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Table 5 Thematic analysis—themes 1 to 4

From: Using video-reflexive ethnography and simulation-based education to explore patient management and error recognition by pre-registration physiotherapists

Theme 1—behaviour
Subtheme Examples
1.1 Professionalism • I feel like I am really loud and might be a bit condescending to be so loud, like the patient is deaf. Yeah, because I always listen to my voice and I am thinking why was I so loud, he can hear me…it’s something that subconsciously I have started doing when I talk to patients and it’s something that I need to tone down.
1.2 Situational awareness • So I went to listen to his chest, noticed the monitor going off, it was the sats (referring to oxygen saturations) dropping but I think they just dropped to 89/88, something like that so I was hoping it was a bit of a drop and he would pick up on his own. But as I started auscultating the saturations continued to drop so I stopped auscultating, increased his oxygen because my main concern was to keep his sats up. Whereas if they dropped too low things could start deteriorating more quickly, so if we get his sats up to a reasonable level and they stay there we could continue with the assessment and find out a little bit more about it. That’s when I called (referring to the healthcare assistant) over to help me just reposition him and see if it was just a matter of positioning, that his sats were dropping. And then, I think as we go on I finally reposition him and he doesn’t pick up quick enough for my liking, so we upped the oxygen.
1.3 Communication • That was me jumping in then, there when I should have stepped back. Sorry. I am vocal too, so it was a bit of a clash because I should have just let you finish talking but you know how it is. It’s hard we are both, both thinking the same thing.
• We are speaking amongst ourselves rather than speaking to him. I think he kept asking us questions, which is good, and I think I started talking a bit more towards him.
1.4 Knowledge and skill deficit • We tried ringing for help but I think if I did that in an actual clinical setting I would feel a bit daft having to ring for the nurse to come and help sort the humidification out. I was a bit confused with it.
• I wasn’t sure whether to use the non-rebreathe mask or the 60 % venturi mask. I was like ask the healthcare assistant…That’s why I hesitated, because I was unsure what to do. Brain freeze there.
1.5 Clinical reasoning • So I also wanted to get him more of a high sitting position because in that slumped position he would be able to breathe more effectively, so to increase his V/Q (referring to ventilation perfusion) matching. I tried to use the sliding sheet to do that.
1.6 Error identification • And then, we are just putting our gloves and things on here, which I should have done at the start but I am just doing that now.
• At this point I didn’t have gloves or an apron on, I should have. I still hadn’t introduced myself after 50 seconds. Throughout all the assessment, I was being quite slow to get the gloves on and should have been quicker.
Theme 2—independent error identification
Subtheme Examples
2.1 No errors • I don’t think I did anything majorly wrong. Like I said the main thing I would have probably, would have left him on his other side. If I did do anything wrong I don’t think it was anything that would have put him any major danger or risk. But as far as I can tell I didn’t do anything that I didn’t clinically reason to be safe and in the patient’s best interest.
• I don’t think so, I think you mentioned about the nebulisers, I don’t know if I would call it a clinical error or not but obviously it would help with the moving the secretions so probably shouldn’t have done suctions straight away.
2.2 Assessment • I wasn’t too sure what I was hearing with the crackles…So if I did it again I would probably try to clinically reason it a bit better so that I wouldn’t make errors like that.
2.3 Communication • I think I would have hopefully done better with the telephone conversation to the nurse to explain what I had done and how Levi was.
2.4 Infection control • Also just things like putting my gloves and aprons on and just simple things like that I forgot to do which maybe I wouldn’t have forgotten to do in a real hospital setting. I would have done that automatically… although that is quite real, it is real patients and I just think about it more when I am in that setting. It just seems to come more naturally to me to do those things. Because it’s a real person they might have real infections, I think it makes you more aware to it.
2.5 Manual handling • I think at one point I did lose control of his head when lifting him up. I would ensure that didn’t happen but I did ensure that didn’t happen afterwards.
• We should have probably put the bed flat as well before we moved him so we were kind of going uphill which made it a lot harder
2.6 Intervention • Well giving him oxygen without asking for a prescription from a doctor that’s a major error.
• When she rolled on the right hand side I kind of mumbled good lung down hoping that she would go towards me. And I grumbled when she rolled towards me, try towards me. But yeah, I think that was one of the errors.
Theme 3—prior experience
Subtheme Examples
3.1 University units • …Something like doing this would have been helpful in uni but anything that we have done has been nothing so life-like, so I don’t think it has prepared me.
• …my work at uni gave me the background knowledge for assessments and treatment interventions. Then clinical placements helped build on that but I hadn’t done the critical care placement.
• …in uni, you’re just doing it on your peers so you don’t think about it as a real patient and deteriorating and you don’t have that pressure on you so I don’t think that’s really prepared you for that kind of situation.
• …Something like doing this would have been helpful in uni but anything that we have done has been nothing so life-like this so I don’t think it has prepared me.
3.2 Placement • I think my clinical placement more so prepared me for it because then, I did a lot of assessments. So, I can visualise assessments and treatments so I drew on those.
• No. No, I don’t because on placement I had done a placement on ICU (Intensive Care Unit). Well partly on ICU but it was a surgical ICU, so people were only there who had major surgery, they weren’t actually poorly as such so I haven’t had experience with people actually deteriorating on me.
3.3 Acute illness management (AIM) course [57] • …when I did the AIM course through uni, I think this helped me understand what to do in a situation like this.
• Even though AIM was a whilst ago, going over that AIM thing constantly it’s kind of in my head…it’s good to know that in my head somewhere, it’s there.
Theme 4—value of simulation and reflexivity
Subtheme Examples
4.1 Skills development • I think so, definitely because it gives you a chance to put the theory into practice without the pressure of it being an actual patient. So, if you go wrong then you can remedy it without feeling bad or worrying about what your educator thinks of you.
4.2 Increased self-awareness • I think it will definitely help me on my elective because I will be doing respiratory, so I might not feel quite so daunted coming to see someone that is acutely ill. I think it’s quite good as well watching back yourself on a video you don’t realise at the time how you come across and how long time seems, when sometimes it feels like its flying but really it’s just not. I think it’s just helpful to get an overall picture of you and then reflecting on that as well.
4.3 Placement preparation • Should I have done this before I went on my ICU placement I wouldn’t have been so overwhelmed when seeing the patients so acutely ill and also when I first went on that placement. I was completely scared but obviously from that scenario that’s what happens in ICU so should I have done this before, I would have been a lot less nervous so more prepared.
• Yeah, it’s like a refresher because it’s been six months now since the last placement and its only three weeks until we go again…I am on orthopaedics, there are not so many nurses, so I am more nervous when I treat them. And I would be able to spot the signs now.
4.4 Added realism • The exposure to the pressure I think it’s a good realistic thing that you wouldn’t get in a skills scenario like [name] said, with the beeping with somebody actually realistically in front of you who is acutely unwell it’s definitely a beneficial thing to be exposed to.
• I feel there is massive benefit to undergraduates and pre-reg experience as it did replicate a clinical environment…and I personally felt that I learnt more about aspects of treatment and assessment rather than undertaking a less realistic assessment on one of your colleagues in university as a student.
4.5 Patient safety • I think it will massively impact on patient safety through continually being to be able to adapt new environments even for the same patient, where many problems could be presented. For example the patient we saw today, a completely different problem could be shown with the same dummy allowing a person to experience all various different types of problems that would present in clinical practice with real patients. Therefore having all these learning experiences to draw from that they have reflected on and thought out loud about would definitely improve their clinical practice with real patients like quality of care and safety.
• …you’re allowed to make mistakes, like the mistake that I made and it’s not going to matter or it’s not going to impact the patient’s safety in this environment anyway and you definitely, I know I do, learn by doing and therefore learn by making mistakes as well. So to have made those mistakes in a safe environment you then go out and don’t make the same mistakes out there when it is going to potentially affect the patient’s life. So definitely.
4.6 Video review • I think the video review is definitely going to have helped because, whilst I was in there it felt like a train wreck but having come out and being able to talk about it and think about it. It helps to recognise where you went wrong, because I think if I hadn’t done this I would have gone away and just thought that was a disaster and tried not to think about it as much as I could. So, I definitely think that’s going to have helped.
4.7 Digital video disc (DVD) • …with the DVD, if I watch it I might be able to see more things that could have been different or better or that were good so I think it will help.
• In reference to general continuous professional development, I am going to complete a written reflection and also I feel the DVD I will continually revisit that so I have got a constant picture of how next time I can always improve my respiratory assessment and treatment.