New Scales Measure What Nurses Say, How They Say It, and What It Costs Them

When a nurse notices something going wrong on a hospital ward, whether she speaks up can determine whether a patient lives or dies. Yet for decades, researchers studying this critical behavior, known in organizational science as voice behavior, have had to borrow measurement tools designed for office workers, tools that fail to capture the unique pressures, hierarchies, and life-or-death stakes of clinical settings. Now, a team of nursing researchers in Türkiye has built and rigorously validated three new instruments specifically designed to measure what nurses speak up about, how they do it, and what negative consequences they face when they do.

The study, published in BMC Nursing, was led by Bahar Kuleyin and Serap Altuntas from the Nursing Management Department at Bandirma Onyedi Eylul University. Their work addresses a persistent gap in healthcare research. Voice behavior, the discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues with the goal of improving situations, has been extensively studied in business contexts. But nursing is different. A nurse who raises a concern may be challenging a physician’s decision, questioning a safety protocol, or flagging a staffing shortage, and the consequences of speaking up or staying silent ripple directly to patient outcomes.

The researchers designed their study in three carefully sequenced phases. First came item generation, where they drew on existing literature and qualitative input to draft candidate questions covering the full landscape of nursing voice. Second, they conducted preliminary evaluation of these items, refining wording and eliminating redundancy. Third, they assessed the psychometric properties of the resulting scales using construct validity and reliability analyses, following evaluation of content and face validity. Data were collected from 890 nurses between December 2024 and June 2025, with institutional permissions obtained from five hospitals where the exploratory phase took place.

From this process emerged three distinct instruments. The Nurses’ Voice Behaviors Topics Scale, or NVBTS, contains 30 items organized into five factors, capturing the range of subjects nurses speak up about. The Nurses’ Voice Behaviors Methods Scale, or NVBMS, includes 12 items across three factors, measuring the different channels and approaches nurses use when voicing concerns. The Nurses’ Voice Behaviors Negative Outcomes Scale, or NVBOS, comprises 10 items with a single factor, assessing the adverse consequences nurses experience as a result of speaking up.

The psychometric validation was thorough. For each scale, the researchers examined explained variance, confirmatory factor analysis fit indices, factor loadings, convergent and discriminant validity, internal consistency, and test-retest reliability. All demonstrated satisfactory properties, meaning the scales measure what they claim to measure, consistently, across time. Convergent validity confirms that items theorized to cluster together actually do so, while discriminant validity ensures the three scales capture genuinely different dimensions rather than overlapping constructs.

Why does this technical achievement matter so much? Because without valid measurement, research on nursing voice is built on sand. Studies using generic voice scales may miss the topics that matter most in clinical settings, such as medication errors, patient handoffs, or equipment failures. They may fail to distinguish between speaking up to a supervisor versus raising concerns in a team huddle. And they rarely capture the negative outcomes, from social exclusion to career damage, that can silence nurses precisely when their input is most needed.

The negative outcomes dimension is particularly significant. Research in healthcare has long documented a culture in some clinical environments where speaking up is perceived as risky, especially across hierarchical lines. Nurses who challenge physicians or question established practices may face dismissiveness, retaliation, or professional isolation. By providing a validated instrument to measure these consequences systematically, the new scales open the door to research that quantifies the cost of voice and identifies organizational conditions that protect nurses who speak up.

The implications extend to patient safety and healthcare quality. Voice behavior among nurses has been linked to error reporting, safety climate, and quality improvement. When nurses feel safe and empowered to voice concerns, organizations catch problems earlier, learn faster, and prevent harm. When they stay silent, near-misses go unreported and systemic weaknesses persist. Having reliable tools to measure voice, its topics, methods, and negative outcomes, allows hospital administrators and researchers to baseline current levels, evaluate interventions, and track change over time.

The study was conducted as a methodological investigation, meaning its primary contribution is the instruments themselves rather than new findings about nurses’ behavior. Ethical approval was obtained from the Bandirma Onyedi Eylul University Health Sciences Non-Interventional Research Ethics Committee in October 2024, and all procedures followed the Declaration of Helsinki. The research received no specific grant from funding agencies, and the authors declare no competing interests. An abstract was presented orally at the 9th International Nursing Management Conference in Ankara in June 2026.

For the global nursing research community, the availability of these validated scales represents a practical advance. Researchers can now assess nurses’ voice behaviors with instruments grounded in the realities of clinical practice rather than adapted from corporate settings. Future studies can explore how voice topics differ across specialties, which methods of voicing are most effective in different team structures, and how negative outcomes vary across organizational cultures. As healthcare systems worldwide grapple with workforce shortages and safety challenges, understanding and encouraging nurses’ voice has never been more urgent, and now researchers have the measurement tools to do it properly.

Subject of Research: “Development and psychometric validation of nurses’ voice behaviors scales: topics, methods and negative outcomes”

Article Title: “Development and psychometric validation of nurses’ voice behaviors scales: topics, methods and negative outcomes”

Article References: Kuleyi̇n, B., & Altuntaş, S. (2026). “Development and psychometric validation of nurses’ voice behaviors scales: topics, methods and negative outcomes”. BMC Nursing. https://doi.org/10.1186/s12912-026-05530-x

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05530-x

Keywords: nursing, voice behavior, psychometrics, scale development, patient safety, BMC Nursing, healthcare quality, nurse voice, Development, psychometric, validation, nurses