Effectiveness of speak-up training programs for clinical nurses: A scoping review

Speaking up about patient safety concerns is critical when bedside nurses encounter unsafe situations. Training programs that encourage nurses' speaking up behavior have been introduced, but there is limited evidence regarding whether such training leads to behavior change or improves patient safety.

The aim of this review was to identify the effectiveness of speak-up training programs for clinical nurses, focusing on program content and outcomes.

A scoping review was conducted using the Joanna Briggs Institute methodology and reported according to the Cochrane and Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines.

This study used bibliographic databases of PubMed, Embase, PsycINFO, Scopus, ProQuest Dissertations and Theses Global for the English language, and NDSL, KCI, RISS, KISS, and DBpia for the Korean language. The literature search used a combination of keywords and subject headings related to speak-up training programs for nurses or any type of nurse training program with an assertiveness component. Training outcomes were evaluated according to the 4-level Kirkpatrick model.

A total of 4808 references were retrieved, of which 21 articles were selected. These 21 studies were conducted in different parts of the world and published from 1981 to 2020. Speak-up training primarily increased some degree of nurses' levels of assertiveness and speak-up behavior, and also led to secondary outcomes such as job stress, work motivation, and communication conflicts. Most studies (n = 19) applied traditional training formats which consisted of multi-session lectures and practice, whereas three studies applied new methodologies such as high-fidelity simulations and online learning. According to the Kirkpatrick model, five studies assessed reactions to speak-up training (level 1), all studies evaluated learning as a result of training (level 2), two studies measured the effect of speak-up training on nurses' behavior (level 3), and one study evaluated nurses' results (level 4) while no studies evaluated patient-level outcomes.

Speak-up training for nurses can improve their levels of assertiveness or speak-up behaviors. Despite inconsistent or mixed findings, speak-up training has the potential to improve nurses' psychological well-being, leading to positive organizational performance. New training methods are directed at specialized education for clinical situations. Future speak-up training should consist of training programs based on real clinical situations in which team members participate together to comprehensively evaluate the effect of training on behavioral changes of health professionals as well as patient safety.