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 ). 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 , 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  as follows: (1) motivation to speak up to help the patient, such as the perceived risk for patients , and the ambiguity or clarity of the clinical situation [36, 39]; (2) contextual factors, such as hospital administrative support [28, 34], interdisciplinary policy-making, 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 ; (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 ; (5) the perceived efficacy of speaking up, such as lack of changes [33, 37] or the personal control of the issues ; and (6) tactics and targets such as collecting facts, showing positive intent, and selecting the person who will be spoken up to . 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 . 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 . 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 . 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.