HEALTHCARE POLICY

Healthcare Policy April 2024

Research Paper

Disclosure of Harm: A Qualitative Study of Nurses'

Experiences in Long-Term Care Facilities
Hoang Nam Vo, Hassan Buzdar and Taranpreet Singh

ABSTRACT
Introduction: Despite extensive research on healthcare delivery, there remains a significant gap in
understanding nurses' experiences with harm disclosure in long-term care facilities, particularly in Alberta,
Canada. This study aims to address this gap by qualitatively exploring nurses' perspectives on harm disclosure,
including challenges, coping strategies, and systemic influences.

Methods: A hermeneutic phenomenological approach was adopted to interpret the narratives and experiences
of nurses regarding harm disclosure in long-term care settings. Semi-structured interviews were conducted
with nurses working in Alberta's long-term care facilities, employing snowball and purposive sampling
methods to ensure diversity in the participant sample.

Findings: Analysis of the interviews revealed several key themes. Firstly, nurses highlighted the importance of
education and training in navigating harm disclosure effectively, emphasizing the need for formalized
interventions to enhance nurses' knowledge, skills, and confidence in engaging in transparent communication
with patients and families. Additionally, the study underscored the critical role of organizational culture and
leadership support in shaping nurses' experiences with harm disclosure, with supportive environments
facilitating open communication and patient-centered care.

Conclusion: The findings of this study contribute to a deeper understanding of harm disclosure practices in
long-term care settings and have implications for policy and practice. By addressing the educational needs of
nurses and fostering supportive organizational cultures, healthcare organizations can enhance patient safety
and satisfaction. Moreover, this research highlights the importance of ongoing inquiry to further strengthen
harm disclosure practices and promote a culture of safety and accountability within healthcare settings.

INTRODUCTION
In the realm of healthcare, the growing senior population in Canada poses significant challenges and
opportunities for long-term care facilities. According to Statistics Canada (2022), seniors currently constitute
nearly one-fifth (18.9%) of the population, a proportion expected to increase to almost one-quarter (24.8%)
within the next two decades. This demographic shift underscores an escalating demand for long-term care
services, pressing the need for robust and responsive healthcare systems capable of managing the complex
needs of an aging population.

In Alberta, the staffing ratios in long-term care facilities highlight the scale of care provision, with an average
of 92 residents per registered nurse (RN), 33 residents per licensed practical nurse (LPN), and 8 residents per
health care aide (HCA) during any given shift (Slaughter et al., 2018). Such ratios present considerable
challenges in maintaining high-quality care and ensuring the safety and well-being of residents.

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Disclosure, defined by the Health Quality Council of Alberta (HQCA, 2023) as the open discussion with a
patient and identified support person(s) about harm incidents or near-miss incidents, plays a crucial role in
maintaining trust and confidence in healthcare environments. Despite the best efforts and commitment of
healthcare providers, unexpected outcomes and errors can occur. The research underscores that openly and
transparently disclosing such incidents not only enhances patient and family confidence in the healthcare
system but also fosters trust within the patient-provider relationship, which is foundational to effective care
and communication (Heenan et al., 2021).

Moreover, timely and honest disclosure provides an opportunity for healing and learning, promoting a Just
Culture where learning from safety incidents is crucial for enhancing system safety (HQCA, 2022). Yet,
despite its importance, there exists a significant research gap concerning the practices of harm disclosure,
particularly within Alberta’s long-term care facilities. Studies such as those by Heenan & Mulvale (2021)
suggest that more attention needs to be given to exploring how nurses' knowledge, confidence, and
competence in disclosing and reporting practice errors can contribute to organizational learning and the
ongoing improvement of care quality and safety (Kim & Lee, 2020).

This paper aims to qualitatively explore nurses’ experiences in harm disclosure within Alberta's long-term care
settings, seeking to understand their challenges, strategies, and the systemic factors that influence the
disclosure process. By filling this research gap, we can better support nurses in their critical roles and enhance
the overall safety and quality of care provided to one of society's most vulnerable populations.

METHODS

Study design
We adopted a hermeneutic phenomenological approach as described by Fuster Guillen (2019) to interpret and
uncover the underlying meanings embedded in the narratives and experiences of our research participants. This
methodology is particularly suited to explore the nuanced experiences and perceptions that healthcare
providers have regarding harm disclosure in long-term care settings.

Study Phases

Phase 1: Scoping – Literature Review & Stakeholder Interviews

The initial phase of the study involved a comprehensive review of the existing literature, research articles, and
official documents related to harm disclosure within healthcare settings, with a specific focus on long-term
care facilities in Alberta. This review helped identify prevailing policies, guidelines, or regulations governing
harm disclosure and highlighted areas lacking in-depth exploration.

Key stakeholders involved in long-term care across Alberta, including healthcare providers, administrators,
and policymakers, were interviewed or surveyed. These discussions aimed to gather diverse perspectives on
harm disclosure practices, existing policies, challenges encountered in implementation, and educational
initiatives currently in place.

Phase 2: Qualitative Interview

Semi-structured virtual and in-person interviews were conducted with nurses in Alberta’s long-term care
facilities between June 01, 2024 and May 31, 2025. The interviews, ranging from 45 minutes with an average
of 60 minutes, were audio-recorded and transcribed verbatim. Each interview followed a flexible format,

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allowing for open-ended exploration of participants' experiences with harm disclosure policies, including their
navigation and implementation within long-term care settings.

Study Sample & Recruitment

The study targeted nurses working in long-term care (LTC) facilities across Alberta. We employed both
snowball and purposive sampling methods to recruit participants:

- Snowball Sampling: This technique was utilized to identify participants who were willing to discuss
their experiences with harm disclosure and to leverage their professional networks.
- Purposive Sampling: This method ensured the diversity of the sample by considering factors such as
the positions held by the nurses and their cultural backgrounds (Kirchherr & Charles, 2018).

The inclusion criteria focused on nurses who had been involved in harm disclosure within the last five years.
New nurses currently undergoing orientation were excluded from the study to maintain a focus on experienced
perspectives.

Phase 3: Data analysis

We applied Colaizzi's method to analyze the data, which involves extracting significant statements,
formulating meanings, and organizing these into theme clusters. This analytic process enabled us to delve
deeply into the lived experiences of nurses and uncover the essence of harm disclosure practices in LTC
facilities. The analysis was supported by NVIVO software, which facilitated the organization and management
of the data.

This methodology and design framework aim to provide a profound understanding of harm disclosure in
Alberta's long-term care facilities, contributing valuable insights to the discourse on improving patient safety
and trust in healthcare systems.

EXPECTED FINDINGS & RESULTS

Educational Interventions on Harm Disclosure

Reviewing the literature reveals the potential of curriculum design in addressing the obstacles nurses encounter
in reporting and disclosing harm effectively (Borz-Baba et al., 2020). Educating nurses on harm disclosure is
essential for enhancing their proactive utilization of reporting systems (Tamuz et al., 2004). However, studies
indicate a gap in healthcare practitioners' reporting of harm events, underscoring the necessity of educating
nurses on the significance of near misses and the value of reporting for patient safety improvement (Rowin et
al., 2008).

Surveys also indicate nurses' lack of familiarity with harm disclosure processes, emphasizing the need for
formal education within nursing curricula (Wu et al., 2020). While nurses may express hypothetical familiarity
with harm disclosure, formal training in pre-disclosure planning, content delivery, and message delivery
techniques is lacking (Wu et al., 2020). Addressing the psychological impact of harm disclosure on nurses,
including increased anxiety and decreased confidence, requires the provision of adequate support systems
(Waterman et al., 2007). Additionally, ongoing evaluation of educational interventions is crucial for
continuous improvement and effectiveness.

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Importance of Organizational Culture & Leadership
The literature underscores the significance of open communication and transparency in healthcare, advocating
for a cultural shift towards patient-centered care through harm disclosure education (Birks et al., 2014;
Australian Commission on Safety and Quality in Healthcare, 2003). Nurses who receive comprehensive
training in harm disclosure demonstrate increased confidence and empathy in difficult conversations, leading
to enhanced patient and family satisfaction (Levinson, 2009).

Strong leadership support for transparency initiatives is pivotal in fostering environments where harm
disclosure is valued and practiced (Vaismoradi et al., 2020). Facilities with robust leadership support witness
significant improvements in nurse preparedness and patient trust.

Improving the Quadruple Aim Framework

The qualitative research anticipates findings that will contribute to improving the patient experience, a crucial
component of the Quadruple Aim. By gaining insights into nurses' perspectives on harm disclosure, the study
aims to identify strategies to enhance communication, empathy, and patient-centered care practices. These
insights may lead to the development of interventions aimed at fostering trust, reducing patient distress, and
improving overall satisfaction with healthcare services. Through a deeper understanding of harm disclosure
practices in long-term care settings, the research aims to contribute to improved population health outcomes.
By identifying barriers to effective harm disclosure and exploring interprofessional dynamics, the study may
inform initiatives to enhance care coordination, prevent adverse events, and promote proactive approaches to
patient safety. These efforts have the potential to contribute to better health outcomes for individuals in long-
term care and the broader population.

The study seeks to address the well-being of healthcare providers, a critical aspect of the Quadruple Aim. By
identifying coping mechanisms and organizational factors that impact nurses' experiences with harm
disclosure, the research aims to inform interventions aimed at reducing burnout, stress, and moral distress
among healthcare professionals. Implementing supportive policies, fostering a culture of psychological safety,
and providing resources for emotional resilience can contribute to improving provider well-being and retention
in long-term care settings. By improving harm disclosure practices and promoting a culture of transparency
and learning, the research aims to contribute to the Quadruple Aim's goal of reducing healthcare costs.
Enhanced communication and collaboration among healthcare teams may lead to more efficient processes,
fewer adverse events, and decreased resource utilization associated with litigation and error management.
Moreover, by focusing on preventive strategies and patient safety initiatives, the study may contribute to long-
term cost savings by mitigating the financial burden of avoidable harm incidents (Bodenheimer & Sinsky,
2014).

Research Gaps and Future Directions

While existing literature offers valuable insights into harm disclosure programs, gaps persist in understanding
long-term effects on patient trust and litigation rates (Kalra et al., 2013). Moreover, few studies address the
unique challenges encountered in long-term care settings, such as cognitive impairment and care continuity
complexities (Kim & Lee, 2020). These gaps underscore the need for further research and highlight the
importance of tailoring harm disclosure education to the specific needs of long-term care populations.

DISCUSSION

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The qualitative exploration of nurses' experiences in harm disclosure within Alberta's long-term care facilities
provides valuable insights into a critical aspect of healthcare delivery. By delving into the lived experiences of
nurses, the study offers a comprehensive understanding of the challenges, coping mechanisms, and systemic
factors influencing the disclosure process. One significant aspect highlighted by the research is the importance
of education and training for nurses in navigating harm disclosure effectively. The findings underscore the
necessity of formalized educational interventions to equip nurses with the knowledge, skills, and confidence
needed to engage in transparent communication with patients and families about adverse events.

Furthermore, the study emphasizes the pivotal role of organizational culture and leadership support in fostering
environments conducive to open communication and patient-centered care. Nurses' experiences with harm
disclosure are intricately tied to the organizational context in which they operate, with supportive leadership
playing a crucial role in shaping their ability to navigate challenging conversations and advocate for patient
safety. By identifying barriers to effective harm disclosure and exploring strategies for organizational
improvement, the research lays the groundwork for policy and practice interventions aimed at enhancing
patient safety and quality of care in long-term care settings.

The study also raises important considerations for future research and practice. While the findings provide
valuable insights into nurses' experiences with harm disclosure, there remain gaps in understanding the long-
term effects of disclosure on patient trust, litigation rates, and healthcare outcomes. Additionally, the unique
challenges encountered in long-term care settings, such as dealing with cognitive impairment and ensuring care
continuity, warrant further exploration. By acknowledging these gaps and advocating for continued inquiry,
the research sets the stage for ongoing efforts to strengthen harm disclosure practices and promote a culture of
safety and accountability within healthcare organizations.

CONCLUSIONS
In conclusion, this qualitative study sheds light on the experiences of nurses regarding harm disclosure in
Alberta's long-term care facilities. The findings underscore the importance of educational interventions and
organizational support in fostering transparent communication and patient-centered care. By addressing the
psychological impact of harm disclosure and enhancing nurses' confidence and competence in navigating
disclosure processes, healthcare organizations can improve patient safety and satisfaction.

About the Author(s)

Hoang Nam Vo, MD, School of Health and Public Safety, Southern Alberta Institute of Technology (SAIT),
Calgary, AB

Hassan Buzdar, MD, School of Health and Public Safety, Southern Alberta Institute of Technology (SAIT),
Calgary, AB

Taranpreet Singh, PharmD, School of Health and Public Safety, Southern Alberta Institute of Technology
(SAIT), Calgary, AB

Acknowledgment
The authors acknowledge the support of the Health Quality Council of Alberta (HQCA) and the Southern
Alberta Institute of Technology (SAIT). We also thank our stakeholders, instructors, and mentors for their
continuous comments on the draft of this paper.

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