Downloaded from http://journals.lww.com/jhqonline by BhDMf5ePHKbH4TTImqenVJsWiCZ2rfmU1DhKHtpOvMns4lImLn1KhQq3IYweBWtomDLMKM1zbx4= on 09/15/2020 Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals’ Speaking-up Skills Training Sara Kim · Nital P. Appelbaum · Neil Baker · Nadia M. Bajwa · Frances Chu · Jay D. Pal · Nancy E. Cochran · Naike Bochatay ABSTRACT Communication failures in healthcare constitute a major root cause of adverse events and medical errors. Considerable evidence links failures to raise concerns about patient harm in a timely manner with errors in medication administration, hygiene and isolation, treatment decisions, or invasive procedures. Expressing one’s concern while navigating the power hierarchy requires formal training that targets both the speaker’s emotional and verbal skills and the receiver’s listening skills. We conducted a scoping review to examine the scope and components of training programs that targeted healthcare professionals’ speaking-up skills. Out of 9,627 screened studies, 14 studies published between 2005 and 2018 met the inclusion criteria. The majority of the existing training exclusively relied on one-time training, mostly in simulation settings, involving subjects from the same profession. In addition, most studies implicitly referred to positional power as defined by titles; few addressed other forms of power such as personal resources (e.g., expertise, information). Almost none addressed the emotional and psychological dimensions of speaking up. The existing literature provides limited evidence identifying effective training components that positively affect speaking-up behaviors and attitudes. Future opportunities include examining the role of healthcare professionals’ conflict engagement style or leaders’ behaviors as factors that promote speaking-up behaviors. Keywords: power hierarchy, speaking up, psychological safety Introduction Healthcare quality encompasses patient safety, which is defined as prevention of harm to patients and absence of adverse events in clinical care. 1 The Institute of Medicine states that effective healthcare delivery systems must have foundations in a culture of safety to meet ultimate goals of healthcare quality in patient care. 2 Therefore, research is much needed toward examining the efficacy of protocols and processes that promote patient safety. One behavior aligned with patient safety is “speaking up” by healthcare professionals. 3,4 Speaking up is described as making one’s privately held in- formation known about risky or deficient actions, such as mistakes, judgment lapses, or unprofessional behav- iors. 3,5-7 Healthcare professionals raise questions, state opinions, offer alternatives, or suggest solutions with an anticipated response from a listener that results in an action. 5,8-12 When voices are dismissed, healthcare professionals’ patient safety concerns may become undiscussable, resulting in organizational silence and leading to avoidable adverse patient outcomes. 13,14 The critical role of speaking up was brought to the forefront by the landmark publication “Silence Kills,” which revealed that less than 10% of the surveyed healthcare professionals reported they directly con- fronted their colleagues about patient safety con- cerns. 15 An individual’s motivation to speak up may be influenced by the following complex and multiple factors: (1) individual personality traits (conscientious- ness, extraversion, 7 perceptions that one is fairly treated, 16 or prior experiences with speaking up 17 ); (2) interpersonal dynamics (relations with higher status individuals, 6,18 leaders’ attitudes, 8,9 and team dynam- ics 19,20 ); and (3) organizational factors (care coordina- tion, 10 policies and culture, 21,22 and workgroup size and structure 23 ). As a result of these factors, an individual may decide not to speak up and resort to strategies that compromise patient safety, such as remaining silent, Journal for Healthcare Quality, Vol. 42, No. 5, pp. 249–263 © 2020 National Association for Healthcare Quality The authors declare no conflicts of interest. For more information on this article, contact Sara Kim at sarakim@uw.edu. The authors wish to acknowledge the following funding sources: The Arnold P. Gold Foundation (Mapping The Landscape, Journeying Together), UW Medicine Patient Safety Innovations Program, and George G. B. Bilsten, Endowed Professorship in the Art of Communication with Peers and Patients. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article at (www.jhqonline.com). DOI: 10.1097/JHQ.0000000000000257 Journal for Healthcare Quality September/October 2020 · Volume 42 · Number 5 249 Original Article Copyright © 2020 by the National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.