Aims: Voice behavior refers to nurses' proactive actions in offering constructive suggestions, providing feedback, or raising concerns in the workplace, which are crucial for enhancing care quality and improving the work environment. This study aims to investigate the current status and influencing factors of voice behavior among nurses in neonatal intensive care units (NICUs) in tertiary hospitals in Sichuan Province, providing empirical evidence for improved nursing management and hospital administration. Design: A multicenter, crosssectional survey. Methods: From January to June 2023, 422 neonatal nurses from tertiary hospitals in Sichuan Province were selected through stratified random sampling. Data were collected through self-reported questionnaires, including a general information questionnaire and a voice behavior scale. The voice behavior scale consists of 10 items, divided into promotive and prohibitive behavior dimensions, using a five-point Likert scale (1 = "never" and 5 = "always"). The scale has been widely used among Chinese nurses and demonstrates good internal consistency (Cronbach's alpha = 0.951). Data analysis was conducted using SPSS Version 26.0. Structural validity was assessed through exploratory factor analysis (KMO > 0.8, Bartlett's test p < 0.05), followed by confirmatory factor analysis using AMOS. For group comparisons, independent t-tests and analysis of variance (ANOVA) were used, with Welch's test for unequal variances. Post hoc multiple comparisons were performed using Tamhane's T2 for unequal variances and LSD for equal variances. A p-value < 0.05 was considered statistically significant. Results: Age, marital status, and number of children significantly influenced voice behavior. Voice behavior increased with age up to 50 years, unmarried individuals exhibited less voice behavior than married or divorced ones, and more children correlated with more voice behavior. Job title, position, and years of experience in the neonatal department also significantly impacted voice behavior. Higher positions and more than 15 years of experience were associated with increased voice behavior. Senior titles correlated with higher prohibitive voice behavior. Conclusion: The voice behavior of NICU nurses is influenced by various factors, including age, marital status, number of children, job title, position, and years of experience in the neonatal department. As age increases, the number of children grows, work experience accumulates, and nurses' voice behavior tends to intensify. In particular, for senior nurses, managers should pay attention to their prohibitive voice behavior and encourage their active involvement in decision-making processes to enhance the quality of care. Nursing managers should tailor management strategies based on these individual characteristics, providing customized support for nurses at different experience levels. At the same time, emphasis should be placed on creating a psychologically safe work environment to stimulate nurses' initiative and creativity, thereby improving team communication and collaboration. This approach will contribute to ensure the quality of care and patient safety in NICUs. Implications for the Profession: Understanding the factors influencing voice behavior helps nursing managers to enhance nurse participation and care quality. Nursing managers can implement the following strategies: (1) create a psychologically safe environment: encourage open communication by ensuring nurses feel their opinions are valued, with clear channels for feedback and action, (2) address senior nurses' prohibitive voice behavior: provide leadership training to senior nurses to transform negative feedback into constructive suggestions, promoting collaboration and work improvement, (3) tailor strategies based on experience: offer support and mentorship to new nurses, while encouraging experienced nurses to take leadership roles and contribute to decision-making, (4) incentivize contributions: develop reward systems to recognize nurses' involvement in improving patient care, such as acknowledging innovative ideas and active participation.
