Speaking up about patient safety in psychiatric hospitals - a cross-sectional survey study among healthcare staff

Speaking Up About Patient Safety, Withholding Voice and Safety Climate in Clinical Settings: a Cross-Sectional Study Among Ibero-American Healthcare Students

Objectives

To explore speaking up behaviours, barriers to openly expressing patient safety concerns, and perceived psychological safety climate in the clinical setting in which healthcare trainees from Ibero-America were receiving their practical training.

Methods

Cross-sectional survey of healthcare trainees from Colombia, Mexico, and Spain (N = 1,152). Before the field study, the Speaking Up About Patient Safety Questionnaire (SUPS-Q) was translated into Spanish and assessed for face validity. A confirmatory factor analysis was conducted to establish the construct validity of the instrument, and the reliability was assessed. The SUPS-Q was used to evaluate voice behaviours and the perceived psychological safety climate among Ibero-American trainees. Descriptive and frequency analyses, tests for contrasting means and proportions, and logistic regression analyses were performed.

Results

Seven hundred and seventy-one trainees had experience in clinical settings. In the previous month, 88.3% had experienced patient safety concerns, and 68.9% had prevented a colleague from making an error. More than a third had remained silent in a risky situation. Perceiving concerns, being male or nursing student, and higher scores on the encouraging environment scale were associated with speaking up.

Conclusion

Patient safety concerns were frequent among Ibero-American healthcare trainees and often silenced by personal and cultural barriers. Training in speaking up and fostering safe interprofessional spaces is crucial.

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.

Speaking Up: Exploring Mental Health Care Workers' Patient Safety Concerns

PURPOSE

To explore the perspectives and experiences of mental health care workers (MHCWs) when speaking up about patient safety concerns.

METHOD

A qualitative study was performed at Farshchian (Sina) Hospital in Iran, involving the purposive sampling of MHCWs from three inpatient psychiatric wards. From July to October 2022, semi-structured interviews were conducted with 23 participants. Data were analyzed using conventional content analysis.

RESULTS

Three major patient safety themes were identified: (a) Voicing Concerns for Daily Safety (subthemes: daily safety check-ins and speaking up to prevent patient harm); (b) Speaking Up to Save Future Lives (subthemes: whistleblowing, leadership, and being open to communication); and (c) Hesitating to Speak Up (sub-themes: ineffectiveness of raising one's voice and whispering).

CONCLUSION

MHCWs have various concerns about speaking up or staying silent. Failure to communicate can result in adverse events and missed opportunities to address patient safety. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

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.

Adaptation and validation of a Korean version of the speaking up about patient safety questionnaire (KSUPS-Q)

BACKGROUND

Speaking up by healthcare providers is an essential assertive communication strategy for ensuring patient safety and preventing incidents. However, more is needed to know about speaking up and instruments to assess it in the Korean context. Therefore, we assessed the psychometric properties of the Korean version of the Speaking Up about Patient Safety Questionnaire (KSUPS-Q) for measuring speaking up-related behavior and climate among nurses.

METHODS

The translation and adaptation process followed the guidelines of the International Society for Pharmacoeconomics and Outcomes Research and the World Health Organization. Content validity was assessed by a six-member expert panel using the content validity index. In total, 314 nurses participated in an online survey to examine the psychometric properties. Internal consistencies were tested using Cronbach's alpha and McDonald's omega. Confirmatory factor analyses were conducted to examine the subscales' construct. The convergent validity of the speaking up-related climate scale was assessed by testing correlations with teamwork and safety climate domains of the Safety Attitudes Questionnaire. In addition, we investigated the convergent validity of the speaking up-related behavior scale by examining its correlation with the climate scale.

RESULTS

The reliability of the 11-item behavior scale was satisfactory. Confirmatory factor analysis confirmed that a three-subscale model (perceived concerns, withholding voice, and speaking up) was appropriate (CFI = 0.98, TLI = 0.98, and SRMR = 0.05). Furthermore, the 11-item climate scale demonstrated satisfactory internal consistency. A three-subscale model (psychological safety, encouraging environment, and resignation) was confirmed (CFI = 0.98, TLI = 0.97, and SRMR = 0.05). The convergent validity of the climate scale was verified based on correlations with the teamwork (r = 0.68, p < 0.001) and safety climate (r = 0.68, p < 0.001) domains of the Safety Attitudes Questionnaire. In addition, speaking up-related behavior and climate showed a significant association, indicating that the behavior scale is conceptually valid.

CONCLUSIONS

This study demonstrates that the KSUPS-Q is a valid and reliable instrument in Korea. This instrument can help nurse managers simultaneously monitor the behavior and climate of their organizations and evaluate the outcomes of interventions to enhance speaking up. Future research is needed to explore diverse factors contributing to speaking up, including clinical roles, team relationships, and supportive culture, to identify areas requiring further improvement.

Iranian nurses' attitudes towards the disclosure of patient safety incidents: a qualitative study

OBJECTIVE

Statistics suggests that patients and officials are unaware of a large number of patient safety incidents in healthcare centres. This study aimed to explore the concept of disclosure of patient safety incidents from the perspectives of Iranian nurses.

DESIGN

Qualitative content analysis.

SETTING

The study population was nurses working in hospitals affiliated with The Hormozgan University of Medical Sciences, military hospitals and private hospitals in Bandar Abbas, Iran. Sampling was done from January 2021 to September 2021.

PARTICIPANTS

11 female and 6 male nurses aged 27-59 years with a work experience of 3-34 years were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

This qualitative content analysis was to explore the experiences of Iranian nurses (n=17) using purposive sampling and semistructured, in-depth interviews. Maximum variation sampling (age, sex, work experience, education level, type of hospital and type of ward) was considered to obtain rich information. Guba and Lincoln criteria were used to increase the study's trustworthiness and rigour, and the Graneheim and Lundman method and MAXQDA 2020 were used to analyse data.

RESULTS

We extracted one theme, four categories and nine subcategories. The main theme was the mental schemas of disclosure of patient safety incidents with four categories: (1) misconceptions of harm to the organisation or self, (2) attributes of the disclosure process and its outcomes, (3) reactions to the disclosing incidents and (4) interpersonal conflicts.

CONCLUSION

Our study identified factors influencing the disclosure of patient safety incidents among nurses, including concerns about reputation, fear of consequences and perceptions of the disclosure process. Positive attitudes towards incident disclosure were associated with supportive organisational environments and transparent communication. Barriers to disclosure included patient and companion reactions, misinterpretation and anxiety. Healthcare organisations should foster a non-punitive reporting culture to enhance patient safety and accountability.

Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

BACKGROUND

The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context.

OBJECTIVE

This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence.

DESIGN

A cross-sectional, correlational study design was employed.

SETTINGS

Study data were collected in 34 general hospitals in South Korea.

PARTICIPANTS

A total of 1255 registered nurses providing direct care to patients were included in this study.

METHODS

Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %.

RESULTS

The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = -0.10, 95 % confidence interval [-0.143, -0.059]) and silence (β = -0.04, 95 % confidence interval [-0.058, -0.014]), and psychological safety also decreased burnout through voice (β = -0.04, 95 % confidence interval [-0.057, -0.016]) and silence (β = -0.07, 95 % confidence interval [-0.101, -0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant.

CONCLUSIONS

It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ.

REGISTRATION

Not applicable.

TWEETABLE ABSTRACT

Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.

South Korean Nurses' Experiences of Speaking up for Patient Safety and Incident Prevention

Despite the importance of speaking up for patient safety, hesitancy to do so remains a major contributing factor to communication failure. This study aimed to investigate the experiences of South Korean nurses in speaking up to prevent patient safety incidents. Twelve nurses responsible for patient safety tasks or with experience in patient safety education were recruited from five hospitals (three university hospitals, two general hospitals) in city "B". Data were collected through open-ended questions and in-depth interviews, transcribed, and analyzed using the inductive content analysis method. The study resulted in the identification of four main categories and nine subcategories that captured commonalities among the experience of the 12 nurses. The four main categories were as follows: the current scenario of speaking up, barriers to speaking up, strategies for speaking, and confidence training. There is a scarcity of research on speaking-up experiences for patient safety among nurses in South Korean. Overall, it is necessary to overcome cultural barriers and establish an environment that encourages speaking up. In addition, developing speaking-up training programs for nursing students and novice nurses is imperative to prevent patient safety incidents.

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.

Patient Safety Culture and Speaking Up Among Health Care Workers

PURPOSE

Although previous research showed the importance of safety culture on health care workers' speaking up behaviors, it is not clear how particular safety culture domains are associated with the speaking up behaviors of hospital staff. Also, researchers have suggested that health care workers' speaking up behaviors vary by profession, but there has been limited research into such differences. Thus, this study examined differences in perceptions of patient safety culture and the promotive and prohibitive speaking up behaviors of health care workers by profession and investigated the relationships between patient safety culture and the two types of speaking up behaviors.

METHODS

A descriptive correlational study was conducted using secondary data collected through an online survey of health care workers at a private, nonprofit, tertiary-level teaching hospital in South Korea. The sample (N = 831) consisted of nurses (54.0%), physicians (13.0%), and other licensed and unlicensed hospital personnel (33.0%). Analyses of variance were conducted to examine differences in study variables by profession. Hierarchical regression analyses were conducted to evaluate the effects of the seven patient safety culture factors on promotive and prohibitive voice after controlling for tenure and profession.

RESULTS

Perceptions of safety culture and promotive voice behaviors were higher for physicians compared with nurses. Communication openness, reporting patient adverse events, and unit supervisors' and hospital managements' support for patient safety were significant predictors of both types of voice behaviors.

CONCLUSION

Hospital administrators and unit managers should create a supportive environment where staff feel free to voice their concerns and suggestions. They should also pay attention to the varying perspectives held by different groups of hospital workers and their different voice behaviors. Knowing which dimensions of patient safety culture are most strongly related to health care workers' voice behaviors can guide patient safety improvement activities in health care organizations.

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.

Effectiveness of speak-up training programs for clinical nurses: A scoping review

BACKGROUND

Speaking up about patient safety concerns is critical when bedside nurses encounter unsafe situations. Training programs that encourage nurses' speaking up behavior have been introduced, but there is limited evidence regarding whether such training leads to behavior change or improves patient safety.

OBJECTIVE

The aim of this review was to identify the effectiveness of speak-up training programs for clinical nurses, focusing on program content and outcomes.

DESIGN

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to the Cochrane and Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines.

METHODS

This study used bibliographic databases of PubMed, Embase, PsycINFO, Scopus, ProQuest Dissertations and Theses Global for the English language, and NDSL, KCI, RISS, KISS, and DBpia for the Korean language. The literature search used a combination of keywords and subject headings related to speak-up training programs for nurses or any type of nurse training program with an assertiveness component. Training outcomes were evaluated according to the 4-level Kirkpatrick model.

RESULTS

A total of 4808 references were retrieved, of which 21 articles were selected. These 21 studies were conducted in different parts of the world and published from 1981 to 2020. Speak-up training primarily increased some degree of nurses' levels of assertiveness and speak-up behavior, and also led to secondary outcomes such as job stress, work motivation, and communication conflicts. Most studies (n = 19) applied traditional training formats which consisted of multi-session lectures and practice, whereas three studies applied new methodologies such as high-fidelity simulations and online learning. According to the Kirkpatrick model, five studies assessed reactions to speak-up training (level 1), all studies evaluated learning as a result of training (level 2), two studies measured the effect of speak-up training on nurses' behavior (level 3), and one study evaluated nurses' results (level 4) while no studies evaluated patient-level outcomes.

CONCLUSIONS

Speak-up training for nurses can improve their levels of assertiveness or speak-up behaviors. Despite inconsistent or mixed findings, speak-up training has the potential to improve nurses' psychological well-being, leading to positive organizational performance. New training methods are directed at specialized education for clinical situations. Future speak-up training should consist of training programs based on real clinical situations in which team members participate together to comprehensively evaluate the effect of training on behavioral changes of health professionals as well as patient safety.

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) Survey: A Brief, Diagnostic, and Actionable Metric for the Ability to Speak Up in Healthcare Settings

OBJECTIVES

The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds).

METHODS

Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives.

RESULTS

The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds.

CONCLUSIONS

The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.

Hospital management and supervisor support and nurse speaking-up behaviors: The mediating role of safety culture perception

AIMS

This study aimed to (a) elucidate the effects of hospital management and unit supervisor support for patient safety on nurse speaking-up behaviors and (b) identify potential mediators of this relationship.

BACKGROUND

Speaking-up behavior among nurses has emerged as a critical source of patient safety. Fuller understanding of the developmental mechanisms contributing to nurses' speaking-up behaviors could help to enhance patient safety in healthcare organizations.

METHODS

A correlational approach was used to conduct a secondary analysis of cross-sectional survey data collected from 450 staff nurses in Korea. Path analysis was performed to test potential mediation effects.

RESULTS

After controlling for nurses' hospital and unit tenure, hospital management and supervisor support for patient safety had significant direct and indirect effects on nurses' speaking-up (promotive and prohibitive voice) behaviors through their perceptions of response to error and communication openness.

CONCLUSIONS

Study findings indicate that when hospital management and supervisors emphasize patient safety and provide necessary resources, nurses are likely to perceive the hospital's safety culture more positively, in turn enhancing their speaking-up behaviors.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital administrators and nurse managers should clearly display hospital management and supervisory support for patient safety through implementation of related policies, resources, and communication standards.

Determinants of the intention to speak up about medical error in primary healthcare settings in Chile

Medical error frequently occurs in ambulatory care, and healthcare professionals may encounter situations in which they need to speak up to ensure better practice. This study aims to investigate the factors that influenced the intention to speak up about medical errors among healthcare professionals in primary care settings. Data were generated through a national cross-sectional survey of primary healthcare centres in the Republic of Chile. A research instrument was designed using the constructs of the theory of planned behaviour and was analysed using the structural equation model technique. In total, 203 healthcare professionals were recruited between March and May 2020. The model showed that the intention to speak up was directly and positively influenced by attitudes towards speaking up and perceived control (standard deviation [SD] = 0.284 and 0.576, respectively). Subjective norms indirectly and negatively influenced the intention to speak up through attitudes towards speaking up and perceived control (total effect SD = -0.303). The exploratory construct of willingness to change self-behaviour positively influenced the attitude towards behaviour. The intention to speak up strongly influenced the speaking up behaviour (total effect SD = 0.631). The proposed model explained 40% of the variance in behaviour. Based on this model, it was concluded that the intention to speak up strongly influenced the speaking up behaviour and predicted it by 40%. Factors that modify the intention to speak up are expected to influence the occurrence of this behaviour. This knowledge will inform strategies to enhance communication among healthcare professionals, improve speaking up behaviour and improve patient care.

Motivators and inhibitors of nurses' speaking up behaviours: A descriptive qualitative study

AIMS

To identify factors that motivate or inhibit nurses' speaking up for patient safety.

DESIGN

A descriptive qualitative study.

METHODS

We conducted semi-structured interviews with 15 nurses from four Korean hospitals between December 2020 and January 2021. Data were analysed using inductive content analysis.

RESULTS

We identified safety culture, supportive unit managers and role models, positive reactions from or familiarity with others, high-risk situations and personal characteristics and beliefs as motivators of nurses' speaking up. Hierarchies and power differentials, seniority and unit tenure, concerns about relationships, and heavy workloads inhibited nurses' speaking up.

CONCLUSION

Individual, organizational and cultural characteristics influence nurses' decisions on whether or not to voice their concerns, suggestions or ideas. Certain characteristics of Korean culture, such as strong hierarchies and the valuing of good relationships, play an important role in nurses' speaking up behaviours. Our findings can be used to inform educational interventions and management expectations about interpersonal behaviours, especially in a culture where age- and seniority-based hierarchies and collectivism are prevalent.

IMPACT

Nurses perceived speaking up as a challenging behaviour, and they sometimes withhold their voices even when speaking up is needed for patient safety. We found that individual, organizational, and contextual factors affect the speaking up behaviours of nurses. Nurse managers can create environments that are more supportive of nurses' speaking up behaviours by using inclusive leadership to create psychological safety, by inviting and showing appreciation for staff input, and by helping physicians and senior nurses understand the importance of all nurses' voices.

NO PATIENT OR PUBLIC CONTRIBUTION

Patient or public contribution does not apply to this study as its purpose was to explore the speaking up experiences of nurses themselves.

Voluntary patient safety incidents reporting in forensic psychiatry-What do the reports tell us?

WHAT IS KNOWN ON THE SUBJECT?: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture; however, there is limited knowledge about patient safety in forensic psychiatric care. There are distinct patient safety issues in psychiatric nursing, associated (inter alia) with the self-harm, violence, seclusion/restrain and restrictions. Many adverse events are preventable. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: No harm was caused to patients in less than half (51%) of all reported incidents (in a Finnish forensic psychiatric hospital during a six-year period) considered in this study. The most common location of violent incidents was corridors (31%), followed by day rooms (20%), and patient rooms (15%). The most common patient safety incidence type was violence against another patient (38%), which typically occurred in corridors (36%), dayrooms (25%) and patient rooms (15%), and was usually related to daily activities in the afternoon (1,400-1,600 hr) and evening (1,800-2,000 hr). Typically, recommendations for improving patient safety focus on human behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need to notify and report all patient safety incidents (following staff training), learn from previous incidents (also learn for success), prevent typical incidents, learn for success, promote patient participation in incident prevention, share development measures outside the ward to enable exploitation by others and strengthen safety culture. In forensic psychiatry, conversation with patients regarding safety measures is strongly recommended to prevent patient safety incidents related to violence. The perspective should be extended from patient-specific factors to general factors such as patient treatment and general comfort and privacy.

ABSTRACT

INTRODUCTION: Patient safety incident reporting has been recognized as a key process for organizational learning and safety culture, but there is limited knowledge about patient safety in forensic psychiatric care.

AIMS

To characterize the types and frequencies of incidents in forensic psychiatric care and assess the implications for practice.

METHODS

Data were collected from a patient safety incident reporting system (PSiRS) database of one forensic psychiatry hospital in Finland and analysed using descriptive statistics.

RESULTS

No harm was caused in more than half of the 2,521 reported incidents examined (51%, n = 1,260). The most frequently recorded incident type was violence (38%), which typically occurred in corridors (31%) or dayrooms (20%). The most frequently recommended action to prevent violent events was that potential risks should be discussed (77%).

DISCUSSION

Patient safety incidents related to violence are common in forensic psychiatric hospitals. Although very few adverse events were classified as causing serious harm to patients, many cases of violence could be prevented by identifying potential circumstances that lead to violence.

IMPLICATIONS FOR PRACTICE

Staff need encouragement and training to detect and report all patient safety incidents. Safety culture is strengthened by learning and sharing development measures to improve patient safety.

Factors associated with medical students speaking-up about medical errors: A cross-sectional study

BACKGROUND

Training medical students to speak up when they witness a potential error is an important competency for patient safety, but details regarding the barriers that prevent medical students from effectively communicating are lacking. Therefore, this study aimed at exploring the factors affecting medical students' willingness to speak up for patient safety when a medical error was observed.

METHODS

This is a cross-sectional study at a medical university in Taiwan, and 151 medical students in clinical clerkship completed a survey including demographic characteristics, conflict of interests/social relationship, personal capability, and personality and characteristics of senior staff domains. Data were analyzed using t-test.

RESULTS

Three of five items in the conflict of interests/social relationship domain showed statistically significant importance, including 'I am afraid of being punished' (Mean difference, MD = 0.37; p < 0.01), 'I do not want to break unspoken rules' (MD = 0.55; p < 0.01), and 'I do not want to have bad team relationship' (MD = 0.58; p < 0.01). Two items (perception of knowledge/understanding and communication skills) in the personal capability domain were significantly important to speaking up. Six of 10 items in personality and characteristics of senior staff domain were rated significantly important in deciding to speak up. The top three factors of them were senior personnel with 'Grumpy' personality (MD = 1.20; p < 0.01), 'hierarchy gap' (MD = 1.12; p < 0.01), and senior personnel with 'Stubborn' personality (MD = 1.06; p < 0.01).

CONCLUSION

Our findings demonstrated medical students' perspectives on barriers to speaking up in the event of medical error. Some factors related to characteristics of senior staff could compromise medical students' ability to speak up in the event of medical error. These results might be important for medical educators in designing personalized educational activities related to medical students' ability to speak up for patient safety.

A concept analysis of psychological safety: Further understanding for application to health care

AIM

To clarify the concept of psychological safety in a healthcare context and to provide the first theoretical framework for improving interpersonal relationships in the workplace to better patient care.

DESIGN

A Rodgers' concept analysis.

METHODS

The concept analysis was conducted using a systematic search strategy on PubMed, CINAHL, PsycINFO and Ichushi-Web.

RESULTS

An analysis of 88 articles studying psychological safety in health care identified five attributes: perceptions of the consequences of taking interpersonal risks, strong interpersonal relationships, group-level phenomenon, safe work environment for taking interpersonal risks and non-punitive culture. The antecedents included structure/system factors, interpersonal factors and individual factors. The four consequences included performance outcomes, organizational culture outcomes, and psychological and behavioural outcomes.

Risk factors for self-harm in psychiatric wards: A judicial case analysis

Patients hospitalized in a psychiatric ward may engage in self-injurious behavior secretly, leading to fatal consequences. This study aimed to identify risk factors for self-harm in psychiatric wards. In this review, the framework of Taylor and Hignett's medical malpractice analysis was utilized. In the search conducted from March to April 2020, keywords were used to collect relevant judgments and previous studies. The final assessment comprised of 5 cases and 13 previous studies. The results of this study emphasize the creation of a ward environment where inpatients can feel secure, and the staff can actively engage in therapeutic communication.

Factors Influencing Nurses' Willingness to Speak Up Regarding Patient Safety in East Asia: A Systematic Review

Speaking up for patient safety among health care professionals is important because it can contribute to the prevention of adverse patient events, such as medication errors, infections, wrong-site surgical procedures, and other sentinel events. This systematic review identified factors that facilitate or inhibit nurses' willingness to speak up regarding patient safety in East Asian hospitals. Following the steps of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four databases, including PubMed, CINAHL, PsycInfo, and Web of Science, were searched. Nine studies were analyzed in this review, including five qualitative and four quantitative studies published between 2014 and 2019. Quality of included studies were evaluated using the Mixed-Method Appraisal Tool. Data synthesis was based upon qualitative-led synthesis adopting two existing multilevel frameworks on safety voice and employee voice signals. Four studies were conducted in Japan, three in South Korea, one in Hong Kong, and one in Taiwan. We organized factors influencing East Asian nurses' willingness to speak up regarding patient safety according to the following four contexts: individual (motivation toward patient safety, organizational commitment, perceived effectiveness and importance of speaking up, and assertive personality), team (positive relationship and team trust, team culture, and mentoring), organizational (hospital administrative support and organizational culture) and sociocultural (hierarchy and power differential and collectivistic culture). However, due to the limited number of studies conducted in East Asian hospitals, further studies with larger cohort samples of nurses in various East Asian countries should be conducted to deepen our understanding of nurses' willingness to voice their concerns for patient safety.