The ideal-reality gap: a qualitative study of nurse middle managers' perspectives on speaking up for patient safety

Background: As pivotal figures in patient safety management, nurse managers are well-positioned to gain comprehensive insights into the barriers and concerns surrounding nurses' speaking up for patient safety (SUPS) due to their close engagement with frontline nurses. However, few studies have investigated nurse managers' perspectives on SUPS. Therefore, this study aimed to explore nurse middle managers' perceptions and recommendations regarding nurses' SUPS, to inform strategies for promoting SUPS practice. Methods: Fourteen nurse middle managers were recruited via purposive and snowball sampling from a tertiary Grade A hospital in Jiangsu Province between June and August 2025. Face-to-face interviews were conducted using a semi-structured interview guide. Data analysis was guided by reflexive thematic analysis. Results: Three themes were identified: (1) conceptualizing SUPS: Intrinsic Duty and Governance Resource; (2) the Ideal-Reality gap: the Dilemma of SUPS Under Multiple Constraints; and (3) The Key to Empowerment: Building a Supportive Ecosystem. Ten subthemes underscored these findings. Conclusion: SUPS serves as a professional duty and a critical governance resource. However, a pronounced "ideal-reality gap" persists, driven by multilevel factors rather than mere individual hesitancy. Consequently, promoting SUPS requires not only training in individual assertiveness but also engineering a resilient institutional ecosystem that incorporates non-punitive governance, manager empowerment, and systemic safeguards to create a supportive organizational environment that promotes speaking up.