Nurses’ voice: the role of hierarchy and leadership

Abstract

Purpose Voicing concerns and suggestions is crucial for preventing medical errors and improving patient safety. Research suggests that hierarchy in health-care teams impair open communication. Hierarchy, however, can vary with changing team composition, particularly during acute care situations where more senior persons join the team later on. The purpose of this study is to investigate how changes in hierarchy and leadership were associated with nurses’ voice frequency and nurses’ time to voice during simulated acute care situations. Design/methodology/approach This study’s sample consisted of 78 health-care providers (i.e. nurses, residents and consultants) who worked in 39 teams performing complex clinical scenarios in the context of interprofessional, simulation-based team training. Scenarios were videotaped and communication behaviour was coded using a systematic coding scheme. To test the hypotheses, multilevel regression analyses were conducted. Findings Hierarchy and leadership had no significant effect on nurses’ voice frequency. However, there were significant relationships between nurses’ time to voice and both hierarchy (γ = 30.00, p = 0.002; 95 per cent confidence interval [CI] = 12.43; 47.92) as well as leadership (γ = 0.30, p = 0.001; 95 per cent CI = 0.12; 0.47). These findings indicate that when more physicians are present and leadership is more centralised, more time passes until the first nurses’ voice occurred. Originality/value This study specifies previous findings on the relationships between hierarchy, leadership and nurses’ voice. Our findings suggest that stronger hierarchy and more centralised leadership delay nurses’ voice but do not affect the overall frequency of voice.

Safety voice and safety listening during aviation accidents: Cockpit voice recordings reveal that speaking-up to power is not enough

“…These approaches have led to the insight that safety voice can be promoted (in terms of likelihood or onset) through leaders acting in low power distance ways. For instance, through providing encouragements, using inclusive language (Barzallo Salazar et al, 2014;Weiss et al, 2018) or shallower hierarchies (Krenz et al, 2020). Furthermore, this research indicated that risk perceptions are necessary for successful interventions (Noort et al, 2019b), and that safety voice emerges after a decision on the trade-off between the benefit of mitigating harm and the cost of leaders' poor safety listening (Schwappach and Gehring, 2014a).…”

“…Yet, crucially, these methods assume generalisability to actual accidents, and insights on the extent to which, and how precisely, safety voice and safety listening contribute to real accidents remain scare and limited (Krenz et al, 2020;Noort et al, 2019b;Peadon et al, 2019). Moreover, the role of power distance for safety voice during naturally occurring scenarios remains an assumption.…”

“…This has led to the widespread assumption that a lack of safety voice is a substantial contributor to accidents, and is therefore important for mitigating declining conditions, errors and accidents (e.g., employee voice, safety voice, psychological safety; Morrison, 2014;Okuyama et al, 2014;Edmondson and Lei, 2014), and a function of wider organisational environments (e.g., safety culture, safety citizenship; Reader et al, 2015;van Dyne et al, 2003). However, to date, there is no systematic exploration of the extent to which a lack of safety voice and poor listening contribute to serious accidents (Krenz et al, 2020), and the level of influence exerted by power on safety voice (rather than, for example, human error) remains a proposition (e.g., Kwon et al, 2016).…”

“…Specifically, accidents are assumed to emerge from people not speaking-up due to fears for the social consequences of incorrectly raising concerns or undermining leaders (Tucker et al, 2008;Enomoto and Geisler, 2017;Gladwell, 2008;Soeters and Boer, 2000), and poor safety listening to voice is understood to arise from norms for communication (Hofstede et al, 2010;Kam and Bond, 2009) and expected asymmetries on expertise for managing safety (Tost et al, 2012). Studies utilising vignette (Schwappach and Gehring, 2014a), laboratory (Noort et al, 2019b), high-fidelity simulator scenarios (Barzallo Salazar et al, 2014) and case studies (Driscoll, 2002) have explored safety voice and safety listening extensively, and show that power dynamics shape how leaders respond to advice (Tost et al, 2012); and that when leaders listen poorly to safety concerns (Edmondson, 1999;Nembhard and Edmondson, 2006); junior team members (i.e., individuals with less authority) are less likely to engage in safety voice, or delay speaking-up (Krenz et al, 2020), which impairs safety management. Thus, safety voice and power distance are recognised as primary causes of organisational accidents (Reader et al, 2015;Conchie et al, 2012;Enomoto and Geisler, 2017;Gladwell, 2008;Soeters and Boer, 2000), and a range of interventions for reducing power distance in teams and enhancing speaking-up (e.g., psychological safety, training; Kolbe et al, 2013;Newman et al, 2017;Kanki et al, 2019) have been developed to improve safety voice and safety listening.…”

Investigating voice in action teams: a critical review

“…This discrepancy between how people think they would behave and how they actually behave is particularly noticeable when it comes to potentially threatening and embarrassing issues, which are prevalent in many voice situations (Argyris 1980). Thus, if research relied solely on self-report data, there would be still a lack of insight regarding when, whether, and how people show voice (Krenz et al 2020).…”