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Background: Symptom management remains a critical challenge at the end of life. Barriers to symptom relief predominantly focus on perspectives of physicians, patients or care systems but rarely acknowledge the views of nurses. Aim: Examine nurses’ perceptions of barriers to adequate end-of-life symptom relief. Methods: Semi-structured interviews with 25 nurses across different settings who routinely prescribed and/or administered symptom relief to patients near the end of life in Queensland and New South Wales, Australia. Data were analysed using a six-stage hybrid thematic analysis technique. Findings: Nurses identified five barriers to adequate symptom management. Firstly, fears concerning symptom relief such as hastening death, causing addiction, loss of consciousness, and legal/professional repercussions affected clinical practice. Secondly, lack of knowledge, experience and training hindered symptom management. Nurses discussed knowledge gaps regarding medication and palliative care, symptom assessments, recognition of dying and relevant laws. Thirdly, personal, cultural and religious beliefs influenced staff's willingness to offer pain relief, and patients’ and families’ willingness to accept it. Lack of communication between medical teams, patients and families further challenged symptom management. Lastly, institutional barriers played a considerable role as time constraints, insufficient staff support and difficulties accessing resources prevented end-of-life symptom management. Discussion: The identified barriers highlight a substantial need for targeted interventions. Setting-specific challenges such as limited access to medication, staff and palliative care services must be addressed. Conclusions: To provide better end-of-life care, services should acknowledge nurses’ unique insights. Particular attention should be on supporting nurses in aged care facilities, community settings and remote areas.

Background: Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses’ concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered. Aim: The aim was to explore nurses’ experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief. Design: Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique. Setting/participants: Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia. Results: While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one’s job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief. Conclusion: Education is urgently required to strengthen nurses’ knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.

PurposeThe purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of “slow science” as a critical yardstick.Design/methodology/approachThe paper is structured in three parts. It first reviews the field of health services research and the approaches that dominate it. It then considers the healthcare research approaches whose principles and methodologies are more aligned with “slow science” before presenting a description of a “slow science” project in which the authors are currently engaged.FindingsCurrent approaches to health service research struggle to offer adequate resources for resolving frontline complexity, principally because they set more store by knowledge generalisation, disciplinary continuity and integrity and the consolidation of expertise, than by engaging with frontline complexity on its terms, negotiating issues with frontline staff and patients on their terms and framing findings and solutions in ways that key in to the in situ dynamics and complexities that define health service delivery.Originality/valueThere is a need to engage in a paradigm shift that engages health services as co-researchers, prioritising practical change and local involvement over knowledge production. Economics is a research field where the products are of natural appeal to powerful health service managers. A “slow science” approach adopted by the embedded Economist Program with its emphasis on pre-implementation, knowledge mobilisation and parallel site capacity development sets out how research can be flexibly produced to improve health services.

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an ‘explanatory theoretical model of change’ that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities—narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome.Trial registration numberThe Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).

To the Editor. Original article published in "Mitchell, Geoffrey, Willmott, Lindy, White, Ben, Piper, Donella, Currow, David, & Yates, Patsy (2019) A perfect storm: fear of litigation for end of life care. Medical Journal Of Australia, 210(10), p. 441. "

Aims To analyse influential policies that inform practice related to pressure injury management in Australia, England, Hong Kong, New Zealand, Scotland and the United States of America. Background Pressure injuries are associated with significant harm to patients, and carry economic consequences for the health sector. Internationally, preventing and managing pressure injuries is a key nursing activity and quality indicator. Evaluation Comparative review and synthesis of pressure injury policies that inform practice. Key issues The predominant focus of policy is on patient risk assessment, compliance with documentation and pressure relief. Financial penalty for institutions is emerging as a strategy where pressure injuries occur. Comparisons of prevalence rates are hampered by the lack of consensus on data collection and reporting. To date there has been little evaluation of policy implementation and implemented policy strategies, associated guidelines remain founded upon expert opinion and low-level evidence. Implications for nursing management The pressure injury policy agenda has fostered a discourse of attention to incidents, compliance and penalty (sanctions). Prevention and intervention strategies are informed by technical and biomedical interpretations of patient risk and harm, with little attention given to the nature or design of nursing work. Considerable challenges remain if this policy agenda is successfully to eliminate pressure injury as a source of patient harm.

Background Engagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness. Methods The model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities. Results Policy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model. Conclusions Engagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

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.

Background: Process evaluations are essential to understand the contextual, relational, and organizational and system factors of complex interventions. The guidance for developing process evaluations for randomized controlled trials (RCTs) has until recently however, been fairly limited. Method/Design: A nested process evaluation (NPE) was designed and embedded across all stages of a stepped wedge cluster RCT called the CORE study. The aim of the CORE study is to test the effectiveness of an experience-based codesign methodology for improving psychosocial recovery outcomes for people living with severe mental illness (service users). Process evaluation data collection combines qualitative and quantitative methods with four aims: (1) to describe organizational characteristics, service models, policy contexts, and government reforms and examine the interaction of these with the intervention; (2) to understand how the codesign intervention works, the cluster variability in implementation, and if the intervention is or is not sustained in different settings; (3) to assist in the interpretation of the primary and secondary outcomes and determine if the causal assumptions underpinning the codesign interventions are accurate; and (4) to determine the impact of a purposefully designed engagement model on the broader study retention and knowledge transfer in the trial. Discussion: Process evaluations require prespecified study protocols but finding a balance between their iterative nature and the structure offered by protocol development is an important step forward. Taking this step will advance the role of qualitative research within trials research and enable more focused data collection to occur at strategic points within studies.

Summary Background This paper presents the findings of three multisite evaluations of Experience-Based Co-design (EBCD) programmes conducted in Emergency Departments (EDs) and associated departments in seven public hospitals in New South Wales, Australia. Method Data for the evaluations were derived from: EBCD documentation provided by the participating sites; interviews with 117 key informants; performance data and the policy and academic literature on EBCD. Results Respondents described EBCD as a successful and sustainable method of improving the individual patient experience and the overall quality of a health service. Demonstrated successes were reported to lead to aspects of the EBCD approach spreading within services. However, like any quality improvement activity, EBCD was not without its challenges. The principal challenge particular to the EBCD projects outlined here was their deployment in ED settings. Because of their ambulant patient populations, these settings made sustaining consumer engagement for the duration of the project problematic and required tailoring EBCD to accommodate consumers’ involvement preferences and constraints. Conclusion The primary strength of EBCD over and above other service development methodologies was reported to be its ability to bring about improvements simultaneously in both the operational efficiency and the inter-personal dynamics of care. However, careful consideration must be given to the constraints inherent in transient patient specialties and what needs to be done to tailor EBCD to suit the particular setting in which it is deployed.

Objectives To understand patients' and health professionals' 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. Design, setting and participants A qualitative method was employed using semi-structured open-ended interviews with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states. Results Both patients and health professionals were positive about Open Disclosure, although each differed in their assessments of practice effectiveness. We found that five major elements influenced patients' and professionals' experience of openly disclosing adverse events namely: initiating the disclosure, apologizing for the adverse event, taking the patient's perspective, communicating the adverse event and being culturally aware. Conclusions Evaluating the impact of Open Disclosure refines policy implementation because it provides an evidence base to inform policy. Health services can use specific properties relating to each of the five Open Disclosure elements identified in this study as training standards and to assess the progress of policy implementation. However, health services must surmount their sensitivity to revealing the extent of error so that research into patient experiences can inform practice and policy development.

Objective: To explore patients' and family members' perceptions of Open Disclosure of adverse events that occurred during their health care. Design: We interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis. Setting: Four States in Australia: New South Wales, Victoria, Queensland and South Australia. Study participants: Twenty-three participants were recruited as part of an evaluation of the Australian Open Disclosure pilot commissioned by the Australian Commission on Safety and Quality in Health Care. Results: All participants (except one) appreciated the opportunity to meet with staff and have the adverse event explained to them. Their accounts also reveal a number of concerns about how Open Disclosure is enacted: disclosure not occurring promptly or too informally; disclosure not being adequately followed up with tangible support or change in practice; staff not offering an apology, and disclosure not providing opportunities for consumers to meet with the staff originally involved in the adverse event. Analysis of participants' accounts suggests that a combination of formal Open Disclosure, a full apology, and an offer of tangible support has a higher chance of gaining consumer satisfaction than if one or more of these components is absent. Conclusions: Staff need to become more attuned in their disclosure communication to the victim s perceptions and experience of adverse events, to offer an appropriate apology, to support victims long-term as well as short-term, and to consider using consumers' insights into adverse events for the purpose of service improvement. © The Author 2008. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness.An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point.The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017.Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.

To analyse rural patients' and their families' experiences of open disclosure and offer recommendations to improve disclosure in rural areas.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.Acute care.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.Patients' and family members' perceptions and experiences of health care incident disclosure, as expressed in interviews.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.This analysis of 13 of the 100 Patient Stories interviews provides guidance to rural health services on how to conduct open disclosure.

Objectives To investigate patients’ and family members’ perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. Design Retrospective qualitative study based on 100 semi-structured, in depth interviews with patients and family members. Setting Nationwide multisite survey across Australia. Participants 39 patients and 80 family members who were involved in high severity healthcare incidents (leading to death, permanent disability, or long term harm) and incident disclosure. Recruitment was via national newspapers (43%), health services where the incidents occurred (28%), two internet marketing companies (27%), and consumer organisations (2%). Main outcome measures Participants’ recurrent experiences and concerns expressed in interviews. Results Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process. This analysis provided the basis for the formulation of a set of principles of effective incident disclosure. Conclusions Despite growing prominence of open disclosure, discussion about healthcare incidents still falls short of patient and family member expectations. Healthcare organisations and providers should strengthen their efforts to meet patients’ (and family members’) needs and expectations.

Objectives: To understand the views of doctors, nurses, allied health professionals and health managers of open disclosure of medical errors. Methods: Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia. Results: Health professionals are positive about open disclosure and are applying the model to patient- clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals. Conclusion: 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.

© 2016 John Wiley & Sons Ltd. AIMS: To analyse influential policies that inform practice related to pressure injury management in Australia, England, Hong Kong, New Zealand, Scotland and the United States of America.BACKGROUND: Pressure injuries are associated with significant harm to patients, and carry economic consequences for the health sector. Internationally, preventing and managing pressure injuries is a key nursing activity and quality indicator.EVALUATION: Comparative review and synthesis of pressure injury policies that inform practice.KEY ISSUES: The predominant focus of policy is on patient risk assessment, compliance with documentation and pressure relief. Financial penalty for institutions is emerging as a strategy where pressure injuries occur. Comparisons of prevalence rates are hampered by the lack of consensus on data collection and reporting. To date there has been little evaluation of policy implementation and implemented policy strategies, associated guidelines remain founded upon expert opinion and low-level evidence.IMPLICATIONS FOR NURSING MANAGEMENT: The pressure injury policy agenda has fostered a discourse of attention to incidents, compliance and penalty (sanctions). Prevention and intervention strategies are informed by technical and biomedical interpretations of patient risk and harm, with little attention given to the nature or design of nursing work. Considerable challenges remain if this policy agenda is successfully to eliminate pressure injury as a source of patient harm.

This article addresses the issue of how government agencies are increasingly attempting to involve users in the design of public services. The article examines codesign as a method for fostering new and purposeful interaction among service-delivery staff and their customers. Codesign brings together stakeholders who, in the past, have had limited input into the way public services are experienced. By participating in this emerging discourse practice, codesign stakeholders can construct new ways of relating and deliberating. The data presented in this article are drawn from a codesign study initiated by the New South Wales Department of Health in an effort to improve the experience of staff, patients, and caregivers. The article concludes that codesign presents service consumers, professionals, and government officials with new opportunities as well as new challenges. Its opportunities reside in codesign bringing stakeholders together across previously impervious boundaries, producing new understandings, relationships, and engagements. Its challenges reside in these new understandings, relationships, and engagements only becoming possible and only continuing to be relevant if and when stakeholders are prepared to adopt and adapt to the new discourse needed to realize them, implicating them in what has been referred to as the "design competency spiral." © 2010 NTL Institute.

Objectives To understand patients' and health professionals' 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. Design, setting and participants A qualitative method was employed using semi-structured open-ended interviews with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states. Results Both patients and health professionals were positive about Open Disclosure, although each differed in their assessments of practice effectiveness. We found that five major elements influenced patients' and professionals' experience of openly disclosing adverse events namely: initiating the disclosure, apologizing for the adverse event, taking the patient's perspective, communicating the adverse event and being culturally aware. Conclusions Evaluating the impact of Open Disclosure refines policy implementation because it provides an evidence base to inform policy. Health services can use specific properties relating to each of the five Open Disclosure elements identified in this study as training standards and to assess the progress of policy implementation. However, health services must surmount their sensitivity to revealing the extent of error so that research into patient experiences can inform practice and policy development. © 2009 Blackwell Publishing Ltd.

© 2018 Thomson Head Office. Anecdotal evidence from Australia and abroad suggests that health professionals may fear potential legal and/or professional repercussions if their patient dies after receiving pain relieving medication at the end of life. As a result, patients may be under-medicated and their pain and other symptoms not adequately relieved. The regulatory repercussions from inappropriate administration of medications are potentially broad and include criminal charges, civil negligence claims, coronial investigations and disciplinary proceedings. But despite these potentially serious repercussions, a review of publicly available cases in Australia reveals there has been comparatively little judicial or quasi-judicial scrutiny where over-medication is alleged to have resulted in a patient's death. In this article, we describe the regulatory framework that governs this field of medical practice and analyse the extent to which the actions of health professionals have been scrutinised, and the consequences of that scrutiny. We identify a number of themes arising from this analysis and conclude that fears of legal or professional repercussions are largely unfounded, and that existing laws and other forms of regulation should not inhibit the prescription and administration of adequate pain and other symptom relief to people at the end of life.

Clinical placement learning experiences are integral to all health and medical curricula as a means of integrating theory into practice and preparing graduates to deliver safe, high-quality care to health consumers. A growing challenge for education providers is to access sufficient clinical placements with experienced supervisors who are skilled at maximising learning opportunities for students. This paper reports on the development and evaluation of an innovative online learning program aimed at enhancing student and clinical supervisors' preparedness for effective workplace-based learning. The evidence-based learning program used 'story-telling' as the learning framework. The stories, which were supported by a range of resources, aimed to engage the learners in understanding student and supervisor responsibilities, as well as the expectations and competencies needed to support effective learning in the clinical environment. Evaluation of this program by the learners and stakeholders clearly indicated that they felt authentically 'connected' with the characters in the stories and developed insights that suggested effective learning had occurred.

Objective: To assess the attitudes of health care professionals engaged in open disclosure (OD) to the legal risks and protections that surround this activity. Design and participants: National cross-sectional survey of 51 experienced OD practitioners conducted in mid 2009. Main outcome measures: Perceived barriers to OD; awareness of and attitudes towards medicolegal protections; recommendations for reform. Results: The vast majority of participants rated fears about the medicolegal risks (45/51) and inadequate education and training in OD skills (43/51) as major or moderate barriers to OD. A majority (30/51) of participants viewed qualified privilege laws as having limited or no effect on health professionals' willingness to conduct OD, whereas opinion was divided about the effect of apology laws (state laws protecting expressions of regret from subsequent use in legal proceedings). In four states and territories (Western Australia, South Australia, Tasmania and the Northern Territory), a majority of participants were unaware that their own jurisdiction had apology laws that applied to OD. The most frequent recommendations for legal reform to improve OD were strengthening existing protections (23), improving education and awareness of applicable laws (11), fundamental reform of the medical negligence system (8), and better alignment of the activities of certain legal actors (eg, coroners) with OD practice (6). Conclusions: Concerns about both the medicolegal implications of OD and the skills needed to conduct it effectively are prevalent among health professionals at the leading edge of the OD movement in Australia. The ability of current laws to protect against use of this information in legal proceedings is perceived as inadequate.

Objective: To determine which aspects of open disclosure “work” for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot. Design, setting and participants: Qualitative analysis of semi-structured and openended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation. Participating health care staff comprised 49 doctors, 20 nurses, and 62 managerial and support staff. In-depth qualitative data analysis involved mapping of discursive themes and subthemes across the interview transcripts. Results: Interviewees broadly supported open disclosure; they expressed uncertainty about its deployment and consequences, and made detailed suggestions of ways to optimise the experience, including careful pre-planning, participation by senior medical staff, and attentiveness to consumers’ experience of the adverse event. Conclusion: Despite some uncertainties, the national evaluation indicates strong support for open disclosure from both health care staff and consumers, as well as a need to resource this new practice. MJA 2008; 188: 397–400

Introduction User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness. Methods An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point. Ethics and dissemination The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017. Trial registration number Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.

In recent years, healthcare incident disclosure has gained increased attention from policy makers, academics, insurers, clinical professionals, patients and consumer groups and lawyers (Australian Commission on Safety & Quality in Health Care, 2013; Clinton & Obama, 2006; Lamo, 2011; Levinson & Pizzo, 2011; Sage et al., 2014; Studdert & Richardson, 2010; Wojcieszak, Banja, & Houk, 2006). Variously described as a form of restorative justice (Berlinger, 2005), a feasible financial risk reduction strategy (Kachalia et al., 2010) and a service responsiveness philosophy (Iedema & Allen, 2012), incident disclosure appears sufficiently flexible to accommodate stakeholders’ different and often competing interests. The institutional and personal benefits of incident disclosure have now been widely reported (Boothman, Blackwell, Campbell, Commiskey, & Anderson, 2009; Kachalia et al., 2010).