Essential Elements of Disclosure and Apology

Deborah Lessard, RN, BSN, MA, JD, CPHRM, FASHRM

Though the purpose of a disclosure/apology communication with a patient is of course disclosure and apology, it should be focused not simply on those elements, but also on informational exchange.

Patients in such situations often expect explanations, and express concerns, beyond those specifically related to the error or adverse event at hand. Consequently, enabling and empowering patient engagement in the disclosure/apology process, and allowing the patient to direct the conversation, will result in a far more successful communication overall.

Understanding that the provider and patient generally operate within different frameworks enables the provider to better plan for a disclosure/apology communication. The provider likely operates within a disease framework, which focuses on the patient’s history, treatment plan, and care management. The patient, on the other hand, often operates within an illness framework, which includes expectations, fears, anxieties, and perceptions (and misperceptions) about their illness, the health-care system, and health insurance at large.

Effective interpersonal communication includes an understanding of the following:

  • It’s not what you say—it’s what the patient hears.
    • It’s crucial to understand that when words leave your mouth, they no longer belong to you—that ultimately, you have no control over how those words are heard, interpreted, and understood. In effect, the act of speaking involves surrender on the part of the speaker, and it is up to the listener—in this case the patient and/or their family—to determine the meaning.
    • To maximize a patient’s understanding of what is being said requires that the provider do more than deliver an explanation: the provider must engage the patient in the conversation. Engaging the patient changes the patient from passive listener to active participant, which associates the conversation with a feeling and results in the patient remembering how they felt during it.
    • Engaging the patient in conversation enables and empowers the patient to feel a sense of control—which is exactly what the error or adverse event made them feel they lost. This recovery of control is ultimately what helps the patient heal, and allows them to remember the experience positively.
  • Verbal communication represents 7 percent of communication—the other 93 percent of communication is made and interpreted nonverbally.
    • Although just 7 percent of a provider’s message, impact, or influence is determined by words, the words still matter. They should be kept simple: the tense should be active and not passive, and the phrases concise and to the point. “Non-words” or fillers like “uh,” “um,” and “so” can convey a lack of confidence or even the avoidance of truthfulness, so they should be avoided. Instead of these non-words, use pauses. Pauses and silence convey confidence and leadership, and can be used to create contrast and emphasis among the words chosen.
    • Nonverbal language, which includes vocal elements (pitch, inflection, tone, rhythm, tempo, and pronunciation), visual appearances, olefactics (smells and scents), posture, eye contact, facial expressions, body movements and gestures, proxemics (uses of space and distance), and haptives (touch cues), is a major determinant of meaning. Among adults, if nonverbal language is inconsistent with verbal language, the listener tends to give more credit to the nonverbal language, and may even disbelieve the spoken word altogether.

Among adults, if nonverbal language is inconsistent with verbal language, the listener tends to give more credit to the nonverbal language, and may even disbelieve the spoken word altogether.

  • It’s critical to establish an emotional connection.
    • Failing to establish initial rapport with the patient and/or their family represents a common and significant communication problem. Providers must deliver a clear explanation of what occurred, and how it resulted in an error or adverse event. Words are certainly used to do this—the left side of the brain is engaged when a person prepares to deliver this type of communication. However, words and conversation do not always result in communication on their own, and emotional connection is necessary for true communication to occur. To establish this kind of connection requires engagement of the right side of the brain, which is often a challenge for highly trained technical professionals like healthcare providers.
    • “E=MC3” is an easy mnemonic to help remember to establish an emotional connection. It stands for “Emotion=Message with Contrast, Content, and Context.” Without these elements present, a disclosure/apology communication cannot be expected to resonate effectively with a patient.
  • Multigenerational communication is also key.
    • Providers and patients alike span generations, so it is imperative that generational communication preferences are understood in order to remove any barriers. While there is no formula for effective and successful multigenerational communication, it generally requires an understanding of generational values and communication preferences. Ask your risk-management consultant about additional multigenerational communication resources that may be available to Physicians Insurance members.
  • Gender is a crucial consideration in communication.
    • Sex (which is biological) and gender (which reflects a psychological orientation) both influence communication. One useful way to conceptualize gender as it applies to communication is to use two continua representing assertiveness and responsiveness to understand gender as a social style, rather than trying to communicate to gender as it may (or may not) relate to sex. Social style, or where a person is situated on these continua, is roughly reducible to four major “gender” types, which relate to how other people perceive that person’s behavior. These four social styles are:
      • Amicable
      • Analytical
      • Driver
      • Expressive
  • Intercultural sensitivity matters, too.
    • The three most significant barriers related to intercultural communication are lack of understanding of the cultural aspects of a patient’s health, verbal language barriers, and nonverbal language barriers.
    • Culture includes traditions, customs, norms, beliefs, values, and thought patterns that are passed down throughout generations, and a lack of cultural knowledge represents a level of disrespect for the patient.

Accountability after an error or adverse event is a difficult, complicated, and uncomfortable subject to address—and may present legal challenges. We at Physicians Insurance encourage our providers to contact us immediately after the discovery of an error or adverse event, so that we can help you prepare for this conversation and coach you through the components of successful interpersonal communication.


Deborah Lessard is a nurse-attorney who has a graduate degree in organizational communication with a focus on patient/provider communication. She has 30 years of experience in combining law, nursing, risk management, decision science/analysis, change management, and communication. She teaches risk management and communication in doctoral programs, has developed disclosure/apology processes and communication-resolution programs for liability carriers and health-care systems, and is an external contractor serving as a senior risk-management consultant for Physicians Insurance.