"Compliant Supporters," "Anxious Skeptics," and "Defiant Deniers": A Latent Profile Analysis of People's Responses to COVID-19 Communications.

This study investigates whether people's responses to official communications about COVID-19 could be "profiled" with respect to socio-economic-demographic and behavioral characteristics. Such profiles could enhance the effectiveness of future crisis management through the use of profile-adapted communications that maximize message comprehension. A representative web panel survey (742 respondents) was conducted across Switzerland in February 2022 to assess the population's reaction to COVID-19 communications during the pandemic. Latent profile analysis was conducted to explore if distinct profiles of reactions to the communications would emerge, and how each of them relate to conspiracy mentality and SED measures. The analyses revealed three latent profiles: "Compliant supporters" (54%), "defiant deniers" (23.6%), and "anxious skeptics" (22.4%). Respondents with high conspiracy mentality were more likely to belong to "defiant deniers" or "anxious skeptics." Each profile was characterized by distinct SED and behavioral features (discussed in the paper). The COVID-19 pandemic demonstrated that one communication does not work for all people. Our study evidenced three different types of respondent profiles that require profile-adapted communications for more effective crisis control. Our study is the first to profile people's responses to COVID-19 communications in a systematic, person-centered way. The results can be used for more effective future crisis management that delivers to each profile's communicative needs.

The aspects of healthcare quality that are important to health professionals and patients: A qualitative study.

OBJECTIVE: Existing quality of care frameworks insufficiently integrate the perspectives of physicians, nurses and patients. We collected narrative accounts from these three groups to explore if their perspectives might add new content to these existing definitions. METHODS: Ninety-seven descriptions of "good" and "poor" care episodes were collected from a convenience sample of physicians, nurses and outpatients at eight regional hospitals. Two coders classified the narrative contents into themes related to structures, processes and outcomes of care. RESULTS: The physicians, nurses and patients raised the following "quality of care" aspects: Successful communication among staff, with patients and care companions; staff motivation; frequency of knowledge errors; prioritization of patient-preferred outcomes; institutional emphasis on building "quality cultures"; and organizational implementation of fluid system procedures. CONCLUSION: Respondents primarily referred to care processes in their descriptions of "quality of care." "Hippocratic pride" (in response to care successes) and "Rapid reactivity" (in response to (near) failures) emerged as two new outcome indicators of high-quality care. PRACTICE IMPLICATIONS: This study provides a first qualitative fundament for understanding the components of "quality of care" from a triangulated frontline perspective. Future research needs to validate our findings with quantitative data to explore their usefulness for completing existing quality frameworks.

"It Matters What I Think, Not What You Say": Scientific Evidence for a Medical Error Disclosure Competence (MEDC) Model.

OBJECTIVE: This study sought to validate the ability of a "Medical Error Disclosure Competence" (MEDC) model to predict the effects of physicians' communication skills on error disclosure outcomes in a simulated context. METHOD: A random sample of 721 respondents was assigned to 16 experimental disclosure conditions that tested the MEDC model's constructs across 2 severity conditions (i.e., minor error and sentinel event). RESULTS: Severity did not affect survey respondents' perceptions of the physician's disclosure style. Respondents who viewed the nonverbally skilled disclosure perceived the disclosure as more adequate compared to respondents in the "low nonverbal skill" disclosure condition. Interpersonal adaptability did not affect respondents' adequacy ratings. Consistent with the MEDC model, those who viewed the physician's error disclosure as inadequate indicated that they would be more prone to engage in relational distancing behaviors, while those who rated the disclosure as adequate were more likely to reinvest into their relationship with their physician. These respondents also had higher resilience scores. In the context of a sentinel event, perceived adequacy significantly predicted endorsing legal redress or remedies (e.g., lawsuit). Verbal apology (e.g., "I'm sorry," "I apologize") did not predict any significant variance in the model beyond the physician's nonverbal skill. CONCLUSION: In a simulated disclosure setting, physicians' communicative skills-particularly effective nonverbal communication during a disclosure-trigger outcomes that affect the patient, the physician, and the provider-patient relationship. Findings from this study suggest that MEDC guidelines may be helpful in reducing financial and reputational risks to individual providers and institutions, particularly in the context of a sentinel event.

When facing our fallibility constitutes "safe practice": Further evidence for the Medical Error Disclosure Competence (MEDC) guidelines.

OBJECTIVE: This study pursues further empirical validation of the "Medical Error Disclosure Competence (MEDC)" guidelines. The following research questions are addressed: (1) What communicative skills predict patients' perceived disclosure adequacy? (2) To what extent do patients' adequacy perceptions predict disclosure effectiveness? (3) Are there any significant sex differences in the MEDC constructs? METHODS: A sample of 193 respondents completed an online survey about a medical error they experienced in the past 5 years, and about the subsequent disclosure of that error to them. RESULTS: One in four patients had experienced a medical error, only a third of them received a disclosure. Only interpersonal adaptability influenced disclosure adequacy, with a large effect size. Adequacy, in turn, predicted both patients' relational distancing and approach behaviors. Nonverbally skillful disclosures significantly decreased the likelihood of patient trauma. Expressions of remorse significantly increased patient resilience. Nonverbal skills (-) and a full account (+) predicted patients' tendency to harm themselves. Males were more reactive to disclosures than female patients. CONCLUSION: MEDC guidelines-adherent disclosure communication maintains the provider-patient relationship, increase patient resilience, and decreases patient trauma after a medical error. PRACTICE IMPLICATIONS: Given the results of this study, adherence to the MEDC-guidelines must be considered "safe practice."

Testing the Integrative Quality Care Assessment Tool (INQUAT).

PURPOSE: Identifying the factors that contribute or hinder the provision of good quality care within healthcare institutions, from the managers' perspective, is important for the success of quality improvement initiatives. The purpose of this paper is to test the Integrative Quality Care Assessment Tool (INQUAT) that was previously developed with a sample of healthcare managers in the USA. DESIGN/METHODOLOGY/APPROACH: Written narratives of 69 good and poor quality care episodes were collected from 37 managers in Italy. A quantitative content analysis was conducted using the INQUAT coding scheme, to compare the results of the US-based study to the new Italian sample. FINDINGS: The core frame of the INQUAT was replicated and the meta-categories showed similar distributions compared to the US data. Structure (i.e. organizational, staff and facility resources) covered 8 percent of all the coded units related to quality aspects; context (i.e. clinical factors and patient factors) 10 percent; process (i.e. communication, professional diligence, timeliness, errors and continuity of care) 49 percent; and outcome (i.e. process- and short-term outcomes) 32 percent. However, compared to the US results, Italian managers attributed more importance to different categories' subcomponents, possibly due to the specificity of each sample. For example, professional diligence, errors and continuity of care acquired more weight, to the detriment of communication. Furthermore, the data showed that process subcomponents were associated to perceived quality more than outcomes. RESEARCH LIMITATIONS/IMPLICATIONS: The major limitation of this investigation was the small sample size. Further studies are needed to test the reliability and validity of the INQUAT. ORIGINALITY/VALUE: The INQUAT is proposed as a tool to systematically conduct in depth analyses of successful and unsuccessful healthcare events, allowing to better understand the factors that contribute to good quality and to identify specific areas that may need to be targeted in quality improvement initiatives.

Determinants of good and poor quality as perceived by US health care managers.

Purpose The scientific literature evidences that the quality of care must be improved. However, little research has focused on investigating how health care managers - who are responsible for the implementation of quality interventions - define good and poor quality. The purpose of this paper is to develop an empirically informed taxonomy of quality care as perceived by US managers - named the Integrative Quality Care Assessment Tool (INQUAT) - that is grounded in Donabedian's structure, process and outcome model. Design/methodology/approach A revised version of the critical incident technique was used to collect 135 written narratives of good and poor quality care from 74 health care managers in the USA. The episodes were thematically analyzed. Findings In total, 804 units were coded under the 135 written narratives of care. They were grouped under structure (9 percent, n=69), including organizational, staff and facility resources; process (52 percent, n=419), entailing communication, professional diligence, timeliness, errors, and continuity of care; outcomes (32 percent, n=257), embedding process- and short-term outcomes; and context (7 percent, n=59), involving clinical and patient factors. Process-related categories tended to be described in relation to good quality (65 percent), while structure-related categories tended to be associated with poor quality (67 percent). Furthermore, the data suggested that managers did not consider their actions as important factors influencing quality, but rather tended to attribute the responsibility for quality care to front-line practitioners. Originality/value The INQUAT provides a theoretically grounded, evidence-based framework to guide health care managers in the assessment of all the components involved with the quality of care within their institutions.

What constitutes "competent error disclosure"? Insights from a national focus group study in Switzerland.

The question is no longer whether to disclose an error to a patient. Many studies have established that medical errors are co-owned by providers and patients and thus must be disclosed. However, little evidence is available on the concrete communication skills and contextual features that contribute to patients' perceptions of "competent disclosures" as a key predictor of objective disclosure outcomes. This study operationalises a communication science model to empirically characterise what messages, behaviours and contextual factors Swiss patients commonly consider "competent" during medical error disclosures, and what symptoms and behaviours they experience in response to competent and incompetent disclosures. For this purpose, ten focus groups were conducted at five hospitals across Switzerland. Sixty-three patients participated in the meetings. Qualitative analysis of the focus group transcripts revealed concrete patient expectations regarding provider's motivations, knowledge and skills. The analysis also illuminated under what circumstances to disclose, what to disclose, how to disclose and the effects of competent and incompetent disclosures on patients' symptoms and behaviours. Patients expected that providers enter a disclosure informed and with approach-oriented motivations. In line with previous research, they preferred a remorseful declaration of responsibility and apology, a clear and honest account, and a discussion of reparation and future forbearance. Patients expected providers to display attentiveness, compo-sure, coordination, expressiveness and interpersonal adaptability as core communication skills. Furthermore, numerous functional, relational, chronological and environmental contextual considerations evolved as critical features of competent disclosures. While patients agreed on a number of preferences, there is no one-size-fits-all approach to competent disclosures. Thus, error disclosures do not lend themselves to a checklist approach. Instead, this study provides concrete evidence-based starting points for the development of a disclosure training that is grounded in a communication science model, aiming to support clinicians, institutions and patients with this challenging task.

Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes.

RATIONALE: This study investigates the intrapersonal and interpersonal factors and processes that are associated with patient forgiveness of a provider in the aftermath of a harmful medical error. OBJECTIVE: This study aims to examine what antecedents are most predictive of patient forgiveness and non-forgiveness, and the extent to which social-cognitive factors (i.e., fault attributions, empathy, rumination) influence the forgiveness process. Furthermore, the study evaluates the role of different disclosure styles in two different forgiveness models, and measures their respective causal outcomes. METHODS: In January 2011, 318 outpatients at Wake Forest Baptist Medical Center in the United States were randomly assigned to three hypothetical error disclosure vignettes that operationalized verbally effective disclosures with different nonverbal disclosure styles (i.e., high nonverbal involvement, low nonverbal involvement, written disclosure vignette without nonverbal information). All patients responded to the same forgiveness-related self-report measures after having been exposed to one of the vignettes. RESULTS: The results favored the proximity model of interpersonal forgiveness, which implies that factors more proximal in time to the act of forgiving (i.e., patient rumination and empathy for the offender) are more predictive of forgiveness and non-forgiveness than less proximal factors (e.g., relationship variables and offense-related factors such as the presence or absence of an apology). Patients' fault attributions had no effect on their forgiveness across conditions. The results evidenced sizeable effects of physician nonverbal involvement-patients in the low nonverbal involvement condition perceived the error as more severe, experienced the physician's apology as less sincere, were more likely to blame the physician, felt less empathy, ruminated more about the error, were less likely to forgive and more likely to avoid the physician, reported less closeness, trust, and satisfaction but higher distress, were more likely to change doctors, less compliant, and more likely to seek legal advice. CONCLUSION: The findings of this study imply that physician nonverbal involvement during error disclosures stimulates a healing mechanism for patients and the physician-patient relationship. Physicians who disclose a medical error in a nonverbally uninvolved way, on the other hand, carry a higher malpractice risk and are less likely to promote healthy, reconciliatory outcomes.

Identifying the field of health communication.

This empirical investigation addresses four paradigmatically framed research questions to illuminate the epistemological status of the field of health communication, systematically addressing the limitations of existing disciplinary introspections. A content analysis of published health communication research indicated that the millennium marked a new stage of health communication research with a visible shift onto macro-level communication of health information among nonhealth professionals. The analysis also revealed the emergence of a paradigm around this particular topic area, with its contributing scholars predominantly sharing postpositivistic thought traditions and cross-sectional survey-analytic methodologies. More interdisciplinary collaborations and meta-theoretical assessments are needed to facilitate a continued growth of this evolving paradigm, which may advance health communication scholars in their search for a disciplinary identity.

Physician-perceived contradictions in end-of-life communication: toward a self-report measurement scale.

Communication is undoubtedly a critical element of competent end-of-life care. However, physicians commonly lack communication skills in this particular care context. Theoretically grounded, evidence-based guidelines are needed to enhance physicians' communication with patients and their families in this important time of their lives. To address this need, this study tests and validates a Contradictions in End-of-Life Communication (CEOLC) scale, which disentangles the relational contradictions physicians commonly experience when communicating with end-of-life patients. Exploratory factors analysis confirmed the presence of eight physician-perceived dialectical tensions, reflecting three latent factors of (1) integration, (2) expression, and (3) dominance. Furthermore, a number of significant intercultural differences were found in cross-cultural comparisons of the scale in U.S., Swiss, and Italian physician samples. Thus, this investigation introduces a heuristic assessment tool that aids a better understanding of the dialectical contradictions physicians experience in their interactions with end-of-life patients. The CEOLC scale can be used to gather empirical evidence that may eventually support the development of evidence-based guidelines and skills training toward improved end-of-life care.

Disclosing medical errors to patients: effects of nonverbal involvement.

OBJECTIVE: The purpose of this study was to test causal effects of physicians' nonverbal involvement on medical error disclosure outcomes. METHODS: 216 hospital outpatients were randomly assigned to two experimental treatment groups. The first group watched a video vignette of a verbally effective and nonverbally involved error disclosure. The second group was exposed to a verbally effective but nonverbally uninvolved error disclosure. All patients responded to seven outcome measures. RESULTS: Patients in the nonverbally uninvolved error disclosure treatment group perceived the physician's apology as less sincere and remorseful compared to patients in the involved disclosure group. They also rated the implications of the error as more severe, were more likely to ascribe fault to the physician, and indicated a higher intent to change doctors after the disclosure. CONCLUSION: The results of this study imply that nonverbal involvement during medical error disclosures facilitates more accurate patient understanding and assessment of the medical error and its consequences on their health and quality of life. PRACTICE IMPLICATIONS: In the context of disclosing medical errors, nonverbal involvement increases the likelihood that physicians will be able to continue caring for their patient. Thus, providers are advised to consider adopting this communication skill into their medical practice.

Relational dialectics theory: Disentangling physician-perceived tensions of end-of-life communication.

Existing literature evidences the centrality of interpersonal communication during end-of-life care, but several barriers currently compromise its effectiveness. One of them is a common lack of communication skills among physicians in this challenging context. Several strategies have been suggested to enhance end-of-life interactions; however, a solid theoretical framework is needed for the development of effective systematic guidelines and interventions that can facilitate this goal. The present research study addresses this gap, choosing to focus particularly on the physician's perspective. It relies on Baxter and Montgomery's (1996) Relational Dialectics Theory to illuminate the complexity of reality doctors commonly face in interactions with their patients during end-of-life care. Semistructured interviews were conducted with 11 physicians in a southern canton of Switzerland who had experienced at least one end-of-life encounter with a patient. The interviews probed whether and under what conditions Baxter and Montgomery's theoretical contradictions translate to physicians' end-of-life communication with their patients and the patients' family members. The results replicated and extended the original theoretical contradictions, evidencing that Relational Dialectics Theory is very applicable to end-of-life conversations. Thus, this study adds a theoretically framed, empirically grounded contribution to the current literature on the communicative challenges physicians commonly face during end-of-life interactions with their patients and their patients' family members.

Emerging issues and future directions of the field of health communication.

The interdisciplinary intersections between communication science and health-related fields are pervasive, with numerous differences in regard to epistemology, career planning, funding perspectives, educational goals, and cultural orientations. This article identifies and elaborates on these challenges with illustrative examples. Furthermore, concrete suggestions for future scholarship are recommended to facilitate compatible, coherent, and interdisciplinary health communication inquiry. The authors hope that this article helps current and future generations of health communication scholars to make more informed decisions when facing some of the challenges discussed in this article so that they will be able to seize the interdisciplinary and international potential of this unique and important field of study.

TRACEing the roots: a diagnostic "Tool for Retrospective Analysis of Critical Events".

OBJECTIVE: The lack of interdisciplinary clarity in the conceptualization of medical errors discourages effective incident analysis, particularly in the event of harmless outcomes. This manuscript integrates communication competence theory, the criterion of reasonability, and a typology of human error into a theoretically grounded Tool for Retrospective Analysis of Critical Events (TRACE) to overcome this limitation. METHODS: A conceptual matrix synthesizing foundational elements pertinent to critical incident analysis from the medical, legal, bioethical and communication literature was developed. Vetting of the TRACE through focus groups and interviews was conducted to assure utility. RESULTS: The interviews revealed that TRACE may be useful in clinical settings, contributing uniquely to the current literature by framing critical incidents in regard to theory and the primary clinical contexts within which errors may occur. CONCLUSION: TRACE facilitates a comprehensive, theoretically grounded analysis of clinical performance, and identifies the intrapersonal and interpersonal factors that contribute to critical events. PRACTICE IMPLICATIONS: The TRACE may be used as (1) the means for a comprehensive, detailed analysis of human performance across five clinical practice contexts, (2) an objective "fact-check" after a critical event, (3) a heuristic tool to prevent critical incidents, and (4) a data-keeping system for quality improvement.

Building bridges: future directions for medical error disclosure research.

OBJECTIVE: The disclosure of medical errors has attracted considerable research interest in recent years. However, the research to date has lacked interdisciplinary dialog, making translation of findings into medical practice challenging. This article lays out the disciplinary perspectives of the fields of medicine, ethics, law and communication on medical error disclosure and identifies gaps and tensions that occur at these interdisciplinary boundaries. METHODS: This article summarizes the discussion of an interdisciplinary error disclosure panel at the 2012 EACH Conference in St. Andrews, Scotland, in light of the current literature across four academic disciplines. RESULTS: Current medical, ethical, legal and communication perspectives on medical error disclosure are presented and discussed with particular emphasis on the interdisciplinary gaps and tensions. CONCLUSION: The authors encourage interdisciplinary collaborations that strive for a functional approach to understanding and improving the disclosure of medical errors with the ultimate goal to improve quality and promote safer medical care. PRACTICE IMPLICATIONS: Interdisciplinary collaborations are needed to reconcile the needs of the stakeholders involved in medical error disclosure. A particular challenge is the effective translation of error disclosure research into practice. Concrete research questions are provided throughout the manuscript to facilitate a resolution of the tensions that currently impede interdisciplinary progress.

"Explicitly implicit": examining the importance of physician nonverbal involvement during error disclosures.

QUESTIONS UNDER STUDY/PRINCIPLES: Medical errors are prevalent, but physicians commonly lack the training and skills to disclose them to their patients. Existing research has yielded a set of verbal messages physicians should communicate during error disclosures. However, considering the emotional message contents, patients likely derive much of the meaning from physicians' nonverbal behaviours. The purpose of this study was to test the causal effects of physicians' nonverbal communication on error disclosure outcomes. METHODS: At a university hospital in the Southeastern United States, 318 patients were randomly assigned to three treatment groups. The first group watched a video vignette of a verbally and nonverbally competent error disclosure by a person acting as a physician. The second group was exposed to a verbally competent but nonverbally incompetent error disclosure. The third group read an error disclosure transcript. Then, all patients responded to measures of closeness, trust, forgiveness, satisfaction, distress, empathy, and avoidance. RESULTS: The results evidenced that holding the verbal message content constant, physician nonverbal involvement was significantly associated with higher patient ratings of closeness, trust, empathy, satisfaction, and forgiveness, and with lower ratings of patient emotional distress and avoidance. These associations were not affected by patient predispositions such as sex, ethnicity, religion and previous experiences with medical errors. CONCLUSION: The findings of this study imply that nonverbal communication has a significant impact on error disclosure outcomes and thus should be considered as an important component of future research and disclosure training efforts.