As a Nurse, When Should You Speak Up?

As a general rule, if you have a question of whether or not you should speak up, you probably should.  When it comes to a patient's safety or care, you should always speak up, no questions or hesitations. 

Professional Statistics

Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behavior and team communication. This review focused on health care professionals’ speaking-up behavior for patient safety and aimed at 

1. Assessing the effectiveness of speaking up
2. Evaluating the effectiveness of speaking-up training
3. Identifying the factors influencing speaking-up behavior
4. Developing a model for speaking-up behavior

Five databases (Pub Med, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were searched for English articles describing health care professionals’ speaking-up behavior as well as those evaluating the relationship between speaking up and patient safety. Influencing factors were identified and then integrated into a model of voicing behavior.

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In total, 26 studies were identified in 27 articles. Some indicated that hesitancy to speak up can be an important contributing factor in communication errors and that training can improve speaking-up behavior. Many influencing factors were found: 

1. The motivation to speak up, such as the perceived risk for patients, and the ambiguity or clarity of the clinical situation.
2. Contextual factors, such as hospital administrative support, interdisciplinary policy-making, teamwork and relationship between other team members, and attitude of leaders/superiors.
3. Individual factors, such as job satisfaction, responsibility toward patients, responsibility as professionals, confidence based on experience, communication skills, and educational background.
4. The perceived efficacy of speaking up, such as lack of impact and personal control.
5. The perceived safety of speaking up, such as fear for the responses of others and conflict and concerns over appearing incompetent.
6. Tactics and targets, such as collecting facts, showing positive intent, and selecting the person who has spoken up.

Hesitancy to speak up can be an important contributing factor to communication errors. Our model helps us to understand how health care professionals think about voicing their concerns. Further research is required to investigate the relative importance of different factors.

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 organization. ‘Speaking up’ is defined as 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 healthcare teams in a hospital environment. Such actions include mistakes (e.g. missed diagnoses, poor clinical judgment), lapses, rule breaking, and failure to follow standardized protocols. Speaking up is expected to have an immediate preventive effect on human errors or to improve technical and system deficiencies. Organizational 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. In healthcare environments, it has been shown that those who are aware of a problem often either speak up or are ignored or do not speak up at all.

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Previous organizational studies indicated that several factors influence employees’ voicing behavior. 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. 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. Morrison integrated the existing theory and research and developed the model of employee voice. In this model, it is presumed that the driving motive for voice is the desire to help the organization 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 judgment about whether it is likely to be effective. The perceived safety of voice is the individual’s judgment 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. organizational culture) and individual factors (e.g. job attitude, personality) affect these perceptions. The employee’s voice has important benefits for organizations 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 organizations 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. 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 organizational contexts speaking up will often relate to the well-being and goals of the organization and its workers, speaking up in health care for patient safety is primarily aimed at promoting the wellbeing of its clients. In health care, several interventions have been introduced to improve teamwork and communication.

While teaching safety theory and/or team training may not be sufficient to empower healthcare professionals to voice their concerns, understanding speaking-up behavior and its related factors can be useful in designing patient safety improvement initiatives that lead to more effective and sustainable behavioral 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 behavior 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 healthcare professionals recently, a conceptualized theoretical model for understanding speaking-up behavior 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 behavior by healthcare professionals, and 
4. Developing a model for healthcare professionals’ speaking-up behavior by integrating these factors into the model of employee speaking-up behavior. 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.

Statistics and facts aside, your supervisor and employer should be appreciative if you speak up regarding the care or treatment of a patient.  As a nurse, you are a mandated reporter, and your number one responsibility is the care and safety of your patients. 

Related: International Nurses Association

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