Dear Editor,
I read with great interest the article by Darawad et al (2020) drawing attention to the perceived structural empowerment of newly qualified nurses and its correlation with speaking-up behaviours. As a medical student at University College London and a recipient of dedicated patient safety teaching, I felt encouraged to reflect on my experiences.
I agree with the authors' conclusions that ‘organisation-wide efforts’ must be adopted in order to empower nurses to assertively challenge unsafe practice. I believe, however, that this issue requires greater emphasis at an earlier stage, in particular during undergraduate training. By enhancing and refining patient safety teaching during training years, I believe that we can form individuals who feel empowered to speak up before and upon entering the profession. Such improvements in education will ultimately improve patient safety, care and outcomes.
As students we are taught the importance of recognising unsafe conditions, reporting errors and near misses, and of raising concerns when patient care or safety is being compromised. This is explained to students as a responsibility and expectation, yet I feel the method of delivery of this core message, largely in lecture-based teaching, is problematic. It renders students unfamiliar with the actual practice of raising concerns and lacking in confidence about how or whether to do so in practice.
Research has identified that students feel uncertain about when to raise a concern and, for numerous reasons, fear doing so (Johnson et al, 2018). Different challenges also affect speaking-up behaviour in students versus more experienced colleagues, indicating that students might require more specific teaching and support (Fagan et al, 2016).
‘Once students overcome the initial fears involved in first practising assertive communication or challenging unsafe behaviour, they are more likely to do so in future practice’
Effective undergraduate teaching should provide opportunities to practise identifying situations that require concerns to be raised, for example through case-based discussion, small group work, role play and simulation. Such strategies allow scenarios to be actively explored and deliberated by students. Teaching should focus on developing important assertive communication skills earlier during training so that we increase confidence in raising concerns in practice.
Once students overcome the initial fears involved in first practising assertive communication or challenging unsafe behaviour, they are more likely to do so in future practice. I hope that this would reduce stress when nurses and doctors do take action, by creating a sense of normality to speaking up.
A memory from my patient safety teaching was an eye-opening account of a personal error in the workplace. I had lasting feelings of empathy for the individual concerned, which was coupled with a drive to replace workplace stigma with acceptance of human mistakes and a resolve to strive for positive change. I found this element of teaching to be especially effective at grasping attention and emphasising the importance of these issues.
I believe that if principles of speaking up and ‘moral courage’ become embedded in individuals early, we can overcome barriers and variation in empowerment due to the organisational factors that Darawad et al noted. In my opinion this would help foster positive attitudes towards speaking up, leading to improvements in patient safety and quality of care.