International Journal of Nursing Studies 64 (2016) 4251

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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, Ofce 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
condence 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 inuence 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 identied 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 identied 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-efcacy 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.
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: [email protected], [email protected]
(K.J. Morrow), [email protected] (A.M. Gustavson),
[email protected] (J. Jones).

http://dx.doi.org/10.1016/j.ijnurstu.2016.09.014
0020-7489/ 2016 Elsevier Ltd. All rights reserved.
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251 43

1. Safety voice combinations of the keywords nurse; employee; speak up; silence;
safety; voice; safety voice; and qualitative. 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 identied from the passive perspective of silence as opposed to the
thoughts and ideas to improve processes (Detert and Burris, 2007). more active perspectives of speaking up or voice. A total of 372
In spite of attempts by healthcare systems to encourage employees articles were identied and abstracts were reviewed. After
to speak up, employee silence remains a common cause of removing duplicates; dissertations; non-related; non-qualitative
communication breakdowns, and contributes to errors resulting in articles; and all articles prior to 2005; 11 relevant articles were
suboptimal care delivery (Haerkens et al., 2012; ODea et al., 2014). retained for this review (see Appendix A Fig. 1 & Table A1).
In a 2009 survey of 54,000 veterans administration health care
employees, nurses scored signicantly lower on communication, 3.2. Quality appraisal
openness, safety perceptions, and teamwork than other healthcare
employees (Sculli et al., 2013). An additional study revealed nurses Each article was evaluated using the McMaster University Tool
exhibit low condence in the ability to assertively suggest for critical review of qualitative studies. This guideline ensured a
treatment plan changes when faced with rude or confrontational comprehensive critique of each studys design, methods, data
behaviors from other team members (Raica, 2009). collection, analysis, overall rigor and appropriateness of ndings
An array of speaking up related safety behaviors are collectively (Letts et al., 2007). Studies took place in Australia, Bulgaria, Canada,
conceptualized as safety voice in the extant literature. Safety Hong Kong, two East African nations, Ireland, Korea, New Zealand,
voice is broadly dened as employee willingness to proactively Sweden, Switzerland, and the United States. 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. Examples of safety voice behaviors meta-synthesis and consisted of 354 nurses (staff nurses, nurse
include willingness to provide constructive suggestions for change, managers, clinical nurse specialists, nurse anesthetists), 130
report potential safety risks or violations of safety practice, and to physicians (surgeons, oncologists, anesthesiologists, medical
challenge the status quo (Conchie, 2013; Conchie et al., 2012; residents), and 20 healthcare workers from other groups
Tucker et al., 2008; Tucker and Turner, 2015; Turner et al., 2015). (technicians, support staff). 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, organizational support for safety (Tucker et al., 2008), healthcare work settings. Five studies were qualitative descriptive,
affect based trust in leadership (Conchie, 2013), relative openness ve were narrative, and one was a critical ethnography. The most
of supervisors, and perception of psychological safety (Tucker and common means of data collection were individual semi-structured
Turner, 2015). interviews and focus groups.

2. Identied gap and study aim 3.3. Data extraction and synthesis

Safety voice is absent in nursing and healthcare literature and The primary author, a nurse educator and PhD student, read all
might be used to collectively conceptualize the desired speaking of the articles multiple times, and the second author, a doctor of
up behaviors for healthcare workers. These speaking up behaviors physical therapy and PhD student, read all of the articles at least
in the specic context of nursing might be conceptualized as twice. The initial reading was completed to obtain an idea of how
nurse safety voice. The utilization of safety voice, or nurse safety each article as a whole contributed to the understanding of safety
voice to study desired speaking up behaviors for nurses, and other voice behaviors in healthcare settings. Subsequent readings
healthcare workers might better facilitate the teaching, learning, focused on identifying patterns of meaning within and across
and study of these essential behaviors from an active, voice-centric these studies. Data were extracted with each reading as ongoing
approach. The aim of this meta-synthesis is to develop an analysis, reection, and theme renement occurred. Data analysis
understanding of how nurses and other healthcare workers relate methods included manually color-coding units of meaning from
to safety voice, and how this might inuence clinical practice and each study and organizing these codes into themes as patterns of
patient safety. meaning were identied. These derived analytic themes were
organized, shared, and discussed using reciprocal translational
3. Methods analysis until these two authors arrived at a consensus regarding
the nal synthesis of themes (see Appendix A Table A2). Each
This interpretive meta-synthesis was conducted using a social author maintained an audit trail throughout the coding process.
constructivist approach with thematic analysis. Social construc- The third author, a known expert in qualitative methodologies
tivism is an inductive methodology that allows for multiple assisted with study design, and offered extensive reective
realities to inform and co-construct new realities. Social construc- consultation during analysis, and theme development.
tivism takes the position that individual meaning is constructed
through social interactions, and is informed by historical or 4. Findings
cultural norms. The goal of this methodology is to illuminate the
complexity of meaning residing within individual accounts The four main themes identied in this meta-synthesis are: 1)
(Creswell, 2013). This is an ideal approach to utilize for performing hierarchies and power dynamics negatively affect safety voice, 2)
an analysis of a broad range of qualitative studies in a diverse open communication is perceived as unsafe and/or ineffective, 3)
collection of healthcare settings. Theme development was con- embedded expectations of nurse behavior affects safety voice,
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 identied. on utilization of safety voice.

3.1. Search strategy and outcomes 4.1. Hierarchies and power dynamics negatively affect safety voice

A literature search was conducted of the PubMed, CINAHL, and The dominant, overarching theme across these diverse,
Academic Search Premier databases using a variety of international studies is hierarchies and power dynamics are
44 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251

Fig. 1. Search strategy and outcome.

negatively affecting the utilization and reception of safety voice having their speech acts ignored or disregarded (Aveling et al.,
behaviors in healthcare team settings. Hierarchy constraints 2015; Gardezi et al., 2009; Garon, 2012; Law, 2015; Malloy et al.,
negatively affect the safety voice behaviors of members from 2009; McBride-Henry and Foureur, 2007; Schwappach and
diverse groups including nurses, medical residents, nurse anes- Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova et al.,
thetists, and anesthesiologists. This results in ineffective commu- 2014). In one study a participant notes, physicians can say no but
nication and conict within and across interdisciplinary teams, not the nurses (Garon, 2006), and in another a participant states
departments, and professions (Aveling et al., 2015; Garon, 2012; there is no support unless an authority backs you up (Bernice,
Malloy et al., 2009; McBride-Henry and Foureur, 2007; Schwap- 2015, p. 1843). In one study nurses cite experiencing a great deal of
pach and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova anxiety related to speaking up because of yelling and screaming
et al., 2014). Differing philosophical approaches, responsibilities, behaviors by physicians (Todorova et al., 2014).
and perceptions of harm particularly decreases the effectiveness of Perceptions of lack of support, instances of being ignored or
safety voice behaviors between nurses and physicians (Gardezi disregarded, and experiences of being disrespected have resulted
et al., 2009; Law, 2015; Malloy et al., 2009; McBride-Henry and in nurses across these studies possessing a pervasive hesitance to
Foureur, 2007; Sundqvist and Carlsson, 2014). speak up (Gardezi et al., 2009; Garon, 2006, 2012; Law, 2015;
In several instances acceptable safety voice behavior varied Malloy et al., 2009; McBride-Henry and Foureur, 2007; Schwap-
depending upon ones hierarchical status. Participants report pach and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova
elites either disrespect or dont recognize those beneath them et al., 2014). Instead of engaging in proactive safety voice behaviors
when they speak up (Law, 2015; Malloy et al., 2009; Schwappach many nurses resort to frequent communication related acts of
and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova et al., resistance to achieve their goals. These acts include engaging in
2014), or that elites are allowed to ignore safety guidelines quiet speech, manipulation of speech, use of subversive or tactical
altogether (Aveling et al., 2015; Gardezi et al., 2009; Malloy et al., silence, or avoidance of follow up speech acts (Gardezi et al., 2009;
2009; McBride-Henry and Foureur, 2007; Schwappach and Garon, 2006; Law, 2015; Malloy et al., 2009; McBride-Henry and
Gehring, 2014). Multiple participants reported or were observed Foureur, 2007; Schwappach and Gehring, 2014; Sundqvist and
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251 45

Carlsson, 2014). The fear of imminent patient harm was identied professional or ethical mandate to advocate for patient safety or
in two studies as being a signicant factor enabling participants to to maintain patient condentiality (Garon, 2006, 2012; Jackson
overcome hierarchical differences (Sundqvist and Carlsson, 2014; et al., 2011; McBride-Henry and Foureur, 2007; Sundqvist and
Todorova et al., 2014). Carlsson, 2014). Nurse participants report when they do utilize
safety voice behaviors they feel empowered by safeguarding nurse
4.2. Open communication is unsafe and ineffective principles, and experienced increased work satisfaction and self-
knowledge (Garon, 2006; Sundqvist and Carlsson, 2014).
The second theme throughout these studies is open communi-
cation is unsafe and/or ineffective. Participants throughout these 4.4. 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., 2009; Garon, 2012; Law, 2015; Malloy et al., 2009; McBride- This theme speaks to the powerful positive or negative effect
Henry and Foureur, 2007; Schwappach and Gehring, 2014; nurse managers have on staff safety voice behaviors. Participants
Sundqvist and Carlsson, 2014; Todorova et al., 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, open, supportive, and respectful space to voice
an array of negative social or professional consequences that can concerns versus working in an environment that is closed,
occur including receiving verbal or physical abuse, being dis- retaliatory, or not authentically safe (Garon, 2006, 2012; Jackson
counted, discredited, disrespected, ignored, or humiliated, and also et al., 2011; Law, 2015; McBride-Henry and Foureur, 2007;
note they are sometimes afraid of humiliating or exposing another Schwappach and Gehring, 2014). Several studies reveal the
person or peer by speaking up (Gardezi et al., 2009; Garon, 2006, importance of having a manager role model, value, and encourage
2012; Jackson et al., 2011; Malloy et al., 2009; McBride-Henry and safety voice behaviors, versus a manager who exhibits the opposite
Foureur, 2007; Schwappach and Gehring, 2014; Sundqvist and behaviors (Garon, 2006, 2012; Jackson et al., 2011; Law, 2015;
Carlsson, 2014; Todorova et al., 2014). Schwappach and Gehring, 2014). 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, 2015; Schwappach and Gehring, 2014; safety (Aveling et al., 2015; Law, 2015). Managers in two studies
Sundqvist and Carlsson, 2014), and report overwhelming feelings report they are sometimes constrained from providing feedback to
of futility, resignation, and powerlessness related to engaging in staff due to privacy concerns and this may contribute to nurses
speaking up behaviors (Garon, 2012; Law, 2015; Malloy et al., 2009; feeling unheard (Garon, 2012; Law, 2015).
Schwappach and Gehring, 2014; Sundqvist and Carlsson, 2014;
Todorova et al., 2014). Nurses report feeling invisible (Todorova 5. Discussion
et al., 2014, p. 212), and silenced by the overwhelming power of
physicians (Malloy et al., 2009). The Exit, Voice, 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 ndings of this
in creating safe spaces to discuss practice and safety concerns meta-synthesis. Hirschmans model proposes employee utilization
(Garon, 2006; McBride-Henry and Foureur, 2007; Todorova et al., of voice results in more effective organizational decision making, is
2014), 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. When employees
or peer-only communications to resolve issues or concerns (Garon, perceive voicing is discouraged or ineffective their commitment to
2012; Law, 2015; McBride-Henry and Foureur, 2007). Other studies organizational goals (loyalty) is diminished. This diminished
reveal peer culture and role modeling affects speaking up commitment may result in the individual resigning (exit) or, if
behaviors (Garon, 2006, 2012; Law, 2015), and gossip and rumors resigning isnt an option, the individual will continue employment
often occur instead of speaking up proactively (Jackson et al., 2011; but will develop a relationship of passive endurance (effective
Law, 2015). exit) with the organization (Cusack, 2009; Hirschman, 1970).
Proactive, loyalty based behaviors such as utilization of safety voice
4.3. Embedded expectations of Nurse behavior affects safety voice can be diminished in such situations. Employee silence or
hesitance to speak up can result and may negatively affect
Embedded expectations of nurse behavior emerged as a organizational outcomes.
theme when the rst author began reecting upon a question Healthcare workers in this meta-synthesis reveal hierarchies
posed in one study, How loud can a nurse speak? (Gardezi et al., and power dynamics are negatively affecting the utilization and
2009; p. 1396). Gardezi and colleagues observed nurses who speak reception of safety voice. 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. 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. Anger is
sergeant and losing it (Gardezi et al., 2009; p. 1396). Nurses in often the primary emotion enabling employees to overcome fear,
several other studies noted feeling there is an unknown balance and often motivates voicing behaviors (Kish-Gephart et al., 2009).
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, 2006, 2012; Jackson et al., 2011; Malloy et al., being too emotional when they bring up concerns (Garon, 2012).
2009; Schwappach and Gehring, 2014). 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.
requests (Garon, 2012). Female nurses in one study identied the Incivility by elite hierarchical groups appears to be a common
cultures they grew up in socialize women to be passive and this occurrence, and can no longer be tolerated or culturally accepted in
affects their professional behaviors related to speaking up (Garon, healthcare organizations seeking to authentically support and
2012). encourage safety voice (Bartholomew, 2014; Clark, 2013). 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
46 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251

down hierarchies. The DCP is a highly collaborative, circular et al., 2012; Tucker and Turner, 2015). Teaching managers to
hierarchy that values the unique expertise of each individual or transform into leaders by exchanging hierarchy based practices for
discipline. Rather than one individual or discipline functioning liberating structures, such as interdisciplinary conversation cafs,
exclusively as leader and nal decision maker, the DCP rotates the and Clearness Committee techniques, is foundational to shifting
individual in the central leadership position depending upon the from control-based hierarchies to caring, partnership-based
type of expertise needed at any given time. Each individual, cultures that promote safety voice (Sherwood and Horton-
including the patient, is respected and valued, and all persons are Deutsch, 2012). Allowing for positive and negative employee
committed to the one being cared for. Team decisions decrease care emotions and contributions (Watson, 1999, 2005, 2008), providing
fragmentation, embed patient-centered goals within interdisci- positive feedback, authentic presence, conducting collaborative
plinary care plans, and focus on what ought to be rather than on interdisciplinary rounds, and shifting to an interactive, non-
individual or disciplinary agendas (Boykin et al., 2014). This cyclical punitive management style (Kingston and Brooks Turkel, 2011), are
hierarchy enhances safety voice by providing safe opportunities to examples of ways healthcare managers can build caring relation-
voice regardless of gender socialization, status, race, or social class. ships with employees, transform unit cultures, and enhance safety
Organizations benet when employees feel heard (Detert and voice. Small efforts at the relational level can affect signicant
Burris, 2007), oppressive hierarchies impede safety voice behav- transformation as behavior patterns change, and relationships and
iors and interfere with the provision of safe, high quality patient cultures are reimagined (Liebovitch et al., 2011).
care. 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, and must be both taught
safety goals. (Bartholomew, 2014; Clark, 2013; Kish-Gephart et al., 2009), and
Healthcare workers in this global meta-synthesis perceive open role modeled by leaders (Garon, 2006, 2012; Jackson et al., 2011;
communication as being unsafe and often ineffective. Nurses in Law, 2015; Schwappach and Gehring, 2014). Studies using crew
particular report multiple fears related to engaging in safety voice resource management techniques and simulation show promise
behaviors, possess a pervasive hesitance to speak up, and for improving safety voice behaviors in nurses and other health-
overwhelmingly report minimal effectiveness of safety voice care workers (Aebersold et al., 2013; ODea et al., 2014; Sculli et al.,
behaviors. Embedded societal expectations of nurses, and some- 2013). Interventional studies incorporating context to achieve
times socialization as females, appears to exacerbate these issues. sociological delity 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, safe patient care in todays complex, settings (Sharma et al., 2011). Healthcare leaders must remember
interdisciplinary, fragmented systems. Protecting the health and Leading with civility and kindness is not a sign of weakness . .
safety of patients is in fact central to fullling the role of being an . true leadership calls for strong commitment to ethical conduct
ethical, professional registered nurse (Twomey, 2008). Some and ability to empathize with others (Clark, 2016). As healthcare
nurses respond to these conicted conditions by exiting the workers begin to develop trust that it is safe to speak up, and their
profession, as evidenced by well documented difculties in nurse individual and collective safety voice is valued, they might gain
retention, and the existence of worldwide nursing shortages satisfaction from speaking up, rediscover their passion for their
(Hayes et al., 2010). Many of those who remain in nursing have work, and begin to embrace opportunities to exercise safety voice
clearly developed a protective stance of passive endurance as part of their professional call (DAlfonso, 2011)
resulting in a widespread culture of effective exit among many
nurses. The effective loss of the nursing voice within healthcare 6. Conclusion
may lead to an overemphasis on disease focused, 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, 1999, 2005, 2008). 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,
surrounding medical futility and end-of-life issues since nurses are peer support, and organizations committed to safe, open cultures,
quicker to understand medical futility, and focus on quality of are key factors necessary to increase proactive utilization of safety
living (Malloy et al., 2009). voice among nurses and other healthcare workers. Many long held
Caring practices and theories clearly offer many solutions to cultural traditions, social factors, and hierarchies existing in
creating a workplace culture that encourages and enhances safety healthcare organizations around the world impede safety voice,
voice. Caring relationships offer a safe haven for employees to feel and interfere with the provision of high quality, safe patient care.
empowered to speak up and to be heard regarding safety issues. As noted by Clark (2016), the work of transforming systems and
Reective practices such as journaling, debrieng with supportive breaking down hierarchies is not for the fainthearted, but it is the
peers, and mindfully visualizing desired actions are highly effective call of our generation. It requires authentic commitment to change
at increasing individual self-awareness, and might facilitate the and cannot be achieved by writing policies, scripting languages, or
formation of caring workplace relationships. Implementing these checking boxes. Healthcare and nursing leaders themselves must
practices into the culture of a hospital unit might empower nurses be willing to look within, 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, collaborative spaces for them to work hierarchies that impede safety voice. Leaders must be committed
through related fears via the creation of a supportive, relationship to authentic change so they can role model, teach, and encourage
focused culture where no one feels invisible, devalued, unheard, or safety voice, while sending a clear message that incivility is no
dehumanized (Sherwood and Horton-Deutsch, 2012) longer part of the culture or social fabric of the organization.
Healthcare workers in this meta-synthesis identify authenti- Continued research targeted to healthcare employees, and nurses
cally open, supportive managers as key to the effective utilization in particular, is necessary to evaluate specic strategies to
of safety voice. This nding coincides with the extant literature effectively motivate, encourage and support these workers as
revealing non-healthcare supervisors and managers who convey a they seek to overcome ingrained fears and embedded expectations,
genuinely open attitude, or are able to engage with employees and to improve low self-efcacy related to safety voice behaviors.
relationally to create trust and psychological safety often achieve Empowered, committed nurses, and other healthcare workers who
success in motivating employees to utilize safety voice (Conchie feel safe, supported, and encouraged as they exercise safety voice
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251 47

are imperative to achieving improved patient care quality and Acknowledgements

safety in healthcare systems of the 21st century.
The authors would like to thank Dr. Sara Horton-Deutsch, PhD,
Conicts of interest RN, PMHCNS, FAAN, ANEF, Certied Caritas Coach, Professor and
Watson Caring Science Endowed Chair, and Director, Watson
None declared. Caring Science Institute, University of Colorado, Denver/AMC, for
her invaluable consultation, support, and assistance in revising the
Sources of funding discussion and conclusion sections of this article.

None declared. Appendix A.

Ethical approval See Tables A1 and A2.

None.

Table A1
Literature yield table.

# Authors Study Purpose Country Study Design Methods Participants Summary of Findings
1 Aveling et al. To give voice to how Two East Qualitative Thematic network analysis 57 healthcare workers Obstacles revealed:
(2015) healthcare workers in low- African descriptive of semi-structured including nurses, 1. Material Context: Poor
income countries identify countries interviews supported by physicians, technicians, building condition and
and explain the major Nvivo software. clinical services staff, infrastructure, lack of
obstacles to ensuring administrative staff, and equipment, supplies, and
patient safety management from 2 overcrowding.
hospitals in East Africa. 2. Stafng Issues: high
turnover, low stafng levels,
perceived decits in staff
competency
3. Inter-professional
working relationships:
Poor teamwork,
professional conicts, weak
communication &
coordination due to
hierarchical dynamics
between professions.
2 Gardezi et al. 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- Ethnography silences observed in inter- members of OR teams silence identied:
professional team brieng professional working in those surgeons 1. Absence of
with a structured checklist communication about the ORs including 116 OR communication, 2. Not
was an effective way to patient and surgical nurses and 74 responding to queries or
support communication in procedure. anesthesiologists at 3 requests, 3. Speaking
the OR. hospitals in Toronto, quietly.
Canada Silence may be defensive or
strategic, may be inuenced
by larger institutional and
structural power dynamics
as well as by the immediate
situational context. There
are multiple, complex ways
constrained
communication is produced
in the OR.
3 Garon To relate nurses stories of USA Qualitative 2-Phase study, 11 19 nurses in staff, charge, Four major categories
(2006) their experiences of acts of Narrative interviews in rst phase, 8 manager, and director emerged:
resistance. in second phase. Average positions. 1. Denitions of resistance,
interview length 30 min 2. Relationships, 3. Core
(range 10 to 1 h). Narratives, 4. Creating
Interviews conducted until Meaning.
saturation of themes and Many acts of resistance
categories occurred. were performed because of
unfair treatment, abuse of
power, or ethical concerns.
It took courage but the acts
had mainly positive effects
on them and their
institutions.
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. 1 year of experience 1. Inuences on speaking
to speak up and be heard in working in staff or up: Culture, education,
the workplace. management positions. doing whats right, learned
Recruited from 2 large at home, peers,
suburban hospitals, and at a management, organization
large university. culture, how message
delivered.
48 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251

Table A1 (Continued)
# Authors Study Purpose Country Study Design Methods Participants Summary of Findings
2. Transmission and
reception of a message:
Strong emotions often
inhibited communication,
some staff silent, some staff
chronic complainers.
3. Outcomes or results:
Staff wants feedback and
timeline, managers feel
constrained to provide
feedback.
Managers are important in
creating open
communication cultures.
These cultures lead to
better patient care,
increased safety, and
improved staff satisfaction.
5 Jackson et al. To reveal the experiences Australia Qualitative Face-to-face semi- 18 Australian nurses with Four emergent themes:
(2011) and meaning of Narrative structured interviews in rst-hand experience of 1. Condentiality as
condentiality for private setting or by whistle blowing. Varied enforced silence, 2.
Australian nurses in the telephone. levels of experience, Condentiality as isolating
context of whistle blowing. training, and qualications. and marginalizing, 3.
Condentiality as creating a
rumor mill, 4.
Condentiality in the
context of the publics right
to know.
Interpretation and
application of
condentiality inuences
whistle blowing in
healthcare services and can
be a protective mechanism
for healthcare institutions.
6 Law (2015) To explore the process of Hong Kong, Narrative Three individual, 18 new graduate nurses. Three threads identied:
learning to speak up in China Qualitative unstructured interviews 1. Learning to speak up
practice among newly- with new graduate RNs at requires more than one-off
graduated registered 12, 18, and 24 months after training and safety tools, 2.
nurses. registration. Mentoring speaking up in
the midst of educative and
mis-educative experiences,
3. Making public spaces safe
for telling secret stories.
Speaking up requires
ongoing mentoring to see
new possibilities for
sustaining professional
identities in the midst of
mis-educative experiences.
Appreciative inquiry might
be used to promote positive
cultural changes to
encourage newly graduated
RNs to learn to speak up to
ensure patient safety.
7 Malloy et al. To explore nurses Canada, Qualitative Thematic content analysis 42 nurses recruited from 4 These nurses suggested that
(2009) perception of how ethical Ireland, descriptive of focus groups conducted countries by nomination their voices were silenced
decisions are made, the Australia, in each country and lasting strategy. Varied specialties. (often voluntarily) or were
nurses hospital role, and and Korea between 1.5 to 2 h. not expressed in terms of
the extent to which their ethical decision-making.
voices were heard. They perceived that their
approach to ethical
decision-making differed
from physicians.
8 McBride- To explore how nurses in a New Qualitative Semi-structured interviews 2 focus groups: Clinically Themes identied:
Henry and secondary care Zealand descriptive, and group discussion with 3 based nurses with 325 1. Staff understanding of
Foureur environment understand narrative focus groups, 610 years of experience. medication culture:
(2007) medication administration analysis of participants in each group. 3rd focus group: Signicance of med admin
safety and the factors that transcripts Clinical nurse specialists lessens over time, errors
contribute to, or from a single service. increase awareness,
undermine, safe practice 2. Team means safety:
during this process. Team provides safe place for
questions or queries but
trust is vital,
3. Communication within
multi-disciplinary team:
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251 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 awed system
that can result in errors,
4. Knowledge of
medication procedures:
Important to know where
to access information,
5. Working with
dysfunctional
organizational systems:
Nurses devised numerous
strategies to improve,
6. Strategies for
improvement: Numerous
suggestions provided.
Nurses can make a
meaningful contribution to
patient safety and should be
included in QI or research
initiatives to improve safe
med administration.
Local contexts (micro &
macro) may inuence
medication safety in ways
that only nurses can
identify.
9 Schwappach To explore factors that Switzerland Qualitative Inductive thematic content 32 doctors and nurses from Preventing patient harm is a
and Gehring affect oncology staffs descriptive analysis of semi-structured 7 oncology units at 6 strong motivator to speak
(2014) decision to voice safety interviews. Interviews hospitals in Switzerland. up. Decisions whether and
concerns or to remain silent averaged 42 min (range 21 how to voice concerns
and to describe the trade- 58 min) involve complex
off they make. considerations and trade-
offs. Many participants
reected on whether risk
level justies cost of
speaking up. Barriers for
voicing include: presence
of others, hierarchical
structures, limited time,
fear of negative
consequences, futility &
resignation, occupational
group constellation.
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. patients life in my hands
(2014) phase from the perspective Subthemes:
of the registered nurse Providing dignied care:
anesthetist Treating patient with
respect, establishing trust,
defending patients rights,
and being the patients
vicarious autonomy.
Providing safe care: Being
one step ahead,
safeguarding the patient
from home, and informing
the patient.
Moral commitment:
Obligation, moral stress and
courage, satisfaction.
11 Todorova To explore health Bulgaria Qualitative Thematic analysis and 27 nurses and 15 physicians Main theme: dynamics of
et al. (2014) professionals perceptions participatory discourse analysis of 7 focus & medical residents (total organizational hierarchies.
of organizational action groups and 4 interviews 42) in 3 university hosptials Subthemes:
hierarchies in Bulgarian research. with Atlas.ti. in Bulgaria. 1. New hierarchies
hospitals and how doctors entrenched hierarchies 2.
and nurses connect these to Metaphors of invisibility
organizational justice. and disempowerment,
3. Illuminating unfairness
and disrespect.
50 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251

Table A2
Reciprocal translation table.

Derived Analytic Themes & Subthemes Articles as listed in Themes from original articles
yield table
1. Hierarchies and power dynamics affect safety voice
Different philosophical approaches, responsibilities, and perceptions of 2(p.1394), 6, 7, 8, 9(p. Absence of communication; Agness story; Philosophy of health,
harm (particularly between nurse and medical models) 46, 8, text & Tables 3 Conclusion; Dysfunctional systems; Barriers/occupational, Trade-offs/
& 4), 10 Judging risk, Differing perceptions, Discussion; Moral stress.
Ineffective interdisciplinary communication and collaboration 1,3, 7, 8,9, 10, 11 Teamwork and hierarchy; Nurse-physician relationships; Professional
resulting in conict between teams, departments, and professions respect; Communication, Dysfunctional systems; Barriers/hierarchy &
fear, Tradeoffs/negative outcomes; Defending patients rights, Moral
stress; New/entrenched hierarchies.
Acceptable voice behavior varies based on status (see breakdown
below)
x The physicians can say no but not the nurses 3(p.254) Nurse-physician relationship
x Speech acts ignored or disregarded 1,2,4,6,7,8,9,10,11 Teamwork and hierarchy; Not responding; Manager inuences; Agness
story, Nancys story; Professional respect; Dysfunctional systems;
Barriers/futility, Discussion; Moral stress; Metaphors of
disempowerment.
x Elite disrespect and dont recognize those beneath them 1(p.5), 6, 7, 9,10, 11 Teamwork and hierarchy; Nancys story; Silenced voice; Barriers/
hierarchy & futility; Moral stress; Metaphors of Disempowerment;
x Elite allowed to ignore or out safety guidelines 1 (p.5), 2,7,8, 9(p.8), Teamwork and hierarchy, Not responding; Constrained obligation;
Dysfunctional systems; Discussion
x Not supported unless authority backs up 6 (p.1843) Agness story
x Hierarchies silence voices and are permeated with unfairness and 7, 9 (p4-6, Tables 34), Constrained obligation, Professional respect, Silenced voice; Barriers/
disrespect 10,11(p.213) hierarchy, Tradeoffs/negative outcomes & predictability, Discussion;
Defending patients rights, Moral stress; Illuminating unfairness.
Pervasive nurse hesitance to speak up 2,3,4,6, 7, 8,9,10, 11 Absence of communication, Nurse-nurse relationship; Personal
inuences; Nings story, Agness story; Discussion; Dysfunctional
systems; Barriers/time, fear, occupational & futility, Trade-offs/
Negative outcomes & predictability, Discussion; Moral stress;
Metaphors of disempowerment.
Acts of resistance occur including quiet speech, subversive acts, 2,3,6,7,8,9, 10 Absence of communication, Not responding, Speaking quietly; Nurse-
subversive or tactical silence, manipulation of speech to achieve physician relationship; Nings story; Professional respect;
goals, and avoidance of follow up speech acts Dysfunctional systems; Discussion; Defending patients rights;
2. Open communication is unsafe and/or ineffective
Experiences of ineffective speech acts or no follow up on speech acts 2,4,6,7,8, 9,10, 11 Not responding; Manager inuences; Nings story, Agness story;
Discussion; Dysfunctional systems; Barriers/futility; Moral stress;
Metaphors of disempowerment.
Fear of social or professional retaliation or negative consequences 2,3,4,5,7,9, 10,11 Speaking quietly, Managers/Staff; Peers; Isolating and marginalizing;
Philosophy of health; Barriers/fear & occupational, Tradeoffs/negative
outcomes, predictability; Defending patients rights, Moral stress;
Illuminating unfairness.
Potential for verbal or physical abuse 2,3,5,7,9,10, 11 Absence of communication; Managers/Staff; Enforced silence, Right to
know; Professional respect; Barriers/fear, Tradeoffs/negative outcomes,
predictability; Defending patients rights, Moral stress; Illuminating
unfairness.
Fear of being discounted, discredited, not valued, disrespected, ignored, 2,3,4,5,7,9, 10, 11 Not responding, Speaking quietly; Creating meaning; Peers, Manager
humiliated, or of humiliating or exposing another person or peer inuences; Creating rumor mill, Right to know; Constrained obligation,
Silenced voice; Barriers/presence & fear, Tradeoffs/negative outcomes,
predictability, Discussion; Moral stress, Metaphors of
disempowerment, Illuminating unfairness.
Must be brave or courageous to speak up 6,9, 10 Agness story, Mentoring speaking up, Nancys story; Barriers/fear &
occupational, Tradeoffs/negative outcomes; Moral stress
Feelings of futility, resignation, and powerlessness 4,6,7,9,10,11 Manager inuences; Agness story; Silenced voice, Discussion; Barriers/
futility; Moral stress; Metaphors of disempowerment
Peer to peer cohesion among nurses creates a safe place to discuss 3, 8, 11 Nurse-nurse relationships; Team means safety, Dysfunctional systems;
practice and safety concerns Illuminating unfairness
Peer culture and role modeling of speaking up (i:e voicing versus 3, 4,6 Nurse-nurse relationships; Peers; Nings story;
conforming)
Nurses engage in secret communications and develop own processes 3,6,8 Nurse-nurse relationships; Nings story; Communication,
for safety Understanding med culture;
Gossip and rumors in place of speaking up 5,6 Creating rumor mill, Agness story;
Fear of imminent patient harm can overcome power dynamics and 9 (p.47), 10 Motivations/protect, Conceptualizing decision; Obligation,
philosophical differences Safeguarding.
3. Embedded expectations of nurse behavior and socialization of nurses affect safety voice
Nurses too emotional when voicing concerns 4 (p.367368), 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 3,4(p368), 7, 9, 10 Nurse-physician relationship; Message delivery, Professional respect;
Barrier/Presence, negative consequences; Defending patients rights;
How loud can a nurse speak? 2(p.1396) Speaking quietly,
Want to be seen as a good employee 3(p. 256) Nurse-nurse relationship
Socialized passively as women and nurses 4(p. 368) Personal inuences
Perceived professional or ethical mandate to advocate for patient 3,4(p.366), 5(661),8, Managers/staff; Doing the right thing; Discussion; Team means safety;
safety or to maintain condentiality 10 Defending patients rights, Vicarious autonomy, Safeguarding,
Informing, Moral stress.
3,10 Creating meaning, Discussion
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251 51

Table A2 (Continued)
Derived Analytic Themes & Subthemes Articles as listed in Themes from original articles
yield table
Safeguarding nurse principles, feeling of empowerment, increased
work satisfaction, self knowledge can result from speaking up/
advocacy
4. Managers have a powerful positive or negative effect on safety voice
Authentically safe, open, supportive, respectful space to voice concerns 3,4,5,6, 8,9 Implications; Manager inuences; Enforced silence, Discussion; Nings
versus closed, retaliatory environment story; Understanding med culture, Team means safety, Knowledge of
med processes; Barrier/time, Discussion.
Prioritization of patient safety 1,6 Teamwork and hierarchy; Nancys story.
Manager role models, values, and encourages speaking up versus the 3,4,5,6,9 Implications; Manager inuences, Outcomes; Discussion; Nings story;
opposite Discussion;
Lack of clear policies and/or no back up for speaking up 1,5,6,7 Teamwork and hierarchy; Isolating and marginalizing; Nings story;
Silenced voice.
Managers constrained on providing feedback 4,5 Outcomes; Isolating and marginalizing;

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