A qualitative interview study of medical residents’ emotions in speaking up on medical rounds

Abstract

Speaking up during inpatient medical rounds involves medical trainees voicing ideas, concerns, or information when unprompted for the benefit of patient care and education. Medical residents encounter a unique set of considerations regarding the decision to speak up during rounds. However, little is known about the role of trainees’ emotions in speaking up in this context. The objective of this study was to explore the role of emotions in speaking up behaviours among medical residents during inpatient medical rounds. We conducted interviews with 21 medical residents inquiring about perspectives on speaking up. We developed a framework for classifying emotions, which consisted of valence (positive or negative), moral emotions (condemning, self-conscious, suffering, or praising), and non-moral emotions (fear, love, schadenfreude). Interview transcripts were deductively coded and analyzed to identify patterns of emotions and their drivers in the context of speaking up during rounds. Medical residents shared a range of positively- and negatively-valenced emotions in association with speaking up during rounds. We identified five types of emotions in speaking up during rounds that were commonly experienced by residents: praising emotions, self-conscious emotions, condemning emotions, suffering emotions, and fear. Specific drivers of these emotions were identified and classified into workplace, relational, patient-related, or personal factors. Ultimately, we found that medical residents experience both positive and negative emotions that influence speaking up behaviours during inpatient rounds. Further exploration into the role that emotions play in speaking up on inpatient medical rounds may provide valuable insights for medical education research and teaching practices.

Introduction

Speaking up in the healthcare context can be defined as the raising of concerns for the benefit of patient safety, quality of care, or medical professionalism [1, 2]. It involves complex interactions among workplace, relational, patient, and individual factors. Speaking up has been shown to reduce medical errors, improve patient outcomes, enhance job satisfaction, and facilitate learning among trainees [1–3].

Despite the benefits of speaking up for learning and patient care, healthcare providers often choose to remain silent [4, 5]. There are many barriers to speaking up in healthcare, including high workload, lack of confidence in clinical skills, feeling powerless, and lack of safety culture [2]. In medical education, curricula have been developed to promote speaking up, many of which involve recognizing inner barriers, activating motivation, developing verbal skills, and promoting emotional strategies [3]. Emotions play a critical role in the work of healthcare providers as they may consciously or unconsciously inform information processing, professional engagement, and decision-making. There has been little exploration into the role of emotions in speaking up behaviour [3, 7, 12].

Medical residents encounter a unique set of considerations regarding the decision to speak up—lower position in the medical hierarchy, lack of confidence in clinical decision making, and desire for approval (e.g., a positive review from their supervisor) may all negatively impact their psychological safety with respect to speaking up. Inpatient medical rounds are a venue in which medical residents in the hospital interact with other healthcare team members. During rounds, medical residents must engage in complex risk–benefit assessments of whether or not to speak up that are likely grounded in emotional states [3]. Yet there has been little exploration into the kinds of emotions that play a prominent role in speaking up among medical residents during rounds [5, 6]. In this brief report, we identify personal emotions that play a role in speaking up behaviours among medical residents during inpatient medical rounds.

Materials and methods

This qualitative study was performed at a single teaching hospital in New York City during the 2021–2022 academic year. We interviewed medical residents in all three post-graduate years who provided informed consent to participate in the study. We chose qualitative analysis to allow for better exploration of emotional range, and one-on-one interviews, rather than focus groups, to enable the gathering of perspectives without influence from others. The study was performed in accordance with the educational IRB guidelines at Weill Cornell Medicine. Interviews began with providing a general definition of speaking up: the voicing of ideas, concerns, and information when unprompted. Residents were then asked: “What is your perspective on speaking up during inpatient rounds?” They were also asked to share examples of times that they did, or did not, speak up, and to reflect upon factors that influenced their decision to speak up during rounds. We avoided leading questions by not specifically prompting residents to speak about their emotions; however, if emotions were mentioned in the response, probing questions were used to gain a deeper understanding of emotions in speaking up (e.g., “Why did you feel that way?”).

Our approach to qualitative analysis involved deductive and inductive coding, analyzing, and identifying patterns within the data related to different emotions and the drivers for these emotions. We used several published frameworks to classify emotions [7–11]. One such framework classifies emotions as having positive or negative valence, whereby individuals tend to approach stimuli or situations that induce positive emotions and avoid those that produce negative emotions [9]. Another framework developed by Haidt describes four groups of moral emotions: (i) condemning emotions, including disgust, anger, or contempt; (ii) self-conscious emotions, including embarrassment, guilt, shame, or moral distress; (iii) suffering emotions, including sympathy, compassion, empathy, and distress at another’s distress; and (iv) praising emotions, including positive, gratitude, elevation, and awe [7]. The non-moral emotions as described by Haidt include fear, love, and schadenfreude (joy that is elicited by the misfortunes of others) [7]. For our analysis, we developed a unified framework for classifying emotions which consisted of valence (positive or negative), moral emotions (condemning, self-conscious, suffering, and praising), and non-moral emotions (fear, love, schadenfreude). We also openly coded factors that contributed to emotions to develop a list of potential drivers of emotions.

Coding was initially performed independently by both co-authors. After coding the first five transcripts independently, we discussed our respective codes and discussed discrepancies. We collaboratively refined the emotions framework and list of drivers in our shared codebook. We re-coded the first five transcripts using our updated codebook and then coded the next five transcripts before meeting again to discuss discrepancies. This analytic process was repeated for all subsequent interviews until data consensus was achieved [12]. This study was approved by the Weill Cornell Medicine Institutional Review Board.

Results

We interviewed 21 residents (9 interns, 7 junior residents, 5 senior residents). All but one resident mentioned or described at least one emotion associated with their speaking up behaviours. Of the 20 transcripts included in our final analysis, all cited both positively- and negatively-valenced emotions in association with speaking up. Table 1 shows the types of emotions identified with representative quotes and the drivers associated with each type of emotion.

Table 1. Types of emotions and their associated drivers described by medical residents

Emotion	Representative quotes	Drivers
Praising	“I suppose [that I speak up in]situations that are serious…I've actually found that it's easier to give recommendations, or question something, because you feel like you have more of a duty or responsibility to do that [in serious situations].”	Desire to improve work circumstances Clinical urgency
	“For me, the best environment is where I feel like I trust my senior [resident]. I feel like I can say something more confidently when I know someone will have my back when I say it.”	Confidence Hierarchy
Self-conscious	“I personally tend to be on the quieter side during rounds just because there's so much going on, and I'm always anxious about my knowledge base, and what I know or don't know. And for me speaking up in front of a group of seven or eight people is intimidating. Especially when med students are there… I'm sometimes embarrassed to look stupid in front of students.”	Hierarchy Safety calculus
	“There are times when I feel like, ‘Is this something that I should know at this point?’ So if I feel like this is something that I should know, should I be asking about it? Should I just look it up?”	Confidence
Condemning	“It is not worth my time or energy to put a stake in the ground for relatively insignificant things because it's just going to cause harm to whoever I talked about, and it's just going to create some stressor that is handled poorly and create more problems as opposed to handled appropriately. And I don't trust it to be handled appropriately.”	Perceived impact Efficacy calculus
	“I had a resident who was not particularly supportive, [and] sometimes could actually be a little bit harsh. That caused me to kind of retreat inside myself and not want to talk or participate at all.”	Safety calculus
Suffering	“I would say that [I speak up for] things that clearly [have] a patient management or safety concern. I feel like if it is actually going to impact the patient, then I'm more likely to bring it up, even if it's a little bit uncomfortable.”	Efficacy calculus Perceived impact
	“The only thing that I really won’t do is [not speak up] if there's potential harm to the patient. I don't have a good example, but if it's something that I think is like morally wrong, or doesn't go along with my own values, then I probably speak up about that.”	Perceived impact
Fear	“How can I go against you by telling you, ‘Hey, I don't think this is right’ It's kind of like me questioning your authority, which could have repercussions for me later on. So I have to think about how to frame what I'm going to say to you in a way that doesn't come back and cause me problems.”	Hierarchy Perceived impact
	“Speaking up and challenging your seniors, or the attending, can be a little frightening if you don't feel like it's immediately a welcoming environment.”	Hierarchy Safety calculus

Praising emotions and self-conscious emotions were most commonly identified in transcripts (at least 80%). Praising emotions, including reflections of positivity, gratitude, and elevation, were associated with positive valence. Reflections often included scenarios in which residents felt gratified and motivated in association with speaking up and/or personal or team-based satisfaction and growth. Self-conscious emotions included reflections of embarrassment, guilt, shame, and vulnerability. Such reflections were largely associated with negative valence and often associated with safety calculus as their driver.

Condemning emotions and suffering emotions were described in approximately half of transcripts (40–50%). Condemning emotions included mentions of anger or contempt and were associated with negative valence, and often with safety calculus or efficacy calculus as drivers. Suffering emotions included reflections of sympathy, empathy, compassion, or distress at another’s distress. Suffering emotions had both positive and negative valence and were often associated with perceived impact as a driver.

Finally, fear was described in one-quarter of transcripts. Fear as an emotion that impacted speaking up behaviours was associated with negative valence. Fear was occasionally mentioned with self-consciousness as a moral emotion.

Drivers of emotions in speaking up were classified into workplace, relational, patient-related, or personal factors. Workplace factors included the speciality of the clinical setting (e.g., critical care, general medicine), clinical urgency, and time constraints. Relational factors included hierarchy, safety calculus (i.e., risk assessment), and number of individuals involved. Patient-related drivers of emotion included efficacy calculus (i.e., how easy will the suggestion be to implement?) and perceived impact (i.e., how impactful will the suggestion be on patient care?). Personal drivers of emotion included feelings of ease, desire to improve workplace circumstances, and confidence. The most frequently noted drivers included hierarchy and safety calculus.

Discussion

Our study demonstrates that medical residents experience a range of positive and negative emotions that influence speaking up behaviours during inpatient rounds. We explore emotions as they pertain to speaking up during inpatient medical rounds, a phenomenon and context that has not yet been examined together in medical education. We believe insights drawn from the kinds of emotions that residents experience, and the factors that drive them, in speaking up (or not speaking up) during rounds will be critically important to consider in the development of curricula for team communication, faculty development of leadership and clinical teaching skills, and the well-being of residents.

The findings of this brief report are meant to serve as a ‘launch pad’ for medical educators and researchers to target certain emotions and their drivers to enhance learning and clinical performance. For example, the pervasiveness of praising emotions as both an influence for and benefit from speaking up may be leveraged as part of formal training regarding speaking up behaviours. Conversely, self-conscious and condemning emotions served as barriers to speaking up; therefore, promoting a collegial and accepting team culture may offset the development of such negative emotions. Importantly, there is likely a complex interplay among positive and negative emotions, whereby negative emotions may actually promote decisions to speak up. With respect to drivers, hierarchy was identified as a driver of emotions with negative valence. This may be addressed by attendings and senior residents by explicitly addressing these dynamics. Additionally, if residents work in an environment where they feel valued, they may feel more empowered to speak up on inpatient rounds [13]. Our findings support that skill-based training in naming and recognizing emotions and the intersection of emotions with speaking up behaviours would be beneficial for trainees and faculty alike.

There are several limitations to our study. This was a single institution study of internal medicine residents from all three postgraduate years, and personal characteristics including age, experience, agency, and seniority were also not systematically addressed. Additionally, given the unstructured nature of our interviews, we did not ask specific questions about various emotions systematically and instead utilized responses to develop a framework of emotions, which can now be applied to future study. We felt that singular pre-existing frameworks failed to capture the nuances and distinguishing features of valence, moral-, and non-moral emotions, and therefore our framework was intentionally built to allow for inclusivity of different classifications of emotions. Future systematic and quantitative study would allow for improved characterization of emotions among focused cohorts of residents, which would aid in more targeted curricular planning.

Ultimately, promoting conditions that drive emotions with positive valence, including praising and suffering emotions, and minimize emotions with negative valence, including fear, condemning, and self-conscious emotions, may foster speaking up behaviours among medical residents. A focus on emotional intelligence, which refers to a person's ability to recognize and respond to the emotions in themselves and other people, in medical education research and curriculum development is needed (14). Optimizing how individuals and teams can recognize and manage emotions may have lasting impacts on learning, patient care, and both personal and professional growth.

Conclusion

Medical residents experience positive emotions, negative emotions, and a series of moral emotions that influence speaking up behaviours during inpatient rounds. Understanding the workplace, relational, patient-related, and personal factors that drive emotion and speaking up behaviour may influence team dynamics, medical education curricula, and patient safety and outcomes.

Authors' contributions

J.C. conceptualized the study, performed data collection and analysis, and contributed edits and final review of the manuscript. J.G. performed data analysis and wrote the main manuscript text.

Funding

Not applicable.

Data availability

There are 21 anonymous transcripts of participant responses that are available for further review should reviewers or readers wish to see them.

Code availability

Not applicable.

Declarations

Competing interests

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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