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Voicing concerns and suggestions is crucial for preventing medical errors and improving patient safety. Research suggests that hierarchy in health-care teams impair open communication. Hierarchy, however, can vary with changing team composition, particularly during acute care situations where more senior persons join the team later on. The purpose of this study is to investigate how changes in hierarchy and leadership were associated with nurses’ voice frequency and nurses’ time to voice during simulated acute care situations.

This study’s sample consisted of 78 health-care providers (i.e. nurses, residents and consultants) who worked in 39 teams performing complex clinical scenarios in the context of interprofessional, simulation-based team training. Scenarios were videotaped and communication behaviour was coded using a systematic coding scheme. To test the hypotheses, multilevel regression analyses were conducted.

Hierarchy and leadership had no significant effect on nurses’ voice frequency. However, there were significant relationships between nurses’ time to voice and both hierarchy (γ = 30.00, p = 0.002; 95 per cent confidence interval [CI] = 12.43; 47.92) as well as leadership (γ = 0.30, p = 0.001; 95 per cent CI = 0.12; 0.47). These findings indicate that when more physicians are present and leadership is more centralised, more time passes until the first nurses’ voice occurred.

This study specifies previous findings on the relationships between hierarchy, leadership and nurses’ voice. Our findings suggest that stronger hierarchy and more centralised leadership delay nurses’ voice but do not affect the overall frequency of voice.