What counts as a voiceable concern in decisions about speaking out in hospitals: A qualitative study

Published in


Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy 2022;3;13558196211043800. https://doi.org/10.1177/13558196211043800

  • 13 March 2023


Why it matters

Healthcare staff are a potentially valuable source of information about safety issues, poor care, faulty systems or inappropriate conduct.

However, staff do not always voice their concerns – perhaps because of how they perceive the organisational climate, what they think about the likely benefits and risks of speaking up, or feeling that they do not have enough authority or job security.

In addition to these challenges, it is not always clear how staff identify which concerns they should voice in the first place. For example, they may not be sure whether a problem really exists or how serious it is.

This study explored the concept of ‘voiceable concern’: what healthcare staff count as a concern that needs voicing.


We conducted 165 interviews with clinical and non-clinical staff with differing levels of seniority in three hospitals in two countries. Participants were asked about when they would raise concerns if they became aware of situations or practices that they felt might be a risk to patient safety, and what influenced their decision on what counts as a voiceable concern.

What we found

Our analysis found that identifying what counts as a concern, and whether it needs voicing, is not as straightforward as applying objective criteria. Instead, it often involves discretionary judgement, exercised in very specific organisational and cultural contexts.

We identified four influences that shape what individuals classify as voiceable concerns:

This work demonstrates that healthcare staff should be supported to have confidence in their judgements and their entitlement to speak up on the basis of those judgements.  What is classified as an occasion for voice is affected by organisational and cultural influences, including expectations, standards, norms and patterns of behaviour. Identifying voiceable concerns also requires shared understanding and a shared vocabulary. Leaders of healthcare organisations can help by providing clear direction on acceptable standards of conduct and practice, and creating forums where staff can share their experiences and reflections.

Understanding how healthcare staff come to recognise what counts as a concern that they need to voice is critical to understanding decisions and actions around speaking up. The concept of a voiceable concern may help to explain behaviour and inform interventions aimed at improving the voicing of concerns.

Licensed under Creative Commons

These symbols show that the contents of this page are published under a Creative Commons licence called CC-BY-NC-ND 4.0.

It means that you’re free to reuse this work. In fact, we encourage it. We want our research to reach people who can help improve quality and safety in healthcare. But we do have a few rules:

  • Make sure you acknowledge The Healthcare Improvement Studies Institute (THIS Institute) as the creator and link back to this webpage.
  • You can’t sell this work for a fee, or use it for any activity that generates revenue without our permission.
  • Please don’t distribute a modified version to others without our permission.

You can read the fine print about the licence on the Creative Commons website. It’s meant to help us keep the integrity of our work and stay true to our values.

But ultimately we want our work to have impact. So if you’ve got a use in mind but you’re not sure it’s allowed, just ask us at enquiries@thisinstitute.cam.ac.uk