Speaking up to Authority in a Simulated Medication Error Scenario

Assertive communication training for nurses to speak up in cases of medical errors: A systematic review and meta-analysis

BACKGROUND

Several authors have previously assessed the effects of assertive communication training for nurses to speak up in cases of medical errors. Inconsistent results regarding the nurses' attitudes, behaviors, and confidence levels were noticed.

OBJECTIVE

To identify the effectiveness of assertive communication training on nurses' behaviors, attitudes, and confidence levels for speaking up in cases of medical errors and to identify vital components for success.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, ERIC, Embase, Scopus, and CINAHL were searched up for studies published from the inception of the database to December 16, 2022.

METHODS

Two researchers independently performed a primary screening of titles and abstracts for relevant studies, followed by a review of full texts if the references met inclusion criteria and quality assessment. Data were retrieved for nurses and nursing students who received medical error-related assertive communication training for speaking up, and learning outcomes for attitudes, behaviors, and confidence levels were reported based on pooled data. Pooled estimates were calculated using a random-effects model.

RESULTS

A total of eleven studies with 1299 participants were included in systematic review, and among them nine studies with 804 participants were analyzed in meta-analysis. From the pooled results, the intervention group, which received assertive communication training, exhibited substantially improved speaking-up behaviors compared with the control group (SMD = 0.58; 95 % CI, 0.14-1.03). Considerable differences were noted in the nurses' times of speaking up in cases of medical errors between pretest (38 %; 95 % CI, 0.14-0.68) and posttest (78 %; 95 %CI, 0.70-0.85) based on the pooled data. The nurses' attitudes and confidence levels for speaking up varied markedly between pretest and posttest.

CONCLUSION

Structured assertive communication training may improve nurses' speaking-up behaviors in cases of medical errors. To conduct effective assertive communication training, nursing educators should incorporate multiple teaching approaches into structured training and ensure an adequate training duration.

Assertiveness educational interventions for nursing students and nurses: A systematic review

OBJECTIVES

The purpose of this study was three-fold: to (1) synthesize evidence from experimental studies regarding educational interventions for developing nursing students' and nurses' assertiveness, (2) examine such interventions and identify their effective components, and (3) recommend future research considerations in this area.

DESIGN

A systematic review of the literature.

DATA SOURCES

Literature searches were conducted using three electronic databases (PubMed, CINAHL, and PsycINFO) in addition to hand searches to identify original research articles published between 2012 and 2022.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed for the systematic review and reporting process. Included studies were critically appraised using the Joanna Briggs Institute Critical Appraisal Checklists.

RESULTS

Fourteen articles were included in this review, with most of the studies conducted in Asian countries. Four intervention methods were used for assertiveness education across the studies: (1) simulation-based learning, (2) classroom-based learning, (3) classroom-based learning with peer support, and (4) hybrid learning. Classroom-based learning interventions were the most common. Among all types of interventions, key concepts included assertiveness, differentiating between assertive and non-assertive behaviors, and assertive communication skills. Most studies measured participants' speaking-up behaviors by self-report. Mixed results were observed in terms of intervention effectiveness, but providing participants with opportunities to practice assertive communication skills benefited their speaking-up.

CONCLUSIONS

Educational interventions can strengthen the skills, confidence, and capacity of current and future nurses to employ assertive communication. Intervention developers should create programs that involve classroom teaching and provide participants with opportunities for practice, either through simulation or role-play. Also, researchers should observe participants' post-intervention use of assertive communication in simulations or clinical practice as opposed to surveying participants' intention to speak up.

A state-of-the-art review of speaking up in healthcare

Throughout healthcare, including education, the need for voicing of concern by speaking up is a globally recognized issue that has come to the fore in the last ten years. There has been a rapid growth in the number of review articles on the topic. To prevent diffusion of knowledge and support future research it is necessary to gather the existing knowledge in a single place. The purpose of the present article is to bring together the existing reviews on speaking up to create a source of unified knowledge representing the current "State of the Art" to advance future research and practice. A State-of-the-Art review was conducted to synthesize the existing knowledge on speaking up. Six databases were searched. Fourteen review articles spanning 2012 to 2021 were identified. Five main research questions have been investigated in the literature and five common recommendations for improvement are made, the knowledge across all reviews related to the research questions and recommendations was synthesized. Additionally, simulation-based research was frequently identified as an important though limited method. Further issues in the literature are identified and recommendations for improvement are made. A synthesis was successfully developed: knowledge about speaking up and research related to speaking up is in an emergent state with more shortcomings, questions, and avenues for improvement than certitude. The whys and how of speaking up remain open questions.

A behavioural study of obedience in health professional students

Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.