Empirical Ethics

Clinical Ethics
0(0) 1–12
Workplace silence behavior and its ! The Author(s) 2021
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DOI: 10.1177/1477750921994284
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Nagah Abd El-Fattah Mohamed Aly1 , Safaa M El-Shanawany2

and Maha Ghanem2

Abstract
Background: Workplace silence behavior is a social collective phenomenon. It refers to nurses choosing to withhold
their ideas, opinions and concerns about critical issues in their workplace. Workplace silence behavior poses a threat to
organizational ethics and success. It also has adverse effects on the performance of nurses in health organizations.
Underlying nursing causes of silence behaviors could be related to individual, social and organizational attributes in
health care settings.
Objectives: The study aimed to develop a new Egyptian validation scale for measuring nursing motives of workplace
silence behavior and identify consequences of workplace silence behavior on nurses.
Methods: A cross-sectional correlational study was implemented using questionnaires on workplace silence behavior,
nursing motives and nurses’ consequences, collected from 332 nurses working in critical and toxicology care settings of
Alexandria Main University Hospital.
Results: Egyptian scale was shown to be a good fit model of exploratory (36 nursing motives emerged in six dimensions
with total variance of 73.3%) and confirmatory factor analysis tests (X2 ¼ 1381.47, NNFI ¼0. 90, CFI ¼ 0.91,
RMSEA ¼ 0.057). It also had high reliability tests with coefficient of alpha (0.85), Pearson (0.75) and Kendall coefficient
of 0.72. High level of workplace silence behaviors showed a negative association with organizational dis-identification,
fair citizenship behavior, and fair nurses’ performance and declined reporting of patient adverse events. It also appeared
to be in a positive association with higher levels of cynicism.
Conclusion: The Egyptian scale was proved to be reliable and valid for measuring the underlying nursing causes of
silence behaviors in the hospital workplace. Measuring nursing motives of workplace silence behaviors will help nurse
managers to reduce negative outcomes of workplace silence behaviors and improve organizational outcomes.

Keywords
Motives, silence, behavior, workplace, nurses

Introduction
Providing safe and high-quality of health care services
has been the most vital issue in health care organiza-
tions.1 High quality of patient care management is not
achieved when health risks and human mistakes are not
reported. Nurses are on the front lines of care in hos-
pitals; therefore they play an important role in commu-
nicating errors for protecting patients.2 Patients in
critical and toxicology care units are more likely than
other hospitalized patients to experience medical errors
due to the complexity of their conditions, the need for
urgent interventions and considerable workload fluctu-
ation.3 Therefore, the willingness of nurses in critical
care and toxicology care units to speak up about med-
ical errors, versus a propensity to remain silent, impacts
the delivery of safe patient care.2
1
Nursing Administration, Faculty of Nursing, Matrouh University, Mersa
Matruh, Egypt
2
Forensic Medicine and Clinical Toxicology, Faculty of Medicine,
Alexandria University, Alexandria, Egypt
Corresponding author:
Nagah Abd El-Fattah Mohamed Aly, Nursing Administration, Faculty of
Nursing, Matrouh University, Egypt.
Email: eldaghar.nagah199@gmail.com
2 Clinical Ethics 0(0)
Although health care policy makers and accredita-
tion agencies have been paying their attention to create
a patient safety culture and implement feedback mech-
anisms in inpatient care units, organizational silence in
the workplace has been hindering these mechanisms to
properly work.1 Silence is an employee’s motivation to
withhold versus express ideas, information, and opin-
ions about work-related improvements (rather than on
the presence or absence of speaking up behaviour).4
Workplace silence behavior refers to the intentional
withholding of knowledge and opinions of employees
to improve their work and organization.4 So, it can
be defined as the intentional act of employees to
remain silent about the technical or behavioral issues
which are related to employees’ duties or workplace
improvement.5
The concept of workplace silence behavior is a
socially constructed phenomenon, which is created at
an organizational level and affected by many organiza-
tional characteristics. These organizational character-
istics involve decision-making processes, management
processes, or culture and defining the silent behavior of
each employee according to how he/she perceives it.6
Therefore, workplace silence behavior can be attribut-
ed to individual, social, management and organization-
al motives in health care settings.4 Individual motives
include being prejudiced and the desire to maintain the
present structure. Social motives contain a climate of
mistrust and obedience to group behaviors. Finally,
management and organizational motives comprise the
coding of certain issues as taboo, not discussing issues
that may be defined as taboo and an emphasis on the
manager and employee relationships.4,6
Workplace silence behavior constitutes a significant
threat to organizational ethics and success. Also, it can
cause harm to organizations and nurses as hidden
damage to the safety of patients, reducing nurses’ per-
formance, declining nurses’ citizenship behaviors and
nurses’ dissatisfaction. Also, it causes organizational
dis-identification and low commitment when cynicism,
stress and turnover are high among nurses.1,7
Several motives’ tools of silence behaviors have been
developed for measuring causes of silence behaviors
among employees in USA and German industrial
organizations, whereas one silence behavior scale has
been developed in Turkey for measuring nursing rea-
sons for silence behaviors in hospital settings.8–11 These
scales have some limitations to generalization in other
occupational culture settings. Regarding employees’
silence scale; it needed further reliability and validity
tests for ensuring suitability for health care organiza-
tions. Motives for silence were different according to
cultural, occupational (as occupational practice and cli-
mate), workplace personality attributes of employees
(as experience, qualification, avoidance, attitude,
beliefs and fear).7 As regards the turkey version of
the nursing silence scale, it could not be also general-
ized for health care settings in other communities for
the following reasons: 1) it was created for use in the
national study hospitals, and 2) it did not sufficiently
achieve construct validity and reliability tests.7
Globally, many studies have attempted to investigate
the motives of silence behavior and their relations to
organizational commitment, change and cynicism as
well as employee burnout, satisfaction, turnover, perfor-
mance and citizenship behaviors.2,6,8,12–14 To our knowl-
edge in Egypt, studies on organizational silence behavior
are not previously studied. Data concerning the presence
of scales for measuring reasons that hinder nurses to
speak out in their workplace is very deficient.
Therefore, it is a pressing necessity to start an action
(Figure 1) for developing a new Egyptian validation
scale for measuring nursing motives of workplace silence
behaviors and identifying the consequences of work-
place silence behaviors on nurses (organizational identi-
fication and cynicism, nurses’ citizenship behavior and
performance as well as reporting patient safety events).
Material and methods
Study settings and design: A cross sectional correlation-
al study was implemented in 14 critical and care
toxicology settings of Alexandria Main University
Hospital.
Sample size: All nurses working in the study units
who agreed to sign an informed consent. They
amounted to 332 nurses.
Data collection: Data were collected through self-
administered questionnaires. It was divided into two
sections
Section (a): Workplace silence behavior and its
motives include
a. Workplace silence behavior among nurses was mea-
sured using one question that described the frequen-
cy of nurses’ preferences to remain silent instead of
speaking out to their supervisors regarding any new
idea, practice complications and patient adverse
events in their workplace (How often did you
choose to keep silent instead of speaking out to
your supervisor).2 Nurses answered their responses
on a 5 Likert scales (where 1 ¼ no, I never remain
silent and 5 ¼ yes, always I remain silent).
b. Nursing motives of workplace silence behaviors: The
scale was developed by the researchers through the
following phases:
• Face and content validity phase: 55 nursing
motives were developed by researchers as a
Mohamed Aly
Figure 1. Conceptual framework of the study.
result of literature reviews.2,6,8–10,15 The question-
naire scale was investigated by 5 experts. The
experts appraised the relevance of questionnaire
items by using a 5 Likert scale (from 1¼ not rel-
evant to 5¼ relevant). Experts were asked if other
appropriate items should be added to the scale
and their comments were collected and revised.
According to experts’ evaluation, 10 irrelevant
items were removed. 45 Likert items were estab-
lished in the finalized scale of the workplace
silence behavior scale. Likert style scale rated
from 1 (extremely disagree) to 5 (extremely agree).
• Inter-rater reliability phase was achieved through
Kendall’s test for measuring consensus and har-
mony among 5 experts.
• Test-retest reliability phase was considered by
Pearson’s correlation test and a pilot test. In a
pilot test, 30 nurses answered the study question-
naires repeatedly at two different times (within
three weeks). Pilot test was used for confirming
comprehensibility and attainability of the
questionnaire.
• Construct validity phase was achieved through
Exploratory Axis Factor Analysis test (EAFAT).
EAFAT analyzed 45 motive items and showed the
following: Scree-plot breaking point curve was
initiated to tail from component number six
(Figure 2); all items correlated with the loading
of more than 0.5 were maintained; 36 motive
items were a strong loading on six components
accounting for 73.3% of the total variance.
Confirmatory factor analysis test (CFAT) was
used to verify the structure of the identified six
factors yielded from EXFAT. The result of con-
firmatory factor analysis was confirmed through
good fit indices.
• Internal consistency reliability phase was investi-
gated by the alpha coefficient of the whole scale
and its six components.
3
section (B): Consequences of workplace silence
behaviors include
(1) Organizational cynicism was measured by thirteen
statements rated from 1 (extremely disagree) to 5
(extremely agree).16 Test-retest and alpha coefficient
reliability of this scale were 0.85 and 0.67 respectively.
(2) Organizational identification was measured using
ten Likert items (from 1¼ have extremely disagreed
to 5¼ have extremely agreed).17,18 The values of test-
retest and alpha coefficient reliability of this scale were
0.91 and 0.82 respectively.
(3) Nurses’ citizenship behavior: was measured using a
five-item scale represented in five dimensions: courtesy,
sportsmanship, civic virtue, conscientiousness and
altruism behaviors).19 Nurses provided their answers
using a 5 Likert scale (1 ¼ have extremely disagreed
to 5 ¼ have extremely agreed). Test-retest and alpha
coefficient reliability of the 5-item scale were 0.80 and
0.89 respectively.
(4) Nurses’ performance: was evaluated by nine scale
items (ranging from 1 ¼ have extremely disagreed to
5 ¼ have extremely agreed).20 Nine items scale had a
test-retest of 0.79 and an alpha coefficient reliability
of 0.85.
(5) Reporting patient safety events: was measured by
two questions adapted from the hospital patient
safety survey of Agency for Healthcare Research and
Quality (AHRQ).21 Nurses were asked to address
patient safety events in their units during the last six
months and frequency of reporting these events to
someone considered able to change the situation.
Nurses’ responses on the two-item scale ranged from
1 (I never report patient safety events) to 5 (I always
report patient safety events). The test-retest reliability
test of this scale was 0.75.
The questionnaire was translated into Arabic and
translated for a second time into English language for
confirming transparency of its content. The finalized
version of the questionnaire scale contained two
4 Clinical Ethics 0(0)
Figure 2. Scree plot of workplace silence behavior scale.
questionnaire sections: (1) workplace silence behavior
and nursing motives and (2) consequences of work-
place silence behavior on nurses. A total of 480 ques-
tionnaires was administered to nurses in the study units
and 460 copies were returned. 332 of 460 copies were
relevant for data analysis. The response rate was
72.2%. The questionnaire copy was attached with an
explanation letter about the research purpose and some
research definitions. The researchers met the nurses to
provide necessary information and clarification for fur-
ther questions.
Ethical considerations: the Faculty of Medicine
Administration provided approval for conducting the
research. After obtaining informed consent, all nurses’
responses were handled by confidentiality and anonym-
ity and researchers created a code number for each
questionnaire during data analysis.
Statistical analysis: was accomplished by SPSS ver-
sion 18. Nurses’ responses were interpreted by descrip-
tive analysis. Nurses’ responses to overall perceptions
of the questionnaire scale and sub-dimensions were cat-
egorized by mean scores into mild score (<3), moderate
score (3–3.9) and high score (4). Effect relationships
between variables were analyzed by Spearman’s corre-
lation and linear regressions. Construct validity was
confirmed by EAFAT with Principal Varimax
Rotation and using Kaiser Normalization with Eigen
value more than one as well as CFAT. CFAT was ana-
lyzed by LISREL version 8.80. The confirmatory
factor analysis model of an Egyptian scale was evalu-
ated using four good fit indices,22–24 as follows: (1) Chi-
square (v2) is a good fit when the ratio of v2 to degrees
of freedom is less than three and the p-value is greater
than 0.05; (2) Root mean square error of approxima-
tion (RMSEA) value equal to or less than 0.05 is an
indication of a good fit model while RMSEA value less
than 0.08 is considered an acceptable fit. The value of
RMSEA greater than 0.1 should lead to model rejec-
tion; (3) Values of Non-Normed Fit Index (NNFI) and
Comparative Fit Index (CFI) equal to or greater than
0.90 are considered a good fit. Reliability tests of inter-
nal consistency, test-retest, and inter-rater were consid-
ered through Pearson’s, Kendall’s and Cronbach’s
alpha coefficient tests respectively.
Results
Exploratory axis factor analysis test of
Egyptian motives scale
36 questionnaire items and six components were
explained in 73.3% of total variance with Eigen value
more than one. Factor loadings ranged from 0.55 to
0.90. KMO Value with a statistical significance of
Bartlett Test for the scale was approximately 0.89
and for the dimensions ranged from 0.68 to 0.85. The
Alpha coefficient for the scale was 0.84 and all sub-
scales ranging from 0.83 to 0.94. Reliability tests of
the inter-rater coefficient and test-retest were 0.72 and
0.75 respectively (Table 1).
Confirmatory factor analysis test of
Egyptian motives scale
The t-value was significant regarding motive factors
and its items (p < 0.01). Standardized coefficient solu-
tions indicated that highly relationships were found
between factors and their items (r  0.81, p < 0.01) as
well as among the factors (r  0.61, p < 0.01). It was
noteworthy that a good fit model of an Egyptian
Mohamed Aly
scale was found by confirmatory factor analysis
(X2 ¼ 1381.47, X2/df ¼ 2.76, NNFI 5 0. 90, CFI ¼ 0.91,
RMSEA ¼ 0.057) (Tables 2 and 3 and Figure 3).
Levels of workplace silence behavior and nursing
motives as well as its consequences
Nurses highly favored to keep silent in their workplace.
The reasons that led nurses to maintain silence in their
workplace were related to personality factors as avoid-
ance, beliefs, attitude and fear; management and orga-
nizational factors. Nurses identified management and
organizational factors as well as fear and avoidance as
the most nursing motives of workplace silence behavior
(Figure 4).
Nursing workplace silence behavior was a positive sig-
nificant predictor of organizational cynicism (Beta ¼ 0.37).
Organizational cynicism seemed to increase when nursing
workplace silence behaviors increased (B ¼ 0.31). Also, it
was a negatively significant predictor of organizational
identification, nurses’ citizenship behavior, nurses’ perfor-
mance and reporting patient safety events (Beta ¼ 0.26,
0.29, 0.33 and -0.35 respectively). Organizational iden-
tification, nurses’ citizenship behavior, nurses’ perfor-
mance and reporting patient safety events appeared to
decrease when nurses’ silence behaviors increase
(B ¼ 0.26, 0.29, 0.36, and 0.67 respectively).
R-Square showed that organizational identification, orga-
nizational cynicism, citizenship behavior, nurses’ perfor-
mance and reporting patient safety events accounted for
7%, 14%, 8.0%, 11% and 13% of nursing workplace
silence behaviors respectively (Table 4).
Discussion
Workplace silence behaviors among nurses are the
most important and significant barriers that influence
organizational effectiveness and efficiencies. The pro-
pensity of nurses to maintain silent would be affecting
the provision of safe care and quality of patient care
versus their willingness to speak up about patient
adverse events and medical errors.25 Thus, nurse man-
agers must consider the effect of workplace silence
behavior on nurses, patient and organization outcomes
in health care settings. Therefore, the current study
intended to develop a new Egyptian validation tool
for measuring nursing motives of workplace silence
behaviors and identify the consequences of workplace
silence behaviors on nurses.
In this respect, the Egyptian scale must attain reli-
ability and validity criteria in several aspects. Factor
analysis is a powerful and essential method for evalu-
ating construct validation.26 Exploratory Axis Factor
Analysis test (EXFAT) is a method of factor analysis
and can be utilized to reduce a greater number of set
5
variables to a small set of data.27,28 The scale items of
current study were exposed to EXFAT and they
emerged into 36 motives and six components. They
were explained in 73.3% of variance and Eigen value
larger than one. The loading of the correlation items of
motives were more than 0.50. According to the factor
analysis criterion,29,30factor analysis was proved to be a
good and meaningful fit analysis tool with appropriate
variance and significant correlation.
Although the Egyptian scale of present study was
confirmed with USA (2003 and 2009) ,10,11 German
(2013)8 and Turkish (2015)9 silence scales, it had dis-
crimination aspects in some of the motives and dimen-
sions. The studied Egyptian scale asserted on motives
that were raised from nurses’ personality traits (avoid-
ance, attitude, beliefs and fear); management oriented
(supervisor attitude and practice); and organization
oriented (organizational workplace practice, culture
and climate).
USA version scale in 200310 classified silence
motives into 15 motives and three major dimensions
(acquiescent, defensive and prosocial silences) while
USA version scale in 200911 was developed into 59
motives and six major dimensions (ineffectual, relation-
al, defensive, diffident, disengaged, and deviant).
German version scale in 20138 was conceptualized
into 12 movies with four major dimensions (namely
quiescent, acquiescent, prosocial, and opportunistic
silence). The discriminations between the Egyptian
study and other scales can be attributed to differences
in personality and occupational workplace attributes of
the research sample. The Egyptian study was carried
out on nursing staff in health care settings while USA
and German studies were conducted on employees in
industrial settings.
On the other hand, Turkish version scale in 20159
addressed 26 motives of nursing silence behaviors and
five dimensions (lack of confidence in senior manage-
ment, fear of senior management’s reaction, getting
along with co-workers, tendency towards prosocial
behavior and meek personality). The turkey version
scale was similar to the studied Egyptian version scale
in some aspects however; it was different in two main
distinctions.
Similarity aspects between the current study and
Turkey study were related to the following: 1) Both
studies were implemented on nursing staff in health
care settings; 2) Both studies had suitable sample size
to accomplish factor analysis (332 nurses in the present
study and 265 nurses in Turkey study). Sample size of
two to three hundred participants has a better consid-
eration for conducting factor analysis;31 3) Kaiser
Normalization was comparable in both studies
(KMO value). It was 0.89 in this study while in the
Turkey study, it was 0.91. KMO value is satisfactory
 6
Table 1. Exploratory axis factor analysis based on principal Varimax rotation and reliability tests on an Egyptian motives scale of workplace silence behavior.
The nurse favors to remain silent because
Factor Alpha
Factors Items Loading KMO Value

Factor (1): (1) Encountering and fighting with his\her nursing colleagues and supervisor .71 .69 .83
Nurse avoids (32.9% (2) Blame from nursing colleagues and supervisor .68
of total Variance) (3) Embarrassing his\her colleagues or hurting their feelings .70
(4) Getting colleagues into trouble and argumentative situations .64
(5) Expressing ideas for self-protection .71
(6) Engagement in negative environment in his\her workplace .80
Factor (2): (7) The nurse has a lack of experience so he\she cannot be speaking openly .68 .82 .87
Nurse believes that (8) The nurse will be misunderstood and nothing will change anyway .82
(46.1 of total (9) The nurse should keep away from the spotlight of supervisor .75
Variance ) (10) The supervisor would not like him/her to speak out .67
(11) The nurse should keep his\her ideas to him\herself because others could take advantage of such ideas .64
Factor (3): (12) Be passive and taciturn .86
Nurse’s attitude tends (13) Keep organizational confidentiality and secrecy .78 .77 .90
to (57.3 of total (14) Refuse disclosure of information that might harm his\her organization .83
Variance )
Factor (4) : (15) Seen as a mischief-maker person .62 .68 .84
Nurse is afraid of (16) Not accepted from others .63
(63.4 of total (17) Loss of trust and reputation .63
Variance) (18) Negative consequences of speaking up as changing workplace and position, lack of promoting or losing his\her job .61
(19) Cracking him\her by additional task assignment and workload .55
(20) Events may grow bigger with involvement in argument situations .79
(21) Reprisal and abandonment of his\her supervisor and colleagues .56
(22) Regretting speaking out due to negative consequences .70
Factor (5): (23) Knows the best for work and will make the right decision .67 .85 .86
Nurse’s opinion about (24) Doesn’t care about his\her opinion and would not give support .56
his / her supervisor (25) Prefers nurses who remain silent, dislikes nurses who speak out and sets them in a precedent blacklist .63
(69.12 of total (26) Does not keep promises .78
Variance ) (27) Disciplinary reactions would not be compatible with nurses’ rights and profession principles of nursing .70
(28) Cannot take into consideration experience of nurses .89
Factor (6): (29) Encourages centralized decisions and only allows mangers to express ideas .85 .76 .94
Nurse’s opinion about (30) Encourages strict hierarchical structure (chain of command ) with lack of open communication .90
workplace (73.3 of (31) Does not support open talking or pay attention to diversity of opinions and ideas .85
total Variance) (32) Does not allow freedom of thought and ideas .71
(33) Most of colleagues who speak out said they were often treated unfairly with say nothing done .75
(34) Does not support nurses who speak out when facing problems .65
(35) Shows very little concern for his\her complaints .65
(36) Builds mistrust culture between nurses and their supervisor .73
KMO value for all items with significant Bartlett Test of Sphericity .89 (P < 0.001)
Cronbach’s Alpha for all items .84
Inter-rater reliability (Kendall’s test) .72 (P < 0.01)
Test-retest reliability (Pearson’s correlation) .75 (P < 0. 01)
Clinical Ethics 0(0)
Mohamed Aly 7

Table 2. Confirmatory factor analysis test of Egyptian motives scale of workplace silence behavior.

Standardized*
Egyptian workplace silence coefficient
behaviors motives scale t Values * solutions R2

Factor (1): Nurses’ avoidance motive

Item (1) 33.67 .89 .78
Item (2) 39.96 .92 .84
Item (3) 33.22 .88 .78
Item (4) 36.32 89 .81
Item (5) 42.08 .91 .83
Item (6) 34.59 .87 .77
Factor (2) : Nurses’ belief motive
Item (7) 36.63 .90 .81
Item (8) 33.02 .91 .82
Item (9) 34.25 .89 .79
Item (10) 31.14 .87 .76
Item (11) 24.58 .82 .66
Factor (3) : Nurses’ attitude motive
Item (12) 33.67 .89 .78
Item (13) 39.96 .92 .84
Item (14) 36.52 .90 .81
Factor (4) : Nurses’ fear motive
Item (15) 37.29 .90 .82
Item (16) 37.04 .90 .82
Item (17) 38.07 .91 .82
Item (18) 35.92 .90 .81
Item (19) 65.44 .96 .92
Item (20) 33.92 .89 0.79
Item (21) 36.15 .90 .81
Item (22) 37.58 .91 .82
Factor (5) : Management oriented motive
Item (23) 33.08 .88 .78
Item (24) 28.51 .85 .72
Item (25) 48.14 .93 .86
Item (26) 45.66 .92 .85
Item (27) 53.23 .94 .89
Item (28) 24.50 .81 .66
Factor (6) : Organization oriented motive
Item (29) 51.36 .94 .88
Item (30) 49.13 .93 .87
Item (31) 37.59 .89 .79
Item (32) 48.62 .93 .86
Item (33) 57.78 .95 .90
Item (34) 28.72 .83 .69
Item (35) 27.35 .82 .67
Item (36) 60.82 .95 .91
Note: All items significant at p < 0.01.

Table 3. The confirmatory factor analysis model of the Egyptian scale.

Index

Model X2 df (X2/df)* CFI NNFI RMSEA (90% CI) SRMR

Model of 36 items 1381.47 480 2.76 0.91 0.90 0.057(0.056–0.059) 0.054

RMSEA: root mean square error of approximation; SRMR: standard root mean square residual; CFI: Comparative fit index; NNFI: Non-Normed Fit
Index.
*p < 0.01.
8 Clinical Ethics 0(0)

Figure 3. Confirmatory factor analysis of Egyptian scale according to standardized solutions.

Figure 4. Levels of workplace silence behavior and nursing motives.

between 0.50 and 0.70 while good KMO is more than
0.70 and excellent KMO is achieved at 0.80;32 4) Eigen
value was more than one with factor loading more than
0.50; it indicated that variance was satisfactory and
factor analysis was significant in both studies. An
Eigenvalue of more than one is essential to explain fit
variance and confirmed meaningful factor analysis;27,28
5) Alpha coefficient was shown to be highly reliable in
both studies (Alpha of turkey scale ¼ 0.91 and Alpha of
Egyptian scale ¼ 0.84). The reliability value of
psychological measurement between 0.60 and 0.70 is
generally thought to be sufficient, greater than 0.70 is
often considered better and higher than 0.80, is gener-
ally indicated to be perfect.33 The findings of both stud-
ies revealed a satisfactory and significant fit of EXFAT
and a high stable factor load with adequacy of sample
size.
As regards distinctions between the present
Egyptian work and Turkish study, the first distinction
was related to criteria of appropriate reliability and
Mohamed Aly
Table 4. Workplace silence behavior outcomes among nurses using linear regression.
Consequences Mean (SD)
Organizational identification 2.81  0.82
Organizational cynicism 4.39  0.39
Nurses’ citizenship behavior 2.93  0.69
Nurses’ performance 2.67  0.83
Reporting patient safety events 2.50  0.75
**P < 0.01 (significant).
validity tests. In the face and content validity phase, the
motives items pool was derived from appropriate liter-
ature reviews using the qualitative data (in-depth inter-
view experts’ views on the internet and two focus group
discussions with nurses) in Turkey study.7 In the cur-
rent Egyptian study, motive items were developed from
relevant literature reviews, using quantitative data
(expert’s Likert scale questionnaire). In the construct
validity phase, exploratory factor analysis test (EFAT)
and confirmatory factor analysis test (CFAT) are ways
of factor analysis that are utilized to consider construct
validity and psychometric scale.34,35 EFAT was estab-
lished in both studies. The total accounted variance in
this study was 73.3%, while it was 67% in Turkey
study. According to the loading criterion, the factors
with accounting 70–80% of the variance should be
kept.29,30 It indicated that the Egyptian scale of the
present work was a better fit factor analysis than
Turkey’s study.
Although EFAT helps to assess the level of con-
struct (factorial) validity in a dataset, it should be asso-
ciated with CFAT to develop a new causal scale. Thus,
CFAT should be especially used when investigating
theoretical causal model of any new scale for examin-
ing causal connections between scale items.36–38
Therefore, a new causal scale should be investigated
by confirmatory factor analysis after conducting
exploratory factor analysis.36–38 in the turkey study,
the construct validity was only achieved through
EFAT. In Egyptian study, constructed validity was
accomplished through using exploratory and confirma-
tory factor analyses. According to the criteria of good-
ness of fit analysis,22–24 the CFAT of the Egyptian scale
used in this study revealed that the Egyptian scale met
the principles of the goodness of fit CFAT. It also indi-
cated a good fit construct validity where v2 value was
significant with lower value; RMSEA value (0.057) was
equal to 0.05 and less than 0.08; NNFI (0.90) and CFI
(0.91) values were equal to 0.90 and greater. The
Egyptian study was similar to other studies in
Germany6 and USA10,11 where they tested the con-
struct validity through using EFAT first before
moving on to CFAT.
9
Workplace silence behaviors
B Beta F (sig.) R2 SE
–0.26 –0.26** 25.50** 0.07 0.67
0.31 0.37** 58.17** 0.14 0.52
–0.29 –0.29** 34.75** 0.08 0.54
–0.36 –0.33** 44.89** 0.11 0.71
–0.67 –0.35** 52.58** 0.13 1.21
Concerning reliability tests, consistency reliability
test was only defined in Turkey study while reliability
tests were completely achieved in the current study. In
this study, Kendall’s coefficient value (r-value ¼ 0.72)
showed sufficiently attainable of inter-rater reliability.
It indicated that homogeneity and consensus among
five experts on Egyptian scale items were found. Test-
retest reliability was achieved through conducting a
pilot study and Pearson’s correlation coefficient.39
The pilot study was implemented in both studies. In
turkey’s study, it was fairly conducted; it was not per-
formed according to its purpose and only used for
gathering and simplifying data without confirming
test-retest reliability. Time intervals of pilot study
between time one and time two were not considered
in turkey study. The trustworthiness of the question-
naire is usually carried out using a pilot test. Two to
four weeks are the reasonable time interval for mini-
mizing the possibility of real or random changes that
would be occurring in the pilot test.40 The pilot study
of this work assessed the practicability and achievabil-
ity of the questionnaire as well as test-retest reliability.
Test-retest reliability was accomplished through
Pearson’s coefficient between the test and the retest
time (Approximately 3 weeks later between two
times). It was 0.72. The correlation coefficient (r)
values were considered well if r  0.70.39 The results
of this study indicated the applicability and stability of
the Egyptian scale over time. Good reliability of this
scale in the present study confirmed that there were
completely measured nursing motives of silence behav-
iors in hospital workplaces from nurses’ perspectives.
The second distinction between this work and turkey
study was concerned with personality, cultural, occu-
pational and workplace qualities. Nursing motives for
workplace silence behavior in turkey health care set-
tings were diverse and were not trustworthy for
Egyptian health care settings. Researchers should
always give attention to cultural circumstances and
occupational characteristics when choosing the scale
that measures reasons to maintain silence in the work-
place.9 As regards, occupational and workplace attrib-
utes, they were different between turkey and Egyptian
10
health care settings of the present study. In the teaching
hospital of this study, the management personality and
style, workload, nurse to patient ratio, nurses’ person-
ality, experience and qualification, physician attributes
and quality efforts were different from the general hos-
pital of Turkey study.
It was evident in this study that the nurses showed a
high tendency to remain silent. Nurses were influenced
by management attitude and organizational attributes
that would create fear culture. Thus, they tended to
avoid expressing their agreements or different opinions
as well as they adopted attitudes and beliefs towards
keeping silent in their workplace. Therefore, manage-
ment and organization oriented as well as nurses’ fear,
and avoidance were perceived as the top nursing
motives of workplace silence behavior in the study
units. Attitude and beliefs of nursing staff were
reported as the lowest motives of silence among
nurses. These findings were similar to another study
in Turkey (2018)4
These findings can be clarified by the fact that the
personality of the nursing staff in Egypt tends to help
others, build close friendly and human social interac-
tions with colleagues and managers. So, nurses tend to
maintain self-face to avoid interpersonal conflict and
protect individual confidence and reputation. They also
have religious beliefs and attitudes towards respecting
other rights. Therefore, they were sensitive regarding
their behavior that would affect others and they
avoided creating problems for other nurses. They also
did not tend to overstate problems.
Generally, nurses in Egyptian occupational culture
are likely to respect authority and to worry about
physicians and head nurses’ concerns. The bureaucratic
management approach and centralized authority in
study units emphasized that making decisions, express-
ing ideas and specific problems should be through hier-
archy channels. The nurse is not allowed to use her skill
abilities and ideas to do nursing tasks, and she is forced
to follow head nurse and medical staff orders without
asking for a rationale for these directives. Therefore,
the nurses favor to withhold their opinion or new ideas
and information because they believe that their opin-
ions are not valued.
In this study, when nurses had no impetus to speak
up, they felt helpless and powerlessness with increasing
frustration. They were more liable to be indulged in
organizational dis-identification, cynicism, and fair
level of citizenship behavior. Nurses, who favored to
remain silent, also refused to share their skills, knowl-
edge and experience among their colleagues. They
became unhelpful and had less energy and desire to
perform their tasks. Furthermore, they became more
reluctant to report patient adverse events.
Consequently, workplace silence behavior among
Clinical Ethics 0(0)
nurses would affect nurses’ performance threatening
patient safety. These findings proved that organization-
al identification, citizenship behavior, nurses’ perfor-
mance and reporting patient safety events appeared
to significantly decrease when nursing workplace
silence behaviors increased. Also, organizational cyni-
cism seemed to significantly increase when nursing
workplace silence behaviors increased. These findings
were consistent with other studies on Turkish (2017
and 2018)4,13 and USA (2018) nurses2 as well as with
German (2013)8 and Pakistan (2016)12 studied on dif-
ferent employees
Conclusions and recommendations
The present study proved that the newly developed
Egyptian motives scale was shown to be a reliable
and valid tool for measuring nursing motives of work-
place silence behavior from the nurses’ perspective
views. 36 item scales emerging into six dimensions
were recognized as nursing motives of workplace
silence behavior. The most nursing causes of workplace
silence behavior were related to management and orga-
nization oriented as well as fear and avoidance by nurs-
ing staff. Workplace silence behavior was likely to
make negative consequences on nurses shown in
increasing organizational dis-identification, high levels
of cynicism, fairly citizenship behavior, low levels of
nurses’ performance, and declined reporting of patient
adverse events. It was also found to be a negative pre-
dictor of nurses’ identification and citizenship behav-
ior, and performance as well as reporting patient safety
events while it was a positive predictor of cynicism.
Generally, nursing management should consider the
nursing reasons that lead to workplace silence behavior
and created trust and justice environment where nurses
feel comfortable and confident when speaking up and
expressing their new ideas, opinion problems or mis-
takes. Nurse Managers should also establish strategies
to encourage speaking up behavior in the nursing
workplace and enhance interactions, collaborative rela-
tionships and teamwork among nurses and physicians;
sharing of nurses in decision making and providing
feedback. They should avoid conflicts and establish a
non-punitive and non-blaming culture environment.
More considerations should be directed towards the
development of educational strategies to make nurses
more aware about silence behavior, its motives, and its
relations to nurses’ performance and patient safety.
Further studies are recommended for studying
the applicability of the newly developed Egyptian
tool in evaluating the consequences of nursing work-
place silence behavior on patients and organizational
outcomes.
Mohamed Aly
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Nagah Abd El-Fattah Mohamed Aly https://orcid.org/
0000-0003-4442-4633
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