The experience of learning to speak up: a narrative inquiry on newly graduated registered nurses

"You're Not Understood, and You're Isolated": A Narrative Account of Loneliness by Black Older Adults in Ontario, Canada

Loneliness among older adults is a leading health and social concern globally and in Canada, including racialized and minoritized groups. Although previous studies have explored loneliness among ethnic minoritized groups in Canada, little is known about the constellating factors contributing to loneliness among native-born and immigrant Black older adults (BOAs) in Canada and their unique ways of dealing with the experience. Our study explores the constellating factors shaping loneliness experiences among BOAs living in Ontario. Using a narrative approach, we purposively selected and interviewed 13 BOAs. Time as a driver of change, a sense of belonging reinforced through place identity, and challenges of making a new home were dominant themes. Our finding highlights the need for increased cultural sensitivity at the micro and macro levels, which will improve a sense of belonging and reduce loneliness among racialized immigrant older adults.

Exploring the role of communication in effective nurse leadership and patient care

Nurses have to be aware of their personal responsibility to demonstrate effective leadership and thereby contribute to safe and effective patient care. One of the primary skills that nurses can use to become effective leaders is communication. This article explores how communication is a vital tool in enabling nurse leaders to motivate their team members and advocate for patients. The author details some of the essential communication skills that nurses require if they are to promote person-centred care and explores the often-neglected areas of non-verbal and written communication. By possessing a full range of communication skills, nurses can empower themselves to lead clinical teams and advocate for patients.

Defining Speaking Up in the Healthcare System: a Systematic Review

BACKGROUND

Communication issues have been shown to contribute to healthcare errors. For years healthcare professionals have been told to "speak up." What "speak up" means is unclear, as it has been defined and operationalized in many ways. Thus, this study aimed to systematically review the literature regarding definitions and measurements of speaking up in the healthcare system and to develop a single, comprehensive definition and operationalization of the concept.

METHODS

PubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete databases were searched from 1999 to 2020. Publications were included if they mentioned speaking up for patient safety or any identified synonyms. Articles that used the term speaking up concerning non-health-related topics were excluded. This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 294 articles met the inclusion criteria, yet only 58 articles focused on speaking up. While the most common synonym terms identified were "speak up" and "raise concern," only 43 articles defined speaking up. Accordingly, a modified definition was developed for speaking up-A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

DISCUSSION

Speaking up is considered important for patient safety. Yet, there has been a lack of agreement on the definition and operationalization of speaking up. This review demonstrates that speaking up should be reconceptualized to provide a single definition for speaking up in healthcare.

The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis

INTRODUCTION

Psychological safety is the shared belief that the team is safe for interpersonal risk taking. Its presence improves innovation and error prevention. This evidence synthesis had 3 objectives: explore the current literature regarding psychological safety, identify methods used in its assessment and investigate for evidence of consequences of a psychologically safe environment.

METHODS

We searched multiple trial registries through December 2018. All studies addressing psychological safety within healthcare workers were included and reviewed for methodological limitations. A thematic analysis approach explored the presence of psychological safety. Content analysis was utilised to evaluate potential consequences.

RESULTS

We included 62 papers from 19 countries. The thematic analysis demonstrated high and low levels of psychological safety both at the individual level in study participants and across the studies themselves. There was heterogeneity in responses across all studies, limiting generalisable conclusions about the overall presence of psychological safety. A wide range of methods were used. Twenty-five used qualitative methodology, predominantly semi-structured interviews. Thirty quantitative or mixed method studies used surveys. Ten studies inferred that low psychological safety negatively impacted patient safety. Nine demonstrated a significant relationship between psychological safety and team outcomes. The thematic analysis allowed the development of concepts beyond the content of the original studies. This analytical process provided a wealth of information regarding facilitators and barriers to psychological safety and the development of a model demonstrating the influence of situational context.

DISCUSSION

This evidence synthesis highlights that whilst there is a positive and demonstrable presence of psychological safety within healthcare workers worldwide, there is room for improvement. The variability in methods used demonstrates scope to harmonise this. We draw attention to potential consequences of both high and low psychological safety. We provide novel information about the influence of situational context on an individual's psychological safety and offer more detail about the facilitators and barriers to psychological safety than seen in previous reviews. There is a risk of participation bias - centres involved in safety research may be more aligned to these ideals. The data in this synthesis are useful for institutions looking to improve psychological safety by providing a framework from which modifiable factors can be identified.

Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff

OBJECTIVES

This study aimed to quantify the presence of psychological safety (defined as an environment 'safe for interpersonal risk taking') in critical care staff, exploring the ways in which this manifested.

DESIGN

Qualitative interview study incorporating a short quantitative survey.

SETTING

Three intensive care units within one National Health Service Trust in London.

PARTICIPANTS

Thirty participants were recruited from all levels of seniority and roles within the multidisciplinary team. A purposive sampling technique was used, with recruitment ceasing at the point of thematic saturation.

INTERVENTIONS

Semistructured interviews explored attitudes towards psychological safety and contained a quantitative assessment measuring the climate of psychological safety present.

RESULTS

Twenty-eight participants agreed that it was easy to ask for help, with 20 agreeing it is safe to take a risk on the team, demonstrating a strong perception of psychological safety in this group.Our thematic analysis highlighted areas where the context influenced an individual's psychological safety including personality, culture and leadership. Possible negative consequences of psychological safety included distraction and fatigue for the team leader. We demonstrated that speaking up can be influenced by motivations other than patient safety, such as undermining or self-promotion.

CONCLUSIONS

Our data demonstrate reassuring levels of psychological safety within the participants studied. This allowed us to explore in depth the participant experience of working within a psychologically safe environment. We add to the current literature by uniquely demonstrating there can be negative consequences to a psychologically safe environment in the healthcare setting. We expand on the influence of context on psychological safety by developing a model, allowing leaders to identify which elements of context can be modified in order to promote speaking up. Team leaders can use these data to help foster a culture of openness, innovation and error prevention while minimising the risk of negative implications.

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.

Appreciative inquiry as an intervention to improve nursing and midwifery students transitioning into becoming new graduates: An integrative review

OBJECTIVE

To identify, critique and synthesise the evidence about the impact of Appreciative Inquiry on improving nursing and midwifery students as they transition into becoming new graduates.

DESIGN

An integrative review.

DATA SOURCES

The databases were: Pubmed, Ovid Medline, Cumulative Index of Nursing and Allied Health and Scopus.

REVIEW METHODS

A Whittemore and Knafl's (2005) five stage approach was used to appraise the primary literature related to nursing and midwifery students transitioning into becoming new graduates.

RESULTS

A total of 805 articles were retrieved and six studies met the inclusion criteria and included in this review. These studies have shown that Appreciative Inquiry as an intervention can be used to improve nursing and midwifery students' experiences as they transition into becoming new graduates. Three overarching themes were identified: caring, connecting and nurturing, transforming the workplace and work practices and appreciating and enabling nurses and midwives as a profession.

CONCLUSION

Appreciative Inquiry offers a creative, exploratory and compassionate method to improve positive change for nursing and midwifery students as they transition into becoming new graduates. The impact of caring, nurturing nurses and midwives who mentor nursing and midwifery students makes a difference in increasing the likelihood that graduates will remain in the profession and establish fulfilling relationships with both colleagues and people.

Diagnosis Between Chaos and Control: Affect and Hospital Clinicians' and Older Adult Patients' Narratives of Urinary Tract Infections

Research has observed that older adults are frequently overdiagnosed with urinary tract infection (UTI) and unnecessarily prescribed antibiotics in hospitals. In this article we explore the overlooked affective dimension of experiences of diagnosis and prescribing. Drawing on interviews with doctors, nurses and older adult patients (n = 41) on UTI diagnosis in two UK hospitals and Arthur Frank's work on illness narratives we identified two affective ways of experiencing diagnosis. Some clinicians and older adult patients articulated chaos narratives about being overwhelmed by contradictory evidence and events, doubting the repeated UTI diagnoses and courses of antibiotics but being unable to do anything about their concerns. Other clinicians and patients articulated control narratives about UTIs being frequently diagnosed and antibiotics prescribed to restore patients' health, echoing certainty and security, even if the processes described typically did not follow current guidance. We contend that analyzing the affective dimension offers conceptual insights that push forward sociological discussions on diagnosis as reflective or dogmatic in the context of the contradiction between acute care and chronic illnesses of old age. Our findings contribute practical ideas of why overdiagnosis and overprescribing happen in hospitals and complicate notions of patients pressuring for antibiotics. We also present methodological suggestions for analyzing how participants tell about their experiences in order to explore the typically not directly spoken affective dimension that influences thoughts and actions about diagnosis.

Organisational empowerment and assertive communication behaviours: a survey of Jordanian newly qualified nurses

BACKGROUND

Newly qualified nurses (NQNs) face several challenges in their early years of practice. Being empowered and able to speak up against unsafe practice are two important pillars for practising nursing safely and competently. Little research has examined the potential correlation between those two dimensions in the context of NQNs in Jordan.

AIMS

To investigate the correlation between NQNs' perceived structural empowerment in their work setting and their willingness to challenge unsafe practice in some hypothetical clinical scenarios.

METHODS

A cross-sectional survey involved 233 NQNs, who completed a self-administered questionnaire between January and March 2016.

FINDINGS

Participants reported moderate levels of both perceived structural empowerment and willingness to speak up against unsafe practice. There was a statistically significant positive correlation between the total structural empowerment score and the mean score for speaking up against unsafe practice.

CONCLUSION

The findings highlight the impact of peer, managerial and overall organisational support on enabling NQNs to become more empowered and assertive. Concrete, collaborative and organisation-wide efforts must be considered to foster greater empowerment of NQNs, but also revisiting work priorities to include supporting and advocating assertive communication skills among the more vulnerable of the newly qualified cohort.

A systematic review of factors that enable psychological safety in healthcare teams

Purpose

The current systematic review will identify enablers of psychological safety within the literature in order to produce a comprehensive list of factors that enable psychological safety specific to healthcare teams.

Data sources

A keyword search strategy was developed and used to search the following electronic databases PsycINFO, ABI/INFORM, Academic search complete and PubMed and grey literature databases OpenGrey, OCLC WorldCAT and Espace.

Study selection

Peer-reviewed studies relevant to enablers of psychological safety in healthcare setting that were published between 1999 and 2019 were eligible for inclusion. Covidence, an online specialized systematic review website, was used to screen records. Data extraction, quality appraisal and narrative synthesis were conducted on identified papers.

Data extraction

Thirty-six relevant studies were identified for full review and data extraction. A data extraction template was developed and included sections for the study methodology and the specific enablers identified within each study.

Results of data synthesis

Identified studies were reviewed using a narrative synthesis. Within the 36 articles reviewed, 13 enablers from across organizational, team and individual levels were identified. These enablers were grouped according to five broader themes: priority for patient safety, improvement or learning orientation, support, familiarity with colleagues, status, hierarchy and inclusiveness and individual differences.

Conclusion

This systematic review of psychological safety literature identifies a list of enablers of psychological safety within healthcare teams. This list can be used as a first step in developing observational measures and interventions to improve psychological safety in healthcare teams.

Whistleblowing over patient safety and care quality: a review of the literature

PURPOSE

The purpose of this paper is to review existing research on whistleblowing in healthcare in order to develop an evidence base for policy and research.

DESIGN/METHODOLOGY/APPROACH

A narrative review, based on systematic literature protocols developed within the management field.

FINDINGS

The authors identify valuable insights on the factors that influence healthcare whistleblowing, and how organizations respond, but also substantial gaps in the coverage of the literature, which is overly focused on nursing, has been largely carried out in the UK and Australia, and concentrates on the earlier stages of the whistleblowing process.

RESEARCH LIMITATIONS/IMPLICATIONS

The review identifies gaps in the literature on whistleblowing in healthcare, but also draws attention to an unhelpful lack of connection with the much larger mainstream literature on whistleblowing.

PRACTICAL IMPLICATIONS

Despite the limitations to the existing literature important implications for practice can be identified, including enhancing employees' sense of security and providing ethics training.

ORIGINALITY/VALUE

This paper provides a platform for future research on whistleblowing in healthcare, at a time when policymakers are increasingly aware of its role in ensuring patient safety and care quality.

Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills Training

Communication failures in healthcare constitute a major root cause of adverse events and medical errors. Considerable evidence links failures to raise concerns about patient harm in a timely manner with errors in medication administration, hygiene and isolation, treatment decisions, or invasive procedures. Expressing one's concern while navigating the power hierarchy requires formal training that targets both the speaker's emotional and verbal skills and the receiver's listening skills. We conducted a scoping review to examine the scope and components of training programs that targeted healthcare professionals' speaking-up skills. Out of 9,627 screened studies, 14 studies published between 2005 and 2018 met the inclusion criteria. The majority of the existing training exclusively relied on one-time training, mostly in simulation settings, involving subjects from the same profession. In addition, most studies implicitly referred to positional power as defined by titles; few addressed other forms of power such as personal resources (e.g., expertise, information). Almost none addressed the emotional and psychological dimensions of speaking up. The existing literature provides limited evidence identifying effective training components that positively affect speaking-up behaviors and attitudes. Future opportunities include examining the role of healthcare professionals' conflict engagement style or leaders' behaviors as factors that promote speaking-up behaviors.

Self-compassion as a Stress Moderator: A Cross-sectional Study of 1700 Doctors, Nurses, and Medical Students

Objectives

Work stress is common in healthcare and reliably predicts negative outcomes, including burnout and lower quality of life (QOL). However, few studies have investigated factors that might attenuate the impact of stress on these negative outcomes. We investigated whether the tendency to be kind to the self during times of difficulty—self-compassion—might buffer the effect of work stress on outcomes.

Methods

Registered nurses (n = 801), physicians (n = 516), and medical students (n = 383) were recruited using convenience sampling in New Zealand. Following consent, participants (N = 1700) completed a survey including the Copenhagen Burnout Inventory, Satisfaction with Life Scale, and Self-Compassion Scale–Short Form.

Results

Across groups, greater work stress consistently predicted greater burnout and lower QOL, while greater self-compassion predicted lower burnout and better QOL. Self-compassion moderated the relationship between stress and burnout in nurses (albeit in the opposite direction to what had been predicted), but not in doctors or medical students.

Conclusions

While self-compassion predicted better outcomes (and may thus represent a target to enhance wellbeing), it strengthened the association between stress and burnout in nurses. How self-compassion impacts the experience of stress and its correlates and why it does so differently in different groups of professionals remains unclear.

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

Speaking up is an important communication strategy to prevent patient harm. The aim of this study was to examine speak up-related behaviour and climate for the first time in psychiatric hospitals. A cross-sectional survey was conducted among healthcare workers (HCWs) in six psychiatric hospitals with nine sites in Switzerland. Measures assessed speak up-related behaviour with 11 items organized in three scales (the frequency of perceived safety concerns, the frequency of withholding voice, and the frequency of speaking up). Speak up-related climate was assessed by 11 items organized in 3 subscales (psychological safety for speaking up, encouraging environment for speaking up, and resignation). Statistical analyses included descriptive statistics, reliability, correlations and multiple regression analysis, confirmatory factor analysis, and analysis of variance for comparing mean scores between professional groups. A total of 817 questionnaires were completed (response rate: 23%). In different items, 45%-65% of HCWs reported perceived safety concerns at least once during the past four weeks. Withholding voice was reported by 13-25% of HCWs, and speaking up was reported by 53%-72% of HCWs. Systematic differences in scores were found between professional groups (nurses, doctors, psychologists) and hierarchical groups (lower vs higher status). The vignette showed that hierarchical level and perceived risk of harm for the patient were significant predictors for the self-reported likelihood to speak up. Situations triggering safety concerns occur frequently in psychiatric hospitals. Speaking up and voicing concerns should be further promoted as an important safety measure.

Critical elements for multigenerational teams: a systematic review

Purpose

Therefore, the purpose of this paper is to review the existing literature on multigenerational teams, to evaluate the maturity of the research area, identify key themes, and highlight areas for future research. Generational differences in the workforce are becoming a critical factor, as four generations (Veterans/Traditionalists, Baby Boomers, Generation X and Generation Y/Millennials) currently co-exist, and a fifth generation (Generation Z) stands poised to enter the workforce. To manage these differences effectively, organizations must first understand the various generations and, ultimately, their interaction and engagement with each other. Whereas some literature on the differences between the generations and how they pertain to the organizational work environment exists, currently, it is unclear what is known about how these differences impact the performance of multigenerational teams.

Design/methodology/approach

This paper presents a systematic literature review on teams and generational differences. A total of 7 platforms were included, resulting in 121 articles in the final paper set.

Findings

The review confirmed a low presence of literature related to generational differences and teams, implying the knowledge area is currently immature; however, despite this, there is an upward trajectory in publications and citations over the past few years, and existing publications and citations span a number of countries, suggesting a likelihood of significant growth in the research area in the near future. Further, key themes were identified in the current literature relating to commitment, leadership, team dynamics, conflict and wages and work environment.

Research limitations/implications

Only seven platforms were included in this review, although the seven platforms chosen are believed to provide comprehensive coverage of the field. The search strings used were “generation” and “team,” which was the word combination found to produce the largest number of results in preliminary trials; however, it is possible that using additional word combinations might have yielded some additional papers. Finally, the review was limited to English-language articles (or their translations); although, ultimately, only two articles were eliminated because of lack of an English language version.

Practical implications

The findings can be used by organizations to identify factors of interest in managing multigenerational teams, as well as what is currently known about influencing those factors to achieve more positive team outcomes.

Originality/value

To the best of the authors’ knowledge, this appears to be the first systematic literature review on generational differences in teams. Given the importance of this topic, this review is critical to provide a baseline on what is currently known in the field and existing research and practice gaps.

Factors Influencing the Implementation of a Hospitalwide Intervention to Promote Professionalism and Build a Safety Culture: A Qualitative Study

BACKGROUND

There is widespread recognition that creating a safety culture supports high-quality health care. However, the complex factors affecting cultural change interventions are not well understood. This study examines factors influencing the implementation of an intervention to promote professionalism and build a safety culture at an Australian hospital.

METHODS

The study was completed midway into the three-year intervention and involved collecting qualitative data from two sources. First, face-to-face interviews were conducted pre- and mid-intervention with a purposely selected sample. Second, a survey with three open-ended questions was completed one year into the intervention by clinical and patient support staff. Data from interviews and survey questions were analyzed using a combination of inductive and deductive approaches.

RESULTS

A total of 25 participants completed preintervention interviews, and 24 took part mid-intervention. Of the 2,047 staff who completed the survey (61% response rate), 59.1% of respondents answered at least one open-ended question. Multiple interrelated factors were identified as enhancing intervention implementation. These include sustaining a favorable implementation climate, leaders consistently demonstrating behaviors that support a safety culture, increasing compatibility of working conditions with intervention aims, building confidence in systems to address unprofessional behaviors, and responding to evolving needs.

CONCLUSION

Strengthening safety culture remains an enduring challenge, but this study yields valuable insights into factors influencing implementation of a multifaceted behavior change intervention. The findings provide a basis for practical strategies that health care leaders seeking cultural improvements can employ to enhance the delivery of similar interventions and address potential impediments to success.

The health promotion role of Australian early primary school teachers supporting students with type 1 diabetes

ISSUE ADDRESSED

Early primary school children with diabetes require adult support for insulin therapy and primary school teachers often fulfil this health promotion role. Availability of support is inconsistent across Australia and insulin administration at school is avoided for some children. The aims of the study were to explore the experiences of Australian early primary school teachers who were supporting a student using intensive insulin therapy and to identify facilitators and implications of this support.

METHOD

A qualitative research design using narrative inquiry was utilised. Early primary school teachers (n = 11) from six Australian states/territories and across Government, Catholic and independent schools participated in semi-structured telephone interviews between August 2015 and May 2016. Narrative analysis was used to interpret the interview data.

RESULTS

Six narrative threads told a collective story of early primary school teachers' experience of supporting a student using intensive insulin therapy. The factors that facilitated support were: suitable class allocation, a transition process, and diabetes education and diabetes models of care. The implications of providing intensive insulin therapy support were legal considerations and burden of responsibility. The outcome was that all teachers supported intensive insulin therapy.

CONCLUSION

School teachers in this study had a pivotal role in promoting the health of students with type 1 diabetes. This role was often associated with anxiety and the burden of responsibility. Support strategies for teachers include formal diabetes skills training, ongoing assistance from both teacher's aides and Diabetes Educators, and greater understanding of the legal aspects of intensive insulin therapy support. The development of consistent health promotion policy for students with type 1 diabetes across all Australian schools is required. SO WHAT?: Adopting the supportive strategies for teachers identified in this study will further promote the health of early primary school children with type 1 diabetes.

Exploring the utility of internal whistleblowing in healthcare via agent-based models

OBJECTIVE

The benefits of internal whistleblowing or speaking-up in the healthcare sector are significant. The a priori assumption that employee whistleblowing is always beneficial is, however, rarely examined. While recent research has begun to consider how the complex nature of healthcare institutions impact speaking-up rates, few have investigated the institutional processes and factors that facilitate or retard the benefits of speaking up. Here we consider how the efficacy of formal inquiries within organisations in response to employees' speaking up about their concerns affects the utility of internal whistleblowing.

DESIGN

Using computational models, we consider how best to improve patient care through internal whistleblowing when resource and practical limitations constrain healthcare operation. We analyse the ramifications of varying organisational responses to employee concerns, given organisational and practical limitations.

SETTING

Drawing on evidence from international research, we test the utility of whistleblowing policies in a variety of organisational settings. This includes institutions where whistleblowing inquiries are handled with varying rates of efficiency and accuracy.

RESULTS

We find organisational inefficiencies can negatively impact the benefits of speaking up about bad patient care. We find that, given resource limitations and review inefficiencies, it can actually improve patient care if whistleblowing rates are limited. However, we demonstrate that including softer mechanisms for internal adjustment of healthcare practice (eg, peer to peer conversation) alongside whistleblowing policy can overcome these organisational limitations.

CONCLUSION

Healthcare organisations internationally have a variable record of responding to employees who speak up about their workplace concerns. Where organisations get this wrong, the consequences can be serious for patient care and staff well-being. The results of this study, therefore, have implications for researchers, policy makers and healthcare organisations internationally. We conclude with a call for further research on a more holistic understanding of the interplay between organisational structure and the benefits of whistleblowing to patient care.

New graduate occupational therapists' narratives of ethical tensions encountered in practice

BACKGROUND/AIM

Professionals in health and social care have high workloads and are working with diverse populations in hierarchical and complicated service delivery systems. There is increasing pressure on new graduates because they are expected to be immediately work ready and may not receive adequate support or supervision. It is well known that there can be issues with satisfaction and retention rates of new graduates due to the challenges they experience. Ethical tensions are an unavoidable part of occupational therapy practice and may contribute to unique challenges for new graduates who may not yet have the personal resources to make sense of these independently. New graduate occupational therapy perceptions of ethical tensions have not yet been explored and this study sought to fill this gap. Exploring the ethical tensions experienced by new graduates can inform appropriate policies, procedures, preparedness and standards.

METHODS

A qualitative study using narrative enquiry was undertaken in which stories were gathered from eight new graduate occupational therapists who had been working for 6-24 months. Semi-structured in-depth interviews were used to gather data. Transcripts were analysed following narrative analysis guidelines. Member checking, reflexivity and keeping an audit trail of methodological and analytical decisions were employed to strengthen the rigour of the study.

RESULTS

Analysis revealed six predominant themes: working in a business model, respecting client choice, dealing with aggression and death, mandatory reporting is hard to do, differing team values, and feeling devalued and unsupported.

CONCLUSION

The findings highlight the importance of understanding the ethical tensions faced by new graduates and of exploring ways to assist new graduates to respond constructively to ethical dilemmas, distress and uncertainties. To address the risk of attrition, graduates need systems in place for accessing support to increase preparedness to respond to ethical tensions when they do arise.

Understanding the knowledge gaps in whistleblowing and speaking up in health care: narrative reviews of the research literature and formal inquiries, a legal analysis and stakeholder interviews

Background

There is compelling evidence to suggest that some (or even many) NHS staff feel unable to speak up, and that even when they do, their organisation may respond inappropriately.

Objectives

The specific project objectives were (1) to explore the academic and grey literature on whistleblowing and related concepts, identifying the key theoretical frameworks that can inform an understanding of whistleblowing; (2) to synthesise the empirical evidence about the processes that facilitate or impede employees raising concerns; (3) to examine the legal framework(s) underpinning whistleblowing; (4) to distil the lessons for whistleblowing policies from the findings of Inquiries into failings of NHS care; (5) to ascertain the views of stakeholders about the development of whistleblowing policies; and (6) to develop practical guidance for future policy-making in this area.

Methods

The study comprised four distinct but interlocking strands: (1) a series of narrative literature reviews, (2) an analysis of the legal issues related to whistleblowing, (3) a review of formal Inquiries related to previous failings of NHS care and (4) interviews with key informants.

Results

Policy prescriptions often conceive the issue of raising concerns as a simple choice between deciding to ‘blow the whistle’ and remaining silent. Yet research suggests that health-care professionals may raise concerns internally within the organisation in more informal ways before utilising whistleblowing processes. Potential areas for development here include the oversight of whistleblowing from an independent agency; early-stage protection for whistleblowers; an examination of the role of incentives in encouraging whistleblowing; and improvements to criminal law to protect whistleblowers. Perhaps surprisingly, there is little discussion of, or recommendations concerning, whistleblowing across the previous NHS Inquiry reports.

Limitations

Although every effort was made to capture all relevant papers and documents in the various reviews using comprehensive search strategies, some may have been missed as indexing in this area is challenging. We interviewed only a small number of people in the key informant interviews, and our findings may have been different if we had included a larger sample or informants with different roles and responsibilities.

Conclusions

Current policy prescriptions that seek to develop better whistleblowing policies and nurture open reporting cultures are in need of more evidence. Although we set out a wide range of issues, it is beyond our remit to convert these concerns into specific recommendations: that is a process that needs to be led from elsewhere, and in partnership with the service. There is also still much to learn regarding this important area of health policy, and we have highlighted a number of important gaps in knowledge that are in need of more sustained research.

Future work

A key area for future research is to explore whistleblowing as an unfolding, situated and interactional process and not just a one-off act by an identifiable whistleblower. In particular, we need more evidence and insights into the tendency for senior managers not to hear, accept or act on concerns about care raised by employees.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

"Hot Seat" Simulation Model for Conflict Resolution: A Pilot Study

BACKGROUND

Unresolved conflicts in health care threaten both clinician morale and quality of patient care. We piloted a training model that targeted clinicians' conflict resolution skills.

METHODS

Sixty clinicians from local hospitals were randomized into an intervention group (n = 30), completing a 3-hour conflict resolution training session, and a control group (n = 30) without training. The training included facilitated practice with actors, coaching, and feedback. Evaluation of 60 participants' conflict resolution skills was done in videotaped simulations with actors portraying interprofessional colleagues. Global ratings and checklist items developed for assessing clinicians' performance mirrored steps in the conflict communication model.

RESULTS

The intervention group's performance exceeded the control group on global scores, 7.2 of 10 (SD = 1.6) versus 5.6 (SD = 1.5), p < .05, and checklist scores, 9.3 of 11 (SD = 2.9) versus 7.9 (SD = 1.5), p < .05. Two checklist items showed statistically significant differences: (1) subjects opened the dialogue on a neutral ground before jumping into conflict discussions (intervention: 97% and control: 73%, p < .05) and (2) subjects elicited the colleague's story before sharing their own story (intervention: 70% and control: 27%, p < .05).

CONCLUSIONS

The pilot results suggest that a health care-specific approach to conflict resolution can be effectively taught through facilitated practice, coaching, and feedback.

The Effect of Education on Parents' "Speak Up" Knowledge Regarding Patients Safety in Hospital

Introduction: Safety is a global issue in hospitals. Unexpected events or errors related to health services occur in children, and about 75% are associated with medical procedures. Parental involvement becomes one of the strategies used to improve patient safety. Families who know patient safety can educate themselves to prevent and detect errors that occur during treatment. Education can improve the general knowledge about patient safety. The Speak Up program is recommended by JCAHO to improve effective communication, and this program has a preventive impact on human error. This study aims to determine the effect of education on parent’s ‘speaking up’ knowledge regarding patient safety in the Children's Wards of Dr. Sardjito Hospital in Yogyakarta.Methods: This research study was quasi-experimental using a one group pre-test and post-test design. The intervention in this research was education. The consecutive sampling technique was used with a total of 62 respondents selected. The Speak Up questionnaire and observation sheet to get to know the changes in the knowledge of Speak Up was used to collect the data. The data analysis used a Paired Sample T-Test.Result: The result of the paired T-test showed a p-value <0,001 (p <0,05) which means that there was a significant influence by way of education on parent’s speak up knowledge regarding patient safety.Conclusion: Education improved the parents' speak up knowledge about patient safety.

Reconciling conceptualizations of ethical conduct and person-centred care of older people with cognitive impairment in acute care settings

Key commentators on person-centred care have described it as a "new ethic of care" which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person-centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person-centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to comply more often with prevailing norms than those championed by person-centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses' ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person-centred care. We argue that nurses' responses to the ethical demand by way of parrhêsia can be an important feature of intra-organizational reflexivity and its transformation towards the delivery care that is more person-centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research.

Ethical tensions: A qualitative systematic review of new graduate perceptions

Background:

New graduate transition into the workforce is challenging and can involve managing ethical tensions. Ethical tensions cause new graduates to doubt their capabilities due to their lack of experience. To support new graduates, we need to know what these ethical tensions are.

Objectives:

To explore the ethical tensions perceived to occur in practice for new graduate health professionals.

Research design:

This qualitative systematic review involved a search of five databases (Medline, EMBASE, AMED, CINAHL and Scopus) which resulted in the retrieval of 3554 papers. After the two-phased screening process, eight studies were identified that met the inclusion criteria and had rich data on the review question. Articles were read several times, critically appraised and analysed through thematic analysis.

Ethical considerations:

No ethical approval was required for the systematic review. The review was conducted following well-established reporting guidelines enabling transparency and rigour.

Findings:

Studies originated from Australia, United States, Iran and China. One study included speech pathologists and seven were with nurses. Four themes included the following: (1) enduring an unknown workplace culture that generates uncertainty without support for new graduates; (2) being vulnerable because of distress from bullying, exclusion and being a scapegoat; (3) constraining systems and institutional restrictions that cause dilemmas; and (4) experiencing disillusionment from lost ideals about ethical practice.

Discussion:

This review has brought to light the vulnerability of new graduates to negative workplace culture and collegial incivility. In addition, new graduates are subjected to ethical tensions created by institutional constraints which can create dilemmas and uncertainties through practice that does not align with what they anticipated.

Conclusion:

Understanding ethical tensions experienced by new graduates enables provision of informed support. There needs to be considerable cultural change for orientation and socialisation of new graduates to enable them to learn and manage ethical tensions.

Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses

OBJECTIVES

Despite growing recognition of the importance of speaking up to protect patient safety in critical care, little research has been performed in this area in an intensive care unit (ICU) context. This study explored the communication openness perceptions of Chinese doctors and nurses and identified their perceptions of issues in ICU communication, their reasons for speaking up and the possible factors and strategies involved in promoting the practice of speaking up.

DESIGN

A mixed-methods design with quantitative and sequential qualitative components was used.

SETTING AND PARTICIPANTS

Eighty ICU staff members from a large public hospital in Hong Kong completed a questionnaire regarding their perceptions of communication openness. Ten clinicians whose survey responses indicated support for open communication were then interviewed about their speak-up practices.

RESULTS

The participating ICU staff members had similar perceptions of their openness to communication. However, the doctors responded more positively than the nurses to many aspects of communication openness. The two groups also had different perceptions of speaking up. The interviewed ICU staff members who indicated a high level of communication openness reported that their primary reasons for speaking up were to seek and clarify information, which was achieved by asking questions. Other factors perceived to influence the motivation to speak up included seniority, relationships and familiarity with patient cases.

CONCLUSIONS

Creating an atmosphere of safety and equality in which team members feel confident in expressing their personal views without fear of reprisal or embarrassment is necessary to encourage ICU staff members, regardless of their position, to speak up. Because harmony and saving face is valued in Chinese culture, training nurses and doctors to speak up by focusing on human factors and values rather than simply addressing conflict management is desirable in this context.

Exploration of difficult conversations among Australian paramedics

Previous studies indicate that healthcare professionals find it challenging to engage in difficult conversations regarding concerning behavior of colleagues. As a result, these conversations are often avoided. The inability to have these difficult conversations is associated with poorer patient outcomes, staff commitment, discretionary effort, and employee satisfaction. This descriptive study used an online questionnaire to examine responses of paramedics employed by Ambulance Victoria (Australia) regarding difficult conversations between colleagues about concerning behavior of co-workers. The results suggest that, like other healthcare professions, many paramedics find it challenging to raise these concerns. To the best knowledge of the authors, this is the first study of its type to be undertaken within the paramedic profession and provides a platform for further research within this and other health professions.

Lastnosti mentorja in mentoriranca z njunih medsebojnih vidikov: opisna raziskava mnenj dijakov, študentov in mentorjev

Uvod: Lastnosti mentorja so za odnos med mentorjem, dijakom in študentom zdravstvene nege zelo pomembne. Namen raziskave je bil ugotoviti, katere lastnosti mentorjev so pomembne z vidika dijakov in študentov zdravstvene nege, in obratno, katere lastnosti mentorirancev, tj. dijakov oz. študentov, so pomembne z vidika mentorjev. Metode: Uporabljena je bila kvantitativna deskriptivna metoda raziskovanja. S spletnim anketnim vprašalnikom je bil anketiran 201 anketiranec, od tega 50 dijakov srednje zdravstvene šole (3. in 4. letnik), 97 študentov prve stopnje zdravstvene nege (2. in 3. letnik) ter 54 mentorjev v kliničnem okolju. Uporabljena je bila deskriptivna statistika, test hi-kvadrat ter metoda analize variance oz. analiza povprečij. Rezultati: Ugotovljeno je bilo, da mentorji menijo, da odnos med mentorirancem in mentorjem ni odvisen od mentorjeve starosti. Komunikacija je pomembna vsem trem skupinam anketirancev. Medsebojno spoštovanje je enako pomembno dijakom, študentom in mentorjem. Mentorjem je poleg dijakovega oz. študentovega spoštljivega odnosa najpomembnejše, da se dijak oz. študent zaveda svojih nalog in zadolžitev (x = 4,6). Najbolj zaželena lastnost mentorja je, da si vzame čas (x = 4,7) za dijaka oz. študenta ter da je organiziran in dostopen. Diskusija in zaključek: Med raziskovalnimi skupinami je opaziti razlike v dojemanju lastnosti in vrlin mentorjev. Vsem raziskovalnim skupinam je pomembna mentorjeva sposobnost komunikacije ter ustvarjanja kreativnega okolja.

Narrative inquiry: A relational research methodology suitable to explore narratives of health and illness

This paper proposes the need for further qualitative research to gain valuable insight into individuals’ experiences of health and illness and the suitability of narrative inquiry as a methodology to investigate these experiences. It is essential to increase qualitative knowledge of individuals’ experiences of illness in order to improve and personalise their care. Narrative inquiry aims to understand knowledge gained from the individual’s narrative of their experiences. Narrative inquiry explores experiences through the dimensions of temporality, sociality and spatiality. The aspect between these dimensions provides an exploratory structure for narratives surrounding health and illness: temporality – when did the illness begin, how will it influence the future; sociality – cultural and personal influences on views of illness; spatiality – surroundings, such as hospitals, and their influence on the health–illness perspective. Narrative inquiry not only provides a deep understanding of the investigated phenomena, it is also provides a rich vibrant narrative presentation of findings for the reader and user of research.