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Speaking up

The term “speaking up” is used to refer to the assertive communication of quality and patient safety concerns by a team member through information, questions, or opinions in situations where a healthcare professional neglects, forgets or even ignores clinical guidelines to prevent patient harm.

Speaking up has a preventive effect on human errors and helps to improve system failures. But the research shows that sometimes those who speak up are ignored, and too often people choose to withhold their voice.1

  • In a recent study in Austria, 32.3% of surveyed physicians and nurses said they had not expressed concerns regarding patient safety and 41.6% had kept ideas to themselves that could have improved patient safety in their unit.2
  • An equivalent study with medical students revealed that 59% had not felt able to speak up in a critical situation. 3
  • A study in Switzerland showed that an encouraging environment was related with higher speaking up frequency and lower withholding voice frequency. A poor climate, with high levels of resignation was associated with higher withholding voice.4 

The work by Manapragada and Bruk-Lee5 identified four main motives behind silence about safety issues:

 Reasons for staying silent about safety issues. Adapted from Manapragada A, Bruk-Lee V. Staying silent about safety issues: Conceptualizing and measuring safety silence motives. Accid Anal Prev. 2016;91:144–56

The study shows that safety motivation is not related with those motives (with the exception of issue-based, which would enable the recognition of the issue) suggesting that a highly motivated for patient safety worker will not be affected by those factors, so they won’t deter him from speaking up. This highlights the importance of an environment where the staff is highly motivated.


  1. Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014;14(61). 
  2. Schwappach D, Sendlhofer G, Häsler L, Gombotz V, Leitgeb K, Hoffmann M, et al. Speaking up behaviors and safety climate in an Austrian university hospital. Int J Qual Heal Care. 2018;30(9):701–7. 
  3. Schwappach D, Sendlhofer G, Kamolz LP, Köle W, Brunner G. Speaking up culture of medical students within an academic teaching hospital: Need of faculty working in patient safety. PLoS One. 2019;14(9):1–13. 
  4. Schwappach D, Richard A. Speak up-related climate and its association with healthcare workers’ speaking up and withholding voice behaviours: A cross-sectional survey in Switzerland. BMJ Qual Saf. 2018;27(10):836–43. 5. Manapragada A, Bruk-Lee V. Staying silent about safety issues: Conceptualizing and measuring safety silence motives. Accid Anal Prev. 2016;91:144–56

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