Healthcare professionals during covid-19 have had to cope with an extra burden beyond providing care. There is evidence that they have been instructed to keep silent about the lack of PPE equipment [1-4]. The pressure put on healthcare workers to keep quiet about the shortage of equipment raises the larger issue of how big a problem is employee silence in healthcare.
We would like to believe that employees will speak out if they witness something unethical or illegal in their organization. However, the accumulated psychological evidence indicates that speaking out is rare and keeping silent is the norm. [5, 6] We have relatively little research on the topic in healthcare, but there is no reason to believe that the problem is less salient. The evidence that does exist indicates when nurses are silent it is linked to the integrity of their leaders, while the chairs of medicine and surgery departments report it is common for faculty not raise or talk about important problems. [7,8]
The importance of healthcare professionals’ speaking up is clearest when we consider the area of patient safety—where improvement and monitoring are dependent on sharing information. Moreover, it would be wrong to think that is a problem confined only to “bad” leaders. As noted by Detert & Trevino  “Many well-meaning leaders are unintentionally reinforcing an authority-ranking social frame that is so pervasive and fundamental that most employees enter organizations expecting to ‘tread lightly’ around those in power.” Healthcare professionals will be less likely to signal issues that need to be addressed if they believe that such information will be viewed by their colleagues or supervisors as negative or threatening. Thus employee silence in healthcare may represent organizational norms rather than a toxic work environment.
Why should healthcare be interested in employee silence?
Employees feeling that they have to be silent in their workplace impacts upon both their personal health and the performance of the organization [10,11]. Additionally, remaining silent can be dangerous if the issue is an ethical one—where the activities of a healthcare organization are contributing to injury or death. Both the Midstaffordshire hospital and Irish Lourdes Drogheda Hospital scandals highlighted how employee silence needs a tipping point to break it down. [12,13] Both events have influenced the introduction of whistleblower procedures, but they may have also unintentionally directed our attention away from the fact that employee silence is a norm in healthcare, and organizations generally. Indeed, the difficult journeys that whistleblowers experience may be indirect evidence that organizational silence is expected and part of the psychological employment contract.
Psychologists have known for a long time that it takes a huge psychological toll to actively inhibit the expression of one’s thoughts, emotions, and behaviours, and that efforts to inhibit or suppress responses can accumulate over time, resulting in physiological and psychological symptoms . Thus, if employees believe that certain forms of silence based on loyalty or “not breaking ranks” is expected of them, they run the risk of underestimating the impact on their wellbeing. Moreover, the need to be silent can spillover into the non-work domain, as employee silence can be experienced as rumination after work which impairs off the job recovery . Apart from the obvious loss for the organization when employees are silent about dysfunctional work practices, there is the potential “powder keg” waiting to explode in terms of conscientious staff walking around hospitals suppressing information that is generating feelings of humiliation, pernicious anger, resentment, and contaminating every interaction. The increasing privatization of the NHS in the UK could be another factor that increases employee silence.
Not all silences are the same
Understanding the different reasons why employees are silent is key to addressing the phenomenon in healthcare. Knoll et al have identified four main reasons behind employee silence . Firstly, there is Quiescent silence which denotes silence that is based on fear, whereby speaking up may have negative effects on one’s career, damage relationships, or lead to being labelled as a “troublemaker” by superiors or colleagues. Secondly, there is Acquiescent silence which denotes silence that is based on resignation whereby one is silent because you think that speaking up will not make a difference and that potential recipients are not responsive or interested in the particular issue. The third type is Prosocial silence which denotes a type of silence where one withholds your views to protect or not to embarrass your superiors and colleagues. Finally, there is Opportunistic silence whereby one is silent due to selfish motives, such as the intention to protect a knowledge advantage or avoid additional workload. Knowing which type is prevalent in a healthcare organizations implies very different solutions.
What can we do?
Two things. Firstly, gather data on what type of silences are prevalent within healthcare, both during covid-19 and after it. Secondly, use this information to promote employee voice within healthcare. To be more specific, figure out what needs to change within medical education so that healthcare professionals are enabled to engage in upward communication behaviour that, although constructive in intent, challenges and seeks to alter the status quo . There is a gap in our knowledge base regarding the phenomenon of employee silence in healthcare.
Anthony Montgomery is a professor of work and organizational psychology at the University of Macedonia in Thessaloniki, Greece.
Competing interests: None declared
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