an Study Design
acute reaction to high-stress situations.17 Some authors The study design consisted of a mixed methods in which
have used the term ‘‘secondary traumatic stress disor- a quantitative survey was administered to a national group
der’’ to identify reactions following exposure to high- of CCRNs, followed by a small qualitative focus group
stress situations. The negative consequences associated of a subset of participants. A mixed-methods approach
with secondary traumatic stress disorder include efforts uses one data set to provide a supportive secondary role
to avoid thoughts or feelings about the event, avoidance in a study based primarily on the other data type.29 In
of activities or events reminding the person of the event, this study, qualitative data from a small subset of partic-
anger, difficulty sleeping and concentrating, and hyper- ipants were used to supplement the quantitative survey.
vigilance.17 Given the high stress that routinely occurs in This design was chosen to provide new information and

340 Dimensions of Critical Care Nursing Vol. 30 / No. 6

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses

add richness to the survey data and provide validation of a 30-item, 5-response Likert-type scale designed to as-
the quantitative findings. sess how the respondent is affected emotionally and psycho-
logically by events associated with the workplace.33 The
Sample ProQOL consists of 3 subscales: compassion satisfaction,
The sample consisted of 205 CCRNs who were members burnout, and CF/secondary trauma. Construct validity
of the American Association of Critical-Care Nurses and reliability coefficients ranging from .71 to .90 have
(AACN) and involved in patient care delivery within the been reported.31-34 In the current study, Cronbach ! = .81.
previous 12 months. Two hundred five CCRNs com-
pleted and returned the mailed survey. Following receipt
of the quantitative mailed surveys, a small subset of the
sample, consisting of 5 CCRNs with current bedside
The ProQOL consists of 3 subscales:
clinical practice, were recruited to participate in a 1-time compassion satisfaction, burnout, and
focus group. compassion fatigue/secondary trauma.
Procedure
A purposive sample of CCRNs with current member- Medication Administration Error Survey is a 77-item
ship in AACN was recruited for the study. Permission survey developed by Wakefield and colleagues35 to assess
to use the AACN mailing list and approval from the nurses’ perceptions of (1) reasons medication errors oc-
University of San Diego institutional review board were cur, (2) reasons medication errors are not reported, and
obtained. All participants gave written, informed con- (3) an estimated percentage of actual medication errors
sent. For the quantitative phase, survey packets contain- reported. The category, ‘‘reasons medication errors oc-
ing study materials were mailed to 1000 CCRNs, using cur,’’ includes 5 subscales: physician communication,
preprinted mailing labels purchased through the CCRN medication packaging, nurse staffing, pharmacy pro-
list rental service. A preaddressed, postage-paid enve- cesses, and transcription related. The category, ‘‘reasons
lope was included to return the study materials. Follow- medication errors are not reported,’’ includes 4 subscales:
ing receipt of the quantitative mailed surveys, a subset disagree with the institution’s definition of medication
of the sample, consisting of 5 CCRNs with current bed- error, reporting effort, fear, and administrative response.
side clinical practice, were recruited to participate in a Participants are asked to indicate a level of agreement with
1-timefocus group regarding the study foci of MD, CF, each statement based on a 6-point Likert scale (1 = strongly
and perceptions of medical errors. disagree to 6 = strongly agree). Construct validity and
reliability have been reported with Cronbach coefficient
Measurement ! ranging from .53 to .78 for the subscales.35
The following materials were mailed to potential partic-
ipants for completion: a demographic questionnaire to RESULTS
document NCs, the Moral Distress Scale, the Professional
Quality of Life Scale (ProQOL), and the Medication Ad- Descriptive Statistics
ministration Error Survey. Completed surveys were returned from 205 CCRNs.
Nurse Characteristics. A demographic questionnaire Participants were primarily female (90%) and married
asked participants to record such relevant NCs as age, sex, (73.6%) and worked full time (74.4%). Mean age was
employment status, marital status, religious affiliation, unit 47.49 years (range, 27-64 [SD, 7.91] years), had been
tenure, nursing tenure, and intent to leave current position. in practice for an average of 23.3 years (range, 4-42
Moral Distress Scale. For the purposes of this study, [SD, 8.49] years), and worked on their unit for an aver-
moral distress was defined as, ‘‘(An) individual knowing age of 13.61 years (range, 0.08-38 [SD, 8.45] years).
the correct course of action to take, but because of real Fewer than 10% (9.5%) were considering resignation.
or perceived institutional constraint or barrier it is im- Respondents reported an elevated level of MD (mean,
possible to carry out the correct course of action.’’5 3.89 [SD, 1.36]) and a low level of CF (mean, 13.82
Moral distress was measured by the Moral Distress Scale, [SD, 6.55]).
a 38-item, 7-response Likert-type scale.7 Scale content Table 1 contains the mean scores for perceived rea-
validity and reliability (! = .86) have been reported.7 In sons for medication error and reasons for not reporting
the current study, Cronbach ! = .97. errors by subscale. As is illustrated in Table 1, on a 1-
The Professional Quality of Life Scale30-34 is the to 6-point scale, with 1 signifying ‘‘strongly disagree’’ and
third and current version of the Compassion Fatigue 6 indicating ‘‘strongly agree,’’ physician communication
Self Test first developed by Figley.17 The ProQOL is and medication packaging were reported as the most

November/December 2011 341

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses

nurse staffing (F1,196 = 6.64, P G .01) by intent to resign.

TABLE 1 Perceived Medication Error Subscales
Mean Scores Certified critical care nurses endorsing intent to resign
reported higher mean CF scores (mean, 17.37 [SD,
Mean (SD) 7.01]), and greater agreement on nurse staffing was the
Reasons medication errors occur reason for medication error (mean, 4.19 [SD, 1.00])
than those not intending to resign (mean, 13.46 [SD,
Physician communication 3.9 (1.04)
6.38]; mean, 3.47 [SD, 1.17]), respectively. A statisti-
Medication packaging 4.0 (1.17) cally significant moderate relationship was found
Nurse staffing 3.6 (1.17) between MD and CF (r = 0.21, P = G .001). Thus, the
Transcription related 2.7 (1.50) more morally distressed the CCRNs felt, the higher their
perceptions of CF.
Pharmacy process 2.6 (1.17)
Reasons medication errors are not reported
Correlational Statistics
Disagree with definition 3.5 (1.14) A correlational matrix is presented in Table 2 that sum-
Reporting effort 3.8 (1.40) marizes the relationships between and among the study
Fear 4.1 (1.20) variables of MD, CF, selected NCs, and the perceived
reasons that medication errors occur, including physician
Administration response 3.8 (1.24)
communication, medication packaging, inadequate nurse
Scale of 1 = strongly disagree to 6 = strongly agree. staffing levels, transcription-related problems, and phar-
macy process.
important reasons that medication errors occur, with a Reasons Medication Errors Occur. Participants who
mean of 3.9 (SD, 1.04) and 4.0 (SD, 1.17), respectively. reported increased levels of MD also reported a greater
For reasons that medication errors are not reported, perception that physician communication is a major
fear (mean, 4.1 [SD, 1.20]), reporting effort (mean, 3.8 reason for medication errors. Medication packaging as
[SD, 1.40]), and administrative response (mean, 3.8 a perceived reason for medication error occurrence was
[SD, 1.24]) received the highest endorsement. positively correlated with years in practice. Moral dis-
tress, CF, intent to resign, and the perception of in-
Relationships Between Variables adequate nurse staffing as the reason for medication
There were statistically significant differences between errors were positively correlated. Moral distress and
the mean scores of (1) CF (F1,195 = 6.32, P G .01) and (2) CF were positively correlated with the perception that

TABLE 2 Pearson Product-Moment Coefficients for Reasons Medication Errors Occur Subscale Scores,
Moral Distress, Compassion Fatigue, and Selected Nurse Characteristics
PC MP NS TR PP MD CF IR YP UT Age

PC V
MP 0.46a V
a
NS 0.39 0.26a V
TR 0.33a 0.13 0.37a V
a a a
PP 0.46 0.25 0.30 0.43a V
a a b
MD 0.24 0.06 0.34 0.20 0.12 V
b b
CF j0.02 j0.09 0.15 0.15 j0.005 0.21a V
a
IR j0.02 j0.04 0.18 j0.002 0.006 0.10 0.18b V
b
YP 0.12 0.15 0.003 j0.05 0.13 0.002 j0.05 j0.09 V
b
UT 0.10 0.13 0.04 0.14 0.17 0.02 0.08 j0.08 0.51a V
b a
Age 0.08 0.12 j0.06 j0.08 0.14 j0.02 0.00 j0.08 0.84 0.44b V

Abbreviations: A, age; CF, compassion fatigue; IR, intent to resign; MD, moral distress; MP, medication packaging; NS, nurse staffing; PC, physician communication;
PP, pharmacy process; TR, transcription related; UT, unit tenure; YP, years of practice.
a
P = .01.
b
P = .05.

342 Dimensions of Critical Care Nursing Vol. 30 / No. 6

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses

transcription-related problems are a reason for error oc- were used when describing a medication error made by
currence. Years on unit and the respondent’s age pos- another staff member, along with ‘‘frustration’’ and
itively correlated with the perception that pharmacy ‘‘anger’’ at the way the error was handled by admin-
process is a major reason for medication errors. istration. ‘‘Devastation,’’ ‘‘fear,’’ and ‘‘the worst thing
that might happen’’ were themes discussed regarding
other nurses’ errors. Some participants described nurses
Medication packaging as a who felt so badly about a medication error, they con-
perceived reason for medication error sidered leaving nursing. Other nurses were described as
occurrence was positively correlated sad, but rationalized their actions or felt justified, given
the context in which the error occurred. These themes
with years in practice. of strong negative emotions and the intent to resign
resonate with the quantitative data from this study and
suggest a previously unexplored dimension to the ex-
Reasons Medication Errors Are Not Reported. A perience of critical care nursing.
correlational matrix is presented in Table 2 that summa-
rizes the relationships between and among the study IMPLICATIONS FOR CRITICAL CARE NURSES
variables of MD, CF, selected NCs, and the perceived We conducted this study to examine a previously un-
reasons that medication errors are not reported, includ- derstudied phenomenon, specifically, the relationships
ing disagreement with an institution’s definition of between MD, CF, PMEs, and NCs. However, the im-
medication error, reporting effort, fear, and administra- plications of these data go far beyond this seemingly
tive response. Moral distress and CF were positively cor- clear-cut purpose. The relevancy of this study to the day-
related with disagreeing with the institution’s definition to-day work of critical care nurses is deeper than we
of medication error and fear as reasons for not reporting anticipated. Although it is intuitive that nurses who feel
medication errors. Moral distress was positively corre- higher CF might also experience higher MD, this study
lated with reporting effort and administrative response as is the first documentation of this correlation in critical
reasons for nonreporting. care nurses. The further correlation of these phenomena
with such variables as intent to resign and the perception
Qualitative Data that medication errors are related to workplace processes
Following the collection of the survey data summarized (eg, poor physician communication, transcription errors,
above, a focus group with 5 participants drawn from pharmacy process) displays a pattern of critical care
the larger sample was conducted. By asking open-ended nurses working in circumstances that would seem to pro-
questions to this small group, the researchers sought mote burnout and turnover, rather than prevent it.
to give an added richness to the survey data and pro-
vide validation of the quantitative findings. The discus- Why Do Medication Errors Occur?
sion questions presented to this group were: ‘‘How has Data from this study demonstrate that medication er-
your work environment implemented medication error rors do not occur in a vacuum. They occur in a complex
reduction strategies?’’; ‘‘What is the central issue re- context in which issues such as physician communica-
lated to nursing medication errors?’’; What feelings have tion, nurse staffing levels, and even medication packaging
you experienced related to medication errors?’’; ‘‘Was are reported as significant reasons that errors occur. Such
there any resource available to discuss these feelings?’’; a ‘‘situational’’ explanation for medication errors is in
‘‘What measures could help reduce medication errors direct opposition to other explanations that tend to cen-
for nurses?’’; and ‘‘How has the increased attention to ter on individual nurses as ‘‘bad’’ or ‘‘careless.’’ Concur-
medication errors affected your professional practice?’’ rent with this view of individual blaming is the creation
Following the focus group discussion, the participants’ of a work culture in which medication errors go unre-
statements were transcribed and studied for central, re- ported, because of such highly charged emotions as fear,
curring themes. horror, and punitive administrative response.
The themes that emerged from this discussion were
congruent with the quantitative data: the need for ‘‘pro- The Critical Care Environment Transformed:
cess and work practice changes’’ to enhance safe medica- Beyond Blame
tion administration was emphasized strongly. In regard Data from this study clearly show that a transformation
to the feelings experienced by CCRNs in relation to is needed in the environment of the critical care unit.
medication error, participants quickly raised the theme That a nationally recruited sample of CCRNs reported
of ‘‘negative emotions.’’ Descriptors such as ‘‘horror’’ elevated levels of MD is a sufficiently important piece of

November/December 2011 343

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Medication Errors and Critical Care Nurses

data by itself to suggest that existing processes in critical vention of medication error. Findings from this study
care environments require further study. The usual re- support building a transformed work culture in which
sponse of ‘‘it goes with the territory’’ is often given for error reporting is actually commended, instead of pun-
the highly stressful work environments that CCRNs in- ished. The adoption of a nonpunitive, blame-free culture
habit. But data from this study suggest that institutional that promotes active reporting of medication errors
processes promote medication errors and that fear pre- could ultimately result in the elimination of errors. The
vents nurses from reporting errors, while simultaneously direct involvement of CCRNs in the creation of such
fostering MD. Is there an alternative to an environment environments is essential. As nurses, we are, ultimately,
of blame? responsible for finding a voice and creating the most
The creation of work settings in which errors are healing environments possible, both for ourselves and
viewed as part of larger systemic problems, rather than for our patients.
individual failure, is a recent development in health care.36
The application of such models to the critical care envi-
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2003;5:33-37. Lomaland Dr, San Diego, CA 92106 ([email protected]).

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DOI: 10.1097/01.DCC.0000406385.17864.ab

November/December 2011 345

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