Employees' ability to speak up—to communicate candidly with workplace leaders about their concerns—improves employee performance, satisfaction, retention, productivity, innovation, and growth [
1,
2]. Similarly, quality and safety experts in medicine stress that open communication (speaking up) about traditional safety concerns (such as hand-washing) and unprofessional behavior (such as disrespectful or inappropriate language) within health care systems is essential to building robust safety cultures and optimizing outcomes [
3]. Patient safety leaders in radiology likewise recognize how organizational culture influences radiologic performance and outcomes [
4–
6]. They specifically emphasize the importance of healthy teamwork dynamics and respectful communication across hierarchies wherein individuals are encouraged to speak up when they have concerns about observed safety breaches or unprofessional behaviors that may compromise safety.
The extent to which health care employees feel empowered to speak up about safety breaches and unprofessional behavior in their workplace is increasingly recognized as an important part of safety culture, and specific survey instruments assessing this topic have been validated [
7,
8]. Studies using these instruments have reported that substantial constraints to speaking up persist within health care, but little is known about the experiences and attitudes of radiologists regarding speaking up [
3,
7,
9]. One study from 2018 explored the culture of speaking up about safety events within a large academic radiology department and reported substantial barriers to reporting safety issues, largely due to the hierarchic environment of the department [
10]. To our knowledge, no other studies of the culture of speaking up within radiology have been published. Therefore, several key questions remain, such as whether similar conditions exist across institutions, how such conditions affect radiology trainees in particular, whether safety event severity affects the likelihood of speaking up, and whether similar experiences and attitudes regarding, for example, hierarchy affect individuals' willingness to speak up about traditional safety concerns (such as nonsterile technique) and unprofessional behavior in radiology. This latter gap is particularly important given the links between cultures of respect and safety and between disrespectful or unsafe behaviors and malpractice [
11–
15].
Discussion
Our study of radiology trainees from nine different training programs suggests that trainees perceive gaps related to speaking up in their clinical environments, especially related to unprofessional behavior. These findings are similar to those of Martinez et al. [
3], who used the same five-item instrument to study a large geographically diverse cohort of medical and surgical residents and found lower self-reported rates of speaking up about unprofessional behavior compared with safety concerns. These findings are notable because unprofessional behavior has been linked to poor team performance and patient outcomes in medicine [
13–
15,
17–
20].
Another notable finding in our study was the effect of hierarchy in attenuating trainees' willingness to speak up. Our respondents' reticence regarding speaking up to an attending radiologist, even when they perceived the potential for patient harm, is similar to what has been reported for medical and surgical trainees [
3]. The results from our multiinstitutional radiology trainee cohort are consistent with those of Siewert et al. [
10], who reported that authority gradients inhibited employees' willingness to speak up about safety within a single large academic radiology department. Together, these studies indicate that a complex web of hierarchic barriers preventing radiology department employees from speaking up about safety is common across institutions. Moreover, these studies place radiology squarely within a ubiquitous cultural milieu in which clinical personnel broadly perceive themselves as restricted in communicating about safety concerns across authority gradients [
3,
21].
Subordinates' perception of their constricted power to speak up about safety concerns is a recognized health care safety liability [
6,
21]. In our study, workplace culture appeared to play an important function in encouraging or suppressing speaking-up behavior among radiology trainees, which is consistent with findings among other clinical cohorts [
6]. Our findings further reinforce that cultures in which such behavior is encouraged represent safer environments not only for patient care but also for trainee well-being, because these cultures provide psychologically safe environments for individuals who are vulnerable within a hierarchy [
21,
22]. Psychologically unsafe environments that inhibit speaking up may contribute to emotional duress, moral distress, and burnout [
3,
22–
24]. In this regard, the fact that respondents who are not White were less likely than White respondents to speak up about the sterile technique breach in the vignette is concerning. This finding merits further study with larger and more diverse cohorts given other research reporting that trainees from populations underrepresented in medicine experience a heightened sense of alienation, fears of repercussions, and perceived pressure to adhere to medical cultural norms [
22].
Overall, our data add to a burgeoning realization within medicine and radiology that systemic remedies are necessary to establish healthier professional cultures for speaking up about both safety concerns and unprofessional behavior [
6,
19,
25,
26]. A first step may involve raising leadership awareness of the problematic effects on patient care and provider well-being resulting from clinical environments that do not support healthy teamwork and safety cultures [
27]. Leadership acceptance of the problem may foster ownership of the solutions [
28,
29]. Once leaders accept the premise, concerted processes can be established to identify, evaluate, and address various barriers to employee engagement in speaking up about reasonable concerns that cross hierarchic boundaries [
19,
29]. Some organizations have used simulation-based and team-building exercises to help both leaders and subordinates acquire the requisite comfort and skills to discuss concerns about safety and unprofessional behavior respectfully and constructively [
19,
21,
26]. Educational interventions, such as the Agency for Healthcare Research and Quality's Team Strategies and Tools to Enhance Performance and Patient Safety program and two-challenge rule assertiveness training, have been adapted for medicine from military and airline industry initiatives developed to enhance speaking up for safety in their respective environments [
26,
30,
31]. Even the provision of such training may signal an institutional cultural priority across authority gradients to modify behavior without additional interventions. This cultural priority would be reinforced by implementation of supportive education-based peer learning mechanisms that frame mistakes as valuable group opportunities to enhance performance quality [
32–
34]. Of course, institutional leaders must model optimal behaviors if they want to institute meaningful adoption of certain cultural norms [
28,
29]. Multipronged interventions will likely be needed, because data suggest that training alone may not be enough to promote speaking up [
35]. Other recommendations from the business literature include creating alternative mechanisms or forums for expressing concerns, focusing on inclusion of diverse voices, and establishing settings outside of formal team or group meetings, where hierarchy may preclude candor [
2,
28]. Anonymous online reporting systems may also empower individuals to voice concerns when they otherwise feel unable to do so [
3,
6,
12]. A comprehensive categorization of barriers to speaking up about safety has been proposed for radiology and, together with our findings (which add concerns related to unprofessional behavior), can serve as a springboard for future research and interventions in radiology departments seeking to enhance their cultures regarding speaking up [
6].
One strength of our study is that we surveyed a sample of trainees from multiple institutions. To our knowledge, our study, though modest in size, is the largest study of culture regarding speaking up among radiology trainees. Our findings also build on existing literature because they include assessment of residents' experiences with and attitudes toward speaking up about unprofessional behavior in addition to more traditional safety concerns.
However, our study does have limitations. We used survey instruments that have undergone psychometric validation in other cohorts of medical trainees, but the survey questions have not been validated specifically for radiology. We did not specify the nature of the unprofessional behavior mentioned in the questions. Respondents may have had varying definitions of un-professional behavior and the harms associated with it. Additionally, what trainees perceive as unprofessional behavior may vary by context and how questions are framed [
36]. Unprofessional behavior may take many forms, from blatant misconduct and harassment to more subtle forms of incivility, unreasonableness, bullying, and disrespect [
19]. Such behaviors have been described in the radiology literature, although their prevalence and related harms remain unknown [
16,
37]. The survey was performed within the context of an educational workshop, which may have artificially inflated response rates and resulted in social or compliance bias, although surveys were administered before any specific educational content.
Additionally, the vignette about patient safety that we used in our questionnaire was hypothetical. Although it is closely adapted from a vignette that was previously validated as a tool for assessing self-reported speaking-up behavior, it may not reflect actual behavior or events. We did not use a corresponding comparison vignette that illustrated unprofessional behavior. Our survey items were selected as a series of trade-offs to explore key safety-related issues in radiology while also maintaining a survey short enough for feasible implementation in our teaching framework. Accordingly, we were unable to assess the odds of speaking up about unprofessional behavior, although this does not undermine our direct findings of trainees' perceptions of cultures regarding safety compared with unprofessional behavior.
We do not know whether the frequency of trainees witnessing errors is associated with their willingness to speak up. Few studies are available on this particular question, which merits future study. In general, institutions that encourage transparency with patients regarding errors have reported improved internal communication about errors, which supports the idea that awareness and communication are linked within healthy systems [
38].
Our small survey population precluded sufficiently powered assessment of differences among the nine programs represented. Further, there were no African American participants, and we did not include a separate category for Latinx participants. Further work would include a more comprehensive national survey of culture regarding speaking up about safety and unprofessional behavior in radiology that captures actual clinical events among a diverse cohort. An ideal instrument would use survey questions validated specifically for radiology and would assess concordance in perception among respondents from the same programs. Optimally, the instruments published for other medical specialties and the survey developed by Siewert et al. [
10] would be combined. Such instruments could then be used over time, and after targeted interventions, to assess improvements in radiology cultures regarding speaking up.