Speaking up is a feature of effective teams, and is important for patient safety. Failure to speak up or unsuccessful attempts at speaking up limit the opportunity for teams to correct mistakes, or prevent flawed decisions or actions progressing to patient harm. In addition, unprofessional behaviour including bullying and discrimination have a negative impact on the team climate, and the latter has been linked to patient outcomes. Calling out these behaviours may limit harm to staff, and improve team climate. Clearly identifying and evaluating factors that predict speaking up will be vital for developing interventions to promote it.
Speaking up can be defined as explicitly communicating observations or concerns, requesting clarification or explanation, or explicitly challenging another’s decision or action. Speaking up provides an opportunity to intervene before patient harm occurs, to mitigate actual harm, or discourage unprofessional behaviour.
The investigators aim to explore factors that promote or inhibit a climate conducive to speaking up, including differences between professional roles such as surgeon, anaesthetist, technician, and nurse.
Semi-structured interviews will be conducted and focus groups used to explore the experiences and perspectives of operating room staff on speaking up. Grounded theory analyses will be undertaken to develop a model to explain the psychosocial factors influencing speaking up in operating room teams which will then inform improvement interventions.
The results of this study will lay the foundations for a program of research on interventions to improve the climate of speaking up in hospitals in New Zealand and beyond. This will also inform development of role specific interventions contributing to further improvement of surgical safety, and communication between operation room staff.
The proposed project will advance our work on improvements of surgical safety focused on effective teamwork and communication using multidisciplinary simulation programs and studies on human factors associated with safe surgery.
Professor Jennifer Weller, Dr Tanisha Jowsey, University of Auckland, Professor Sandy Garden, Wellington Regional Hospital, New Zealand.
The project was awarded $A68,635 through the ANZCA research grants program for 2019.
Speaking up with concerns is an important issue for patient safety. Team members must feel safe to voice concerns, suggestions, or questions. This continuing problem contributes to a high proportion of unintended patient harm.
While efforts to help staff to speak up against hierarchy gradients or professional boundaries are worthwhile, the investigators proposed that clinical leaders have responsibility for creating an environment where staff can speak freely, confident that they will be listened to respectfully.
This study began a clinical program aimed initially at understanding why clinical leaders might react negatively to being spoken up to, and subsequently at using new understandings to develop and evaluate interventions to help leaders to create environments where all team members have a voice and are actively involved in their patients’ care and safety.
Interviews and focus groups were conducted with surgeons, anaesthetists, nurses, and anaesthetic technicians in operating theatres across New Zealand. With data from 79 participants, the team conceptualised three phases in the speaking up interaction: 1) content of speaker message and delivery tone; 2) message interpretation through receiver filters including personal fallibility and leadership beliefs, respect for the speaker, understanding the challenges of speaking up, and personal cultural and professional communication norms; and 3) the receiver’s response and its effects on the speaker, observing operating theatre staff, and patient care.
The research led to an in depth understanding of the basis of responses to being spoken up to. The findings led to development of a grounded theory model-based new critical reflection questionnaire, which is now being used in a communications workshop on ‘giving the team a voice’.
The workshop is currently being incorporated into the instructor training course in New Zealand’s ‘NetworkZ’ national multidisciplinary simulation-based team training intervention, reflecting a pathway from research to translation, and then to implementation into clinical environments.
The potential implications are that ultimately, the findings will play an influential role in effecting change in the culture of healthcare workplaces towards ones of respect and inclusion.
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 Dec 1;125(6):1099-106.