Voice of Dissension: When Nurse Teamwork and Patient Safety Diverge


Dissension (from the series Pareidolia), charcoal & graphite on paper, 12″ x 9,”
2012 by Julianna Paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology. The illustration of this post is by the author.

The term “voice” gets thrown around a lot these days, usually in reference to creative content. Visual artists, writers, musicians, and actors rise to their unique place in the art world on the originality of their voice, not merely for mastery and talent.

In nursing, voice is important too. Hospitals spend a small fortune in paid staff hours for team-building meetings or retreats for nurses to smooth the rough edges of staff members, reducing friction among unit nurses with the ultimate goals of nurse retention and improved patient care. While these are admirable goals, I’m beginning to wonder if too much emphasis on team building may also diminish a nurse’s unique voice, thereby inadvertently interfering with patient safety? A team is only as strong as its individual members.

For example, let’s say you’re busy taking care of patients when you overhear a coworker describing her patient’s symptoms to the charge nurse. The symptoms are serious enough to grab your attention, and you recognize that the course of action is not assertive enough to protect the patient. What do you do? Do you involve yourself, uninvited, into the conversation and voice your opinion? Maybe you pull a “Colombo,” by which I mean you start asking leading questions as if they are breadcrumbs, hoping to guide your colleagues to the right interventions. Or do you continue with your own busy assignment, afraid to voice dissent by questioning your peers’ assessment?

In the course of my nursing practice, I’ve exercised all three options, depending on the severity of the need, with varying results. Most of the time, my voice is appreciated as a contribution to the team approach of patient care, but on occasion I’ve been told to mind my own business by nurses who did not appreciate the input. As one nurse said, “Sometimes you just have to let things break.” I’m okay with this philosophy when it’s applied to changing a process, but not if patient safety is sacrificed. I know I’m not the only nurse with these experiences. It begs the question: “When is the voice of dissension imperative to patient safety regardless of being part of a team?”

This question is not easily answered. In fact, a quick Google search reveals many people have studied the correlation between the nurse–physician relationship and patient safety, but I didn’t find a single reference addressing the nurse–nurse relationship and its effect on patient safety.

There are times when groupthink is dangerous. Have nurses been overtrained to believe that voicing dissension about patient safety is contrary to being a team player? Somehow the individual role of nurse as patient advocate has become at odds with being a team member. Have nurses become so homogenized and task oriented that we no longer view patient assessment as more than the clicking of boxes on the EHR without pause for critical thinking?

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2016-11-21T13:05:33+00:00 January 29th, 2014|career, nursing perspective, patient safety|5 Comments

About the Author:

Julianna Paradisi, RN, OCN, finds inspiration where science, humanity, and art converge, creating compelling images as both a writer and a painter. She is the author of https://jparadisirn.com/, and also blogs frequently for http://www.theonc.org/ and https://ajnoffthecharts.com/, the blog of the American Journal of Nursing (AJN).


  1. Megen Duffy February 4, 2014 at 4:05 pm
  2. Carol January 30, 2014 at 7:26 am

    I believe a hallmark of a strong team is speaking up if something doesn’t seem right. The skills needed to speak up about a concern and the skills to consider concerns brought up (if you are the receiver of the concern) were not taught to me in my initial education as a nurse. However, establishing a culture that is safe for our patients and each other requires that we develop these skills and are supported by colleagues when we use them.

  3. BJ Krall January 30, 2014 at 12:27 am

    If a patient’s safety is at risk, I would speak up. The patient is the priority. I do not view patients as clients.

  4. Sheryl January 29, 2014 at 2:55 pm

    Like the author, I have found myself at odds with whether to speak up or be silent, how to guide or ignore. In 30+ years I can honestly say if I felt a client was at risk for eminent danger I would and have spoke up. I had a nurse tell me to “mind my own business” and my conversation with her (later) was “are you mad at me for being right or yourself for not seeing it?” I do know there is no “one size fits all” answer. #nursing ethics

  5. […] blog post for Off the Charts, the blog of the American Journal of Nursing. The latest post, Voice of Dissension: When Nurse Teamwork and Patient Safety Diverge published today. I think it’s worth a read, and even a comment, if I do say so myself. For […]

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