Background Although under-resourcing of healthcare facilities and high workload is known to undermine patient safety, there is a dearth of evidence about how these factors affect employee voice and silence about unsafe care. We address this gap in the literature by exploring how resource constraints and high workload influence the willingness of staff to speak up about threats to patient safety in surgical departments in Ghana.

Method Semistructured interviews with a purposeful sample of 91 multidisciplinary professionals drawn from a range of specialities, ranks and surgical teams in two teaching hospitals in Ghana. Conservation of Resources theory was used as a theoretical frame for the study. Data were processed and analysed thematically with the aid of NVivo 12.

Results Endemic resource constraints and excessive workload generate stress that undermines employee willingness to speak up about unsafe care. The preoccupation with managing scarce resources predisposes managers in surgical units to ignore or downplay concerns raised and not to instigate appropriate remedial actions. Resource constraints lead to rationing and improvising in order to work around problems with inadequate infrastructure and malfunctioning equipment, which in turn creates unsupportive environments for staff to air legitimate concerns. Faced with high workloads, silence was used as a coping strategy by staff to preserve energy and avoid having to take on the burden of additional work.

Conclusion Under-resourcing and high workload contribute significantly towards undermining employee voice about unsafe care. We highlight the central role that adequate funding and resourcing play in creating safe environments and that supporting ‘hearer’ courage may be as important as supporting speaking up in the first place.