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International Journal of Nursing Studies 64 (2016) 42–51

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International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns

Speaking up behaviours (safety voices) of healthcare workers: A
metasynthesis of qualitative research studies
Kelly J. Morrowa,b,* , Allison M. Gustavsonc , Jacqueline Jonesd
a
School of Nursing, University of Nevada, Las Vegas, 4505 South Maryland Parkway, Box 453018, Las Vegas, NV, United States
b
College of Nursing, University of Colorado, Denver/AMC, United States
c
Rehabilitation Science, University of Colorado, Denver/AMC, United States
d
College of Nursing, Contexts of Care and Patient Safety, University of Colorado, Denver/AMC, Building P28, ED 2 North, Office 4216, 13120 East 19th Avenue,
Aurora, CO, 80045, United States

A R T I C L E I N F O A B S T R A C T

Article history: Background: A critical characteristic of effective teams in any setting is when each member is willing to
Received 23 May 2016 speak up to share thoughts and ideas to improve processes. In spite of attempts by healthcare systems to
Received in revised form 14 September 2016 encourage employees to speak up, employee silence remains a common cause of communication
Accepted 19 September 2016
breakdowns, contributing to errors and suboptimal care delivery. Nurses in particular have reported low
confidence in their communication abilities, and cite the belief that speaking up will not make a
Keywords: difference.
Caring
Objective: To develop an understanding of how nurses and other healthcare workers relate to safety voice
Employee
Healthcare
behaviors and how this might influence clinical practice. Data Sources: A search of the PubMed, CINAHL,
Hierarchies and Academic Search Premier databases was conducted using keywords employee, nurse, qualitative,
Nursing speak up, silence, safety, voice, and safety voice identified 372 articles with 11 retained after a review of
Qualitative the abstracts. Studies took place in Australia, Bulgaria, Canada, Hong Kong, East Africa, Ireland, Korea,
Safety New Zealand, Sweden, Switzerland, and the United States representing 504 healthcare workers including
Voice 354 nurses.
Safety voice Methods: This interpretive meta-synthesis of 11 qualitative articles published from 2005 to 2015 was
conducted using a social constructivist approach with thematic analysis.
Results: The four themes identified are: 1) hierarchies and power dynamics negatively affect safety voice,
2) open communication is unsafe and ineffective, 3) embedded expectations of nurse behavior affect
safety voice, and 4) nurse managers have a powerful positive or negative affect on safety voice.
Conclusions: Healthcare workers worldwide report multiple social and hierarchy related fears
surrounding the utilization of safety voice behaviors. Hesitance to speak up is pervasive among nurses,
as is low self-efficacy related to safety voice. The presence of caring leaders, peer support, and an
organizational commitment to safe, open cultures, may improve safety voice utilization among nurses
and other healthcare workers.
ã 2016 Elsevier Ltd. All rights reserved.

What is already known about the topic?  Relative openness of supervisors.
Extant literature reveals safety voice in non-healthcare work-
ers is increased by: What this paper adds:
This meta-synthesis reveals safety voice in healthcare workers 
Perceived organizational support for safety. is: 
Affect based trust in leadership.
 Impeded by hierarchies and power dynamics.
 Increased by open, supportive managers.
 Perceived as unsafe and ineffective.
* Corresponding author at: School of Nursing, UNLV, 4505 South Maryland
Parkway, Box 453018, Las Vegas, NV, 89154, United States.
E-mail addresses: Kelly.morrow@unlv.edu, Kelly.morrow@ucdenver.edu
(K.J. Morrow), Allison.gustavson@ucdenver.edu (A.M. Gustavson),
Jacqueline.jones@ucdenver.edu (J. Jones).

http://dx.doi.org/10.1016/j.ijnurstu.2016.09.014
0020-7489/ã 2016 Elsevier Ltd. All rights reserved.

analysis. 2008. retained for this review (see Appendix A Fig. 3. and the second author.000 veteran’s administration health care employees. a nurse educator and PhD student.1. on utilization of safety voice. tivism takes the position that individual meaning is “constructed” through social interactions. focused on identifying patterns of meaning within and across and study of these essential behaviors from an active. overall rigor and appropriateness of findings An array of speaking up related safety behaviors are collectively (Letts et al. overarching theme across these diverse. 2013). and offered extensive reflective realities to inform and co-construct new realities. After to speak up. voice is broadly defined as employee willingness to proactively Sweden. 2014). Participants possessed from under Safety voice may be increased in non-healthcare workers by peer 1 year to over 30 years of experience in a variety of roles and attitudes. CINAHL. Data analysis understanding of how nurses and other healthcare workers relate methods included manually color-coding units of meaning from to safety voice. data behaviors from other team members (Raica. The third author.. 2013). and how this might influence clinical practice and each study and organizing these codes into themes as patterns of patient safety. and to physicians (surgeons. These speaking up behaviors physical therapy and PhD student. Canada. These derived analytic themes were organized. Findings cultural norms. anesthesiologists. Hierarchies and power dynamics negatively affect safety voice A literature search was conducted of the PubMed. and The dominant. / International Journal of Nursing Studies 64 (2016) 42–51 43 1. clinical nurse specialists. oncologists. shared.. collection. Search strategy and outcomes 4. voice-centric these studies. employee silence remains a common cause of removing duplicates. 2008). non-related. more active perspectives of speaking up or voice. voice. learning. An additional study revealed nurses Each article was evaluated using the McMaster University Tool exhibit low confidence in the ability to assertively suggest for critical review of qualitative studies. 2012. nurses scored significantly lower on communication. Data were extracted with each reading as ongoing approach. 3. Studies took place in Australia. Identified gap and study aim 3. and theme development. Safety Hong Kong. nurse anesthetists). Subsequent readings healthcare workers might better facilitate the teaching. O’Dea et al. or nurse safety each article as a whole contributed to the understanding of safety voice to study desired speaking up behaviors for nurses. Each This interpretive meta-synthesis was conducted using a social author maintained an audit trail throughout the coding process. silence. K. 3) collection of healthcare settings. The most of supervisors. safety perceptions. medical challenge the status quo (Conchie. two East African nations. 2012.2. Academic Search Premier databases using a variety of international studies is hierarchies and power dynamics are . 2. managers. non-qualitative communication breakdowns.. 11 relevant articles were suboptimal care delivery (Haerkens et al. Morrow et al. and one was a critical ethnography. employee. and is informed by historical or 4... Korea. This is an ideal approach to utilize for performing hierarchies and power dynamics negatively affect safety voice. organizational support for safety (Tucker et al. residents).. (technicians. The aim of this meta-synthesis is to develop an analysis. Quality appraisal openness.J. affect based trust in leadership (Conchie. ducted to facilitate the organization of coded data as patterns of and 4) nurse managers have a powerful positive or negative affect new meaning were identified. Five studies were qualitative descriptive. The initial reading was completed to obtain an idea of how “nurse safety voice”. 2) an analysis of a broad range of qualitative studies in a diverse open communication is perceived as unsafe and/or ineffective. The utilization of safety voice. read all of the articles at least in the specific context of nursing might be conceptualized as twice. Switzerland. safety. support staff). meaning were identified. consultation during analysis. and teamwork than other healthcare employees (Sculli et al. and all articles prior to 2005.3. A total of 372 In spite of attempts by healthcare systems to encourage employees articles were identified and abstracts were reviewed. 2013). speak up. Data extraction and synthesis Safety voice is absent in nursing and healthcare literature and The primary author. Examples of safety voice behaviors meta-synthesis and consisted of 354 nurses (staff nurses. New Zealand. Turner et al. 2009). Tucker and Turner. In a 2009 survey of 54. and 20 healthcare workers from other groups Tucker et al. Social construc. and theme refinement occurred. 2007). nurse include willingness to provide constructive suggestions for change. A total of 504 participate in communication related behaviors for the purpose of healthcare workers participated in the 11 studies included in this improving workplace safety. 130 report potential safety risks or violations of safety practice. and perception of psychological safety (Tucker and common means of data collection were individual semi-structured Turner. relative openness five were narrative. embedded expectations of “nurse” behavior affects safety voice. a known expert in qualitative methodologies tivism is an inductive methodology that allows for multiple assisted with study design.. and contributes to errors resulting in articles. methods. Ireland. Bulgaria.. and the United States. Safety voice combinations of the keywords nurse. Conchie et al. and qualitative. a doctor of up behaviors for healthcare workers. More than double the A critical characteristic of effective workplace teams in any number of articles exploring safety voice behaviors in nursing were setting is when each member is willing to speak up to share identified from the passive perspective of silence as opposed to the thoughts and ideas to improve processes (Detert and Burris. and other voice behaviors in healthcare settings. 1 & Table A1). The goal of this methodology is to illuminate the complexity of meaning residing within individual accounts The four main themes identified in this meta-synthesis are: 1) (Creswell. conceptualized as “safety voice” in the extant literature. reflection. Theme development was con. 2015. 2013. safety voice. 2015). dissertations. 2015). Methods analysis until these two authors arrived at a consensus regarding the final synthesis of themes (see Appendix A Table A2). and discussed using reciprocal translational 3. 2007). healthcare work settings. read all might be used to collectively conceptualize the desired speaking of the articles multiple times. This guideline ensured a treatment plan changes when faced with rude or confrontational comprehensive critique of each study’s design. interviews and focus groups. Social construc. constructivist approach with thematic analysis.1.

. 2006. Hierarchy constraints 2015. and professions (Aveling et al. p. negatively affecting the utilization and reception of safety voice having their speech acts ignored or disregarded (Aveling et al. Todorova “elites” either disrespect or don’t recognize those “beneath them” et al. 2006. Multiple participants reported or were observed Foureur.. 2007. 2009... there is no support “unless an authority backs you up” (Bernice. Sundqvist and . 2015.. These acts include engaging in 2014). and anesthesiologists. Schwappach many nurses resort to frequent communication related acts of and Gehring. use of subversive or tactical altogether (Aveling et al. Sundqvist and Carlsson. Differing philosophical approaches. 2014). Law. 2006). 2014). resistance to achieve their goals. Gardezi et al. 2014). Schwap- depending upon one’s hierarchical status.44 K. 2014. negatively affect the safety voice behaviors of members from 2009.J. Sundqvist and Carlsson. 2015. 2015... Sundqvist and Carlsson. responsibilities. 2014. 2009. In one study a participant notes. Garon. 2014). 2009. 2009. or avoidance of follow up speech acts (Gardezi et al. 2014. 2015. 2015. Sundqvist and Carlsson. manipulation of speech. Malloy et al... Malloy et al. Search strategy and outcome. Law. Sundqvist and Carlsson. McBride-Henry and Foureur. and perceptions of harm particularly decreases the effectiveness of Perceptions of lack of support. and experiences of being disrespected have resulted et al. 2007. 1. 2012. 2015. 2009. In one study nurses cite experiencing a great deal of pach and Gehring. Schwap.. 2007. Malloy et al. 2009. behaviors by physicians (Todorova et al. 2007. Gehring. Schwappach and diverse groups including nurses. 2012. “physicians can say no but nication and conflict within and across interdisciplinary teams. McBride-Henry and Foureur. Todorova et al. speak up (Gardezi et al. and in another a participant states departments. Garon. or that elites are allowed to ignore safety guidelines quiet speech. 1843).. 2009. 2007.. Schwappach and Gehring. Gardezi et al. Morrow et al. 2012. Instead of engaging in proactive safety voice behaviors when they speak up (Law. 2014).. 2007.. 2009. Malloy et al. thetists. 2014. 2009.. Todorova et al. Malloy et al. Todorova anxiety related to speaking up because of “yelling and screaming” et al.... 2014. Schwappach and Garon. 2009. Participants report pach and Gehring. Malloy et al. 2015. 2014. 2014). 2014. 2015.. nurse anes. In several instances acceptable safety voice behavior varied Malloy et al. McBride-Henry and Foureur. 2009.. Garon. McBride-Henry and Gehring. medical residents. not the nurses” (Garon. Law. behaviors in healthcare team settings. instances of being ignored or safety voice behaviors between nurses and physicians (Gardezi disregarded. This results in ineffective commu. McBride-Henry and Foureur. silence. 2014. 2014. / International Journal of Nursing Studies 64 (2016) 42–51 Fig. Law. McBride-Henry and in nurses across these studies possessing a pervasive hesitance to Foureur.

2009.. Female nurses in one study identified the Incivility by elite hierarchical groups appears to be a common cultures they grew up in socialize women to be passive and this occurrence. Law. 2012. p. This theme speaks to the powerful positive or negative effect Henry and Foureur. 2015. McBride-Henry and Foureur. 2015). 2009. disrespected. 2014). Law. 2014). 2006. for how they are supposed to speak up and what they can say when This illuminates a possible reason managers describe nurses as speaking up (Garon. 2014. et al. 1970). 2009. Nurses attempting to complete institutionally inadvertently impede safety voice by perpetuating ingrained fears required procedures were observed being referred to as “drill in employees who are lower on the hierarchical spectrum.. supportive. 2012. McBride-Henry and Foureur. and report overwhelming feelings report they are sometimes constrained from providing feedback to of futility.. Todorova et al. Two studies note the importance Nurses perceive speaking up as a behavior requiring bravery of organizations and managers placing a high priority on patient and courage (Law. Schwappach and Gehring. ignored. 2014. Participants across several studies highlight the importance of having an report they are afraid of engaging in safety voice behaviors due to authentically safe. 2012. / International Journal of Nursing Studies 64 (2016) 42–51 45 Carlsson. 2011. Hirschman’s model proposes employee utilization (Garon. Discussion et al. Law. 2009. and some peer groups develop their own processes to the right of those who are affected by organizational decisions. and ensure patient safety and have been observed engaging in “secret” is positively related to organizational loyalty. Proactive. Law. 2014). being “too emotional” when they bring up concerns (Garon. 2015).. note they are sometimes afraid of humiliating or exposing another Schwappach and Gehring. 2015. 212)... 2015. 2014.. exit) with the organization (Cusack. 2007. McBride-Henry and Foureur. When employees or peer-only communications to resolve issues or concerns (Garon. 2014. 2009. Employee silence or hesitance to speak up can result and may negatively affect Embedded expectations of “nurse” behavior emerged as a organizational outcomes. The Positive aspects of embedded expectations of nurse behavior Dance of Caring Persons (DCP) is a team-based model of care that is comes in the form of many nurses reporting a perceived an especially relevant alternative to potentially oppressive top . 2014). Nurse participants report when they do utilize safety voice behaviors they feel empowered by safeguarding nurse 4. Nurses report feeling “invisible” (Todorova 5. 2012.. Todorova et al. resignation. The “Exit. Schwappach and Gehring. and can no longer be tolerated or culturally accepted in affects their professional behaviors related to speaking up (Garon.4. if behaviors (Garon. Jackson et al. 2014. discredited. Jackson et al. Open communication is unsafe and ineffective principles. Malloy et al. feeling unheard (Garon..3. Jackson overcome hierarchical differences (Sundqvist and Carlsson.. and encourage 2012. several other studies noted feeling there is an “unknown balance” and often motivates voicing behaviors (Kish-Gephart et al. 2014). Law. importance of having a manager role model. 2014). 2012. encourage safety voice (Bartholomew.. occur including receiving verbal or physical abuse. Law.. 2006. 2014). Schwappach and Gehring. McBride-Henry and Foureur.. 2015).. Jackson counted. Sundqvist and behaviors (Garon. p. 2012.. 2012). nurse managers have on staff safety voice behaviors. 2011. Nurse managers have a powerful positive or negative effect on studies have experienced engaging in ineffective speech acts or safety voice have received no follow up after engaging in a speech act (Gardezi et al. 2014). Jackson et al. 2012. Clark. and also et al. Voice. Participants Sundqvist and Carlsson. 2012. Malloy et al. 2007. Managers in one study It is likely these nurses required an emotional build up of anger to reported staff nurses are often “too emotional” when voicing effectively overcome deeply ingrained fears related to exercising concerns and speak of needing to teach them how to “reframe” safety voice. Anger is sergeant” and “losing it” (Gardezi et al. Garon. 2006. and gossip and rumors resigning isn’t an option. 2014.2. Malloy et al. 2014).. or humiliated. 2007. 2011. 2014. Schwappach and Gehring. 2014). 2007. retaliatory. 2009. 2007). and silenced by the “overwhelming power of physicians” (Malloy et al. Nurses in often the primary emotion enabling employees to overcome fear. 2014). is 2014). 2013).J. 2011. Other studies organizational goals (loyalty) is diminished. 2006. 2009. Gardezi and colleagues observed nurses who speak reception of safety voice. 2014. Garon. 2015). 2015. being dis. safety (Aveling et al. The fear of imminent patient harm was identified professional or ethical mandate to advocate for patient safety or in two studies as being a significant factor enabling participants to to maintain patient confidentiality (Garon. value. 2015.. 2006. Todorova et al. perceive voicing is discouraged or ineffective their commitment to 2012. and respectful space to voice an array of negative social or professional consequences that can concerns versus working in an environment that is closed. Law. Carlsson. Healthcare organizations with strong top loudly risk losing authority or being stigmatized or isolated in the down hierarchies resulting in large power differentials may work setting. McBride. Managers in two studies Sundqvist and Carlsson. Malloy et al. p. 2009). open. and power dynamics are negatively affecting the utilization and 2009. Law. “How loud can a nurse speak?” (Gardezi et al. Schwappach and Gehring. 2011. the individual will continue employment often occur instead of speaking up proactively (Jackson et al. 2014. of voice results in more effective organizational decision making. McBride-Henry and safety voice behaviors. Carlsson.. 2014. Sundqvist and Carlsson. 2009. The second theme throughout these studies is open communi- cation is unsafe and/or ineffective. 2015.. Todorova et al. requests (Garon. healthcare organizations seeking to authentically support and 2012). Participants throughout these 4. Several studies reveal the person or peer by speaking up (Gardezi et al. and experienced increased work satisfaction and self- knowledge (Garon. but will develop a relationship of “passive endurance” (effective Law. or not authentically safe (Garon.. 2006. 2006. 2015. 1396). theme when the first author began reflecting upon a question Healthcare workers in this meta-synthesis reveal hierarchies posed in one study. Sundqvist and Carlsson. 1396). Hirschman. Sundqvist and Todorova et al. and powerlessness related to engaging in staff due to privacy concerns and this may contribute to nurses speaking up behaviors (Garon.. 2012). Embedded expectations of “Nurse” behavior affects safety voice can be diminished in such situations.. 2007. This diminished reveal peer culture and role modeling affects speaking up commitment may result in the individual resigning (exit) or. K. 2009). 2006. Schwappach and Gehring. versus a manager who exhibits the opposite Foureur. loyalty based behaviors such as utilization of safety voice 4. Morrow et al.. 2011. and Loyalty” (EVL) model proposed by Hirsch- Nurses in several studies credit peer group cohesion as a factor man (1970) provides insight into the thematic findings of this in creating safe spaces to discuss practice and safety concerns meta-synthesis.

collaborative spaces for them to work hierarchies that impede safety voice. but it is the peers. 2011) resulting in a widespread culture of effective exit among many nurses. 2010). Conclusion may lead to an overemphasis on disease focused. oppressive hierarchies impede safety voice behav. 2012). exclusively as leader and final decision maker. Healthcare and nursing leaders themselves must practices into the culture of a hospital unit might empower nurses be willing to look within. 2011. professional registered nurse (Twomey. open cultures. is necessary to evaluate specific strategies to of safety voice. relationship to authentic change so they can role model. scripting languages. The DCP provides an example of one way to reinvent Safety voice behaviors can and should be proactively empha- healthcare hierarchies to better serve patient care quality and sized by healthcare organizations. O’Dea et al. non-holistic approaches that rob staff and patients alike of their dignity and What would healthcare look like if every team member felt inherent humanity (Watson. and the existence of worldwide nursing shortages satisfaction from speaking up. 2014. 2011). as evidenced by well documented difficulties in nurse individual and collective safety voice is valued. Kish-Gephart et al. 2008).. 2011). This finding coincides with the extant literature effectively motivate. 2009). such as interdisciplinary conversation cafés. and must be both taught safety goals. Continued research targeted to healthcare employees. non- individual or disciplinary agendas (Boykin et al.. 2013. or social class. 2005. and begin to embrace opportunities to exercise safety voice clearly developed a protective stance of passive endurance as part of their professional call (D’Alfonso. (Bartholomew. debriefing with supportive breaking down hierarchies is not for the fainthearted. and nurses cally open. is foundational to shifting individual in the central leadership position depending upon the from control-based hierarchies to caring. The DCP is a highly collaborative. social factors. and hierarchies existing in creating a workplace culture that encourages and enhances safety healthcare organizations around the world impede safety voice. or formation of caring workplace relationships. and enhance safety Organizations benefit when employees feel heard (Detert and voice. safe patient care in today’s complex. 2013. Leaders must be committed through related fears via the creation of a supportive. rediscover their passion for their (Hayes et al.46 K. surrounding medical futility and end-of-life issues since nurses are peer support. . embed patient-centered goals within interdisci. and encourage focused culture where no one feels invisible.. Morrow et al. 2015). sociological fidelity will be necessary to adequately evaluate the Proactive nurse engagement in safety voice behaviors is essential complex interplays that affect safety voice behaviors in healthcare to achieve high quality. and other healthcare workers who success in motivating employees to utilize safety voice (Conchie feel safe. Sculli et al. appears to exacerbate these issues. status. Many long held Caring practices and theories clearly offer many solutions to cultural traditions. Clark. Interventional studies incorporating context to achieve times socialization as females. Studies using crew particular report multiple fears related to engaging in safety voice resource management techniques and simulation show promise behaviors. relationally to create trust and psychological safety often achieve Empowered. voice among nurses and other healthcare workers.. safe patient care. Tucker and Turner. transformation as behavior patterns change. Some and ability to empathize with others” (Clark. positive feedback. Teaching managers to hierarchy that values the unique expertise of each individual or transform into leaders by exchanging hierarchy based practices for discipline. 2011). 2016). care. 1999. fragmented systems.J. safety of patients is in fact central to fulfilling the role of being an . and shifting to an interactive. possess a pervasive hesitance to speak up.. 2012) longer part of the culture or social fabric of the organization. and take an honest appraisal of how their and other healthcare workers to more proactively utilize safety own fears and insecurities might be contributing to control-based voice by providing safe. conducting collaborative plinary care plans. Rather than one individual or discipline functioning liberating structures. and focus on “what ought to be” rather than on interdisciplinary rounds. partnership-based type of expertise needed at any given time. 2012. and their profession. and all persons are Deutsch. high quality patient cultures are reimagined (Liebovitch et al. and mindfully visualizing desired actions are highly effective call of our generation. committed nurses. Team decisions decrease care emotions and contributions (Watson. they might gain retention. Implementing these checking boxes. authentic presence.. 2008). As noted by Clark (2016). / International Journal of Nursing Studies 64 (2016) 42–51 down hierarchies. 2005. and organizations committed to safe. and relationships and iors and interfere with the provision of safe.. Many of those who remain in nursing have work. while sending a clear message that incivility is no dehumanized (Sherwood and Horton-Deutsch. behaviors. cultures that promote safety voice (Sherwood and Horton- including the patient. “quicker to understand medical futility.. or safety voice. supportive managers as key to the effective utilization in particular. 2015. Small efforts at the relational level can affect significant Burris. and Healthcare workers in this global meta-synthesis perceive open role modeled by leaders (Garon. 2009). providing fragmentation. Jackson et al. communication as being unsafe and often ineffective. and some. 2012. Each individual. transform unit cultures. teach. 2014). Allowing for positive and negative employee committed to the one being cared for. Caring relationships offer a safe haven for employees to feel and interfere with the provision of high quality.. the DCP rotates the and Clearness Committee techniques. unheard. Schwappach and Gehring. 2007). is respected and valued. and encouraged as they exercise safety voice .. 2014. voice. encourage and support these workers as revealing non-healthcare supervisors and managers who convey a they seek to overcome ingrained fears and embedded expectations. empowered to speak up and to be heard regarding safety issues. Healthcare leaders must remember interdisciplinary. circular et al. and might facilitate the and cannot be achieved by writing policies. Embedded societal expectations of nurses. 2008). 2013).. and focus on quality of are key factors necessary to increase proactive utilization of safety living” (Malloy et al. ships with employees. supported. 2006. These non-holistic empowered to exercise safety voice? How many errors might be approaches are particularly detrimental during ethical debates prevented? How many lives saved? The presence of caring leaders. 1999. It requires authentic commitment to change at increasing individual self-awareness. devalued. the work of transforming systems and Reflective practices such as journaling. genuinely open attitude. Protecting the health and “Leading with civility and kindness is not a sign of weakness . true leadership calls for strong commitment to ethical conduct ethical. are hierarchy enhances safety voice by providing safe opportunities to examples of ways healthcare managers can build caring relation- voice regardless of gender socialization. Healthcare workers in this meta-synthesis identify authenti. 2014). settings (Sharma et al. or are able to engage with employees and to improve low self-efficacy related to safety voice behaviors. and for improving safety voice behaviors in nurses and other health- overwhelmingly report minimal effectiveness of safety voice care workers (Aebersold et al. As healthcare nurses respond to these conflicted conditions by exiting the workers begin to develop trust that it is safe to speak up. The effective loss of the nursing voice within healthcare 6. race. Nurses in Law. This cyclical punitive management style (Kingston and Brooks Turkel.

There are multiple. 4. peers. African descriptive of semi-structured including nurses. professional conflicts. 8 manager. Definitions of resistance. and patient safety management from 2 overcrowding. Certified Caritas Coach. for her invaluable consultation. University of Colorado. To explore whether a 1 to Canada Critical Retrospective study of 11 general surgeons and all Three forms of recurring (2009) 3 min preoperative inter. PhD. or ethical concerns. Conflicts of interest RN. organization large university. and director emerged: resistance. Canada Silence may be defensive or strategic. anesthesiologists at 3 requests. Narratives. K. 1. FAAN. Creating Interviews conducted until Meaning. in second phase. Sara Horton-Deutsch. building condition and and explain the major Nvivo software. 2. Absence of with a structured checklist communication about the ORs including 116 OR communication. weak communication & coordination due to hierarchical dynamics between professions. 1. culture. / International Journal of Nursing Studies 64 (2016) 42–51 47 are imperative to achieving improved patient care quality and Acknowledgements safety in healthcare systems of the 21st century. Relationships. Material Context: Poor income countries identify countries interviews supported by physicians. Caring Science Institute. Table A1 Literature yield table. Inter-professional working relationships: Poor teamwork. Influences on speaking to speak up and be heard in working in staff or up: Culture. Watson None declared. infrastructure. how message delivered. The authors would like to thank Dr. clinical services staff. 3 Garon To relate nurses’ stories of USA Qualitative 2-Phase study. Four major categories (2006) their experiences of acts of Narrative interviews in first phase.members of OR teams silence identified: professional team briefing professional working in those surgeons’ 1. Appendix A. Morrow et al. Core (range 10” to 1 h). 2 Gardezi et al. Staffing Issues: high turnover. Average positions. were performed because of unfair treatment.J. learned Recruited from 2 large at home. # Authors Study Purpose Country Study Design Methods Participants Summary of Findings 1 Aveling et al. Denver/AMC. Professor and Watson Caring Science Endowed Chair. None declared. hospitals in East Africa. abuse of power. . quietly. supplies. ANEF. doing what’s right. 11 19 nurses in staff. To give voice to how Two East Qualitative Thematic network analysis 57 healthcare workers Obstacles revealed: (2015) healthcare workers in low. perceived deficits in staff competency 3. PMHCNS. suburban hospitals. low staffing levels. saturation of themes and Many acts of resistance categories occurred. hospitals in Toronto. 2. and equipment. may be influenced by larger institutional and structural power dynamics as well as by the immediate situational context. the workplace. complex ways constrained communication is produced in the OR. education. management positions. interview length 30 min 2. It took courage but the acts had mainly positive effects on them and their institutions. lack of obstacles to ensuring administrative staff. and Director. Speaking the OR. charge. technicians. 3. 3. None. Ethnography silences observed in inter. and at a management. support. 1 year of experience 1. Not was an effective way to patient and surgical nurses and 74 responding to queries or support communication in procedure. and assistance in revising the Sources of funding discussion and conclusion sections of this article. 4 Garon (2012) To explore nurses’ USA Qualitative Thematic content analysis 33 nurses with at least Three categories: perceptions of their ability descriptive of 5 focus group interviews. Ethical approval See Tables A1 and A2.

Learning to speak up practice among newly. 2. Qualitative Thematic content analysis 42 nurses recruited from 4 These nurses suggested that (2009) perception of how ethical Ireland. Confidentiality as creating a rumor mill. Team provides safe place for questions or queries but trust is vital. medication culture: (2007) medication administration analysis of participants in each group. 3. descriptive of focus groups conducted countries by nomination their voices were silenced decisions are made. managers feel constrained to provide feedback. levels of experience. Confidentiality in the context of the public’s right to know. Varied specialties. / International Journal of Nursing Studies 64 (2016) 42–51 Table A1 (Continued) # Authors Study Purpose Country Study Design Methods Participants Summary of Findings 2. 18 new graduate nurses. Interpretation and application of confidentiality influences whistle blowing in healthcare services and can be a protective mechanism for healthcare institutions. 6 Law (2015) To explore the process of Hong Kong. 8 McBride. and and Korea between 1. Varied enforced silence. Speaking up requires ongoing mentoring to see new possibilities for sustaining professional identities in the midst of mis-educative experiences. Australian nurses in the telephone. 5 Jackson et al. To explore nurses’ Canada. Morrow et al. with new graduate RNs at requires more than one-off graduated registered 12.48 K. in each country and lasting strategy. They perceived that their approach to ethical decision-making differed from physicians. To explore how nurses in a New Qualitative Semi-structured interviews 2 focus groups: Clinically Themes identified: Henry and secondary care Zealand descriptive. Appreciative inquiry might be used to promote positive cultural changes to encourage newly graduated RNs to learn to speak up to ensure patient safety. some staff “chronic complainers”. nurses. “Team means safety”: during this process. Confidentiality as confidentiality for private setting or by whistle blowing. Confidentiality as isolating context of whistle blowing. undermine. the Australia. some staff silent. or from a single service. 3. Making public spaces safe for telling secret stories. Communication within multi-disciplinary team: . 2. and marginalizing. training. and group discussion with 3 based nurses with 3–25 1. 6–10 years of experience. Narrative Three individual. registration. increase awareness. not expressed in terms of the extent to which their ethical decision-making. and qualifications. 18 Australian nurses with Four emergent themes: (2011) and meaning of Narrative structured interviews in first-hand experience of 1. Staff understanding of Foureur environment understand narrative focus groups. Three threads identified: learning to speak up in China Qualitative unstructured interviews 1. increased safety. Managers are important in creating open communication cultures. 7 Malloy et al. (often voluntarily) or were nurses’ hospital role. Outcomes or results: Staff wants feedback and timeline. These cultures lead to better patient care. 3rd focus group: Significance of med admin safety and the factors that transcripts Clinical nurse specialists lessens over time.5 to 2 h. errors contribute to. voices were heard. Mentoring speaking up in the midst of educative and mis-educative experiences. and 24 months after training and safety tools. safe practice 2. Transmission and reception of a message: Strong emotions often inhibited communication. To reveal the experiences Australia Qualitative Face-to-face semi.J. 4. 18. 3. 3. and improved staff satisfaction.

Knowledge of medication procedures: Important to know where to access information. with Atlas. 58 min) involve complex off they make. Strategies for improvement: Numerous suggestions provided. establishing trust. and disempowerment. 5. . and being the patient’s vicarious autonomy. Moral commitment: Obligation. moral stress and courage. (2014) professionals’ perceptions participatory discourse analysis of 7 focus & medical residents (total organizational hierarchies. 3. occupational group “constellation”. considerations and trade- offs. New hierarchies— hospitals and how doctors entrenched hierarchies 2. and informing the patient. 4. Many participants reflected on whether risk level ‘justifies’ cost of speaking up. Nurses can make a meaningful contribution to patient safety and should be included in QI or research initiatives to improve safe med administration. 1. Illuminating unfairness and disrespect. patient’s life in my hands” (2014) phase from the perspective Subthemes: of the registered nurse Providing dignified care: anesthetist Treating patient with respect. 11 Todorova To explore health Bulgaria Qualitative Thematic analysis and 27 nurses and 15 physicians Main theme: dynamics of et al. Providing safe care: Being one step ahead. 9 Schwappach To explore factor’s that Switzerland Qualitative Inductive thematic content 32 doctors and nurses from Preventing patient harm is a and Gehring affect oncology staff’s descriptive analysis of semi-structured 7 oncology units at 6 strong motivator to speak (2014) decision to voice safety interviews. 10 Sundqvist To describe advocacy Sweden Qualitative Content analysis of 20 nurse anesthetists from Main theme: “Holding the and Carlsson during the perioperative descriptive individual interviews 2 hospitals in Sweden. Local contexts (micro & macro) may influence medication safety in ways that only nurses can identify. of organizational action groups and 4 interviews 42) in 3 university hosptials Subthemes: hierarchies in Bulgarian research. limited time. safeguarding the patient from home. Morrow et al. and nurses connect these to Metaphors of invisibility organizational justice. Interviews hospitals in Switzerland.J. Decisions whether and concerns or to remain silent averaged 42 min (range 21– how to voice concerns and to describe the trade. hierarchical structures. K. / International Journal of Nursing Studies 64 (2016) 42–51 49 Table A1 (Continued) # Authors Study Purpose Country Study Design Methods Participants Summary of Findings Ineffective or absent communication undermines patient care and creates a flawed system that can result in errors.ti. satisfaction. Working with dysfunctional organizational systems: Nurses devised numerous strategies to improve. futility & resignation. up. 6. fear of negative consequences. in Bulgaria. Barriers for voicing include: presence of others. defending patient’s rights.

9.5. Safeguarding. Nancy’s story. Obligation. occupational & futility. Potential for verbal or physical abuse 2. Moral stress. Ning’s story. 7.8.7. Dysfunctional systems. 8. Nancy’s story. Professional respect.6. 2.9. Moral stress. x Elite allowed to ignore or ‘flout’ safety guidelines 1 (p. Barriers/fear & occupational. Acceptable voice behavior varies based on status (see breakdown below) x “The physicians can say no but not the nurses” 3(p. Trade-offs/ Negative outcomes & predictability. Ning’s story. Enforced silence. Moral stress Feelings of futility. Metaphors of Disempowerment. ignored. Fear of imminent patient harm can overcome power dynamics and 9 (p. and powerlessness 4. Defending patient’s rights. 11 Teamwork and hierarchy. Discussion. Barriers/presence & fear.9. Manager humiliated. Defending patient’s rights. Not responding. Personal influences.1843) Agnes’s story x “Hierarchies silence voices and are permeated with unfairness and 7.3.4–7). Open communication is unsafe and/or ineffective Experiences of ineffective speech acts or no follow up on speech acts 2. Communication. safety or to maintain confidentiality 10 Defending patient’s rights. Constrained obligation. Isolating and marginalizing.7. Barriers/ futility. Barriers/ hierarchy & futility. Discussion.9. Message delivery. Ning’s story. Barrier/Presence. Must be brave or courageous to speak up 6. subversive acts. Silenced voice. negative consequences.10. predictability. 10. Message delivery Nurses who speak loudly may lose authority and risk being stigmatized 2 Speaking quietly or isolated “Unknown balance” for how/what to say 3.9. Acts of resistance occur including quiet speech. Doing the right thing. Moral stress. Trade-offs/ & 4). Nurse-physician relationships. conforming) Nurses engage in ‘secret’ communications and develop own processes 3.6.1396) Speaking quietly. 6. Metaphors of disempowerment. Want to be seen as a “good” employee 3(p. Absence of communication. harm (particularly between nurse and medical models) 4–6.3. resignation. 7. Metaphors of disempowerment Peer to peer cohesion among nurses creates a safe place to discuss 3. Discussion. 11 Absence of communication.3.10 Creating meaning. Speaking quietly. and avoidance of follow up speech acts Dysfunctional systems. Right to know. responsibilities.11(p. 10 Agnes’s story.3. Illuminating unfairness. goals. Barriers/fear & occupational.7. Embedded expectations of “nurse” behavior and socialization of nurses affect safety voice Nurses “too emotional” when voicing concerns 4 (p. Pervasive nurse hesitance to speak up 2. Agnes’s story.4. philosophical differences Safeguarding. Tradeoffs/negative outcomes. 10.213) hierarchy. Hierarchies and power dynamics affect safety voice Different philosophical approaches. Manager influences.5. Moral stress.9.8 Nurse-nurse relationships. Barriers/hierarchy & fear.6. Nurse-nurse relationship. 11 Nurse-nurse relationships. Dysfunctional systems. or of humiliating or exposing another person or peer influences. 368) Personal influences Perceived professional or ethical “mandate” to advocate for patient 3.1394). Agnes’s story.3. Dysfunctional systems. Metaphors of disempowerment.J. 10 Nurse-physician relationship. 6. Moral stress.10. Fear of being discounted. 10 Motivations/protect. Discussion. Defending patient’s rights. Moral stress.6 Nurse-nurse relationships. Constrained obligation. Not responding. 9(p.10.10. 11 Not responding.8). predictability. Creating meaning. discredited. Professional respect. Barriers/futility. Philosophy of health. Morrow et al. Manager influences. Tradeoffs/negative outcomes. Barriers/ disrespect” 10. predictability. Dysfunctional systems. Agnes’s story.4.7. Constrained obligation. Managers/Staff. not valued. 9. Moral stress. Right to know. Illuminating unfairness. Professional respect. fear. departments. New/entrenched hierarchies. 11 Teamwork and hierarchy. Dysfunctional systems. Fear of social or professional retaliation or negative consequences 2. Speaking quietly. Communication.11 Teamwork and hierarchy. Discussion. Conceptualizing decision.254) Nurse-physician relationship x Speech acts ignored or disregarded 1. Tradeoffs/negative outcomes. 8.8.11 Speaking quietly.4. 10 Judging risk.10. Metaphors of disempowerment. Agnes’s story. 10 Absence of communication. Peers. Barriers/futility. 2. Nurse- subversive or tactical silence.50 K. 3. “How loud can a nurse speak? “ 2(p. Team means safety.6. Illuminating unfairness. Discussion. Tables 3–4).7. 7.2.11 Manager influences. 9 (p4-6. 9.6 Creating rumor mill. Moral stress.7.6. 7. Discussion. Mentoring speaking up. Agnes’s story. Ning’s story. Agnes’s story.9.8.5). Silenced voice. Gossip and rumors in place of “speaking up” 5. 11 Not responding. Silenced voice. Silenced voice. Differing perceptions. Team means safety. Professional resulting in conflict between teams. 256) Nurse-nurse relationship Socialized passively as women and nurses 4(p. Nancy’s story. manipulation of speech to achieve physician relationship. Illuminating unfairness.7.9. 5(661). Barriers/fear. / International Journal of Nursing Studies 64 (2016) 42–51 Table A2 Reciprocal translation table. 8.4. Discussion x Not supported unless ‘authority’ backs up 6 (p. disrespected. Managers/staff. 2.3.9. Tradeoffs/negative outcomes. 2. practice and safety concerns Illuminating unfairness Peer culture and role modeling of speaking up (i:e voicing versus 3. Moral stress. Defending patient’s rights. Dysfunctional systems. 9(p. Discussion.10. Moral stress. Peers. Barriers/occupational. Not responding. and professions respect. 8. x Elite disrespect and “don’t recognize” those beneath them 1(p. Tradeoffs/negative outcomes. 7.5. Discussion. Discussion.4.367–368). Teamwork and hierarchy.8. Managers/Staff.366). Defending patient’s rights. Derived Analytic Themes & Subthemes Articles as listed in Themes from original articles yield table 1. Barriers/time. 11 Absence of communication.7. Creating rumor mill. 9. Professional respect. Discussion . Informing.8. 8.4(p368). Vicarious autonomy. Philosophy of health. 10. Metaphors of disempowerment. Tradeoffs/negative outcomes & predictability. Ning’s story.5). Defending patient’s rights. Peers. and perceptions of 2(p.6. Moral stress. text & Tables 3 Conclusion. Moral stress. for safety Understanding med culture. 3. Professional respect. 4. Dysfunctional systems.4(p. Ineffective interdisciplinary communication and collaboration 1.

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