You are here

  • Home
  • Archive
  • Volume 28, Issue 1
  • Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses’ willingness to speak up

Article Text

Article menu

Download PDFPDF

Original research
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}eshpm.eur.nl

Abstract

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

https://doi.org/10.1136/bmjqs-2017-007163

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    Speaking up is important for patient safety. Healthcare professionals who question clinical practices that may compromise patient safety and who raise ‘concerns […] upon recognising or becoming aware of the risky or deficient actions of others within healthcare teams’ can prevent the occurrence of adverse events, improve team performance and facilitate a learning environment.1–3 Despite these potential benefits, prior research showed that healthcare professionals often hesitate to speak up and choose to remain silent.4–6

    A key factor influencing whether employees dare to speak up is the behaviour of their direct supervisor.7 8 Supervisors may, for example, stimulate their staff to voice concerns by actively inviting and appreciating staff input, coaching workers, showing authentic leadership and building trustful relationships with their subordinates.3 9–12 So far, only a few studies empirically tested the relationship between leader behaviour and employee voice.9 10 13 Consequently, ‘a clear picture of exactly what it is that leaders do or do not that shapes employees’ perceptions’ about whether speaking up is safe and worthwhile is still lacking.8 The concepts of control-based and commitment-based safety management may help to shed light on this.

    Control-based and commitment-based safety management reflect different aspects of how direct supervisors manage patient safety.14 15 In a control-based safety management approach, managers stress the importance of following safety rules, monitor compliance and provide employees with feedback. In a commitment-based safety management approach, managers clearly prioritise patient safety by exhibiting role modelling behaviour; they show determination to ensure safe care delivery, encourage employees to participate in safety improvement initiatives and create awareness on safety issues.16 Both management approaches could influence how professionals perceive the risks (psychological safety) and priorities (climate for safety) when it concerns safety behaviour. In the following paragraphs, we will outline the hypothesised relationships between the safety management approaches, team psychological safety, climate for safety and employees’ willingness to speak up (see figure 1; in the text below, the hypotheses are numbered between brackets).

    Figure 1
    Figure 1

    Hypothesised model. Hypothesis 1: (a) Commitment-based safety management is positively and (b) control-based safety management is negatively related to team psychological safety. Hypothesis 2: (a) Commitment-based and (b) control-based safety management are positively related to climate for safety. Hypothesis 3: Team psychological safety is positively related to speaking up. Hypothesis 4: Climate for safety is positively related to speaking up. Hypothesis 5: (a) Team psychological safety and (b) climate for safety mediate the relationship between safety management approaches and speaking up.

    Team psychological safety is defined as ‘a shared belief that the team is safe for interpersonal risk taking’.17 A recent meta-analysis showed that employee perceptions of direct supervisor’s behaviour play a crucial role in fostering (team) psychological safety.18 Various leadership behaviours were found to be relevant, including being accessible to employees, inviting and appreciating staff contributions and ensuring behavioural integrity (ie, practice what you preach).19–21 So, psychological safety seems to be encouraged especially when employees experience supportive leadership, which is in line with a commitment-based safety management approach (H1a).16 22 In contrast, control-based safety management rather entails a risk of creating a climate of mistrust or even a culture of blame (H1b).23 Prior research has shown that employee perceptions of the (team) psychological safety are positively related to open communication, speaking up, individual and team learning as well as organisational performance.22 24 If leaders create a climate in which their staff feels psychologically safe, the benefits of speaking up in terms of preventing patient harm are more likely to outweigh the costs in terms of potentially negative personal consequences in healthcare professionals’ decision whether or not to voice their concerns (H3).8 22 24

    A climate for safety reflects employees’ shared ‘perceptions of the priority of safety at their unit’.25 Leaders are considered to create this climate,26 by showing commitment, aligning their words and deeds, and clearly signalling that delivering safe care is important (H2a).20 27 28 Employees may also get the message that patient safety is highly valued if their manager emphasises safety rules and procedures, and provides them with feedback on safety compliance (H2b).16 29 Prior research has shown that a climate for safety is positively related to employees’ safety motivation as well as patient safety performances (eg, reported treatment errors).20 30 In line with this, employees may experience normative pressures to voice safety concerns and consider it worthwhile to speak up if their direct supervisor demonstrates that patient safety is highly valued (H4).11 12

    Extending the aforementioned lines of reasoning, team psychological safety and climate for safety might have a mediating role in the relationship between the safety management approaches and employees’ speaking up (H5a and H5b).22 24 31 The current study, first, aims to gain insight into the direct relationships between control-based and commitment-based safety management, (team) psychological safety and climate for safety, and between (team) psychological safety, climate for safety and nurses’ willingness to speak up about patient safety concerns in clinical hospital wards. Subsequently, we explore the potential mediating role of nurses’ perceptions of the team psychological safety and climate for safety.

    Methods

    Study design

    We conducted a cross-sectional survey study among nurses and nurse managers working in clinical hospital wards in the Netherlands. Data were collected using two different questionnaires: one for nurses and one for nurse managers (ie, the direct supervisors of these nurses). The nurse managers answered questions on the ‘actual’ safety management approaches they put into practice, whereas nurses rated their perceptions of the safety management approaches implemented by the nurse manager by whom they are supervised. The safety management approaches were rated by both groups of respondents in order to explore a potential divergence between manager and employee ratings of the management approaches,32 33 as well as a potential variation in the strength of the associations between the management approaches and nurses’ safety-related attitudes and behaviour. According to the literature, employee perceptions of a management approach appear to be stronger predictors of employee behavioural reactions than are manager ratings of the management practices used in a department.34 Furthermore, in order to test the associations between the safety management approaches, climate and speaking up (hypotheses 1–5, see figure 1), nurses did also answer questions about the departmental climate for safety, psychological safety and their willingness to speak up about patient safety concerns. During the analysis, we took into account the hierarchical nature of the data, as the nurses are nested within wards that are managed by a nurse manager.

    The Ethics Review Board confirmed that our study was outside the scope of the Netherlands’ Medical Research Involving Human Subjects Act and that the rights and privacy of study participants have been taken into account sufficiently (Administration no. EC-2017.62).

    Sample

    Via hospital associations, all of the 84 Dutch hospitals were invited to participate, resulting in a sample of seven general hospitals, eight top-clinical teaching hospitals and two university medical centres (respectively 15%, 29% and 25% of all hospitals in the Netherlands).35 Between September 2014 and May 2015, all of the nurse managers and nurses working at the 334 clinical wards in these hospitals (ie, medical wards, surgical wards and intensive care units) were invited to complete a questionnaire. All of the nurses hold a staff position; they provided direct patient care and were not directly involved in managerial tasks within their department. Potential participants received a letter or email to inform them of the study purpose and to ask them to participate anonymously; the correspondence included a link to the online questionnaire. Non-responders received reminders after 2 and 4 weeks. No incentives in the form of money or gifts were offered. Passive consent was obtained from all participants as they voluntary agreed to complete the questionnaire and were free to quit at any time during the research.

    Measures

    Nurse managers rated the safety management approach they put into practice. Nurses answered questions on the perceived safety management approach of their direct supervisor (ie, the nurse manager of their ward), the climate for safety, psychological safety and their speaking up intentions. Three nurses as well as three nurse managers were interviewed to check the comprehension of items before we determined the content of the final version of the questionnaire.

    Control-based and commitment-based safety management: Nurses’ perceptions of the safety management approaches used by their direct supervisor were measured using the 33-item ConCom Safety Management Scale.36 An example item is: ‘The actions of my supervisor show that patient safety is a top priority’. All items were answered on a four-point or five-point Likert scale plus the option ‘I don’t know’. The item scores were respectively multiplied by five or four to calculate mean scores on a 20-point scale. Higher scores indicate that nurses perceive more control-based or commitment-based safety management. For both management approaches, aggregation of the data to the ward level was justified (control-based safety management ICC(1)=0.19, ICC(2)=0.71, mean rwg=0.97; commitment-based safety management ICC(1)=0.32, ICC(2)=0.83, mean rwg=0.97).37 Cronbach’s alpha of the aggregated scales was 0.86 for control-based and 0.97 for commitment-based safety management.

    Nurse managers answered the same set of items, although here the items were adapted in order to assess self-rated control-based and commitment-based safety management approaches. To illustrate, in the aforementioned item ‘The actions of my supervisor’ was replaced by ‘I’. In other words, nurse managers responded to the item: ‘I show that patient safety is a top priority’. For supervisors, two items were dropped from the initial commitment-based management scale because of high risks of social desirable answers (namely: ‘My supervisor does not actually prioritise safety issues as highly as he/she says he/she does’ and ‘Regarding safety, my supervisor’s words do not match his/her deeds’). Confirmatory factor analysis provided support for construct validity of the scale measured among nurse managers (χ2=2090.52, df=456, p<0.05; RMSEA=0.04; TLI=0.98; CFI=0.98). Cronbach’s alpha was 0.74 for control-based and 0.80 for commitment-based safety management.

    Team psychological safety was measured using the seven-item scale developed by Edmondson.17 Items were answered on a five-point Likert scale, ranging from completely disagree (1) to complete agree (5) and included ‘If you make a mistake in this team, it is often held against you’. Higher scores indicate that nurses feel safer to take interpersonal risks. We obtained support for aggregating data to the ward level (ICC(1)=0.09, ICC(2)=0.50, mean rwg=0.92).37 Cronbach’s alpha of the aggregated scale was 0.77.

    Climate for safety was measured using one dimension of the organisational climate scale by Patterson and colleagues aligning with the recent interest to focus on facet-specific climates, that is, climates that focus on a specific goal of the organisation.38 Climate for safety was measured with four items from the climate for quality scale adapted from a ‘quality’ to a ‘patient safety’ perspective.39 The scale of Patterson and colleagues best fitted our conceptualisation of a climate for safety because we specifically focused on the perceived importance of patient safety rather than adopting a more hybrid definition incorporating multiple climate dimensions such as common in patient safety literature.25 40 The items were appropriately modified to the ward level: ‘Patient safety is taken very seriously in this department’. All items were answered using a four-point Likert scale ranging from totally not true (1) to totally true (4). Higher scores indicate that nurses consider patient safety to be more valued within their ward. We obtained support for aggregating data to the ward level (ICC(1)=0.12, ICC(2)=0.59, mean rwg=0.90).37 Cronbach’s alpha of the aggregated scale was 0.81.

    Individual speaking up attitudes were assessed using a three-item scale based on the communication openness scale.41 In this study, items were specifically targeted at the individual level: ‘I speak up if I see something that may negatively affect patient care’, ‘I feel free to question the decisions or actions of those with more authority’ and ‘I am afraid to ask questions when something does not seem right’. All items were answered using a five-point Likert scale ranging from never (1) to always (5). Higher scores indicate that nurses are more willing to speak up. Speaking up was found to be an individual level construct (ICC(1)=0.04, ICC(2)=0.29, mean rwg=0.90).37 Cronbach’s alpha of this scale was 0.77.

    Mean scores were calculated for all of the subscales included in the analysis. To calculate the mean, all of the item scores were added up and then divided by the total number of items in the specific subscale.42

    Analysis

    A total of 302 nurse managers (response rate 42%) and 2627 nurses (response rate 22%) completed the survey. We were unable to conduct a non-response analysis because we did not have insight into the relevant characteristics of all of the nurses invited to complete a questionnaire. Yet in terms of age and gender, the characteristics of nurses in our sample resemble the characteristics of the nursing workforce in Dutch hospitals in general.43 Respondents were included in the analysis if they answered a maximum of 20% of the control-based and commitment-based safety management items with the option ‘I don’t know’ and gave valid scores for all items of the team psychological safety, climate for safety and speaking up scales. A ward is in turn included in the analysis if one nurse manager and at least five nurses working under direct supervision of this nurse manager met the inclusion criteria, well exceeding the minimum number of respondents per group as recommended by Gerhart et al and used in previous studies.20 44 More details about the sample selection are available in online supplementary appendix A.

    Supplementary file 1

    First, descriptive statistics and correlations were calculated at ward level for all of the subscales. In order to compare managers’ ratings and nurses’ perceptions of control-based and commitment-based safety management, we conducted paired-samples t-tests (two-tailed). A manager’s self-rated safety management approach was compared with the (aggregated) perceptions of the nurses working under direct supervision of this particular manager. Furthermore, correlation coefficients were used to gain insight into the strength of the relationships between the manager-rated and nurse-rated management approaches, climate and nurses’ speaking up intentions. Subsequently, we used the data collected from nurses to test the associations between the perceived safety management approaches, climate for safety, psychological safety and nurses’ willingness to speak up (hypotheses 1–5). Hierarchical regression analyses were carried out to assess the relationships between nurse-perceived safety management and team psychological safety as well as climate for safety. In the analysis, we adjusted for differences between types of wards or hospitals as well as group size, both of which might influence nurses’ willingness to speak up.8 Therefore, we included the following control variables: type of department (intensive care unit (ICU), medical, surgical or mixed ward), type of hospital (general hospital or top-clinical teaching hospital/university medical centre) and the number of respondents per ward. The hierarchical regression analyses were conducted at the ward level of analysis. To examine the association between climate for safety or team psychological safety and nurses’ speaking up attitudes, multilevel regression analyses were conducted to take into account the hierarchical nature of our data.45 After all, data on climate for safety and team psychological safety were aggregated to the ward level, whereas nurses’ willingness to speak up was found to be an individual-level construct. In these multilevel analyses, we adjusted for individual characteristics associated with variation in speaking-up8—namely gender, tenure within the department (in years) and type of contract (open-ended, fixed-term)—as well as type of ward, type of hospital and number of respondents per department.

    To assess mediation effects, we used the procedure recommended by MacKinnon et al.46 According to these guidelines, a mediation effect exists when the independent variable (ie, nurse-rated control-based or commitment-based safety management) has a significant effect on the mediating variable (ie, team psychological safety, climate for safety) and the mediating variable has, in turn, a significant effect on the dependent variable (ie, speaking up attitudes). Finally, we performed two-tailed Sobel tests and the Monte Carlo method using bootstrapping to assess the significance of a mediation effect.47 48 All analyses were conducted using SPSS V.23.0. Results are considered statistically significant if p value <0.05.

    Results

    A total of 93 clinical wards with 93 nurse managers and 980 nurses were included in this study (table 1). The clinical wards consisted of 50 medical, 23 surgical, 9 mixed medical/surgical wards and 11 ICUs. Per ward, one nurse manager and an average of 11 nurses (range 5–40) completed the questionnaire.

    View this table:
    Table 1

    Sample characteristics of nurses and nurse managers

    Table 2 presents means, SD and correlations at ward level between the included variables. Small (but positive) correlations are found between manager-rated and nurse-rated control-based and commitment-based safety management, respectively r=0.30 (p<0.01) and r=0.18. Paired-samples t-tests reveal statistically significant differences in control-based safety management scores between nurse managers (M=15.73, SD=1.46) and the nurses working under these nurse managers (M=14.77, SD=0.94), t(92)=6.28, p<0.001. For commitment-based management, significant differences between nurse managers (M=16.68, SD=1.28) and nurses (M=15.31, SD=1.57) are found as well, t(92)=7.19, p<0.001. Furthermore, only small correlations were found between manager-rated control-based and commitment-based safety management and nurses’ attitudes and speaking up intentions (r ranges from −0.01 to 0.14). Nurses’ perceptions of the management approaches were more strongly related to climate for safety, team psychological safety and nurses’ speaking up attitudes (r ranges from 0.17 to 0.72). Therefore, nurse ratings of the safety management approaches will be used to test our hypotheses.

    View this table:
    Table 2

    Means, SD and correlations at ward level (n=93)

    Hierarchical regression analyses show that none of the control variables has a significant impact on team psychological safety neither on climate for safety (table 3). A significantly positive association is found between nurse-rated commitment-based safety management and team psychological safety (β=0.36; p<0.01). The safety management approaches explain an additional 24% of the variance of team psychological safety compared with a model that only includes the control variables. These results provide support for hypothesis 1a whereas hypothesis 1b is rejected (β=0.18; n.s.). Furthermore, a significantly positive association is found between nurse-perceived control-based safety management and climate for safety (β=0.74; p<0.001). Here, a model in which both management approaches are included explains an additional 56% of the variance of climate for safety compared with a model in which we only include the control variables. These results provide support for hypothesis 2b whereas hypothesis 2a is rejected (β=0.05; n.s.).

    View this table:
    Table 3

    Hierarchical regression analysis of nurse-rated safety management approaches on climate for safety and team psychological safety (n=93)

    Table 4 presents the multilevel analyses of the relationships between team psychological safety, climate for safety and nurses’ speaking up attitudes. Model 1 shows that the control variable tenure within the department has a significant effect on nurses’ willingness to speak up (B=0.01; t=2.11; p<0.05). In model 2, both management approaches were added to the analysis, followed by team psychological safety and climate for safety in model 3. Nurses’ perceptions of neither control-based (B=0.02; n.s.) nor commitment-based safety management (B=0.02; n.s.) were found to be significant predictors of nurses’ willingness to speak up; nor was climate for safety (B=0.15; n.s.). Only team psychological safety was significantly and positively related to nurses’ speaking up intentions (B=0.24; t=2.04; p<0.05). As a result, hypothesis 3 is supported, whereas hypothesis 4 is rejected.

    View this table:
    Table 4

    Multilevel analyses of climate for safety and team psychological safety on nurses’ speaking up attitudes

    Mediation of climate for safety is precluded since no significant relationship was found between climate for safety and speaking up. Team psychological safety did, however, meet the criteria for mediation.46 Results of a two-tailed Sobel test show that team psychological safety marginally significantly mediates the relationship between nurse-rated commitment-based safety management and nurses’ willingness to speak up (t=1.67; p<0.1). Additional bootstrap results (2000 samples) provide further support for mediation because zero is not included in the 95% CI (bootstrap 95% CI: lower level 0.0003, upper level 0.0295). As a result, hypothesis 5a is supported, whereas hypothesis 5b is rejected.

    Discussion

    This study aimed to explore the relationships between control-based and commitment-based safety management, climate for safety, team psychological safety and speaking up of nurses working in clinical hospital wards. In line with prior evidence, results reveal a divergence between nurses’ and managers’ perceptions of the safety management approaches that managers put into practice: nurse managers say they do more on safety management than what is actually perceived by nurses.32 33 An explanation for this discrepancy could be that nurses’ perceptions of the management approaches are influenced by variation in the actual management practices and also by the quality of communication of their direct supervisor, their attributions of the motives underlying management practices and individual characteristics.32 34 49 In other words, nurses are possibly not always aware of everything their manager does with regard to patient safety management. If nurses perceive that their nurse manager stresses the importance of safety rules, monitors compliance and provides them with feedback (ie, control-based safety management), they consider patient safety to be highly valued (climate for safety). Nurses who perceive that their direct supervisor shows commitment and role modelling behaviour, creates awareness and encourages them to participate (ie, commitment-based safety management) perceive the environment to be psychologically safe for taking interpersonal risks. Team psychological safety is found to be positively related to nurses’ willingness to speak up. In other words, when nurses feel safer to take interpersonal risks, they will more frequently raise concerns about patient safety issues. Furthermore, the relationship between nurse-perceived commitment-based safety management and speaking up attitudes is found to be fully mediated by team psychological safety.46

    In contrast with prior research, no statistically significant association was found between nurses’ perceptions of commitment-based safety management and climate for safety.20 28 Post hoc analysis showed that in the absence of control-based management, perceived commitment-based safety management does positively relate to climate for safety, but this effect is cancelled out if both management approaches are included in the analysis simultaneously. Thus, our results suggest that nurses in clinical wards receive stronger signals that patient safety is prioritised if their managers emphasise safety rules and foster compliance rather than when they create safety awareness, show commitment and encourage participation. Notably, the levels of climate for safety were lower in medical wards and surgical wards compared with ICUs. Prior research already demonstrated differences in safety climate between clinical wards, and future research is needed to further explore variation in the priority of patient safety between different types of wards.50 51 Furthermore, against our expectations, nurse-rated control-based management is not negatively related to team psychological safety; in fact, a (non-significant) positive association is found. In the absence of commitment-based management, nurses’ perceptions of control-based safety management do significantly and positively relate to climate for safety, but again this effect is cancelled out if both management approaches are included in the analysis. It seems that, in contrast to the negative connotation that control-based management carries in the literature, nurses do not experience managerial control as a sign of mistrust but rather as a signal that patient safety is highly valued.14 15 This might explain why higher levels of perceived control do not damage a trustworthy environment and do not damage the relationships between employees and their supervisors, which are considered important preconditions for team psychological safety.24 Thus, both control-based and commitment-based management seem to be relevant for managing patient safety: the former to highlight the priority of delivering safe patient care and the latter to create a climate in which nurses feel psychologically safe to take interpersonal risks.

    Our findings confirm prior evidence that psychological safety is positively related to nurses’ willingness to speak up and that it mediates the relationship between perceived leader behaviour and employee voice.22 24 As established before, team psychological safety mitigates the fear that speaking up will lead to negative repercussions and, consequently, seems to provide a baseline condition for employees to raise concerns.52 Just like Martinez and colleagues, we did however not find a significant relationship between climate for safety and nurses’ speaking up attitudes.53 Possibly, nurses’ willingness to speak up is mainly driven by the confidence that raising patient safety concerns will not have negative personal consequences (ie, the team psychological safety), whereas a climate for safety may be more important for other types of voice behaviour, such as coming up with new ideas or suggestions. If nurses experience that patient safety is prioritised, they will perhaps consider it more worthwhile and effective to voice suggestions for patient safety improvement because they expect their input to be taken seriously. Prior research showed that unique patterns of relationships exist between antecedents (eg, personality traits) and voice behaviour for different types of voice.52 54 Future research is needed to explore whether this is also the case for the relationship between climate for safety and individual’s speaking up attitudes.

    Even though our findings strengthen the idea that perceived leader behaviour is a key determinant of employee voice, a substantial part of the variance in speaking up still remains unexplained.7 Our results suggest that the choice to speak up or remain silent about safety concerns typically is an individual consideration, depending on whether the individual nurse feels safe to speak up or not. Prior research showed that whether somebody dares to speak up is influenced by perceived leader behaviours and also by one’s personality, sense of commitment, communication skills, taken-for-granted beliefs and prior experiences with speaking up. Furthermore, situational factors such as team relationships, the type of message to convey (eg, traditional vs professionalism-related safety threats), the potential patient harm and perceived effectiveness of speaking up as well as perceptions of organisational support may also guide employee voice behaviour.2 3 6 11 55–57 Moreover, Kakkar and colleagues showed that individual traits may interact with situational features to influence employee voice.58 Therefore, it may be interesting to combine future research on the influence of leader behaviour with individual-level characteristics such as individuals’ personality, prior experiences with speaking up and professional commitment.2 8

    The present study has some limitations. First, the cross-sectional design does not support causal relations. Although theoretical insights provide support that leader behaviours influence employee attitudes, which do in turn affect employees’ willingness to show certain behaviour, additional research using longitudinal data is needed to rule out reverse causality.59 Nurses’ attitudes and behaviour could, potentially, also influence the management practices adopted by nurse managers. Second, our analyses are partly based on same source data, entailing a risk of common method bias.60 Although we collected multisource data, single source data were used to test our hypotheses. In line with prior evidence, employees’ perceptions of the safety management approaches appear to be more strongly related to employee attitudes and behavioural reactions than manager ratings of the ‘actual’ management approaches that are put into practice.33 34 Furthermore, nurses’ experiences of team psychological safety, climate for safety and their intentions towards speaking up can only be mapped by nurses themselves. Third, despite our large sample, the response rate was relatively low, raising questions about representativeness. The characteristics of nurses in our sample do, however, resemble the characteristics of the nursing workforce in Dutch hospitals in general.43 Fourth, climate for safety was measured using an adapted subscale of the organisational climate scale instead of a previously validated safety climate questionnaire. The scale of Patterson and colleagues did better fit our facet-specific conceptualisation of a climate for safety than do commonly used safety climate scales, which adopt a more hybrid definition incorporating multiple climate dimensions.39 40 Fifth, the speaking up scale used in this study focused on individual speaking up attitudes rather than actual voice behaviours. Our study does not give insight whether nurses’ willingness to speak up does actually result in the expression of patient safety concerns. Future research is needed to explore the relationship between perceived control-based and commitment-based safety management, climate for safety, team psychological safety and nurses’ speaking up behaviour. Finally, in this study, we exclusively focused on nurse managers and nurses in clinical hospital wards. Future research is needed to test whether our findings hold in other settings and for other occupational groups.

    In conclusion, this study provides some first evidence 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 individual’s speaking up attitudes, a commitment-based safety management approach seems to be most valuable.

    References

    1. 1.↵
      2. Kolbe M ,
      3. Burtscher MJ ,
      4. Wacker J , et al
      . Speaking up is related to better team performance in simulated anesthesia inductions: an observational study. Anesth Analg 2012;115:1099–108.doi:10.1213/ANE.0b013e318269cd32
      OpenUrlCrossRefPubMedWeb of Science
    2. 2.↵
      2. Okuyama A ,
      3. Wagner C ,
      4. Bijnen B
      . Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res 2014;14:61.doi:10.1186/1472-6963-14-61
      OpenUrlCrossRefPubMed
    3. 3.↵
      2. Morrison EW
      . Employee voice and silence. Annual Review of Organizational Psychology and Organizational Behavior 2014;1:173–97.doi:10.1146/annurev-orgpsych-031413-091328
      OpenUrlCrossRefWeb of Science
    4. 4.↵
      2. Schwappach DL ,
      3. Gehring K
      . Frequency of and predictors for withholding patient safety concerns among oncology staff: a survey study. Eur J Cancer Care 2015;24:395–403.doi:10.1111/ecc.12255
      OpenUrl
    5. 5.↵
      2. Maxfield D ,
      3. Grenny J ,
      4. McMillan R , et al
      . Silence kills: the seven crucial conversations for healthcare. Vital Smarts 2005.
    6. 6.↵
      2. Martinez W ,
      3. Lehmann LS ,
      4. Thomas EJ , et al
      . Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. BMJ Qual Saf 2017;26:869–80.doi:10.1136/bmjqs-2016-006284
      OpenUrlAbstract/FREE Full Text
    7. 7.↵
      2. Ashford SJ ,
      3. Sutcliffe KM ,
      4. Christianson MK
      . Speaking up and speaking out: the leadership dynamics of voice in organizations. In: Greenberg J , Edwards MS , eds. Voice and silence in organizations. Bingley: Emerald, 2009:175–202.
    8. 8.↵
      2. Morrison EW
      . Employee voice behavior: integration and directions for future research. Acad Manag Ann 2011;5:373–412.doi:10.5465/19416520.2011.574506
      OpenUrl
    9. 9.↵
      2. Edmondson AC
      . Speaking up in the operating room: how team leaders promote learning in interdisciplinary action teams. Journal of Management Studies 2003;40:1419–52.doi:10.1111/1467-6486.00386
      OpenUrl
    10. 10.↵
      2. Wong CA ,
      3. Spence Laschinger HK ,
      4. Cummings GG
      . Authentic leadership and nurses' voice behaviour and perceptions of care quality. J Nurs Manag 2010;18:889–900.doi:10.1111/j.1365-2834.2010.01113.x
      OpenUrlCrossRefPubMed
    11. 11.↵
      2. Morrow KJ ,
      3. Gustavson AM ,
      4. Jones J
      . Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies. Int J Nurs Stud 2016;64:42–51.doi:10.1016/j.ijnurstu.2016.09.014
      OpenUrlCrossRefPubMed
    12. 12.↵
      2. Robbins J ,
      3. McAlearney AS
      . Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes. Am J Infect Control 2016;44:1224–30.doi:10.1016/j.ajic.2016.03.007
      OpenUrl
    13. 13.↵
      2. Detert JR ,
      3. Burris ER
      . Leadership behavior and employee voice: is the door really open? Acad Manage J 2007;50:869–84.doi:10.5465/amj.2007.26279183
      OpenUrlAbstract/FREE Full Text
    14. 14.↵
      2. Walton RE
      . From control to commitment in the workplace. Harv Bus Rev 1985;63:76–84.
      OpenUrlWeb of Science
    15. 15.↵
      2. Khatri N ,
      3. Baveja A ,
      4. Boren SA , et al
      . Medical errors and quality of care: from control to commitment. Calif Manage Rev 2006;48:115–41.doi:10.2307/41166353
      OpenUrlFREE Full Text
    16. 16.↵
      2. Alingh CW ,
      3. van Wijngaarden JDH ,
      4. Paauwe J , et al
      . Commitment or control: patient safety management in Dutch hospitals. In: Valle-Cabrera R , López-Cabrales A , eds. New clues for analysing the HRM black box. Newcastle upon Tyne: Cambridge Scholars, 2015.
    17. 17.↵
      2. Edmondson A
      . Psychological safety and learning behavior in work teams. Adm Sci Q 1999;44:350–83.doi:10.2307/2666999
      OpenUrlCrossRefWeb of Science
    18. 18.↵
      2. Frazier ML ,
      3. Fainshmidt S ,
      4. Klinger RL , et al
      . Psychological safety: a meta-analytic review and extension. Pers Psychol 2017;70:113–65.doi:10.1111/peps.12183
      OpenUrl
    19. 19.↵
      2. Hirak R ,
      3. Peng AC ,
      4. Carmeli A , et al
      . Linking leader inclusiveness to work unit performance: the importance of psychological safety and learning from failures. Leadersh Q 2012;23:107–17.doi:10.1016/j.leaqua.2011.11.009
      OpenUrl
    20. 20.↵
      2. Leroy H ,
      3. Dierynck B ,
      4. Anseel F , et al
      . Behavioral integrity for safety, priority of safety, psychological safety, and patient safety: a team-level study. J Appl Psychol 2012;97:1273–81.doi:10.1037/a0030076
      OpenUrlCrossRefPubMed
    21. 21.↵
      2. Nembhard IM ,
      3. Edmondson AC
      . Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav 2006;27:941–66.doi:10.1002/job.413
      OpenUrlCrossRefWeb of Science
    22. 22.↵
      2. Newman A ,
      3. Donohue R ,
      4. Eva N
      . Psychological safety: a systematic review of the literature. Human Resource Management Review 2017;27:521–35.doi:10.1016/j.hrmr.2017.01.001
      OpenUrl
    23. 23.↵
      2. Khatri N ,
      3. Halbesleben JR ,
      4. Petroski GF , et al
      . Relationship between management philosophy and clinical outcomes. Health Care Manage Rev 2007;32:128–39.doi:10.1097/01.HMR.0000267789.17309.18
      OpenUrlPubMed
    24. 24.↵
      2. Edmondson AC ,
      3. Lei Z
      . Psychological safety: the history, renaissance, and future of an interpersonal construct. Annual Review of Organizational Psychology and Organizational Behavior 2014;1:23–43.doi:10.1146/annurev-orgpsych-031413-091305
      OpenUrlCrossRef
    25. 25.↵
      2. Zohar D ,
      3. Livne Y ,
      4. Tenne-Gazit O , et al
      . Healthcare climate: a framework for measuring and improving patient safety. Crit Care Med 2007;35:1312–7.doi:10.1097/01.CCM.0000262404.10203.C9
      OpenUrlCrossRefPubMedWeb of Science
    26. 26.↵
      2. Zohar D
      . Thirty years of safety climate research: reflections and future directions. Accid Anal Prev 2010;42:1517–22.doi:10.1016/j.aap.2009.12.019
      OpenUrlCrossRefPubMedWeb of Science
    27. 27.↵
      2. Barling J ,
      3. Hutchinson I
      . Commitment vs. control-based safety practices, safety reputation, and perceived safety climate. Canadian Journal of Administrative Sciences / Revue Canadienne des Sciences de l’Administration 2000;17:76–84.doi:10.1111/j.1936-4490.2000.tb00208.x
      OpenUrl
    28. 28.↵
      2. McFadden KL ,
      3. Stock GN ,
      4. Gowen CR
      . Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. Health Care Manage Rev 2015;40:24–34.doi:10.1097/HMR.0000000000000006
      OpenUrlCrossRefPubMed
    29. 29.↵
      2. Clarke S
      . An integrative model of safety climate: linking psychological climate and work attitudes to individual safety outcomes using meta-analysis. J Occup Organ Psychol 2010;83:553–78.doi:10.1348/096317909X452122
      OpenUrlCrossRefWeb of Science
    30. 30.↵
      2. Neal A ,
      3. Griffin MA
      . A study of the lagged relationships among safety climate, safety motivation, safety behavior, and accidents at the individual and group levels. J Appl Psychol 2006;91:946–53.doi:10.1037/0021-9010.91.4.946
      OpenUrlCrossRefPubMedWeb of Science
    31. 31.↵
      2. Cafferkey K ,
      3. Dundon T
      . Explaining the black box: HPWS and organisational climate. Personnel Review 2015;44:666–88.doi:10.1108/PR-12-2012-0209
      OpenUrl
    32. 32.↵
      2. Den Hartog DN ,
      3. Boon C ,
      4. Verburg RM , et al
      . HRM, communication, satisfaction, and perceived performance: a cross-level test. J Manage 2013;39:1637–65.doi:10.1177/0149206312440118
      OpenUrl
    33. 33.↵
      2. Liao H ,
      3. Toya K ,
      4. Lepak DP , et al
      . Do they see eye to eye? Management and employee perspectives of high-performance work systems and influence processes on service quality. J Appl Psychol 2009;94:371–91.doi:10.1037/a0013504
      OpenUrlCrossRefPubMed
    34. 34.↵
      2. Nishii LH ,
      3. Wright PM
      . Variability within organizations: implications for strategic human resource management, 2007. CAHRS Working Paper #07-02.
    35. 35.↵
      Dutch Hospitals Association. Innovating health care: general hospitals branch report 2014, 2015.
    36. 36.↵
      2. Alingh CW ,
      3. Strating MMH ,
      4. van Wijngaarden JDH , et al
      .The ConCom Safety Management Scale: developing and testing a measurement instrument for control-based and commitment-based safety management approaches in hospitals. BMJ Qual Saf 2018;27:807–17.doi:10.1136/bmjqs-2017-007162
      OpenUrlAbstract/FREE Full Text
    37. 37.↵
      2. Klein KJ ,
      3. Kozlowski SWJ
      . From micro to meso: critical steps in conceptualizing and conducting multilevel research. Organ Res Methods 2000;3:211–36.doi:10.1177/109442810033001
      OpenUrlCrossRef
    38. 38.↵
      2. Kuenzi M ,
      3. Schminke M
      . Assembling fragments into a lens: a review, critique, and proposed research agenda for the organizational work climate literature. J Manage 2009;35:634–717.doi:10.1177/0149206308330559
      OpenUrl
    39. 39.↵
      2. Patterson MG ,
      3. West MA ,
      4. Shackleton VJ , et al
      . Validating the organizational climate measure: links to managerial practices, productivity and innovation. J Organ Behav 2005;26:379–408.doi:10.1002/job.312
      OpenUrlCrossRef
    40. 40.↵
      2. Halligan M ,
      3. Zecevic A
      . Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Qual Saf 2011;20:338–43.doi:10.1136/bmjqs.2010.040964
      OpenUrlAbstract/FREE Full Text
    41. 41.↵
      2. Smits M ,
      3. Christiaans-Dingelhoff I ,
      4. Wagner C , et al
      . The psychometric properties of the ’Hospital Survey on Patient Safety Culture' in Dutch hospitals. BMC Health Serv Res 2008;8:230.doi:10.1186/1472-6963-8-230
      OpenUrlCrossRefPubMed
    42. 42.↵
      2. Field A
      . Discovering statistics using IBM SPSS statistics. London: SAGE Publications, 2013.
    43. 43.↵
    44. 44.↵
      2. Gerhart B ,
      3. Wright PM ,
      4. Mahan GC , et al
      . Measurement error in research on human resources and firm performance: how much error is there and how does it influence effect size estimates? Pers Psychol 2000;53:803–34.doi:10.1111/j.1744-6570.2000.tb02418.x
      OpenUrl
    45. 45.↵
      2. Snijders TAB ,
      3. Bosker RJ
      . Multilevel analysis: an introduction to basic and advanced multilevel modeling. London: Sage Publications, 1999.
    46. 46.↵
      2. MacKinnon DP ,
      3. Fairchild AJ ,
      4. Fritz MS
      . Mediation analysis. Annu Rev Psychol 2007;58:593–614.doi:10.1146/annurev.psych.58.110405.085542
      OpenUrlCrossRefPubMedWeb of Science
    47. 47.↵
      2. Sobel ME
      . Asymptotic intervals for indirect effects in structural equations models. Leinhart S , ed. Sociological methodology. San Francisco: Jossey-Bass, 1982;13:290–312.doi:10.2307/270723
      OpenUrlCrossRef
    48. 48.↵
      2. Mackinnon DP ,
      3. Lockwood CM ,
      4. Williams J
      . Confidence limits for the indirect effect: distribution of the product and resampling methods. Multivariate Behav Res 2004;39:99–128.doi:10.1207/s15327906mbr3901_4
      OpenUrlCrossRefPubMedWeb of Science
    49. 49.↵
      2. Nishii LH ,
      3. Lepak DP ,
      4. Schneider B
      . Employee attributions of the “why” of HR practices: their effects on employee attitudes and behaviors, and customer satisfaction. Pers Psychol 2008;61:503–45.doi:10.1111/j.1744-6570.2008.00121.x
      OpenUrl
    50. 50.↵
      2. Campbell EG ,
      3. Singer S ,
      4. Kitch BT , et al
      . Patient safety climate in hospitals: act locally on variation across units. Jt Comm J Qual Patient Saf 2010;36:319–26.doi:10.1016/S1553-7250(10)36048-X
      OpenUrlPubMed
    51. 51.↵
      2. Singer SJ ,
      3. Gaba DM ,
      4. Falwell A , et al
      . Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care 2009;47:23–31.doi:10.1097/MLR.0b013e31817e189d
      OpenUrlCrossRefPubMedWeb of Science
    52. 52.↵
      2. Liang J ,
      3. Farh CIC ,
      4. Farh J-L
      . Psychological antecedents of promotive and prohibitive voice: a two-wave examination. Acad Manage J 2012;55:71–92.doi:10.5465/amj.2010.0176
      OpenUrlAbstract/FREE Full Text
    53. 53.↵
      2. Martinez W ,
      3. Etchegaray JM ,
      4. Thomas EJ , et al
      . ’Speaking up' about patient safety concerns and unprofessional behaviour among residents: validation of two scales. BMJ Qual Saf 2015;24:671–80.doi:10.1136/bmjqs-2015-004253
      OpenUrlAbstract/FREE Full Text
    54. 54.↵
      2. Maynes TD ,
      3. Podsakoff PM
      . Speaking more broadly: an examination of the nature, antecedents, and consequences of an expanded set of employee voice behaviors. J Appl Psychol 2014;99:87–112.doi:10.1037/a0034284
      OpenUrlCrossRefPubMed
    55. 55.↵
      2. Nembhard IM ,
      3. Labao I ,
      4. Savage S
      . Breaking the silence: determinants of voice for quality improvement in hospitals. Health Care Manage Rev 2015;40:225–36.doi:10.1097/HMR.0000000000000028
      OpenUrl
    56. 56.↵
      2. Schwappach DL ,
      3. Gehring K
      . Trade-offs between voice and silence: a qualitative exploration of oncology staff’s decisions to speak up about safety concerns. BMC Health Serv Res 2014;14:303.doi:10.1186/1472-6963-14-303
      OpenUrl
    57. 57.↵
      2. Detert JR ,
      3. Edmondson AC
      . Implicit voice theories: taken-for-granted rules of self-censorship at work. Acad Manage J 2011;54:461–88.doi:10.5465/amj.2011.61967925
      OpenUrlAbstract/FREE Full Text
    58. 58.↵
      2. Kakkar H ,
      3. Tangirala S ,
      4. Srivastava NK , et al
      . The dispositional antecedents of promotive and prohibitive voice. J Appl Psychol 2016;101:1342–51.doi:10.1037/apl0000130
      OpenUrl
    59. 59.↵
      2. Boxall P ,
      3. Purcell J
      . Strategy and human resource management. Hampshire: Palgrave Macmillan, 2011.
    60. 60.↵
      2. Podsakoff PM ,
      3. MacKenzie SB ,
      4. Lee JY , et al
      . Common method biases in behavioral research: a critical review of the literature and recommended remedies. J Appl Psychol 2003;88:879–903.doi:10.1037/0021-9010.88.5.879
      OpenUrlCrossRefPubMedWeb of Science

    Footnotes

    • 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.