Identifying factors which impact health staff speaking up about unprofessional behaviours

Introduction: Evidence of the association between patient safety and unprofessional behaviours such as bullying, harassment and incivility has substantially grown. A recent study1 of US surgeons showed that those with more co-worker complaints had patients who experienced significantly higher rates of medical and surgical complications. In the UK, a National Guardian Freedom to Speak up Office has been established to support health staff raise concerns about patient safety. In 2019 over 19,000 cases were reported, 41% of these included elements of bullying and harassment impacting safety.

An important question for health care organisations internationally is what individual and organisational factors enable or inhibit staff to speak up about behaviours which may jeopardise their own or patients’ well-being?

Objective: To identify individual and organisational factors that may enable or inhibit staff to speak up about behaviours which may jeopardise their own or their patients’ well-being.

Methods: All staff at 7 hospitals across 3 Australian states were invited to complete a survey about how often they experienced 26 ‘unprofessional behaviours’ (UB), ranging from mild ‘incivility behaviours’ (e.g. being spoken to rudely) to serious (e.g. physical or sexual assault). Respondents were asked about the impact of these behaviours on their personal wellbeing and patient safety, and whether they had the skills to speak up about UB. Staff were asked about potential organisational factors influencing speaking up including whether they were encouraged to speak up by colleagues; knew the proper channels to raise concerns; were confident that they would be believed and taken seriously if they reported UB; and felt comfortable to speak up about UB. They were also asked whether they thought UB was effectively managed in their hospital and whether they felt that speaking up or reporting UB was likely to have a negative impact on their career.

Logistic regression models were applied to identify factors associated with experiencing UB and with feeling comfortable speaking up about UB.

Results: 5,178 staff completed the survey (response rate 34.0%). Overall, 94.1% (n=4875) of respondents had experienced one or more of 26 unprofessional behaviours in the past 12 months, with 38.8% (n=2009) experiencing ≥1 incivility behaviours weekly or more frequently. Overall, 38.4% (n=1989) indicated that UB had a moderate/major impact on their own wellbeing; 49.8% (n=2580) that UB had a major/moderate impact on any of: patient care, errors or quality of service; and 54.7% (n=2832) reported that UB had a moderate/major negative impact on teamwork.

Modelling factors associated with feeling comfortable to speak up or report UB, we found that, independent of demographics and professional group, positive responses to all items (listed in Figure 1) were associated with a greater likelihood of feeling comfortable to speak up or report UB. The strongest association with the outcome “I feel comfortable to speak up about UB” were for the items “I have the skills to speak up about UB” (OR 4.25) and “I am confident I would be believed and taken seriously if I reported UB” (OR 3.05).

Staff over 54 years, non-clinical and management/administrative staff, and males were more likely to report comfort to speak up compared to the reference groups (Fig 1).

Conclusion: These results identify specific areas that hospitals should target in interventions to increase the likelihood that staff will speak up about UB and reduce safety risks to patients and staff wellbeing. These factors include both individual skill development and organisational cultural factors.

References:
1Cooper WO et al. JAMA Surgery 2019;154:828-34