An integrative systematic review of employee silence and voice in healthcare: what are we really measuring?

The history of inquiries into the failings of medical care have highlighted the critical role of communication and information sharing, meaning that speaking up and employee silence have been extensively researched. However, the accumulated evidence concerning speaking-up interventions in healthcare indicates that they achieve disappointing outcomes because of a professional and organizational culture which is not supportive. Therefore, there is a gap with regard to our understanding of employee voice and silence in healthcare, and the relationship between withholding information and healthcare outcomes (e.g., patient safety, quality of care, worker wellbeing) is complex and differentiated. The following integrative review is aimed at addressing the following questions; (1) How is voice and silence conceptualized and measured in healthcare?; and (2) What is the theoretical background to employee voice and silence?. An integrative systematic literature review of quantitative studies measuring either employee voice or employee silence among healthcare staff published in peer-reviewed journals during 2016-2022 was conducted on the following databases: PubMed, PsycINFO, Scopus, Embase, Cochrane Library, Web of Science, CINAHL and Google Scholar. A narrative synthesis was performed. A review protocol was registered on the PROSPERO register (CRD42022367138). Of the 209 initially identified studies for full-text screening, 76 studies met the inclusion criteria and were selected for the final review (N = 122,009, 69.3% female). The results of the review indicated the following: (1) concepts and measures are heterogenous, (2) there is no unifying theoretical background, and (3) there is a need for further research regarding the distinction between what drives safety voice versus general employee voice, and how both voice and silence can operate in parallel in healthcare. Limitations discussed include high reliance on self-reported data from cross-sectional studies as well as the majority of participants being nurses and female staff. Overall, the reviewed research does not provide sufficient evidence on the links between theory, research and implications for practice, thus limiting how research in the field can better inform practical implications for the healthcare sector. Ultimately, the review highlights a clear need to improve assessment approaches for voice and silence in healthcare, although the best approach to do so cannot yet be established.

Employee silence in health care: Charting new avenues for leadership and management

ISSUE

Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive.

CRITICAL THEORETICAL ANALYSIS

Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture.

INSIGHT/ADVANCE

The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice.

PRACTICE IMPLICATIONS

Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care.

Silence Among First-Line Managers in Eldercare and Their Continuous Improvement Work During Covid-19

Eldercare sector faced severe needs, and unexplained difficulties, to manage daily work and the continuous improvement of routines at operative levels during Covid-19. First-line managers in eldercare have a key role to facilitate learnings but may be hindered in public, hierarchical organizations. This is the first study on the conditions and importance of silence for managerial work in terms of daily operations and continuous improvement work. To identify first-line managers’ silence in eldercare, its contextual and supportive conditions, its reasons and its implications for managerial work with regard to daily operations and continuous improvement work. Mixed-method study based on a questionnaire to first-line managers (n = 189) in Swedish public eldercare in 33 randomly selected municipal organizations and one city. The instruments Communication of Critical Issues at Work, Managers Stress Inventory and Managerial Work and an open question were analyzed using: (1) qualitative coding to explore organizational conditions, (2) descriptive statistics, and (3) stepwise regressions to identify associations. The most common forms of silence were quiescent (based on fear of the consequences of speaking up) and acquiescent (based on resignation and demotivation). Organizational conditions shaping managerial silence were due to strict governance and control in a hierarchical organization, lack of support and participation in decision-making and the experience of not being valued. Managers’ silence had a negative impact on managerial work and especially work on continuous improvements. The pandemic also offered space for values of occupational professionalism and learning at operational levels. Organizational conditions of support through superiors and management teams decreased silence. Manager silence is detrimental for continuous improvement work and may arise in organizations with dominant values of organizational professionalism. Supportive conditions based on trust and space for occupational professionalism may be important and should be improved to decrease managerial silence and better support continuous improvements.