Speaking up behaviors and safety climate in an Austrian university hospital

Speaking up behaviors and safety climate in an Austrian university hospital Abstract Objective To analyze speaking up behavior and safety climate with a validated questionnaire for the first time in an Austrian university hospital. Design Survey amongst healthcare workers (HCW). Data were analyzed using descriptive statistics, Cronbach’s alpha was calculated as a measure of internal consistencies of scales. Analysis of variance and t-tests were used. Setting The survey was conducted in 2017. Participants About 2.149 HCW from three departments were asked to participate. Intervention To measure speaking up behavior and safety climate. Main Outcome Measure To explore psychological safety, encouraging environment and resignation towards speaking up. Results About 859 evaluable questionnaires were returned (response rate: 40%). More than 50% of responders perceived specific concerns about patient safety within the last 4 weeks and observed a potential error or noticed rule violations. For the different items, between 16% and 42% of HCW reported that they remained silent though concerns for safety. In contrast, between 96% and 98% answered that they did speak up in certain situations. The psychological safety for speaking up was lower for HCW with a managerial function (P < 0.001). HCW with managerial functions perceived the environment as less encouraging to speak up (P < 0.05) than HCW without managerial function. Conclusions We identified speaking up behaviors for the first time in an Austrian university hospital. Only moderately frequent concerns were in conflict with frequent speaking up behaviors. These results clearly show that a paradigm shift is needed to increase speaking up culture. Speaking up, patient safety, safety culture, communication, survey Introduction Medical error alertness is an important determinant of increased patient safety [1]. It is assumed that medical errors are already the third leading cause of death in the US hospitals [2]. To minimize the number of medical errors, several instruments were implemented in healthcare environments. Clinical risk assessment tools were introduced, campaigns were launched aiming, for example, at improving hand hygiene behaviors, and checklists were introduced to ensure that surgical procedures are followed [1, 3, 4]. However, such instruments and campaigns can only be effective if they are deployed correctly. Furthermore, many kinds of tasks are increasingly accomplished by teams and for enhanced team performance, communication plays a major role [5, 6]. Poor communication can weaken patient safety and is for example, the second major source of errors in surgery [7, 8]. Speaking up can be defined as assertive communication of patient safety concerns through information, questions or opinions in clinical situations where immediate action is needed to avoid harm for the patient [7, 9–13]. However, under-reporting of problems and clinician silence is a well-recognized phenomenon in healthcare [7]. Many barriers to speaking up exist, for example, fears to damage social relationships, reprisal and social pressure [12, 14, 15]. For example, clinician silence can be well observed in surgical teams where teams are encouraged to use a designated checklist. Though surgical teams’ perception of the checklist as an important patient safety instrument is high, checklist compliance remains low, in part due to hierarchical barriers and breakdowns of teamwork and communication [16–19]. Of all these barriers, the existence of strong authority gradients is likely a significant factor. One study found that nursing staff believes speaking up would have no impact on patient safety in a hierarchically structured environment [9]. Furthermore, it is not only nurses but also junior physicians who are reluctant to speak up to senior physicians [20]. This suggests that a paradigm shift is needed to increase speaking up, as habitual processes of healthcare workers (HCW) need to change. Low hierarchies, psychological safety, a strong communication culture, teamwork and leadership which encourages speaking up, the ability to take criticism paired with the aspiration to increase patient safety are a prerequisite for speaking up [12, 21]. Recently, a ‘speaking up about patient safety questionnaire (SUPS-Q)’ was developed by the Swiss Patient Safety Foundation to assess systematically different speaking up dimensions [22]. This tool is the first to combine scales of clinician speaking up behaviors and speak up related climate within one questionnaire. The validated SUPS-Q allows an efficient assessment speaking up behaviors and of constructs that are known to have an influence on speaking up behaviors. Within the University Hospital Graz patient safety is an important topic and several initiatives were implemented in the past [1, 4, 23, 24]. However, no data on speaking up behaviors of clinicians exists so far. Therefore, the primary aim of this study was to survey HCW of three different high risk departments in a tertiary university hospital in order to assess self-reported speaking up related behaviors, climate and perceived barriers. Secondly, results were stratified in order to identify differences between HCW with and without managerial function, between professional groups and between medical disciplines. Methods The study was approved by the Ethics Committee of Medical University of Graz (vote#: 29–096 ex16/17). Study Population The survey was conducted in 2017, using the validated SUPS-Q in three departments (Department of Surgery (SU), Department of Anesthesiology and Intensive Care Medicine (AN) and Department of Internal Medicine (IM)) [22]. In total, 2.149 HCW were asked to participate (nSU = 759; nAN = 530; nIM = 860). Corresponding to the number of HCW working in each organizational unit, the correct number of questionnaires was given to all HCW with a managerial function by the Department of Quality and Risk Management. Line managers were asked to inform their colleagues about the aim of the survey in individual team meetings and invited them to participate. Within this study, we differentiated between HCW with and without managerial function. HCW with managerial function were for example head nurse of a ward or an intensive care unit, head nurse of a division or a department, a chief resident, medical head of a division or a department. Each potential participant was informed that collected data was going to be stored with the Department of Quality and Risk Management and that data analysis performed by the Foundation of Patient Safety in Switzerland would be strictly anonymous. The survey was open for 4 weeks (11 September– 09 October 2017) and after 2 weeks a reminder was sent by email to all HCW. About 907 questionnaires were returned and of these, 48 were deleted due to excessive missing values, leaving 859 evaluable questionnaires in the sample (response rate 40%). Scales of the SUPS-Q The SUPS-Q consists of three behavior-related scales, three climate related scales, perceived barriers items and a vignette assessing hypothetical speaking up behaviors. Speaking up behaviors are assessed with 11 items, asking for perceived safety concerns due to errors and rule violations (PC1-3), past withholding voice behaviors (WV1-4) and past speaking up (SU1-4). These items are scored on a five-point Likert scale from ‘never (0 times)’ to ‘very often (>10 times in the last 4 working weeks)’. Speak up related climate is assessed with three scales covering 11 items. They address psychological safety of speaking up such as perceived support of colleagues when addressing safety concerns (PSS1-5), encouraging environment for speaking up such as empowerment of HCWs to speak up by supervisors (EES1-3) and resignation towards speaking up (RES1-3). These items are scored on a 7-point Likert scale ranging from ‘strongly disagree with this statement’ (value 1) to ‘strongly agree with this statement’ (value 7). Barriers for speaking up are surveyed with one multiple choice item asking for the relevance of 6 predefined barriers. The vignette describes a hypothetical speaking up situation in which a consultant on a daily ward round fails to comply with hand hygiene standards. Four items ask the survey participant about the perceived risk of harm for the patient, how realistic the situation is, whether he would speak up and whether he would feel uncomfortable with speaking up. These items are scored on a 7-point Likert scale ranging from ‘1’ corresponding to ‘not at all realistic, not dangerous, very unlikely, not at all uncomfortable’ to ‘7’ corresponding to ‘very realistic, very dangerous, very likely, very comfortable’. Statistical analysis Data were analyzed using descriptive statistics (mean, standard deviations). For easier interpretation, responses were also dichotomized: Behavior items were split and recoded as ‘0’ (value ‘never’) or ‘1’ (values 2 through 5 ‘at least once in the past 4 weeks’). For scales, mean scale scores were computed. Cronbach’s alpha was calculated as a measure of internal consistencies of scales. Analysis of variance (ANOVA) and t-tests were used to determine whether mean ratings differed significantly between respondents of different professional groups (nurses versus physicians), function (with versus without managerial function) and departments (surgery versus internal medicine versus anesthesiology/intensive care). A P-value <0.05 was considered statistically significant. Results The response was 30% in AN, 38% in SU and 44% in IM. For further characteristics of the study sample, see Table 1. Table 1 Characteristics of the study sample (may not sum up to 100% due to missing values) Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Table 1 Characteristics of the study sample (may not sum up to 100% due to missing values) Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Safety concerns and speaking up behaviors For the different items, between 57% and 69% of HCW had perceived concerns about patient safety (PC1-3), observed a potential error or noticed rule violations (Table 2). There was a significant difference in mean concerns scale score between the departments (P < 0.001), whereas no difference emerged between nurses and physicians. HCW with managerial function reported more frequent concerns than HCW without a managerial function (P < 0.01). Table 2 Frequencies of perceived concerns, withholding voice and speaking up for the total group in % and at scales score level, and stratified by managerial function as well as for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology and Intensive Care (AN) In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  aMF, managerial function. Table 2 Frequencies of perceived concerns, withholding voice and speaking up for the total group in % and at scales score level, and stratified by managerial function as well as for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology and Intensive Care (AN) In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  aMF, managerial function. Between 16% and 42% of HCW reported having remained silent over the last 4 weeks and did not speak up (WV1-4). There was a significant difference in mean withholding voice scale score between the departments (P < 0001). Between nurses and physicians as well as between HCW with and without managerial function no significant differences emerged. Contrary to withholding voice results, between 96% and 98% of HCW reported speaking up in certain situations (SU1-4). There was a significant difference in mean speaking up scale score between the departments (P < 0.01). Between nurses and physicians no differences emerged. HCW without a managerial function reported having expressed themselves more frequently (P < 0.001). Overall, reliabilities (Cronbach α) of all scales can be rated as acceptable to good. For further characteristics of speaking up behavioral attitudes, see Table 2. Speaking up related climate Overall, mean scales scores were low to medium. The psychological safety for speaking up (PSS1-5) was lower for HCW with a managerial function (P < 0.001). For departments significant differences emerged for the scale scores for psychological safety (P < 0.05) and resignation (P < 0.001). HCW with managerial functions perceived the environment as less encouraging (EES1-4) to speak up (P < 0.05) than HCW without managerial function. Nurses reported a higher psychological safety (P < 0.05) and a higher resignation (RES1-2) (P < 0.001). Across all three scales the speaking up climate can be seen as neutral, neither obstructive nor encouraging. Generally, psychological safety was rather low (see Tables 3 and 4). Overall, internal reliabilities (Cronbach α) of all scales can be rated good. Table 3 Means and standard deviations (SD) of speaking up related climate scales     Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82      Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82  aNegatively worded items. Table 3 Means and standard deviations (SD) of speaking up related climate scales     Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82      Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82  aNegatively worded items. Table 4 Means of the speaking up related attitude scales for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN)     Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244      Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244  aMF, managerial function. Table 4 Means of the speaking up related attitude scales for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN)     Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244      Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244  aMF, managerial function. Vignette HCW considered the described situation with the missing hand hygiene as rather realistic in a healthcare setting (VIG1-4). Differences emerged between departments (P < 0.001). The possibility of harm to the patient was considered to be rather low. The self-reported likelihood to speak up towards the consultant was low. There were significant differences between HCW with and without managerial function (P < 0.05). HCW with managerial functions considered the described situation to be less realistic but perceived the danger as being higher (Table 5). Table 5 Means and standard deviations (SD) for the hypothetical situation (vignette) for the total, and stratified by managerial function and for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN) You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  aMF, managerial function. Table 5 Means and standard deviations (SD) for the hypothetical situation (vignette) for the total, and stratified by managerial function and for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN) You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  aMF, managerial function. Barriers for speaking up The top 3 of the 6 predefined barriers for speaking up were ineffectiveness of speaking up (39.9%), presence of patients or relatives (30.5%) and unpredictability of the actor’s reaction (25.5%). Rankings of barriers differed only marginally between departments (see Fig. 1). Figure 1 View largeDownload slide Frequency of barriers for the units of surgery (SU), internal medicine (IM) and anaesthesiology (AN) Figure 1 View largeDownload slide Frequency of barriers for the units of surgery (SU), internal medicine (IM) and anaesthesiology (AN) Discussion This study is the first to report speaking up behaviors and climate for a tertiary university hospital in Austria using the validated SUPS-Q. At a university hospital, the diversity of disciplines is high, nevertheless, within this study we focused on three main disciplines, namely, surgical and anesthesiological disciplines including intensive care units and internal medicine. In general, surgical disciplines are known as high risk areas, where the ability of speaking up behaviors is very important. HCW of these disciplines spend most of their time working together as teams in the OR [16–19]. On the other side, it was part of the research question, if a non-surgical discipline perceives speaking up behaviors in the same manner or not. Furthermore, these three departments represented nearly one-third of all HCW within our university hospital and are, therefore, an important sample for our university hospital. Results showed that more than half of HCW perceived specific concerns about patient safety at least once and up to 42% of HCW remained silent and did not speak up in a critical situation during the last 4 weeks. Moderate perceived concerns were in conflict with frequent speaking up behaviors during the last 4 weeks. Also, HCW considered the described vignette to be a realistic scenario in a healthcare setting; however, possible harm and their consequences for patients seem to be rather underestimated. It was likelihood that nurses would withhold their voice more often than physicians and would not make aware of the missing disinfection as described in the vignette. Overall, the psychological safety for speaking up was rather low. Concerning speaking up behaviors at scales score level, it was obvious that overall there were rarely concerns about patient safety aspects even though 69% of HCW had at least once a specific concern in the past 4 weeks, 57% had observed an error and 58% noticed HCW who had ignored a patient safety rule. Between HCW professions there were no differences, however, physicians had slightly more perceived concerns than nurses as well as had HCW with managerial function. This finding stands in contrast to previously published results [22, 25]. However, HCW of surgical and anaesthesiological disciplines perceived concerns more frequently. Reasons for this could be that especially surgical and anaesthesiological HCW developed a differentiated perception of patient safety relevant aspects due to the introduction of the surgical safety checklist. Though surgical and anaesthesiological HCW had more patient safety concerns they also significantly kept more often silent than HCW of non-surgical disciplines. This could be an indicator of hierarchical barriers which are known to be high in surgical disciplines [16]. There was a certain inconsistency as rare concerns were in conflict with frequent speaking up behaviors in recent 4 weeks. Nearly, 100% reported having spoken up and HCW without managerial function spoke up significantly more often than HCW with a managerial function, in line with previous research [22]. Though according to self-report HCW frequently speak up, they also mentioned ineffectiveness, the presence of patients or relatives and unpredictability of the reaction of the person causing concern as common barriers to speaking up. The inconsistent results of the survey may be explained by HCW giving a socially desirable response. One reason for this might be that HCW do not want to be perceived as not supporting patient safety as required by the management. In general, psychological safety is a prerequisite for a speaking up culture. According to Nembhard [26], psychological safety is positively associated with professional status in healthcare which is a key antecedent of speaking up. However, our survey results indicated that psychological safety was significantly lower for HCW with a managerial function and higher for nurses, which contrasts theory and previous empirical results. The psychological safety was rather low, also from this point of view commonly reported speaking up is surprising in this survey. Also, HCW with managerial function perceive the environment as less encouraging. For all three scales, psychological safety, encouraging environment and resignation to speak up, results can be interpreted as neither obstructive nor beneficial and were also not comparable to previously published data [22]. Why the psychological safety was low remains unclear, considering that the management strongly supports HCW in terms of patient safety. These results clearly show that a paradigm shift is needed to increase speaking up culture. It also needs further investigations to find out the reasons and to be able to counteract in the near future. The vignette was considered to be a realistic scenario. However, nurses thought that the vignette was more realistic, and—surprisingly—they considered the risk for the patient to be lower. In previous studies, the vignette scored twice as much with regard to the dangerousness of the scenario compared with our study [22]. Respondents were also relatively unlikely to instruct the senior physician regarding the missing hand disinfection, i.e. to speak up. The lower risk assessment by nurses compared with physicians was also very unlikely. As perceived risk for patient harm is one of the key determinants of speaking up, our results are consistent that a low perceived risk is correlated with low likelihood to speak up [7, 13, 25]. The transferability of our results to non-university hospitals is unclear. In general, withholding safety concerns is a common phenomenon in many acute care settings [12]. However, a few factors indicate that speaking up is more difficult and therefore less frequent among staff of university hospitals: First, hierarchy and authority gradients are often steeper in teaching settings. In a survey in the USA, most medical students were willing to speak up to other students about poor hand hygiene practices but only few would speak up towards consultants [27]. Second, recent research suggests that knowing colleagues well and thus being able to predict their reaction towards one speaking up is an important facilitator of speaking up [11]. In university hospitals residents rotate quite frequently between clinical units making it hard for nurses in particular to speak up towards them. Again, this would suggest that speaking up is less likely among staff of university hospitals settings. This study has several strengths and limitations. First, a major strength is that in contrast to surveys performed in the past, we decided to use a traditional paper–pencil questionnaire in order to increase the response rate. Compared with 20% return rates acquired by using online questionnaires the return rate within this study improved significantly. Possible reasons for this are diverse, however, the most plausible explanation is that emails with an invitation to an online survey are deleted relatively easily and that HCW have concerns about secure data management and the traceability of online surveys. Secondly, it is the first study assessing speaking up behaviors in Austria and results gave a valuable insight into behavioral patterns of HCW at an Austrian hospital. A major limitation of this survey was that the results indicate that HCW may have responded in a socially desirable pattern. However, it is also possible that the scales of concern were understood differently than intended. Furthermore, this study was performed in a university hospital setting, therefore, it is questionable, how results are transferable to non-university hospitals. To conclude, speaking up behavior was assessed in Austria for the first time, using the validated questionnaire. Moderate perceived concerns were in conflict with frequent speaking up behaviors in the recent 4 weeks. Results suggest that HCW gave a socially desirable response. While speak up related climate was rated rather moderate, respondents reported frequent speak up behaviors. Surprisingly, psychological safety was not positively associated with professional status in healthcare. These results support further investments into research on patient and employee safety within our university hospital. Further into deep investments are needed to identify why HCW with managerial function perceive the environment as less encouraging and why socially desirable response was most common. The vignette also showed that even more investments are needed throughout training by hygiene experts to increase awareness concerning hand hygiene aspects. Acknowledgements The authors wish to express their gratitude to all HCWs for their willingness of study participation. 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Abstract

Abstract Objective To analyze speaking up behavior and safety climate with a validated questionnaire for the first time in an Austrian university hospital. Design Survey amongst healthcare workers (HCW). Data were analyzed using descriptive statistics, Cronbach’s alpha was calculated as a measure of internal consistencies of scales. Analysis of variance and t-tests were used. Setting The survey was conducted in 2017. Participants About 2.149 HCW from three departments were asked to participate. Intervention To measure speaking up behavior and safety climate. Main Outcome Measure To explore psychological safety, encouraging environment and resignation towards speaking up. Results About 859 evaluable questionnaires were returned (response rate: 40%). More than 50% of responders perceived specific concerns about patient safety within the last 4 weeks and observed a potential error or noticed rule violations. For the different items, between 16% and 42% of HCW reported that they remained silent though concerns for safety. In contrast, between 96% and 98% answered that they did speak up in certain situations. The psychological safety for speaking up was lower for HCW with a managerial function (P < 0.001). HCW with managerial functions perceived the environment as less encouraging to speak up (P < 0.05) than HCW without managerial function. Conclusions We identified speaking up behaviors for the first time in an Austrian university hospital. Only moderately frequent concerns were in conflict with frequent speaking up behaviors. These results clearly show that a paradigm shift is needed to increase speaking up culture. Speaking up, patient safety, safety culture, communication, survey Introduction Medical error alertness is an important determinant of increased patient safety [1]. It is assumed that medical errors are already the third leading cause of death in the US hospitals [2]. To minimize the number of medical errors, several instruments were implemented in healthcare environments. Clinical risk assessment tools were introduced, campaigns were launched aiming, for example, at improving hand hygiene behaviors, and checklists were introduced to ensure that surgical procedures are followed [1, 3, 4]. However, such instruments and campaigns can only be effective if they are deployed correctly. Furthermore, many kinds of tasks are increasingly accomplished by teams and for enhanced team performance, communication plays a major role [5, 6]. Poor communication can weaken patient safety and is for example, the second major source of errors in surgery [7, 8]. Speaking up can be defined as assertive communication of patient safety concerns through information, questions or opinions in clinical situations where immediate action is needed to avoid harm for the patient [7, 9–13]. However, under-reporting of problems and clinician silence is a well-recognized phenomenon in healthcare [7]. Many barriers to speaking up exist, for example, fears to damage social relationships, reprisal and social pressure [12, 14, 15]. For example, clinician silence can be well observed in surgical teams where teams are encouraged to use a designated checklist. Though surgical teams’ perception of the checklist as an important patient safety instrument is high, checklist compliance remains low, in part due to hierarchical barriers and breakdowns of teamwork and communication [16–19]. Of all these barriers, the existence of strong authority gradients is likely a significant factor. One study found that nursing staff believes speaking up would have no impact on patient safety in a hierarchically structured environment [9]. Furthermore, it is not only nurses but also junior physicians who are reluctant to speak up to senior physicians [20]. This suggests that a paradigm shift is needed to increase speaking up, as habitual processes of healthcare workers (HCW) need to change. Low hierarchies, psychological safety, a strong communication culture, teamwork and leadership which encourages speaking up, the ability to take criticism paired with the aspiration to increase patient safety are a prerequisite for speaking up [12, 21]. Recently, a ‘speaking up about patient safety questionnaire (SUPS-Q)’ was developed by the Swiss Patient Safety Foundation to assess systematically different speaking up dimensions [22]. This tool is the first to combine scales of clinician speaking up behaviors and speak up related climate within one questionnaire. The validated SUPS-Q allows an efficient assessment speaking up behaviors and of constructs that are known to have an influence on speaking up behaviors. Within the University Hospital Graz patient safety is an important topic and several initiatives were implemented in the past [1, 4, 23, 24]. However, no data on speaking up behaviors of clinicians exists so far. Therefore, the primary aim of this study was to survey HCW of three different high risk departments in a tertiary university hospital in order to assess self-reported speaking up related behaviors, climate and perceived barriers. Secondly, results were stratified in order to identify differences between HCW with and without managerial function, between professional groups and between medical disciplines. Methods The study was approved by the Ethics Committee of Medical University of Graz (vote#: 29–096 ex16/17). Study Population The survey was conducted in 2017, using the validated SUPS-Q in three departments (Department of Surgery (SU), Department of Anesthesiology and Intensive Care Medicine (AN) and Department of Internal Medicine (IM)) [22]. In total, 2.149 HCW were asked to participate (nSU = 759; nAN = 530; nIM = 860). Corresponding to the number of HCW working in each organizational unit, the correct number of questionnaires was given to all HCW with a managerial function by the Department of Quality and Risk Management. Line managers were asked to inform their colleagues about the aim of the survey in individual team meetings and invited them to participate. Within this study, we differentiated between HCW with and without managerial function. HCW with managerial function were for example head nurse of a ward or an intensive care unit, head nurse of a division or a department, a chief resident, medical head of a division or a department. Each potential participant was informed that collected data was going to be stored with the Department of Quality and Risk Management and that data analysis performed by the Foundation of Patient Safety in Switzerland would be strictly anonymous. The survey was open for 4 weeks (11 September– 09 October 2017) and after 2 weeks a reminder was sent by email to all HCW. About 907 questionnaires were returned and of these, 48 were deleted due to excessive missing values, leaving 859 evaluable questionnaires in the sample (response rate 40%). Scales of the SUPS-Q The SUPS-Q consists of three behavior-related scales, three climate related scales, perceived barriers items and a vignette assessing hypothetical speaking up behaviors. Speaking up behaviors are assessed with 11 items, asking for perceived safety concerns due to errors and rule violations (PC1-3), past withholding voice behaviors (WV1-4) and past speaking up (SU1-4). These items are scored on a five-point Likert scale from ‘never (0 times)’ to ‘very often (>10 times in the last 4 working weeks)’. Speak up related climate is assessed with three scales covering 11 items. They address psychological safety of speaking up such as perceived support of colleagues when addressing safety concerns (PSS1-5), encouraging environment for speaking up such as empowerment of HCWs to speak up by supervisors (EES1-3) and resignation towards speaking up (RES1-3). These items are scored on a 7-point Likert scale ranging from ‘strongly disagree with this statement’ (value 1) to ‘strongly agree with this statement’ (value 7). Barriers for speaking up are surveyed with one multiple choice item asking for the relevance of 6 predefined barriers. The vignette describes a hypothetical speaking up situation in which a consultant on a daily ward round fails to comply with hand hygiene standards. Four items ask the survey participant about the perceived risk of harm for the patient, how realistic the situation is, whether he would speak up and whether he would feel uncomfortable with speaking up. These items are scored on a 7-point Likert scale ranging from ‘1’ corresponding to ‘not at all realistic, not dangerous, very unlikely, not at all uncomfortable’ to ‘7’ corresponding to ‘very realistic, very dangerous, very likely, very comfortable’. Statistical analysis Data were analyzed using descriptive statistics (mean, standard deviations). For easier interpretation, responses were also dichotomized: Behavior items were split and recoded as ‘0’ (value ‘never’) or ‘1’ (values 2 through 5 ‘at least once in the past 4 weeks’). For scales, mean scale scores were computed. Cronbach’s alpha was calculated as a measure of internal consistencies of scales. Analysis of variance (ANOVA) and t-tests were used to determine whether mean ratings differed significantly between respondents of different professional groups (nurses versus physicians), function (with versus without managerial function) and departments (surgery versus internal medicine versus anesthesiology/intensive care). A P-value <0.05 was considered statistically significant. Results The response was 30% in AN, 38% in SU and 44% in IM. For further characteristics of the study sample, see Table 1. Table 1 Characteristics of the study sample (may not sum up to 100% due to missing values) Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Table 1 Characteristics of the study sample (may not sum up to 100% due to missing values) Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Total, n  859  Internal medicine n (%)  381 (45.9)  Surgery n (%)  292 (35.2)  Anesthesiology n (%)  157 (18.9)  Females, %  620 (74.6)  Profession, %   Nurse  587 (70.9)   Nurse with managerial function  38 (4.6)   Physician  80 (9.7)   Physician with managerial function  51 (6.2)   Other  72 (8.7)  Medical area, %   Inpatient ward  247 (30.6)   Intensive care unit  188 (23.3)   Operating room, recovery room  93 (11.5)   Outpatient ward  134 (16.6)   Other area  35 (4.3)   In several areas equally  109 (13.5)  Duration of employment   ≤2 Years  122 (14.6)   >2 and ≤5 years  150 (18.0)   >5 and ≤10 years  138 (16.6)   >10 and ≤20 years  209 (25.1)   >20 years  215 (25.8)  Working hours per week of patient care   <10 h  37 (4.5)   ≥10 and <24 h  123 (15.0)   ≥24 and <40 h  278 (33.9)   ≥40 h  381 (46.5)  Safety concerns and speaking up behaviors For the different items, between 57% and 69% of HCW had perceived concerns about patient safety (PC1-3), observed a potential error or noticed rule violations (Table 2). There was a significant difference in mean concerns scale score between the departments (P < 0.001), whereas no difference emerged between nurses and physicians. HCW with managerial function reported more frequent concerns than HCW without a managerial function (P < 0.01). Table 2 Frequencies of perceived concerns, withholding voice and speaking up for the total group in % and at scales score level, and stratified by managerial function as well as for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology and Intensive Care (AN) In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  aMF, managerial function. Table 2 Frequencies of perceived concerns, withholding voice and speaking up for the total group in % and at scales score level, and stratified by managerial function as well as for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology and Intensive Care (AN) In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  In everyday work, it sometimes happens that things go wrong and risks to patients arise. This could be as a result of medication error, poor hand hygiene or missing documentation. Over the last 4 weeks, how often…  At least once, %  Total  MFa  No MF  IM  SU  AN  Physician  Nurses  Perceived concerns (α = 0.79)   PC1  … have you had specific concerns about patient safety?  68.8  67.8  69.2  63.3  74.7  71.9  69.8  68.9   PC2  … have you observed an error which—if uncaptured—could be harmful to patients?  57.3  63.2  56.4  49.6  65.6  59.9  55.6  64.8   PC3  … have you noticed that your workplace colleagues haven’t followed important patient safety rules, intentionally or unintentionally?  58.4  69.0  58.1  51.1  63.4  67.7  60.5  59.1  Scale score, mean  1.93  2.15  1.91  1.76  2.10  2.02  2.01  1.92  P-value    0.0057  <0.001  0.2126  Withholding voice (α = 0.74)                   WV1  … did you choose not to bring up your specific concerns about patient safety?  32.3  26.1  33.4  24.1  42.8  33.1  31.3  32.8   WV2  … did you keep ideas for improving patient safety in your unit to yourself?  41.6  27.9  43.3  35.9  49.8  41.2  38.0  42.3   WV3  … did you remain silent when you had information that might have prevented a safety incident in your unit?  16.4  11.4  16.5  13.3  21.7  14.7  17.8  15.5   WV4  … did you not address a colleague (physicians and/or nurses) if he/she didn’t follow important patient safety rules, intentionally or unintentionally?  39.6  39.5  39.1  35.4  45.8  40.0  37.8  39.4  Scale score, mean  1.5  1.43  1.47  1.38  1.61  1.51  1.47  1.47  P-value    0.5023  <0.001  0.9446  Speaking up (α = 0.88)                   SU1  … did you bring up specific concerns about patient safety?  97.3  91.9  97.7  97.6  96.2  98.1  96.9  97.1   SU2  … did you address an error which—if uncaptured—could be harmful for patients?  96.5  96.6  96.9  96.0  96.5  97.4  96.9  96.2   SU3  … did you address a colleague (physicians and/or nurses) when he/she didn’t follow important patient safety rules, intentionally or unintentionally?  97.3  96.6  96.9  97.8  96.1  97.4  97.6  96.7   SU4  … did you prevent an incident from occurring as a consequence of bringing up specific concerns about patient safety?  98.2  97.6  98.1  98.6  96.8  100  99.21  97.8  Scale score, mean  3.9  3.54  3.98  4.04  3.82  3.90  3.94  3.93  P-value    <0.001  <0.0052  0.8634  aMF, managerial function. Between 16% and 42% of HCW reported having remained silent over the last 4 weeks and did not speak up (WV1-4). There was a significant difference in mean withholding voice scale score between the departments (P < 0001). Between nurses and physicians as well as between HCW with and without managerial function no significant differences emerged. Contrary to withholding voice results, between 96% and 98% of HCW reported speaking up in certain situations (SU1-4). There was a significant difference in mean speaking up scale score between the departments (P < 0.01). Between nurses and physicians no differences emerged. HCW without a managerial function reported having expressed themselves more frequently (P < 0.001). Overall, reliabilities (Cronbach α) of all scales can be rated as acceptable to good. For further characteristics of speaking up behavioral attitudes, see Table 2. Speaking up related climate Overall, mean scales scores were low to medium. The psychological safety for speaking up (PSS1-5) was lower for HCW with a managerial function (P < 0.001). For departments significant differences emerged for the scale scores for psychological safety (P < 0.05) and resignation (P < 0.001). HCW with managerial functions perceived the environment as less encouraging (EES1-4) to speak up (P < 0.05) than HCW without managerial function. Nurses reported a higher psychological safety (P < 0.05) and a higher resignation (RES1-2) (P < 0.001). Across all three scales the speaking up climate can be seen as neutral, neither obstructive nor encouraging. Generally, psychological safety was rather low (see Tables 3 and 4). Overall, internal reliabilities (Cronbach α) of all scales can be rated good. Table 3 Means and standard deviations (SD) of speaking up related climate scales     Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82      Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82  aNegatively worded items. Table 3 Means and standard deviations (SD) of speaking up related climate scales     Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82      Mean  SD  Psychological Safety for Speaking up (α = 0.83)  PSS1  I can rely on my colleagues (physicians and/or nurses), whenever I encounter difficulties in my work.  2.37  1.55  PSS2  I can rely on the shift supervisor (person in charge of a shift) whenever I encounter difficulties in my work.  2.65  1.93  PSS3  The culture in my unit/clinical area makes it easy to speak up about patient safety concerns.  3.21  1.81  PSS4  My colleagues (physicians and/or nurses) react appropriately, when I speak up about my concerns about patient safety.  3.07  1.68  PSS5  My shift supervisors (person in charge of a shift) react appropriately, when I speak up about my patient safety concerns.  2.91  1.80  Encouraging Environment for Speaking up (α = 0.79)  EES1  In my unit/clinical area, I observe others speaking up about their patient safety concerns.  3.34  1.79  EES2  I am encouraged by my colleagues (physicians and/or nurses) to speak up about patient safety concerns.  3.79  2.03  EES3  I am encouraged by my shift supervisor (person in charge during a shift) to speak up about patient safety concerns.  3.71  2.12  Resignation towards Speaking up (α = 0.70)  RES1  Having to remind staff of the same safety rules again and again is frustrating.a  4.05  2.16  RES2  Sometimes I become discouraged because nothing changes after expressing my patient safety concerns.a  3.60  2.09  RES3  When I have concerns regarding patient safety, it is difficult to submit thema  2.86  1.82  aNegatively worded items. Table 4 Means of the speaking up related attitude scales for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN)     Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244      Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244  aMF, managerial function. Table 4 Means of the speaking up related attitude scales for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN)     Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244      Total  MFa  No MF  IM  SU  AN  Physician  Nurse  PSS  Psychological Safety for speaking up  2.84  2.36  2.89  2.71  3.01  2.85  2.58  2.88    P-value    <0.001  0.0156  0.0196  EES  Encouraging environment for speaking up  3.61  3.18  3.60  3.47  3.72  3.73  3.63  3.53    P-value    0.0242  0.0941  0.5335  RES  Resignation toward speaking up  3.50  3.22  3.54  3.23  3.79  3.61  2.88  3.64    P-value    0.0738  <0.001  <0.001    Total climate scale (α = 0.89)  3.68  3.53  3.67  3.66  3.71  3.70  3.70  3.65    P-value    0.1424  0.7307  0.5244  aMF, managerial function. Vignette HCW considered the described situation with the missing hand hygiene as rather realistic in a healthcare setting (VIG1-4). Differences emerged between departments (P < 0.001). The possibility of harm to the patient was considered to be rather low. The self-reported likelihood to speak up towards the consultant was low. There were significant differences between HCW with and without managerial function (P < 0.05). HCW with managerial functions considered the described situation to be less realistic but perceived the danger as being higher (Table 5). Table 5 Means and standard deviations (SD) for the hypothetical situation (vignette) for the total, and stratified by managerial function and for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN) You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  aMF, managerial function. Table 5 Means and standard deviations (SD) for the hypothetical situation (vignette) for the total, and stratified by managerial function and for the departments of Internal Medicine (IM), Surgery (SU) and Anesthesiology (AN) You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  You are on a daily round with several doctors and nurses. During the round, the consultant doctor shakes hands with a patient. However, prior to examining the patient’s wound the consultant does not apply gloves and/or does not disinfect their hands.  Total  MFa  No MF  IM  SU  AN  Physician  Nurse  VIG1  How realistic is this situation? (1 = not at all, 7 = very realistic)  4.84  4.18  4.97  4.38  5.08  5.53  3.69  5.14    P-value    <0.001  <0.001  <0.001  VIG2  If nobody acts, how dangerous do you think this situation is for the patient? (1 = not dangerous at all, 7=very dangerous)  2.44  2.76  2.41  2.41  2.58  2.22  3.15  2.30    P-value    0.048  0.05  <0.001  VIG3  How likely is it that you try to alert the consultant to the missed hand disinfection/gloves (using words or gestures)? (1 = very unlikely, 7 = very likely)  3.11  2.43  3.06  3.17  3.18  2.82  3.02  2.98    P-value    0.006  0.16  0.823  VIG4  Would you feel uncomfortable to instruct the consultant to disinfect their hands/wear gloves? (1 = uncomfortable, 7 = very comfortable)  3.38  2.36  3.39  3.47  3.40  3.13  3.05  3.32    P-value    <0.001  0.29  0.199  aMF, managerial function. Barriers for speaking up The top 3 of the 6 predefined barriers for speaking up were ineffectiveness of speaking up (39.9%), presence of patients or relatives (30.5%) and unpredictability of the actor’s reaction (25.5%). Rankings of barriers differed only marginally between departments (see Fig. 1). Figure 1 View largeDownload slide Frequency of barriers for the units of surgery (SU), internal medicine (IM) and anaesthesiology (AN) Figure 1 View largeDownload slide Frequency of barriers for the units of surgery (SU), internal medicine (IM) and anaesthesiology (AN) Discussion This study is the first to report speaking up behaviors and climate for a tertiary university hospital in Austria using the validated SUPS-Q. At a university hospital, the diversity of disciplines is high, nevertheless, within this study we focused on three main disciplines, namely, surgical and anesthesiological disciplines including intensive care units and internal medicine. In general, surgical disciplines are known as high risk areas, where the ability of speaking up behaviors is very important. HCW of these disciplines spend most of their time working together as teams in the OR [16–19]. On the other side, it was part of the research question, if a non-surgical discipline perceives speaking up behaviors in the same manner or not. Furthermore, these three departments represented nearly one-third of all HCW within our university hospital and are, therefore, an important sample for our university hospital. Results showed that more than half of HCW perceived specific concerns about patient safety at least once and up to 42% of HCW remained silent and did not speak up in a critical situation during the last 4 weeks. Moderate perceived concerns were in conflict with frequent speaking up behaviors during the last 4 weeks. Also, HCW considered the described vignette to be a realistic scenario in a healthcare setting; however, possible harm and their consequences for patients seem to be rather underestimated. It was likelihood that nurses would withhold their voice more often than physicians and would not make aware of the missing disinfection as described in the vignette. Overall, the psychological safety for speaking up was rather low. Concerning speaking up behaviors at scales score level, it was obvious that overall there were rarely concerns about patient safety aspects even though 69% of HCW had at least once a specific concern in the past 4 weeks, 57% had observed an error and 58% noticed HCW who had ignored a patient safety rule. Between HCW professions there were no differences, however, physicians had slightly more perceived concerns than nurses as well as had HCW with managerial function. This finding stands in contrast to previously published results [22, 25]. However, HCW of surgical and anaesthesiological disciplines perceived concerns more frequently. Reasons for this could be that especially surgical and anaesthesiological HCW developed a differentiated perception of patient safety relevant aspects due to the introduction of the surgical safety checklist. Though surgical and anaesthesiological HCW had more patient safety concerns they also significantly kept more often silent than HCW of non-surgical disciplines. This could be an indicator of hierarchical barriers which are known to be high in surgical disciplines [16]. There was a certain inconsistency as rare concerns were in conflict with frequent speaking up behaviors in recent 4 weeks. Nearly, 100% reported having spoken up and HCW without managerial function spoke up significantly more often than HCW with a managerial function, in line with previous research [22]. Though according to self-report HCW frequently speak up, they also mentioned ineffectiveness, the presence of patients or relatives and unpredictability of the reaction of the person causing concern as common barriers to speaking up. The inconsistent results of the survey may be explained by HCW giving a socially desirable response. One reason for this might be that HCW do not want to be perceived as not supporting patient safety as required by the management. In general, psychological safety is a prerequisite for a speaking up culture. According to Nembhard [26], psychological safety is positively associated with professional status in healthcare which is a key antecedent of speaking up. However, our survey results indicated that psychological safety was significantly lower for HCW with a managerial function and higher for nurses, which contrasts theory and previous empirical results. The psychological safety was rather low, also from this point of view commonly reported speaking up is surprising in this survey. Also, HCW with managerial function perceive the environment as less encouraging. For all three scales, psychological safety, encouraging environment and resignation to speak up, results can be interpreted as neither obstructive nor beneficial and were also not comparable to previously published data [22]. Why the psychological safety was low remains unclear, considering that the management strongly supports HCW in terms of patient safety. These results clearly show that a paradigm shift is needed to increase speaking up culture. It also needs further investigations to find out the reasons and to be able to counteract in the near future. The vignette was considered to be a realistic scenario. However, nurses thought that the vignette was more realistic, and—surprisingly—they considered the risk for the patient to be lower. In previous studies, the vignette scored twice as much with regard to the dangerousness of the scenario compared with our study [22]. Respondents were also relatively unlikely to instruct the senior physician regarding the missing hand disinfection, i.e. to speak up. The lower risk assessment by nurses compared with physicians was also very unlikely. As perceived risk for patient harm is one of the key determinants of speaking up, our results are consistent that a low perceived risk is correlated with low likelihood to speak up [7, 13, 25]. The transferability of our results to non-university hospitals is unclear. In general, withholding safety concerns is a common phenomenon in many acute care settings [12]. However, a few factors indicate that speaking up is more difficult and therefore less frequent among staff of university hospitals: First, hierarchy and authority gradients are often steeper in teaching settings. In a survey in the USA, most medical students were willing to speak up to other students about poor hand hygiene practices but only few would speak up towards consultants [27]. Second, recent research suggests that knowing colleagues well and thus being able to predict their reaction towards one speaking up is an important facilitator of speaking up [11]. In university hospitals residents rotate quite frequently between clinical units making it hard for nurses in particular to speak up towards them. Again, this would suggest that speaking up is less likely among staff of university hospitals settings. This study has several strengths and limitations. First, a major strength is that in contrast to surveys performed in the past, we decided to use a traditional paper–pencil questionnaire in order to increase the response rate. Compared with 20% return rates acquired by using online questionnaires the return rate within this study improved significantly. Possible reasons for this are diverse, however, the most plausible explanation is that emails with an invitation to an online survey are deleted relatively easily and that HCW have concerns about secure data management and the traceability of online surveys. Secondly, it is the first study assessing speaking up behaviors in Austria and results gave a valuable insight into behavioral patterns of HCW at an Austrian hospital. A major limitation of this survey was that the results indicate that HCW may have responded in a socially desirable pattern. However, it is also possible that the scales of concern were understood differently than intended. Furthermore, this study was performed in a university hospital setting, therefore, it is questionable, how results are transferable to non-university hospitals. To conclude, speaking up behavior was assessed in Austria for the first time, using the validated questionnaire. Moderate perceived concerns were in conflict with frequent speaking up behaviors in the recent 4 weeks. Results suggest that HCW gave a socially desirable response. While speak up related climate was rated rather moderate, respondents reported frequent speak up behaviors. Surprisingly, psychological safety was not positively associated with professional status in healthcare. These results support further investments into research on patient and employee safety within our university hospital. Further into deep investments are needed to identify why HCW with managerial function perceive the environment as less encouraging and why socially desirable response was most common. The vignette also showed that even more investments are needed throughout training by hygiene experts to increase awareness concerning hand hygiene aspects. Acknowledgements The authors wish to express their gratitude to all HCWs for their willingness of study participation. 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For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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International Journal for Quality in Health CareOxford University Press

Published: Apr 26, 2018

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