PERSPECTIVE
published: 31 March 2022
doi: 10.3389/fpsyt.2022.818393
Understanding the Link Between
Burnout and Sub-Optimal Care: Why
Should Healthcare Education Be
Interested in Employee Silence?
Anthony Montgomery* † and Olga Lainidi †
Department of Educational and Social Policy, University of Macedonia, Thessaloniki, Greece
Edited by:
Charlotte R. Blease,
Beth Israel Deaconess Medical
Center and Harvard Medical School,
United States
Reviewed by:
Colin West,
Mayo Clinic, United States
Vida Demarin,
International Institute for Brain Health,
Croatia
*Correspondence:
Anthony Montgomery
antmont@uom.edu.gr
† ORCID:
Anthony Montgomery
orcid.org/0000-0002-1118-7398
Olga Lainidi
orcid.org/0000-0002-7149-7902
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 19 November 2021
Accepted: 16 February 2022
Published: 31 March 2022
Citation:
Montgomery A and Lainidi O
(2022) Understanding the Link
Between Burnout and Sub-Optimal
Care: Why Should Healthcare
Education Be Interested in Employee
Silence?
Front. Psychiatry 13:818393.
doi: 10.3389/fpsyt.2022.818393
Frontiers in Psychiatry | www.frontiersin.org
Evidence on the association of burnout with objective indicators of performance is
scarce in healthcare. In parallel, healthcare professionals ameliorate the short-term
impact of burnout by prioritizing some tasks over others. The phenomenon of employee
silence can help us understand the evolution of how culture is molded toward the
prioritization of some tasks over others, and how this contributes to burnout. Silence
in healthcare has been associated with concealing errors, reduced patient safety, and
covering up errors made by others. Conversely, there is evidence that in organizations
where employees are encouraged to speak up about concerns, and where concerns
are responded to appropriately, better patient outcomes such as improved patient safety
and patient experience occur. Interventions to promote “speaking-up” in healthcare have
not been successful and are rooted in a professional culture that does not promote
speaking out. In this paper, we review the evidence that exists within healthcare to
argue why healthcare education should be interested in employee silence, and how
silence is a key factor in understanding how burnout develops and impacts quality
of care. The following key questions have been addressed; how employee silence
evolves during medical education, how is silence maintained after graduation, and
how can leadership style contribute to silence in healthcare. The impact of withholding
information on healthcare professional burnout, patient safety and quality of care
is significant. The paper concludes with a suggested future research agenda and
additional recommendations.
Keywords: employee silence, burnout, Quality of care (QoC), healthcare education and training, wellbeing
INTRODUCTION
Burnout is accepted as a significant problem in healthcare, and there is a plethora of research to
demonstrate the links with patient safety and quality of care. However, evidence on the association
of burnout with objective indicators of performance (as opposed to self-report) is scarce in all
occupations, including healthcare (1, 2). But, the research that does exist indicates an important
relationship between burnout and sub-optimal care. For example, intensive care units in which staff
reported high levels of emotional exhaustion had higher patient standardized mortality ratios, even
after objective unit characteristics such as workload had been controlled for Welp et al. (3). Thus,
we have a challenge in identifying the links that connect burnout and performance in healthcare (4).
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Employee Silence and Burnout
WHAT IS EMPLOYEE SILENCE AND
WHY IS IT IMPORTANT?
An under-researched area in the literature is the way that
healthcare professionals maintain performance during stressful
conditions. For example, there is some evidence that even when
staff lacks mental or physical energy (5) they use “performance
protection” strategies to maintain high priority clinical tasks and
neglect low priority secondary tasks (such as reassuring patients)
(6). The simplest example of this is the existence and frequent
use of “work arounds” in healthcare, whereby staff develop
creative solutions to resource and/or staff shortages (7). The drive
for healthcare professionals to “keep going” and “get the job
done” has a dark side referred to as pathological altruism (8),
which refers to behaviors that attempt to promote the welfare
of another but can have pernicious long-term consequences
for the care giver. Healthcare exploits the professional ethic of
healthcare professionals which results in a form of dysfunctional
professionalism that support maladaptive healthcare structures in
education and practice (9). The gap between what our healthcare
workers would need to balance maintaining quality of care with
their wellbeing and the reality of their day-to-day experience is
significant—as is evidenced by increasing levels of burnout. Selfcare equals safe care, but that is not happening as burnout and
the associated mental health problems are not dealt with until a
tipping point is reached.
The phenomenon of employee silence in healthcare can help
us to understand how culture is molded toward the prioritization
of some tasks over others. Indeed, a common phenomenon
among healthcare staff is a feeling that they are unable to share
their concerns, and their managers are anxious about even
seeking them or having honest informal conversations. Thus
silence is the result of such “protective hesitancy” as both may
not feel it is “psychologically safe” to have such discussions
(10, 11). Understanding what healthcare workers consider to be
a priority can be understood via what they speak-up about and
keep silent about at work. Remaining silent about important
issues is a complex phenomenon in healthcare that is rooted in
early educational experiences and career development. Silence is
connected with low levels of psychological safety (12), which in
turn is connected with burnout and poorer care (13, 14). From
this perspective, burnout and sub-optimal care are symptoms
of a dysfunctional system. Such systems are difficult to analyze
directly, but employee silence provides an important bridge into
how healthcare workers make sense of their work via what they
choose to speak-up about and what they remain silent about.
Moreover, viewing this phenomenon through the educational
journey of healthcare professionals delineates the evolution of
what is acceptable/not acceptable to discuss which is directly
linked to employee wellbeing, patient safety and quality of care.
In this paper, we review the evidence that exists within
healthcare to argue why healthcare education should be
interested in employee silence. We will focus on the experience
of physicians, given their pivotal role in healthcare delivery, but
the conclusions we reach are relevant for healthcare education
generally. The following key questions have been addressed;
how employee silence evolves during medical education, how is
silence maintained after graduation, and how can leadership style
contribute to silence in healthcare. The paper concludes with the
future research agenda and some recommendations.
Frontiers in Psychiatry | www.frontiersin.org
Employee silence denotes the withholding of genuine expressions
about employees’ evaluations of personal, social, and/or
organizational circumstances at work to persons who are capable
of effecting change at work (15). Employee silence in healthcare
falls into two broad categories; voluntary and involuntary forms
of silence. Silence in healthcare can take a number of forms that
include being silent about patient safety concerns and covering
up errors (16–18), ethical issues (19), discrimination issues (20),
inappropriate behavior (21, 22), neglected care (23), and lack of
resources (24). Conversely, there is evidence that in organizations
where employees are encouraged to speak up about concerns,
and where concerns are responded to appropriately, better
patient outcomes such as improved patient safety and patient
experience occur (25). The need for us to address employee
silence in healthcare has been highlighted by a recent systematic
review which concluded that speaking-up interventions in
healthcare are largely ineffective, due to a global pervasiveness
and dominance of professional cultures that are inimical to
speaking-up interventions (26).
In the following, we will argue that the phenomenon of
employee silence has its roots in medical education systems
that reflect the prevailing values within society that valorize
competitiveness and status. Prompts toward silence and the
need to protect the in-group (i.e., physicians) starts in medical
school and is entwined in the continuous forms of education that
healthcare professionals attend to during their career. Physicians
are educated to be clinicians first, and their role as a leader, team
member, or manager is secondary (27). This system results in a
formal culture that values professionalism, but a hidden one that
valorizes performance and competitiveness above collaboration
(28, 29). Figure 1 highlights examples of forces that contribute
to employee silence during the career of a physician. In the
first part of the paper, we will review the evidence indicating
how employee silence evolves and is maintained. In the second
part of the paper, we will identify avenues for future research
and make recommendations as to what can be done to address
employee silence.
HOW DOES EMPLOYEE SILENCE
EVOLVE DURING MEDICAL
EDUCATION?
There is significant evidence that medical training is plagued
by difficulties with the delivery of undesirable information
regarding the assessment of students (30), which represents a lost
opportunity in terms of modeling the sharing of information.
A systematic review on selection methods used in medical
education highlights the fact that outcome measures used to
evaluate selection methods most often focus on indicators of
attainment and maximal performance (e.g., medical school
achievements, performance in licensure examinations) rather
than indicators relating more directly to clinical practice (31).
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Employee Silence and Burnout
FIGURE 1 | Examples of forces contributing to silence.
sacrifice can dovetail in a dysfunctional way with being loyal, and
not speaking up.
The significant literature on the hidden curriculum suggests
that the induction period for many young physicians is
characterized by a toxic performance culture, whereby adversity
is viewed as “character building” and emotional repression is
valorized (41, 42). Moreover, evidence indicates that medical
students report inaction in the face of emotionally challenging
situations (43, 44), and dysfunctional emotion regulation
strategies can be a risk factor for burnout (i.e., emotional
exhaustion, and cynicism) (45). Ultimately, it appears that young
physicians learn early on that certain dysfunctional behaviors are
valued (e.g., working long hours without appropriate breaks as an
indicator of “commitment”).
This begs the question as to whether healthcare education
is building a culture of performance first; where individual
wellbeing and asking difficult questions is far down the list of
priorities (8, 9). The fact that such high percentages of physicians
consistently report symptoms of burnout (32) suggests that there
is a significant problems with the job and its ability to adequately
support individuals to meet its demands (33), and this problem
will not be ameliorated if the response of healthcare organizations
is to focus predominately on individual-focused solutions (e.g.,
extended leave, mediation, psychotherapy) (34). A “performance
first” culture does not encourage speaking-up. For example, a
BMJ blog written by two new United Kingdom medical students
argues that there is unhealthy focus on individual resilience which
results in them compensating for a flawed system, and sounds
more like compliance than resilience. The students conclude by
arguing that junior doctors need to be empowered to build more
resilient systems, by whistleblowing, advocating, and speaking
out against wrong (35).
The profile of the “average” medical student is someone
with high scholastic performance and high levels of adaptive
perfectionism (36). Unfortunately, the “average” medical student
commonly reports symptoms of depression (37) and burnout
(38) as a consequence of the demands of medical training. The
inhibition of emotion that results from having to remain silent
can have a huge psychological toll (39). If junior healthcare
staff 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 own wellbeing. Moreover,
staff can carry this rumination home making recovery from
work less effective (40)—with medical education being the
first exposure to this phenomenon. The challenge for medical
education is to avoid promoting the value of self-sacrifice as the
characteristic of a good healthcare professional, as the ideal of
Frontiers in Psychiatry | www.frontiersin.org
HOW IS SILENCE MAINTAINED POST
RESIDENCY?
As young physicians begin their careers, there are many prompts
from their environments that reinforce the tendency toward
withholding information. As already noted, the use of “work
arounds” is frequent in healthcare. Work arounds could be
viewed as an organic response to acquiescent silence (i.e.,
apathy)—resulting from a belief that problems need to be
“worked around” because change is not forthcoming. Ultimately,
such adaptations may not be spoken about because they grow
out of the situation the staff is in, and they are seen as
natural necessities rather than as true innovations. Thus, there
is acceptance that being “silent” about gaps in care is practical
and solution-focused. Congruently, open discussions of medical
errors are sensitive due to the legal ramifications of sharing
information that may identify the malpractice of a coworker, thus
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Employee Silence and Burnout
culture and adversely affect “low power” members’ perception
regarding their willingness to speak up, which inhibits productive
communication (24, 53).
We can view employee silence as an “appropriate” reaction to
certain leadership styles, group dynamics and/or as a vehicle for
participation in the organization rather than a withdrawal from
it. Given the widespread nature of employee silence in the health
sector, the complexity of medical healthcare provision and the
augmented stress that characterizes healthcare professions, we
should also consider that the extent to which employee silence
can be identified in the healthcare sector might also be a type of
participative group climate (or intragroup norm), in particular
if we take into account all plausible motivations for being
silent about medical errors and mental health issues faced by
healthcare professionals or other problems in the sector. Group
climate is characterized by shared employee perceptions and it
has been suggested through research findings that group-level
perceptions related to psychological safety can predict individual
voice behaviors (54). In this case, if speaking up is perceived as
a threat to the psychological safety on a group level, then the
tendency to be silent—or speak up less—as an individual, could
be an expression of a participative climate.
limited sharing of such information can be viewed as critical to
maintaining work team cohesion.
Policies or interventions to give healthcare professionals
opportunities to voice may not effectively reduce silence, and
therefore fail to reduce burnout, if employees still withhold
issues they do not feel comfortable sharing (46). Researchers
and practitioners cannot assume that physicians who frequently
speak up are not withholding other issues (47). For example,
in 2016 the UK National Health Service (NHS) introduced
the “Freedom to Speak Up Guardian” (FTSUG) role, with the
objective of improvements in the way staff concerns were handled
and responded to (especially with regard to patient safety).
Interestingly, thousands of NHS staff have spoken up to FTSUGs,
but the majority of concerns raised were about bullying and
harassment behaviors by colleagues, rather than direct patient
safety concerns (48). The challenge for healthcare education is
enable physicians to speak about professional behavior more
directly. Additionally, there is a secondary issue as to whether
bullying/harassment is a “strategy” to encourage employee
silence. For example, in the paper of Edwards et al. a step-by-step
analysis of the case of “Dr. Death” at the Bundaberg Hospital in
Australia revealed that numerous allegations of harassment and
bullying were filed prior to the official inquiry starting (49). The
inquiry concluded that 13 patients died due to negligence, and
highlighted how harassment and bullying behaviors were used to
intimidate junior staff into silence.
Thus, the challenge for continuous professional development
(CPD) is to understand the processes that result in organizations
consisting of people who promote silence as a norm, and
understand how CPD can be used to equip healthcare
professionals with tools to promote the appropriate sharing of
information. A good place to start is to explore how CPD
can contribute to building an inclusive workplace, meaning
workplaces and teams where the differences and uniqueness
that staff bring are valued, as organizations are more likely to
be “psychologically safe” workplaces where staff feel confident
in expressing their true selves, raising concerns and admitting
mistakes without fear of being unfairly judged (50).
CHARTING THE FUTURE RESEARCH
AGENDA
Future research in the field of heath professional education
needs to meaningfully reflect the influence of individual factors,
group factors, and context on learning, performance, and
wellbeing. Education is an organized activity, and shouldn’t
be treated as a value-free preparation for professional life.
Issues that are related to group dynamics, like collaboration,
competitiveness, leadership, effectiveness, decision making,
organizational culture and development—which are the focus
of the medical profession—should also be the focus of medical
education. In this context, behaviors that are considered
individual choices—e.g., to speak up or to remain silent—can be
also studied as “organizational phenomena,” and in healthcare
some of those organizational phenomena are very likely to also
have their roots in education. Medical education needs to move
from a focus on individual attainment to collective effectiveness,
which is more likely to promote individual wellbeing and thus
patient safety. Figure 2 outlines suggested questions that future
research needs to address.
HOW CAN LEADERSHIP STYLE
CONTRIBUTE TO SILENCE IN
HEALTHCARE?
Healthcare professionals often fear blame, loss of jobs, legal
issues or breaking the hierarchy as they hesitate to speak
about errors and transgressions. There is considerable anecdotal
evidence in healthcare that the silence norm is top-down. For
example, the chairs of medicine and surgery departments report
it is common for faculty not raise or talk about important
problems (51). What are the types of behaviors modeled by
leadership and line-management that promote silence? The
evidence indicates that toxic supervisors, who avoid adopting
subordinate’s ideas, can lead employees to be more silent (52).
If the aforementioned behaviors are characteristic of clinical
leaders, they will feed into the group climate of the unit and/or the
department. Large power discrepancies are ingrained in medical
Frontiers in Psychiatry | www.frontiersin.org
FURTHER THOUGHTS AND
RECOMMENDATIONS
Evidence from industries outside of healthcare is instructive.
For example, Shaukat and Khurshid (55) found that burnout
mediated the relationship between employee silence and
employee performance, leading to withdrawal behaviors and
turnover intention among telecom engineers. Thus, if supervisors
do not encourage employees to share their work-related
concerns, silence functions as a workplace stressor that starts
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Employee Silence and Burnout
FIGURE 2 | Research agenda for addressing silence in health professionals education (HPE).
modeling desired behaviors such as humble inquiry, minimizing
assumptions, and developing rapport (60). Employee silence is
maintained at both the hospital board and senior management
levels, in that the messages about work practices that compromise
safety can be viewed as unwelcome. This results in perverse
organizational dynamics—where people (i.e., clinical leaders as
safety gatekeepers) are used as a means to an end, as tools and
commodities rather than respected citizens (61). However, more
contact between senior leaders and day-to-day operations at the
ward level has the potential to reduce the gap between abstract
policy and the reality of managing patient demands. Moreover,
the emergence of kindness and compassionate leadership have
the potential to create environments where information is shared
earlier and more openly (62)—preventing larger problems that
eventually need whistleblowers to illuminate them (63). The
challenge for medical education is to figure out how it can
stop healthcare professionals recycling the dysfunctional “rites of
passage” behaviors that they have suffered under, if kindness and
compassion are to be adopted.
a loss of resources process, in agreement with the resource
depletion principle predicted by the Conservation of Resources
(COR) theory (56). In this context, one could argue that the
more pervasive silence is, the more intense is the effect on the
experience of burnout, specifically emotional exhaustion (57).
The concept of organizational memory is very useful. For
example, research on the dark side of policing highlights the
norms that can support police silence and which are integrated
into organizational memory (58). Such norms include; not
“ratting” on another officer, not implicating your colleagues if
you’re caught doing something, not interfering with the activities
of other police offices, not trusting new people until they have
been socialized into the norms, and not volunteering information
about any event that could implicate a colleague. The important
point is that such behaviors are learned early in the educational
experiences. Not surprisingly, corrupt decisions that result in
positive outcomes are included in organizational memory, and
provide guidelines for future behavior. The police force and
military represent good comparison industries in the sense that
mistakes have a high legal cost and hiding and/or covering up
problems can be a common strategy.
Employee silence in healthcare may simply reflect the
social psychological need of individuals to identify with their
organization. This is referred to as the “Abilene paradox,”
which involves a common breakdown of group communication
in which each member mistakenly believes that their own
preferences are counter to the group’s and, therefore, does
not raise objections (59). The Abilene Paradox is a desire
not to “rock the boat.” So, how can we counter this desire?
Obviously, leaders increasing psychological safety as a deterrent
against employee silence should be the goal in the long-term,
but the short to mid-term goals can include clinical leaders
Frontiers in Psychiatry | www.frontiersin.org
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author.
AUTHOR CONTRIBUTIONS
AM and OL contributed equally to the conceptualization of the
idea and contributed to writing the manuscript. Both authors
contributed to the article and approved the submitted version.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
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