Patient safety events (PSEs), such as errors, adverse events, and unanticipated outcomes, are identified as a leading cause of death in the United States (James, 2013). Approximately 70% of the root causes of PSEs are related to failures in communication (Zhani, 2015). Thus, a considerable amount of research has focused on improving communication processes about PSEs (Gallagher, Garbutt, et al., 2006; Gallagher, Waterman, et al., 2006). Although this research has led to some improvements in the clinical setting, existing research on PSE communication has yet to result in an overall transformation—or enhancement—of nurses' leadership role in this communication process.
The communication process in nursing homes (NHs) differs considerably from that in the acute care setting, where physicians lead the communication process generally to the exclusion of nurses (Shannon, Foglia, Hardy, & Gallagher, 2009). In NHs, residents' (the terminology used to refer to clients or patients in this setting) providers (physician, physician's assistant, or nurse practitioner) are often not present during their day-to-day care. Because licensed nurses (i.e., RNs and licensed practical/vocational nurses [LPN/LVNs]) provide the majority of health care services, these professionals are often the individuals communicating PSEs (Wagner, Harkness, Hébert, & Gallagher, 2012, 2013).
In NHs, caring for residents with complex care needs increases the chance of an error or preventable adverse event. Despite best efforts to ensure safety, adverse events and errors are a common occurrence and an inevitable part of nursing care (Hughes, 2008). Examples of common PSEs in NHs include medication errors, falls, pressure ulcers, skin tears, and abuse. Communicating such events can be challenging for nurses, and there is little research available on nurses' role in this type of communication. One study surveyed 1,180 nurses and found that RNs who had higher levels of nursing education and greater prior experience with disclosing errors, as compared with LPNs/LVNs, were more likely to disclose more information regarding a hypothetical PSE. In most cases, nurses' communication offered limited details about the cause of the event and how it would be prevented in the future. Overall, apologies were only offered one half of the time when a medication error was involved. Approximately two thirds of respondents stated they were interested in receiving further education on how to improve their communication of PSEs (Wagner et al., 2012, 2013).
Researchers have tested interventions and identified key components necessary for successfully disclosing PSEs to patients and family members. These components include: fully open, empathic, and apologetic communication between providers and families/patients; follow up for learning opportunities; and support systems in place for families and staff. To date, no study has focused on empowering nurses in communicating these components of PSEs in NHs. Educating nurses working in NHs is crucial for patient safety, as NH residents are particularly vulnerable to errors and adverse events due to their complex physical and mental health care needs as well as challenges endemic to NHs, including staffing shortages, frequent turnover, and poor safety culture (Kapp, 2003).
Therefore, the purpose of the current research was to test an intervention aimed at educating nurses who work in NH settings to improve their communication of PSEs to NH residents and family members. This study aimed to examine whether nurses' knowledge and execution of the communication process improved as a result of the education.
Study Design and Sample
The current study used a mixed-methods quasi-experimental research design. Using a convenience sampling approach, six San Francisco Bay Area NHs served as the research setting. Extraneous variables were controlled through study design, including maximizing external validity by selecting NHs representative of the industry (e.g., profit status, bed size). The sample of participants across all sites was a convenience sample of RNs and LVNs who volunteered their time. Nurses were provided the opportunity to be released from their work duties for all research activities.
Instruments and Measures
Anticipate, Listen, Empathize, Explain, Follow-up Tool. The Situation-Background-Assessment-Recommendation (SBAR) tool is now widely used as a structured care process for communicating PSEs between health care providers (Renz, Boltz, Capezuti, & Wagner, 2015). The SBAR tool serves as an analogue to the Anticipate, Listen, Empathize, Explain, Follow-up (ALEEF) tool introduced in the current study, which provides guidance for nurses in communicating PSEs to residents/family members. The ALEEF tool is a communication framework included in the Disclosing Unanticipated Medication Outcomes (DUMO) workshop designed by the Institute for Healthcare Communication (n.d.) and was modified with permission. A copy of the ALEEF tool, as well as a description of each step and example communication phrases, can be found in the Figure. The principal investigator (PI; L.M.W.) modified the existing tool language through key informant interviews with staff nurses at one NH (n = 10), research staff (n = 3), and the creators of this structured care process (n = 4). In Round 1 of the revisions, modifications of the tool were made to be consistent with the NH environment (i.e., NH resident instead of patient). In Round 2, the “Follow-Up” category was added, given the importance of this care process as part of the disclosure process (Robinson Wolf & Hughes, 2008). Content validity testing was used to quantify the agreement of audit items among experts. The kappas were >0.80 in both rounds.
Patient safety event communication tool.
Modified with permission from the Institute for Healthcare Communication.
Communicating About Nursing Errors Survey. The Communicating About Nursing Errors (CANE) survey was the primary survey used to collect data in the first five sites. This survey has been tested with >3,000 nurses. Overall, >75% of the sample reported that the survey had adequate clarity (e.g., options easily understood), utility (e.g., likely to elicit candid information), face validity (e.g., questions accurately reflected factors influencing disclosure), and content validity (e.g., degree of gaps in the items in the questionnaire) (Wagner et al., 2012, 2013). The CANE survey takes approximately 10 minutes to complete.
Participants completed the paper-based survey pre- and post-intervention. The survey consisted of two parts: (a) background information (e.g., type of nurse, employment position); and (b) a hypothetical clinical scenario involving a medication error, in which a nurse gives the resident a one-time dose of Vitamin C instead of Vitamin K to correct an elevated international normalized ratio, to evaluate how he/she would communicate the PSE.
The hypothetical scenario included 11 options in two sections. The first section, concerning nurses' own perceptions of the PSE, included six questions with Likert-level responses about the type of situation, their responsibility, how upset they would be, the concern for their reputation, the likelihood they would be reprimanded, and how likely they would disclose the event to the resident/family. The second section, concerning how nurses would communicate the PSE to the resident/family, included five questions about what they would say about what happened, the amount of detail provided, a discussion regarding prevention of a future similar PSE, expression of an apology, and the cause of the event (Gallagher, Garbutt, et al., 2006; Gallagher, Waterman, et al., 2006). These five questions included a response, corresponding to one of three hypothetical Likert-level options: not communicating the PSE, partially communicating the PSE, or fully communicating the PSE.
To ensure confidentiality, the research team kept track of participants' pre- and post-responses using the same number. Individual responses were not shared with the NH administration.
The study received ethics approval from the University of California San Francisco Human Research Protection Program. The COMmunicating about Resident ADverse Events (COMRADE) intervention was based on evidence-based disclosure programs (Gallagher et al., 2015), and is theoretically guided by the Conceptual Model for Disclosure of Medical Errors (Fein et al., 2005) framework. This framework purports that there are four main factors impacting disclosure: (a) error factors (e.g., error severity); (b) NH resident factors (e.g., presence of cognitive impairment); (c) provider/nurse factors (e.g., level of training); and (d) institutional culture (e.g., punitive response to PSEs). These factors, and a discussion about their impact on communicating PSEs, were included in the education. To gauge feasibility and timing of the intervention as well as face validity, the COMRADE intervention was piloted with nine graduate nurse practitioner and clinical nurse specialist students with current or prior clinical experience as an RN or LVN in NHs. After pilot testing was completed, nursing staff (RNs and LVNs) at all six NHs completed the COMRADE education. The COMRADE intervention included two separate 30-minute workshops, occurring within 1 week of each other. The total education time of 1 hour was the result of negotiation with NH administration, based on nurses' limited opportunities to be “off the unit” for a staff education activity.
The first 30-minute session focused on the significance and research supporting PSE communication as well as the importance of the four factors impacting error communication. During the second session, participants were introduced to the ALEEF tool. Participants discussed two hypothetical PSEs common in NH settings. The first scenario was of a resident who had recently fallen and was transported to the hospital for a suspected hip fracture. In this scenario, participants watched a short video clip of a nurse actor communicating with the daughter about her father's transport to the emergency department. Participants were then asked to discuss as a group about how the communication process did (or did not) follow the ALEEF format. The second scenario included an older adult resident who was recently found to have a pressure ulcer. Participants were paired up, with one nurse playing the role of the family member and the other playing the role of the nurse communicating about the pressure ulcer to the family member using the ALEEF format. During this scenario, educators and observers from the study team observed the scenario and provided feedback to participants on how they followed the ALEEF format. Participants then switched roles.
As part of the treatment fidelity plan, during the COMRADE intervention, trained research staff observed participant dyads and completed an intervention delivery checklist during each of the pressure ulcer scenario role plays (Resnick et al., 2005). The purpose of this observation was to strengthen internal validity during all education sessions and to ensure points of the ALEEF format were covered in the role play. Participants were provided a copy of the ALEEF form to guide the simulated conversation. Treatment fidelity was further maximized by ensuring the intervention time and content during the COMRADE intervention was the same for each session.
A decision was made midway through the study period to further assess treatment fidelity. A sixth nursing facility was engaged in the final phase to measure whether the intervention had an impact on nurses' communication of a PSE. In the sixth facility, quantitative (e.g., frequency of empathic statements) and qualitative (e.g., statements from participants) measurements were sought regarding how a simulated PSE communication would occur. The pre- and post-intervention CANE survey was not completed at this site to minimize participant burden. Nurses participated in a pre-COMRADE role-play simulation involving a resident fall situation. A trained research assistant/nurse practitioner student (J.K.) played the part of the family member in all role plays. Internal validity was supported in that the research assistant followed a script and was trained in how to respond based on the participant's response. Within 1 week, participants received the same two sessions of the COMRADE intervention and role-playing exercises as the prior five sites. One week following the intervention training, nurses participated in the same resident fall role-play simulation as they did pre-intervention.
Data analysis was achieved through use of SPSS (version 21). Descriptive statistics (e.g., nurse and facility characteristics) were analyzed on all background data. Information detailing type of nurse (i.e., RN or LVN) and employment position were collected about each participant. Nurse characteristics were not collected at the sixth site. The Wilcoxon signed-rank sum test was used to compare pre–post COMRADE education responses to each of the 11 items in the hypothetical Vitamin K scenario in the survey.
To analyze role play simulation data from the sixth site, the simulated PSE communications were audiore-corded, transcribed, and analyzed. A research assistant (H.D.P.) blinded to timing (e.g., pre or post) independently reviewed each recording and transcribed, coded, and analyzed the data. The research team conducted qualitative analysis of the participant interview role plays. Qualitative content analysis of the simulated interview role plays was guided by methods described by Berg and Lune (2011). The blinded research assistant used the ALEEF format to structure data analysis coding by placing participant responses into their corresponding categories. Coding checks were conducted by the PI to ensure the data were coded consistently. Once the phrases were coded, they were quantified (e.g., number of empathic statements).
Responses to Hypothetical Scenario (Sites 1–5)
A total of 77 nurses participated in the COMRADE education and completed the survey in Sites 1–5. Among the 77 nurses, years of nursing experience ranged from 0 to 44 years, with a median of 4 years. A summary of demographic findings is presented in the Table.
Participant and Nursing Home Site Characteristics
In general, respondents felt extremely responsible if they were the nurse committing the error, and would be extremely upset and concerned about getting reprimanded and damaging their reputation. However, using the Wilcoxon signed-rank sum test, no statistical change was found in participant responses from pre- to post-intervention with the hypothetical Vitamin K medication error scenario regarding nurses' own perceptions of their level of responsibility (Z = −1.61, p = 0.11); how upset they would be (Z = −0.02; p = 0.98); the concern for their reputation (Z = −1.81; p = 0.71); the likelihood of being reprimanded (Z = −0.19; p = 0.851); and the likelihood they would communicate the event (Z = −0.62; p = 0.53).
In terms of what nurses would say and the level of detail they would provide about the error, participants favored fully disclosing the PSE and the level of detail they provided, yet there were no statistically significant improvements from pre- to post-intervention. The impact of the COMRADE education on stating an apology or expression of empathy was mixed and not significant, with nine participants improving (i.e., more apologetic/empathic) in the post-test and seven participants downgrading their response with less apology/empathy in the post-test (Z = 0.000; p = 1.00). There were, however, significantly more nurses favoring full disclosure in the post-test with regard to what they would say about what happened (Z = −2.29; p = 0.02), the cause (Z = −2.52; p = 0.01), and how the PSE could be prevented in the future (Z = −3.51; p = 0.001). (Full details of pre- and post-results are available from the authors.)
Interview Role Play (Site 6)
An additional 11 nurses participated in the education at Site 6. In the sixth NH, a total of 20 interview role plays were completed among 11 participants. Nine participants completed both the pre- and post-intervention role plays. Data from two participants who did not complete the post-intervention role play are not included in the results. The average time for each pre-interview role play was 3 minutes and 47 seconds. The average time for each post-interview role play was 3 minutes and 56 seconds. Most nurses said they were “very confident” regarding their communication skills when talking to family members. When asked to rate this numerically, participants reported their average level of confidence when talking to family members about PSEs was 9 of 10. Three nurses also noted that their confidence levels “depend on the family I am speaking with.”
Using the ALEEF framework (Figure) to guide the data analysis and coding of the 18 role plays, all participants used clear and understandable language. The topic of conversation was clearly outlined and no language barriers were present. It was difficult to assess how nurses anticipated the resident/family member's thoughts and feelings and adjusted their behavior, as nurses were not asked to verbalize this to keep the conversation as realistic as possible. Thus, data are not available on this step.
Regarding listening, the analyst determined that nurses did not provide time for pauses after the family member spoke, as nurses began explaining right away. Only six participants allowed pauses before explaining. Of these six participants, two participants allowed pauses during the pre-education assessment and four participants allowed pauses during the post-COMRADE education. One nurse asked in the post-interview role play, “How can I be most helpful?” None of the participants summarized what the family member said to ensure understanding.
Although nurses explained the situation clearly and succinctly, they did not offer expressions of empathy at the pre-test. In the post-COMRADE role plays, nurses who used empathic statements were able to empathize without becoming defensive. Seven statements of empathy were expressed in the post-COMRADE intervention recording session. One of the example statements noted was “I understand your point and I'm sorry this happened.” Many of the nurses said, “I'm sorry this occurred” but were not apologetic or empathic with regard to painful emotions that might be felt by the family member. Of the 12 “I'm sorry statements,” four were from pre-interview role plays and eight occurred after the post-COMRADE interview role plays.
Among all participants, only two nurses asked permission to explain what happened in the post-education interview role play. For example, one nurse stated, “Would you like me to describe what happened?” Other nurses explained the situation fully but without first asking if the recipient was ready to receive the information. Analysis revealed that the nurses' tone and explanations were “mechanical or robotic.” Eleven participants blamed the resident for not using the call light. Statements included, “The resident did not use his call light.”
In pre- and post-COMRADE intervention role plays, nurses (n = 16) indicated that the follow-up plan would be to “continue to monitor the resident,” “monitor the resident more closely,” or to “remind the resident to use the call light.” Although this is an appropriate follow-up plan, it lacks specificity as well as an identifiable time frame. One nurse suggested in the post-role play simulation to have a meeting with the family member and resident to discuss any barriers to using the call light. This plan was specific and personalized to the family.
The analysis also indicated that nurses often used medical jargon when talking with family members throughout the PSE communication. In the majority of interview role plays (n = 13), medical terminology, as opposed to empathic statements, dominated the interaction. Examples of this terminology are “the resident is alert and oriented,” “a neuro check was completed,” “full assessment was completed,” and “the resident denies pain.”
To the current authors' knowledge, no other studies have tested the communication of PSEs in NH settings. The findings of the current study demonstrate the need to provide nurses with opportunities to further improve their communication when a PSE occurs. One of the most notable findings from the audiorecorded PSE communication simulations at the sixth site was that nurses increased their number of empathic and “I'm sorry” statements when communicating with the family member actor following the COMRADE intervention. Although no statistically significant changes were found in nurses' own perceptions to hypothetical scenarios as a result of the intervention, this research revealed important findings. There were significant improvements following the intervention, with more nurses fully disclosing what they would say about what happened, the cause of the event, and how it would be prevented in the future. Most nurses favored fully disclosing the hypothetical scenario except in the case of the apology, for which most participants chose the partial disclosure option (i.e., “I am sorry about what happened” as opposed to “I am sorry you were given the wrong medication”).
The ALEEF model was found to have an effect on the research by restructuring nurses' communication process with residents/family members—to explain after the nurse has listened to the resident about what happened and empathizes about the situation. Although empathy is an essential prerequisite for nursing practice, the literature suggests that nurses lose their ability to express empathic communication in favor of task-centered communication (McCabe, 2004).
Although there are numerous models available on how to communicate PSEs (Gallagher et al., 2015; Institute for Healthcare Communication, n.d.), their focus has not been on nurses' roles and they have not been conducted in a NH setting, which makes it difficult to compare findings. Thus, the current study provides a first step toward empowering nurses to lead in a setting where they provide care to frail older adults on a daily basis. This education is congruent with the Institute of Medicine's (2010) Future of Nursing recommendations aimed at expanding opportunities for nurses to lead (Recommendation 2) as well as to prepare and enable nurses to lead change (Recommendation 7). Given that one principal way to influence quality and safety is through leadership, nurse leaders need to provide their employees with the knowledge, skill, and attitudes to lead and communicate PSEs to their patients and families (Cronenwett et al., 2009).
Several areas for improving PSE communication were identified. Teaching nurses about the importance of listening to NH residents/families and allowing time for pauses and reflection during a conversation are critical pieces of the PSE communication process. As reported in the current study, in many cases, nurses responded to family members in a “mechanical” or “robotic” tone rather than one that flowed naturally between the nurse and resident/family. This finding is supported in other research (Tober & Raistrick, 2014).
The current research also found that nurses were provided numerous opportunities to improve their explanation of the PSE. First, nurses included a statement of blaming the resident for the cause of his/her fall in their explanation. Although it may be the case that the resident did not “use the call light” in the hypothetical scenario, nursing staff, administrators, and families all need to work together to move away from the “blame and shame” response to PSEs, as identified in other studies (Robinson Wolf & Hughes, 2008). Rather, instilling a culture of safety (Castle, Wagner, Ferguson, & Handler, 2011; Castle, Wagner, Perera, Ferguson, & Handler, 2010; Castle, Wagner, Sonon, & Ferguson-Rome, 2012; Wagner, Capezuti, & Rice 2009; Wagner, McDonald, & Castle, 2012) in high-risk health care environments that is blame-free for all stakeholders, including residents, will help encourage collaboration and commitment to address the root causes of PSEs.
Furthermore, nurses included numerous statements that were not considerate of the family member's level of health literacy. Medical jargon may not resonate with family members, as only an average of 3% of older adults have a proficient level of health literacy (U.S. Department of Education, 2006). Although the statements by nurses are appropriate in communicating with other health care professionals, they may not convey tangible or meaningful information to a family member with low health literacy. During debriefing sessions with nursing staff after the completion of the COMRADE intervention, and compared to prior research (Wagner, Damianakis, Pho, & Tourangeau, 2013; Wagner et al., 2012, 2013), staff nurses reported they do not participate in leading the communication of more serious PSEs (e.g., involving harm). This communication is often left to the nurse manager, director of nursing, or administration/risk management personnel. Given the lack of interventional research studies examining the role of nurses in the PSE communication process, an implication of the current study is to implement a teaching strategy by including the substantive role the ALEEF model can play in structuring the PSE communication process with staff nurses as the key recipients of this education.
Although the external validity was a strength and the participating NHs were representative of the market, the researchers were challenged to change nurses' communication process given the time constraints. The researchers were only provided two 30-minute sessions to conduct the intervention, yet this means the study was ecologically valid. The issues of time constraints are compounded by the ability to draw conclusions based on a 3- to 4-minute interview role play. Further, it was assumed that individuals were starting in the same place with regard to communication and the same strength would result in a change in behavior. Because this research was conducted in a simulated environment, how nurse participants' performance in a simulation would transfer to the actual clinical setting was unable to be assessed (Ironside, Jeffries, & Martin, 2009). Future research could engage nurses subsequent to the COMRADE intervention to compare nurse and resident/family's satisfaction of actual PSE communication events following the education. Future intervention trials also must factor in the needed sample and effect size to quantitatively measure the difference necessary between groups to establish statistical significance.
The current study—the first to test the process of PSE communication among nurses—highlights the value of nursing contributions to safety and quality as well as factors that can improve the quality of care nurses provide. The ALEEF framework provides a structure to teach gerontological nurses about a communication process essential to their leadership role in further improving the culture of safety in NH care.
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Participant and Nursing Home Site Characteristics
|Type of nurse (N = 77; Sites 1–5)|
| LVN||27 (35.1)|
| RN||30 (39)|
| Preferred not to respond||20 (26)|
|Employment position (N = 77; Sites 1–5)|
| Staff nurse||46 (59.7)|
| Nurse manager||11 (14.3)|
| Other||9 (11.7)|
| Preferred not to respond||11 (14.3)|
|Nursing home (N = 88; Sites 1–6)|
| Site 1 (rural for-profit center)||32 (36.4)|
| Site 2 (suburban for-profit center)||9 (10.2)|
| Site 3 (urban non-profit center)||20 (22.3)|
| Site 4 (rural for-profit center)||6 (6.8)|
| Site 5 (suburban non-profit center)||10 (11.4)|
| Site 6 (urban non-profit center)||11 (12.5)|