Opportunities for nurses to address employee voice in health care providers: a scoping review

If employees choose to stay silent, this indicates that they are aware of certain issues and fail to address them [6], often because they are afraid to share their perspective [7]. Consequently, important information or concerns about the organization are withheld, and mistakes can occur or further development becomes impossible [6‐8]. The opposite of staying silent is speaking up. Speaking up means speaking out about meanings, concerns, and inquiries when there are uncertainties [1, 9‐11]. There are a various definitions and approaches of speaking up and staying silent in the literature. Most definitions of speaking up emphasize the safe treatment of people in need of care, error management and whistleblowing, as well as on team communication [1, 2, 12]. However, speaking up and staying silent also involves an organizational perspective, having a voice in an organization as an employee [2, 13]. This engagement element of workplace democracy is known as employee voice. Employee voice refers to all organizational structures, mechanisms or practices in which employees participate and through which they try to influence their work and the performance of their organization [13, 14]. It is necessary to mention that the definitions come from different fields of organizational behaviour not only specific from the health care sector. Kolbe and Grande [1], Mannion et al. [12] and Lainidi et al. [2] focus specifically on voice and silence in healthcare organizations. While there is no clear definition of employee voice in health care [2], there are studies that attempt to analyze the various challenges of employee voice in health care. Challenges in the healthcare sector are generally related to a variety of social, hierarchical factors and the measurement of voice in health care. As collaboration in health care is multidisciplinary and employee voice affects all professional groups, studies have included different healthcare workers, but primarily nurses and physicians [1, 12, 15].

Nurses, in particular, have been shown to be reluctant to express their opinions and to have low self-efficacy regarding safety precautions [16]. For this reason, this review attempts to focus on nurses. Recent evidence from the pandemic addresses this issue and shows that opportunities to learn from nurses to optimize processes have been missed. It has been found that, especially in times of crisis where short-term turnarounds change patient safety and personal protective equipment every day, it is necessary that nurses have a voice [17]. According to Umoren et al. [18], one of the barriers that explains why health care professionals stay silent is the hierarchical culture in health care organizations. Other influencing factors on voice and silence include organizational identification [19] and trust from the management [20]. The consequences of employees staying silent are well researched [8, 21‐23]. For example, if an employee does not feel valued, they perceive a lack of control or experience employee cognitive dissonance, which is regarded as low commitment, low trust, and further low internal motivation; this can result in low satisfaction, turnover, stress, and withdrawal [8]. Holland et al. [21] found that mechanisms for employee voice and responsive approaches to addressing the concerns of nurses are important for lowering burnout and promoting employee well-being. Lee et al. [24] identified factors that facilitate or inhibit nurses’ willingness to raise voice regarding patient safety in East Asia. The review results indicate that various factors, including socio-cultural, organizational and team-related, as well as individual factors, can either encourage or discourage individuals to raise their voices or remain silent. Another study by Lee et al. [25] shows that positive factors to promote the voice of staff include a culture of safety, management support, positive role models, familiarity with others, and personal characteristics. Negative factors include hierarchies, power differences, seniority, length of service, relationship anxiety and heavy workloads [25].

In their review, Lainidi et al. [2] summarize influencing factors on voice and silence and developed a framework. The framework of conditions and issues that affect employee voice and silence, describes three aspects of silence and voice: motivation, behaviour and outcome. The conditions that influence the three aspects of voice and silence are organizational, leadership, team, and individual. Additionally, the type, orientation, context, and severity of the problem also influence these three aspects of voice and silence. A fundamental aspect of supporting employee voice is the comprehension of the motivating factors [2].

In summary, individual, organizational and contextual characteristics influence nurses' decisions about whether to raise concerns and initiate change or remain silent. Therefore, an organizational culture is needed that encourages nurses to raise their voice and address negative factors. Managers can create an environment that supports nurses by using transformational leadership and developing strategies to promote nurses' perceived influence and psychological safety, by inviting and valuing staff, creating an open communication culture, giving feedback and by helping to understand the importance of all nurses' voices. And, by developing different strategies as the influences on voice and silence are different [26‐29]. A review of interventions to promote speaking up in health care was conducted, encompassing all speak-up initiatives and focusing on workplace strategies. Their focus was directed towards the factors that needed to be considered in the implementation phase. Their results showed, that existing research as well national and international policy contexts are rarely considered and built upon when developing speak-up interventions. Furthermore, raise your voice is shaped by socio-cultural norms and values outside the organization [30]. This review is distinct from previous ones in that it concentrates on nursing and the characteristics of opportunities, as well as considering the various definitions of employee voice.

We used the following inclusion and exclusion criteria (Table 2). The criteria are based on the aims of the review. It should be noted that only studies that actually focused on opportunities (such as interventions and tools) were included in terms of the context employee voice. Included studies have used for example a management tool to support employee voice and described the role of management in relation to the opportunity to address employee voice. Studies were excluded if their focus was only on leadership style and did not describe opportunities for employee voice. A further exclusion criterion was studies that did not include nurses.

The search was conducted in April 2023 in the following databases: MEDLINE via PubMed, CINHAL via EBSCO, Scopus via Elsevier, Wiley/Web of Science and Cochrane Library. The selected databases were chosen according to the health care setting and the concept of employee voice. Therefore, health-related databases and business-related databases were used. A three-stage search strategy guided by the manual for literature search in specialized databases, RefHunter [35], was used. Specifically, the three phases include a preliminary search, a systematic search, and a supporting search. As previously described, a preliminary search of MEDLINE via PubMed was performed to refine the inclusion and exclusion criteria, to define the search components, and to identify key words and MeSH terms. The preliminary search was conducted by KA and discussed by the research team. As a result of the preliminary search, it became necessary to modify the selected inclusion and exclusion criteria, and consequently the search terms, in order to ensure the optimal scope and precision of the subsequent search. Specifically, the search was restricted to nurses, employee voice and digital tools, but no relevant results were yielded. Consequently, the scope was broadened to include healthcare organizations and, in addition, and all opportunities which address employee voice, not only digital tools. In the first step of the second stage, the systematic search, a search string in Medline via PubMed was developed by KA and discussed and adapted by the research team. The search string was then adapted for the other databases and the systematic search was conducted. Furthermore, in the third stage, we used citation tracking by screening the reference lists of relevant results and identified them via Google Scholar. The used search components, search terms and MeSH terms can be seen in the Table 3. Furthermore, the search terms and their synonyms are linked to search strings using the boolean operators (OR, AND). Filters were applied to the English and German languages. Truncations and MeSH terms were adapted to the databases used.

As shown in the PRISMA search flowchart (Fig. 1) we identified 951 studies in five databases and via citation tracking. All these results were imported into COVIDENCE. COVIDENCE is a software for managing and simplifying reviews. The software removed duplicates and allowed the two reviewers to screen the literature simultaneously. Specifically, the title and abstract were reviewed against the inclusion and exclusion criteria to identify appropriate studies separately by two researchers. The software identified disagreements between the two reviewers. Any disagreements were discussed in a follow-up meeting until a consensus was reached. If consensus could not be reached, a third reviewer (RM or FA) was involved. Once all open issues had been resolved, the full text analysis was carried out. The full text reports of the relevant studies were reviewed in the next step, just as in the abstract screening. The screening process was entirely carried out by two independent reviewers, following the inclusion and exclusion criteria (KA and BA). The studies selected by the two reviewers (KA and BA) were then discussed by the research team. The next step was to analyze the included studies.

For the data extraction, an extraction form was developed based on TIDieR (Template for Intervention Description and Replication) [36] and CReDECI 2 (Criteria for Reporting the Development and Evaluation of Complex Interventions in health care) [37] by the two reviewers (KA and BA). The data extraction form included the following details: source (authors(s), year of publication, origin), aims, study design and methods, characteristics of the sample, outcomes and the definition of speaking up/employee voice, as well as a description of the opportunity to address employee voice. The data extraction form was developed by KA and validated by BA. To fulfill the search requirements, one reviewer (KA) extracted data, while the other reviewer (BA) cross-checked the data extraction. Disagreements between reviewers (KA and BA) were resolved by discussion. If consensus could not be reached, a third reviewer (RM or FA) was involved.

The included studies were heterogeneous in their definition and understanding of employee voice, described opportunities and contexts. Accordingly, the included studies are illustrated in Table 4 and presented in a narrative summary based on the aims of the review. This enables the identification of opportunities for employee voice and insights into the characteristics of these opportunities. The articles were analysed by the two reviewers (AK and BA). There was a regular exchange about the complete analysis [38].

In addition to the aspects of organizational culture and the role of management that have been described thus far, the employees themselves also play an important role in determining whether or not employee voice is possible. The included studies describe different ways to support the individual aspects of employees being able to speak up and initiate change [5, 41, 43, 44].

Using a pretest–posttest control group design, Ginsberg and Bain [41] developed a role-playing simulation workshop to promote speaking up. The aim of the research was to evaluate the impact of the multifaceted intervention to encourage staff to speak up when they have patient care concerns and when faced with unprofessional behaviors from team members. The survey was performed before the workshop and three and four months after the workshop at a community hospital in Ontario, Canada. The control group was the intensive care unit, and the intervention group was the emergency department. The primary participants were nurses, although physicians and other allied health professionals were also involved. The multifaceted intervention is described with the following components. First, there was a role-playing simulation workshop (opening monologues, debriefing sessions and an exit survey). Second, there were the follow-up interventions and the initiative for department-led leadership (staff huddles, one-on-one meetings). In summary, the multifaceted approaches that have been described can improve employees’ perceptions and, as a consequence, the team working climate. A good team working climate can further improve speaking up. The results refer to being aware of different context and internal organizational factors, as already described [41]. In a qualitative study, Kee et al. [43] analyzed how members of lower-status occupational groups can develop voice behavior that transcends hierarchical levels in the Netherlands. The study included observations of 5 Dutch home-care organizations and interviews with 14 registered nurses (4 years education), 10 auxiliary nurses (3 years education) and 12 supervisors. 14 participants joined a trajectory and were interviewed twice, halfway through and at the end of the trajectory. The trajectory was developed from the Dutch Nurses Association and included 8 full-day plenary training sessions, individual assignments, moments of personal reflection and individual coaching sessions. The role of members of low-status occupational groups are placed at the center of the research in this study. In doing so, it addresses the role of a specific group of employees and how they can have a voice in an organization. The results show that it is important for low-status occupational groups to receive special training in how to speak and how to give feedback. More specifically, there is a need for support to develop voice behavior to exert upward influence in their organization and initiate change that actually benefits their work group [

43].

Law and Chan [44] extend the findings of Kee et al. [43] that it is necessary to teach speaking up and that a continuous learning process is necessary from the beginning to generate a safe and open speaking culture. They used a narrative inquiry approach to explore the experiences of newly qualified registered nurses in speaking up. Their aim was to understand the learning process by which newly graduated registered nurses learn to speak up. These findings demonstrate that it is necessary to consider that a learning process is formed by cultural aspects and generational differences. In addition, they analyzed data showing that people need more than one-time training and safety tools to develop speaking up skills and promote culture. Suggested ways to support the learning process of speaking up include being mentored by others, self-mentoring and reflecting on mistaken experiences to see new possibilities for the future. More specifically, nurses were trained to speak up through mentoring before, during and after each experience of speaking up. Along with recommending that speaking up be seen as an ongoing learning process, this process can help to create an open and safe organizational culture [44].

Wilkinson et al. [5] also focused on the role of the employee in speaking up in their research, similar to Kee et al. [43]. In particular, they examined the impact of cultural issues on the voice of the employee. For example, they investigated whether ethnicity has an impact on whether employees speak up or remain silent. Their results show that regarding the cultural aspect, top-down communication can be misinterpreted. In general, the art of communication varies from one culture to another. In conclusion, CALD factors such as cultural norms, literacy, language and limited space have to be considered to build an organizational culture of employee voice.

The findings of Ginsburg and Bain [41], Kee et al. [43], Law and Chan [44], and Wilkinson et al. [5] showed that if the opportunities that deal with employee voice are to be used and have an impact, it is necessary to improve the level of education, provide ongoing training on how to use the opportunities, perhaps offer technical support and consider cultural and generational aspects.

Kaine’s [42], Sexton et al. [45] and Wilkinson et al. [5] found that there are opportunities such as the support and facilitator role of leaders, for example, through WalkRounds™ [45], to address and enable employee voice as a leader. However, for the opportunities to be effective, frameworks need to be embedded in organizations. Kaine's [42] case study explored employee voice in three aged care facilities in Australia. They conducted interviews with nurses and managers occupying a range of roles across the facilities, and they analysed internal documents. The findings suggest that there are various opportunities, which are described in the three cases that try to improve employee voice, such as a continuous quality improvement process (CQI), section staff meetings, clinical care committees, employee surveys conducted by third parties every 18 months and feedback forms. It is not clearly described in the studies that the nurses are using the trade unions to have a voice or to get a voice and how they are using them. In summary, the factors or opportunities that have an impact on the regulation of voice cannot be ranked in order of importance. However, the results of the case study highlight four areas that need to be considered to address employee voice in aged care: location, social norms, labor law and organizational norms. These findings clearly indicate that the location of an organization (local labor market), social norms (social meaning of elderly care), the expectations of the labor market and labor law interact with the internal regulation of an organization. Such internal regulations are most often expressed through the exercise of the management. This leads to the fact that leaders have a key role in enabling employees to have a voice in the organization [42].

Wilkinson et al. [5] concluded in their single-case study residential aged care facilities in Australia. The aim of this research was to understand the challenges of multicultural voices within an organization (managerial and employee perspective) in terms of what encourages or inhibits the propensity of employees to speak up. The analysis of 21 semistructured interviews, 10 interviews with managers and 11 with hospitality and nursing staff in one aged care facility highlights a voice system that includes voice and communication channels, as well as the designers of the voice system. Furthermore, the identified voice system blockages. Blockage in the voice system is summarized in three factors: management (lack of safety, futility, no dobbing culture), organizational (lack of skills to use voice opportunities and budget) and CALD factors (cultural norms, literacy, language, limited space to build social capital).The analysis of the designers involved in the voice systems showed that the management genuinely cared about the communication and voice processes in the organization. However, the focus was more on ensuring that all staff were informed and less on giving upward feedback to initiate change [5].

WalkRounds™ (WR) is a tool for connecting leadership to patient safety and inculcating safety ideas into health care systems. The WR consists of a core group (employees such as nurses and other available staff), which includes executives who conduct weekly visits to different areas of the hospital. The aim is to talk about specific questions, adverse events and the factors or system issues that led to these events. In summary, it is an informal opportunity for leaders to have discussions about safety issues with front-line staff [49]. The findings of Sexton et al. [45] provide important insights into the effects of WR. This cross-sectional web-based survey of 31 hospitals used the SCORE to understand relationships between WR with feedback and health care work setting norms (safety culture, employee engagement, burnout and work-life balance). The sample consisted of a diverse range of healthcare professionals and administrative staff. Of these, nurses constituted the largest proportion of any professional group, representing approximately 31% of the total sample. The results show that work settings reporting more WR with feedback had substantially higher safety culture domain scores and significantly higher engagement scores for four of its six domains. In conclusion, the authors recommended that WR with feedback is a potential intervention to address speaking up [45]. In a case study of four hospitals, Adelman [39] conducted a document analysis and interviewed individuals in various roles within each hospital, including the Chief Executive Officer and frontline nurses. The results of this study represent key elements of leadership promoting employee voice. Each of their key elements – culture, voice opportunity, risks and costs, voice instrumentality – positively influenced employee voice. Voice opportunities include investigations to give employees the opportunity to speak up through both formal and informal communication channels. For these opportunities to be used and work, a certain leadership behavior is needed. The results demonstrated that approachability and visibility are important. Leaders need to be present and visible in their organization. They are role models and should offer face-to-face communication and listening. Voice instrumentality refers to leaders’ response and impact when employees speak up. What happens when employees give feedback? What consequences and responses might follow? The key elements of culture, risk and costs describe the organizational culture. This includes whether employees felt comfortable talking about their concerns. In practical detail, this involves psychological safety, relationships, and trust as important factors when employees speak out or remain silent. It also includes education and training to learn to speak up to further create continuous improvement [39].

Krenz et al. [46] showed that the formal hierarchy in a team as well as the behavior of the team leader can influence nurses’ voice. They analysed 78 different health care providers (36 nurses, 29 junior doctors, 13 consultants) in a large university hospital during ten different one-day simulation-based team training sessions. The results provide a clear account of the effects of leadership and hierarchy on nurses' actual voice. They show that hierarchy and leadership delay nurses' first voice but do not affect the overall frequency of their voice [46].

In their research, Adelman [39] describes voice opportunities as key element of promoting employee voice. As already mentioned, voice opportunities should contain formal and informal communication channels. Formal communications approaches that were used in the four analyzed cases were, for example, rounding logs to track trends, tracking employee recognition, and following up on issues. All CEOs discussed rounding as their primary means for soliciting upward feedback. Additionally, computerized communication and feedback repositories for employees to submit questions or concerns directly to senior leaders were mentioned. Further formal approaches to communication were ad hoc focus groups, compliance hotlines, cross-functional committees, meetings, retreats, employee culture and opinion surveys, knowledge boards, suggestion boxes, volunteer satisfaction surveys, steering committees, process improvement committees, and one-on-one meetings/luncheons. The informal communication strategies used in the four cases were e-mail or telephone calls and an open-door policy. Furthermore, they mentioned BBQ days, employee breakfasts and luncheons as informal ways to communicate. One case also described the use of podcasts, blogging, and other social media to communicate in the variety of ways that people may prefer [39].

In their case study, Wilkinson et al. [5] describe a voice system that includes voice and communication channels. The voice and communication channels used in the analyzed long-term care facilities were divided into upward (top down) and downward (bottom up) channels that carried information to or from employees. In the explored case, the bottom-up tools that were implemented included learning circles, open door policy, improvement log, whistleblowing line and informal voice, performance reviews and climate surveys. To communicate information to employees (top-down), Wilkinson et al. [5] identified and described the use of a touchscreen tablet messaging system, communication rooms, newsletters/magazine and access to information via an intranet system. Furthermore, the findings indicate that communication systems that are oriented top-down management ought to be considered in order to prevent misinterpretations of diverse work cultures. Additionally, the long-term care facilities used opportunities for two-way communication, such as different forms of meetings, a communication system within the company and daily briefings/shift handovers [5].