Defining Speaking Up in the Healthcare System: a Systematic Review

Abstract

Background

Communication issues have been shown to contribute to healthcare errors. For years healthcare professionals have been told to “speak up.” What “speak up” means is unclear, as it has been defined and operationalized in many ways. Thus, this study aimed to systematically review the literature regarding definitions and measurements of speaking up in the healthcare system and to develop a single, comprehensive definition and operationalization of the concept.

Methods

PubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete databases were searched from 1999 to 2020. Publications were included if they mentioned speaking up for patient safety or any identified synonyms. Articles that used the term speaking up concerning non-health-related topics were excluded. This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

A total of 294 articles met the inclusion criteria, yet only 58 articles focused on speaking up. While the most common synonym terms identified were “speak up” and “raise concern,” only 43 articles defined speaking up. Accordingly, a modified definition was developed for speaking up—A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

Discussion

Speaking up is considered important for patient safety. Yet, there has been a lack of agreement on the definition and operationalization of speaking up. This review demonstrates that speaking up should be reconceptualized to provide a single definition for speaking up in healthcare.

INTRODUCTION

The publication of To Err is Human¹ raised major concerns regarding the safety of care delivery in the healthcare system. Two decades later, efforts are being made to identify potential antecedents to medical errors, thereby improving patient safety.^2,3 Effective, timely communication between healthcare providers is widely acknowledged as essential to preventing medical errors and maintaining a safe patient environment.^4,5 One form of communication that is often advocated for is speaking up. This has become a popular catchphrase in healthcare, especially concerning patient safety.^6,7 Healthcare providers are told they need to speak up and ask questions if they see something unsafe.^8,9 This notion is expressed through campaigns like “Silence Kills” and teamwork trainings such as TeamSTEPPS, which stress the importance of speaking up if providers see something that endangers patients.^8,10,11 Prior research has also shown the importance of open communication and a supportive culture to healthcare professionals’ job satisfaction and well-being.^12,13 Yet, most discussions around speaking up end with admonishments for providers to do it without first defining what it means to speak up or providing effective tools.^14,15

One definition of speaking up, provided by Okuyama et al.,¹⁶ is “the raising of concerns by health care professionals for the benefit of patient safety and care quality upon recognizing or becoming aware of the risky or deficient actions of others within health care teams in a hospital environment”. Speaking up is mentioned in many articles and patient safety campaigns, but often without a definition or even description of what it entails.^8,14,15 For example, silence and ineffective speaking up are often grouped and treated as the same thing, further clouding precisely what speaking up entails.⁸ Additionally, terms like whistleblowing are common in some countries and are used interchangeably with speaking up. It seems that speaking up and whistleblowing are similar constructs that possibly fall on a continuum based on the severity of the case, perceived self-risk, and the focus of the concern.¹⁷ As Francesca West, chief executive of Public Concern at Work, stated, “Often ‘whistleblowing’ is used as a term when a concern feels unwelcome or when it’s external, and ‘speaking up’ is seen as being at the softer end of the spectrum, when a staff member first raises a concern.”¹⁸

The conflation of definitions of speaking up leads to confusion about how it is operationalized in healthcare practice. In the published literature on speaking up, several studies used the Hospital Survey on Patient Safety Culture (HSOPSC)^19,20 or one of its subscales (e.g., communication openness),^21,22 other studies have used unstructured surveys,^13,23 a few established criteria for evaluating behaviors they equated to speaking up,^6,15,24 and the rest of the studies did not provide any operationalization of the concept.^25,26 Thus, there is a need to explore how speaking up has been defined and measured in the literature.^6,7 To that end, this study aimed to review the literature systematically focused on definitions and measurements of speaking up in the healthcare system. It also aims to recommend a single, comprehensive definition of the concept.

METHODS

This systematic review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Covidence online literature review management system.^27,28

Search Strategy

Four databases were searched: PubMed, CINAHL, PsychoInfo, and Communication/Mass Media Complete. Search terms to identify articles relating to speaking up and patient safety can be found in Table 1. The search was limited to studies published in the English language. Search was also limited to retrieving articles published after 1999 when To Err is Human¹ was published, as it raised awareness of patient safety issues. No dissertations or theses were included.

Table 1.

Search Strategy

Search term	Results
[“patient safety” [MESH] AND (“Speak* up” OR “Voice*” OR “concerns” OR “whistleblowing” OR “advocate*” OR “rais* concerns” OR “report* concerns” OR “address* concerns” OR “Communication openness” OR “Share views” OR “Share concerns” OR “Sharing concerns” OR “Announce* concerns” OR “Confront*” OR “Question authority”)] OR (“Speak* up” AND “medical error”)	3598

Study Selection Criteria and Data Extraction

Articles were reviewed for any mention of speaking up for patient safety or any of the identified synonyms. Some articles used the term speaking up but were excluded from this literature review if the phrase was used concerning non-health-related topics, such as labor disputes, or referred to speaking up by patients or family members. Four independent reviewers were in charge of the title and abstract screening process (JK, LM, ES, and SK), consisting of two reviewers per screening process. The reviewers discussed disagreements in decisions to include or exclude a study, and a consensus was reached before continuing.

Data Extraction

The full texts of the included articles were uploaded to Covidence (an online literature review management website), and each article was reviewed by one of the four reviewers. A sample of 20% of the articles was reviewed by a second reviewer with a high agreement rate of 0.95. The data collected for each study included the article title, authors, publication year, the type of article/study, population, and setting, the rigor and value of the article, if and how speaking up was defined by the author(s), and if and how speaking up is operationalized.

Assessment of Studies

Because the current systematic review aims to define and operationalize the term “speaking up” for patient safety rather than assess the methodologies and/or results of the studies, per se, no quality assessment of the included studies was conducted.

Data Synthesis

First, descriptive statistics provide cumulative information on the articles included in this systematic review. Second, the synthesis focused on how healthcare professionals’ speaking up for patient safety was defined and operationalized, exploring differences and similarities across the articles. The synthesis also examines the language used as synonyms for speaking up through narrative analysis and generating a word cloud, a graphic representation of text frequency.

RESULTS

Summary

Our searches produced 2,661 unique articles; 294 met eligibility criteria and were included in the review (Fig. 1). The articles were published between 1999 and 2020, with the majority published from 2017 to 2019. Articles were primarily published in the USA (n=121), the United Kingdom (n=61), Australia (n=20), and Canada (n=14). The remaining articles were published from other countries and global regions, including Europe, the Middle East, Asia, and Oceania.

Figure 1.

PRISMA flowchart for speaking up for patient safety review.

Types of Articles

We categorized each article according to focus, defined as a focus on speaking up, whistleblowing, or “other.” These categories were determined by evaluating the title, abstract, aim(s), and article content. A total of 58 articles were focused on speaking up (n=51) or whistleblowing (n=7). The remaining 236 had another focus, such as patient safety, communication, teamwork, etc. Of the 294 articles, 177 were classified as studies, including qualitative, quantitative, and mixed methods studies and case studies. For this review, quality improvement projects were classified as non-studies, along with literature reviews, theory articles, news reports, and commentaries. Of the articles classified as studies, only 34 focused on speaking up.

Populations and Settings

Because of the different types of articles included in the review, the population was defined as the study population or the targeted audience. It was determined from the journal where the article was published and the article title and content. Most articles were focused on all healthcare professionals (n=108), and the second most common were nurses only (n=71), followed by learners (n=37), nurses and providers (n=24), and providers only (n=17). While most articles broadly focused on a hospital or healthcare setting (n=156), some focused on specific areas such as the perioperative setting (n=47).

Definitions of Speaking Up

Of the 294 articles reviewed, only 43 defined speaking up. There was some overlap in definitions, with 11 distinct definitions identified. Table 2 displays the definitions for speaking up. Some articles included synonyms for speaking up or whistleblowing, which were also collected and imported into a word cloud generator to identify frequent terms and phrases (Fig. 2). The most common synonym terms identified were “speak up” and “raise concern.” Information on synonyms identified across articles is provided in Table 3. Based on the definitions derived from the literature, we suggest the broadest definition for speaking up for patient safety, adapted from Law and Chan,²⁹ which they attribute to Sayre et al.³⁰: “A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.”

Table 2.

Speaking Up Definitions

Definition

Speak up—(that is, initiate a message) to draw attention to the situation before harm is caused.43,45,52,53

SU to power—preventing a situation where one member of a perioperative team recognizes a clear and present danger or a potential danger to a patient but is inhibited from calling attention to the danger because of a sociocultural inequality, intimidation, fear of reprisal (such as job loss), or simply being ignored.54

Assertive communication in clinical situations that requires immediate action through questions, statements of opinion, or information with appropriate persistence aiming for resolution.55–57

An individual using his/her voice to convey to someone in higher authority specific information that might make a difference to patient safety.29

Stating concerns (e.g., filing a report, sharing concerns with a supervisor, or speaking directly with the individual(s) involved) rather than saying nothing.58–60

Voice—Discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues to improve organizational or unit functioning.12,61–63

The raising of concerns by healthcare professionals for the benefit of patient safety and care quality upon recognizing or becoming aware of the risky or deficient actions of others within healthcare teams in a hospital environment.16,42,64–66

To raise concerns about risky or inappropriate actions of other team members.24,67,68

Using one’s voice to make known to someone with positional power or authority to take action on specific information or knowledge that is privately held.44

Using voice to make specific information that is privately held known to someone—with positional power or authority—to take action.30

Assertive communication in clinical situations that require (immediate) action through questions or statements of opinion or information with appropriate persistence until there is a clear resolution to prevent error or harm from reaching the patient.13,15,34,69–78

Figure 2.

Word Cloud of frequently used synonyms for speaking up.

Table 3.

Synonym to Speaking up Definitions

Definition

Peer-to-peer accountability—a process of “speaking up” when one observes a peer doing something not according to acceptable practice or standards.68

Assertive communication—stating concerns with persistence until there is a clear resolution.69

Assertive communication—(1) an individual provider asserts their opinion (through questions or statements of opinion) during critical times, OR (2) individuals speak up and state their information with appropriate persistence until there is a clear resolution.34

Assertive communication—speaking up and persistently stating concerns until a clear resolution is reached.15,33

Safety voice—employee willingness to proactively participate in communication-related behaviors to improve workplace safety.12

Communication Openness—characterized by the freedom to disclose errors among colleagues within a less punitive environment.79

Collaborative Inquiry Combined with Advocacy Collaborative inquiry—public testing of conclusions and reasoning, inquiry into alternative points of view, and seeking to enhance free and informed choice. Advocacy—a statement that describes the trainee’s opinion or position.36

Advocate—one who defends, pleads the cause of, promotes the rights of, or attempts to change systems on behalf of an individual or group.80

Operationalization and Measurement of Speaking Up

We defined operationalization as the process by which researchers measured, observed, and practically defined speaking up. There was difficulty in clearly identifying the operational definition of speaking up due to the diversity of language used by the authors. Thus, we categorized how authors measured the term within studies, the wording of instruments used, and by reviewing tools authors suggested for speaking up.

In 79 articles, survey instruments were used to measure and/or operationalize speaking up. A variety of scales were used to measure speaking up behaviors. The HSOPSC was referenced or used in 39 articles and was the most frequently used instrument. In 20 of these studies, the HSOPSC was modified from its original format. The Safety Attitudes Questionnaire (SAQ) was used in five studies, but in most instances, the instrument was modified, or only certain instrument subscales were used. In the remaining 36 studies that used a survey instrument to measure speaking up, the scales used were either locally created or modified existing instruments.

Less than 20 articles operationalized speaking up through a tool or evaluation criteria. The most common tool discussed was CUS (Concerned, Uncomfortable, Safety Issue), taught in the Agency for Healthcare Quality’s TeamSTEPPS program.³¹ The Two-Challenge Rule, adopted from Crew Resource Management, and SBAR (Situation, Background, Assessment, and Recommendation) was the other most frequently discussed tool.^32–36 Only one article evaluated an intervention to teach these tools.³² All other articles just discussed these tools as potential strategies to encourage speaking up.

DISCUSSION

The results of this review indicate that the term speaking up and its synonyms are pervasive in the literature. Of the 294 articles included in this review, none discouraged speaking up; instead, all articles reviewed portrayed speaking up as a desirable behavior that should be promoted. However, the primary focus of most papers was not on “speaking up.” Instead, many mentioned the term briefly in discussing other topics, such as improving communication.^37,38 This suggests that the current literature on speaking up is most frequently viewed as a smaller part of a larger issue or one of several options to improve patient safety.

The review demonstrated a surprising lack of consistency in defining and operationalizing speaking up across the literature. There was wide variability across studies in the different terms or synonyms used for speaking up. While articles published in the USA and Switzerland frequently used the term speaking up, which can be defined as “actively and constructively trying to improve conditions through discussing problems with a supervisor or coworkers, taking action to solve problems, suggesting solutions, seeking help from an outside agency like a union or whistle-blowing”,³⁹ Australia and the United Kingdom frequently used the term whistleblowing interchangeably with speaking up, which can be defined as “the disclosure by organization members (former and current) of illegal, immoral, or illegitimate practices under the control of their employers, to persons or organizations that may be able to effect action”.⁴⁰ While these two terms are different, they might present a continuum. If a manager is prepared to take action in response to concerns regarding the quality or safety of patient care, an employee may choose to ‘speak up.’ Nevertheless, if the employee feels this action was insufficient and the issue remains unresolved, they may wish to inform a more senior individual or speak to someone outside the organization.¹⁷ The current systematic review identified two common themes: (1) raising concerns about patient safety and, (2) bringing the concern to the attention of someone with the power to intervene. Yet, the details about how, when, and to whom vary widely in the literature reviewed, perhaps due to the different contexts in which the studies were conducted.⁴¹

Interestingly, even studies focused on speaking up behaviors, including those conducting interventions to increase the behavior, often failed to define speaking up.^{24,30,42–44} It is possible this is due to the belief that speaking up is a generally understood term in health care (e.g., patient safety or critical care) or that it is considered a generic communication term. The absence of a specific expected outcome for “speaking up” may act as a barrier for those who are encouraged to do so. Moreover, while two main tools are presented in the literature for encouraging speaking up—CUS and the Two-Challenge Rule—no evidence has been presented to support CUS’s effectiveness in promoting speaking up,³¹ and evidence regarding the effectiveness of the Two-Challenge Rule is inconclusive.^24,36 More research is needed on clinical tools that increase speaking up behaviors.

Whether or not speaking up ended at the speech itself or required additional action also varied between definitions. Is it fair to say speaking up did not occur if action did not result from it? Since several authors have classified unsuccessful speaking up speech acts as silence, the answer to this question might be yes.^8,30 But to define speaking up this way is an oversimplification. Speaking up is a type of communication, and, as such, successful communication is not solely within the power of the person speaking. Communication requires a sender (speaker) and a receiver (listener) to succeed.⁴⁵ If the sender is completely silent, they can be liable for communication failure. But if the sender does speak up, the listener is now part of the communication and must be considered when evaluating the success or failure of that communication. A lack of action is not the same as a lack of speech, and that distinction must be made clear in the language around speaking up. Therefore, our suggested definition for speaking up for patient safety was adapted from Law and Chan²⁹ attributed to Sayre et al.³⁰—A healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it. This definition does not require a specific response or outcome from the speaking up and therefore is an individual action solely in the control of the speaker. However, speaking up that elicits action, along with other speech acts like whistleblowing to an external agency, are types of speaking up, and the expansiveness of this definition allows them to be included.

Implications for Practice and Future Research

First, although speaking up is common in the patient safety literature, its conceptualization and definition are unclear. It may be helpful to look to non-healthcare disciplines for conceptualizations and definitions that could be brought in to clarify this term. It is also possible to stratify the literature by context (e.g., hospitals, ambulatory surgery centers, etc.) to better define the operationalization of speaking up.⁴¹ Second, the articles and studies found in our literature review were overwhelmingly focused on the speaker, the importance of them speaking up, examining how they spoke up, feelings and issues around their speaking up, and suggestions to make their speaking up more successful. Yet, only a few articles considered speaking up concerning the listener or intended audience.^46,47

The results are surprising, as overall safety can only be increased through speaker and listener collaboration. For example, medical students were found to speak up more than twice as often in a group where a surgeon listener encouraged them (82%) compared to a group where no such encouragement was given (30%).⁴⁶ Thus, future studies should consider speakers and listeners to promote a safe healthcare system. Finally, closely related to the previous point, multiple studies have found that providers report difficulty getting their intended audience to listen and respond to their concerns.^47–49 In addition, the ability to speak up and feel heard about issues in the workplace is important not only for patient safety but also for the well-being of healthcare workers.⁵⁰ Going forward, exploring the reasons for these issues will be important if interventions effectively increase speaking up, leading to better patient outcomes.

Limitations

The first challenge was determining the search terms for this systematic review. Many alternative terms were possible without a clear definition of the term speaking up. Therefore, it is possible other terms for speaking up were not included in the search terms of this review. Nevertheless, a posteriori examination of the papers included in this systematic review revealed no new terms. Therefore, if this were a bias of the current review, it might be a relatively small one. Second, the systematic review was limited to English language papers, and no search for gray literature was conducted. Yet, systematic reviews and meta-analyses are prone to this bias.⁵¹ Finally, there might be a publication bias due to the possibility that studies that showed no or even a negative effect of speaking up were under-reported in the literature.

CONCLUSIONS

Speaking up is discussed frequently in the patient safety literature. Definitions vary, and there are many more articles and studies examining beliefs and perceptions around speaking up than those reporting intervention studies to increase speaking up. Having a multidisciplinary team rethink the entire process and continuum around speaking up and responses to speaking up would be beneficial to provide clearer definitions and operationalization. Although it appears universally agreed upon that speaking up is good and desirable in healthcare, there is far less agreement on how all forms of speaking up should be defined and operationalized.

Funders

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Declarations

Conflict of Interest

The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication.