Search results and article overview
The initial literature search identified 3,211 citations (Figure 1). Most of the 1,564 excluded articles were based solely on experts’ opinions or commentaries or did not examine speaking-up behaviour in health care teams. In total, 292 articles were filtered for detailed review to determine whether they met the inclusion criteria. Following a title and abstract review by two researchers (AO, Research Assistant), the value of Cohen’s kappa was calculated to be 0.64. A total of 18 articles were found to meet the inclusion criteria; 6 other articles were retrieved from the reference lists, and 3 more were acquired through hand searches. Thus, a total of 26 studies in 27 articles were identified; 7 articles were published in 2012, 2 or 3 were published between 2006 and 2011 each year, and 3 were published before 2006 [3, 5, 16–40]. More than half of the selected studies (19, 73%) came from the U.S., and of the remaining 7, 3 came from the U.K. (12%). One study was conducted in two countries (the U.S. and Japan) [32]. Most of the selected studies employed interviews and/or surveys, and 8 of the 26 (31%) identified studies described the speaking-up behaviour of physicians. Of the remaining 18 studies, 8 (31%) described the speaking-up behaviour of nurses, and 10 (38%) described the speaking-up behaviour of both physicians and nurses. In all of the included studies, aim, study process, and analysis method were described. Study designs for research purposes were generally selected appropriately. Most of the studies provided sufficient data to support the conclusions, but some provided limited data (Additional file 2).
Effectiveness of speaking up for patient safety
A few studies directly addressed the relationship between speaking-up behaviour and patient safety outcomes. Among them, three studies [18–20] investigating the pattern of communication failures indicated that, in the case of hesitancy to speak up, insufficient information transfer from residents/nurses to senior physicians could contribute to actual communication errors and/or adverse events. Kolbe et al. demonstrated that nurses’ level of speaking up was a predictor of technical team performance (R2 = 0.18, p = 0.17) [16]. Studies that investigated health care professionals’ experiences of speaking up reported that they hesitated to speak up even when they were aware of patient safety risks [33, 34, 38–40]. Another study reported that 74–78% of residents and attending physicians recalled an incident in which the resident spoke up to prevent an adverse event [27]. All of these studies supported the notion that health care professionals voicing their concerns can be a good opportunity to prevent an adverse event. Churchman and Doherty reported that nurses questioned doctors’ practices only under specific circumstances (e.g. when hospital policies supported the nurse’s position) [34]. Raising concerns was perceived as a high-risk, low-benefit action for nurses [37]. These studies also suggested that by keeping silent, we miss the opportunity to prevent an adverse event and improve patient safety. On the other hand, Jeffs et al. reported that collective vigilance (e.g. the process by which health care professionals would pick up on potentially harmful errors made by another clinician) can potentially create risk by eroding individual professional accountability through reliance on other team members to catch and correct their errors [17]; their study included a limited number of participants from each speciality (e.g. three physicians and one technician). This phenomenon should be evaluated in further study.
Effectiveness of speaking-up training
Two of the included studies illustrated that the speaking-up behaviour of interns and residents improved after intervention [21, 22]; three others reported that, after intervention, the number of participants who felt able to speak up in a clinical setting was increased [24–26]. Stevens et al. reported in their case study that, following team training, communication was enhanced by addressing team members by their names and paying more attention to ‘closing the loop’ in verbal communication, but the amount of data presented by the authors was limited [25].
Factors influencing speaking up
Previous studies have shown that many factors can have an effect on the speaking-up behaviour of health care professionals. These influencing factors could be assigned to the following categories: motivation and clinical context, general contextual factors, individual factors, the perceived safety of speaking up, and the perceived efficacy of speaking up (Figure 2).
Most of the articles that explored the factors influencing speaking-up behaviour used the exploratory approach to find the barriers and promoters of speaking up. All studies described their aim, study design, and results with sufficient data. A few studies investigated the relationship between these factors and speaking-up behaviour [5, 29–31].
Motivation and clinical context
Perception of a risk for patient or organisation is a prerequisite for speaking up. In one exploratory study, physicians rated potential harm in common clinical scenarios lower than nurses did, and this harm rating could also be one of the predictors of speaking up [5]. Also, clarity or, in contrast, ambiguity of the clinical situation is an important predictor of the decision to speak up [36, 39]. Clarity of the clinical context can be a powerful contributor to the confidence and speaking-up behaviour of health care professionals.
General contextual factors
Strong and visible hospital administrative support has been shown to enhance the speaking-up behaviour of health care professionals [28, 34]. It has been observed that nurses tend to voice their concerns when hospital policies openly support their position [34]. Furthermore, nurses have been shown to want more collegial practice environments in which health care professionals would have more opportunities for interaction, colleagues would treat each other with kindness and consideration, and the ‘different but equal’ contributions of nurses and physicians would be respected (interdisciplinary policy-making) [28]. On the other hand, perceived pressure from the nursing team has also been found to have an adverse impact on speaking up for junior physicians [35]. The so-called ‘power nurses’ place those junior physicians, who rely on their assistance, in a vulnerable position; the physicians feel uncomfortable and hesitant at refusing the nurses’ requests, even when they strongly disagree. Moreover, several studies report that teamwork and a person’s relationships with other team members influence speaking-up behaviour [3, 19, 20, 27–30, 32, 34–36]. In particular, the attitude of a senior or team leader can have a strong impact on speaking-up behaviour [3, 27, 30, 32]. Coaching by team leaders helps team members to learn from problems and errors [3].
Individual factors
It has been found that persons who positively voice their concerns are generally more satisfied with their workplace and exhibit more discretionary efforts to speak up [29, 39]. Having a sense of responsibility toward patients can also have some effect on speaking-up behaviour [34, 36, 39]. Those who voice their opinions or concerns feel that they create a safer environment for others. The degree of identification with their roles as physicians or professionals has been shown to be one of the factors influencing speaking-up behaviour by health care professionals [5, 19, 38, 39]. Perception of a lack of sufficient knowledge is a barrier to speaking up, as health care professionals tend to hesitate to speak up when they feel they are not adequately informed. A feeling of confidence and previous favourable experiences of speaking up can enhance such behaviour [5, 35, 36, 38, 39].
One study illustrated that health care professionals’ communication skills, such as the ability to use assertive and critical language, have an influence on self-confidence and speaking-up behaviour [40].
Furthermore, the educational background is also important in understanding a nurse’s speaking-up behaviour [28].
Perceived safety of speaking up
Some studies also illustrated that a perceived response from the addressed person (e.g. fear of reprisal, concerns of appearing incompetent) is an important factor controlling speaking up for both medical and nursing professionals [3, 20, 28, 32, 34, 37]. Health care professionals were also concerned that voicing their concern could lead to conflicts within the health care team [3, 32, 34].
Perceived efficacy of speaking up
Prediction that nothing will be done about raised concerns inhibits health care professionals from voicing their concerns [33, 37]. Personal control (e.g. perceptions of autonomy and impact at work) has been found to positively affect the speaking-up behaviour of nurses [29].
Tactics and targets
Some nurses collected facts as much as possible, ran pilot tests, and worked behind the scenes when the issues were not urgent [40]. They explained their positive intent—‘how they wanted to help the caregivers as well as the patient’—while avoiding telling negative stories or making accusations [40]. Nurses sometimes avoided voicing their concern directly to the addressed person, instead telling another person, such as a nurse manager (selecting person) [40].