Communication issues have been recognized as a contributing factor in the majority of health care errors and in negatively impacting the working environment (Joint Commission, 2013; Wachter, 2012). Failure to share critical information or concerns with other health care professionals is one type of communication issue, and for years health care professionals have been told to “speak up” for patient safety when they have information or concerns (Maxfield, Grenny, Lavandero, & Groah, 2011; Spruce, 2014; Wachter, 2012). Available data does indicate that speaking up is effective in preventing health care errors, but how to encourage and increase this behavior is less clear (Blanco et al., 2009). What is meant by speak up varies widely, as it has been defined and operationalized in many different ways. A literature review was conducted utilizing PRISMA guidelines and the Matrix Method to explore the meaning of speak up, and 187 articles were evaluated for usage of the term speak up and related synonyms. Eleven different definitions of speaking up were found in the literature review, with another fourteen definitions found for whistleblowing, a term that was found to be used interchangeably with speaking up in many articles. Many articles also discussed speaking up without offering a definition or operationalization, including some intervention studies to increase the behavior. Results from the literature review indicate significant interest and discussion around the concept of speaking up but also a great deal of difference in how it is being defined and operationalized. Intervention studies were also evaluated for outcomes and types of interventions utilized.
A mixed methods study was also conducted at a large academic medical center, utilizing survey data to identify units with high and low levels of speaking up behaviors. Interviews were then conducted with nurses to explore how they define and operationalize speaking up. This led to a description of the phenomenon of speaking up for medical surgical nurses at one hospital. Definitions of speaking up were also collected from each participant. Results from the study indicate nurses feel they do speak up if patient safety is at risk but also felt there was often no one listening or interested in their concerns. Nurses also viewed speaking up as risky and possibly detrimental to their careers, and found environments where speaking up was seen as discouraged to be unhealthy.
The definitions from the literature review and the study participants were reviewed and a new definition for speaking up is suggested. Results from the study and the literature review also indicate that most health care professionals report that they do speak up when they see a patient safety issue, indicating we need to examine issues around raising concerns beyond encouraging people to do it. The importance of perceived management support for speaking up was also clear. Recommendations for future research, including the need to examine speaking up from the listening side, are discussed.
