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Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses’ willingness to speak up
  1. Carien W Alingh1,2,
  2. Jeroen D H van Wijngaarden1,
  3. Karina van de Voorde2,
  4. Jaap Paauwe1,2,
  5. Robbert Huijsman1
  1. 1 Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
  2. 2 Department of Human Resource Studies, Tilburg University, Tilburg, The Netherlands
  1. Correspondence to Carien W Alingh, Erasmus School of Health Policy & Management , Erasmus University Rotterdam, Rotterdam, 3000 DR, The Netherlands; alingh{at}


Background Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers’ behaviour and employees’ perceptions about whether speaking up is safe and worthwhile is still lacking.

Aim To explore the relationships between control-based and commitment-based safety management, climate for safety, psychological safety and nurses’ willingness to speak up.

Methods We conducted a cross-sectional survey study, resulting in a sample of 980 nurses and 93 nurse managers working in Dutch clinical hospital wards. To test our hypotheses, hierarchical regression analyses (at ward level) and multilevel regression analyses were conducted.

Results Significantly positive associations were found between nurses’ perceptions of control-based safety management and climate for safety (β=0.74; p<0.001), and between the perceived levels of commitment-based management and team psychological safety (β=0.36; p<0.01). Furthermore, team psychological safety is found to be positively related to nurses’ speaking up attitudes (B=0.24; t=2.04; p<0.05). The relationship between nurse-rated commitment-based safety management and nurses’ willingness to speak up is fully mediated by team psychological safety.

Conclusion Results provide initial support that nurses who perceive higher levels of commitment-based safety management feel safer to take interpersonal risks and are more willing to speak up about patient safety concerns. Furthermore, nurses’ perceptions of control-based safety management are found to be positively related to a climate for safety, although no association was found with speaking up. Both control-based and commitment-based management approaches seem to be relevant for managing patient safety, but when it comes to encouraging speaking up, a commitment-based safety management approach seems to be most valuable.

  • patient safety
  • management
  • nurses

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  • Contributors All authors (CWA, JDHvW, KvdV, JP, RH) designed the study. CWA collected the data and initiated the analysis of the data in close collaboration with KvdV. The methods for analysis and preliminary results were frequently discussed with JDHvW, JP and RH. CWA drafted the first version of the manuscript. JDHvW, KvdV, JP and RH gave input and made suggestions for restructuring or reformulating parts of the manuscript. Based on this input, CWA revised the manuscript in close collaboration with all of the other authors. All authors read and approved the definitive version of the manuscript and agreed to be accountable for all aspects of the study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Ethics Review Board of the School of Social and Behavioral Sciences—Tilburg University.

  • Provenance and peer review Not commissioned; externally peer reviewed.