Current approaches to patient safety do not address fully the needs of dying patients and their families. Patients and their families regard poor communication with and by health professionals to be harmful in and of itself.
Objectives To understand patientsÕ and health professionalsÕ experience of Open Disclosure and how practice can inform policy.Background Open Disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to base models of patient-clinician communication and policy development is scant.
Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.
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.
This article presents an inquiry into how clinicians realize a health policy reform initiative called Open Disclosure. Open Disclosure mandates that discussions with patients/family and team staff about "adverse events" are now no longer ad hoc, individualized, and without consequences for how the work is done, but planned, collaborative, and leading to systems change. The article presents an empirical analysis of a corpus of interviews about the impact of Open Disclosure on clinicians' practices. It situates Open Disclosure in the context of arguments that health care workers are increasingly expected to do "emotional labor" with patients and their families, in that staff are advised to practise "reflexive listening" as a means of managing patients' and family members' emotions in response to incidents. The analysis suggests that thanks to the intensity of Open Disclosure interactions, clinicians may be introduced to an affective-interactive space that they were hitherto unaware of and unable to enter or attain what Nigel Thrift calls "a new structure of attention."
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