title: Breaking the silence: Determinants of voice for quality improvement in hospitals.
abstract: BACKGROUND
  Research suggests that staff voice-discretionary communication of ideas, suggestions, concerns, or opinions about work-related issues with the intent to improve organizational or unit functioning-is associated with quality improvement, which most agree is needed in health care. Nevertheless, health professionals often do not voice. Little research has explored their reluctance to speak up and, relatedly, the conditions under which they voice.
  
  
  OBJECTIVE
  We examine the drivers of voice for health professionals in hospitals. Specifically, we investigate the factors that influence their voice, why these factors are influential, and the purposes for which staff use their voice.
  
  
  METHODS
  We conducted a qualitative study using data from 99 in-depth interviews with diverse staff at 12 randomly sampled hospitals in the United States. Data were collected from December 2007 to December 2008, the first year of a 4-year study of improvement. By national standards, all of the hospitals had significant room for improvement in their care of patients experiencing heart attack, suggesting that there were potentially issues and suggestions for staff to voice.
  
  
  RESULTS
  Factors related to individuals (e.g., tenure), work (e.g., work configuration), organizational context (e.g., culture), data (e.g., benchmarking), and the external environment (e.g., attention) influenced health professionals' voice. These factors shaped their sense of safety, efficacy, opportunity, and/or legitimacy, all of which affected their belief about the risk and benefit of voice and willingness to voice. They voiced for three purposes: to learn for themselves, inform others, and protect patients.
  
  
  CONCLUSIONS
  These findings indicate that hospitals and their leaders must attend to multiple factors (e.g., work configuration, culture, etc.) if they wish to increase staff voice in service of quality improvement. The presence of many influential factors suggests that there are several levers that leaders can use to elicit voice, noting that voice can be used in multiple ways to facilitate improvement.
authors.affiliation: Ingrid M. Nembhard, PhD, MS, is Associate Professor, Yale School of Public Health and Yale School of Management, Yale University, New Haven, Connecticut. E-mail: ingrid.nembhard@yale.edu. Israel Labao, MPH, is Research Assistant, Yale School of Public Health, Yale University, New Haven, Connecticut. Shantal Savage, MPH, is Research Assistant, Yale School of Public Health, Yale University, New Haven, Connecticut.
authors.forename: Ingrid M
authors.initials: IM
authors.lastname: Nembhard
authors.forename: Israel
authors.initials: I
authors.lastname: Labao
authors.forename: Shantal
authors.initials: S
authors.lastname: Savage
mesh_terms: D015906:Angioplasty, Balloon, Coronary; D003299:Cooperative Behavior; D003659:Decision Making, Organizational; D017598:Efficiency, Organizational; D019317:Evidence-Based Medicine / Q000458:organization & administration; D006302:Health Services Research / Q000458:organization & administration; D006739:Hospital Administration; D006801:Humans; D033183:Interdisciplinary Communication; D009203:Myocardial Infarction / Q000628:therapy*; D010348:Patient Care Team / Q000458:organization & administration; D058996:Quality Improvement / Q000458:organization & administration*; D013996:Time and Motion Studies; D014481:United States