Supplementary file 1_The ideal-reality gap: a qualitative study of nurse middle managers' perspectives on speaking up for patient safety.pdf

BackgroundAs 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.
MethodsFourteen 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.
ResultsThree 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.
ConclusionSUPS 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.

背景 作为患者安全管理的核心主体，护理管理者因与一线护士的紧密协作，能够全面洞悉护士为患者安全发声（speaking up for patient safety，SUPS）所面临的障碍与顾虑。然而，目前鲜有研究聚焦于护理管理者对SUPS的看法。因此，本研究旨在探讨中层护士长对护士SUPS的认知与建议，以期为推动SUPS实践的策略制定提供参考。
方法 本研究于2025年6月至8月间，在江苏省某三级甲等医院通过立意抽样与滚雪球抽样法招募了14名中层护士长。研究采用半结构化访谈指南开展面对面访谈，数据分析以反身性主题分析为指导框架。
结果 本研究共提炼出3个核心主题：（1）SUPS的内涵认知：固有职责与治理资源；（2）理想与现实的鸿沟：多重约束下的SUPS困境；（3）赋能的关键：构建支持性生态系统。另有10个子主题支撑上述研究发现。
结论 SUPS既是一项专业职责，也是一项关键的治理资源。然而，显著的“理想-现实鸿沟”依然存在，其驱动因素来自多个层级，而非仅仅源于个体的犹豫。因此，推动SUPS实践不仅需要开展个体果敢性训练，还需打造具有韧性的制度生态系统，融入非惩罚性治理、管理者赋能与系统性保障措施，从而构建支持发声的良好组织环境。