Research Article| Volume 30, ISSUE 3, P433-439, June 2023

Download started.


Registered nurses’ perceptions and experiences with speaking up for patient safety in hospitals

Published:February 28, 2023DOI:



      Despite evidence showing the importance of open communication in improving patient safety, communication failure remains one of the main causes of patient adverse events.


      This study explored nurses’ perceptions and experiences with speaking up for patient safety in Korean hospitals.


      Fifteen nurses were recruited from four tertiary hospitals in two cities in South Korea to participate in an online semistructured interview. Data were categorised by inductive content analysis techniques.


      Although most nurses perceived that speaking up is important and half of them claimed that they were assertive in general, only one-third reported that they would speak up for patient safety without hesitation in their workplace. Speaking up was challenging for nurses, particularly with senior nurses and physicians, at least partly due to the social characteristics embedded in Korean culture, such as respect for the hierarchy and value of groups’ ideas more than that of individuals. When speaking up, nurses used a variety of strategies such as using polite language with embedded signals of subordination. We found that nurses used not only problem-focused voice, but also suggestion-focused voice. The nurses’ speaking-up behaviours resulted in positive or negative consequences, impacting their future communication behaviours.


      Investing in individual skill building and organisational supports to ensure a safe environment for speaking up is crucial for overcoming the barriers from the longstanding cultural influences in Korean hospitals and for empowering nurses to speak up for patient safety.


      There are gaps between nurses’ perceptions of the importance of speaking up and their ease with speaking up in practice.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Collegian
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bracq M.S.
        • Michinov E.
        • Le Duff M.
        • Arnaldi B.
        • Gouranton V.
        • Jannin P.
        “Doctor, please”: educating nurses to speak up with interactive digital simulation tablets.
        Clinical Simulation in Nursing. 2021; 54: 97-104
        • Chamberlin M.
        • Newton D.W.
        • Lepine J.A.
        A meta‐analysis of voice and its promotive and prohibitive forms: identification of key associations, distinctions, and future research directions.
        Personnel Psychology. 2017; 70: 11-71
        • Clapper T.C.
        TeamSTEPPS® is an effective tool to level the hierarchy in healthcare communication by empowering all stakeholders.
        Journal of Communication in Healthcare. 2018; 11: 241-244
        • Graneheim U.H.
        • Lundman B.
        Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
        Nurse Education Today. 2004; 24: 105-112
        • Hughes H.
        Freedom to speak up–the role of freedom to speak up guardians and the National Guardian’s Office in England.
        Future Healthcare Journal. 2019; 6186
      1. Korean Hospital Nurses Association (2020). Hospital Nurse Staffing Status Survey. Available from 〈〉.

      2. Lee, C.J. (2021). Male Nurses Doubled in 10 Years. Total 17 863: Medical Times. Available from 〈〉.

        • Lee S.E.
        • Choi J.
        • Lee H.
        • Sang S.
        • Lee H.
        • Hong H.C.
        Factors influencing nurses’ willingness to speak up regarding patient safety in East Asia: a systematic review.
        Risk Management and Healthcare Policy. 2021; 14: 1053-1063
        • Lee S.E.
        • Dahinten V.S.
        • Ji H.
        • Kim E.
        • Lee H.
        Motivators and inhibitors of nurses' speaking up behaviours: a descriptive qualitative study.
        Journal of Advanced Nursing. 2022; 78: 3398-3408
        • Martinez W.
        • Lehmann L.S.
        • Thomas E.J.
        • Etchegaray J.M.
        • Shelburne J.T.
        • Hickson G.B.
        • et al.
        Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.
        BMJ Quality & Safety. 2017; 26: 869-880
        • Morrison E.W.
        Employee voice and silence.
        Annual Review of Organizational Psychology and Organizational Behavior. 2014; 1: 173-197
        • Morrow K.J.
        • Gustavson A.M.
        • Jones J.
        Speaking up behaviours (safety voices) of healthcare workers: a metasynthesis of qualitative research studies.
        International Journal of Nursing Studies. 2016; 64: 42-51
        • Ng G.W.Y.
        • Pun J.K.H.
        • So E.H.K.
        • Chiu W.W.H.
        • Leung A.S.H.
        • Stone Y.H.
        • et al.
        Speak-up culture in an intensive care unit in Hong Kong: a cross-sectional survey exploring the communication openness perceptions of Chinese doctors and nurses.
        BMJ Open. 2017; 7e015721
        • Noort M.C.
        • Reader T.W.
        • Gillespie A.
        Speaking up to prevent harm: a systematic review of the safety voice literature.
        Safety Science. 2019; 117: 375-387
        • Okuyama A.
        • Wagner C.
        • Bijnen B.
        Speaking up for patient safety by hospital-based healthcare professionals: a literature review.
        BMC Health Services Research. 2014; 1461
        • Omura M.
        • Stone T.E.
        • Maguire J.
        • Levett-Jones T.
        Exploring Japanese nurses' perceptions of the relevance and use of assertive communication in healthcare: a qualitative study informed by the Theory of Planned Behaviour.
        Nurse Education Today. 2018; 67: 100-107
        • Oner C.
        • Fisher N.
        • Atallah F.
        • Son M.A.
        • Homel P.
        • Mykhalchenko K.
        • et al.
        Simulation-based education to train learners to “speak up” in the clinical environment: results of a randomized trial.
        Simulation in Healthcare. 2018; 13: 404-412
        • Polit D.
        • Beck C.T.
        Nursing research: generating and assessing evidence for nursing practice.
        11th edn. Wolters Kluer, 2021
        • Robb A.
        • White C.
        • Cordar A.
        • Wendling A.
        • Lampotang S.
        • Lok B.
        A comparison of speaking up behavior during conflict with real and virtual humans.
        Computers in Human Behavior. 2015; 52: 12-21
        • Sandelowski M.
        Whatever happened to qualitative description?.
        Research in Nursing & Health. 2000; 23: 334-340
        • Schwappach D.L.
        • Gehring K.
        'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns.
        BMJ Open. 2014; 4e004740
        • Schwappach D.L.
        • Niederhauser A.
        Speaking up about patient safety in psychiatric hospitals–a cross‐sectional survey study among healthcare staff.
        International Journal of Mental Health Nursing. 2019; 28: 1363-1373
        • Schwappach D.
        • Richard A.
        Speak up-related climate and its association with healthcare workers' speaking up and withholding voice behaviours: a cross-sectional survey in Switzerland.
        BMJ Quality & Safety. 2018; 27: 827-835
      3. Slawomirski, L., Klazinga, N. (2020). The Economics of Patient Safety From Analysis to Action. Available from 〈〉.

        • Tong A.
        • Sainsbury P.
        • Craig J.
        Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.
        International Journal for Quality in Health Care. 2007; 19: 349-357
        • Voogt J.J.
        • Taris T.W.
        • van Rensen E.L.
        • Schneider M.M.
        • Noordegraaf M.
        • van der Schaaf M.F.
        Speaking up, support, control and work engagement of medical residents. A structural equation modelling analysis.
        Medical Education. 2019; 53: 1111-1120
        • Weiss M.
        • Kolbe M.
        • Grote G.
        • Spahn D.R.
        • Grande B.
        Why didn’t you say something? Effects of after-event reviews on voice behaviour and hierarchy beliefs in multi-professional action teams.
        European Journal of Work and Organizational Psychology. 2017; 26: 66-80
        • World Health Organization
        10 Facts on patient safety.
        World Health Organization, 2019
        • Yang J.E.
        The influence of Korean collectivism(Uri, we-mess) on interpersonal communication behaviors.
        Journal of the Korea Contents Association. 2019; 19: 1-14