Learning from speaking up by learning to speak up

Of all the events that contribute to deaths due to preventable medical errors in healthcare, ineffective communication is one of the most frequently identiﬁed primary causes. Failure to speak up or to get others to listen is part of this ineffective communication. Therefore, speaking up behavior of healthcare workers is seen as an important factor to improve patient safety. However, more research is needed to understand 1) the most important inﬂuencing factors of speaking up behavior, 2) what kind of speaking up behavior is used and is most effective in preventing adverse events and 3) what is the role of the receiver and the work environment.


INTRODUCTION
The COVID-19 pandemic has shed a new light on the importance of the relationship between the safety of patients and that of healthcare professionals (World Health Organization, 2020).However, the safety of both parties are important topics that should be considered, whatever the circumstances.Therefore, it is important to study topics that contribute to both, because the safety of patients and healthcare professionals go hand in hand.In this paper, we will discuss the issues surrounding remaining silent and the importance of speaking up behavior.The aim of this paper is to map the landscape of remaining silent and speaking up behavior in healthcare as well as the research that has been carried out in this domain.

THE PROBLEM OF REMAINING SILENT IN HEALTHCARE
Remaining silent has been a problem in healthcare for a long time.According to various studies, ineffective communication is a contributing factor to medication errors, incidents and preventable medical errors that could lead to death (Maxfield et al., 2005;Palatnik, 2016;Sutcliffe et al., 2004).Research of Langelaan and colleagues (2017) shows that in 55% of the cases, miscommunication is an important contributing factor.Failure to speak up when something is wrong and could possibly harm the patient is part of this ineffective communication (Palatnik, 2016).Although speaking up is part of 96 van Dongen et al.
the professional standard, it is not self-evident that healthcare professionals speak up when necessary.
One of the first studies showing the problem of remaining silent in healthcare is the study of Maxfield and colleagues (2005).With their report Silence kills they draw attention to the issue of not speaking up.In their study, they describe the seven most crucial concerns for patient safety: rule breaking, making mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement.The participating healthcare professionals were asked if they observed these concerns at their work, and the majority did.Different factors play a role in the decision of speaking up or remaining silent about the concerns they witness, such as: the concern itself, the situation and the person to speak up to.On average, only 5 to 15% of healthcare professionals states they would speak up.This means that 85% to 95% of the healthcare professionals finds it difficult or impossible to speak up after witnessing crucial issues regarding patient safety (Maxfield et al., 2005).
In 2011, Maxfield and colleagues did a follow up study.They studied how frequently nurses remain silent when they know they have reason to speak up.The participants were asked how often warning tools (i.e., tools designed to prevent unintentional slips and errors) warned them.85% of the participants stated they had been in such a situation at least once, and 29% indicated they had been in such a situation multiple times a month.However, 58% of the participants stated they felt unsafe to speak up or had been unable to get others to listen at least once, and 17% of the participants indicated they had been in such a situation multiple times a month (Maxfield et al., 2011).This indicates that even when supported by warning tools, speaking up still remains difficult.Which means that the problem surrounding speaking up does not only concern the person who speaks up (messenger), but also the receiving party (target) and the organization as a whole.
Other studies show similar results.A study by Schwappach and Gehring (2015) among oncology nurses and doctors showed that 54% of the respondents recognized their colleagues were making potentially harmful errors at least sometimes.Most of the respondents indicated they were withholding concerns about patient safety more than once.37% of the respondents said they remained silent at least once when they had information that might have helped prevent an incident.Influencing factors according to this study are interpersonal, communication and coping skills as well as perceived advocacy and psychological safety.A few years later, Schwappach and colleagues (2018) did another study, but this time among healthcare workers in general.In this study, more than half of the participants had concerns about patient safety within the last four weeks and observed a potential error or noticed rule violation.Depending on the issue, 16% to 42% of the participants stated they remained silent and did not speak up in that situation.However, 96% to 98% of the participants indicated that they did speak up in some situations, but not in all (Schwappach et al., 2018).This means there are situations or circumstances in which healthcare workers do speak up.Again, psychological safety seemed an important influencing factor for speaking up behavior.
Not only healthcare workers, but also medical students struggle with speaking up or asking questions.According to Bowman and colleagues (2013), a majority of medical students (56%) reported they will not speak up when witnessing a possible adverse event and they are afraid to ask questions when things do not seem right.According to this study, two influencing factors are: bad communication flow in the medical hierarchy (45%) and a fear for a punitive response, because speaking up is seen as a sign of incompetence (21%).
Besides raising concerns about patient safety issues, physicians also do not always raise concerns about working conditions that directly or indirectly have a negative impact on either them or their patients.According to a study by Creese and colleagues among Irish doctors (2021), 25% of the doctors would not speak up about their working conditions.Discouraging factors for speaking up are reputational risk, lack of energy or time, or a perceived (lack of) ability to change the cultural norms.
Based on the research cited, we can conclude the healthcare system has a problem with a work environment that does not support or makes it difficult for healthcare workers to speak up.As these studies describe, much research is carried out about why individuals remain silent instead of speaking up.However, less research is done into tools an organization offers to facilitate or improve speaking up behavior of an individual, a team or the organization.Therefore, it is important to point out that it is a problem of the healthcare system and not that of one individual.
Not all studies, but some of the studies mentioned above indicate a few influencing factors of why healthcare workers speak up or remain silent.Despite the fact that both internal and external factors can be motivating or inhibiting, most influencing factors relating to the decision of speaking up or remaining silent are influenced by the work environment.Giving an overview of these factors is outside the scope of this article, but an overview of factors influencing speaking up behavior in general can be found in Morrison (2014) and for an overview of factors specifically in healthcare, see Okuyama and colleagues (2014).
Until now, research into speaking up behavior in healthcare has been mainly focused on the person who speaks up or remains silent and not on the target and type of voice.The target of voice is the person to whom speaking up is directed at and the type of voice is the type of information that is being voiced (Morrison, 2011).However, less is known about the response or behavior of the target and the relationship between the messenger and the target.For example, does the way in which an issue is voiced make it easier for a messenger to speak up and for the target to act upon?To what extent can the target make it easier for the messenger to speak up?Or what are the factors that make the communication between messenger and target easier or better?To what extent is there a difference between raising a concern or voicing an idea or suggestion?
To get a better understanding of why we ask these questions and what the added value might be for the healthcare domain, we first describe the history and different definitions of speaking up behavior.Based on this knowledge, we will provide suggestions for further research.

HISTORY AND DEFINITION OF SPEAKING UP
In the 1970s and 1980s awareness of the relevance of employee participation and employee voice increased (Wilkinson et al., 2018).Before that, these topics also received some attention, but research regarding voice was still in its infancy (Swuste et al., 2019).According to Mowbray and colleagues (2014) and Morrison (2014) it was the study of Hirschman in 1970 on employee voice and the exit-voice-loyalty model that people became interested in studying this topic.In the study of Hirschman, employee voice focusses on individual or collective voice to the management or people in charge with the intention to force change in management.However, employee voice is something different than speaking up behavior (Premeaux, 2001).People who speak up do so because they are motivated to improve the organization, and not because they are frustrated.It was not until about 2000 that the topic of speaking up behavior also received significantly more attention in research (Edmondson, 1999;Morrison & Milliken, 2000, 2003;Sutcliffe et al., 2004).
Research into speaking up behavior has been carried out in different domains.Morrison (2014) combined the definitions of speaking up behavior that are used in a variety of studies, conceptualizing it as: Informal and discretionary communication by an employee of ideas, suggestions, concerns, information about problems, or opinions about work-related issues to the person who might be able to take appropriate action, with the intent to bring about improvement or organizational change.As this definition highlights, the context and the target of the message can be quite different.This definition can be used in a variety of domains, including healthcare.However, researchers who studied speaking up behavior in healthcare used a different definition, namely: Raising concerns by healthcare professionals for the benefit of patient safety and care quality upon recognizing or becoming aware of deficient or risky actions (of others) within healthcare (Nacioglu, 2016;Okuyama et al., 2014).
Both these definitions can be used to study speaking up behavior in healthcare.However, the abovementioned definition of speaking up behavior that is most used in healthcare, has its limitations.Firstly, this definition focusses only on one type of voice, namely raising concerns about patient safety, which leaves out, for example, speaking up about ideas to improve working conditions.Despite the fact that other types of voice can also contribute to patient safety and quality of care, this is not the focus of speaking up studies in healthcare.Secondly, in the definition of Morrison (2014) the target of speaking up behavior also has a role in the communication, because the target is responsible for an appropriate action or reaction on what is voiced.To the best of our knowledge, most research into speaking up behavior in healthcare does not focus on the response of the target.We can therefore say that speaking up behavior in healthcare is not yet studied fully.

CONCLUSION AND FUTURE DIRECTIONS
Based on the information described in this paper, three suggestions for future research are given.To start with, future research should focus on speaking up behavior as a whole and not only on one type of voice, namely raising concerns.By leaving out the study of voicing ideas, suggestions and opinions, much information about speaking up behavior in healthcare remains underexposed.According to Edmondson and Lei (2014) there is reason to believe that for an organization or a team to improve, it is not only important to raise concerns, but also ideas, suggestions, and opinions.Morrison (2011) provides an overview of the different types of voice that can be used in future research.A distinction is made between problem-, suggestion-, and opinion-focused voice.Firstly, problem-focused voice can be defined as the communication of concerns, incidents or harmful behavior to people or the organization; this is a negatively framed type of voice.Secondly, suggestionfocused voice can be defined as the communication of ideas, suggestions about how work can be improved; this is a positively framed type of voice.Lastly, opinion-focused voice can be defined as the communication about work-related issues.All types of voice challenge the status quo and have the purpose to improve the work or organization (Morrison, 2011).There is also reason to believe that the type of voice may be of importance in the way information is perceived and acted upon (Morrison, 2014;Tarrant et al., 2017).However, little is known about the effects of different types of voice on patient safety, therefore more research is needed.
A second suggestion would be to focus not only on the messenger, but also on the target of speaking up behavior.According to Long and colleagues (2020), it is not only important to focus on the messenger, but also on the target.Most research on the target of voice focusses on speaking UP, thus to someone higher in the hierarchy (Milliken et al., 2003;Rhee et al., 2014;Sutcliffe et al., 2004).In general, people lower in the hierarchy find it difficult to speak up to someone higher in the hierarchy.Possible reasons for this are: fear for a negative reaction, being seen as incompetent, or being ignored.In general, people higher in the hierarchy fear less negative outcomes or reactions and thus they speak up more (Islam & Zyphur, 2005).Therefore, to improve speaking up behavior it is not only important to focus on the messenger, but also on the target.An environment in which healthcare professionals feel safe to speak up, take interpersonal risks and get others to listen is called a psychological safe environment (Edmondson 1999(Edmondson , 2019)).More research is needed into the role of the target and the interaction between the messenger and the target.
Finally, in healthcare there is a need for good interventions aiming at better communication and speaking up behavior.Because until now, too many unnecessary mistakes are made due to communication errors (Maxfield et al., 2005;Palatnik, 2016;Sutcliffe et al., 2004).According to the Agency of Healthcare Research and Quality (Chaves & Wilson, 2005) there is a need for interventions that translate evidence-based practices into real-word settings that change communication.A deeper understanding of the underlying mechanisms of speaking up behavior is needed to develop and study communication and speaking up interventions (Tarrant et al., 2017).According to Law and Chan (2015), Appreciative Inquiry might be a new and fitting approach that can be used to achieve that and to promote a positive cultural change to encourage healthcare workers who learn to speak up and to ensure patient safety.
To conclude, thus far there is a good overview of the frequency in which healthcare professionals speak up or remain silent and much is known about internal and external influencing factors that can either be motivating or inhibiting the decision to speak up or remain silent.However, more insight is needed into the relation between the messenger and the target of voice, what the role is of the type of voice and the relationship with patient safety and with healthcare professionals.