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Challenging authority and speaking up in the operating room environment: a narrative synthesis - 11/2/2019

Br J Anaesth 2019; 122: 233-44


Effective communication between teams in the in the operating theatre is crucial, especially during crisis situations where patient safety can be in acute danger. An often-neglected skillset in educational curriculums is challenging authority. These authors carried out a narrative synthesis, with the aim of exploring the literature on challenging authority in the operating theatre environment.


A systematic search of Medline, EBM reviews and PsycINFO was conducted using terms related to challenging authority, speaking up, communication, patient safety, gradients and hierarchy. The initial search identified 4822 publications, of which 31 studies were included. The data synthesis of the included studies was grouped into three distinct categories following a meta-aggregative approach: discussion and review articles, observational or qualitative studies, and studies identifying the role of specific barriers or investigating the effect of educational interventions.



Themes emerging from expert beliefs, what reality tells us and what we test were consistent. Hierarchy, organisational culture and education were the most frequently observed and tested themes. Simulation research has been successful in eliciting and confirming the role of specific barriers to speaking up.



The authors conclude that barriers and enablers are largely modifiable within institutions, but point out that education on the importance of speaking up will need to accompany these modifications for any significant changes to occur.

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