Effects of Hierarchical Unit Culture and Power Distance Orientation on Nurses' Silence Behavior: The Roles of Perceived Futility and Hospital Management Support for Patient Safety

Abstract

Background: Patient safety is paramount in healthcare, and effective communication is a cornerstone of preventing adverse patient events. Despite nurses' crucial role in improving patient safety, they often keep silent about their concerns. This study investigated links among hierarchical unit culture, nurses' power distance orientation, perception of futility, and silence behavior in healthcare environments. Moreover, we aimed to determine whether nurse-perceived hospital management support for patient safety moderated the association between nurses' perceived futility and silence behavior. Methods: This cross-sectional, correlational study utilized survey data from 730 direct-care nurses working in 88 medical, surgical, or medical-surgical units across 34 hospitals in South Korea. Validated psychometric scales measured the study variables, and data were analyzed using a 2-1-1 type of multilevel structural equation model. Results: Hierarchical unit culture and power distance orientation showed significant positive associations with nurses' perception of futility (b = 0.62, p < 0.001, and b = 0.37, p < 0.001, respectively) and subsequently with their silence behavior (b = 0.22, p < 0.01, and b = 0.31, p < 0.001, respectively). Futility was found to mediate the relationship of both hierarchical unit culture (indirect effect = 0.222, 95% confidence interval (CI) [0.006, 0.438]) and power distance orientation (indirect effect = 0.132, 95% CI [0.003, 0.261]) to silence behavior. Hospital management support for patient safety significantly moderated the relationship between futility and silence behavior (b = 0.04, p < 0.05); nurses were less likely to remain silent when they perceived high management support as opposed to low support, regardless of their futility level. Conclusion: Our findings highlight the crucial influence of organizational culture on nurses' silence behavior. The findings also underscore the importance of hospital management support with respect to patient safety. Management support may be necessary to combat nurses' perceived futility and to promote open communication.

Keywords: nurses; organizational culture; patient safety; silence; voice.

Figure 1

Hypothesized model.

Figure 2

Graph of the interaction effect.

Figure 3

Results of the multilevel structural equation modeling. Only significant paths with standardized coefficients are reported. The dashed lines indicate relationships with the control variables. ⁣^∗p < 0.05, ⁣^∗∗p < 0.01, ⁣^∗∗∗p < 0.001.