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01.12.2014 | Research article | Ausgabe 1/2014 Open Access

BMC Health Services Research 1/2014

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

BMC Health Services Research > Ausgabe 1/2014
David LB Schwappach, Katrin Gehring
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-14-303) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Both authors made significant contributions to study conception and design, coordination, and data analysis and interpretation. DS drafted the manuscript. KG revised it critically for important intellectual content. Both authors read and approved the final manuscript.



Research 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.


In 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.


Preventing 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.


While 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.
Authors’ original file for figure 1
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