Perception of Nursing Staff towards Disclosure of Adverse Events

The patients and their relatives today are well educated and have better awareness of their medical conditions and rights. This narrowed information and knowledge gap between the patients and the healthcare workers have increased the expectation that they be informed of any adverse events in a truthful and timely manner. Disclosure of adverse events to the patients and their families is also morally and ethically important [1,2].


Introduction
The patients and their relatives today are well educated and have better awareness of their medical conditions and rights. This narrowed information and knowledge gap between the patients and the healthcare workers have increased the expectation that they be informed of any adverse events in a truthful and timely manner. Disclosure of adverse events to the patients and their families is also morally and ethically important [1,2].
Adverse events are occurrences that result in harm or unexpected outcomes as a result of the interventions in our healthcare organisation.
While disclosure of adverse events is ethically right and beneficial, our medical and nursing culture and training do not support disclosure. It is often clouded by feelings of shame and fears of loss of professional standing amongst our peers. There is also a disconnect between the legal and healthcare workers that an apology and expression of regret does not naturally lead to an admission of guilt.
This study explored the nurses' knowledge, attitude and practice of disclosure of adverse events in our hospital.

Design of study
We conducted a cross sectional, blinded and anonymous questionnaire survey amongst the nursing staff working in the Changi General Hospital. The nurses surveyed were drawn from all the work areas within the hospital. Participation was strictly voluntary. The paper based survey questionnaires had an attached explanatory note and were distributed during the department meet-ings. Respondents were asked to return the completed questionnaire into sealed drop boxes to ensure confidentiality.

Survey instrument
The questions in the survey were designed to answer the objectives of this study with inputs from the staff as well as publications in the literature. A pilot was done for the survey and the feedback incorporated into the final instrument used for data collection.
The basic epidemiological data of the responders were collected together with their work experiences and seniority in the hospital. Information regarding their past experience with adverse events either at work or in their personal capacity was collected as well.
Questions measuring their perception and practice of disclosure were also asked using a 5-point Likert scale.

Statistics
The data was analysed using SPSS 17.0 (Chi Inc.). Comparisons of discrete variables were done using the chi square test where applicable.
Responses from the 5-point Likert scale were grouped into those who "agreed", "did not agree" and "unsure". Those who responded as "strongly agree" and "agree" were reclassified as "agreed". Those who responded as "disagree" and "strongly disagree" were reclassified as "did not agree".
The nurses were grouped into whether they were "senior" or "junior" nurses based on the nursing position held. The nursing managers, nurse practitioners and nursing directors were grouped as "senior" nurses while the registered and enrolled nurses were grouped as "junior" nurses. The discrete variables for the "senior" and "junior" nurses were compared using the chi square test where applicable.

Results
1095 of the 1500 questionnaires distributed were returned (response rate of 73%) during the study period from 16 May 2012 and 23 May 2012.
Junior nurses made up 92.2% of the respondents. 59.7% were less than 30 years of age and 56% of them had less than 5 years' experience in the job. The demographics, work experience and areas of work of the respondents are shown in Table 1. 134 (12.2%) of the respondents had been involved in an adverse event during the course of their work and 60 (44.8%) of them were involved in doing the disclosure to the patient or their family. 103 (89.2%) of these adverse events were classified as either "mild" or "insignificant". 129 (97%) of these adverse events were notified to the supervisors and this was done within a day in 120 (92.3%) of the adverse events.
The nurses' concerns with disclosure affecting their professional standing and relationship with the patients and their "preparedness" to perform disclosure are tabulated in Table 2 and Table 3 respectively.
270 (24.7%) of the respondents have attended training related to disclosure of adverse events. 710 (64.8%) agreed that training in disclosure of adverse events should be made mandatory for all staff and 1021 (93.2%) are willing to attend this training. 1008 (92.1%) also agreed that training in disclosure will better equip them to handle these disclosures more efficiently.

Discussion
The fundamental role of a healthcare organisation is to provide high quality care to their patients. This is built on good clinical practices in an environment where there is a high level of trust between the provider and receiver of this service [3].
It is every patient's expectation that they be informed when an adverse event had occurred to them. An apology and a review of the incident to put in place prevent similar occurrence must also be taken. This is the right thing to do both operationally and ethically; and it must be developed as part of the culture within the organisation [4].
This study identified a gap in the knowledge and preparedness of performing disclosure of adverse events to our patients. This is evident as only 41% and 33.5% of the nurses felt that they have enough skills to perform disclosure and are familiar with disclosure procedures respectively. Overall, only 30.9% felt that they are ready to conduct a disclosure. This is a concern especially in the setting of an acute hospital where adverse events occurs. This will also have a grave impact of our patient's perception of the "trustworthiness" of the hospital. There are also no differences of the level of knowledge and preparedness in disclosure procedure amongst the junior and senior nurses.
Furthermore, only 24.7% of the respondents reported that they have attended training in performing disclosure. However, most of the respondents (93.2%) are willing to participate in training for disclosure and in order for them to be better equipped (92.1%) to handle such situations.
This study has also identified the concerns of the nursing staff in performing disclosure of adverse events to the patient of their family as indicated in Table 2. These concerns and fears are also reported in various studies [1,2,[5][6][7] and it allows the organisation to include them as part of the training curriculum. This increased awareness has also lead to a change in attitude and also lessen the fears and concerns in performing disclosure of adverse events [7].
There is an urgent need to reassure staff that disclosure of adverse events also serves as a form of closure to the staff concerned. It is often beneficial for the staff concerned to verbalise their thoughts of the incident instead. This will allow both the staff and the organisation to learn from the event and put in place preventive measures to prevent future occurrence of similar events [8].
The hospital has thus taken proactive steps to put in place a program to educate staff at all levels (including medical and allied health workers) in the area of disclosure. These programs cover the areas of identifying situations where disclosure are needed, who shall conduct these disclosures and also how to actually conduct one.
This will serve to arm our staff with the ability to effectively engage, empathise with and disclose an adverse event to the patient and their family. While it may be difficult for frontline staff to immediately explain why an incident happened and the reasons behind it, it will put the patient and their family at ease if the frontline staff are able to meaningfully engage, empathise and reassure the patient and their family that the organisation will look into the event before more details are communicated to them in a timely manner subsequently.
There is also an urgent need to educate the public, the medical and legal fraternity that disclosure after an adverse event is a huge step forward for improvement of the overall care. The fact that expression of regret does not always equate admission of liability must be emphasises [2].  In addition to training and education to allay concerns of performing disclosure, the organisation has also established policy to be proactive in performing disclosure to the patient and their family when an adverse event occurs. The policy also encompasses support for the staff involved to ensure that peer and emotional support are given to the staff concerned. This will send the right signal to the staff that the organisation supports this initiative and will also ensure the well-being of the staff is not neglected for the sake of patient satisfaction. They are in fact equally important to ensure the success of the organisation. This will help inculcate the value system within the organisation and also build up trust between the patients, the staff and the healthcare organisation.

Conclusion
The long-term progress of the healthcare environment can only benefit when it is conducted in an open and honest way. The need to educate the healthcare providers on the disclosure of adverse events must move in tandem with the concurrent progress in the education of the public and the legal structures to ensure that the society at large benefit from this progress.

New Knowledge Added by the Study
Despite recent development and reassurances health care staff remains uncomfortable with performing disclosure of adverse events.