Cultures of Silence Threaten Patient Safety, Innovation

ALISO VIEJO, Calif. – April 21, 2026 – Cultures of silence among healthcare professionals remain a significant threat to patients and healthcare innovation, according to results from a national survey of more than 3,500 clinicians and healthcare administrators.

“Silence Kills 2.0: How Communication Failures Stifle Innovation and Harm Patients,” built upon a seminal 2005 survey and expanded it to gain additional insights. The study is published online ahead of print in the May 2026 issue of American Journal of Critical Care (AJCC). Crucial Learning and the American Association of Critical-Care Nurses (AACN) co-sponsored the original and follow-up studies.

Among the latest findings, nearly a third (32%) of respondents indicated that they speak up when witnessing potentially harmful activities among colleagues, a marked improvement from 10% who answered similarly during the 2005 study but an indication of the challenges that remain.

The first part of the study asked about respondents’ willingness and ability to address the seven crucial moments identified in the 2005 study: observing colleagues (1) break rules, (2) make mistakes, (3) show incompetence, (4) demonstrate a lack of support, (5) fail to be good teammates, (6) act disrespectfully or (7) micromanage. An eighth element was added to the new study to assess how perceived workplace bias may affect one’s willingness to speak up.

While researchers saw a significant improvement in respondents’ willingness to speak up directly to the individual they have a concern with and to fully express their views, the study also revealed alarming data indicating that silence still kills. Specifically:

• 40% of healthcare workers report they witness rules being broken at least weekly or more frequently.
• 22% witness outright mistakes in patient care at least weekly.
• Of those who witness rules being broken and mistakes, only about half directly confront the person and completely express their concerns (47% for broken rules and 53% for mistakes).

Vicki Good, AACN’s chief clinical officer and co-lead researcher for Silence Kills 2.0, says the results underscore that communication is critical to healthy, agile work environments.

“Speaking up continues to be the vehicle for shaping the norms that govern behavior and results in healthcare,” Good said. “Conversely, a failure to speak up indicates an absence of healthy norms that will inevitably impact patient safety and staff outcomes.”

Silence Kills 2.0 found that those who speak up and fully express their concerns report better patient safety outcomes, patient experiences, and clinical outcomes than those who don’t. The study also showed that those who fully speak up during crucial moments are significantly less likely to consider leaving their organization within the next six months.

In addition to measuring the impact of silence on patient safety and other critical outcomes, Silence Kills 2.0 examined the relationship between candor and the capacity to absorb new technology and practices, including AI and machine learning.

The findings reveal that a culture of candid communication correlated strongly with behavioral agility. High-candor teams (those that scored in the top decile) are more likely to implement new technology and clinical practices and look for ways to improve outcomes. Notably, 89% of these top-decile teams are more proactive in looking for ways to improve patient outcomes and quality of care and feel more empowered to propose new, more effective practices for their unit, compared with 32% of lower-decile teams.

Joseph Grenny, cofounder of Crucial Learning, co-author of “Crucial Conversations” and co-lead researcher, says Silence Kills 2.0 offers healthcare leaders clear direction on where to invest their time, attention and resources.

“Leaders who create cultures where clinicians are both motivated and able to speak up in these common but costly situations will reap significant short- and long-term improvement,” Grenny said. “In the short term, if more work is done to create cultures of candor, better patient outcomes and patient experiences are likely to follow. In the long term, teams that routinely speak up appear more likely to quickly adopt new practices and technology.”

To access the article and full-text PDF, visit the AJCC website at www.ajcconline.org. An accompanying white paper with additional findings is available at CrucialLearning.com/resource-center/healthcare/.

About Crucial Learning: Crucial Learning improves the world by helping people improve themselves. We create flexible learning experiences that teach crucial behaviors that have a disproportionate impact on outcomes and solve life’s most stubborn problems. Our award-winning courses, assessments, and accompanying bestselling books include Crucial Conversations^® for Mastering Dialogue, Crucial Conversations^® for Accountability, Crucial Influence^®, The Power of Habit™, Getting Things Done^®, Crucial Teams^®, and the Strength Deployment Inventory^® (SDI^®). CrucialLearning.com

About the American Journal of Critical Care: The American Journal of Critical Care (AJCC), a bimonthly scientific journal published by the American Association of Critical-Care Nurses, provides leading-edge clinical research that focuses on evidence-based-practice applications. Established in 1992, the award-winning journal includes clinical and research studies, case reports, editorials and commentaries. AJCC enjoys a circulation of more than 134,000 acute and critical care nurses and can be accessed at www.ajcconline.org.

About the American Association of Critical-Care Nurses: For more than 55 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. AACN is the world’s largest specialty nursing organization, with more than 134,000 members and over 170 chapters in the United States.

American Association of Critical-Care Nurses
27071 Aliso Creek Road, Aliso Viejo, CA 92656; 949-362-2000; www.aacn.org