This study examined the relationships among the variables of perception of open disclosure of PSIs, perception of patient safety culture, and ethical awareness in nurses of general hospitals or tertiary hospitals in Korea. Among the participants of this study, 57.6% were staff nurses while 42.5% were nurse managers. Their working units/areas ranged widely, from general wards to special units, and the mean length of nursing career was 11.7 years. Therefore, we were able to recruit a broad spectrum of participants, but there were no differences in the perception of open disclosures of PSIs according to nurses’ general characteristics and work-related characteristics.
The perception of open disclosure of PSIs was positively correlated with ethical awareness. This is similar to previous findings that emphasized the fundamentals and importance of ethics by shedding light on ethically tense situations in the emergency department, which features a high incidence of PSIs and high significance of openly disclosing PSIs . According to Kant’s theory, lying by healthcare professionals is morally unacceptable, and regulations that strictly obligate them to be honest with patients need to be implemented . However, healthcare professionals, including nurses, are faced with ethical dilemmas when practicing open disclosure: they risk litigation, loss of relationship with patient, fear of hurting one’s own reputation, lack of support from the healthcare institution; they lack communication training to conduct effective disclosure . If nurses withhold PSIs, the error will not be addressed; thus, it would be difficult for the concerned parties to improve, and other nurses would likely repeat the same mistake. The perception of open disclosure of PSIs was significantly correlated with the teamwork within units, organizational learning/continuous improvement, overall perceptions of patient safety, and staffing components of the perception of patient safety culture. This is in line with previous results that reported that inadequate staffing, information, and education hinder efforts to improve the perception of PSIs and implement patient safety programs . Therefore, fostering a patient safety culture in healthcare institutions is a pressing matter—it promotes positive perception of open disclosure and helps healthcare professionals to practice it. By acknowledging safety management and patient identification as important factors in preventing PSIs (in accident-prone areas in the course of care), the certification system will impact nurses’ patient safety awareness . If we can institutionalize a system within the hospital to identify the causes of PSIs, we can reduce the recurrence of errors . Moreover, to establish patient safety culture, hospitals must work hard to initiate patient safety management procedures or systems in the ward to secure the necessary evidence for improvement in the event of PSIs. Further, it is also essential to establish regulations and guidelines for open disclosure of PSIs, and to educate and train healthcare professionals. The importance of nursing ethics and patient safety should be continuously emphasized and taught through the nursing undergraduate curriculum. However, in Korea, culture and awareness have not been widely adopted in relation to patient safety cases. Therefore, to raise ethical awareness among nurses and awareness of the patient safety culture in PSIs, it is necessary to continuously provide a culture of education, awareness, and practice of essential ethical values.
Ethical awareness was found to have the most potent impact on the perception of open disclosure of PSIs. Ethical principles such as autonomy, patient's right to know, respect for humanity, transparency, honesty, trust, loyalty, good deeds, and undesirable behavior can be applied to disclosure of PSIs ; thus, as shown in the results of this study, ethical awareness may be closely correlated with perception of open disclosure of PSIs. However, perception of open disclosure of PSIs may not be directly related to the actual intention for disclosure of PSIs. Nurses are aware that acknowledging their mistakes when disclosing nursing error is the right thing to do . However, it has been reported that nurses face the reality of being unable to disclose PSIs due to reasons such as immature patient safety culture, lack of resources for protection and support of disclosure, and events with unknown causes . Especially, honest disclosure is difficult in Korea amid lack of any legal regulations or protection for healthcare professionals in the processing of medical malpractice. That said, as time goes by, hospitals would have to take up the people’s demands for transparency, as did enterprises and the government; concealing or remaining silent about an error or malpractice is becoming increasingly difficult. It has been reported that what patients and caregivers want are explanations for the incident, measures to prevent future incidents, and a sincere apology . It is important to gain the patient’s trust by being truthful and forthcoming in explaining how the hospital will deal with the incident. An explanation is the beginning of crisis management, and providing a thorough explanation in the early stage helps the hospital earn more trust from the patient. Nurses must not be financially punished or be pressed by the management from their honest and ethical disclosure of a PSI. Open disclosure of PSIs could be further normalized only with the enactment of legal safety nets that prohibit the use of healthcare professionals’ apologies against them in court, such as the apology law or disclosure law. The apology law stipulates that any expressions of sympathy, regret, or apology used by a healthcare professional during the disclosure of a PSI is not viewed as an admission of legal responsibility in court ; this law has been enacted in about 30 US states. Such legal systems not only lower the psychological burden of each healthcare professional but also can cultivate more positive views towards open disclosure of PSIs. Further, it is also necessary to initiate open disclosure programs and introduce success stories to healthcare professionals and the public so as to foster a clearer patient safety culture.
The overall perceptions of patient safety and staffing components of perception of patient safety culture were found to have significant effects on the perception of open disclosure of PSIs. This shows the need to improve nurses’ perception of patient safety culture as well as the need for additional staffing [29, 30]. Developed countries, including the United States, argue that it is important to not only improve nurses’ perceptions about patient safety through education about ethical awareness, patient safety, and communication but also improve the organization, implement continuous and systematic accreditation program, and create a safe environment, and these countries have carried out relevant measures . The most important thing is to systematize how healthcare professionals should communicate a PSI and foster an organizational culture that promotes healthcare professionals, including nurses, to effectively communicate with patients and caregivers. Patient safety and the quality of healthcare service are influenced by nursing staffing and quality . Moreover, an inadequate nursing staffing has been reported to cause frequent medication errors and surgical site infections as well as accidents such as bedsores and falls . The International Council of Nurses stressed that providing quality nursing service by securing an appropriate nurse staffing ensures patient safety and health . The number of active nurses per capita is 4.6 per 1,000 population, which substantially falls short of the OECD average of 9.3 per 1,000 population . In addition to expanding nursing staffing, policy support is also needed, such as by reflecting responsibility through salary.
This study has great significance in that there are little studies examining the perception of open disclosure of PSIs among nurses and factors that affect it, and that it administered a survey on nurses in a country that currently lacks an apology law. This study has a few limitations. First, our study population consisted of nurses working in large hospitals such as general hospitals and tertiary hospitals, so our findings cannot explain PSI-related aspects among nurses in small and medium-sized hospitals and thus cannot be generalized. Second, this study is a cross-sectional survey, which limits our ability to clearly describe the causal relationships among the perception of open disclosure of PSIs, ethical awareness, and perception of patient safety culture. Thus, additional qualitative and quantitative studies are needed to substantiate the casual relationships among these factors. Third, Jang’s tool measured ethical awareness, including the contents of nurses' daily duties, responsibilities, and conflict situations. In Milliken's research, ethical awareness is a key element of ethical sensitivity and is described as something that should be done. We agree with this point and think it would have been better if we used Milliken's Ethical Awareness Scale, which has established reliability and validity.
Lastly, the true response rate might not be determined because we only included participants with passionate feelings on the topic, thus, leading to selection bias.