The message needs room to be heard
Speaking up across professional hierarchies means raising a concern when differences in role, seniority or authority make the conversation difficult. The practical objective is a shared understanding of the safety issue and a clear next action. Winning an argument is a poor substitute for resolving the concern.
AHRQ TeamSTEPPS includes assertive advocacy, the CUS phrases and the Two-Challenge Rule to support these exchanges. CUS makes the level of concern explicit: concerned, uncomfortable and a safety issue. These tools are most useful when the team has discussed how it will respond to them.
Describe the discrepancy
When possible, name the observation that does not fit the current plan. Separate that observation from assumptions about another person’s motives. “The two records show different instructions” gives the team a problem to resolve. “You never listen” changes the subject to a personal dispute.
Use a direct request. Ask for a pause, review, clarification or additional assessment as the situation requires and within local procedures. If you are uncertain, describe the uncertainty. You do not need to pretend to know the answer before asking the team to examine a possible problem.
SBAR can help organize the supporting details. It also creates space for a specific request and confirmation of the response. For an urgent situation, use the established immediate-response route rather than wait for a convenient conversation.
What the receiver can do
In a fictional orientation exercise, a new nurse questions an instruction from a senior colleague. The receiver can acknowledge the concern, ask for the observation behind it and explain what will happen next. If the original plan remains appropriate, explain why and check whether the concern has actually been resolved.
Avoid treating rank, speed or confidence as the explanation. A response such as “I reviewed the two entries; this one is the current order, and I will correct the conflicting display” is more useful than “Just do it.” The example illustrates communication, not a direction for handling any particular order.
Practice escalation and repair
Agree in advance on the route for unresolved concerns, including a backup when the usual supervisor is unavailable. Practice the words in short scenarios so staff can use them without needing a polished speech. Include students, assistants and other team members in that practice.
After a difficult exchange, review both the safety issue and the interaction. What information was missing? Was the request clear? Did the receiver acknowledge it? What would make the next exchange easier? Handle misconduct through the appropriate organizational process rather than expecting a communication script to solve every problem.
Related guidance on escalating safety concerns covers the response pathway; incident reports support subsequent learning when an event or hazardous condition needs review.
Sources
- AHRQ TeamSTEPPS: Mutual Support (accessed 2026-09-17).
- AHRQ TeamSTEPPS: SBAR (accessed 2026-09-17).