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


Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy 2022;3;13558196211043800.

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:

  • Certainty that that something is wrong and that they should be the person to speak up about it.
  • Whether the concern is a system issue or a conduct issue.
  • The extent to which the concern is seen as being forgivable.
  • The extent to which the issue relating to the concern is normalised in the organisation.

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.

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