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Exploring barriers to employee voice among certified nursing assistants: A qualitative study
Abstract
Background:
Research shows that voice-the communication of ideas, concerns, and perspectives by employees to those in positions to instigate changes-is related to job satisfaction, retention, and organizational improvement. Nevertheless, health care professionals often do not exercise voice. Although researchers have explored the barriers registered nurses working in hospitals experience in expressing their voices, there has been a notable lack of attention in research and practice to the voice of certified nursing assistants working in long-term care settings.
Purposes:
Ensuring that certified nursing assistants can exercise voice is essential for the welfare and well-being of this occupational group and critical for the success of their organizations. Therefore, we explore the barriers certified nursing assistants encounter that hinder them from exercising voice.
Methodology:
We conducted seven focus groups in which 24 Dutch certified nursing assistants participated.
Results:
The results show that respondents were not always willing to exercise voice, which stemmed primarily from negative prior experiences with exercising voice. Respondents were further not always able to exercise voice, as the conditions under which they had to do so were unfavorable. Finally, respondents sometimes lacked the necessary skills to convey their ideas, concerns, and perspectives effectively.
Practice implications:
Our findings indicate that health care managers must address multiple factors if they wish to enhance the voice of certified nursing assistants.
... Healthcare professionals ask themselves if it is safe for them to express themselves. This question is referred to in various ways in survey and focus group studies: perceived personal safety [53], psychological safety [54][55][56], the safety calculus [41], lack of safety [57], or safety climate [58]. If healthcare professionals perceive the environment as psychologically unsafe, they fear negative consequences, such as negative or harsh reactions or being labelled negative or a troublemaker [31,40,57,59], or they are afraid of a bad evaluation [52], retaliation [60] or retribution [61,62]. ...
... This question is referred to in various ways in survey and focus group studies: perceived personal safety [53], psychological safety [54][55][56], the safety calculus [41], lack of safety [57], or safety climate [58]. If healthcare professionals perceive the environment as psychologically unsafe, they fear negative consequences, such as negative or harsh reactions or being labelled negative or a troublemaker [31,40,57,59], or they are afraid of a bad evaluation [52], retaliation [60] or retribution [61,62]. Positive and negative experiences with speaking up influence someone's consideration of speaking up again [63,64]. ...
... Positive and negative experiences with speaking up influence someone's consideration of speaking up again [63,64]. Prior negative experiences influence this unsafe feeling and leave healthcare professionals hesitant to speak up [57]. If healthcare professionals perceive the environment as psychologically safe, the frequency of withholding voice significantly decreases [55]. ...
Background
Speaking up among healthcare professionals plays an essential role in improving patient safety and quality of care, yet it remains complex and multifaceted behaviour. Despite awareness of potential risks and adverse outcomes for patients, professionals often hesitate to voice concerns due to various influencing factors. This complexity has encouraged research into the determinants of speaking-up behaviour in hospital settings. This review synthesises these factors into a multi-layered framework. It aims to provide a more comprehensive perspective on the influencing factors, which provides guidance for interventions aimed at fostering environments contributing to speaking up in hospitals.
Methods
A systematic review was conducted in November 2024, searching databases: PubMed, Scopus and Web of Science. Following PRISMA guidelines and the three stages for thematic synthesis, we developed the classification of influencing factors. Out of 1,735 articles identified articles, 413 duplicates were removed, 1,322 titles and abstracts were screened, and 152 full texts (plus six additional articles) were assessed. Ultimately, 45 articles met the inclusion criteria.
Results
The review categorised influencing factors into four categories: individual (29 articles, 64%), relational (21 articles, 47%), contextual (19 articles, 42%), and organisational (26 articles, 58%). These categories encompass motivating, hindering and trade-off factors affecting speaking up among healthcare professionals in hospitals.
Conclusions
The multi-layered framework highlights the dynamic interplay of factors influencing speaking up among healthcare professionals. A systems approach is essential for identifying barriers and enablers and designing effective speaking up interventions. This framework serves as a foundation for more focused research and practical guidance, enabling healthcare leaders to address barriers across all categories. By fostering environments that support open communication, organisations can enhance patient safety and quality of care.
Aim
Whereas voice behaviour has been identified as a key precursor to safe and high‐quality patient care, little is known about how voice relates to key workforce outcomes. This study aimed to investigate the relationships between certified nursing assistants' perceived promotive voice behaviour (speaking up with suggestions for future improvement) and prohibitive voice behaviour (speaking up about problems or potentially harmful situations) and their self‐reported levels of job satisfaction, work engagement and turnover intentions.
Design and methods
Dutch certified nursing assistants were recruited for a two‐wave survey study through non‐random convenience sampling. The final sample contained 152 respondents. The data were analysed using multiple linear regression analyses. In all analyses, the dependent variable at time one was controlled for.
Results
Certified nursing assistants' promotive and prohibitive voice behaviour at time one were found to be positively related to their level of job satisfaction at time two while controlling for job satisfaction at time one. No relationships with work engagement or occupational turnover intentions were found.
Conclusion
While previous research has found positive effects of voice on patient safety outcomes and team and organizational improvements in care organizations, we demonstrate that voice is also related to a key workforce outcome, that is, certified nursing assistants' job satisfaction.
Implications and impact
Recognizing the interplay between voice behaviour and job satisfaction underscores the importance of creating work environments where certified nursing assistants feel able and willing to make their voices heard—with ideas and suggestions, as well as information regarding problems and concerns.
Patient or public involvement
Three certified nursing assistants have contributed to the development of the survey.
Introduction
At all levels, effective collaboration between actors with different backgrounds lies at the heart of integrated care. Much attention has been given to the structural features underlying integrated care, but even under structurally similar circumstances, the effectiveness of collaboration varies largely.
Theory and methods
Social and organizational psychological research shows that the extent to which collaboration is effective depends on actors’ behaviours. We leverage insights from these two research fields and build a conceptual framework that helps untangle the behavioural processes underlying effective collaboration.
Results
We delineate that effective collaboration can be realized when actors (1) speak up about their interests, values, and perspectives (voice behaviour), (2) listen to the information that is shared by others, and (3) thoroughly process this information. We describe these behaviours and explain the motivations and conditions driving these. In doing so, we offer a conceptual framework that can be used to explain what makes actors collaborate effectively and how collaboration can be enhanced.
Discussion and conclusion
Fostering effective collaboration takes time and adequate conditions, fitting the particular context. As this context continuously changes, the processes and conditions require continuous attention. Integrated care, therefore, actually requires a carefully designed process of integrating care.
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.
Aims
To identify crucial programme characteristics and group mechanisms of, and lessons learned from hindrances in an empowerment programme for certified nursing assistants and contribute to the development of similar programmes in other care settings.
Design
Exploratory qualitative study.
Methods
Between May 2017 and September 2020, we used in‐depth interviews and participant observations to study four groups participating in an empowerment programme for certified nursing assistants (N = 44).
Results
We identified three crucial empowerment‐enhancing programme characteristics: (1) inviting participants to move outside their comfort zone of caregiving; (2) stimulating the use of untapped talents, competencies and interests; (3) supporting the rediscovery of participants' occupational role and worth. Crucial group mechanisms encompassed learning from and with each other, as well as mechanisms of self‐correction and self‐motivation. Hindrances included a perceived lack of direction, and a lack of organizational support and facilitation.
Conclusion
We showed the significance of creating an inviting and stimulating environment in which participants can explore and function in ways they otherwise would not. Likewise, we identified how this can help participants learn from, critically correct and motivate one another.
Impact
The programme under study was uniquely aimed to empower certified nursing assistants. Our insights on crucial programme characteristics and group mechanisms may benefit those who develop empowerment programmes, but also policymakers and managers in supporting certified nursing assistants and other nursing professions in empowerment endeavours. Such empowerment may enhance employee retention and make occupational members more likely to address challenges affecting their occupational group and the long‐term care sector.
Background:
Psychological safety-the belief that it is safe to speak up-is vital amid uncertainty, but its relationship to feeling heard is not well understood.
Purpose:
The aims of this study were (a) to measure feeling heard and (b) to assess how psychological safety and feeling heard relate to one another as well as to burnout, worsening burnout, and adaptation during uncertainty.
Methodology:
We conducted a cross-sectional survey of emergency department staff and clinicians (response rate = 52%; analytic N = 241) in July 2020. The survey measured psychological safety, feeling heard, overall burnout, worsening burnout, and perceived process adaptation during the COVID-19 crisis. We assessed descriptive statistics and construct measurement properties, and we assessed relationships among the variables using generalized structural equation modeling.
Results:
Psychological safety and feeling heard demonstrated acceptable measurement properties and were correlated at r = .54. Levels of feeling heard were lower on average than psychological safety. Psychological safety and feeling heard were both statistically significantly associated with lower burnout and greater process adaptation. Only psychological safety exhibited a statistically significant relationship with less worsening burnout during crisis. We found evidence that feeling heard mediates psychological safety's relationship to burnout and process adaptation.
Conclusion:
Psychological safety is important but not sufficient for feeling heard. Feeling heard may help mitigate burnout and enable adaptation during uncertainty.
Practice implications:
For health care leaders, expanding beyond psychological safety to also establish a feeling of being heard may further reduce burnout and improve care processes.
Members of frontline low-status occupational groups often have access to a vast pool of knowledge, expertise, and experience that may be valuable for organizations. However, previous research has shown that members of these occupational groups are often reluctant to exhibit voice behavior due to their low position in the organizational hierarchy and perceived status differences. Drawing on in-depth interviews with auxiliary nurses (ANs) who participated in a development trajectory, as well as with their colleagues and supervisors, we demonstrate how members of this low-status occupational group develop voice behavior. Our findings show how acquiring three different types of knowledge and acting on this knowledge can lead to forming new and different types of relationships with members of higher status occupational groups in the organization. Subsequently, these relational changes enhanced voice behavior, as the ANs under study became more skillful in navigating the organization and felt better equipped to share their ideas, concerns, and perspective. We contribute to the literature on voice behavior by members of low-status occupational groups by moving beyond the findings of previous studies that have shown that low-status employees are unlikely to exhibit voice behavior. We detail how the development of knowledge, as well as relationships between different occupational groups, is crucial for the enhancement of voice behavior that transcends hierarchical levels. Moreover, we add to the literature on upward influence of subordinates by showing how such voice allows subordinates to exert upward influence in their organizations and initiate change that benefits their own occupational group.
Purpose:
Workplace silence impedes productivity, job satisfaction and retention, key issues for the hospital workforce worldwide. It can have a negative effect on patient outcomes and safety and human resources in healthcare organisations. This study aims to examine factors that influence workplace silence among hospital doctors in Ireland.
Design/methodology/approach:
A national, cross-sectional, online survey of hospital doctors in Ireland was conducted in October-November 2019; 1,070 hospital doctors responded. This paper focuses on responses to the question "If you had concerns about your working conditions, would you raise them?". In total, 227 hospital doctor respondents (25%) stated that they would not raise concerns about their working conditions. Qualitative thematic analysis was carried out on free-text responses to explore why these doctors choose to opt for silence regarding their working conditions.
Findings:
Reputational risk, lack of energy and time, a perceived inability to effect change and cultural norms all discourage doctors from raising concerns about working conditions. Apathy arose as change to working conditions was perceived as highly unlikely. In turn, this had scope to lead to neglect and exit. Voice was seen as risky for some respondents, who feared that complaining could damage their career prospects and workplace relationships.
Originality/value:
This study highlights the systemic, cultural and practical issues that pressure hospital doctors in Ireland to opt for silence around working conditions. It adds to the literature on workplace silence and voice within the medical profession and provides a framework for comparative analysis of doctors' silence and voice in other settings.
The upward voicing of ideas is vital to organizational performance. Yet power differences between voicers and those with authority may result in valuable ideas being overlooked. In this ethnographic, 31-month longitudinal study of a multi-disciplinary team in the healthcare sector, we examine how upwardly voiced ideas can endure to reach implementation. Of 208 upwardly voiced ideas, most were rejected in the moment, but 49 reached implementation despite appearing to be initially rejected. These ideas were kept alive by other team members who later drew upon and revived the initial ideas through what we call the voice cultivation process. We detail this process and describe five pathways through which voiced ideas stayed alive to reach implementation by overcoming different forms of resistance. We illustrate how the allyship of others can help voice live on beyond its initial utterance to reach implementation and generate change, even when the person who initially spoke up is no longer on the team or advocating for the idea. By reconceptualizing voice as a collective, interactional process rather than a one-time dyadic event, this paper develops new theory on how employees can help one another’s voice be heard to positively impact their teams and organizations.
We draw on Gouldner's (1960, Am. Sociol. Rev., 25, 161) norm of reciprocity to accomplish three goals: (1) theoretically depict the employee voice process as an exchange relationship that is maintained when both parties provide benefits ‘in kind’ to each other; (2) introduce the notion of voice resilience, defined as subsequent engagement in voice despite adversity in the process (i.e., voice non‐endorsement); and (3) demonstrate the importance of voice safety as a key mechanism that facilitates voice resilience. When employees speak up to their leaders with suggestions for change, this behaviour is positively intended and represents a contribution to the leader and to the mutual relationship because voice is a risky behaviour. When leaders do not implement employee suggestions (non‐endorsement of voice) but reciprocate by providing adequate explanations for non‐endorsement, this should foster employee perceptions of voice safety and make it more likely that employees will speak up with suggestions in the future (subsequent voice). In sum, this mutual exchange of benefits, voice from the employee and adequate explanations for non‐endorsement from the leader, should foster voice resilience. Results across two studies (field and laboratory) demonstrate that sensitivity of explanations for non‐endorsement (not specificity) predicts follower's voice safety and subsequent voice. We discuss the theoretical implications of the more personal nature of sensitive explanations compared to the more descriptive and factual nature of specific explanations and consider the practical benefits of encouraging leaders and organizations to view the voice process as a mutual exchange relationship.
Practitioner points
• Organizations can offer training and development on how to maintain voice exchange relationships even when leaders do not endorse employee suggestions.
• Our work demonstrates that it is critically important for leaders to exhibit sensitivity in their non‐endorsement responses to employee suggestions.
• If explanations in the voice process are delivered in a sensitive manner, our research shows that voice resilience can be achieved by fostering voice safety such that employees are significantly more likely to engage in subsequent voice.
Background: Healthcare aides (HCAs) are the primary caregivers for vulnerable older persons. They have many titles and are largely unregulated, which contributes to their relative invisibility. The objective of this scoping review was to evaluate the breadth and depth of the HCA workforce literature.
Methods: We conducted a search of seven online bibliographic databases. Studies were included if published since 1995 in English, peer-reviewed journals. Results were iteratively synthesized within and across the following five categories: education, supply, use, demand and injury and illness.
Results: Of 5,045 citations screened, 82 studies met inclusion criteria. Few examined HCA education; particularly trainee characteristics, program location, length and content. Results in supply indicated that the average HCA was female, 36–45 years and had an education level of high school or less. Home health HCAs were, on average, older and were more likely to be immigrants than those working in other settings. The review of studies exploring HCA use revealed that their role was unclear – variation in duties, level of autonomy and work setting make describing “the” role of an HCA near impossible. Projected increased demand for HCAs and high rates of turnover, both at the profession and facility-level, elicit predictions of future HCA shortages. Home health HCAs experienced comparatively lower job stability, earned less, worked the fewest hours and were less likely to have fringe benefits than HCAs employed in hospitals and nursing homes. The review of studies related to HCA illness and injury revealed that they were at comparatively higher risk of injury than registered nurses and licensed practical nurses.
Conclusions: This is the largest, most comprehensive scoping review of HCA workforce literature to date. Our results indicate that the HCA workforce is both invisible and ubiquitous; as long as this is the case, governments and healthcare organizations will be limited in their ability to develop and implement feasible, effective HCA workforce plans. The continued undervaluation of HCAs adversely impacts care providers, the institutions they work for and those who depend on their care. Future workforce planning and research necessitates national HCA registries, or at minimum, directories.
In four studies, we examine implicit voice theories - taken-for-granted beliefs about when and why speaking up at work is risky or inappropriate. In Study 1, interview data from a large corporation suggest that fine-grained implicit theories underlie reluctance to voice even pro-organizational suggestions. Study 2 survey data address the generalizability of the implicit theories identified in Study 1. Studies 3 and 4 develop survey measures for five such theories, establishing the measures' discriminant validity and incremental predictive validity for workplace silence. Collectively, our results indicate that implicit voice theories are widely held and significantly augment explanation of workplace silence.
When employees voluntarily communicate suggestions, concerns, information about problems, or work-related opinions to someone in a higher organizational position, they are engaging in upward voice. When they withhold such input, they are displaying silence and depriving their organization of potentially useful information. In this article, I review the current state of knowledge about the factors and motivational processes that affect whether employees engage in upward voice or remain silent when they have concerns or relevant information to share. I also review the research findings on the organizational and individual effects of employee voice and silence. After presenting an integrated model of antecedents and outcomes, I offer some potentially fruitful questions for future research.
This paper introduces the construct of leader inclusiveness—words and deeds exhibited by leaders that invite and appreciate others' contributions. We propose that leader inclusiveness helps cross-disciplinary teams overcome the inhibiting effects of status differences, allowing members to collaborate in process improvement. The existence of a professional hierarchy in medicine and the differential status accorded to those in different disciplines is well established in the health care literature, as is the need for quality improvement. We build on this foundation to suggest that profession-derived status is positively associated with psychological safety (H1)—a key antecedent of speaking up and learning behavior—in health care teams. We hypothesize that this effect varies across teams (H2), and furthermore, that leader inclusiveness predicts psychological safety (H3) and moderates the relationship between status and psychological safety (H4). Finally, we suggest psychological safety predicts engagement in quality improvement work (H5) and mediates the relationship between leader inclusiveness and engagement (H6). Survey data collected in 23 neonatal intensive care units involved in quality improvement projects support our hypotheses. These results provide insight into antecedents of and strategies for fostering improvement efforts in health care and other sectors in which cross-disciplinary teams engage in collaborative learning to improve products or services. Copyright © 2006 John Wiley & Sons, Ltd.
Background
There is increasing recognition that beyond frontline workers’ ability to speak up, their feeling heard is also vital, both for improving work processes and reducing burnout. However, little is known about the conditions under which frontline workers feel heard.
Purpose
This inductive qualitative study identifies barriers and facilitators to feeling heard among nurses in hospitals.
Methodology
We conducted in-depth semistructured interviews with registered nurses, nurse managers, and nurse practitioners across four hospitals ( N = 24) in a U.S. health system between July 2021 and March 2022. We coded with the aim of developing new theory, generating initial codes by studying fragments of data (lines and segments), examining and refining codes across transcripts, and finally engaging in focused coding across all data collected.
Findings
Frontline nurses who spoke up confronted two types of challenges that prevented feeling heard: (a) walls, which describe organizational barriers that lead ideas to be rejected outright (e.g., empty solicitation), and (b) voids, which describe organizational gaps that lead ideas to be lost in the system (e.g., structural mazes). We identified categories of responsive practices that promoted feeling heard over walls (boundary framing, unscripting, priority enhancing) and voids (procedural transparency, identifying a navigator). These practices appeared more effective when conducted collectively over time.
Conclusion
Both walls and voids can prevent frontline workers from feeling heard, and these barriers may call for distinct managerial practices to address them. Future efforts to measure responsive practices and explore them in broader samples are needed.
Practice Implications
Encouraging responsive practices may help ensure that frontline health care workers feel heard.
Talk by members of executive hospital boards influences the organizational positioning of nurses. Talk is a relational leadership practice. Using a qualitative‐interpretive design we organized focus group meetings wherein members of executive hospital boards (7), nurses (14), physicians (7), and managers (6), from 15 Dutch hospitals, discussed the organizational positioning of nursing during COVID crisis. We found that members of executive hospital boards consider the positioning of nursing in crisis a task of nurses themselves and not as a collective, interdependent, and/or specific board responsibility. Furthermore, members of executive hospital boards talk about the nursing profession as (1) more practical than strategic, (2) ambiguous in positioning, and (3) distinctive from the medical profession. Such talk seemingly contrasts with the notion of interdependence that highlights how actors depend on each other in interaction. Interdependence is central to collaboration in hospital crises. In this paper, therefore, we depart from the members of executive hospital boards as leader and “positioner,” and focus on talk—as a discursive leadership practice—to illuminate leadership and governance in hospitals in crisis, as social, interdependent processes.
As the target of employee voice, supervisors have been depicted as the driving force behind enacting employee input. In reality, voicing employees often remain key players in the enactment process as supervisors may delegate implementation responsibilities to voicers. Although the voice literature suggests that voice enactment promotes subsequent voice by giving employees evidence that their voice fosters improvements, we suggest that supervisor delegation following employee voice can, instead, turn enactment into an unintended deterrent to voice. Integrating conservation of resources theory with theory on counterfactual thinking, we argue that supervisor delegation following employee voice elicits employee overload. Subsequently, counterfactual thinking about an avoidable increase in workload evokes regret for having spoken up. This regret leads to decreased voice as employees intentionally withhold input to protect personal resources. However, we theorize that supervisor consultation represents a cost-offsetting resource that attenuates the negative effects of supervisor delegation following employee voice. We find converging support for our theoretical model in a multi-wave field study and two experimental studies. This research offers novel insights into the personal costs of voice for employees by contextualizing voice within the voice-enactment process and revealing supervisor delegation as an unforeseen impediment to employee voice.
Since its renaissance in the 1990s, psychological safety research has flourished—a boom motivated by recognition of the challenge of navigating uncertainty and change. Today, its theoretical and practical significance is amplified by the increasingly complex and interdependent nature of the work in organizations. Conceptual and empirical research on psychological safety—a state of reduced interpersonal risk—is thus timely, relevant, and extensive. In this article, we review contemporary psychological safety research by describing its various content areas, assessing what has been learned in recent years, and suggesting directions for future research. We identify four dominant themes relating to psychological safety: getting things done, learning behaviors, improving the work experience, and leadership. Overall, psychological safety plays important roles in enabling organizations to learn and perform in dynamic environments, becoming particularly relevant in a world altered by a global pandemic.
Expected final online publication date for the Annual Review of Organizational Psychology and Organizational Behavior, Volume 10 is January 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Over the past decade, hundreds of studies have been published on employee voice and silence. In this review, I summarize that body of work, with an emphasis on the progress that has been made in our understanding of when and why employees choose to speak up or remain silent, as well as the individual and organizational implications of these choices. I identify underexplored issues, limitations in how voice has been conceptualized and studied, and promising avenues for future research. Although there has been notable progress in our knowledge of voice and silence, numerous key questions remain, and there are opportunities for the literature on voice to adopt a broader view of that construct. One of the objectives of this review is to motivate and guide research that will address those questions and explore that broader view.
Expected final online publication date for the Annual Review of Organizational Psychology and Organizational Behavior, Volume 10 is January 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Constructive voice is a type of communicative act involving both voicers and managers. However, research on constructive voice has developed in two separate streams, with studies adopting either a voicer-or a manager-centric perspective, thereby failing to provide a holistic understanding of constructive voice. This unilateral approach results in missed opportunities for scholars to understand the dyadic and dynamic nature of constructive voice. To address this limitation , we draw on social exchange theory to introduce a four-phase (felt voice, expressed voice, managerial responses to voice, and relational voice outcomes) dyadic model of constructive voice. By conceptualizing constructive voice as a dyadic exchange between voicers and managers , we detail the ongoing processes in which employees initiate voice and managers subsequently endorse and/or implement voicers' input. We also introduce feedback loops to highlight the dynamic nature of constructive voice over time and explain the consequences of repeated constructive-voice exchange processes on relational outcomes. Finally, we review the literature, summarize gaps and opportunities, and provide directions for future research.
The importance of employee voice—speaking up and out about concerns—is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation—the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity—could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.
Background
Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees’ concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased.
Methods
A systematic narrative review, informed by complex systems perspectives addresses the question: “What workplace strategies and/or interventions have been implemented to promote speaking-up by employees”?
Results
Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al. (2018) [1]) hierarchical, interdisciplinary and cultural relationships and (Francis (2015) [2]) psychological safety.
Conclusions
We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.
Certified nursing assistants (CNAs) provide the majority of direct care to nursing home residents in the United States and, therefore, are keys to ensuring optimal health outcomes for this frail older adult population. These diverse direct care workers, however, are often not recognized for their important contributions to older adult care and are subjected to poor working conditions. It is probable that social‐based discrimination lies at the core of poor treatment toward CNAs. This review uses perspectives from critical social theory to explore the phenomenon of social‐based discrimination toward CNAs that may originate from social order, power, and culture. Understanding manifestations of social‐based discrimination in nursing homes is critical to creating solutions for severe disparity problems among perceived lower‐class workers and subsequently improving resident care delivery.
With many European countries facing health workforce shortages, especially in nursing, and an increasing demand for healthcare, the importance of healthcare assistants (HCAs) in modern healthcare systems is expected to grow. Yet HCAs' knowledge, skills, competences and education are largely unexplored. The study 'Support for the definition of core competences for healthcare assistants' (CC4HCA, 2015-2016) aimed to further the knowledge on HCAs across Europe. This paper presents an overview of the position of healthcare assistants in 27 EU Member States (MSs) and reflects on the emerging country differences. It is shown that most learning outcomes for HCAs across Europe are defined in terms of knowledge and skills, often at a basic instead of more specialized level, and much less so in terms of competences. While there are many differences between MSs, there also appears to be a common, core set of knowledge and skills-related learning outcomes which almost all HCAs across Europe possess. Country differences can to a large extent be explained by the regulatory and educational frameworks in which HCAs operate, influencing their current and future position in the healthcare system. Further investments should be made to explore a common understanding of HCAs, in order to feed discussions at policy and organisational levels, while simultaneously investments in the development and implementation of context-specific HCA workforce policies are needed.
Background:
Frontline staff are well positioned to conceive improvement opportunities based on first-hand knowledge of what works and does not work. The innovation contest may be a relevant and useful vehicle to elicit staff ideas. However, the success of the contest likely depends on perceived organizational support for learning; when staff believe that support for learning-oriented culture, practices, and leadership is low, they may be less willing or able to share ideas.
Purpose:
We examined how staff perception of organizational support for learning affected contest participation, which comprised ideation and evaluation of submitted ideas.
Methodology/approach:
The contest held in a hospital cardiac center invited all clinicians and support staff (n ≈ 1,400) to participate. We used the 27-item Learning Organization Survey to measure staff perception of learning-oriented environment, practices and processes, and leadership.
Results:
Seventy-two frontline staff submitted 138 ideas addressing wide-ranging issues including patient experience, cost of care, workflow, utilization, and access. Two hundred forty-five participated in evaluation. Supportive learning environment predicted participation in ideation and idea evaluation. Perceptions of insufficient experimentation with new ways of working also predicted participation.
Conclusion:
The contest enabled frontline staff to share input and assess input shared by other staff. Our findings indicate that the contest may serve as a fruitful outlet through which frontline staff can share and learn new ideas, especially for those who feel safe to speak up and believe that new ideas are not tested frequently enough.
Practice implications:
The contest's potential to decentralize innovation may be greater under stronger learning orientation. A highly visible intervention, like the innovation contest, has both benefits and risks. Our findings suggest benefits such as increased engagement with work and community as well as risks such as discontent that could arise if staff suggestions are not acted upon or if there is no desired change after the contest.
Intense emotions such as frustration, anger, and dissatisfaction often drive employees to speak up. Yet the very emotions that spur employees to express voice may compromise their ability to do so constructively, preventing managers from reacting favorably. I propose that to speak up frequently and constructively, employees need knowledge about effective strategies for managing emotions. Building on theories of emotion regulation, I develop a theoretical model that explains the role of managing emotions in the incidence and outcomes of voice. In a field study at a health care company, emotion regulation knowledge (1) predicted more frequent voice, (2) mediated by the emotional labor strategies of deep acting and surface acting, and (3) enhanced the contributions of voice to performance evaluations. These results did not generalize to helping behaviors, demonstrating that emotion regulation uniquely affects challenging but not affiliative interpersonal citizenship behaviors. This research introduces emotion regulation as a novel influence on voice and its consequences.
The literature on employees’ voice is characterized by 2 influential perspectives on its antecedents—1 that focuses on the importance of managerial behaviors and the other that emphasizes the role of employees’ internal motivational states. In this study, we integrate these perspectives and examine the proposition that (a key managerial behavior) consultation—that is, the extent to which the manager is seen to solicit and listen to suggestions on work issues from the employees, enhances employees’ upward voice by increasing their perceived influence at work (an important motivational state). Using multisource survey data from 640 nurses and their managers, we found that managers’ consultation was positively related to employees’ upward voice, with employees’ perceived influence acting as the mediator. We further delineate key moderators of this mediated relationship and discuss implications for theory and practice.
Research suggests that staff voice-discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues with the intent to improve organizational or unit functioning-is associated with quality improvement, which most agree is needed in health care. Nevertheless, health professionals often do not voice. Little research has explored their reluctance to speak up and, relatedly, the conditions under which they voice.
Although several organizational behavior management (OBM) intervention techniques have been used to improve designated behaviors related to patient safety, there remains a lack of patient-safety-focused behavioral interventions among healthcare workers. OBM interventions are often applied to needs already identified within an organization, and the means by which these needs are determined vary across applications. The current research addresses gaps in the literature by translating OBM intervention techniques to identify and improve the prevention potential of responses to reported medical errors. A content analysis of 17 months of descriptions of follow-up actions to error reports for nine types of the most-frequently occurring errors was conducted. Follow-up actions were coded according to a taxonomy of behavioral intervention components, with accompanying impact scores based on criteria developed by Geller et al. Two error types were selected for intervention, based on the highest frequency of reporting and lowest average follow-up intervention impact score. Over a 3-month intervention period, managers were instructed to respond to these two error types with active communication, group feedback, and positive recognition strategies. Results indicate improved prevention potential as a consequence of improved corrective action for targeted errors, with rates of individual and group feedback delivery increasing by 10–35% for managers' responses to targeted error types. Future implications for identifying and classifying responses to medical error are discussed.
The aim of the present study was to explore nurses' perceptions of their own ability to speak up and be heard in the workplace.
Nurses are central to patient care and patient safety in hospitals. Their ability to speak up and be heard greatly impacts their own work satisfaction, team work as well as patient safety.
The present study utilized a qualitative approach, consisting of focus group interviews of 33 registered nurses (RNs), in staff or management positions from a variety of healthcare settings in California, USA. Data were analysed using thematic content analysis.
Findings were organized into three categories: influences on speaking up, transmission and reception of a message and outcomes or results. The present study supported the importance of the manager in setting the culture of open communication. IMPLICATIONS FOR NURSE MANAGERS: It is anticipated that findings from the present study may increase understandings of nurse views of communication within healthcare settings. The study highlights the importance of nurse managers in creating the communication culture that will allow nurses to speak up and be heard. These open communication cultures lead to better patient care, increased safety and better staff satisfaction.
Focus group interviews are a method for collecting qualitative data and have enjoyed a surge in popularity in health care research over the last 20 years. However, the literature on this method is ambiguous in relation to the size, constitution, purpose and execution of focus groups.
The aim of this article is to explore some of the methodological issues arising from using focus group interviews in order to stimulate debate about their efficacy.
Methodological issues are discussed in the context of a study examining attitudes towards and beliefs about older adults in hospital settings among first-level registered nurses, nursing lecturers and student nurses. Focus group interviews were used to identify everyday language and constructs used by nurses, with the intention of incorporating the findings into an instrument to measure attitudes and beliefs quantitatively.
Experiences of conducting focus group interviews demonstrated that smaller groups were more manageable and that groups made up of strangers required more moderator intervention. However, as a data collecting strategy they are a rich source of information.
Making work meaningful. A way to attract nurses to remain in their jobs
- J M C Both-Nwabuwe
Both-Nwabuwe, J. M. C. (2020). Making work meaningful. A way to attract nurses
to remain in their jobs [doctoral dissertation].