Table 4.

Trade-offs between voice and silence

Themes	Example quotes from interviewees
Judging the level of risk	• “This is a matter of risk assessment. Of course, there is the risk of infection, no doubt. But in this case, the patient was not in a condition which would make an infection dangerous. But, if, for example, she had had no leucocytes and would develop fever and she would have been at high risk for an infection, than it would be a different situation. I do this risk assessment mentally”. Resident, ward (J118)
	• “It is a deliberate balance…when to voice, or how important it is, that you’ll have to voice, and when you don’t have to. I believe there is some grey area. But if something is really dangerous for the patient, then I have to speak up”. Nurse, pediatric ward (L230)
	• “I evaluate how high the risk is and, with a missed hand disinfection, would not regard it as high enough to say something. Contrary, if somebody would walk into an isolation room without appropriate clothes, I would say ‘Stop’. No doubt”. Resident, ambulatory unit (B103)
	• “But, if I see that someone gives the wrong IV to a patient, I would react immediately. Or if Inotice that the premedication was not given with antibodies and there is the risk that the patient reacts, than I would instantly intervene”. Nurse, ward (C114)
Differing perceptions of harm between professions	• “It is quite common that they [doctors] use unsterile gloves for the wound dressings and they believe it’s sufficient. It is different from what we [nurses] learned in our education. I find it difficult to argue. I have never experienced a wound has worsen because of that. But I ask myself why do I take gloves, and they …don’t? What is the evidence then?“ Nurse, ward (X215)
Anticipation of negative outcomes (for the patient, the actor, and themselves)	• “Because I would have had shown her [the actor, doctor] up, and the patient would become anxious then. I wanted to avoid that”. Nurse, ambulatory unit (C113)
	• “To me, the risk that something severe happens is considerably lower than the fact that the chief’s authority is questioned in front of the patient. This harm is considerably higher than not disinfecting hands once”. Senior, ward (B102)
	• “I feel that, if it would be really important for the patient, then I speak up. And I would even speak up to the director, but it would cost me quite an effort”. Nurse, pediatric ward (J224)
	• “I rather prefer to risk hassle; that she [the actor, senior doctor] would not respond adequately and would be angry with me…I would rather hazard these consequences than doing something I’m not fully convinced of or doing something which I know is not correct”. Resident, ward (J118)
Predictability of the actor’s response	• “In our team, you can forecast how the response will be. You know how people react, what people can accept and what not. With someone you have only seen once or twice, you do not know that”. Nurse, ambulatory unit (P225)
	• “Because residents alternate so frequently, relations are not so much established and we do not have the trust in them, and they probably not in us”. Nurse, ward (B205)
	• “With the surgeons it is difficult in particular. I have known our oncologists for years now and I know how they will respond to my speaking up. With doctors I see once a year, I find it difficult to intervene”. Nurse, ward (X215)