Speaking up or staying silent? Confidence, barriers and institutional readiness among Syrian medical and dental students

BACKGROUND: Raising concerns (speaking up or whistleblowing) is essential to detect and prevent unsafe practice and to uphold professional standards. While medical and dental students are frontline observers during clinical rotations, they face barriers to escalation. However, to guide policy and training, it is essential to gather local data on students' confidence and the readiness of institutions to support them in raising concerns. This study aimed to assess Syrian medical and dental students' institutional awareness and exposure to safety concerns, confidence in speaking up, perceived barriers to raising concerns, and institutional readiness to support reporting during clinical training. METHODS: A cross-sectional survey was administered to a total of 812 medical and dental students in clinical training from all 13 universities offering undergraduate medical education in Syria between 15 October and 22 December 2025. A scenario-based Arabic questionnaire, translated and back-translated, was delivered via online and paper modes to maximize inclusion, with a pilot study of 40 students demonstrating excellent internal consistency (Cronbach's α = 0.95). Data were analyzed using descriptive statistics, t-tests, one-way ANOVA with Tukey's post-hoc tests, and multivariate linear regression to identify predictors of confidence (SPSS v27). Sample size calculations indicated a minimum requirement of 385 participants, and statistical significance was set at p < 0.05. RESULTS: Among participants, 40.9% reported encountering unsafe or unprofessional behavior, while 17.6% reported the presence of an institutional whistleblowing policy and 4.8% had received formal training, despite 82.3% expressing interest in such training. Overall confidence in raising concerns was moderate, with the highest confidence reported for patient safety issues and reporting to clinical supervisors. Confidence declined significantly with each advancing academic year (p < .001) and was independently associated with formal training in multivariable analysis (p = .001). The most frequently reported barriers were reluctance to "cause trouble" (42.6%), uncertainty about whom to contact (41.9%) and perceived lack of institutional support (39.0%); top enablers were assurances of reporter safety (74.1%) and ensuring changes will be implemented following reporting (59.9%). CONCLUSION: A substantial proportion of students reported exposure to unsafe or unprofessional behavior, while reporting policies, training, and institutional support were limited. These findings suggest gaps in reporting preparedness and perceived safety that may influence students' willingness to raise concerns. Further research is needed to evaluate strategies to improve reporting confidence and institutional support. In this context, educational institutions should incorporate practical, scenario-based training into their curricula. Future research should also assess the long-term effects of these measures on students, and extend the evaluation to include residents and practitioners.

Curriculum · MEDLINE · Program evaluation · Qualitative research · Dental Education, Practice, Research · Global Health Workforce Issues · Medical Education and Admissions