When Nurses Stay Silent: Fairness at Work Holds the Key to Speaking Up

In the high-stakes world of hospital care, the most dangerous sound is often no sound at all. When nurses notice a medication error brewing, a faulty protocol, or a colleague cutting corners, their willingness to voice those concerns can mean the difference between a near miss and a tragedy. Yet a growing body of research shows that many nurses choose to keep quiet, a phenomenon organizational scientists call organizational silence. A new study from Iran, published in BMC Nursing, offers fresh evidence that the roots of this silence run deep into how fairly nurses believe they are treated by the institutions that employ them.

The research, led by Amin Soheili and colleagues at Khoy University of Medical Sciences, set out to answer a deceptively simple question: do nurses who perceive their hospitals as just and fair speak up more often than those who do not? To find out, the team surveyed 309 nurses working across three public hospitals, drawing participants from inpatient wards, intensive care units, emergency departments, and operating rooms. The settings matter, because these are precisely the environments where rapid, honest communication is most critical and where the costs of withheld information are highest.

Organizational silence is not a single behavior but a family of them, and the researchers were careful to distinguish its different flavors. Acquiescent silence describes the passive withdrawal of effort and opinion, a kind of learned resignation in which employees stop offering ideas because they have concluded that speaking is futile. Defensive silence is more calculated: employees withhold information deliberately to protect themselves from trouble, blame, or retaliation. A third form, often labeled prosocial silence, involves staying quiet to protect colleagues or the organization itself. Understanding which form dominates a workplace tells managers something important about why employees are withholding what they know.

In the Khoy hospitals, acquiescent silence scored highest among the participating nurses, while defensive silence scored lowest. That pattern is telling. It suggests that the silence observed was less a matter of nurses actively fearing punishment and more a matter of them having given up on the idea that their voices would make a difference. Resignation, rather than fear, appears to be the dominant force muting these frontline clinicians, a finding that carries sobering implications for hospital leadership hoping to fix the problem with a few open-door policies.

The study used a descriptive cross-sectional design, with participants selected through proportionate stratified random sampling to ensure that the mix of wards, roles, and experience levels in the sample mirrored the hospitals as a whole. Nurses completed validated questionnaires measuring organizational silence and organizational justice, along with a single-item measure of job satisfaction. The researchers then applied a battery of statistical tools: descriptive statistics to characterize the sample, Pearson correlations to test simple associations, and hierarchical multiple regression to isolate the unique contribution of fairness perceptions while controlling for demographic and job-related factors.

The headline result is a moderate but statistically robust inverse relationship between organizational justice and organizational silence, with a correlation coefficient of −0.31 and a p-value below 0.001. In plain terms, nurses who perceived their workplaces as fairer were measurably less likely to withhold their opinions and concerns. Correlation alone cannot prove causation, and the authors are appropriately cautious on this point, but the association aligns with a well-established theoretical framework in organizational psychology: employees constantly monitor how resources, decisions, and respect are distributed, and their willingness to invest discretionary effort, including the effort of speaking up, tracks closely with those perceptions.

The hierarchical regression added a more striking layer to the story. Demographic and job-related variables, things like age, experience, and employment conditions, explained 28.9 percent of the variance in organizational silence. When the researchers added organizational justice to the model, the explained variance climbed to 35.5 percent. That additional 6.6 percentage points may sound modest, but in the noisy world of human behavior, where dozens of factors shape any single attitude, a perceived-fairness variable adding that much predictive power on top of a strong demographic baseline is a meaningful signal. It suggests that fairness is not just another correlate but a substantive lever.

Not all forms of fairness carried equal weight. The study found that interactional justice, the perceived quality of interpersonal treatment, whether nurses feel respected, heard, and treated with dignity by supervisors, and procedural justice, the perceived fairness of the processes by which decisions are made, were particularly associated with lower silence. This distinction matters for intervention design. A hospital can distribute pay and shifts with mathematical precision, but if the process behind those decisions is opaque and the conversations around them are dismissive, nurses will still conclude that speaking up is not worth the risk. Fairness, in other words, is experienced as much in tone and transparency as in outcomes.

The practical stakes are considerable. Organizational silence among nurses has been linked in prior literature to hindered communication, reduced team effectiveness, and compromised patient safety. A nurse who notices a subtle change in a patient’s condition but has learned that raising concerns invites eye-rolls rather than action becomes a broken sensor in a system that depends on thousands of such sensors working in real time. The authors of the new study argue that strengthening fair communication, transparent decision-making, and respectful interpersonal interactions could help create a climate that encourages speaking up and enhances psychological safety, the shared belief that a team is safe for interpersonal risk-taking.

There are, of course, limits to what a single cross-sectional survey can establish. The study captures a snapshot of perceptions at one moment in three hospitals within one Iranian university network, and the direction of causality remains open: it is at least plausible that nurses who stay silent come to view their organizations as less fair, rather than the reverse. Self-reported questionnaires also carry the usual risks of social desirability bias. Still, the study’s strengths, its stratified random sampling, validated instruments, and careful statistical modeling, make it a valuable addition to a literature that has long underexplored the justice-silence link in nursing specifically. For hospital administrators everywhere, the message is clear and actionable: if you want your nurses to speak, the first step is convincing them, through both fair processes and fair treatment, that their voices genuinely count.

Subject of Research: The relationship between perceived organizational justice and organizational silence among hospital nurses in Iran

Article Title: Iranian nurses’ perceptions of organizational silence and its relationship with organizational justice

Article References: Iranian nurses’ perceptions of organizational silence and its relationship with organizational justice. (n.d.). https://doi.org/10.1186/s12912-026-05250-2

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05250-2

Keywords: organizational silence, organizational justice, nurses, patient safety, psychological safety, hospital management, Iran, nursing workforce, procedural justice, interactional justice, cross-sectional study, BMC Nursing