Table 4 Explanatory accounts for improvements in open disclosure: what works, when and how from a staff perspective (bolded explanatory accounts for services (eas) have been included in final c-m–o configurations (Table 6)

EAsf1

EVENT IDENTIFICATION

Incident may be catastrophic or gradually identified; outcomes may be uncertain or develop over time (6 references)

Confidence in reporting systems (equity of response; learning from event); feedback on outcomes of incident reporting [49, 50, 67]; confidence in colleagues leading disclosure/investigations [58]; non-punitive reporting environment [49, 52]; systems for identifying good practice formalised [49]

Will increase confidence in when to trigger a formal response to an adverse event [49, 50, 52, 67]; with less anxiety over possible impact on reputation, relationships, and career [58]

EAsf2

Recognition of different views of incident severity [50]

More frequent reporting of adverse events [50]

EAsf3

Protocols to support consistent decisions on when to investigate [50]; availability of decision-making tools for use with anxious/bereaved parents [58]

Will clarify expectations (including involving the family) [50]; the supported consent process will be less difficult [58]

EAsf4

ONGOING CARE

AFTER EVENT

When the incident has happened (4 references)

Capacity (resources, skills, behaviours, attitudes [61]) of staff to respond with emotional intelligence to needs/requests and choices of bereaved/traumatised parents [58, 65, 69] and sufficient opportunity to reinforce this across teams [61]

Reduces likelihood of expressions of anger and aggression toward staff [61]; staff more able to understand women’s requests [58, 65]

EAsf5

Availability of staff with specialist skills to share/model/disseminate responsive approaches to injured families

Leads to dissemination of skills and recognition of this work [61]

EAsf6

Provision of support during/after care of avoidable/unavoidable serious incident [62]

Reduces personal and emotional toll of the work (emotional difficulties that lead some clinicians to give up practice) [62]

EAsf7

DISCLOSURE PROCESS

Structures and Strategies (8 references)

Disclosure processes are supported and monitored by experienced colleagues [58]; are embedded in robust clinical governance systems [58]; and are provided by skilled staff [51] who have ongoing support, advice, and practical help [52, 74]

Reduces inherent uncertainties over disclosure practice (impact on own and organisational reputations or with a reduction in legal action by families searching for explanation [58]; disclosure practices by individuals is better supported [51, 52, 74])

EAsf8

National mandate (Regulation 20) with ‘Being Open’ guidance [51, 74]

Emphasises organisational value of disclosure [74]; encourages organisational support for staff involved in this work [51, 74]

EAsf9

Collaborative Implementation of improvement work (e.g. new protocols) across service [75] or organisation [78]; demonstrated benefits of investment in specialist and senior support [75, 78]

Decreases uncertainty of clinical staff and managers and decreases resistance about changes in practice [75]/ they are less likely to resist [78]

NB: (collaboratively developed protocol revisions over 80% more likely to be implemented [78])

EAsf10

Educational programs and staff support are critical elements of disclosure programmes [54, 77]

Increases staff competence and relationship to involve family throughout process [54, 77]

EAsf11

Legally protected ‘safe spaces’ for disclosure conversations [50]

Decreases clinicians’ fear around legal consequences and increases the likelihood that families will learn the truth from clinicians; increases open relationship with a family [50]

EAsf12

Ethos (4 references)

Wider organisational landscape of trust between organisations and clinicians in which policies, tools, and programmes are operationalised [61, 81]

Engages clinicians in an ethos of early reporting and disclosure [81]; and improves positive relationships with injured patients [61]

EAsf13

Established practice that is supported consistently and clearly by local physicians and managers [78]; senior doctors role-modelled disclosure with patients [67]

Openness with families becomes ‘part of the mind set of all practitioners’ (about three months after initial implementation) [78]; medical students and junior doctors will aspire to emulate disclosure practice [67]

EAsf14

Governance (3 references)

Implementation of disclosure widely supported by Trust leaders and managers (and government) [50, 73] and modelled by Trust leads[49]

Leads to the development of local cultures of reporting, openness, and learning [50]; reassures staff of this work[49] (and will not rely on a few champions [48]); promotes disclosure work as a clinical priority for services and teams [73]

EAsf15

Accessibility/Availability (5 references)

Managing parent expectations/questions (e.g. limited PMRT ‘free-text’) [71]

Services are able to manage questions in the time available for reporting [71] and to provide answers to the questions that families are asking [71]

NB (however 50% stakeholders voted against time limit set for addressing parent questions in PMRT meeting) [71]

EAsf16

Inclusion in staff in review meeting schedules and invitations [49, 70, 82]; staff sensitively informed/kept informed of investigations involving them [52]

Staff are able to attend panel discussions that involve them [70] and feel less fearful and isolated during this time [52]

EAsf17

Places Enacted (1 reference)

Time alone and with colleagues to prepare for disclosure conversation following a guide (who to contact; accommodating different understandings; what to say; body posture and proximity; how to respond; what is required) [69]

Equips staff to plan the conversation and follow-up [69] and leads to better conversations with families [69]

EAsf18

Initial Disclosure Conversations (13 references)

Communication training [66, 75, 82] for staff to acquire necessary interactional skills for difficult conversations [82]; training offered to all labour and delivery clinicians [78] and as part of the trainee curriculum [66], including multi-disciplinary training to prepare for the disclosure conversation [69]

Staff who attend have increased skills and confidence [66, 75]and greater willingness to be involved in discussions with families [68, 82]. Their levels of stress and risk of burn-out are reduced [68] notably with all team approaches [66, 78]. Staff might also develop wider collaborative relationships [69]

EAsf19

Time to prepare together for a conversation (plan private environment; contact with risk manager; share views on event; plan what to say; anticipate response and need) [69]

Clinicians are better equipped for an effective conversation [69]

EAsf20

Training for clarification of difference between expressing regret and admitting liability [50]; of the pressures arising from instructions to give a partial apology (when staff would prefer to give a full apology [54, 79]); management of risks associated with tort system [72, 81]

Apologies are given with less fear/sense of risk [50, 81] of personal responsibility. Promotes that an apology is the right thing to offer regardless of review/investigation findings [79]

EAsf21

Knowledge of use of ‘appropriate words’ [78] /recognition of ‘profound effects of subtle changes in language’ [75] in disclosure meetings; use of established cognitive aid as best practice guidelines [69]

Clinicians will be better able to integrate own feelings into an honest account for the family [78] guidelines will improve (simulated) disclosure conversations, notably, posture/tone towards patient by experienced practitioners [69]

Staff are more likely to have successful meeting [58]

NB (Staff with best practice guidelines were more likely to apologise to patients [in simulations] however this training did not make the task of disclosure feel any easier for them [78])

EAsf22

Engagement of wider range of HCPs (e.g. for co-design of communication training) [75]

Different staff will realise that the challenges of disclosure work are common across health care teams (e.g. chaplains, clinicians, service managers) [75]

EAsf23

Explanations (2 references)

Approaches that identify learning and ‘fair culture’(rather than apportion blame) [49, 65]

Staff will be less reluctant to report and disclose events [49]; the devastating effects of an incident that is hidden will be reduced; and opportunities for professional and service and personal learning are available [49, 65]

EAsf24

Navigation Strategies (3 references)

Named family contact/liaison has capacity (emotions and time) [80]; training and support [52]; sufficient influence and experience [52]

This contact will be able to work effectively [52], responding to family needs throughout reviews/investigations (from routine updates to unmet expectations) [80]

EAsf25

Clear pathways of contact/open communication with staff (raising concerns) developed by Trust [51]

Staff will be less fearful of contact with families with more compassionate communication and possibilities forcollaboration [51]

EAsf26

DISCLOSURE DURING REVIEWS AND INVESTIGATIONS

When incident review and/or investigation initiated (11 references)

Standardised review tools and protocols that include communication with parents [30, 34]; dedicated support materials developed with parents [30, 34]

Staff will have guidance for when and how to involve a family [30, 34]

NB (Staff feedback indicates more structured approach to review improves staff communication with parents [30, 34])

EAsf27

Chaired meetings with trained and experienced senior administratiors [71]

Meetings will be more reliable and robust [71]

EAsf28

Dedicated/protected time for family involvement in reviews and investigations (and part of job plans) [50]; administrative support for reviews [30, 34, 52]

This work will be recognised as a necessary clinical responsibility [50]; with sufficient time, the quality of reviews will be improved [50];

less burdensome for investigators [30] (more time for discussion and identification of care improvements [30])

EAsf29

Professional duty of candour followed [50]

There will be more active participation in reviews (by staff as review leads and information-providers [50])

EAsf30

Systems that seek to reduce need for litigation against Trusts (e.g., early notification/compensation of costs) [81, 82]

There will be a reduction in fear of consequences of incident reporting and candour [81, 82]

EAsf31

Training and expertise development for family involvement in investigations [50]; specialist training for investigators [50, 74] (national and mandated [74]); ongoing/facilitated team/peer-support programs [74, 80]

The competency of investigators will be improved [74], including their confidence and resilience to effectively involve families [50, 74, 80];. These competencies of investigation and engagement skills [74]

EAsf32

Staff emotional support that is routinised [61], dedicated, joined-up [82], during incident investigation [74] and post-incident [61, 74, 82]

Trusts (OH, Workforce Wellbeing and Board) responsible for provision of range of flexible care packages and specialist referrals [82]

Staff wellbeing will be better supported [61]; staff will be more likely to report and disclosure to a family next time [82]; trainee attrition might be reduced [74]

NB (evidence of staff support offered in about 60% of NHS claims; no evidence of uptake or quality/continuity of support offered [74])

Support needs will be met as part of Trust-level duty of care to staff [82]

EAsf33

OUTCOMES OF DISCLOSURE PROCESS

Reporting and Feedback (2 references)

Informed of investigation progress and findings by key contact/liaison (not ‘kept in the dark’ [52, 82])

Staff uncertainty and stress will be reduced [52, 82]

EAsf34

System-Wide Change/QI (3 references)

Evidence of corrective action/improvements from learning after incident (taken by teams/departments) [50, 67]; regular updates on shared lessons from reviews/investigations [51]

Leads to a reduction of stress in staff [67]; staff will feel that organisation is open with them; and they will be involved in learning for improvement [51]

EAsf35

Resolution of Staff (5 references)

Permission to communicate truthfully’ about event [78]; demonstrated effort by service to address harm to patient (amelioration) (taken by teams/departments) [67] with sincere apology and offer of compensation [82]; new systems for early notification/settlement of costs [82] dedicated and confidential post-incident support for staff [49, 82]

Leads to a reduction in staff stress, concern and trauma with the possibility of a just resolution [67, 78]; reduction of fear of litigation (‘barrier to safety’) [82], anger is diffused and relationships with family might be preserved [82]

EAsf36

Wider Revisions in Social and Healthcare Relationships

New practices (views on fallibility/expertise/care decisions) entailed in disclosure [8, 54, 63]

Will encourage new ways of working with staff and patients [8, 54, 63]

EAsf37

Parents/families central in post-incident events and care [76, 80]

Will ‘upskill’ staff in new perspectives on user involvement in care planning [76, 80]