Where are we now? Contribution of the Paper to Clinical Practice and What it says about me as a Researcher?

The impact that this article has made in the medical literature could be gauged by the fact that it has been cited 28 times. The Altmetric Attention score is 34 based on it being mentioned by 1 news outlet, in 1 blog and been mentioned on Twitter 27 times. There has also been engagement with this article 40 times on Mendeley. The impact factor of the Journal of Anaesthesia is 5.8 (2018-2019). This journal was chosen as it is read on a regular basis by consultant and trainee anaesthetists who are working in hospitals in the United Kingdom. The Journal is also circulated to members of the Association of Anaesthetists of Great Britain and Ireland. Two citations of this article were to develop my own work:

Jones CP, Fawker-Corbett J, Groom P, Morton B, Lister C, Mercer SJ. Human Factors in Preventing Complications in Anaesthesia. Anaesthesia 2018; 73(S1): 12-24

Mercer SJ. Team-working, communication and use of communication aids and checklists (Book Chapter) Section 2 - The impact of human factors in clinical practice in Decision-Making and Simulation in Obstetric Anaesthesia. Cambridge University Press. 2019 Chapter 8 Pg 45-51.

The articles listed in Table 2.2 have also cited this publication (I have only listed articles published in English). Of note, it is a particularly pleasing to see that this paper is mentioned in a very recent editorial by Jennifer Weller(81) who I consider to be one of the world anaesthesia leads on patient safety and human factors. Several papers in Table 8 have cited our paper to define Speaking Up .

Table 2.2. Publications citing Beament T, Mercer SJ. Speak Up! Barriers to Challenging Erroneous Decisions of Seniors in Anaesthesia. Anaesthesia 2016; 71: 1332 1340

Paper Summary

Tarrant C, Leslie M, Bion J, Dixon-Woods M.

A qualitative study of speaking out about patient safety concerns in intensive care units

Social Science & Medicine 2017; 193: 8-15

This study reports the outcomes of ethnographic observations and interviews of personnel working in intensive care units in England and focuses on concerns about patient safety and poor practice.

The article concluded that formal reporting or communication training as the solution to giving voice to safety concerns was simplistic and that a more sophisticated understanding of social control was needed. Our work is cited here in the context that the challenging of seniors by trainees or junior members of the team was thought to be a particular issue of concern.

Almghairbi DS, Marufu TC, Moppett IK.

Conflict resolution in anaesthesia:

systematic review. BMJ Simulation and Technology 2019; 5: 1 7.

This is a systematic review that focuses on conflict resolution interventions and strategies and their impact on educational, behavioural and patient-level outcomes. The authors reviewed the concept of speaking up and used the definition in our paper, eaking i h one , and/o o he eam members doubts, differing opinions or potential problems about decision or course of action in medical care hen conducting their literature search. The literature review revealed 3830 records initially and this was narrowed down to 11 eligible studies of which our paper was one of these. Our paper was then excluded at the full text screening stage. The article commented that an environment with and atmosphere of open and clear speaking up was essential and concluded that currently the evidence for training to improve conflict resolution in the clinical environment was sparse.

Martinez W, Lehmann LS, Thomas EJ.

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

BMJ Quality and Safety 2017; 26: 869 880.

This paper reports the results of an anonymous survey of 1800 medical and surgical trainees on their attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Our article is cited as one of a number of articles that describe the factors that influence trainees in speaking up about patient safety threats. The conclusions were that trainees commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential

E Paradis, CR Whitehead. Beyond the lamppost: A proposal for a fourth wave of education for collaboration. Academic Medicine 2018; 93: 1457-1463

This article is a historical review of interprofessional learning described in four aves . Our publication is cited with two other articles in the context that new health care professionals are not thought to be in a position to confront harmful and unsafe professional hierarchies. Another article that I have published was also cited in this publication (68)

Richard A, Pfeiffer Y, Schwappach DDL.

Development and Psychometric Evaluation of the Speaking Up About Patient Safety Questionnaire. Journal of Patient Safety 2017 Aug 28.

This publication investigates speaking up in hospital organisations in Switzerland in the form of a questionnaire. Our article is cited just in the context that barriers to challenging have been investigated in the past.

Schwappach D, Sendlhofer G, Häsler L.

Speaking up behaviors and safety climate in an Austrian University

Hospital. International Journal for Quality in Health Care 2018; 30: 701 707

This publication sought to analyse speaking up behaviour and safety climate in an Austrian University Hospital via a questionnaire and concluded that only moderately frequent concerns were in conflict with frequent speaking up behaviours. Our article was cited whist defining speaking up.

Pattni N, Arzola C, Malavade A.

Challenging authority and speaking up in the operating room environment: a narrative synthesis British Journal of Anaesthesia 2019; 122: 233-244.

This publication is a narrative synthesis which explores the literature on challenging authority in the operating room environment. Articles were identified as either discussion or review articles, observational or qualitative studies, or studies identifying the role of specific barriers or investigating the effect of educational interventions. It was noted that hierarchy, organisational culture and education were most frequent and that simulation studies were important (our study used simulation in part). Our article is a listed publication in the analysis and is cited as a source of qualitative research to offers insight into a trainees perception of hierarch in the operating room and the perceived barriers and enablers to speaking up.

Guris RJD, Duarte SS, Miller CR, et al.

Training novice anaesthesiology trainees to speak up for patient safety. British Journal of Anaesthesia 2019 (In Press)

This publication had the primary aim of testing whether repeated simulation-based practice was of benefit to trainees in enabling them to speak up about patient management concerns. Our article was cited in respect to novice anaesthetists and also that different individuals are more predisposed to speaking out than others. The conclusion was that novice anaesthesia trainees benefited from simulation training to improve intrapersonal factors and communication.

Cooke G, Mitchell B. Silence is golden.

Medical Education 2018; 52: 780 788 This editorial discusses pauses and hesitations in clinical practice in the context of the interactions between trainers and trainees. Our article is cited as hesitancy could be viewed as a feature of a learner about to learn. For learners, operating at the edge of their ability, but not too far beyond it, implies their actions are difficult, and therefore hesitation or uncertainty are features of a learner in the right space to progress. Here, interpreting uncertainty as incompetence, although perhaps correct at that moment, may also result in the missing of a golden opportunity for a teachable moment.

Price Y. Barriers to challenging senior anaesthetists' decisions. Anaesthesia 2017; 72: 272.

This is a correspondence to the editor in response to our article. The author commented that it was disappointing that patients were potentially at risk

due to trainee s reluctance to speak up and challenge senior colleagues. The author suggested that a reluctance to challenge may have been due to a lack confidence in knowledge. They also commented that the cost-risk conceptual model was interesting and should be used in other clinical decisions involving significant patient risk and uncertain management.

Ng GWY, Pun JKH, So EHK, et al. Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses. BMJ Open 2017; 7: e015721

This study uses a questionnaire to explore the perception of issues in ICU communication in Chinese Doctors and Nurses, their reasons for speaking up and the possible factors and strategies to promote speaking up. Our article is cited in the context that indirect speaking strategies by the Chinese to maintain harmony may also be related to the training that they receive on human factors involved in speaking up. It is stated that an inability to challenge authority is often attributed to a lack of training in conflict management. Another abstract that I have published was also cited in this article (82).

Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia 2019, 74, 508 517

This editorial describes safety science in terms of three ages , defined as the age of technolog , the age of human factors and the age of safet management . The authors argue that clinical and organisational work can be made safer by fostering excellence and promoting resilience in addition to talking negative comments. Our article is cited in the context that trainees should be able to raise concerns.

Bringans C. Medicine Needs Medical Student-Scientists: Update on an Old Theory. The New Zealand Medical Student Journal 2017; 25

This article is a discussion on medical students speaking out

Schwappach D, Sendlhofer G, Kamolz L- P, Ko le W, Brunner G. Speaking up culture of medical students within an academic teaching hospital: Need of faculty working in patient safety. PLoS ONE 2019; 14(9): e0222461.

This paper reports a survey amongst medical students using a validated questionnaire. Our paper is quoted to define speaking up . The stud concluded that the more experienced the student the more frequently they reported perceived patient safety concerns or rule violations.

Etherington N, Wu M, Cheng-Boivin O, Larrigan S, Boet S. Interprofessional communication in the operating room: a narrative review to advance research and practice Canadian Journal of Anesthesia 2019; 66: 1251 1260

This paper is a narrative review that outlines the importance of interprofessional communication for surgical patient safety. It also maps the barriers and facilitators to communication and highlights key strategies for enhancing its quality in the operating room. Our paper is cited to emphasise that there are many barriers to speaking up in the operating room (e.g., hierarchy, lack of training, relationships, personality). A research agenda to inform best practices in interprofessional operating room communication has been suggested based on this work.

Weller JM, Long JA. Creating a climate for speaking up. British Journal of

Anaesthesia 2019; 122: 710-713

This is an Editorial in the British Journal of Anaesthesia and provides an overview of the literature on speaking up. The authors reveal an imbalance in efforts to promote speaking up and note that the predominance of studies are actually directed at junior staff. Our paper is cited and

editorial comments that barriers are due to poor communication between senior and junior medical staff, the behaviour of senior staff, the perceived hierarchy in operating theatre teams, and the low status of an individual.

Newsam R. Operating department practitioners and midwives: The

undervalued obstetric care collaboration.

British Journal of Midwifery 2018;

26. https://doi.org/10.12968/bjom.2018.26.

11.714

This is a case study of communication on the labour ward and gives an example of when communication broke down between a junior and senior practitioner.

Novak A. Improving safety through speaking up: An ethical and financial imperative. Journal of Healthcare Risk Management 2019; 39: 19-27

This article describes an initiative at one institution to encourage staff to Speak Up!

Best JA, Kim S. The FIRST Curriculum:

Cultivating Speaking Up Behaviors in the Clinical Learning Environment. The Journal of Continuing Education in Nursing 2019; 50: 355-361

This paper describes an educational program to encourage speaking up. The conclusion is that training improved participants motivations to speak up concerns.

Toy S, Guris RJ, Duarte SS, Dwivedi P.

Development of a scale to measure intrapersonal factors influencing speaking up in the operating room.

Perspectives on Medical Education 2019;

8: 253 260

This paper reported on the development of a scale to measure intrapersonal factors that may

influence speaking up behaviour in the operating room. Our research was cited as one article that identified individual factors as the main barriers to speaking up.

The following individual thesis have also cited this article which demonstrates that my work is now starting to be acknowledged in current research and being further developed.

Ann-Sofie Sundqvist (PhD Thesis)

Title: Perioperative patient advocacy - having the patient's best interests at heart Institution: rebro University

enay Sarmaso lu (Program of Medical Education Master of Science Thesis) Title: Intern doctors likelihood of speaking up for patient safet

Institution: Republic of Turkey Hacettepe University Graduate School of Health Sciences

Jamie White (PhD Thesis)

Title: Empowering medical personnel to challenge through simulation-based training Institution: University of Birmingham

2.2.7 Where this paper places me with reference to being at the forefront of my area