Voice Behavior and Patient Safety in Healthcare Settings

Voice behaviour in healthcare encompasses the decisions and actions through which staff raise—or choose not to raise—concerns, questions and observations relevant to patient welfare. It ranges from direct challenges to subtle, indirect cues within interprofessional teams. Effective voice behaviour supports early error detection, fosters a culture of safety and underpins quality improvement. Barriers such as hierarchical power gradients, fear of repercussion, unclear reporting channels and variation in individual confidence can hinder speaking up. Conversely, environments characterised by psychological safety, clear communication protocols and leadership endorsement of open dialogue encourage healthcare workers to articulate safety concerns. Globally, interventions have targeted both individuals (through training in assertiveness and self-efficacy) and organisations (through flattening hierarchies, clarifying escalation pathways and embedding regular debriefing) to strengthen voice as a key patient-safety strategy.

Research from Nature Portfolio

Recent qualitative analysis of internal medicine residents during attending ward rounds has delineated how team culture, psychological safety, self-efficacy and resident autonomy converge to shape speaking-up behaviour. Feedback—especially non-verbal cues—from senior clinicians strongly influences trainees’ willingness to articulate clinical reasoning or raise safety concerns. Four themes emerged as critical enablers of voice: the promotion of a learning culture, creation of interpersonal safety, development of individual confidence in speaking up and fostering graduated responsibility. The study highlights the need for attending physicians to adopt consistent supportive behaviours and to recognise both explicit and implicit signals of hesitation among learners.

Voice Behavior and Patient Safety in Healthcare Settings publication trend

The graph below shows the total number of articles in voice behavior and patient safety in healthcare settings across all publications each year (not limited to Nature Index journals).

Technical terms

Voice behaviour: The spectrum of actions by which healthcare personnel express concerns, suggestions or objections related to patient safety.

Speaking up: The deliberate act of verbalising a safety concern or question to colleagues or superiors.

Withholding voice: The decision to remain silent about observed risks or errors, whether strategic or constrained by fear.

Psychological safety: A shared belief that one can raise questions or admit mistakes without fear of humiliation or punishment.

Indirect communication: Use of nuanced or roundabout language to convey a safety concern to higher-status team members.

Self-efficacy: An individual’s confidence in their ability to perform voice behaviours effectively under challenging circumstances.

References

1. “The patient is awake and we need to stay calm”: reconsidering indirect communication in the face of medical error and professionalism lapses. Advances in Simulation (2024).
2. What inhibits “speaking up” for patient safety among healthcare workers? A cross-sectional study in Malaysia. Human Resources for Health (2024).
3. Opportunities for nurses to address employee voice in health care providers: a scoping review. BMC Nursing (2024).
4. Speaking up on attending ward rounds: a qualitative study of internal medicine residents. Humanities and Social Sciences Communications (2024).