The Journal of Continuing Education in Nursing

Original Article 

The FIRST Curriculum: Cultivating Speaking Up Behaviors in the Clinical Learning Environment

Jennifer A. Best, MD; Sara Kim, PhD

Abstract

Expressing concerns that arise during patient care is essential to protecting patient safety. A speaking up episode occurs within a power hierarchy and carries high potential for personal and professional consequences. Existing curricula that promote speaking up, such as TeamSTEPPS, extensively focus on verbal skills without recognizing the important emotional dimensions of speaking up. We developed the FIRST Speaking Up curriculum that covered the following: (a) inner barriers related to expectations of one's own identity, (b) cognitive distortions associated with speaking up, (c) the speaking up environment, (d) dialogue skills for the speaker and the listener, and (e) resilience strategies. The curriculum was delivered via 2 to 3 hours of interactive workshops to 109 participants, including 40 nursing staff and leaders, 24 plastic surgery residents, and 45 internal medicine residents. Evidence showed that training improved participants' motivations to speak up concerns. Our work expands on existing strategies for speaking up training by targeting both verbal and emotional skills. [J Contin Educ Nurs. 2019;50(8):355–361.]

Abstract

Expressing concerns that arise during patient care is essential to protecting patient safety. A speaking up episode occurs within a power hierarchy and carries high potential for personal and professional consequences. Existing curricula that promote speaking up, such as TeamSTEPPS, extensively focus on verbal skills without recognizing the important emotional dimensions of speaking up. We developed the FIRST Speaking Up curriculum that covered the following: (a) inner barriers related to expectations of one's own identity, (b) cognitive distortions associated with speaking up, (c) the speaking up environment, (d) dialogue skills for the speaker and the listener, and (e) resilience strategies. The curriculum was delivered via 2 to 3 hours of interactive workshops to 109 participants, including 40 nursing staff and leaders, 24 plastic surgery residents, and 45 internal medicine residents. Evidence showed that training improved participants' motivations to speak up concerns. Our work expands on existing strategies for speaking up training by targeting both verbal and emotional skills. [J Contin Educ Nurs. 2019;50(8):355–361.]

Speaking up involves raising concerns toward recognizing risks or deficiencies (e.g., mistakes, judgment lapses, or unprofessional behaviors) (Friedman et al., 2015; Okuyama, Wagner, & Bijnen, 2014; Schwappach & Gehring, 2014). In the landmark publication, “Silence Kills” (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005), health care professionals skilled in confronting colleagues' incompetence, poor teamwork, disrespect, or abuse experienced better patient outcomes, higher job satisfaction, and retention. Yet, most sentinel events involving medication errors, hygiene and isolation, treatments, and procedures still stem from communication failures (Chiang & Pepper, 2006; The Joint Commission, 2015).

The health care power hierarchy limits speaking up, rendering those in a perceived lower status, such as nurses, allied professionals, and trainees, fearful of raising concerns (Greenberg et al., 2007; Kim et al., 2016; Kim et al., 2017). The hierarchy is organizationally defined (e.g., reporting structures), professionally determined (e.g., ordering privileges), or accepted as the cultural norm (e.g., surgical services over medicine services) (French & Raven, 1959; Gabel, 2012). An individual in a speaking up moment engages in a complex risk-benefit assessment, weighing barriers such as self-doubt (e.g., “I may be wrong”) or helplessness (e.g., “What's the point?”) (Beament & Mercer, 2016; Morrow, Gustavson, & Jones, 2016; Okuyama et al., 2014; Reese, Simmons, & Barnard, 2016).

Current training models, such as high-fidelity simulations, pose challenges (Barzallo Salazar et al., 2014; Kim et al., 2018; Raemer, Kolbe, Minehart, Rudolph, & Pian-Smith, 2016; Robb et al., 2015). First, they often involve single interventions without coaching for sustaining speaking up skills. Second, data demonstrating training effectiveness remain elusive (Raemer et al., 2016; Sydor et al., 2013). Third, training emphasizes verbal over emotional skills. TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) advocates for protocols, known as CUS (“I am Concerned; I am Uncomfortable; This is a Safety issue”) or the “two-challenge rule” (King et al., 2008). Although verbal protocols may be practical, health care professionals require a tool kit to express both acute and nonemergent patient care concerns. Raemer et al. (2016) succinctly captured the limitations with current approaches: “… rubrics, code words, encouragement, rationale, analogies, and slogans may be insufficient on their own to get clinicians to speak up more readily” (pp. 534–535). Instead, what we need is: “how to invite speaking up, how to speak up, how to deal with being spoken up to, and how to speak up even when uncertainty is present” (Raemer et al., 2016, p. 536). We report a speaking up curriculum that promotes verbal strategies and emotional regulation for health care professionals.

Curriculum Development and Content

Curriculum Development

From 2016 to 2017, the Arnold P. Gold Foundation funded the development of the FIRST Speaking Up Curriculum. Availability of only a few curricular frameworks led us to consult experts in speaking up culture (Martinez et al., 2015; Martinez, Bell, Etchegaray, & Lehmann, 2016; Martinez et al., 2017), followed by broader literature reviews of health care conflict and power (Kim et al., 2017), shame (Bynum & Goodie, 2014), identity (Cruess, Cruess, Boudreau, Snell, & Steinert, 2014; Fagermoen, 1997), and resilience (Hodges, Keeley, & Troyan, 2008; McKenna, Hashimoto, Maguire, & Bynum, 2016). We also consulted Brené Brown's work on shame and resilience (Brown, 2012, 2015). With permission, we adapted elements of Dr. Brown's shame resilience curriculum, Connection (Brown, 2009) in the following FIRST learning objectives:

  • Develop strategies for recognizing inner barriers.
  • Activate the motivation to speak up.
  • Engage in effective inquiry.
  • Sustain resilience as an agent of change in a complex system.
  • Adapt speaking up strategies for an individual role as speaker or receiver.

FIRST was designed as a 3-hour interactive workshop. We offer details of the curriculum content in Table 1 with key elements of the curriculum described below.

First Workshop Outline (Based on A 3-Hour Session)

Table 1:

First Workshop Outline (Based on A 3-Hour Session)

Curriculum Content

Introduction. After defining speaking up, we introduced sources of power and influence in the clinical environment (Okuyama et al., 2014). Psychological safety, which enables speaking up, was addressed as a composite of three factors: perception of power distance, leader inclusivity, and employee empowerment (Appelbaum, Dow, Mazmanian, Jundt, & Appelbaum, 2016).

Section 1: Find Your Why. In small groups, participants recalled incidents when they were agents of speaking up or bystanders and shared their speaking up barriers. Barriers were expressed as concerns placed in the following domains (Beament & Mercer, 2016; Morrow et al., 2016; Okuyama et al., 2014; Reese et al., 2016): self (e.g., “Will I be humiliated?”), others (e.g., “Will I embarrass my superior?”), context (e.g., “Is this the right time to speak up?”), and content (e.g., “What if I got this wrong?”). We highlighted published barriers to speaking up: fear of “getting someone in trouble,” “eliciting anger or conflict,” and “alienating myself from my team,” all of which jeopardize team affiliation in the clinical environment (Martinez et al., 2017). We emphasized the need for a culture that cultivates shame resilience (Brown, 2012)—acknowledging the possibility of shame, but recognizing patient safety as the more compelling “why.”

Section 2: Identify Barriers and Context. Participants explored desired identities (“How do you want to be perceived at work?”) and undesired identities (“How do you NOT want to be perceived?”) (Brown, 2009). Rather than placing value on certain desired identities (“I am competent”), participants were encouraged to pair-share potential impacts of these identities on speaking up behaviors. Subsequently, participants completed an inventory of cognitive distortions (Burns, 1990), known as automatic negative thoughts, including personalization, that may lead individuals to assume blame for an event, rather than attributing cause to a system failure.

Finally, participants explored their unit's speaking up landscape (or norms):

  • What are the expectations around speaking up in our clinical environment?
  • Who sets these expectations?
  • How are these expectations communicated to us?
  • Who has the most power in our clinical environment on our team?

Each group's report helped construct a shared mental model of speaking up across units.

Section 3: Rehearse the Encounter. This section shifted to skill development (using our tool kit), beginning with decatastrophizing—cognitive restructuring that challenges catastrophic thinking. We presented key components of Seligman's (1995) framework:

  • Identify one worse thing that might happen and ways in which you can stop it from happening.
  • Identify one worse thing that might happen and ways in which you can stop it from happening.
  • Identify one best thing that might happen and ways in which you can make it happen.
  • Identify one most likely thing that will happen and ways in which you can handle it if it were to happen.

These questions combat overestimation of an event's likelihood and awfulness, and underestimation of an individual's personal coping ability if the worst occurs. Having learned that speaking up supersedes verbal skills and involves identity and the larger landscape, participants returned to their original stories, considering language, tone, and behaviors that might have been useful in those moments.

Section 4: Speak and Listen Humbly. We introduced an individual's dual role as a speaker and a listener, as each requires unique verbal and attitudinal skills. First, Edmondson's (TED, 2014) safety accountability framework was explained (Schein, 2013):

  • Framing work as learning, not execution.
  • Acknowledging one's own fallibility.
  • Modeling curiosity by asking questions.

Second, we offered humble inquiry as a technique for seeking information in the least biased method by accessing personal ignorance.

Third, we addressed reframing, a technique for coping with an emotional flooding of strong emotions (e.g., anger, uncertainty, or anxiety) that could impair cognition or judgment during an observed patient safety lapse. Reframing is essential to generating time for emotional deescalation (Miller & Rollnick, 2013). Borrowing from motivational interviewing techniques, we introduced reflective methods to manage resistance from a speaking up receiver. Simple reflection is a paraphrase of pressing concerns: “I am hearing that reviewing our protocol would be difficult.” Amplified reflection uses exaggerated expression: “Are you saying it is impossible for us to review our protocol?” Double-sided reflection juxtaposes two statements for acknowledging naysayers' concerns and opening dialogue for future action: “So, on the one hand, you think reviewing the protocol is important, but on the other hand, you believe the nursing leadership's buy-in is essential?”

Participants practiced reframing with a vignette involving a medication error in “batting cage” groups of six to seven (Senge, 1991). One participant stood in the center and spoke to each participant on the perimeter, who verbalized resistance. The center participant responded with a reframing technique and repeated the exercise with every person on the perimeter.

Section 5: Take Stock and Take Care. To reinforce a speaking up episode as a learning opportunity, we offered SpeakAGAIN as a structured debrief (Table 2) along with evidence-based practices (Seligman, Steen, Park, & Peterson, 2005) for sustaining resilience:

  • Hardwire the positive (create a daily list of “three good things” at work).
  • Find gratitude (e.g., Who am I thankful for at work and why?). They offset the depersonalization and emotional exhaustion associated with patient care advocacy.
  • Rally your people, which involved identifying two colleagues for practicing a difficult conversation or debriefing a speaking up attempt.
Speak Again Debrief Model

Table 2:

Speak Again Debrief Model

The concluding question was: “What do you believe would be the most effective intervention to improve the speaking up culture in our clinical workplace?” Participants posted responses on the wall, which were then synthesized for sharing with unit leadership.

Workshop Participants

Residents in medicine and plastic surgery were required to complete the training. These two programs were previously included in a multisite speaking up survey (Martinez et al., 2015). Nursing staff from one clinical unit were required to receive training and another unit made the training optional—both were at affiliated hospitals. They completed pre- and postintervention surveys. The institution's human subjects division approved the study.

Preliminary Evaluation

Five FIRST workshops (12 hours in total) were delivered to a total of 109 participants: 40 targeted nursing staff and leaders (100% participation), 24 plastic surgery residents (100% participation), and 45 internal medicine residents (25% participation). Participants reported higher postintervention means versus preintervention for four questions (Figures 14).

Survey responses: Speaking up patient safety concerns is my professional responsibility.

Figure 1.

Survey responses: Speaking up patient safety concerns is my professional responsibility.

Survey responses: When I encounter patient safety concerns, I am likely to speak up to a team member.

Figure 2.

Survey responses: When I encounter patient safety concerns, I am likely to speak up to a team member.

Survey responses: When I encounter patient safety concerns, I am likely to speak up to the person who is in a position of power and influence.

Figure 3.

Survey responses: When I encounter patient safety concerns, I am likely to speak up to the person who is in a position of power and influence.

Survey responses: Speaking up patient safety concerns requires moral courage.

Figure 4.

Survey responses: Speaking up patient safety concerns requires moral courage.

Their representative responses associated with speaking up barriers and strategies are included in Table 3. Overall workshop quality was rated at 4.6 of 5.0 (1 = very poor; 5 = excellent), with “likelihood to recommend” rated at 4.5 of 5.0 (1 = strongly disagree; 5 = strongly agree). The annual Accreditation Council for Graduate Medical Education (ACGME, n.d.-b) Resident Survey item, “Able to speak concerns without fear,” that administered pre- and post-FIRST training, showed high agreement levels: 93% versus 94% (medicine) and 79% versus 100% (plastic surgery).

Participants' Speaking Up Barriers and Strategies

Table 3:

Participants' Speaking Up Barriers and Strategies

The following comment highlighted positive curriculum elements: “I thought sharing people's stories was helpful. It made me feel supported by my co-residents and removed some of the feelings of isolation.” Participants reported that they would use the following skills in future speaking up encounters:

  • Humble inquiry techniques.
  • Just putting myself in people's shoes (new employees below me in the power hierarchy).
  • Purposefully rephrasing the question.

Suggestions for future improvements included additional time for interaction, using videos, presenting examples of concrete language, working through a longitudinal case, and including interprofessional participants across diverse roles, teams, and specialties.

Conclusion

A speaking up moment is a complex interaction of workplace (e.g., psychological safety, hierarchy, norms), relational (e.g., power distance, existing relationship), patient (e.g., acuity), and individual (e.g., role, previous experience, desired identity, conflict style, cognitive distortions, resilience) factors. We piloted a novel curriculum that reflects this complexity and acknowledges the reality of power dynamics.

The FIRST curriculum was a low-resource intervention. Sponsorship of stakeholder leaders (e.g., residency program directors and nursing administrators) who granted time for training and staff access was crucial to success. Lack of champions may pose training limitations, yet strong extrinsic incentives for speaking up training remain. Through ACGME's (n.d.-a) Clinical Learning Environment Review, health care systems and training programs share responsibility for explicit patient safety education. Similar to the ACGME survey item, the Agency for Healthcare Research and Quality Culture of Safety Survey (n.d., p. 3) includes: “Staff will freely speak up if they see something that may negatively affect patient care.” The Joint Commission (2018) also recently revamped its Speak Up campaign targeting patients and advocates, which may increase listening opportunities for health care professionals.

An overall increase in participant postintervention responses indicates that training may have contributed to attitudinal engagement regarding speaking up. In addition, diverse cohorts of participants (physicians, nurses, technicians, social workers, administrators) consistently requested interdisciplinary, interprofessional training—this reflects the current imperative of team-based patient care.

The ACGME survey item revealed that plastic surgery residents were more likely to speak concerns following FIRST training, compared with medicine residents. Cultural differences in the power hierarchy between specialties may explain the difference. FIRST was deployed to approximately 25% of 183 medicine trainees due to scheduling logistics. All plastic surgery residents and chief residents (N = 24) underwent FIRST. FIRST was the only formal training in speaking up offered in either program—we speculate that exposure to training for all surgical learners may have helped in attaining a greater shared mental model of speaking up within that program.

We recognize key limitations of our study, such as:

  • Single institution-based pilot with selected specialties and nursing staff, who completed a single training session.
  • A one-time data collection assessing participants' perceived training value.

Demonstrating long-term changes in health care professionals' speaking up behaviors and thus, organizational culture, requires a coordinated partnership with hospital leadership, patient safety officers, risk management, and others. This partnership must target formalized training programs, reward systems for promoting speaking up, just-in-time coaching interventions, and monitoring core metrics tied to institutional culture and climate.

Future curricular improvements will target customized content for broader needs of various groups and a train-the-trainer model to meet increasing training demands. The alignment our pilot findings with institutional priorities resulted in an award of $50,000 from the institution's patient safety and innovations program. We are currently piloting a self-paced tool that facilitates deliberate practice of speaking and listening skills, activated in the right moment and under the right circumstances.

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First Workshop Outline (Based on A 3-Hour Session)

ModuleLearning ObjectiveKey PointsDurationInstructional Method
Introduction

Describe ground rules specifying confidentiality and respectful speaking and listening to others.

Explain key concepts related to speaking up and listening skills.

Definition of speaking up

Introduction to social bases of power

Key factors to establishing psychological safety: power distance, leader inclusivity, and empowerment

Consequences of voice suppression

20 minutes

Didactic

Section 1: Finding your why

Identify the personal meaning of speaking up or abstaining from speaking up.

Explain the need to cultivate a shame-resilient culture.

Identify a personal connection to speaking up.

Reflect on the past speaking up event that posed challenges.

Understand factors that facilitate and impede speaking up motivations and behaviors.

Return discussion to patient safety.

30 minutes

Open self-reflection

Table discussion

Didactic

Section 2: Identity barriers and context

Describe personal cognitive distortions and perceptions of identity as barriers to speaking up.

Identify cultural expectations for speaking up within units.

Introduction to factors that shape one's personal and professional identity

Describe the role of cognitive distortions that affect one's situational awareness.

Connect one's identity to the larger collective landscape.

Assess the speaking up landscape in the clinical environment.

40 minutes

Worksheet self-reflection

Pair–share interactive exercise: large group “landscape construction”

Break—15 min.

Section 3: Rehearse the encounterUse cognitive restructuring techniques for speaking up, both verbal and emotional.

Prepare for the speaking up event through decatastrophizing a worst case scenario.

Recognize speaking up event as an emotional experience.

30 minutes

Self-reflection with worksheet didactic

Section 4: Speak and listen humblyApply reframing techniques for engaging in humble inquiry as a speaking up and listening technique.

Introduction to definition and techniques of humble inquiry

Recognize that a speaking up event creates learning opportunities through inquiry and respectful listening.

Understand the dual importance of speaking up and listening skills.

Practice reframing skills.

35 minutes

Didactic interactive exercise: batting cage

Section 5: Take stock and take careRecognize techniques for sustaining resilience by debriefing learning opportunities for future speaking up events.

Reflect on speaking up events using the Speak AGAIN tool.

Review resilience strategies:

Hardwire the positive.

Find gratitude.

Rally your people.

Conclude with writing intervention suggestions on Post-It® notes for improving speaking up culture in the clinical workplace.

10 minutes

Didactic

Speak Again Debrief Model

AcronymDescriptorPrompt
AAcknowledge emotionsWhat were they and how did I manage them?
GBe Generous with yourselfWhat did I do well?
AAdapt in responseWhat will I do differently next time based on this experience?
IIdentify meaningRecall how speaking up has affected me and my patients.
NNurture your effortWhat is a next step I can take on this issue?

Participants' Speaking Up Barriers and Strategies

What Is Your Top Reason for Withholding from Speaking Up Patient Safety Concerns?What Strategies Do You Use When Speaking Up Patient Safety Concerns in a Timely Manner?
“Don't want to be looked at as a troublemaker.” “My concerns will be ignored.” “Feeling that I could be wrong about the situation and offend someone.” “Someone else will do the job for me.” “Feeling like my superiors have experience/knowledge that I do not have.” “Time.” (Multiple responses)“Being direct.” (Multiple responses). “Problem solving immediate needs; assure safe status first, then notify leadership regarding the safety concerns.” “Try not to come off as punitive, but collaborative.” “Have a plan, be nonthreatening, make it a two-way conversation.” “I ask questions to clarify rather than to directly confront.” “Patient safety net reporting system.” (Multiple responses).
Authors

Dr. Best is Associate Professor, Department of Medicine, and Associate Dean for Graduate Medical Education, and Dr. Kim is Research Professor, Department of Surgery, and Associate Dean for Educational Quality Improvement, George G.B. Bilsten Professor in the Art of Communication With Peers and Patients, School of Medicine, University of Washington, Seattle, Washington.

This study was supported in part by the Arnold P. Gold Foundation, and the George G.B. Bilsten Endowed Professorship in the Art of Communication With Peers and Patients, University of Washington, Seattle, Washington.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the following project consultants for their invaluable input: Sigall Bell, MD, Christian Coté, Kelly Edwards, PhD, Ross Ehrmantraut, RN, Stephanie Schulz, and Chuck Sloane, JD. They also thank the Arnold P. Gold Foundation, as well as the George G.B. Bilsten Endowed Professorship in the Art of Communication With Peers and Patients for the generous support of their project. Finally, they thank the generous sharing of expertise and resources by Dr. Ronda Dearing, PhD, Graduate College of Social Work, University of Houston, and Susan Mann, MS, Chief Learning Officer, Brené Brown Education and Research Group.

Address correspondence to Sara Kim, PhD, Research Professor, Department of Surgery, and Associate Dean for Educational Quality Improvement, School of Medicine, University of Washington, Seattle, WA 98195; e-mail: sarakim@uw.edu.

Received: November 20, 2018
Accepted: February 28, 2019

10.3928/00220124-20190717-06

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