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.

Why Talking Is Not Cheap: Adverse Events and Informal Communication.

Healthcare management faces significant challenges related to upward communication. Sharing information in healthcare is crucial to the improvement of person-centered, safe, and effective patient care. An adverse event (AE) is an unintended or unexpected incident that causes harm to a patient and may lead to temporary or permanent disability. Learning from adverse events in healthcare is crucial to the improvement of patient safety and quality of care. Informal communication channels represent an untapped resource with regard to gathering data about the development of AEs. In this viewpoint paper, we start by identifying how informal communication played a key factor in some high-profile adverse events. Then, we present three Critical Challenge points that examine the role of informal communication in adverse events by (1) understanding how the prevailing trends in healthcare will make informal communication more important, (2) explaining how informal communication is part of the group-level sensemaking process, and (3) highlighting the potential role of informal communication in "breaking the silence" around critical and adverse events. Gossip, as one of the most important sources of informal communication, was examined in depth. Delineating the role of informal communication and adverse events within the healthcare context is pivotal to understanding and improving team and upward communication in healthcare organizations. For clinical leaders, the challenge is to cultivate a climate of communication safety, whereby informal communication channels can be used to collect soft intelligence that are paths to improving the quality of care and patient safety.

Creating healthy workplaces in healthcare: Are we delaying progress by focusing on what we can do rather than what we should do?

All the available evidence points to the fact that healthcare is under considerable stress, and while change is urgently needed there is no quick fix; systemic and sustained changes in organizational cultures within healthcare are required. Moreover, the fragility of healthcare systems globally has been starkly exposed by the Coronavirus 2019 pandemic. We have gathered enough evidence to know what is driving poor wellbeing, and how these processes impact on quality of care and patient safety. Indeed, we have a good idea of what we need to do to improve the situation. Therefore, this begs a simpler question; If we know how to create healthy workplaces, why is it so difficult to achieve this in healthcare? In the following perspective paper, we will argue that we can do better if we address the following three issues: (1) we are ignoring the real problems, (2) limited successes that we are achieving are moving us further from tackling the real problems, (3) culture change is accepted as crucial, but we are not accepting what the evidence is telling us about healthcare culture. Tackling burnout is useful and necessary, but we must increase dignity among healthcare employees. Moreover, we need to train line managers to recognize and facilitate the need of employees to feel competent and be appreciated by others, while helping them set wellbeing boundaries.

Employee silence, job burnout and job engagement among teachers: the mediational role of psychological safety.

Background: Teaching is a highly demanding profession, with teachers reporting increasing levels of burnout. Accumulated evidence indicates that inhibiting the expression of one's thoughts, emotions, and behaviors continuously can take a psychological toll actively resulting in physiological and psychological symptoms (e.g. stress, emotional exhaustion, strain). The purpose of this study was to assess the different types of employee silence among teachers and examine their relationship with job burnout, job engagement and psychological safety. Methods: A convenience sampling method approach was used whereby 150 primary school education teachers from Greece participated in a survey. Self-reported measures for burnout, work-engagement, psychological safety and employee silence motives were used in this cross-sectional study. Results: Psychological safety mediated the relationship between burnout and employee silence, and more specifically between the three core components of burnout and both acquiescent and quiescent silence, but not prosocial silence. In terms of engagement, the indirect effect was significant between vigor/dedication and both quiescent and acquiescent silence. Conclusions: The present research highlighted the importance of acquiescent and quiescent silence, two forms of silence that are rooted in fear and hopelessness respectively. This research adds to the growing picture of teaching as a profession that is characterized by increasing levels of burnout, employee silence and low levels of psychological safety.

The Greek Burnout Assessment Tool: Examining Its Adaptation and Validity.

Burnout is a significant challenge in the workplace. Its extent is global and its unfavourable consequences are diverse, affecting the individual, the organization, and society. The aim of the present study was to examine the adaptation and assess the validity of the Greek version of the Burnout Assessment Tool (BAT). The adaptation process included the translation and back-translation of the BAT. Data were collected from 356 Greek employees from diverse sectors. Confirmatory factor analysis and item response theory were utilized to assess the validity of the Greek version of the BAT. According to the findings of the present research, the core symptoms scale and the secondary symptoms scale of BAT-23 and BAT-12 models demonstrated adequate structures for the analysis and measurement of burnout in the Greek context. Finally, the psychometric performance of the BAT-GR-12 compared to the BAT-GR-23 establishes it as a more optimum instrument for the assessment of burnout across Greek working adults.

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.

Understanding the Link Between Burnout and Sub-Optimal Care: Why Should Healthcare Education Be Interested in Employee Silence?

Evidence on the association of burnout with objective indicators of performance is scarce in healthcare. In parallel, healthcare professionals ameliorate the short-term impact of burnout by prioritizing some tasks over others. The phenomenon of employee silence can help us understand the evolution of how culture is molded toward the prioritization of some tasks over others, and how this contributes to burnout. Silence in healthcare has been associated with concealing errors, reduced patient safety, and covering up errors made by others. Conversely, there is evidence that in organizations where employees are encouraged to speak up about concerns, and where concerns are responded to appropriately, better patient outcomes such as improved patient safety and patient experience occur. Interventions to promote "speaking-up" in healthcare have not been successful and are rooted in a professional culture that does not promote speaking out. In this paper, we review the evidence that exists within healthcare to argue why healthcare education should be interested in employee silence, and how silence is a key factor in understanding how burnout develops and impacts quality of care. The following key questions have been addressed; how employee silence evolves during medical education, how is silence maintained after graduation, and how can leadership style contribute to silence in healthcare. The impact of withholding information on healthcare professional burnout, patient safety and quality of care is significant. The paper concludes with a suggested future research agenda and additional recommendations.

Emotional Labor and Burnout among Teachers: A Systematic Review.

A significant amount of emotional labor takes place during teaching. Teaching is a multitasking profession that consists of both cognitive and emotional components, with teachers engaging in emotional labor on a daily basis as an instrumental part of achieving teaching goals and positive learning outcomes. The purpose of the present review was to explore the relationship between emotional labor and burnout in school settings. The review focused specifically on teachers from elementary and high schools, between January 2006 and August 2021, and 21 studies fit the inclusion criteria. Overall, the review of the literature supports the significant associations between burnout and emotional labor with the majority of results pointing to the consistent relationship between surface acting and burnout. However, the results regarding the association of deep acting and naturally felt emotions with burnout were mixed. There is considerable scope for improvement in our study of emotional labor in terms of the study designs we employ, the variables we study and our appreciation of the historical and cultural factors that moderate and mediate the relationship between emotional labor and burnout.