Open Access Highly Accessed Research article

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

David LB Schwappach12* and Katrin Gehring1

Author Affiliations

1 Swiss Patient Safety Foundation, Asylstr. 77, 8032 Zuerich, Switzerland

2 Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland

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BMC Health Services Research 2014, 14:303  doi:10.1186/1472-6963-14-303

Published: 14 July 2014



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.

Communication; Safety culture; Qualitative research; Patient safety; Oncology