Tag: <span>managers</span>

Managers influence speaking-up at the sharp end.



Managers have an important role in influencing speaking-up. A recent paper discusses how managerial approaches may directly influence speaking-up by nurses.


Alingh et al (2018) have published an interesting paper in BMJ Quality & Safety (available here). They focus on the influence of managerial safety approaches on speaking-up. Survey data collected from nurses and nurse managers in the Netherlands. Findings compare well to similar studies undertaken elsewhere and with different professional groups. Also notable is the sample size of 302 nurse managers (response rate 42%) and 2627 ward nurses (response rate 22%) who completed the survey.

The study looked at difference between

  • Control-based safety management approaches – where managers stress the importance of following safety rules, monitor compliance and provide employees with feedback and
  • Commitment-based safety management approaches, where 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.


The findings, in a nutshell, suggest the following:

  • Both control-based and commitment-based management approaches seem to be relevant for managing patient safety.
  • Control-based safety management is positively related to a climate for safety, although no association was found with speaking up.
  • When it comes to encouraging individual’s speaking up attitudes, a commitment-based safety management approach seems to be most valuable.
  • Communications are important. There is a divergence between nurses’ and managers’ perceptions. Nurse managers say they do more on safety management than what is actually perceived by nurses.  Nurses are possibly not always aware of everything their manager does with regard to patient safety management.

So what could this mean for speaking-up?

Displaying a preference for monitoring compliance, rule-bound safety thinking and feedback seems to inhibit speaking-up. Role-modelling and encouraging employees towards safe care is more valuable. This resonates somewhat with Martin et al’s recent paper on soft and hard intelligence and challenges to voicing safety concerns (see here). This found that formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. I see parallels here between control-based management (prioritizing hard intelligence) and commitment based management (prioritizing softer intelligence). To paraphrase Martin and colleagues – rule-bound and compliance driven (control-based) management which equates to finding  the ‘facts of the matter’ through proceduralised processes—turning the soft intelligence into hard intelligence —might actually result in information losses rather than gains.

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