Understanding transgression in respiratory rate observation collection methods in the Emergency Department: A classic grounded theory analysis

Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency department patients. Despite the importance of respiratory rate observations, this vital sign is often missing or misrepresented on emergency department observation charts, compromising patient safety. Concurrently, there is a paucity of research reporting why this phenomenon occurs. This research project employed a classic grounded theory analysis of qualitative data with the aim of developing a substantive theory explaining emergency department registered nurses’ reasoning when they miss or misreport respiratory rate observations. Seventy nine registered nurses currently working in emergency departments within Australia provided detailed responses from individual interviews and open ended responses from an online questionnaire. Classic grounded theory research methods were utilised, therefore coding was central to the abstraction of data and its reintegration as theory. The three types of constant comparison synonymous with classic grounded theory methods were employed to code data. This overall approach facilitated the identification of the main concern of the participants from the substantive area of interest, and aided in the generation of theory explaining how the participants processed this issue. The main concern identified was that registered nurses did not want to perform respiratory rate observations at each round, however organizational requirements dictate a value for the respiratory rate be included each time vital signs are collected. The theory ‘Rationalising Transgression’, explains how the participants continually resolve this problem. The study found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observations, and then rationalise this behaviour by employing several strategies that adjust the significance of the organisational requirement. These strategies include compensating, when nurses believe they are compensating for errant behaviour by adding value to the patient’s outcome. Minimalizing is employed when nurses believe that the patient’s outcome would be no different if they performed and recorded an accurate respiratory rate or not. The Trivialising strategy sanctions negligent behaviour and occurs when nurses ‘cut corners’ to get the job done. This research reveals that despite years of continuing education regarding best practice guidelines for respiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must occur regarding nurses’ understanding of acceptable practice methods in regards to patient safety. Nurses must receive education in a way that permeates their understanding of the relationship between the regular collection of accurate respiratory rate observations and optimal patient outcomes.