title: Being open about unanticipated problems in health care: the challenges of uncertainties.
abstract: 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.
authors.affiliation: Professor of Health and Social Care, Social Policy Research Unit, University of York, UK yvonne.birks@york.ac.uk.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Birks
authors.affiliation: Professor of Health Services Research and Ethics, Health Services Research Unit, University of Aberdeen, UK.
authors.forename: Vikki
authors.initials: V
authors.lastname: Entwistle
authors.affiliation: Lecturer and Research Fellow, School of Public Health, Sydney Medical School, The University of Sydney, Australia.
authors.forename: Reema
authors.initials: R
authors.lastname: Harrison
authors.affiliation: Research Fellow, Department of Health Sciences, University of York, UK.
authors.forename: Kate
authors.initials: K
authors.lastname: Bosanquet
authors.affiliation: Professor of Primary and Community Care, Department of Health Sciences, University of York, UK.
authors.forename: Ian
authors.initials: I
authors.lastname: Watt
authors.affiliation: Professor of Healthcare Innovation, School of Health Sciences, University of Tasmania and Research Manager, Agency for Clinical Innovation, New South Wales, Ministry of Health, Australia.
authors.forename: Rick
authors.initials: R
authors.lastname: Iedema
mesh_terms: D001291:Attitude of Health Personnel; D003142:Communication; D004739:England; D005190:Family; D006282:Health Personnel / Q000523:psychology*; D006302:Health Services Research; D006801:Humans; D057766:Policy; D013222:State Medicine; D014342:Truth Disclosure; D035501:Uncertainty
keywords: adverse events; disclosure; policy