Voice, silence, perceived impact, psychological safety, and burnout among nurses: A structural equation modeling analysis

Seung Eun Lee, Ja kyung Seo, Allison Squires

Research output: Contribution to journalArticlepeer-review


Background: The organizational studies' literature suggests that employees' expressions of voice and silence may be distinct concepts with different predictors. Organizational researchers also argue that both employees' voice and silence are related to burnout; however, these relationships have not been adequately examined in the healthcare context. Objective: This study aimed to investigate the relationships among nurses' perceived impact, psychological safety, voice behaviors, and burnout using a theoretical model. Voice behaviors were conceptualized as voice and silence. Design: A cross-sectional, correlational study design was employed. Settings: Study data were collected in 34 general hospitals in South Korea. Participants: A total of 1255 registered nurses providing direct care to patients were included in this study. Methods: Using a convenience sampling method, a web-based survey was conducted to obtain data. All variables were measured using standardized instruments. A structural equation modeling analysis was employed to test a hypothesized model positing that perceived impact and psychological safety have both direct and indirect effects on nurse burnout through voice and silence. The response rate was 72.8 %. Results: The findings supported the hypothesized model. Both perceived impact and psychological safety were positively related to expressions of voice, but both were negatively associated with silence. We also found that perceived impact was more strongly associated with voice than with silence, while psychological safety had a stronger impact on silence than on voice. Furthermore, voice reduced burnout, while silence increased it. Finally, perceived impact reduced burnout through voice (β = − 0.10, 95 % confidence interval [− 0.143, − 0.059]) and silence (β = − 0.04, 95 % confidence interval [− 0.058, − 0.014]), and psychological safety also decreased burnout through voice (β = − 0.04, 95 % confidence interval [− 0.057, − 0.016]) and silence (β = − 0.07, 95 % confidence interval [− 0.101, − 0.033]). Additional analyses revealed that prohibitive voice and silence significantly mediated the associations between psychological safety and burnout and perceived impact and burnout, but the mediating role of promotive voice was not statistically significant. Conclusions: It is important to recognize that voice and silence are distinct concepts. Moreover, to reduce nurse burnout, nurse managers and hospital administrators should develop separate strategies for promoting nurses' perceived impact and psychological safety, as their influences on voice and silence differ. Registration: Not applicable. Tweetable abstract: Voice and silence both influence nurse burnout. Separate strategies should be applied to voice and silence, as they are different concepts.

Original languageEnglish (US)
Article number104669
JournalInternational Journal of Nursing Studies
StatePublished - Mar 2024


  • Assertiveness
  • Burnout, professional
  • Burnout, psychological
  • Health workforce
  • Nurses
  • Nursing
  • Organizations
  • Safety

ASJC Scopus subject areas

  • General Nursing


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