Social and environmental conditions creating fluctuating agency for safety in two urban academic birth centers

Clinical Nurses' Perceptions of a "Brain-Friendly" Peer Feedback Program

BACKGROUND

While clinicians routinely observe issues with safety and quality, they may not always speak up and intervene. Peer feedback supports nurses to speak up about errors or near misses and actively improve nursing care quality. Effective peer feedback requires addressing barriers to speaking up.

PURPOSE

The purpose of this mixed methods study was to evaluate a'brain-friendly'peer feedback program´s effect on clinical nurses´ perceptions of peer review.

METHODS

Nurses were surveyed before and after the implementation of a peer feedback program that integrated social cognitive neuroscience principles. Open comments were analyzed using thematic analysis.

RESULTS

Responses to nearly half of survey questions improved. Thematic analysis identified institutional and personal barriers to peer feedback use, revealing the personal and social complexity of speaking up.

CONCLUSIONS

Social cognitive neuroscience may enhance peer feedback programs. Research using immersive qualitative methods is needed to better understand factors supporting or impeding peer feedback.

Defining Speaking Up in the Healthcare System: a Systematic Review

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

The 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.

Facing hierarchy: a qualitative study of residents’ experiences in an obstetrical simulation scenario

Background

Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety.

Methods

Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30–45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached.

Results

Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging — a mere reporting of existing clinical information; (2) interpretive — a deliberate construction of clinical facts aimed at swaying supervising physician’s clinical decision; and (3) advocative — a readiness to confront the staff physician’s clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety.

Conclusions

Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00232-1.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review

PROBLEM

Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance.

ELIGIBILITY CRITERIA

Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals.

SAMPLE

Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool.

RESULTS

Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning.

CONCLUSIONS

Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability.

IMPLICATIONS

Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

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.

Making infection prevention and control everyone's business? Hospital staff views on patient involvement

CONTEXT

Ensuring an infection-free environment is increasingly seen as requiring the contribution of staff, patients and visitors. There is limited evidence, however, about how staff feel about collaborating with patients and relatives to co-produce that environment.

AIMS

This study aims to understand how hospital staff perceive the involvement of patients and relatives in infection prevention and control (IPC) and the main challenges for staff in working together with patients and relatives to reduce the threat of infection.

METHODS

Qualitative semi-structured interviews were conducted with 35 frontline health-care professionals and four executive staff, from two hospital trusts.

FINDINGS

We found that staff were more supportive of approaches that encourage co-operation from patients and relatives, than of interventions that invoked confrontation. We identified challenges to involvement arising from staff concerns about shifting responsibility for IPC onto patients. Staff were not always able to work with patients to control infection risks as some patients themselves created and perpetuated those risks.

CONCLUSIONS

Our work highlights that IPC has particular features that impact on the possibilities for involving patients and relatives at the point of care. Staff acknowledge tensions between the drive to involve patients and respect their autonomy, and their duty to protect patients from risk of unseen harm. The role that patients and relatives can play in IPC is fluctuating and context dependent. Staff responsibility for protecting patients from the risk of infection may sometimes need to take priority over prerogatives to involve patients and relatives in the co-production of IPC.

Nurses' perceptions of the dynamics and impacts of teamwork with physicians in labour and delivery

Interprofessional teamwork is touted as essential to positive patient, staff, and organizational outcomes. However, differing understandings of teamwork and divergent professional cultures amongst healthcare providers influence the success of teamwork. In labour and delivery, nurse-physician teamwork is vital to safe, family-centered maternity care. In this focused ethnography, the perceptions of obstetrical nurses were sought to understand nurse-physician teamwork and the features that facilitate or impede it. These nurses acknowledged working in a normative hierarchy, with physicians ultimately responsible for patient care decision-making. They described myriad ways in which they navigated traditional power dynamics and smoothed working relationships with physicians, such as circumventing disrespectful behaviors, venting with each other, highlighting their own autonomy, using tactical communication, and managing unit resources. According to these nurses, key facilitators of functional nurse-physicians relationships were time, trust, respect, credibility, and social connection. Further, the nature of their working relationships with physicians influenced their perceptions regarding intent to stay, workplace morale, and patient outcomes.

Midwifery abdication - is it acknowledged or discussed within the midwifery literature: An integrative review

INTRODUCTION

In this review we explore the concept of Midwifery Abdication and whether it is acknowledged or discussed within the midwifery literature.

METHODS

A modified Whittemore and Knafl integrative review framework of 2005 enabled consideration of quantitative and qualitative literature. A total of 1508 papers were located. Duplicate records were removed, leaving 1197 records. All titles, abstracts, or case facts were reviewed using a framework derived from the definition of Midwifery Abdication. Three qualitative studies were selected for analysis; the NICE Quality Appraisal Checklist was used to determine study quality.

RESULTS

Midwifery Abdication occurs, as reported within the wider midwifery literature, and indicated in three studies from different countries. However, the original constructs need to be widened to include: 'external perceptions of midwifery practice' and 'how can reflection facilitate change'. The extent of philosophy in these environments leads to the adoption of midwifery philosophy failure. Such an environment impacts on a midwife's ability to fully exercise autonomy, and to advocate for normality and women. This renders Midwifery Abdication almost inevitable or at least very difficult to prevent. A midwife's professional identity, environmental hierarchy and associated culture of social obedience, acceptance and finding one's place, all act as influencing factors in abdication.

CONCLUSIONS

Midwifery education needs to ensure that midwives are prepared and able to embrace their professional status as independent practitioners. Promotion of reflexive practice to facilitate personal and professional change is warranted. Practice policies that are not supportive of a midwife's professional autonomy and scope of practice reinforce the technocratic work environment.

A qualitative study of speaking out about patient safety concerns in intensive care units

Much policy focus has been afforded to the role of "whistleblowers" in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 h of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), we studied how personnel gave voice to concerns about patient safety or poor practice. We observed much low-level social control occurring as part of day-to-day functioning on the wards, with challenges and sanctions routinely used in an effort to prevent or address mistakes and norm violations. Pre-emptions were used to intervene when patients were at immediate risk, and included strategies such as gentle reminders, use of humour, and sharp words. Corrective interventions included education and evidence-based arguments, while sanctions that were applied when it appeared that a breach of safety had occurred included "quiet words", bantering, public exposure or humiliation, scoldings and brutal reprimands. These forms of social control generally functioned effectively to maintain safe practice. But they were not consistently effective, and sometimes risked reinforcing norms and idiosyncratic behaviours that were not necessarily aligned with goals of patient safety and high-quality healthcare. Further, making challenges across professional boundaries or hierarchies was sometimes problematic. Our findings suggest that an emphasis on formal reporting or communication training as the solution to giving voice to safety concerns is simplistic; a more sophisticated understanding of social control is needed.

Parents' Perspectives on Navigating the Work of Speaking Up in the NICU

OBJECTIVE

To describe parents' perspectives and likelihood of speaking up about safety concerns in the NICU and identify barriers and facilitators to parents speaking up.

DESIGN

Exploratory, qualitatively driven, mixed-methods design.

SETTING

A 50-bed U.S. academic medical center, open-bay NICU.

PARTICIPANTS

Forty-six parents completed questionnaires, 14 of whom were also interviewed.

METHODS

Questionnaires, interviews, and observations with parents of newborns in the NICU were used. The qualitative investigation was based on constructivist grounded theory. Quantitative measures included ratings and free-text responses about the likelihood of speaking up in response to a hypothetical scenario about lack of clinician hand hygiene. Qualitative and quantitative analyses were integrated in the final interpretation.

RESULTS

Most parents (75%) rated themselves likely or very likely to speak up in response to lack of hand hygiene; 25% of parents rated themselves unlikely to speak up in the same situation. Parents engaged in a complex process of Navigating the work of speaking up in the NICU that entailed learning the NICU, being deliberate about decisions to speak up, and at times choosing silence as a safety strategy. Decisions about how and when to speak up were influenced by multiple factors including knowing my baby, knowing the team, having a defined pathway to voice concerns, clinician approachability, clinician availability and friendliness, and clinician responsiveness.

CONCLUSION

To engage parents as full partners in safety, clinicians need to recognize the complex social and personal dimensions of the NICU experience that influence parents' willingness to speak up about their safety concerns.

Thematic analysis of barriers and facilitators to implementation of neonatal resuscitation guideline changes

OBJECTIVE

To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project.

STUDY DESIGN

Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general.

RESULTS

Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation.

CONCLUSION

Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.

Attitudes of Mashhad Public Hospital's Nurses and Midwives toward the Causes and Rates of Medical Errors Reporting

INTRODUCTION

Patient's safety is one of the main objective in healthcare services; however medical errors are a prevalent potential occurrence for the patients in treatment systems. Medical errors lead to an increase in mortality rate of the patients and challenges such as prolonging of the inpatient period in the hospitals and increased cost. Controlling the medical errors is very important, because these errors besides being costly, threaten the patient's safety.

AIM

To evaluate the attitudes of nurses and midwives toward the causes and rates of medical errors reporting.

MATERIALS AND METHODS

It was a cross-sectional observational study. The study population was 140 midwives and nurses employed in Mashhad Public Hospitals. The data collection was done through Goldstone 2001 revised questionnaire. SPSS 11.5 software was used for data analysis. To analyze data, descriptive and inferential analytic statistics were used. Standard deviation and relative frequency distribution, descriptive statistics were used for calculation of the mean and the results were adjusted as tables and charts. Chi-square test was used for the inferential analysis of the data.

RESULTS

Most of midwives and nurses (39.4%) were in age range of 25 to 34 years and the lowest percentage (2.2%) were in age range of 55-59 years. The highest average of medical errors was related to employees with three-four years of work experience, while the lowest average was related to those with one-two years of work experience. The highest average of medical errors was during the evening shift, while the lowest were during the night shift. Three main causes of medical errors were considered: illegibile physician prescription orders, similarity of names in different drugs and nurse fatigueness.

CONCLUSION

The most important causes for medical errors from the viewpoints of nurses and midwives are illegible physician's order, drug name similarity with other drugs, nurse's fatigueness and damaged label or packaging of the drug, respectively. Head nurse feedback, peer feedback, fear of punishment or job loss were considered as reasons for under reporting of medical errors. This research demonstrates the need for greater attention to be paid to the causes of medical errors.

Patient Advocacy in an Obstetric Setting

A correlation study design was used to examine the interrelatedness of power, attitudes regarding intermittent fetal monitoring, and perceived barriers to research utilization with a labor and delivery nurse’s attitude toward patient advocacy using the conceptual framework of the science of unitary human beings. The linear combination of the three independent variables was significantly correlated to attitude toward patient advocacy and power as knowing participation in change had the greatest impact on patient advocacy.

A rapid assessment of barriers and facilitators to safety culture in an intensive care unit

The Hospital Survey on Patient Safety was used to identify opportunities for safety culture improvement in a 30-bed intensive care unit. Based on the survey results, a core team decided to focus on three safety domains: reporting errors, approachability of authority figures and handovers. The project team subsequently interviewed 39 intensive care unit staff members, gathering information on these three domains that will inform future safety efforts. Numerous barriers and facilitators to improvement were described. This mixed-methods approach could be applied in other hospitals seeking to quickly yet thoroughly understand how their safety culture can be improved. Developing local strategies to reduce these barriers may promote a safer patient experience at our hospital.

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.

Parents' perspectives on safety in neonatal intensive care: a mixed-methods study

BACKGROUND & OBJECTIVES

Little is known about how parents think about neonatal intensive care unit (NICU) safety. Due to their physiologic immaturity and small size, infants in NICUs are especially vulnerable to injury from their medical care. Campaigns are underway to integrate patients and family members into patient safety. This study aimed to describe how parents of infants in the NICU conceptualise patient safety and what kinds of concerns they have about safety.

METHODS

This mixed-methods study employed questionnaires, interviews and observation with parents of infant patients in an academic medical centre NICU. Measures included parent stress, family-centredness and types of safety concerns.

RESULTS

46 parents completed questionnaires and 14 of these parents also participated in 10 interviews (including 4 couple interviews). Infants had a range of medical and surgical problems, including prematurity, congenital diaphragmatic hernia and congenital cardiac disease. Parents were positive about their infants' care and had low levels of concern about the safety of procedures. Parents reporting more stress had more concerns. We identified three overlapping domains in parents' conceptualisations of safety in the NICU, including physical, developmental and emotional safety. Parents demonstrated sophisticated understanding of how environmental, treatment and personnel factors could potentially influence their infants' developmental and emotional health.

CONCLUSIONS

Parents have safety concerns that cannot be addressed solely by reducing errors in the NICU. Parent engagement strategies that respect parents as partners in safety and address how clinical treatment articulates with physical, developmental and emotional safety domains may result in safety improvements.

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.

Predictors of likelihood of speaking up about safety concerns in labour and delivery

BACKGROUND

Despite widespread emphasis on promoting 'assertive communication' by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care.

METHODS

The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units.

RESULTS

The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2-10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations.

DISCUSSION

This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.

Trade-offs between voice and silence: a qualitative exploration of oncology staff's decisions to speak up about safety concerns

Background

Research suggests that “silence”, i.e., not voicing safety concerns, is common among health care professionals (HCPs). Speaking up about patient safety is vital to avoid errors reaching the patient and thus to prevent harm and also to improve a culture of teamwork and safety. The aim of our study was to explore factors that affect oncology staff’s decision to voice safety concerns or to remain silent and to describe the trade-offs they make.

Methods

In a qualitative interview study with 32 doctors and nurses from 7 oncology units we investigated motivations and barriers to speaking up towards co-workers and supervisors. An inductive thematic content analysis framework was applied to the transcripts. Based on the individual experiences of participants, we conceptualize the choice to voice concerns and the trade-offs involved.

Results

Preventing patients from serious harm constitutes a strong motivation to speaking up but competes with anticipated negative outcomes. Decisions whether and how to voice concerns involved complex considerations and trade-offs. Many respondents reflected on whether the level of risk for a patient “justifies” the costs of speaking up. Various barriers for voicing concerns were reported, e.g., damaging relationships. Contextual factors, such as the presence of patients and co-workers in the alarming situation, affect the likelihood of anticipated negative outcomes. Speaking up to well-known co-workers was described as considerably easier whereas “not knowing the actor well” increases risks and potential costs of speaking up.

Conclusions

While doctors and nurses felt strong obligation to prevent errors reaching individual patients, they were not engaged in voicing concerns beyond this immediacy. Our results offer in-depth insight into fears and conditions conducive of silence and voicing and can be used for educational interventions and leader reinforcement.

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

OBJECTIVES

To explore the experiences of oncology staff with communicating safety concerns and to examine situational factors and motivations surrounding the decision whether and how to speak up using semistructured interviews.

SETTING

7 oncology departments of six hospitals in Switzerland.

PARTICIPANTS

Diverse sample of 32 experienced oncology healthcare professionals.

RESULTS

Nurses and doctors commonly experience situations which raise their concerns and require questioning, clarifying and correcting. Participants often used non-verbal communication to signal safety concerns. Speaking-up behaviour was strongly related to a clinical safety issue. Most episodes of 'silence' were connected to hygiene, isolation and invasive procedures. In contrast, there seemed to exist a strong culture to communicate questions, doubts and concerns relating to medication. Nearly all interviewees were concerned with 'how' to say it and in particular those of lower hierarchical status reflected on deliberate 'voicing tactics'.

CONCLUSIONS

Our results indicate a widely accepted culture to discuss any concerns relating to medication safety while other issues are more difficult to voice. Clinicians devote considerable efforts to evaluate the situation and sensitively decide whether and how to speak up. Our results can serve as a starting point to develop a shared understanding of risks and appropriate communication of safety concerns among staff in oncology.

Speaking up for patient safety by hospital-based health care professionals: a literature review

Background

Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behaviour and team communication. This review focused on health care professionals’ speaking-up behaviour for patient safety and aimed at (1) assessing the effectiveness of speaking up, (2) evaluating the effectiveness of speaking-up training, (3) identifying the factors influencing speaking-up behaviour, and (4) developing a model for speaking-up behaviour.

Methods

Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were searched for English articles describing health care professionals’ speaking-up behaviour as well as those evaluating the relationship between speaking up and patient safety. Influencing factors were identified and then integrated into a model of voicing behaviour.

Results

In total, 26 studies were identified in 27 articles. Some indicated that hesitancy to speak up can be an important contributing factor in communication errors and that training can improve speaking-up behaviour. Many influencing factors were found: (1) the motivation to speak up, such as the perceived risk for patients, and the ambiguity or clarity of the clinical situation; (2) contextual factors, such as hospital administrative support, interdisciplinary policy-making, team work and relationship between other team members, and attitude of leaders/superiors; (3) individual factors, such as job satisfaction, responsibility toward patients, responsibility as professionals, confidence based on experience, communication skills, and educational background; (4) the perceived efficacy of speaking up, such as lack of impact and personal control; (5) the perceived safety of speaking up, such as fear for the responses of others and conflict and concerns over appearing incompetent; and (6) tactics and targets, such as collecting facts, showing positive intent, and selecting the person who has spoken up.

Conclusions

Hesitancy to speak up can be an important contributing factor to communication errors. Our model helps us to understand how health care professionals think about voicing their concerns. Further research is required to investigate the relative importance of different factors.

Confronting safety gaps across labor and delivery teams

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.

Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review

BACKGROUND

Although there is a sizeable body of evidence regarding the nature of hostile behaviours among clinicians in the nursing workplace, what is less clear is the nature of the relationship between these behaviours and patient care. To inform the development of appropriate intervention strategies we examine the level of evidence detailing the relationships between hostile clinician behaviours and patient care.

METHODS

Published qualitative and quantitative studies that examined hostile clinician behaviours and patient care were included. Quality assessment, data extraction and analysis were undertaken on all included studies. The search strategy was undertaken in July and August 2011 and comprised eight electronic databases (CINAHL, Health Collection (Informit), Medline (Ovid), Ovid Nursing Full Text, Proquest Health and Medicine, PsycInfo, Pubmed and Cochrane library) as well as hand searching of reference lists.

RESULTS

The search strategy yielded 30 appropriate publications. Employing content analysis four themes were refined: physician-nurse relations and patient care, nurse-nurse bullying, intimidation and patient care, reduced nurse performance related to exposure to hostile clinician behaviours, and nurses and physicians directly implicating patients in hostile clinician behaviours.

CONCLUSIONS

Our results document evidence of various forms of hostile clinician behaviours which implicate nursing care and patient care. By identifying the place of nurse-nurse hostility in undermining patient care, we focus attention upon the limitations of policy and intervention strategies that have to date largely focused upon the disruptive behaviour of physicians. We conclude that the paucity of robustly designed studies indicates the problem is a comparatively under researched area warranting further examination.

Nurses' perspectives on the intersection of safety and informed decision making in maternity care

OBJECTIVE

To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety.

DESIGN

Constructivist grounded theory.

SETTING

Four hospitals in the western United States.

PARTICIPANTS

Forty-six (46) nurses and physicians practicing in maternity units.

METHOD

Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, 2006; Clarke, 2005; Schatzman, 1991).

RESULTS

The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication.

CONCLUSIONS

The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.

Perspectives on promoting breastmilk feedings for premature infants during a quality improvement project

OBJECTIVE

This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.

STUDY DESIGN

From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.

RESULTS

Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.

CONCLUSIONS

Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.

Understanding the moral nature of intrapartum nursing

OBJECTIVE

To explore how intrapartum nurses understand and negotiate their moral responsibilities toward women during childbirth.

DESIGN

Qualitative critical narrative.

SETTING

Labor and birth unit in an urban Canadian hospital.

PARTICIPANTS

Fourteen intrapartum registered nurses.

METHODS

Critical narrative analysis using a feminist ethics perspective.

RESULTS

Nurses understood their moral responsibilities to laboring women in a variety of ways depending on the nurses' personal and professional experiences, the people involved, and the context of care. Four themes were identified: organizing and coordinating care, responding to the unpredictable, recognizing limits of responsibilities to others, and negotiating care with women and families. A key factor influencing responses to women was the degree to which expectations related to birth were deemed to be reasonable and mutually agreed upon among nurses, physicians, women, and their families. Although nurses were able to identify contextual influences that constrained their ability to maintain effective relationships with women, the influence of their own values on the care they provided was less apparent. Nurses also described limits of their responsibilities for others, which departed from the idealized expectations often reflected in professional guidelines

CONCLUSION

These findings suggest a need to challenge assumptions related to the provision of choice and family centered care to create environments that can support and sustain understanding and trust between nurses and women giving birth. In addition, given the lack of shared understandings of what constitutes best care, there is a need to develop collaborative models of care that include the voices of women as a central component.

Role of effective teamwork and communication in delivering safe, high-quality care

Healthcare is delivered in an extraordinary complex environment. Despite highly skilled, dedicated clinicians, there are currently unacceptably high levels of communication failures and adverse events. Effective teamwork, in conjunction with reliable processes of care, is essential for the consistent delivery of high-quality care. Practical concepts and tools are provided that address the team behaviors of structured communication, effective assertion/critical language, psychological safety, situational awareness, and effective leadership. Examples of the mounting clinical evidence of improved patient outcomes and reduced harm resulting from effective teamwork training are cited.

Effective physician-nurse communication: a patient safety essential for labor and delivery

Effective communication is a hallmark of safe patient care. Challenges to effective interprofessional communication in maternity care include differing professional perspectives on clinical management, steep hierarchies, and lack of administrative support for change. We review principles of high reliability as they apply to communication in clinical care and discuss principles of effective communication and conflict management in maternity care. Effective clinical communication is respectful, clear, direct, and explicit. We use a clinical scenario to illustrate an historic style of nurse-physician communication and demonstrate how communication can be improved to promote trust and patient safety. Consistent execution of successful communication requires excellent listening skills, superb administrative support, and collective commitment to move past traditional hierarchy and professional stereotyping.

Barriers to the use of hydrotherapy in labor

OBJECTIVE

To determine nurses' perceived barriers to the use of hydrotherapy in labor. While effective in relieving pain, reducing anxiety, encouraging relaxation, and promoting a sense of control, hydrotherapy is rarely used during labor.

DESIGN

Comparative descriptive survey design.

SETTING

A national convention and perinatal listserves.

PARTICIPANTS

Intrapartum nurses (N=401) attending a national convention (Association of Women's Health, Obstetric, and Neonatal Nurses, 2007; n=225) and members of perinatal listserves (n=176) were recruited.

METHODS

A questionnaire was designed for this study (Nurses' Perception of the Use of Hydrotherapy in Labor). The questionnaire was available in paper format and online.

RESULTS

Institutional but not individual characteristics (age, education, and role) were associated with Nurses' Perception of the Use of Hydrotherapy in Labor. Nurses who reported higher epidural rates (r=.45, p=.000) and Cesarean section rates (r=.30, p=.000) reported more barriers. There was no difference in perception of barriers for nurses at hospitals providing different levels of care; there were significant differences when primary care providers were considered. Intrapartum nurses in facilities where certified nurse-midwives do most deliveries reported significantly fewer barriers than nurses who worked in facilities where physicians attended most deliveries (F=6.84, df=2, p=.000).

CONCLUSION

The culture of the birthing unit in which nurses provide care influences perception of barriers to the use of hydrotherapy in labor. Providing hydrotherapy requires a supportive environment, adequate nursing policies and staffing, and collaborative relationships among the health care team.

Childbirth embodiment: problematic aspects of current understandings

The experience of childbirth is one of the most corporeal of the human condition. Against a backdrop of profound change in the milieu of birthing over the past 30 years, especially in the developed world, a number of discourses now compete for the status of the safest, most fulfilling birth experience. Supporters of biomedical and 'natural' approaches make their respective claims to those, with obstetricians broadly aligning their professional interests with the former and midwives with the latter. There is mounting evidence that childbearing women's experiences of birth are often shaped in the uneasy space between the two. Within sociological discourse in health, embodiment is a dominant theme but, to date, research has concentrated mainly on new reproductive technologies, and there is a dearth of recent research and theorising around the act of parturition itself. This paper argues that because of this, there has been a polarising tendency in current discourses which is having a largely negative impact on women, professionals and the maternity services. A call is made for an integration of traditional childbirth embodiment theories, mediated through compassionate, relationally focused maternity care, especially when labour complications develop.

Perinatal safety: from concept to nursing practice

Communication and teamwork problems are leading causes of documented preventable adverse outcomes in perinatal care. An essential component of perinatal safety is the organizational culture in which clinicians work. Clinicians' individual and collective authority to question the plan of care and take action to change the direction of a clinical situation in the patient's best interest can be viewed as their "agency for safety." However, collective agency for safety and commitment to support nurses in their role of advocacy is missing in many perinatal care settings. This article draws from Organizational Accident Theory, High Reliability Theory, and Symbolic Interactionism to describe the nurse's role in maintaining safety during labor and birth in acute care settings and suggests actions for supporting the perinatal nurse at individual, group, and systems levels to achieve maximum safety in perinatal care.

Criminal prosecution for nursing errors

Headlines describing nurses being prosecuted for crimes related to nursing errors raise numerous questions for nurses and their managers. Nurse managers need to be aware of situations in which nurses may be subject to criminal prosecution to assist staff in educating themselves and acting to minimize risk. After reading this article, the reader should be able to (a) identify the legal basis for criminal charges for nursing errors, (b) list 3 errors likely to result in criminal prosecution, and (c) discuss licensure implications of criminal charges for nursing errors.

Research summaries for normal birth

In this column, the author summarizes research studies relevant to normal birth. The studies summarized include a large trial evaluating the effect of prior vaginal births after a cesarean on outcomes in subsequent births; a study linking umbilical cord blood pH with intellectual outcomes in childhood; and a prospective trial evaluating the effect of routine antenatal nonstress testing on maternal anxiety. The author also highlights four articles about normal birth in a recent nursing journal series dedicated to the topic.