Understanding and addressing gaps in research is essential to develop strategies to help nurses resolve ethical dilemmas and to avoid moral distress and burnout.

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Although speaking up to protect patients is a key ethical and moral mandate for nurses, silence still prevails in many situations. On the basis of concepts of safety culture, generational theory, personal cultural literature, advocacy theory, oppressed group theory, and moral distress theory, the author conducted a literature review and offers a new theoretical framework. The proposed theory identifies primary factors of speaking up: generational, personal culture, and organizational.