Journal of Arak University of Medical Sciences

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The Loud Silence of Nurses: Is Our Voice Being Heard?

Mir Amirhossein Seyednazari, Amir Mohammad Dorosti,
Volume 28, Issue 3 (8-2025)

Abstract

In global healthcare systems, nurses are recognized as the main pillars of care, but their voices, despite their vital role, are often lost amidst a cacophony of loud silences. This silence does not signify tranquility, but rather reflects hidden pressures, unexpressed fears, and an imposed passivity in the face of structures that limit the freedom of expression.
"Organizational silence," a concept recognized for years in the fields of management and organizational psychology, has become a global crisis in nursing. According to a qualitative meta-synthesis, over 91% of nurses have experienced organizational silence at least once in their professional careers [1].
The causes of silence among nurses are multifaceted. Part of it stems from defensive silence, meaning a nurse refrains from speaking up before superiors or in hierarchical structures for fear of negative consequences. At other times, we encounter acquiescent silence, where the nurse believes that speaking out is futile and will not bring about any change. Previous experiences of having concerns ignored or autocratic leadership styles reinforce this feeling [1,2]. Furthermore, in some cultures, such as Japan or Egypt, prioritizing group harmony over individual expression leads to the normalization of silence [3].
Silence is not just an individual reaction but a response to an inefficient work environment. Nurses who feel their voices are not heard eventually experience job burnout, decreased motivation, and ultimately, leave the profession [2,3,4]. In a study from Spain, half of the nurses surveyed had considered leaving the profession [3,5]. Job burnout not only harms the nurse's mental health but also reduces the quality of patient care. Fatigue, reduced concentration, and impaired communication with patients increase the risk of clinical errors [1,6].
This vicious cycle of silence and its consequences creates a downward spiral in healthcare organizations:
Silence on staff or resource shortages → Increased stress and workload → Job burnout → Decreased quality of care → Intensified dissatisfaction → More silence.
If nurses feel that their concerns are ignored even when expressed, silence becomes an adaptive strategy [4].
Meanwhile, the financial impact of nurse turnover is also significant. According to estimates, the turnover cost for a single nurse in the United States is over $44,000, and hospitals lose an average of $3.6 to $6.1 million annually due to nurse turnover [7]. This substantial figure provides an economic incentive for systemic interventions to reduce silence and retain human resources.
Solving this problem is not possible through individual training or psychological resilience alone. Although strengthening skills like professional assertiveness can be effective, it will not be sustainable without structural and cultural support [4]. Creating psychological safety in the workplace—where nurses can freely express their concerns without fear of punishment—is a vital starting point for change [6].
Leaders of healthcare organizations play a key role in shaping or dismantling a culture of silence. When managers interact with nurses with empathy, a listening ear, and responsiveness, trust is built, and the space for expression becomes safer. A transformational leadership style, participation in decision-making, and the creation of professional growth paths are among the most important factors in retaining nurses and reducing silence [8].
There is also a need for macro-level policymaking at national and international levels. Programs like the "Global Nursing Workforce," which focuses on supporting the sustainability of the profession, can be effective in addressing the root causes of the problem [7]. Moreover, new guidelines from bodies such as The Joint Commission on preventing workplace violence (effective July 2024), which define requirements for reporting and accountability, can serve as models for combating silence on other issues as well [8].
Ultimately, organizational silence in nursing is not just a communication issue; it is an alarming indicator of the ethical, psychological, and systemic health of healthcare institutions. This phenomenon should be considered an "organizational vital sign." The healthcare system has a duty not only to listen but to act. The voices of nurses must lead to decisions, policies, and structural reforms, so that their silence is no longer loud, but is transformed into an effective cry on the path to improvement.

When Caregivers Need Care: The Hidden Challenges of Nurses in the Workplace

Mir Amirhossein Seyednazari, Amir Mohammad Dorosti,
Volume 28, Issue 4 (10-2025)

Abstract

Nurses, as one of the main pillars of the healthcare system, have always been at the forefront of delivering medical services. However, recent studies reveal that this professional group is facing serious challenges in terms of mental health and job satisfaction, largely due to structural and systemic failures in the workplace (1). Data from the COVID-19 pandemic underscore the severity of this issue, revealing high rates of burnout among nurses. 34.1% experienced emotional exhaustion, and 12.6% reported a loss of professional identity. These figures reflect not only a transient crisis but also chronic deficiencies within the healthcare system (2).
Key factors exacerbating nurse burnout include workforce shortages, inadequate resources, and workplace violence
(3, 4). The global shortage of nurses is estimated at around 5.9 million, placing excessive pressure on the remaining staff. Additionally, lack of resources and specialized training, particularly during crises, significantly contribute to burnout risk. Workplace violence, particularly in emergency departments and psychiatric units, is on the rise, and many reports suggest that the actual number of incidents is much higher than what is officially recorded (2, 5).
The consequences of these conditions extend beyond individual nurse wellbeing, directly compromising patient care quality and safety. Meta-analyses have shown significant associations between nurse burnout and reduced patient safety, increased hospital-acquired infections, and medication errors (5). Furthermore, only 50% of nurses in 2021 felt that their organizations prioritized their health and safety (1).
The mental health crisis among nurses is also alarming. Rates of anxiety, depression, post-traumatic stress disorder (PTSD), and insomnia are considerably higher in this group compared to other professions. Predictive factors include understaffing, excessive workload, workplace violence, and lack of organizational support. In addition, the stigma surrounding mental health services acts as a major barrier for nurses seeking professional help (6).
Effective solutions include adjusting nurse-to-patient ratios, banning mandatory overtime, enforcing zero-tolerance policies against workplace violence, and strengthening managerial support. For example, California’s implementation of minimum nurse-to-patient ratio laws has led to increased direct care time, better patient outcomes, and higher nurse retention. Emphasis must shift from merely increasing nurse numbers to retaining the current workforce—a crucial step in healthcare reform.
In conclusion, considering the critical importance of nurse wellbeing and its direct impact on patient care, structural and supportive reforms must be prioritized by health policymakers and administrators.

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