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Table 3 Barriers to speak up

From: Trade-offs between voice and silence: a qualitative exploration of oncology staff’s decisions to speak up about safety concerns

Barrier Example quotes from interviewees
Presence of other persons “I do not want to humiliate anyone”. Nurse, ward (C114)
 Erosion of trust between patient and caregiver “It is very challenging to speak up directly. There is the patient, and mother or father present. These are very tough situations, where you know you should voice and you want to, and still, it is difficult. You cannot voice your concerns in front of the patient”. Nurse, pediatric ambulatory unit (L232)
 Embarrassment and humiliation of the actor
“This basic trust of the patient towards doctors, you do not want to shake their confidence. Thus, not in front of the patient, if possible”. Resident, ward (J118)
Hierarchical structures and relations “Because I have the feeling… that it is just not done. I would be so worried with how to say it to him [the chief of department], that it would be too late then, or I would end up sweating”. Resident, pediatric ward (J122)
 Experience/knowledge gap (observer/actor)
“I, as a junior doctor, just feel uncomfortable to speak up towards a senior colleague with ages of experience. It…doesn’t feel right. You ask yourself whether these shoes aren’t too large…to challenge someone with lots of experience, knowledge and responsibilities. That’s a problem”. Resident, ambulatory unit (P126)
Limited time “If you have lots of things to do you think, well okay, it just is like this now”. Nurse, ambulatory unit (C113)
 Speed of the incident
 Observer’s limited time resources “He [the senior] has several ward rounds to do, he is under stress, he is under time pressure. And to hold him back with something like this – difficult”. Resident, ambulatory unit (B101)
 Actor’s time constraints and distress “Sometimes, raising concerns makes me feel guilty because time is so short at the rapport”. Resident, ambulatory unit (X110)
Fears of negative consequences “Fear, of course. Will I find the right words and tone?” Nurse, ward (J221)
“..and when you are still in training, challenging the supervisors is not good. Too much confrontation is not good at all”. Resident, ambulatory unit (P127)
 Prompt negative or harsh reactions
 Being labelled as “difficult” “Because she is a special character and beliefs that she does not make errors. When you tell her that she did something wrong she will be touchy for days”. Resident, pediatric ward (J122)
 Damaging good relationships
 Actor’s personality
Occupational group constellation (observer/actor) “Simply, because he is a surgeon and we are nurses. Not everybody has the courage to speak up to a surgeon”. Nurse, ward (J221)
“It is not really well received if you as a doctor point them [nurses] to their lapses. They think that we have no idea of these issues, .. removing catheters, check IV lines more closely or positioning of a patient. Thus we should remain silent”. Senior doctor, ward (B102)
Futility and resignation “If there is a person, and you can say it over and over, and it doesn’t change. That is difficult”. Nurse, pediatric ambulatory unit (L232)