case study emotionally disturbed students

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Symptoms of Emotionally Disturbed Students

Children with an emotional disturbance disability need help to manage their lives in and outside of the classroom. If your child is in this category or you work with children with emotional disturbances, it's important to know what this term means and the symptoms students with this disability display. Here is what you need to know.

Emotional Disturbance

The Individuals With Disabilities Education Act ( IDEA ) is a federal law that specifies emotional disturbance as one of the 13 categories of eligibility for special education services. Emotional disturbance is also known as serious emotional disturbance (SED) or emotional behavioral disability (EBD). By the IDEA definition, an emotional disturbance is a condition in which a child exhibits one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance.

• Emotionally disturbed children have an inability to learn that cannot be explained by intellectual, sensory, or health factors.
• They may be unable to develop and keep appropriate, satisfactory social relationships with family, peers, and adults in the school system.
• They may have a tendency to display inappropriate behavior or feelings in response to normal situations.
• They may have a pervasive mood of unhappiness or depression.
• They may be inclined to develop negative physical symptoms or fears related to personal or school problems.

The category of emotional disturbance includes schizophrenia. Children with emotional disturbance may also be diagnosed with behavioral disorders such as attention deficit hyperactivity disorder (ADHD). However, emotional disturbance is not diagnosed in children who are primarily socially maladjusted unless an underlying emotional disturbance also exists.

Other disorders that fall under this umbrella include anxiety disorders, bipolar disorder, eating disorders, obsessive-compulsive disorder, and conduct disorders.

Risks for Students With Emotional Disturbances

Students with emotional disturbances are at risk for school failure and often require both specially designed instruction and psychotherapy or counseling services. If they don't receive a diagnosis of emotional disturbance, however, they're likely to be pushed out of school by punitive discipline policies such as suspension or expulsion.

Children who face such policies have a high risk of dropping out of school and entering the criminal justice system. This phenomenon is colloquially known as the school-to-prison pipeline.

Before they are diagnosed, children with emotional disturbances may be perceived as simply "bad" or "unruly" by teachers, administrators, and peers. Being thought of in this way can damage the self-esteem of emotionally disturbed children. These children not only feel shunned but also must work through the circumstances that led to the emotional disturbance.

They may have been abandoned by their parents or sexually, physically, or emotionally abused. They may have been diagnosed with a mental health condition such as a personality disorder that will follow them throughout life, making it difficult for them to maintain friendships, romantic relationships, or professional careers.

A Word From Verywell

Parents and caregivers of children with an emotional disturbance disability must advocate for them to see to it that they're not isolated in school or in the community. They may need to partner with parents of children having a similar experience, and/or get guidance from a mental health provider. While emotional disturbance disability is definitely a challenge, it can be managed to help children live a fulfilling life.

U.S. Department of Education. Individuals with Disabilities Education Act. Sec. 300.8 Child with a disability .

U.S. Department of Education. Individuals with Disabilities Education Act. Sec. 300.8 (c) (4) .

Mizel ML, Miles JNV, Pedersen ER, Tucker JS, Ewing BA, D'Amico EJ. To educate or to incarcerate: Factors in disproportionality in school discipline . Child Youth Serv Rev . 2016;70:102-111. doi:10.1016/j.childyouth.2016.09.009

DeRosier ME, Lloyd SW. The impact of children's social adjustment on academic outcome . Read Writ Q . 2011;27(1):25-47. doi:10.1080/10573569.2011.532710

Guilé JM, Boissel L, Alaux-Cantin S, Garny de la Rivière SG. Borderline personality disorder in adolescents: Prevalence, diagnosis, and treatment strategies . Adolesc Health Med Ther . 2018;9:199-210. doi:10.2147/AHMT.S156565

Brain & Behavior Research Foundation. Advice for parents of children with behavioral and psychiatric disorders .

By Ann Logsdon Ann Logsdon is a school psychologist specializing in helping parents and teachers support students with a range of educational and developmental disabilities. 

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Refining an intervention for students with emotional disturbance using qualitative parent and teacher data

Rohanna buchanan.

a Oregon Social Learning Center, 10 Shelton McMurphey Blvd., Eugene, OR 97401, USA

Rhonda N.T. Nese

b University of Oregon, Educational and Community Supports, 1235 University of Oregon, Eugene, OR 97403, USA

Lawrence A. Palinkas

c School of Social Work, University of Southern California, Montgomery Ross Fisher Building, Room 339, Los Angeles, CA 90089, USA

Traci Ruppert

Intensive supports are needed for students with emotional disturbance during high-risk transitions. Such interventions are most likely to be successful if they address stakeholder perspectives during the development process. This paper discusses qualitative findings from an iterative intervention development project designed to incorporate parent and teacher feedback early in the development process with applications relevant to the adoption of new programs. Using maximum variation purposive sampling, we solicited feedback from five foster/kinship parents, four biological parents and seven teachers to evaluate the feasibility and utility of the Students With Involved Families and Teachers (SWIFT) intervention in home and school settings. SWIFT provides youth and parent skills coaching in the home and school informed by weekly student behavioral progress monitoring. Participants completed semi-structured interviews that were transcribed and coded via an independent co-coding strategy. The findings provide support for school-based interventions involving family participation and lessons to ensure intervention success.

1. Introduction

Students with emotional disturbance (ED) are at risk for multiple negative outcomes, including school failure, low rates of employment in adulthood, and involvement with mental health and social work agencies ( U.S. Department of Education, 2005 ). Students with ED often are removed from mainstream educational settings and placed in treatment classrooms. Once their treatment programs have been completed, they are then transitioned back to their home schools. However, national data show that when reintegrating students with ED into less restrictive school environments the intensive services provided in more restrictive settings are not replicated, and that the intensity of supports abruptly decreases ( Wagner & Davis, 2006 ). Consequently, students with ED who have experienced success in highly structured, well supervised, and encouraging settings typically are at risk when they transition to larger schools with less teacher attention ( Wagner & Davis, 2006 ). For example, data from the Education Service District (ESD) participating in this study indicates that the majority of students who transitioned from a day-treatment school (DTS) were not successful in district public school (DS) settings during the 4 years prior to this study. Specifically, within 1 year of transitioning back to DSs in their home district, the majority of the middle school students in the ESD’s DTS were placed in self-contained classrooms, alternative placements, treatment centers, or received out-of-school tutoring due to emotional and behavioral problems. In addition, over 50% of students had high rates of truancy, high rates of involvement in social services (e.g., child welfare, mental health, and juvenile justice), and low levels of parental support. These national and local data clearly indicate that intensive supports for students with ED are critical to promote their successful transition to less restrictive environments.

Prior research has shown that students with emotional and behavior disorders respond to intensive efforts that incorporate individualized behavioral interventions involving their parents as partners and that use data to guide treatment decisions ( Vernberg, Jacobs, Nyre, Puddy, & Roberts, 2004 ). Parents have the most information regarding the history of their child and are the most knowledgeable about their child’s history and home environment. Therefore, it is essential for parents to be actively involved in planning and implementing behavioral interventions to maximize their effectiveness ( Ingersoll & Dvortcsak, 2006 ; Lucyshyn, Horner, Dunlap, Albin, & Ben, 2002 ; Park, Alber-Morgan, & Fleming, 2011 ). Data that is effective to monitor and guide treatment must be easy to collect and reviewed frequently, while sufficiently dynamic to inform parents and teachers of behavioral changes ( Fisher, Burraston, & Pears, 2005 ; Fuchs & Fuchs, 1999 ).

Development of intensive supports for transitioning at-risk students maps on to the public health model of prevention and intervention ( Pluymert, 2014 ), which has informed the triangle of support that outlines a three-tiered structure of supports for students. Within these tiers, Tier 3 consists of the most intensive interventions reserved for students at greatest risk for significant behavior problems ( Gresham, 2004 ; Pluymert, 2014 ). Consistent with prior research on interventions for students with emotional and behavior disorders ( Chamberlain & Reid, 1998 ; Leve, Chamberlain, & Reid, 2005 ), the need for intervention development at the tertiary level of support is imperative for students, especially during a difficult transition phase that is often accompanied by school failure.

1.1. The iterative development process

Leaders in education have long advocated for the integration of feasible, socially valid, data-based, comprehensive, useful, and well-coordinated school-based prevention and intervention efforts ( Greenberg et al., 2003 ; Merrell, Ervin, & Peacock, 2012 ; Reschly & Ysseldyke, 2002 ; Upah & Tilly, 2002 ). Family involvement as collaborative partners with an active voice in the process and decision-making for student supports is essential if researchers are to learn what works for students and their families ( Albin, Dunlap, & Lucyshyn, 2002 ). Additionally, intervention collaboration between parents and teachers has been shown to improve the fit and feasibility as well as the sustainability of supports ( Albin, Lucyshyn, Horner, & Flannery, 1996 ). The present study was designed to produce an intervention that met these criteria for transitioning students with ED using the Institute of Education Sciences (IES) intervention development funding mechanism. The guidelines for the IES intervention development process require, “a systematic process for creating and refining the intervention” ( IES, 2011 , p. 42) that emphasizes qualitative data collection and analysis to inform intervention development and revision based on consumer feedback. Under these guidelines, researchers implement intervention components or the intervention as a whole, collect and analyze relevant data, then make refinements or revisions to the intervention or components based on the data.

Evidence-based programs often fail when implemented in real-world environments because they fail to take into consideration local perspectives and input ( Elliott & Mihalic, 2004 ; Hurlburt & Knapp, 2003 ). A truly collaborative intervention planning and implementation approach should reduce the likelihood that interventions will fail ( Marshall & Mirenda, 2002 ). Collaboration facilitates the development, implementation, and evaluation of comprehensive behavioral interventions to not only improve the contextual fit for students and their families, but also to improve the sustainability of supports over time ( Albin et al., 1996 ). Further, interventions implemented consistently as a result of a good contextual fit are more likely to produce outcomes that are generalizable to new settings and situations ( Kuhn, Lerman, & Vorndran, 2003 ). The iterative process outlined here is designed to introduce stakeholder input early in the development process, which is only beginning to be described in the literature (e.g. Kern, Evans, & Lewis, 2011 , Mautone et al., 2012 ). This paper was written to describe and reflect on that process and produce some lessons learned that could apply to the adoption of any innovative program.

1.2. Students With Involved Families and Teachers: SWIFT

SWIFT is an intervention to support at-risk students during difficult school transitions. The intervention includes four-components adapted for implementation in school settings from two evidence-based interventions for youth with emotional and behavioral disorders that include progress monitoring and a parent component: Multidimensional Treatment Foster Care (MTFC; Chamberlain & Reid, 1998 ; Leve et al., 2005 ) and Keeping Foster Parents Skilled and Supported (KEEP; Chamberlain, Moreland, & Reid, 1992 ; Chamberlain et al., 2008 ; Price et al., 2008 ). MTFC and KEEP are based on social learning theory (see Patterson, 1982 ) and were selected because they intended to serve youth with similar behaviors and experiences as those eligible for SWIFT. Students eligible for SWIFT include students receiving intensive and individualized school-based supports for severe emotional and behavioral problems (i.e., Tier 3 interventions). See Methods, below, for additional details on the intervention and participants.

1.3. The purpose of this paper

The purpose of this paper is twofold. First, to illustrate the development of a feasible home and school intervention, SWIFT, and second, to outline the process by which stakeholder feedback was actively solicited to improve the feasibility of the intervention. Qualitative interview data was collected from parents of transitioning students, DTS teachers, and DS teachers for the purposes of highlighting features of the intervention that should be retained because of their likeability and ease of use, features that should be modified or intensified to improve their effectiveness in their students’ transition process, and features that should be removed from the intervention based on the level of resources needed to implement them. This paper provides researchers and practitioners an example of the iterative development process with the goal of improving the sustainability of evidenced-based interventions.

2.1. Participants and setting

Maximum variation purposive sampling was used to capture a range of perspectives from informants with experience related to the development project goals ( Berg & Lune, 2012 ; Padgett, 2008 ). Of interest, were the perspectives of the parents and teachers of students involved in a DTS’s transition process and our strategy to establish a range of perspectives was to include: (a) parents of middle school age students (grades 6–8) with ED, participating in SWIFT, and transitioning from a DTS to DS, (b) the students’ teachers from the DTS, and (c) the students’ post-transition middle and high school teachers from multiple school districts. All participants were recruited by a study representative and participated in an in-person Institutional Review Board (IRB) approved informed consent procedure.

2.1.1. Parents

Nine parents were recruited for participation in the qualitative interviews. The majority of the parents were female ( n = 8, 89%) and identified as Caucasian ( n = 7, 78%) or African American ( n = 2, 22%). The relationship to the student included foster parents ( n = 4, 44%), biological parents ( n = 4, 44%), and a grandparent guardian ( n = 1, 11%). Six parents (67%) reported that there was a secondary caregiver in the home. Highest education included GED ( n =1, 11%), community college ( n = 3, 33%), 4-year college ( n = 2, 22%), and some graduate courses/graduate degree ( n = 3, 33%). The median household income was $35,000 and five parents reported that their family participated in some type of assistance (e.g., food stamps or low-income housing). Each parent had a student displaying severe emotional (e.g., anxiety, depression) or behavioral (e.g., aggression, defiance, property destruction) problems who was transitioning from the DTS to the DS in their home. Students were eligible for school-based Tier 3 interventions due to the severity of their behavior at school.

2.1.2. Teachers

Seven teachers working with transitioning students at the DTS or post-transition in DS’s were recruited from six schools across three school districts. Each teacher had worked with at least one of the students in the homes described in Parents , above. Four teachers were female (57%) and the majority identified as Caucasian ( n = 6, 86%) and one identified as more than one race (Pacific Islander and White, 14%). They reported teaching special education classes ( n = 5, 71%) or general education classes in alternative high school classrooms ( n = 2, 29%) with caseloads of 7–50 students. The mean years of teaching experience was 11.86 ( SD = 10.68) with between 13 and 31 years for four of the teachers and less than 3 years for the other teachers. Teachers also reported a range of experiences working with students with severe emotional or behavior problems including setting behavior goals, designing and implementing school-based behavior support plans, and coordinating with mental health professionals.

2.2. The SWIFT intervention

SWIFT includes four primary components: (a) behavioral progress monitoring, (b) case management of the intervention elements and coordination with the new school as the student transitions, (c) parent support to promote parent engagement/collaboration with the school and study routines in the home, and (d) behavioral skills coaching for students. These components are intended to provide customized supports to each student to enhance the transition process. See Fig. 1 for an illustration of the SWIFT intervention process. Behavioral progress monitoring data is collected weekly through the Parent Daily Report (PDR; Chamberlain & Reid, 1987 ) and Teacher Daily Report (TDR; Buchanan & Pears, In review ). The PDR and TDR are 3–5 min assessments that provide a snapshot of a student’s behaviors in the home and at school in the last 24 h. The PDR and TDR includes both problem (e.g., arguing, destructiveness, and swearing) and prosocial (e.g., calm, flexible, and on-task) behaviors. SWIFT case managers and the intervention team utilize PDR and TDR data to identify students’ behavior patterns across DTS and DS settings, generate intervention ideas, and evaluate students’ progress. The case manager’s role within the SWIFT intervention is to ensure regular communication across team members (SWIFT staff, parents, and school staff at both schools) and to provide weekly group supervision to the SWIFT staff. Once a participating student is fully transitioned to the DS, the school-based case management for the student transfers from a DTS homeroom teacher to a special education teacher at the DS. The role of the parent coach is to provide participating families with supports related to developing strategies at home for setting up consistent rules, expectations, and systems of reinforcement to enhance students’ positive behavior change. Parent coaches meet with parents weekly to work on home-based strategies and to track progress of students’ behaviors. Lastly, skills coaches provide weekly sessions to students before, during, and after their transition to the DS. Skills coaches model appropriate behaviors across community and school settings, coach the youth on developing prosocial skills, and reinforce the use of positive adaptive skills and peer relations. These four components of the SWIFT intervention are initiated when the students are in their treatment settings and follow them as they transition to their new schools, for a total of 9–12 months of support.

SWIFT intervention process.

2.3. qualitative interviews

A semi-structured, individually administered interview format was used for all interviews. Questions in the interview protocol were designed to solicit feedback on each of the four components of SWIFT, the intervention timeline, and the transition process as it related to each of the transitioning students. An expert on qualitative methods (3rd author) reviewed and approved the interview protocol outlining questions and procedures, and all materials and procedures were approved by our IRB. An experienced interviewer who was trained in techniques to elicit feedback from the participants, remain neutral to a range of responses to reduce response bias, and move the discussion through the semi-structured format conducted all interview assessments. The interviewer was not involved in the intervention. Interviews were scheduled 3 months apart and at the convenience of the participants. One hour was scheduled for each interview though most were shorter in length (parent: M = 20 min, Range = 10–52 min; teacher: M = 30 min, Range = 17–54 min). All interviews were collected once participants had been involved in SWIFT for at least 3 months. Most parent interviews took place at our research center ( n = 17, 89%) with one conducted at home and another at a private work office. Nineteen parent interviews were collected for eight students and all families participated in an initial interview and one (50%) or two (50%) follow-up interviews. All teacher interviews took place at the school. Fourteen interviews were collected for the eight students with 1–3 teachers interviewed for each student. Four teachers completed one interview (57%) and three teachers (43%) completed follow-up interviews. Due to teacher changes over the course of the year at the middle schools, follow-up interviews were only conducted with teachers who maintained continuing involvement with the student at later interview waves. Follow-up interviews with parents and teachers were conducted every 3 months to collect timely feedback on whether refinements made to the intervention sufficiently addressed concerns raised in initial interviews.

2.4. Analysis

All qualitative interviews were audio-recorded and transcribed verbatim by a trained transcriptionist supervised by the lead researcher (first author). Once initial transcriptions were complete, the interviewer verified all transcripts by comparing 100% of the audio to the text and entered bracketed notes to provide context to the transcripts. All caregivers, teachers, students, and schools referenced in the transcribed interviews were assigned an identification number to protect confidentiality, increase cross-group comparisons, and reduce subjectivity in the analysis ( Padgett, 2008 ).

An independent co-coding strategy was used where the second author was the primary coder who developed a codebook and coded the majority ( n = 25, 76%) of the interview transcripts ( Padgett, 2008 ). A second coder coded the remaining transcripts. Next, the lead researcher reviewed each coded interview in detail and worked with the coding team to adjust or update the codebook. The codebook evolved over the course of the longitudinal data collection with new codes added or modified over time and previously coded transcripts updated with the new codes as necessary. The coders assigned portions of text (ranging in size from individual words to short phrases) to one or more codes, then compared the coded content across each interview. Using the method of constant comparison ( Glaser & Strauss, 1967 ), codes were then grouped into categories or themes that mapped on to questions in the interview, with anywhere from 5 to 30 subthemes within each primary theme.

Parent and teacher feedback was largely positive and included specific suggestions to improve the intervention. Six themes emerged from the parent and teacher interviews to inform the intervention refinement: (a) the recruitment and intervention timeline, (b) length of transition supports, (c) behavioral progress monitoring collection and data entry, (d) case management coordination, (e) benefits of skills coaching supports, and (f) the parent coach role. These themes are described below.

3.1.1. Recruitment and intervention timeline

The typical transition from the DTS to the DS takes approximately 5 months. During this time, the student begins attending one or two periods per day at the DS, and maintains a schedule for the rest of the day at the DTS. Additional periods are added as the student demonstrates success, or the timeline may be modified if the student does not meet their behavioral targets. The initial recruitment plan for the study was to invite students to participate with an anticipated 3 months before the full transition to the DS. However, in the first year, participating parents and DTS teachers suggested that establishing these supports 4–6 weeks earlier would be beneficial to establishing rapport with the student and the family before their contact began with the DS. One parent commented, “I wish he had a little more time before the transition with you guys,” while a teacher stated, “The earlier that we can get them signed up with SWIFT and then, you know, getting on board with the program, the better.” Several parents and teachers commented that many students need more time to make a connection with SWIFT staff before starting their transition. One teacher reported, “I think that it’s pretty important to having that up-front time…and then easing into the transition, I think, is the ideal way to go,” with a parent reiterating the importance of utilizing the time, “…before the actual transition to build rapport and a relationship.” The parent and teacher data were consistent with SWIFT staff reports that some participating students seemed overwhelmed by meeting SWIFT staff so close in time to meeting new teachers and students at the DS.

Starting in the fall of Year 2, student recruitment was timed to include 4–6 weeks of additional support at the DTS. After the adjustment, parents and teachers reported feeling that this change allowed adequate time for the student and their family to build rapport with SWIFT staff. When asked if two students who transitioned at the end of the second year had enough time to get acquainted with SWIFT, one teacher said “More than enough time.”

3.2. Length of transition supports

The initial timeline for transition supports included up to 9 months: Three months at the DTS, then six at the DS. As students progressed through the intervention, it became clear that many students were not fully settled at the DS within the 9-month window. The need for more time was increasingly true once 4–6 weeks were added to the beginning of the intervention. Parents and teachers reported that extending services would be beneficial to ensure maintenance of gains at the district setting. A participating parent stated, “I would want as much of you guys actually in the transition part where she’s going to the school.” Likewise, one teacher specifically highlighted the need for additional time at the DS by saying, “…the more support you can provide until they are ready to go off on their own the better” and went on to explain that although the target student had many supports at the school, he had been enrolled full time for 3 months and he wasn’t seeking them out. Rather, it seemed that he was still getting those supports from SWIFT staff.

At the end of Year 1, the intervention timeline was modified to include up to a full year of support, including: (a) contact over the summer months, (b) school readiness skills for students and parents at the end of summer in the 4 weeks prior to the start of school, (c) additional time at the DTS, and (d) additional time at the DS. Teachers reported being pleased with this change, and noted that transitions were smoother with the addition of more time. For example, with regard to one students’ smooth transition, a teacher stated,

She, [student’s experience] to me, should be like the standard. The amount of time that SWIFT provided, the amount of support that her home school provided, the amount of support that we provided, the communication that happened between all three, um, and yeah just the amount of time that it took. We didn’t rush it at all, we took our time.

Similarly, the parent of this student stated, “I think just her starting off going there [the DS] slowly a couple hours a day, and then working her way up till she was there all day was really the key.”

3.3. Behavioral progress monitoring collection and data entry

Parents and teachers described the behavioral progress monitoring tools (PDR for parents, TDR for teachers), as easy to complete and time efficient. For example, “… doesn’t take long to do them. The system seems pretty clear” and, “… convenient…the whole process is good.” A teacher working with multiple SWIFT students remarked, “The TDRs are manageable” and “I find it [the TDR data entry system] very user friendly.” A parent shared that, “I never found them [PDRs] to be a burden… they’re so quick but they’re real thought provoking.” Most teachers said that they preferred an online direct-entry method and as teachers tested the system, we were able to refine the program to provide a more streamlined experience. Many parents and some teachers preferred a weekly call saying, “Is there any way you guys could just call me?” Others talked about how they liked getting a call from the PDR/TDR caller, “She’s very wonderful.” One parent shared how pleasant and efficient the interactions with the caller were: “She’s very professional and sticks right to the questions and we do them and we tell each other have a great day and we’re done, and it’s very easy.” Throughout the project, parents and teachers said that they liked getting weekly phone, email, or text reminders for the PDR/TDR based on their preferred method of contact, and one said, “She [the PDR/TDR caller] actually will give me like the pre-warning… I got another email today!”

Some teachers talked about how reporting the TDR reminded them to pay attention to student behavior in a different way, “I’m much more in tune to how they are doing now… I’m really making mental notes.” Parents reiterated that feeling, with one commenting that, “The PDRs just make you always remind yourself of what you already know and want to keep doing and then things that you maybe haven’t thought of.” Another teacher made a similar statement,

It just keeps me aware of what he is doing even though other things might be going on in the day and … I need to be watching and observing because these questions are going to be asked to me later on.

Teachers who were newer to the project reported not knowing what the TDR was for, wanting to know more about how the TDR data were used for decision-making purposes, and what they showed in regards to behavior change. One teacher simply stated, “I don’t know how the TDRs are used.” Another guessed about the long-term utility of the TDR by saying,

I would imagine that you guys are using that data as the student moves forward, so I don’t know how helpful it is in the immediate, while they are working with us, but I would guess that the data I provide in the TDRs is being used to make decisions for that student as they move on in their transition.

The confusion about the TDR and requests for more information about the data led to case managers showing the teachers TDR graphs and bringing them to school meetings. Additionally, parent coaches began showing participating parents PDR data at their weekly meetings and discussing behavior changes that they were seeing both at home and at school. In follow-up interviews, parents and teachers more often reported that they understood the purpose of the PDR/TDR data. For example, later in the project one teacher new to SWIFT demonstrated greater understanding about the TDR saying that, “It gives you another set of data to look at and see if…the behaviors are increasing or decreasing.” One parent noted that the PDR data helped her keep track of her student’s behaviors and gave her direction for the skills she wanted to work on with him:

I’ve found it as a tracking tool and a reminder tool for things I wanted to be able to focus on and work on… it was the positive behaviors you know, noticing in him, always keeping track of that, how often that didn’t happen, and trying to help him.

The utility of the TDR as a tool for tracking behavioral change over time came up in several interviews once the TDR data were shared more routinely, for example,

It’s just kind of data to show, ‘Is this working or is it not?’ And at what points?…what were we doing when the student had all these great days? What were we doing when there was all this really not so great behavior?

3.4. Case management coordination

Throughout the interviews, parents and teachers described the SWIFT case managers as being instrumental in organizing the transition process, maintaining communication between the school and the family, and coordinating student supports across schools. The importance of the case manager in facilitating communication among team members was illustrated in the first parent interview: “I think her role was to just try and keep things moving forward, keep it going smoothly, making sure there was a lot of communication for everybody…” as well as the first teacher interview: “As a student begins to transition, starts to spend more time over there, I’m relying more on her to communicate and facilitate…” and repeated in nearly all of the following interviews related to communicating with the family and with the various school staff: “Just keeping them apprised of what’s happening” and, “…coordinates between the school and the coaches and me” and, “…does a great job of making sure they stay coordinated with us…” and, “Coordinates us all…there are multiple students, and other staff members and many sites that she’s trying to put all together.”

Participating parents saw the SWIFT case manager as supportive individuals who could make things run smoothly, describing the role as, “The overseer of things, the fire puter-outer” and “The buck stops here person. She’s also at the meetings and is very supportive of me and my son” and “Her role is to troubleshoot… and deal with big issues.” Parents also viewed the case manager’s ability to coordinate services and tie information together as extending outside of the school supports:

She listens to everything like from the PDRs to what the parent coach says. I knew with my answers on the PDR I was going to get a call from her saying, ‘What’s going on? How can I help?’ and that’s reassuring.

DS teachers described the existing relationship with the student and family as a benefit of the SWIFT case manager, “that she has a relationship already with the family is helpful” and, “that there is someone to call to problem solve…someone else has some experience with the family and the student when I have never met the student before.” Teachers in both the DTS and DS settings consistently reported wanting the SWIFT case manager’s help with organizing and coordinating team members for the students in transition. One teacher emphasized the need for coordination help by saying,

Anytime we have to make a big decision that involves gathering all the players, parents and staff members at the home school, just gathering all those players together can be a challenge sometimes… So having help from the [SWIFT] case manager with coordinating all that would be helpful.

Feedback from parents and teachers led to refinements for the SWIFT case manager role including working more closely with the DTS leadership to engage the DS in the early stages of the transition, then to work closely with the DS leadership to translate effective student supports and services to the district setting, and continuing to facilitate communication between the parents and both schools. In follow-up interviews, teachers highlighted that this modification resulted in increased communication between the DTS and DS staff and fewer delays in implementing effective supports and services, “[The SWIFT case manager] has really been taking the lead with these guys and setting up meetings at the home schools and making the necessary contacts.”

3.5. The benefits of skills coaching supports

Parents and teachers regularly emphasized the importance of the skills coaches in helping students meet their behavioral goals. One parent commented,

The skills coach and my daughter were doing things I had asked, like my daughter learning about her facial expressions, her tones, learning how to hang out with kids at lunch and to do the social things that she’s lacking in, and the skills coach was there to help and teach her.

With regard to a student’s behavior, one teacher said,

A lot of times I can only address it on the fly and without as much detail or not in as much depth as I would like… just because of time. But the skills coaches are able to have that one-on-one time and can address those issues that I’m not able to thoroughly.

Teachers were very familiar with the skills coaches and their role, because most skills coaching sessions took place in the schools. Teachers describe the role as, “to help them [students] build the skills, you know, that they need to be successful in the new environment.” Several parents commented that their knowledge about the role of the skills coaches came from information that was shared with them by their sons and daughters. One parent stated, “I see him as a mentor, a role model, and a skill builder for my son, and my son views it that way” while another parent shared, “My son really talks about the skills he’s working on.”

Parents reported that they felt the skills coaches were a valuable support for their students during the transition, stating that they saw the skills coach as, “Someone who is in his court, and advocates for my son.” Teachers reiterated that skills coaches were an important link between the DTS and the DS, where “just being in their home school setting” meant that skills coaches could observe and coach students’ behavior in both DTS and DS settings. Teachers also highlighted the skills coaches’ role in the home-school connection saying that they were an “awesome bridge between what goes on here in our classroom and then what’s going on at home…they’re also being able to see them outside of our school too… that’s key.” Both parents and teachers shared that students enjoyed meeting with their skills coaches, were actively engaged in skills coaching sessions, saying things like, “… they look forward to it” and “they’re excited to see their coaches and have them see what they’re doing and be a part of what’s happening.”

Almost all participating parents commented that they felt involved and informed in the development of the skills coaching content and the progress of the skills coaching sessions. In regards to having input on the skills coaching sessions, one parent commented, “absolutely, yeah, I never felt left out of that part” while another stated, “What I’ve talked to the parent coach about has come out in the skills coaching sessions based on interactions we’ve had at the house with my son.” However, teachers in all settings asked for more communication about the skills coaching sessions, such as the behavioral strategies that were being discussed and practiced, and the goals that were set with the students. This was illustrated by one teacher’s suggestion that, “It could be helpful to kinda get a mini-recap. Like when she goes for her skills coaching in the school area…‘these are the things we touched on,’ and you know, ‘this is how it went’” so that school staff could try the same things and they would, “continually be followed up on.” To emphasize this point a teacher said,

So if they worked on a specific skill and the skills coach said to me, ‘we worked on this and this is the language I’ve taught her,’ then I can follow up and reinforce that language and she [the student] sees that we’re all working together.

Following the requests for increased communication, case managers built in regular updates to teachers on the progress of skills coaching sessions. Additionally, case managers advised skills coaches to briefly check-in with teachers regarding session content and skills practice, then update the case manager on what was shared with teachers. Teachers reported that this change provided more consistent supports for transitioning students between SWIFT and the classroom saying things like, the skills coach “… would check-in with me either before or after” weekly sessions, and, “…sometimes she’d come in and say…‘I did let him know about this, he shared this with me.’ And just in that brief dialogue it was pretty huge because sometimes you get information that I wasn’t aware of!” The communication structure between SWIFT and the teachers expanded from the case manager alone to include the skills coaches, and teachers seemed to like that saying,

If I see things and I’m not able to address it then I’ll just shoot over a quick email to the skills coach and say hey, this kind of came to our attention, do you think you could go over it when you have your one-on-one time?

3.6. The parent coach role

While parents were overwhelmingly positive about their interactions with the parent coaches and their role with helping facilitate a smooth transition process for their students, teachers had minimal or low levels of contact with SWIFT parent coaches because communication with the schools was done primarily through the case manager who then met regularly with the parent and youth skills coaches. This role stratification was intended to provide the teachers with a single conduit for communication for the SWIFT team, a filter through which relevant information about the family was shared with the school, and a consistent source of information for the SWIFT staff. Therefore, it was not surprising that some teachers reported not knowing as much about the role of the parent coach or the content of their sessions compared to other SWIFT components.

Participating parents described the role of the parent coach as one that was both supportive and helpful with developing appropriate structures for the students at home, with one parent stating, ”… it wasn’t just supporting me but also giving me some ideas.” While the parent coach was often described as, “real understanding and real supportive,” other parents shared that, “she motivates me to put together the charts and to do the weekly check-ins and weekly supports.” Several parents stated that these supports translated into more positive interactions between them and their students. One parent shared,

She’s helped support me in any ideas or plans we’ve come up…in terms of point charts, supporting my son, encouraging my son, listening to what I was saying and coming up with some ideas that she thought might be helpful.

In general, foster and kinship parents identified similar things that they liked about the parent coach role. One topic that was different was related to the unique experiences of foster/kinship parents, specifically that they liked working with a parent coach who understood that foster/kinship parents of youth with significant behavior problems can have different strengths and limitations than biological parents. One foster parent talked at length about how their family had a consistent high volume of appointments for their foster children with “therapy and case workers coming…the certifier coming” and he appreciated that the parent coach would use “text or email” instead of a lot of phone calls and would keep sessions short, “a half an hour is wonderful.” Other foster parents talked about frustration with other support providers who didn’t understand that they were experienced professional parents and highlighted the importance of parent coaching sessions that focused on supporting skilled parents. One foster parent said that she was already “doing a homework routine” and had “rewards” for the youth and the SWIFT parent coach would “encourage me with those things” and another foster parent said that the parent coach helped to “remind yourself of what you already know and want to keep doing and then things that you maybe haven’t thought of.”

Many teachers reported that the parent coaches were an asset because communication with parents increased dramatically, without teachers feeling like they were telling them, “how to parent” their students. Instead, “I relayed that information to the case manager and she relayed it to the parent coach and it hasn’t been an issue since. So yeah, it’s been pretty helpful.” Teachers described the support that parents received from their parent coach as pertinent to students’ success across settings because, “The home has been a real focal point where their struggles kind of originate from and they are bringing those struggles to school” and as teachers, “we have no control or say” in what happens at home. The teacher later gave an example of a student who was “having a really hard time getting to bed on time and that was really impacting him at school.” The parent coach worked with his mother to set up “an incentive-based bedtime routine… after they worked on it a few weeks he was coming to class energetic and aware the whole day.” In another interview, a teacher reflected on a positive change in a parent’s response to planning and suggestions from the school as, “more open, more trusting, and just calm…” In the same vein, another teacher said, “Collaboration not just demanding” and went on to explain her impression that the parent coach did, “some encouragement and some coaching and maybe teaching and suggestions that are about contacting the teacher and asking them for what I want.”

Although all participating parents reported being comfortable with the role stratification that SWIFT provided, some teachers expressed that they didn’t like the lack of direct communication between teachers and parent coaches. One teacher said,

It would be helpful for the parent coach to have more communication with the school, more information coming back to us, even if it’s just positive stuff. It allows us to get a fuller picture of where or how home is going.

This teacher later stated,

If I could communicate directly with the parent coach that might have been at least a little bit easier…it came to a point where I had the mother’s cell phone number and I was just texting her because I was finding that stuff wasn’t being passed on. So it’d be great if I could just maybe shoot the parent coach an email and say hey, if you talk to his mom can you just remind her of the meeting tomorrow?

One result of this feedback was that case managers began providing teachers with more frequent updates on the progress of parent coaching sessions relevant to school. Case managers also introduced the concept of the case manager/parent coach role stratification and communication structure earlier in their first contacts with teachers to explain the limits to sharing family information with the school and the role parent coaches play in the transition process.

4. Discussion

The fit or feasibility of an intervention is a vital consideration when stakeholders are determining which programs to adopt ( Glasgow, Lichtenstein, & Marcus, 2003 ; Merrell & Buchanan, 2006 ). In this study we actively solicited stakeholder feedback regarding the strengths of the multi-component intervention throughout the initial development phase. We also solicited feedback on and areas that needed improvement to learn what would make SWIFT, and interventions like it, sustainable in real-world school settings. The use of the structured iterative refinement process incorporating regular parent and teacher feedback was integral to the development of SWIFT as an intervention that is feasible to implement and useful for key stakeholders. Our qualitative findings provide initial evidence to suggest that SWIFT and similarly intensive interventions are feasible for home and school implementation. The six themes that emerged from the teacher interviews fell under two broad categories: timeline for intervention supports and refinements to each of the four intervention components. Refinements made to the implementation process and intervention components, the relevance of the stakeholder informed iterative development for intervention/program adoption, limitations of this study, and directions for future research are further discussed.

4.1. Timeline for intervention supports

Parents and teachers regularly asked for more intervention time for their students. Our findings suggest that parents will engage with socially valid, intensive school related supports and teachers are willing and even eager to connect their at-risk students to such supports. A clear message from parents and teachers was that students should connect to transition supports well before planned transitions. This suggestion is consistent with best practices outlined for students with ED highlighting the importance of meaningful relationships ( Wagner & Davis, 2006 ). The enthusiasm expressed by participating parents and teachers for ongoing involvement with SWIFT, an intensive intervention spanning home and school settings, might be due to the severity of students’ needs and a lack of existing coordinated supports for students receiving tertiary level supports.

4.2. Refinements to the intervention components

Throughout the interviews, communication and cross-setting consistency were identified by teachers for what to retain or refine within each of the four SWIFT components. Specifically, teachers consistently asked for more information on students’ home life, wanted to know what students’ were practicing in their one-on-one sessions, and said that this information helped them provide a more appropriate and consistent educational experience for students. Such consistent teacher requests for home and intervention information were not a surprise, given that the relationship between home and school is increasingly considered a key ingredient for educational success by educators ( Epstein, 2011 ). Our findings highlight the importance of clearly explaining the purpose of a communication structure specific to an intervention as well as the need for proactive communication with all team members. With our sample, the context of requests for more home and intervention information indicated that: (a) teachers thought that the home context contributed to school-behavior, (b) teachers saw their students use their new skills in the classroom, and (c) teachers wanted their classrooms to be a consistent support along with skills coaching and the home. In addition, we found that teachers spoke respectfully of the participating families and considered parents important partners in their child’s education.

Parents consistently noted how important the team approach was to making the transition of their students between day-treatment and district settings successful. Specifically, parents valued having a case manager who was coordinating the transition of services that needed to be delivered in the new setting, a skills coach who was the champion for their student and an adult their student enjoyed spending time with, a parent coach being the person they could bounce ideas off of and gain support from, and having several team members (case manager, skills coach, and parent coach) serve as the voice of support for participating students and their families at meetings with school leadership.

As a result of the consistent feedback from parents and teachers, the case manager role was refined to include working more closely with the DTS leadership to engage the DS in the early stages of the transition, the skills coach and parent coach began attending all transition meetings with both DTS and DS personnel, and the team continued to facilitate communication between the parents and both schools.

Parents and teachers reported that providing brief, weekly student behavioral ratings was not only not a burden, but in fact useful for their interactions with the students. This finding is consistent with research showing that the act of participating in assessments can change behavior ( Salvia & Ysseldyke, 2004 ). Notably, parents and teachers talked about the ways in which completing regular PDR/TDR ratings helped them focus on tracking specific problem behaviors over time and pay more attention to what students were doing well. Parent and teacher comments about the PDR and TDR also illustrate the importance of a quick, positive interaction with data collectors to maintain high levels of adherence to assessment protocols.

4.3. Iterative intervention development involving stakeholder input

Soliciting input from parents and teachers provided validation for the SWIFT intervention elements that had been working and gave us information into how we might change those that were not working in order to improve fit. Examining qualitative data from stakeholder groups simultaneously not only enhanced a comprehensive comparison of feedback, but also allowed for real-time adjustment to the package of supports provided across settings. Our findings suggest that through the use of this iterative process, we were able to develop an intervention with potential to be implemented with fidelity and maintained over time in real-world settings, which are important considerations for schools and districts in selecting interventions for their systems ( Merrell & Buchanan, 2006 ).

4.4. Limitations and future directions

A few important limitations of this study should be noted. First, although the researchers sought to collect qualitative data from a variety of teachers across the DTS’s and DS settings, the current study is limited because the majority of teachers were from DS settings. All participating students transitioned through the same DTS; therefore there were fewer DTS’s teachers to recruit for the interviews. However, the inclusion of a larger sample of DS teachers greatly contributed to our understanding of SWIFT feasibility across multiple DS settings.

Second, although all of the foster, kinship, and biological parents participated in 2–3 interviews, we were unable to interview all teachers more than once due to the nature of participating middle school students moving into new schools and new classrooms with new teachers throughout the year. Thus, not all teachers were able to give follow-up feedback. Additionally, we did not include the perspectives of the students themselves. Follow-up studies should explore the consistency between parent and teacher feedback with that of the participating students. Interviews conducted with students may shed light on intervention elements, aspects of the transition process, and the overall experience of transitioning into a new school setting that parents and teachers may not be aware of. Since students are the primary recipients of SWIFT, and it is their growth and development that highlights the impact of this intervention, their voice and experience through this process is vital to the intervention’s long-term contextual fit.

Finally, this intervention was developed in one ESD in a mid-sized community in the Pacific Northwest with limited cultural diversity. Testing the intervention in regions with greater multi-cultural representation could contribute to our knowledge of how SWIFT can meet the needs of diverse students and their families.

Some additional next steps include collecting mixed-method research to evaluate student outcomes to evaluate the impact of SWIFT. Questions remain related to differences between students, parents, and teachers receiving SWIFT supports and those who are not receiving such supports and for whom SWIFT is most effective. Specifically, we plan to examine mediators (e.g., whether changes in parent behavior mediate changes in student outcomes) and moderators (e.g., whether factors such as family background characteristics, student cognitive functioning, or school characteristics moderate changes in student outcomes) in future studies of SWIFT. While the present study provides initial evidence of feasibility for parents and teachers, a randomized controlled trial could provide important data to establish the efficacy of SWIFT. We plan to test the impact of the SWIFT intervention on both short-term and long-term outcomes. Parent, teacher, and student engagement with SWIFT along with key student outcomes such as attendance, behavior, and academic engagement in district settings will be important to examine.

5. Conclusion

Fit, feasibility, and utility of an intervention are important considerations for educators adopting innovative programs. The iterative development process described in this paper allowed us to query parents and teachers at multiple timepoints and across multiple settings. This strategy provided ongoing stakeholder data as we refined the intervention, and reflected increased satisfaction with the intervention over time. One important finding suggests that intensive school-based interventions that include parent and teachers as partners can be designed to be feasible and useful, and fit with the needs of stakeholders to support students with significant behavior problems. Our data suggest that involving teachers and parents early on in the development of SWIFT contributed to the fit and feasibility of the intervention to the intended delivery environment. This collaborative and feedback-seeking approach serves to be incredibly useful when serving a population of Tier 3 students at risk for school failure. As previously discussed, such students and their families typically do not receive the type of coordinated supports needed to improve the likelihood that they will be successful in their new school environments. The candid feedback expressed by participating parents and teachers throughout this study make us hopeful that this model for soliciting key stakeholder feedback will serve as a way of improving supports for at-risk students through a difficult transition point in their academic careers.

Acknowledgments

This research was supported by the Institute of Education Sciences under Grant R324A110370 and the Division of Epidemiology, Services and Prevention Research, NIDA, U.S. PHS under Grant P50DA035763. The opinions expressed are those of the authors and do not represent views of the Institute of Education Sciences or the National Institute on Drug Abuse.

The authors would like to thank Patti Chamberlain for support on the design and implementation of this project; Alice Holmes, Janet Morrison, and Lizzy Utterback for conducting, transcribing, and coding interviews; Diana Strand for editorial support; the SWIFT intervention team; the school districts where we conducted this study; and the parents and teachers who participated in the interviews.

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Home > ETDS > DISSERTATIONS > 2811

Seton Hall University Dissertations and Theses (ETDs)

Influences impacting child study team school social workers decision-making in a new jersey urban district on placement of students classified emotionally disturbed.

Pia D. Moore Follow

Date of Award

Summer 8-17-2020

Degree Type

Dissertation

Degree Name

EdD Education Leadership, Management and Policy

Education Leadership, Management and Policy

Michael Kuchar, Ph.D.

Committee Member

Daniel Gutmore, Ph.D.

Ligia Alberto, Ed.D.

Special Education, Emotionally Disturbed Students, School Social Workers, Least Restrictive Environment, Child Study Team

Research on students classified as Emotionally Disturbed (ED) shows that a disproportionate number of ED students are educated outside of the general education setting. In New Jersey a little more than half of students classified as ED are not educated in general education classrooms for most of their school day. The academic performance of ED students is often lower in self-contained environments than in the general education setting (Oelrich, 2012). ED students overall have poor academic and life experiences. The educational program and setting in which an ED student is primarily educated might have an impact on their current and future academic and life outcomes. There are limited studies on the educational placement decision-making process for students with disabilities, including ED students. Studies continue to conclude that inclusive education is more beneficial (academically and socially) for students with disabilities

This study explored how one member of the child study team (CST), the school social worker, considers various points of information when considering placing ED students outside of the general education setting. A qualitative case study was utilized to collect and analyze information. The researcher conducted one-to-one in-depth semi-structured interviews via a virtual video call with 10 CST school social workers in one urban New Jersey school district. The participants met the criteria of being tenured in the school district and had experience with placement of ED students. The digitally audio recorded semi-structured interviews ranged in length from 32 minutes to 1 hour and 10 minutes.

The study revealed a multitude of factors that can influence the CST school social worker recommendations for placement of ED students. The most prominent factors included teacher qualities, school culture and climate, availability and appropriateness of resources, and special education programs. Although student academics and behavior were also factors, many participants indicated that with welcoming environments, resources, and staff trainings, many ED students could find success in regular education classes.

Recommended Citation

Moore, Pia D., "Influences Impacting Child Study Team School Social Workers Decision-Making in a New Jersey Urban District on Placement of Students Classified Emotionally Disturbed" (2020). Seton Hall University Dissertations and Theses (ETDs) . 2811. https://scholarship.shu.edu/dissertations/2811

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Case Study Analysis of a Resource Room and Self-Contained Classroom Model with Emotionally Disturbed Students

Introduction.

According to the United States Department of Education, National Center for Education Statistics (2012), there were 407,000 students with a diagnosis of emotional disturbance (ED) in the United States schools during the 2009-2010 school year. The number of students diagnosed with this type of disability has not increased much over the past 40 years. During the 1976-1977 school year, students with special needs who had an emotional disturbance diagnosis were at 0.6% of the total school population, and this percentage only increased to 0.8% by the 2009-2010 school year. This type of disability tends to affect more males than females, by three to one, according to some estimates (Friend, 2011), and an ED student’s intelligent quotient (IQ) is typically within the average range (around 100). These students struggle with behavioral and emotional issues to the point that their academic abilities in school and their social lives are severely affected.

Forness and Kavale (2000) found that students with emotional and behavioral disorders are the most under-identified and underserved special needs category in education. Also troubling to this population of students is the lack of positive outcomes that have arisen since the early 1980s (Bradley, Doolittle, & Bartoloota, 2008), based on these students’ academic achievements, social interactions, and long-term adult outcomes. Critics believe that many of the difficulties in this field are connected to the definition and criteria of emotional disturbance. The Individuals with Disabilities Education Act (IDEA, 2004) defines emotional disturbance as:

… a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance: (a) an inability to learn that cannot be explained by intellectual, sensory, or health factors; (b) an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; (c) inappropriate types of behavior or feelings under normal circumstances; (d) a general pervasive mood of unhappiness or depression; and (e) a tendency to develop symptoms or fears associated with personal or school problems. (§ 300.8[c][4])

According to (IDEA, 2004), emotional disturbance does include schizophrenia. However, it does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance.

Once a student is diagnosed and labeled emotionally disturbed, teachers and other professionals must understand how to reach them in an academic setting. Students with emotional and behavioral disorders lack the ability to make wise behavioral choices. They should be offered instruction that introduces these skills while being taught how to think (Robinson, 2007). Student-centered outcomes are a major part of any service delivery model designed for ED students. Researchers believe that “a comprehensive examination is needed to look at both the context of the students’ education and associated services along with the outcomes they experience” (Bradley et al., 2008, p. 5). In essence, service delivery providers are charged with the responsibility of caring for the whole child. This translates to a service delivery model embedded in the individual student, the student’s environment, and the behaviors of the adults who influence the student’s life.

This chapter will:

Examine the needs of emotionally disturbed students and the challenges they face on a daily basis.

Discuss the causes and characteristics, educational placement and intervention strategies, and eligibility criteria for students with an emotional disturbance.

Present and analyze two case studies that utilize the resource room/self-contained classroom service delivery model.

Anticipate future trends for students with emotional disturbances.

Complete Chapter List

An investigation of the effects of music on two emotionally disturbed students’ writing motivations and writing skills.

Kariuki, P. & Honeycutt, C. (1998). An investigation of the effects of music on two emotionally disturbed students’ writing motivations and writing skills. Paper presented at the Annual Conference of the Mid-South Research Association, New Orleans, LA, November 4-6, 1998.1

Researchers conducted a case study of two fourth-grade boys in a special education class of students classified as “emotionally disturbed” to determine whether music listening could motivate these boys to improve in writing. Both students improved their writing skill by two letter grades when listening to music. Students wrote more words when listening to music. Students also felt more positive about writing when listening to music, and observations suggested they were more focused when writing to music than when writing without music. Students reported that the music made the writing exciting and helped them stay focused.

Key Findings:

Both students improved their writing skill by two letter grades when listening to music. Unfortunately, however, the grades were not broken down by creativity vs. technical skill. Students wrote more words when listening to music. For instance, one student increased his word count from five to 40; the other increased his count from nine to 92. Students also felt more positive about writing when listening to music, and observations suggested they were more focused when writing to music than when writing without music. Students reported that the music made the writing exciting and helped them stay focused.

Significance of the Findings:

This study employed a design valuable for the study of effects of music listening in the context of language arts activities. It is of value to see that music listening heightened by various activities can contribute to the quantity and quality of the written work of students classified as emotionally disturbed. The use of music listening as an effective tool for improving children’s attitude toward writing suggests that music may allow children to focus on tasks rather than serve as a distraction to the writing process itself.

Methodology:

Researchers conducted a case study of two fourth-grade boys in a special education class of students classified as emotionally disturbed to determine whether music listening could motivate these boys to improve in writing. The study consisted of four time periods, each lasting about four weeks. In the first and third periods, the boys completed weekly writing assignments without listening to music. During the second and fourth periods, students completed weekly writing assignments while listening to music (through headphones) in a wide range of styles. The writing assignments in the music sessions were related to the type of music heard. Researchers scored the writing for technical skills, creativity, and volume. Researchers also observed the students while writing and interviewed them about their reactions to the assignments. Students completed a questionnaire about their attitude about each assignment.

Limitations of the Research:

It is not clear who scored the students’ writing, nor if the scorers knew whether the writing they were scoring was carried out with or without music. Moreover, when writing to music, students were asked to write in reaction to the music, but when writing in silence, students had no outside stimulus to react to. It is possible that the improved writing during music listening was due to having a stimulus to react to, rather than due to music. This report is missing additional important details that would help readers understand its significance. For example, we do not know what the qualitative differences look like in the writing samples. Nor do we know what was taken as evidence of the “more creative” writing.

Questions to Guide New Research:

What are the interconnections among music, writing, and such constructs as motivation and self-efficacy?

How might this research be replicated with larger samples and the use of controlled methods?

1 The text of this summary is adapted from the Arts Education Partnership’s 2002 research compendium: Deasy, R. J. (Ed.). (2002). Critical links: Learning in the arts and student academic and social development. Washington, DC: Arts Education Partnership.

ArtsEdSearch is the nation’s hub for research on the impact of the arts in education.

• Open access
• Published: 03 December 2022

Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data

• Sanu Mahat 1 ,
• Anne Marie Rafferty 2 ,
• Katri Vehviläinen-Julkunen 3 , 4 &
• Marja Härkänen 1  

BMC Health Services Research volume  22 , Article number:  1474 ( 2022 ) Cite this article

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Medication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident.

This is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents ( n  = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data.

Analysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error.

Negative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice.

Peer Review reports

Medication Errors (MEs) are recognized by the World Health Organization as the leading cause of injury and avoidable harm in healthcare, costing approximately 42 billion dollars annually, which is nearly 1% of total global health expenditure [ 1 ]. The safety of patients is at the forefront of the healthcare system; however, healthcare staff can also be traumatized by the aftermath of MEs. Although the healthcare mantra is “first do no harm”, healthcare professionals involved in adverse events can feel guilt, shame, anger, fear, and anxiety [ 2 ]. They are often neglected with only a few coping strategies and support systems available to help them [ 3 ]. Negative consequences of an adverse event can reach far beyond the “first victim” i.e., the patient. Thus, affecting healthcare staff psychologically making them “second victims” [ 4 ]. The term “second victim” was first coined by Dr. Albert Wu to explain the emotions of a young resident who committed an error and had experienced ridicule, shame, and lack of support, from his peers [ 2 ]. Although this concept was first applied to physicians, other healthcare staff, including nurses, also experience similar emotions. Scott et al. [ 5 ] described the term second victim as “a healthcare provider involved in an unanticipated adverse patient event, medical error and/or a patient-related injury who has become victimized in the sense that the provider is traumatized by the event. Frequently, second victims feel personally responsible for the unexpected patient outcomes and experience as though they have failed their patient, feeling doubts about their clinical skills and knowledge base”[ 5 ].

The use of the term second victim has been criticized recently [ 6 , 7 ] arguing that it might act as a way in which healthcare providers can evade responsibility and accountability and it might be offensive to affected patients and families [ 6 ]. Laying accountability at the door of an individual, ignoring the wider organizational ramifications of accountability in terms of the conditions which trigger errors in the first place, can let the organization off the hook. Even though the use of the term “victim” may sound spurious and uncomfortable to many healthcare professionals, patients, and families, it is indubitably an advantage in reinforcing the seriousness and urgency of the problem among policymakers and healthcare managers [ 8 ]. Wu et al.[ 8 ] have suggested the importance of the use of the term second victim as it is notable and denotes urgency. These assumptions regarding the use of the term second victim are inherent in both positions. Therefore, our research is designed to take this debate one step further by analyzing the consequences of errors in terms of emotional response and lived experiences of healthcare staff.

Regardless of the degree of patient harm, the mere thought of potential patient injury caused by ME is sufficient to induce the feelings of fear, distress, anger, anxiety, guilt and remorse in healthcare staff [ 9 , 10 , 11 ]. Although evidence suggests multiple system-based causes of MEs, the error-maker still tends to blame themselves i.e., they should have functioned proficiently [ 11 ]. If the seriousness of these issues remains unaddressed, it can negatively affect healthcare workers’ personal and professional well-being causing depression, burnout, Post Traumatic Stress Disorder (PTSD), and even suicidal thoughts [ 4 , 12 , 13 ]. Error prevention has therefore been a focus of major attention for healthcare organizations for years but the impact of MEs on the healthcare professional involved has received less attention. A more nuanced and textured exploration of the impact of the problem upon healthcare workers is required if preventative strategies are to be effective [ 11 ].

Previous studies have shown that often MEs causing harm are reported whereas near misses are often under-reported [ 14 ]. This underestimates the number of healthcare staff going through negative experiences [ 15 ]. Fear of legal consequences, blame, losing patients’ trust, and punishment have been recognized as barriers to ME reporting[ 16 ] leading healthcare staff to suffer in silence, sometimes struggling alone in isolation and burdened with a sense of shame [ 9 ]. Therefore, a system is needed to mitigate these barriers and create a “just culture guide” which helps healthcare managers to treat staff involved in adverse events fairly, support open and fair culture and maximize learning from errors [ 17 ]. However, it is apparent that irrespective of organizational effort in promoting a just and no-blame culture, the stigma persists with respect to speaking up about errors [ 18 ].

Patient safety incident reporting has become a common practice, but little is known about the feelings of those who commit or witness incidents. Despite the recent debate regarding the use of the term second victim, we are adopting this terminology throughout our research to analyse the consequences of MEs in terms of psychological responses from healthcare staff. Previous research into second victims has mainly been carried out in a single setting, but this study uses reported incidents at a national level drawing from a range of settings. Also, no previous studies, as far as we are aware, have focused only on Medication Administration Errors (MAEs). To our knowledge, none of these studies have used free-text descriptions of reported medication incidents to review the feelings and emotional responses associated with reporting nor text mining as an innovative method for such analysis.

The aim of this study was to investigate negative emotions expressed by healthcare staff in their reported MAE incidents along with the immediate responses they received from their seniors and colleagues after the incident.

Study design and setting

A retrospective study using qualitative descriptive method and text-mining with an inductive content analysis of the incident data related to Medication Administration (MA) reported in England and Wales was done.

Description of the data

The data consists of MA incidents ( n  = 72,390) retrieved from the National reporting and Learning System (NRLS) database based on inclusion criteria: (1) incidents reported to have occurred in England and Wales between 1 January and 31 December 2016, (2) medication incident, (3) administration/supply of medicine from a clinical area, and (4) acute National Health Services (NHS) trust (either specialist or non-specialist). The data included incident reports from all levels of healthcare staff ranging from student nurses to senior-level health professionals who were involved in and who have witnessed the MAE incidents.

Data were acquired from NHS England and NHS Improvement. NRLS is largely voluntary and is the only database that includes all types of patient safety incidents. This study used free-text descriptions of the incidents i.e., healthcare staffs’ descriptions of “what has happened?” or “when the incident occurred?” during the medication process.

Data analysis

First, negative emotional expressions associated with MAEs were defined using the literature and dictionaries (Oxford Learners’ Dictionary, Merriam-Websters’ Dictionary, and Cambridge Dictionary) to define synonyms of the negative emotional expressions (Table  1 ). Second, those expressions were searched from the free-text descriptions of the incidents which were specifically related to MA. For that, The SAS® Enterprise Miner 13.2 and its Text Miner tool were used. Multiple steps were followed for data analysis as described in Fig.  1 . SAS® Text Miner automatically processes the data using ‘text parsing’ i.e., converting unstructured text into a structured form. Text parsing includes tokenization (breaking text into words/terms), stemming (which chops off the end of words reducing words to their stem or root forms), and part-of text tagging (for each word, the algorithm decides whether it is a noun, verb, adjective, adverb, preposition and so on). ‘Text filtering’ was then used to reduce the total number of parsed terms and check the spellings. The English language was chosen for parsing and filtering the text. Using an interactive filter viewer, negative emotional expressions described in the free text were identified and the number of each expression was collected (See Supplementary file  1 ). For the next phase of the analysis, the most common expressions were chosen which are bolded in online-only material 2 (See Supplementary file  2 ).

Analysis process of medication administration incident reports’ free text descriptions

Expressions chosen for analysis were used as a search term in an interactive filter viewer. All the descriptions of the incidents that included those expressions (a total of 1861 incident reports) were collected and read through repeatedly. In the first phase of this analysis, the aim was to define who had experienced the emotional feeling. Most of negative emotions were expressed by patients or relatives (See Supplementary file  1 ). Those descriptions of incidents that included negative emotions expressed by healthcare staff and which were expressed in relation to MAEs ( n  = 93) were then selected for further analysis.

Content analysis was used to analyze the data. The lead author followed an inductive content analysis where the researchers carefully read, organized, and integrated and formed categories, concepts, and themes by comparing the similarities and differences between the coded data [ 19 ]. The lead author read through the data repeatedly and during this process, identified the main theme which is: Emotional expressions of healthcare staff after MAEs. The data were organized into main themes and sub-themes. After the preliminary classification, a co-coder [the last author of this paper] participated in the analysis and read the classification structure and the related data independently. Once thematic saturation was achieved, both researchers analyzed the entire data corpus according to standard thematic analysis techniques [ 20 ]. All authors contributed to the final form of the analysis. Finally, direct quotes were used to support the findings.

Negative emotional expressions of healthcare staff after MAEs

We found 15 different types of negative emotional expressions used including worry, anxiety, annoyance, agitation, stress, unhappiness, distress, concern, anger, upset, shock, sorry, fault, depression, and frustration. These 15 different types of emotions were expressed 1,861 times in the incident reports (See Supplementary file  1 ).

Among those emotional expressions, 12 were exhibited by the healthcare staff and were mentioned 154 times. Only eight of those 12 expressions: worry, upset, agitation, faulty, sorry, concerned, stressed, and distress were expressed by healthcare staff in direct relation to MAEs, the frequency of expression here was 93 times. The data extraction process in presented as a flowchart in Fig.  2 .

Typology and frequency of emotional expressions

The key emotions revealed were further classified into four categories: (1) feeling of fear, (2) feeling of upset, (3) feeling of sadness, and (4) feeling of guilt (Table  2 ).

Feeling of fear

Healthcare staff described their feeling of fear regarding MAEs using four different synonyms i.e., distressed, concerned, stressed, and worried. Staff mentioned how fearful they were when they discovered their mistakes. Distress was revealed in three of the incident reports as expressions of fear of healthcare staff. Usually, MAE incidents were reported either by the error-makers themselves or by those witnessing their errors. One of the staff described the fear felt by her colleague (staff nurse) by reporting how distressed he was after he administered a medication through wrong route (intravenous instead of oral):

“ I was assessing a patient on Ward X when a staff nurse approached me extremely distressed and agitated. He then ran into the utility without explaining what the problem was. I followed him…nurses were present who proceeded to explain that the nurse who approached me had given a patient 2mls of Oramorph [liquid morphine that has to be given orally] intravenously …"

Healthcare staff also expressed the extreme pressure which acted as an important contextual trigger, driving intense the feelings of fear. Another emotion linked to fear was “concerned” which was expressed in 23 cases by healthcare staff after making an error. One of the healthcare staff reported an error (prescribed wrong strength), which the staff realized two hours later and became concerned about it:

" Prescribed TTA (to take away) of ‘Augmentin [Amoxicillin Clavulanate] Duo’125/31 8 ml TDS [three times a day]. As written, this would be a drug error-there is no 125/31 strength of …This was my error, which I realized and became concerned about 2 hours later …"

Stress was expressed in three cases by healthcare staff while reporting the incident; however, this emotion was expressed by staff not as their feelings after MAEs, but as the reason underlying MAEs. These kinds of explanations were found in many incident reports where healthcare staff accepted the error but eventually pointed towards other hidden causes behind the error:

" Gave Clexane [Enoxaparin] 60 mg to wrong patient. Ward extremely busy- heavy workload and was very stressed due to workload …"

Being “worried” was another expression of fear reported in 11 incident reports by healthcare staff. They were found to be worried about several situations such as the health of patient, degree of harm caused by error, associated legal procedures, and their professional career. One staff nurse was worried about the patients’ condition as he did not administer insulin dosage to one of his patients:

" Staff nurse came to me at the end of the shift and stated that he thought that the patients’ insulin was prescribed prn [whenever necessary] and had not given any…I explained he needed to inform the nurse in charge…he was very sincere and worried that he had not given this insulin …"

Feeling disturbed

The feeling of being disturbed was expressed using two synonyms: upset and agitated. They addressed themselves as being upset in 24 incident reports following MAEs committed either by themselves or by their fellow staff. Healthcare staff reported the error made by fellow staff member and described the emotion of his/her colleague as:

" Nurse called me was very upset to explain that she had given wrong treatment to patient …"

Even near miss situations have caused healthcare staff to get emotionally disturbed. Even after apologizing with patient and family, healthcare staff felt upset thinking that if they were not aware of the near miss situation in time, patients’ condition would have been severe:

" SN asked me to do a syringe driver with her for a palliative patient…on drawing up the ketamine driver, myself and SN made a drug error in which we drew 5 times more ketamine than the required dose…The family and patient have been informed of the drug error we made and we gave our sincere apology for our faults…both myself and SN are very upset with the near miss situation and aware that things could have gone very differently …"

Healthcare staff expressed being agitated in two reports after discovering that they had committed MAEs, except in some situations, where staff though agitated denied their mistake by underestimating the severity of the error they made:

" Patient was discharged off the system by the nurse without confirming with medical team/pharmacy that patient was ready to go… Patient left without anti-sickness medication which the team had told her she could have…Nurse was evidently agitated that the incident was being reported and did not understand that she should check with the team before authorizing …"

Some reports revealed extreme negative emotions associated with feelings of upset such as being devastated and questioning one’s own professional competence. The use of such intense and traumatic language can reflect how much the healthcare staff were impacted and even emotionally wrecked after MAE. One healthcare staff after accidentally administering wrong dosage to the patient, reported that the error was entirely his/her own fault:

" Pt px 120 mg on gentamicin on EOMA, I accidentally gave 210 mg in error. This was entirely my fault …The checker confirmed what I had done. I am so devastated about this and really upset I’d made such a mistake…today was just hectic and I lost concentration ..."

Feeling of sadness

Healthcare staff expressed their feeling of sadness at being sorry for the mistake they had made; it was one of the most common negative emotional expressions expressed in 13 cases. Most staff used this to express a sense of remorse after the error. After missing a dose of insulin for a patient, one healthcare staff expressed his/her sadness by stating that he/she is sorry about the incident:

" I am sorry to say that I missed one dose of insulin (at 22.30…) for one of my patients …"

Along with the feeling of sadness, one healthcare staff also mentioned about learning from the error and how he/she have accepted that she was wrong to assume things:

" I was sitting at the desk, staff nurse handed me a tray with intravenous antibiotics and said, here is one because I had given her patient drug chart, I assume it was patients’ medication. I did not take the drug chart with me to the patient and afterwards when staff nurse came with patients’ drug, I realized I have given the wrong drug. I was very upset as I have never done anything in this form before. I always take the drug chart with me to the patient. I am deeply sorry, and this is a massive learning curve for me, I hold my hand up it was wrong to assume this ."

Healthcare staff who had mentioned learning from the error was quite common in many incident reports. However, there were few cases where the staff did not understand the seriousness of the error she has caused:

"… I spoke to the student nurse about the seriousness of her actions, she said sorry; however, I did not feel she understood the seriousness of what she did …"

Feeling of guilt

In 14 incident reporting cases, healthcare staff were aware of their mistakes and the consequences they might have. They expressed their guilt and identified themselves as being at fault and blaming themselves.

" IV flucloxacillin drawn up and checked by myself and staff nurse…administered drug however in error name band/ allergy band not checked. Realized immediately after administration that I had gone to the wrong patient and given the incorrect medication…conversation with senior staff nurse about error. Explained that the error was my fault completely…patient does not appear to have come to any harm …"

However, this emotion was not just expressed following the error, but also as another reason for error attribution. For example, in the report below, a staff member made an error, and blamed herself and phone reception for being muffled:

" I had to hand over two diabetic patients to the 5–8 pm. I rang Ward sister and confirmed this again later. However, patient was not reallocated, and insulin omitted…Ward sister apologized for yesterday missed patient…she said the reception to her phone was muffled and that it was her fault …"

Immediate response from seniors and colleagues

Some of the healthcare staff while reporting their feelings behind MAE incidents also discussed regarding the immediate responses they received from their seniors and colleagues. Healthcare staff explained how their seniors and colleagues responded after they were informed about MAEs. These responses are categorized into two sub-categories: (1) Reassurance and support and (2) Guidance on what to do after an error.

Reassurance and support

In three incident reports, healthcare staff mentioned about the reassurance and positive support they received from their seniors and colleagues after the disclosure of MAEs, about how they tried to handle the situation very calmly without getting angry. This helped them to cope effectively without undue stress and burden. A nurse mentioned that she reassured one of her colleagues who was very disturbed after she gave the wrong medication to her patient:

" Staff nurse by mistake gave the patient wrong medication…. misread the information by being interrupted by a patient and member of staff…. I reassured the staff nurse as she was very upset …"

Even a little support and reassurance and few kind words during the time of MAEs can help the healthcare staff to cope up with the situation effectively. As one member remarked:

" Medication error – digoxin prescribed in two doses (125mcg and 62.5mcg) did not realize and administered…Immediately alerted sister in-charge of ward and contacted doctor. Doctor did not come to the ward but was happy that observations had been recorded…and told us not to worry …"

Guidance on what to do after error

In 11 incident reports, healthcare staff mentioned about receiving advice from their seniors and colleagues regarding the right thing to do after making an error. They have been guided to observe the situation of the patient to ensure that no serious harm would be caused to them:

"… Administered the oramorph in an unlabeled syringe which was in the same tray as a 10ml flush…I discussed the situation with the medical registrar on call who advised me to monitor observations regularly …" "… I spoke to the nurse in charge after the error from the following shift who said that I should speak to the ward manager at the earliest opportunity which I did …"

Furthermore, in cases where healthcare staff neglected to document the incident, a colleague intervened to guide the staff member to follow the protocol. As one staff member described:

"… I discussed the incident with a colleague shortly afterwards. However, I neglected to escalate and correctly document the incident…The aforementioned colleague has since approached me to discuss the incident, further to this I approached and discussed the incident with my ward manager …"

Our study identified four categories of negative emotions expressed in incident reports: feelings of fear, disturbed, sadness, and guilt with various sub-categories. In addition, this study also captured the immediate responses received by healthcare staff after they informed their seniors and colleagues about MAEs including the reassurance, support, and guidance on what to do after an error. Incident reporting by healthcare staff in this study indicated that unintentional harm caused due to MAEs and even near misses can affect the healthcare staff involved in error emotionally, increasing their risk of becoming the second victim of MAEs, confirming previous research [ 9 , 21 ].

A major finding of this study was the negative emotions experienced by healthcare staff after MAEs. Healthcare staff in this study expressed their fear while reporting incidents by using negative emotions such as stressed, distressed, concerned, and worried. They not only blamed themselves for these mistakes, but also considered other additional explanations which, they perceived as causing the error. These kinds of emotions can be related to staff members’ narration of fear and anxiety for patients’ well-being and for their own professional careers [ 22 ]. Similarly, feelings of being disturbed expressed as being upset and agitated were widely mentioned in incident reports. Identical reasons such as realization of the error and thoughts of the possible seriousness of the error and associated issues lay behind emotions. Further, feeling of sadness expressed as being sorry for the mistake made was another most common emotional expression. Also, healthcare staff felt a deep burden of responsibility for their actions. Feelings of being guilty or at fault is one of the risk factors for healthcare staff for becoming the second victim of MEs. It can also cause loss of self-esteem and inculcate a sense of failure and hopelessness. In a similar study by Treiber & Jones [ 22 ], nurses, upon committing even minor errors, expressed raw and painful emotions, regardless of the degree of harm. Nurses can often recall the details of the error and what they felt at that time [ 22 ]. While the lack of any apparent linkage between emotional response and degree of patient harm might appear counter intuitive, one possible explanation might be that healthcare professionals are not well enough supported by their organizations to cope with any form of negative experience. Thus, those affected might develop strong negative emotion [ 23 ].

Making an error might also have serious consequences for disrupting the personal and professional lives of staff, causing personal and moral distress, and affecting the quality and safety of patient care [ 23 ]. It is crucial to pay attention to these emotional expressions as incidents that are sensitive and make an impact, are often remembered, and reflected in the attempt to prevent recurrence. On the other hand, these incidents can unintentionally impose a mental burden on healthcare staff making them second victim [ 2 ]. Our findings confirms that MAEs can generate negative feelings in healthcare staff associated with it, which can endure long beyond the immediate effect.

Research has confirmed a direct relationship between nurse staffing and missed patient care [ 24 , 25 ], revealing poor nurse staffing as a risk factor for MEs along with other organizational factors such as poor working conditions, distractions, and high workload [ 26 ]. Similarly, in this study, reporters mentioned their own actions as a trigger for MAEs along with the above-mentioned factors whereas some reporters explained organizational and environmental conditions and context surrounding the error as reasons to reduce blame. In the absence of support, self-blame seems to assume greater prominence. This can have long-term repercussions for maintaining emotional health and well-being, a major failure of workforce strategy, especially during the pandemic situations.

The current study also found other healthcare authorities responding in several ways after being informed about MAEs. Sometimes, staff may not know what to do after MEs, they might panic and lose control. Thus, adequate support from colleagues and seniors sensitive to these issues may prevent the error-makers from translating further into second victimhood of MEs. How the organization and related individuals responds is clearly linked to the emotional impact the error can have on the healthcare staff who made the error. Appropriate support and guidance from seniors and colleagues have been found to alleviate the suffering, while lack of support has increased their psychological burden [ 27 ]. Some of the healthcare professionals in our study also opted for consulting with their seniors: doctors, colleagues, and mentors after MAEs and reported about how they have received guidance and suggestions, which helped them to cope effectively. Emotional support plays a vital role in restoring faith and confidence among healthcare professionals in patient safety. Support from co-workers and healthcare institution helps the error-makers to retain a sense of control [ 2 ]. Reassurance from seniors and colleagues can also strengthen healthcare staff’s self-esteem and facilitate the correct reporting of MAEs. As is well known, only a fraction of incidents are reported thus deterring the improvement of patient safety with barriers identified as time pressure, fear of the consequences [ 28 ], poor institutional support, lack of feedback, a blame culture, and inadequate training [ 15 ]. Yet, we can still improve patient safety by identifying these barriers. Moreover, while some staff members perhaps too readily assumed responsibility for errors, as reflected in the prominence of self-blame, others demonstrated reluctance, which could be linked to fear of the consequences of MAEs. Furthermore, little is known about the dynamics and consequences of reporting-what prompts some to report and others not to do so. We demonstrate that the emotional expression of staff can be extremely distressing and negatively impact health and well-being of healthcare staff.

Implications for practice

Our findings indicate that immediate negative feelings experienced by healthcare staff after making MAEs can have long-lasting impacts that stretch far beyond the event itself thus potentially traumatizing them and inducing ruminative thoughts, which trigger the memory. The short, medium, and long-term consequences of errors are unknown as yet but could contribute to burnout and other factors associated with intention to leave the profession. Indeed, a negative memory that will stay with them forever, if not handled accurately. They could potentially become second victims of an error, if unable to confront and deal with negative feelings associated with the error. One source of challenge could be stigma related to this making it difficult to continue to work after MAE. Our findings suggest appropriate guidance and support from fellow staff members could help healthcare staff to handle the situation effectively. Therefore, it should be paramount to tailor appropriate support from persons in-charge and colleagues and to promote an open culture where it is understood. Errors can impair mental health of those who are involved, hence, the system triggers surrounding such errors need to be understood and prevented. In addition, more detailed information about these emotions after incidents and their long-term consequences on emotional well-being should be studied in future.

Implications for research

The negative feelings expressed by healthcare staff after MAEs identified in this study could provide the basis for designing an intervention study to support emotionally affected staff in healthcare institutions. It could be helpful to design a support program which recognizes the importance of expressed emotion and its consequences for internationalizing a sense of self blame and victimhood and the long-term repercussions this might have for the mental health and well-being of the health workforce.

Strengths and Limitations

As far as we are aware, this is the first-time text-mining and content analysis have been used to identify negative emotions reported by healthcare staffs’ MAEs, derived from free text in a large national database. A text-mining approach was used for identifying reports that included emotional expressions, as manual data analysis would have been almost impossible for such a big data set and this approach has been recognized to be time-effective in analysing big-data regarding medication incidents (Härkänen et al., 2019). Further, the emotional expressions identified in this study are relatively rare. These descriptive data of emotional expressions nevertheless cast light on the issues related to MAEs. Furthermore, the researchers adhered to the Standards for Reporting Qualitative Research (SRQR) checklist (see the list in Supplementary file  3 ).

However, while analyzing the free-text descriptions, we may have missed some important expressions as this was a pilot methodology we were testing, subjective decisions were made. Similarly, it was very difficult to combine the synonyms of the word used to express the negative emotions which can give rise to ambiguities. For example, in many cases, one single word could either be a verb, or noun or an adjective i.e., words can have different implication [ 29 ]. On the contrary, this study sheds some light upon how important it is to write incident report and to identify the negative emotions of staff, to prevent further consequences from occurring, encourage reporting and put support mechanisms in place. Patient safety incident data is likely to contain some limitations, more specifically, reporting error and bias which will affect the number, type and temporality of reported incidents and data interpretation [ 30 ]. Since reporting is largely voluntary, there are some potential limitations of NRLS being a reliable indicator of exact number of incidents. Nevertheless, increasing number of incidents may reflect an improved reporting culture. Further, the methodology did not allow for the identification of any positive emotions that might have been expressed by healthcare staff when reporting MAE incidents, as only free-text descriptions which included negative emotions were analyzed .From the free text-descriptions, most of the reports were found to be from nurses, however, staff-specific generalizability and scope is limited due to lack of staff type identification in NRLS data i.e., ST01 [ 31 ]. This makes it difficult to precisely quantify the impact and potential benefits of this research.

A wide range of negative emotions was expressed by healthcare staff after reported MA incidents. However, the associated psychological trauma and low mood expressed by healthcare staff represent significant negative impacts underlying reported negative emotions. It is more likely that MAE incidents are under-reported, therefore problems could be much higher in terms of prevalence and magnitude. There was tremendous variation in reports of healthcare staff encountering with MAEs; some reacted in extremely negative ways, whereas the majority expressed little about their feelings. Although many of the incident reporters did not express their feelings in their reports, there is also the possibility of them being affected by the aftermath of MAEs. Several actions were taken by healthcare staff to help cope with the error: which included, seeking guidance, reassuring, and supporting each other. This calls for further efforts from healthcare organizations to support healthcare staff as a matter of routine when encouraging reporting. Though we do know little about the long-term consequences, from what we see in our data, the scarring effect could potentially be considerable. Therefore, support programs need to be co-designed but incentivize to reward reporting without imposing an emotional burden on already overburdened staff. This is vital for error reporting, safety, and ultimately prevention to flourish in the long run. First and foremost, the system needs to promote psychological safety for its users, which our research currently demonstrates.

Availability of data and materials

Data supporting the findings of this study are made available from NRLS/NHS Improvement. However, restrictions apply to the availability of these data. For this current study, these data were used under license, therefore, are not publicly available. Data are however available if contacted to authors (MH, AMR, SM) upon reasonable request and with permission from NRLS/NHS Improvement.

Abbreviations

Medication Error

Medication Administration Error

Medication Administration

National Reporting and Learning System

National Health Services

Standards for Reporting Qualitative Research

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Acknowledgements

The authors want to thank the NHS England and the NHS Improvement Patient safety team for helping the authors through the data acquisition process and refining the data extraction.

This study has been partially supported from the grant received from Sairaanhoitajien Koulultussäätiö and from early-stage researcher position from the University of Eastern Finland for the first author.

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Department of Nursing Science, University of Eastern Finland, Yliopistonranta 1c, Kuopio, Finland

Sanu Mahat & Marja Härkänen

King’s College London: Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA, London, UK

Anne Marie Rafferty

Department of Nursing Science, University of Eastern Finland, Kuopio, Yliopistonranta 1, 70210, Finland

Katri Vehviläinen-Julkunen

Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland

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Contributions

SM conducted the analysis, but all authors (SM, AMR, KV-J, and MH) participated in interpretation of data and in drafting and revising the manuscript critically and gave final approval of the version to be submitted.

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Correspondence to Sanu Mahat .

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Ethics approval and consent to participate.

Data sharing agreement (Ref: 063.DSA.17) between NHS Improvement and King’s College London dated 22.08.2019 allowed us to use this data. As the data used for this study were voluntarily and anonymously submitted incident reports data (a register study), the need for seeking informed consent from the incident reporters was waived from the ethics committee. The King’s College London ethics committee (LRS-17/18-5150) gave ethical approval for this study in October 2017. Incident data used for this study did not comprise any personal or professional identifiers. Therefore, the anonymity and confidentiality of the data and the persons involved were fully ensured. Further, data handling was made confidential and ethical guidelines were followed.

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Supplementary Information

Additional file 1: supplementary file 1..

Number of incident reports with negative emotional expressions and description about the healthcare staffs’ feeling.  Supplementary file 2. Number of negative emotional expressions related specifically to medication administration incident reports ( n =72,390).  Supplementary file 3. SRQR checklist for reporting qualitative studies.

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Mahat, S., Rafferty, A.M., Vehviläinen-Julkunen, K. et al. Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data. BMC Health Serv Res 22 , 1474 (2022). https://doi.org/10.1186/s12913-022-08818-1

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Received : 29 June 2022

Accepted : 09 November 2022

Published : 03 December 2022

DOI : https://doi.org/10.1186/s12913-022-08818-1

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