Original Research
Policy, Quality, and Practice Management
February 3, 2021

Radiology Trainees' Perceptions of Speaking up Culture Related to Safety and Unprofessional Behavior in Their Work Environments

Abstract

OBJECTIVE. The purpose of this study was to compare radiology trainees' perceptions of the culture regarding speaking up about patient safety and unprofessional behavior in the clinical environment and to assess the likelihood that they will speak up in the presence of a medical hierarchy.
MATERIALS AND METHODS. The study included radiology trainees from nine hospitals who attended a communication workshop. Trainees completed questionnaires assessing their perceptions of the support provided by their clinical environment regarding speaking up about patient safety and unprofessional behavior. We also queried their likelihood of speaking up within a team hierarchy about an error presented in a hypothetical clinical vignette.
RESULTS. Of 61 participants, 58 (95%) completed questionnaires. Of these 58 participants, 84% felt encouraged by colleagues to speak up about safety concerns, and 57% felt encouraged to speak up about unprofessional behavior (p < .001). Moreover, 17% and 34% thought speaking up about safety concerns and unprofessional behavior, respectively, was difficult (p < .02). Trainees were less likely to agree that speaking up about unprofessional behavior (compared with speaking up about safety concerns) resulted in meaningful change (66% vs 95%; p < .001). In a vignette describing a sterile technique error, respondents were less likely to speak up to an attending radiologist (48%) versus a nurse, intern, or resident (79%, 84%, and 81%, respectively; p < .001). Significant predictors of the likelihood of trainees speaking up to an attending radiologist included perceived potential for patient harm as a result of the error (odds ratio [OR], 6.7; p < .001), perceptions of safety culture in the clinical environment (OR, 5.0; p = .03), and race or ethnicity (OR, 3.1; p = .03).
CONCLUSION. Radiology trainees indicate gaps in workplace cultures regarding speaking up, particularly concerning unprofessional behavior and team hierarchy.
Employees' ability to speak up—to communicate candidly with workplace leaders about their concerns—improves employee performance, satisfaction, retention, productivity, innovation, and growth [1, 2]. Similarly, quality and safety experts in medicine stress that open communication (speaking up) about traditional safety concerns (such as hand-washing) and unprofessional behavior (such as disrespectful or inappropriate language) within health care systems is essential to building robust safety cultures and optimizing outcomes [3]. Patient safety leaders in radiology likewise recognize how organizational culture influences radiologic performance and outcomes [46]. They specifically emphasize the importance of healthy teamwork dynamics and respectful communication across hierarchies wherein individuals are encouraged to speak up when they have concerns about observed safety breaches or unprofessional behaviors that may compromise safety.
The extent to which health care employees feel empowered to speak up about safety breaches and unprofessional behavior in their workplace is increasingly recognized as an important part of safety culture, and specific survey instruments assessing this topic have been validated [7, 8]. Studies using these instruments have reported that substantial constraints to speaking up persist within health care, but little is known about the experiences and attitudes of radiologists regarding speaking up [3, 7, 9]. One study from 2018 explored the culture of speaking up about safety events within a large academic radiology department and reported substantial barriers to reporting safety issues, largely due to the hierarchic environment of the department [10]. To our knowledge, no other studies of the culture of speaking up within radiology have been published. Therefore, several key questions remain, such as whether similar conditions exist across institutions, how such conditions affect radiology trainees in particular, whether safety event severity affects the likelihood of speaking up, and whether similar experiences and attitudes regarding, for example, hierarchy affect individuals' willingness to speak up about traditional safety concerns (such as nonsterile technique) and unprofessional behavior in radiology. This latter gap is particularly important given the links between cultures of respect and safety and between disrespectful or unsafe behaviors and malpractice [1115].
To address these issues further, we used instrument domains previously validated for medical and surgical trainees to survey a cohort of radiology trainees from nine training programs [7]. Our specific objectives were to understand radiology trainees' perceptions of the cultures in their work environments regarding speaking up about safety concerns and unprofessional behavior, to assess their anticipated likelihood of speaking up about a medical error to different team members within the medical hierarchy, and to examine factors associated with the anticipated likelihood of speaking up, including respondents' perceptions of the culture regarding speaking up, the perceived potential for patient harm associated with the error, and demographic characteristics.

Materials and Methods

Questionnaires

We surveyed 61 radiology residents and fellows from nine different academic hospital-based training programs in New England who attended one of six daylong communication training workshops held between 2013 and 2017 at Boston Children's Hospital (Program to Enhance Relational and Communication Skills for Radiologists). The workshop, which has been described previously [16], included both general communication training and specific training on error disclosure and radiation risks.
Participants completed a paper questionnaire just before the workshop. We used items from previously validated scales assessing internal medicine and surgery trainees' self-reported perceptions of workplace climates regarding speaking up about traditional safety concerns and unprofessional behavior [3, 7]. Specifically, we asked participants about their perceptions of support for speaking up about traditional patient safety concerns and unprofessional behavior within their clinical environments. Questionnaire items are presented in Table 1. We also provided participants with a previously published hypothetical vignette, adapted for radiology, in which a clinician inadvertently breaches sterile technique during an imaging-guided central line placement [3] (Appendix 1). We assessed the likelihood that trainees would speak up about the error to an attending radiologist versus a nurse, resident, or intern and their perception of the potential for patient harm resulting from the error.
TABLE 1: Perceptions of the Cultures Regarding Speaking up About Safety Concerns Versus Unprofessional Behavior Among 58 Trainees
ItemNo. (%) of Trainees Who AgreeOdds Ratiop
Colleague encouragement 4.12< .001
 I am encouraged by my colleagues to speak up about traditional patient safety concerns49 (84)  
 I am encouraged by my colleagues to speak up about unprofessional behavior33 (57)  
Difficulty speaking up 0.40.02
 In my clinical area, it is difficult to speak up if I have traditional patient safety concerns10 (17)  
 In my clinical area, it is difficult to speak up if I observe unprofessional behavior20 (34)  
Meaningful change 9.65< .001
 Speaking up about traditional patient safety concerns results in meaningful change in my clinical area55 (95)  
 Speaking up about unprofessional behavior results in meaningful change in my clinical area38 (66)  
Clinical culture 3.37< .001
 The culture in my clinical area makes it easy to speak up about traditional patient safety concerns that do not involve me or my patients44 (76)  
 The culture in my clinical area makes it easy to speak up about unprofessional behavior that does not involve me or my patients28 (48)  
Observe others speaking up 4.15< .001
 In my clinical area, I observe others speaking up about traditional patient safety concerns even if they are not directly involved in the patient's care44 (76)  
 In my clinical area, I observe others speaking up about unprofessional behavior even if they are not directly involved in the patient's care25 (43)  

Note—Data were recorded on a 5-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). For the purposes of analysis, these scores were dichotomized as 0 for values less than 4 and 1 for values of 4 or higher.

Statistical Analysis

We used the McNemar test to compare respondents' perceptions of support within their work environment for speaking up about safety concerns versus unprofessional behavior. For each questionnaire item, 5-point Likert scale variables (where 1 = strongly disagree and 5 = strongly agree) were dichotomized to 0 for values less than 4 and 1 for values of 4 or greater. Thus, the probability being estimated was agreement (agree or strongly agree). A binary summary measure was calculated to assess respondents' overall perception of the culture regarding speaking up about safety in their work environment. A value of 1 was assigned if their responses to at least four of the five dichotomized safety culture questions were 1 (i.e., agree or strongly agree), and a value of 0 was assigned otherwise (value assignments were reversed for one item querying whether respondents found it difficult to speak up). A binary summary measure was similarly calculated for their perception of the culture regarding speaking up about unprofessional behavior.
For the 232 binary scores (58 × 4), we used correlated logistic models to assess respondents' willingness to speak up to clinicians of varying hierarchy rankings about the mistake presented in the vignette and to assess other factors associated with this likelihood, including respondents' perceptions of the culture regarding speaking up about safety, the perceived potential for patient harm associated with the error in the vignette, and respondent demographics.
The outcome variable for the logistic models was the dichotomized speak-up response (1 = highly likely, 0 = not highly likely). The primary predictor of interest was clinician type, a categoric factor with four levels (attending radiologist, intern, nurse, or resident). Other predictors were binary: the perceived potential for patient harm (high vs low), perceptions of the culture regarding speaking up about safety in respondents' work environments (positive vs negative), sex, clinical experience (0 = less than 5 years vs 1 = 5 years or more), age (0 = under 30 years old vs 1 = 30 years old or more), and two binary ethnicity variables (White vs Other, Asian vs Other), which simplified to the single binary variables for White (White, Other) following variable selection. Race and ethnicity were dichotomized as White versus Other for purposes of statistical analysis given the distribution of these characteristics in the study sample. In addition to clinician type, other predictors for the logistic model were selected using a variant of the stepwise selection method. Candidate predictors were selected if they were significant at the 10% level as individual factors. Those not significant at the 10% level in the context of the overall model were subsequently discarded in a sequential fashion. The remaining predictors were deemed significant if their p values were less than 5%.
All statistical analyses were performed using the FREQ and GENMOD procedures of the SAS/STAT software (version 14.1, SAS Institute) [1]. Tests were two sided and set at the 5% significance level. Logistic models were estimated via generalized estimating equation methods using an exchangeable working correlation structure. The estimated variance matrix for the vector of parameter estimates was based on the sandwich method.
This study was granted an exemption by the Boston Children's Hospital Committee on Clinical Investigation (institutional review board).

Results

Of 61 study participants, 54 (89%) fully completed the surveys, and four (7%) were missing a total of five data points: three for race or ethnicity, one for sex, and one for potential for patient harm. We imputed these missing data points using a multinomial model. Therefore, our analysis was based on 58 of the 61 participants (95%). Demographic characteristics are presented in Table 2. There were no African American participants, and we did not include a separate category for Latinx participants.
TABLE 2: Respondent Demographics
Demographic VariableNo. (%)
Sex 
 Male33 (57)
 Female25 (43)
Race or ethnicity 
 White38 (66)
 Asian14 (24)
 Multiracial2 (3)
 Unspecified4 (7)
Age (y) 
 ≥ 3045 (78)
 < 3013 (22)
Clinical experience (y) 
 ≥ 533 (57)
 < 525 (43)

Perceived Support for Speaking up About Safety and Unprofessional Behavior

Table 1 depicts trainees' perceptions of support within their clinical environments for speaking up about traditional patient safety concerns and unprofessional behavior. According to the binary summary measures of respondents' overall perceptions, 45 of the 58 radiology trainees (78%) had positive perceptions regarding speaking up about safety, but only 38% had positive perceptions regarding speaking up about unprofessional behavior. In each of the five scale items, participants reported significantly less support for speaking up about unprofessional behavior than for speaking up about safety (p < .02).

Speaking up About a Medical Error Within a Clinical Hierarchy

Table 3 shows the variables associated with the likelihood of participants speaking up about the error in the hypothetical vignette. Respondents were significantly less likely to speak up to an attending radiologist (48%) compared with a nurse, intern, or resident (79%, 84%, and 81%, respectively; p < .001). The odds of speaking up to any nonattending clinician were 7.9 times higher than the odds of speaking up to an attending radiologist. Nonattending clinicians were considered as a group because their pairwise differences were not significant (p > .20).
TABLE 3: Predictors Affecting the Odds of Speaking up About a Medical Error in the Hypothetical Vignette
PredictorOdds 1Odds 0Odds Ratio95% CIpa
Nonattending clinician (1) vs attending radiologist (0)5.10.67.93.7–17.3< .001
High (1) vs low (0) potential for patient harm7.81.26.72.4–18.6< .001
Positive (1) vs negative (0) perception of safety culture in work environment6.81.45.01.7–14.6.003
White (1) vs Otherb (0) trainee5.31.73.11.1–8.5.03
a
The p value corresponds to a test of null hypothesis (odds ratio = 1).
b
Race and ethnicity were dichotomized as White versus Other for purposes of statistical analysis given the distribution of these characteristics in the study sample.
Of the 58 radiology trainees, 21 (36%) believed the vignette error had a high potential for patient harm, and 11% expressed hesitancy to speak up about the error. Significant predictors of the likelihood of speaking up to an attending radiologist included respondents' perception of the potential for patient harm, their perceptions of the safety culture in their environments, and their race or ethnicity (Table 3).

Discussion

Our study of radiology trainees from nine different training programs suggests that trainees perceive gaps related to speaking up in their clinical environments, especially related to unprofessional behavior. These findings are similar to those of Martinez et al. [3], who used the same five-item instrument to study a large geographically diverse cohort of medical and surgical residents and found lower self-reported rates of speaking up about unprofessional behavior compared with safety concerns. These findings are notable because unprofessional behavior has been linked to poor team performance and patient outcomes in medicine [1315, 1720].
Another notable finding in our study was the effect of hierarchy in attenuating trainees' willingness to speak up. Our respondents' reticence regarding speaking up to an attending radiologist, even when they perceived the potential for patient harm, is similar to what has been reported for medical and surgical trainees [3]. The results from our multiinstitutional radiology trainee cohort are consistent with those of Siewert et al. [10], who reported that authority gradients inhibited employees' willingness to speak up about safety within a single large academic radiology department. Together, these studies indicate that a complex web of hierarchic barriers preventing radiology department employees from speaking up about safety is common across institutions. Moreover, these studies place radiology squarely within a ubiquitous cultural milieu in which clinical personnel broadly perceive themselves as restricted in communicating about safety concerns across authority gradients [3, 21].
Subordinates' perception of their constricted power to speak up about safety concerns is a recognized health care safety liability [6, 21]. In our study, workplace culture appeared to play an important function in encouraging or suppressing speaking-up behavior among radiology trainees, which is consistent with findings among other clinical cohorts [6]. Our findings further reinforce that cultures in which such behavior is encouraged represent safer environments not only for patient care but also for trainee well-being, because these cultures provide psychologically safe environments for individuals who are vulnerable within a hierarchy [21, 22]. Psychologically unsafe environments that inhibit speaking up may contribute to emotional duress, moral distress, and burnout [3, 2224]. In this regard, the fact that respondents who are not White were less likely than White respondents to speak up about the sterile technique breach in the vignette is concerning. This finding merits further study with larger and more diverse cohorts given other research reporting that trainees from populations underrepresented in medicine experience a heightened sense of alienation, fears of repercussions, and perceived pressure to adhere to medical cultural norms [22].
Overall, our data add to a burgeoning realization within medicine and radiology that systemic remedies are necessary to establish healthier professional cultures for speaking up about both safety concerns and unprofessional behavior [6, 19, 25, 26]. A first step may involve raising leadership awareness of the problematic effects on patient care and provider well-being resulting from clinical environments that do not support healthy teamwork and safety cultures [27]. Leadership acceptance of the problem may foster ownership of the solutions [28, 29]. Once leaders accept the premise, concerted processes can be established to identify, evaluate, and address various barriers to employee engagement in speaking up about reasonable concerns that cross hierarchic boundaries [19, 29]. Some organizations have used simulation-based and team-building exercises to help both leaders and subordinates acquire the requisite comfort and skills to discuss concerns about safety and unprofessional behavior respectfully and constructively [19, 21, 26]. Educational interventions, such as the Agency for Healthcare Research and Quality's Team Strategies and Tools to Enhance Performance and Patient Safety program and two-challenge rule assertiveness training, have been adapted for medicine from military and airline industry initiatives developed to enhance speaking up for safety in their respective environments [26, 30, 31]. Even the provision of such training may signal an institutional cultural priority across authority gradients to modify behavior without additional interventions. This cultural priority would be reinforced by implementation of supportive education-based peer learning mechanisms that frame mistakes as valuable group opportunities to enhance performance quality [3234]. Of course, institutional leaders must model optimal behaviors if they want to institute meaningful adoption of certain cultural norms [28, 29]. Multipronged interventions will likely be needed, because data suggest that training alone may not be enough to promote speaking up [35]. Other recommendations from the business literature include creating alternative mechanisms or forums for expressing concerns, focusing on inclusion of diverse voices, and establishing settings outside of formal team or group meetings, where hierarchy may preclude candor [2, 28]. Anonymous online reporting systems may also empower individuals to voice concerns when they otherwise feel unable to do so [3, 6, 12]. A comprehensive categorization of barriers to speaking up about safety has been proposed for radiology and, together with our findings (which add concerns related to unprofessional behavior), can serve as a springboard for future research and interventions in radiology departments seeking to enhance their cultures regarding speaking up [6].
One strength of our study is that we surveyed a sample of trainees from multiple institutions. To our knowledge, our study, though modest in size, is the largest study of culture regarding speaking up among radiology trainees. Our findings also build on existing literature because they include assessment of residents' experiences with and attitudes toward speaking up about unprofessional behavior in addition to more traditional safety concerns.
However, our study does have limitations. We used survey instruments that have undergone psychometric validation in other cohorts of medical trainees, but the survey questions have not been validated specifically for radiology. We did not specify the nature of the unprofessional behavior mentioned in the questions. Respondents may have had varying definitions of un-professional behavior and the harms associated with it. Additionally, what trainees perceive as unprofessional behavior may vary by context and how questions are framed [36]. Unprofessional behavior may take many forms, from blatant misconduct and harassment to more subtle forms of incivility, unreasonableness, bullying, and disrespect [19]. Such behaviors have been described in the radiology literature, although their prevalence and related harms remain unknown [16, 37]. The survey was performed within the context of an educational workshop, which may have artificially inflated response rates and resulted in social or compliance bias, although surveys were administered before any specific educational content.
Additionally, the vignette about patient safety that we used in our questionnaire was hypothetical. Although it is closely adapted from a vignette that was previously validated as a tool for assessing self-reported speaking-up behavior, it may not reflect actual behavior or events. We did not use a corresponding comparison vignette that illustrated unprofessional behavior. Our survey items were selected as a series of trade-offs to explore key safety-related issues in radiology while also maintaining a survey short enough for feasible implementation in our teaching framework. Accordingly, we were unable to assess the odds of speaking up about unprofessional behavior, although this does not undermine our direct findings of trainees' perceptions of cultures regarding safety compared with unprofessional behavior.
We do not know whether the frequency of trainees witnessing errors is associated with their willingness to speak up. Few studies are available on this particular question, which merits future study. In general, institutions that encourage transparency with patients regarding errors have reported improved internal communication about errors, which supports the idea that awareness and communication are linked within healthy systems [38].
Our small survey population precluded sufficiently powered assessment of differences among the nine programs represented. Further, there were no African American participants, and we did not include a separate category for Latinx participants. Further work would include a more comprehensive national survey of culture regarding speaking up about safety and unprofessional behavior in radiology that captures actual clinical events among a diverse cohort. An ideal instrument would use survey questions validated specifically for radiology and would assess concordance in perception among respondents from the same programs. Optimally, the instruments published for other medical specialties and the survey developed by Siewert et al. [10] would be combined. Such instruments could then be used over time, and after targeted interventions, to assess improvements in radiology cultures regarding speaking up.

Conclusion

Our survey of radiology trainees from multiple programs shows gaps in perceived support for speaking up and suggests that trainees are more likely to speak up about patient safety concerns than about unprofessional behavior in the workplace. Trainees are particularly reluctant to speak up to an attending radiologist, even when the risk of patient harm is considered to be high. Trainees who are not White are less likely to speak up, even when patient safety is a concern, which has implications for patient care as efforts to create diversity in the workforce continue. The overall finding that residents are more likely to speak up for safety than for unprofessional behavior has interesting implications for organizational culture in radiology. Given the barriers to speaking up related to authority-based gradients in medical facilities, system-based solutions are needed to promote healthier team environments and ultimately safer care.

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APPENDIX 1: Hypothetical Vignette

Please review the following hypothetical scenario and answer the follow questions. Please respond to each case as though you were in your usual role.
You are working in the radiology suite when a clinician comes in to place a central catheter on the patient under radiographic guidance. The clinician sets up the supplies and prepares the patient. The clinician puts on a sterile gown and gloves. The clinician then accidentally places a gloved hand on a nonsterile part of the ultrasound machine and proceeds to grab the catheter, preparing to place the line.
Q. How inclined would you be to speak up about the breach in sterile technique if the clinician was a(n): (1–5, not at all likely–completely likely)
a.
Nurse?
b.
Intern?
c.
Resident?
d.
Attending?
Q. What is the potential for harm to the patient in this situation? (1–5, very low–very high)

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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 1081 - 1087
PubMed: 33534622

History

Submitted: January 16, 2020
Revision requested: February 21, 2020
Revision received: May 8, 2020
Accepted: May 29, 2020
Version of record online: February 3, 2021

Keywords

  1. organizational culture
  2. patient safety
  3. professionalism
  4. radiology
  5. speaking up

Authors

Affiliations

Donna Luff, PhD
Department of Anesthesia, Critical Care Medicine, and Pain Medicine, Boston Children's Hospital, Boston, MA
Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA
Melissa O'Donnell, BA
Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA
Patrick R. Johnston, MMath, MSc
Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115
William Martinez, MD, MS
Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
Priscilla Slanetz, MD
Department of Radiology, Boston Medical Center, Boston, MA
Sigall K. Bell, MD
Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Stephen D. Brown, MD
Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA
Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115

Notes

Address correspondence to S. D. Brown ([email protected]).
The authors declare that they have no disclosures relevant to the subject matter of this article.

Funding Information

Supported by the Arnold P. Gold Foundation for Humanism in Medicine (S. K. Bell).

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