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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

What inhibits "speaking up" for patient safety among healthcare workers? A cross-sectional study in Malaysia

BACKGROUND

In healthcare, "speaking up" refers to when healthcare workers raise concerns regarding patient safety through questions, sharing information, or expressing their opinion to prevent harmful incidents and ensure patient safety. Conversely, withholding voice is an act of not raising concerns, which could be beneficial in certain situations. Factors associated with speaking up and withholding voices are not fully understood, especially in strong authoritarian societies, such as Malaysia. This study aimed to examine the factors associated with speaking up and withholding the voices of healthcare workers in Malaysia, thus providing suggestions that can be used in other countries facing similar patient safety challenges.

METHODS

This cross-sectional study was conducted in a tertiary hospital in Sarawak State, Malaysia. Data were collected from 474 healthcare workers from 43 departments using a self-administered questionnaire for speaking up and withholding voices measures in 4 weeks prior to data analysis as well as socio-demographic factors of healthcare workers (sex, age group, profession, department, weekly work hours for patient care, years of employment in the hospital, and the hierarchical level) and speaking up related climate of the working environment were recorded. Data were analyzed using descriptive statistics. Logistic regression was performed to find out (adjusted) odds ratio of frequent speaking up and withholding voices.

RESULTS

Nurse compared to doctors and healthcare workers with short weekly working hours were more likely to speak up. Healthcare workers in emergency and intensive care department, those with short years of employment, and those who worked at low hierarchical levels were less likely to speak up. Healthcare workers in discouraging environment towards speaking up were more likely to withhold their voices.

CONCLUSIONS

This study demonstrates the characteristics of healthcare workers who speak up and those who withhold their voices in Malaysia. To ensure patient safety and prevent harm, it is essential to establish an encouraging environment that promotes speaking up and prevents withholding voices among healthcare worker, especially in circumstances where multiple types of healthcare workers with different socio-demographic backgrounds work together.

Speaking Up: Exploring Mental Health Care Workers' Patient Safety Concerns

PURPOSE

To explore the perspectives and experiences of mental health care workers (MHCWs) when speaking up about patient safety concerns.

METHOD

A qualitative study was performed at Farshchian (Sina) Hospital in Iran, involving the purposive sampling of MHCWs from three inpatient psychiatric wards. From July to October 2022, semi-structured interviews were conducted with 23 participants. Data were analyzed using conventional content analysis.

RESULTS

Three major patient safety themes were identified: (a) Voicing Concerns for Daily Safety (subthemes: daily safety check-ins and speaking up to prevent patient harm); (b) Speaking Up to Save Future Lives (subthemes: whistleblowing, leadership, and being open to communication); and (c) Hesitating to Speak Up (sub-themes: ineffectiveness of raising one's voice and whispering).

CONCLUSION

MHCWs have various concerns about speaking up or staying silent. Failure to communicate can result in adverse events and missed opportunities to address patient safety. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].

Association between abusive supervision and nurses' withholding voice about patient safety: the roles of impression management motivation and speak up-related climate

BACKGROUND

Abusive supervision by the nurse manager significantly influences nurses' withholding voice about patient safety. The role of impression management motivation and speak up-related climate is crucial in understanding their connection. This study aimed to explore the relationship between abusive supervision, impression management motivation, speak up-related climate, and withholding voice about patient safety.

METHODS

This cross-sectional study employed a convenience sampling method to recruit 419 clinical nurses from Taizhou Hospital, Zhejiang Province, China, between 1 November 2022 and 31 January 2023. The study adhered to the STROBE checklist. Abusive supervision and impression management motivation were assessed using the Chinese versions of the Abusive Supervision Scale and the Impression Management Motivation Scale, respectively. Withholding voice about patient safety and speak up-related climate were identified using the Chinese version of the Speaking Up about Patient Safety Questionnaire.

RESULTS

Nurse leaders' abusive supervision (β=0.40, p<0.01) and nurses' impression management motivation (β=0.10, p<0.01) significantly and positively influenced nurses' withholding voice about patient safety. We introduced impression management motivation as a mediating variable, and the effect of abusive supervision on nurses' withholding voice decreased (β from 0.40 to 0.38, p< 0.01). Nurses' speak up-related climate played a moderating role between abusive supervision and impression management motivation (β= 0.24, p<0.05).

CONCLUSIONS

Abusive supervision by nursing leaders can result in nurses withholding voice about patient safety out of self-protective impression management motives. This phenomenon inhibits nurses' subjective initiative and undermines their proactive involvement in improving patient safety, and hinders the cultivation of a culture encouraging full participation in patient safety, which should warrant significant attention.

The Speaking Up Climate of Nurses for Patient Safety Concerns and Unprofessional Behaviors: The Effects of Teamwork and Safety Climate

PURPOSE

This study aims to investigate the influence of teamwork and safety climate on nurses' speaking up for patient safety concerns and unprofessional behaviors.

DESIGN

This study incorporates a cross-sectional research design.

METHODS

The study included 217 surgical nurses employed in a Turkish university hospital. The research data were collected between April and June 2023 using the Teamwork Climate, Safety Climate Survey, Speaking Up Climate for Patient Safety, and Speaking Up Climate for Professionalism instruments. The relationships between these scales were assessed using Pearson correlation analysis. The Turkish validity and reliability of the Speaking Up Climate for Patient Safety and Speaking Up Climate for Professionalism scales were verified. The research model was tested using path analysis.

FINDINGS

The mean age of the 217 surgical nurses was 25.88 ± 5.64 years. Teamwork climate showed a positive effect on safety climate and speaking up climate about patient safety concerns and unprofessional behaviors. Safety climate showed a positive association with nurses' speaking up climate about patient safety concerns and unprofessional behaviors.

CONCLUSIONS

Teamwork climate and safety climate both positively affect the speaking up climate about patient safety concerns and unprofessional behaviors. Nurse managers who wish to promote a culture of speaking up about patient safety and unprofessional behaviors should prioritize improvements in the teamwork climate and safety climate.

Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

BACKGROUND

The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context.

OBJECTIVE

This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence.

DESIGN

A cross-sectional, correlational study design was employed.

SETTINGS

Study data were collected in 34 general hospitals in South Korea.

PARTICIPANTS

A total of 1255 registered nurses providing direct care to patients were included in this study.

METHODS

Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %.

RESULTS

The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = -0.10, 95 % confidence interval [-0.143, -0.059]) and silence (β = -0.04, 95 % confidence interval [-0.058, -0.014]), and psychological safety also decreased burnout through voice (β = -0.04, 95 % confidence interval [-0.057, -0.016]) and silence (β = -0.07, 95 % confidence interval [-0.101, -0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant.

CONCLUSIONS

It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ.

REGISTRATION

Not applicable.

TWEETABLE ABSTRACT

Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.

Understanding Employee Voice Behavior Through the Use of Digital Voice Channel in Long-Term Care: Protocol for an Embedded Multiple-Case Study

BACKGROUND

Specific challenges in the health care sector, such as hierarchical structures, shortages of nursing staff, and high turnover of nursing staff, can be addressed by a change process of organizational culture into shared governance. Data from business organizations show that the use of digital voice channels provides employee voice. This approach makes concrete the opportunity for employees to raise their voices by answering surveys and making comments in an anonymous forum, which subsequently positively influences staff turnover and sick leave. Since there is no clear understanding of how a digital voice channel can be used in long-term care to address employee voice, a research gap has been identified.

OBJECTIVE

The purpose of ADVICE (Understanding Employee Voice Behavior; the acronym for this study) is to understand how the use of a digital voice channel performs in long-term care (residential long-term care and home care facilities). The aim of this study is to understand how the digital voice channel can support staff in making their voices heard and to see what managers need to use the voice channel to change the work environment.

METHODS

An embedded multiple-case study will be used to explore the experiences of 2 health care providers who have already implemented a digital voice channel. ADVICE is organized into two main phases: (1) a scoping review and (2) an embedded multiple-case study. For this purpose, focus group interviews with employees, discursive-dialogical interviews with managers, meeting protocols, and data from the digital voice channel will be analyzed. First, all units of analysis from every embedded unit will be separately analyzed and then comprehensively analyzed to obtain a case vignette from every embedded unit (within-analysis). In the second stage, the analyzed data from the embedded units will be compared with each other in a comparative analysis (cross-analysis).

RESULTS

The results will provide insight into how digital voice channels can be used in long-term care to address employee voice. We expect to find how the digital voice channel can empower nurses to speak up and, consequently, create a better work environment. Data collection began in August 2023, and from a current perspective, the first results are expected in summer 2024.

CONCLUSIONS

In summary, the results may help to better understand the use of a digital voice channel in the health care sector and its transformative potential for leadership. At the organizational level, research can help to improve the attractiveness of the workplace by understanding how to give employees a voice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/48601.

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.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals

BACKGROUND

Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability.

METHODS

A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work.

CONCLUSIONS

The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

Safety voice climate: A psychometric evaluation and validation

INTRODUCTION

Speaking up about safety issues, termed "safety voice," is a proactive response where people across all levels of the organization express their concerns to prevent physical hazards. An understanding of safety voice requires insight into its antecedents. A perceived need to fit in with the organization and fear of consequences can trump the courage to speak out about safety concerns. Safety voice climate can be seen as a manifestation of the social exchanges in an organization and functions as a roadmap of which speaking out behaviors are encouraged and which behaviors are not. This study conceptualizes safety voice climate, presents the Safety Voice Climate Scale (SVCS) as a measurement tool, and gathers initial evidence for its validity. The study also assesses the associations between the SVCS and safety voice behavior.

METHOD

The SVCS and the measurement of safety voice behavior were derived from the Trends in Risk Level in the Norwegian Petroleum Activity questionnaire. The SVCS includes the two theoretical dimensions Work colleagues' encouragement of safety voice and Leaders' attitudes towards safety voice. Psychometric properties were tested with a representative sample from the Norwegian petroleum sector (n = 7,624).

RESULTS

Confirmatory factor analyses supported the proposed two-factor model, and the internal consistency of the factors was good. Furthermore, a structural equation model including the SVCS as predictors of safety voice behavior showed a good fit, indicating acceptable criterion validity, although only the Work colleagues' encouragement of safety voice variable was significantly associated with safety voice behavior. Conclusion and practical application: The SVCS can be used as a tool to detect some of the barriers and supporting elements relating to safety voice and guidance on the efforts needed to foster work climates that promote communication of safety issues.

Speak-Up Behavior of Oncology Nurses: Organizational Trust and Structural Empowerment as Determinants

OBJECTIVE

The aim of this study is to examine the mediating roles of organizational trust and structural empowerment on the speak-up behavior of oncology nurses.

BACKGROUND

Organizational trust can create opportunities for a good working environment. Structural empowerment is an important factor affecting the speak-up behavior of nurses. The intermediary roles of organizational trust and structural empowerment on speak-up behavior are not specific.

METHODS

A correlational descriptive research design was used, and 232 nurses from 2 different hospital levels (the Ministry of Health hospital and university hospital) responded to 4 questionnaires.

RESULT

The results reflect that organizational trust and structural empowerment are a factor on nurses' speak-up behavior.

CONCLUSION

The findings demonstrate that a work environment where organizational trust is developed and a structural empowerment framework is in place contributes to nurses' speak-up behavior among oncology nurses.

South Korean Nurses' Experiences of Speaking up for Patient Safety and Incident Prevention

Despite the importance of speaking up for patient safety, hesitancy to do so remains a major contributing factor to communication failure. This study aimed to investigate the experiences of South Korean nurses in speaking up to prevent patient safety incidents. Twelve nurses responsible for patient safety tasks or with experience in patient safety education were recruited from five hospitals (three university hospitals, two general hospitals) in city "B". Data were collected through open-ended questions and in-depth interviews, transcribed, and analyzed using the inductive content analysis method. The study resulted in the identification of four main categories and nine subcategories that captured commonalities among the experience of the 12 nurses. The four main categories were as follows: the current scenario of speaking up, barriers to speaking up, strategies for speaking, and confidence training. There is a scarcity of research on speaking-up experiences for patient safety among nurses in South Korean. Overall, it is necessary to overcome cultural barriers and establish an environment that encourages speaking up. In addition, developing speaking-up training programs for nursing students and novice nurses is imperative to prevent patient safety incidents.

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring?

The history of inquiries into the failings of medical care have highlighted the critical role of communication and information sharing, meaning that speaking up and employee silence have been extensively researched. However, the accumulated evidence concerning speaking-up interventions in healthcare indicates that they achieve disappointing outcomes because of a professional and organizational culture which is not supportive. Therefore, there is a gap with regard to our understanding of employee voice and silence in healthcare, and the relationship between withholding information and healthcare outcomes (e.g., patient safety, quality of care, worker wellbeing) is complex and differentiated. The following integrative review is aimed at addressing the following questions; (1) How is voice and silence conceptualized and measured in healthcare?; and (2) What is the theoretical background to employee voice and silence?. An integrative systematic literature review of quantitative studies measuring either employee voice or employee silence among healthcare staff published in peer-reviewed journals during 2016-2022 was conducted on the following databases: PubMed, PsycINFO, Scopus, Embase, Cochrane Library, Web of Science, CINAHL and Google Scholar. A narrative synthesis was performed. A review protocol was registered on the PROSPERO register (CRD42022367138). Of the 209 initially identified studies for full-text screening, 76 studies met the inclusion criteria and were selected for the final review (N = 122,009, 69.3% female). The results of the review indicated the following: (1) concepts and measures are heterogenous, (2) there is no unifying theoretical background, and (3) there is a need for further research regarding the distinction between what drives safety voice versus general employee voice, and how both voice and silence can operate in parallel in healthcare. Limitations discussed include high reliance on self-reported data from cross-sectional studies as well as the majority of participants being nurses and female staff. Overall, the reviewed research does not provide sufficient evidence on the links between theory, research and implications for practice, thus limiting how research in the field can better inform practical implications for the healthcare sector. Ultimately, the review highlights a clear need to improve assessment approaches for voice and silence in healthcare, although the best approach to do so cannot yet be established.

Testing the association between the enabling and enacting factors of patient safety culture and patient safety: structural equation modelling

BACKGROUND

Despite evidence linking a safety culture with patient safety, the processes by which aspect of safety culture influences patient safety are not yet well understood. Thus, this study aimed to test a theoretical model of the relationships between three enabling factors (supervisor/clinical leader support for patient safety, hospital management support for patient safety, and psychological safety), and four enacting factors of patient safety culture (handoffs and information exchange, teamwork, error reporting intention, and withholding voice) with nurse assessments of patient safety.

METHODS

A cross-sectional, descriptive correlational study design was used. Between May and June 2020, 526 nurses who provided direct care to patients in medical surgical units in three Korean hospitals completed an online survey that included four standardized scales or subscales. Structural equation modelling was used to test the hypothesized model.

RESULTS

Among the three enabling factors, psychological safety was associated with all four enacting factors, and all enacting factors were associated with overall patient safety. Hospital management support was associated with all enacting factors except teamwork, but supervisor/clinical leader support was associated with only handoffs and information exchange, and withholding voice. Thus, teamwork was influenced only by psychological safety. Findings demonstrate overall support for the theoretical model of safety culture wherein enabling factors influence enacting factors which, in turn, lead to patient safety outcomes, but emphasize the critical nature of psychological safety among nursing staff.

CONCLUSION

This study provides further insight into the importance of support from hospital management and unit supervisors/clinical leaders for patient safety to motivate and enable hospital nurses to enact behaviours necessary for patient safety. However, such support must also take the form of enhancing psychological safety for nursing staff.

Patient Safety Culture and Speaking Up Among Health Care Workers

PURPOSE

Although previous research showed the importance of safety culture on health care workers' speaking up behaviors, it is not clear how particular safety culture domains are associated with the speaking up behaviors of hospital staff. Also, researchers have suggested that health care workers' speaking up behaviors vary by profession, but there has been limited research into such differences. Thus, this study examined differences in perceptions of patient safety culture and the promotive and prohibitive speaking up behaviors of health care workers by profession and investigated the relationships between patient safety culture and the two types of speaking up behaviors.

METHODS

A descriptive correlational study was conducted using secondary data collected through an online survey of health care workers at a private, nonprofit, tertiary-level teaching hospital in South Korea. The sample (N = 831) consisted of nurses (54.0%), physicians (13.0%), and other licensed and unlicensed hospital personnel (33.0%). Analyses of variance were conducted to examine differences in study variables by profession. Hierarchical regression analyses were conducted to evaluate the effects of the seven patient safety culture factors on promotive and prohibitive voice after controlling for tenure and profession.

RESULTS

Perceptions of safety culture and promotive voice behaviors were higher for physicians compared with nurses. Communication openness, reporting patient adverse events, and unit supervisors' and hospital managements' support for patient safety were significant predictors of both types of voice behaviors.

CONCLUSION

Hospital administrators and unit managers should create a supportive environment where staff feel free to voice their concerns and suggestions. They should also pay attention to the varying perspectives held by different groups of hospital workers and their different voice behaviors. Knowing which dimensions of patient safety culture are most strongly related to health care workers' voice behaviors can guide patient safety improvement activities in health care organizations.

Impact of inclusive leadership on employees' innovative behavior: A relational silence approach

Introduction

Although employees' silence is a common phenomenon in organizations, the mediating role of relational silence has not been studied in inclusive leadership and innovative behavior. In this study, based on the theory of social exchange, relational silence is used as a mediating variable to explore the internal mechanisms of inclusive leadership on employees' innovative behavior.

Methods

Data from 263 in-service leaders and employees were collected using convenience sampling and analyzed using Amos and SPSS statistical software package via questionnaires distributed to companies in six cities in the Guangdong province of China.

Results

The results showed that inclusive leadership has a significant positive predictive effect on employees' innovative behavior (β = 0.590, p < 0.01), while inclusive leadership is negative and significantly correlated with relational silence (β = -0.469, p < 0.01). More so, relational silence has a significant negative correlation with employees' innovative behavior (β = -0.408, p < 0.01), and relational silence partially mediates the relationship between inclusive leadership and employee innovation behavior.

Discussion

The mediating role of relational silence between inclusive leadership and employees' innovative behavior is revealed for the first time, theoretically broadening and enriching the connotation of inclusive leadership's influence mechanism on employees' innovative behavior and providing new ideas in practice for constructing inclusive leadership styles, reducing the incidence of relational silence, and evoking employees' innovative behavior.

Nurses' perceptions of their role in antimicrobial stewardship within the hospital environment. An integrative literature review

BACKGROUND

Antimicrobial stewardship (AMS) has traditionally been the domain of doctors and pharmacists but there is a growing recognition that successful stewardship incorporates a multidisciplinary approach that includes nursing staff. This literature review explores nurses' perceptions of their role in antimicrobial stewardship within the hospital environment and provides new insights to inform future practice.

METHODOLOGY

An integrative literature review was undertaken. Five academic databases were searched, which identified six relevant studies. Whittemore and Knafl's method for conducting an integrative review was followed. ENTREQ guidelines have been adhered to.

FINDINGS

Two themes were identified: nurses' working in partnership with other professionals and engagement in education.

DISCUSSION

Antimicrobial stewardship illustrates the role of the nurse within the wider multidisciplinary team regarding wider patient safety issues and the need for education to enhance this role.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a clear role to play in antimicrobial stewardship but need to be fully cognisant of the issues involved. Further clarity on how nurses should enact this role in their complex working environments is required. It is essential that both student and qualified nurses are able to speak up in order to maximise patient safety, fulfil their professional duty and promote the overall effectiveness of AMS if they witness poor antibiotic management practices.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) Survey: A Brief, Diagnostic, and Actionable Metric for the Ability to Speak Up in Healthcare Settings

OBJECTIVES

The current study aimed to guide the assessment and improvement of psychological safety (PS) by (1) examining the psychometric properties of a brief novel PS scale, (2) assessing relationships between PS and other safety culture domains, (3) exploring whether PS differs by healthcare worker demographic factors, and (4) exploring whether PS differs by participation in 2 institutional programs, which encourage PS and speaking-up with patient safety concerns (i.e., Safety WalkRounds and Positive Leadership WalkRounds).

METHODS

Of 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate, 81%) completed the 6-item PS scale, demographics, safety culture scales, and questions on exposure to institutional initiatives. Psychometric analyses, correlations, analyses of variance, and t tests were used to test the properties of the PS scale and how it differs by demographic factors and exposure to PS-enhancing initiatives.

RESULTS

The PS scale exhibited strong psychometric properties, and a 1-factor model fit the data well (Cronbach α = 0.80; root mean square error approximation = 0.08; Confirmatory Fit Index = 0.97; Tucker-Lewis Fit Index = 0.95). Psychological Safety scores differed significantly by role, shift, shift length, and years in specialty. The PS scale correlated significantly and in expected directions with safety culture scales. The PS score was significantly higher in work settings with higher rates of exposure to Safety WalkRounds or Positive Leadership WalkRounds.

CONCLUSIONS

The PS scale is brief, diagnostic, and actionable. It exhibits strong psychometric properties; is associated with better safety, teamwork climate, and well-being; differs by demographic factors; and is significantly higher for those who have been exposed to PS-enhancing initiatives.

Factors influencing newly graduated registered nurses' voice behavior: An interview study

AIM

To gain insight into the factors that affect newly graduated registered nurses' voice behavior.

BACKGROUND

Employees with little work experience may experience difficulties with speaking up. Given that a lack of voice can negatively affect the delivery of safe client care and lower nurses' job satisfaction, it is important to understand which factors facilitate and hinder newly graduated nurses' voice behavior.

METHODS

A qualitative descriptive study was conducted using semi-structured interviews with 17 newly graduated registered nurses working in inpatient hospital settings.

RESULTS

In total, seven factors emerged from our data, which were grouped in four, overarching themes. Whether newly graduated nurses speak up depends on (1) their levels of self-confidence; (2) whether they feel encouraged and welcome to speak up; (3) their relationship with the voice target; and (4) the content of their voice message.

CONCLUSION

Factors that affect newly graduated nurses' voice behavior are multifaceted, but mostly center around time spent in and relationships at the workplace.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers and colleagues can build an environment that fosters newly graduated nurses' voice behavior. Specifically, induction programs, assigning mentors and offering additional training can support newly graduated nurses in developing voice behavior.

Hospital management and supervisor support and nurse speaking-up behaviors: The mediating role of safety culture perception

AIMS

This study aimed to (a) elucidate the effects of hospital management and unit supervisor support for patient safety on nurse speaking-up behaviors and (b) identify potential mediators of this relationship.

BACKGROUND

Speaking-up behavior among nurses has emerged as a critical source of patient safety. Fuller understanding of the developmental mechanisms contributing to nurses' speaking-up behaviors could help to enhance patient safety in healthcare organizations.

METHODS

A correlational approach was used to conduct a secondary analysis of cross-sectional survey data collected from 450 staff nurses in Korea. Path analysis was performed to test potential mediation effects.

RESULTS

After controlling for nurses' hospital and unit tenure, hospital management and supervisor support for patient safety had significant direct and indirect effects on nurses' speaking-up (promotive and prohibitive voice) behaviors through their perceptions of response to error and communication openness.

CONCLUSIONS

Study findings indicate that when hospital management and supervisors emphasize patient safety and provide necessary resources, nurses are likely to perceive the hospital's safety culture more positively, in turn enhancing their speaking-up behaviors.

IMPLICATIONS FOR NURSING MANAGEMENT

Hospital administrators and nurse managers should clearly display hospital management and supervisory support for patient safety through implementation of related policies, resources, and communication standards.

Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture

BACKGROUND AND OBJECTIVES

Nurses are challenged by numerous day-to-day unexpected problems due to poorly performing work systems that hinder patient care. These operational failures persist in hospitals, partly because nurses tend to prefer quick fixes or workarounds over real improvements that prevent recurrence. The aim of this review is to shed light on the barriers to and enablers of nurses' second-order problem-solving behavior and their consequences, so that hospitals can learn from failure and improve organizational outcomes.

METHODS

We conducted a systematic review, with quantitative, qualitative, and mixed-method articles, searching 6 databases (PubMed, Embase, Web of Science, CINAHL, and Google Scholar) following the Preferred Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality assessment for inclusion was performed by 2 independent authors using the Mixed Methods Appraisal Tool (MMAT). A descriptive synthesis was used for analysis.

RESULTS

This study reveals the barriers and enablers for second-order problem-solving behavior, and synthesizes improvement proposals within 3 perspectives, namely the "empowerment" perspective, the "process improvement" perspective, and the "time" perspective. Furthermore, we found that limited attention is given to the patient's perspective, and the existence of a no-action behavior.

CONCLUSION

Although operational failures have several important consequences for hospital staff and organizations, there has been hardly any research into the barriers and enablers that initiate second-order problem-solving behavior; stemming this nursing behavior has thus rarely appeared as a suggestion for improvement.

A behavioural study of obedience in health professional students

Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.

Studies on the second victim phenomenon and other related topics in the pan-European environment: The experience of ERNST Consortium members

Background

Patient safety is a priority worldwide. When things go wrong in the provision of patient care, the healthcare professionals involved can be psychologically affected (second victims, SVs). Recently, different initiatives have been launched to address this phenomenon.

Aim

To identify through the ERNST Pan-European Consortium the current study lines in Europe on SVs and other topics related to how the lack of well-being of healthcare professionals can affect the quality of care.

Methods

A cross-sectional study was conducted based on an ad hoc online survey. All 82 academics and clinicians who had formalized their membership to the COST Action 19113 by September 2020 and represented 27 European and one neighboring country were invited to participate. The survey consisted of 19 questions that explored the participants’ scientific profile, their interests, and previous experiences in the SVs’ topic, and related areas of work in Europe.

Results

Seventy (85.4%) COST Action members responded to the survey. Thirty-seven (37.1%) had conducted SV studies in the past or were doing so at the moment of the survey. Seventeen participants were involved in implementing interventions to support SVs. Future lines of study included legal issues, open disclosure, training programs, and patient safety curricula.

Conclusions

Studies have been conducted in Europe on the magnitude of the SV phenomenon and the usefulness of some techniques to promote resilience among healthcare professionals. New gaps have been identified. The COST Action 19113 aims to foster European collaboration to reinforce the healthcare professionals’ well-being and thus contribute to patient safety.

Leveraging a Safety Event Management System to Improve Organizational Learning and Safety Culture

BACKGROUND AND OBJECTIVES

Safety event management systems (SEMS) are rich sources of patient safety information, which can be used to improve organizational safety culture. An ideal SEMS can accomplish this when the system is improved with the intention of increasing learning and engagement across the organization. To support a global aim of improving overall patient safety and becoming a highly reliable learning health system, focus was directed toward increasing event review and follow-up completion and using this information to drive resource allocation and improvement efforts.

METHODS

A new integrated SEMS was customized, tested, and implemented based on identified organizational need. Revised policies were developed to define expectations for event review and follow-up. The new SEMS incorporated a closed-loop communication process which ensured information from events was shared with the event submitters and facilitated shared learning. The expected impacts, improved event reporting, and follow-up were studied and guided ongoing improvements.

RESULTS

After transitioning to a new SEMS, we experienced increased overall reporting by 8.6% and improved event follow-up, demonstrated by documentation on specified system forms, by 53.7%.

CONCLUSIONS

By implementing a new, efficient, and standardized SEMS, which decentralized event management processes, the organization saw increased reporting and better engagement with patient safety event review and follow-up. Overall, these results demonstrated a stronger reporting culture, which allowed for local problem solving and improved learning from every event reported. A robust reporting culture positively impacted the overall organizational culture of safety.

Bias and the Psychological Safety in Healthcare Teams

The levels of biases, stereotypes, and prejudices are present at the same level within our healthcare teams as they are in society in general. The effect of biases on teams, team development, and team functioning is less known, but what to do with bias is known and important for all healthcare clinicians to understand. Exploring bias and psychological safety is vital for optimal team development. Teams need trust, sense of belonging, and a culture of open communication to provide the best care possible for their patients; yet often teams do not address their own biases or stereotypes nor do they feel prepared to open these conversations. In this article, we present a case study, provide definitions of bias and psychological safety, as well as offer strategies to combat biases, provide steps all of the healthcare team can employ to promote belongingness in the interprofessional team, and offer strategies of supporting team members experiencing biases.

Exploring the Relationship between Organisational Silence and Organisational Learning in Nurses: A Cross-sectional Study

AIMS

To assess the Organisational Silence and Learning levels among nurses of a University Hospital, and explore the relationship between the socio-demographics, Organisational Silence and Learning.

BACKGROUND

Organisational Learning is an active process needed for improving organisational performance, and silence has a devastating impact on an organisation's capacity to learn.

METHODS

A cross-sectional quantitative design was applied using two tools: the Organisational Silence and the Organisational Learning scales. Over three months, data were collected from 724 nurses. The data were then analysed using suitable statistical methods.

RESULTS

The Organisational Silence level is moderate. The Organisational Learning level is predominantly moderate. The association between the two scales is a weak negative correlation, yet statistically significant. The multiple regression analysis was better in predicting Organisational Learning scores.

CONCLUSIONS

There is a highly statistically significant negative weak correlation between overall organizational silence and overall organizational learning. More researchers are invited to implement of interventions to promote speaking-up behaviours and organizational learning in nurses IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders can create a work atmosphere that encourages and promotes open communication among nurses and other health-care team members. Likewise, creating an environment conducive to translating experiences into organizational learning.

Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

BACKGROUND

Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.

METHODS

We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.

RESULTS

Data saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years' experience.When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages' motives and consider gaming.Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient.

CONCLUSION

Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.

TRIAL REGISTRATION NUMBER

ISRCTN11126923.

A concept analysis of psychological safety: Further understanding for application to health care

AIM

To clarify the concept of psychological safety in a healthcare context and to provide the first theoretical framework for improving interpersonal relationships in the workplace to better patient care.

DESIGN

A Rodgers' concept analysis.

METHODS

The concept analysis was conducted using a systematic search strategy on PubMed, CINAHL, PsycINFO and Ichushi-Web.

RESULTS

An analysis of 88 articles studying psychological safety in health care identified five attributes: perceptions of the consequences of taking interpersonal risks, strong interpersonal relationships, group-level phenomenon, safe work environment for taking interpersonal risks and non-punitive culture. The antecedents included structure/system factors, interpersonal factors and individual factors. The four consequences included performance outcomes, organizational culture outcomes, and psychological and behavioural outcomes.

Changing safety culture

Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital?

Background

Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital.

Methods

In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere.

Results

Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed.

Conclusions

An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect.

Keywords

Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.

Why do nurses choose to stay silent?: A qualitative study

AIM

This study aimed to explore nurses' views and experiences regarding remaining silent.

BACKGROUND

Silence is a barrier for organizational improvement and can occur for many reasons; it cannot be simply defined as the opposite of speaking out.

METHOD

An exploratory qualitative design was used for this study. Data were collected using semi-structured interviews in 2016 with 24 nurses who were recruited by using a snowball sampling method.

RESULTS

Three themes emerged as a result of the thematic analysis: fear, silence climate and disengagement. The first theme contained three subthemes: avoidance of being seen as a troublemaker, financial loss and reluctance to reveal lack of ability or knowledge. The results indicated that nurses remained silent when they felt unsupported or psychologically unsafe in their work environment.

CONCLUSION

Encouraging nurses to express their opinions is essential for creating a psychologically safe nursing work environment and an organizational climate that supports open communication. Because the majority of healthcare professionals are nurses, they can act as role models and change agents for other nurses if they are encouraged to share their ideas and opinions without fear of retribution.

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.

Nursing practice environment and employee silence about patient safety: The mediating role of professional discrimination experienced by nurses

AIMS

To examine the associations between nurse work environment with nurses' silence about patient safety and the mediating effects of professional discrimination experienced by nurses.

DESIGN

Multicentre cross-sectional study.

METHODS

Between January and April 2019, 607 nurses and nursing assistants from seven hospitals in Greece assessed their clinical environment using the 'Practice Environment Scale of the Nursing Work Index Revised-PES-NWIR', and the silence about patient safety. The 'Experiences of Discrimination Index' was adapted to specifically address experienced discrimination based on the nursing profession. The PROCESS macros for SPSS were used to examine the above associations.

FINDINGS

Better nurse practice environment, with the exception of 'staffing and resource adequacy' dimension, was directly associated with less experienced professional discrimination, and directly and indirectly associated with less silence about patient safety, through the mediating role of professional discrimination experienced by nurses.

CONCLUSIONS

Silence about patient safety is dependent on the clinical work environment and may be a response of nurses to discrimination in the work context. Both an improvement in the nurse work environment and a decrease in professional discrimination would minimize silence about patient safety.

IMPACT

On many occasions, nurses are directly or indirectly discouraged from voicing their concerns about patient safety or are ignored when they do, leading to employee silence and decreasing the standard of care (Alingh et al., BMJ Quality & Safety, 2019, 28, 39; Pope, Journal of Change Management, 2019, 19, 45). Nurses' work-related determinants for silence are not clearly understood in the patient safety context. A favourably evaluated nurse practice environment is associated with less experienced professional discrimination and less silence about patient safety. To minimize silence about patient safety, both the nurse work environment and the experienced professional discrimination should be taken into consideration by nurse and healthcare managers.

An Examination of Nurses' Empowerment and Speaking Up During Postanesthesia Clinical Hand Overs

Hierarchical relationships can negatively affect nurses' psychological empowerment and interprofessional hand overs. We explored nurses' perceptions of their psychological empowerment, teamwork, and work engagement; relationships between these concepts during interprofessional clinical hand overs; and observed interactive communication behaviors during hand overs. We used surveys and observations of interprofessional clinical hand overs to collect data from 39 nurses in a postanesthesia care unit in Australia. Nurses reported high scores for psychological empowerment and work engagement. Relationships between empowerment and teamwork (r = 0.41, P = .01) and empowerment and work engagement (r = 0.65, P < .001) were positive and significant. Relationships between nurses' observed communication behaviors and perceptions of empowerment, teamwork, and work engagement were nonsignificant. Additional research is needed to better understand how empowerment, teamwork, and work engagement affect nurses' interactive communication behaviors during interprofessional clinical hand overs in the postanesthesia care unit.

Psychological Safety as a Mediator of the Relationship Between Inclusive Leadership and Nurse Voice Behaviors and Error Reporting

Purpose

The purpose of this study was to examine psychological safety as a mediator of the relationship between inclusive leadership and nurses’ voice behaviors and error reporting. Voice behaviors were conceptualized as speaking up and withholding voice.

Design

This correlational study used a web‐based survey to obtain data from 526 nurses from the medical/surgical units of three tertiary general hospitals located in two cities in South Korea.

Methods

We used model 4 of Hayes’ PROCESS macro in SPSS to examine whether the effect of inclusive leadership on the three outcome variables was mediated by psychological safety.

Findings

Mediation analysis showed significant direct and indirect effects of nurse managers’ inclusive leadership on each of the three outcome variables through psychological safety after controlling for participant age and unit tenure. Our results also support the conceptualization of employee voice behavior as two distinct concepts: speaking up and withholding voice.

Conclusions

When leader inclusiveness helps nurses to feel psychologically safe, they are less likely to feel silenced, and more likely to speak up freely to contribute ideas and disclose errors for the purpose of improving patient safety.

Clinical Relevance

Leader inclusiveness would be especially beneficial in environments where offering suggestions, raising concerns, asking questions, reporting errors, or disagreeing with those in more senior positions is discouraged or considered culturally inappropriate.

How and when organization identification promotes safety voice among healthcare professionals

AIM

The aim of this study is to examine the effect of organizational identification on safety voice behaviour, focusing on the mediating role of safety motivation and the moderating role of management commitment to safety and psychological safety.

DESIGN

The study used a cross-sectional questionnaire and a convenience sampling method.

METHOD

Data were collected online during November 2019 from 165 staff members from a disability healthcare organization in Australia that employs over 800 staff. Nearly 80% of the study sample were healthcare workers without supervisory responsibilities, and the remainder were senior staff with some operational duties. Measures of organizational identification, safety motivation, perceived management commitment to safety, psychological safety and safety voice were collected. Data were analysed using a moderated mediation model available with the SPSS PROCESS macro.

RESULTS

Findings show that organizational identification interacted with management commitment to safety to predict safety motivation, such that only healthcare employees who identified with their organization and perceived that their management cares about safety would feel that safety was personally important to them. In turn, safety motivation predicted safety voice. However, the effect of safety motivation on safety voice was only significant when psychological safety was low.

CONCLUSION

These findings offer initial evidence for the important role of organizational identification in prompting safety voice, how the relationship is contingent on management commitment to safety and psychological safety.

IMPACT

Healthcare professionals' discretionary sharing of ideas and suggestions are crucial to organizational performance and both staff and patient safety. However, safety voice involves inherent social risks because speaking up might not always be perceived positively by co-workers and leaders. We recommend that managers implement specific strategies to cultivate employee identification with the organization and demonstrate a genuine and visible commitment to safety so that employees will be motivated to raise safety concerns.

Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study

Objectives

Despite training and the recognition that speaking up can mitigate harm to patients and save lives, healthcare professionals do not consistently speak up when they have patient safety concerns. The purpose of this study was to identify barriers to and facilitators of speaking up about patient safety concerns to inform the development of interventions that will increase this behaviour.

Design

From October 2017 to February 2018, the study team conducted focus groups and interviews with nurses, advanced practice providers and physicians at three healthcare facilities. Participants were prompted to share their personal experiences with and perspectives on speaking up about patient safety concerns and to discuss strategies for communicating those concerns.

Setting

Tertiary academic healthcare centre.

Participants

62 healthcare professionals participated in the study. Purposeful sampling was used to include participants of different health professions and experience levels.

Main outcome measures

We planned to answer questions about why more healthcare professionals do not consistently speak up when they have legitimate patient safety concerns and to identify ways to enhance current interventions on speaking up behaviours,

Results

Twelve focus group discussions and two interviews were conducted with 62 participants. We identified two recurring themes: (1) The predominantly hierarchical culture of medicine is a barrier to speaking up and (2) Institutional, interpersonal and individual factors can modulate the impact of medicine’s hierarchical culture on speaking up behaviours and inform the strategies employed.

Conclusions

The data highlighted the importance of moving beyond targeting front-line healthcare professionals for training in the skills of speaking up and engaging institutional leaders and systems to actively promote and reward speaking up behaviours.

Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study

BACKGROUND

Psychological safety is the concept by which individuals feel comfortable expressing themselves in a work environment, without fear of embarrassment or criticism from others. Psychological safety in healthcare is associated with improved patient safety outcomes, enhanced physician engagement and fostering a creative learning environment. Therefore, it is important to establish the key levers which can act as facilitators or barriers to establishing psychological safety. Existing literature on psychological safety in healthcare teams has focused on secondary care, primarily from an individual profession perspective. In light of the increased focus on multidisciplinary work in primary care and the need for team-based studies, given that psychological safety is a team-based construct, this study sought to investigate the facilitators and barriers to psychological safety in primary care multidisciplinary teams.

METHODS

A mono-method qualitative research design was chosen for this study. Healthcare professionals from four primary care teams (n = 20) were recruited using snowball sampling. Data collection was through semi-structured interviews. Thematic analysis was used to generate findings.

RESULTS

Three meta themes surfaced: shared beliefs, facilitators and barriers to psychological safety. The shared beliefs offered insights into the teams' background functioning, providing important context to the facilitators and barriers of psychological safety specific to each team. Four barriers to psychological safety were identified: hierarchy, perceived lack of knowledge, personality and authoritarian leadership. Eight facilitators surfaced: leader and leader inclusiveness, open culture, vocal personality, support in silos, boundary spanner, chairing meetings, strong interpersonal relationships and small groups.

CONCLUSION

This study emphasises that factors influencing psychological safety can be individualistic, team-based or organisational. Although previous literature has largely focused on the role of leaders in promoting psychological safety, safe environments can be created by all team members. Members can facilitate psychological safety in instances where positive leadership behaviours are lacking - for example, strengthening interpersonal relationships, finding support in silos or rotating the chairperson in team meetings. It is anticipated that these findings will encourage practices to reflect on their team dynamics and adopt strategies to ensure every member's voice is heard.

Factors Influencing Nurses' Willingness to Speak Up Regarding Patient Safety in East Asia: A Systematic Review

Speaking up for patient safety among health care professionals is important because it can contribute to the prevention of adverse patient events, such as medication errors, infections, wrong-site surgical procedures, and other sentinel events. This systematic review identified factors that facilitate or inhibit nurses' willingness to speak up regarding patient safety in East Asian hospitals. Following the steps of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four databases, including PubMed, CINAHL, PsycInfo, and Web of Science, were searched. Nine studies were analyzed in this review, including five qualitative and four quantitative studies published between 2014 and 2019. Quality of included studies were evaluated using the Mixed-Method Appraisal Tool. Data synthesis was based upon qualitative-led synthesis adopting two existing multilevel frameworks on safety voice and employee voice signals. Four studies were conducted in Japan, three in South Korea, one in Hong Kong, and one in Taiwan. We organized factors influencing East Asian nurses' willingness to speak up regarding patient safety according to the following four contexts: individual (motivation toward patient safety, organizational commitment, perceived effectiveness and importance of speaking up, and assertive personality), team (positive relationship and team trust, team culture, and mentoring), organizational (hospital administrative support and organizational culture) and sociocultural (hierarchy and power differential and collectivistic culture). However, due to the limited number of studies conducted in East Asian hospitals, further studies with larger cohort samples of nurses in various East Asian countries should be conducted to deepen our understanding of nurses' willingness to voice their concerns for patient safety.

Associations of emotional burden and coping strategies with sick leave among healthcare professionals: A longitudinal observational study

OBJECTIVES

To investigate 1) whether care-related regrets (regret intensity, number of recent regrets) are associated with sick leave, independently of personality traits, perceived safety climate, and physical activity; and 2) whether these associations were mediated or moderated by coping strategies.

METHODS

Using a longitudinal international observational study (ICARUS), data were collected by the means of a weekly web survey. Descriptive and generalized estimation equations were performed.

RESULTS

A total of 276 newly practicing healthcare professionals (nurses, physicians, others) from 11 countries were included in this study. The average proportion of weeks with at least one day of sick leave was 3.2%. Nurses' sick leave increased with number of care-related regrets (Relative Risk [RR]=1.52; 95% Confidence Interval [CI]=[1.18; 1.95], p=.001), while physicians' sick leave increased with intensity of care-related regret (RR=1.21; 95%CI=[1.00; 1.21], p=.049). Coping was associated with lower risk of sick leave for nurses (RR _{problem-focused strategies} = 0.53; 95%CI=[0.37; 0.74], p=.001, and RR_{physical activity}=0.68; 95%CI:[0.54; 0.85], p<.001), but not for physicians. Nevertheless, the association of regret with sick leave remained significant even when adjusting for coping. Finally, this study did not find evidence of moderation by the coping strategies.

CONCLUSION

Regrets are associated with increased risks of sick leave, even in young healthcare professionals. Use of coping strategies partially mediated these associations in nurses. The results of this study should be used to inform interventions to reduce emotional burdens and enhance protective coping strategies.

A brief intervention to standardize postanesthetic clinical handoff

This naturalistic, pre- and post-design study explored the feasibility and acceptability of a brief patient safety intervention to introduce a tool to standardize interdisciplinary communication processes at patient handoff between anesthetists and postanesthesia nurses in the postanesthetic care unit. Observation and interview data were collected pre- and post-intervention from a convenience sample of 27 nurses and 23 anesthetists in a large tertiary hospital in Melbourne, Australia. Following the intervention, significant improvement was observed in nurses' performance of several patient safety behaviors, but trends in nurses' interdisciplinary communication behaviors such as asking questions and escalation of care were nonsignificant. This research provides evidence that tools to standardize clinical handoff communication may empower nurses to perform desired patient safety behaviors during interprofessional handoff. It underpins future research to explore strategies to empower nurses to advocate for patient safety during interdisciplinary communication, and provides a foundation for patient handoff improvement, education, and further research.

Understanding the peer, manager, and system influence on patient safety

A unique view of the Hospital Survey on Patient Safety Culture.

Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data

BACKGROUND

Psychological safety allows healthcare professionals to take the interpersonal risks needed to engage in effective teamwork and to maintain patient safety. In order to improve psychological safety in healthcare teams, an in-depth understanding of the complex and nuanced nature of psychological safety is needed. Psychological safety concepts, including voice, silence, learning behaviour, support and familiarity, informed the current study's investigation of psychological safety. This study aims to use a mixed-methods approach to develop an in-depth understanding of psychological safety within healthcare teams and to build on this understanding to inform the development of future interventions to improve it.

METHODS

Survey, observational and interview data are triangulated in order to develop an in- depth understanding of psychological safety within four healthcare teams, working within one case study hospital. The teams taking part included one multidisciplinary and three unidisciplinary teams. Observational and survey data were collected during and immediately following team meetings. Individual interviews were conducted with 31 individuals across the four teams. Thematic analysis was used to analyse these interviews.

RESULTS

Survey results indicated a high level of psychological safety. However, observations and interviews captured examples of silence and situations where participants felt less psychologically safe. Findings from across all three data sources are discussed in relation to voice and silence, learning, familiarity and support.

CONCLUSION

The results of this study provide a detailed description and in-depth understanding of psychological safety within four healthcare teams. Based on this, recommendations are made for future research and the development of interventions to improve psychological safety.