The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge, Cambridge, UK.
TH Chan School of Public Health, Harvard University, Boston, MA, USA.
Soc Sci Med. 2021 Jul;280:114050. doi: 10.1016/j.socscimed.2021.114050. Epub 2021 May 20.
The importance of employee voice-speaking up and out about concerns-is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation-the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity-could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.
员工表达意见（对关注的问题直言不讳）对于患者安全和护理质量至关重要，这一观点已得到广泛认可。然而，意见表达失败的情况仍时有发生，且往往会造成灾难性的后果。在本文中，我们认为，非正式组织和正式组织这两个持久的社会学概念，可以为理解这些问题的原因以及如何解决这些问题提供分析依据。我们报告了一项涉及三个高收入国家的三个医疗保健组织的 165 次访谈的定性研究。我们的分析强调了正式组织和非正式组织的相互依存关系。正式组织描述了行使发言权的结构、程序和流程的规范化和正式化要素，但参与者常常发现这些要素令人沮丧、模糊且设计不佳。非正式组织——决定组织活动的非正式实践、社会联系和决策方法——通过帮助人们理解复杂的过程、理解他们的关注，并以可能促使组织做出适当反应的方式来表达他们的关注，从而促进了意见的表达。有时，非正式组织可以弥补正式政策和系统中的空白、模糊性和不一致性。与此同时，非正式组织也有其阴暗面，可能会通过创建非正式层级、优先考虑社会凝聚力以及提供报复机会来抑制发言权。正式组织和非正式组织并非相互排斥或独立的：它们相互作用并相互加强。我们的研究结果对改善医疗保健组织中与发言权相关的文化和流程的努力具有启示意义，这表明需要解决正式组织中的缺陷，并利用非正式组织中的优势，这些优势对于支持发言权至关重要。
