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‘Speaking up’ about patient safety concerns and unprofessional behaviour among residents: validation of two scales
  1. William Martinez1,
  2. Jason M Etchegaray2,
  3. Eric J Thomas3,
  4. Gerald B Hickson4,
  5. Lisa Soleymani Lehmann5,
  6. Anneliese M Schleyer6,
  7. Jennifer A Best6,
  8. Julia T Shelburne7,
  9. Natalie B May8,
  10. Sigall K Bell9
  1. 1Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  2. 2The RAND Corporation, Santa Monica, California, USA
  3. 3Memorial Hermann Center for Healthcare Quality and Safety, The University of Texas Medical School at Houston, Houston, Texas, USA
  4. 4Quality, Safety & Risk Prevention, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  5. 5Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  6. 6Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
  7. 7Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas, USA
  8. 8Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA
  9. 9Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr William Martinez, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-8300, USA; william.martinez{at}


Objective To develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour.

Method Residents from six large US academic medical centres completed an anonymous, electronic survey containing questions regarding safety culture and speaking up about safety and professionalism concerns.

Results Confirmatory factor analysis supported two separate, one-factor speaking up climates (SUCs) among residents; one focused on patient safety concerns (SUC-Safe scale) and the other focused on unprofessional behaviour (SUC-Prof scale). Both scales had good internal consistency (Cronbach's α>0.70) and were unique from validated safety and teamwork climate measures (r<0.85 for all correlations), a measure of discriminant validity. The SUC-Safe and SUC-Prof scales were associated with participants’ self-reported speaking up behaviour about safety and professionalism concerns (r=0.21, p<0.001 and r=0.22, p<0.001, respectively), a measure of concurrent validity, while teamwork and safety climate scales were not.

Conclusions We created and provided evidence for the reliability and validity of two measures (SUC-Safe and SUC-Prof scales) associated with self-reported speaking up behaviour among residents. These two scales may fill an existing gap in residency and safety culture assessments by measuring the openness of communication about safety and professionalism concerns, two important aspects of safety culture that are under-represented in existing metrics.

  • Communication
  • Graduate medical education
  • Patient safety
  • Safety culture
  • Statistics

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