Voice Behavior of Clinical Nurses and Leadership Behavior: Finding the Connection

Sunday, 8 November 2015: 4:40 PM

Gina D. Aranzamendez, PhD, RN-BC1
Robin Toms, PhD, MN, BSN, RN, NEA-BC2
Rae W. Langford, EdD, MS, BS, RN2
Lene Symes, PhD, RN3
Debora Simmons, PhD, RN4
(1)Office of Performace Improvement, M.D. Anderson Cancer Center, Sugar Land, TX, USA
(2)College of Nursing, Texas Woman's University, Houston, TX, USA
(3)College of Nursing, Texas Woman's University - Nelda C. Stark College of Nursing, Houston, TX, USA
(4)Administration, CHI St Lukes Health System, Houston, TX, USA

Problem of study

Quality improvement is at the heart of patient safety. Nurses, who act as front line staff, are in the best position to identify issues and concerns that affect the care of their patients. They have firsthand knowledge of what works and what does not work. Their reluctance to voice concerns and issues has grave implications with regards to patient safety and on the organization’s ability to learn from error. Further investigation of the front line staff’s concerns can prevent errors and provide resolution leading to greater safety for patients. This study explored the relationship of leadership style and the quality of leadership affiliation to the voice behavior of clinical nurses. The outcomes from this study may influence healthcare organization in promoting voice behavior to staff.

Theoretical framework

Two leadership theories, Full Range leadership theory and Leader-Member Exchange theory, were used to guide the study. It was conceptualized that leadership style defined by specific leadership behaviors and the high quality of leadership affiliation has impact on clinical nurses’ voice behavior. In addition, clinical nurses’ perceived psychological safety mediates the relationship between leadership characteristics and the nurses’ voice behavior.


This study is a non-experimental, correlational research design developed to examine the relationship between clinical nurse’s perception on their direct supervisor’s leadership style, their leader-member affiliation, and their voice behavior.  A cross-sectional survey was conducted after the Institutional Review Board (IRB) approval from the Texas Woman’s University was obtained. There were 154 total responses but only 146 responses were used in the analysis due to set criteria. Hierarchical regression analysis was employed to explore the relationship between variables. Participants’ age, tenure, gender, and work shift were used as control variables. Preliminary analysis was conducted to ensure that no assumption was violated.


The full regression model accounted for 26.4% (p<.0001) of the total variance in voice behavior. The introduction of the socio-demographic variables explained 1% of the variance (F=.339, p =.851).  Adding leadership affiliation and leadership styles, the model explained 24.4% of the variance (F= 5.664, p <.0001) and indicated that leadership behaviors do affect voice behaviors. After entry of the PS at step 3, the variance explained by the model as a whole was 26.4%, (F= 5.258, p <.0001). In the final model, only leadership affiliation, (beta = .262) and transformational leadership (beta=.229) showed any strength of contribution.


The study findings indicate that contextual leadership characteristics are a significant contributing factor in the clinical nurses’ decision to engage in speaking up regarding their issues and concerns. Leaders play an important role in employees’ decisions to voice work related ideas and concerns. Creating an environment where ideas for improvement are respected and supported is a step towards higher quality care.