Why Speaking Up Training in Healthcare Isn’t Working — And What Needs to Change

We’ve all seen the stats. Communication breakdowns are one of the leading causes of harm in healthcare. So why aren’t our training programs fixing the problem?

After 30 years as a nurse — and more than 20 as an educator — I’ve worked across many hospitals and seen countless speaking up programs. I’ve even written one for a major health service. And here’s what I’ve noticed: most programs teach how to speak up, but not how to have the conversation that follows.

I define speaking up as explicit communication that challenges the status quo and persists until a resolution is reached — to prevent harm to staff or patients. That’s not a one-way street. It’s a conversation. And yet, most training focuses only on the act of speaking up, graded assertiveness, escalation pathways, scripts. We teach people to speak, but not to engage.

Take the NHS’s “Speak Up, Listen Up” training. It’s a great initiative with three modules: one for all staff, one for managers, and one for senior leaders. I love that there’s a module on listening. But why is that only for managers?

Yes, managers hold power. Their response can make or break someone’s confidence. But fear, futility, and powerlessness don’t just show up in boardrooms, they show up in everyday clinical conversations. Between junior and senior clinicians. Between nurses and doctors. Across disciplines.

If we want to build a culture of psychological safety, everyone needs to know how to listen — not just hear but really listen. That means managing your own emotions, staying open, and responding in ways that invite dialogue, not shut it down.

And here’s the kicker: clinical skills don’t happen in isolation. Every physical intervention, from inserting a cannula to performing surgery, is embedded in a web of cognitive and social processes. We communicate with patients and colleagues before, during, and after. The idea that technical skill can be separated from communication is not just outdated — it’s dangerous.

Speaking up isn’t just about courage. It’s about connection. Until our training reflects that, we’re only solving half the problem.

Training Programs that Reframe Communication trianing:

·       Reframing Safety Through Conversations

·       Reframing Feedback

·       Your Team Culture

·       Listening Mindset

·       Workplace Conversations: The Essentials

·       Building you Communication Muscles