BMJ Open 4:e004740 doi:10.1136/bmjopen-2013-004740
  • Health services research
    • Research

‘Saying it without words’: a qualitative study of oncology staff's experiences with speaking up about safety concerns

  1. K Gehring1
  1. 1Swiss Patient Safety Foundation, Zurich, Switzerland
  2. 2Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
  1. Correspondence to Dr David Schwappach; schwappach{at}
  • Received 23 December 2013
  • Revised 24 April 2014
  • Accepted 30 April 2014
  • Published 16 May 2014


Objectives To explore the experiences of oncology staff with communicating safety concerns and to examine situational factors and motivations surrounding the decision whether and how to speak up using semistructured interviews.

Setting 7 oncology departments of six hospitals in Switzerland.

Participants Diverse sample of 32 experienced oncology healthcare professionals.

Results Nurses and doctors commonly experience situations which raise their concerns and require questioning, clarifying and correcting. Participants often used non-verbal communication to signal safety concerns. Speaking-up behaviour was strongly related to a clinical safety issue. Most episodes of ‘silence’ were connected to hygiene, isolation and invasive procedures. In contrast, there seemed to exist a strong culture to communicate questions, doubts and concerns relating to medication. Nearly all interviewees were concerned with ‘how’ to say it and in particular those of lower hierarchical status reflected on deliberate ‘voicing tactics’.

Conclusions Our results indicate a widely accepted culture to discuss any concerns relating to medication safety while other issues are more difficult to voice. Clinicians devote considerable efforts to evaluate the situation and sensitively decide whether and how to speak up. Our results can serve as a starting point to develop a shared understanding of risks and appropriate communication of safety concerns among staff in oncology.

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