Speaking Up


  • ‘Speaking up’ refers to a person in a non-dominant or non-leader role expressing a concern or suggested course of action to another person in a dominant or leader role
  • Speaking up here refers to raising a concern before an act of commission or omission, rather than after it has occurred, which is distinct from reporting sentinel events or ‘whistleblowing’; it is sometimes referred to as ‘speaking out’ or ‘assertiveness’
  • Health care professionals are expected to speak up about their concerns before a critical event reaches a patient to provide a chance to correct the plan or intervention
  • Speaking up is vital to maintaining patient safety in critical care settings, yet often does not occur
  • We must always advocate for our patients and never leave a situation thinking ‘I should have said something!’
  • Patients should also be encouraged to speak up
  • Speaking up requires courage and skill, but is essential!

“Primum non tacere – first do not be silent”


  • Speaking up can help avoid patient care errors or assist in recovering from them
  • The safety and transparency of an organisation can in part be gauged by the freedom of their staff to ‘speak up’ when the time is right
  • speaking up is a predictor of technical team performance
  • Failure to speak up is common
    • The 2010 Silence Treatment study of 6,500 nurses and nurse managers in the USA found that 84% reported >10% of their colleagues taking dangerous shortcuts, and 26% said these shortcuts have actually harmed patients. Despite these risks, only 17% shared their concerns with the colleague in question.


Individual factors

  • the follower may be uncertain that they are correct
  • uncertainty about how to ‘speak up’ effectively
  • perceived effectiveness of speaking up (“won’t change anything anyway”)
  • lack of a feeling of responsibility or not feeling like it is his/ her ‘job’ (e.g. emergency nurse who observes that an anaesthetist keeps repeating attempts at a difficult intubation instead of performing a cricothyroidotomy)
  • fear of being wrong, getting ridiculed or looking incompetent
  • fear of creating inter-personal conflict or being seen as a trouble maker
  • lack of job satisfaction (people with higher levels of job satisfaction are more likely to speak up)
  • lack of sense of personal control and autonomy (a sense of making an impact at work)
  • previous experience

Situational factors

  • unclear or ambiguous situations
  • not wanting to interrupt other activities
  • perceived low risk of harm from concerning behaviour/ action
  • excessive cognitive load
  • lack of inter-disciplinary hospital policies dealing with the situation

Interpersonal and cultural factors

  • lack of a ‘speaking up’ culture in the workplace and administrative support
  • intimidation
  • steep power gradient
  • cultural and linguistic differences
  • team/ leader attitudes


  • The common approach of speaking indirectly in a ‘hint and hope’ fashion is ineffective
  • The person speaking up must be assertive
  • Graded assertiveness approaches are effective; an alternative is the ‘Two challenge approach’
  • Focus on the problem, avoid the issue of who is right and who is wrong
  • Always be respectful
  • If there is time, start off curious rather than adversarial, use appropriate body language and tone of voice
  • In emergencies you may not have time for niceties!



  • graded assertiveness allows the junior person to avoid conflict or triggering defensiveness initially, but allows them to escalate if required
  • It gives the senior person a chance to correct any mistakes or misunderstandings and to save face
  • Different approaches include CUSS, PACE, and 5-step advocacy

CUSS approach

  • Concern – “I’m concerned that…”
  • Unsure – “I’m unsure that…”
  • Safety – “It is not safe…”
  • Stop – “Stop what you are doing…”

PACE approach

  • Probe – e.g. “Do you know that…?”, “I don’t understand why you want to do…”
  • Alert – e.g. “I think that will cause…””
  • Challenge – “Your approach will harm…”
  • Emergency action – e.g. “STOP what you are doing!” “For the safety of the patient we need to…”

5-step advocacy

  • Attention getter – “Excuse me, Doctor”
  • State your concern – “The patient is hypotensive”
  • State the problem as you see it – “I think we need to get help now”
  • State a solution – “I’ll phone ICU to arrange transfer”
  • Obtain an agreement – “does that sound good to you?”


Approach described by Pian-Smith et al, 2009:

  • First challenge using advocacy-inquiry e.g. “I see that you plan to administer a spinal anesthetic to this patient. She has a platelet count of 80,000. I learned that we shouldn’t do a spinal unless the count was at least 100,000. Can you clarify your view?”
  • If no sensible response then provide second challenge with advocacy-inquiry; e.g. “I see that you plan to administer a spinal anaesthetic, but I worry her platelets are too low. I think it’s unsafe and we should do a general anaesthetic. What do you think?”
  • If no sensible response then get additional help to protect the patient and resolve the disagreement


  • Raise awareness
  • Establish a culture of ‘speaking up’ through leadership and actionable, sustainable policies and practices (some studies show nurses are unlikely to speak up unless supported by specific policies)
  • Provide training in open, non-defensive team-working principles and communication skills (e.g. team-based simulation)
  • Role modelling of best practice (including thanking/ praising those who speak up appropriately)

References and Links

Journal articles

  • Bolsin S, Pal R, Wilmshurst P, Pena M. Whistleblowing and patient safety: the patient’s or the profession’s interests at stake? J R Soc Med. 2011 Jul;104(7):278-82. PMC3128871.
  • Dwyer J. Primum non tacere. An ethics of speaking up. Hastings Cent Rep. 1994 Jan-Feb;24(1):13-8 PMID: 8045760.
  • Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. PMC1765783.
  • Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014 Feb 8;14:61. PMC4016383.
  • Pian-Smith MC, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc. 2009 Summer;4(2):84-91.PMID: 19444045.
  • Srivastava R. Speaking up–when doctors navigate medical hierarchy. N Engl J Med. 2013 Jan 24;368(4):302-5.PMID: 23343060. [Free Full Text]

FOAM and web resources

  • American Association of Critical-Care Nurses. The silent treatment: why safety tools and checklists aren’t enough to save lives. Aliso Viejo (CA): The Association. Available from: Silent Treatment Study

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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