Speaking up, support, control and work engagement of medical residents. A structural equation modelling analysis

Trends in patient safety education research for healthcare professional students over the past two decades: a bibliometric and content analysis

Research and practice in patient safety education have garnered widespread attention; however, a comprehensive bibliometric analysis is lacking. This study aimed to provide a comprehensive understanding of the research focus and research trends in the globalization of the field of patient safety education and to describe the general characteristics of publications. Data on articles and reviews about student safety education were extracted from Web of Science. Microsoft Excel 2019, CiteSpace 6.1.R3, VOSviewer 1.6.18, SATI 3.2, Scimago Graphica, and Pajek were used for quantitative analysis. Collaboration networks of countries, institutions, journals, authors, and keywords were visualized based on publications from January 2000 to September 2022. A total of 573 papers were published between 2000 to 2022, showing an overall increasing trend. The USA, England, and Australia are the top three most prolific countries; Johns Hopkins University, the University of Technology Sydney, and the University of Toronto are the top three most productive institutions; Nurse Education Today, Journal of Nursing Education, and BMC Medical Education are the most productive journals; Based on content analysis five research hotspots focused on: (1) Quality Improvement of Patient safety Teaching and Learning; (2) Patient safety Teaching Content; (3)Specialized Teaching in Patient Safety; (4) Integrating Patient Safety and Clinical Teaching; (5)Patient Safety Teaching Assessment Content. Through keyword clustering analysis, five research hotspots and relevant contents were identified. According to this study, simulation, communication, collaboration, and medication may attract more attention from researchers and educators, and could be the major trend for future study.

The effects of psychological safety and employee voice behavior on flight attendants' mindful safety practices adoption

Introduction

Flight attendants, as the front-line staff in the cabin, play a crucial role in improving air travel safety. This research explores how psychological safety affects flight attendants' adoption of mindful safety practices through voice participation. This mechanism also identifies ethical leadership and traditionality as two moderators.

Methods

A self-reported questionnaire was used to collect data from 621 flight attendants in Chinese private commercial airline companies. PLS-SEM (partial least square structured equation modeling) is used to examine the hypotheses proposed in the present study.

Results

After data analysis, the results reveal that the underlying mechanism covering both mediating and moderating effects through which flight attendants' voluntary and extra-role safety behavior could be improved.

Discussion

The findings extend the existing literature regarding the antecedents of flight attendants' mindful safety practices adoption and obstacles to employee voice participation. Managerial implications are also provided in the commercial aviation industry and discussed along with future research directions.

Finding Your Voice: A Large-Scale Nursing Training in Speaking up and Listening Skills

BACKGROUND

Training in speaking up skills for nursing professionals provides the groundwork for promoting a culture of curiosity and inquiry. At the foundation of speaking up is psychological safety for team members to disagree, offer alternative ideas, and ask questions.

METHOD

A large-scale training session, Finding Your Voice: Speaking Up & Listening Skills, was designed and delivered to 1,306 nurses at an academic medical center.

RESULTS

Most participants reported that the session met the training goals (97%). There was an increase in participants' confidence in speaking up (pretraining 69% ± 19%; posttraining 73% ± 15%; p < .0001), and listening (pretraining 68% ± 19%; post-training 74% ± 15%; p < .0001). Leaders showed greater increases in confidence in listening and responding to nurses speaking up (leaders 5.6% vs. nonleaders 4.2%, p < .00001).

CONCLUSION

Nurses benefited from an interactive educational experience by practicing strategies for speaking up and listening. [J Contin Educ Nurs. 2024;55(6):309-316.].

Towards inclusive learning environments in post-graduate medical education: stakeholder-driven strategies in Dutch GP-specialty training

BACKGROUND

A recent study found that ethnic minority General Practice (GP)-trainees receive more negative assessments than their majority peers. Previous qualitative research suggested that learning climate-related factors play a pivotal role in unequal opportunities for trainees in post-graduate medical settings, indicating that insufficient inclusivity had put minority students at risk of failure and dropout.

STUDY OBJECTIVES

We aimed to develop broadly supported strategies for an inclusive learning climate in Dutch GP-specialty training.

METHODS

We employed Participatory Action Research (PAR)-methods, incorporating Participatory Learning and Action (PLA)-techniques to ensure equal voices for all stakeholders in shaping Diversity, Equity, and Inclusion (DEI)-strategies for GP-specialty training. Our approach engaged stakeholders within two pilot GP-specialty training institutes across diverse roles, including management, support staff, in-faculty teachers, in-clinic supervisors, and trainees, representing ethnic minorities and the majority population. Purposeful convenience sampling formed stakeholder- and co-reader groups in two Dutch GP-specialty training institutes. Stakeholder discussion sessions were based on experiences and literature, including two relevant frameworks, and explored perspectives on the dynamics of potential ethnic minority trainees' disadvantages and opportunities for inclusive strategies. A co-reader group commented on discussion outcomes. Consequently, a management group prioritized suggested strategies based on expected feasibility and compatibility.

RESULTS

Input from twelve stakeholder group sessions and thirteen co-readers led to implementation guidance for seven inclusive learning environment strategies, of which the management group prioritized three: • Provide DEI-relevant training programs to all GP-specialty training stakeholders; • Appoint DEI ambassadors in all layers of GP-specialty training; • Give a significant voice to minority GP-trainees in their education.

CONCLUSION

The study's participatory approach engaged representatives of all GP-specialty training stakeholders and identified seven inclusive learning climate strategies, of which three were prioritized for implementation in two training institutions.

Junior doctors receiving supervisor and peer support are more work-engaged professionals who express their voice for quality improvement

PURPOSE

In daily practice, junior doctors can contribute to quality improvement by providing innovative suggestions for change, referred to as voice behavior. Junior doctors are more likely to engage in voice behavior when they receive sufficient support from supervisors and peers. Such support has also been associated with less burnout and more work engagement. However, whether less burned-out and more work-engaged junior doctors demonstrate more voice behaviors in the face of sufficient supervisor and peer support is unclear. Therefore, we studied whether and how associations of supervisor and peer support with junior doctors' voice behaviors are mediated by burnout and work engagement.

MATERIALS & METHODS

Participants were 301 junior doctors that completed a web-based survey including validated questionnaires on supervisor and peer support, burnout, work engagement, and voice behavior.

RESULTS

Supervisor and peer support were associated with lower levels of burnout and higher levels of work engagement. Work engagement, but not burnout, mediated the associations of supervisor and peer support with voice behaviors.

CONCLUSIONS

Junior doctors who received more supervisor or peer support were more work-engaged and reported more voice behaviors. Thus, supervisor and peer support should be cultivated to facilitate junior doctors' roles as work-engaged professionals in quality improvement.

Healthcare professionals' voice as a road to burnout and work engagement? The role of relational outcomes: An exploratory study of European countries

PURPOSE

Healthcare professionals are key in healthcare organisations but are subject to long working hours and may have to make complex life-and-death decisions. As frontline agents dealing with human lives, giving them a voice is paramount. This study explores the impact of employee voice (assessed based on employee perceptions on how much they are consulted and how much influence they have on task-related decisions) on health professionals' work engagement and burnout when mediated by relational outcomes (perceived organisational support, workplace trust, workplace recognition and meaningful work).

DESIGN/METHODOLOGY/APPROACH

A sample of 3,266 health professionals retrieved from the European Working Condition Survey was used. The quantitative analysis was performed using the partial least square structural equation modelling and multiple regression analyses.

FINDINGS

The results indicate that employee voice has a direct positive impact on work engagement, but employee voice's direct effects on burnout still need to be confirmed. Relational outcomes are found to mediate the relationship between employee voice and burnout (decreasing it) and between employee voice and work engagement (increasing it).

PRACTICAL IMPLICATIONS

Practices of employee voice in the workplace are fundamental to promoting health professionals' well-being. Trust, recognition, support and the feeling of doing meaningful work increase the influence of employee voice, especially in reducing the levels of burnout.

ORIGINALITY/VALUE

This is the first study that assesses, at a European level, the importance that 'giving health professionals a voice' has on crucial employee outcomes: work engagement, burnout and relational outcomes.

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.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Medical Students' Socialization Tactics When Entering a New Clinical Clerkship: A Mixed Methods Study of Proactivity

PURPOSE

Socialization into clinical clerkships is difficult in part due to ambiguity around students' new roles and expected behaviors. Being proactive reduces ambiguity and is essential to socialization. Proactive behavior can be taught and goes beyond having a proactive personality. Among students entering new undergraduate clinical clerkships, this study aimed to investigate (1) reported proactive behaviors and their association with social integration and (2) enabling and inhibiting factors for proactive behavior.

METHOD

This study was conducted at the 5-year MBBS program at Western Sydney University during academic year 2019-2020. Using a convergent mixed methods approach, survey and interview data from third-, fourth-, and fifth-year students were collected. Surveys explored 5 proactive behaviors: feedback seeking, information seeking, task negotiation, positive framing, and relationship building. Interviews elicited descriptions of how students described their proactivity and what influenced students to be proactive when entering a new clerkship. Data were integrated using the following the thread and mixed methods matrix techniques.

RESULTS

Students exhibited all 5 proactive behaviors. Survey data showed positive framing and task negotiation had the highest and lowest scores, respectively. Only positive framing correlated significantly with social integration scores (r = 0.27; P < .01), but this contrasted to interviews, in which students described how other proactive behaviors also led to social integration. Proactive behavior scores decreased across academic years. Integrated data showed 3 linked antecedents to whether students exhibited proactive behavior: feeling capable of being proactive, individual intention to be proactive, and the immediate environment and system-level factors.

CONCLUSIONS

Students who framed the experience positively were more likely to report increased social integration. Initiating task negotiation was challenging for most students. The authors propose a conceptual model for proactivity and social integration to support socialization and learning during clinical transitions for future research and interventional design.

An act of performance: Exploring residents' decision-making processes to seek help

CONTEXT

Residents are expected to ask for help when feeling insufficiently confident or competent to act in patients' best interests. While previous studies focused on the perspective of supervisor-resident relationships in residents' help-seeking decisions, attention for how the workplace environment and, more specifically, other health care team members influence these decisions is limited. Using a sociocultural lens, this study aimed to explore how residents' decision-making processes to seek help are shaped by their workplace environment.

METHODS

Through a constructivist grounded theory methodology, we purposively and theoretically sampled 18 residents: 9 juniors (postgraduate year 1/2) and 9 seniors (postgraduate year 5/6) at Amsterdam University Medical Centers. Using semi-structured interviews, participating residents' decision-making processes to seek help during patient care delivery were explored. Data collection and analysis were iterative; themes were identified using constant comparative analysis.

RESULTS

Residents described their help-seeking decision-making processes as an 'act of performance': they considered how asking for help could potentially impact their assessments. They described this act of performance as the product of an internal 'balancing act' with at its core the non-negotiable priority for providing safe and high-quality patient care. With this in mind, residents weighed up demonstrating the ability to work independently, maintaining credibility and becoming an accepted member of the health care team when deciding to seek help. This 'balancing act' was influenced by sociocultural characteristics of the learning environment, residents' relationships with supervisors and the perceived approachability of other health care team members.

CONCLUSIONS

This study suggests that sociocultural forces influence residents to experience help-seeking as an act of performance. Especially, a safe learning environment resulting from constructive relationships with supervisors and the approachability of other health care team members lowered the barriers to seek help. Supervisors could address these barriers by having regular conversations with residents about when to seek help.

Students' social networks are diverse, dynamic and deliberate when transitioning to clinical training

CONTEXT

Transitions in medical education are dynamic, emotional and complex yet, unavoidable. Relationships matter, especially in times of transition. Using qualitative, social network research methods, we explored social relationships and social support as medical students transitioned from pre-clinical to clinical training.

METHODS

Eight medical students completed a social network map during a semi-structured interview within two weeks of beginning their clinical clerkships (T0 ) and then again four months later (T1 ). They indicated meaningful interactions that influenced their transition from pre-clinical to clinical training and discussed how these relationshipsimpacted their transition. We conducted mixed-methods analysis on this data.

RESULTS

At T0 , eight participants described the influence of 128 people in their social support networks; this marginally increased to 134 at T1 . People from within and beyond the clinical space made up participants' social networks. As new relationships were created (eg with peers and doctors), old relationships were kept (eg with doctors and family) or dissolved over time (eg with near-peers and nurses). Participants deliberately created, kept or dissolved relationships over time dependent on whether they provided emotional support (eg they could trust them) or instrumental support (eg they provided academic guidance).

CONCLUSIONS

This is the first social networks analysis paper to explore social networks in transitioning students in medicine. We found that undergraduate medical students' social support networks were diverse, dynamic and deliberate as they transitioned to clerkships. Participants created and kept relationships with those they trusted and who provided emotional or instrumental support and dissolved relationships that did not provide these functions.

Time for change: Overcoming perpetual feelings of inadequacy and silenced struggles in medicine

Focusing on support of psychological wellness in medical students, residents and physicians, this commentary highlights the need for cultural change and the accompanying importance of leadership.