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In 2005, the American Association of Critical-Care Nurses (AACN) and Vital Smarts (an innovator in best-practices training products and services), documented outcomes from research in Silence Kills: The Seven Crucial Conversations for Healthcare. The paper identified seven concerns that contribute to avoidable medical errors and linked the inability of healthcare professionals to discuss risky topics to key safety indicators, such as patient safety, quality of care and nursing turnover.

The study reported that a majority of healthcare workers regularly observe colleagues taking dangerous shortcuts, making mistakes, failing to offer support, or appearing critically incompetent. Yet, the research reveals fewer than one in 10 actually speak up to express their concern.

In 2011, Nurse researchers wrote a document entitled The Silent Treatment. The paper demonstrates how nurses’ failure to speak up when risks are known undermines the effectiveness of our current safety tools. It also focuses on three specific concerns that often result in the decision not to speak up:  Dangerous shortcuts, incompetence and disrespect. The Silent Treatment tracks the frequency and impact of these communication breakdowns and then uses a blend of data to determine actions that individuals and organizations can take to resolve avoidable breakdowns (Maxfield et al., 2011).

The Silent Treatment details the success and limitations of current safety tools. Most of these tools work by warning caregivers of potential problems. But warnings are only effective when communicated correctly. The data in this study reveals that nurses are often unable to accomplish this level of candor. As a result, they often fail to exert their influence -- and patients are harmed (Maxfield et al., 2011).

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How Nurses Can Speak Up For Safety

Maxfield and his colleagues (2011) maintain that there are seven strategies that lead to successful communication between nurse communicators and other healthcare providers. The following strategies are crucial in effectively delivering patient safety messages to colleagues:

  1. Collect the facts: When possible, it is best to collect facts, run pilot tests and gather relevant data before beginning a conversation behind-the-scenes.Use hospital protocol; utilize your facility’s existing Policies and Procedures to guide discussion and develop a worksheet that is relevant to the issue at hand.
  2. Assume the best, and speak up: Sometimes it just takes one person to pave the way.
  3. Begin by explaining your positive intent: Start the conversation by explaining that the purpose is to improve patient safety.
  4. Avoid creating defensiveness: Make a special effort to open the conversation and present the facts in an objective and impersonal manner.
  5. Use facts and data as much as possible: This depersonalizes the situation and increases objectivity.
  6. Avoid negativity and accusations: This makes people angry and defensive. Try to deflate anger at all times.
  7. Keep your own emotions in check: Never display signs of frustration or anger.


Getting a handle on communication proficiency is a good first step toward resolving the problem of organizational silence in healthcare.  Check out’s CE Course, Professional Communication: Speak Up, Speak Well, which offers important tools and tips to help improve one’s verbal communication skills. In learning how to effectively communicate with others, you can make a real difference in patient safety!


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