Introduction
The concept of organizational silence was first coined by Morrison and Milliken, describing it as a phenomenon of a collective culture of silence on the organizational level [1]. Subsequently, Pinder and Harlos emphasized the silent behavior of individuals [2], stating that individuals retain their true feelings about the behavioral, cognitive, or emotional aspects of the organizational environment without reporting them to those they think can make changes or corrections. Building on these foundations, Dyne scholars further expanded the conceptual scope of organizational silence to define it as intentionally withholding ideas, information, and opinions by employees that are relevant to improvements in work and work organizations [3]. Nowadays, organizational silence has become an important focus of research in different fields, attracting scholars from various fields to conduct in-depth discussions. In nursing, organizational silence refers to the phenomenon in which nurses have their views and opinions about problems or potential problems in clinical work and choose to retain or filter their views for various reasons [4]. A study in China revealed that nurses generally perceive moderate levels of organizational silence [5], which is consistent with the findings from countries such as Switzerland and Egypt [6, 7]. Nurses have varying degrees of organizational silence in different healthcare systems worldwide.
Due to the complexities and idiosyncrasies of the medical field, nurses’ organizational silence is pervasive. According to the survey [8], almost 91.2% of nurses have experienced organizational silence at some point during their work, while 61.6% chose to remain silent when faced with critical issues. An increasing body of research indicates that the organizational silence of nurses is detrimental to both individuals and organizations. On the one hand, it reduces nurses’ work motivation and job satisfaction, exacerbates professional burnout, enhances their willingness to quit, and seriously threatens the stability of the nursing team [9, 10]. On the other hand, silence hinders the sharing and transmission of information between nurses, leaders, and colleagues, affects the capacity of the organization to identify and correct errors, and creates potential problems that are not found and solved in time, which in turn hinders the improvement of organizational performance and the promotion of organizational reform [11, 12]. Furthermore, nurses’ organizational silence may endanger patient safety and treatment quality [13]. Consequently, organizational silence in the nurse community needs to be given adequate attention and addressed urgently.
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Considering the prevalence and severity of the phenomenon of nurses’ organizational silence, the behavior of organizational silence among nurses should be comprehensively examined. Our review aimed to identify the underlying mechanisms and influencing factors and the effects they produce. Scholars from various countries have explored and analyzed the silent behavior of nurse organizations through qualitative research; however, findings from single qualitative studies are not enough to comprehensively elucidate the issue. Therefore, the aim of this study was to synthesize existing qualitative research to explore the real experiences of nurses’ organizational silence behavior and gain insight into the motivations and feelings behind it. The research question was: What are the motivations and feelings of nurses in maintaining organizational silence in clinical work?
Methods
Study design
In this qualitative meta-synthesis study, detailed reporting was performed following the normalized structure established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [14]. Drawing inspiration from Sandelowski et al. [15], the meta-synthesis of qualitative research is predicated on comprehending its philosophical ideas and methodology, scrutinizing the included literature multiple times, deeply exploring the connotation of the phenomenon, and carrying out detailed summaries and analyses to extract new insights and form new classifications. By integrating these new findings, it is possible to construct a more comprehensive framework of understanding, which can lead to more in-depth analysis and conclusions that have developmental implications for this particular phenomenon.
Search strategy
As shown in Table 1, this study’s inclusion and exclusion criteria were created using the PICoS model theory. The following databases were thoroughly searched for relevant literature published from the database inception until July 2024: PubMed, Ovid, CINAHL, Cochrane Library, Psyinfo, Medline, Web of Science, Embase, CNKI, CECDB, VIP Database, and China Biomedical Database. Searches were conducted using a combination of subject headings and free words. Search terms: “nurs*”, “organizational silence”, “silence behavior”, “voice behavior”, “organizational voice”, “employee silence”, “experience”, “qualitative study”, “Research, Qualitative”, “phenomenology”. Throughout the retrieval process, composition was done using boolean operators. For additional processing, the retrieval results were loaded into EndNote X9. In case of disagreements, the third researcher made the final decision after two independent reviewers sorted the literature and applied inclusion and exclusion criteria.
Table 1
Inclusion and exclusion criteria
Inclusion criteria |
Study Design(S) |
The research’s methodology is not restricted and encompasses phenomenological methods, ethnography, grounded theory, and other approaches. Both qualitative research and mixed methodological research incorporating qualitative research were included. |
Participant(P) |
Clinical nurses certified as nurse practitioners. |
Interest of Phenomena(I) |
Nurses experiencing organizational silence. |
Context(Co) |
The study subject is working in the clinic. |
Exclusion criteria |
Non-Chinese subjects and non-English literature; case studies; conference papers; secondary sources; official reports; full-text literature that is not currently accessible. |
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Screening and data extraction
The software EndNote X9 was utilized to remove duplicate references. The remainder of the literature was subsequently carefully examined in accordance with the inclusion criteria after the titles and abstracts were reviewed to remove extraneous material; the precise procedures for this process are depicted in Fig. 1. The researchers extracted the following information: author and year, source, goal, approach, and conclusion. A third scholar resolved any disagreements that arose throughout the data extraction procedure that was performed by two scholars working together. Table 2 shows the ultimate outcomes.
Fig. 1
PRISMA flow diagram
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Table 2
Characteristics of the included studies (n = 12)
Authors and year | Origin | Aim | Methodology | Results |
|---|---|---|---|---|
Lee et al. [16] | Korea | To identify factors that motivate or inhibit nurses’ speaking up for patient safety | Qualitative descriptive study, semi-structured in-depth interview using online video conferencing. Purposive and snowball sampling methods. 15 respondents | Nine themes emerged: (1) Non-judgmental and non-punitive unit culture (2) Open communication for continuous learning (3) Communication about patient safety issues and priorities (4) Designated as clinical champion (5)Protocols/policies about patient safety or speaking up (6) Supportive unit Manager (7) Role models (8) Positive reactions from others (9) Familiarity with others |
Abrams et al. [17] | UK. | To critically examine nurses’ experiences of speaking up during COVID-19 and the consequences of doing so | Longitudinal qualitative study, Remote semi-structured interviews. Purposive sampling method. 50 respondents | Three themes emerged: (1) Under threat: The ability to speak up or not (2) Risk tolerance and avoidance: Consequences of speaking up (3) Deafness and hostility |
O’Donovan et al. [18] | Ireland | To gain a fuller understanding of the influence team leaders, interpersonal relationships, and individual characteristics have on individuals’ psychological safety and their decisions to engage in voice or silence behavior | Qualitative research, Thematic analysis, individual semi-structured interviews. Purposive sampling method.34 respondents | Four themes emerged: (1) Personal Characteristics (2) Past Experiences (3) Individual Perceptions of Being Valued (4) Judged Appropriateness of Issues/Concerns |
Yalçın et al. [19] | To explore nurses’ views and experiences regarding remaining silent | Exploratory qualitative study, face-to-face semi-structured in-depth interview. Snowball sampling method.24 respondents | Three themes emerged: (1) Fear (2) Silence climate (3) Disengagement | |
Schwappach et al. [20] | Switzerland | To explore the factors affecting oncology staff members’ choices to express safety concerns or remain silent and to outline the compromises they have to make | Qualitative research, Thematic analysis, face-to-face semi-structured interviews. Purposive sampling method.32 respondents | Three themes emerged: (1) Motivations for speaking up (2) Barriers to speaking up (3) Risk assessment and deliberate trade-offs |
Lee et al. [21] | Korea | Explore nurses’ perceptions and experiences with speaking up for patient safety in Korean hospitals. | A qualitative descriptive approach was used, and a semi-structured in-depth interview was conducted using online video. Purposive sampling method. 15 respondents | Four themes emerged: (1) Perceptions regarding speaking up (2) Situations requiring nurses’ decisions on whether or not to speak up (3) Strategies for speaking up (4) Consequences of speaking-up behaviors. |
Kee et al. [22] | Netherlands | To obtain an understanding of the elements influencing the voice behavior of newly registered nurses. | Qualitative descriptive study, semi-structured interviews. Convenience and snowball sampling method. 17 respondents | Four themes emerged: (1) NGRNs’ levels of self-confidence (2) Feeling encouraged and welcome to speak up (3) Relationship with voice target (4) Voice content |
Liu et al. [23] | China | Explores the experience and meaning of male nurses’ organizational silence | Qualitative research, phenomenological approach, face-to-face semi-structured in-depth interview. Purposive sampling method. 14 respondents. | Three themes emerged: (1) Silent worry and concern (2) Silent awe and obedience (3) Silent harmony and courtesy |
Binyan et al. [24] | China | To describe the experience of organizational silence among nurses | Qualitative research, phenomenological approach, semi-structured in-depth interview. Purposive Sampling method. 12 respondents. | Four themes emerged: (1) Negative emotional experiences (2) Lack of organizational belonging (3) Trade-offs pros and cons, choose silence (4) Lack of ability, choose silence |
Weidan et al. [25] | China | To understand the feelings and experiences of junior nurses’ organizational silence | Qualitative research, phenomenological approach, face-to-face semi-structured in-depth interview. Purposive sampling method.12 respondents. | Three themes emerged: (1)Silent worry and concern (2) Lack of organizational belonging (3)Silent harmony |
Li et al. [26] | China | Learn about the real psychological experience of orthopedic clinical nurses about the phenomenon of tissue silencing | Qualitative research, phenomenological approach, semi-structured in-depth interview. Purposive Sampling method. 16 respondents. | Five themes emerged: (1) Negative emotional experiences (2) Diverse organizational silence factors (3) Increased burnout (4) Negative leadership behavior (5) Increase the potential safety hazards of nursing quality and safety |
Jinfen et al. [27] | China | To explore the deeper experience of the organizational silent behavior of nurses in the operating room | Qualitative research, phenomenological approach, face-to-face semi-structured in-depth interview. Purposive sampling method. 12 respondents. | Three themes emerged: (1) The phenomenon of silence (2) Reasons for silence (3) Coping styles |
Quality appraisal
Two researchers evaluated each of the 12 included studies independently using the quality evaluation criteria of Qualitative research of the Australian Joanna Briggs Institute (JBI) Evidence-based Health Care Center [16]. The evaluation was based on 10 items, each of which was evaluated as “yes”, “no”, “unclear” or “not applicable”. A level indicated that all criteria were met and there was a low likelihood of bias; B level showed that criteria were partially satisfied, and the likelihood of bias was moderate; C level indicated that criteria were not satisfied at all, and there was a high probability of bias. In case of disagreement, the two researchers discussed and, if necessary, asked the third researcher to assist in the ruling. Following assessment, the quality of 12 included studies was rated as being at least grade B. The results of the quality assessment are displayed in Table 3.
JBI Australian Centre for Evidence-based Health Care Qualitative research Quality evaluation criteria [16]: ① Is there congruity between the stated philosophical perspective and the research methodology?② Is there congruity between the research methodology and the research question or objectives?③ Is there congruity between the research methodology and the methods used to collect data?④ Is there congruity between the research methodology and the representation and analysis of data?⑤ Is there congruity between the research methodology and the interpretation of results?⑥ Is there a statement locating the researcher culturally or theoretically?⑦ Is the researcher’s influence on the research, and vice-versa, addressed?⑧ Are participants and their voices adequately represented?⑨ Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?⑩ Do the conclusions drawn in the research report flow from the analysis,/or interpretation of the data?
Table 3
Evaluation of methodological quality
Included studies | ① | ② | ③ | ④ | ⑤ | ⑥ | ⑦ | ⑧ | ⑨ | ⑩ | Score |
|---|---|---|---|---|---|---|---|---|---|---|---|
Lee et al. [16] | Y | Y | Y | U | Y | U | Y | Y | Y | Y | 8 |
Abrams et al. [17] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
O’Donovan et al. [18] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
Yalçın et al. [19] | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 9 |
Schwappach et al. [20] | Y | Y | Y | Y | Y | U | N | Y | Y | Y | 8 |
Lee et al. [21] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
Kee et al. [22] | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 9 |
Liu et al. [23] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10 |
Binyan et al. [24] | Y | Y | Y | Y | Y | N | U | Y | N | Y | 7 |
Weidan et al. [25] | Y | Y | Y | Y | Y | Y | U | Y | N | Y | 8 |
Li et al. [26] | Y | Y | Y | Y | Y | N | Y | Y | N | Y | 8 |
Jinfen et al. [27] | Y | Y | Y | Y | Y | N | U | Y | Y | Y | 8 |
Synthesis and analysis of data
The research findings, which encompassed themes, latent meanings, and classifications, were gathered through a thorough understanding of the philosophical foundations of several qualitative research approaches. After repeatedly reading and analyzing the results of the included studies, similar results were combined to form new categories, and the new categories were summarized into integrated results.
ConQual-assessment of evidence confidence
The reliability and credibility of the evidence were assessed through the ConQual system. Credibility assesses the degree of agreement between integrated outcomes and supporting evidence, whereas reliability concentrates on the quality of the original study used in the analysis. The JBI Center for Evidence-Based Health Care created the ConQual system in 2014 to evaluate and rank bodies of meta-synthesized data that were obtained from qualitative studies [17]. When assessing reliability and credibility, meta-synthetic evidence is assumed to be of high quality and assessed based on three aspects of credibility and five dimensions of reliability. ConQual quality rating resulting from this could be classified as high, medium, low, or extremely low. Table 4 shows the ConQual system scores for this review.
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Table 4
ConQual system scores and the specific reason
Synthesized findings | Type of research | Dependability | Credibility | ConQual score | Comments |
|---|---|---|---|---|---|
Traits of the Silencer | Qualitative | Downgrade one level - Moderate* | Remains unchanged** | Moderate | The findings came from 7 papers *Downgraded one level as the majority of studies (4 out of 7) scored 3 on questions related to the appropriateness of the conduct of the study |
The motives for silence | Qualitative | Remains unchanged - High* | Remains unchanged** | High | The findings came from 11 papers * remains unchanged as the majority of studies (8 out of 11) scored 4 or 5 on questions related to the appropriateness of the conduct of the study |
The consequences of silence | Qualitative | Remains unchanged - High* | Remains unchanged** | High | The findings came from 4 papers * remains unchanged as the majority of studies (3 out of 4) scored 4 or 5 on questions related to the appropriateness of the conductof the study |
Results
After carefully screening 661 relevant articles that were initially detected, 12 with a total of 253 participants were included in the final analysis. Three of the publications did not specify whether the ethics committee approved them. The relevant literature was from the following countries: China (n = 5), Korea (n = 2), United Kingdom (n = 1), Ireland (n = 1), Turkey (n = 1), Switzerland (n = 1), and Netherlands (n = 1). The research methods included phenomenological methods (n = 5), descriptive qualitative research (n = 3), thematic analysis (n = 2), longitudinal qualitative research (n = 1), and exploratory qualitative research (n = 1). Most studies were published in the last five years and were original articles. Through repeated reading, the researchers distilled 48 main results, grouped similar results into eight new categories, and finally synthesized them into three aggregate results. Figure 2 displays the subjects and subtopics that have been summarized.
Fig. 2
Themes and subthemes structure
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Synthesized finding 1: traits of the silencer
Individual character
In a given situation, a person’s personality traits determine their behavior. Some respondents attributed the act of remaining silent to an individual’s personality type. Furthermore, they thought it was their right to keep silent about destructive phenomena or problems. In addition, due to the underestimation of their own capabilities and values, as well as the difference in roles with doctors in terms of division of responsibilities, professional knowledge and skills, some nurses gradually developed an inferiority complex. They generally referred to themselves as “little nurses” and would choose to remain silent because of their lack of courage,
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“That might be just their personality style, and that might be how they are with their friends” [18].
“It’s not forced, I don’t like to say much” [19].
“I’m just a little nurse; how can I speak? Even if I say something, who will listen? It is better not to say anything” [20].
“ Simply because he is a surgeon and we are nurses. Not everybody dares to speak up to a surgeon” [21].
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Seniority and experience
As a junior nurse who had just started his career, he would be extra cautious and afraid to speak up in front of coworkers and a new workplace. In addition, they experienced a role change at the beginning of their careers, which led to many new job tasks, and they were often intimidated by a lack of self-confidence. They chose to remain silent, believing they were not ready to face challenges on their own. At the same time, due to their limited experience and ability, they chose to remain silent because they could not provide constructive advice.
“ When I first came here, I felt that it was extremely unfortunate to see nurses not following patient safety protocols, but I couldn’t speak up about it because I was new to this unit. I also felt extremely careful about addressing patient safety issues or concerns related to other nurses in the unit” [22].
“You have to process so much new info and perform different types of tasks. It was really a lot in the beginning, and it made me quite insecure. Instead of getting involved in discussions right away, I prefer to wait ” [23].
“ What frightened me a bit was that from one day to the next, I graduated and was on my own. I was responsible for my patients. That was quite scary” [23].
“When discussing and expressing opinions, I feel that I can make better suggestions, but I can’t explain the specifics, so it’s better not to say anything at all” [22].
Synthesized finding 2: the motives for silence
Defensive silence
Defensive Silence is defined as withholding relevant ideas, information, or opinions [3]. It is a form of fear-based self-preservation, i.e., actively choosing silence because of the fear of harming your career.
Many respondents chose to be silent because they were worried about the adverse consequences of interpersonal relationships caused by speaking out. On the one hand, they were worried about destroying the relationship between colleagues. They were afraid that speaking out could cause unpleasantness with their colleagues, and by remaining silent, they reduced the risk of becoming victims of horizontal violence. Some respondents said they were worried that speaking out would cause misunderstandings. Some respondents said they did not want to be labeled negatively. Some respondents said they did not want to offend their colleagues and cause interpersonal barriers. On the other hand, they were worried about destroying their relationship with patients. They were worried that speaking in front of patients might lead to losing trust in medical staff.
“And I think that is my main issue: if I had whistleblown, I would have been considered a problem, and it is not that I particularly want to go further in my career, but people are then wary of you” [24].
“I do not want to be seen as someone who makes trouble. Because of that, I accept the issues that bother me and don’t speak up” [25].
“I decided to remain silent when I saw a senior nurse colleague humiliate a junior nurse in front of other staff in my unit because I did not want to ruin my relationship ” [26].
“Sometimes some of the status quo is unreasonable, but it will have a certain impact on other colleagues; they may feel that this is right, everyone works together every day, and I also work with those teachers, there is no need to offend them” [27].
“I feel like if I spoke up to a physician in front of a patient, the patient would lose his trust in the physician or something like that” [22].
In addition, the hierarchical differences between nurses and nurse managers and between doctors and nurses made nurses remain silent for fear of offending those in authority by speaking out. Some respondents feared offending the leader and causing economic losses and image damage. Some nurses would carefully and selectively convey the message and had reservations about the negative news.
“I was too scared to speak up because she was the manager” [26].
“At one point, I experienced such a large hierarchy in my relationship with the cardiologists that I did not even dare to call them anymore” [23].
“The possibility of getting a low-performance review scares me because I can lose my job or not get a good raise in my salary. Because of that, sometimes I choose to stay silent” [25].
“The head nurse is the same as ordinary female nurses; she is under more stress, and sometimes she is worried that she will leave a bad impression if she says the wrong thing” [28].
“When talking to the leader, there are some bad things, and you may have some reservations when you talk about them” [28].
Disregardful silence
Disregardful silence refers to employees’ negative, reserved views about the low commitment and involvement in their current work or organization, which involves ignoring the organization’s interests [29].
Organizational citizenship behavior was hampered by the low organizational commitment of many nurses, which was based on an inadequate feeling of belonging and responsibility for the organization. Some nurses showed a detached and indifferent attitude, with a certain distance between the emotion and the organization, ignoring their relationship with the organization. Furthermore, some nurses tended to put personal interests first when weighing personal and organizational interests. On the one hand, in hiding knowledge, it was reflected that some nurses deliberately kept “pretending to be ignorant”. Some nurses avoided exposing their lack of knowledge by concealing it. On the other hand, it was reflected in the unwillingness to increase the extra workload. Respondents said that the nursing work of nurses themselves was heavy and complicated, and the originally limited working hours would reduce their willingness to speak. They preferred to remain silent if speaking up would increase their workload.
“Whenever the leader asked us to put forward ideas, I pretended not to hear them; where could I get so many ideas from? I just want to do a good clinical job and not worry about anything else” [20].
“If I think I am inadequate at work or in completing a certain task, I choose to stay silent about it, so people won’t find out about my weakness” [25].
“We’re extremely busy, you know. Every minute and second is important, and we do not even have time to provide basic nursing care, let al.one speak up” [22].
“I have a tendency not to speak up in case a doctor reacts negatively to my words because this usually increases my workload or work-related stress. I do not want to spend my time arguing unnecessarily” [26].
“I don’t think it matters. It doesn’t affect me much anyway, I don’t mind” [20].
Acquiescent silence
Acquiescent silence is when employees believe that speaking up will not make a difference and that potential recipients have no reaction or interest in a particular issue and thus conceal their opinions [2]. It is a more profound silence that implies a disengagement of the employee.
Many nurses remained silent and showed negative obedience based on their inability to change the situation, which was mainly related to past negative experiences. Some nurses said their experience of not being listened to in the past made them think it was pointless. Not only that, but the respondent mentioned that his suggestions to his leaders were not recognized, and this frustration led him to stop speaking out. Moreover, this chronic lack of positive feedback left nurses feeling powerless and bored, choosing silence as a way to protect their emotional and mental health needs. Moreover, respondents said that leaders with a high sense of authority were less inclined to hear opinions that conflicted with their ideas and that their negative experiences of challenging the leader’s authority in the past caused them to remain silent and obedient to their leaders afterward.
“By the way the interaction went, you know that they aren’t on board with what you said, and possibly if you’re kind of a younger member of staff or you look young or something like that, they might just be just like, ‘oh yeah, whatever like’ ” [18].
“Maintain a good relationship with the leader, and choose to remain silent after giving advice many times and not being adopted” [30].
“I made many suggestions, but they were not followed, and I was tired of this environment, so I chose to leave” [19].
“Last time, I made some suggestions to the leader, but he didn’t like them too much, didn’t accept them, and seemed to be a bit unhappy, thinking that I was questioning the department’s decision-making, which was quite embarrassing. I won’t talk nonsense anymore; after all, not every leader likes to be dissented by others [20]”.
Prosocial silence
ProSocial Silence is defined as withholding work-related ideas, information, or opinions to benefit others or the organization – based on altruism or cooperative motives [3]. It is a positive silence. This type of silence serves positive purposes, such as fostering teamwork and preserving organizational harmony, and embodies the nurse’s considerate attitude towards others and the collective well-being.
Many nurses chose to remain silent out of the interests of others and organizations. Their decision to keep silent stems from a desire to foster a harmonious atmosphere in the workplace, prompting some interviewees to adopt a protective stance, hiding their true feelings. At the same time, some nurses indicated that the nursing work itself was a heavy task, and they kept silent so as not to add extra pressure on their colleagues or affect their work progress. Not only that, keeping silent was motivated by the need to maintain a harmonious relationship between subordinates and superiors, some nurses showed submissive attitudes based on their respect for the leader’s authority, while some nurses showed active cooperation with the leader’s decisions based on their trust in the leader. In addition, keeping silent was out of concern for the overall interests and reputation of the hospital. Some nurses said that they would choose to keep silent in front of patients to uphold the hospital’s professional image and prevent it from becoming entangled in disputes.
“Dealing with the relationship between colleagues, in order to maintain a good relationship with colleagues, they will adopt the luck psychology of covering up and choose to remain silent” [30].
“I know they are too busy to follow the protocol, so I decide to remain silent” [22].
“Nurses’ position is to listen to manager’s orders, so I don’t think I would ever speak up to my manager” [22].
“We will still do what the leader says, and from the perspective of the overall situation, the head nurse has some ideas that make sense” [28].
“If the protocol is not being followed and the patient realizes that they have been poorly treated, the relationship between the patient and hospital will aggravate and potentially result in legal issues with the hospital. That is why I feel as if I cannot speak up” [22].
Synthesized finding 3: the consequences of silence
Causing negative effects
Some nurses said they experienced feelings of guilt when they remained silent, which was related to their feeling that they had not fulfilled their duty to keep patients safe. In addition, the long-term silence of respondents caused them to have increased burnout and reduced motivation and innovation. Moreover, long-term silence could increase the risk of safety and quality of care.
“I could not speak up at the time, and I have never talked about this anywhere… but it remains in my heart, so I guess I still feel a lot of regret and guilt” [26].
“Choosing to be silent in the organization for a long time can reduce the motivation to work. At the same time, it deprives the work of many possibilities for innovation” [30].
“Recently, I was more passive, and there was an adverse event at my work and I had taken timely remedial measures at that time, and I concealed it without causing an impact on the patient, and the leader criticized me fiercely after learning about it, and my emotions were affected that day, resulting in no record of the nursing documents the next day” [30].
Causing positive effects
Some nurses who remained silent would actively seek social support such as peer support, family support, and organizational support to rebuild their psychology and improve their resilience to cope with the dilemma caused by organizational silence.
“I think that in clinical work, many times teams must cooperate with each other, everyone you let me, I let you, and the team can do things more smoothly” [27].
“I would talk to my family and friends about some of the problems in the department to consult their attitudes and opinions, which made me feel relaxed” [19].
Discussion
Our findings suggest that the experience of organizational silence among nurses can be distilled into three themes: traits of the silencer, the motives for silence and the consequences of silence. Among them, the motives for silence can be divided into four different forms, i.e., defensive silence, disregardful silence, acquiescent silence, and prosocial silence, while defensive silence, disregardful silence, and acquiescent silence have negative intentions. This study showed that the main influencing factors affecting defensive silence are fear of destroying interpersonal relationships, avoiding horizontal violence, and fear of authority, while the main influencing factors affecting disregardful silence are lack of organizational belonging and responsibility, and acquiescent silence mainly occurs due to past negative experiences. These findings are consistent with Dr. Chen Ming’s silent motivational integration model [29], as shown in Fig. 3. In addition, based on Professor Hobfull’s Conservation of Resources Theory (COR), individuals are inclined to take action to protect further resource depletion when faced with a threat to resources [31]. Therefore, combining the COR and Dr. Chen Ming’s integrated model, this paper deeply explored the phenomenon and motivation of organizational silence among nurses and proposed targeted interventions to provide management strategies for managers to minimize organizational silence among nurses, as shown in Fig. 4.
Fig. 3
The integration model of the influence mechanism of employee silence based on different motivations
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Fig. 4
Based on COR — organizational silence of nurses
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It is necessary to improve the self-confidence level of nurses and guide them to speak up. Our results showed that nurses’ silence was influenced by individual factors such as individual character and seniority. Some nurses may prefer to remain silent in a particular situation due to being introverts or having conservative personality tendencies and view this behavior as a reflection of their personality. In addition, newly recruited nurses face many challenges when transitioning to professional nursing practice [32]. Our findings showed that uncertainty during this transition phase decreases nurses’ propensity to speak up, primarily due to low self-confidence. According to COR, silence in this situation is an act of protection in the face of insufficient resources. However, extended periods of such silence can exacerbate the negative emotions among new nurses [33]. Therefore, to avoid the accumulation of negative emotions, it is necessary to invest resources and increase nurses’ self-confidence, thus improving the phenomenon of organizational silence. On the one hand, managers should act as role models and lead by example, encouraging nurses to try and boost their self-confidence through positive results. On the other hand, managers should help nurses establish correct perceptions and increase their sense of self-worth. A study on the analysis of 14 decisive educational interventions tailored to nursing students and professionals found that educational formats such as simulation-based learning, classroom-based learning, classroom-based learning with peer support, and online and offline blended educational learning effectively improved nurses’ communication skills, confidence, and competence [34]. In addition, studies have found that mentors can help new nurses overcome initial feelings of insecurity and that the good relationships they build with mentors might make them feel more comfortable sharing advice [23]. As a result, managers can offer mentorship programs for newly recruited nurses and update them based on the evolving requirements of nursing mentors and new nurses.
Enhancing nurses’ psychological safety and breaking defensive silence is important. This paper found that nurses exhibited organizational silence due to fear of the breakdown of social relationships, the threat of victimization by lateral violence, and the consequences of offending authority. Based on COR, this form of silence is an act of avoiding risk to oneself and one’s career. In healthcare organizations, nurses may remain silent to maintain relationships with colleagues for fear of being seen as critical or out of touch. At the same time, the existence of hierarchies and power differentials reflect underlying inequalities [35], with high power distance leading nurses to choose silence to better thrive in the workplace and avoid bullying [36]. In addition, in clinical settings, nurses’ perceived marginalization by medical colleagues, as well as status inequalities among healthcare professionals, can intensify their fear of authority and postpone their willingness to exhibit it [37]. Psychological stability might minimize the sense of interpersonal risk [38], assisting to break down hierarchical barriers and increase communication and collaboration between various hierarchies [39]. Dr. Chen Ming’s integrative model also points out that psychological safety has a mediating role in relational orientation and defensive silence [29]. Therefore, leaders can use the leadership toolkit proposed by Professor Edmondson to create a psychologically safe environment in their organization and increase nurses’ sense of security to speak up by setting the stage, inviting participation, and responding productively [40]. Self-awareness also influences nurses’ defensive silence. To address this, organizations should strengthen education and training, using diverse training formats such as simulation exercises, leaders’ video presentations, educational workshops, video presentations, and case studies [41]. These should cover professional knowledge, leadership skills, and conflict resolution techniques to minimize the status gap between nurses and supervisors, enhance conflict management capabilities, and increase psychological safety [42].
Enhancing nurses’ emotional commitment and breaking disregardful silence is necessary. Our results showed that nurses’ disregardful silence is due to their lack of organizational belonging and responsibility, which is actually a lack of emotional commitment to the organization. Given the COR, this act of silence is an attempt to protect one’s own resources, such as capacity and time. Dr. Chen Ming’s integrative model also noted that affective commitment was significantly associated with disregardful silence [29]. Nurses with high emotional commitment tend to have a solid organizational identity and are more willing to contribute, which leads to fewer silent behaviors. Therefore, managers can improve nurses’ emotional commitment through talent management, promoting organizational values, optimizing the relationship between upper and lower levels, and meeting multi-level needs [43, 44]. Additionally, various leadership styles positively influence nurses’ emotional commitment and behaviors [45‐47]. Given the varying emphases of different leadership styles and the differences between hospital organizational cultures, hospitals should creatively integrate the strengths of these styles based on their unique organizational culture and actual needs, which would help develop a leadership model that aligns with hospital characteristics and enhances leadership effectiveness, stimulating nurses’ favorable attitudes and actions about the organization.
Enhanced organizational support for nurses is essential to dismantle acquiescent silence. Our results showed that the acquiescent silence exhibited by nurses was mainly due to the negative behavior of the leader, which led to their negative self-assessment and their inability to change the status quo. Based on COR, this strategy is adopted to avoid further emotional and spiritual consumption due to a lack of organizational support. Dr. Chen Ming’s integrative model also pointed out that the sense of organizational support was significantly associated with acquiescent silence and was moderated by attribution orientation [29]. Based on the multiple motivations of acquiescent silence, there is a need for a multi-level perspective to explore and practice interventions to improve nurses’ organizational support. At the organizational level, it is necessary to establish a fair and open communication environment and improve the feedback mechanism [25]. At the level of management practice, a culture of trust should be built, job expectations should be clarified, consistent messaging should be maintained, and the voice of nurses should be accepted. At the same time, incentives should be implemented, and nurses should be encouraged to participate in decision-making. In terms of personal development, according to the recommendations of Martinko and Gardner’s model of organization-induced helplessness [48], attribution training can be provided for nurses to help them attribute inappropriate failures to extrinsic dimensions, thereby improving their perception of organizational support.
There is a need for an objective assessment of organizational silence and an effort to optimize its beneficial effects. Our results showed that long-term organizational silence can negatively affect individuals and patients and potentially threaten the organization. The first step is to increase the sense of burnout, reduce work enthusiasm, increase the willingness to leave, and threaten the stability of the nursing team. Second, there is a potential threat to the quality of patient care. Based on COR, these two are a direct manifestation of resource loss. In addition, studies have shown that appropriate silence can avoid interpersonal conflicts and information overload, protect the privacy of personal information, and improve organizational efficiency and decision-making effectiveness [19]. In view of the positive effects of appropriate silence, managers should also allow a certain degree of silence to exist when improving organizational silence, and should objectively identify and evaluate nurses’ organizational silence before intervening. In addition, we found that long-term silence may make nurses actively seek psychological support from close people to maintain high work motivation. A previous study revealed that nurses’ organizational silence decreased with the degree of family support [49]. Therefore, it is necessary for managers to be mindful of nurses’ psychological endurance and formulate relevant policies to improve the social support system, thus helping nurses to actively face various pressures and fully develop their personal values.
This study has a few limitations. This analysis comprised 12 papers from 7 different nations, having a somewhat limited size. One piece of literature included in this paper was a study of male nurses, which lacks some generalisability. In addition, our literature search was limited to articles published in Chinese and English, while eligible studies written in other languages were omitted. This may lead to an incomplete understanding of certain ideas or trends, or we may overlook unique insights that may exist in other cultures. Moreover, our study was limited in providing a more thorough understanding of nurses’ experiences with silent conduct because it was restricted to qualitative research.
Conclusion
This meta-synthesis explored the experience of silent behavior in nurse organizations. We extracted three themes: traits of the silencer, the motives for silence, and the consequences of silence. Nurses’ organizational silence results from a combination of factors and can have both positive and negative effects. There are significant differences in the motivations and experiences behind different types of silent behaviors, and appropriate silence has certain positive effects. Therefore, when managers observe nurses’ silent behaviors in the organization, they should first identify and evaluate the motivation and degree of silence and then carry out targeted measures. In our future research, we plan to keep exploring the motivations behind silent behavior, develop a list of targeted interventions, and evaluate the long-term effects of intervention strategies.
Acknowledgements
The authors would like to extend their sincere gratitude to all the anonymous reviewers, the editors, the participants in this study, and Shanghai 10th People’s Hospital for their support.
Declarations
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This is not required since the study is a meta-synthesis of qualitative studies.
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Not required for this review paper.
Competing interests
The authors declare no competing interests.
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