Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents

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.

The Science of Health Care Worker Burnout: Assessing and Improving Health Care Worker Well-Being

CONTEXT.—

Problems with health care worker (HCW) well-being have become a leading concern in medicine given their severity and robust links to outcomes like medical error, mortality, and turnover.

OBJECTIVE.—

To describe the state of the science regarding HCW well-being, including how it is measured, what outcomes it predicts, and what institutional and individual interventions appear to reduce it.

DATA SOURCES.—

Peer review articles as well as multiple large data sets collected within our own research team are used to describe the nature of burnout, associations with institutional resources, and individual tools to improve well-being.

CONCLUSIONS.—

Rates of HCW burnout are alarmingly high, placing the health and safety of patients and HCWs at risk. To help address the urgent need to help HCWs, we summarize some of the most promising early interventions, and point toward future research that uses standardized metrics to evaluate interventions (with a focus on low-cost institutional and personal interventions).

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Interdisciplinary differences in patient safety culture within a teaching hospital in Southeast Asia

BACKGROUND

Patient safety represents a global issue which leads to potentially avoidable morbidity and mortality. The healthcare providers perception and their role are utmost important in delivering quality care and patient safety. This study aimed to determine the interdisciplinary differences in patient safety culture in a tertiary university hospital.

METHOD

A cross-sectional study using the Safety Attitude Questionnaire (SAQ) self-administered electronically in the English and Malay languages to evaluate safety culture domains. A positive percentage agreement scores of 60% was considered satisfactory. Comparisons were made between doctors, nurses, allied health professionals, nursing assistants and support staff.

RESULTS

Of 6562 respondents, 5724 (80.4%) completed the questionnaire; 3930 (74.5%) women, 2263 (42.9%) nurses, and 1812 (34.2%) had 6-10 years of working experience. The mean overall positive percentage agreement scores were 66.2 (range = 31.1 to 84.7%), with job satisfaction (72.3% ± 21.9%) and stress recognition (58.3 ± 25.6%) representing the highest and lowest mean domain scores, respectively. Differences were observed between all five job categories. Linear regression analyses revealed that the other four job categories scored lower in teamwork, safety climate, job satisfaction and working conditions compared to nurses.

CONCLUSIONS

The overall mean SAQ score was above the satisfactory level, with unsatisfactory percentage agreement scores in the stress recognition domain. Interventions to improve patient safety culture should be developed, focusing on stress management.

Safety culture in healthcare: mixed method study

PURPOSE

Healthcare providers' perceptions of management's effectiveness in achieving safety culture improvements are low, and there is little information in the literature on the subject. Objective: The overall aim of this study was to examine the patient safety culture within an interprofessional team - physicians, nurses, nurse technicians, speech therapist, psychologist, social worker, administrative support - practicing in an advanced neurology and neurosurgery center in Southern Brazil.

DESIGN/METHODOLOGY/APPROACH

The authors applied the safety attitudes questionnaire (SAQ) in a mixed methods study, with a quan→QUAL sequential explanatory approach.

FINDINGS

In the quantitative phase, the authors found a negative safety climate through the SAQ. In the qualitative phase, the approach enabled participants to identify specific safety problems. For that, participants proposed improvements that were directly and quickly implemented in the workplace during the study. The joint analysis of the quantitative and qualitative data inferred that the information and reflections of the focus group participants supported and validated the SAQ statistical analysis results. This integrated approach illustrated the importance of various safety culture aspects as a multifaceted phenomenon related to healthcare quality.

ORIGINALITY/VALUE

This study provides explanations for why management is associated negatively with safety climate in healthcare institutions. In addition, the study provides a novel contribution adding value to mixed methods research methodology.

Just Culture for Medical Students: Understanding Response to Providers in Adverse Events

INTRODUCTION

Individual and organizational response to an adverse event is a key part of the life cycle of a patient safety event. Just culture is a safety concept that emphasizes system drivers of human behavior. We developed a learning activity for medical students to teach and discuss just culture as part of a patient safety curriculum.

METHODS

This small-group, discussion-based learning activity was aimed at third-year medical students. Over 5 years, 628 students participated in it. The session had three components: a presession case-based survey, a didactic lecture, and a facilitated small-group discussion. Participants evaluated the session using our institution's standard learner assessment. They also took a postcourse test that contained multiple-choice questions relating to the session.

RESULTS

On a 5-point Likert scale (1 = poor, 3 = good, 5 = excellent), students rated the large-group lecture (3.2) and small-group discussion (3.2) moderately. Over 85% of students answered all knowledge items on a course posttest correctly.

DISCUSSION

This learning activity provides an easy-to-implement case-based discussion to introduce the concepts of just culture.

Third year medical students impersonalize and hedge when providing negative upward feedback to clinical faculty

Medical students provide clinical teaching faculty with feedback on their skills as educators through anonymous surveys at the end of their clerkship rotation. Because faculty are in a position of power, students are hesitant to provide candid feedback. Our objective was to determine if medical students were willing to provide negative upward feedback to clinical faculty and describe how they conveyed their feedback. A qualitative analysis of third year medical students' open-ended comments from evaluations of six clerkships was performed using politeness theory as a conceptual framework. Students were asked to describe how the clerkship enhanced their learning and how it could be improved. Midway through the academic year, instructions to provide full names of faculty/residents was added. Overall, there were significantly more comments on what worked well than suggestions for improvement regarding faculty/residents. Instructing students to name-names increased the rate of naming from 35% to 75% for what worked well and from 13% to 39% for suggestions for improvement. Hedging language was included in 61% of suggestions for improvement, but only 2% of what worked well. Students described the variability of their experience, used passive language and qualified negative experiences with positive ones. Medical students may use linguistic strategies, such as impersonalizing and hedging, to mitigate the impact of negative upward feedback. Working towards a culture that supports upward feedback would allow students to feel more comfortable providing candid comments about their experience.

"I feel I have no voice": hospital doctors' workplace silence in Ireland

Purpose

Workplace silence impedes productivity, job satisfaction and retention, key issues for the hospital workforce worldwide. It can have a negative effect on patient outcomes and safety and human resources in healthcare organisations. This study aims to examine factors that influence workplace silence among hospital doctors in Ireland.

Design/methodology/approach

A national, cross-sectional, online survey of hospital doctors in Ireland was conducted in October–November 2019; 1,070 hospital doctors responded. This paper focuses on responses to the question “If you had concerns about your working conditions, would you raise them?”. In total, 227 hospital doctor respondents (25%) stated that they would not raise concerns about their working conditions. Qualitative thematic analysis was carried out on free-text responses to explore why these doctors choose to opt for silence regarding their working conditions.

Findings

Reputational risk, lack of energy and time, a perceived inability to effect change and cultural norms all discourage doctors from raising concerns about working conditions. Apathy arose as change to working conditions was perceived as highly unlikely. In turn, this had scope to lead to neglect and exit. Voice was seen as risky for some respondents, who feared that complaining could damage their career prospects and workplace relationships.

Originality/value

This study highlights the systemic, cultural and practical issues that pressure hospital doctors in Ireland to opt for silence around working conditions. It adds to the literature on workplace silence and voice within the medical profession and provides a framework for comparative analysis of doctors' silence and voice in other settings.

Why do few medical students report their experiences of mistreatment to administration?

INTRODUCTION

Over 50% of medical students worldwide report experiencing mistreatment and abuse during their clinical education, yet only a small proportion of students report these concerns to administration. It is unknown how medical students make sense of their experiences of mistreatment and come to decide whether to formally report these experiences. Improved understanding of this phenomenon will facilitate changes at the administrative and institutional levels to better support students.

METHODS

Using Constructivist Grounded Theory, we interviewed 19 current and former medical students from one institution about their experiences with mistreatment and reporting. Data were analysed in an iterative fashion, using focused and theoretical forms of coding.

RESULTS

The decision of whether to report mistreatment is only one phase in the process that students report experiencing when encountering mistreatment. This process can be understood as a journey consisting of five phases: Situating, Experiencing and Appraising, Reacting, Deciding and Moving Forward. Students move through these phases as they come to understand their position as medical learners and their ability to trust and be safe within this institution. Each experience of mistreatment causes students to react to what has happened to them, decide if they will share their experiences and reach out for support. They choose if they are going to report the mistreatment, at what cost and for what outcomes. Students continue through their training while incorporating their experiences into their understanding of the culture in which they are learning and continually resituating themselves within the institution.

DISCUSSION

Student perceptions of trust or mistrust in their educational institution are highly influential when it comes to reporting mistreatment. Interventions designed to support students and decrease exposure to mistreatment may be best focused on increasing organisational trust between students and the medical school.

Pediatric Trainees' Speaking Up About Unprofessional Behavior and Traditional Patient Safety Threats

OBJECTIVE

Speaking up is increasingly recognized as essential for patient safety. We aimed to determine pediatric trainees' experiences, attitudes, and anticipated behaviors with speaking up about safety threats including unprofessional behavior.

METHODS

Anonymous, cross-sectional survey of 512 pediatric trainees at 2 large US academic children's hospitals that queried experiences, attitudes, barriers and facilitators, and vignette responses for unprofessional behavior and traditional safety threats.

RESULTS

Responding trainees (223 of 512, 44%) more commonly observed unprofessional behavior than traditional safety threats (57%, 127 of 223 vs 34%, 75 of 223; P < .001), but reported speaking up about unprofessional behavior less commonly (48%, 27 of 56 vs 79%, 44 of 56; P < .001). Respondents reported feeling less safe speaking up about unprofessional behavior than patient safety concerns (52%, 117 of 223 vs 78%, 173 of 223; P < .001). Respondents were significantly less likely to speaking up to, and use assertive language with, an attending physician in the unprofessional behavior vignette than the traditional safety vignette (10%, 22 of 223 vs 64%, 143 of 223, P < .001 and 12%, 27 of 223 vs 57%, 128 of 223, P < .001, respectively); these differences persisted even among respondents that perceived high potential for patient harm in both vignettes (20%, 16 of 81 vs 69%, 56 of 81, P < .001 and 20%, 16 of 81 vs 69%, 56 of 81, P < .001, respectively). Fear of conflict was the predominant barrier to speaking up about unprofessional behavior and more commonly endorsed for unprofessional behavior than traditional safety threats (67%, 150 of 223 vs 45%, 100 of 223, P < .001).

CONCLUSIONS

Findings suggest pediatric trainee reluctance to speak up when presented with unprofessional behavior compared to traditional safety threats and highlight a need to improve elements of the clinical learning environment to support speaking up.

Nurses' perspectives of recognising and responding to unsafe practice by their peers: A national cross-sectional survey

AIMS

This study aimed to identify behaviours and cues that nurses recognise as indications of unsafe practice, perceived factors that contribute to unsafe practice and actions nurses take in response.

DESIGN

Cross-sectional survey.

METHODS

National cross-sectional survey of a random sample of registered nurses (n = 231) in New Zealand, in 2017-2018. The STROBE Checklist was used to report this study.

RESULTS

Nurses reported a high rate of episodes of unsafe practices and recognised a range of behaviours and cues that alerted them to the potential for unsafe practice. Several organisational issues were perceived to contribute to unsafe practice occurring. The reporting of episodes of unsafe practice and perceived organisational support was low for nurses compared with managers.

CONCLUSION

Failure to recognise and respond to unsafe practice may indicate a tolerance for substandard practice by individual nurses, or by the organisation. Nurses who recognise unsafe practice must be supported by the organisation.

Radiology Trainees' Perceptions of Speaking up Culture Related to Safety and Unprofessional Behavior in Their Work Environments

OBJECTIVE. The purpose of this study was to compare radiology trainees' perceptions of the culture regarding speaking up about patient safety and unprofessional behavior in the clinical environment and to assess the likelihood that they will speak up in the presence of a medical hierarchy. MATERIALS AND METHODS. The study included radiology trainees from nine hospitals who attended a communication workshop. Trainees completed questionnaires assessing their perceptions of the support provided by their clinical environment regarding speaking up about patient safety and unprofessional behavior. We also queried their likelihood of speaking up within a team hierarchy about an error presented in a hypothetical clinical vignette. RESULTS. Of 61 participants, 58 (95%) completed questionnaires. Of these 58 participants, 84% felt encouraged by colleagues to speak up about safety concerns, and 57% felt encouraged to speak up about unprofessional behavior (p < .001). Moreover, 17% and 34% thought speaking up about safety concerns and unprofessional behavior, respectively, was difficult (p < .02). Trainees were less likely to agree that speaking up about unprofessional behavior (compared with speaking up about safety concerns) resulted in meaningful change (66% vs 95%; p < .001). In a vignette describing a sterile technique error, respondents were less likely to speak up to an attending radiologist (48%) versus a nurse, intern, or resident (79%, 84%, and 81%, respectively; p < .001). Significant predictors of the likelihood of trainees speaking up to an attending radiologist included perceived potential for patient harm as a result of the error (odds ratio [OR], 6.7; p < .001), perceptions of safety culture in the clinical environment (OR, 5.0; p = .03), and race or ethnicity (OR, 3.1; p = .03). CONCLUSION. Radiology trainees indicate gaps in workplace cultures regarding speaking up, particularly concerning unprofessional behavior and team hierarchy.

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

BACKGROUND

Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees' concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased.

METHODS

A systematic narrative review, informed by complex systems perspectives addresses the question: "What workplace strategies and/or interventions have been implemented to promote speaking-up by employees"?

RESULTS

Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al., 2018 (a)) hierarchical, interdisciplinary and cultural relationships and (Francis, 2015 (b)) psychological safety.

CONCLUSIONS

We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.

Tools for measuring medical internship experience: a scoping review

BACKGROUND

Appropriate and well-resourced medical internship training is important to ensure psychological health and well-being of doctors in training and also to recruit and retain these doctors. However, most reviews focused on clinical competency of medical interns instead of the non-clinical aspects of training. In this scoping review, we aim to review what tools exist to measure medical internship experience and summarize the major domains assessed.

METHOD

The authors searched MEDLINE, Embase, PsycINFO, ERIC, and the Cochrane Library for peer-reviewed studies that provided quantitative data on medical intern's (house officer, foundation year doctor, etc.) internship experience and published between 2000 and 2019. Three reviewers screened studies for eligibility with inclusion criteria. Data including tools used, key themes examined, and psychometric properties within the study population were charted, collated, and summarized. Tools that were used in multiple studies, and tools with internal validity or reliability assessed directed in their intern population were reported.

RESULTS

The authors identified 92 studies that were included in the analysis. The majority of studies were conducted in the US (n = 30, 32.6%) and the UK (n = 20, 21.7%), and only 14 studies (15.2%) were conducted in low- and middle-income countries. Major themes examined for internship experience included well-being, educational environment, and work condition and environment. For measuring well-being, standardized tools like the Maslach Burnout Inventory (for measuring burnout), Patient Health Questionnaire-9 (depression), General Health Questionnaire-12 or 30 (psychological distress) and Perceived Stress Scale (stress) were used multiple times. For educational environment and work condition and environment, there is a lack of widely used tools for interns that have undergone psychometric testing in this population other than the Postgraduate Hospital Educational Environment Measure, which has been used in four different countries.

CONCLUSIONS

There are a large number of tools designed for measuring medical internship experience. International comparability of results from future studies would benefit if tools that have been more widely used are employed in studies on medical interns with further testing of their psychometric properties in different contexts.

The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre

BACKGROUND

Speaking up is important for patient safety, but only if the concern raised is acknowledged and responded to appropriately. While the power to change the course of events rests with those in charge, research has focussed on supporting those in subordinate positions to speak up. We propose responsibility also rests with senior clinical staff to respond appropriately. We explored the perceptions of senior staff on being spoken up to in the operating theatre (OT), and factors moderating their response.

METHODS

We undertook interviews and focus groups of fully qualified surgeons, anaesthetists, nurses, and anaesthetic technicians working in OTs across New Zealand. We used grounded theory to analyse and interpret the data.

RESULTS

With data from 79 participants, we conceptualise three phases in the speaking up interaction: 1) the content of the speaker's message and the tone of delivery; 2) the message interpreted through the receiver's filters, including beliefs on personal fallibility and leadership, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional norms around communication; and 3) the receiver's subsequent response and its effects on the speaker, the observing OT staff, and patient care.

CONCLUSIONS

The speaking up interaction can be high stakes for the whole OT team. The receiver response can strengthen team cohesion and function, or cause distress and tension. Our grounded theory uncovers multiple influences on this interaction, with potential for re-framing and optimising the speaker/receiver interaction to improve team function and patient safety.

A multi-method exploratory study of health professional students' experiences with compliance behaviours

BACKGROUND

Research in healthcare, including students as participants, has begun to document experiences with negative compliance, specifically conformity and obedience. There is a growing body of experimental and survey literature, however, currently lacking is a direct measure of the frequency at which health professional students have negative experiences with conformity and obedience integrated with psychological factors, the outcomes of negative compliance, and students' perceptions.

METHODS

To develop empirical knowledge about the frequency of negative compliance and student perceptions during health professional education a multi-methods survey approach was used. The survey was administered to health professional students across ten disciplines at four institutions.

RESULTS

The results indicated students regularly experience obedience and conformity and are influenced by impression management and displacement of responsibility. Moral distress was identified as a consistent negative outcome. Student self-reported experiences aligned with the empirical findings.

CONCLUSIONS

The findings of the present study demonstrate the pervasiveness of experiences with negative compliance during health professional's education along with some attendant psychological factors. The findings have educational and practical implications, as well as pointing to the need for further integration of social and cognitive psychology in explaining compliance in healthcare. The results are likely generalizable to a population level however replication is encouraged to better understand the true frequency of negative compliance at a health professional population level.

Investigating voice in action teams: a critical review

Team communication is considered a key factor for team performance. Importantly, voicing concerns and suggestions regarding work-related topics-also termed speaking up-represents an essential part of team communication. Particularly in action teams in high-reliability organizations such as healthcare, military, or aviation, voice is crucial for error prevention. Although research on voice has become more important recently, there are inconsistencies in the literature. This includes methodological issues, such as how voice should be measured in different team contexts, and conceptual issues, such as uncertainty regarding the role of the voice recipient. We tried to address these issues of voice research in action teams in the current literature review. We identified 26 quantitative empirical studies that measured voice as a distinct construct. Results showed that only two-thirds of the articles provided a definition for voice. Voice was assessed via behavioral observation or via self-report. Behavioral observation includes two main approaches (i.e., event-focused and language-focused) that are methodologically consistent. In contrast, studies using self-reports showed significant methodological inconsistencies regarding measurement instruments (i.e., self-constructed single items versus validated scales). The contents of instruments that assessed voice via self-report varied considerably. The recipient of voice was poorly operationalized (i.e., discrepancy between definitions and measurements). In sum, our findings provide a comprehensive overview of how voice is treated in action teams. There seems to be no common understanding of what constitutes voice in action teams, which is associated with several conceptual as well as methodological issues. This suggests that a stronger consensus is needed to improve validity and comparability of research findings.

Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

How to identify, address and report students' unprofessional behaviour in medical school

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Medical students' opinions on professional behaviours: The Professionalism of Medical Students' (PoMS) study

Introduction: The Professionalism of Medical Students (PoMS) study aimed to develop a comprehensive understanding of Australian and New Zealand (Aus/NZ) medical students' opinions and experience with professionalism dilemmas.Methods: A confidential, online survey for medical students was developed and distributed to all Aus/NZ medical schools. Students submitted de-identified demographic information, gave opinions on the acceptability of a range of student behaviours for professionally challenging situations, and whether they had encountered similar situations.Results: 3171 medical students participated from all 21 Aus/NZ medical schools (16% of the total student population). Medical students reported encountering many of the professionally challenging situations and had varying opinions on what was acceptable behaviour for the scenarios. In general, students' opinions were not influenced by the seniority, gender or the type of health professional involved in the scenario. Participant demographic factors appeared to have significant effects on professional opinions - particularly male gender and being a student in the latter stages of the course.Discussion: Medical students' professional opinions are a complex area. The PoMS data provides a reference point for students, their educators and other health professionals in identifying current student professional behaviour norms, determining the effects of demographic factors on their decision making, and where important gaps exist in medical students' approaches to professionalism.

Nurses’ voice: the role of hierarchy and leadership

Purpose

Voicing concerns and suggestions is crucial for preventing medical errors and improving patient safety. Research suggests that hierarchy in health-care teams impair open communication. Hierarchy, however, can vary with changing team composition, particularly during acute care situations where more senior persons join the team later on. The purpose of this study is to investigate how changes in hierarchy and leadership were associated with nurses’ voice frequency and nurses’ time to voice during simulated acute care situations.

Design/methodology/approach

This study’s sample consisted of 78 health-care providers (i.e. nurses, residents and consultants) who worked in 39 teams performing complex clinical scenarios in the context of interprofessional, simulation-based team training. Scenarios were videotaped and communication behaviour was coded using a systematic coding scheme. To test the hypotheses, multilevel regression analyses were conducted.

Findings

Hierarchy and leadership had no significant effect on nurses’ voice frequency. However, there were significant relationships between nurses’ time to voice and both hierarchy (γ = 30.00, p = 0.002; 95 per cent confidence interval [CI] = 12.43; 47.92) as well as leadership (γ = 0.30, p = 0.001; 95 per cent CI = 0.12; 0.47). These findings indicate that when more physicians are present and leadership is more centralised, more time passes until the first nurses’ voice occurred.

Originality/value

This study specifies previous findings on the relationships between hierarchy, leadership and nurses’ voice. Our findings suggest that stronger hierarchy and more centralised leadership delay nurses’ voice but do not affect the overall frequency of voice.

Validação psicométrica de instrumento que avalia a cultura de segurança na Atenção Primária

Resumo Objetivo: Analisar a confiabilidade e validade das propriedades psicométricas da versão brasileira do instrumento para Pesquisa sobre Cultura de Segurança do Paciente para Atenção Primária à Saúde. Métodos: Estudo transversal quantitativo, realizado com profissionais da equipe multiprofissional atuantes na Atenção Primária à Saúde de um município da região noroeste do Estado do Rio Grande do Sul, Brasil. O instrumento utilizado foi “Pesquisa sobre Cultura de Segurança do Paciente para Atenção Primária à Saúde”. Resultados: O Alfa de Cronbach foi considerado satisfatório. A análise fatorial alcançou cargas satisfatórias no conjunto de seus fatores. O instrumento apresentou viabilidade de aplicação e potencial de avaliação da estrutura para a qual se propõe. Conclusão: A versão brasileira do questionário mostrou-se válida e confiável, podendo contribuir com pesquisas sobre a cultura de segurança do paciente na Atenção Primária à Saúde no país.

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care

PURPOSE

The authors previously found that attending physicians conceptualize hospital admission purpose according to 3 perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams.

METHOD

Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis.

RESULTS

The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge focused vs optimization focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspectives, using authority to shut down and redirect discussion. Trainees' maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover).

CONCLUSIONS

Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and to trainees participating in covert maneuvers, potentially affecting trust and professional identify development.

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.

Professional practice behaviour: Identification and validation of key indicators

Introduction

Professional behaviour is regarded as an important competency for occupational therapy practice, yet little guidance exists for indicators underpinning development or remediation in the educational or practice settings. This study sought to confirm the content validity of observable professional behaviour indicators from an existing evaluation framework for representativeness and relevance for occupational therapy practice.

Methods

A modified Delphi approach was conducted with expert panellists ( n = 30) consisting of regulators, administrators, faculty members, practitioners, and students for professional behaviour indicator consensus, together with a cross-sectional survey of practitioners ( n = 119). Fleiss’ κ and χ2 contingency tables were completed for agreement across panellists, and between panellist and survey groups. Cross-case qualitative analyses identified facilitators and barriers for professional behaviour practice.

Results

Content validity of 17 professional behaviour indicators was achieved, with >85% agreement from the expert panellists and the cross-sectional survey group. Main professional behaviour reporting issues in practice included fear of reprisal, lack of formal policies, and an unsupportive culture. Support from others, documented workplace policies, and self-regulation/duty to monitor were the critical facilitators for supporting professional behaviour in practice.

Conclusion

The professional behaviour indicators in this study offer observable behaviours from which assessment rubrics or tools may be developed. Further study is warranted.

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

OBJECTIVES

Medical residents can play key roles in improving health care quality by speaking up and giving suggestions for improvements. However, previous research on speaking up by medical residents has shown that speaking up is difficult for residents. This study explored: (i) whether two main aspects of medical residents' work context (job control and supervisor support) are associated with speaking up by medical residents, and (ii) whether these associations differ between in-hospital and out-of-hospital settings.

METHODS

Speaking up was operationalised and measured as voice behaviour. Structural equation modelling using a cross-sectional survey design was used to identify and test factors pertaining to speaking up and to compare hospital settings.

RESULTS

A total of 499 medical residents in the Netherlands participated in the study. Correlational analysis showed significant positive associations between each of support and control, and voice behaviour. The authors assumed that the associations between support and control, and voice behaviour would be partially mediated by engagement. This partial mediation model fitted the data best, but showed no association between support and voice. However, multi-group analysis showed that for residents in hospital settings, support is associated with voice behaviour. For residents outside hospital settings, control is more important. Engagement mediated the effects of control and support outside hospital settings, but not within the hospital.

CONCLUSIONS

This study shows that in order to enable medical residents to share their suggestions for improvement, it is beneficial to invest in supportive supervision and to increase their sense of control. Boosting medical residents' support would be most effective in hospital settings, whereas in other health care organisations it would be more effective to focus on job control.

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.

Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level

Burnout has been implicated in higher physician turnover, reduced patient satisfaction, and worsened safety, but understanding the degree of burnout in a given physician or team does not direct leaders to solutions. The model proposed integrates a long list of variables that may ameliorate burnout into a prioritized, easy-to-understand hierarchy. Modified from Maslow's hierarchy, the model directs leaders to address physicians' basic physical and mental health needs first; patient and physician physical safety second; and then address higher-order needs, including respect from colleagues, patients, processes, and the electronic health record; appreciation and connection; and finally, time and resources to heal patients and contribute to the greater good. Assessments based on this model will help leaders prioritize interventions and improve physician wellness.

Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study

PURPOSE

Employee voice plays an important role in organizational intelligence about patient safety hazards and other influences on quality of patient care. The authors report a case study of an academic medical center that aimed to understand barriers to voice and make improvements in identifying and responding to transgressive or disruptive behaviors.

METHOD

The case study focused on an improvement effort at Johns Hopkins Medicine that sought to improve employee voice using a two-phase approach of diagnosis and intervention. Confidential interviews with 67 individuals (20 senior leaders, 47 frontline personnel) were conducted during 2014 to diagnose causes of employee reluctance to give voice about behavioral concerns. A structured intervention program to encourage voice was implemented, 2014-2016, in response to the findings.

RESULTS

The diagnostic interviews identified gaps between espoused policies of encouraging employee voice and what happened in practice. A culture of fear pervaded the organization that, together with widespread perceptions of futility, inhibited personnel from speaking up about concerns. The intervention phase involved four actions: sharing the interview findings; coordinating and formalizing mechanisms for identifying and dealing with disruptive behavior; training leaders in encouraging voice; and building capacity for difficult conversations.

CONCLUSIONS

The problems of giving voice are widely known across the organizational literature but are difficult to address. This case study offers an approach that includes diagnostic and intervention phases that may be helpful in remaking norms, facilitating employee voice, and improving organizational response. It highlights specific actions that are available for other organizations to adapt and test.

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 care concerns in the ICU: patient and family experiences, attitudes and perceived barriers

BACKGROUND

Little is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up.

METHODS

In collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience.

RESULTS

105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%-70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a 'troublemaker', 'team is too busy' or 'I don't know how'. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up.

CONCLUSION

Speaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create 'trouble' may help promote open discussions about care concerns and possible errors in the ICU.

Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient Safety

Diagnostic error research has largely focused on individual clinicians' decision making and system design, while overlooking information from patients. We analyzed a unique new data source of patient- and family-reported error narratives to explore factors that contribute to diagnostic errors. From reports of adverse medical events submitted in the period January 2010-February 2016, we identified 184 unique patient narratives of diagnostic error. Problems related to patient-physician interactions emerged as major contributors. Our analysis identified 224 instances of behavioral and interpersonal factors that reflected unprofessional clinician behavior, including ignoring patients' knowledge, disrespecting patients, failing to communicate, and manipulation or deception. Patients' perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. Health systems should develop and implement formal programs to collect patients' experiences with the diagnostic process and use these data to promote an organizational culture that strives to reduce harm from diagnostic error.

The Relationship Between the Learning and Patient Safety Climates of Clinical Departments and Residents' Patient Safety Behaviors

PURPOSE

Improving residents' patient safety behavior should be a priority in graduate medical education to ensure the safety of current and future patients. Supportive learning and patient safety climates may foster this behavior. This study examined the extent to which residents' self-reported patient safety behavior can be explained by the learning climate and patient safety climate of their clinical departments.

METHOD

The authors collected learning climate data from clinical departments in the Netherlands that used the web-based Dutch Residency Educational Climate Test between September 2015 and October 2016. They also gathered data on those departments' patient safety climate and on residents' self-reported patient safety behavior. They used generalized linear mixed models and multivariate general linear models to test for associations in the data.

RESULTS

In total, 1,006 residents evaluated 143 departments in 31 teaching hospitals. Departments' patient safety climate was associated with residents' overall self-reported patient safety behavior (regression coefficient [b] = 0.33; 95% confidence interval [CI] = 0.14 to 0.52). Departments' learning climate was not associated with residents' patient safety behavior (b = 0.01; 95% CI = -0.17 to 0.19), although it was with their patient safety climate (b = 0.73; 95% CI = 0.69 to 0.77).

CONCLUSIONS

Departments should focus on establishing a supportive patient safety climate to improve residents' patient safety behavior. Building a supportive learning climate might help to improve the patient safety climate and, in turn, residents' patient safety behavior.

Investigating US medical students' motivation to respond to lapses in professionalism

CONTEXT

As unprofessional behaviour in physicians can compromise patient safety, all physicians should be willing and able to respond to lapses in professionalism. Although students endorse an obligation to respond to lapses, they experience difficulties in doing so. If medical educators knew how students respond and why they choose certain responses, they could support students in responding appropriately.

OBJECTIVES

The aim of this study was to describe medical students' responses to professionalism lapses in peers and faculty staff, and to understand students' motivation for responding or not responding.

METHODS

We conducted an explorative, qualitative study using template analysis, in which three researchers independently coded transcripts of semi-structured, face-to-face interviews. We purposefully sampled 18 student representatives convening at a medical education conference. Preliminary open coding of a data subset yielded an initial template, which was applied to further data and modified as necessary. All transcripts were coded using the final template. Finally, three sensitising concepts from the Expectancy-Value-Cost model were used to map participants' responses.

RESULTS

Students mentioned having observed lapses in professionalism in both faculty staff and peers. Students' responses to these lapses were avoiding, addressing, reporting or initiating policy change. Generally, students were not motivated to respond if they did not know how to respond, if they believed responding was futile and if they feared retaliation. Students were motivated to respond if they were personally affected, if they perceived the individual as approachable and if they thought that the whole group of students could benefit from their actions. Expectancy of success, value and costs each appeared to be influenced by (inter)personal and system factors.

CONCLUSIONS

The Expectancy-Value-Cost model effectively explains students' motivation for responding to lapses. The (inter)personal and system factors influencing students' motivation to respond are modifiable and can be used by medical educators to enhance students' motivation to respond to lapses in professionalism observed in medical school.

Conflict resolution in anaesthesia: systematic review

Background

Conflict is a significant and recurrent problem in most modern healthcare systems. Given its ubiquity, effective techniques to manage or resolve conflict safely are required.

Objective

This review focuses on conflict resolution interventions for improvement of patient safety through understanding and applying/teaching conflict resolution skills that critically depend on communication and improvement of staff members’ ability to voice their concerns.

Methods

We used the Population-Intervention-Comparator-Outcome model to outline our methodology. Relevant English language sources for both published and unpublished papers up to February 2018 were sourced across five electronic databases: the Cochrane Library, EMBASE, MEDLINE, SCOPUS and Web of Science.

Results

After removal of duplicates, 1485 studies were screened. Six articles met the inclusion criteria with a total sample size of 286 healthcare worker participants. Three training programmes were identified among the included studies: (A) crisis resource management training; (B) the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training; and (C) the two-challenge rule (a component of TeamSTEPPS), and two studies manipulating wider team behaviours. Outcomes reported included participant reaction and observer rating of conflict resolution, speaking up or advocacy-inquiry behaviours. Study results were inconsistent in showing benefits of interventions.

Conclusion

The evidence for training to improve conflict resolution in the clinical environment is sparse. Novel methods that seek to influence wider team behaviours may complement traditional interventions directed at individuals.

The dilemma of patient safety work: Perceptions of hospital middle managers

Patient safety continues to be a challenge for health care. Medical errors are not decreasing but continue to show roughly the same patterns in Sweden and other Western countries. This interview study aims to explore how 27 hospital middle managers responsible for patient safety work in a Swedish university hospital perceive this task. A qualitative analysis was performed. A code template was created, and each code was explored in depth and summarized into six categories. We conclude that patient safety work appears to have low priority; hospital top management does not seem to have any real interest in patient safety; incidents are underreported; and the organization of patient safety work seems to be insufficient and carried out insofar as resources are available. These parameters may explain why medical errors remain on a certain level and do not seem to decrease in spite of various support programs.

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses’ willingness to speak up

Background

Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers’ behaviour and employees’ perceptions about whether speaking up is safe and worthwhile is still lacking.

Aim

To explore the relationships between control-based and commitment-based safety management, climate for safety, psychological safety and nurses’ willingness to speak up.

Methods

We conducted a cross-sectional survey study, resulting in a sample of 980 nurses and 93 nurse managers working in Dutch clinical hospital wards. To test our hypotheses, hierarchical regression analyses (at ward level) and multilevel regression analyses were conducted.

Results

Significantly positive associations were found between nurses’ perceptions of control-based safety management and climate for safety (β=0.74; p<0.001), and between the perceived levels of commitment-based management and team psychological safety (β=0.36; p<0.01). Furthermore, team psychological safety is found to be positively related to nurses’ speaking up attitudes (B=0.24; t=2.04; p<0.05). The relationship between nurse-rated commitment-based safety management and nurses’ willingness to speak up is fully mediated by team psychological safety.

Conclusion

Results provide initial support that nurses who perceive higher levels of commitment-based safety management feel safer to take interpersonal risks and are more willing to speak up about patient safety concerns. Furthermore, nurses’ perceptions of control-based safety management are found to be positively related to a climate for safety, although no association was found with speaking up. Both control-based and commitment-based management approaches seem to be relevant for managing patient safety, but when it comes to encouraging speaking up, a commitment-based safety management approach seems to be most valuable.

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.

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns

Background

Healthcare organisations often fail to harvest and make use of the ‘soft intelligence’ about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns.

Methods

Qualitative study involving personnel from three academic hospitals in two countries. Interviews were conducted with 165 participants from a wide range of occupational and professional backgrounds, including senior leaders and those from the sharp end of care. Data analysis was based on the constant comparative method.

Results

Leaders reported that they valued employee voice; they identified formal organisational channels as a key route for the expression of concerns by employees. Formal channels and processes were designed to ensure fairness, account for all available evidence and achieve appropriate resolution. When processed through these formal systems, concerns were destined to become evidenced, formal and tractable to organisational intervention. But the way these systems operated meant that some concerns were never voiced. Participants were anxious about having to process their suspicions and concerns into hard evidentiary facts, and they feared being drawn into official procedures designed to allocate consequence. Anxiety about evidence and process was particularly relevant when the intelligence was especially ‘soft’—feelings or intuitions that were difficult to resolve into a coherent, compelling reconstruction of an incident or concern. Efforts to make soft intelligence hard thus risked creating ‘forbidden knowledge’: dangerous to know or share.

Conclusions

The legal and bureaucratic considerations that govern formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. Leaders responsible for quality and safety should consider complementing formal mechanisms with alternative, informal opportunities for listening to concerns.