Can I make a difference? Hospital staff’s sense of agency and patient safety

A sense of control in practice

In a hospital, a useful way to begin discussing control is with a concrete question: what can a staff member stop when they spot a risk, and what must they escalate? Being able to report a concern does not necessarily mean believing that someone will make a decision. Rather than asking only about engagement, find out whether a staff member could influence what happened after they noticed a problem. Three studies involving a total of 792 people examined associations between safety locus of control and personal characteristics and behaviors, including in nursing samples. They concerned occupational safety, however: they cannot predict clinical errors or justify selecting staff using a simple risk profile. Understood this way, agency adds to conversations about safety climate but does not replace an assessment of what staff can actually do.

When a concern goes nowhere

A staff member notices a hazard, tells their supervisor, and waits for a decision. If nothing changes, it is worth tracing the concern from start to finish: exactly what was reported, who received the information, and whether the person who raised it received a response, even if the decision was not to act. A concern can be lost despite the staff member expressing it clearly. A systematic review of 294 publications shows that raising concerns in healthcare is defined in different ways; it proposes understanding it as communicating a concern to someone able to respond. This helps structure the conversation but does not establish which intervention works. For a manager, the task is therefore not just to encourage staff to speak up, but to check whether their concern reached someone with decision-making authority.

What depends on the system

It is difficult to build a sense of agency when equipment, time, or an accessible reporting route is lacking. Managers should identify these barriers rather than treat inaction as a staff member’s personal failing. It is also important to identify who can make a decision when the manager is not on duty. Staff then know where to take matters that require authority beyond their own role. If staffing or equipment shortages persist, calling for greater responsibility does not give people the means to act. A conversation about agency is useful only if it distinguishes decisions staff can make from those management must make, and from resources the organization must provide.

Feedback makes action visible

After a concern is raised, follow up with the staff member about what was done and why. An acknowledgment alone is not an improvement: what matters is a decision they can see, or an explanation of why action was declined and what would allow the issue to be revisited. In a cross-sectional study of 16,797 responses across 829 work settings, feedback after leadership rounds was associated with more positive ratings of safety culture and greater engagement. The direction of the relationship is unclear, however; the study does not prove that feedback itself causes these changes. For the team, transparency has practical value: people can see whether a report led to a decision instead of having to guess what happened to it.

Questions to guide the conversation

The conversation can begin with a recent example of a staff member’s action making a difference, followed by a question about what held up other ideas. Comparing the two helps distinguish opportunities to act from barriers that require support. A manager can agree with the team which decisions its members will make themselves, which require a supervisor’s approval, and how they will know whether a report led to change. In a one-to-one conversation, it is worth clarifying which tasks the staff member can carry out independently and which require a decision or safeguards. End by agreeing on one change within that person’s actual scope of influence, rather than with a general call to be more proactive.

The risk of calling for responsibility

Calls for responsibility become risky when they are used in place of adequate staffing, equipment, or a working procedure. A staff member can be responsible for noticing and communicating a problem, but not for a resource decision they have no authority to make. If management promises influence without defining decision-making boundaries, the person who raised the concern may later be blamed for the consequences of a barrier they could not remove. It is better to check how many reported barriers have actually been removed and, for those that remain, clearly identify who can decide on the next steps. This pairs the expectation that staff stay alert with the organization’s responsibility for working conditions, rather than shifting the burden onto staff.

Tracking change

To track change, ask questions grounded in daily work: does a staff member know who can respond to a concern, do they receive an answer, and how long does it take to reach a decision after a report? You can also check whether staff help develop solutions. The number of reports alone needs careful interpretation: an increase does not necessarily mean safety has worsened. Guidelines on incident reporting and learning help explain the limitations of such data, but they are not experimental evidence that a particular system works. Likewise, changes in patient outcomes should not be attributed to a single conversation. The main aim of tracking is to see whether a problem, once noticed, has a route to a response and a decision.

A staff member may report a hazard yet still doubt that anyone will make a decision. A sense of agency requires clear authority, an accessible reporting route, and a response.

Empatyzer in conversations about staff influence on safety

Before discussing staff influence, a manager can use Em to prepare questions about previous attempts to act: what staff did, what held the matter up, and who could have made a decision at the time. They can then prepare a message that separates decisions the team can make from those that belong to management, rather than issuing a general appeal for motivation. In team mode, Em helps clarify that distinction, while the team view makes it easier to explain the rules to different professional groups. The manager’s own profile in “About me” may prompt them to examine how they react to critical feedback before asking staff to raise more concerns. After the conversation, micro-lessons can remind them to follow up after the first step has been taken and help them practice a specific response: what has changed, what has not yet been done, and who will make the next decision. The tool thus supports preparation and conversation, but does not replace providing resources or acting on reports.