Table 7

Summary of factors that may affect the likelihood speaking up about threats to patient safety

Knowledge base/judgement/certainty
Perceived personal responsibility for patient
Clinical autonomy; perceived agency and ability to change clinical decisions
Communication skills
Perceived efficacy of speaking up
Moral courage
Prioritisation of personal ‘likeability’
Psychological safety
  • Fear of conflict/anger

  • Anticipated emotional discomfort, fear of ‘looking stupid’ or fear of retribution

  • Potential for anonymity

Job satisfaction
Causal attribution
  • Internal/innate (personality or character trait) vs external/situation (situation/environment)

Familiarity with individual/approachability
Encouragement from senior clinicians
  • Presence of patients/families

  • Public vs private forum

Prior experience with speaking up and/or exposure to disruptive behaviour
Fear of self-alienation from team members
Fear of getting someone else in trouble
Other expected repercussions
  • Fear of poor evaluation, negative impact on reputation, etc

Individual case-based factors:
  • Potential for harm

  • Quality of evidence

  • Repeat occurrence of rule violation

  • Type of safety threat

    • ‘Traditional’ vs professionalism-related

Global environment factors:
  • Hierarchies/power dynamics

  • Patient safety culture

    • Teamwork climate

    • Safety climate

    • Speaking up climate for patient safety

    • Speaking up climate for professionalism

  • Fatigue, workload and other environmental stressors

Belief in inevitability of event
Meaningful change after speaking up
Preparation and support
  • Speaking up rubric

  • Getting help

  • Leadership

  • Positive recognition