Team culture is an important antecedent to safety behaviours such as speaking up. A positive safety culture in the operating theatre has been linked to fewer adverse events. Psychological safety, a component of safety culture, is the belief that the team is safe to take risks such as raising concerns. Power dynamics can influence active speaking up behaviour or ‘voice’. When theatre team members chose to remain silent rather than voice concerns this can be a protective or defensive strategy rather than passive inactivity.
BerwickD.2013Berwick review into patient safetyLondon, Department of Health
2.
BienefeldN., GroteG.2012Silence that may killAviation Psychology and Applied Human Factors21–10
3.
BrownR L., HolmesH.1986The use of a factor-analytic procedure for assessing the validity of an employee safety climate modelAccident Analysis and Prevention18(6) 455–70
4.
CarmeliA., GittellJ H.2009High-quality relationships, psychological safety and learning from failures in work organizationsJournal of Organizational Behavior30(6) 709–29
5.
CoxS., CoxT.1991The structure of employee attitudes to safety: A European exampleWork and Stress5(2) 93–106
6.
DetertJ.R., EdmondsonA.C.2011Implicit voice theories: Taken-for-granted rules of self-censorship at workAcademy of Management Journal54(3) 461–88
7.
EdmondsonA.C.2004Learning from failure in health care: frequent opportunities, pervasive barriersQuality and Safety in Health Care13(2) ii3–ii9
8.
FrancisR.2013The Mid Staffordshire NHS Foundation Trust Public Inquiry (Chaired by Robert Francis QC) Report of the Mid Staffordshire NHS Foundation Trust London, HMSO
9.
FrancisR.2015Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHSLondon, HMSO
10.
GardeziF., LingardL., EspinS.2009Silence, power and communication in the operating roomJournal of Advanced Nursing65(7) 1390–99
11.
GlennC.2004Unspoken: A rhetoric of silenceSouthern Illinois University Press
12.
GuldenmundF.W.2000The nature of safety culture: a review of theory and researchSafety Science34(1) 215–57
13.
GuldenmundF.W.2010(Mis)understanding safety culture and its relationship to safety managementRisk Analysis30(10) 1466–80
14.
HalbeslebenJ.R., RathertC.2008Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patientsHealth Care Management Review33(1) 29–39
15.
HalversonA.L., CaseyJ.T., AnderssonJ.2011Communication failure in the operating roomSurgery149(3) 305–10
16.
HammondJ.S., KeeneyR.L., RaiffaH.1998The hidden traps in decision makingHarvard Business Review76(5) 47–58
17.
HansenL.O., YoungR.S., HinamiK.2011Interventions to reduce 30-day rehospitalization: A systematic reviewAnnals of Internal Medicine155(8) 520–28
18.
HenriksenK., DaytonE.2006Organizational silence and hidden threats to patient safetyHealth Services Research41(42) 1539–54
19.
HofmannD.A., MarkB.2006An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomesPersonnel Psychology59847–69
20.
HofmannD.A., MorgesonF.P.1999Safety-related behavior as a social exchange: The role of perceived organizational support and leader-member exchangeJournal of Applied Psychology84(2) 286
21.
HofmannD.A., StetzerA.1996A cross-level investigation of factors influencing unsafe behaviors and accidentsPersonnel Psychology49(2) 307–39
22.
HudsonD., BerenholtzS., ThomasE., SextonJ.2009A safety culture primer for the critical care clinicianContemporary Critical Care (5) 1–11
23.
Institute of Medicine2000To err is human: Building a safer health systemNational Academies Press
24.
KathL.M., MarksK.M., RanneyJ.2010Safety climate dimensions, leader-member exchange and organizational support as predictors of upward safety communication in a sample of rail industry workersSafety Science48(5) 643–50
25.
KobayashiH., Pian-SmithM., SatoM.2006A cross-cultural survey of residents’ perceived barriers in questioning/challenging authorityQuality and Safety in Health Care15(4) 277–83
26.
KohnL.T., CorriganJ.M., DonaldsonM.S.2000To err is human: building a safer health systemNational Academies Press
27.
KolbeM., BurtscherM.J., WackerJ.2012Speaking up is related to better team performance in simulated anesthesia inductions: an observational studyAnesthesia and Analgesia115(5) 1099–108
28.
LeonardM., GrahamS., BonacumD.2004The human factor: the critical importance of effective teamwork and communication in providing safe careQuality and Safety in Health Care13(Suppl 1) i85–i90
29.
LiaoJ.M., ThomasE.J., BellS.K.2014Speaking up about the dangers of the hidden curriculumHealth Affairs33(1) 168–71
30.
LingardL., EspinS., WhyteS.2004Communication failures in the operating room: an observational classification of recurrent types and effectsQuality and Safety in Health Care13(5) 330–34
31.
MakaryM.A., SextonJ.B., FreischlagJ.A.2006Operating room teamwork among physicians and nurses: teamwork in the eye of the beholderJournal of the American College of Surgeons202(5) 746–52
32.
ManiasE., StreetA.2001Nurse–doctor interactions during critical care ward roundsJournal of Clinical Nursing10(4) 442–50
33.
MardonR.E., KhannaK., SorraJ.2010Exploring relationships between hospital patient safety culture and adverse eventsJournal of Patient Safety6(4) 226–32
34.
MazzeiL.A.2007Toward a problematic of silence in action researchEducational Action Research15(4) 631–42
35.
MazzoccoK., PetittiD.B., FongK.T.2009Surgical team behaviors and patient outcomesAmerican Journal of Surgery197(5) 678–85
36.
MillsP., NeilyJ., DunnE.2008Teamwork and communication in surgical teams: implications for patient safetyJournal of the American College of Surgeons206(1) 107–12
37.
MorrisonE.W., Wheeler-SmithS.L., KamdarD.2011Speaking up in groups: a cross-level study of group voice climate and voiceJournal of Applied Psychology96(1) 183
38.
NembhardI.M., EdmondsonA.C.2006Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teamsJournal of Organizational Behavior27(7) 941–66
39.
OkuyamaA., MartowironoK., BijnenB.2011Assessing the patient safety competencies of healthcare professionals: a systematic reviewBMJ Quality and Safety20991–1000
40.
OkuyamaA., WagnerC., BijnenB.2014Speaking up for patient safety by hospital-based healthcare professionals: a literature reviewBMC Health Services Research14(1) 1
41.
Pian-SmithM.C., SimonR., MinehartR.D.2008Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safetyJournal of the Society for Simulation in Healthcare4(2) 84–91
42.
PichertJ.W., MooreI.N., HicksonG.B.2011Professionals promoting professionalismThe Joint Commission Journal on Quality and Patient Safety37(10) 446
43.
PronovostP.J., ThompsonD.A., HolzmuellerC.G.2006Toward learning from patient safety reporting systemsJournal of Critical Care21(4) 305–15
44.
RileyR.G., ManiasE.2006Governance in operating room nursing: nurses’ knowledge of individual surgeonsSocial Science and Medicine62(6) 1541–51
45.
SayreM.M., McNeese-SmithD., LeachL.S., PhillipsL.R.2012An educational intervention to increase ‘speaking-up’ behaviors in nurses and improve patient safetyJournal of Nursing Care Quality27(2) 154–60
46.
StevensL.M., CooperJ.B., RaemerD.B.2012Educational program in crisis management for cardiac surgery teams including high realism simulationJournal of Thoracic and Cardiovascular Surgery144(1) 17–24
47.
SureshG., HorbarJ.D., PlsekP.2004Voluntary anonymous reporting of medical errors for neonatal intensive carePaediatrics113(6) 1609–18
48.
ThomasE.J., TaggartB., CrandellS.2007Teaching teamwork during the Neonatal Resuscitation Program: a randomized trialJournal of Perinatology27(7) 409–14
49.
UndreS., AroraS., SevdalisN.2009Surgical performance, human error and patient safety in urological surgeryBritish Journal of Medical and Surgical Urology2(1) 2–10
50.
WeiserT.G., RegenbogenS.E., ThompsonK.D.2008An estimation of the global volume of surgery: a modelling strategy based on available dataThe Lancet372(9633) 139–44
51.
WiegmannD.A., ElBardissiA.W., DearaniJ.A.2007Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigationSurgery142(5) 658–65
52.
ZoharD.1980Safety climate in industrial organizations: theoretical and applied implicationsJournal of Applied Psychology65(1) 96
