Trade-offs between voice and silence: a qualitative exploration of oncology staff’s decisions to speak up about safety concerns

Abstract

BackgroundResearch suggests that “silence”, i.e., not voicing safety concerns, is common among health care professionals (HCPs). Speaking up about patient safety is vital to avoid errors reaching the patient and thus to prevent harm and also to improve a culture of teamwork and safety. The aim of our study was to explore factors that affect oncology staff’s decision to voice safety concerns or to remain silent and to describe the trade-offs they make.MethodsIn a qualitative interview study with 32 doctors and nurses from 7 oncology units we investigated motivations and barriers to speaking up towards co-workers and supervisors. An inductive thematic content analysis framework was applied to the transcripts. Based on the individual experiences of participants, we conceptualize the choice to voice concerns and the trade-offs involved.ResultsPreventing patients from serious harm constitutes a strong motivation to speaking up but competes with anticipated negative outcomes. Decisions whether and how to voice concerns involved complex considerations and trade-offs. Many respondents reflected on whether the level of risk for a patient “justifies” the costs of speaking up. Various barriers for voicing concerns were reported, e.g., damaging relationships. Contextual factors, such as the presence of patients and co-workers in the alarming situation, affect the likelihood of anticipated negative outcomes. Speaking up to well-known co-workers was described as considerably easier whereas “not knowing the actor well” increases risks and potential costs of speaking up.ConclusionsWhile doctors and nurses felt strong obligation to prevent errors reaching individual patients, they were not engaged in voicing concerns beyond this immediacy. Our results offer in-depth insight into fears and conditions conducive of silence and voicing and can be used for educational interventions and leader reinforcement.

As a critical behavior to improve quality and patient safety in health care: speaking up!

“…Presence of an audience (such as fear of causing lose in trust of the patient), perceived response of addressed actor (colleague) (fear of appearing incompetent, concerns and reprisal), seniority of the actor and his/her role, existence of senior encouragement towards speaking up behaviors, existence of common understanding of patient and patient needs, uncertainty about the issue, actual or perceived punishment towards the employee reporting an event and the fear, cost and results of raising concerns are found influencing factors about remaining silent or speaking up [11,19,[22][23][24][27][28][29]. Likelihood of speaking up is strongly influenced by seniority of the actor.…”

“…Predictors of the decision to speaking up have multiple influential factors such as: limited time, cumbersome documentation systems, clinical frame, lack of managerial support or follow up for an event, the level of perceived potential harm (varied perception in harm rating) and clinical situation (clarity, ambiguity, contrast) [19,20,22,23].…”

“…4). Speaking up is varied towards well-known coworker and unknown person [23,24]. Lover expressed likelihood of speaking up is linked to younger age, male gender, being nurse and working on ward [22].…”

“Speaking Up” for Patient Safety in the Pediatric Emergency Department

“…Furthermore, when deciding to voice concerns clinicians implicitly evaluate the trade-off between the costs and benefits of multiple factors. 57 These include, on the one hand, the degree of perceived harm to the patient, potential positive impact on their public image, and whether they believe speaking up will make a difference. On the other hand, clinicians weigh the potential negative consequences and risks, such as deleterious effect on relationships, being labeled as "difficult," or being humiliated.…”

“…On the other hand, clinicians weigh the potential negative consequences and risks, such as deleterious effect on relationships, being labeled as "difficult," or being humiliated. 57 Even if those in leadership positions across professions within a health care setting (eg, nursing leaders, senior residents, and attending physicians) engage in behaviors to promote psychological safety, there is no guarantee that people will speak up. Everyone engages in "self-censorship" to varying degrees at work, 58 electing to remain silent even when there are few or any risks associated with it; this tendency is hard to overcome.…”