Speaking up as a vital part of a safety culture (BrattebĂž, Whitaker)

Safe and effective communication between team members is a vital part of health care, and this is why communication instruction is seen now as very important in our professional training. Good and open communication is also essential to a safety culture. It is hard to find any adverse event that has no element of communication issues as one of the contributing factors, such as misunderstandings, under-communication or withholding of information. Often, the analysis of such events concludes that someone in the team involved had some relevant information, which possibly could have avoided the event or at least influenced the outcome. The safety challenges span from established safety threats (e.g. lack of hand washing) to more delicate professionalism-related issues.

The big question is why didn’t the individuals in the situation speak up and make their voice heard, if that could have prevented possible harm? Do we only need to better train healthcare providers in expressing assertiveness, or are there other action points that also have to be addressed?

The current chapter presents and discusses relevant research on various perspectives of this subject, as well as the challenges of speaking up in relation to factors both inhibiting and encouraging this safety behaviour. Examples of promising ways of building an environment, in which all types of safety threat concerns can be easily aired by anyone without any fear of retributions or other negative actions, will also be presented.


It is always easy to blame the front-line individuals involved in an adverse event. It is also common on an institutional level to decide that, for example, in our department we now urge everyone to speak up for ensuring safety. However, as healthcare professionals we often find ourselves in situations where we observe that safety may be threatened, but find speaking up to be a significant challenge.162–164

Issues like culture, professional groupings and organisational socialisation may predispose personnel to avoid speaking up in hierarchies where this might be interpreted as disloyalty, disobedience or disrespect.165 A recent study among 1800 interns and residents in the United States reported that 47% of the respondents had experienced a patient safety breach during the last month.166 However, even more interesting, 75% of them had also observed what they saw as examples of unprofessional behaviour.166 The first type of safety issues are, for example, regarding hand hygiene and handling of medications, while the latter may be bad professional behaviour like hiding adverse events and disrespect for patients. To be able to speak up, an individual healthcare provider must be able to express assertiveness.

Assertiveness can be defined as a form of behaviour characterised by a confident declaration or affirmation of a statement without need of proof; this affirms the person’s rights or point of view without either aggressively threatening the rights of another (assuming a position of dominance) or submissively permitting another to ignore or deny one’s rights or point of view. Assertive communication respects the boundaries of both oneself and the others, lying between ineffective passive or aggressive responses.167

Assertive statements can be used to facilitate speaking up when there is concern for patient safety, and team leaders should try to create an atmosphere in which every medical team member can make their voice heard and their input is valued. Also, their input should be expected in situations that threaten safety. Team members must respect and support the authority of the team leader while at the same time clearly asserting alternative suggestions or communicating concerns.

Challenges and barriers to speaking up

In aviation the problem of failed communication has received extensive focus and empowering crew members to speak up has especially been identified as an important factor for improving flight safety.168 Studies from aviation, which have been exploring the reasons for remaining silent when actually being concerned about safety, have identified the fear of damaging relationships, of punishment or high operational pressures as the most common causes. Silence was lowest for captains, while first officers and pursers more often did not speak up.168 Like in aviation, healthcare personnel may refrain from speaking up due to a number of reasons as listed in Table 5. These factors are real and affect our behaviour, whether we like it or not. Another barrier to speaking up is the individual healthcare provider’s ability to use the appropriate wording to communicate their concern or to question a decision or situation that may threaten safety.169

Table 5: Reasons for not speaking up with corresponding statements (165, 169, 170)


Yet another consequence may be that instead of speaking up, individuals may accumulate their concerns over time, and then one day when, ‘the glass is full’ the resulting cannonade will be aimed in several directions, instead of addressing each specific safety issue. Ende171 published a valuable article in JAMA many years ago, giving some advice in the art of providing useful clinical feedback. Some of his advice on professional feedback is listed in Table 6. The point of explicitly addressing specific behaviour, decisions and actions, and not generalisations, is important, as well as using descriptive nonevaluative language.

Table 6: Guidelines for giving feedback (171)


The aviation industry developed the so-called two-challenge rule to empower everyone in a flight team, who often have not met each other before, to feel shared responsibility for safety and that they are required to speak up (even repeatedly) if they observe something that they think may represent a safety hazard. This communication rule is meant to empower all team members to ‘stop the line’ if they sense or discover an essential safety breach. If an initial assertive statement is ignored, it is the team member’s responsibility to assertively voice concern at least two times to ensure that it has been heard. The team member being challenged must acknowledge that concern has been heard. If the safety issue still has not been addressed, the person who raised a concern must take a stronger course of action, and if necessary, utilise a supervisor or chain of command. The US AHRQ has coined the acronym ‘CUS’ (Fig. 3). This is part of a teamwork system developed jointly by the Department of Defence and the AHRQ to improve institutional collaboration and communication relating to patient safety, called TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety: https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html). This course specifically addresses assertiveness, when a given situation dictates that team members must be assertive and address concerns regarding patient care. Ideally, this should be done in a nonthreatening, respectful way to make sure the concern or critical information is addressed. AHRQ has also suggested a constructive approach for managing and resolving conflict; the DESC script (Table 7).

Fig 3: The CUS acronym explained (from: ): it involves a five-step process: open the discussion; state the concern; state the problem – real or perceived; offer a solution; obtain an agreement.


Table 7: The DESC Script: a constructive approach for managing and resolving conflict


An example from aviation would be the following:

Draw the error to the captains attention.

I see there is high ground over this way.

If the captain ignores the remark, or fails to make a satisfactory response, the first officer should express concern in nonconfrontational language.

I’m concerned that this direction will take us too close to the mountains.

If the captain ignores the remark, or fails to make a satisfactory response, the first officer should clearly state a preferred alternative.

Let’s turn right to move toward lower ground.

If the captain ignores the remark, or fails to make a satisfactory response, the first officer should ask the captain why he/she has decided not to follow the first officer’s suggestion.

‘Can you please explain why you’re not concerned about the high ground?’ If the captain ignores the remark, or fails to make a satisfactory response, the first officer should loudly and clearly make an imperative statement that the captain must pay attention to his/her colleague.

Captain, you must listen!

We are dangerously close to the mountains! We must climb now!

At this point, regardless of what else happens, the captain’s career is in jeopardy at a safety-conscious airline.

A respective example from anaesthesia would be:

No Trace = Wrong Place (https://www.youtube.com/watch?v=t97G65bignQ)

After an uneventful operation and extubation the patient deteriorated, has a cardiac arrest on the operating table and is re-intubated. There is no trace on the waveform capnograph.

Draw the error to the consultants attention

To me there seems to be no trace on the waveform capnograph

If the consultant ignores remark, or fails to make a satisfactory response such as ‘well that is what you would expect in a cardiac arrest’ the trainee should express concern in a non confrontational language

I am concerned that even in cardiac arrest without any CPR if we are ventilating we should still see a capnograph trace. The tube may be in the oesophagus

If the consultant ignores the remark, or fails to make a satisfactory response the trainee should clearly state a preferred alternative

Let’s re-intubate the tube may in the oesophagus

If the consultant ignores the remark or fails to make a satisfactory response the trainee should ask the consultant why they have decided not to follow the first of their suggestions

Can you please explain why you’re not concerned about the possibility of an oesophageal intubation. The No Trace = Wrong Place campaign says it means an oesophageal intubationuntil proven otherwise

If the consultant ignores the remark or fails to make a satisfactory response the trainee should loudly and clearly make an imperative statement that the consultant must pay attention to their colleague

Consultant you must listen The No Trace = Wrong Place campaign says a flat capnograph trace even in cardiac arrest means an oesophageal intubation until proven otherwise. We must re-intubate now or use a laryngeal mask or the patient will die.

Different perspectives and actors

Usually the value of speaking up is discussed in relation to healthcare providers’ roles in ensuring patient safety, but the patients are also valuable partners in this endeavour. While we, as professionals, have the medical knowledge and know the procedures and signs of something that may be a warning signal in a given situation, the patient (and their next of kin) often may be an expert on his/her own disease and treatment/care. Patients may often feel that they should be silent and grateful beneficiaries of the healthcare provided, and not ask questions or be a ‘difficult customer’. This attitude will miss a safety opportunity. On the other hand, encouraging and empowering the patients and relatives to speak up if they see something that seems unusual or not according to what they have been told, for example, concerning medications or procedures, is a valuable source of improving safety that has not been fully utilised.172

Students, nurses and other health personnel may also be reluctant to voice concerns towards physicians, managers and seniors if they are raised in or part of a system that does not seem to welcome questions or other input from ‘below’. An organisation with a leadership proactively fostering a culture in which both patient advocacy and safety threats are openly invited and positively responded to, is far more likely to experience their staff speaking up about concerns regarding safety issues (https://www.virginiamasoninstitute.org/2014/03/terrible-tragedy-and-powerful-legacy-of-preventable-death/).162,166 Likewise, reducing the hierarchy among doctors has been repeatedly mentioned as a way of increasing junior doctors’ willingness to speak up.166,173

The WHO safe surgery checklist section on time-out before surgery is started includes an item where everyone in the operating room is required to introduce themselves and say out loud their name and function.174 This is a way of empowering every team member to speak up, because the fact that they already have raised their voice to the team increases the likelihood for them to later say something during the procedure if they see something that they feel may represent a safety hazard.

Salazar et al.175 reported an interesting simulation study where they randomly allocated 55 medical students to surgical teams in which the senior surgeon either encouraged or discouraged input from the juniors. During the scenarios, the surgeon made an obvious procedural error, which the student was expected to comment on. The students in the groups where the surgeon welcomed concerns were significantly more likely to speak up (82 vs. 30%). The authors concluded that senior surgeons could improve the safety-related communication between junior and senior staff in the operating room, thereby increasing patient safety. A recent Dutch study of 27 interns also concludes that opinions and actions of supervisors have a considerable influence on residents’ decision on speaking up or remaining silent.171 Seniors with an open and proactive attitude will increase the residents’ willingness to speak up.

Useful ways of encouraging speaking up behaviour

The Norwegian patient safety campaign (In safe hands – 24-7, https://helsenorge.no/rettigheter/rad-til-deg-som-skal-pa-sjukehus) has included the patients and relatives in the strive for safety by producing a booklet with some examples of questions that they may ask if hospitalised as shown in Table 8. The suggested questions are easy to use for a given patient needing some help to find the appropriate words for their concerns. It is a way of reducing the power-distance between the healthcare provider and the patient, and it also opens up for a more informative dialogue between them. Patients who are unable to speak for themselves or are small children will have to rely on their carer or next of kin.

Table 8: Some examples of questions and concerns patients may be encourged to raise (from the Norwegian patient safety campaign, https://helsenorge.no/rettigheter/rad-til-deg-som-skal-pa-sjukehus)


The Keystone Center in Michigan has published an interesting article on the ethical and financial imperative of making the front line staff in their organisation speak up if they experience quality and safety issues.176 One novel approach in this project was to ask staff to report when a chain of events, which might have led to an adverse event, was intercepted. In addition, they were asked to suggest an award for those who intervened. An electronic toolkit was developed to collect information of the possible adverse events that were prevented (Fig. 4). The cost savings for each prevented event was then calculated; for every instance of speaking up expenses of 13 000 US dollar was avoided. The author reports that encouraging personnel to speak up may also have a positive financial side.

Fig 4: The Keystone Center Speaking up award toolkit176 (©2019 Thelished by John Wiley & Sons Ltd Published online in Wiley Online Library (wileyonlinelibrary.com) (INK https://onlinelibrary.wiley.com/doi/pdf/10.1002/jhrm.21360).


The EBA recommends that all staff should speak up when they believe that the safety of the patient is compromised (http://www.eba-uems.eu/resources/PDFS/safety-guidelines/EBA-recommemdation-Speaking-up-for-Safety-2016.pdf). A particularly useful technique promoted by Cooper et al.177 is ‘to be curious’ and start the discussion about something you are concerned about in a nonthreatening way pretending you are not very knowledgeable. For example, ask the operator Those gallipots have not got any labels on them, like the ones used in Theatre 3, or I wonder why you are doing that?

All grades of staff should be encouraged that, if for a moment they are ever ‘wondering’ about the safety of what is going on, it is time to speak up! Often, just starting a conversation about safety encourages others present, who may also be concerned, to join in. Investigation of patient safety incidents has shown that other members of staff in the room often have private misgivings about what is happening as colleagues drift away from safety, and someone speaking up will give them confidence to express their unease as well.177 In health care, physician behaviour is closely observed and imitated, therefore showing leadership in this way may promote a positive culture.

Some studies have concluded that it is possible to train junior staff to voice their concerns in a clinical setting, and several factors which may increase the likelihood for speaking up have been identified.166,170,178 A number of these factors are listed in Table 9. However, the challenge remains to create a clinical environment which ensures that speaking up is the norm. On the other hand, one study concluded that speaking-up behaviours seem to be so deeply rooted, meaning that educational interventions alone do not seem to make any change.165

Table 9: Factors that may increase the likelihood for speaking up (partly based on Refs.4,5,10)


Improving healthcare providers’ ability for and willingness to speak up is a complex undertaking. Barriers against, and factors enabling speaking up behaviour have been identified. Just offering training in assertiveness and speaking up will fail to improve safety, if it is not accompanied by addressing the culture throughout the organisation. This requires leadership and commitment right from the top down board level to make the entire organisation take ownership and responsibility for ensuring safety, and to make everyone feel that voicing their concerns is encouraged and welcomed. Further, such behaviour should be met with an open attitude, eager to respond by making necessary adjustments or changes to ensure safety. However, we must not expect that changing and maintaining a multiprofessional culture is achieved overnight but will be an on-going and dedicated effort for any organisation striving for safety.

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