Exploring Open Disclosure of Patient Safety Incidents in Healthcare: A Multidisciplinary Perspective through a Mixed-Methods Study

Abstract

Background: Open disclosure is an ethical, moral and professional approach to fostering transparent and empathetic communication of Patient Safety Incidents (PSIs) to patients and relevant persons(s). While this approach empowers healthcare professionals (HCPs) to engage in honest discussions, barriers to effective disclosure practices persist. The rising rates of PSIs, heightened public health concerns, and the complex medico-legal and regulatory implications emphasise the need for HCPs to be equipped with the necessary strategies to facilitate open disclosure. Despite policy reforms, legislative frameworks, educational initiatives, and the establishment of a national steering committee in Ireland, empirical evidence on HCPs' attitudes and perceptions towards open disclosure remains limited. This gap highlights the need for further research to support its effective implementation across the Irish healthcare system.

Aim: This study explores multidisciplinary perspectives on the open disclosure of PSIs in Ireland. It examines HCPs' attitudes and perceptions, identifies key barriers and facilitators and aims to inform future practice.

Methodology and Methods: This study is underpinned by a pragmatist philosophical paradigm and employs a sequential explanatory mixed-methods design. The research was conducted across eight hospital sites within the RCSI Hospital Group. Ethical approval was obtained from each site. The quantitative phase involved survey data from a census of HCPs (N = 417) to examine their attitudes and perceptions of open disclosure following PSIs. In the qualitative phase, semi-structured interviews were conducted with a purposively selected subset of survey respondents (N = 42), using stratified and maximum variation sampling. These interviews explored key barriers, facilitators, and strategies to support open disclosure practice and training. Integration was achieved through joint display analysis, enabling systematic comparison and identification of convergence, divergence, and expansion across data from both phases. Theoretical pluralism further informed the analysis, drawing on multiple frameworks to interpret the interplay between individual attitudes, behaviours, and organisational contexts.

Findings: The findings highlight that HCPs perceived disclosure of PSIs as fundamental to fostering patient trust and promoting patient safety. While many HCPs expressed confidence in supporting colleagues through the disclosure process, some conveyed concerns about their professional competence being questioned following involvement in a PSI. Participants described how multidisciplinary teams (MDTs) prioritise patient care; manage PSIs and their associated disclosures collaboratively, rather than attributing individual blame. Survey data revealed that HCPs perceived a risk of disciplinary action associated with open disclosure and expressed concern about potentially negative responses from patients and families. Most respondents remained neutral regarding the likelihood of increased litigation. Nonetheless, a clear majority believed that disclosure helps to reduce feelings of guilt following a PSI. Age appears to play a significant role in shaping HCPs' attitudes, values, and communication behaviours, with a statistically significant association (p < .001). Respondents aged 21-30 years (n = 72) placed greater emphasis on ethical principles in interprofessional practice. Those aged 41-50 years (n = 114), particularly within medical teams, focus on identifying incident causes, assigning responsibility, and facilitating communication across disciplines. Nursing and midwifery professionals (n = 278) reported higher levels of comfort in advising and supporting colleagues during disclosure. Across all age groups, participants advocated for disclosure regardless of assumptions about patient preferences or the severity of harm. HCPs with more than 31 years of experience (n = 44) reported heightened concerns about the potential repercussions of disclosure. Approximately 55.8% of participants have engaged in open disclosure processes, including initial discussions, preparatory meetings, and formal disclosure conversations. Many perceived that open disclosure contributes to service improvement and enhances professional commitment to patient safety. The majority also acknowledged the importance of structured training in ensuring effective implementation, promoting interdisciplinary collaboration, and increasing awareness of legal protections. Canonical Correlation Analysis identified a statistically significant multivariate relationship between attitudes and perceptions, indicating a strong positive correlation. It is primarily influenced by interprofessional communication, perceived justifications for disclosure, and access to institutional facilitators. Weaker communication between professionals correlates with greater reliance on institutional mechanisms. Hierarchical Linear Regression further shows that perception significantly predicts attitude. HCPs who expressed stronger justification for open disclosure also demonstrated greater alignment with professional values and ethical reasoning. Additionally, perceptions of legal, professional or emotional consequences impact attitudes, while previous experience with PSIs, socio-demographic factors, and personal ethics also shape disclosure related behaviours.

Reflexive thematic analysis indicates that HCPs viewed open disclosure as the "right thing to do", irrespective of potential consequences. Participants reported that their experiences with and exposure to the disclosure of PSIs significantly shaped their confidence and competence in undertaking disclosure. They identified key facilitators such as mentorship, supportive leadership, peer encouragement, fact-based enquiry, robust documentation and alignment between organisational culture and open disclosure policies, which fostered a strong sense of responsibility and accountability to patients and their relevant person(s) throughout the process. HCPs emphasised the importance of focusing on solutions rather than assigning blame and of prioritising what is best for the patient over determining who is at fault. They also valued training that provided practical tools and de-escalation techniques to manage emotional dynamics and facilitate empathetic, patient-centred communication. However, participants identified several barriers to effective disclosure, including limited resources, a pervasive culture of blame, fear of repercussions, psychological strain and complex legal and regulatory frameworks. They further highlighted the lack of consistent access to high quality training as a significant limitation. These findings suggest that advancing open disclosure in healthcare requires a multifaceted, multi-level, and multidisciplinary strategy underpinned by a non-punitive, humanistic perspective. Embedding open disclosure within professional development and organisational learning through accessible, well-structured training is essential to fostering sustained, ethical practice.

Discussion and Conclusion: The integrated findings reveal that HCPs' ethical principles and self-efficacy shaped their values, behaviours, and motivation to engage in open disclosure with patients and their relevant person(s). However, prior experiences, influence of role models, emotional and psychological states, and feedback mechanisms influenced their decision-making and depth of engagement. Although hierarchical structures and professional boundaries often constrained disclosure conversations, policy frameworks, organisational support, team-based approaches, and targeted training enabled HCPs to navigate uncertainties across various stages of the disclosure process. Awareness of convergence and divergence strategies appeared to mitigate hostility and promote more effective, patient-centred communication. Moreover, public and media engagement in raising awareness was perceived as a powerful influence on the broader implementation and outcomes of open disclosure. Despite the challenges presented by the COVID-19 pandemic, the study maintained methodological rigour and fulfilled research aims.