Individual and unit-level predictors of promotive voice in nursing: a multilevel analysis

Abstract

Background: Nurses' promotive voice behavior, or the act of proactively suggesting improvements in the workplace, is crucial for enhancing healthcare services. Despite its importance, the factors that influence promotive voice, particularly within hierarchical environments, remain insufficiently explored. Understanding these factors is essential to creating work environments that encourage open communication and innovation among nursing staff. This study aimed to investigate the individual-level and unit-level factors that influence promotive voice among nurses, with a particular focus on the roles of age, unit tenure, power distance orientation, leadership style, and work climate.

Methods: This study, employing a cross-sectional and correlational design, analyzed data from 1,255 registered nurses with over six months of clinical experience, all of whom were involved in direct patient care across 145 nursing units. Multilevel analysis was employed to examine the relationships between individual-level characteristics (age, unit tenure, power distance orientation) and unit-level factors (leadership style, work climate) on promotive voice behavior. The analysis accounted for the hierarchical structure of the data, with nurses nested within nursing units.

Results: The analysis revealed that individual nurse's age (B = 0.04, 95% CI [0.03, 0.05]) and unit tenure (B = 0.01, 95% CI [0.01, 0.02]) were positively associated with promotive voice, while power distance orientation was negatively associated with promotive voice (B = -0.08, 95% CI [-0.15, -0.01]). At the unit level, inclusive leadership style (B = 0.23, 95% CI [0.08, 0.38]) and a positive speaking-up work climate (B = 0.34, 95% CI [0.11, 0.57]) were significantly related to higher levels of promotive voice.

Conclusions: This study highlights the significant influence of both individual characteristics and unit-level factors on promotive voice among nurses. The findings suggest that fostering inclusive leadership and a supportive speaking-up climate, while addressing hierarchical barriers, can enhance the propensity of nurses to engage in promotive voice. This, in turn, has the potential to improve patient outcomes and enhance overall organizational performance by promoting a culture of open communication and continuous improvement.