See original article: 22 (2): 182.

This article has a correction

Please see: BMJ Qual Saf 2013;22:182

BMJ Qual Saf doi:10.1136/bmjqs.2010.050211
  • Original research

Predictors of likelihood of speaking up about safety concerns in labour and delivery

  1. Robert M Wachter5
  1. 1Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, California, USA
  2. 2Duke University Health System, Durham, North Carolina, USA
  3. 3Labor and Delivery, St John's Mercy Medical Center, St Louis, Missouri, USA
  4. 4Physician Wellness, San Francisco, California, USA
  5. 5Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Audrey Lyndon, Department of Family Health Care Nursing, University of California San Francisco, 2 Koret Way, Box 0606, San Francisco, CA 94143, USA; audrey.lyndon{at}
  1. Contributors Study conception and design: AL, KAL, KRS, RMW. Instrument development and testing: AL, KRS, AR, RMW. Data aquisition: AL. Data analysis and interpretation: AL, JBS, KAL, RMW. Drafting manuscript: AL. Critical revisions: AL, JBS, KRS, AR, KAL, RMW.

  • Accepted 16 June 2011
  • Published Online First 1 July 2011


Background Despite widespread emphasis on promoting ‘assertive communication’ by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care.

Methods The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units.

Results The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2–10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations.

Discussion This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.


  • Funding This project was supported by a grant from the University of California School of Nursing Research Committee and NIH/NCRR/OD UCSF-CTSI Grant Number KL2 RR024130. All funds were administered through the University of California San Francisco.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the University of California San Francisco and participating hospitals.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Free sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of BMJ Quality & Safety.
View free sample issue >>

Email alerts

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


Navigate This Article