1. Creating a Speak Up
Culture in Healthcare
Mr. Joven Botin Bilbao,BSN, RN, MAN
Director of Nursing –IMS-MOH Critical Crae Unit Project
Deputy Chief Nurse Officer- Al Hayat National Hospital-Jizan
Clinical Educator/Accreditation - Al Inma Medical Services

2. We Will Discuss:
• What Is Speaking Up?
• Why Speaking Up Doesn’t Occur
• Why Speaking Up Is Critical to
Patient Safety:
• Ways to Create a Speak Up
Culture in Healthcare

3. SILENCE ISN’T “SAFE”.
SPEAKING UP IS.
No matter their position or speciality, most medical and nursing
professionals have had some experience in hesitating with
speaking up when they see a safety risk. Even when the
medical professional is fully aware of the potential hazard to
the patient, staying silent can be seen as a “safe” option. In
a large-scale study, 50% of nurses described situations where
they should have spoken up, yet only 10% of the time did they
voice their concerns.
It’s important to create a “speak up” culture where staff
members feel comfortable going to management when delicate
problems arise. This is especially true in healthcare, where one
persons decisions have the potential to affect hundreds of

4. What Is Speaking Up?
Speaking up is defined as “The raising of concerns by health care
professionals for the benefit of patient safety and care quality upon
recognizing or becoming aware of the risky or deficient actions of others
within health care teams in a hospital environment.”
Safety concerns that require speaking up about include:
 Mistakes such as missed diagnoses
 Violating hygiene protocol
 Rule breaking
 Medication errors
 Administration errors
 Patient management decisions such as delayed transfer to intensive care
unit
 Outdated safety protocol

5. Why Speaking Up Doesn’t Occur
If not speaking up can cause patient’s harm, then why do people stay silent? The
answer is not quite straight-forward.
Whether an individual speaks up or not is influenced by a number of
factors; personal (such as age or personality), organisational (such as position in
hierarchy), and contextual (such as the organisation’s policies and safety culture). It
is suggested that the contextual factors are the primary motive for employees
staying silent. In a qualitative study undertaken in the US, the top three reasons
that employees didn’t speak up about their concerns or problems were out of fear
of being viewed negatively, feeling as if they did not have enough experience or
tenure to speak up, and considering their organization to have an intimidating
hierarchical structure and/or an unsupportive climate.
How an organization responds to their staff speaking up is also a factor. Some
nurses feel that raising concerns is a high-risk, low-benefit action, as nurses who

7. Why Speaking Up Is Critical to
Patient Safety:
When medical professionals are speaking up about safety concerns, the
hospital, clinic, or other healthcare institution are able to detect, correct,
and prevent unsafe work practices and complications during patients’
stay.
Staying silent has deeply negative effects including interfering with
employees’ psychological safety, decreasing teamwork among units,
increasing employee turnover, ceasing opportunities to learn and improve,
increasing costs, and ultimately increasing risks to patients.
Speaking up is essential to the safety climate of a healthcare
organization, which has been shown to be a crucial aspect for patient

8. Why Speaking Up Is Critical to
Patient Safety: ( Can't)
Therefore, healthcare organizations are
obligated to encourage a culture of safety that
values staff input. To achieve this, the
organization should both encourage and
empower speaking up in staff of all positions,
and reinforce their commitment by
responding to voiced concerns adequately.
Tolerating unsafe and disrespectful behaviors
will make it impossible for healthcare
organizations to cultivate the norms and
values necessary to provide safe, and efficient
care for the patient, and a joyful work
environment for the staff.

10. Make Giving And Receiving
Feedback A Habit
Please stop relying on the annual performance reviews as your
mandatory opportunity to provide your employees with feedback.
Giving ongoing feedback is an essential part of everyone’s
growth and development. Feedback should be delivered at
minimum, monthly during a one-on-one conversation with your
employees. Make sure you include these key pieces:
“This is what you are doing well (and be specific).”
“This is something you could work on (and be specific).”
Ask your employees to give YOU feedback about your role as
their leader. Ask these:
“Tell me one thing I’m doing really well as your leader.”
“Tell me one thing I could do better.”

11. Reduce Anonymous Options To Voice
Concerns
I’m an advocate for having a mechanism to allow for the
anonymous reporting of disruptive behaviors, especially if
an employee is really being targeted and tortured.
However, encouraging people to call the corporate hotline
or submit an anonymous tip in the comment box just
encourages passivity and reinforces the fear that speaking
up honestly may lead to negative consequences.
You want people to get comfortable with being
uncomfortable any time they witness or experience
anything that may impact patient care. You accomplish this

12. Be visible
As a leader, you need to BE where your people are. If your office
is in a different building or up three flights of stairs, your
employees are less likely to seek you out. If you can’t move your
office to be closer to your staff, at least spend time on the unit with
them – not just a drive by – but hang out with them throughout the
day.
One of the leaders in online academy shared a great way to
handle this situation! Her office was on another floor, so once or
twice a day she would take her laptop and set up at the nurses’
station to answer emails, review reports, etc. Her staff knew she
was working, but because she was so visible they became more
comfortable letting her know about situations on the unit in real

13. Take Action
The number one reason why employees DON’T speak up isn’t fear; it’s
complacency. They don’t believe you will do anything about it. I hear it all
the time. An employee tells their manager about a concerning situation, but
doesn’t SEE the results. Even if the manager takes action, if they don’t
close the loop, the employee assumes they didn’t do anything about it.
Letting them know how you take action can be very helpful. For example:
“Thank you for bringing this to my attention. Here is my process for
addressing concerns like the one you just brought to me. I investigate…then
I…then I… I might not be able to share the details of that investigation with
you due to confidentiality but I promise to at least let you know that the
situation was handled.”
Then make sure you keep your employee informed. Not doing so will

14. Be The Role Model
Ultimately, it’s what you DO that influences the behavior of your employees
– not what you SAY. If your employees give you constructive feedback and
you freak out on them, you’ve taught them to never give you feedback
again.
If your employee confides in you about a situation with a coworker or
physician and asks that you not tell them the information came from them,
and then you walk immediately out to the nurses’ station, grab that
employee and force them to talk about it in your office – that employee will
never come to you again.
If YOU complain about other people, the other leaders, and the
organization in front of your staff and add phrases like, “Oh he’s
untouchable…nobody is going to do anything about him” or “That’s just the
way it is here. Better get used to it” or “It’s better just to keep quiet so you

15. Recommendations
We all have an ethical responsibility to our patients and each other as human
beings to cultivate a culture where EVERYONE speaks up no matter what. It’s okay
to be uncomfortable – speak up anyway.
To encourage healthcare workers to speak up, leaders should start to cultivate a
culture of safety and open communication. Some recommended ways to begin this
are by;
Talking to staff frequently and positively about speaking up,
Reviewing the chain of command policies so that all staff know their options if
facing resistance to their objections,
Conducting role playing activities to explore how to handle difficult conversations,
Share the stories of situations where speaking up protected patients or stories
ts