Objective: The purpose of this study was to understand speaking up behavior among RNs.

Background: Speaking up is the use of one’s voice to share information or alert those in authority of one's concerns about patients, and is primarily influenced by organizational culture, personal culture, and workforce generation. Failure to speak up can lead to moral distress; speaking up can lead to moral courage.

Methods: A cross-sectional electronic survey was distributed to several thousand RNs resulting in 301 surveys providing usable data.

Results: We found that organizational culture was a strong predictor of speaking-up behaviors, and that speaking up partially mediated the relationship between organizational culture and moral distress, but not between organizational culture and moral courage. Workforce generation or personal culture did not explain nurses using their voice (U=3217, z=1.54, p=.124, r=.12).

Conclusions: The strong role of organizational culture supports the efforts toward healthy work environments. Because not speaking up is related to moral distress, efforts must be escalated to ensure nurses are empowered to use their voices.