Speaking up: psychological safety and graded assertiveness

graded assertiveness human factors psychological safety Sep 21, 2026

There are moments in perioperative care when something simply does not feel right. A change in the patient, a plan that raises concern, or an important detail that may have been missed. Speaking up in these moments is not about challenging someone’s authority. It is about protecting the patient.

Psychological safety helps create a clinical environment where perioperative nurses feel able to ask questions, raise concerns and acknowledge uncertainty without fear of embarrassment or blame. But even in supportive teams, hierarchy, workload and fear of being wrong can make speaking up difficult.

Graded assertiveness gives us a practical way to communicate a concern clearly while increasing the urgency of our language when needed.

🔹 Start with curiosity. Ask a question or clarify what you are seeing.

🔹 State your concern. Be specific about what is worrying you and keep the focus on the patient.

🔹 Increase the language if needed. Frameworks such as PACE move from Probe and Alert through to Challenge and Emergency action.

🔹 Be prepared to escalate. If the concern remains unresolved and patient safety is at risk, stronger language and additional help may be necessary.

For perioperative nurses, this might mean questioning an unexpected change in observations, raising concern about deterioration or clarifying a plan before proceeding. Practising these phrases before we need them can make them easier to find when the pressure is on.

The clinical takeaway is simple: respectful communication does not have to be quiet communication. When patient safety is at stake, speaking up is part of advocacy, and having a framework can give us the confidence to do it clearly.

References

Victorian State Trauma System (2024). Dealing with issues. Victorian Department of Health.

Hanson, J., Walsh, S., Mason, M., Wadsworth, D., Framp, A. and Watson, K. (2020). ‘Speaking up for safety’: A graded assertiveness intervention for first year nursing students in preparation for clinical placement: Thematic analysis. Nurse Education Today, 84, 104252

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