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: 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/ 2016 Elsevier Ltd. All rights reserved.
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251
1. Safety voice
A critical characteristic of effective workplace teams in any
setting is when each member is willing to speak up to share
thoughts and ideas to improve processes (Detert and Burris, 2007).
In spite of attempts by healthcare systems to encourage employees
to speak up, employee silence remains a common cause of
communication breakdowns, and contributes to errors resulting in
suboptimal care delivery (Haerkens et al., 2012; ODea et al., 2014).
In a 2009 survey of 54,000 veterans administration health care
employees, nurses scored signicantly lower on communication,
openness, safety perceptions, and teamwork than other healthcare
employees (Sculli et al., 2013). An additional study revealed nurses
exhibit low condence in the ability to assertively suggest
treatment plan changes when faced with rude or confrontational
behaviors from other team members (Raica, 2009).
An array of speaking up related safety behaviors are collectively
conceptualized as safety voice in the extant literature. Safety
voice is broadly dened as employee willingness to proactively
participate in communication related behaviors for the purpose of
improving workplace safety. Examples of safety voice behaviors
include willingness to provide constructive suggestions for change,
report potential safety risks or violations of safety practice, and to
challenge the status quo (Conchie, 2013; Conchie et al., 2012;
Tucker et al., 2008; Tucker and Turner, 2015; Turner et al., 2015).
Safety voice may be increased in non-healthcare workers by peer
attitudes, organizational support for safety (Tucker et al., 2008),
affect based trust in leadership (Conchie, 2013), relative openness
of supervisors, and perception of psychological safety (Tucker and
Turner, 2015).
2. Identied gap and study aim
Safety voice is absent in nursing and healthcare literature and
might be used to collectively conceptualize the desired speaking
up behaviors for healthcare workers. These speaking up behaviors
in the specic context of nursing might be conceptualized as
nurse safety voice. The utilization of safety voice, or nurse safety
voice to study desired speaking up behaviors for nurses, and other
healthcare workers might better facilitate the teaching, learning,
and study of these essential behaviors from an active, voice-centric
approach. The aim of this meta-synthesis is to develop an
understanding of how nurses and other healthcare workers relate
to safety voice, and how this might inuence clinical practice and
patient safety.
3. Methods
This interpretive meta-synthesis was conducted using a social
constructivist approach with thematic analysis. Social construc-
tivism is an inductive methodology that allows for multiple
realities to inform and co-construct new realities. Social construc-
tivism takes the position that individual meaning is constructed
through social interactions, and is informed by historical or
cultural norms. The goal of this methodology is to illuminate the
complexity of meaning residing within individual accounts
(Creswell, 2013). This is an ideal approach to utilize for performing
an analysis of a broad range of qualitative studies in a diverse
collection of healthcare settings. Theme development was con-
ducted to facilitate the organization of coded data as patterns of
new meaning were identied.
3.1. Search strategy and outcomes
A literature search was conducted of the PubMed, CINAHL, and
Academic Search Premier databases using a variety of
43
combinations of the keywords nurse; employee; speak up; silence;
safety; voice; safety voice; and qualitative. More than double the
number of articles exploring safety voice behaviors in nursing were
identied from the passive perspective of silence as opposed to the
more active perspectives of speaking up or voice. A total of 372
articles were identied and abstracts were reviewed. After
removing duplicates; dissertations; non-related; non-qualitative
articles; and all articles prior to 2005; 11 relevant articles were
retained for this review (see Appendix A Fig. 1 & Table A1).
3.2. Quality appraisal
Each article was evaluated using the McMaster University Tool
for critical review of qualitative studies. This guideline ensured a
comprehensive critique of each studys design, methods, data
collection, analysis, overall rigor and appropriateness of ndings
(Letts et al., 2007). Studies took place in Australia, Bulgaria, Canada,
Hong Kong, two East African nations, Ireland, Korea, New Zealand,
Sweden, Switzerland, and the United States. A total of 504
healthcare workers participated in the 11 studies included in this
meta-synthesis and consisted of 354 nurses (staff nurses, nurse
managers, clinical nurse specialists, nurse anesthetists), 130
physicians (surgeons, oncologists, anesthesiologists, medical
residents), and 20 healthcare workers from other groups
(technicians, support staff). Participants possessed from under
1 year to over 30 years of experience in a variety of roles and
healthcare work settings. Five studies were qualitative descriptive,
ve were narrative, and one was a critical ethnography. The most
common means of data collection were individual semi-structured
interviews and focus groups.
3.3. Data extraction and synthesis
The primary author, a nurse educator and PhD student, read all
of the articles multiple times, and the second author, a doctor of
physical therapy and PhD student, read all of the articles at least
twice. The initial reading was completed to obtain an idea of how
each article as a whole contributed to the understanding of safety
voice behaviors in healthcare settings. Subsequent readings
focused on identifying patterns of meaning within and across
these studies. Data were extracted with each reading as ongoing
analysis, reection, and theme renement occurred. Data analysis
methods included manually color-coding units of meaning from
each study and organizing these codes into themes as patterns of
meaning were identied. These derived analytic themes were
organized, shared, and discussed using reciprocal translational
analysis until these two authors arrived at a consensus regarding
the nal synthesis of themes (see Appendix A Table A2). Each
author maintained an audit trail throughout the coding process.
The third author, a known expert in qualitative methodologies
assisted with study design, and offered extensive reective
consultation during analysis, and theme development.
4. Findings
The four main themes identied in this meta-synthesis are: 1)
hierarchies and power dynamics negatively affect safety voice, 2)
open communication is perceived as unsafe and/or ineffective, 3)
embedded expectations of nurse behavior affects safety voice,
and 4) nurse managers have a powerful positive or negative affect
on utilization of safety voice.
4.1. Hierarchies and power dynamics negatively affect safety voice
The dominant, overarching theme across these diverse,
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
behaviors in healthcare team settings. Hierarchy constraints
negatively affect the safety voice behaviors of members from
diverse groups including nurses, medical residents, nurse anes-
thetists, and anesthesiologists. This results in ineffective commu-
nication and conict within and across interdisciplinary teams,
departments, and professions (Aveling et al., 2015; Garon, 2012;
Malloy et al., 2009; McBride-Henry and Foureur, 2007; Schwap-
pach and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova
et al., 2014). Differing philosophical approaches, responsibilities,
and perceptions of harm particularly decreases the effectiveness of
safety voice behaviors between nurses and physicians (Gardezi
et al., 2009; Law, 2015; Malloy et al., 2009; McBride-Henry and
Foureur, 2007; Sundqvist and Carlsson, 2014).
In several instances acceptable safety voice behavior varied
depending upon ones hierarchical status. Participants report
elites either disrespect or dont recognize those beneath them
when they speak up (Law, 2015; Malloy et al., 2009; Schwappach
and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova et al.,
2014), or that elites are allowed to ignore safety guidelines
altogether (Aveling et al., 2015; Gardezi et al., 2009; Malloy et al.,
2009; McBride-Henry and Foureur, 2007; Schwappach and
Gehring, 2014). Multiple participants reported or were observed
having their speech acts ignored or disregarded (Aveling et al.,
2015; Gardezi et al., 2009; Garon, 2012; Law, 2015; Malloy et al.,
2009; McBride-Henry and Foureur, 2007; Schwappach and
Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova et al.,
2014). In one study a participant notes, physicians can say no but
not the nurses (Garon, 2006), and in another a participant states
there is no support unless an authority backs you up (Bernice,
2015, p. 1843). In one study nurses cite experiencing a great deal of
anxiety related to speaking up because of yelling and screaming
behaviors by physicians (Todorova et al., 2014).
Perceptions of lack of support, instances of being ignored or
disregarded, and experiences of being disrespected have resulted
in nurses across these studies possessing a pervasive hesitance to
speak up (Gardezi et al., 2009; Garon, 2006, 2012; Law, 2015;
Malloy et al., 2009; McBride-Henry and Foureur, 2007; Schwap-
pach and Gehring, 2014; Sundqvist and Carlsson, 2014; Todorova
et al., 2014). Instead of engaging in proactive safety voice behaviors
many nurses resort to frequent communication related acts of
resistance to achieve their goals. These acts include engaging in
quiet speech, manipulation of speech, use of subversive or tactical
silence, or avoidance of follow up speech acts (Gardezi et al., 2009;
Garon, 2006; Law, 2015; Malloy et al., 2009; McBride-Henry and
Foureur, 2007; Schwappach and Gehring, 2014; Sundqvist and
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251
Carlsson, 2014). The fear of imminent patient harm was identied
in two studies as being a signicant factor enabling participants to
overcome hierarchical differences (Sundqvist and Carlsson, 2014;
Todorova et al., 2014).
4.2. Open communication is unsafe and ineffective
The second theme throughout these studies is open communi-
cation is unsafe and/or ineffective. Participants throughout these
studies have experienced engaging in ineffective speech acts or
have received no follow up after engaging in a speech act (Gardezi
et al., 2009; Garon, 2012; Law, 2015; Malloy et al., 2009; McBride-
Henry and Foureur, 2007; Schwappach and Gehring, 2014;
Sundqvist and Carlsson, 2014; Todorova et al., 2014). Participants
report they are afraid of engaging in safety voice behaviors due to
an array of negative social or professional consequences that can
occur including receiving verbal or physical abuse, being dis-
counted, discredited, disrespected, ignored, or humiliated, and also
note they are sometimes afraid of humiliating or exposing another
person or peer by speaking up (Gardezi et al., 2009; Garon, 2006,
2012; Jackson et al., 2011; Malloy et al., 2009; McBride-Henry and
Foureur, 2007; Schwappach and Gehring, 2014; Sundqvist and
Carlsson, 2014; Todorova et al., 2014).
Nurses perceive speaking up as a behavior requiring bravery
and courage (Law, 2015; Schwappach and Gehring, 2014;
Sundqvist and Carlsson, 2014), and report overwhelming feelings
of futility, resignation, and powerlessness related to engaging in
speaking up behaviors (Garon, 2012; Law, 2015; Malloy et al., 2009;
Schwappach and Gehring, 2014; Sundqvist and Carlsson, 2014;
Todorova et al., 2014). Nurses report feeling invisible (Todorova
et al., 2014, p. 212), and silenced by the overwhelming power of
physicians (Malloy et al., 2009).
Nurses in several studies credit peer group cohesion as a factor
in creating safe spaces to discuss practice and safety concerns
(Garon, 2006; McBride-Henry and Foureur, 2007; Todorova et al.,
2014), and some peer groups develop their own processes to
ensure patient safety and have been observed engaging in secret
or peer-only communications to resolve issues or concerns (Garon,
2012; Law, 2015; McBride-Henry and Foureur, 2007). Other studies
reveal peer culture and role modeling affects speaking up
behaviors (Garon, 2006, 2012; Law, 2015), and gossip and rumors
often occur instead of speaking up proactively (Jackson et al., 2011;
Law, 2015).
4.3. Embedded expectations of Nurse behavior affects safety voice
Embedded expectations of nurse behavior emerged as a
theme when the rst author began reecting upon a question
posed in one study, How loud can a nurse speak? (Gardezi et al.,
2009; p. 1396). Gardezi and colleagues observed nurses who speak
loudly risk losing authority or being stigmatized or isolated in the
work setting. Nurses attempting to complete institutionally
required procedures were observed being referred to as drill
sergeant and losing it (Gardezi et al., 2009; p. 1396). Nurses in
several other studies noted feeling there is an unknown balance
for how they are supposed to speak up and what they can say when
speaking up (Garon, 2006, 2012; Jackson et al., 2011; Malloy et al.,
2009; Schwappach and Gehring, 2014). Managers in one study
reported staff nurses are often too emotional when voicing
concerns and speak of needing to teach them how to reframe
requests (Garon, 2012). Female nurses in one study identied the
cultures they grew up in socialize women to be passive and this
affects their professional behaviors related to speaking up (Garon,
2012).
Positive aspects of embedded expectations of nurse behavior
comes in the form of many nurses reporting a perceived
45
professional or ethical mandate to advocate for patient safety or
to maintain patient condentiality (Garon, 2006, 2012; Jackson
et al., 2011; McBride-Henry and Foureur, 2007; Sundqvist and
Carlsson, 2014). Nurse participants report when they do utilize
safety voice behaviors they feel empowered by safeguarding nurse
principles, and experienced increased work satisfaction and self-
knowledge (Garon, 2006; Sundqvist and Carlsson, 2014).
4.4. Nurse managers have a powerful positive or negative effect on
safety voice
This theme speaks to the powerful positive or negative effect
nurse managers have on staff safety voice behaviors. Participants
across several studies highlight the importance of having an
authentically safe, open, supportive, and respectful space to voice
concerns versus working in an environment that is closed,
retaliatory, or not authentically safe (Garon, 2006, 2012; Jackson
et al., 2011; Law, 2015; McBride-Henry and Foureur, 2007;
Schwappach and Gehring, 2014). Several studies reveal the
importance of having a manager role model, value, and encourage
safety voice behaviors, versus a manager who exhibits the opposite
behaviors (Garon, 2006, 2012; Jackson et al., 2011; Law, 2015;
Schwappach and Gehring, 2014). Two studies note the importance
of organizations and managers placing a high priority on patient
safety (Aveling et al., 2015; Law, 2015). Managers in two studies
report they are sometimes constrained from providing feedback to
staff due to privacy concerns and this may contribute to nurses
feeling unheard (Garon, 2012; Law, 2015).
5. Discussion
The Exit, Voice, and Loyalty (EVL) model proposed by Hirsch-
man (1970) provides insight into the thematic ndings of this
meta-synthesis. Hirschmans model proposes employee utilization
of voice results in more effective organizational decision making, is
the right of those who are affected by organizational decisions, and
is positively related to organizational loyalty. When employees
perceive voicing is discouraged or ineffective their commitment to
organizational goals (loyalty) is diminished. This diminished
commitment may result in the individual resigning (exit) or, if
resigning isnt an option, the individual will continue employment
but will develop a relationship of passive endurance (effective
exit) with the organization (Cusack, 2009; Hirschman, 1970).
Proactive, loyalty based behaviors such as utilization of safety voice
can be diminished in such situations. Employee silence or
hesitance to speak up can result and may negatively affect
organizational outcomes.
Healthcare workers in this meta-synthesis reveal hierarchies
and power dynamics are negatively affecting the utilization and
reception of safety voice. Healthcare organizations with strong top
down hierarchies resulting in large power differentials may
inadvertently impede safety voice by perpetuating ingrained fears
in employees who are lower on the hierarchical spectrum. Anger is
often the primary emotion enabling employees to overcome fear,
and often motivates voicing behaviors (Kish-Gephart et al., 2009).
This illuminates a possible reason managers describe nurses as
being too emotional when they bring up concerns (Garon, 2012).
It is likely these nurses required an emotional build up of anger to
effectively overcome deeply ingrained fears related to exercising
safety voice.
Incivility by elite hierarchical groups appears to be a common
occurrence, and can no longer be tolerated or culturally accepted in
healthcare organizations seeking to authentically support and
encourage safety voice (Bartholomew, 2014; Clark, 2013). The
Dance of Caring Persons (DCP) is a team-based model of care that is
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
hierarchy that values the unique expertise of each individual or
discipline. Rather than one individual or discipline functioning
exclusively as leader and nal decision maker, the DCP rotates the
individual in the central leadership position depending upon the
type of expertise needed at any given time. Each individual,
including the patient, is respected and valued, and all persons are
committed to the one being cared for. Team decisions decrease care
fragmentation, embed patient-centered goals within interdisci-
plinary care plans, and focus on what ought to be rather than on
individual or disciplinary agendas (Boykin et al., 2014). This cyclical
hierarchy enhances safety voice by providing safe opportunities to
voice regardless of gender socialization, status, race, or social class.
Organizations benet when employees feel heard (Detert and
Burris, 2007), oppressive hierarchies impede safety voice behav-
iors and interfere with the provision of safe, high quality patient
care. The DCP provides an example of one way to reinvent
healthcare hierarchies to better serve patient care quality and
safety goals.
Healthcare workers in this global meta-synthesis perceive open
communication as being unsafe and often ineffective. Nurses in
particular report multiple fears related to engaging in safety voice
behaviors, possess a pervasive hesitance to speak up, and
overwhelmingly report minimal effectiveness of safety voice
behaviors. Embedded societal expectations of nurses, and some-
times socialization as females, appears to exacerbate these issues.
Proactive nurse engagement in safety voice behaviors is essential
to achieve high quality, safe patient care in todays complex,
interdisciplinary, fragmented systems. Protecting the health and
safety of patients is in fact central to fullling the role of being an
ethical, professional registered nurse (Twomey, 2008). Some
nurses respond to these conicted conditions by exiting the
profession, as evidenced by well documented difculties in nurse
retention, and the existence of worldwide nursing shortages
(Hayes et al., 2010). Many of those who remain in nursing have
clearly developed a protective stance of passive endurance
resulting in a widespread culture of effective exit among many
nurses. The effective loss of the nursing voice within healthcare
may lead to an overemphasis on disease focused, non-holistic
approaches that rob staff and patients alike of their dignity and
inherent humanity (Watson, 1999, 2005, 2008). These non-holistic
approaches are particularly detrimental during ethical debates
surrounding medical futility and end-of-life issues since nurses are
quicker to understand medical futility, and focus on quality of
living (Malloy et al., 2009).
Caring practices and theories clearly offer many solutions to
creating a workplace culture that encourages and enhances safety
voice. Caring relationships offer a safe haven for employees to feel
empowered to speak up and to be heard regarding safety issues.
Reective practices such as journaling, debrieng with supportive
peers, and mindfully visualizing desired actions are highly effective
at increasing individual self-awareness, and might facilitate the
formation of caring workplace relationships. Implementing these
practices into the culture of a hospital unit might empower nurses
and other healthcare workers to more proactively utilize safety
voice by providing safe, collaborative spaces for them to work
through related fears via the creation of a supportive, relationship
focused culture where no one feels invisible, devalued, unheard, or
dehumanized (Sherwood and Horton-Deutsch, 2012)
Healthcare workers in this meta-synthesis identify authenti-
cally open, supportive managers as key to the effective utilization
of safety voice. This nding coincides with the extant literature
revealing non-healthcare supervisors and managers who convey a
genuinely open attitude, or are able to engage with employees
relationally to create trust and psychological safety often achieve
success in motivating employees to utilize safety voice (Conchie
et al., 2012; Tucker and Turner, 2015). Teaching managers to
transform into leaders by exchanging hierarchy based practices for
liberating structures, such as interdisciplinary conversation cafs,
and Clearness Committee techniques, is foundational to shifting
from control-based hierarchies to caring, partnership-based
cultures that promote safety voice (Sherwood and Horton-
Deutsch, 2012). Allowing for positive and negative employee
emotions and contributions (Watson, 1999, 2005, 2008), providing
positive feedback, authentic presence, conducting collaborative
interdisciplinary rounds, and shifting to an interactive, non-
punitive management style (Kingston and Brooks Turkel, 2011), are
examples of ways healthcare managers can build caring relation-
ships with employees, transform unit cultures, and enhance safety
voice. Small efforts at the relational level can affect signicant
transformation as behavior patterns change, and relationships and
cultures are reimagined (Liebovitch et al., 2011).
Safety voice behaviors can and should be proactively empha-
sized by healthcare organizations, and must be both taught
(Bartholomew, 2014; Clark, 2013; Kish-Gephart et al., 2009), and
role modeled by leaders (Garon, 2006, 2012; Jackson et al., 2011;
Law, 2015; Schwappach and Gehring, 2014). Studies using crew
resource management techniques and simulation show promise
for improving safety voice behaviors in nurses and other health-
care workers (Aebersold et al., 2013; ODea et al., 2014; Sculli et al.,
2013). Interventional studies incorporating context to achieve
sociological delity will be necessary to adequately evaluate the
complex interplays that affect safety voice behaviors in healthcare
settings (Sharma et al., 2011). Healthcare leaders must remember
Leading with civility and kindness is not a sign of weakness . .
. true leadership calls for strong commitment to ethical conduct
and ability to empathize with others (Clark, 2016). As healthcare
workers begin to develop trust that it is safe to speak up, and their
individual and collective safety voice is valued, they might gain
satisfaction from speaking up, rediscover their passion for their
work, and begin to embrace opportunities to exercise safety voice
as part of their professional call (DAlfonso, 2011)
6. Conclusion
What would healthcare look like if every team member felt
empowered to exercise safety voice? How many errors might be
prevented? How many lives saved? The presence of caring leaders,
peer support, and organizations committed to safe, open cultures,
are key factors necessary to increase proactive utilization of safety
voice among nurses and other healthcare workers. Many long held
cultural traditions, social factors, and hierarchies existing in
healthcare organizations around the world impede safety voice,
and interfere with the provision of high quality, safe patient care.
As noted by Clark (2016), the work of transforming systems and
breaking down hierarchies is not for the fainthearted, but it is the
call of our generation. It requires authentic commitment to change
and cannot be achieved by writing policies, scripting languages, or
checking boxes. Healthcare and nursing leaders themselves must
be willing to look within, and take an honest appraisal of how their
own fears and insecurities might be contributing to control-based
hierarchies that impede safety voice. Leaders must be committed
to authentic change so they can role model, teach, and encourage
safety voice, while sending a clear message that incivility is no
longer part of the culture or social fabric of the organization.
Continued research targeted to healthcare employees, and nurses
in particular, is necessary to evaluate specic strategies to
effectively motivate, encourage and support these workers as
they seek to overcome ingrained fears and embedded expectations,
and to improve low self-efcacy related to safety voice behaviors.
Empowered, committed nurses, and other healthcare workers who
feel safe, supported, and encouraged as they exercise safety voice
 K.J. Morrow et al. / International Journal of Nursing Studies 64 (2016) 4251
are imperative to achieving improved patient care quality and
safety in healthcare systems of the 21st century.
Conicts of interest
None declared.
Sources of funding
None declared.
Ethical approval
None.
Table A1
Literature yield table.
# Authors Study Purpose
1 Aveling et al. To give voice to how
(2015) healthcare workers in low-
income countries identify
and explain the major
obstacles to ensuring
patient safety
2 Gardezi et al. To explore whether a 1 to
(2009) 3 min preoperative inter-
professional team brieng
with a structured checklist
was an effective way to
support communication in
the OR.
3 Garon To relate nurses stories of
(2006) their experiences of acts of
resistance.
4 Garon (2012) To explore nurses USA
perceptions of their ability
to speak up and be heard in
the workplace.
47
Acknowledgements
The authors would like to thank Dr. Sara Horton-Deutsch, PhD,
RN, PMHCNS, FAAN, ANEF, Certied Caritas Coach, Professor and
Watson Caring Science Endowed Chair, and Director, Watson
Caring Science Institute, University of Colorado, Denver/AMC, for
her invaluable consultation, support, and assistance in revising the
discussion and conclusion sections of this article.
Appendix A.
See Tables A1 and A2.
Country Study Design Methods Participants Summary of Findings
Two East Qualitative Thematic network analysis 57 healthcare workers Obstacles revealed:
African descriptive of semi-structured including nurses, 1. Material Context: Poor
countries interviews supported by physicians, technicians, building condition and
Nvivo software. clinical services staff, infrastructure, lack of
administrative staff, and equipment, supplies, and
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.
Canada Critical Retrospective study of 11 general surgeons and all Three forms of recurring
Ethnography silences observed in inter- members of OR teams silence identied:
professional working in those surgeons 1. Absence of
communication about the ORs including 116 OR communication, 2. Not
patient and surgical nurses and 74 responding to queries or
procedure. anesthesiologists at 3 requests, 3. Speaking
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.
USA Qualitative 2-Phase study, 11 19 nurses in staff, charge, Four major categories
Narrative interviews in rst phase, 8 manager, and director emerged:
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.
Qualitative Thematic content analysis 33 nurses with at least Three categories:
descriptive of 5 focus group interviews. 1 year of experience 1. Inuences on speaking
working in staff or up: Culture, education,
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
5 Jackson et al. To reveal the experiences Australia
(2011) and meaning of
condentiality for
Australian nurses in the
context of whistle blowing.
6 Law (2015) To explore the process of
learning to speak up in
practice among newly-
graduated registered
nurses.
7 Malloy et al. To explore nurses
(2009) perception of how ethical
decisions are made, the
nurses hospital role, and
the extent to which their
voices were heard.
8 McBride- To explore how nurses in a
Henry and secondary care
Foureur environment understand
(2007) medication administration
safety and the factors that
contribute to, or
undermine, safe practice
during this process.
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.
Qualitative Face-to-face semi- 18 Australian nurses with Four emergent themes:
Narrative structured interviews in rst-hand experience of 1. Condentiality as
private setting or by whistle blowing. Varied enforced silence, 2.
telephone. levels of experience, Condentiality as isolating
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.
Hong Kong, Narrative Three individual, 18 new graduate nurses. Three threads identied:
China Qualitative unstructured interviews 1. Learning to speak up
with new graduate RNs at requires more than one-off
12, 18, and 24 months after training and safety tools, 2.
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.
Canada, Qualitative Thematic content analysis 42 nurses recruited from 4 These nurses suggested that
Ireland, descriptive of focus groups conducted countries by nomination their voices were silenced
Australia, in each country and lasting strategy. Varied specialties. (often voluntarily) or were
and Korea between 1.5 to 2 h. not expressed in terms of
ethical decision-making.
They perceived that their
approach to ethical
decision-making differed
from physicians.
New Qualitative Semi-structured interviews 2 focus groups: Clinically Themes identied:
Zealand descriptive, and group discussion with 3 based nurses with 325 1. Staff understanding of
narrative focus groups, 610 years of experience. medication culture:
analysis of participants in each group. 3rd focus group: Signicance of med admin
transcripts Clinical nurse specialists lessens over time, errors
from a single service. increase awareness,
2. Team means safety:
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
1. Hierarchies and power dynamics affect safety voice
Different philosophical approaches, responsibilities, and perceptions of 2(p.1394), 6, 7, 8, 9(p.
harm (particularly between nurse and medical models)
Ineffective interdisciplinary communication and collaboration
resulting in conict between teams, departments, and professions
Acceptable voice behavior varies based on status (see breakdown
below)
x The physicians can say no but not the nurses
x Speech acts ignored or disregarded
x Elite disrespect and dont recognize those beneath them
x Elite allowed to ignore or out safety guidelines
x Not supported unless authority backs up
x Hierarchies silence voices and are permeated with unfairness and
disrespect
Pervasive nurse hesitance to speak up
Acts of resistance occur including quiet speech, subversive acts,
subversive or tactical silence, manipulation of speech to achieve
goals, and avoidance of follow up speech acts
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
Fear of social or professional retaliation or negative consequences
Potential for verbal or physical abuse
Fear of being discounted, discredited, not valued, disrespected, ignored, 2,3,4,5,7,9, 10, 11
humiliated, or of humiliating or exposing another person or peer
Must be brave or courageous to speak up
Feelings of futility, resignation, and powerlessness
Peer to peer cohesion among nurses creates a safe place to discuss
practice and safety concerns
Peer culture and role modeling of speaking up (i:e voicing versus
conforming)
Nurses engage in secret communications and develop own processes 3,6,8
for safety
Gossip and rumors in place of speaking up
Fear of imminent patient harm can overcome power dynamics and
philosophical differences
3. Embedded expectations of nurse behavior and socialization of nurses affect safety voice
Nurses too emotional when voicing concerns
Nurses who speak loudly may lose authority and risk being stigmatized 2
or isolated
Unknown balance for how/what to say
How loud can a nurse speak?
Want to be seen as a good employee
Socialized passively as women and nurses
Perceived professional or ethical mandate to advocate for patient
safety or to maintain condentiality
Articles as listed in Themes from original articles
yield table
Absence of communication; Agness story; Philosophy of health,
46, 8, text & Tables 3 Conclusion; Dysfunctional systems; Barriers/occupational, Trade-offs/
& 4), 10 Judging risk, Differing perceptions, Discussion; Moral stress.
1,3, 7, 8,9, 10, 11 Teamwork and hierarchy; Nurse-physician relationships; Professional
respect; Communication, Dysfunctional systems; Barriers/hierarchy &
fear, Tradeoffs/negative outcomes; Defending patients rights, Moral
stress; New/entrenched hierarchies.
3(p.254) Nurse-physician relationship
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.
1(p.5), 6, 7, 9,10, 11 Teamwork and hierarchy; Nancys story; Silenced voice; Barriers/
hierarchy & futility; Moral stress; Metaphors of Disempowerment;
1 (p.5), 2,7,8, 9(p.8), Teamwork and hierarchy, Not responding; Constrained obligation;
Dysfunctional systems; Discussion
6 (p.1843) Agness story
7, 9 (p4-6, Tables 34), Constrained obligation, Professional respect, Silenced voice; Barriers/
10,11(p.213) hierarchy, Tradeoffs/negative outcomes & predictability, Discussion;
Defending patients rights, Moral stress; Illuminating unfairness.
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.
2,3,6,7,8,9, 10 Absence of communication, Not responding, Speaking quietly; Nurse-
physician relationship; Nings story; Professional respect;
Dysfunctional systems; Discussion; Defending patients rights;
Not responding; Manager inuences; Nings story, Agness story;
Discussion; Dysfunctional systems; Barriers/futility; Moral stress;
Metaphors of disempowerment.
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.
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.
Not responding, Speaking quietly; Creating meaning; Peers, Manager
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.
6,9, 10 Agness story, Mentoring speaking up, Nancys story; Barriers/fear &
occupational, Tradeoffs/negative outcomes; Moral stress
4,6,7,9,10,11 Manager inuences; Agness story; Silenced voice, Discussion; Barriers/
futility; Moral stress; Metaphors of disempowerment
3, 8, 11 Nurse-nurse relationships; Team means safety, Dysfunctional systems;
Illuminating unfairness
3, 4,6 Nurse-nurse relationships; Peers; Nings story;
Nurse-nurse relationships; Nings story; Communication,
Understanding med culture;
5,6 Creating rumor mill, Agness story;
9 (p.47), 10 Motivations/protect, Conceptualizing decision; Obligation,
Safeguarding.
4 (p.367368), Message delivery
Speaking quietly
3,4(p368), 7, 9, 10 Nurse-physician relationship; Message delivery, Professional respect;
Barrier/Presence, negative consequences; Defending patients rights;
2(p.1396) Speaking quietly,
3(p. 256) Nurse-nurse relationship
4(p. 368) Personal inuences
3,4(p.366), 5(661),8, Managers/staff; Doing the right thing; Discussion; Team means safety;
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
Table A2 (Continued)
Derived Analytic Themes & Subthemes Articles as listed in
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
versus closed, retaliatory environment
Prioritization of patient safety 1,6
Manager role models, values, and encourages speaking up versus the 3,4,5,6,9
opposite
Lack of clear policies and/or no back up for speaking up 1,5,6,7
Managers constrained on providing feedback 4,5
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