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Journal of Nursing Care Quality:
doi: 10.1097/NCQ.0b013e31822abf81

Not Overstepping Professional Boundaries: The Challenging Role of Nurses in Simulated Error Disclosures

Jeffs, Lianne PhD, RN; Espin, Sherry PhD, RN; Rorabeck, Lisa BA; Shannon, Sarah E. PhD, RN; Robins, Lynne PhD; Levinson, Wendy MD; Gallagher, Thomas H. MD; Gladkova, Olga PhD; Lingard, Lorelei PhD

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Author Information

St. Michael's Hospital (Dr Jeffs) and Daphne Cockwell School of Nursing, Ryerson University, (Dr Espin, Ms Rorabeck and Dr Gladkova), Toronto, Ontario, Canada; Biobehavioral Nursing and Health Systems, University of Washington, Seattle (Dr Shannon) and Department of Medical Education, University of Washington (Dr Robins), Seattle; Department of Medicine, University of Toronto (Dr Levinson), Toronto, Ontario, Canada; Division of General Internal Medicine, University of Washington (Dr Gallagher), Seattle; and The Centre for Education Research and Innovation at the Schulich School of Medicine & Dentistry, University of Western Ontario (Dr Lingard), London, Ontario, Canada.

Correspondence: Lianne Jeffs, PhD, RN St. Michael's Hospital, Room 5-060 Bond Wing, 30 Bond St, Toronto, Ontario M5B 1W8, Canada (

Funding was provided for this study by the Canadian Patient Safety Institute Research Competition 2006.

The authors declare no conflict of interest.

Accepted for publication: June 23, 2011.

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This article provides findings on the role of the nurse in simulated team-based error disclosures. Triangulation of 3 qualitative data sets revealed that a tension exists for nurses in the error disclosure process as they attempt to balance professional boundaries. Study findings point to multilevel strategies including cultural, structural, and educational approaches to enhancing the key roles that nurses need to play in error disclosure to patients and families.

DISCLOSING ERRORS to patients and/or family members is a health care issue that has received national attention in the United States with the National Quality Forum's endorsement of disclosure and delineation of standards of safe disclosure practices in 20061 and in Canada with the Canadian Disclosure Guidelines released in 2008.2 Errors in health care are defined as a failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (commission). This definition also includes failure of an unplanned action that should have been completed (omission).3 To date, the majority of research on error disclosure has primarily focused on physicians', patients', and parents' attitudes and experiences.48 However, current error disclosure practices in many hospitals involve other health care professionals in addition to physicians and risk managers.7 For example, a recent study identified that it was common practice for nurses to independently disclose minor nursing errors but found that nurses face challenges when errors are more severe and team-based in nature.9 This same study revealed that nurses reported wanting to be involved in the error disclosure process as both a professional courtesy and to enable them to communicate more honestly with patients about the error that had occurred.9

The lack of participation of nurses and other health care professionals may be a result of limited disclosure training, which renders them unprepared for engaging in difficult conversations with each other and with patients.4,1013 Other barriers to disclosing errors to patients include lack of time, lack of knowledge, and not being sure of what to report to patients.13 Another reason for the lack of nursing participation is that nurses have not been considered key individuals in the disclosure process. This lack of involvement in the error disclosure process presents a tension for nurses because they want to be involved in this process with the patient and/or family members. Moreover, nurses may fear being blamed for the error to the patient if they are not present during the disclosure.13

Although there is a growing literature base on error disclosure,413 an understanding of the experiences and tensions associated with team-based error disclosure is limited. A closer examination of the role of nurses in simulated error disclosures may yield insights that can inform improvements in team communication following errors and disclosure of these events to patients. Over the last decade, the use of simulation has grown because it is a relatively risk free way to learn tasks and enhance competencies.14 A large, mixed methods study was conducted using simulation with teams of nurses and physicians to delineate perceptions and experiences associated with a team-based error disclosure.15 In this article, we describe the benefits and challenges and nurses' perceived roles and responsibilities associated with their participation in team-based disclosure of errors during simulation.

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Design and procedures

The findings presented in this article are derived from a multimethods qualitative approach to exploring the use of simulation as a means to train physicians and nurses to disclose errors as a team. The study was conducted with clinicians from 3 health care organizations (a 550-bed and a 521-bed teaching hospital and a 365-bed community hospital). This article reports results of the analysis of the aggregate data from the interviews of 12 female registered nurses (RNs) with 6 from internal medicine units and 6 from surgical services and discourse analysis of a smaller subset of participants (n = 3). The return of findings involved a sample of 8 nurses from the 3 participating study sites. This latter sample involved nurses who had participated in the simulation study (n = 4) and nurses who had not participated in it (n = 4). This sampling strategy was selected to ensure that the emergent themes resonated with those who participated in the study as well as with nurses who work on the same units but did not participate in it.

The simulation intervention was developed on the basis of error scenarios in which participants were in teams composed of either a general internist or surgeon and a RN. Error scenarios included 2 surgical cases (lost specimen and retained sponge) and medication cases (insulin and enoxaparin [Lovenox] overdose). The scenarios were developed to represent different types of error events, varying participants in the scenarios, and a range of team-based errors rather than individual profession specific errors. The scenario-based methodology allowed for the prompting of discussion on a case to capture diverging perceptions, reactions, and roles. For the purposes of this study, a root cause analysis of the error events did not factor into this study design. Planning in the prediscussion focused on the disclosure to the patient of the error event. The scenarios are described elsewhere.15 There was a 4-step process for the simulation exercise, which involved the following: (1) team discussion of the error case (nature of the error); (2) team planning of the disclosure process (whether and how the error should be disclosed); (3) disclosure conversation (disclosure of error to a standardized patient); and (4) team briefing with disclosure coach. The disclosure coaches from all 3 sites were staff from the quality and risk departments at the hospital who had expertise and experience in disclosing errors to patients and family members. The simulated disclosure process was then repeated with a second case study. The simulation process ranged between 45 minutes and 1 hour in length.

The study received ethics approval from the institutional research boards of the participating hospitals and at an academic institution in Toronto, Ontario, Canada. Informed consent was obtained from study participants, and data are presented in aggregate form with no identifying information of participants.

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Semistructured interview methods

Semistructured individual interviews were conducted with 12 nurses following their participation in the team-based simulation intervention. Participants were asked a series of open-ended questions focusing on their perceptions of discussion of the error and team-based disclosure to the standardized patient. Interviews were tape-recorded and transcribed. Data were analyzed initially independently followed by consensus using a content analysis approach that identified codes and categories leading to emergent themes through saturation.16,17 NVIVO (QSR International Inc., Cambridge, MA) software was used to explore the relationship across themes and verify the final coding schema.

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Discourse analysis methods

Discourse analysis with elements of rhetorical criticism was used for the taped simulated team-based disclosures along with the pre- and postdisclosure discussions. Discourse analysis explores how language is used in the social context. Rhetorical criticism seeks to systematically explore how symbols or options act on people to create opportunities for communication. The identification and selection of analytical objects and categories was a result of the investigative team's consultations during a pilot analysis of the taped disclosures. The purpose of the pilot was to identify the salient and relevant features of organization related to the success of communication. At this stage the communicative success was estimated on the basis of the team cohesion and patients' positive feedback during the disclosures. Two researchers reviewed separately 3 disclosures from the full study database that were representative of the typical affective strategies and behaviors in the whole set and varying measures of communicative success for error disclosure. The researchers interpreted and verified emerging analytic generalizations on the basis of their frequency in the text with secondary research data and ethnomethodological evidence from pre- and postdisclosure discussions. In addition, the time in which nurses participated in the actual disclosure process was recorded.

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Return of findings methods

Key findings from the combined interview and discourse analysis datasets were presented to a sample of nurses, some who had participated in the intervention and some who had not. As part of the return of findings, nurses were presented with the following summary statement: Interestingly, our findings revealed nurses often grappled with their position on the team, and in particular their role on the team as the “patient advocate.” These results demonstrated how within the context of team-based disclosure of errors, nursing's roles and the conditions underpinning these roles can create tension for nursing.

After presenting the findings, study parti- cipants were asked to reflect on the findings and were asked the following questions: How do these results resonate with you? What are your thoughts, feelings, and concerns about the apparent disconnect between the nurses' actions (or lack thereof) during the team-based disclosures and during the interview process? Why do you think the nurses participated in such different manners during both stages of the study? This dataset was analyzed by comparing the aggregated responses (same content analysis method described in the semistructured interview method subsection) by the nurses who participated in the return of findings with the emergent themes from the interviews and the narrative analysis of the disclosure process.

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Key themes that emerged through triangulation of the 3 data sources (interviews, observation, and return of findings) to describe how nurses perceived their role and how their role was enacted in the simulated team-based error disclosures. The key themes that emerged are sharing responsibility for the error disclosure process, having a secondary role in the error disclosure process, and balancing professional boundaries during this process.

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Sharing responsibility in error disclosure process

Nurses described the need for patients to hear from all members of the team involved in the patient's error. The majority of nurses believed that sharing the task and responsibility of the disclosure and taking a team approach to disclosure were beneficial. Many nurses also believed that including multiple perceptions of those involved in the error as part of the disclosure was advantageous. Moreover, nurses suggested that discussing the error as a team prior to speaking to the patient ensured that everyone knew in advance what would be said. For example, a medical nurse explained: “Just being on the same page, I could not imagine going into that situation without having a little bit of a team discussion.”

When nurses participated in the error disclosure, they primarily would participate in the apology and make attempts to repair the situation. Repairing the situation involved one or a combination of the following actions: acknowledging an explicit apology and providing emotional support including offering support/resources. Nurses were observed to provide either the initial apology or second apology after the physician. The following is an excerpt from a surgical nurse during the disclosure: “I'm so sorry this has happened Mrs. D. It's my job to look after you when you're in the operating room, along with Dr. A, and I apologize that this has happened.”

When repairing the situation, nurses provided emotional support to the patient, empathizing with patients by conveying they understood the patient's fear and offered to help to make the patient feel better. As part of providing emotional support to patients, nurses also expressed feelings of guilt and informed the patient that efforts were being made to ensure this error would not occur again. One nurse said: “We are looking at changing some policies and making sure this doesn't happen again.”

Part of the support provided to the patient during the simulation exercise included offering to contact family members and link the patients with services and resources available to them in the hospital (eg, quality and risk, social work). The following excerpt from the observation illustrates this type of repair:

First, I want to start off, I want to get your weight to make sure we get you on the proper medication, and if I can offer a social worker, as you said you've got some legal problems, she can look into that, and she can help you from there. Do you have any questions about that?

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Having a secondary role in the error disclosure process

Although nurses reported the value of participating in the error disclosure process, many also described having a secondary role in the actual disclosure to the patient. The following 2 narratives illustrate this theme:

I would have no problem going there and participating fully, but I would take the secondary role, the leading role would still be Dr X and I would be the support to him if he needed me. We are the team players, but we are support to his case. So if he needed us more, he would have us. But I let him sort of lead the whole scenario because I think that it is appropriate.

Another nurse commented: “We take an active role in pushing for what we believe in is needed behind the scene and during clinician's group discussions but allow physician leadership to discuss issues in front of the patient.”

In some cases, knowing the physician or having worked with a physician before often helped nurses feel more comfortable as they had an established relationship and therefore trusted the physician with their decisions during the disclosure process. Interestingly, for one surgical nurse this trusting relationship was so secure that she let the physician lead the disclosure without her. Analysis also revealed that nurses spoke little in comparison to physicians who often led the conversations. Sometimes these cases went smoothly, with the nurse accompanying the physician during the entire error disclosure though saying little. In other cases, physicians, with the team's concurrence, began the error disclosure process individually and then brought the team in later. The nurses also spoke later (waiting until the 5th minute on average) of the disclosure to the standardized patient.

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Balancing professional boundaries during the error disclosure process

Many of the nurses described having difficulty in knowing what their role was supposed to be within the disclosure process. Moreover, they did not want to overstep their boundaries when collaborating with physicians. One nurse explained the need to know her role was to ensure “you are not stepping on peoples' toes and overstepping your boundaries.” Nurses continued to describe the difficulty in not being able to frame their contributions during the disclosure and ensuing frustration this caused during the disclosure process. This frustration stemmed from nurses wanting to participate in the disclosure to express regret for the error and that they had learned from being involved in the error. As one surgical nurse commented:

...because a lot relies on the human being and humans make errors, there are going to be long as you learn from them...dissecting what happened and where it went wrong.

In summary, the triangulation of data revealed a tension between what nurses described in the interviews and how this role was observed to be enacted in the team-based disclosure simulation. Specifically, many nurses described the importance of being involved in the team-based error disclosure and played an active role during the planning discussion. However, during the actual disclosure, many nurses displayed different behaviors, including remaining silent during the disclosure process and taking a secondary role.

Hierarchy and time constraints to be involved in team-based error disclosure also emerged, as one study participant noted: “I have found it challenging to figure out a best time to voice concerns when in the presence of a physician. Often I have found physicians overpower the conversation, they want to get to the point and move on, leaving you with little time to actually advocate patient concerns.”

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Our findings provide insight into the challenging role that nurses encounter when they are part of a team planning and eventually disclosing an error to patients. Having a secondary role and the conflicts experienced by nurses in this study are consistent with other empirical work that explores professional roles and identities in health care1821 and more recently a study exploring nurses role in error disclosure.9 This work suggests that tensions between professional roles within an interprofessional context existed. One explanation for this finding is within social systems professional identities arise in which each profession's role is determined by its position in relation to others. In this study, nurses often reported frustration and distress with not being able to be fully engaged and enact their advocacy role in the disclosure process. In one study, the failure to integrate nurses into the disclosure process created conditions for moral distress for the nurses.9

Our findings also revealed that nurses possessed strong attitudes and feelings toward being active participants in the error disclosure planning and discussion. This finding is similar to what was reported in another study that explored nurses' perceptions associated with error disclosure.9 Specifically, nurses expected physicians to lead the disclosure process, but nurses envisioned a shared approach to error disclosure and welcomed the opportunity to communicate directly to the patient about nursing's role in the event.9 When nurses participated in the error disclosure, they ensured that the patient understood what happened by repairing the disclosure that they perceived was not going well for the patient, offering empathy by apologizing or acknowledging regret for the error, and providing social support and resources to patients. In this study, the ways in which nurses actively engaged in error disclosure to meet patients' information and emotional needs was consistent with other empirical work in nurse advocacy.22,23

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Study findings have important implications for organizational practice, education, and research. Given the mounting evidence that patients and families prefer to have an interprofessional approach to error disclosure4,5 and that a lack of team-based approach may diminish the quality of the disclosure experienced by patients and families,9 the emergent tension of balancing professional boundaries during the error disclosure process requires further attention. Multi-level strategies are needed to address existing hierarchies that are influencing professional identities and perpetuating traditional roles of nursing in the error disclosure process. At a leadership level, nurse executives and managers need to create safe and supportive environments where nurses practice team-based error disclosure.9 This will require ethos and structures that involve new patterns in the organization of professional work in which collaborative interdependence is enacted.18 Inclusion of the role of nurses in disclosure policies is showing promising signs as it provides nurses with the authority to proactively initiate a team approach in the error disclosure process.9

In this study, findings suggest that educational strategies are required to enhance nurses' confidence in participating in the error disclosure process. Nurse leaders need to invest in time for clinical nurses to engage in learning strategies, including participation in simulated exercises similar to what were used in the current study. Through participation in simulated and other learning strategies, the interprofessional team members will gain the confidence required to tackle team-based tensions10,24 to advance more effective error disclosures to patient and families. By incorporating nurses into simulation exercises, other health care team members may realize the complementary role that nurses can have to them in disclosing errors to patients. For example, study findings elucidated a key role that nurses play in providing information and emotional support to patients. Opportunities for nurses to provide these to patients during the disclosure process may result in nurses having confidence to participate actively in it. Furthermore, the emerging themes from this work elucidate the well-understood issues of power and hierarchy that continue to exist within health care teams. Thus, these findings have implications for how nurses and other health care professionals are educated. Specifically opportunity exists for students in formal educational programs to come together and learn as a team during simulation the roles and responsibilities of others in the disclosure process of adverse events.

Given that this study only involved medical and surgical specialties from 1 city in an urban area, study findings may not be transferable to other health care settings. The key themes and tension that emerged from this study need further exploration expanding to other clinical specialties creating different error scenarios that are tested out in a multisite, national study. This exploration also should include a postintervention interview with the health care professionals 3 to 6 months after participation in the intervention. The key aim of this postintervention interview would be to gain insight into how they have engaged in the error disclosure process in their practice setting since their participation in the intervention. Further inquiry should collect data on actual disclosures of error following participation in a team-based disclosure inter-vention.

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This study revealed that nurses perceived their role in team-based error disclosure as secondary and as balancing professional boundaries. When nurses did speak in the error disclosure to the patient, they would most often apologize for the error and make attempts to repair the situation by providing emotional support and resources to the patients. Study findings point to multilevel strategies including cultural, structural, and educational approaches to enhancing the key roles that nurses should have in error disclosure to patients and families. Given this is one of the first studies that explored team-based error disclosure using simulation, more research efforts are required to test a variety of strategies aimed at enhancing interprofessional approaches to error disclosure in different clinical contexts.

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patient safety; simulation; team-based error disclosure

© 2011 Lippincott Williams & Wilkins, Inc.


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