Speaking Up in Hierarchical Operating Rooms: A Qualitative Descriptive Study of Nurses' Safety Communication With Surgeons and Anaesthetists

BACKGROUND: Hierarchy can inhibit nurses from raising patient-safety concerns in operating rooms, yet how Chinese peri-operative nurses navigate this with surgeons versus anaesthetists remains underexplored. AIM: To explore when and how peri-operative nurses in Chinese operating rooms voice, withhold, or adapt patient-safety concerns with surgeons and anaesthetists. DESIGN: A multi-site qualitative descriptive study using the Critical Incident Technique, supplemented by an interpretive interprofessional workshop. METHODS: Twenty peri-operative nurses from three tertiary hospitals in Taiyuan, China, were recruited through stratified purposive sampling. Each completed one in-depth interview, generating 40 critical incidents, and a subsequent workshop informed interpretation. Template thematic analysis was conducted, using psychological safety and power distance as sensitizing concepts. RESULTS: Three themes were developed: (1) nurses spoke up mainly when risk was concrete and imminent; (2) they used cautious linguistic and non-verbal strategies to preserve professional relationships and face; (3) voice depended on prior punitive experiences, perceived openness, and task relationship. Anaesthetist-directed concerns were more collaborative, whereas surgeon-directed concerns required greater deference. CONCLUSION: Speaking up was situational, relational, and shaped by hierarchical norms and local team climate, with nurses adapting concerns to different professional audiences. IMPACT: Nurse voice in Chinese operating rooms is target-specific, shaped by professional jurisdiction and local team climate. Findings support nurse managers, peri-operative educators, and interprofessional leaders in developing psychologically safer climates, hierarchy-sensitive communication training, and role-specific strategies for raising concerns with surgeons and anaesthetists. PATIENT OR PUBLIC CONTRIBUTION: Not applicable.