'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns

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.

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.

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.

Personal protective equipment and medical students in times of COVID-19: experiences and perspectives from the final clerkship year

BACKGROUND

The availability and correct use of personal protective equipment (PPE) to prevent and control infections plays a critical role in the safety of medical students in clinical placements. This study explored their experiences and perspectives in their final clerkship year with PPE during the COVID-19 pandemic.

METHODS

This qualitative study was based on social constructivism and was conducted in 2021 at the Charité - Universitätsmedizin Berlin. In three online focus group discussions, 15 medical students in their final clerkship year reported their experiences with PPE training and use during the COVID-19 pandemic. Data were recorded, transcribed and analysed based on Kuckartz's approach to content analysis. We drew upon the a priori dimensions of the capability, opportunity, motivation - behaviour (COM-B) model as main categories as well as emergent issues raised by the study participants (subcategories).

RESULTS

In addition to the three main categories of the COM-B model, eleven subcategories were identified through inductive analysis. The study participants reported several factors that hindered the correct use of PPE. In the area of capabilities, these factors were related to learning experience with PPE in terms of both theoretical and practical learning together with later supervision in practice. In the area of opportunities, these factors included the limited availability of some PPE components, a lack of time for PPE instruction and supervision and inappropriate role modelling due to the inconsistent use of PPE by physicians and nursing staff. The area of motivation to use PPE was characterized by an ambivalent fear of infection by the SARS-CoV-2 virus and the prioritization of patient safety, i.e., the need to prevent the transmission of the virus to patients.

CONCLUSIONS

Our study revealed several limitations pertaining to the enabling factors associated with the trainable behaviour "correct use of PPE". The concept of shared responsibility for student safety was used to derive recommendations for future improvement specifically for the medical school as an organization, the teachers and supervisors, and students themselves. This study may guide and stimulate other medical schools and faculties to explore and analyse components of student safety in clinical settings in times of infectious pandemics.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN AND METHODS

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

SETTING/PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The assertiveness of final year student radiographers during their clinical practice: A study in Ghana

INTRODUCTION

Speaking up by health professionals is essential for patient safety. To ensure that student radiographers are well equipped in professional practice at the time of graduation, their capacity to speak up openly in the clinical setting is very important. This study assessed student radiographers' ability to speak up in the face of patient safety compromises during their clinical rotation and how it impacts their learning.

METHODS

Twenty-four (24) final-year radiography students at the University of Ghana, who were then the only final years in the country, were recruited for the study. Questionnaires about assertive communication using a harm index score were given to the students who consented to participate in the study. The data were analysed using Microsoft Excel version 13 and SPSS version 20.

RESULTS

The study recorded a response rate of 96% of which the majority (66.7%) were males. The majority (75%) of the participants would not speak up about patient safety issues for reasons. Moreover, 95.8% of the participants got confused when they observed a disparity between clinical practice and lessons taught in the lecture room.

CONCLUSION

The ability of students to speak up is dependent on several factors encountered in the clinical area. For students to be able to function well in a clinical team, they need to be competent to speak up to ensure patient safety irrespective of who they work with. This study identified that students preferred to express themselves non-verbally in some situations that deal with patient safety compromises, instead of speaking up. Improving a culture of respect and freedom to speak up in healthcare settings would ensure patient wellbeing.

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.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVES

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

KEY FINDINGS

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

CONCLUSION

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

IMPLICATIONS FOR PRACTICE

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

Organizational Silence among Hospital Nurses in China: A Cross-Sectional Study

Objective

To analyze the factors that contribute to organizational silence among Chinese nurses.

Methods

A descriptive, comparative, and cross-sectional study was performed with the participation of 866 nurses from public hospitals in China. The data were collected using an online questionnaire that included sociodemographic information and a silence scale.

Results

The overall level of organizational silence among nurses was moderate (51.35 ± 14.99). Nurses indicated that they remained silent about administrative (2.97 ± 1.10) and organizational topics (2.94 ± 1.11) yet were more vocal about matters related to responsibility (1.68 ± 0.86), honor (1.87 ± 0.95), and enthusiasm (2.07 ± 0.99). Moreover, data analysis demonstrated that department, educational status, professional title, years of employment, and employment status had effects on nurses' organizational silence (p < .05).

Conclusion

This study provides information that could facilitate an understanding of organizational silence for both nurses and nursing managers. The results helped to identify the urgent need to adopt effective strategies to address the problem of nurses' organizational silence. Changes in management practices and organizational culture should be implemented to remove communication and other barriers that impede nurses' contributions to their organizations.

Development and Psychometric Evaluation of the Speaking Up About Patient Safety Questionnaire

OBJECTIVE

Speaking up about safety concerns by staff is important to prevent medical errors. Knowledge about healthcare workers' speaking up behaviors and perceived speaking up climate is useful for healthcare organizations (HCOs) to identify areas for improvement. The aim of this study was to develop a short questionnaire allowing HCOs to assess different aspects of speaking up among healthcare staff.

METHODS

Healthcare workers (n = 523) from 2 Swiss hospitals completed a questionnaire covering various aspects of speak up-related behaviors and climate. Psychometric testing included descriptive statistics, correlations, reliabilities (Cronbach α), principal component analysis, and t tests for assessing differences in hierarchical groups.

RESULTS

Principal component analysis confirmed the structure of 3 speaking up behavior-related scales, that is, frequency of perceived concerns (concern scale, α = 0.73), withholding voice (silence scale, α = 0.76), and speaking up (speak up scale, α = 0.85). Concerning speak up climate, principal component analysis revealed 3 scales (psychological safety, α = 0.84; encouraging environment, α = 0.74; resignation, α = 0.73). The final survey instrument also included items covering speaking up barriers and a vignette to assess simulated behavior. A higher hierarchical level was mostly associated with a more positive speak up-related behavior and climate.

CONCLUSIONS

Patient safety concerns, speaking up, and withholding voice were frequently reported. With this questionnaire, we present a tool to systematically assess and evaluate important aspects of speaking up in HCOs. This allows for identifying areas for improvement, and because it is a short survey, to monitor changes in speaking up-for example, before and after an improvement project.

Associations of form and function of speaking up in anaesthesia: a prospective observational study

BACKGROUND

Speaking up with concerns in the interest of patient safety has been identified as important for the quality and safety of patient care. The study objectives were to identify how anaesthesia care providers speak up, how their colleagues react to it, whether there is an association among speak up form and reaction, and how this reaction is associated with further speak up.

METHODS

Data were collected over 3 months at a single centre in Switzerland by observing 49 anaesthesia care providers while performing induction of general anaesthesia in 53 anaesthesia teams. Speaking up and reactions to speaking up were measured by event-based behaviour coding.

RESULTS

Instances of speaking up were classified as opinion (59.6%), oblique hint (37.2%), inquiry (30.7%), and observation (16.7%). Most speak up occurred as a combination of different forms. Reactions to speak up included short approval (36.5%), elaboration (35.9%), no verbal reaction (26.3%), or rejection (1.28%). Speaking up was implemented in 89.1% of cases. Inquiry was associated with an increased likelihood of recipients discussing the respective issue (odds ratio [OR]=13.6; 95% confidence interval [CI], 5.9-31.5; P<0.0001) and with a decreased likelihood of implementing the speak up during the same induction (OR=0.27; 95% CI, 0.08-0.88; P=0.03). Reacting with elaboration to the first speak up was associated with decreased further speak up during the same induction (relative risk [RR]=0.42; 95% CI, 0.21-0.83; P=0.018).

CONCLUSION

Our study provides insights into the form and function of speaking up in clinical environments and points to a perceived dilemma of speaking up via questions.

On collective self-healing and traces: How can swarm intelligence help us think differently about team adaptation?

BACKGROUND

Health care teams are increasingly forced to navigate complex challenges to achieve their collective aim of delivering high-quality, safe patient care. The teamwork literature has struggled to develop strategies that promote effective adaptive behaviours among health care teams. In part, this challenge stems from the fact that truly collective adaptive behaviour requires members of the teams to abandon the human urge to act self-sufficiently. Nature contains striking examples of collective behaviour as seen in social insects, fish and bird colonies. This collective behaviour is known as Swarm Intelligence (SI). SI remains poorly described in the health care team literature and its potential benefits hidden.

OBJECTIVE

In this cross-cutting edge paper, I explore the principles of SI as they pertain to systemic or collective adaptation in human teams. In particular, I consider the principles of trace-based communication and collective self-healing and what they might offer to team adaptation researchers in medical education.

RESULTS

From a SI perspective, a solution to a problem emerges as a result of the collective action of the members of the swarm, not the individual action. This collective action is achieved via four principles: direct and indirect communication, awareness, self-determination and collective self-healing. Among those principles, trace-based communication and collective self-healing have been purposefully used by other industries to foster team adaptation. Trace-based communication relies on leaving 'traces' in the environment to drive the behaviour of others. Collective self-healing is the ability of the swarm to cope with failure and adapt to changes by permitting swarm members to be interchangeable.

CONCLUSIONS

While allowing teams to rely on indirect communication and to be interchangeable might create discomfort to our ways of thinking, teams outside health care are demonstrating their value to advance human teamwork. SI offers a helpful analogy and a constructive language for thinking about team adaptation.

A qualitative study of Ghanaian pediatric oncology nurses' care practice challenges

BACKGROUND

Pediatric cancer is a global problem, and some studies have emphasized that nurses caring for these children experience work-related challenges. This has caused many children diagnosed with cancer to have a prolonged hospital stay and suffer unnecessary pain. However, there is insufficient documentary evidence on this issue. This study aims to explore and understand the challenges faced by pediatric oncology nurses in caring for children in Ghana.

METHODS

An exploratory qualitative research design study was conducted from August 2019 to April 2020. The study was conducted at the pediatric oncology unit which is located at the Tamale Teaching Hospital (TTH), Ghana. The study was conducted among 14 Ghanaian pediatric oncology nurses who were purposively sampled. A semi-structured interview guide was used to collect data. The interviews were recorded, transcribed verbatim, and analyzed inductively using Elo and Kyngas content analysis approach. The criteria proposed by Guba and Lincoln were used to ensure the validity of the study.

RESULTS

From the analysis of participants transcripts, eight subcategories emerged from two major categories. The subcategories were; time-consuming care, low job motivations, inadequate logistics, work stress, reduced labour force, low knowledge level, lack of teamwork and the perception of contracting cancer.

CONCLUSIONS

The results point to several organizational and personal constraints experienced by the nurses who work at the pediatric oncology ward. It is hoped that by addressing these challenges, it would lead to further improvement in the care that is provided to children with cancer. There is the need for the administrative managers of hospitals, government and other stakeholders to invest in human, material and financial resources for delivering childhood cancer care services.

Qualitative investigation of trace-based communication: how are traces conceptualised in healthcare teamwork?

OBJECTIVES

This interview-based qualitative study aims to explore how healthcare providers conceptualise trace-based communication and considers its implications for how teams work. In the biological literature, trace-based communication refers to the non-verbal communication that is achieved by leaving 'traces' in the environment and other members sensing them and using them to drive their own behaviour. Trace-based communication is a key component of swam intelligence and has been described as a critical process that enables superorganisms to coordinate work and collectively adapt. This paper brings awareness to its existence in the context of healthcare teamwork.

DESIGN

Interview-based study using Constructivist Grounded Theory methodology.

SETTING

This study was conducted in multiple team contexts at one of Canada's largest acute-care teaching hospitals.

PARTICIPANTS

25 clinicians from across professions and disciplines. Specialties included surgery, anesthesiology, psychiatry, internal medicine, geriatrics, neonatology, paramedics, nursing, intensive care, neurology and emergency medicine.

INTERVENTION

Not relevant due to the qualitative nature of the study.

PRIMARY AND SECONDARY OUTCOME

Not relevant due to the qualitative nature of the study.

RESULTS

The dataset was analysed using the sensitising concept of 'traces' from Swarm Intelligence. This study brought to light novel and unique elements of trace-based communication in the context of healthcare teamwork including focused intentionality, successful versus failed traces and the contextually bounded nature of the responses to traces. While participants initially felt ambivalent about the idea of using traces in their daily teamwork, they provided a variety of examples. Through these examples, participants revealed the multifaceted nature of the purposes of trace-based communication, including promoting efficiency, preventing mistakes and saving face.

CONCLUSIONS

This study demonstrated that clinicians pervasively use trace-based communication despite differences in opinion as to its implications for teamwork and safety. Other disciplines have taken up traces to promote collective adaptation. This should serve as inspiration to at least start exploring this phenomenon in healthcare.

Errors During Resuscitation: The Impact of Perceived Authority on Delivery of Care

OBJECTIVE

The aim of this study was to determine the influence of perceived authority on pediatric resuscitation teams' response to an incorrect order given by a medical superior.

METHODS

As part of a larger multicenter prospective interventional study, interprofessional pediatric resuscitation teams (n = 48) participated in a video-recorded simulated resuscitation scenario with an infant in unstable, refractory supraventricular tachycardia. A confederate actor playing a senior physician entered the scenario partway through and ordered the incorrect dose and delivery method of the antiarrhythmic, procainamide. Video recordings were analyzed with a modified Advocacy Inquiry Scale, assessing the teams' ability to challenge the incorrect order, and a novel confederate hierarchical demeanor rating. The association between Advocacy Inquiry score and hierarchical demeanor rating, and whether or not the confederate's incorrect order was followed were determined.

RESULTS

Fifty percent (n = 24) of resuscitation teams followed the confederate's incorrect order. The teams' ability to challenge the incorrect order (P < 0.0001) and confederate hierarchical demeanor rating (P < 0.05) were significantly associated with whether or not the incorrect order was followed. Significant differences between rates of following the incorrect order at different study sites were observed (P < 0.05).

CONCLUSIONS

The reluctance of resuscitation teams to appropriately challenge the incorrect order resulted in a high rate of inappropriate medication administration. The rate of teams following the incorrect order was significantly associated with poor challenging of the incorrect order and the hierarchical demeanor of the perceived authority figure. Institution-based factors may impact this rate of incorrect medication administration.

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.

A theory-based study of doctors' intentions to engage in professional behaviours

BACKGROUND

The Theory of Planned Behaviour (TPB) has been proposed as an appropriate model for creating a theory-driven approach to teaching medical professionalism. However, there is a lack of empirical evidence into its efficacy. This study explores if the TPB can assess UK medical doctors' professional behaviours and explores if there are differences in the TPB's efficacy depending on doctors' primary medical qualification (UK or outside).

METHODS

Three hundred fourteen doctors in England at 21 NHS Trusts completed a questionnaire about reflective practice, using the General Medical Council's confidentiality guidance, and raising a patient safety concern. The majority of participants were male (52%), white (68%), consultants (62%), and UK medical graduates (UKGs) (71%).

RESULTS

The TPB variables of attitudes, subjective norms, and perceived behavioural control were predictive of intention to engage in raising concerns (R² = 35%), reflection (R² = 52%), and use of confidentiality guidance (R² = 45%). Perceived behavioural control was the strongest predictor of intentions to raise a concern (β = 0.44), while attitude was the strongest predictor of intentions to engage in reflective practice (β = 0.61) and using confidentiality guidance (β = 0.38). The TBP constructs predicted intention for raising concerns and reflecting for both UKGs and non-UKGs (Fs ≥ 2.3; ps ≤ .023, βs ≥ 0.12). However, only perceived behaviour control was predictive of intentions to use guidance for both UKGs and non-UKGs (β = 0.24) while attitudes and norms were just predictive for UKGs (βs ≥ 0.26).

CONCLUSIONS

This study demonstrates the efficacy of the TPB for three professional behaviours. The implications for medical educators are to use the variables of the TPB (attitudes, subjective norms, and perceived behavioural control) in the education of professionalism, and for medical education researchers to further our understanding by employing the TPB in more empirical studies of non-clinical behaviours.

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.

Speaking up culture of medical students within an academic teaching hospital: Need of faculty working in patient safety

BACKGROUND

Speaking up behavior is a manifestation the culture of safety in an organization; however, withholding voice is commonly observed. Within one academic teaching hospital, it was the aim to assess students' speaking up behaviors and perceived culture in order to stimulation of the academic development in terms of patient safety.

METHODS

Survey amongst medical students using a validated questionnaire. Data were analysed using descriptive statistics.

RESULTS

326 individuals completed the questionnaire (response rate 24%). 37% of responders were in their 5th- 6th clinical term, 32% were in their 7th-8th term and 31% were in the 9th-12th term. 69% of students had a specific safety concern in the past four weeks, 48% had observed an error and 68% noticed the violation of a patient safety rule. Though students perceived specific patient safety concerns, 56% did not speak up in a critical situation. All predefined barriers seemed to play an important role in inhibiting students' voicing concerns. The scores on the psychological safety scale were overall moderately favourable. Students felt little encouraged by colleagues and, in particular, by supervisors to speak up.

CONCLUSION

Speaking up behaviour of students was assessed for the first time in an Austrian academic teaching hospital. The higher the term the more frequent students reported perceived patient safety concerns or rule violations and withholding voice. These results suggest the need to adapt the curriculum concept of the faculty in order to address patient safety as a relevant topic.

Understanding the healthcare workplace learning culture through safety and dignity narratives: a UK qualitative study of multiple stakeholders' perspectives

OBJECTIVES

While studies at the undergraduate level have begun to explore healthcare students' safety and dignity dilemmas, none have explored such dilemmas with multiple stakeholders at the postgraduate level. The current study therefore explores the patient and staff safety and dignity narratives of multiple stakeholders to better understand the healthcare workplace learning culture.

DESIGN

A qualitative interview study using narrative interviewing.

SETTING

Two sites in the UK ranked near the top and bottom for raising concerns according to the 2013 General Medical Council National Training Survey.

PARTICIPANTS

Using maximum variation sampling, 39 participants were recruited representing four different groups (10 public representatives, 10 medical trainees, 8 medical trainers and 11 nurses and allied health professionals) across the two sites.

METHODS

We conducted 1 group and 35 individual semistructured interviews. Data collection was completed in 2015. Framework analysis was conducted to identify themes. Theme similarities and differences across the two sites and four groups were established.

RESULTS

We identified five themes in relation to our three research questions (RQs): (1) understandings of safety and dignity (RQ1); (2) experiences of safety and dignity dilemmas (RQ2); (3) resistance and/or complicity regarding dilemmas encountered (RQ2); (4) factors facilitating safety and/or dignity (RQ3); and (5) factors inhibiting safety and/or dignity (RQ3). The themes were remarkably similar across the two sites and four stakeholder groups.

CONCLUSIONS

While some of our findings are similar to previous research with undergraduate healthcare students, our findings also differ, for example, illustrating higher levels of reported resistance in the postgraduate context. We provide educational implications to uphold safety and dignity at the level of the individual (eg, stakeholder education), interaction (eg, stakeholder communication and teamwork) and organisation (eg, institutional policy).

Speaking up behaviors and safety climate in an Austrian university hospital

Objective

To analyze speaking up behavior and safety climate with a validated questionnaire for the first time in an Austrian university hospital.

Design

Survey amongst healthcare workers (HCW). Data were analyzed using descriptive statistics, Cronbach's alpha was calculated as a measure of internal consistencies of scales. Analysis of variance and t-tests were used.

Setting

The survey was conducted in 2017.

Participants

About 2.149 HCW from three departments were asked to participate.

Intervention

To measure speaking up behavior and safety climate.

Main Outcome Measure

To explore psychological safety, encouraging environment and resignation towards speaking up.

Results

About 859 evaluable questionnaires were returned (response rate: 40%). More than 50% of responders perceived specific concerns about patient safety within the last 4 weeks and observed a potential error or noticed rule violations. For the different items, between 16% and 42% of HCW reported that they remained silent though concerns for safety. In contrast, between 96% and 98% answered that they did speak up in certain situations. The psychological safety for speaking up was lower for HCW with a managerial function (P < 0.001). HCW with managerial functions perceived the environment as less encouraging to speak up (P < 0.05) than HCW without managerial function.

Conclusions

We identified speaking up behaviors for the first time in an Austrian university hospital. Only moderately frequent concerns were in conflict with frequent speaking up behaviors. These results clearly show that a paradigm shift is needed to increase speaking up culture.

Walking the Plank: An Experimental Paradigm to Investigate Safety Voice

The investigation of people raising or withholding safety concerns, termed safety voice, has relied on report-based methodologies, with few experiments. Generalisable findings have been limited because: the behavioural nature of safety voice is rarely operationalised; the reliance on memory and recall has well-established biases; and determining causality requires experimentation. Across three studies, we introduce, evaluate and make available the first experimental paradigm for studying safety voice: the “Walking the plank” paradigm. This paradigm presents participants with an apparent hazard (walking across a weak wooden plank) to elicit safety voice behaviours, and it addresses the methodological shortfalls of report-based methodologies. Study 1 (n = 129) demonstrated that the paradigm can elicit observable safety voice behaviours in a safe, controlled and randomised laboratory environment. Study 2 (n = 69) indicated it is possible to elicit safety silence for a single hazard when safety concerns are assessed and alternative ways to address the hazard are absent. Study 3 (n = 75) revealed that manipulating risk perceptions results in changes to safety voice behaviours. We propose a distinction between two independent dimensions (concerned-unconcerned and voice-silence) which yields a 2 × 2 safety voice typology. Demonstrating the need for experimental investigations of safety voice, the results found a consistent mismatch between self-reported and observed safety voice. The discussion examines insights on conceptualising and operationalising safety voice behaviours in relationship to safety concerns, and suggests new areas for research: replicating empirical studies, understanding the behavioural nature of safety voice, clarifying the personal relevance of physical harm, and integrating safety voice with other harm-prevention behaviours. Our article adds to the conceptual strength of the safety voice literature and provides a methodology and typology for experimentally examining people raising safety concerns.

Speaking Up about Patient Safety in Perioperative Care: Differences between Academic and Nonacademic Hospitals in Austria and Switzerland

Purpose of the Study: In perioperative care, communication about patient safety concerns is both difficult and valuable. Research into speaking up has mostly been conducted in single countries; the aim of this study was to compare speaking up-related climate and behaviors in academic and nonacademic hospitals. Materials and Methods: The study is based on two surveys conducted in Austria and Switzerland. The Swiss survey was conducted in five nonacademic hospitals, the Austrian survey in one university hospital. Results: 768 questionnaires were returned (nonacademic: n = 360; response rate: 37%; academic: n = 408; response rate: 32%). There were differences (p < 0.001) concerning speaking up episodes (at least one episode of speaking up in the past four weeks) between nonacademic hospitals (68%) and the academic hospital (96%). Withholding voice was reported by 32% of nonacademic and 43% of academic staff (p = 0.003). The speak up-related climate in the Swiss sample was more positive. Nurses compared to doctors scored higher on all items of the "resignation scale." Important differences emerged in ratings of a clinical scenario of missed hand disinfection: Nonacademic health-care workers perceived the risk of harm for patients higher compared to academic (5.3 vs. 2.5; p < 0.001). Responders higher in hierarchy felt better with speaking up in nonacademic hospitals. Conclusions: The study is one of the first to address differences in academic and nonacademic hospitals in speaking up behaviors and demonstrated differences. This analysis helps to put local data in perspective and to target further activities for improvement.

Speaking up about hand hygiene failures: A vignette survey study among healthcare professionals

BACKGROUND

Speaking up by healthcare professionals (HCPs) is an important resource to reduce risks to patient safety. Due to complex tradeoffs, HCPs are often reluctant to voice their concerns. A survey investigated HCPs' likelihood to speak up.

METHODS

A cross-sectional survey study among HCPs in 5 Swiss hospitals addressed speaking-up behaviors, safety climate, and likelihood to speak up about poor hand hygiene practice described in a vignette. Likelihood to speak up was analyzed using a multilevel regression model.

RESULTS

Of surveyed HCPs (n = 1217), 56% reported that they would speak up to a colleague with poor hand hygiene practice. Nurses as compared to doctors rated the situation as more realistic (5.25 vs 4.32, P < .001), felt more discomfort with speaking up (4.00 vs 3.34, P < .001), and reported a slightly lower likelihood of speaking up (4.41 vs 4.77, P < .001). Clinical function (hierarchy) was strongly associated with speaking-up behavior (P < .001). Higher risk of harm to the patient (P < .001) and higher frequencies of past speaking-up behaviors (P = .006) were positively associated with the likelihood to speak up. Higher frequencies of past withholding voice (P = .013) and higher levels of resignation (P = .008) were both associated with a lower likelihood to speak up.

CONCLUSIONS

Infection control interventions should empower HCPs to speak up about non-adherence with prevention practices by addressing authority gradients and risk perceptions and by focusing on resignation.

Examining influences on speaking up among critical care healthcare providers in the United Arab Emirates

Objective

Assess perceived barriers to speaking up and to provide recommendations for reducing barriers to reporting adverse events and near misses.

Design, setting, participants, intervention

A six-item survey was administered to critical care providers in 19 Intensive Care Units in Abu Dhabi as part of an organizational safety and quality improvement effort.

Main outcome measures

Questions elicited perspectives about influences on reporting, perceived barriers and recommendations for conveying patient safety as an organizational priority. Qualitative thematic analyses were conducted for open-ended questions.

Results

A total of 1171 participants were invited to complete the survey and 639 responded (response rate = 54.6%). Compared to other stakeholders (e.g. the media, public), a larger proportion of respondents 'agreed/strongly agreed' that corporate health system leadership and the health regulatory authority encouraged and supported error reporting (83%; 75%), and had the most influence on their decisions to report (81%; 74%). 29.5% of respondents cited fear of repercussion as a barrier, and 21.3% of respondents indicated no barriers to reporting. Barriers included perceptions of a culture of blame and issues with reporting procedures. Recommendations to establish patient safety as an organizational priority included creating supportive environments to discuss errors, hiring staff to advocate for patient safety, and implementing policies to standardize clinical practices and streamline reporting procedures.

Conclusions

Influences on reporting perceived by providers in the UAE were similar to those in the US and other countries. These findings highlight the roles of corporate leadership and regulators in developing non-punitive environments where reporting is a valuable and safe activity.

Speak up-related climate and its association with healthcare workers' speaking up and withholding voice behaviours: a cross-sectional survey in Switzerland

Objectives

To determine frequencies of healthcare workers (HCWs) speak up-related behaviours and the association of speak up-related safety climate with speaking up and withholding voice.

Design

Cross-sectional survey of doctors and nurses. Data were analysed using multilevel logistic regression models

Setting

4 hospitals with a total of nine sites from the German, French and Italian speaking part of Switzerland.

Participants

Survey data were collected from 979 nurses and doctors.

Main outcome measures

Frequencies of perceived patient safety concerns, of withholding voice and of speaking up behaviour. Speak up-related climate measures included psychological safety, encouraging environment and resignation.

Results

Perceived patient safety concerns were frequent among doctors and nurses (between 62% and 80% reported at least one safety concern during the last 4 weeks depending on the single items). Withholding voice was reported by 19%–39% of HCWs. Speaking up was reported by more than half of HCWs (55%–76%). The frequency of perceived concerns during the last 4 weeks was positively associated with both speaking up (OR=2.7, p<0.001) and withholding voice (OR=1.6, p<0.001). An encouraging environment was related to higher speaking up frequency (OR=1.3, p=0.005) and lower withholding voice frequency (OR=0.82, p=0.006). Resignation was associated with withholding voice (OR=1.5, p<0.001). The variance in both voicing behaviours attributable to the hospital-site level was marginal.

Conclusions

Our results strengthen the importance of a speak up-supportive safety climate for staff safety-related communication behaviours, specifically withholding voice. This study indicates that a poor climate, in particular high levels of resignation among HCWs, is linked to frequent ‘silence’ of HCWs but not inversely associated with frequent speaking up. Interventions addressing safety-related voicing behaviours should discriminate between withholding voice and speaking up.

'And you'll suddenly realise 'I've not washed my hands': medical students', junior doctors' and medical educators' narratives of hygiene behaviours

OBJECTIVE

Compliance to hygiene behaviours has long been recognised as important in the prevention and control of healthcare associated infections, but medical doctors still display some of the lowest rates of compliance of all healthcare workers. We aim to understand compliance to hygiene behaviours by analysing medical students', junior doctors' and medical educators' narratives of these behaviours to identify their respective attitudes and beliefs around compliance and how these are learnt during training. Such an understanding can inform future interventions to improve compliance targeted to areas of greatest need.

DESIGN

A qualitative study, using narrative interviews (nine focus groups and one individual interview). Data were analysed thematically using inductive framework analysis.

SETTING

Teaching hospitals in the UK.

PARTICIPANTS

Convenience sample of 25 participants: third-year medical students in their first clinical year (n=13), junior doctors (n=6) and medical educators (n=6).

RESULTS

We identified four main themes: (1) knowledge, (2) constraints, (3) role models/culture and (4) hygiene as an added extra. Knowledge varied across participant groups and appeared to influence behaviours; medical students relied on what they have been told by seniors, while medical educators relied on their own knowledge and experience. There was a strong belief that evidence for the effectiveness of good hygiene behaviours is lacking. Furthermore, medical educators' behaviour appears to strongly influence others. Finally, hygiene was predominately viewed as an added extra rather than an integral part of the process.

CONCLUSIONS

Awareness of the evidence around good hygiene needs to be improved at all levels. Medical students and junior doctors should be encouraged to consider why they are asked to perform certain hygiene behaviours in order to improve ownership of those behaviours. Medical educators need to recognise their responsibilities as role models for their junior counterparts, thereby understanding their role in developing the culture of hygiene practices within their clinical domains.

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.

[When silence is dangerous: "Speaking-up" about safety concerns]

BACKGROUND

Open and direct communication ("speaking-up") about errors, bypassed safety rules and risky behaviours among hospital staff is required to avoid patient harm, and it is an essential characteristic of an established safety culture. In German-speaking countries, little is known about speaking-up behaviour among health care professionals (HCPs) in hospitals.

METHOD

Safety concerns and speaking-up behaviours among HCPs of nine oncological units of eight hospitals were assessed using a self-administered survey. A vignette was embedded to assess hypothetical speaking-up and its predictors. The association of hierarchical position and speaking-up was investigated. 1,013 physicians and nurses completed the survey (65 % response rate).

RESULTS

53 % of the HCPs reported having concerns about patient safety at their unit, "sometimes", "frequently", or "very frequently". Colleagues bypassing important safety rules at least "sometimes" were reported by 30 %. A considerable fraction of responders reported episodes of withholding of voice. Nearly 20 % said they did not communicate safety problems at their unit at least sometimes. 73 % of higher-ranking staff and 60 % among those at lower ranks said they had never withheld information which could have reduced threats to patients (OR=1.8, p≤0.001). Many responders felt that speaking-up is often difficult and challenging. 32 % responded that they would not speak-up about a missed hand disinfection towards a colleague assessing the wound of a recently operated oncological patient.

CONCLUSIONS

HCPs in hospital frequently experience safety concerns and often withhold them. An important resource for better patient safety is lost. The development of interventions to improve speaking-up culture is warranted.

Infections and interaction rituals in the organisation: clinician accounts of speaking up or remaining silent in the face of threats to patient safety

Clinician silence in the face of known threats to patient safety is a source of growing concern. Current explanations for the difficulties clinicians have of speaking up are conceptualised at the individual or organisational level, with little attention paid to the space between--the interaction context. Drawing on 103 interviews with clinicians at one hospital in the United States this article examines how clinicians talk about speaking up or not in the face of breaches in infection prevention technique. Accounts are analysed using a microsociological lens as stories of interaction, through which respondents appeal to situational and organisational realities of medical work that serve to justify speaking up or remaining silent. Analysis of these accounts reveals three influences on the decision to speak up, shaped by background conditions in the organisation; mutual focus of attention, interactional path dependence and the presence of an audience. These findings suggest that the decision to speak up in a clinical setting is dynamic, highly context-dependent, embedded in the interaction rituals that suffuse everyday work and constrained by organisational dynamics. This article develops a more sophisticated and distinctly sociological understanding of the reasons why speaking up in healthcare is so difficult.

Frequency of and predictors for withholding patient safety concerns among oncology staff: a survey study

Speaking up about patient safety is vital to avoid errors reaching the patient and to improve a culture of safety. This study investigated the prevalence of non-speaking up despite concerns for safety and aimed to identify predictors for withholding voice among healthcare professionals (HCPs) in oncology. A self-administered questionnaire assessed safety concerns, speaking up beliefs and behaviours among nurses and doctors from nine oncology departments. Multiple regression analysis was used to identify predictors for withholding safety concerns. A total of 1013 HCPs returned the completed survey (response rate 65%). Safety concerns were common among responders. Fifty-four per cent reported to recognise their colleagues making potentially harmful errors at least sometimes. A majority of responders reported at least some episodes of withholding concerns about patient safety. Thirty-seven per cent said they remained silent at least once when they had information that might have helped prevent an incident. Respondents believed that a high level of interpersonal, communication and coping skills are necessary to speak up about patient safety issues at their workplace. Higher levels of perceived advocacy for patient safety and psychological safety significantly decreased the frequency of withholding voice. Remaining silent about safety concerns is a common phenomenon in oncology. Improved strategies are needed to support staff in effective communication and make cancer care safer.

Silence that can be dangerous: a vignette study to assess healthcare professionals' likelihood of speaking up about safety concerns

Purpose

To investigate the likelihood of speaking up about patient safety in oncology and to clarify the effect of clinical and situational context factors on the likelihood of voicing concerns.

Patients and Methods

1013 nurses and doctors in oncology rated four clinical vignettes describing coworkers’ errors and rule violations in a self-administered factorial survey (65% response rate). Multiple regression analysis was used to model the likelihood of speaking up as outcome of vignette attributes, responder’s evaluations of the situation and personal characteristics.

Results

Respondents reported a high likelihood of speaking up about patient safety but the variation between and within types of errors and rule violations was substantial. Staff without managerial function provided significantly higher levels of decision difficulty and discomfort to speak up. Based on the information presented in the vignettes, 74%−96% would speak up towards a supervisor failing to check a prescription, 45%−81% would point a coworker to a missed hand disinfection, 82%−94% would speak up towards nurses who violate a safety rule in medication preparation, and 59%−92% would question a doctor violating a safety rule in lumbar puncture. Several vignette attributes predicted the likelihood of speaking up. Perceived potential harm, anticipated discomfort, and decision difficulty were significant predictors of the likelihood of speaking up.

Conclusions

Clinicians’ willingness to speak up about patient safety is considerably affected by contextual factors. Physicians and nurses without managerial function report substantial discomfort with speaking up. Oncology departments should provide staff with clear guidance and trainings on when and how to voice safety concerns.