Guest editorial: Employee voice and silence in the health sector

Citation

Wilkinson, A., Mowbray, P., Barry, M. and Avgar, A. (2024), "Guest editorial: Employee voice and silence in the health sector", Journal of Health Organization and Management, Vol. 38 No. 7, pp. 961-970. https://doi.org/10.1108/JHOM-10-2024-516

Introduction

Healthcare systems worldwide are facing dramatic challenges in providing high-quality and error-free patient care. While there are many factors contributing to these challenges, inadequate frontline worker voice is often seen as an antecedent to poor quality of patient care and high medical and medication error rates (for examples of voice related to patient care, see Avgar et al., 2016; Schwappach and Gehring, 2014). In addition, voice in the healthcare setting has been shown to alleviate other persistent challenges, such as stress, burnout and turnover (Holland et al., 2013; Forde-Johnston and Stoermer, 2022). In short, voice (or silence) is widely identified as a key safety issue with life and death implications in the health context (Hague et al., 2023).

Healthcare organisations are complex organisations due to a number of factors such as their scale, multiple stakeholders, heavy regulation, rapid technological advancements, consequences of errors and mistakes, the significant role of hierarchy, varying levels of occupational status and the need for various professional groups to interact not only between themselves but also with various other professions (Nembhard and Edmondson, 2006; Okuyama et al., 2014). Coupled with a “labour-intensive” operating structure, where more than 70% of a hospital’s expenditure is incurred on employment costs, these factors give rise to both opportunities and challenges to improve workplace practices and affect quality of care. Indeed, hospitals are increasingly experimenting with workplace innovations designed to improve the quality of patient care, alleviate financial pressures and retain staff through mechanisms such as high-performance work systems (HPWS), which include employee voice as a core feature. This research has documented the benefits of work practices that enhance frontline worker voice for patients, workers and organisations (Avgar et al., 2011a, b). In this context, it clearly makes sense for healthcare providers to implement systems and practices that encourage employees to speak up to improve work unit and organisational performance (Detert and Burris, 2007).

Although voice is integral to the delivery of high-quality patient care and to employee well-being, the aforementioned combination of the need for high functioning teamwork and the presence of organisational complexity and clear differentials in occupational status poses a particular challenge for the management and encouragement of employee voice within the healthcare context. It is not that hospitals do not have voice structures: indeed, most have a large and complex array of voice mechanisms, but implementation and use of these can be difficult and time-consuming due to rigid hierarchies and occupational status differences. Voicing can be facilitated through employer-provided mechanisms and professional associations (e.g. medical colleges) or unions. Furthermore, it is evident that some systems overlap with each other, causing confusion for employees when attempting to make use of different voice options and considering which mechanism may be the most effective. In short, voice mechanisms in the healthcare setting do not comprise a coherent system. Rather, they are part of a patchwork of interrelated or discrete practices, reflecting different agendas and governed by different groups within large and complex organisations. This can result in mixed messages about the value that is placed on voice (Creese et al., 2021; Wilkinson et al., 2020a).

Making matters even more complicated, voice in healthcare is affected by the different ways in which professionals interact with and view different value systems. As Hall (2005) notes, physicians are trained to take charge and be leaders, so learning to share power and providing others with a say in interprofessional team settings is an engrained and longstanding challenge. Physicians traditionally learn independently in a highly competitive academic environment, while nurses are trained to work as a team, collectively working out problems and exchanging information across shifts to ensure appropriate continuity of care for their patients (Wilkinson et al., 2015; Mawuena and Wilkinson, 2024). Furthermore, employees may be encouraged to avoid intruding into the jurisdiction of other professions, and this creates difficulty incorporating the different voices that emerge from various professional perspectives (Kee et al., 2021).

Hence, there are multiple factors that may discourage healthcare workers from speaking up, despite the fact that doing so is essential to the delivery of high-quality patient care (Okuyama et al., 2014, Lainidi et al., 2023). Unfortunately, there is an abundance of examples demonstrating the consequences associated with the reluctance or difficulty to voice, including highly publicised inquiries and government reforms. In Australia, we saw the Queensland Public Hospitals Commission of Inquiry (QPHCI) arose from complaints relating to the actions of Dr Jayant Patel at Bundaberg base hospital in 2004 and early 2005 and the inability of other staff to voice their concerns (Wilkinson et al., 2015). Similarly, in the UK, the Francis Report (2013) was instigated after it was found that staff concerns over standards of poor care were ignored at Mid Staffordshire National Health Foundation Trust, with the Silence Kills study showing that 58% of nurses felt powerless to speak up despite 85% of nurses being warned about a problem by a patient safety tool (Maxfield et al., 2005). In the United States of America, it is estimated that upwards of 400,000 annual deaths are the result of preventable harm caused by healthcare organisations (James, 2013). While it is not clear how many of these could be prevented as a result of better voice, it is clear that providing frontline workers with more avenues to voice is likely to reduce this number considerably.

Interestingly, there is significant evidence related to the role that unions play in addressing quality of care issues (for a recent review, see Avgar et al., 2024). A number of USA studies comparing different quality of care indicators in union and non-union hospitals have documented a union advantage (see, for example, Ash and Seago, 2004). What might explain this union effect on patient care outcomes? One obvious possibility is the role that unions play in providing institutionalised and robust forms of individual and collective voice (Avgar, 2021). Unions also play a role in providing support for worker concerns, which may serve to enhance levels of psychological safety. As Freeman and Medoff observed (1984), unions provide workers with a collective voice, whereas individuals often choose to exit, which may take many forms such as demotivation (i.e. “quiet quitting”), absenteeism and turnover. Taken together, there is conceptual support for the argument that unions play a positive role in delivering better patient care by promoting meaningful voice and enhancing psychological safety.

There are a number of factors that contribute to organisational silence. For example, Morrison and Milliken (2000) argue that organisational culture is key to stimulating or suppressing voice, and Milliken et al. (2003) suggest that silence stems from employees' perceptions about what issues are permissible to raise and what issues are effectively off the table. Pindor and Harlos (2001) note that voice may fall on “deaf ears” when a climate of silence leads employees to perceive voicing to be futile or dangerous due to potential retaliation. Here again, indirect voice may play a role in encouraging such voice, but only where unions or other structures, such as worker-management committees, are present and working effectively. Reluctance among frontline employees to speak up in healthcare has been linked to team-level psychological safety (Nembhard and Edmondson, 2006; Etchegaray et al., 2020). Psychological safety concerns an individual’s perception of whether it is safe to take interpersonal risks such as engaging in open communication, voicing concerns and asking questions (Edmondson, 1999). Such research on psychological safety in healthcare highlights the importance of the organisational climate and context in promoting effective forms of voice and, no less important, supporting their use.

This need for a safe environment that encourages speaking up was highlighted as an issue for healthcare teams during the COVID-19 pandemic, where successful leadership was identified with having a strong, collaborative response that enabled staff to experiment, take risks and learn from mistakes (Stoller, 2020). Similarly, Kerrissey et al.’s (2022) study of emergency staff and clinicians during the pandemic found that it was not just psychological safety to speak up that was important but also feeling heard, which may have helped to mitigate burnout and enabled adaptation during a time of extreme uncertainty. Nevertheless, despite the clear benefits, there are a number of barriers to feeling heard, with Kerrissey et al. (2024) identifying factors such as preemptive dismissal, empty solicitation, script reading (being treated in a standardised or emotionally distanced manner), structural mazes whereby the complexity of the hierarchy and channel of approvals halts the ideas and authority vacuums where it was unclear who was actually responsible for seeing through the recommendations.

While, as discussed, much of the existing research on voice has given weight to the importance of hierarchical differences, lateral voice, i.e. voicing between peers, has also been found to be an important factor enabling ideas raised by healthcare workers to be implemented. For example, Satterstrom et al.’s (2021) ethnographic study of multidisciplinary healthcare teams showed the importance of allyship and team members advocating the ideas of others in order for those ideas to be implemented, while Jung et al.'s (2024) study of interdisciplinary innovation healthcare teams identified numerous factors that could help facilitate frontline engagement in innovation and foster ideas through implementation, such as soliciting and encouraging voice from others, and cultivating voice by building on the ideas of others and legitimising and validating these. Similarly, in their qualitative study of doctors and nurses in a Chinese hospital, Jing et al. (2023) discovered that these healthcare professionals were able to speak among themselves in order to build support for their ideas and cultivate collective vertical voice towards those in higher hierarchical positions with the power to act on those ideas. But at that same time, some were afraid that they may damage co-worker relationships if they engaged in this lateral form of voice and hence would stay silent. Therefore, ensuring there is a positive psychological safety climate that encourages voice between peers is also critical if healthcare organisations are to leverage the power of voice. Bahadurzada et al. (2024, p. 2) found that joint problem solving (JPS), i.e. “emphasizing problems as shared and viewing solutions as requiring co-production”, and psychological safety were complementary factors, with the positive relationship between psychological safety and patient safety improvement being stronger in the presence of JPS.

It is important to note that worker voice in the healthcare context is not just related to patient concerns but also to employees’ own issues and working conditions. Research conducted on worker voice in healthcare, however, rarely considers voice around worker needs and interests (for an exception, see Clark et al., 2001). Unfortunately, the evidence points to significant issues impacting healthcare workers’ own welfare, and hence, a consideration of voice in relation to their own interests is important. For example, the findings of the Standing Committee on Community Affairs: Inquiry into the Medical Complaints Process in Australia found that bullying and harassment was a widespread and significant problem (2016, p. 41). Indeed, in a study conducted by the Australasian College for Emergency Medicine (ACEM), it was found that more than a third of those surveyed said they had experienced bullying, with almost 50% stating they had been subject to discrimination, bullying, sexual harassment or harassment in the workplace (ACEM, 2017).

We also know that there is a clear link between worker outcomes and patient care (Avgar, 2011). As such, it is likely that voice that serves to enhance and improve working conditions will also translate into better quality of patient care. Wilkinson et al. (2020c) argue that not only is voice related to worker needs important, but there is likely to be a reciprocal relationship with patient care voice, such that the use of voice to address employee concerns about working conditions is also likely to influence and promote voice that targets issues related to patient care. Thus, staff who do not speak up about unfair treatment and other dimensions of poor working conditions, such as work intensification and burnout, may also be less likely to make suggestions for organisational improvements related to patient care. As such, organisations should encourage both forms of voice, as they are likely to create a reinforcing cycle.

As Hirschman (1970) theorised, faced with dissatisfying conditions and without access to voice, individuals are likely to exit (see also Freeman and Medoff, 1984; Forster, 2005). Certainly, the inability of healthcare organisations to manage staff successfully and address concerns about employee welfare and employment conditions is resulting in excessive turnover and a demoralised workforce, leading to other withdrawal behaviours such as high levels of absenteeism. In their study of patient-centred care (PCC), Avgar et al. (2011a, b) found that PCC could lower employee turnover intentions and that the effectiveness of PCC is enhanced by work practices that can be seen as voice enhancing. This evidence supports our examination of the central and underexplored role that voice plays in the healthcare context (O’Donovan and McAuliffe, 2020).

Given its centrality to any effort to improve the healthcare system, this special issue explores the role that different forms of worker voice play in promoting the conditions for the delivery of high-quality patient care. To improve patient care outcomes, research on voice in the healthcare context must, therefore, conceptualise and empirically document the type of voice practices made available by employers and the range of voice strategies employed by frontline healthcare workers.

There is some debate across academic disciplines regarding how employee voice is studied and conceptualised (Barry and Wilkinson, 2016; Mowbray et al., 2015; Wilkinson et al., 2020a), but in this issue we take an inclusive view of employee voice and consider it as involving all of the ways and means through which employees attempt to have a say about, and influence, issues that affect their work, the delivery of care and the functioning of the organisation. Given the focus in this special issue on voice in the healthcare context, we encapsulate speaking up in relation to issues such as operational errors and patient care, concerns regarding employee rights and grievances with management decisions and workers speaking up to offer constructive suggestions and opinions to enhance the overall performance of the organisation. We also conceive voice as occurring through a variety of practices, including formal and informal mechanisms and channels, direct and indirect (such as via unions and representatives) and individual and collective (Wilkinson et al., 2020b). Taken together, the papers in this special issue help to provide a road map for future research on voice and, no less important, ways in which healthcare organisations can enhance the availability and effectiveness of voice opportunities provided to frontline workers.

The papers

Pinho et al. (2024) explore employee perceptions regarding how much they are consulted and how much influence they have on task-related decisions, health professionals' work engagement and burnout when mediated by relational outcomes, perceived organisational support, workplace trust, workplace recognition and meaningful work. A sample of 3,266 health professionals from the European Working Condition Survey was used, and the results indicate that employee voice has a direct positive impact on work engagement, but that the direct effects of voice on burnout still need to be confirmed. Relational outcomes are found to mediate the relationship between employee voice and burnout (decreasing it) and between employee voice and work engagement (increasing it), i.e. increasing trust, recognition, support and the feeling of doing meaningful work increases the influence of employee voice, especially in reducing the levels of burnout.

The manner in which receivers respond to a voiced patient safety concern is frequently cited as a barrier to health professionals speaking up. Barlow et al. (2024) advocate a novel Receiver Mindset Framework (RMF) to help health professionals understand the importance of their response to voice. The framework draws on the broader receiver-focused literature and integrates findings from a series of empirical studies, including vignettes using hypothetical interactions, retrospective descriptions of real interactions and behaviour and observed behaviour within a simulated patient discharge round. The authors' findings indicated that speaking up is an intergroup interaction where social identities, context and speaker stance intersect, directly influencing both perceptions of and responses to the message. The studies demonstrated that when spoken to, health professionals poorly manage their emotions and ineffectively clarify the speaker’s concerns.

Mawuena and Wilkinson (2024) explore how professional disrespect in the doctor–nurse relationship stifles voice by making nurses less likely to raise concerns about threats to patient safety. The study included 57 semi-structured interviews with nurses drawn from a range of specialities, ranks and surgical teams in three hospitals. The study revealed that nurses routinely felt disrespected and condescended to by doctors. When nurses do voice legitimate concerns, doctors tend to downplay or dismiss them, compromising effective teamworking and leading to severe negative patient outcomes. Interprofessional contempt had the effect of motivating nurses to withhold voice as many elected to engage in silence as “punishment” for the behaviour displayed by doctors. In doing so, they highlight the role of social and relational aspects of interprofessional working on voice behaviour in clinical contexts and how these can impact patient safety.

Boesten et al. (2024) highlight a contradiction: while nurses are capable of acting as advocates for patients, as they hold valuable knowledge on patient preferences and their psychosocial needs, in practice they tend to contribute little to multidisciplinary team meetings (MDTMs). They analyse the factors that influence whether nurses will speak up so as to increase patient-centred decision-making in MDTMs. The multiple case study with cross-case comparison of 12 tumour groups across 2 Belgian hospitals, including 50 structured non-participant observations and 41 semi-structured interviews with participants from the 12 tumour groups, identified key elements influencing nurses’ speaking-up behaviour including professional roles, time constraints and case complexity.

Friary et al. (2024) note that little is known about the voice behaviours of new graduates in allied health and that current theory, from medical and nursing research, does not adequately apply to this sector. They report on a study examining the voice-behaviour experiences of new allied health graduates over one year. Using a realist perspective and narrative analysis, they uncover what works, with whom and under what conditions. Four synthesised narratives outline the contexts and mechanisms that result in different voice behaviour outcomes – speaking up effectively, speaking up with unmet expectations, not speaking up and a reduction in speaking up over time. Their findings show that experiences in positive interprofessional collaboration and reflective supervision supported effective voice behaviour.

Semyonov-Tal (2024) points to a rise in the use of website posts for the expression of work-related views. The research evaluates how frontline workers utilise anonymous media platforms to express their views and work-related concerns and demonstrates how anonymous voice systems can encourage frontline health workers to provide feedback and express dissatisfaction. The study utilises the thematic analysis method to review the content of posts by psychologists on a collaborative consultation website administrated by Israel’s Ministry of Health, discussing their perceptions of work-related concerns. The analysis identified three work-related themes including insufficient support from management, conflicts and excessive occupational demands. The workers expressed their apprehension with regard to organisational pressures, deficient budget allocations, excessive workloads, lack of recognition and work-life imbalances.

Wilkinson et al. (2020a) discuss the concept of a voice system – that is, the existence of complementary voice mechanisms designed to allow employees to speak up and explore the existence of a voice system in a healthcare organisation as comprising structures and cultures as seen from different stakeholder perspectives. Interviews and focus groups were conducted in three units within a metropolitan hospital: an oncology department, an intensive care unit and a community health service. Overall, a total of 62 staff members participated in this study. The study revealed that although a plethora of formal voice structures existed, these were not always visible or accessible to staff, leading to confusion as to who to speak up to about which issues. Equally, other avenues that were not designated voice platforms were used by employees to get their voices heard.

Davies et al. (2024) examines the influence of the relationship between employee voice and intersectional inequalities in a culture of care, noting national cultural differences on employee voice and in delivering culturally congruent care. Drawing on the culture care theory, they conceptualise employee voice within an intersectional inequality framework by integrating macro-, meso- and micro-level perspectives to highlight cultural incongruence, which reduces workforce retention. They contribute to understanding employee voice in non-Western contexts where cross-cultural differences and perceived and/or actual intersection inequalities mediate levels of constrained truth-telling and employees’ intentions to quit. Recommending culturally congruent enablers, they call for culturally sensitive feedback mechanisms, collaborative decision-making, intercultural competencies on the job and in nursing and medical schools and promoting and respecting nursing as a profession.

Conclusion

This issue incorporates papers on employee voice in healthcare related to both patient care and for employees’ own interests, the latter being an underdeveloped area of healthcare voice research. By focusing on improving employee voice, we aim to harness and leverage the potential vested in frontline workers to affect and improve working conditions and to deliver high-quality patient care. More effective voice systems can enhance the efficiency and effectiveness of hospitals in terms of their services to patients as well as improve the quality of working lives of hospital professionals. As such, voice can yield social and economic benefits by enhancing the ability to provide consistent, safe patient care by reducing errors and incidents that harm patients as well as improving employee welfare. A focus on enabling voice to improve employee well-being is of benefit in its own right, but it will also flow into better patient outcomes if employees feel that their voice is being heard.

With governments and other policymakers focused on the escalating costs of delivering healthcare, the research reported in this special issue is more relevant than ever. Creating stronger and more effective voice systems is, as well as important to patient care, the key to reducing the very high costs associated with employee turnover and exit from the sector by providing a viable alternative to those exit decisions. This research is highly relevant to the debates on both patient welfare and employee welfare. Our hope is that this special issue pushes both of these debates forward and informs scholars and practitioners alike.