Jens Schneider

Maurice Crul

Hans Vermeulen

Segmented assimilation and cross-national comparative research on the integration of immigrants and their children

Keywords: integration, segmented assimilation, Second Generation, United States, downward assimilarion, Europe integration, segmented assimilation, downward assimilation, second generation, Europe, United States

In the study of immigrant integration --understood as the integration of immigrants and their offspring --segmented assimilation theory stands out as the most comprehensive, coherent and systematic approach in its field. It is much discussed, but also much contested. This article attempts a critical evaluation of the theory. It looks also at the question if the theory applies to Europe and if it can thus be used in cross-national research.

Segmented assimilation: the three variants SA theorists have repeatedly argued that the old idea of adopting majority culture as a precondition for upward social mobility has lost its validity. They advance two reasons for this. In the first place, 'there are circumstances at present in which assimilation does not lead to economic progress and social acceptance, but to precisely the opposite results' (Portes 1995, p. 249). Portes refers here to immigrants with little human capital --i.e. education and work experience --who settle in inner city areas, where they come into contact with the indigenous, predominantly black population of the ghettos. If these immigrants take on the adversarial or oppositional culture of the latter, thereby generating what is called reactive ethnicity, this will result in downward assimilation or assimilation into the underclass, a situation of 'permanent poverty' (Portes & Zhou 1993, p. 82). This pattern of downward mobility is judged to be characteristic for groups such as Mexicans and Haitians.

The second argument is that upward mobility, or economic integration into the middle class, can go together with a deliberate retention of one's own culture and group: 'Immigrant youth who remain firmly ensconced in their respective ethnic communities may, by virtue of this fact, have a greater chance of educational and economic mobility through access to the resources that their community makes available' (Portes 1995, p. 251; see e.g. also Zhou 1997). This variant is characterised by a high degree of linear ethnicity, which Portes (1995, p. 256) describes as 'a continuation of cultural practices learned in the homeland.' Preservation of one's own group and culture serves primarily as a buffer against downward assimilation. This pattern is said to manifest itself in groups such as Cubans, Punjabi Sikhs and Vietnamese. I will refer to this variant as the pluralistic integration mode, borrowing from Dietrich Thränhardt (see below). In addition to these two mobility patterns, the old, traditional pattern of individual assimilation into the majority middle class still exists. This 'classical pattern of assimilation' is said nowadays to be only open for those immigrants who arrive with more than average human capital and who are, partly as a result of that, positively received by the government and the general population. Their children tend to be successful and easily move into the middle class.

The three variants of assimilation are fostered by three corresponding forms of acculturation: dissonant, selective and consonant (e.g. Portes & Rumbaut 2001a, p. 54).

In the case of downward assimilation we see that parents cannot keep up with the acculturation of their children. They tend to lose control over them (dissonant acculturation). In pluralistic integration parents remain in control. There is less parentchild conflict, the process of acculturation is retarded and parts of the parental culture and language are maintained while the new culture is learned (selective acculturation).

In the case of 'classical assimilation' parents can support their children in the process of acculturation since they more or less go through it together (consonant acculturation).

From the standpoint of the individual immigrant, the three patterns of social mobility imply assimilation into one of three segments of American society -the middle class, the underclass or an ethnic community -which is why they are designated as three forms of segmented assimilation.

Downward assimilation: the United States

Though segmented assimilation theory was developed on the basis of American data it is still highly debated there and some believe that the theory is hardly relevant for understanding immigrant integration in the United States or at least in some of its cities. In their book on the second generation in New York Kasinitz, Mollenkopf and Waters (2004, p. 397) conclude for example that '(…) these chapters give the striking impression that their subjects rarely fit in the three boxes posited by segmented assimilation theory (…).' There is no doubt, however, that the theory has stimulated debate on the integration of the second generation and has been productive of research.

Debate focuses especially on the downward assimilation variant. 2 According to the segmented assimilation school in the era of the old immigration immigrant groups followed the path of classical, straight-line assimilation into a society with a more or less monolithic culture. Nowadays immigrants are confronted by a society with a variety of racial and ethnic subcultures (e.g. Portes and Rumbaut 1996, p. 247). The children of immigrants with little human capital now run the risk of downward assimilation into the native black underclass. Following Wilson (e.g. 1987) Portes describes the culture of this underclass as follows:

'Each instance of downward levelling norms has been preceded by extensive periods, often several generations, in which the upward mobility of a minority has been blocked. This has been followed by the emergence of collective solidarity based on opposition to those conditions and an accompanying explanation of the group's economic and social inferiority as caused by outside oppression. Although accurate from a historical standpoint, the emergence of such norms further reduces chances for individual advancement to the extent that youth are socialized into the futility of "making it" on the basis of one's own merit' (Portes 1995, p. 253). Assimilation into the underclass thus means the adoption of a culture and life-style that further reduces the chances for advancement. So, in order to assess if we can speak of downward assimilation we must know if an underclass subculture exists. In Wilson's view (1997, p. 72) this requires a subtle cultural analysis such as given in some ethnographies. Most research on the SA theory is quantitative and is obviously not suited for such a subtle cultural analysis. Quantitative researchers have to resort to a variable number of indicators, such as unemployment, weak attachment to the labour force, dropping out of school, premature childbearing and being arrested or incarcerated for a crime (e.g. Portes, Fernández-Kelly and Haller 2005). One could argue that as a result in practice often a weak version of the concept of underclass is used. Downward assimilation is often described as leading to a state of permanent poverty and underclass position. There is little information of what is meant by 'permanent', but it suggests that even third and later generations will not be able to escape their predicament and move up on the social ladder. Only in one place I found some confirmation of this:

There is no empirical evidence at present that groups confined to the working class or that have moved downward into the native underclass would miraculously rise during the third generation to alter their collective status (Portes and Rumbaut 2001a, p. 283).

This statement seems to conflict with the previous quote that suggests that it takes several generations for an underclass culture to emerge. Central and Eastern European immigrants, non-Jews) at the beginning of the twentieth century. Perlmann includes native blacks in his comparison since they play an important role in segmented assimilation theory. Perlmann's detailed and complex analysis focuses on education and the labour market. Like the SCEN the Mexican second generation is making progress, but it progresses more slowly than the SCEN did. So it may perhaps take four to five generations rather than three to four to reach parity with the native-white mainstream. The Mexican second generation fares better than the native blacks, particularly because they show much less socially dysfunctional behaviours, such as young unwed childbearing for women and low labour force attachment, high incarceration rates and high rates of disappearance for men (p.123). In other words they do not show (yet) 'typical' underclass attitudes and behaviours.

Though Perlmann believes a 'downward slide' to be possible, he thinks it is not very likely to occur. In his judgment his analysis partly confirms segmented assimilation theory: in the United States today upward mobility is more difficult for immigrant groups with a low level of education than in the past. 3 This is in Perlmann's view a consequence of the increasing wage differential that affects most American workers, not only immigrants. He believes that if this trend could be reversed, 'it would transform the dynamics we have reviewed and much else in American social life' (p.124). Mexicans may not qualify for the label 'downward assimilation', but (part of) the second generation is at risk. Waldinger and Feliciano (2004) come to similar conclusions, though they seem to see virtually no risk of downward assimilation. But what is actually being asserted by the proponents of the downward assimilation thesis? As I argued in actual research practice a weak version of the concept of underclass is being used. And often no clear distinction is made between being at risk of following the downward assimilation path or having reached already a point of no return. In the same text both formulations may occur. The disagreement seems not to be so much on the data, but on their interpretation and the predictions based on it. This explains probably why Portes, Fernández-Kelly and Haller (2005, p. 1003; see also Portes and Fernández-Kelly 2008, p. 16) are so surprised that their opponents such as Perlmann can deny the existence of downward assimilation while their data in their eyes so clearly prove its existence.

Downward assimilation: Europe

According to some people downward assimilation in Europe cannot possibly exist since there is no native black underclass in European inner cities and the presence of such an underclass is basic to the process of downward assimilation of the 'new' immigrants in the United States.

Certainly the process in Europe is not taking place in exactly the same way, but the issue is not how an ethnic group or large part of it becomes part of the underclass, but if that happens. Contact with a native black underclass is not a necessary condition for that to occur. A pre-existing underclass may have other colours; to some degree the underclass may be 'imported' and underclass formation is also a product of structural factors such as the hourglass economy and processes of exclusion. During the eighties and first half of the nineties the 'underclass' concept was a key concept in the debate on poverty, ethnicity and inequality in the Netherlands as well as elsewhere in Europe. 4 I will restrict myself here mainly to the Dutch case. During the first part of the nineties Dutch society was almost yearly warned that a substantial number of the Surinamese, Antilleans, Moroccans and Turks could end up in the underclass (se e.g. Vermeulen & Penninx 2000, pp. 224-226). Most debate on ethnic underclass formation focused on the two largest groups of immigrants, the Moroccans and the Turks. On the basis of Dutch research Margaret Gibson (1997, p. 438) argued that Turks and Moroccans represented cases of downward assimilation. Dutch researchers have usually been more cautious arguing that it was still too early to arrive at such a conclusion since the notion of underclass formation requires the reproduction of a low social position over generations and the emergence of an underclass culture and presupposes at least the existence of a second generation that has been on the labour market for quite some time (e.g. Roelandt 1994, p. 219; see also Roelandt and Veenman 1993;Vermeulen 1998, p. 104-107). The first results of the TIES-project 5 for the Netherlands point to what the authors call a strong polarization within both groups (Crul and Heering 2008). While about a quarter of second-generation Turks and Moroccans is doing very well, especially if we take into account that the first generation has an extremely low level of education or no education at all, a roughly equal part is staying far behind and may perhaps risk stagnation or joining the underclass. It confirms the importance of diversification and polarization in the second generation noted also by others and makes characterization of ethnic groups as a whole in terms of one of the categories of segmented assimilation dangerous. Roughly a quarter, however, is clearly 'at risk'. Children of Moroccan immigrants have always have been more involved in street-crime and street violence than Turkish youth in the Netherlands and they are considered to be more at risk of 'marginalization' 6 or joining the underclass. According to some researchers processes of marginalization among Moroccan youth had already started before migration as a result of a long period of absence of the father and related late family reunion resulting in weak parental control (see Van Niekerk 1993, p. 66;cf. Waldinger and Perlmann 1998, p.10). The risk of downward assimilation of lower-class Antilleans is more clearly a continuation of pre-migration developments. Up to the early eighties the small Antillean community in the Netherlands served as the example of successful integration. Many Antillean immigrants had arrived as students and were doing well. When in the 1980s 'Other Antilleans' 7 , from the lower class or volksklasse, started to migrate the picture changed dramatically. These new Antilleans came mainly from neighborhoods of Curaçao with a high percentage of unemployment, one-parent families, criminality and violence. 8 Roxane Silberman, Richard Alba and Irène Fournier (2007) pose the question if downward assimilation exists in France in the case of the Maghrebins. They conclude that it does. The Maghrebins are more often unemployed than the French (18.7 vs. 7.2 per cent) or other immigrant groups. The differences cannot be explained only by differences in the level of education between them and the French. They also perceive more discrimination against them on the labour market than other groups. The only exception is the sub-Saharan Africans. They score almost the same as the Maghrebians on both unemployment and perceived discrimination. In the conclusion the authors briefly mention that North African families are concentrated in the poorest neighbourhoods and that 'youthful members of the second generation are relatively likely to be engaged in petty crime and gang violence ' (2007, p. 23). On this basis the authors conclude that the 'segmented-assimilation phenomenon' exists, though it must be added that at one point they speak of the North Africans as a group at risk of downward assimilation, a description that seems to me more appropriate. The data the authors provide are rather limited. The authors speak about the North African group as a whole, but one wonders to what percentage of the population the risk of downward assimilation applies.

Silberman, Alba and Fournier also point to a difference between the American and European situation. In segmented assimilation theory racism is thought to have a central role in the creation of downward assimilation. In the case of France, however, skin-colour based racism does not have the same power as in the United States.

Religious difference is more often the basis of discrimination and exclusion. The mechanisms producing downward assimilation are thus not the same in Europe and the United States. In my view the authors are right to argue that SA theory should be reformulated in such a way that it can be applied to a broader range of settings.

It is a pretty well established fact that not only in France but also in other Western-European countries with black populations skin-colour based racism, as understood here, is weaker than in the very race conscious USA (Marable 1995, p. 185; see also Vermeulen 1999). As has been noted also by others, in Europe it is less the blacks who are at the bottom of the 'ethno-racial' hierarchy and who are most often the object of prejudice and discrimination, but the Muslims (e.g. Modood 1991; Lucassen 2005). Silberman, Alba and Fournier even conclude that religion-based discrimination is the mechanism that produces downward assimilation in France. It is however striking that only about 5 per cent of their respondents mention 'religion' when asked about why they are discriminated. 'Name' and 'skin colour' come first. 9 These data can be explained in several ways. It can, for example, be that the North Africans are Name, skin colour, religion (e.g. the scarf) and place of residence may all be just markers for this.

Pluralistic integration: the United States and Europe

Pluralistic integration is less often a topic of debate than downward assimilation. Like downward assimilation pluralistic integration is not considered to be a pre-1965 phenomenon. The segmented assimilationists tell their readers more than once that classical assimilation was characteristic for the past, while now there is not one, but there are three variants of assimilation.

I will try to show the relevance of the pluralistic variant for the study of past and present, in the United States and Europe. I will present the reader here very briefly with two cases and make some, partly critical remarks on this mode of integration or assimilation as presented by the segmented assimilationists. My cases are Greeks in the United States in the early twentieth century and in post-1960 Germany (Vermeulen and Venema 2000; Vermeulen 2008).

Case 1: The Greeks in the United States

In the period from 1880 to 1930, some 28 million people migrated to the United States.

Among them Greeks who arrived mainly between 1900 and 1920. In total about 10 per cent of the Greek population left for America, a similar percentage as in the case of Italy. Initially Greek communities were composed largely of men and return migration was very high. Most of the Greeks came from the Peloponnesus. Emigration was not The villagers in the Peloponnesus were simple and poor peasant smallholders, but they were well integrated in the market. Moreover, many had some schooling. The region had a dense network of primary schools and even a number of secondary schools. These schools were largely financed by the trading diaspora, either directly or via the state. The Peloponnesus had, moreover, a strong relation with the state bureaucracy in Athens. The Greek government offices, from janitor to minister, were largely staffed by people from the Peleponnesus. Peasants thus valued education and saw it as a means of upward social mobility, either in the state bureaucracy or the diaspora.

In Kostas Tsoukalas ' (1977) phrasing the migrants who left for the Unites States were 'over-educated' poor peasants with a petit-bourgeois mentality. 10 There were few skilled workers among them when compared to the Italians. After their arrival in the US the Greeks found work as unskilled labourers, initially in the mines and in the construction of railways. They settled predominantly in the larger cities, such as New York and Chicago. Soon the Greeks began to improve their socio-economic situation through both entrepreneurship and education. Relatively large numbers of Greek immigrants were quick to succeed in business, especially in the restaurant business. Some, coming from the Greek diaspora, were already experienced entrepreneurs. 11

Greeks were also quick to organize themselves. Their organizations were not only inward-looking. Many had a utilitarian character and kept in frequent contact with the outside world. The Greeks stood out in their educational achievements. For many the ideal was 'first generation in business, second generation into the professions'. In the US censuses of 1960 and 1970 the second-generation Greeks could boast the highest educational levels of all ethnic groups and were surpassed only by the Jews in average income (Moskos 1980, p. 111).

Case 2: Greeks in Germany

Greek mass migration to 'Europe' --as the Greeks tend to say --started a decade after the civil war (1946-9) ended. The large majority of migrants went to Germany. The migrants came overwhelmingly from a rural background --mainly from Northern Greece --and had little or no education, partly as a result of the World War II and the civil war. 12 There were few skilled workers among the Greeks in comparison to other Mediterranean groups, including the Turks. Both men and women came to work in industry, but many lost their jobs with the restructuring of the economy after 1973.

Since the economic prospects in Greece had improved many Greeks returned, especially after the dictatorship ended in 1974.

Since the mid-1970s the proportion of self-employed --mainly in the restaurant, catering and hotel sector --rose very strongly: according to the micro-census of 2004 15.5 per cent of persons with the Greek nationality are entrepreneurs, 13 while other immigrant groups show lower levels of entrepreneurial activity. Both Spanish and Greek immigrants attach much significance to the education of their children and put a lot of energy in it, but while the Spanish put their energy in integration in the German school system, 14 the Greeks were and are very active in developing and maintaining a network of 'national', i.e. Greek schools at both primary and secondary level. The precise way in which these Greek national schools function differs between the German federal states (Länder). Greek schools may be attended instead of or in addition to the German schools. They are financed partly by the Greek state. One reason why many Greek parents attach much significance to Greek education is that they want their children to have the possibility to study in Greece. Relations with the country of origin remain strong, movements between Greece and Germany are frequent and return migration remains relatively high. Greek children perform well in education, including higher education; a bit less than Spanish children, but much better than Italians and Turks.

The high degree of ethnic cohesion is also evident in other domains. The children of Greek immigrants do not marry often with native Germans, they have many co-ethnic friends, keep their mother tongue alive and are not very eager to obtain German citizenship. In his research among young Greeks Schultze (1992: 264) found that just over half of these mostly second-generation Greeks rejected the idea of acquiring German citizenship, even if that would not mean losing Greek citizenship.

Greeks are well organized and have a large number of voluntary associations. These associations are often directed at issues of (Greek) education and Greek culture and many have strong relations with the country and regions of origin. Thränhardt and Hunger characterize the Greek pattern as pluralistic integration, while they consider the Spanish to be assimilationist (e.g. Thränhardt 2000, pp. 33-6;Hunger 2004, p. 24). To characterize the Greek case, they also use the term 'immigrant colony' (Einwandererkolonie; e.g. Thränhardt 2000, p. 36).

Though I have not used the vocabulary of segmented assimilation in describing the cases of the Greeks in the United States and Germany, the analogy with the descriptions given for the third mode of integration is striking. It is, among others, evident in the Why is it that some immigrant communities with little human and financial capital follow the road of downward assimilation while others follow the pluralistic integration path? The SA authors often stress that among immigrants of limited means the role of social capital is vital (e.g. Zhou and Bankston 1996; Portes, Fernández-Kelly and Haller 2005, p.1013). Strong families and strong ethnic communities thus seem at first sight to make the difference. At the same time, however, when discussing downward assimilation Portes rejects the idea that it is characterized by anomie or low social capital. Quite the contrary, the downward levelling norms can be sustained by the very virtue of the existing social networks and community structures. Portes (1995, p.254) argues that it is better to see this as an example of the potentially negative effects of social capital. The question remains: what explains the difference? 15 How come some groups can dispose over more social capital than others or --if we assume all groups enter with the same amount of social capital as SA theorists seem to suggest --why does it have these different effects?

In my opinion at least part of the answer can be found in the premigration history and the socio-cultural legacy immigrants brought with them. Perhaps the most important difference between Italians and Greeks in the US is that the Italian community was internally divided in several ways. The sharpest divide was between Northern and Southern Italians. The Northern Italians deeply disdained the Southerners and even went so far to persuade the American authorities to register the Southerners separately. There was no such divide between diaspora Greeks and Greeks from the mainland. The second could profit from the first, who acted as role models and sources of knowledge and experience. The Greeks entered the United States with a different background and world view than Southern Italians, coming from a region often described as an internal colony.

SA theory --and it is not alone in this respect --tends to see immigrants at the moment of immigration as 'people without history' (Wolf 1982). 16 Only in very few places SA theorists touch on the issue: Portes and MacLeod (1999), for example, argue that the importance of social capital has perhaps been overestimated in recent research.

It is rather the entire weight of experience of an immigrant group that has to be taken into account for understanding their children's educational careers. I suppose this includes pre-migration experiences. And more recently Portes and Fernández-Kelly (2008, p.18) drew attention to the importance of differences in 'family patterns', brought from the countries of origin.

The SA theory presents pluralistic integration as the ideal mode of integration or at least as the one to be preferred over the other two. A main reason for this is that it reduces parent-child conflict and promotes self-esteem and psychological well-being (e.g. Portes and Rumbaut 2001b, p. 274). There are indications that this holds true also for the Greeks in Germany. But this mode may also have some disadvantages. Ethnic cohesion and hierarchical family relations may have negative consequences for the position of women (Crul and Vermeulen 2003, p. 974). And under certain circumstances this mode of integration may promote ethnocentrism and narrow-minded nationalism. In her book on 'Greek emigration ideology ', Helene Manos (2001) criticizes the 'ethnocentric character' of Greek life in Germany and the role of the Greek state in promoting this. She points out that this does not tally with the needs of countries like Germany that have become more culturally diverse as a result of immigration. And --one might add --it does also not tally with the needs of Greece, a country that in the last two decades has become more and more culturally diverse as a result of immigration.

Conclusion

Segmented assimilation theory has greatly contributed to our understanding that cultural assimilation is not a guarantee for upward mobility and that, on the other hand, a selective keeping to the old ways may promote such mobility. It makes also a good case for the existence of the three variants of assimilation. Nevertheless, it has in my view a number of weak points.

The 'straight-line assimilation' variant gets very little attention in the literature, presumably because it seems least problematic and most similar to 'classical assimilation' in the past. But is it really so similar? If the classical variant is nowadays only open to people with more than average human capital --presumably including a reasonable knowledge of the English language and of American culture --who move almost straight into the American middle class, the assimilation process is clearly 'straight-line', but it seems quite different from the often-cited 'classical' pattern which was perhaps not that straight-line after all (as my case study above has shown). It looks more like a new variant, which is at least partially a product of globalization.

A second point of critique concerns the concept of downward assimilation. I argued that in order to make a strong case for downward assimilation one would have to show the existence of 'downward levelling norms' (Portes, see above) and of an oppositional underclass subculture. Partly because much of the research is quantitative this is often not convincingly done. In many cases research convinces this reader of a risk of downward assimilation, but not of downward assimilation itself. This is not a minor difference.

A third point raising questions is the usual suggestion that downward assimilation and pluralistic integration are end-stages, resulting in respectively 'permanent poverty' or upward assimilation combined with permanent biculturalism.

There is little or no discussion about the possibility of change here. This is actually remarkable because the phenomena which are used as indicators of downward assimilation --such as unemployment, school dropout, and criminality --may clearly be temporary. This was, for example, the case for the black Surinamese in the Netherlands.

The same holds true for reactive ethnicity. If downward assimilation is a process taking several generations it is in many cases too early to come to final conclusions. Pluralistic integration is also better not conceived as an end-state. It functions often as a springboard, a 'reculer pour mieux sauter' as the French expression goes. 17 When secondgeneration children succeed well in education this often results in joining the mainstream. This does not necessarily mean the dissolution of the ethnic community.

Even though entering the mainstream the second and third generation may maintain relations with the ethnic community and not all of them leave the ethnic community.

Moreover, those who do may be replaced by newcomers. Ethnic entrepreneurs often prefer newcomers over the 'spoiled' second generation and may actively recruit people from their home area. 18 Then there is the question of the 'old' versus 'new' migration. SA theorists (and many others) believe that the old migration was characterized by 'straight-line' assimilation. My case of the Greeks in the USA suggests that pluralistic integration existed also in the old migration. And some groups, such as the Italians, could also be Their integration process shows at least some resemblance to that of the Mexicans (e.g.

Perlmann 2005).

The previous point relates perhaps to the fact that there is hardly any discussion among the SA theorists on the origins of their own theory. The downward assimilation variant builds on or relates to theories of the underclass or the ghetto poor and to the culture-of-poverty theory [START_REF] Lewis | The culture of poverty[END_REF]), 19 and the pluralistic variant has parallels with theories of trading or middlemen minorities (e.g. Vermeulen 1991; Zenner 1991). This makes it quite questionable that these variants would be new phenomena of the new migration. It is no coincidence, for example, that the old trading minorities (e.g.

Chinese, Jews and Greeks) are well represented in the pluralistic integration variant, then and now.

My case studies are intended to convey the message that 'the entire weight of the experience of a group' is relevant for understanding their integration process, including the pre-migration experience. Giving attention to the pre-migration experience may help us understanding why two groups with low human capital and perhaps many other similarities nevertheless may follow a different integration track.

Though in my opinion SA theory is as applicable to the USA as to Europe, it is not that clear how much of the cross-national differences in the ways immigrants and their children integrate can be explained by it. For cross-national research it is indispensable to include an institutional approach, 20 which focuses on nation-state differences, either as a supplement to or as a replacement of the SA approach -depending on the 'intellectual problems' to be solved. 2 It should be emphasized that the concept segmented assimilation refers to the three variants of assimilation (e.g. Portes and Rumbaut 2001: 44-46). It is often wrongly applied to only one of its variants: downward assimilation.

3 It is incorrect to state --as Portes and Fernández-Kelly (2008. p. 15) are doing --that Perlmann argues 'that there is really nothing new in today's process of second-generation assimilation'.

4 See e.g. Engbersen1990, Faist 1993, Martiniello 1996, Mingione 1996, and Morris 1994. 5 See the article of Maurice Crul and Jens Schneider in this special issue for more details. 6 Marginalization refers here to alcohol and drug abuse, playing truant, hanging around on the street and small street crime (note the similarity with indicators for downward assimilation). 7 This was the title of the first study drawing attention to the changing picture of Antillean immigration (Amesz, Steijlen and Vermeulen 1989). 8 In the case of the lower-class Afro-Surinamese there is a similar pre-migration influence. The situation of the Afro-Surinamese has improved more than that of the working-class Antillean population. On the Surinamese see Van Niekerk 2002. 9 When asked why they are discriminated 26.5 percent of the men and 18.9 percent of the women mention 'name', 22.2 percent of the men and 8.8 percent of the women mention skin colour. 10 The Marxist sociologist Tsoukalas used the word 'overeducation' because the educational system had developed far beyond what one would expect given the stage of development of the productive sectors of the economy. This is not to say Greeks had -what we now would consider -a high level of education: 52 percent of the Greeks who settled in the United States had some schooling (against 25 percent of the Italians). Tsoukalas uses the term petit bourgeois mentality because many left with the idea of setting up one's own business, usually after working in the business of a relative or co-villager.

11 About 20 percent of the immigrants came from the Greek diaspora.

12 Even in the 1980s still 6 percent of the male and 21 percent of the female immigrant population in Germany was illiterate (Vermeulen 2008, p.19). 13 The percentage of the population of Greek descent dependent on the ethnic economy is much higher. 17 'Reculer pour mieux sauter' can be translated as 'to step backwards to take a run-up for a better jump'.

18 See e.g. Vermeulen 1984: 91-112 on the Chinese in Surinam. 19 It seems that the lower class can be included in this short list: '(…) what we now call the underclass bears a striking resemblance to what sociologists used to call the lower class. Both are characterized by high levels of joblessness, illiteracy, illegitimacy, violence, and despair' (Jencks 1991: 28). 20 An institutional approach is understood here as an approach which looks at the effects the way institutions such as the labour market and education -i.e. the different ways they are organized from state to state -have on the process of integration of immigrant groups.

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Ethnic and Racial Studies

  There is clearly no consensus on the phenomenon of downward assimilation.

  their low socio-economic status or for being Maghrebin.

  region. Many villagers had left earlier to start a new life in the Greek trading diaspora in Romania, Southern Russia, Asia Minor, Egypt or elsewhere. Education was important in the diaspora communities and more than a few children of migrants became doctors and lawyers.

  social cohesion and the success in education. When comparing Greeks and Italians in the United States(Vermeulen and Venema 2000) there are a number of striking differences which cannot easily be explained by conditions in the United States: the two groups have in many respects a similar cultural background, started out in the same occupations, settled at roughly the same time in the same places and were subject to similar forms of racism.

  for (non-permanent) downward assimilation or at least of having been at risk of downward assimilation and showing periods of 'stagnation'.

1

  1994 Dangerous Classes: The Underclass and Social Citizenship, London: Routledge MOSKOS, CHARLES C. Jr, 1980 Greek Americans, Englewood Cliffs NJ: Prentiche Hall NIEKERK, MIES VAN 1993 Kansarmoede: Reacties van Allochtonen op Achterstand, Amsterdam: Het Spinhuis --2002 Premigration Legacies and Immigrant Social Mobility, Lanham: Lexington Books PERLMANN, JOEL 2005 Italians Then, Mexicans Now: Immigrant Origins and Second-Generation Progress, 1890-2000, New York: Rusell Sage Foundation PORTES, ALEJANDRO 1995 'Children of Immigrants: Segmented Assimilation and its Determinants', in Alejandro Portes (ed.), The Economic Sociology of Immigration: Essays on Networks, Ethnicity, and Entrepreneurship, New York: Russell Sage Foundation, pp. 248-79 PORTES, ALEJANDRO and FERNÁNDEZ-KELLY, PATRICIA 2008 'No margin for error: Educational and occupational achievement among disadvantaged children of immigrants', Annals of the American Academy of Political and Social Science vol.620 (November), pp. 12-36 PORTES, ALEJANDRO and MACLEOD, D.1999 'Educating the second generation. Determinants of academic achievement among children of immigrants in the United States', Journal of Ethnic and Migration Studies vol. 25, no.3, pp. 373-396 PORTES, ALEJANDRO and RUMBAUT, RUBÉN 1996 Immigrant America: A Portrait, 2 nd edn, Berkeley CA: University of California Press, --2001a Legacies: The Story of the Immigrant Second Generation, Berkeley CA: University of California Press Conclusion, The forging of a new America: Lessons for theory and practice, in Rubén Rumbaut and Alejandro Portes (eds.), Ethnicities: Children of Immigrants in America, Berkeley, CA: University of California Press, pp. 301-317 PORTES, ALEJANDRO and ZHOU, MIN 1993 'The new second generation. Segmented assimilation and its variants among post-1965 immigrant youth', Annals of the American Academy of Political and Social Science vol. 530 (November), pp. 74-96 PORTES, ALEJANDRO, FERNÁNDEZ-KELLY, PATRICIA and HALLER, WILLIAM 2005 'Segmented assimilation on the ground: The new second generation in early adulthood', Ethnic and Racial Studies vol.28, no. 6, pp. 1000-40 ROELANDT, THEO 1994 Verscheidenheid in Ongelijkheid: Een Studie naar Etnische Stratificatie en Onderklassevorming in de Nederlandse Samenleving, Amsterdam: Thesis Publishers ROELANDT, THEO and VEENMAN, JUSTUS 1993 'Ethnic groups and underclass formation in the Netherlands: The Dutch case', in H.Entzinger, J.Siegers and F.Tazelaar (eds), Immigrant Ethnic Minorities in the Dutch Labour Market: Analysis and Policies, Amsterdam: Thesis Publishers, pp. 47-69 SCHULZE, GÜNTHER 1992 'Die Bundesrepublik Deutschland auf dem Weg zur multikulturellen Gesellschaft? Zum Eingliederungsprozess van griechischen Jugendlichen und Türken der erste und zweiten Generation', Archiv für Sozialgeschichte 32, pp.247-269 SILBERMAN, ROXANE, ALBA, RICHARD and FOURNIER, IRÈNE 2007 'Segmented assimilation in France? Discrimination in the labour market against the second generation', Ethnic and Racial Studies vol. 30, no.1, pp. 1-27 THRÄNHARDT, DIETRICH 2000 'Einwandererkulturen und soziales Kapital: Eine komparative Analyse', in Dietrich Thränhardt and Uwe Hunger (eds), Einwanderer-Netzwerke und ihre Integrationsqualität in Deutschland und Israel, Münster, LIT Verlag, pp. 53-81 TSOUKALAS, KOSTAS 1976 'Some aspects of "over-education" in Greece' in M. Dimen and E. Friedl (eds), Regional Variation in Modern Greece and Cyprus: Toward a Perspective on the Ethnography of Greece, Annals of the New York Academy of Sciences vol. 268, pp. 419-42 VERMEULEN, HANS 1984 Etnische Groepen en Grenzen: Surinamers, Chinezen en Turken, Weesp: Het Wereldvenster --1991 'Handelsminderheden: een inleiding', Focaal no.15, pp. 7-28 --1998 'Natiestaten en immigranten: Theoretische perspectieven', in: Rinus Penninx, Henk Münstermann and Han Entzinger (eds), Etnische Minderheden en de Multiculturele Samenleving, Groningen: Wolters Noordhoff, pp. 85-111 --1999 'Essentializing difference? The census, multiculturalism and the multiracials in the USA', in: M.C. Foblets and C.L. Pang (eds), Culture, Ethnicity and Migration, Liber Amicorum Prof.Dr. E.Roosens, Leuven: Acco, pp. 81-98 --2001 Culture and Inequality: Immigrant Cultures and Social Mobility in Long-term Perspective, Amsterdam: Institute for Migration and Ethnic Studies. --2008 'The Greek labour diaspora in Western Europe, its integration in the receiving societies, especially Germany, and its relation with the home country', in Martin Baldwin-Edwards (ed.), Ethnicity and Migration: A Greek Story, special issue of Migrance, nr. 30, pp. 18-36 (Also available in French) VERMEULEN, HANS and PENNINX, RINUS 2000, Immigrant Integration: The Dutch Case, Amsterdam, Het Spinhuis VERMEULEN, HANS and VENEMA, TIJNO 2000 'Peasantry and trading diaspora: Differential social mobility of Italians and Greeks in the United States', in: Hans Vermeulen and Joel Perlmann (eds), Immigrants, schooling and social mobility: Does culture make a difference?, Houndmills: Macmillan, 124-59 WALDINGER, ROGER and FELICIANO, CYNTHIA 2004 'Will the second generation experience 'downward assimilation'? Segmented assimilation re-assessed',Ethnic and Racial Studies, vol. 27, no.3, pp. 376-402 WALDINGER, ROGER and PERLMANN, JOEL 1998 'Second generations: past, present, future', Journal of Ethnic and Migration Studies, vol. 24, no.1, pp. 5-24 WILSON, WILLIAM J. 1987 The Truly Disadvantaged: The Inner City, the Underclass and Public Policy, Chicago: The University of Chicago Press --1997 When Work Disappears: The World of the Urban Poor, New York: Alfred A. Knopf WOLF, ERIC R. 1982 Europe and the People without History, Berkeley: University of California Press ZENNER, WALTER P. 1991 Minorities in the Middle: A Cross-cultural Analysis, New York: State University of New York Press ZHOU, MIN 1997 'Segmented assimilation: Issues, controversies, and recent research on the new second generation', International Migration Review vol. 31, no.3, pp. 975-1008 ZHOU, MIN and BANKSTON, CARL.N.1996 'Social capital and the adaptation of the Second Generation: The case of Vietnamese youth in New Orleans', in A. Portes (ed.),The New Second Generation , New York: Russell Sage, pp. 197-220 HANS VERMEULEN is emeritus professor in the Institute for Migration and Ethnic Studies, University of Amsterdam. ADDRESS: Milies-Volou, 37010, Greece. Email: hansvermeulen@uva.nl. In this article I use 'integration' and 'assimilation' as synonymous.

  partly the result of an unproductive culture versus structure debate (see Vermeulen 2001), resulting in the fear of 'blaming the victim'.

  The Mexicans are the crucial test-case for the downward assimilation hypothesis. The Mexicans are the largest immigrant group in the United States and are

	often mentioned as a case of downward assimilation or at least as at risk of following
	that road (e.g. López and Stanton-Salazar 2001). So let us have a brief look at a study
	by Joel Perlmann (2005) who compares the Mexicans today with the SCEN (Southern,
	F o r
	P
	e
	e r
	R
	e
	v i e
	w
	O n l
	y

The Spanish abolished special Spanish classes, even against the will of German authorities.

Another possible explanation is to be found in differential racism, but if that occurs it needs an explanation too and one that goes further than just a reference to skin colour.


Ajit Sarvadikar
email: ajitls@yahoo.com

Gordon Prescott

David Williams

Attitudes to reporting medication error among differing healthcare professionals

Keywords:

Aims Medication error reporting is an important measure to prevent medication error incidents in a healthcare system and can serve as an important tool for improving patient safety. This study aimed to investigate attitudes of healthcare professionals (doctors, nurses, and pharmacists) in reporting medication errors. Methods Fifty-six healthcare professionals working at a 900-bed tertiary referral hospital were surveyed. A questionnaire using two different clinical scenarios (involving oral and intravenous administration of a drug) and four questions with an ascending order of worsening patient outcome was used. A Likert scale ranging from 1 (unlikely) to 5 (likely) was used to describe the likelihood of reporting a medication error. Results The overall response rate was 57% (43% for doctors, 68% for nurses, and 64% for pharmacists). Results showed that doctors were unlikely to report less-serious medication errors (median value of 2 on the Likert scale). Nurses and pharmacists (median value of 5) were likely to report less-serious as well as serious medication errors despite their fears of receiving disciplinary action. All healthcare professionals were more likely to report an error as the clinical scenarios had a progressively worsening outcome for the patient. Conclusions These results suggest that among healthcare professionals, there are differing attitudes to reporting medication errors. Differing approaches are therefore required to encourage medication error reporting among different healthcare professionals. Future study is required to further investigate these findings and improve reporting rates.

Introduction

Adverse events (AEs) have been shown to cause harm in between 3% and 17% of hospital inpatients [START_REF] Vincent | Adverse events in British hospitals: preliminary retrospective record review[END_REF][START_REF] Baker | The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada[END_REF][START_REF] Thomas | A comparison of iatrogenic injury studies in Australia and the USA[END_REF]. A significant number of these AEs are the result of medication errors that lead to injury in 2-15% of hospital admissions in UK and are the single most preventable cause of patient harm [START_REF] Vincent | Adverse events in British hospitals: preliminary retrospective record review[END_REF][START_REF] Shaw | Adverse events and near miss reporting in the NHS[END_REF]. Medication-error reporting is an important measure to prevent future medication incidents in the healthcare system. Such reporting provides important feedback to reporters and identifies systematic failures in the medication cycle. Prescribing errors are common among junior doctors, in part as a result of inadequate training at undergraduate level [START_REF] Aronson | A prescription for better prescribing[END_REF]. In 1995, the majority of hospitals in England and Wales established an error-reporting system in compliance with the development of national risk management standards [START_REF] Ashcroft | Likelihood of reporting adverse events in community pharmacy: an experimental study[END_REF]. In particular, this system aims to help identify trends and patterns relating to medication safety, thereby allow-ing identification of contributory factors, their preventability and the impact on patient outcome. One difficulty with medication errors is that they are often underreported [START_REF] Maidment | A medication error reporting scheme: analysis of the first 12 months[END_REF]. Indeed, routine incident-reporting systems may report as little as 5% of AEs detected by case note review [START_REF] Sari | Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review[END_REF]. Barriers to reporting medication errors include feeling of shame [START_REF] Davidoff | Shame: the elephant in the room[END_REF], fear of punishment [START_REF] Evans | Attitudes and barriers to incident reporting: a collaborative hospital study[END_REF], complicated reporting systems [START_REF] Maidment | A medication error reporting scheme: analysis of the first 12 months[END_REF], fear of litigation [START_REF] Ashcroft | Likelihood of reporting adverse events in community pharmacy: an experimental study[END_REF] and an unsupportive culture towards medical errors within the organisation [START_REF] Maidment | A medication error reporting scheme: analysis of the first 12 months[END_REF]. These barriers are associated either with self-made errors or are a reflection of the administrative difficulty in reporting error.

Among different healthcare professionals, it has been suggested that nurses feel more guilty, worried, embarrassed, and afraid of disciplinary action than doctors and pharmacists as a result of a greater feeling of responsibility for an error, ear of the consequences for the patient and fear of further punishment from senior staff [START_REF] Firth-Cozenes | Barriers to incident reporting[END_REF]. As little information is available on the differing attitudes of healthcare professionals to reporting error, we conducted a study to determine the attitudes of differing healthcare professionals to reporting medication error and to determine how differing levels of patient outcome influence medication-error reporting.

Methods

The study was performed at Aberdeen Royal Infirmary (ARI), a 900-bed tertiary referral hospital serving a population of 500,000 in the northeast of Scotland. Permission to perform the study was obtained from the medication safety group who also approved the format of the questionnaire, which was piloted in a previous study performed by the Psychology Department at the University of Aberdeen. Healthcare professionals consisting of doctors, nurses and pharmacists were surveyed using a set of questionnaires specific to each profession (condensed versions of the questionnaires are in Appendices I, II and III). A month after the first questionnaires had been sent, a reminder questionnaire and a further covering letter were sent to the same staff. Due to measures to protect anonymity, those who responded to the first request could not be identified. The questionnaire had two different scenarios, each of which had four different patient outcomes of worsening degree. In the first scenario (SC1), the respondents were asked to imagine that they had made a prescription error while dealing with a 50-year-old man admitted with acute congestive heart failure. The prescription error led to administration of Inderal (propranolol) 10 mg t.i.d. instead of Isordil (isosorbide mononitrate) 10 mg t.i.d. In the second scenario (SC2), respondents were asked to imagine they had made an incorrect infusion-rate error. The consequences of these errors were presented in four imaginary scenarios that had progressively worsening outcomes for the patient (Fig. 1)

Within each of these patient outcomes, respondents were then asked four further subquestions relating to their likelihood of being blamed, disciplined, discharged from employment and reporting the medication error (Fig. 2). The likelihood of a particular response was measured using a 5-point Likert scale. Subquestion 1 in patient outcome A of SC1 is referred as SC1A1. Similar terminology was used to refer to other subquestions/patient outcomes/scenarios. How likely do you think that you will be blamed and criticised due to this error?

Statistical analysis

2.

How likely do you think that you will receive disciplinary action due to this error?

3.

How likely do you think that you will be discharged from employment due to this error?

Results

From a total of 98 questionnaires sent to healthcare professionals, there were 56 (57%) responses. The response rates after the first questionnaire and a reminder had been sent were 43% for doctors (18/42), 68% for nurses (22/32), and 64% for pharmacists (16/25). The 18 doctors consisted of five Foundation Year 1 (FY1), one FY2, three senior house officers (SHO), two registrars and seven consultants. The 22 nurses consisted of two ward sisters and 20 staff nurses. These professionals had varying years of experience, with doctors having between 1-33 years, nurses less than 1-40 years and pharmacists 4-25 years.

Blame and criticism scenario

The responses to the question "How likely do you think it is that you will be blamed and criticised due to this error"? are shown in Fig. 3.

Similar responses on the likelihood of criticism and blame were found in the three professions for many scenarios. However, nurses and pharmacists were more likely to think that they would be blamed and criticised than did doctors in SC1B1 and SC2B1 (p<0.05) (Fig. 3). As patient outcome worsened, most participants from all three professions felt they were likely to be blamed for a medication error.

Disciplinary action scenario

Responses to the question: "How likely do you think it is that you will receive disciplinary action due to this error"? are shown in Fig. 4. All healthcare professionals expressed increased expectation of disciplinary action being taken as the severity of patient outcome increased. Nurses showed a greater expectation of disciplinary action than the other professions (Fig. 4).

Discharge from employment scenario

Responses to the question: "How likely do you think it is that you will be discharged from employment due to this error"? are shown in Fig. 5.

Few healthcare professionals thought it likely that they would be discharged from employment as an outcome of a medication error. However, nurses expressed a significantly higher expectation of being dismissed for an error that resulted in severe patient harm in comparison with doctors or pharmacists (p=.029 for SC1D3) (Fig. 5).

Likelihood to report medication error scenario

The responses to the question: "How likely do you think it is you would report this error"? are shown in Fig. 6. Responses of most nurses and pharmacists indicated that they were likely to report all types of errors irrespective of the patient outcome, whereas the likelihood of doctors reporting medication errors increased with worsening patient outcomes (Fig. 6).

Discussion

Our results suggest that the type and severity of medication error influence healthcare professionals differently. Whereas nurses and pharmacists were likely to report all medication errors, doctors were only likely to report an error that resulted in an adverse outcome. Other studies have also reported that nurses are more likely to report medication errors than are doctors [START_REF] Evans | Attitudes and barriers to incident reporting: a collaborative hospital study[END_REF], whereas all healthcare professionals are more likely to report errors that are serious and cause actual harm to patients [START_REF] Firth-Cozenes | Barriers to incident reporting[END_REF], suggesting that it is the severity of outcome that influences medication error reporting among doctors.

Blame and criticism

This study demonstrated that nurses and pharmacists have a higher expectation of being blamed and criticised than do doctors. As the patient outcome in scenarios became worse in SC1C1, SC1D1, SC2C1 and SC2D1, all participants equally believed they were likely to be blamed. However, nursing and pharmacy staff were more likely to report an error than were doctors, suggesting that though the fear of blame is high in nurses and pharmacists, this is not as strong a barrier to reporting an error as it may be among doctors.

Disciplinary action and discharge from employment

All healthcare professionals expressed an increased fear of disciplinary action with an increase in severity of patient outcome. Nurses were most concerned about disciplinary action in most scenarios, in keeping with a previous study that suggested that nurses have greater fear of disciplinary action because of a greater feeling of responsibility for an error, fear about the consequences for the patient and attitudes of senior staff to errors [START_REF] Wolf | Responses and concerns of healthcare providers to medication errors[END_REF]. Doctors were least likely to expect disciplinary action as an outcome of a medication error, whereas pharmacists showed a similar expectation to that doctors towards disciplinary action when patient outcome was less severe. However, responses became more similar as patient outcome worsened. Despite nurses and pharmacists being more likely to think they would receive disciplinary action than were doctors, they were still more likely to say they would report an error. Whereas most healthcare professionals thought being dis- charged from employment was an unlikely outcome of a medication error, nurses expressed a greater expectation of being discharged for a medication error that resulted in severe patient harm (SC1D3). This may suggest a perception of an unsupportive working culture for reporting medication errors among nursing staff [START_REF] Wolf | Responses and concerns of healthcare providers to medication errors[END_REF].

Likelihood of reporting medication errors Doctors were more likely to report errors that had a more severe outcome (Fig. 6), whereas nurses and pharmacists were more likely to report all types of errors irrespective of the patient outcome. These findings were in accordance with another study demonstrating that doctors were less likely to report near misses or less-serious patient outcomes in comparison with nurses, who were more likely to report all types of errors [START_REF] Evans | Attitudes and barriers to incident reporting: a collaborative hospital study[END_REF][START_REF] Wolf | Responses and concerns of healthcare providers to medication errors[END_REF][START_REF] Alrwisan | Medication incidents reported to an online incident reporting system Proceedings of the British Pharmacological Society Clinical Pharmacology Section[END_REF]. This may be due to a lack of knowledge among doctors of the need to report less-serious errors or a perception of being too busy to have time to report such errors [START_REF] Evans | Attitudes and barriers to incident reporting: a collaborative hospital study[END_REF]. A previous study has suggested that pharmacists would take patient outcome into account when reporting errors [START_REF] Ashcroft | Likelihood of reporting adverse events in community pharmacy: an experimental study[END_REF]. However, our study suggested that pharmacists would report all types of errors irrespective of patient outcome.

Effect of severity of scenario on the responses

Changes in responses with increasing severity (Fig. 6) were in line with a previous study that demonstrated that all healthcare professionals are more likely to report errors that are serious and cause actual harm to patients [START_REF] Firth-Cozenes | Barriers to incident reporting[END_REF].

Limitations of the study

A weakness was that formal calculations to determine the appropriate sample size, including inflation to take account of estimated response rates, were not undertaken during the study design stage. To preserve anonymity, very few details of personal characteristics were requested, in particular, age and sex data were not collected, which made it impossible to compare participants and nonparticipants to assess generalisability. The study was performed in a single centre on a relatively small sample size of 56 healthcare professionals consisting of 18 doctors, 22 nurses and 16 pharmacists. Therefore, it may be difficult to generalise these results further. However, the findings are broadly consistent with earlier work on single and multiple professional groups and provide an important insight into the attitudes of differing healthcare professionals to reporting almost identical medication errors. Whereas the majority of physicians did not respond to the questionnaire, we feel that the information provided, albeit limited, does provide an important insight into physician attitudes to reporting medication error.

Conclusions

This study demonstrated that nursing and pharmacy staff members are likely to believe they will be blamed and criticised for an error, although they are still more likely to report an error than are doctors. Nurses expressed a much higher expectation of disciplinary action for all types of medication errors, whereas doctors and pharmacists believed they would receive disciplinary action only for serious errors. Accurate reporting of individual medication errors is essential for identifying system faults that can contribute to the likelihood of future errors [START_REF] Yu | Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?[END_REF]. Therefore, error reporting helps improve medication safety by addressing systems failures and helps to prevent future errors by allowing appropriate staff training [START_REF] Firth-Cozenes | Barriers to incident reporting[END_REF]. Our results suggest that hospitals should review their policies on error reporting to ensure they actively encourage staff of all healthcare professions to report medication errors and to support a blame-free culture in the organisation.

Do you work in:

an inpatient nursing unit? an outpatient nursing unit? Questions on working in adult or paediatric services as for medical staff. Questions on having ever reported a medication error as for medical staff.

Fig. 1

 1 Fig. 1 Four stages A, B, C & D showing ascending order of worsening stages of patient outcome in both scenarios

Fig. 2

 2 Fig. 2 Subquestions asked in stages A, B, C and D of scenarios 1 & 2. Answers to these questions were analysed on a Likert scale ranging from 1 (unlikely) to 5 (likely)

Fig. 3

 3 Fig. 3 Median values of participants' concept of likelihood of blame and criticism on a Likert scale for scenarios SC1A1 to SC2D1. SC1A1 Scenario 1 question A1, Likert Scale: 1=unlikely, 5=likely); SC1B1 (P = .024) and SC2B1 (p = .030) yielded significant p values

Fig. 4

 4 Fig. 4 Median values of participants' concept of likelihood of disciplinary action on a Likert scale for each scenario

Fig. 6 Fig. 5

 65 Fig. 6 Median values of participants' attitudes to reporting medication error showing likelihood on a Likert scale for each scenario. (All p values were significant)

Eur J Clin Pharmacol (2010) 66:843-853

Eur J Clin Pharmacol (2010) 66:843-853

Acknowledgement We thank the medical, nursing and pharmacy staff of Aberdeen Royal Infirmary who participated in this study. We thank Mr. Tim Delaney for use of the questionnaire used in this study.

Eur J Clin Pharmacol (2010) 66:843-853

Appendix I-Medical Staff Questionnaire

MEDICAL STAFF QUESTIONNAIRE REGARDING ERROR REPORTING

Scenario #1

You are clerking in a 50 year old man who has been admitted with congestive heart failure. In transcribing from his list of drugs on admission you prescribe Inderal(Propranolol) 10mg TID (Three Times a Day) instead of Isordil(Isosorbide dinitrate) 10mg TID.

Please indicate your opinion by circling a number 1 to 5 for each of the following questions.

A.

The nurse administering the drug detects the error prior to the patient receiving the wrong medication.

Sub questions SC1A1-SC1A4 as listed in figure2.

B.

The error is detected by your registrar after the patient receives the wrong medication for 24 hours. The patient suffers no adverse outcome resulting from this error.

Sub questions SC1B1-SC1B4 as listed in figure2.

C.

The error is detected after the patient becomes haemodynamically unstable and is transferred to the ICU (Intensive Care Unit). The patient suffers no permanent adverse outcome resulting from this error.

Sub questions SC1C1-SC1C4 as listed in figure2.

D.

The error is detected after the patient becomes haemodynamically unstable and is transferred to the ICU. The patient dies several days later resulting from this error.

Sub questions SC1D1-SC1D4 as listed in figure2.

Scenario #2

You mis-prescribe the rate for administering heparin. The incorrect rate is 10 times greater than the correct dose.

A.

The error is detected by you prior to the patient receiving the wrong infusion.

Sub questions SC2A1-SC2A4 as listed in figure2.

B.

Same scenario, but the error is detected by a fellow staff member after the patient receives the wrong dose for 24 hours. The patient suffers no adverse outcome resulting from this error.

Sub questions SC2B1-SC2B4 as listed in figure2.

C.

The error is detected when the patient experiences a large gastrointestinal haemorrhage and increased APTT (Activated Partial Thromboplastin Time) ratio. The patient is being transferred to the ICU. The patient suffers no permanent damage resulting from this error.

Sub questions SC2C1-SC2C4 as listed in figure2.

D.

The error is detected due to the patient having a gastrointestinal haemorrhage and increased APTT ratio. The patient is transferred to the ICU. The patient dies several days later resulting from this error.

Sub questions SC2D1-SC2D4 as listed in figure2. If yes, please comment on any action taken regarding the error.

Please briefly explain below why, in your opinion

Appendix II-Nursing Staff Questionnaire

Scenario #1

You misread a doctor's prescription, written for a 50 year old man who has been admitted with congestive heart failure. You mistakenly prepare for administration Inderal 10mg TID (Three Times a Day) instead of Isordil 10mg TID.

[The four sub questions presented in figure 2 are asked after each statement below as for the medical staff.]

A.

The checking nurse detects the error prior to the patient receiving the wrong medication.

B.

The error is detected by fellow nursing staff after the patient receives the wrong medication for 24 hours. The patient suffers no adverse outcome resulting from this error.

C.

The error is detected by the doctor after the patient becomes haemodynamically unstable and is transferred to the ICU (Intensive Care Unit). The patient suffers no permanent adverse outcome resulting from this error.

D.

The error is detected by the doctor after the patient becomes haemodynamically unstable and is transferred to the ICU. The patient dies several days later resulting from this error.

Scenario #2

You mis-programme an infusion pump for a heparin infusion. The misprogrammed dose is 10 times greater than the prescribed dose.

A.

The error is detected by you prior to the patient receiving the wrong infusion.

B.

Same scenario, but the error is detected by a fellow staff member after the patient receives the wrong dose for 24 hours. The patient suffers no adverse outcome resulting from this error.

C.

The error is detected when the doctor questions the nursing staff, due to the patient having a large gastrointestinal haemorrhage and increased APTT (Activated Partial Thromboplastin Time) ratio. The patient is being transferred to the ICU. The patient suffers no permanent damage resulting from this error.

D.

The error is detected when the doctor questions the nursing staff due to the patient having a gastrointestinal haemorrhage and increased PTT ratio. The patient is transferred to the ICU. The patient dies several days later resulting from this error.

Please briefly explain below why, in your opinion, medication errors are gathered and investigated.

Questions on praise for reporting errors as for medical staff.

Questions on employment duration similar to those for medical staff.

Are you employed as: a Ward Sister a Staff Nurse

Appendix III-Pharmacist's Questionnaire

Scenario #1

You receive a prescription, written for a 50 year old man who has been admitted with congestive heart failure. You mistakenly dispense Inderal 10mg TID (Three Times a Day) instead of Isordil 10mg TID. (The correct label is placed on the box, but the wrong drug is placed inside).

[The four sub questions presented in figure 2 are asked after each statement below as for the medical staff.]

A.

The nurse administering the drug detects the error prior to the patient receiving the wrong medication.

B.

The error is detected by nursing staff after the patient receives the wrong medication for 24 hours. The patient suffers no adverse outcome resulting from this error.

C.

The error is detected by the doctor after the patient becomes haemodynamically unstable and is transferred to the ICU (Intensive Care Unit). The patient suffers no permanent adverse outcome resulting from this error.

D.

The error is detected by the doctor after the patient becomes haemodynamically unstable and is transferred to the ICU. The patient dies several days later resulting from this error.

Scenario #2

You receive a telephone call on a Saturday morning to prepare a high dose methotrexate infusion for a paediatric patient. In producing the labels and worksheet you choose the incorrect regimen and hence an incorrect infusion rate. The infusion rate is 10 times greater than the prescribed rate. Questions on praise for reporting errors as for medical staff. Questions on employment duration similar to those for medical staff. Questions on working in adult or paediatric services as for medical staff. Questions on having ever reported a medication error as for medical staff.