O R I G I N A L A R T I C LE

The experience of learning to speak up: a narrative inquiry on newly graduated registered nurses Bernice Yee-Shui Law and Engle Angela Chan

Aims and objectives. To explore the process of learning to speak up in practice among newly graduated registered nurses. Background. Speaking up is an important aspect of communication to ensure patient safety within a healthcare team. However, nurses have reported being hesitant about speaking up or being unable to be heard, despite adopting various safety tools. A power differential could be a factor in their hesitation to speak up. While a large number of new graduates are employed in the lower rungs of the hospital hierarchy to resolve local and global nursing shortages, the process of their learning to speak up remains under-explored. Design. The narrative concept of experience is addressed through the threedimensional space of a narrative inquiry. Methods. Eighteen new graduates were recruited. Stories of experiences of speaking up emerged naturally during repeated unstructured interviews and ongoing email conversations with three participants. Results. The complex process of learning to speak up is schematically represented. Three interrelated narrative threads were identified: (1) learning to speak up requires more than one-off training and safety tools, (2) mentoring speaking up in the midst of educative and miseducative experiences and (3) making public spaces safe for telling secret stories. Conclusions. Speaking up requires ongoing mentoring to see new possibilities for sustaining professional identities in the midst of miseducative experiences under the potential shaping of the Chinese culture and generational differences. Appreciative inquiry might be a new approach that can be used to promote positive cultural changes to encourage newly graduated registered nurses to learn to speak up to ensure patient safety. Relevance to clinical practice. Cultivating a safe and open culture of communication and mentoring new graduates to speak up will benefit patient safety now and in the future by helping to retain committed patient advocates who could mentor future generations. Key words: assertiveness, communication, experiential learning, Hong Kong, mentorship, narrative, new graduate nurse, patient safety

What does this article contribute to the wider global clinical community?

• Gives a schematic representation

•

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of the complex process of learning to speak up to guide hospital leaders and educators in mentoring and promoting speaking up and fostering positive cultural changes. Mentoring by others and self-mentoring of new graduates are required in the midst of miseducative experiences to see new possibilities for sustaining their professional identities and continuing to speak up in the future. Highlights the importance of being aware of narrative histories and cultural differences when transplanting successful patient safety programmes to another culture. Provides suggestions on using appreciative inquiry to minimise impositions and encourage co-participation and positive dialogue to facilitate integration of the collective programme goals into practice and to promote positive cultural changes. A new positive meaning of the intention to leave to preserve one’s professional identity as a patient advocate and to continue to speak up, contrary with the common negative conception of the intention to leave and turnover.

Accepted for publication: 26 January 2015 Authors: Bernice Yee-Shui Law, BSN, RN, PhD Candidate, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong; Engle Angela Chan, PhD, RN, Associate Professor and Associate Head, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848, doi: 10.1111/jocn.12805

Correspondence: Bernice Yee-Shui Law, PhD Candidate, School of Nursing, The Hong Kong Polytechnic University, Yuk Choi Road, Hung Hom, Hong Kong. Telephone: +852 27664369. E-mail: [email protected]

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Introduction Communication is integral to ensuring patient safety in the healthcare context. Patients are vulnerable, as their capacity for self-protection is reduced or they have limited knowledge about when they are being exploited (Sellman 2005). Frontline healthcare professionals are therefore well-positioned to report early signs of unsafe conditions in the delivery of healthcare. Speaking up is important in intraand inter-professional communication (Sammer et al. 2010), which is a subject included in the World Health Organization’s (WHO) ‘Multi-professional patient safety curriculum guide’ (WHO 2011). However, nurses have reported feeling unsafe about speaking up or being unable to be heard, despite the administrative emphasis on patient safety and the expectations of professionals to provide safeguards by having many safety tools and checklists (Maxfield et al. 2011). There is disparity between written policies and the actual implementation at the frontline and a power differential is one reason why nurses hesitate to speak up (Okuyama et al. 2014).

Literature review Although various definitions have been adopted by different researchers, in this paper, speaking up is defined as an individual using his/her voice to convey to someone in higher authority specific information that might make a difference to patient safety (Sayre et al. 2012). Okuyama et al. (2014) asserted that various contextual and individual factors, together with the perceived risks and efficacy, affect the deliberate action of whether to speak up for patient safety. Contextual factors include hospital policy, team relationships and the attitudes of leaders. Individual factors encompass job satisfaction, responsibility towards patients, roles as professionals, confidence, communication skills, previous experiences and educational background (Okuyama et al. 2014). Speaking up and being heard generally brings better patient outcomes (Maxfield et al. 2011) and positive consequences to the organisation in terms of decision making, error correction, learning and improvement (Morrison 2011). However, its impact on other colleagues and group harmony are mixed (Morrison 2011). The negative or mixed consequences are related to one’s hesitation to speak up, for instance, repercussions, retribution and stress level (Attree 2007). Different education programmes have been adopted to encourage nurses and other healthcare professionals to speak up on improving team communication and patient safety. The components of these programmes vary from a

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discussion of barriers to speaking up and the use of peer support (Sayre et al. 2012), to interdisciplinary education about crew resources management (CRM) concepts and communication techniques using videos (Johnson & Kimsey 2012) and a simulation-based approach (Stevens et al. 2012). Participants tend to report an increase in their selfefficacy of speaking up. Locally, the Hong Kong Hospital Authority (HA) (2014) has also adopted a similar speaking up programme based on CRM alongside three safety tools (Table 1). CRM was originated from the aviation industry, to reduce human errors and foster a culture of patient safety. However, the evidence of its effectiveness in healthcare in terms of an improved culture of safety is inconclusive with limited validity (Verbeek-van Noord et al. 2014). Also, there is no strong direct evidence to show whether the knowledge gained from these education programmes can be applied in actual practice or whether the voices of those who speak up will be heard by the healthcare team. Speaking up is also an ethic of care that has to be learned and developed over time through experience, and which depends on one’s recognition of salient contextual ethical distinctions in practice (Benner 1991). However, the process by which newly graduated registered nurses (NGRNs) learn to speak up in practice is under-explored, given that a large number of them are employed to resolve global and local nursing shortages. Nevertheless, fostering the process of speaking up and being heard could potentially facilitate the identity formation of nurses, and address the issue of the world-wide nursing shortages by retaining nurses who are passionate about patient safety and quality care. The aim of this article is to explore the process by which NGRNs learn to speak up in practice. This study is part of a larger narrative inquiry undertaken from 2011–2012 to understand the meanings of ‘mentoring’ NGRNs in transition and in the pursuit of good work (Gardner et al. 2001).

Methodology Narrative inquiry is an interpretive and relational inquiry for studying experience as story (Clandinin & Connelly 2000). It is strongly influenced by the Deweyan view of experience, which emphasises the inextricable link between experience and education, and the two principles of continuity and interactions (Dewey 1938). Therefore, Clandinin and Connelly’s (2000) narrative inquiry involves a transactional ontology and evolutionary epistemology within a pragmatic framework and narrative thinking within the three-dimensional space of narrative inquiry (Table 2). Experience that is conducive to growth, not only physical, but intellectual and moral, for instance, a perception of the © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

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Table 1 Components of the CRM programme piloted in Hong Kong Hospital Authority (Hospital Authority 2014) A one-day interdisciplinary classroom-based CRM programme teaching about CRM concepts & three safety tools for nurses, doctors & other allied healthcare professionals of various tenure, seniority & specialties Crew resource Originated from the aviation industry, to reduce human error & foster patient safety culture management (CRM) Emphasised key concepts: communication, teamwork, situational awareness, assertion, problem solving & decision making Modified early warning A bedside clinical scoring system that is based on data derived from four physiological readings score (MEWS) (systolic blood pressure, pulse rate, respiratory rate & temperature) & one observation (level of consciousness) to identify patients at risk of deterioration & urgent need for active intervention & enhance communication between healthcare professionals for safe & effective patient management with excellent outcomes ISBAR A standardised team communication approach, (i.e. identify, situation, background, assessment & recommendation for patient management) to facilitate handover of patient’s conditions in a multi-disciplinary setting in a succinct & concise manner Assertion model 1. Get person’s attention (Make eye contact, face the person & use person’s name) 2. Express concern (Focus on the common goal i.e. patient safety & quality care) 3. State problem clearly & concisely 4. Propose action (Understood by all parties) 5. Reach decision (Escalation by jumping rank if necessary) MEWS is taught to all staff but it is not used in some specialties such as the paediatrics. Table 2 Three-dimensional narrative inquiry space (Clandinin & Connelly 2000) Temporal dimension

Personal-social interaction dimension

Place dimension

No event, person, culture, institution & place exists alone at that moment independent from its past & from its impact on the future. Each is shaped by its narrative history & is shaping its future (Clandinin & Connelly 2000). Experience that is conducive to growth, not only physical, but intellectual & moral (for instance, a perception of the efficacy of speaking up in the future), is an educative experience. Conversely, a miseducative experience is an experience that stops or distorts the growth of further experiences as a result of decreased sensitivity & responsiveness (Dewey 1938) Narrative inquirers not only think inwardly about the personal conditions of both the participants & researcher such as feelings, identities, hopes & moral dispositions, but also think outwardly about social conditions such as the existential conditions, environment & people surrounding the factors & forces that form each individual’s context (Clandinin & Connelly 2000). Therefore, the experience of speaking up is not only shaped by the narrative histories of newly graduated registered nurses with a temporal dimension of their past, present & future, but also shapes & is being shaped by others & their narratives in the clinical landscapes. Narrative inquirers are also aware that the stories told throughout the inquiry are influenced by the participant-researcher relationship, & their interpretations & interactions Refers to the places where both the events & inquiry take place, as each place has an impact on the experience (Clandinin & Connelly 2000)

In thinking narratively within the conceptual framework put forward by Clandinin and Connelly (2000) that guides the entire study, the intention is not to reduce stories to themes or to focus on the microanalysis of language from a socio-linguistic perspective as in other narrative methodologies. Rather, the inquiry space is used with openness to capture the complexity, dynamism, emotionality and particularity of stories of experience, to challenge dominant discourses, and to imagine new possibilities for a better future.

efficacy of speaking up in the future, is an educative experience. Conversely, a miseducative experience is an experience that stops or distorts the growth of further experiences as a result of decreased sensitivity and responsiveness (Dewey 1938). Storytelling is a recommended approach to better understand the moral experiences of nurses. The stories capture concerns, tensions, meanings and feelings that can be examined to better understand the contextual, relational and configurational knowledge lived out in the practice of speaking up (Benner 1991). © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

Study design and participants Four methods of collecting data and four sources of data were employed. Three individual unstructured interviews were conducted with NGRNs at 12, 18 and 24 months after registration to understand the temporal dimension of their transitional experience. This design is also in alignment with the duration of the preceptorship programme in Hong Kong public hospitals (HA 2010) and with the development of practice readiness along the career trajectory (Wolff et al. 2010). Unstructured interviews are likely to produce stories

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that are important to the participants, and to prevent data from being confined by the existing literature and the knowledge of the researchers (Clandinin & Connelly 2000). The NGRNs were also invited to share their ongoing experiences and reflections via email on a voluntary and monthly basis during their personal time and in a comfortable space between interviews. The interviews and email conversations complemented each other and facilitated further in-depth discussions of ongoing experiences and the development of a relationship of trust between the participants and the researcher (Polkinghorne 2007). Document analysis was the third method used. It involved reviewing relevant hospital documents relating to the participants’ stories of their experiences. The focus group interview was the fourth method used. The interviews included four preceptor groups and stakeholder groups (senior nurses, ward managers and doctors), as NGRNs are interacting with others while learning about themselves. In this article, the particular aspect of focus is NGRNs learning to speak up. The aim behind the larger study is to understand the meaning of ‘mentoring’ NGRNs not merely to help them transition into their new role, but for good work in nursing when excellence meets ethics (Gardner et al. 2001), for the well-being of patients and their families. Therefore, the criteria for selecting NGRN participants were those who had been identified as committed to doing good work (Box 1). Snowball sampling was used to recruit participants through referrals from earlier participants (Creswell 2007). The study was approved by the ethics committee of the university with which we are affiliated and those of the hospitals where the participants work. Each participant took part in the study on a voluntary basis and signed an informed consent form. Process consent was obtained before the interviews.

Data collection Each new interview was constantly compared with previously collected data. In the course of the research, 23

Box 1. Inclusion criteria of Newly Graduated Registered Nurse (NGRN) participants (1) 2010 registered nurse graduates employed by the public hospitals of the Hong Kong Hospital Authority. (2) Those recommended by senior nurses or former faculty members, who, based on interactions with them and observations of their performance, recognised their dedication to pursuing good work or delivering high-quality nursing care

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NGRNs were recommended and invited to participate in the study. Eighteen NGRNs from seven public hospitals were recruited. Interviews began with an open-ended question: ‘Tell me about your transition from a nursing student to an RN?’ The NGRN participants took the lead in telling their own stories. Each interview lasted between one–three hours. All of the NGRN participants shared stories of their good work in caring and making a difference in the lives of their patients and their patients’ families, however, not all of these stories involved voicing their thoughts to a higher authority. NGRN participants from the general medical, surgical, orthopaedics and gynaecology units did not share any experiences of speaking up. This might be related to their patients being in better condition to exercise their right to receive treatment that did not endanger their safety (Vaartio & Leino-Kilpi 2005). In contrast, a series of dramatic stories involving incidents in which a patient’s safety was endangered, which demanded extra effort on the part of the NGRNs to speak up, emerged naturally during repeated interviews and email conversations with three NGRNs, Ning, Agnes and Nancy (pseudonyms), who worked in the neuroscience, neonatal intensive care unit (NICU) and special baby care unit, respectively. The occurrence of these incidents might be related to the highly specialised areas in which these nurses worked, where the patients are more vulnerable and less capable of protecting themselves due to age, diseases and difficulties in communicating than the average patient. The stories of these nurses were therefore theoretically relevant to shed light on the process of learning to speak up in practice.

Data analysis The analysis was iterative and on two levels. Details of the procedures involved in the analysis are provided in Table 3. The trustworthiness of the findings was strengthened by method triangulation (individual unstructured interviews, email conversations and document analysis), quotations from the participants, member-checking and prolonged engagement with NGRNs (Polkinghorne 2007). The first author is herself a nurse of seven years, which facilitated the establishment of a trusting participantresearcher relationship and an understanding of the participants’ experiences. Meanwhile, she became aware of her prejudgments and assumptions through reflexivity, constant reflections and regular discussions with the second author.

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

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Table 3 Procedures of the data analysis Data analysis was carried out simultaneously with data collection. The data analysis had two levels & was an iterative process First level of data analysis 1. All audio-recordings of the interviews were transcribed verbatim with all names & identifying information changed to unique codes for protecting identities & ensuring anonymity 2. All collected data, including interview transcripts, email conversations & relevant hospital documents, of increasing volume as the inquiry proceeded were read & reread to gain a holistic understanding of the participants 3. The data were then analysed by thinking narratively & openly within the three-dimensional narrative inquiry space of temporality, sociality & place (Clandinin & Connelly 2000). Thinking along the temporal dimension diverse storied experiences were arranged chronologically. The narrative histories of each storied experience, person & place, & the links between one event & another were examined. In the personal-social interaction dimension, both the personal conditions of the participants & researcher & the social conditions of each storied experience & the process of inquiry were scrutinised. The shaping effects of the stories of individuals, other people in the context, & institution on the storied experience were understood by thinking inwardly & outwardly. For instance, how the hospital stories embodied in the hospital guidelines shaped the experience & practice of newly graduated registered nurses (NGRNs) & their senior colleagues. The shaping effects of the place on the storied experience & process of inquiry were also considered in the place dimension 4. Narrative codings were then used to identify possible plotlines, interconnections, tensions, continuities & discontinuities for each NGRN participant 5. The meanings & significance of each experience in relation to the research questions were continuously scrutinised for writing an account in chronological form in capturing the identified narrative codings, complexity, multiple-layered, dynamism, emotionality & particularity of the storied experience for each NGRN participant 6. Each account was then member checked by each participant to validate the interpretations of the researchers & determine whether their personal identities were adequately camouflaged & there were any changing perspectives across time until agreement was reached Second level of data analysis 7. Chronicled accounts of each NGRN participant were compared & contrasted with each other to search for similarities & differences & therefore the narrative threads that were woven into & across stories of participants 8. The narrative threads were juxtaposed with other data, relevant hospital documents & researcher’s memo to examine if data collected from different data sources by using different methods were pointing towards the same findings for data & method triangulation 9. The iterative process continued until theoretical saturation, which was indicated by adequately explained narrative threads & no new insights are obtained (Strauss & Corbin 1990)

Findings The findings of the first level of data analysis are presented. The interpretations of the researchers are interwoven with the chronicled accounts as an audit trail for illustrating auditability.

Box 2. Ethical consideration of Ning before withholding the prescription Knowing the patient. . .he probably would pull out the tube by himself, and he would then be restrained. But this seems inhumane. Also, are you going to tube feed even if he continues to eat well? (Ning, first interview)

Ning’s story The process of learning to speak up, began as an educative experience for Ning, situated in a context that emphasised following hospital guidelines for patient safety. After the late and rushed doctor round, Ning found a prescription for nasogastric tube insertion troubling. While this patient’s oral intake had recently been poor, it had improved that day. Ning critically evaluated the purposes and consequences of tube insertion by considering both the physiological and moral perspectives of the act with her up-to-date knowledge of her patient (Box 2). However, the busy neurosurgeons had left and no clarification could be made before the end-of-shift handover. Ning was in a state of tension about withholding the prescription and speaking up for her patient. After considering the potential risk of © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

being blamed for not completing her task, Ning made the moral decision to speak up, and prevented the patient from suffering unnecessarily with the understanding and support of her colleagues. Although Ning identified the incident as a ‘trifle’, she felt satisfied, as her action was consistent with her professional identity. ‘Good work in nursing means being patient-oriented and acting in a patient’s best interests.’ The experience was educative, in that it led to personal growth and encouraged Ning and other nurses to speak up to protect patient safety in the future. It also potentially shaped another experience (Box 3). Ning’s patient has bloody incontinence-associated dermatitis (IAD) because of diarrhoea. Though zinc oxide is the

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Y-S Law and AE Chan Box 3. Miseducative experience of speaking up shared by Ning in

Box 4. Document analysis of hospital guidelines on chronic wound

email and interview

management

I was borrowing stomahesive [a powder] from the other unit titis [IAD] because of diarrhoea. My mentor [wound team lea-

No concrete and relevant guidelines on the management of IAD could be found in document analysis, with the exception of the following statement:

der] noticed and disagreed. I restated that zinc oxide [the usual

Use an appropriate dressing that manages exudates to keep the

practice of the unit] can’t be successfully applied on the skin.

pressure sore moist, but prevent maceration of surrounding

“Yes, it doesn’t stick. Just use it. We don’t use stomahesive”

skin

for my patient who has bloody incontinence-associated derma-

my mentor said bluntly without giving her rational. Finally, I borrowed and used stomahesive secretly. The secret story was told to supportive senior colleagues and peers and all healthcare assistants who perform bathing and napkin changing. When I handed over to other unsupportive senior colleagues about the IAD, a cover story was told without mentioning about the stomahesive (Email from Ning and second interview)

usual practice of the unit, it could not be applied on the wound with serous exudate and watery stool. Ning borrowed stomahesive powder from another unit since both zinc oxide and stomahesive are recommended for IAD (Gray 2010). Ning’s use of the stomahesive was part of her practical knowledge in witnessing its effectiveness for IAD as a nursing student and learning from other wound experts. Ironically, the influential figure in her unit, her mentor, insisted on following the usual practice, despite its ineffectiveness even on application. An open discussion between Ning and her mentor on exploring alternatives for the best interests of patient was not encouraged, nor was any rationale given for not using stomahesive. Rather than becoming involved in a direct confrontation with her mentor, Ning made another moral decision in advocating secretly for her patient. The secret story was told to supportive senior colleagues, peers and all healthcare assistants who perform bathing and napkin changing. The wound healed gradually with the use of stomahesive. Ning used to avoid interpersonal conflicts by remaining silent or living secret stories. She was, however, empowered by other supportive seniors and peers to speak up, ironically, not by her mentor. Then, an opportunity arose for her to speak up collectively with other NGRNs in suggesting the use of stomahesive to the ward manager, who agreed to conduct a pilot study. Later, and unexpectedly, the ward manager said that some seniors found that the stomahesive was not good; however, he gave no further explanation. These few words left Ning and other NGRNs confused. They did not understand why the ward manager had changed his mind without examining the effectiveness of the alternative approach, and the opinions of the nurses.

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The ward manager appeared to have an open mind when they spoke up, but failed to cultivate an open space for nurses with different narrative histories and practical knowledge to negotiate in searching for the best way to care for the patients. The document analysis further unveiled how hospital guidelines might have shaped the process of learning to speak up. Having a general hospital guideline on wound management is good, as the intention may be to give nurses the autonomy and resources to apply their practical knowledge. However, it may inadvertently have blocked the voices of NGRNs from being heard. The statement seems too vague (Box 4), which implicitly gives influential figures the power to dictate the practices of NGRNs and impedes their learning to speak up. Ning’s experience is complicated, and cannot simply be classified as miseducative when thinking narratively. The experience is miseducative in the social dimension, and might have made Ning and other NGRNs hesitant about speaking up in the future. Meanwhile, Ning took the initiative to transform this miseducative experience into an educative one in the personal dimension by searching for new possibilities to sustain her professional identity. The new possibilities include her secret use of stomahesive and, later, a request for a clinical rotation. She wanted to sustain her learning and her professional identity in a place where it was possible to speak up for patient safety in public and evidence-based practice (EBP) was not simply rhetoric. The following participant’s story also reflects the point that, for NGRNs, learning to speak up requires recognising and living with conflicting institutional stories of safety told by NGRNs and other stakeholders.

Agnes’s story Agnes emphasises EBP. For her, ‘good work’ means working from the standpoint of a nurse rather than ‘merely following the doctor’s prescriptions’. Her experience of © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

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learning to speak up began from miseducative experiences in the NICU, which had a culture of conformity to the instructions of doctors or senior nurses. Agnes had spoken up and reported the problem of a distended abdomen as an early-warning sign of an intestinal obstruction, but her voice was not listened to by the doctors. She felt powerless to transform her professional identity in practice and make changes (Box 5). These series of experiences are miseducative in that nurses became hesitant about speaking up in the future. The social dimension is also miseducative, as there was no role-model for speaking up. Many nursing colleagues noticed problems of patient safety, but merely chose to gossip in secret rather than to bring the problems to the attention of a higher authority. A further example of the power of hierarchy in hospitals was revealed. A nursing officer (an influential figure in the unit) wrongly scolded Agnes for not using the humidifier with a tracheostomy patient, who already had a thermovent. Despite the scolding, Agnes spoke up for her patient. However, she was ignored. The wrong connection caused harm to the patient, as his oxygen consumption increased 10-fold. An advanced practice nurse (APN) (of same rank as a nursing officer but with a shorter tenure), witnessed the entire exchange, but remained silent. It was not until Agnes was recounting the incident to another NGRN in secret with the absence of the nursing officer that this APN indicated that Agnes’s comment was correct. The connection was finally removed by Agnes’s mentor, also an APN, who spoke up for the patient and Agnes. Focusing on the outcome, the experience seems to have been educative for Agnes in learning to speak up, as her mentor proved to be a good role-model as a patient advocate. At the same time, it was miseducative, as the support of someone in power and authority was required before speaking up was heard. Agnes, who had once been committed to being assertive,

Learning to speak up in practice

experienced a strong sense of powerlessness as an NGRN and her sense of professional identity was shaken. In the midst of miseducative experiences, both mentoring by others and self-reflection empower NGRNs to speak up and reaffirm their shaken professional identities. In another incident, Agnes realised that the prescription contradicted the neonate’s condition, despite clarifying the matter with the junior doctor. Shaped by her past experiences of being ignored, Agnes hesitated to assert herself by going over the junior doctor’s head and seeking further clarification from the senior doctor. Her mentor raised questions that guided her to think critically of the situation and to brave the hospital hierarchy, and reassured her of the correctness of speaking up for patient safety. Agnes also took the initiative to transform miseducative experiences into educative ones. Despite the desirable nurse-to-patient ratio in the NICU, like Ning, she requested a clinical rotation to a place where she would be able to sustain her professional identity.

Nancy’s story Similar to Agnes and Ning, Nancy learned to speak up in the midst of both educative and miseducative experiences,

Box 6. A miseducative experience shared by Nancy in an email A neonate had marginal blood pressure despite observation and re-checking. This could be easily resolved by inserting an arterial line and giving a saline bolus. I informed the group of doctors but they challenged my readings were inaccurate though they have obtained similar results when they measured themselves. Instead of measuring the blood pressure when the neonate was calm, they tapped the neonate’s foot and stimulated crying to achieve a higher and “satisfactory” blood pressure for documentation without other intervention. Surprisingly, the incoming nurses followed the “management” of the doctors for the entire afternoon shift. The conditions of the neonate repre-

Box 5. Miseducative experience shared by Agnes in the first inter-

sented in the documentation appeared to be “stable”, but she

view

was not. The acts of the medical and senior nursing colleagues

Regarding disagreement with the doctor’s prescriptions, nurses merely gossip behind the doctor’s back, while continuing to follow the doctor’s instructions.. . . There were times when you informed the doctors about a distended abdomen, which could indicate an intestinal obstruction, but they didn’t take you seriously. I felt helpless seeing the neonates deteriorate, to the point where they needed surgery, and sad about the limited power of those in my profession to help patients and influence the treatment regime (Agnes, first interview)

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

could not be reflected in the documentation, but were immoral. That night I kept close observation of the neonate and persisted to report the abnormal vital sign to the doctor. The neonate was finally stabilised late until midnight after the saline bolus was administered. The incident triggered me to reflect on the importance of conscience in nursing and meanings of documentation. Since then, I am more thoughtful in using the documentation for revealing the actual needs of patients (Email from Nancy)

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in a context that emphasised documentation for patient safety. However, the incident in Box 6 shows that people sometimes care more about the documentation than about the care that is provided. Nancy spoke up for a neonate with hypotension, which can easily be resolved by inserting an arterial line and giving a saline bolus. Her voice was not heard, nor was space provided for discussion with a group of doctors. Instead of measuring the neonate’s blood pressure when the neonate was calm, they continued to tap the neonate’s foot and stimulated crying to achieve a higher and ‘satisfactory’ blood pressure for documentation without any other intervention. Although Nancy had limited educative experiences in speaking up and being heard, she took the initiative to preserve her professional identity and persisted in speaking up for her hypotensive patient, and the saline bolus was finally given to stabilise the neonate. Nancy was disappointed with the acts of her colleagues. Instead of affecting her negatively, her persistence in speaking up and reflections about the incident can be interpreted as a process of selfmentoring. The miseducative experience was then transformed into an educative one by her identification of the discontinuities of values, self-affirmation of her professional identity and the importance of conscience in nursing, and

Box 7. Email from Nancy after member checking of this manuscript You help me to review my past nursing experiences and value. Sometimes I have doubts, and feel lost or frustrated when being “re-educated”. You help me to clear my mind [of doubt] and strengthen my confidence (Email from Nancy)

her determination to address the actual needs of patients in the future. In an email replying to Nancy, I [first author] shared with her my experience, resonance and reflections on the importance of upholding and sustaining the value of acting in the best interests of the patients. After member checking this manuscript, Nancy and I grew in moral awareness as we continue to situate our learning educatively in the midst of sub-optimal conditions of which one’s growth in learning to speak up could be retarded as miseducative without the needed support and continuous conviction (Box 7). This further substantiated that the process of learning to speak up is an important, continuous and complex one that cannot be satisfied by one-off training, but requires ongoing

Figure 1 Schematic view of the newly graduated registered nurses process of learning to speak up in practice.

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Table 4 Illustrations of Fig. 1 Layer

Descriptions

Outer Layer

Represents the shaping of the hospital stories, for instance, training in speaking up, the hospital hierarchy, time pressure & the emphasis on & use of hospital guidelines & documentation for patient safety (Place dimension of the conceptual framework – the three-dimensional space of narrative inquiry) Represents the people in the situated context of newly graduated registered nurses (NGRNs). It is important to note the dynamic flow of people in each situation, even in the same unit (Personal-social interaction dimension). This dynamic flow of people leads to the third layer Classifies into safe & unsafe spaces. The space is considered safe when the people in the situation are supportive & willing to listen to NGRNs who speak up for patient safety. The experience is educative (white in colour) when those speaking up are being heard in a safe space. The educative experience could potentially shape the NGRNs themselves, but also other colleagues who witness or hear about the experience in the context. Vice versa for unsafe space with the experience is miseducative (black in colour) when speaking up is not being heard. This might be shaped by the idiosyncrasy of authoritative figures, Chinese culture & generational differences which are represented in the bomb Refers to the personal dimension of the NGRNs who have experienced not one but ongoing educative & miseducative experiences (Temporal dimension). Under the shaping of ongoing educative experiences, NGRNs experience a sense of satisfaction with the affirmation of their professional identity & a perception of the efficacy of speaking up in the future. Under the shaping of ongoing miseducative experiences, NGRNs feel doubt, confusion, & powerless, & a shaken professional identity. They might hesitate or even be unwilling to speak up for their patients in the future. Nevertheless, the process of learning to speak up is not simply dichotomous but dynamic. An experience might not be purely educative/miseducative as the stories telling & living in a secret space could have an opposite shaping effect. E.g. In the midst of educative experience, speaking up might not be heard & supported in public space but only in secret one Through mentoring by peers & other senior healthcare professionals, & by self-mentoring new possibilities emerge & miseducative experiences can be transformed into educative ones, in the personal dimension, thus preserving the professional identity of the NGRNs. For instance, NGRNs can advocate for their patients secretly in living a secret story in secrecy & telling a cover story in public space, or ask for clinical rotation where the public space is safe for telling secret stories. Through appreciative inquiry with different levels of practitioners, the public space is hoped to be transformed into a safe one for telling secret stories for patient safety

Second Layer

Third Layer

Inner Layer

Transformation

AI, Appreciative inquiry; PI, Professional identities.

mentoring, including self-mentoring and peer-mentoring. Figure 1 presents a schematic view of the complex process of learning to speak up in practice among NGRNs and Table 4 provides an illustration of Fig. 1.

Narrative threads and discussion In the second level of analysis, three narrative threads were identified by comparing and contrasting the narrative accounts within the conceptual framework. The following three threads are interrelated and captured the complexity of the process that the NGRNs went through in learning to speak up.

Learning to speak up requires more than one-off training and safety tools The learning to speaking up as revealed in the participants’ multi-layered stories is a complex process, which is continuously shaped by ongoing educative and miseducative experiences. The training in speaking up and the use of safety tools are thought to have empowered healthcare professionals to speak up with courage, knowledge and skills within a © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

seemingly endorsed culture of safety as part of the institutional story. However, the NGRNs’ voices for patient safety were not being heard by the higher authority. Also, this ‘imposed’ cultural change on staff needs to be appreciated and led by senior leaders in the wards. A lack of understanding and trust among colleagues of different generations and the perceived power of the authority figures will potentially create much cynicism and many secret stories. That is why training in speaking up and safety tools merely belong to the outer layer depicted in Fig. 1 as more are needed for the complex learning process. This study provides practice-based evidence to the suggestion that the learning process has been oversimplified and over-standardised (Fawcett & Rhynas 2014). At the same time, the effectiveness of safety tools (Riesenberg et al. 2009) alongside the one-off CRM training (Stevens et al. 2012, Verbeek-van Noord et al. 2014) remains questionable.

Mentoring speaking up in the midst of educative and miseducative experiences It is necessary to offer NGRNs mentoring before, during and after each experience of speaking up, as in the process

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of learning, NGRNs are continuously shaped by ongoing educative and miseducative experiences. Mentoring is not confined to one particular person, but can include anyone who moves in and out of the context in which NGRNs are situated. They include senior nurses, doctors, ward managers, peers (peer-mentoring) and NGRNs themselves (through self-mentoring), as presented in the second layer of Fig. 1. Before speaking up, NGRNs might struggle and hesitate, as shaped by their previous miseducative experiences, such as Agnes, who needed to be mentored, reassured and supported. When NGRNs are courageous about speaking up, their moral decision should therefore be supported. Speaking up involves gathering the courage to transform a hidden transcript into a public one (Garon 2006). This narrative thread contributes to a better understanding of the process of gathering courage through ongoing mentoring, peer-mentoring and self-mentoring. After speaking up, the moral courage and actions of NGRNs should be openly appreciated, as these provide an example not only to NGRNs but to others in the context in fostering a culture of patient safety. The writing of this manuscript is to appreciate their courage and allow their voices to be heard. Those whose voices are not being heard should be mentored and debriefed in a safe and open mentoring space. If their voices are ignored, they should be given an explanation, rather than being left to wonder about the reasons for this. If the experience is miseducative in the social dimension, mentoring by others and/or self-mentoring are necessary to transform the experience into an educative one in the personal dimension. Their shaken sense of professional identity should be reaffirmed, and their experience should be reconstructed to determine new possibilities for growth and sustenance in speaking up, such as applying for a clinical rotation. This study revealed a new positive meaning to the intention to leave, which was to preserve one’s professional identity and to continue to speak up, contrary with the common negative conception of the intention to leave and turnover (Hayes et al. 2012). Self-mentoring was revealed to be important to the process of learning to speak up among all three NGRN participants. Self-mentoring is a process of how we make choices and connections with others, and teach and guide ourselves through active self-involvement and self-reflection (Darling 2007). Participants’ self-mentoring may have embodied the process of becoming Ren or self-perfection of Confucious’s lifelong moral striving (Coopamah & Khan 2011). Fostering good work and speaking up with a sense of commitment, courage, confidence and competence through selfmentoring is a tall order for NGRNs, especially for those who might have lower self-mentoring capacity. Educative

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mentoring is essential to their formation and development of professional identity.

Making public spaces safe for telling secret stories This refers to the cultivation of a culture of safety among all levels of healthcare professionals to ensure that people voicing concerns about patient safety and care will be heard and that the raised issues will be discussed not only in secrecy but also in a public space. The public space is considered unsafe when the dynamic flow of people in the situation is unsupportive and unwilling to listen to the voices of NGRNs. Some authoritative figures might be close-minded in believing that their ways are the only correct ones. Conformity, paternalism, face-saving and the maintenance of a harmonious working relationship, emphasised in Confucianism, might also be elements (Coopamah & Khan 2011, Jeong et al. 2012). Conflicts might also result when senior nurses who emphasise respect for authority and hierarchy and perceive NGRNs are sabotaging these values, and NGRNs who value diversity and prefer collaboration must work together (Bell 2013, Hendricks & Cope 2013). These contextual understandings of the safe and unsafe spaces by NGRNs are captured in the bomb, and third and inner layers of Fig. 1. They revealed how a unique ingrained culture impedes the process of learning to speak up among NGRNs and the need for deep cultural changes to make the public spaces safe for telling secret stories. But how? Thinking narratively, we do not think that cultural changes can be achieved by leaders or researchers imposing pre-digested materials in isolation from the narrative histories of people and places (Dewey 1938), although leadership is imperative. The effort made by hospital leaders to initiate cultural changes by introducing CRM should be appreciated. However, the multiple tensions created from a simple top-down approach without an understanding from the staff of the frontline need to be addressed. This narrative inquiry provides empirical evidence to support the concept of cultural-compatibility (Jeong et al. 2012) when adopting successful patient safety programmes from other contexts. Unless collective visions and actions are generated, any programmes might only introduce another layer of shock when NGRNs futilely apply their knowledge, while various hospital guidelines, documentations and hierarchies continue to be abused. This might further reduce the trust between NGRNs and management, and ultimately jeopardise patient safety. We suggest that hospital leaders could use Fig. 1 together with the appreciative inquiry (AI) (Cooperrider 1986), a strength-based approach, instead of the traditional problem© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1837–1848

Original article

Learning to speak up in practice

solving approach, to make the public space safe for telling secret stories. AI is rooted in action research and relational constructionism that focuses on affirmation, appreciation and positive dialogue to promote positive transformational change and collective learning from what works well within an organisation. The flexible framework of AI is also suitable for different organisations with a unique culture and needs (Trajkovski et al. 2013). The findings of this study revealed that, despite the CRM programme, the NGRNs felt powerless to speak up and that other people reacted defensively when the NGRNs did raise issues of patient safety. The engaging, inclusive and collaborative nature of AI could have empowered individuals and groups to envision new possibilities for the future by reflecting on their successful narrative histories and appreciating other perspectives. Under cultural changes and mentoring, it is hoped that passionate NGRNs will not experience professional dissonance (Attree 2007) when speaking up for their patients. The narrative unity (MacIntyre 1984) between their professional identities and practices will potentially increase their rate of retention (Gardner et al. 2001) and cause them to continue to be patient advocates. It is also hoped that they will mentor and be a role-model to others, especially in showing younger generations the value of learning and continuing to speak up for patient safety.

Limitations The findings of the inquiry are not meant to be generalised to all NGRNs. It is important to note that the purposive sampling of the NGRN participants were those recommended to pursue good work. They might have greater moral courage and maturity than the average NGRNs, which led to their speaking up despite repeated miseducative experiences. However, their stories raise our moral awareness in the midst of promoting the learning about cultural safety for all NGRNs.

Conclusions To our knowledge, this is the first study with NGRNs to understand their learning process to speak up for patient safety. NGRNs have the moral knowledge and courage to speak up; however, their voices might not be heard. This narrative inquiry revealed that the learning process is com-

plex under the potential shaping of Chinese culture and generational differences that requires more than one-off training and safety tools. Mentoring by others and selfmentoring are required, especially in the midst of miseducative experiences, to see new possibilities for sustaining their professional identity and continuing to speak up in the future, which is rarely reported in the literature. Appreciative inquiry might be a new research methodology to promote positive cultural changes to make the public spaces safe for telling secret stories for patient safety.

Relevance to clinical practice It is hoped that this narrative inquiry will resonate with readers and encourage critical reflections on the problem of people who speak up but are not heard, despite contemporary assertiveness training programmes and patient safety measures. Cultivating a safe and open culture of communication and mentoring NGRNs on the importance of speaking up will benefit patient safety now and in the future by increasing the retention rate of committed patient advocates who could mentor and support future generations.

Acknowledgements The authors would like to express their deepest gratitude to the participants of the study for making this research possible by contributing their valuable time and thoughts. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content and (3) final approval of the version to be published.

Conflict of interest The authors declare no conflicts of interest.

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