Hospital director: why does a staff member speak up on one ward but stay silent on another?

Differences between wards

The same staff member may raise a concern on one hospital ward but keep it to themselves on another. Rather than asking only about the hospital’s overall culture, check where people receive a response after raising a concern and what happens to that information at the next handover. Compare escalation procedures as well as survey results: similar claims of openness do not necessarily mean similar day-to-day conversations. Psychological safety is a team-level concept, so it is worth observing behaviour in specific groups. The foundational study that introduced it involved 51 teams at a manufacturing company. It provides an important basis for asking questions, but it does not itself describe medical wards; separate research conducted in healthcare is also relevant to them.

The manager sets the tone

A manager sends a particularly clear signal when someone asks a difficult question in front of others for the first time. Do they ask about the risk and promise a response, or shut the conversation down? Watch for this at a handover, especially when the person speaking has a lower professional status. In a survey of 23 neonatal intensive care units, inclusive leadership behaviours were associated with a greater ability for such staff to speak up. This is an observed association, not proof that a manager’s style alone causes every difference between wards. So do not substitute a hospital-wide average for the results of a particular team. Look, too, at how the rest of the group reacts after the manager’s initial response.

Norms among colleagues

Even an open manager cannot make staff feel comfortable speaking up if colleagues ridicule newcomers’ questions. During everyday shifts, pay attention to how people of similar professional standing respond: do they help clarify a concern, or signal that it is better to stay quiet? Check, too, whether an informal leader filters information before it reaches the whole team. A meta-analysis of 136 samples, covering more than 22,000 people and almost 5,000 groups, supports the importance of psychological safety, but combines different levels of analysis. Many of the included studies were correlational. So do not treat a single reaction as representative of a ward’s entire culture; look for recurring patterns of conversation.

Investigate rather than label

Before calling a ward ‘open’ or ‘closed’, gather examples from different professions and shifts. Compare the same situation on two wards: who asks questions at handover, how the manager responds, and whether the person who spoke up later learns what was done with their concern. Identical survey questions can help structure the comparison, but should not replace descriptions of the work and conversations involved. Account for team composition and size, and the nature of the work, because wards do not operate under identical conditions. One unpleasant remark deserves attention, but does not by itself justify labelling a ward ‘toxic’. The investigation should reveal where information about risk gets stuck or makes its way back to the staff member, not identify people to blame on the basis of a single incident.

Transferring good practices

If concerns are handled more effectively on one ward, describe the practice in enough detail for others to know what would be transferred. How does the team receive a concern, who considers it, and how do they respond to the person who raised it? Simply praising a ‘good culture’ will not tell another ward what to do at its next handover. Ask what organisational conditions make the practice possible, too: does it fit the tasks, team composition and flow of a shift in the new setting? It is worth trying a specific way of conducting the conversation on another shift before considering wider use. If it works differently there, that does not necessarily mean staff are resistant; the approach may need adapting to local work.

The impact of staff changes

A change of manager or the departure of a substantial part of the team is a good time to revisit how people talk about risk on the ward. Check which practices have survived the staffing changes: is there still room for a difficult question at handover, and does the person raising it receive a response later? Staff who rotate between wards can agree when and to whom they should raise concerns, so they do not have to guess the local customs each time. An increase or decrease in the number of reports tells us little without knowing how they are received. After staffing changes, watch how people respond to a concern and whether that response reaches the team. Norms develop through ongoing relationships and can change as people change.

The limits of what we can conclude

Comparing wards helps frame questions, but it does not prove that a mechanism observed on one will work the same way on another. Consider staffing, patient groups and management practices before attributing a difference to a single practice. A review of 14 interventions to support psychological safety and speaking up found mixed results, and measurements often relied on self-reports. So do not promise that copying a handover routine will automatically change a team’s culture. Instead, decide how you will recognise a change in the way concerns are received, and report the findings and next steps to those who took part in the comparison. Without that response, simply collecting opinions may leave staff unsure why they were asked to speak up.

The same staff member may speak up differently on two wards. What matters is how local managers and colleagues respond, and whether a report receives a follow-up.

Empatyzer and understanding differences between hospital wards

A hospital director who notices differences in how concerns are raised across wards can start in Empatyzer by comparing aggregate views of their cultures and motivators. Team views can reveal shared patterns and differences, but cannot explain on people’s behalf where those differences come from. The next step is therefore a conversation: the director can ask Em how to open meetings with ward managers differently while keeping questions about specific situations similar on each ward. The similarity map may suggest differences worth investigating, such as descriptions of collaboration, which then need to be discussed with staff. Em can also help prepare a separate message for a ward with a different culture of collaboration. After the meetings, the director can compare accounts of similar conversations rather than announce a ranking of teams based on the views alone. In this way, the tool helps prepare questions and communication, while answers about local norms still come from the people who work on the wards.