International Journal of Nursing Studies 74 (2017) 67–75

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Explaining transgression in respiratory rate observation methods in the MARK

emergency department: A classic grounded theory analysis
⁎
Tracy Flenady , Trudy Dwyer, Judith Applegarth
Central Queensland University, School of Nursing & Midwifery, Building 18, Bruce Highway, Rockhampton 4702, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Abnormal respiratory rates are one of the first indicators of clinical deterioration in emergency
Patient safety department(ED) patients. Despite the importance of respiratory rate observations, this vital sign is often in-
Emergency nursing accurately recorded on ED observation charts, compromising patient safety. Concurrently, there is a paucity of
Deteriorating patient research reporting why this phenomenon occurs.
Grounded theory
Objective: To develop a substantive theory explaining ED registered nurses' reasoning when they miss or mis-
Respiratory rates
Transgression in recording methods
report respiratory rate observations.
Design: This research project employed a classic grounded theory analysis of qualitative data. Participants:
Seventy-nine registered nurses currently working in EDs within Australia. Data collected included detailed re-
sponses from individual interviews and open-ended responses from an online questionnaire.
Methods: Classic grounded theory (CGT) research methods were utilised, therefore coding was central to the
abstraction of data and its reintegration as theory. Constant comparison synonymous with CGT methods were
employed to code data. This approach facilitated the identification of the main concern of the participants and
aided in the generation of theory explaining how the participants processed this issue.
Results: The main concern identified is that ED registered nurses do not believe that collecting an accurate
respiratory rate for ALL patients at EVERY round of observations is a requirement, and yet organizational re-
quirements often dictate that a value for the respiratory rate be included each time vital signs are collected. The
theory ‘Rationalising Transgression’, explains how participants continually resolve this problem. The study
found that despite feeling professionally conflicted, nurses often erroneously record respiratory rate observa-
tions, and then rationalise this behaviour by employing strategies that adjust the significance of the organisa-
tional requirement. These strategies include; Compensating, when nurses believe they are compensating for
errant behaviour by enhancing the patient’s outcome; Minimalizing, when nurses believe that the patient’s
outcome would be no different if they recorded an accurate respiratory rate or not and; Trivialising, a strategy
that sanctions negligent behaviour and occurs when nurses ‘cut corners’ to get the job done. Nurses’ use these
strategies to titrate the level ofemotional discomfort associated with erroneous behaviour, thereby rationalising
transgression
Conclusion: This research reveals that despite continuing education regarding gold standard guidelines for re-
spiratory rate collection, suboptimal practice continues. Ideally, to combat this transgression, a culture shift must
occur regarding nurses' understanding of acceptable practice methods. 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.

What is already known about the topic? patient outcomes and decreases mortality rates associated with ad-
verse events such as cardiac or respiratory arrest.
• An abnormal respiratory rate is an accurate indicator of clinical
deterioration and can precede life threatening adverse events such What this paper adds
as cardiac and/or respiratory arrest.
• Respiratory rates are the least often recorded vital sign. This study adds to the body of knowledge related to respiratory rate
• Early identification of and response to deterioration improves

⁎
Corresponding author.
E-mail address: t.flenady@cqu.edu.au (T. Flenady).

http://dx.doi.org/10.1016/j.ijnurstu.2017.06.001
Received 28 August 2016; Received in revised form 29 May 2017; Accepted 2 June 2017
0020-7489/ © 2017 Elsevier Ltd. All rights reserved.
T. Flenady et al.
collection methods in that this research:
• Corroborates previously published findings confirming that re-
spiratory rate observations are often omitted or erroneously re-
corded in an emergency department setting.
• Reveals insight to emergency department registered nurses’ rea-
soning when they choose to miss or misreport respiratory rates.
• Explains the three main strategies (compensating, minimalizing and
trivialising)that ED RNs employ when they rationalise erroneous
recording behaviours.
• This study makes recommendations for improved practice with the
goal of improving the accuracy of early warning scores for all emer-
gency department patients.
1. Introduction and background
International literature acknowledges that recognising and re-
sponding to a patient who is clinically deteriorating is essential if op-
timal patient outcomes are to be achieved (Australian Commission on
Safety and Quality in Health Care [ACSQHC], 2012; National Institute
for Clinical Excellence, 2007; National Patient Safety Agency, 2007;
Thompson, 2007). Undeniably, when clinical decline heralding re-
spiratory or cardiac arrest is detected early, potentially lifesaving in-
terventions can be expedited judiciously (Buist et al., 2002; Calzavacca
et al., 2010).
Two factors that contribute to undetected patient deterioration are
inconsistent monitoring of vital sign observations and a lack of under-
standing regarding the significance of physiological changes patients’
exhibit preceding clinical decline (Australian Commission on Safety and
Quality in Health Care [ACSQHC], 2012). This is significant, as vital
sign observations provide health care clinicians with insight to each
patient’s clinical acuity at various stages throughout their admission,
therefore inconsistent monitoring and recording of vital signs produces
inaccurate data which then compromises patient safety.
Hospitals are now encouraged to utilise observation charting sys-
tems that require nurses to measure and record scores for each vital sign
observed, with the combined value of scores referred to as an early
warning score (EWS) (Australian Commission on Safety and Quality in
Health Care [ACSQHC], 2012; Day and Oxton, 2014). The total EWS
from each round of observations is a reliable predictor of clinical de-
terioration, therefore when the score reaches a certain threshold a
predetermined response is triggered (Ludikhuize et al., 2012; Silcock
et al., 2015). One of the vital signs that contribute to the EWS is the
respiratory rate and is noteworthy in that abnormal respiratory rates
have been recognised as an accurate precursor of clinical deterioration
(Considine, 2004; Hosking et al., 2014; Jonsson et al., 2011; Ljunggren
et al., 2016). Abnormal respiratory rates provide health care clinicians
with an opportunity to recognise and respond efficaciously to poten-
tially life threatening conditions, to prevent high acuity unit admis-
sions, reduce hospital length of stay and significantly reduce mortality
rates (Cretikos et al., 2008; McBride et al., 2005; Odell, 2015). It is
therefore imperative that respiratory rate observations are collected
regularly, obtained correctly and recorded accurately for each patient.
Emergency departments(ED) have been identified as high pressure,
time driven environments, where many patients experiencing a diverse
range of medical conditions require care simultaneously (Queensland
Government, 2015). In acute care settings such as this, adverse events
are often associated with errors of commission or omission (Donaldson
et al., 2000; Fordyce et al., 2003). Published studies report the efficacy
of early warning scores to identify the deteriorating patient whilst in an
ED setting (Day and Oxton, 2014; Hogan, 2006; Lam et al., 2006; So
et al., 2015). The value of detecting clinical decline early, when patients
are still in an ED setting is evident when considering the literature that
reveals a high percentage of patients admitted to hospital wards from
EDs are likely to meet the criteria for an emergency call within hours of
arriving on the wards (Considine et al., 2014). Further, it is understood
68
International Journal of Nursing Studies 74 (2017) 67–75
that the in-hospital mortality rate for patients who go on to trigger an
emergency review can be as high as 34% (Buist et al., 2002; Calzavacca
et al., 2010). In view of this, it is evident that to improve in-hospital
mortality rates, everything possible should be done to capture patients’
clinical deterioration before they move to the wards.
Despite this, a review of the available literature reveals that the
respiratory rate is often missing from ED observation charts and can be
misrepresented in that the previous or initial score is simply repeated
(Ansell et al., 2014; Gravel et al., 2006; Hosking et al., 2014; Parkes,
2011). While there is emergent literature that this practise is occurring,
what is not known is why it occurs. One of the main aims of this re-
search is to add insight around this topic area.
2. Methods
2.1. Research aims
This study aims to understand the behaviours of registered nurses
when they observe, collect and record respiratory rates in an ED setting,
and to gain an understanding of the reasoning this cohort employ when
they decide to miss or misreport respiratory rate observations. To
achieve these aims, the researcher set out to identify the main concern
of the participants within the substantive area of interest and generate a
substantive theory that resolved this problem.
2.2. Design
The inductive methodology of classic grounded theory was chosen
as the most appropriate means to analyse the qualitative data collected
as this approach facilitates the generation of theory that resolves, or
explains, the main concern of the participants in the substantive area
under investigation (Glaser and Strauss, 1967). Classic grounded theory
methods drive the researcher to focus on revealing the main problem
common to the majority of participants in the substantive area of in-
terest, as opposed to focusing on the researcher’s problem. Grounded
theory analysis methods are ideal when researchers are trying to un-
derstand participants’ unique perspective, or experience of a specific
event or action, as the participants are encouraged to speak about their
understanding of certain experiences, and tell their stories in their own
words (Bradley et al., 2007; Richards and Morse, 2007). Researchers
are then able to identify patterns of behaviour from within the sub-
stantive area that explicates how those involved continually resolve the
identified problem (Glaser, 1992).
2.3. Participants
The study collected data from seventy nine registered nurses cur-
rently working in EDs across four states and one territory of Australia.
Participant recruitment involved the dissemination of a link via
social media, directing interested parties to a website (http://
resprateresearch.wixsite.com/resp-rate-research) that provided details
about the research and participation. To be eligible, participants had to
be a registered nurse currently working in an Australian ED. Visitors to
the website, if eligible, were invited to complete an anonymous survey,
involving open-ended questions, and/or register their interest in par-
ticipating in individual interviews. All potential participants were di-
rected to complete the demographic survey, collected to aid in theo-
retical sampling requirements. Demographical data that was collected
is outlined below in Table 1. An online consent form had to be viewed
and acknowledged if participants were to be involved in the interview
process. Participation in the research was voluntary and confidential.
2.4. Ethical review of study
Ethical approval to conduct the study was received from the
University ethics committee (HREC Clearance number H16/02-027).
T. Flenady et al. International Journal of Nursing Studies 74 (2017) 67–75

Table 1 participants telephoned and interviewed based on theoretical sampling

Demographic details of participants (n = 79). needs between February and June 2016. Of the twenty-one interviews
conducted, the primary researcher had previously met four of the in-
Item Response n
terviewees in a work context. Each interview began with the grand tour
Geographical location of the hospital that Queensland 74 question:
participant worked in at time of study
New South Wales
Northern Territory
2
2 • Please share with me your experience around collecting respiratory
Western Australian 1 rate observations whilst working in the emergency department.
Regional 42
Rural/remote 21
Despite advice from Glaser (1998) to the contrary, face to face in-
Metropolitan 16 terviews were recorded and transcribed verbatim. Interviews varied in
length between 35 and 105 min each, and were all conducted in private
Gender Female 70
Male 8 interview room. Field notes were produced for each interview, jour-
Other 1 naling details such as the interview setting, dates and times. When no
Age 20–29 22 new information or insight was revealed from the interview process, the
30–39 25 researcher recognised that theoretical saturation had been achieved
40–49 17 (Glaser and Strauss, 1967) and interviews ceased.
50–60 13
Did not report 2
2.6. Data analysis
Qualifications Undergraduate or higher 73
Hospital Certified 6
Glaser and Strauss (1967) classic grounded theory methodology was
Years working as a Registered Nurse 1–4 19 utilised, therefore coding was central to the abstraction of data and its
5–9 20
reintegration as theory. The three modes of coding employed; sub-
10–19 22
20–29 11 stantive, selective and theoretical, meant that the substantive coding
30+ 7 broke down, or fractured the data via open and selective procedures
and the theoretical coding wove the fractured pieces back together as
the emergence of theory (Glaser, 1978; Glaser and Strauss, 1967).
The study was guided by, and complied with, the National Health and
Medical Research Council (NHMRC) guidelines for voluntary partici- 2.6.1. Substantive coding
pation (National Health Medical Research Council, 1999). It was a re- There are two variations of substantive codes; in vivo, which are
quirement that all participants involved in the interview process view words abstracted directly from the participants, and implicit, codes that
and acknowledge the study’s online consent form. All participants were are generated by the researcher (Glaser, 1978, 1992). Initially, in the
advised that they had the right to withdraw from the research at any words of Glaser (1978, p. 56), the data was run open, with the data
time without penalty. Confidentiality and anonymity conditions of the coded every way imaginable, including with and against all other data.
study were explained to all participants. Each datum was manually analysed, with the focused intent of identi-
fying what concept it was indicative of, with the researcher inductively
2.5. Data collection generating categories and their properties from actual incidents ab-
stracted from the data. Coded incidents were not restricted to classifi-
Whilst the data were collected solely by the primary researcher, a cation within one category, for as Glaser suggests, codes are flexible and
PhD candidate and experienced ED nurse, the coding was supervised by not mutually exclusive. For example, participant 67 stated in one sen-
two doctoral qualified experienced researchers, both with extensive tence, “...I would guess sometimes, especially if I have been looking
grounded theory and qualitative analysis experience. Data collection after the patient for many hours and had been counting and was rushed
comprised several sources, including demographic data, open ended and thought the patient's respirations looked the same” (P67) this data
responses from a questionnaire, detailed responses from face to face or were coded into two categories; ‘time as a commodity’, an in vivo code,
telephone interviews, memos, and anecdotal evidence. Glaser (1978, p. and, ‘erroneous conformity’, an implicit code generated by the re-
8), when discussing doing grounded theory, confirms that data can be searcher that captured incidents that indicated respiratory rates were
collected from any public or private record, irrespective of form, the recorded without being counted. Thus, incidents, or indicators, were
only mandate being, the data must come from, or be about, the sub- coded into as many substantive categories as they fit. Questions that the
stantive area, or substantive population. researcher continued to ask herself in this early stage included, “what is
As part of the online registration process, participants were offered this study about conceptually”, “what is actually going on in the data”,
the opportunity to provide written answers to the following two open- “what emotional problems are the participants revealing”, “what ac-
ended questions: counts for, or resolves the exhibited behaviour/s”, “what basic social
processes are occurring”(Glaser, 1998, p. 140). Memoing continued
• If you have ever NOT included the respiratory rate when performing throughout this iterative process, ensuring an audit trail was developed
a full set of vital sign observations, can you write about the reason/s that explained the relationships between incidents and the coding
why? choices made for each. This constant comparative process facilitated
• If you have ever recorded a respiratory rate observation as “in the the emergence of the core category ‘rationalising transgression’. This
normal range” without actually counting it, can you write about the category had the most explanatory power, accounting for most of the
reason/s why? substantive codes and their properties.

The study comprised seventy-nine participants in total and fifty-five
respondents chose to provide written responses to the above two
questions. Twenty-four respondents indicated they would participate in
one on one interviews. Interviewees were chosen randomly from the
total pool of respondents, with eleven face to face in-depth interviews
occurring between February and April 2016, and another ten
2.6.2. Selective coding
As the researcher continued to simultaneously collect, analyse, code
and memo data, the analysis of each datum was now guided by ques-
tions such as, ‘what property of’, ‘what category of’ and/or ‘what part
of’, the emerging theory does this incident indicate (Glaser, 1978,
1992). Whilst data continued to be collected and analysed, the data was

69
T. Flenady et al.
now delimited to only include variables of the main categories in order
to achieve saturation (Glaser, 1998). Categories that coded out early,
for example, ‘Fear of negative judgement’ and ‘Exceptions to the rule’,
were discarded or re-sorted into one of the other main categories once
relevance was recognised. It was from this constant comparative pro-
cess that the three categories and their properties that accounted for
nearly all variations in behaviour exhibited by the cohort were identi-
fied.
2.6.3. Theoretical coding
Theoretical coding is unique to the CTG approach (Glaser, 1978)
and is a crucial component of a fully integrated, explanatory sub-
stantive theory. Theoretical codes are used to highlight the theoretical
relationship between the substantive codes and categories, and the core
category (Hernandez, 2009). This study’s researcher employed Glaser’s
(1978) six C coding family [causes, contexts, contingencies, con-
sequences, covariance and conditions] to organise the data. Initially,
the researcher had found the main concern of the participants to be that
they did not feel as though accurate respiratory rates were a require-
ment for ALL patients at EVERY round of observations. The use of the
six C’s coding family revealed the emotional impact the cohort ex-
perienced when they erroneously recorded a respiratory rate without
counting, in order to meet organisational requirements.
2.6.4. Memos
Glaser (1978, p. 83) suggests there are four fundamental goals when
memoing; the researcher is to theoretically develop ideas that are not
restricted by boundaries and then file them in a highly sortable memo
fund. In regards this study, in the first stages of simultaneous data
collection and analysis, memos were used to extrapolate the theoretical
properties of the substantive codes. Memoing thus ensured these first
level codes were saturated as their boundaries were defined. Memos
were written that revealed the empirical criteria upon which the
identified code was based, for example, in the case of the substantive
code, ‘patient’s presenting condition’, memos were generated around
first level abstractions from the data that defined this code, including,
but not limited to: clinically stable, superficial laceration, minor com-
plaint, nil co-morbidities, minor injuries, nature of presentation, not
clinically indicated, nil respiratory issues on presentation, triaged a
category 5. Therefore as memos about each of these indicators were
developed, the conditions under which the substantive code ‘patient’s
presenting condition’ were able to be identified.
2.7. Quality and rigour
The three components required to ensure quality and therefore ri-
gour, when performing grounded theory research are the inclusions of
researcher expertise, methodological congruence and procedural pre-
cision throughout all stages of the project (Birks and Mills, 2011; Grix,
2010). Researchers involved in this project include doctoral qualified,
acknowledged experts in the fields of early warning scores and the re-
cognition of clinical deterioration. Methodological congruence is pre-
sent when there is resonance between the stated aims of the research,
the personal philosophical position of the researcher, and the metho-
dological approach employed to achieve the set objective (Birks and
Mills, 2011). The research paradigm chosen for this study is metho-
dologically congruent, in that the primary researcher’s pragmatic
epistemological viewpoint facilitated the emergence of theory through
an inductive approach, utilising a CTG analysis. Finally, procedural
precision was demonstrated by the generation and maintenance of a
detailed audit trail, consisting of a vast memo bank comprising detailed
memos, transcriptions of interviews, numerous field notes and copious
researcher notes.
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International Journal of Nursing Studies 74 (2017) 67–75
3. Results
3.1. The main concern
The main concern of the participants from the substantive area
under consideration (ED Registered Nurses [RN]) is that this cohort
does not believe counting and recording a respiratory rate is a re-
quirement for ALL ED patients at EVERY round of observations. This
study’s cohort feel that counting the respiratory rate for all ED patients
is a superfluous or redundant job and wastes valuable time, as evi-
denced from comments such as this from participant 9; “I have more
important things to do than stand around confirming something I al-
ready know” (P9). This poses a dilemma however, as organizational
(documentation requirements such as observation chart fulfilment)
professional and/or clinical requirements demand that at each round of
observations, nurses must document scores for each of the prescribed
vital signs to calculate an accurate Early Warning Score (EWS).
Registered nurses are held accountable for their professional practice,
and incomplete documentation could be perceived as professional
negligence (American Nursing Standards, 2016; American Nurses
Association, 2010; Nursing and Midwifery Board of Australia, 2016;
Nursing and Midwifery Council UK, 2016). Another impact from a
missing value for any one vital sign is that the total score given to in-
dicate the patient’s clinical acuity at that round of observations will be
incorrect due to the incompleteness of scoring for each observation.
Nurses included in this study explained that to avoid the appearance of
professional neglect, and to ensure the patient had an EWS for each
round of observations (albeit possibly inaccurate), they will record a
value for the respiratory rate without actually counting the respirations
for certain patients. For example, participant 30 had this to say “…
unless they came in with a breathing problem or something, then yeah I
wouldn’t stand there and count their breathing...I’ll just tick the box so
it’s done” (P30).
Based on participant’s responses, the erroneous recording of the
respiratory rate triggered by the forced compliance to organisational
requirements resulted in varying degrees of internal conflict. As well as
implicit data, explicit indicators such as “...I know I’m not doing it
properly” (P70), “I know I should improve my practice” (P69), “I have
good intentions…” (P39) indicated the conflict was caused due to the
disparity between their professional and/or personal beliefs and the
erroneous behaviour employed to comply with organisational require-
ments. The level of distress associated with their incongruent behaviour
varies between individuals and is evidenced by both implicit and ex-
plicit indicators including spoken language, choice of adjectives, their
tone of voice, facial expressions and body language.
3.2. The theory
Analysis of all collected data led to the development of the theory
‘Rationalising Transgression’. The visual depiction in Fig. 1 is included to
add clarity to the theory. We found that nurses believe respiratory rates
are not required for all patients at every round of observations. How-
ever often, there is a conflicting issue when they must record re-
spiratory rates for these patients. In these circumstances, nurses re-
ported that they estimate a respiratory rate without counting in order to
appear to be conforming. This erroneous behaviour triggers varying
levels of emotional discomfort which nurses reduce or negate entirely
by rationalising their transgression.
The theory rationalising transgression explains how ED RNs are able
to rationalise their erroneous behaviour by adjusting the importance of
the conflicting issue or their erroneous behaviour. The conflicting issue
is that organisational requirements are incongruent with professional
and/or personal values and beliefs. We found that when nurses reduce
or even negate the importance of the organisational requirements, or
their erroneous behaviour, they were able to titrate the level of emo-
tional discomfort they felt when they acted erroneously. In other words,
T. Flenady et al. International Journal of Nursing Studies 74 (2017) 67–75

Fig. 1. The theory Rationalising Transgression.

if they could make the organisational requirement seem less important, Table 2
or if their erroneous behaviour could be justified, they experience less Rationalising Transgression’s categories and properties.
emotional discomfort.
Category Properties (strategies)
Rationalising Transgression is achieved through compensating,
minimalizing and trivialising and explains how nurses view, experi- Compensating Valuing time
ence, and react to the conflicting issue from different perspectives. Valuing experience
Minimalizing Labelling the patient
These varying perspectives impact the level of emotional discomfort
Trivialising Cutting corners
that is experienced when erroneous behaviours are employed to meet ED is a special place
organisational requirements. The degree of emotional discomfort ex-
perienced by each nurse dictates which strategy he or she employs to
rationalise the erroneous behaviour. The three categories and their behaviour. Participants believe they are compensating for erroneous
properties explain the various strategies that are employed to adjust the behaviour by adding value to, or enhancing, the patient’s outcome. This
value of the conflicting issue. This study identified that adjusting the rationalising transgression is evident when positive outcomes of errant
value of the conflicting issue titrates the level of emotional discomfort behaviour are identified by the cohort that outweigh the outcomes of
associated with erroneous behaviour, thereby rationalising transgres- conforming. This study identified two strategies used to balance the
sion. These strategies are accounted for within the properties of the scales thus.
main categories and are outlined in Table 2 below.
3.3.1. Valuing time
3.3. Compensating Valuing time is a strategy that ED RNs utilise to rationalise errant
behaviour that occurs when their prioritisation of tasks conflicts with
Compensating conceptualises how the value of the conflicting issue organisational demands. Time as a commodity was expressed in many
is adjusted by taking into account perceived benefits or gains of errant iterations, permeating the data with its significance as a resource to

71
T. Flenady et al.
‘spend’ wisely. Just some of the codes collected that relate to time in-
clude: spending time, wasting time, running, taking time, restricted by
time, standing around, flat out. Time was continually referred to as
being very valuable and wasting time as something to be avoided at all
costs. This perspective, coupled with the nurses’ belief that in many
cases respiratory rates are a superfluous task, facilitate erroneous re-
porting. It emerged that allotted time was critically assessed and under
certain conditions or circumstances is able to be justified to be spent on
issues other than counting respiratory rates. In some instances, social
norms play a role in nurses’ perception of the use of time. For example,
participants voiced concerns that they (P59) “appeared to be doing
nothing if they just stood around counting” (P11) “looks like I am just
wasting time, when I am counting respiratory rates”. It was considered
that if nurses stood still long enough, other nurses, doctors or even
patients would allocate them more work and/or ask them questions
which take up more time.
“A minute standing still in the ED seems like it takes forever. I know
what it looks like…you’re in the middle of this perfect storm, no
beds, ambulance’s ramping, buzzers going off, patients needing
medications, dressings, a blanket, a cup of tea…and I am standing
still apparently doing nothing”.
This perception that counting for a minute was a waste of time
seemed to be perpetuated by other participants stating they felt an-
noyed when (P59) “other staff appeared to waste time by completing a
respiratory rate for all patients”. Examples of codes that contributed to
the conceptualisation of this category include (P78) “blood transfusions
matter, not counting a resp rate”, and (P70) “when I have to decide
between giving pain relief and standing around counting, I will ease
pain every time”. When this strategy is employed to rationalise erro-
neous reporting, it is inferred that time is being spent more wisely on
alternative tasks, and as a consequence, the patient is benefiting from
the transgression in behaviour.
3.3.2. Valuing experience
Valuing experience is a strategy that nurses utilise to rationalise the
erroneous behaviour that occurs when they are directed to conform to
organizational requirements they consider superfluous to the patients’
needs, or unworthy of the level of the ED RN’s experience. When ED
RNs choose to perform more highly skilled tasks over apparently
mundane organisational requirements, they are valuing experience and
believe they are enhancing patients’ outcomes by doing so. Valuing
experience is identified when the value of professionally gained quali-
fications and clinical experience is purported to be of more use when
applied to other more ‘seemingly important’ tasks than counting re-
spiratory rates. P34 explained “From experience I feel I can tell by
looking at the patient whether their respiratory rate is out of normal
range, so I don’t have to count” and this from P23: “I usually don’t
count because I can tell whether they are outside of the normal range by
watching my patient breathe”. It is evident that when this strategy is
employed to rationalise transgression, the value of highly esteemed
qualifications and clinical experience is thought to be ‘wasted’ on
mundane paperwork requirements and would add ‘more value’ if ap-
plied elsewhere. Comments such as this “I’m not a machine, I’m an
educated person” (P6), and this from P9: “if numbers are all that
matters, anybody can count, get the AIN [assistant in nursing] to count.
I can see when someone is breathing up. I have more important things
to do then stand around confirming something I already know” added
to this category’s conceptualisation. When it came to performing a
seemingly superfluous task such as counting and recording a respiratory
rate, participants spoke about their level of experience (not always
expressed in years) as being an enabling agent to participate in the
errant behaviour of erroneously documenting. Whilst participants that
employ this strategy believe they are doing ‘more good’ by doing
something other than not counting a respiratory rate, other participants
rationalised their transgression in recording methods by minimalizing
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International Journal of Nursing Studies 74 (2017) 67–75
the importance of the task in regards to certain patients.
3.4. Minimalizing
Minimalizing as a main category conceptualises how the value of
the conflicting issue is adjusted by reducing the importance of the or-
ganisational requirement. To minimalize is to make less of something,
to give the impression that an action is small or unimportant (Oxford
Dictionary, 2016a). It was identified that when this strategy is utilised,
the emotional discomfort associated with transgression is reduced, thus
errant behaviour such as entering a value for an uncounted respiratory
rate is rationalised. Nurses who employ this strategy assess the im-
portance of accurately assessing respiratory rates for each patient. If the
task is seen as less important for a particular patient, errant behaviour
can be rationalised because it is believed the outcome would not be any
different if the task is performed correctly or incorrectly. When orga-
nisational requirements dictate that a value be entered for this type of
patient, a score is entered without counting, but the emotional dis-
comfort associated with erroneous recording methods is minimalized as
the importance of the task (no impact on outcome) is minimalized.
When this strategy is employed, transgression is rationalised when it is
considered that little to no consequence would occur if the entry is
correct or wrong. The cohort in this study achieved minimalizing by
labelling the patient.
3.4.1. Labelling
Labelling is a strategy that nurses utilise to rationalise errant be-
haviour that occurs when they are required to perform tasks that they
perceive as having no benefit or value to certain types of patients.
Labelling is done when nurses use labels to quantify patients’ conditions
and it is usually based on a subjective assessment of patients’ condi-
tions. Whilst it is understood that erroneously recording a respiratory
rate is jeopardising the maintenance of professional standards, ratio-
nalising this transgression by labelling the patient’s condition as un-
worthy of requiring respiratory rates appears to be an acceptable
practice. For example, this from P30 was a common theme throughout
the interviews: “I never do a full set of obs on a presentation like a sore
toe, or small lac, or a chronic condition. I would do the basics, like BP
and heart rate, and temp, but wouldn’t bother with a resp rate, that
kind of presentation does not require it”. Or this from P39: “If it’s not a
complaint to do with respiratory then I would do the first round of obs,
counting the resps for 30 s, and unless something changed, I would just
repeat that score for the duration of that patient’s admission.” Labelling
was evident throughout the interviews as well, with this from P39: “I
might be looking after a DKA (Diabetic ketoacidosis is a serious medical
condition that warrants close clinical attention) and have to run and do
obs on a migraine, there is no way I’m going to count resp rates for the
migraine when I have to get back to the DKA”. Once a patient is labelled
as not requiring respiratory rate observations, the level of emotional
discomfort by not actually counting respiratory rates is reduced as the
importance of collecting a respiratory rate for this type (Label) of pa-
tient (the conflicting issue) is reduced. Participants that employ mini-
malizing as a strategy still express a degree of emotional discomfort by
erroneously recording a respiratory rate without actually counting,
however those that use trivialising, reduce their emotional discomfort
to close to nothing.
3.5. Trivialising
Trivialising is the third main category and conceptualises how the
value of the conflicting issue is adjusted by trivialising the errant be-
haviour, and/or trivialising the organisational requirement. To trivia-
lise is to make (something) appear trivial; and something trivial is of
little or no importance; insignificant; trifling (Oxford Dictionary,
2016b). It emerged that sanctioning negligent behaviour, and/or ne-
gating the importance of organisational requirements are strategies
T. Flenady et al.
utilised to achieve trivialisation. These tactics result in adjusting the
deficit between organisational requirements and personal beliefs or
values to virtually nil. When nurses employ this category’s strategies,
they achieve a reduction in the emotional discomfort which is triggered
by their erroneous behaviour, thus, they rationalise transgression. The
analysis of data throughout this study identified latent patterns in be-
haviour identifying two distinct properties within this category, ‘Cut-
ting corners’ and ‘ED is a special place’.
3.5.1. Cutting corners
Cutting corners is a strategy that ED RNs use to rationalise erro-
neous behaviour that is carried out to just “get the job done”. It was
revealed that when this strategy is utilised, ED RNs experience little to
no guilt or remorse when they cut corners in order to demonstrate the
appearance of conformity. Cutting corners is done when nurses perform
allotted duties with a tick and flick attitude with a minimal amount of
effort, and then experience little to no emotional discomfort from doing
so. Incidents in the data that were coded to this category shared the
common theme of ‘cutting corners’ to get the job done. Along with
coded incidents, participants’ body language and tone of voice revealed
that those who employ trivialising, experience minimal emotional dis-
comfort regarding the erroneous reporting methods they employ.
Comments such as “more bloody paperwork” (P42), and “bureaucratic
bull****” (P44) highlight the belligerence directed towards the orga-
nisational requirements, thus trivialising them. When codes such as
(P27) “Lack of time, I guess and ummm, you know, bad habits, it’s easy
to just tick the box” and “…just lazy sometimes…it’s not done by a
machine….” (P30) were collected, field notes associated with these
entries included researcher comments such as ‘lack of concern’, ‘com-
placency’, ‘no sense of guilt’ ‘diminished conflict’. The absence of guilt
or remorse attached to these incidents directed their coding to this
overall category. It became obvious that this method of rationalising
transgression is achieved by trivialising the organisational require-
ments, thus avoiding internal conflict when erroneous behaviour is
employed.
3.5.2. ED is a special place
When participants spoke about the ED as an environment in contrast
with other hospital wards, it appeared that the usual organisational
requirements were not an expectation in ED. Organisational require-
ments were trivialised by comments such as this from P51: “we are too
busy saving lives to stand still and count a respiratory rate, high pres-
sured situations call for extreme measures” and this from P37: “this isn’t
a ward you know…things are different down here”. P52 added to the
data with this: “when I worked on the medical ward it was a routine,
that’s what we did, but now I am in ED, it’s different…there are way
more important things to do than count a respiratory rate”. Social
norms also contribute to the coding to this property, in that participants
compare themselves to others, and rationalise their poor behaviour
through comments such as “everybody does it” (P42) and from P44:
“this is the way I’ve always done it. I have worked in many EDs and this
is how everyone does it”. It is by these strategies that erroneous re-
cording methods are trivialised as a commonality among staff in this
environment, correspondingly reducing the amount of conflict experi-
enced. It emerged that when ED is contrasted to other wards, where
conformity to ‘normal’ organisational requirements is an expectation,
the unique ED environment is used as a method of trivialising organi-
sational requirements. Once trivialised, the degree of emotional dis-
comfort experienced due to non-compliance is removed, and trans-
gression is rationalised.
4. Discussion
4.1. The main concern
Data collected and analysed through the course of our study
73
International Journal of Nursing Studies 74 (2017) 67–75
indicate that whilst nurses state they are aware of the best practice
guidelines for respiratory rate observations, they continue to believe it
is a superfluous action for many patients. These results corroborate
previous studies’ findings that nurses do not believe they need to per-
form regular vital sign observations unless it is clinically indicated
(Burchill and Polomano, 2016; Gravel et al., 2006; Johnson et al.,
2014). For example, a recent study involving 81 emergency nurses,
found that 76% of those interviewed, felt that performing regular vital
signs on clinically stable patients was a redundant action (Burchill and
Polomano, 2016). Of interest, and pertinent to the emergent theory
from our study, over half those interviewed in the Burchill and Polo-
mano study said the only reason they did perform vital signs regularly
was to safeguard their practice in case of litigious events. The concept
that patients must exhibit explicit signs of clinical distress to warrant
more frequent vital sign observations continues to be perpetuated
(Johnson et al., 2014), as does the misconception that it is acceptable to
omit the respiratory rate if the nurse believes the patients’ level of
clinical acuity does not indicate it (Gravel et al., 2006). These results fly
in the face of published best practice guidelines regarding respiratory
rate collection methods that confirm a much more accurate overview of
a patient’s clinical acuity is achieved when data is gathered both sub-
jectively and objectively (Flenady et al., 2017; Heazell et al., 2016;
Jacques, 2016; Long Khanh Dao Le, 2016; Walsh et al., 2010; Weber
and Kelley, 2010).
As can be seen, our study is certainly not the first to present research
that reveals registered nurses’ reluctance to perform respiratory rate
observations on all patients. The significance of our study is that it
indicates that in many cases, when a value is recorded on an ED pa-
tient’s chart, it may have been entered by rote, and not been counted at
all. Participants involved in this study reveal that if mandated to record
a value for the respiratory rate (due to documentation, professional or
organisational requirements) when their patient was seemingly clini-
cally stable, they were more than likely to just ‘tick the box’, and not
count.
4.2. Compensating
Whilst there is scant literature reporting on the reasons ED clin-
icians decide not to follow organisational requirements, the papers that
do discuss this phenomenon reveal findings that correlate with our
results. For example, a study aimed at identifying barriers preventing
emergency nurses from following organisational protocols found that
clinicians believe organizational protocols are more akin to guidelines
and that their clinical experience empowers them to decide to follow
the protocols or not (Ebben et al., 2014). This resonates with the
compensating category identified and discussed in our paper, where-
upon the participants believe the benefit of their professional experi-
ence is more appropriately utilised on facets of patient care other than
the collection of accurate respiratory rates. As substantiated in studies
that report on clinicians’ belief that under some circumstances, they are
doing ‘more good’ by not following specific clinical guidelines than by
following them by Jansson et al. (2013), McCluskey et al. (2013). A
commonality among our study and those mentioned here is clinicians’
concern that the one size fits all approach disadvantages certain pa-
tients and detracts from individualised care. Another perceived nega-
tive of forced compliance with organisational protocols and/or policies
is the idea that clinicians’ autonomy becomes diminished and highly
developed critical thinking skills are in jeopardy of stagnating due to
lack of application (Quiros et al., 2007). This sentiment was evident in
our study when the cohort examined claimed they felt undervalued
when tasked with mundane, seemingly redundant duties.
4.3. Minimalizing
In regards to the minimalizing strategy discussed in our paper,
several published studies report similar findings, in that when nurses
T. Flenady et al.
believe the patient’s outcomes do not benefit from compliance with
certain organisational requirements, they are more likely not to comply
(Ebben et al., 2014; Sinuff et al., 2007; van de Steeg et al., 2014). For
example, participants included in the Ebben et al. (2014) study reported
that incongruence between organisational requirements and patients’
needs was a factor that influenced protocol adherence.
4.4. Trivialising
Of interest, the cohort in van de Steeg et al. (2014) study utilised
strategies similar to those identified in our paper as trivialising. When
the participants from the van de Steeg et al. (2014) study explained why
they did not always comply with organisational requirements they re-
ferred to paperwork as an extra burden on an already overworked staff.
Participants also revealed that the paperwork requirements were only
completed because they were mandated, and not because the clinicians
thought it was useful (van de Steeg et al., 2014).
As evidenced, the importance of our research is that the findings
provide insight to ED registered nurses’ reasoning when they decide to
miss or misreport respiratory rate observations. The strategies em-
ployed to rationalise this erroneous behaviour, discussed within this
publication, could be the key educators need to overcome the perpe-
tuating belief that respiratory rate observations are only required to be
accurately recorded on certain patients.
5. Recommendations for improved practice
The purpose of this study was to understand the behaviours of re-
gistered nurses when they observe, collect and record respiratory rates
in an ED setting, and to gain an understanding of the reasoning this
cohort employ when they decide to miss or misreport respiratory rate
observations. Despite well documented evidence indicating the sig-
nificance of an abnormal respiratory rate as indicative of impending
clinical decline, the results of this study add to the body of knowledge
confirming that unacceptable practice around the collection methods of
respiratory rates persists (Cooper et al., 2014; Cretikos et al., 2008;
Hosking et al., 2014; Kennedy, 2007; Long Khanh Dao Le, 2016; Odell,
2015; Parkes, 2011). A significant contribution from our study, is the
finding that Emergency Department registered nurses can rationalise
this unacceptable practice.
Our study highlights the need for nurses to be more cognisant of
their professional and ethical responsibility in regards to the correct
fulfilment of vital sign observation chart records. Further, this research
highlights a deficit between researched best evidence and current
practice employed by registered nurses working in ED across Australia.
This could perhaps be explained by research that confirms regardless of
seemingly efficacious attempts to implement researched evidence into
practice, the uptake success is unpredictable (Kitson et al., 2008; Ullrich
et al., 2014). Given the results from our study, the main re-
commendation is that health care organisations reassess existing
methods of implementing evidence into practice in order to achieve the
change in practice required to improve patient outcomes. The results
from this study demonstrate that traditional ‘one size fits all’ education
packages are not the most effective method of translating evidence into
practice due to diverse human factors and workplace culture. Education
packages must be developed and delivered that permeate nurses’ un-
derstanding of the relationship between physiological causes of ab-
normal respiratory rates and the link to clinical deterioration these
changes herald. Successful implementation of evidence into practice in
regards to the topic discussed in this study will translate into improved
accuracy of early warning scores for ALL ED patients. Accurate early
warning scores facilitate early recognition of deterioration of ED pa-
tients, which in turn activates potentially lifesaving intervention judi-
ciously, thereby improving patient outcomes.
74
International Journal of Nursing Studies 74 (2017) 67–75
6. Limitations
Limitations of the research study include the involvement of only
participants working within Australia. Whilst a good spread of parti-
cipants was recruited covering four states and a territory of Australia, it
is recommended that further similar studies be conducted inter-
nationally, to support conceptual transferability at a global level.
Another limitation is that as participants were passively recruited, it
could be perceived that only those willing to share their experiences
were included and as such, were a likeminded cohort; therefore there is
the possibility that the study missed out on inclusion from a more di-
verse cohort.
7. Conclusion
The analysis of data throughout this study revealed, that despite
years of continuing education regarding the best practice guidelines for
respiratory rate collection, suboptimal practice continues. Ideally, to
combat the transgression in respiratory rate recording methods, a cul-
ture shift must occur around nurses’ understanding of acceptable
practice methods in regards to patient safety. Nurses must receive
education in a way that permeates their understanding of the re-
lationship between optimal patient outcomes and the regular collection
of accurate respiratory rate observations for ALL patients in an ED
setting.
Funding
The primary researcher is a recipient of the Central Queensland
University Postgraduate Research Award – WOMEN (UPRA-W).
This research is supported by an Australian Government Research
Training Program (RTP) Scholarship.
Conflict of interest
There is no known conflict of interest.
Acknowledgments
The research team would like to thank all the nurses who gener-
ously shared their time, experience, and stories for the purposes of this
research project. The rich and detailed data each and every one of you
contributed aided in the generation of this new grounded theory.
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