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Discussion of unanticipated problems in care with patients and their families ('open disclosure') is now widely advocated. Despite international efforts and the introduction of a range of policies and guidance to promote such discussions, the expectations of policy makers and patients are often not matched in practice. We consider some reasons for the persistence of shortfalls in the occurrence and quality of open disclosure. We draw on research conducted to investigate the implementation of a 'Being open' policy in England, reflecting particularly on insights derived from interviews with health care professionals. Health care professionals were broadly supportive of the idea of open disclosure. Some expressed well-recognized concern about punishment and being blamed, but this did not appear to be the main driver of their communication practices. Their accounts of what happened around particular problems in health care indicated that they brought a complex range of considerations to bear on questions of whether and how these were discussed with patients and relatives. Guidance about open disclosure based on assessments of levels of harm to patients can complicate and perhaps distort health care professionals' approaches, particularly when the extent and/or cause of harm was uncertain. Health care professionals who engage in open disclosure must be able to negotiate appropriate ways through complex and sensitive discussions. The responses of patients and relatives are not always predictable and even the best open disclosure practice may not resolve problems and concerns. Guidance, training and support for staff need to reflect these challenges., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: The built environment in acute care settings is a new focus in patient safety research, with few studies focusing primarily on the design of ward environments and the location and choice of material objects such as light fittings and hand-washing basins., Methods: We report on an interventionist video-reflexive ethnographic (VRE) study that explored how clinicians used the built environment to achieve safe communication in an intensive care unit (ICU) in a metropolitan Sydney hospital. We conducted 40 semistructured interviews, 5 weeks of observation and four reflexive focus groups with a total of 87 participants (including medical, nursing, allied health and clerical staff)., Results: We found that the accessibility of staff and patients in the open spaces of the ICU was both a safety feature and a safety risk, enabling safe communication flow, but also allowing potentially unsafe interruptions. Staff managed interruptions while allowing for a safe degree of accessibility by creating temporary protected spaces, using physical markers such as curtains, tape and signs as well as behavioural cues, movement and the development of policies restricting activities at certain areas. Furthermore, clinicians were able to use the VRE method to gain insight into their own practices and problems, and to develop meaningful solutions for other problematic spaces., Conclusions: ICU staff enable safe communication in their wards by creating temporary spaces that are both 'connected' and 'protected'. The flexibility of these 'soft' strategies is especially well suited to the fast-paced clinical context of intensive care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Poor prognosis is difficult to impart, particularly across a cultural divide. This study compared prognostic communication with immigrants (with and without interpreters) versus native-born patients in audio-taped oncology consultations., Methods: Ten oncologists, 78 patients (31 Australian-born, 47 immigrants) and 115 family members participated. The first two consultations after diagnosis of incurable disease were audiotaped, transcribed and coded. 142 consultations were included in the analysis., Results: Fifty percent of doctor and 59% of patient prognostic speech units were not interpreted or interpreted non-equivalently when an interpreter was present. Immigrant status predicted few prognostic facts, and oncologist characteristics no prognostic facts, disclosed. Oncologists were significantly less likely to convey hope to immigrants (p=0.0004), and more likely to use medical jargon (p=0.009) than with Australian-born patients. Incurable disease status and a limited life span were commonly acknowledged, generally with no timeframe provided. Physical issues were discussed more commonly than emotional aspects., Conclusions: While culture did not appear to influence doctor speech, interpreters filtered or blocked much prognostic communication., Practice Implications: Initiatives to empower all patients to attain needed information, optimise communication when an interpreter is present and train cancer health professionals in culturally appropriate care, are urgently required., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Disclosure of health care incidents to patients and family members, as an ethical imperative, is becoming increasingly prevalent. The experiences of a woman whose husband died forms the basis for a case study of how she and her family and friends were able to renegotiate clinicians' understandings of what had gone wrong and influence their views of what needed to be done in response., Methods: The case was constructed in late 2010 using the replicated single-case approach, which involved repeated checking and correcting details of an interview with the patient's wife. Her husband, diagnosed with multiple myeloma in 2006, was hospitalized in January 2009 following a hip replacement. While in the hospital, he received a vasopressin overdose. He died in February 2009. THE DISCLOSURE PROCESS: The basis of the disclosure was the drug error, yet the patient's wife informed the caller (the head of the ICU), "You've got a greater problem than a drug error... you've got a massive, big communication problem here." The disclosure process, which unfolded in a series of phone calls and meetings, enabled the patient's wife and her family not only to ask questions but to put forward their knowledge, views, and concerns, and it moved from "disclosing an incident" (the vasopressin overdose) to addressing repeated communication failures and inappropriate behaviors. As a result, the disclosure process became a genuine dialogue that informed the clinicians as much as the family., Conclusions: This case study expands our understanding of what is possible as part of disclosure communication. Patients and family members can and should play a critical role in quality improvement and patient safety, given their knowledge and questions about the trajectory of care and their passion for ensuring that similar incidents do not recur to harm others.

Objective: Immigrants report challenges communicating with their health team. This study compared oncology consultations of immigrants with and without interpreters vs Anglo-Australian patients., Methods: Patients with newly diagnosed incurable cancer who had immigrated from Arabic, Chinese or Greek speaking countries or were Anglo-Australian, and family members, were recruited from 10 medical oncologists in 9 hospitals. Two consultations from each patient were audio-taped, transcribed, translated into English and coded., Results: Seventy-eight patients (47 immigrant and 31 Anglo-Australian) and 115 family members (77 immigrant and 38 Anglo Australian) participated in 141 audio-taped consultations. Doctors spoke less to immigrants with interpreters than to Anglo-Australians (1443 vs. 2246 words, p=0.0001), spent proportionally less time on cancer related issues (p=0.005) and summarising and informing (p≤0.003) and more time on other medical issues (p=0.0008) and directly advising (p=0.0008). Immigrants with interpreters gave more high intensity cues (10.4 vs 7.4). Twenty percent of cues were not interpreted. Doctors tended to delay responses to or ignore more immigrant than Anglo-Australian cues (13% vs 5%, p=0.06)., Conclusions: Immigrant cancer patients with interpreters experience different interactions with their doctors than Anglo-Australians, which may compromise their well-being and decisions., Practice Implications: Guidelines and proven training programmes are needed to improve communication with immigrant patients, particularly those with interpreters., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Clinical handover is an area of critical concern, because deficiencies in handover pose a patient safety risk. Redesign of handover must allow for input from frontline staff to ensure that designs fit into existing practices and settings. The HELiCS (Handover--Enabling Learning in Communication for Safety) tool uses a "video-reflexive" technique: handover encounters are videotaped and played back to the practitioners involved for analysis and discussion. Using the video-reflexive process, staff of an emergency department and an intensive care unit at two different tertiary hospitals redesigned their handover processes. The HELiCS study gave staff greater insight into previously unrecognised clinical and operational problems, enhanced coordination and efficiency of care, and strengthened junior-senior communication and teaching. Our study showed that reflexive and "bottom-up" handover redesign can produce outcomes that harbour local fit, practitioner ownership and (to date) sustainability.

In this article, we outline a study method with which structural changes to clinical communication were achieved within a local intensive care unit (ICU). The study method involved in-depth, round-the-clock observation, interviewing, and video filming of how intensivists conducted their practices, as well as showing selected footage to the clinicians for feedback. This feedback component iteratively engaged clinicians in problem-solving their own communication difficulties. The article focuses on one such feedback meeting and describes changes to the morning ward round and planning meeting that this feedback process catalyzed: greater time efficiency, a greater presence of intensivists in the ICU, more satisfied nursing staff, and a handover sheet to improve the structure of clinical information exchanges. We argue that in embodying not a descriptive but an interventionist approach to health service provision, this video-ethnographic method has great significance for enhancing clinicians' and researchers' understanding of the rising complexity of in-hospital practices, and for enabling them to intervene in these practices.

Purpose: The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology., Design/methodology/approach: This paper explains how this is carried out, and explores some of the adverse consequences for patient care. Evolutionary psychology provides a means of explaining important mental capacities and constructs including theory of mind and the social brain hypothesis. To have a theory of mind is to be able to read others' behaviours, linguistic and non-verbal cues, and analyse their intentions. To have a social (or Machiavellian) brain means being able to assess, compete with and, where necessary, outwit others. In the tough and complex environment of the contemporary health setting, not too different from the Pleistocene, humans display a well-developed theory of mind and social brains and, using mental attributes and behavioural repertoires evolved for the deep past in hunter-gatherer bands, survive and thrive in difficult circumstances., Findings: The paper finds that, while such behaviours cannot be justified, armed with an evolutionary approach one can predict survival mechanisms such as turf protection, competitive strategies, sending transgressors and whistleblowers to Coventry, self-interest, and politics and tribal behaviours., Originality/value: The paper shows that few studies examine contemporary health sector behaviours through an evolutionary psychology lens or via such deep accounts of human nature.

In this paper we argue that whiteboards in clinical settings play a hybrid role: communicating inter- and intraprofessional directives, mediating professional tensions, and mitigating potentially face-threatening acts. The data upon which this paper is based emanate from two independently conducted ethnographic studies: the first explored a range of nurse-nurse and nurse-doctor communication practices in operating rooms, while the second explored work routines and communication methods in oncology wards. Data collection included fieldwork using observations, interviews assisted by photographic methods, and in the first study, a personal diary. A deconstructive analysis was independently undertaken. As a communication method, the use of whiteboards in clinical settings provided a focal point for the coordination of clinical work activities and for the dissemination of information to large groups of people. Whiteboards were a conduit for potentially face-threatening information in that they facilitated the policing and disciplining of staff, while distancing communicators from one another. We conclude that whiteboards are 'pseudo-synchronous' in nature, enabling 'communication at a distance'. In doing so, whiteboards may facilitate and economize clinical communication but they also perpetuate the invisibility of nurses' contribution to ensuring safe care, and they mask the symbolic violence that is committed within and between health professionals.

This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that non-medical factors-the capacity and willingness to withstand continuing treatment-are essential to ensure that decisions taken are in the patient's best interest. We argue that including this dimension of patient care not commonly considered gives balance to decisions about continuing treatment where its benefit is diminishing. Drawing on a qualitative study of intensive care nursing in a large public hospital in Sydney, Australia, the paper exemplifies and interprets the tendency of some clinicians to not disclose the medical and nonmedical status to conscious patients, and the environment of mistrust and conflict that can result. We propose a process of 'conferencing'-a regular, inclusive, ongoing, and dynamic process of communication begun early in the patient's admission-to allow multidisciplinary clinicians to manage their differences, agree on patient-care goals, and prepare the patient and their family for the experience of dying. By integrating both medical and nonmedical factors, conferencing becomes the means of enacting and embedding a multidisciplinary, multidimensional approach to end-of-life care.

This article addresses how professionals working in an intensive care unit in Australia speak about dying, with particular reference to the contradictions and complexities that characterize their work in this setting. The article reflects on the incommensurabilities in these clinicians' talk, and the consequences of this for how different professionals work together and care for extremely ill patients. Examples are drawn from talk recorded during ward rounds and focus groups. The article argues that intensive care units are settings where being reflexive about one's work and assumptions is especially difficult because it involves negotiating decisions and taking moral responsibility for decisions affecting very sick patients. These decisions and responsibilities put into sharp relief the 'wicked problems and tragic choices' of end-of-life existence and of intensive care in specific. This article shows some of the complex ways in which specific clinicians' discourse absorbs and manifests these tensions and responsibilities. The article concludes that these kinds of complexities are unlikely to be resolved with reference to formal knowledge or in-principle conviction, and that a new interactive basis needs to be found where clinicians can rehearse alternative ways of speaking with which to approach each other, the dying, and their families.

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This paper considers the ways in which clinicians enact 'being a team', by analysing how they inform one another about critical patient information. The process where this information exchange happens is known as 'clinical handover'. The study that informs this paper spanned ten months of data collection in four hospitals, involving 150 clinicians and five patients. The analysis presented here draws on data collected at one of the hospital sites: an emergency department at a regional tertiary teaching hospital. Our analysis reveals how central clinical handover is to 'being a team' in health care, and how deficiencies in handover weaken clinical teams' ability to provide continuous and safe care for their patients. We further discuss how clinical practitioners' own responses to the footage foregrounded different issues compared to those revealed by formal analysis; namely, issues centring on relationships, and on practical steps to ensure these relationships could be improved. We reflect on the differences between our own formal analysis of the footage, and practitioners' 'lived response' to the footage, and the implications of these differences for how we as analysts conceptualise 'teamness' in organisations. [ABSTRACT FROM AUTHOR]

This paper presents the findings of a research project which has involved the establishment of a maternal health phone line in Milne Bay Province of Papua New Guinea (PNG). Mobile phones and landline phones are key information and communication technologies (ICTs). This research study uses the "ICTs for healthcare development" model to ascertain benefits and barriers to the successful implementation of the Childbirth Emergency Phone. PNG has a very high maternal mortality rate. The "three stages of delay" typology was developed by Thaddeus and Maine to determine factors that might delay provision of appropriate medical treatment and hence increase risk of maternal death. The "three stages of delay" typology has been utilised in various developing countries and also in the present study. Research undertaken has involved semi-structured interviews with health workers, both in rural settings and in the labour ward in Alotau. Additional data has been gathered through focus groups with health workers, analysis of notes made during phone calls, interviews with women and community leaders, observations and field visits. One hundred percent of interviewees (n = 42) said the project helped to solve communication barriers between rural health workers and Alotau Provincial Hospital. Specific examples in which the phone line has helped to create positive health outcomes will be outlined in the paper, drawn from research interviews. The Childbirth Emergency Phone project has shown itself to play a critical role in enabling healthcare workers to address life-threatening childbirth complications. The project shows potential for rollout across PNG; potentially reducing maternal morbidity and maternal mortality rates by overcoming communication challenges. [ABSTRACT FROM AUTHOR]

Objective To analyse rural patients' and their families' experiences of open disclosure and offer recommendations to improve disclosure in rural areas. Design Retrospective qualitative study based on a subset of 13 semistructured, in-depth interviews with rural patients from a larger dataset. The larger data set form a nationwide, multisite, retrospective-qualitative study that included 100 semistructured, in-depth interviews with 119 patients and family members who were involved in high-severity health care incidents and incident disclosure. The larger study is known as the '100 Patient Stories' study. Interviews were transcribed verbatim and analysed by one analyst ( D.P.) for recurrent experiences and concerns. Setting Acute care. Participants A sub-set of 13 of the 100 participants from the '100 Patient Stories' study who identified as experiencing an adverse incident in a rural or regional area. Main outcome measures Patients' and family members' perceptions and experiences of health care incident disclosure, as expressed in interviews. Results Rural patients and clinicians experience additional challenges to metropolitan patients and clinicians in their experiences of health care incidents. These additional barriers include: a lack of resources at small hospitals; delays in diagnosis and transfer; distance between services; and a lack of communication between providers. These challenges impact not only upon how patients and their families experience incidents, but also how open disclosure is implemented. Conclusions This analysis of 13 of the 100 Patient Stories interviews provides guidance to rural health services on how to conduct open disclosure. [ABSTRACT FROM AUTHOR]

Objective: Clinical handover is a critical point in medical care in the ED, which can contribute to adverse effects for patient care and staff workloads. Over a 4 and a half months in a tertiary referral hospital ED, a centralized whiteboard handover was performed followed by a multidisciplinary review of each patient. This round was referred to as the 'Cow Round'. Methodology: This observational study used a standardized feedback survey of clinicians leading each Cow Round. The survey asked participants in the round to report issues found, which were not handed over during the centralized whiteboard handover. Data were analysed for the number of issues identified, the type of issue identified, and to determine if there was a relationship between the number of issues reported and patients in the department. Results: 204 surveys met inclusion criteria. Clinical issues not handed over at the standard whiteboard round were found in 64% of Cow Rounds. Of the 2411 patients reviewed on Cow Rounds, 14.1% had at least one clinical issue not handed over during the whiteboard round. A mean of 2.2 issues per round (95% CI 1.9-2.5) were found. Pearson correlation found a relationship between the number of issues identified and the total number of patients in the department ( r= 0.246 P= 0.005). Conclusion: Review of patients led by a senior member of medical staff, at the patient bedside enables the timely identification and management of issues not communicated during the whiteboard handover process. This review is important when more patients are receiving treatment in the department. [ABSTRACT FROM AUTHOR]

Recent advances in cross-disciplinary studies linking architecture and neuroscience have revealed that much of the built environment for health-care delivery may actually impair rather than improve health outcomes by disrupting effective communication and increasing patient and staff stress. This is also true for maternity care provision, where it is suggested that the design of the environment can also impact on the experiences and outcomes for birthing women. The aim of this paper is to describe the development of a conceptual model based on literature and understandings of design, communication, stress and model of care. The model explores potential relationships among a set of key variables that need to be considered by researchers wishing to determine the characteristics of optimal birth environments in relation to birth outcomes for women and infants. The conceptual model hypothesises that safe satisfying birth is reliant on the level of stress experienced by a woman and the staff around her, stress influences the quality of communication with women and between staff, and this process is mediated by the design of the birth unit and model of care. The conceptual model is offered as a starting point for researchers who have an appreciation of the complexity of birth and the ability to bring together colleagues from a range of disciplines to explore the pre-requisites for safe and effective maternity care in new ways. [Copyright &y& Elsevier]

In this article, we examine the current and increasing emphasis on accountability and patient safety in health care, focusing on practices of incident reporting and management in New South Wales, Australia. We describe the frames of accountability associated with an incident reporting system, and explore how this system manifests in practice. In contrast to literature that situates incident reporting and local practices as oppositional, we used ethnographic methods to observe the incident management practices of clinical staff in a hospital, and found evidence to characterize this relationship differently. We found that accountability has multiple conceptualizations, and we present three findings that demonstrate how the reporting system and incident management policy are interwoven with local enactments of accountability. We suggest that systematic efforts toward improvement cannot be divorced from the local context, and emphasize the importance of local ecologies of practice in facilitating the meaningful utilization of such incident reporting systems. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology. Design/methodology/approach – This paper explains how this is carried out, and explores some of the adverse consequences for patient care. Evolutionary psychology provides a means of explaining important mental capacities and constructs including theory of mind and the social brain hypothesis. To have a theory of mind is to be able to read others' behaviours, linguistic and non-verbal cues, and analyse their intentions. To have a social (or Machiavellian) brain means being able to assess, compete with and, where necessary, outwit others. In the tough and complex environment of the contemporary health setting, not too different from the Pleistocene, humans display a well-developed theory of mind and social brains and, using mental attributes and behavioural repertoires evolved for the deep past in hunter-gatherer bands, survive and thrive in difficult circumstances. Findings – The paper finds that, while such behaviours cannot be justified, armed with an evolutionary approach one can predict survival mechanisms such as turf protection, competitive strategies, sending transgressors and whistleblowers to Coventry, self-interest, and politics and tribal behaviours. Originality/value – The paper shows that few studies examine contemporary health sector behaviours through an evolutionary psychology lens or via such deep accounts of human nature. [ABSTRACT FROM AUTHOR]

The author reflects on the applied linguistic analysis of communication in hospitals. The author comments on the methodological importance for researchers concerned with understanding contemporary health care practices. The author also explores the applied linguistic studies and discourses of specialist and institutional practices.

Formality indexes interactional closure: it limits the possibilities for the renegotiation of agreements and decisions. In this article the focus is on how formality is constructed in organizational settings. The article proposes that organizational formalization is achieved on the strength of the recontextualization of meaning from one discourse or practice to another. Importantly, organizational processes of recontextualization tend to increasingly technologize meanings with respect to both what they signify and their materialization. This means that discursive practices will mobilize, aside from human or embodied modes of meaning making, increasingly disembodied or exosomatic modes of meaning making, such as electronic kinds of communication, as well as other kinds of inscription of meaning (infrastructure, architecture, and so on). [ABSTRACT FROM AUTHOR]

This commentary explores the nature of creating safety in the here-and-now. Creating safety encompasses two dimensions: revisiting specific behaviours by focusing on substandard performance (reflection), and a more broad-ranging attention to everyday behaviours that are taken as given (reflexivity). The piece pays particular attention to this second dimension of creating safety. Two techniques that promote reflexivity are discussed: video-filming real-time, everyday clinical practice and inviting clinicians' feedback about their own footage, and reflecting on the knowledge and questions that patients and families have about their care, and about unexpected outcomes and clinical incidents. The piece concludes that feedback about everyday practice using these methods is critical to enhancing the safety of everyday activity. [ABSTRACT FROM PUBLISHER]

Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations. [ABSTRACT FROM AUTHOR]