A better understanding of these influences on speaking up behaviors is required for the design of effective improvement activities such as Polyphyllin-VI training programs. There is, however, a paucity of research into the contextual factors that make speaking up about rule violations and errors in healthcare more or less likely. Research from health care and other industries shows that differences in hierarchical status make speaking up difficult. Power discrepancies are an important inhibitor to speaking up in action teams, e.g., between nurses and surgeon in the operating room. In a survey study among residents the decision to challenge a senior surgeon in the operating room was affected by the relationship and anticipated response of the superior. Potential of patient harm has been identified as a major motivation for speaking up about safety concerns in labour and delivery whereas the fear to damage personal relationships and novelty of an alarming situation are strong barriers. Earlier experiences of speaking up which did not produce the desired outcome often results in decreased perceived effectiveness of speaking up and feelings of futility and resignation. Perceptions that voicing concerns will not make a difference are important barriers for future speaking up behaviour. Finally, presence of patients or family in the situation has been reported to inhibit speaking up of health care workers towards their colleagues to avoid damage to the patient-provider relationship. In our previous qualitative research in oncology, nurses and doctors reported that they frequently experience situations which raise their concerns and require questioning, clarifying and correcting but that they occasionally decide to withhold concerns. Oncology clinicians indicated that speaking up was related to the type of safety issue concerned. For example, medication safety concerns were Atractylenolide-III easier to discuss whereas violations of hospital hygiene rules were rather difficult to voice. Clinicians typically felt strong obligation to prevent patient harm but this motivation competes with anticipated negative outcomes of speaking up.