Interventions promoting employee "speaking-up" within healthcare workplaces: A systematic narrative review of the international literature

Exploring barriers to employee voice among certified nursing assistants: A qualitative study

BACKGROUND

Research shows that voice-the communication of ideas, concerns, and perspectives by employees to those in positions to instigate changes-is related to job satisfaction, retention, and organizational improvement. Nevertheless, health care professionals often do not exercise voice. Although researchers have explored the barriers registered nurses working in hospitals experience in expressing their voices, there has been a notable lack of attention in research and practice to the voice of certified nursing assistants working in long-term care settings.

PURPOSES

Ensuring that certified nursing assistants can exercise voice is essential for the welfare and well-being of this occupational group and critical for the success of their organizations. Therefore, we explore the barriers certified nursing assistants encounter that hinder them from exercising voice.

METHODOLOGY

We conducted seven focus groups in which 24 Dutch certified nursing assistants participated.

RESULTS

The results show that respondents were not always willing to exercise voice, which stemmed primarily from negative prior experiences with exercising voice. Respondents were further not always able to exercise voice, as the conditions under which they had to do so were unfavorable. Finally, respondents sometimes lacked the necessary skills to convey their ideas, concerns, and perspectives effectively.

PRACTICE IMPLICATIONS

Our findings indicate that health care managers must address multiple factors if they wish to enhance the voice of certified nursing assistants.

Transforming medical students' speaking-up behaviors in medical errors: The impact of simulation and personalized debriefing

INTRODUCTION

Sharing mental models is essential for high-performance teams, and speaking up is key for exchanging critical insights, especially during medical errors. Understanding how health providers and trainees voice their concerns is crucial for improving speaking-up behavior. This study aims to fill a gap in the literature by examining how medical students speak up when they encounter medical errors and assessing the impact of training on their speaking-up patterns.

METHOD

A quasi-experimental study involving 146 students, who were divided into two groups, was conducted in Northern Taiwan. One group of students encountered life-threatening scenario before intervention, followed by a faculty-led personalized debriefing session, then a non-life-threatening scenario after the intervention. Another group of students underwent these sessions in the reverse order. Students' Speaking-up patterns, including expression style, form and attitude, and their speaking-up confidence were assessed at pre- and post-intervention scenarios.

RESULTS

During pre-intervention scenario, in expression style, 50 students (34.5%) addressed their concerns to medical errors with direct expression and 14 students (9.7%) utilized indirect hint to express their concerns. In expression form, 31 students (21.4%) addressed their concerns to medical errors with affirmative sentences and 33 students (22.8%) asked questions to express their concerns. In speaking-up attitude, 47 students (32.4%) used unoffensive words, while 17 students (11.7%) used offensive words. After intervention, significantly change of speaking-up styles, forms, and attitude were observed along with their speaking-up confidence (p < 0.001).

DISCUSSION

Medical students are inclined to speak up in the event of medical errors using more direct expression and affirmative sentences, along with increased speaking-up confidence after simulation scenario learning and faculty-led personalized debriefing. Healthcare educators can focus more on discussing with students the advantages and disadvantages of various approaches of speaking-up in medical errors, helping them to develop effective speaking-up behaviors in a variety of medical contexts.

Parents' perceptions of patient safety in paediatric hospital care-A mixed-methods systematic review

AIM(S)

To identify and summarize evidence on paediatric patient safety in a hospital setting from parents' point of view.

DESIGN

A mixed-methods systematic review.

PROSPERO ID

ID number CRD42023453626.

DATA SOURCES

PubMed, Scopus, ScienceDirect, the Cochrane Library and the Wiley database were searched in July 2023.

REVIEW METHODS

Two researchers independently applied eligibility criteria, selected studies and conducted a quality appraisal. Data-based convergent synthesis and thematic content analysis were employed.

RESULTS

Twelve studies were included: eight qualitative research studies, two cross-sectional studies, one non-randomized experimental study and one mixed-methods study. The results were grouped into two themes-parental perceptions of inclusion in paediatric patient safety and parental perceptions of exclusion from paediatric patient safety-and comprised seven main subthemes: comfort in communication, parental engagement, communication difficulties, withdrawal from activity, uncertainty about available information and threats to patient safety.

CONCLUSIONS

Parents are willing to be engaged in care but require support from healthcare professionals, as they are often anxious about the condition of their children and actions they believe might be helpful. They need to be treated as valuable partners and be engaged in communication and decision processes.

IMPACT

The development and implementation of interventions involving parents in ensuring the safety of hospitalized paediatric patients should be of the utmost priority to healthcare organizations, as the common theme throughout the included studies was the need for improved communication with and recognition of parents as allies.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was followed.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Austerity Measures and the Resilience of Zimbabwe's Healthcare System: Challenges and Solutions

Austerity measures have become a contentious topic, shaping the landscape of health care systems around the world. As governments grapple with economic challenges, the impact of austerity on health care has emerged as a critical concern. This study focuses on the consequences of austerity actions adopted by the Zimbabwean government under the Transitional Stabilization Program (TSP) from August 2018 to December 2025. This research examines the impact of austerity measures on Zimbabwe's health care sector, exploring its connections with health infrastructure and resources, accessibility and affordability of health care, health funding, health care inequalities, and the health care workforce. Using a quantitative approach and data from 970 participants, including the general populace, health care providers, and government officials, significant positive correlations between austerity measures and these health care variables were identified. The findings indicated a noteworthy positive correlation between the independent variable "austerity measures" and five dependent variables: health care accessibility and affordability, health care inequalities, infrastructure and resources, health care funding, and health care workforce. The t-statistics values exceeded the threshold of 1.96, with values of 5.085, 3.120, 6.459, 8.517, and 3.830, respectively. These findings highlight the importance of considering the effects of austerity on health care access, health funding, health care inequalities, health workforce, health infrastructure and resources development. Policymakers should prioritize equitable resource allocation and targeted investments to strengthen the resilience of the health care system during economic challenges. Understanding these associations is crucial for evidence-based policy decisions and fostering a more equitable and resilient health care system in Zimbabwe.

Medical Students' Speak-Up Barriers: A Randomized Controlled Trial With Written Vignettes

OBJECTIVES

Little is known about medical students' speak-up barriers upon recognizing or becoming aware of risky or deficient actions of others. Improving our knowledge on these helps in preparing student to function in actual health care organizations. The aim was to examine medical students' perceived reasons for silence in respect to different speak-up situations (i.e., vignette content) and to test if vignette difficulty had an effect on reasons indicated.

METHODS

This study was a randomized, controlled, single-blind trial, with text-based vignettes to investigate speak-up barriers. Vignette contents described speak-up situations that varied systematically with respect to speak-up barrier (i.e., environmental norm, uncertainty, hierarchy) and difficulty (i.e., easy, difficult). For each vignette, participants indicated which speak-up barriers they regarded as important.Descriptive analysis was performed for the study population, the numbers of barriers perceived and rating of vignette difficulty. Logistic regression analysis was used to examine the association between barriers perceived and vignette contents, designed vignette difficulty and subjectively rated vignette difficulty.

RESULTS

A total of 265 students were included. The response rate was 100%. Different barriers were relevant for the different vignettes and varied in a consistent way with the theme of the vignette. Significantly more speak-up barriers were indicated for participants with the difficult version for vignette 1 (not an environmental norm) and vignette 3 (hierarchy) with odds ratio (OR) = 1.52 and 95% confidence interval (95% CI: 1.33-1.73) and OR = 1.25 (95% CI: 1.09-1.44). For (OR) estimates, confidence intervals were rather large.

CONCLUSIONS

Perceived barriers for speak-up vary consistently with the characteristics of the situation and more barriers preventing speak-up were related to the difficult versions of the vignettes.

Perceptions of U.S. and U.K. Incident Reporting Systems: A Scoping Review

OBJECTIVE

The aim of the study is to evaluate the extent, range, and nature of the literature that concerns healthcare providers' perceptions following the use of incident reporting systems (IRSs) in the United States (U.S.) and the United Kingdom (U.K.). Literature was compared describing providers' perceptions of reporting patient safety incidents using IRSs from healthcare systems built on public, private, for-profit, or nonprofit insurers in the U.S., with providers' perceptions using an IRS within a universal government supported healthcare system in the U.K.

METHODS

This scoping review searched literature from 4 electronic databases, producing 4863 articles between January 2010 to March 2023.

RESULTS

Eleven U.S. and 8 U.K. articles met the inclusion criteria. Providers described system and individual barriers when using IRSs. The U.S. providers described more concerns regarding individual barriers (fear of punitive response or retaliation, feel incapable or shamed, unsure of what constitutes a patient safety incident, and concerned about litigation) than providers in the U.K. Both countries had similar responses regarding system barriers, except for U.K. providers who were more concerned than the U.S. about damage to professional culture. Providers in both countries believed incident reporting was ineffective and time consuming with hospital leaders seldom acknowledging or integrating improvement measures based on reported incidents.

CONCLUSIONS

Sustainable improvements in patient care must be driven by hospital leadership who create just cultures where reporting of safety concerns is encouraged and respected within nonpunitive milieus.

Care Under Pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill health in nurses, midwives and paramedics

BACKGROUND

Nurses, midwives and paramedics comprise over half of the clinical workforce in the UK National Health Service and have some of the highest prevalence of psychological ill health. This study explored why psychological ill health is a growing problem and how we might change this.

METHODS

A realist synthesis involved iterative searches within MEDLINE, CINAHL and HMIC, and supplementary handsearching and expert solicitation. We used reverse chronological quota screening and appraisal journalling to analyse each source and refine our initial programme theory. A stakeholder group comprising nurses, midwives, paramedics, patient and public representatives, educators, managers and policy makers contributed throughout.

RESULTS

Following initial theory development from 8 key reports, 159 sources were included. We identified 26 context-mechanism-outcome configurations, with 16 explaining the causes of psychological ill health and 10 explaining why interventions have not worked to mitigate psychological ill health. These were synthesised to five key findings: (1) it is difficult to promote staff psychological wellness where there is a blame culture; (2) the needs of the system often over-ride staff psychological well-being at work; (3) there are unintended personal costs of upholding and implementing values at work; (4) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; and (5) it is challenging to design, identify and implement interventions.

CONCLUSIONS

Our final programme theory argues the need for healthcare organisations to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires high standards for patient care to be balanced with high standards for staff psychological well-being; professional accountability to be balanced with having a listening, learning culture; reactive responsive interventions to be balanced by having proactive preventative interventions; and the individual focus balanced by an organisational focus.

PROSPERO REGISTRATION NUMBER

CRD42020172420.

"They say they listen. But do they really listen?": A qualitative study of hospital doctors' experiences of organisational deafness, disconnect and denial

The sharing of information and feedback directly from service-providing staff to healthcare organisational management is vital for organisational culture and service improvement. However, hospital doctors report feeling unable to communicate effectively with management to provide evidence and affect improvement, and this can impact job satisfaction, workplace relations, service delivery and ultimately patient safety. In this paper, we draw on data elicited from a Mobile Instant Messaging Ethnography (MIME) study involving 28 hospital doctors working in Irish hospitals, to explore the barriers preventing them from speaking up and effecting change, and the impact of this on staff morale and services. We identify three major barriers, consistent with previous literature, to effective feedback and communication: (1) organisational deafness, (2) disconnect between managers and frontline staff, and (3) denial of the narratives and issues raised. We draw these together to identify key implications from these findings for healthcare managers, and suggest policy and practice improvements.

What inhibits "speaking up" for patient safety among healthcare workers? A cross-sectional study in Malaysia

BACKGROUND

In healthcare, "speaking up" refers to when healthcare workers raise concerns regarding patient safety through questions, sharing information, or expressing their opinion to prevent harmful incidents and ensure patient safety. Conversely, withholding voice is an act of not raising concerns, which could be beneficial in certain situations. Factors associated with speaking up and withholding voices are not fully understood, especially in strong authoritarian societies, such as Malaysia. This study aimed to examine the factors associated with speaking up and withholding the voices of healthcare workers in Malaysia, thus providing suggestions that can be used in other countries facing similar patient safety challenges.

METHODS

This cross-sectional study was conducted in a tertiary hospital in Sarawak State, Malaysia. Data were collected from 474 healthcare workers from 43 departments using a self-administered questionnaire for speaking up and withholding voices measures in 4 weeks prior to data analysis as well as socio-demographic factors of healthcare workers (sex, age group, profession, department, weekly work hours for patient care, years of employment in the hospital, and the hierarchical level) and speaking up related climate of the working environment were recorded. Data were analyzed using descriptive statistics. Logistic regression was performed to find out (adjusted) odds ratio of frequent speaking up and withholding voices.

RESULTS

Nurse compared to doctors and healthcare workers with short weekly working hours were more likely to speak up. Healthcare workers in emergency and intensive care department, those with short years of employment, and those who worked at low hierarchical levels were less likely to speak up. Healthcare workers in discouraging environment towards speaking up were more likely to withhold their voices.

CONCLUSIONS

This study demonstrates the characteristics of healthcare workers who speak up and those who withhold their voices in Malaysia. To ensure patient safety and prevent harm, it is essential to establish an encouraging environment that promotes speaking up and prevents withholding voices among healthcare worker, especially in circumstances where multiple types of healthcare workers with different socio-demographic backgrounds work together.

"The patient is awake and we need to stay calm": reconsidering indirect communication in the face of medical error and professionalism lapses

BACKGROUND

Although speaking up is lauded as a critical patient safety strategy, it remains exceptionally challenging for team members to enact. Existing efforts to address the problem of silence among interprofessional teams involve training low-authority members to use direct language and unambiguous challenge scripts. The role or value of indirect communication in preventing medical error remains largely unexplored despite its pervasiveness among interprofessional teams. This study explores the role of indirect challenges in the face of medical error and professionalism lapses.

METHODS

Obstetricians at one academic center participated in an interprofessional simulation as a partial actor. Thirteen iterations were completed with 39 participants (13 obstetrician consultants, 11 obstetric residents, 2 family medicine consultants, 5 midwives, and 8 obstetrical nurses). Thirty participants completed a subsequent semi-structured interview. Five challenge moments were scripted for the obstetrician involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the obstetrician's partial actor role. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim and analyzed using a constructivist qualitative approach.

RESULTS

Low-authority team members primarily relied on indirect challenge scripts to promote patient safety during simulation. Faculty participants were highly receptive to indirect challenges from low-authority team members, particularly in front of awake patients. In the context of obstetric care, direct challenges were actually viewed by participants as threatening to patient trust and disruptive to the interprofessional team. Instead of exclusively focusing our efforts on encouraging low-authority team members to speak up through direct challenges, it may be fruitful to expand our attention toward teaching faculty to identify, listen for, and respond to the indirect, subtle challenges that are already prolific among interprofessional teams.

Health professionals' experiences of whistleblowing in maternal and newborn healthcare settings: A scoping review and thematic analysis

PROBLEM

Whistleblowing, which involves raising concerns about wrongdoing, carries risks yet can be crucial to ensuring the safety of health service users in maternal and newborn healthcare settings. Understanding of the experiences of health care professionals that enact whistleblowing in this context is currently limited.

BACKGROUND

Notable inquiries involving maternity services such as those reported upon by Ockenden and Kirkup and the Lucy Letby case in the United Kingdom have shone an international spotlight on whistleblowing failures.

AIM

To identify and synthesise available literature addressing the experiences of healthcare professionals enacting whistleblowing in maternal and newborn care settings.

METHODS

This scoping review followed Arksey and O'Malley's framework. Five academic databases were systematically searched for documents published between January 2013 and October 2023 with additional searches of Google Scholar and related reference lists.

FINDINGS

Whilst 35 papers from international sources were identified, the majority originated from the United Kingdom, where recent high-profile incidents have occurred. Thematic analysis identified three main themes: 'Structural Power', 'Perfectionism' and 'Bravery, Hope and Disappointment', each with sub-themes.

DISCUSSION

Whistleblowing is frequently an altruistic act in a hierarchical system. It exposes poor practices and disrupts power dynamics, especially in challenging workplace cultures. Open disclosure, however, requires psychological safety. Obstacles persist, emphasising the need for a culture of trust and transparency led by individuals who embody the desired values.

CONCLUSION

Primary research on whistleblowing in maternal and newborn healthcare settings is limited. This study sheds light on power dynamics and factors that affect whistleblowing.

Supporting nurses in acute and emergency care settings to speak up

Nurses' competence and confidence in raising concerns with senior clinicians is integral to patient safety and the quality of patient care. If nurses do not speak up when needed it can contribute to incidences of failure to rescue. There are many barriers to nurses speaking up in busy emergency departments and complex major trauma patient cases. Assessment and communication tools such as the SBAR (situation, background, assessment, recommendation) approach and communication techniques such as graded assertiveness can help to overcome some of these barriers. This article uses a case study to discuss how nurses can respectfully but efficiently escalate their concerns to the trauma team leader. It describes barriers to nurses speaking up and tools that can support nurses to speak up, with a focus on graded assertiveness.

Promoting speaking-up behaviours among nurses working in the care for older people: A scoping review

AIM

To explore interventions employed to foster speaking-up behaviours of registered nurses (RNs) working in the care of older people.

DESIGN

Scoping review.

METHODS

The updated Joann Briggs Institute scoping review methodological guidelines were followed.

DATA SOURCES

CINAHL, PubMed, PsycINFO, and Scopus were searched.

RESULTS

A total of 1691 titles and abstracts were screened, resulting in 11 articles that met the inclusion criteria. Analysis focused upon intervention types, methodologies, speaking up strategies, barriers and effectiveness. Education was the most used intervention.

CONCLUSION

There is a lack of published research on successful interventions to promote speaking-up behaviours in the care of older people, particularly relating to poor care practices. Evidence of speaking-up interventions in the residential aged care setting is absent. This highlights the need to develop strategies to support the RN to lead and enable others to raise care concerns.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Developing strategies that enable staff, care recipients and their families to speak up about care concerns is a vital future area for nursing practice development. Nursing leadership of such strategies is central to improving the quality of care for older people, particularly those living in residential aged care.

IMPACT

Older people receiving care should feel respected and be treated humanely. Evidence suggests this is often not the case. This review found a paucity of interventions to promote speaking-up about poor care practices among RNs working in the care of older people. Future research needs to address this, to empower RNs and improve the care afforded to older people.

REPORTING METHOD

The PRISMA-ScR (Tricco et al., Annals of Internal Medicine, 169, 467-473, 2018) were adhered to throughout this scoping review.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in this review.

The moderating role of just culture between nursing practice environment and oncology nurses' silent behaviors toward patient safety: A multicentered study

BACKGROUND

Patient safety is a critical part of healthcare delivery that must be prioritized to guarantee optimal patient outcomes. Oncology nursing is a specialized area of nursing that demands great focus on patient safety because of the high-risk nature of this patient group. Nurses play an important role in ensuring that patients receive safe and effective care. However, the nursing practice environment can have a substantial impact on how nurses respond to patient safety problems. A just culture can promote open communication and identify potential safety issues, whereas a culture of silence can have a negative impact on patient outcomes.

OBJECTIVE

Firstly, assess the relationship between the nursing practice environment and oncology nurses' silent behavior towards patient safety. Secondly, the interaction effect of just culture as a moderator in this relationship.

METHOD

A cross-sectional, correctional research design was employed. Data was collected from 303 nurses working at the oncology departments of five hospitals in Egypt using three questionnaires. Data was analyzed using SPSS-PROCESS Macro (v4.2).

RESULTS

There was a moderate, negative, and significant correlation between the nurse practice environment and silent behavior of nurses towards patient safety. The interaction effect of just culture with nurse practice environment strengthens this relationship, thus enhancing errors reporting.

CONCLUSIONS

This study emphasized on the importance of creating a just culture that facilitates open communication and eliminating the potential hazards result from nurses' silence. Thus, oncology nurses must be encouraged to report issues related to patient safety.

Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Background

Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves.

Aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines.

Data sources

First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied.

Results

We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Conclusions

Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being.

Future work

Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs.

Limitations

The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample.

Study registration

This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

Overcoming walls and voids: Responsive practices that enable frontline workers to feel heard

BACKGROUND

There is increasing recognition that beyond frontline workers' ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard.

PURPOSE

This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals.

METHODOLOGY

We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals ( N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected.

FINDINGS

Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time.

CONCLUSION

Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed.

PRACTICE IMPLICATIONS

Encouraging responsive practices may help ensure that frontline health care workers feel heard.

Raising professionalism concerns as a medical student: damned if they do, damned if they don't?

BACKGROUND

Understanding professionalism is an essential component of becoming a doctor in order to ensure the trust of patients and wider society. Integrally linked to the concept of professionalism is the importance of identifying and raising concerns to ensure high quality, safe patient care. It is recognised that medical students are uniquely placed to identify and report concerns given their frequent rotations through multiple clinical placements and their peer relationships and, in so doing, develop and enact their own medical professionalism. Although there is existing literature exploring medical students' willingness to raise concerns about observed professionalism lapses, this has largely been in the context of clinical interactions. Medical students will however undoubtedly encounter concerning behaviours or attitudes in their fellow students, an area that has not specifically been reported upon. This study therefore set out to explore medical students' willingness to report professionalism concerns they encounter both within and away from the clinical setting, particularly focusing on peer-related concerns.

METHODS

10 medical students, in later clinical years of a large UK medical school, volunteered to take part in in-depth semi-structured interviews. Interviews were recorded, transcribed and then analysed thematically to generate themes and subthemes to represent central organising concepts.

RESULTS

Three broad themes were generated from the data. Hidden curricular effects including role models, hierarchical structures and the operational systems in place to raise concerns subconsciously influenced students' decisions to raise concerns. Secondly, students offered a range of justifications to defend not taking action, including considering their own vulnerabilities and values alongside demonstrating empathy for perceived mitigating circumstances. The third theme highlighted the complex interplay of influencing factors that students considered when encountering professionalism issues in their peers including wider peer cohort effects and a desire to maintain individual peer-relationships.

CONCLUSIONS

Medical students will inevitably encounter situations where the professionalism of others is brought into question. However, despite clear curricular expectations to report such concerns, these findings demonstrate that students undergo a complex decision-making process in determining the threshold for reporting a concern through navigating a range of identified influencing factors. This study highlights the important role medical schools play in helping reduce the inner conflict experienced by medical students when raising concerns and in ensuring they provide supportive processes to empower their students to raise concerns as part their own developing professionalism.

The anatomy of safe surgical teams: an interview-based qualitative study among members of surgical teams at tertiary referral hospitals in Norway

BACKGROUND

In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department.

METHODS

This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes.

RESULTS

The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning.

CONCLUSIONS

This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.

Understanding Employee Voice Behavior Through the Use of Digital Voice Channel in Long-Term Care: Protocol for an Embedded Multiple-Case Study

BACKGROUND

Specific challenges in the health care sector, such as hierarchical structures, shortages of nursing staff, and high turnover of nursing staff, can be addressed by a change process of organizational culture into shared governance. Data from business organizations show that the use of digital voice channels provides employee voice. This approach makes concrete the opportunity for employees to raise their voices by answering surveys and making comments in an anonymous forum, which subsequently positively influences staff turnover and sick leave. Since there is no clear understanding of how a digital voice channel can be used in long-term care to address employee voice, a research gap has been identified.

OBJECTIVE

The purpose of ADVICE (Understanding Employee Voice Behavior; the acronym for this study) is to understand how the use of a digital voice channel performs in long-term care (residential long-term care and home care facilities). The aim of this study is to understand how the digital voice channel can support staff in making their voices heard and to see what managers need to use the voice channel to change the work environment.

METHODS

An embedded multiple-case study will be used to explore the experiences of 2 health care providers who have already implemented a digital voice channel. ADVICE is organized into two main phases: (1) a scoping review and (2) an embedded multiple-case study. For this purpose, focus group interviews with employees, discursive-dialogical interviews with managers, meeting protocols, and data from the digital voice channel will be analyzed. First, all units of analysis from every embedded unit will be separately analyzed and then comprehensively analyzed to obtain a case vignette from every embedded unit (within-analysis). In the second stage, the analyzed data from the embedded units will be compared with each other in a comparative analysis (cross-analysis).

RESULTS

The results will provide insight into how digital voice channels can be used in long-term care to address employee voice. We expect to find how the digital voice channel can empower nurses to speak up and, consequently, create a better work environment. Data collection began in August 2023, and from a current perspective, the first results are expected in summer 2024.

CONCLUSIONS

In summary, the results may help to better understand the use of a digital voice channel in the health care sector and its transformative potential for leadership. At the organizational level, research can help to improve the attractiveness of the workplace by understanding how to give employees a voice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48601.

The application of communication accommodation theory to understand receiver reactions in healthcare speaking up interactions

Speaking up for patient safety is a well-documented, complex communication interaction, which is challenging both to teach and to implement into practice. In this study we used Communication Accommodation Theory to explore receivers' perceptions and their self-reported behaviors during an actual speaking up interaction in a health context. Intergroup dynamics were evident across interactions. Where seniority of the participants was salient, the within-profession interactions had more influence on the receiver's initial reactions and overall evaluation of the message, compared to the between profession interactions. Most of the seniority salient interactions occurred down the hierarchy, where a more senior professional ingroup member delivered the speaking up message to a more junior receiver. These senior speaker interactions elicited fear and impeded the receiver's voice. We found that nurses/midwives and allied health clinicians reported using different communication behaviors in speaking up interactions. We propose that the term "speaking up" be changed, to emphasize receivers' reactions when they are spoken up to, to help receivers engage in more mutually beneficial communication strategies.

Voice is not enough: A multilevel model of how frontline voice can reach implementation

ISSUE

When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

CRITICAL THEORETICAL ANALYSIS

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

INSIGHT/ADVANCE

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

PRACTICE IMPLICATIONS

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Using storytelling in undergraduate dental education: Students' experiences of emotional competence training

AIM

The aim of the study was to explore the use of storytelling as a teaching method for emotional competence interventions within undergraduate dental curriculum (dental and dental hygiene students).

MATERIALS AND METHODS

Students participated in five sessions related to emotional competence: one theoretical and four practical. During the latter, divided in small groups, students told individually two stories: a story about a clinical situation in which they had an emotional experience and a story concerning a patient's experience of the same emotion. Each session focused on a single emotion: happiness, fear, anger and shame. A questionnaire was used to collect perceptions about enjoyment, how stories were chosen, what was learned and if the sessions were stimulating in any way. A focus group was organised to collect reflections about the learning environment, process of learning and specific skill set developed during these sessions.

RESULTS

The majority of the students enjoyed listening, telling and preparing the stories. They reported to experience social support and feeling a sense of community during the sessions. The students believed that stories helped them to reflect on their clinical work and to regulate their emotional experiences more efficiently in clinical situations. Regarding the learning environment, the dental students pointed out the distinctiveness and dissimilarities between the dental and dental hygiene students, but also expressed that they had a desire to learn more about the other student group.

CONCLUSION

Storytelling used as part of an emotional competence course appears to have benefits for students' reflection about their role as dental health professionals. This teaching method was well-perceived by the students included in this study.

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations

PURPOSE

The response of the receiver to a voiced patient safety concern is frequently cited as a barrier to health professionals speaking up. The authors describe a novel Receiver Mindset Framework (RMF) to help health professionals understand the importance of their response when spoken up to.

DESIGN/METHODOLOGY/APPROACH

The framework draws on the broader receiver-focussed literature and integrates innovative findings from a series of empirical studies. These studies examined different receiver behaviour within vignettes, retrospective descriptions of real interactions and behaviour in a simulated interaction.

FINDINGS

The authors' findings indicated that speaking up is an intergroup interaction where social identities, context and speaker stance intersect, directly influencing both perceptions of and responses to the message. The authors' studies demonstrated that when spoken up to, health professionals poorly manage their emotions and ineffectively clarify the speaker's concerns. Currently, targeted training for receivers is overwhelmingly absent from speaking-up programmes. The receiver mindset framework provides an evidence-based, healthcare specific, receiver-focussed framework to inform programmes.

ORIGINALITY/VALUE

Grounded in communication accommodation theory (CAT), the resulting framework shifts speaking up training from being only speaker skill focussed, to training that recognises speaking up as a mutual negotiation between the healthcare speaker and receiver. This framework provides healthcare professionals with a novel approach to use in response to speaking up that enhances their ability to listen, understand and engage in point-of-care negotiations to ensure the physical and psychological safety of patients and staff.

Using an Educational Intervention to Map our Surgical Teams' Function, Emotional Intelligence, Communication and Conflict Styles

OBJECTIVE

The leadership team invited surgical team members to participate in educational sessions that created self and other awareness as well as gathered baseline information about these topics: communication, conflict management, emotional intelligence, and teamwork.

DESIGN

Each educational session included an inventory that was completed to help participants understand their own characteristics and the characteristics of their team members. The results from these inventories were aggregated, relationships were identified, and the intervention was evaluated.

SETTING

A level 1 trauma center, Baylor Scott and White Health, in central Texas; a 636-bed tertiary care main hospital and an affiliated children's hospital.

PARTICIPANTS

An open invitation for all surgical team members yielded 551 interprofessional OR team members including anesthesia, attending physicians, nursing, physician assistants, residents, and administration.

RESULTS

Surgeons' communication styles were individual focused, while other team members were group focused. The most common conflict management mode for surgical team members on average was avoiding, and the least common was collaborating. Surgeons primarily used competing mode for conflict management, with avoiding coming in a close second. Finally, the 5 dysfunctions of a team inventory revealed low accountability scores, meaning the participants struggled with holding team members accountable.

CONCLUSIONS

Helping team members understand their own and others' strengths and blind spots will help create opportunity for more purposeful and clear communication. Additionally, this knowledge should improve efficiency and safety in the high-stakes environment of the operating room.

Speak-Up Behavior of Oncology Nurses: Organizational Trust and Structural Empowerment as Determinants

OBJECTIVE

The aim of this study is to examine the mediating roles of organizational trust and structural empowerment on the speak-up behavior of oncology nurses.

BACKGROUND

Organizational trust can create opportunities for a good working environment. Structural empowerment is an important factor affecting the speak-up behavior of nurses. The intermediary roles of organizational trust and structural empowerment on speak-up behavior are not specific.

METHODS

A correlational descriptive research design was used, and 232 nurses from 2 different hospital levels (the Ministry of Health hospital and university hospital) responded to 4 questionnaires.

RESULT

The results reflect that organizational trust and structural empowerment are a factor on nurses' speak-up behavior.

CONCLUSION

The findings demonstrate that a work environment where organizational trust is developed and a structural empowerment framework is in place contributes to nurses' speak-up behavior among oncology nurses.

"Asking for help is a strength"-how to promote undergraduate medical students' teamwork through simulation training and interprofessional faculty

The ability to team up and safely work in any kind of healthcare team is a critical asset and should be taught early on in medical education. Medical students should be given the chance to "walk the talk" of teamwork by training and reflecting in teams. Our goal was to design, implement and evaluate the feasibility of a simulation-based teamwork training (TeamSIM) for undergraduate medical students that puts generic teamwork skills centerstage. We designed TeamSIM to include 12 learning objectives. For this pre-post, mixed-methods feasibility study, third-year medical students, organized in teams of 11-12 students, participated and observed each other in eight simulations of different clinical situation with varying degrees of complexity (e.g., deteriorating patient in ward; trauma; resuscitation). Guided by an interprofessional clinical faculty with simulation-based instructor training, student teams reflected on their shared experience in structured team debriefings. Using published instruments, we measured (a) students' reactions to TeamSIM and their perceptions of psychological safety via self-report, (b) their ongoing reflections via experience sampling, and (c) their teamwork skills via behavior observation. Ninety four students participated. They reported positive reactions to TeamSIM (M = 5.23, SD = 0.5). Their mean initial reported level of psychological safety was M = 3.8 (SD = 0.4) which rose to M = 4.3 (SD = 0.5) toward the end of the course [T(21) = -2.8, 95% CI -0.78 to-0.12, p = 0.011 (two-tailed)]. We obtained n = 314 headline reflections from the students and n = 95 from the faculty. For the students, the most frequent theme assigned to their headlines involved the concepts taught in the course such as "10 s for 10 min." For the faculty, the most frequent theme assigned to their headlines were reflections on how their simulation session worked for the students. The faculty rated students' teamwork skills higher after the last compared to the first debriefing. Undergraduate medical students can learn crucial teamwork skills in simulations supported by an experienced faculty and with a high degree of psychological safety. Both students and faculty appreciate the learning possibilities of simulation. At the same time, this learning can be challenging, intense and overwhelming. It takes a team to teach teamwork.

Human-AI teaming: leveraging transactive memory and speaking up for enhanced team effectiveness

In this prospective observational study, we investigate the role of transactive memory and speaking up in human-AI teams comprising 180 intensive care (ICU) physicians and nurses working with AI in a simulated clinical environment. Our findings indicate that interactions with AI agents differ significantly from human interactions, as accessing information from AI agents is positively linked to a team's ability to generate novel hypotheses and demonstrate speaking-up behavior, but only in higher-performing teams. Conversely, accessing information from human team members is negatively associated with these aspects, regardless of team performance. This study is a valuable contribution to the expanding field of research on human-AI teams and team science in general, as it emphasizes the necessity of incorporating AI agents as knowledge sources in a team's transactive memory system, as well as highlighting their role as catalysts for speaking up. Practical implications include suggestions for the design of future AI systems and human-AI team training in healthcare and beyond.

Identification of the barriers and enablers for receiving a speaking up message: a content analysis approach

BACKGROUND

Within healthcare, the barriers and enablers that influence clinicians' ability to speak up are well researched. However, despite the receiver of the message being identified as a key barrier to a speaker voicing a concern, there have been very few receiver-focused studies. As a result, little is known about the barriers and enablers that influence message reception. Understanding these can help inform speaking up training and ultimately enhance patient safety through more effective clinical communication.

OBJECTIVES

To identify enabling or inhibiting factors that influence the receiver's reception and response to a speaking up message, and if the identified barriers and enablers are related to speaker or receiver characteristics.

DESIGN AND METHODS

Twenty-two interdisciplinary simulations were video recorded and transcribed. Simulation participants formed the patient discharge team and were receivers of a speaking up message, delivered by a nurse at the patient's bedside. How the message was delivered (verbose or abrupt wording), was manipulated and counterbalanced across the simulations. Within the post simulation debriefs, barriers and enablers of being a receiver of a message were explored using content analysis.

SETTING/PARTICIPANTS

This study took place in a large Australian tertiary healthcare setting. Participants were qualified clinicians of varying disciplines and specialties.

RESULTS

A total of 261 barriers and 285 enablers were coded. Results showed that how the message was delivered (differing tone, phases, and manner) influenced what receivers identified as barriers and enablers. Additionally, the receiver's own cognitive processes, such as making positive attributions of the speaker and attempting to build rapport and collegiality, better enabled message reception and response. Receiver behaviour was negatively impacted by listening to fix, rather than understand, and not knowing in the moment how to manage their own reactions and appropriately frame a response.

CONCLUSION

The debriefings identified key barriers and enablers to receiving a speaking up message that differ from those previously identified for senders of the speaking up message. Current speaking up programs are predominately speaker centric. This study identified that both speaker and receiver behaviour influenced message reception. Therefore, training must place equal attention on both the speaker and receiver and be inclusive of experiential conversational rehearsal of both positive and challenging encounters.

Retrospective analysis of factors influencing the implementation of a program to address unprofessional behaviour and improve culture in Australian hospitals

BACKGROUND

Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers.

METHOD

Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers.

RESULTS

Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers.

CONCLUSION

Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring?

The history of inquiries into the failings of medical care have highlighted the critical role of communication and information sharing, meaning that speaking up and employee silence have been extensively researched. However, the accumulated evidence concerning speaking-up interventions in healthcare indicates that they achieve disappointing outcomes because of a professional and organizational culture which is not supportive. Therefore, there is a gap with regard to our understanding of employee voice and silence in healthcare, and the relationship between withholding information and healthcare outcomes (e.g., patient safety, quality of care, worker wellbeing) is complex and differentiated. The following integrative review is aimed at addressing the following questions; (1) How is voice and silence conceptualized and measured in healthcare?; and (2) What is the theoretical background to employee voice and silence?. An integrative systematic literature review of quantitative studies measuring either employee voice or employee silence among healthcare staff published in peer-reviewed journals during 2016-2022 was conducted on the following databases: PubMed, PsycINFO, Scopus, Embase, Cochrane Library, Web of Science, CINAHL and Google Scholar. A narrative synthesis was performed. A review protocol was registered on the PROSPERO register (CRD42022367138). Of the 209 initially identified studies for full-text screening, 76 studies met the inclusion criteria and were selected for the final review (N = 122,009, 69.3% female). The results of the review indicated the following: (1) concepts and measures are heterogenous, (2) there is no unifying theoretical background, and (3) there is a need for further research regarding the distinction between what drives safety voice versus general employee voice, and how both voice and silence can operate in parallel in healthcare. Limitations discussed include high reliance on self-reported data from cross-sectional studies as well as the majority of participants being nurses and female staff. Overall, the reviewed research does not provide sufficient evidence on the links between theory, research and implications for practice, thus limiting how research in the field can better inform practical implications for the healthcare sector. Ultimately, the review highlights a clear need to improve assessment approaches for voice and silence in healthcare, although the best approach to do so cannot yet be established.

The uses of Patient Reported Experience Measures in health systems: A systematic narrative review

BACKGROUND

Many governments have programmes collecting and reporting patient experience data, captured through Patient Reported Experience Measures (PREMs). Our study aims to capture and describe all the ways in which PREM data are used within healthcare systems, and explore the impacts of using PREMs at one level (e.g. national health system strategy) on other levels (e.g. providers).

METHODS

We conducted a narrative review, underpinned by a systematic search of the literature.

RESULTS

1,711 unique entries were identified through the search process. After abstract screening, 142 articles were reviewed in full, resulting in 28 for final inclusion. A majority of papers describe uses of PREMs at the micro level, focussed on improving quality of front-line care. Meso-level uses were in quality-based financing or for performance improvement. Few macro-level uses were identified. We found limited evidence of the impact of meso‑ and macro- efforts to stimulate action to improve patient experience at the micro-level.

CONCLUSIONS

PREM data are used as performance information at all levels in health systems. The use of PREM data at macro- and meso‑ levels may have an effect in stimulating action at the micro-level, but there is a lack of systematic evidence, or evaluation of these micro-level actions. Longitudinal studies would help better understand how to improve patient experience, and interfaces between PREM scores and the wider associated positive outcomes.

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study

BACKGROUND

Research focused on understanding what enables or hinders health professionals to speak up about a safety concern has been to date predominately atheoretical and speaker focused. However, the role the receiver of the message plays in these often-difficult encounters is highly influential. To date, speaking up programs have created conversational mnemonics that technically should respectfully engage the receiver, yet speaking up remains challenging. This paper utilises Communication Accommodation Theory to explore the impact the communication behaviour and speaker characteristics has on the receiver of a speaking up message, and if these impacts differ between receiver groups (clinical disciplines).

METHOD

Clinicians (N = 208) from varying disciplines responded to two hypothetical speaking up vignettes, where participants were the receivers of speaking up messages. Analysis of variance was used to explore any potential differences between receiver groups.

RESULTS

Findings indicated that the level of perceived accommodation and group membership, whether defined by speaker discipline or seniority, collectively influenced how the receiver of a speaking up message evaluated the interaction, which influenced their anticipated response to the speaker.

CONCLUSIONS

The receiver's perceptions and evaluations of the message, their own professional identity and the presence of others, influenced receivers' anticipated responses. This has direct implications on healthcare speaking up training and provision of care, as the varying clinical disciplines received and responded to the same messages differently.

Reducing preventable adverse events in obstetrics by improving interprofessional communication skills - Results of an intervention study

BACKGROUND

Progress in medicine involves the structured analysis and communication of errors. Comparability between the individual disciplines is only possible to a limited extent and obstetrics plays a special role: the expectation of a self-determined and joyful event meets with possibly serious complications in highly complex care situations. This must be managed by an interdisciplinary team with an increasingly condensed workload. Adverse events cannot be completely controlled. However, taking controllable risk factors into account and with a focused communication a reduction of preventable adverse events is possible. In the present study, the effect of interprofessional team training on preventable adverse events in an obstetric department was investigated.

METHODS

The training consisted of a 4-h interdisciplinary training session based on psychological theories. Preventable adverse events were defined in six categories according to potential patterns of causation. 2,865 case records of a refence year (2018) and 2,846 case records of the year after the intervention (2020) were retrospectively evaluated. To determine the communication training effect, the identified preventable adverse events of 2018 and 2020 were compared according to categories and analyzed for obstetrically relevant controllable and uncontrollable risk factors. Questionnaires were used to identify improvements in self-reported perceptions and behaviors.

RESULTS

The results show that preventable adverse events in obstetrics were significantly reduced after the intervention compared to the reference year before the intervention (13.35% in the year 2018 vs. 8.83% in 2020, p < 0.005). Moreover, obstetrically controllable risk factors show a significant reduction in the year after the communication training. The questionnaires revealed an increase in perceived patient safety (t(28) = 4.09, p < .001), perceived communication behavior (t(30) = -2.95, p = .006), and self-efficacy to cope with difficult situations (t(28) = -2.64, p = .013).

CONCLUSIONS

This study shows that the communication training was able to reduce preventable adverse events and thus increase patient safety. In the future, regular trainings should be implemented alongside medical emergency trainings in obstetrics to improve patient safety. Additionally, this leads to the strengthening of human factors and ultimately also to the prevention of second victims. Further research should follow up implementing active control groups and a randomized-controlled trail study design.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of University Hospital  (protocol code 114/19-FSt/Sta, date of approval 29 May 2019), study registration: NCT03855735 .

Employee silence in health care: Charting new avenues for leadership and management

ISSUE

Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive.

CRITICAL THEORETICAL ANALYSIS

Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture.

INSIGHT/ADVANCE

The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice.

PRACTICE IMPLICATIONS

Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care.

Creating healthy workplaces in healthcare: Are we delaying progress by focusing on what we can do rather than what we should do?

All the available evidence points to the fact that healthcare is under considerable stress, and while change is urgently needed there is no quick fix; systemic and sustained changes in organizational cultures within healthcare are required. Moreover, the fragility of healthcare systems globally has been starkly exposed by the Coronavirus 2019 pandemic. We have gathered enough evidence to know what is driving poor wellbeing, and how these processes impact on quality of care and patient safety. Indeed, we have a good idea of what we need to do to improve the situation. Therefore, this begs a simpler question; If we know how to create healthy workplaces, why is it so difficult to achieve this in healthcare? In the following perspective paper, we will argue that we can do better if we address the following three issues: (1) we are ignoring the real problems, (2) limited successes that we are achieving are moving us further from tackling the real problems, (3) culture change is accepted as crucial, but we are not accepting what the evidence is telling us about healthcare culture. Tackling burnout is useful and necessary, but we must increase dignity among healthcare employees. Moreover, we need to train line managers to recognize and facilitate the need of employees to feel competent and be appreciated by others, while helping them set wellbeing boundaries.

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals

PURPOSE

The study aimed to understand the significance of how employee personhood and the act of speaking up is shaped by factors such as employees' professional status, length of employment within their hospital sites, age, gender and their ongoing exposure to unprofessional behaviours.

DESIGN/METHODOLOGY/APPROACH

Responses to a survey by 4,851 staff across seven sites within a hospital network in Australia were analysed to interrogate whether speaking up by hospital employees is influenced by employees' symbolic capital and situated subjecthood (SS). The authors utilised a Bourdieusian lens to interrogate the relationship between the symbolic capital afforded to employees as a function of their professional, personal and psycho-social resources and their self-reported capacity to speak up.

FINDINGS

The findings indicate that employee speaking up behaviours appear to be influenced profoundly by whether they feel empowered or disempowered by ongoing and pre-existing personal and interpersonal factors such as their functional roles, work-based peer and supervisory support and ongoing exposure to discriminatory behaviours.

ORIGINALITY/VALUE

The findings from this interdisciplinary study provide empirical insights around why culture change interventions within healthcare organisations may be successful in certain contexts for certain staff groups and fail within others.

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.

Why Is Patient Safety a Challenge? Insights From the Professionalism Opinions of Medical Students' Research

OBJECTIVES

Despite increased emphasis on education and training for patient safety in medical schools, there is little known about factors influencing decision making regarding patient safety behaviors. This study examined the nature and magnitude of factors that may influence opinions around patient safety-related behaviors as a means of providing insights into how Australian doctors and medical students view these issues relative to members of the public.

METHODS

A national, multicenter, prospective, cross-sectional survey was conducted using responses to hypothetical patient safety scenarios involving the following: fabricating results, personal protective equipment, presenteeism, and reporting concerns.Australian enrolled medical students, medical doctors, and members of the public were surveyed.Participant responses were compared for the different contextual variables within the scenarios and the participants' demographic characteristics.

RESULTS

In total, 2602 medical student, 809 doctors, and 503 members of the Australian public participated. The 3 demographic groups had significantly differing opinions on many of the patient safety dilemmas. Doctors were more tolerant of medical students not reporting concerning behaviors and attending placements despite recent illness. Medical students' opinions frequently demonstrated a "transition effect," bridging between the doctors and publics' attitudes, consistent with professional identity formation.

CONCLUSIONS

Opinions on the acceptability of medical students' patient safety-related behaviors were influenced by the demographics of the cohort and the contextual complexity of the scenario. Although the survey used hypothetical scenarios, doctors and medical students' opinions seem to be influenced by cognitive dissonances, biases, and heuristics, which may negatively affect patient safety.

The Impact of a 22-Month Multistep Implementation Program on Speaking-Up Behavior in an Academic Anesthesia Department

BACKGROUND

Speaking-up is a method of assertive communication that increases patient safety but often encounters barriers. Numerous studies describe programs introducing speaking-up with varying success; the common denominator seems to be the need for a multimodal and sustained approach to achieve the required change in behavior and culture for safer health care.

METHODS

Before implementing a 22-month multistep program for establishing and strengthening speaking-up at our institution, we assessed perceived safety culture using the "Safety Attitudes Questionnaire." After program completion, participants completed parts of the same Safety Attitudes Questionnaire relevant to speaking-up, and preresult and postresult were compared. In addition, levels of speaking-up and assertive communication were compared with a Swiss benchmark using results from the "Speaking-up About Patient Safety Questionnaire."

RESULTS

Safety Attitudes Questionnaire scores were significantly higher after program completion in 2 of 3 answered questions (median [first quartile, third quartile), 5.0 [4.0, 5.0] versus 4.0 [4.0, 5.0], P = 0.0002, and 5.0 [4.0, 5.0] versus 4.0 [4.0, 4.0] P = 0.002; n = 34). Our composite score on the Speaking-up About Patient Safety Questionnaire was significantly higher (mean ± SD, 5.9 ± 0.7 versus 5.2 ± 1.0; P < 0.001) than the benchmark (n = 65).

CONCLUSIONS

A long-term multimodal program for speaking-up was successfully implemented. Attitude and climate toward safety generally improved, and postprogram perceived levels of assertive communication and speaking-up were higher than the benchmark. These results support current opinion that multimodal programs and continued effort are required, but that speaking-up can indeed be strengthened.

Exposure to incivility does not hinder speaking up: a randomised controlled high-fidelity simulation-based study

BACKGROUND

Speaking up with concerns is critical for patient safety. We studied whether witnessing a civil (i.e. polite, respectful) response to speaking up would increase the occurrence of further speaking up by hospital staff members as compared with witnessing a pseudo-civil (i.e. vague and slightly dismissive) or rude response.

METHODS

In this RCT in a single, large academic teaching hospital, a single simulated basic life support scenario was designed to elicit standardised opportunities to speak up. Participants in teams of two or three were randomly assigned to one of three experimental conditions in which the degree of civility in reacting to speaking up was manipulated by an embedded simulated person. Speaking up behaviour was assessed by behaviour coding of the video recordings of the team interactions by applying 10 codes using The Observer XT 14.1. Data were analysed using multilevel modelling.

RESULTS

The sample included 125 interprofessional hospital staff members (82 [66%] women, 43 [34%] men). Participants were more likely to speak up when they felt psychologically safe (γ=0.47; standard error [se]=0.19; 95% confidence interval [CI], 0.09-0.85; P=0.017). Participants were more likely to speak up in the rude condition than in the other conditions (γ=0.28; se=0.12; 95% CI, 0.05-0.52; P=0.019). Across conditions, participants spoke up most frequently by structuring inquiry (n=289, 31.52%), proactive (n=240, 26.17%), and reactive (n=148, 16.14%) instruction statements, and gestures (n=139, 15.16%).

CONCLUSION

Our study challenges current assumptions about the interplay of civility and speaking up behaviour in healthcare.

Speaking-up for patient safety: A scoping narrative review of international literature and lessons for radiography in Ghana and other resource-constrained settings

OBJECTIVES

Employees 'speaking-up', or raising concerns about unsafe practices, has gained traction across healthcare, however, the topic has not been widely discussed within radiography generally or within resource-constrained healthcare settings. A systematic scoping narrative review identified the experiences of radiographers in speaking-up about safety concerns, which was extended to healthcare professionals more broadly. The scope of the review was further extended to cover speaking-up in non-healthcare resource-constrained settings in Africa.

KEY FINDINGS

Sixty-three studies were included in the review. The majority originated from westernised and/or higher resource health systems, with a dearth of literature from Africa and other resource-constrained settings. Several studies identified barriers and enablers confronting healthcare workers wishing to speak-up. While 'speaking-up' as a concept has gained international interest, most studies are, however, focussed on nursing and medical practice contexts, overlooking other healthcare professions, including radiography. The findings are synthesised into a series of key lessons for healthcare and radiography practitioners in Ghana and other resource-constrained settings.

CONCLUSION

The topic has been largely overlooked by policy makers, both within healthcare generally and specifically within radiography in Ghana. This is particularly concerning given the many complexities and risks inherent to radiography. A radiography and a healthcare workforce lacking in voice is poorly positioned to improve workers' safety and patient safety. More generally, promoting speaking up could enhance Ghana's ambitions to deliver a high-quality health care system and Universal Health Coverage (UHC) in the future.

IMPLICATIONS FOR PRACTICE

National and regional policy makers need to implement speaking-up processes and procedures reflecting the lessons of the literature review, such as ensuring no detriment as result of speaking-up and making staff feel that their concerns are not futile. Speaking-up processes should be implemented by individual organisations, alongside staff training and monitoring.

Understanding the Link Between Burnout and Sub-Optimal Care: Why Should Healthcare Education Be Interested in Employee Silence?

Evidence on the association of burnout with objective indicators of performance is scarce in healthcare. In parallel, healthcare professionals ameliorate the short-term impact of burnout by prioritizing some tasks over others. The phenomenon of employee silence can help us understand the evolution of how culture is molded toward the prioritization of some tasks over others, and how this contributes to burnout. Silence in healthcare has been associated with concealing errors, reduced patient safety, and covering up errors made by others. Conversely, there is evidence that in organizations where employees are encouraged to speak up about concerns, and where concerns are responded to appropriately, better patient outcomes such as improved patient safety and patient experience occur. Interventions to promote "speaking-up" in healthcare have not been successful and are rooted in a professional culture that does not promote speaking out. In this paper, we review the evidence that exists within healthcare to argue why healthcare education should be interested in employee silence, and how silence is a key factor in understanding how burnout develops and impacts quality of care. The following key questions have been addressed; how employee silence evolves during medical education, how is silence maintained after graduation, and how can leadership style contribute to silence in healthcare. The impact of withholding information on healthcare professional burnout, patient safety and quality of care is significant. The paper concludes with a suggested future research agenda and additional recommendations.

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service

Employee voice is an important source of organizational intelligence about possible problems in quality and patient safety, but effective systems for encouraging and supporting those who seek to speak up have remained elusive. In the English National Health Service, a novel role known as the 'Freedom to Speak Up Guardian' has been introduced to address this problem. We critically examine the role and its realization in practice, drawing on semi-structured interviews with 51 key individuals, including Guardians, clinicians, managers, policymakers, regulators and others. Operationalizing the new role in organizations was not straightforward, since it had to sit in a complex set of existing systems and processes. One response was to seek to bound the scope of Guardians, casting them in a signposting or coordinating role in relation to quality and safety concerns. However, the role proved hard to delimit, not least because the concerns most frequently voiced in practice differed in character from those anticipated in the role's development. Guardians were tasked with making sense of and dealing with issues that could not always straightforwardly be classified, deflected to the right system or escalated to the appropriate authority. Our analysis suggests that the role's potential contribution might be understood less as supporting whistleblowers who bear witness to clear-cut wrongdoing, and more as helping those with lower-level worries to construct their concerns and what to do with them. These findings have implications for how voice is understood, imagined and addressed in healthcare organizations.