Hospital team leaders: Why do staff stay silent when they see a risk?

The moment between noticing and speaking

A hospital employee spots a discrepancy, but senior colleagues are leading the discussion. Can they interrupt? Before speaking, they weigh whether they have identified the risk correctly, have enough information, and can expect their supervisor to take the question seriously. Silence does not necessarily mean indifference, nor does it have one fixed cause. Raising a concern involves both recognizing a possible safety risk and telling someone who can act on it. A systematic review of 294 publications clarifies the concept but also shows that studies defined and measured it differently. It cannot tell us which intervention will prompt this particular employee to speak; their hesitation must be understood in the context in which they work.

Risk depends on the relationship

Whether a question feels safe also depends on who is listening. An employee may speak freely with a colleague but fall silent in front of a respected department head, especially when others are present. In a survey of 23 neonatal intensive care units, professional status was associated with psychological safety, while inclusive leader behavior lessened the significance of status differences. This is an association observed in teams, not proof that a particular response improves patient outcomes. It is therefore worth asking who people feel comfortable questioning, and when questions dry up. Before a difficult conversation, they can also prepare an opening based on what they observed, rather than immediately putting the other person on the defensive.

What someone who hesitates needs to know

Someone who hesitates needs to know which warning signs to report even without complete certainty, whom to tell first, and where to take the matter if nobody responds. They also need to know when to expect an answer and what to do if their direct supervisor is involved in the situation. Asking about a possible risk is not the same as accusing a colleague. A simple formula may help: “I saw X at time Y. I’m concerned about Z. Can you confirm who will check this and when I’ll hear back?” In the review, speaking up means communicating a concern to someone able to act. Listening without following up leaves the employee unsure what happened to their report.

The recipient needs skills too

The person receiving the concern needs a practical skill too. They can begin by acknowledging it, asking about the observed facts, and explaining what they will do or who will assess the matter. “Let’s clarify what you noticed” opens a conversation differently from immediately questioning the employee’s competence. If the concern proves unfounded, it is worth explaining how it was assessed rather than ending contact. It is especially important that a good-faith report that turns out to be mistaken does not lead to social punishment. Employees learn not only how to frame questions, but also whether they will receive a substantive answer and feel able to raise another concern.

Why training may not be enough

Training staff to speak up boldly is not enough if raising a concern leads to punishment or no response. A review of 14 interventions addressing psychological safety and speaking up found mixed results; measures often relied on self-reports. The authors noted the limits of educational measures in the face of entrenched behavior. That does not make conversation practice worthless, but it does make it hard to promise improvement from communication training alone. In practice, it is worth rehearsing both a brief report from the employee and a supervisor’s response: clarifying the concern, identifying the next step, and following up. This approach covers both sides of the conversation and helps reveal where the process breaks down.

How to discuss past silence

A conversation about earlier silence should not begin by accusing someone of lacking courage. It is better to ask what they expected would happen if they spoke up: dismissal, conflict, or no decision. It is also important to check whether they knew which channel to use, how soon to expect a response, and whether they could count on hearing back. Do not demand names in a team discussion; what matters more is reconstructing the point at which a safe opportunity to report the concern was lost. Only then can changes to the conditions for conversation or the reporting route be considered. Silence does not explain itself, so questions and observation are needed in the specific workplace.

How to assess change

Change should not be judged solely by how many people speak during briefings. It is better to collect examples of concerns raised early enough and check how they were received, who took the next step, and whether the person who raised them got a response. New employees and those with less influence should also be asked separately whether they know whom to approach and what happens next. Another important question is whether people speak up to senior figures, not just to peers. This kind of review covers the whole path from observation to response. It distinguishes a situation in which staff speak more often from one in which important information actually reaches someone able to assess it.

Between noticing a risk and reporting it, an employee weighs not only the facts but also whom they would tell and how that person might respond.

Empatyzer in preparing an employee to raise a concern

A nurse notices something concerning during a shift but is apprehensive about speaking to the doctor on duty. With Em, they can rehearse a brief report: state what they observed, the possible risk to the patient, and the decision they are asking about. A comparison with that specific person then helps them choose how to start the conversation, while talking with Em about the reporting relationship helps refine the question without turning it into an accusation. The “You and the team” view shows differences in preferences for direct confrontation and asking questions; it may help them choose an approach, but it does not replace reporting the concern. Micro-lessons can help them practise expressing a concern and acknowledging receipt of information. At the same time, the supervisor can prepare a response that clarifies the facts and identifies the next step. The exercise must still be followed by a real conversation with someone able to act, and agreement on who will make a decision and when they will respond. The tool helps prepare the words, but it does not remove the hierarchy or the duty to act.