Table 7

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

Personal	Relational	Contextual
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 Bravery/assertiveness/confidence 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 Privacy ▸ 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

Personal

Relational

Contextual

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
Bravery/assertiveness/confidence
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
Privacy

▸ 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