Meanings and senses of organisational silence by male nurses in the emergency department: an interpretative phenomenological study protocol.

INTRODUCTION: The organisational silence of nursing teams has received increasing attention from managers. Chinese nurses have a relatively high score for organisational silence, and male nurses score higher than female nurses. Lack of professional empathy, high pressure in the work environment, and traditional Chinese cultural factors suggest that Chinese male nurses' experiences of and reasons for organisational silence are complex and unique. Taking male nurses in the emergency department as an example, this study explores the experience and meaning of male nurses' organisational silence and provides ideas for nursing managers to understand the silence of male nurses. METHODS AND ANALYSIS: An interpretative phenomenological approach underpins the study design. In this study, the purposive sampling method will be used to select male nurses who meet the inclusion criteria with maximum differentiation as a strategy. Face-to-face semistructured interviews and Van Manen analysis methods will be used for data collection and analysis. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (ethical approval ID: 2019-KL-036-01). Participants will provide informed consent, will be able to withdraw at any time and will have their contributions kept confidential. The findings of the study will be shared with relevant stakeholders and disseminated in conference presentations and journal publications. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry (ChiCTR2100047057). © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This study provides an in-depth exploration of male nurses’ understanding of how to express themselves in the workplace.

This study will mainly be conducted in a hospital in Zhejiang Province, China, and it will not be possible to represent all male nurses.

This is the first qualitative study to explore the organisational silence experience of male nurses in the emergency department.

Introduction

There are powerful forces in many organisations that cause widespread withholding of information about potential problems or issues among employees. This collective-level phenomenon is defined as organisational silence.1 It is closely related to turnover intention, organisational justice and patient safety.2–5 In recent years, organisational silence in nursing has been frequently discussed in various studies and is a very common phenomenon among nurses.6 When they realise that there is a problem, only 10% of nurses will directly raise the risk of conflict with their colleagues, and most nurses will choose to remain silent.7

In China, the proportion of registered male nurses rose from 1% in 2010 to 2.6% in 2019.8 In 2019, there were approximately 1.15 million registered male nurses, and they have become an indispensable part of nursing teams. However, nursing is still a female-dominated profession worldwide, and men who choose nursing professions will be questioned because of people’s stereotypes of masculinity. A survey on the silent behaviour of nurses in China’s tertiary hospitals showed that male nurses scored higher on the silent questionnaire than female nurses, a finding that is unexpected, given the traditional impression that women tend to be more silent in the workplace.9

Organisational silence is a complex behaviour with multidirectional motivations.10 Previous studies have emphasised that the connotation of organisational silence may be very different in different situations.11 Brinsfield’s12 research shows that men are more willing to take risks than women and more commonly engage in organisational silence behaviours, and the ‘cognitive gap’ created by this gender perspective difference sheds light on the reasons for the organisational silence of male nurses. At the same time, the current situation of male nurses’ low professional identity13 14 and high turnover intention15 may be one of the internal reasons for the culture of silence. The distinct hierarchical system in the nursing profession may be one of the external factors that increase organisational silence.16 In addition, traditional Chinese Confucian culture advocates the value orientation that ‘silence is golden’, which may be the cultural environment that nurtures and strengthens the silence of male nurses.17 Based on the above analysis, we believe that the reasons for the high organisational silence scores of Chinese male nurses are complex and unique and require more attention and deeper exploration.

Male nurses in China are usually assigned to work in emergency departments or intensive care units due to their physical advantages over female nurses. Nursing managers usually think that assigning male nurses to the emergency department will give full play to the advantages of male nurses. However, studies have shown that male nurses in the emergency department do not show a higher degree of professional satisfaction.18 In fact, the emergency department is one of the most intense and high-pressure departments as the front line of saving lives in hospitals. As a result, male nurses often show a low level of professional identity and a high level of willingness to leave.13 14 19 At the same time, as a ‘triage hub’, the emergency department is one of the most prone to medical disputes, and nurses in the emergency department must have good communication skills and communication efficiency. In view of the importance of communication to the medical and nursing work of the emergency department, the potential harm of organisational silence to the quality of emergency care cannot be ignored. Therefore, it is particularly important for nursing managers to understand the reasons for and experience of organisational silence among male nurses in the emergency department.

However, the occurrence of organisational silence is hidden. Organisational silence is a deliberate decision, but there is no outward sign of activity.20 At the moment of silence, everyone has relevant thoughts. What made the male nurses in the emergency department choose to be silent? What did the male nurses experience when they were involved in silence? What meaning does a male nurse give to silence? These issues are worthy of in-depth study. However, previous studies have mostly focused on the organisational silence of corporate employees. Research on the organisational silence of medical staff has only recently emerged, and studies focusing on the organisational silence of male nurses are even rarer.

Conceptual qualitative research will play a fundamental role in exploring the experience and nature of the organisational silence of male nurses. Phenomenology, as one of the methods of qualitative research, emphasises finding the roots of phenomena with an open attitude, searching for the connections between phenomena and exploring the essence of experience.21 Organisational silence emphasises interpersonal interaction and relationships, which are particularly suitable for phenomenological discussion.22

In view of the above reasons, this study will adopt interpretative phenomenological research methods, taking male nurses in the emergency department as the starting point to interpret and understand the silent experience of male nurses in the emergency department, and provide a theoretical reference for nursing managers to break organisational silence and support the participation of men in the nursing profession.

Aims and objectives

Aims

The aims of this study are to understand the experience of male nurses in the emergency department when they are involved in organisational silence and to explore the underlying causes of organisational silence via interpretative understanding.

Understand the inner experience of male nurses in the emergency department when they are involved in organisational silence.

Explore the background reasons for the occurrence and development of organisational silence among male nurses.

Identify management strategies that can reduce organisational silence among male nurses in the emergency department.

Methods and analysis

Study design

This study will include a qualitative methodology underpinned by Heideggerian phenomenology, which focuses on interpreting and understanding the meaning of lived experiences.23 24 Phenomenology grounded on hermeneutic phenomenologists such as Heidegger, Gadamer and Ricoeur focuses on the interpretation of meaning in which preconceptions are integrated into the research findings. Phenomenology seeks to illuminate the lived experience of a shared phenomenon.25 Emphasis is placed on the subjective experience of the participants and the meanings they attribute to their experience, thereby allowing the researcher to gain insights into people’s motivations and actions.26 Phenomenology integrates the relationship between socialisation, enculturation and how we interpret our lifeworld.27 Therefore, our interpretations, or the meanings we place on a phenomenon, are constructed within a sociocultural context.

Organisational silence usually occurs in the workplace and in the process of interpersonal interaction. It is the ‘real-world’ experience of male nurses in the emergency department and will inevitably be affected by factors such as the work environment, interpersonal relationships and organisational atmosphere. Burns23 suggested that the understanding gained in interpretative inquiry is key to ‘become more effectively, skilfully or humanely engaged in practice’ and is a particularly useful approach when one seeks to understand meaning and practices that are often taken for granted and assumed. The insights generated are co-constructed within an interpretative dialogue.

Data collection

The data collection method of this research will adopt the semistructured interview method.28 The researcher records the non-verbal actions and key information of the interviewee during the interview and writes interview notes after the interview to collect as much effective information as possible. Data collection is ongoing and concurrent with data analysis. The data collection steps include the following:

Drawing up an interview outline

Based on the questions and objectives of this research, we have initially drawn up an interview outline (box 1) in a combination of three ways: literature review, open discussion and pre-interview. The outline based on the basic principle of ‘avoiding leading questions’ in qualitative interviews and the concept of organisational silence. First, the interviewer asks respondents to openly recall their practices based on the most common occurrence of organisational silence, namely ‘finding a problem at work or disagree with your colleagues’. The interviewee will then indicate whether they remain silent or speak up and will be pressed on what considerations are involved in their decision in an attempt to understand the reasons behind the silence. At the same time, we hypothesise different situations to try to understand which organisational factors contribute to male nurses’ silence. In addition, by understanding male nurses’ perceptions of their own communication and affects, the emotional connection between male nurses and nursing organisations can be understood to further clarify the experience and meaning of organisational silence.

What will you do when you find a problem at work or disagree with your colleagues?

On some occasions, when you choose to remain silence or speak up, what are your considerations?

How do you feel when you remain silent? Does this feeling change over time?

If the situation was not like that at the time, what would you do?

How do you think this will affect yourself and others?

Do you think that your status as a male nurse will affect your communication or speaking behaviour at work?

It should be noted that the inclusion criteria for pre-interview research subjects are the same as those for formal interviews. The difference is that after the pre-interview, the researcher invites the research subjects to put forward personal opinions and suggestions from the interviewee’s perspective and listens to the recording repeatedly to reflect on the deficiencies in the interview process. Through the pre-interview, the researcher revises and improves the interview outline, improves his or her interview skills and increases his or her interview experience. Of course, with the gradual development of the confirmation interview, new problems may emerge. We will further adjust the interview outline as needed under the guidance of the instructor.

Interview time and place

The interview time will be arranged according to the interviewee’s wishes, and the interview will be arranged to be free and energetic. The interview location will be mainly convenient for the interviewee, choosing quiet, comfortable and private interview rooms, cafes and other places.

Implementation of the interview

The following necessary materials and tools will be prepared before the start of the interview: research informed consent form, general situation survey form of male nurses in the emergency department, self-rating organisational silence scale, dedicated voice recorder with sufficient power and small gifts. Before the interview, the interviewer will explain the purpose, significance and research process of this research to each interviewee, have the interviewee sign an informed consent form after obtaining their consent, explain the recording requirements and record the entire interview. The interviewer will employ reasonable interview techniques such as repetition, clarification, and inquiry during the interview process and record key content and non-verbal information. At the end of the interview, the researcher will ask the research subjects if there is any content that needs to be added and indicate that there may be a second interview and follow-up questions to verify the research content. At the end of the interview, the researcher will present a small gift to the interviewee as a token of gratitude.

Sample

Non-random sampling is used in qualitative studies, and here, we will use a purposive approach.29 Persons eligible to participate in this study are male nurses working in the emergency department. This study adopts the largest difference strategy for sampling and selects male nurses from different hospitals (different regions and different grades), ages, educational backgrounds, professional titles, working years, marital status and personnel relations to obtain as much information as possible. In this study, male nurses from three tertiary hospitals and two secondary hospitals in Zhejiang Province will be selected as the research subjects.

Qualitative studies do not make any claims about generalisability, so a sample size calculation is not appropriate. Instead, qualitative studies use the concept of data saturation to assess the completeness of findings. When no more essential information on the phenomenon of interest is generated in the interviews, the data are considered to have reached a point of saturation.30 The sample size is based on data saturation, that is, the data of the interviewees are repeated, and no new themes or subthemes are presented during data analysis. We aim to recruit 10–20 participants for the individual semistructured interviews, which we expect to be sufficient for data saturation. If saturation is not reached, the sample size can be increased. This study will follow the inclusion and exclusion criteria of the sample to recruit and screen research subjects. The inclusion criteria will be as follows: on-the-job male nurses in the emergency department; a nurse’s qualification certificate; engagement in emergency clinical nursing work for more than 1 year; and informed consent and willingness to participate in the study. The exclusion criteria will be as follows: training nurses, intern nurses and probationary nurses, and those who refused to be recorded.

Data analysis

This study will use Van Manen data analysis method,31 32 and the data collection and analysis will be carried out simultaneously; that is, the data will be analysed after completing an interview. The specific steps are as follows:

Determine the overall sense of the text: at the beginning of the data analysis, repeated reading of the textual data transcribed after the first three interviews will be conducted and combined with the interview notes to gain an overall sense of the whole intuitively.

Refining meaning unit: this study will choose to encode meaningful statements related to the research question, such as the subject’s experience of silence and perceptions of silence or speech, focusing on understanding the inner experience of male nurses’ silence and refining the meaning unit.

Inductive meaning unit: inductive meaning will be interpreted on the basis of fully understanding each meaning unit, with the interviewer immersed in the interview data and engaging repeated comparisons and attempts to understand the experience of male nurses, forming a dialogue between the researcher and the male nurses, and informed by the coding of the data and the psychological knowledge possessed by the researcher. The interviewer will inquire about the meaning of the experience of the interviewee in a specific situation, eliminate repetitive or irrelevant meaning units, refine and process them, and cluster related meaning units from an analytical or theoretical perspective to form a topic group.

Theme analysis: based on the previous inductive meaning units and clustering theme groups, the researcher will summarise and sort out the various themes and subthemes. As the analysis involves different perspectives, different categories may be obtained. Therefore, the process is cyclical and continuously improved. In the process of thematic analysis, the researcher strengthens the rationality and objectivity of the thematic analysis process by reporting and communicating with the mentor and through team member discussions and peer review, and finally forms themes and subthemes.

Establish the themes and clarify the connections between themes: the researcher compares the themes and subthemes with text data and meaning units again and checks whether the themes reflect the essence of the phenomenon. The internal logic and relationship between the topics are further analysed and repeatedly discussed with the members of the tutor group, the topic is established and the corresponding excerpts from the data are identified to form an explanatory text.

Information verification: the themes and subthemes obtained are fed back to the research subjects, and the interviewees are invited to verify and confirm whether these results accurately reflect their inner experience. The researcher clarifies or answers the questions raised by the male nurse and accepts their suggestions or opinions.

Rigour

The rigour of qualitative research is related to the reliability and validity of the research results, which is the self-correcting part of the research process.33 Guba proposed the trustworthiness of qualitative research containing credibility, transferability, dependability and confirmability.34 Within these were specific methodological strategies for demonstrating qualitative rigour, such as the careful study design and audit trail, addressing the nature of relationship between interviewer and interviewees, self-reflection, peer debriefing, member checks, employing triangulation, negative case analysis and referential material adequacy.35–37 In addition to careful study design and keeping as much information as possible for audit trail, this study will take the following measures at different stages to promote research rigour.

Establish a good relationship with interviewees. The interview content of this research involves some sensitive questions, especially those related to the interaction between the interviewee and his superior. The interviewee may be unwilling to answer or may not give a true answer. Therefore, it is very important for the researcher to establish a trust relationship with the interviewee in the early stage. This is important and conducive to truthfulness and in-depth interview content.36 Before the start of the study, the interviewer (the author herself) will participate in nursing work in the emergency department as a nursing intern to establish a good relationship with male nurses. At the same time, the researcher will participate in various activities organised by the Male Nurses Union, and by increasing the interaction and communication with the male nurses, long-term good relationships will be established more naturally.

Self-reflection. The concept of reflexivity acknowledges the role played by the researcher in qualitative work. Good qualitative work recognises that perspectives are integral components of human-centred research.36 Therefore, explicit declaration of the position of the researcher that reflects on his or her own role is necessary. The researcher herself is a postgraduate student of nursing with a master’s degree, female, unmarried, with no social work experience, and has not had in-depth communication with male nurses in the course of clinical practice in the past, nor has personally experienced organisational silence and is thus in the role of an ‘outsider’ in this study. However, because the researchers have read much of the literature about organisational silence and male nurses, they are worried about the status quo of organisational silence and male nurses’ career development. Therefore, the researcher may already be an ‘insider’ of the silence study of male nurses at the cognitive level. To reduce the impact of personal bias on the research results, the researchers will record their own opinions 2 weeks before the official launch of this study and carefully understand and analyse the data when they encounter ‘similar’ codes during the data analysis, and the researchers will avoid reading the related literature to avoid contamination by other research results. With the gradual deepening of research, researchers’ understanding of organisational silence will be rerooted in the research materials to ensure the scientific nature of the research.

Peer debriefing. This refers to the gathering peers who are experienced or interested in research methods and research phenomena to provide opinions and suggestions on the researched issues.33 34 The prejudice of the author could be effectively identified in this way. The members participating in this research discussion will mainly include the researcher’s dissertation supervisor, five tutor group members, one phenomenological research peer and one scholar of Chinese as a foreign language. Repeated discussions and exchanges with peers will play an active role in monitoring, correcting and improving the data analysis process, reducing the bias of the researcher towards the research results, and enhancing the objectivity and rigour of the data analysis process.

Member checks. Member checks refer to a continuous process during data analysis; this has largely been interpreted and used by researchers as verification of the overall results with participants.34 35 For this study, we will go back to the research site again, asking participants about hypothetical situations, feeding back the research data and results to the research subjects, and systematically soliciting the opinions of the participants. The specific content includes asking the participants whether the interpretation of the data truly and objectively describes their real experience and encouraging participants to provide additional insights.

Ethics and dissemination

The study was approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang Chinese Medical University (ethical approval ID: 2019-KL-036-01). All participants will be informed fully about the study methods, risks and benefits through the participant informed consent. A cooling off period of 48 hours will be given to all those who express an interest in the study and then electronic consent will be taken. Participants will be able to withdraw at any time and request their data are withdrawn from the interviews for up to 2 days following their completion. After this period, these data cannot be withdrawn as analysis will have commenced. When the interview has been completed, we will anonymise the data prior to data analysis. Similarly, all interview data will be anonymised on transcription. Participants will be told that anonymised quotes will be published in the findings of this study. Participants in this study will be sent a summary of the findings once analysis has been completed. This study will also be disseminated in conference presentations and journal publications.

Patient and public involvement

Our research question asks for the views of male nurses in the emergency department and therefore we do not intend to include patients or the public in the design of, or data collection for, this study.