Approximately 10% of hospital inpatients experience adverse events due to their medical treatment.1 It has been suggested that patients themselves could play an active role in improving the safety of their healthcare.23 There are opportunities for patients to contribute in their healthcare through, for example, accurate provision of diagnostic information, involvement in treatment decisions, choice of healthcare provider, disease treatment, and the management and monitoring of adverse events.23 Specific instances in which patient involvement can make a difference include the reporting of surgical complications and reduction in rates of hospital acquired infections (HAIs) and medication errors.45

A number of initiatives and campaigns have been introduced in the UK, the US and other countries6^–11 which aim to facilitate patient involvement in safety. In the UK, the National Patient Safety Agency’s (NPSA) “Clean your hands campaign,” designed to reduce rates of HAI’s encourages patients to regularly ask staff if they have washed their hands.6 Further, the “Please Ask” campaign launched by the NPSA in 2006 aims to help patients feel comfortable asking healthcare staff questions and voice their concerns on their National Health Service experiences.7

However, while such initiatives are well intentioned, there is a paucity of empirical research on the acceptability of such interventions from the patients’ perspective. It is unclear to what extent patients would be willing to act upon such information and factors that may affect this. Research from other areas investigating the role of the patient in healthcare such as literature on patient involvement in treatment decision-making indicates that patients’ preferences for involvement can be mediated by patients’ demographic characteristics (eg, age, sex, education, employment)12^–15 and interactions with healthcare staff.16^–19 The potential role of these factors and their relative impact on patient involvement in safety is yet to be determined.

In this study, we conducted a cross-sectional survey on postoperative patients with the aim to investigate:

• surgical patients’ willingness to question healthcare staff about their treatment;

• differences between patients’ willingness to ask factual versus challenging questions related to the quality and safety of their healthcare;

• patient characteristics that could affect patients’ willingness to ask safety-related questions;

• the impact of doctors’ instructions on patients’ willingness to ask safety-related questions.

METHOD

Design

Cross-sectional design using a patient self-report survey.

Participants

A convenience sample of patients who had undergone a number of different surgical procedures was employed (see table 1 for descriptives on patients’ characteristics). Patients were recruited postoperatively over a 3-month period from four wards in an inner city London teaching hospital. The inclusion criteria for the study were any patient over the age of 18 years that had undergone a surgical operation, spoke the English language and was able and willing to give informed consent to participate in the study. In total, 101 patients were approached by the researcher; from this, 80 agreed to participate. Reasons for not participating were due to the patients’ limited understanding of the English language (n = 8); the patient was feeling too tired (n = 7); the patient was unwell or in too much pain (n = 3); or the patient did not want to be involved in the study (n = 3).

Measures

Patient Willingness to Ask Safety Questions Survey

A “Patient Willingness to Ask Safety Questions Survey” (PWASQS) was developed, comprising 28 questions in total which assessed patients’ willingness to ask healthcare staff questions that current safety initiatives (mainly from the UK and the US) advise patients to ask (see table 2). Patients were told that the purpose of the questionnaire was to assess how willing patients are to ask questions relating to the quality and safety of their healthcare. They were asked to think about how willing they would be in general (ie, in any medical encounter) to ask safety-related questions. The researcher went through all the questions in the PWAQSQ with the patient. Six different aspects of patient willingness to ask safety-related questions were considered (referred to hereafter as “patient willingness levels” (PWLs), including patients’ willingness to ask: (a) doctors: (1) factual questions (eg, would you be willing to ask: “how long will I be in hospital for?”); (2) challenging questions (eg, would you be willing to ask: “have you washed your hands?”); (3) challenging questions if instructed to by a doctor (eg, if instructed to by a doctor would you be willing to ask: “have you washed your hands?”); and (b) nurses: (4) factual questions; (5) challenging questions; and (6) challenging questions, if instructed to by a doctor.

Patients’ had to answer on a 4-point scale how willing they would be to ask each question in the PWASQS (scores ranged from 1 to 4; the higher the score, the more willing the patient was to ask the question). The response format was “definitely not,” “probably not,” “probably yes” or “definitely yes.”

Patient characteristics questionnaire

Patients’ demographic data on sex, age, ethnicity, employment and education were collected from each participant. Information on the type of operation the patient had undergone was also gathered (see table 1).

Statistical analyses

Data were analysed using SPSS for Windows Version 14. Non-parametric tests were used (Mann–Whitney U, Wilcoxon Signed Ranks and Kruskal–Wallis tests) because data did not meet normality assumptions, and relevant transformations did not improve the distributions of the data.

Data analysis

PWLs were calculated by using the mean score of the questions relevant to each PWL. Within-subjects comparisons were computed to assess the extent to which (1) the content of the question (ie, factual versus challenging), (2) who the question was directed to (ie, doctor versus nurse) and (3) the impact of doctor’s instructions (on willingness to challenge doctors versus nurses) were related to patient willingness to ask safety-related questions. Between-subjects comparisons were conducted to explore the relative impact of patients’ characteristics on scores on each of the PWLs (eg, are women more likely to challenge doctors than men?). Owing to the nature of the distribution of the data, separate statistical analyses (ie, different statistical tests) were conducted for the within-subjects and between-subjects comparisons because non-parametric tests do not allow the direct analysis of both these types of factors together.

RESULTS

Findings from the PWASQS

To investigate the extent to which patients’ willingness to ask questions is dependent on: (1) the content of the question, (2) who (ie, doctor/nurse) the question is directed at and (3) doctor’s instructions for the patient to ask challenging questions to doctors or nurses, within-subjects comparisons using Wilcoxon Signed Ranks tests were conducted. The results indicated significant differences. Patients were more willing to ask doctors factual as opposed to challenging questions (z = 7.59, p<0.001). Similarly, patients were more likely to ask nurses factual than challenging questions (z = 5.39, p<0.001). Patients were less willing to ask nurses factual questions than doctors (z = 4.98, p<0.001), and less willing to ask challenging questions to doctors than nurses (z = 4.40, p<0.001). Doctors’ instructions to the patient increased patient willingness to challenge doctors (z = 6.56, p<0.001) and nurses (z = 6.15, p<0.001). Table 3 displays the descriptive statistics for patients’ scores on each of the questions in the PWASQS together with the descriptive statistics for each of the PWLs investigated.

Findings from patients’ demographic characteristics

The above data were then examined further with respect to patients’ demographic characteristics to investigate the extent to which patients’ age, sex, ethnicity, education and employment status were related to their willingness to question healthcare staff. Significant differences (p<0.05) were found for sex, education and employment status.

Sex differences in willingness to ask safety-related questions

To investigate whether men and women differed significantly on each of their scores on the PWLs, a series of Mann–Whitney U tests were conducted using sex as the between-subjects variable. Women were more likely than men (p<0.05) to ask both factual and challenging questions to nurses. Women were also more willing to challenge nurses and doctors, if instructed to by a doctor (see table 4 for test results and descriptives).

Educational level and willingness to ask safety-related questions

To investigate whether patients with a degree and without a degree differed significantly on each of their scores on the PWLs, a series of Mann–Whitney U tests were conducted using educational status (degree versus no degree) as the between-subjects variable. Patients with a degree were more willing than those without a degree (p<0.05) to ask doctors and nurses challenging questions, doctors factual questions, and challenging questions to nurses and doctors, if instructed to by a doctor (see table 5 for test results and descriptives).

Employment status and willingness to ask safety-related questions

To investigate whether patients’ scores on each of the PWLs differed with respect to employment status (employed, unemployed, student, retired), Kruskal–Wallis tests were conducted using employment status as the between-subjects variable. Patients who were registered disabled were excluded from analysis because the sample size of this particular group was too small (n = 2). Test results yielded significant differences (p<0.05) on the basis of employment status on patients’ willingness to ask factual questions to doctors and challenging questions to doctors and nurses, if instructed to by a doctor. Follow-up procedures using Mann–Whitney U tests were used to locate significant differences between employment groups and patients’ scores on the above three PWLs. Patients who were employed were significantly more willing to ask factual questions to doctors than those patients who were retired or students. In addition, employed patients were more willing to follow doctors’ instructions to challenge doctors or nurses (see table 6 for test results and descriptives).

DISCUSSION

This study empirically investigated surgical patients’ willingness to ask healthcare staff safety-related questions as recommended by current patient safety initiatives. Our findings indicate that postoperative patients’ willingness to question doctors and nurses is dependent on the content of the question, who the question is directed to and whether the patient received instruction to ask the question. Patient’s demographic characteristics also play a role. Here, we consider these findings in more detail.

The majority of patients were willing to ask healthcare staff factual questions regarding the delivery of their healthcare (eg, “how long will I be in hospital for?” or “what are the alternatives to surgery?”); however, significantly fewer were willing to pose challenging questions (eg, “have you washed your hands?”). These findings could have significant implications for the efficacy of patient safety initiatives (considered in this study) which aim to encourage patients to ask questions if they have any concerns regarding the medical treatment that they receive. Our findings suggest that, at least for postoperative patients, the extent to which these initiatives will facilitate patients in questioning healthcare staff is likely to be content-dependent; patients may be unwilling to adhere to recommendations in those initiatives that they perceive as challenging the healthcare staff’s clinical abilities.

The professional role of the healthcare staff (ie, whether they were a doctor or nurse) influenced patient-reported willingness to ask questions. Patients reported that they were more willing to ask doctors as opposed to nurses factual questions. The reason for this could be to do with the nature of the factual questions used in the PWASQS. All these questions were related to the patient’s surgical treatment and subsequent recovery process. Patients’ may view doctors as a more appropriate resource for such information. Patients were also more willing to ask nurses rather than doctors challenging questions. This finding replicates that of a study aimed at empowering medical and surgical patients to ask doctors and nurses if they had washed their hands; while all patients would ask a nurse, only about a third would pose the same question to a doctor.4 While the exact reason for this is unclear, it could be in part due to patients’ viewing doctors as more authoritarian figures than nurses, and the fact that doctors will have more power and control over their treatment. Patients may therefore be less likely to ask doctors versus nurses questions that they perceive as causing offence or challenging the doctor’s clinical abilities.

Significant improvements in patients’ willingness to ask challenging questions to doctors or nurses was achieved if the patient was instructed to ask such a question by the doctor. These findings support previous research which suggests healthcare staff’s attitudes and behaviours can be a salient contributory factor to patient involvement.16^–19 This effect can have important implications for initiatives that encourage the active involvement of the patient in patient safety. It seems that for such initiatives to be effective, they must be perceived by both patients and healthcare staff as beneficial to the medical encounter rather than challenging the clinician’s clinical skills and abilities.

Demographic differences were also evident in patients’ willingness to ask doctors and nurses questions. Patients who were men, unemployed or not educated to degree level were markedly less willing to question doctors and nurses. These patient groups may benefit from extra input in facilitating their engagement in safety-related behaviours, and these differences could be taken into account for improving the potential success of safety-related initiatives. These findings replicate observations from a number of previous studies which have reported demographic differences in patients’ preferences for involvement in their healthcare.12^–15

However, future research is needed to investigate patients’ views on the relevance of the safety-related questions, as for example, in this study, patients were less willing to ask a doctor “how is the procedure done?” than “when will I return to my normal activities?” This could be partly explained by the fact that participants were postoperative patients, so the former of these questions may seem less relevant (because the patient has already had the operation) than the latter (which would be of more relevance to their current situation). In addition, the safety culture of the healthcare professionals needs to be assessed in parallel to patients’ willingness to be involved in safety. The relationship of the two needs to be evaluated, as in different hospitals or indeed even on different wards in the same hospital, some doctors or nurses may encourage patient involvement more than others. Given our finding that doctors can play a salient contributory role to patients’ willingness to ask healthcare staff safety-related questions, future research should try to replicate this finding and assess the extent of its generalisability on healthcare units exhibiting a range of safety culture levels. In addition, research is needed to investigate to what extent patient self-reported willingness to ask safety-related questions is related to actual and relevant patient safety-related behaviours. Replication and assessment of the generalisability of the current findings to other patient groups also need to be examined to determine the extent that the patient’s condition, demographic characteristics and healthcare staff’s attitudes, beliefs and behaviours could affect patient involvement.

CONCLUSION

The findings of the present study provide preliminary evidence-based insight into patients’ willingness to question healthcare staff on quality and safety issues in their healthcare. Our research indicates that, at least for postoperative patients, the success of current safety initiatives which aim to encourage patients to ask questions may be limited to those questions that the patient does not perceive as challenging clinical skills and abilities. Clinicians and patients need to be in agreement of what is considered appropriate questions for the patient to ask, because patients need to feel they can ask questions that may be perceived as challenging without causing offence to those involved in their healthcare treatment. With this in mind, it seems relevant to take into account patient characteristics, the perspectives of patients and the potential facilitating role of healthcare staff, in the development and implementation of safety initiatives aimed at encouraging patient involvement.