Intellectual disability is associated with increased risk for childhood obesity, and the factors most often associated with this risk are incorrect eating behavior and insufficient amount and intensity of physical activity. As is well known, there area whole range of factors determining lifestyle, but many currently available reports in this field refer to the functioning of children without a diagnosis of intellectual disability, and, as we know, due to numerous individual and environmental barriers, children with ID may function differently in this context than their peers. Therefore, we examined the relationships between the selected variables and divided them into two models: (1) first regression model: child’s willingness to engage in physical activity (dependent variable), child’s physical limitations related to disabilities and/or comorbidities, child’s independence, parents’ willingness to engage in physical activity, child’s body dissatisfaction (independent variables/predictors); (2) second regression model: child’s emotional eating (dependent variable), child’s coping with emotions, parents’ attitudes, beliefs, and practices about child feeding (restriction and pressure to eat), parents’ emotional eating, parents’ happiness (independent variables/predictors). A group of 503 parents  completed: the Contour Drawing Rating Scale, the Child Feeding Questionnaire, the Emotional Overeating Questionnaire, the Scale of Experiencing Happiness, and the supplementary survey. Our results allow partial confirmation of the hypotheses related to both of these models: (1) model I: the relationships between the child’s willingness to engage in physical activity and all predictors are significant, but the direction of the relationship between the dependent variable and one of the predictors—body dissatisfaction—is opposite to the assumed one (negative relationship); (2) model II: the relationships between the child’s emotional eating and almost all predictors are significant, except for the relationship between the dependent variable and pressure to eat. In conclusion, (to the authors’ knowledge) this study is the first to assess dyadic predictors of willingness to engage in physical activity and emotional eating in children and adolescents with mild and moderate intellectual disability. It allows for a better understanding of the attitudes, beliefs, and experiences of children with intellectual disabilities and their parents, which gives the opportunity  to better design strategies to support pro-health behaviors in children and adolescents from this group (which may improve the effectiveness of overweight prevention and obesity). These findings emphasize how important it is to consider the dynamic of the child-parent dyad when considering how parenting contributes to a child’s willingness to engage in physical activity, as well as thatchild’s emotional eating. The definition of intellectual disability (ID) given by the American Association on Intellectual and Developmental Disabilities (AAIDD) indicates a condition characterized by significant limitations in intellectual functioning, as well as in adaptive behavior, which includes many social and practical skills developed before the age of 22 . In thisIt is well known that physical activity has a beneficial effect on people with intellectual disabilities . PhysicaEqually important as physical activity for children with intellectual disabilities is their adequate intake of energy and nutrients, which play a very important role in their development . BalanceTo sum up, in the present study, we examined the predictors of children’s willingness to engage in physical activity and emotional eating in children and adolescents with mild and moderate intellectual disability. Variables related to the functioning of the children themselves  and their parents  were taken into account as predictors. Therefore, in the main analysis, we examined the relationships between all the above-mentioned variables and divided them into two models: (1) model I: child’s willingness to engage in physical activity (dependent variable), child’s physical limitations related to disabilities and/or comorbidities, child’s independence, parents’ willingness to engage in physical activity, child’s body dissatisfaction (independent variables/predictors); (2) model II: child’s emotional eating (dependent variable), child’s coping with emotions, parents’ attitudes, beliefs, and practices about child feeding (restriction and pressure to eat), parents’ emotional eating, parents’ happiness (independent variables/predictors). In our main hypotheses, we assumed that: (1) the first hypothesis—model I: the higher levels of the last two of the above-mentioned variables  would be associated with higher willingness of the child to engage in physical activity, after accounting for the effects of foregoing the child functioning-related variables  and; (2) the second hypothesis—model II: the higher levels of the parental feeding-related practice and parents’ emotional eating and the lower level of the parents’ happiness would be associated with the child’s emotional eating, after accounting for the effect of foregoing the child functioning-related variable (child’s coping with emotions).Our cross-sectional study complies with the Declaration of Helsinki and was performed according to Ethics Committee approval (no. KEUS 239/04.2022). Participants were recruited by disseminating information about the possibility of participating in the study in places where medical practitioners, psychologists, pedagogists, and other healthcare providers can meet the parent of a child with an intellectual disability  in 2022. A non-probability sampling technique was used (a voluntary method of sampling). Each parent interested in participating in the study was initially informed about its purpose and that the study was voluntary and anonymous. Participants who were ultimately interested in participating in the study, after contacting the investigator, received informed consent to participate in the study for approval. They then completed the measures described in the next section of this manuscript. Parents were not remunerated for their participation. At this point, it should be remembered that it was the parents who completed the answers regarding the functioning of themselves and their children in all the measures used. Initially, 675 parents signed up for the study . Finally, a group of 503 parents of children and adolescents with mild and moderate intellectual disability was selected for analysis in this manuscript . (1)child’s willingness to engage in physical activity—to what extent is the child willing to engage in physical activity ?(2)child’s physical limitations related to disabilities and/or comorbidities—how strong are the child’s physical limitations resulting from disabilities and/or comorbidities ?(3)child’s independence—child’s independence ;(4)parents’ willingness to engage in physical activity—how willing are you to engage in physical activity ?(5)child’s emotional eating—does the child overeat under the influence of experiencing negative emotions ;(6)child’s coping with emotions—on a scale of 0 (completely bad) to 100 (completely good), rate how your child copes with emotions in everyday life;(7)sociodemographic and other variables—gender, education, levels of an intellectual disability, financial status, professional activity, age, weight, height.This measure included:This scalecontains 9 silhouettes (ranking from the thinnest to the fattest) . ParentsThis 31-item questionnaire includes seven subscales: restriction, pressure to eat, monitoring, perceived responsibility, parent perceived weight, perceived child weight, parents’ concerns about child weight . This stThis 9-item questionnaire shows how often people have eaten excessive amounts of food over the last 28 days when they feel: sadness, loneliness, anxiety, anger, tiredness, happiness, guilt, boredom, and physical pain . The scoThis Polish 40-item questionnaire reflects the level of happiness  . The scoThe relationships between all variables were analyzed by Pearson’s correlation coefficient. This analysis was a preparatory step for regression analyses. Hierarchical regressions were used to verify our hypotheses.In the first regression model (model I), the child’s willingness to engage in physical activity was a criterion variable. As a first step, we entered the child’s physical limitations related to disabilities and/or comorbidities and the child’s independence. As a second step, we entered the parents’ willingness to engage in physical activity, and, as a third step, we entered the child’s body dissatisfaction. In this way, it was possible to examine the extent to which parental willingness to engage in physical activity and child body dissatisfaction incrementally predicted the child’s willingness to engage in physical activity, after accounting for variance associated with the other variables . In the second regression model (model II), the child’s emotional eating was a criterion variable. As a first step, we entered the child’s ability to cope with emotions. As a second step, we entered two variables related to parents’ attitudes, beliefs, and practices about child feeding (restriction and pressure to eat), and, as a third step, we entered parents’ emotional eating and parents’ happiness. In this way, it was possible to examine the extent to which parental feeding-related practice, and parents’ emotional eating and happiness incrementally predicted the child’s emotional eating, after accounting for variance associated with the child’s coping with emotions.For both models, the main assumptions underlying multiple regression models have been met. Variance inflation factors did not exceed 10 and tolerance was higher than 0.2 ,43.Pearson correlation coefficient and descriptive statistics (M and SD) for all analyzed variables in the first and second regression models are presented in The regression analyses results are shown in The main objective of our study was to assess the relationships in the two following regression models related to the functioning of children and adolescents with mild and moderate intellectual disability (ID): (1) model I: child’s willingness to engage in physical activity (dependent variable), child’s physical limitations related to disabilities and/or comorbidities, child’s independence, parents’ willingness to engage in physical activity, child’s body dissatisfaction (independent variables/predictors); (2) model II: child’s emotional eating (dependent variable), child’s coping with emotions, parents’ attitudes, beliefs, and practices about child feeding (restriction and pressure to eat), parents’ emotional eating, parents’ happiness (independent variables/predictors). Our results allow partial confirmation of the hypotheses related to both of these models: (1) model I: the relationships between the child’s willingness to engage in physical activity and all predictors are significant, but the direction of the relationship between the dependent variable and one of the predictors—body dissatisfaction—is opposite to the assumed one (negative relationship); (2) model II: the relationships between the child’s emotional eating and almost all predictors are significant, except for the relationship between the dependent variable and pressure to eat.With regard to the relationships in the first regression model, it turns out that the increasing level of the child’s willingness to engage in physical activity can be predicted on the basis of a decrease in the level of the child’s physical limitations (related to disabilities and/or comorbidities) and body dissatisfaction, and an increase in the level of the child’s independence and parents’ willingness to engage in physical activity. Our findings seem to be consistent with previous reports, which show that such basic factors as the child’s physical limitations (related to disabilities and/or comorbidities) or child’s independence largely determine various behaviors of children and adolescents with ID  ,13,14. TConsidering the relationships in the second regression model, it turns out that an increasing level of a child’s emotional eating can be predicted on the basis of a decrease in the level of a child’s coping with emotions, as well as their parents’ happiness, and an increase in the level of restriction and parents’ emotional eating . Our results are consistent with previous reports that indicated a similar positive relationship between emotional eating in children without ID and their parents ; the baReferring to the findings described above, some researchers have analyzed physical activity, eating patterns, and body mass index among children and adolescents with ID ,53,54,55Our study had several important limitations, mainly: (1) it was a cross-sectional design; (2) it used only self-report measures (based on the parents’ assessment of their children’s functioning); (3) although our sample consisted of fathers and mothers, there was a significant advantage of mothers; (4) a convenience sampling method was used to recruit participants; (5)  not all questionnaires have been previously validated in a Polish sample; (6) our study did not focus on a detailed assessment of a child’s IQ ; (7) neurologic conditions in comorbidity or the intellectual disability due to syndromes were not excluded or considered in detail ; (8) caregivers’ burdenrelated to child’s intellectual disability was not analyzed, and, as is known, parents play a central role in the education and rehabilitation processes , they may be at a much greater risk of developing psychosocial problems, including severe stress, depression, and parental burnout) ,61,62.ItAs mentioned above, our findings partially confirm our hypotheses: (1) the relations between a child’s willingness to engage in physical activity and all predictors are significant (only the relationship with body dissatisfaction is opposite to the assumed one); (2) the relationship between the child’s emotional eating and almost all predictors are significant (except for the relationship with pressure to eat). In conclusion, using the perspective of dyadic research (based on data from both persons from the child-parent pair), it was analyzed in more detail how we can predict  children’s tendenciesto engage in physical activity, and the tendency in children and adolescents with mild and moderate intellectual disabilityto eat under the influence of emotions. Such studies seem important because (as mentioned above): (1) the vast majority of previously available reports in the analyzed field refer to the functioning of children without a diagnosis of intellectual disability ; (2) these dyadic studies allow for a deeper and fuller (richer) understanding of the attitudes, beliefs, and experiences of the study participants than a single perspective; (3) these results may be the basis for creating equitable healthcare quality and safety for children and adolescents with ID.To the authors’ knowledge, this study is the first to assess dyadic predictors of willingness to engage in physical activity and emotional eating in children and adolescents with mild and moderate intellectual disability. Moreover, it allows for a better understanding of the attitudes, beliefs, and experiences of children with intellectual disabilities and their parents, which gives the opportunity  to better design strategies to support pro-health behaviors in children and adolescents from this group (which may improve the effectiveness of overweight prevention and obesity). These findings emphasize how important it is to consider the dynamic of the child-parent dyad when considering how parenting contributes to a children’s willingness to engage in physical activity and children’s emotional eating. As the prevalence of children’s emotional eating is increasing  and sta


Within healthcare, the barriers and enablers that influence clinicians’ ability to speak up are well researched. However, despite the receiver of the message being identified as a key barrier to a speaker voicing a concern, there have been very few receiver-focused studies. As a result, little is known about the barriers and enablers that influence message reception. Understanding these can help inform speaking up training and ultimately enhance patient safety through more effective clinical communication.To identify enabling or inhibiting factors that influence the receiver’s reception and response to a speaking up message, and if the identified barriers and enablers are related to speaker or receiver characteristics.Twenty-two interdisciplinary simulations were video recorded and transcribed. Simulation participants formed the patient discharge team and were receivers of a speaking up message, delivered by a nurse at the patient’s bedside. How the message was delivered (verbose or abrupt wording), was manipulated and counterbalanced across the simulations. Within the post simulation debriefs, barriers and enablers of being a receiver of a message were explored using content analysis.This study took place in a large Australian tertiary healthcare setting. Participants were qualified clinicians of varying disciplines and specialties.A total of 261 barriers and 285 enablers were coded. Results showed that how the message was delivered  influenced what receivers identified as barriers and enablers. Additionally, the receiver’s own cognitive processes, such as making positive attributions of the speaker and attempting to build rapport and collegiality, better enabled message reception and response. Receiver behaviour was negatively impacted by listening to fix, rather than understand, and not knowing in the moment how to manage their own reactions and appropriately frame a response.The debriefings identified key barriers and enablers to receiving a speaking up message that differ from those previously identified for senders of the speaking up message. Current speaking up programs are predominately speaker centric. This study identified that both speaker and receiver behaviour influenced message reception. Therefore, training must place equal attention on both the speaker and receiver and be inclusive of experiential conversational rehearsal of both positive and challenging encounters.The online version contains supplementary material available at 10.1186/s41077-023-00256-1. Speaking up is a complex social interaction with a dynamic relationship between the speaker and receiver. We define a speaking up interaction as voicing a concern that challenges the status quo  until a Healthcare speaking up has been well researched with respect to barriers and enablers to voicing a concern , 7. Yet,With few receiver-focused healthcare studies, evidence informing speaking up has been translated from other domains. Message reception has been studied in social psychology where Krenz, Burtscher  looked aA review of the healthcare literature revealed two receiver focused studies both conducted within the perioperative environment. Lemke, Burtscher  exploredThe current identified gaps in speaking up literature are (1) the identification and deeper understanding of the receivers’ barriers and enablers for message reception and response, (2) understanding receiver behaviour outside of the perioperative environment and across multiple healthcare disciplines. We aimed to address these gaps by identifying barriers and enablers to message reception and response within an interprofessional environment, and general inpatient ward. Simulation was used as a means to create a situation where a patient safety negotiation was required. The authors have previously studied receiver behaviour (message reception and response) in one-to-one interactions  , 25. ThiCommunication Accommodation Theory (CAT)  posits tThe authors observed and explored receiver behaviours (message reception and response) through the lens of the constructivist approach. This approach believes that there is no one truth but rather multiple realities regarding speaking up experience which are best explored through qualitative methodologies . This stThe simulation study was conducted within a single health organisation providing both public and private health services across adult medical and surgical services, oncology, maternity, neonatal and adult critical care. Data collection occurred between May and November 2019. Purposive sampling was used to recruit qualified clinicians from varying clinical disciplines and specialties. Simulation provided a context that helped to facilitate meaningful interactions between the disciplines. All participants were clinicians attending a mandated speaking up training program. Participants self-enrolled into the program, which included simulation as a core training element. Participants then chose to either undertake the standard program , or voluntarily consent and participate in the research simulation activity (receivers of a message). Both activities ran concurrently within the program. As a result, each simulation differed in size and clinical discipline. At least two nurse/midwifes were present in each simulation, medical officers were present in 11 and allied health in 10 simulations. The study consisted of 22 sessions for data collection.The simulation was a clinical scenario where a junior nurse named Mary (embedded simulated participant) had to speak up to a multidisciplinary discharge team (the participants) during a patient bedside round. The patient was Mrs Williams (manikin voiced by a simulation technician via microphone) who had had a fall at home and was being cared for by Mary. The study participants formed the patient discharge team undertaking the round and were therefore the receivers of the nurse’s speaking up message. Upon arrival of the team to the bedside, Mary spoke up about her concern including that the patient discharge had not been completed and no home support was in place; therefore, the patient was at high risk of another fall. Moreover, the ambulance was on the way to transport the patient home and Mary did not believe the patient should go home without appropriate care in place.Mary consistently spoke up using hint and hope methodology across all 22 simulations. Hint and hope is when one person wants another person to do/know something specific, or change behaviour, but is unwilling to address the issue directly , 29. ThiTo study the impact of message delivery, two different message types informed by CAT, were designed and alternated across the 22 simulations. The nurse hinted and hoped by being theoretically accommodative (respectful and polite) and providing a lot of general information (being verbose) about the situation in eleven simulations. In the other eleven simulations, the nurse hinted and hoped by being less polite and more abrupt (less accommodative), see Table Prior to data collection, debriefers attended an onboarding session outlining research simulations and objectives. All debriefers had previously undertaken formal debriefing training. For the first round of data collection, faculty worked in pairs to help ensure a consistent approach to the debriefing process. This was supported by an Objective-Orientated-Debriefing tool, to help structure and guide the debriefing process . The facAll the debriefs were video recorded by both Go-Pro camera and the simulation centres inbuilt audio-visual (AV) system to mitigate the risk of audio-visual recording failure. Video data were stored on a password protected external hard drive and then uploaded into a research data management system. All 22 debrief videos were reviewed for audio quality and were included for analysis. The debriefs were transcribed verbatim using NVivo transcription  and crosCoding of the barriers and enablers for receiving the speaking up message were inductively analysed and deductively categorised using a content analysis approach . FirstlyBoth coders were Caucasian, female registered nurses with an extensive history in healthcare education and simulation and had experience in developing and delivering speaking up training programs. Author MB acknowledges that prior personal confronting experiences with receivers of speaking up messages may have influenced the qualitative analysis process. One in particular, resulted in patient harm . Author DASH ratings were completed on the 22 video recorded debriefings by the two researchers (MB & KM). The DASH utilises a 1 to 7 scale and has undergone prior validity and reliability testing . The twon = 96), allied health, [AH] comprising of social workers, physiotherapists, radiographers, pharmacists, and phlebotomists (n = 22) and medical officers [MO] (doctors) (n = 20), refer to Table Twenty-two debriefs were analysed, 11 with accommodative/verbose wording and 11 with less accommodating, abrupt wording. The average debrief time was 14:37 min (range 10:0–20:10 min). There were 138 clinicians who participated in the debriefing sessions. Nurses/midwives [NM] (n = 69) participants in each of the accommodative, verbose, and less accommodative, abrupt simulations .The debriefing transcripts were coded, and frequencies of codes obtained, see Table Each code was presented as the percentage of the total codes for both barriers and enablers, see Figs. “I guess you get that tunnel vision, you get so focused on the task that we had were there to discharge a patient that afternoon that it took the repetition of her saying three times before I actually stopped and took a second to realize, okay, I need to address something here” (NM 42).Listening to fix referred to receivers listening to identify tasks to be done, rather than listening to understand the concern being raised, and was identified as the most frequent theme across both message types.Message structure is related to the clarity of the concern and the phrasing used by the speaker. Receivers described that the message was either not clear or direct enough, e.g. “I think just a bit more direct about what you need. I think it's very hard to pick out what she was actually wanting us to do” (NM63), or the message only contained the problem and no solutions or recommendations “The nurse couldn't show any solutions” (AH07). The more accommodative and ‘polite’ messaging was for many seen as a barrier, as speaking up is not normally framed as a ‘polite’ conversation, e.g., “We haven't really practiced it in a positive way. It's always a matter of disagreement or trying to approach something that's bad that's happened” (NM09). Knowing how to receive a non-confrontational message was an identified barrier, “I think I was quite confused. Because I think I was expecting a complication. Just didn't really know what the crux of it was” (NM10).“If they're like a doctor or someone, I'm just gonna [sic] cop it. I'm just going to say, okay, I'll agree with you. You know, unless it's something that is really completely unsafe to the patient, then you have to” (NM45).The conversation occurring in the presence of the patient, influenced receiver responses and the evaluation of the situation, particularly with the more abrupt messaging, e.g,. “I did feel like we should not have been having that conversation in front of the patient” (AH 04). The speaker’s discipline and the perceived hierarchy of that discipline in relation to the receiver’s own, was described as impeding receiver voice and their ability to effectively engage. Speaker discipline was predominately described by receivers as apprehension to receive messages and communicate with medical officers within real clinical practice.Nursing, midwifery, and allied health participants did not describe a medical officer speaking up as speaking up, rather it was perceived as a nonnegotiable order. See Supplementary data Table SThere was a larger distribution of identified enablers compared to barriers. For the more accommodative/verbose speaking up message, the four most identified enablers were message structure , making positive attributions , building rapport and collegiality , and message delivery . Within the simulations where the message delivery was less accommodative and more abrupt, the four most identified enablers were building rapport and collegiality , making positive attributions , knowing how to receive , and shared professional identity .“When she used those key words, I'm concerned, and she was able to list off her concerns. And then using the word 'safe' where you say, I'm concerned about the safety of my patient, when you use particular keywords, that makes you think a little bit differently and you take it a lot more seriously” (NM42).Receivers described message structure as an enabler only within the more accommodative and verbose speaking up messages. Receivers described that the message was clear and easily interpreted, e.g. “I think she was concerned she was going to cope at home. She communicated that very clearly, I thought.” (MO05), and/or the speaker used a known safety phrase ‘I’m concerned’ that made the receiver pay more attention to the speaker.“Yeah. I think also with the tone and stuff, my mood almost like made me feel a bit more respected… if someone's yelling at you, I feel like they're not respecting you very much. But if they're being calm and like talking to you, then there's a bit more of respect going back and forth (AH03).Message delivery, that is the way the message was delivered, was only described as an enabler again, with the more accommodative and verbose speaker message.Building rapport and collegiality, e.g., the conversation was, or aimed to be collaborative, through building rapport and/or perceiving equal accountability, “It felt like we were all working together” (NM08), and “it's more like asking, do you think this is the right thing? Like, you know, I'm not really sure myself, like maybe let's think about this together, more than, I'm right and you are wrong” (MO02).“I think just understanding. Like others, you know, we are all busy and if things aren't done the way you want them to be done, or in the time you want them to be done in, there is often a good reason” (MO10).Making positive attributions about the speaker related to the receiver giving the speaker the benefit of the doubt and/or holding them in positive regard, regardless of how speaker behaviour was perceived. Receivers described making more positive attributions about speaker intent with the less accommodating/abrupt messaging.Receivers described when spoken up to with the more abrupt wording, that knowing how to receive and respond to a message was important to have an effective conversation. One receiver described that instead of getting defensive to the message instead say “I'm thinking that you're really worried about this patient. I'm wondering what I can do for you?” (NM26).Sharing a professional  identity  enabled receivers to align themselves with the speaker and internally empathise with the speaker’s situation; “It's easier to hash it out with someone if you're a similar job role, because you both understand the minute problems you face, like so you kind of both understand what delaying someone's discharge will mean to this and that” (NM76).See Supplementary data Table SThis study sought to identify barriers and enablers of receiving speaking up messages by undertaking a qualitative analysis of 22 debriefs. We found that the characteristics of message delivery  influenced what receivers identified as barriers and enablers. Additionally, the receiver’s own cognitive processes, such as making positive attributions of the speaker and attempting to build rapport and collegiality, better enabled receiver responses.Overall, there were a greater number of enablers  identified than barriers (predominately Self). However, the distribution and frequency of the enablers were more dispersed. This could indicate that what helps receivers to hear and process the message, is harder to define than the barriers. It may be that receivers genuinely do not have clarity as to what enables them to effectively listen, process the message, and frame a response. Not knowing how to receive the message was identified as a key barrier, and the prospect of being trained how to receive a message, was perceived as an important enabler.The first research question was to identify enabling and inhibiting factors for receivers when engaging in a speaking up conversation. Results demonstrate that the ability of the receiver to make positive attributions, or hold ‘The Basic Assumption’  of the sThis desire to be, or appear to be collegial, may have been due to the presence of the patient. The patient’s presence was a clear barrier for receivers across both message types. Unlike feedback conversations, speaking up most frequently occurs, and needs to occur, during clinical practice where others are present. Schwappach and Gehring  found thInterestingly, regardless of how the message was delivered, receivers described an overall unpreparedness to receive and respond when spoken up to, specifically what to say, and how to clarify further to help their understanding. This resulted in extrapolated conversations and a delay in understanding the problem . Bodie aWhat may help, is for speaking up mnemonics to include recommendations or desired outcomes the speaker is seeking. Receivers often discussed frustration as the speaker didn’t offer solutions and recommendations when raising the concern, often referring to the handover tool ISBAR  as a poiThe second research question aimed to understand if the identified barriers and enablers were due to characteristics of the speaker, or the receiver. Fundamentally, it was both. The barriers and enablers show that there is equal accountability on the speaker and receiver for the conversation to be successful. What was unusual, was that receivers in the more accommodative, verbose messaging described message structure as both a key enabler and barrier, whereas the more abrupt messaging (structure and delivery) was only identified as a barrier.The accommodative, verbose message was an enabler due to the manner of the speaker being evaluated as polite and the concern being more legitimate. Where this messaging was seen as a barrier, receivers explained that the general narrative around speaking up in healthcare is that it is framed as a ‘difficult conversation’, and training programs discuss and rehearse more confrontational examples and situations. By doing so, receivers were unsure how to respond when the interaction was not confrontational. Vauk, Seelandt  also repHow the message was delivered had impact. The seemingly ‘politer’ hint and hope messaging adopted by nurses, has shown to cause frustration for medical officer receivers, influencing the sense of situational urgency and increased cognitive burden . Within Along with the messaging, receivers discussed the negative impact of the speaker’s emotions. Receivers described and evaluated the speaker as being stressed, frustrated and anxious which directly impacted their own behavioural reactions. Receiver’s not knowing how to receive, not just what to say, but how to manage their own internal reactions, were key identified barriers. Schein and Schein  describeWhen the conversation was generalised to real clinical practice, receivers identified speaker discipline impacted their reception of a message. Nurses, midwives, and allied health described that they did not define a medical officer raising a concern as speaking up, rather it was a non-negotiable order. This finding was supported in a recent article describing real speaking up encounters. To enhance interdisciplinary receiver response, medical officers need to clearly verbalise when they are speaking up, and actively invite receiver input. This invitation to speak, has shown to enhance junior speaking up behaviour  and needLimitations of the study included the simulated environment. To offset this, substantial effort was made to design and deliver the highest quality of simulation in consideration of creating an authentic experience and by aligning to best practice standards and evidence. Additionally, all debriefers were trained in the same methodology of debriefing and demonstrated consistent, high-quality debriefing, as supported by DASH results. Secondly, the participants still knew they were being observed, and participation in an interdisciplinary round may not be part of their normal clinical role, potentially impacting their ability to fully engage. Data collection occurred at a single site and although participation in the receiver focused simulation was voluntary, we acknowledge that attendance to the speaking up program was not. Finally, the clinical event simulated in the scenario was a not an occasion where patient harm was imminent, and therefore caution extrapolating the results to high stress, high emergent situations need to be taken into consideration.Simulation debriefs identified key barriers and enablers to receiving a speaking up message within the context of a patient discharge with an interdisciplinary team. Findings demonstrated that both speaker and receiver behaviour influenced message reception. The results indicated that speaking up programs need to include training for receivers: to help shift from listening to reply or fix, to listen to understand, manage both the speaker’s and their own emotions in the moment, and view speaking up as a shared accomplishment. To do this, educational programs must train the speaker and receiver equally through conversational rehearsal of both positive and challenging encounters. Simulation is uniquely positioned to provide the learning space for this training.Additional file 1: Supplementary data Table S1. Codes, Definitions and Examples of the Barriers to Receiving a Speaking Up Message. Supplementary data Table S2. Codes, Definitions and Examples of the Enablers to Receiving a Speaking Up Message.


In the field of sport psychology, research on emotional intelligence and its relationship with other psychological variables to determine how it affects the athlete’s performance is becoming more frequent and prevalent. Among these psychological variables, research in this field has focused on the evaluation of the influence of aspects such as motivation, leadership, self-concept, and anxiety. The main objective of this research is to analyze the levels of each of the dimensions of emotional intelligence  and their relationship with each of the SCAT items to measure pre-competitive anxiety. To do so, we analyzed the influence that one psychological construct has on the other, in order to establish the type of relationships that are established between them. The design of this research corresponds to be transversal, observational, quantitative, and descriptive. The sample consisted of 165 students belonging to university degrees (bachelor’s and master’s) related to physical activity and sport sciences. The main finding of this study allows us to affirm the relationship between emotional intelligence and anxiety. This confirms the hypothesis that anxiety is an indispensable component of any competitive situation, and that neither the total absence of anxiety nor high levels of it leads to better sports performance. Therefore, sport psychology should focus on the emotional preparation of athletes so that they can manage and control their anxiety at intermediate levels, which in addition to being typical of a competitive situation, is also synonymous with good sporting performance. The contributions of sport psychology aim to investigate all those variables of a psychological nature that allow us to analyze their impact on sporting performance ,2, i.e.,Regarding emotional intelligence, in this research, we start from the theoretical contributions based on the ability model  from whiHowever, research on emotional intelligence is not only relegated to this construct, but there is also an increasing prevalence of research focused on the analysis of the relationship established between this construct and other psychological variables, such as adaptation ,10 or thFocusing on anxiety, in the field of sport, a conception of anxiety that refers to a negative emotional state in which the athlete feels a state based on worry, nervousness, tension, and apprehension associated with the activation of bodily arousal has been adopted . ConceptResearch on anxiety in the field of sport has shown that these emotions appear in pre-competitive situations , where tIn addition, there are many factors that affect the presence of anxiety, corresponding to the place where the competition takes place, the athlete–coach relationship, the level of performance of the opponent, the expectations placed on the competition, etc. ,33,34,35Therefore, the main objective of this research is to analyze the levels of each of the dimensions of emotional intelligence  and their relationship with each of the items related to pre-competitive anxiety that make up the SCAT (Sport Competition). In addition, this research aims: to investigate the influence that one psychological construct has on the other; to investigate the type of relationships that are established between them; and to answer the following research question: Is anxiety an ever-present element in competitive situations, and can sport psychology, specifically, emotional intelligence and emotional training, help the athlete to manage it?To this end, the following hypotheses are established:Hypothesis 1 (H1).The total absence of anxiety does not lead to better sporting performance, and is not related to any of the dimensions of emotional intelligence. Hypothesis 2 (H2).High levels of anxiety are typical in athletes and are even considered as an emotional drive for sports practice.Hypothesis 3 (H3).Moderate levels of anxiety correspond to good sporting performance, which can be obtained through emotional training.This research uses a quantitative, exploratory, descriptive, and explanatory methodological approach and is based on the survey technique through the use of two validated and standardized questionnaires . The useFurthermore, it is an ex post facto design because we selected participants whose basic requirement is to be a student of degrees related to physical activity and sport sciences. Thus, students of a degree in physical activity and sport sciences, students of a degree in primary education specializing in physical education, students of a master’s degree in research on physical activity and sport sciences, and students of a master’s degree in secondary education specializing in physical education participated in this research.The total sample is made up of 165 students who belong to university degrees (undergraduate and master’s degrees) related to physical activity and sports sciences. Regarding sex, 70.9% (n = 117) were men and 27.9% (n = 46) women, while the mean was 20.33 years, with a standard deviation DE = 3.44. The type of sample used is simple and random. Since the questionnaires were completed by the students who attended class on the day selected to provide them. Therefore, it corresponds to a non-probabilistic and convenience sample. The fundamental reason for choosing students who study degrees related to physical activity and sports sciences is due to the main purpose of this work, in terms of knowledge of the relationship between pre-competitive anxiety and emotional intelligence in university students, future professionals of physical activity and sports sciences. In addition, this work takes an interest in analyzing what knowledge about them they have or need, and how, from the initial training, it is appropriate to work on training in emotions as a protective factor against anxiety in athletes and students. The sample size was calculated using Soper’s a priori sample size calculator for structural models, based on which the recommended minimum effect size was 200 cases, so the total sample of this research is close to the recommended number. As criteria for inclusion of the participants we chose that the participating students were enrolled in the subject and course in question, that they accepted their participation through informed consent  and that they were of legal age. All participants completed the official informed consent form of the University of Almería (Spain) and were informed of the data protection protocol. On the other hand, as exclusion criteria, we discarded those incomplete booklets.The N of the universe of the study understood as the set from which the information is extracted was a total of 277 participants, taking as a guide for its calculation: the total number of students enrolled in each of the four courses of the official degree in sciences of physical activity and sport; the total number of students enrolled in the specialty of physical education of the official title of primary education; the total number of students enrolled in the master’s degree in physical activity and sports science; and the total number of students enrolled in the specialty of physical education within the official master’s degree in teacher training. We used the margin of error calculator, and we specified the total population size, the desired confidence level , and the sample size. The score obtained was 3.20%. In this sense, the further the percentage is from 50%, the smaller the margin of error turns out to be.The data collection procedure for this research is as follows: Phase 1: Design and temporary and theoretical planning of the investigation. Specifically, it is an empirical study based on a quantitative, descriptive, and cross-sectional methodology. Phase 2: Our design and planning were submitted to evaluation by the Bioethics Committee of the University of Almería, being approved by the Institutional Review Board of the University of Almería (UALBIO2022/035), given that the Helsinki Declaration guidelines on research ethics are met. Phase 3: To access the data collection, we first contacted each of the teachers of each of the undergraduate or master’s degree subjects by email. Through it, we informed them of the reason and purpose of the investigation, and we asked for permission to attend their class in person, and we agreed on a visit date, either at the end or at the beginning of the class.Phase 4: The collection of information was carried out during the first four-month period of the 2021/2022 academic year in each of the four courses of the official degree in physical activity and sports sciences, in the specialty of physical education of the official title degree of primary education, in the official master’s degree in physical activity and sports sciences, and in the physical education specialty of the official master’s degree in teacher training. During the data collection, the principal investigator was always present to invite the participants to participate in the study and obtain their informed consent, as well as offering brief information on the objectives of the research and the pertinent instructions to complete the questionnaire, taking emotional intelligence and anxiety as variables. Before beginning, the anonymity of the answers and the confidentiality of the data were guaranteed, dedicating around 20 min to their answers, without any of them reporting problems to complete it.To measure pre-competitive anxiety, we used the Sport Competition Anxiety Test (SCAT)  adapted To measure emotional intelligence, the “TMMS-24” was used as an instrument  to measuFor this research we created a kind of booklet which was made up of the following instruments: First, different sociodemographic data corresponding to age, sex, degree, course, marital status, or sports practiced were requested. Then, two standardized and validated scales were included in the booklet to measure each of the psychological constructs that articulate the thematic axis of this research, which correspond to the following: Both the hierarchical omega  and the Descriptive data analysis involved calculating the mean, standard deviation, and bivariate correlations. In addition, the reliability was calculated, and finally, a second-order structural equation model (SEM) was performed. This statistical test not only demonstrates the higher-level structure and its consequences for certain dependent variables, but also offers us the opportunity to confront irrefutable forms of multicollinearity ,47,48. TThe results are presented according to each of the dimensions of emotional intelligence, emotional attention, emotional clarity, and emotional regulation. Thus, Structural equation modelThe hypothetical model of predictive relationships  shows thp < 0.001, RMSEA = 0.0, GFI = 0.89.- Overall fit indices  and are adequate: ○Item 1, “competing against others is fun”, was not correlated with emotional attention. ○p < 0.001). Item 2, “before competing I feel agitated”, was positively correlated with emotional attention . Item 3, “before competing I worry about not performing well”, was positively correlated with emotional attention . Item 4, “I am a good athlete when I compete”, was positively correlated with emotional attention . Item 5, “when I compete, I worry about making mistakes”, was positively correlated with emotional attention . Item 6, “before competing I am calm”, was positively correlated with emotional attention . Item 7, “setting a goal is important when competing”, was positively correlated with emotional attention . Item 8, “before competing I have an unpleasant feeling in my stomach”, was positively correlated with emotional attention . Item 10, “I like to compete in physically demanding activities”, was positively correlated with emotional attention . Item 11, “before competing I feel relaxed”, was positively correlated with emotional attention . Item 12, “before competing I feel nervous”, was positively correlated with emotional attention . Item 13, “team sports are more exciting than individual sports”, was positively correlated with emotional attention . Item 14, “It makes me nervous wanting the competition to start”, was positively correlated with emotional attention .Item 15, “before competing I usually feel tense”, was positively correlated with emotional attention  and are adequate: ○Item 1, “competing against others is fun”, did not correlate with the emotional clarity dimensions. ○p < 0.001). Item 2, “before competing I feel agitated”, was positively correlated with emotional clarity . Item 3, “before competing I worry about not performing well”, was positively correlated with emotional clarity . Item 4, “I am a good athlete when I compete”, was positively correlated with emotional clarity . Item 5, “When I compete, I worry about making mistakes”, was positively correlated with emotional clarity . Item 6, “before competing I am calm”, was positively correlated with emotional clarity . Item 7, “setting a goal is important when competing”, was positively correlated with emotional clarity . Item 8, “before competing I have an unpleasant feeling in my stomach”, was positively correlated with emotional clarity . Item 10, “I like to compete in physically demanding activities”, was positively correlated with emotional clarity . Item 11, “before competing I feel relaxed”, was positively correlated with emotional clarity . Item 12, “before competing I feel nervous”, was positively correlated with emotional clarity . Item 13, “team sports are more exciting than individual sports”, was positively correlated with emotional clarity . Item 14, “It makes me nervous wanting the competition to start”, was positively correlated with emotional clarity . Item 15, “before competing I usually feel tense”, was positively correlated with emotional clarity  and are adequate: ○Item 1, “competing against others is fun”, did not obtain a correlation with emotional regulation. ○p < 0.001). Item 2, “before competing I feel agitated”, was positively correlated with emotional regulation . Item 3, “before competing I worry about not performing well”, was positively correlated with emotional regulation . Item 4, “I am a good athlete when I compete”, was positively correlated with emotional regulation . Item 5, “When I compete, I worry about making mistakes”, was positively correlated with emotional regulation . Item 6, “before competing I am calm”, was positively correlated with emotional regulation . Item 7, “setting a goal is important when competing”, was positively correlated with emotional regulation . p < 0.001). Item 8, “before competing I have an unpleasant feeling in my stomach”, was positively correlated with emotional regulation . Item 10, “I like to compete in physically demanding activities”, was positively correlated with emotional regulation . Item 11, “before competing I feel relaxed”, was positively correlated with emotional regulation . Item 12, “before competing I feel nervous”, was positively correlated with emotional regulation . Item 13, “team sports are more exciting than individual sports”, was positively correlated with emotional regulation . Item 14, “It makes me nervous wanting the competition to start”, was positively correlated with emotional regulation .Item 15, “before competing I usually feel tense”, was positively correlated with emotional regulation (=0.06, The relationships established in the structural equation model between emotional regulation and the SCAT items are specified below: Since the SCAT lacks factors created as such, mean scores and their relationship between the total scores obtained on the SCAT and emotional attention, emotional clarity, and emotional regulation was also calculated see . The datThe results show the direct and positive relationship between SCAT mean scores and emotional attention.The main objective of this research was to analyze the relationship between the two thematic focuses of this work, that is, between anxiety and emotional intelligence. This objective was met. This fact shows that emotional intelligence refers to a set of skills related to the reflection of emotions and its feasibility to facilitate and govern thought . AdditioRegarding the hypotheses, hypothesis one is fulfilled, and it is demonstrated that the total absence is not related to any of the dimensions of emotional intelligence, which is in line with what has already been provided by other research that establishes that a lack of anxiety is not synonymous with good sports performance ,50,51. RFor this reason, the results obtained indicate the importance of betting not only on a physical or cognitive level, but also on an emotional level in the initial training of future professionals in the physical activity and sports sciences. Different implications of an educational nature are derived from this, which go through the promotion of the treatment of emotional intelligence in athletes, based on the theoretical contributions of ability models . The heyday and power of research focused on emotional intelligence within the psychological field in the 21st century is undeniable. In this sense, our research shows the importance of studying this construct from the perspective of sport psychology, a field in which its study is also acquiring great importance ,58,59. In this way, the results provided indicate the close relationship and influence that it has on such important aspects in the field of sport, such as sports performance, training effectiveness, social skills, problem solving, and anxiety ,61,62. IIn addition, another large amount of research has also analyzed the relationship of anxiety with other psychological constructs such as resistance, performance, or the type of training ,65,66. IWe must be cautious with the findings obtained, due to the sample size of this research and because it corresponds to a cross-sectional research design. Therefore, we consider that it would be appropriate to repeat this investigation, increasing the number of participants to analyze whether these findings are maintained, this being the main limitation of this investigation. Future research topics will focus on the differential analysis according to the type of sport practiced and the time dedicated to the sport. In this way, future research will seek to investigate setbacks according to the degree of professionalization of each sport practiced by future participants, as well as the size of the difference between different groups.In conclusion, the present study provides evidence of the relationships hypothesized in the proposed models between the dimensions of emotional intelligence and anxiety. It is shown that anxiety is something of its own in sports practice, mainly before competitions, and it can even be an impulse for the athlete. In turn, emotional intelligence is postulated as a key element in athletes learning to manage these levels of anxiety and being able to maintain them at medium and moderate levels. For this reason, this study has established the importance of providing emotional training to future professionals in physical activity and sports sciences from their initial training, since it will trigger an adequate regulation of their own emotions and anxiety that will allow them to successfully face any sports or work situation.