Background
Learning effective communication and teamwork skills is crucial to improving patient safety for health care professionals [
1]. The frontline staff, such as medical residents and nurses, is well positioned to observe early signs of unsafe conditions in care delivery and bring them to the attention of the organisation [
2,
3]. ‘Speaking up’ is defined as the raising of concerns by health care professionals for the benefit of patient safety and care quality upon recognising or becoming aware of the risky or deficient actions of others within health care teams in a hospital environment [
4,
5]. Such actions include mistakes (e.g. missed diagnoses, poor clinical judgement), lapses, rule breaking, and failure to follow standardised protocols. Speaking up is expected to have an immediate preventive effect on human errors or to improve technical and system deficiencies. Organisational research illustrates that, in many cases, people choose the ‘safe’ response of silence, withholding input that could be valuable to others or thoughts that they wish they could express [
6,
7]. In health care environments, it has been shown that those who are aware of a problem often either speak up and are ignored or do not speak up at all [
8,
9].
Previous organisational studies indicated that several factors influence employees’ voicing behaviour. Silence can be caused by fear, by the desire to avoid conveying bad news or unwelcome ideas, and by normative and social pressures that exist in groups [
6,
7]. In addition, hesitance in speaking up or failure to indicate or correct errors can be caused by disproportionate authority gradients, excessive professional courtesy, and/or deficiencies in resource or task management [
10]. Morrison integrated the existing theory and research and developed the model of employee voice [
11]. In this model, it is presumed that the driving motive for voice is the desire to help the organisation or work unit to perform more effectively or to make a positive difference for the collective. The voice reflects a deliberate decision process whereby the individual considers both positive and negative consequences and the perceived efficacy and safety of voicing his or her concerns. The perceived efficacy of voice is the individual’s judgement about whether it is likely to be effective. The perceived safety of voice is the individual’s judgement about the risk of potential negative outcomes. The individual is faced with a balancing act of trying to be pro-social and constructive while at the same time being mindful of personal costs. Contextual factors (e.g. organisational culture) and individual factors (e.g. job attitude, personality) affect these perceptions. The employee’s voice has important benefits for organisations and work groups as well as for the one who speaks up. The message type, tactic, and target are also important factors in voicing.
The Morrison model for organisations provides us with a basic framework, but for the clinical setting two factors have to be taken into account. The first is that the type of information that is being conveyed is usually one of concern [
11]. An employee may for instance think very differently about the potential benefits and risks of speaking up when bringing up such an issue of concern compared to voicing a novel suggestion. The second is that while in organisational contexts speaking up will often relate to the well-being and goals of the organisation and its workers, speaking up in health care for patient safety is primarily aimed at promoting the well-being of its clients. In health care, several interventions have been introduced to improve teamwork and communication [
12]. While teaching safety theory and/or team training may not be sufficient to empower health care professionals to voice their concerns [
13], understanding speaking-up behaviour and its related factors can be useful in designing patient safety improvement initiatives that lead to more effective and sustainable behavioural change and safety improvement outcomes. This review was aimed at developing a model that integrates evidence from the existing literature on health care professionals’ speaking-up behaviour on the basis of their particular characteristics (e.g. concerns related to patients’ well-being). Such a model is expected to help us to understand why health care professionals often prefer silence to speaking up when patient safety is at stake. While there have been a growing number of studies on factors that enhance or inhibit speaking up by health care professionals recently, a conceptualised theoretical model for understanding speaking-up behaviour and its related factors is not yet available. In light of this, the current review aims at (1) assessing the effectiveness of speaking up for patient safety, (2) evaluating the effectiveness of speaking-up training, (3) identifying the influencing factors of speaking-up behaviour by health care professionals, and (4) developing a model for health care professionals’ speaking-up behaviour by integrating these factors into the model of employee speaking-up behaviour. This study does not consider whistle-blowing to the public or the authorities but focuses on performance monitoring within teams for patient safety. Likewise, our study focuses on the preventive aspect of speaking up rather than on other aspects such as sharing of ideas.
Discussion
Health care professionals are expected to speak up about their concerns before a critical event reaches a patient to provide a chance to correct the plan or intervention. There have been some studies investigating the relationship between the speaking-up behaviour of health care professionals and patient safety outcomes. They indicate that hesitancy to speak up can be an important contributing factor in communication errors and/or adverse events [
18‐
20]. Most medical and nursing professionals, irrespective of their position and specialty, have some experience of hesitating in voicing their concerns over patient safety risks, even when they are aware of the hazards and immorality of not speaking up [
5,
27,
33‐
35,
38‐
40]. These studies indicate that, if health care professionals voice their concerns, it may provide the opportunity to recover from errors and avoid adverse consequences, even if there are some biases (e.g. people were likely doing what they were doing because they thought they were right, given their understanding and the pressure of the situation [
41]). It is difficult to observe speaking-up behaviour in the clinical setting and to evaluate its effectiveness. Organisational research has illustrated the importance of the voluntary sharing of ideas and information for organisational learning and improvement [
3,
11,
29]. Collecting the cases of speaking up and its outcomes, including the impact on team members, can be an important first step to understanding the consequences of speaking up. Speaking up may affect not only the patient but also the messengers themselves, other team members, and/or the organisation. In this review, we did not focus on these latter issues, and further research is needed to pay attention to how they should be addressed to enhance speaking-up behaviour.
Where training programs have been introduced in order to improve health care professionals’ speaking-up behaviour, there is no strong direct evidence that coaching in speaking up improves patient safety. However, Kolbe et al. demonstrated that a nurse’s level of speaking up is a predictor of technical team performance [
16], and appropriate training has been shown to have a positive influence on the speaking-up attitudes [
23‐
25] and behaviour of health care professionals in a simulated setting [
21,
22]. This provides a rather strong case for health care professionals to undergo training in communication skills (e.g. the use of critical language, assertion, and standardized communication tools) to obtain the know-how to alert team members to unsafe situations [
4,
42]. The model of speaking-up behaviour helps trainers to design programs that will lead to more effective and sustainable behavioural changes and safety improvement outcomes.
From the literature, we identified various factors that influence speaking up by health care professionals. We integrated these factors into Morrison’s model of employee voice [
11] as follows: (1) motivation to speak up to help the patient, such as the perceived risk for patients [
5], and the ambiguity or clarity of the clinical situation [
36,
39]; (2) contextual factors, such as hospital administrative support [
28,
34], interdisciplinary policy-making[
28], team work and a person’s relationship with other team members [
3,
19,
20,
27,
28,
30,
34‐
36], and attitude of leaders/superiors [
3,
27,
31,
32]; (3) individual factors, such as satisfaction with the job [
29,
39], a sense of responsibility toward patients [
34,
36,
39], responsibility as professionals [
5,
19,
38,
39], confidence based on experience [
5,
29,
35,
36,
38,
39], communication skills [
3,
40], and educational background [
28]; (4) the perceived safety of speaking up, such as fear of the responses of others and conflict [
3,
28,
32,
34,
37] and concerns over appearing incompetent [
20]; (5) the perceived efficacy of speaking up, such as lack of changes [
33,
37] or the personal control of the issues [
29]; and (6) tactics and targets such as collecting facts, showing positive intent, and selecting the person who will be spoken up to [
40]. The model is comprehensive and gives us an overview that helps us to understand why health care professionals do or do not voice their concerns for patient safety. For example, many studies in this review emphasised the importance of team relationships or leaders’ attitudes for speaking up. Thus, for instance, leaders’ inclusiveness can increase a feeling of safety and efficacy of speaking up. However, a recent study found that the perceived behaviour of actual leaders was only modestly correlated with speaking up against them [
43]. The authors, therefore, concluded that an employee’s silence is influenced as much by his or her own cognitive frameworks as by a current boss’s behaviour or by organisational factors [
43]. Speaking-up behaviour might, accordingly, not be directly influenced by perceived team relationships and leaders’ attitude so much as indirectly by the perception of efficacy or safety of speaking up.
Factors influencing speaking-up behaviour will depend upon the organisation. Voicing in another organisation may be aimed at defending the interests of the organisation, client, third party, speaker, or a combination of these. The motivation to speak up for patient safety is primarily intended to prevent avoidable injury to the client. On the other hand, there is a potential to learn further from other sectors. For instance, no study in a health care setting focuses on work-group size and structure, while these are reported to influence employees’ voicing behaviour in other organisations [
11]. This may be a topic for future research.
This review has its own limitations. First, we developed the model of speaking-up behaviour by health care professionals based on previous studies in the health care setting. Further study based on this theoretical framework is required to investigate the relative importance of the different factors influencing speaking-up behaviour in various health care settings and the validity of the model. Second, in this review, similarities were found between factors influencing the speaking-up behaviour of junior physicians and factors influencing that of nurses, but the impact of these factors may differ between these groups. In addition, most selected studies were conducted in Western countries, so the factors influencing speaking up may be different in other countries. Further research is necessary to determine the impact of each controlling factor on the speaking-up behaviour of different caregivers with different cultural backgrounds. Finally, due to the variation in language used to express the term ‘speaking up’ in the literature, we used several keywords in searching for articles. Despite using combinations of search terms and a thesaurus, we were unable to further improve upon either the sensitivity or specificity of our literature search; some articles may, therefore, have been overlooked. To compensate for this, we consulted several experts and checked relevant journals to find related articles. Despite these limitations, this review helps us to understand how health care professionals think about voicing their concerns for patient safety.
Competing interest
The authors declare that they have no competing interests.
Authors’ contributions
AO had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of data analysis. AO, CW, and BB designed the study and analysed data. AO drafted the manuscript. CW and BB supervised the study and provided comments on subsequent versions of the manuscript. All authors read and approved the final manuscript.