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&apos; crucial role in improving patient safety, they often keep silent about their concerns. This study investigated links among hierarchical unit culture, nurses&apos; 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&apos; 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&apos; 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&apos; 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&apos; perceived futility and to promote open communication.