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Speaking up: Fostering “silence breaking” through leadership

Hall, Nicole, EdD; Klein, Valerie, PhD; Betts, Kristen, EdD; DeRanieri, Joseph, DM

Nursing Management (Springhouse): June 2018 - Volume 49 - Issue 6 - p 51–53
doi: 10.1097/01.NUMA.0000533774.22167.f2
Department: Performance Potential

Nicole Hall is an assistant professor at Salisbury (Md.) University. At Drexel University in Philadelphia, Pa., Valerie Klein is an assistant clinical professor and Kristen Betts is a clinical professor. Joseph DeRanieri is the president and CEO of JTD Consultants.

The authors have disclosed no financial relationships related to this article.



The practice of speaking up about sexual harassment versus choosing to stay silent has surfaced as a current event issue that's gaining much media attention. In fact, TIME magazine even named the “silence breakers” as its Person of the Year for 2017. Speaking up when there's a patient care concern, as well as sexual harassment, is a highly relevant issue for nursing.

It's well known that clinical nurses regularly face the dilemma of whether to speak up or stay silent when they have a concern about patient care. Unique to the healthcare setting is the fact that nurses are obligated to speak up as part of their professional responsibility as patient advocates and in concordance with the nursing code of ethics.1 Yet the practice of speaking up hasn't been consistently implemented and studies show that nurses are hesitant to do so.2-5 Research has also identified barriers to speaking up, such as fearing negative consequences or experiencing feelings of intimidation.2,6,7

There's urgency surrounding the need to better establish speaking up in healthcare because medical errors are currently the third-leading cause of death in the United States.8 Research shows that communication is a related factor.9 For the sake of improving patient safety, nurse leaders and the healthcare industry as a whole have a responsibility to identify ways to foster speaking up.

No matter the circumstance, whether in one's personal life or professional career, there are a multitude of factors to consider when deciding to speak up or stay silent. This study was designed to determine how hospitals can better support nurses in speaking up so that this critical practice can be more firmly established. (See Research overview.)

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A mixed-methods approach was used, with quantitative analysis of secondary employee engagement survey data and qualitative analysis of individual interviews. The employee engagement data were obtained using a commercially available survey tool. The employee engagement survey was implemented in 2015 and had a strong return rate of 96%, with over 2,500 patient care and nonpatient care employees responding. Findings from the quantitative phase were used to identify areas of focus for the interview questions in the qualitative phase. Because the desire was to know how nurses can be better supported to speak up, a phenomenologic approach was used, which enabled the investigator to learn from the lived experiences of interviewees by understanding what had influenced them in their decisions to speak up or stay silent.

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Both the quantitative and qualitative portions of this study were implemented at one midsize community hospital after the study was granted Institutional Review Board approval. A portion of the secondary data from the hospital's 2015 employee engagement survey was studied, including hospital staff (n = 321) from seven inpatient nursing units. Of these staff members, 65% (n = 208) were RNs, 30% (n = 94) were unlicensed assistive personnel (UAP) and patient care techs, and the remaining 5% (n = 19) were undefined. Due to the nature of the survey data supplied, RNs couldn't be further isolated. The Spearman's correlation coefficient was calculated using statistical software to determine the strength of relationships between 63 survey questions and the outcome variable focused on nurse willingness to speak up.

Following the quantitative phase, five interviewees (n = 5) were selected using purposive sampling. All interviewees were RNs; two leaders and three clinical nurses were interviewed to obtain different perspectives on the topic. Interviews occurred over a 4-day period in March 2017 and were conducted with one interviewee at a time. Using a semistructured approach, each interview lasted about 1 hour. Coding was performed by the researcher, with both unstructured and structured readings of the interview manuscripts. A modified validity strategy was used, employing another researcher who confirmed coding accuracy.

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Each of the 63 employee engagement questions were found to correlate significantly with one's willingness to speak up at the P < .01 level. The Spearman's correlation tests identified 42 of the questions on the survey as being moderately related and 21 questions as having strong relationships with speaking up. Results showed that the major factors influencing nurse willingness to speak up were perceptions regarding leadership, process improvement, quality, safety, and culture. Physician-staff relationships were found to have the lowest correlation with willingness to speak up.



Three main factors—quality/process improvement, safety, and physician-staff relationships—were chosen from the quantitative phase as being important to investigate further via qualitative methods. Both quality/process improvement and safety were selected to explore with interview questions because they emerged as being strongly related to willingness to speak up. The last interview question was aimed at understanding more about the influence of physician-staff relationships on speaking up, which had an unexpectedly low Spearman's correlation.

After coding the interviews, six major themes emerged; one of which, professional integrity, was identified as having seven subthemes. The six themes were:

  1. Charge nurse and teaching: The charge nurse who's assigned responsibility on a unit for a specific shift can collaborate with and teach other nurses to speak up.
  2. Nonpunitive: Speaking up is influenced by whether the nurse perceives that there won't be punishment or retaliation afterward.
  3. Novice/young: Younger age and less experience may decrease a nurse's willingness to speak up.
  4. Positive recognition: Recognition after speaking up can encourage nurses in their future decisions to do so.
  5. Relationships: Physician-staff relationships may impact a nurse's comfort in speaking up.
  6. Professional integrity: Displaying characteristics and behaving in a manner that encourages staff to speak up, professional integrity includes seven subthemes, each of which can influence a nurse's decision to speak up.
  • 1) Common goal: The idea that a nurse's and hospital leadership's goals are the same.
  • 2) Process: Hospital processes and policies can impact a nurse's willingness to speak up.
  • 3) Professionalism: Nurses need to feel that the response of the individual to whom they spoke was appropriate and respectful.
  • 4) Accountability: Whether rules and values are upheld in an equitable manner by leadership can affect speaking up.
  • 5) Value employee's voice: Nurses need to feel that their input and concerns are valued.
  • 6) Action: The perception that actions or improvements will be undertaken after a nurse speaks up is important.
  • 7) Safety in anonymity/confidentiality: A nurse needs to know that, if desired, confidentiality won't be broken.

Aside from the six themes that emerged during coding, analysis also showed evidence that past experiences may impact which theme an individual nurse feels is most important when deciding to speak up. For example, one interviewee addressed the importance of confidentiality more often than the other interviewees. This theme may have been the most frequently cited because of a past experience in which the interviewee believed that confidentiality wasn't maintained.

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Nurse leaders can support speaking up by ensuring that they're implementing certain practices related to the themes identified in this study. For instance, the theme of professionalism emerged, which shows that nurses are more likely to speak up to leaders who behave professionally and respectfully. Leaders must also ensure that they're holding staff and physicians accountable to the established rules of the unit and organization.

Nurses need to feel as though leaders are listening to them and that their input is valued. It's crucial that leaders act on information shared and communicate back to the nurse after following up on the concern. Nurses need to know that if they speak up, the leader won't break confidentiality. Additionally, nurses reported that when they felt the leader's goals aligned with their own, such as with quality care, they were more apt to speak up.

Finally, leaders must also be aware that solely practicing in ways to address these themes, while necessary, is inadequate. Leaders must understand that qualitative data showed the frequency with which interviewees discussed themes varied greatly and past experiences influenced their future decisions and willingness to speak up. Therefore, leaders must know that speaking up isn't only complicated by multiple influencing themes impacting a nurse's decision, but it's also individualized in that nurses may consider specific themes more important than others. For example, assurances of confidentiality may be more important to some nurses than others when choosing to speak up or stay silent.

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It's necessary to point out three key limitations to this study. First, the study was implemented using a single research site; for the qualitative phase, a small purposive sampling of nurses was used. Both of these elements impact generalizability. Second, the survey used for quantitative analysis as a whole was designed to measure employee engagement, not speaking up. Lastly, the employee engagement survey data set didn't consist solely of nurses.

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Using our voices

Speaking up has earned national attention recently and the healthcare industry needs to similarly focus on the importance of encouraging staff to verbalize concerns. Speaking up is recognized as a method to positively impact patient safety, but it's also known to be a complex phenomenon where an individual considers multiple factors when choosing whether to voice concerns. This study found that nurse leaders are integral to helping nurses feel supported in speaking up. It's critical that leaders recognize their role in facilitating nurses' willingness to speak up because the practice has the potential to prevent medical errors and improve patient safety. Ultimately, changes still need to occur so that the practice of speaking up in nursing can become the norm.

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