Predicting Likelihood of Speaking up In Labor & Delivery
- Briefly describe the evidence on the importance of effective communication in maintaining perinatal safety.
- Discuss the basic methods used to develop the likelihood of speaking up scale and perception of harm scale for this research study.
- Identify the clinical implications of differences in risk perception among perinatal health care providers.
Clinician silence and ineffective communication can undermine patient safety and contribute to poor maternal and neonatal outcomes. “Assertive communication” is described as a central component of perinatal patient safety, yet little is known about clinicians’ use of assertive communication to voice safety concerns. We propose that speaking up about concerns is a complex social process. We hypothesize that clinician voice is promoted by personality traits of bravery and assertiveness and inhibited by disruptive behaviors, fatigue, work stress, and lower perceived status in the organizational hierarchy. Based on this framework, we report the development and testing of a measurement of speaking up in Labor & Delivery, and efforts to identify predictors of clinician voice.
Design:
Cross-sectional survey.
Setting:
Two labor and delivery units in the western United States with annual volumes of 1800 and 2800 births.
Patients/Participants:
We distributed the survey to all registered nurses and obstetricians practicing in the two units. Response rate was 54%; 43% of 77 possible physicians and 53% of 153 possible registered nurses returned surveys. Respondents were predominantly female, white, experienced clinicians working at least 80% time.
Methods:
We developed and pre-tested a scenario-based measure of clinician’s perception of harm and likelihood of speaking up in response to perceived harm. We embedded this scale in a survey with other measures of safety climate, teamwork climate, disruptive behavior, work stress, and personality traits of bravery and assertiveness. Analysis included descriptive statistics, tests of bivariate relationships, evaluation of internal consistency, and assessment of item-level associations. We modeled relationships between predictors and likelihood of speaking up using linear regression.
Results:
Higher perception of harm, respondent role, and specialty experience predicted likelihood of speaking up when controlling for bravery and assertiveness. Physicians and nurses differed in rating potential for harm in common clinical scenarios (15.3 vs. 17.6 on 4-20 scale; p<0.001). Some (12%) indicated they were unlikely to speak up despite perceiving a high potential for harm in certain situations.
Conclusion/Implications for nursing practice:
This exploratory study into predictors of speaking up found that clinicians’ risk perception is one important predictor. This finding may partially explain the persistent discrepancy between physicians and nurses in teamwork perceptions reported in safety culture surveys. Results from this study have implications for patient safety in labor and delivery practice. Differing perceptions of risks inherent in everyday practice may be a critical new target for teamwork intervention in maternity care.
Keywords: Patient safety; communication; teamwork
