NURS 721 Week 2 Discussion Board Forum 2 on Leadership, Communication and Patient Safety Example

Discussion Board Forum 2: Leadership, Communication and Safety

NURS 721 Leadership, Policy and Ethics, Discussion Board Forum 2

Thread by [Student Name]

The hospital, the event and the classmates replied to are composites written for a model discussion.

Last month a nurse eight weeks out of orientation on one of my units noticed that a heparin infusion order for a post-operative patient appeared to be ten times the usual dose. She checked the protocol, asked another new nurse, rechecked the protocol, and finally called the surgical resident forty minutes after she first saw the order. The resident corrected it immediately and thanked her for the call. The infusion had not been started, and no harm occurred. When the nurse manager and I met with her afterward, she said she had been afraid of being wrong and of the reaction she might get. She had heard stories about a surgeon who shouted at nurses who questioned him. That surgeon left the hospital three years before she was hired.

Clawson (2012) argues that what people do is driven by what lies beneath: the values, assumptions, beliefs and expectations they carry, often without examining them. The nurse's delay was not a knowledge problem; she knew the dose was wrong. It was a belief, inherited from stories told on the unit, that questioning a physician carries a personal cost. Leaders who want nurses to speak up must change that belief, and the evidence suggests how. A belief about what happens to people who speak up can outlive every person who created it.

A 2026 scoping review of 25 sources on how nurse managers promote psychological safety and patient safety culture found that relational behaviors, including visible presence, active listening, emotional support and constructive feedback, were the key strategies, and that psychological safety may link leadership to communication, speaking up, incident reporting and learning (Augusto et al., 2026). The same review found that leadership alone is not enough: punitive environments, hierarchy, workload and resource constraints were barriers that leaders must also address.

A second 2026 study complicated the picture in a useful way. Abousoliman and Elgamal (2026) surveyed 288 nurses working in thirteen Egyptian hospitals. Nurses who rated their leaders as courageous also reported a fairer response to errors, felt safer with colleagues and spoke up more. The surprise came in the pathway analysis: feeling psychologically safe did not, in this sample, travel with speaking up, and the fair-culture and safety measures together did not explain why courageous leadership and voice went together. What remained was a direct association between a leader's courage and nurses' willingness to raise concerns. Because everything was measured at one point in time, the design cannot establish which came first, but the pattern hints that nurses may learn to speak up partly by watching their leaders do it. It also cautions against assuming that a pleasant, supportive unit will automatically be a vocal one.

That finding changes my plan. Beyond asking nurses to speak up, I will practice three behaviors. I will round on each unit during the evening shift change, when new nurses are most often alone with questions. I will tell the story of this near miss, with the nurse's permission, as an example of a good catch, and thank her publicly for it. And I will question unsafe orders or practices myself in front of staff when I see them, so the belief that speaking up is dangerous meets visible evidence that it is not. Esther hesitated before approaching the king unsummoned, but she went, saying, "If I perish, I perish" (English Standard Version Bible, 2001/2016, Esther 4:16). Leaders cannot ask nurses for courage they do not show themselves.

Reply to Jordan

Jordan, you wrote that servant leadership is the answer to speaking up because nurses speak freely to leaders who care for them. I agree that caring matters, but a 2026 study of Japanese nurses suggests it may not be enough by itself. In that study, organizational climate was significantly associated with psychological safety, which in turn was associated with work engagement, but servant leadership showed no significant effect on either psychological safety or engagement in the tested model (Hontake et al., 2026). The authors concluded that the wider workplace environment, one where nurses can speak openly and seek consultation, may matter more than any single leader's style. Clawson (2012) would describe that climate as a set of shared expectations that outlast individual leaders. On my unit, the surgeon's legacy was part of the climate. Do you think a servant leader on your unit could change the climate alone, or would it take changes in policies, such as how errors are reviewed, as well?

Reply to Priya

Priya, you pointed out that new graduates on your night shift rarely call physicians because they are afraid of waking them for nothing. That is the hierarchy barrier in concrete form. Augusto et al. (2026) found hierarchical structures and workload pressures among the main barriers to psychological safety, alongside punitive environments, and concluded that leadership must be aligned with organizational conditions and system-level support. One system change that has helped on my units is a written escalation guide that lists situations in which nurses are expected to call, so the decision does not rest on the nurse's judgment of whether the call is worth it. Another is pairing each new graduate with a named night resource nurse for the first three months. A third is to ask residents to end every night call with a short thank-you, which costs nothing and slowly changes the expectation of a hostile response. Has your unit considered something similar, and how do your residents respond when nurses call at night?

References

Abousoliman, A. D., & Elgamal, H. G. (2026). Courageous leadership and nurses' speaking-up behavior: The indirect roles of just culture and psychological safety: A cross-sectional study. International Journal of Nursing Studies Advances, 11, Article 100663. https://doi.org/10.1016/j.ijnsa.2026.100663

Augusto, C., Pereira, S., Cunha, D., Rocha, I., Lumini, M. J., Santos, R., & Gonçalves, P. (2026). The role of nurse managers in promoting psychological safety and patient safety culture in nursing teams: A scoping review. Healthcare, 14(16). https://doi.org/10.3390/healthcare14162590

Clawson, J. G. (2012). Level three leadership: Getting below the surface (5th ed.). Pearson.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Hontake, T., Nishi, M., Kuzushima, S., & Kamizawa, N. (2026). Effects of organizational climate and servant leadership on work engagement among Japanese nurses: The mediating role of psychological safety. Journal of Nursing Management, 2026(1), Article e5755950. https://doi.org/10.1155/jonm/5755950