However, the magnitude of its effect only slightly exceeded that of the discomfort rating in regression analysis. These results show impressively the difficult trade-offs clinicians face when deciding to speak up and have important consequences: First, clinical leaders need to be made aware of the emotional demands of speaking up prevalent among their subordinates and that their own perception of the challenges associated with speaking up is likely to differ from those of lower hierarchical status. A similar finding has been reported for safety climate perceptions which tend to be more positive among senior managers. Second, decision difficulty and anticipated distress may be modifiable by team training and guidance about which clinical situations warrant speaking up. Our results suggest such trainings to be as close to reality as possible to take into account the Trichilinin-D relevance of situational conditions conducive of ����silence����. Our 8-Shogaol vignettes may serve as valuable triggers in team discussions or could be used for role-play in team trainings. A number of attributes used to characterize the vignettes significantly affected oncology clinicians�� anticipated likelihood of speaking up. Regression analysis indicates that the presence of ����others���� plays an important role for the decision to voice concerns in some contexts but not in others. Clinicians avoided public forums to raise their concerns and were more likely to ����voice behind closed doors����, a finding that has been reported from outside the healthcare setting. One motivation is to avoid compromising the actor in public, risking to be humiliated in front of peers in response, and to mitigate the risks of challenging a supervisor or coworker. Preserving trust of patients in clinicians is a strong motivation to withhold voice in the presence of patients. In our study, responders were very reluctant to point coworkers to a missed hand disinfection when the vignette suggested that patients would follow this communication. A considerable fraction indeed indicated they would withhold voice, even at the price of potential patient harm.