An unspoken doubt: an interval nobody else can see

Review and sources

Not clinically reviewed. No clinician has signed this scenario.

• Pattni N, Arzola C, Malavade A, Varmani S, Krimus L, Friedman Z. Challenging authority and speaking up in the operating room environment: a narrative synthesis. Br J Anaesth. 2019;122(2):233-244. Narrative synthesis of the literature on challenging authority in the operating room, searching Medline, EBM reviews and PsycINFO for terms related to challenging authority, speaking up, communication, patient safety, gradients and hierarchy. The initial search identified 4,822 publications, of which 31 studies were included, grouped by meta-aggregation into discussion and review articles, observational or qualitative studies, and studies of specific barriers or educational interventions. Hierarchy, organisational culture and education were the most frequently observed and tested themes; simulation research successfully elicited and confirmed the role of specific barriers. The authors state that barriers and enablers are largely modifiable within institutions, but that education about the importance of speaking up must accompany those modifications for significant change to occur.
• Toy S, Daly Guris RJ, Duarte SS, Dwivedi P. Development of a scale to measure intrapersonal factors influencing speaking up in the operating room. Perspect Med Educ. 2019;8(4):253-260. Scale development study among postgraduate year 2, 3 and 4 anaesthesiology residents and practising faculty anaesthesiologists at a large quaternary care academic hospital. Exploratory factor analysis indicated a three-factor solution accounting for 73% of the variance: a four-item self-efficacy subscale (Cronbach’s alpha 0.86), and three-item social outcome expectations (alpha 0.86) and assertive attitude (alpha 0.67) subscales. Training level was significantly associated with self-efficacy (p<0.001) and assertive attitude (p<0.001) scores, and multiple ordinal regressions indicated that these intrapersonal factors predicted participants’ likelihood of speaking up in hypothetical scenarios. The authors note the instrument needs validation in other cohorts.
• O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour. BMC Health Serv Res. 2020;20(1):101. Systematic review with narrative synthesis, PROSPERO CRD42018100659, searching PsycINFO, ABI/Inform, Academic Search Complete, PubMed and grey literature. Fourteen interventions were reviewed, falling into five categories: educational interventions using simulation, video presentations, case studies and workshops, and non-educational approaches using holistic facilitation, forum play and action research meetings. Mixed results were found for efficacy or effectiveness; while some interventions showed improvement in outcomes related to psychological safety, speaking up and voice, this was not consistently demonstrated across interventions. The authors attribute this to a lack of objective outcome measures and to the limited ability of educational interventions alone to change deeply rooted speaking-up behaviours, and call for longitudinal and multifaceted interventions.