Helping Nurses to Speak Up

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Many nurse leaders are now trying to reset their cultures to focus more on quality and safety. Professional accountability is undoubtedly one of the hottest topics on the minds of frontline leaders. It is only possible to have a culture of quality and safety if nurses hold themselves and their peers accountable. Consider the following story one manager told in a recent program:

During COVID, I only sometimes addressed professional performance issues. I was happy that the staff came to work because we were short-staffed. Now, I am trying to do a reset, focusing on returning to the basics, and boy, am I meeting resistance. I need help to do this alone, but I have observed that my younger staff is far less willing to address poor practice when they see it. They bring it to me and tell me they feel unsafe confronting their peers. 

It was interesting that she brought up this problem. Many nurse leaders observe the same thing – poor practice going unchecked and nurses staying silent even when they know things are wrong. One CNO told me about a patient incident that had reached her desk that shocked her, but what shook her the most was that no one said anything. When did this happen – she asked – when did nurses stop speaking up when there were quality and safety issues? The answer is complicated.

The Covid-19 pandemic has been massively disruptive to nursing teams. Turnover has skyrocketed, and the nurse experience versus patient acuity gap has expanded. A key aspect of ensuring quality and safety on teams is the willingness of nurses to speak up and speak out if something is wrong. Yet, too often, young nurses are reluctant to speak up for the following reasons:

• A concern that other team members will see them as ignorant.
• A concern that they will be judged as incompetent.
• A concern that they will be seen as being negative.
• A concern that they will be seen as disruptive.

If the environment is perceived as psychologically unsafe, nurses are hesitant to speak up to other team members out of fear. For young Generation Z nurses, these crucial conversations are incredibly stressful. Nurse leaders are essential in creating psychologically safe cultures for staff to question practices, report problems, or propose new ideas. Dr. Amy Edmonson, an expert on psychological safety, recommends that leaders check in with their teams by asking for feedback on the following statements:

1. It is easy to speak up about what is on your mind on this team.
2. If you make a mistake on this team, it is often held against you.
3. People on your work team are usually comfortable discussing problems and disagreements.
4. People on this team are eager to share information about what does and does not work.
5. Keeping your cards close to your vest is the best way to get ahead on this team.

With so many inexperienced nurses in acute care settings today, nurse leaders should talk openly about speaking up and speaking out. There is no better way to do this than by providing examples of situations where burying a problem is not the right approach. Some examples you can give include the following:

• A normalization of bullying behaviors on the team.
• Acceptance of assignments you don’t feel competent to perform.
• Family or patient disrespect toward clinical staff.
• When you see a colleague demonstrating an unsafe practice.
• The omission of nursing care that is vital for patient recovery.
• A repeated absence of critical supplies needed to give care.
• Professionals who perform activities outside their scope of practice.
• Violation of essential policies and procedures.

Simon Sinek has noted that good leaders make us feel safe and more confident about speaking up and speaking out. As we lead a younger and sometimes less confident nursing workforce, that should be our goal.

© emergingrnleader.com 2023

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Recommended Book by the Association of Critical Care Nurses – The Nuts and Bolts of Nursing Leadership: Your Toolkit for Success