Background: Workplace silence behavior has adverse effects on the nurses and the organization. Underlying nursing causes of silence behaviors were related to individual, social and organizational attributes in health care settings. Objectives: The study aimed to develop a new Egyptian validation scale for measuring nursing motives of workplace silence behavior and identify consequences of workplace silence behavior on nurses. Methods: The cross-sectional descriptive correlational study was carried out on 302 nurses in the critical and toxicology care units of the Alexandria Main University Hospital. It was collected through questionnaires of workplace silence behavior, nursing motives, and nurses' outcomes. Results: the Egyptian scale was found to be a good fit model of exploratory (36 nursing motives emerged in six dimensions explaining by 73.0 % of the total variance) and confirmatory factor analyses (X2 = 1145, NNFI =0.90, CFI = 0.91, RMSEA = 0.044). It also had highly reliability tests with an alpha of 0.85, Pearson coefficient of 0.75, and Kendall’s coefficient of 0.72. The high level of workplace silence behaviors seemed to be a negative association with organizational dis-identification, fair citizenship behavior, fair nurses' performance, and decline reporting of patient adverse events. It also appeared to be a positive association with higher levels of cynicism. Conclusion: The Egyptian scale was found to be reliable and valid for measuring the underlying nursing causes of silence behaviors in the hospital workplace. Measuring nursing motives of workplace silence behaviors will help nurse managers to reduce negative outcomes of workplace silence behaviors and improve an organization's effectiveness and efficiency.
Keywords: Egyptian tool. Motives, Silence behaviors, Nursing workplace, Outcomes
The most important issue in modern health care settings is ensuring safety and improving the quality of care. When risks and mistakes are not reporting, patient safety and quality of care are not achieved. Although health care policymakers and accreditation agencies have been paying their attention to create a culture of safety and implement feedback mechanisms in inpatient care units, organizational silence has been hindered these mechanisms to properly work. (39) Organizational silence behavior is the intentional withholding of knowledge and opinions of employees to improve their work and organization. It can harm both nurses and organizations, in the form of hidden damage to the safety of patients, reducing nurses' performance, decline nurses' citizenship behaviors, and nurses' dissatisfaction. Also, it causes organizational dis-identification and low commitment when cynicism, stress, and turnover are high among nurses.(39,41) It can be attributed to individual, social, management, and organizational motives in health care settings. (40)
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Several motives' scales of organizational silence behavior have been developed for measuring causes of silence behaviors among employees in USA and Germany industrial settings, whereas one silence behavior scale has been developed in Turkey for measuring nursing reasons for silence behaviors in hospital settings.(4,7,10,11) These scales have some limitations to generalization in other occupational culture settings. For employees' silence scale, it needed further reliability and validity tests for ensuring applicability in health care settings. Motives for silence were different according to cultural, occupational, workplace personality attributes of employees. (7) As regards the turkey version of the nursing silence scale, it could not be also generalized for other health care settings for the following reasons: 1) it was created for use in the national study hospitals, and 2) it did not sufficiently achieve construct validity and reliability tests. (7)
Globally, many studies have attempted to investigate the motives of silence behavior among employees and its impact on organizational commitment, organizational change, burnout, job satisfaction, turnover, cynicism, employee performance, and organizational citizenship behaviors. ( 34,9,4,37, 38,8,42 ) Based on our knowledge in Egypt, studies on organizational silence behavior are quite new. Data concerning the presence of scale for measuring reasons that hinder nurses to speak out in their workplace is seriously lacking. Therefore, it is a pressing necessity to start an action for developing a new Egyptian validation scale for measuring nursing motives of workplace silence behaviors and identifying the consequences of workplace silence behaviors on nurses (organizational identification and cynicism, nurses' citizenship behavior, and performance and reporting patient safety events).
Material and Methods:
- Study setting: The study carried out in critical and toxicology care units of the Alexandria Main University Hospital.
- Study design: Across sectional descriptive correlational study.
- Sample size: All nurses worked in the study units who provided their agreement on informed consent. They amounted to 302 nurses.
Data collection: Self-administered questionnaires were used for the following:
I. Workplace Silence Behavior and its motives:
(a) Workplace silence behavior among nurses was measured using one question that described the frequency of nurses' preferences to remain silent instead of speaking out to their supervisors regarding any new idea, practice problems and patient safety events in their workplace (How often did you prefer to remain silent instead of speaking out to your supervisor). (4) Nurses answered their responses on a 5-point Likert scale (where 1 = no, I never remain silent and 5 = yes, always I remain silent).
(b) Nursing motives of workplace silence behaviors: The scale was developed by the researcher through the following stages:
- Face validity phase: Based on literature reviews(5-10), the questionnaire items were designed by researchers. 55 questionnaire items were developed
- Content validity phase: the scale was evaluated by 5 experts having a doctoral degree in health care management. The experts evaluated the relevance of questionnaire items by using a 5 -point Likert scale (from 1= not relevant to 5= relevant). Experts were asked if other appropriate items should be added to the scale and their comments were collected and revised. According to experts' evaluation, 10 irrelevant items were removed. 45 Likert items were established in the final version of the workplace silence behavior scale. Likert style scale ranged from 1 (strongly disagree) to 5 (strongly agree) )
- The inter-rater reliability phase was achieved through Kendall’s test. It was also used to measure agreement among 5 experts.
- The test-retest reliability phase was investigated by Pearson's correlation test which was achieved through a pilot study. A pilot study was carried out on the same 30 nurses at two different times (about three weeks between the two times). It also used for assuring clarity and feasibility of the questionnaire.
- The construct validity phase was achieved through Exploratory axis factor Analysis (EXFA) and confirmatory factor analysis (CFA). EXFA analyzed 45 motives items and showed the following: Scree-plot breaking point curve initiated to tail from component number six (Figure 1); all items correlated with the loading of more than 0.5 were maintained; 36 motives item was a strong loading on six components accounting for 73.0% of the total variance. Confirmatory factor analyze investigated the factor structure of the offered 6 factors model yield from (EXFA) 6 Factors
Figure (1): Scree plot of workplace silence behavior scale
- Internal consistency The reliability phase was investigated by Cronbach's alpha reliability coefficient of the whole scale and six components.
II. Consequences of nursing workplace silence behaviors among nurses :
- Organizational cynicism was measured by thirteen rating statements which ranged from 1 (strongly disagree) to 5 (strongly agree). (27) The cynicism scale had Cronbach's Alpha coefficient of 0.67 and a test-retest reliability of 0.85.
- Organizational identification was measured by using ten Likert items ( from 1= 'strongly disagree' to 5=' strongly agree'). (28,29) Cronbach's Alpha coefficient and test-retest reliability of identification scale were 0.97 and 0.88 respectively.
- Nurses' citizenship behavior: was measured by using a five-items scale represented in five dimensions: courtesy, sportsmanship, civic virtue, conscientiousness, and altruism). (2) The nurses rated their answers by using a 5 Likert point scale ( 1 = strongly agree to 5 = strongly disagree). The 5-item scale had an Alpha coefficient of 0.89 and a test-retest reliability of 80.
- Nurses' performance: was measured by nine Likert items (ranging from 1 = strongly disagree to 5 =strongly agree. (1) Nine items scale had an Alpha coefficient of 0.85 and a test-retest reliability of 0.79.
- Reporting Patient safety events: was measured by two questions adapted from the hospital patient safety survey of AHRQ in 2017. (3) The nurse asked to address patient safety events in their units during the last six months and frequency of reporting these events to someone who was able to change the situation. Nurses' responses on the two-item scale ranged from 1 (no, I never report patient safety events) to 5 (yes, I always report patient safety events ). Test-retest reliability of this scale was 0.75
The questionnaire was translated into Arabic and translated back into English for assuring clarity of its content. The final version of the questionnaire scale contained two questionnaire sections: (1) workplace silence behavior and nursing motives; and (2) consequences of workplace silence behavior on nurses. A total of 460 questionnaires were administered to nurses in the study units and 410 copies were returned. 302 of 410 copies were relevant for data analysis. The response rate was 73.7 %. The questionnaire copy was attached with an explanation letter about the research purpose and some research definitions. The researchers met the nurses to provide necessary information and clarification for further questions.
Ethical Considerations: the Faculty of Medicine Administration provided approval for conducting research. All nurses' responses were handled by confidentiality and anonymity and researchers created a code number for each questionnaire during data analysis.
Statistical Analysis: SPSS version 18 was used for data analysis. Descriptive analysis was used to describe demographic characteristics and nurses' responses. Nurses' responses to overall perceptions of the questionnaire statements were classified by mean scores as the follow: < 3 = Mild score, 3 – 3.9 = moderate score, ≥ 4 = high score. Effect relationships between variables were analyzed by Spearman's correlation and linear regressions. Construct validity was confirmed by EXFA with Principal Varimax Rotation and using Kaiser Normalization with eigenvalue more than one as well as CFA. CFA was analyzed by LISREL version 8.80. Reliability tests were assessed through Pearson’s correlation (test-retest reliability), Kendall’s correlation (inter-rater reliability), and Cronbach’s Alpha coefficient (internal consistency reliability). Additionally, statistical significance was set at P-values