Unintended patient harm in hospital is a leading cause of patient morbidity and death, and this harm could often be avoided if someone had spoken up with a concern or suggestion. Healthcare teams make better decisions if everyone in the team can voice concerns, ask questions and contribute to problem solving and decision-making. The patient, as an expert on their own health, could also be a member of this team. While multiple studies and interventions have focused on helping members of the clinical team to speak up, less attention has been paid to the role of senior clinical staff in creating psychologically safe environments enabling the whole team to contribute to patient care.
In a previous study (1) we explored perspectives of senior operating room staff on their reactions to being spoken up to; how and why they might respond when a staff member voices concerns about their decisions or questions their actions, and how their response may affect ongoing patient care. We produced a grounded theory model of the speaking up interaction. From this model we developed and pilot-tested a questionnaire that prompts critical reflection on being challenged or admitting error. The questionnaire comprised eight statements requiring a rating of level of agreement, and a written explanation of the rating for each statement.
In a multi-centre study in New Zealand and Australia we will invite up to 200 clinical staff from multiple disciplines to complete the critical reflection questionnaire. We will undertake inductive thematic analysis on the written comments and evaluate our reflective questionnaire as a tool to promote critical reflection on leadership and psychological safety in a range of acute healthcare teams. We will evaluate the extent to which it helps uncover bias, assumptions and ingrained attitudes to being challenged and admitting fallibility. This analysis will inform semi-structured in-depth interviews with clinical staff on creating psychological safety in the teams in which they work, and their perspectives on the role of patients as members of the healthcare team. Synthesis of these two data sets will confirm, extend and / or refine our previous grounded theory model of the speaking up interaction.
Our data on clinician perspectives on the role of the patient as a member of the healthcare team will be the first step in a new body of work on patient perspectives on psychological safety and their role in healthcare teams in acute care environments.
Our results will inform an intervention study exploring critical self-reflection as a vehicle for change. We anticipate a future randomised controlled intervention study, measuring improvement in staff psychological safety, staff perceptions of safety climate, and staff well-being.
Our ultimate goal is to build psychological safety in healthcare teams, promoting an environment where specialists, trainees, nurses, anaesthetic assistants and patients do not hesitate to speak up, knowing they will be listened to and their opinions valued.
1.Long J, Jowsey T, Garden A, Henderson K, Weller J. The flip side of speaking up: a new model to facilitate positive responses to speaking up in the operating theatre. British Journal of Anaesthesia. 2020;125(6):1099-106.
Professor Jennifer Weller, University of Auckland; Dr James Hamill, Paediatric Surgery, Starship Children’s Health; Associate Professor Andrew MacCormick, University of Auckland and Department of Surgery, Counties Manukau, New Zealand; Associate Professor Tanisha Jowsey, Bond University, Queensland.
The project was awarded A$69,902 funding through the ANZCA research grants program for 2025.