Nurses speak up when they feel safe, study says

When nurses feel safe admitting to their supervisors that they’ve made a mistake regarding a patient, they are more likely to report the error, according to an international team of researchers.

In addition, when nurse leaders’ safety actions mirror their spoken words — when they practice what they preach — unit nurses do not feel caught between adhering to safety protocols and speaking up about mistakes against protocols, says Deirdre McCaughey, PhD, assistant professor of health policy and administration at The Pennsylvania State University in University Park and a lead author of the study. The results appeared online in the Journal of Applied Psychology. (An abstract and full text purchase option are available online at

“Patient errors remain a major source of avoidable patient harm in the United States,” McCaughey says.

McCaughey and her colleagues examined the notion that care providers might experience a conflict between the strong enforcement of safety procedures on the one hand and the reporting of safety/patient errors on the other hand.

The researchers surveyed 54 nursing teams in four hospitals in Belgium to determine if the leadership actions of head nurses were aligned with the verbal expectations they had given to staff nurses, as well as to examine the effect of that congruence on nurse/employee commitment to following safe work protocols and willingness to report a patient treatment error. Six months later, the team then examined the relationship between fostering safety and reporting patient errors to determine if they were related to a reduction in errors regarding patients.

In their study, the researchers considered a team to be composed of one head nurse and a minimum of three nurses who reported directly to the head nurse. They distributed paper surveys to nurses and head nurses within the different nursing departments and asked the nurses to deposit the surveys in a sealed box or envelope to ensure anonymity.

The surveys examined the behavioral integrity of head nurses, the psychological safety felt by staff nurses, and team priority of safety using a variety of statements that participants ranked on a scale ranging from “completely disagree” to “completely agree.” To examine the behavioral integrity of head nurses, the surveys included such statements as, “My head nurse always practices the safety protocols he/she preaches.”

To examine the psychological safety felt by staff nurses, the surveys included such statements as, “If you make a mistake in this team, it is often held against you.” To examine team priority of safety, the surveys included such statements as, “In order to get the work done, one must ignore some safety aspects.” The researchers then analyzed the data using structural equation modeling.

The researchers found that when nurse managers’ spoken expectations regarding safety aligned with their commitment to safety, their teams had a stronger commitment to acting safely while carrying out work duties, as well as a greater rate of reporting errors. In addition, this greater emphasis on safety resulted in a reduction in patient treatment errors.

“The study offers support for the efficacy of leaders’ behavioral integrity — walking the talk, if you will — and it demonstrates the importance of leadership in promoting a work environment in which employees feel it is safe to reveal performance errors,” McCaughey says. “This benefits patients because work environments in which error is identified offer employees the opportunity to learn from those errors and, ultimately, prevent similar errors from occurring.”


  • Deirdre McCaughey, PhD, Assistant Professor of Health Policy and Administration, The Pennsylvania State University, University Park. Telephone: (814) 863-8130. Email: