Abstract
Background:
This exploratory study investigates the code of silence in healthcare, exploring its origins and outlining its negative impact on healthcare quality and patient safety. Drawing parallels with other professions where similar codes exist, the research delves into the reasons healthcare professionals may choose not to report inappropriate practices.
Objective:
This article outlines the reasons for the existence of the code of silence in healthcare, assesses its prevalence, and suggests strategies to address it.
Design and methods:
This is a qualitative study which uses in-depth interviews with 88 licensed healthcare providers (physicians, nurses, administrators, and pharmacists) to identify common types of inappropriate practices, the actions taken to address them, and the reasons why observers chose to remain silent.
Results:
We find that the majority of healthcare providers in the sample (nearly 70%) either witnessed or were made aware of incidents of inappropriate practices. In a substantial proportion (about 40%) of the cases, no action was taken after reporting the inappropriate practice. The findings are discussed in the context of existing codes of professional ethics and the organizational cultures that either encourage or discourage transparency. The study highlights the tension healthcare professionals face between their personal values, institutional goals, and fear of retribution.
Conclusion:
Breaking the code of silence is both a personal and organizational responsibility. The paper concludes with actionable recommendations to break the code of silence, such as fostering a supportive reporting culture, improving anonymous reporting mechanisms, and encouraging leadership to prioritize accountability.
Keywords
Introduction
Highly regarded professionals—such as nurses, physicians, pharmacists, attorneys, accountants, psychologists, teachers, and other service providers—must be licensed by their respective regulatory agencies to offer their specialized services. These professionals are subject to strict codes of professional, personal, and ethical conduct by both their professional organizations and their employers. Despite these codes and regulations, it is not uncommon for professionals to ignore or overlook instances when a colleague is not adhering to professional and ethical standards.
This silence often harms the public perception of these professions and reduces consumer trust, leading people to seek alternative solutions when possible. Notable examples include:
■ Business scandals, such as Boeing (2023-2024), Theranos (2018) and Wells Fargo (2016), where employees aware of the unethical practices felt pressured to remain silent;
■ High-profile medical cases, such as the 2017 incident of RaDonda Vaught at the Vanderbilt University Medical Center where a fatal medication error exposed systemic issues in healthcare, including gaps in training and the usability of medical technology. 1
Despite the significant negative impact of withholding information in healthcare, a comprehensive theory explaining why and how this occurs is lacking. A review of 209 recently published peer-reviewed studies concluded that even though 76 of these studies were quantitative and measured employee voice or employee silence in healthcare, the concepts and measures were heterogenous, and a unifying theoretical background was missing. 2 Thus there is a need for further research regarding the distinction between what drives safety voice versus general employee voice, and how both voice and silence can operate in parallel in healthcare. This exploratory qualitative study contributes to the understanding on the code of silence within healthcare. Our findings demonstrate that inappropriate practices are not isolated events and offer valuable insights into the behavioral responses of licensed healthcare professionals concerning the reporting and correction of patient care breaches.
It is well-established that quantitative studies ask the question “how many” and qualitative studies ask the questions “why” and “how”. 3 This study responds to the call for further research beyond quantitative measures. The code of silence refers to informal, often unspoken norms and practices within medical institutions that discourage healthcare professionals from reporting mistakes, unethical behavior, or inappropriate practices by their colleagues. 2 We trace its roots developmentally and in other professions and analyze its occurrence in various situations in healthcare. We outline the factors that underlie it and outline its adverse effects on the quality of healthcare. We present an exploratory qualitative study conducted with 88 healthcare providers about situations involving inappropriate practices, actions taken to correct them, and the specific situations when observers chose to remain silent. We discuss the findings in the context of existing professional ethics codes and values in healthcare organizations. Finally, we make recommendations to reduce the effects of the code of silence and improve patient safety and the quality of healthcare.
The Code of Silence in Healthcare
Following a landmark report by the Institute of Medicine 4 , the healthcare industry and public interest groups have engaged in efforts to improve patient safety as critical component of service delivery. Many of these efforts have focused on “impersonal” factors such as technological advancements (e.g., hospital pharmacy systems and drug barcoding) and “systems errors”.5,6
While technological advances and systems redesign are essential for reducing medical errors, they are not sufficient on their own. A significant number of medical errors are linked to the “personal” behaviors of healthcare professionals. For example, professional associations have identified substance abuse as a patient safety issue, and most states have implemented programs to address it. 7 Similarly, factors such as sleep deprivation, long working hours, mental health challenges, physical problems related to aging, and basic competence all impact patient safety.
However, it is widely believed—and supported by emerging evidence—that medical care professionals often fail to confront personal behavioral issues in their colleagues, either directly or through institutional reporting channels.8,9 Without addressing these personal behavioral issues, any patient safety program will be insufficient for achieving lasting success. To truly improve patient safety and services delivery, personal responsibility must be addressed. An essential first step is to raise awareness of the code of silence itself.
The Origins of The Code of Silence
The term “code” refers to any set of secret or unspoken rules of conduct “considered morally binding upon the individual as a member of a particular group, a resident of a particular place, or a participant in a particular activity”. 10 Silence in this context is “the withholding of potentially important input or to instances when an employee fails to share what is on his or her mind.” 11 Historically, the code of silence has initially been associated with law enforcement, where informal rules often prevent officers from reporting the misconduct of their colleagues.12,13 Law enforcement officers face potentially life-threatening situations daily, and this work-related stress fosters a deep bond among them. They learn to trust each other, as they all face similar risks.
The code of silence emerges early in life, as children quickly learn its benefits: avoiding ostracism from their peer group for being a “tattletale” or avoiding reprimands from parents for revealing embarrassing family information. Remaining silent also allows children to prove themselves as trustworthy friends, build camaraderie, and fulfill their need for acceptance. In adulthood, the stakes become higher, encompassing jobs, reputations, status, and income, which perpetuates the code of silence. Professionals from diverse fields as university professors and clergy also participate in the code of silence. For example, faculty members often underreport students cheating. 14 In the Roman Catholic Church, an unspoken rule—“Thou shalt not accuse fellow clergy”—has been applied to sexual abuse scandals, protecting the perpetrator and the institution while disclosure risks public embarrassment and ostracism. 15
According to the Global Business Ethics Survey, 16 almost two-thirds of employees observed at least one act they believed violated their organization’s standards or the law in the preceding twelve months. Yet only 72% of those who witnessed misconduct reported it, demonstrating how pervasive the code of silence is at the workplace. Moreover, nearly half of those who reported wrongdoing faced retaliation (46% in that study), which underscores the silencing effect poses a significant concern.
The Code of Silence Among Healthcare Professionals
Healthcare professionals, who are held in high regard by patients and the public as intelligent, selfless problem-solvers, often adhere to a dangerous code of silence. Each year, hundreds of thousands of patients worldwide are harmed because of actions or inactions by healthcare professionals. Annually, one in twenty inpatients at hospitals receives the wrong medication. About 3.5 million acquire infections from improper hand washing or other inadequate precautions, and 195,000 die from medical errors during hospitalization. 9 Notably, patients affected by such misconduct are often powerless, unaware of the errors, or incapable of defending themselves.
In response to these alarming statistics, healthcare institutions have aggressively implemented new technologies and quality-improvement systems. While these initiatives are important, they fail to address a deeper issue: the code of silence in healthcare, perpetuated by a “conspiracy of tolerance”. 9 Every day, healthcare professionals witness colleagues breaking rules, exercising poor judgment, making mistakes, cutting corners, abusing drugs or alcohol, working when sleep-deprived, or demonstrating severe incompetence. 9 Despite these obvious problems, only a small percentage of these professionals speak up or report what they observe. The code of silence persists, leading to compromised patient safety, high turnover, decreased morale, and reduced productivity.
Equally concerning is the collusion among “silent partners.” Healthcare professionals, hospitals, and insurance companies often work together to perpetuate the code of silence. Physicians and nurses are often shielded from public scrutiny, as hospitals and insurance companies prefer to handle situations internally through confidential peer reviews. This approach puts patient care at risk. If the public is not aware of the quality of care provided by a physician or hospital, how can individuals make informed decisions about their healthcare?
For example, Wendy Ann Noon Berner of Shawnee, KS underwent radical surgery after being misdiagnosed with a pancreatic tumor, resulting in the removal of part of her pancreas and other organs. However, post-surgery, multiple pathologists confirmed that no cancer was present. When one pathologist reported this diagnostic error, the hospital allegedly retaliated against him. Berner only discovered the misdiagnosis after the pathologist's lawsuit against the hospital became public. 17 This case highlights how the initial diagnostic mistake was compounded by attempts to cover it up, reflecting a significant breach of medical ethics and the harmful impact of the “code of silence” among healthcare providers.
One of the authors recently accompanied their partner for a surgical heart procedure. During the admission process, they were given a patient’s rights booklet with the admissions clerk recommending that it be read. After reviewing the booklet, the author asked, “Nowhere in this booklet does it say if the hospital, physician, nurse, or anyone else makes a mistake, they are obligated to tell us? Is that correct?” The admissions clerk paused and replied, “That is correct.” This prompted the author to research the patient rights commitment of 15 different healthcare systems across the U.S.—five nonprofit, five religious-affiliated, and five for-profit. Only three of the 15 systems (one nonprofit and two religious-affiliated) included a patient’s rights statement committing to informing patients of “unintended outcomes.” This underscores how healthcare organizations often participate in the code of silence to protect themselves.
The Impact of Medical Malpractice Settlements
Malpractice lawsuits and the settlements which often accompany them also contribute to perpetuating the code of silence. These settlements typically include non-disclosure agreements that prevent both parties from discussing the terms, and rarely involve a public admission of guilt or an apology to the harmed patient. Moreover, in the rare cases that go to trial, physicians are discouraged from testifying for the prosecution in malpractice cases. In Florida, for instance, some physicians publish the names of colleagues who testify for the prosecution and patients, creating a strong disincentive for doctors to testify in malpractice cases. 18
Reporting Medical Misconduct
Healthcare professionals, including physicians, nurses, and other licensed providers, must recognize the importance of reporting misconduct by their colleagues. However, to encourage this reporting, first we must first understand why many professionals remain silent. While there is extensive literature on medical malpractice and cases of physicians making errors or practicing illegally, these issues are often exposed by the victims’ families rather than the healthcare community. Families, after suffering a tragic loss, are often left to uncover the truth about their loved ones’ care.
Within the medical community, the peer reviews remain confidential, making it difficult for patients to learn about prior proceedings involving a physician. This confidentiality is legally protected by regulations such as the Healthcare Quality Improvement Act (HCQIA) and various state laws. For example, the General Laws of Massachusetts stipulate that the proceedings, reports, and records of a medical peer review committee are confidential and exempt from disclosure. They are also protected from subpoena or discovery in most judicial or administrative proceedings. 19
Why Does the Code of Silence Persist in Healthcare?
Healthcare professionals face a profound internal conflict. The public turns to hospitals, physicians, nurses, and other medical professionals in times of crisis, desperation, and vulnerability, expecting answers and solutions. However, healthcare professionals, especially physicians, are not omnipotent beings capable of remedying every illness, alleviating every pain, or preventing every death. Physicians long to provide the outcomes their patients hope for, but they are often unable to do so, a reality that is difficult for the public to accept. Physicians endure a lifetime of stress and inadequate support, all while managing life-and-death situations and pretending to have powers that truly do not exist. 20
Physicians constantly work under a heightened sense of vulnerability. How can one criticize a colleague for an error or accident when they themselves could make the same mistake tomorrow? “All doctors have made mistakes; often serious ones, and their experiences create a powerful pool of mutual empathy and an unforgettable sense of shared vulnerability”. 20 This uncertainty and shared vulnerability within the profession contribute to a “conspiracy of tolerance” among medical professionals, much like what is seen among police officers.
A study by the American Association of Critical-Care Nurses, “Silence Kills,” reports that among the 1,700 healthcare professionals surveyed, only 5% to 15%, depending on the issue, would speak up about infractions. Alarmingly, 85% to 95% of their co-workers on the same unit or floor did not feel they could do so. They cited fear of retaliation, a belief that it was not their responsibility, or a lack of confidence, skill, and time for confrontation. Confronting a peer can create a tense work environment, so many choose to avoid difficult discussions, hoping someone else will address the issue. 9 Additionally, employees fear that breaking the code of silence may jeopardize their chances for professional advancement, salary increases, continued employment, or social acceptance among co-workers.
Inappropriate Practices That Trigger the Code of Silence
The literature suggests the following common types of inappropriate practices and reasons why observers chose to remain silent: abuse of power, impairment, incompetence, sleep deprivation, and medical errors.
Qualitative Research Study: Origin
This exploratory, qualitative research originated in a graduate course on healthcare ethics led by one of the authors as part of the health administration MBA track at a US university in a mid-Atlantic state. During the second session of the course, MBA students were assigned an individual project requiring them to research an ethical dilemma they had encountered or observed in their healthcare workplace.
During the class discussion, one student shared a recent experience: “A co-worker, a nurse, came to me today and told me she observed what was believed to be inappropriate medical practice by a colleague yesterday. She could not sleep last night and was troubled because the coworker didn’t want to say anything that may ‘rock the boat’ in their unit.” The student then asked, “Is this an example of an ethical dilemma, since I am now involved indirectly?”
This question sparked an intense discussion about the nature of ethical dilemmas, during which nearly all students identified ethical concerns in their healthcare work environments. The discussion ultimately led to the students proposing a research project investigating the “code of silence” in healthcare, which became the foundation for this qualitative study.
Data Collection and Ethical Considerations
The study involved eleven graduate students, all full-time healthcare professionals, including six nurses working in acute care settings (seven women, four men – which closely matches the distribution of nurses versus all other health care workers in the US). The students were trained to conduct in-depth, semi-structured interviews. The project followed a judgment sampling approach which relies upon those with subject matter knowledge to select a useful sample. 25 Thus the students, themselves experienced healthcare workers, selected interviewees based on their professional judgment about who might have relevant experiences with medical errors or inappropriate clinical practices. The interviewers were instructed to include colleagues with at least five years of experience in healthcare who were employed full-time at their place of work. Thus trainees and people from other healthcare organizations were excluded. Given the nature of the sampling method, participants were typically drawn from the interviewers’ own professional networks and disciplines (e.g., nurses recruiting other nurses). This approach enabled access to candid accounts of sensitive experiences, particularly those involving inappropriate practices and the code of silence, which may not have been accessible without a foundation of interpersonal trust.
The students tasked themselves with conducting eight interviews each, resulting in a total of 88 interviews with physicians, medical providers, nurses, pharmacists, and other healthcare professionals. Each student was instructed to:
Select colleagues in their current work unit or in closely related units.
Assess the likelihood of their colleague being exposed relevant incidents,
Explain the research project and its voluntary nature to each potential participant and provide a printed copy of the open-ended questionnaire before asking for consent,
Obtain verbal informed consent prior to conducting an interview. The rationale for obtaining verbal consent, rather than written consent, was to minimize any perceived formality or burden associated with participation in a brief, voluntary interview focused on gathering open-ended perspectives. This approach aimed to foster a more comfortable and open dialogue with participants.
Interviews lasted about 15 minutes on average. No names or other identifiable personal information were recorded; students took verbatim notes without collecting personal information. These notes explicitly documented that verbal consent was obtained after the explanation of the project and before the commencement of questioning. Confidentiality was maintained at the level of the student interviewers—who knew their respondents but ensured that no identifying details were recorded—and anonymity was ensured at the level of the course instructor and the coauthor, who had no way of linking responses to specific individuals.
The questions were designed to be straightforward and directly address the research questions regarding healthcare professionals' experiences with and responses to instances of potentially inappropriate practice. As the questions were factual and exploratory in nature, focusing on eliciting descriptive accounts rather than measuring specific constructs, we determined that formal validation was not the most appropriate approach for this study. Still, to ensure the clarity and appropriateness of the questions and interviewing, we conducted a training process early in the study. After conducting one initial interview each, student researchers took part in a structured in-class debrief and role-play session to review techniques and standardize their use of the interview protocol. This process helped align their approach and ensured the interview questions were applied consistently. Based on this early feedback, the final version of the questionnaire was confirmed and used for the remaining interviews. The final questionnaire is presented in the Appendix.
At the time of data collection, this project was conducted solely as a class assignment intended for educational purposes. In accordance with U.S. federal and university guidelines, classroom-based projects conducted for educational purposes typically do not require IRB approval. Consequently, no IRB application was submitted at that time. However, the consistent and powerful themes that emerged ex post from the data—particularly regarding the extent of the code of silence—suggested broader relevance and motivated the authors to prepare the findings for scholarly dissemination. Throughout the project, the study adhered to key principles of research ethics: informed consent was obtained, participation was voluntary, and no identifiable information was collected or retained.
Data Analysis Approach
Our study follows a grounded theory approach, which is well-suited for exploring psycho-social processes and uncovering patterns of behavior and professional experience in specific social contexts. It aims not only to describe phenomena but also to develop conceptual insights into how and why individuals act as they do. Grounded theory is effective in capturing the complexity of healthcare experiences and making visible the underlying social mechanisms that shape behavior. 26 In line with this tradition, we sought to identify recurring themes and explanatory processes related to the “code of silence” in healthcare settings. This involved iterative reading of interview notes, constant comparison across cases, and open coding to identify emergent categories and relationships among them. A collaborative coding session was held early in the process, during which students transcribed the first and second responses for each interview question onto individual index cards. These were sorted by question, with initial and follow-up responses reviewed separately. The entire class participated in discussions to identify preliminary thematic patterns. Given the descriptive nature of many responses and the consistency across participant reports, initial open coding was conducted manually by the primary researcher in the same work session with all student researchers to identify recurrent patterns and categories. These themes were then reviewed collaboratively by the second author to reach consensus. While formal inter-rater reliability statistics were not calculated—due to the descriptive and often straightforward nature of the responses—analytic consistency was ensured through discussion and iterative review. Data saturation was achieved, as no new themes emerged in the later stages of analysis.
Sample
With a sample size of 88, this study exceeds the often-cited minimum threshold of 32 to 35 participants typically recommended for stable descriptive analysis. Although inferential statistics are not employed, the sample is sufficient to identify meaningful patterns, including the observation that the code of silence extends beyond isolated incidents.
The study sample represents a diverse group of healthcare professionals. Among the 88 respondents, 14 were physicians (15.9%), 6 were medical providers (physician assistants or nurse practitioners; 6.8%), 53 were nurses (60.2%), 10 were pharmacists (11.4%), and 5 were other healthcare workers such as CNAs and medical administrators (5.6%). The majority of the sample were experienced professionals, with 51 (58.0%) having worked in healthcare for more than 10 years, and 15 (17.2%) having six to nine years of experience. Nurses are the largest group of hospital employees in the United States, outnumbering physicians about four to one, 27 thus the sample broadly reflects the composition of professionals in healthcare. Sixty-one of the respondents (69.3%) worked in acute care hospital settings, and twelve (13.6%) were employed in nursing homes, long term care, or assisted living facilities.
Respondents’ Awareness of Inappropriate Practice that Colleagues Witnessed
The first substantive question in the study asked, “Thinking back over the most recent five years of your healthcare career, have you ever been told by a friend or colleague that they were aware of a situation where a licensed healthcare professional has not been practicing appropriately?” Overall, 69.3% of the sample (61 of 88) responded “yes,” including 71.4% of the physicians, 75.5% of the nurses, and 90% of the pharmacists. One person (1.1%) did not answer this question.
These results highlight the pervasive awareness of inappropriate practices, with only about 30% of respondents indicating they had never been informed of such situations by a friend or colleague. The relatively high percentage of awareness may be influenced by the fact that 23.9% of the respondents had been practicing for fewer than five years, potentially limiting their exposure to these situations and the trust relationships necessary for colleagues to share sensitive information. These findings are consistent with the literature reviewed earlier.
For the 61 respondents (69.3%) who reported being aware of inappropriate practices, the follow-up question asked, “Can you give me a general idea of what the situation was without telling me any of the names of the people or organization?” Their responses, recorded verbatim, provide insights into the underlying reasons for the code of silence, which fall into seven broad categories of inappropriate practice:
It is not the intent of this qualitative study to precisely delineate a hierarchy of inappropriate practices. Instead, we aim to demonstrate that (1) healthcare professionals are aware of inappropriate practice, and (2) they are willing to acknowledge this awareness to their colleagues, providing enough detail to understand the situation.
As a follow-up question, respondents were asked, “What did they do about it?" referring to the inappropriate practice situation. The most common response was “nothing was done” (27 respondents or 44.3% of those 61 who reported awareness of inappropriate action). This indicates that the remaining healthcare professionals took some form of action, including:
Informed their supervisor (20 respondents or 32.8%), reported the situation to the administration (2 respondents or 3.3%), or to an internal review body (3 respondents or 4.9%);
Discussed the situation with the individual involved (3 respondents or 4.9%);
Reported to a licensing board (2 respondents or 3.3%)
These findings demonstrate that slightly more than half of the healthcare professionals in the study who shared with a colleague that they had observed inappropriate practices took action, fulfilling their professional responsibility. However, the large proportion (44.3%) who observed inappropriate practice and indicated that nothing was done clearly illustrates the existence and scale of the code of silence.
When respondents were asked the follow-up question, “What were the reasons nothing was said?”, three primary and three secondary rationales emerged from the data.
The primary rationales included:
“Intimidation by their employer,” indicated by 8 respondents, or 29.6% of those who responded that nothing was done;
“Wasn’t their business,” again 8 respondents (29.6%); and
“No harm came to the patient,” 6 respondents (22.2%).
The secondary rationales included:
“Not wanting to get involved with the law,” 3 respondents (11.1%);
“The patient wasn’t suffering,” one respondent (3.7%); and
“It was easier to fix the problem than to report it,” one respondent (3.7%).
Interestingly, “fear of lawsuits” was not reported by the respondents as a reason for not reporting inappropriate practice. This is a surprising finding, and perhaps a sample with a higher proportion of physicians might have revealed that concern.
The final question in this sequence asked respondents who reported action taken regarding inappropriate practice by a colleague, “What was the outcome of their action?” The 34 respondents who reported an inappropriate medical practice described the following outcomes:
Fifteen respondents or 45.5% reported that the individual identified as practicing inappropriately was fired;
Four or 12.1% reported filing an incident report, but the outcome was unknown;
In one case (3.0%) the inappropriate practice stopped after an investigation.
Approximately 40% of those 34 respondents reported “nothing” as the outcome of the action taken by their colleague, but with importance nuances. These respondents reported:
“Nothing was done” (6 respondents or 18.2%);
“Nothing—individual found new job” (2 respondents or 6.1%);
“Nothing—talked with residents” (4 respondents or 12.1%);
“Nothing—after agency investigation” (one respondent or 3.0%).
These results demonstrate that in a substantial proportion of the cases, no action is taken once an inappropriate practice is reported. In discussions with senior executives of acute care settings, it was often commented that management’s priority is to keep the reported event as quiet as possible both within and beyond the organization. This nuanced form of the code of silence further perpetuates the overall culture of silence in healthcare.
A Shift in Perspective: Respondent’s Direct Observation of Inappropriate Practice by Others
The next sequence of questions began by asking respondents “Thinking back over the most recent five years of your healthcare career, have you ever been directly aware of a situation where a licensed healthcare professional has not been practicing appropriately?” This was followed by similar probing questions regarding respondents’ awareness of their colleagues’ observations of inappropriate behavior, as discussed earlier. Here, in this case, respondents had direct personal and professional licensing responsibility for the decision they made based on their awareness of inappropriate practices.
Overall, 68.2% of the sample (60 of 88) responded “yes” to having been directly aware of a situation where a licensed healthcare professional was not practicing appropriately.” This includes 64.3% of the physicians, 69.8% of the nurses, and 90% of the pharmacists. These findings closely mirror those regarding respondents’ awareness of inappropriate practices observed by a friend or colleague.
The 60 respondents (68.2%) who indicated that they were directly aware of inappropriate practice were asked, “Can you give me a general idea of what the situation was without telling me any of the names of the people or organization?” Once again, these findings closely aligned with those related to colleague awareness of inappropriate practice. The incidents were categorized into the same seven broad categories as before:
Patient-related drug abuse and provider impairment combined account for 29.7% of all situations where the study’s respondents had direct awareness of inappropriate practices. Another significant area was provider errors (18.0%). These direct experiences align with observations of inappropriate practices by others, underscoring the need for further exploration of actions taken and the persistence of the code of silence, when no action is taken.
As a follow-up to the direct awareness question, respondents were asked, “What did you do about it?" In contrast to the earlier finding that 44.3% of respondents reported that their colleagues did nothing, only 18.0% (11 respondents) admitted that they themselves took no action when witnessing inappropriate behavior. The remaining respondents reported taking various actions:
Informed a supervisor: 20 respondents (32.8%);
Reported to the administration: 10 respondents (16.4%);
Notified an internal review body: 2 respondents (3.3%);
Reported to a licensing board: 6 respondents (9.8%).
Discussed the situation with the individual: 3 respondents (4.9%); and
Took direct administrative action: one respondent (1.6%).
In summary, slightly more than two-thirds of the healthcare professionals participating in this study observed inappropriate practice and took some action in response. However, the 18% (11 respondents) who witnessed inappropriate practices and reported that nothing was done is again a clear recognition of the persistence and magnitude of the code of silence—with almost one in five taking no action.
When respondents were asked the follow-up question “What were the reasons nothing was said?”, the responses were often vague and, at times, defensive. The largest group of respondents, five (31.3% of those who answered), stated that they did not believe their behavior was inappropriate. Three respondents (18.8%) indicated “did not want to get involved.” Other reasons for not speaking up included: not wanting to “rock the boat,” a desire to avoid confrontation, belief that no one was in direct danger, assumption that someone else would report it, and lack of clear proof. Interestingly, as in previous findings, “fear of lawsuits/being sued” was not mentioned as a reason for inaction.
The final question in this sequence asked for respondents about the outcome of their actions. Slightly over 60% reported corrective actions:
Twelve respondents (23.5%) reported that the individual identified as practicing inappropriately was fired;
Other corrective actions were indicated, such as investigation or pending legal action in 6 cases (10.7%), remedial training in 4 cases (7.8%), individual facing jail time in 2 cases (3.8%), and in individual cases, the healthcare provider went to rehab, an additional year was added to a doctor’s residency, and a nurse was placed on probation;
Four respondents (7.8%) reported filing an incident report but were unaware of the final outcome.
For nearly a third of the respondents, the outcome of the action taken by their colleague was described as “nothing,” but with important nuances. These respondents reported different interpretations of “nothing being done:
“Nothing was done—inappropriate behaviors stopped” was reported by 9 respondents (17.6%).
“Nothing—inappropriate behaviors continued” was noted by 4 respondents (7.8%).
“Nothing happened–complaint was not taken seriously” was reported by 2 respondents (3.9%).
One respondent reported that the nurse involved quit after the incident.
These results suggest that while inaction was perceived in some cases, it is nuanced. In fact, once inappropriate practice is reported, corrective action is taken the vast majority of the time, though the outcomes and the perceptions of what constitutes “action” can vary significantly.
Discussion
Our qualitative study demonstrates that, in the first place, inappropriate practices occur in healthcare, with more than two-thirds of our sample of healthcare providers indicating that they have either directly witnessed or have been indirectly made aware of such practices. Second, it provides meaningful insights into the behavioral responses of licensed healthcare professionals (physicians, nurses, and pharmacists) who are bound by professional responsibility to report breaches in patient care. While this study does not offer a precise measurement of the frequency or prevalence of these occurrences, it is clear that such practices are not isolated. Rather, they align with the existing literature, suggesting that inappropriate practices may be common in healthcare settings.
In a little over half of the situations reported by our respondents (55%), an action is taken to address the inappropriate practice, such as informing a supervisor, the administration, the internal review body, or discussing the issue with the individual healthcare provider involved. In many cases, this action resulted in corrective measures, including termination. However, in a substantial portion of the situations (over 40% of those that respondents knew about but did not directly witness), no action was taken. This describes the extent of the code of silence, i.e., the situations in which healthcare providers prefer not to address inappropriate practices performed by colleagues. In doing so they violate their professional responsibilities required by licensing boards and professional codes of ethics.
These findings suggest that a form of bystander effect 28 in which observers of inappropriate practices feel less compelled to take action, perhaps believing their responsibility is fulfilled by merely informing a colleague. This passivity might also be a result of the strong interdependence among caregiving teams. That should not be surprising, as humans do make errors, and healthcare professionals are not immune, despite their high qualifications, commitment, required annual training and certification, and the existing institutional, professional associations, and technical safeguards in place. What makes such practices a particularly important issue is that a) they can potentially adversely impact a patient’s health, recovery process, and even result in death—which we saw reported in the study results, and b) there is a substantial unwillingness among members of the medical care team to report such inappropriate practices conducted by colleagues.
In addition to the bystander effect, the phenomenon of the normalization of deviance 29 offers a valuable lens through which to understand the persistence of the code of silence in healthcare settings. This concept refers to the process by which deviant practices become standard operating procedures within an organization, especially when such practices do not immediately result in adverse outcomes. Over time, these deviations from established protocols can become entrenched, leading staff to overlook or accept unsafe behaviors as the norm. Repeated exposure to such deviations, coupled with institutional pressures and rationalizations, can erode professional standards and compromise patient safety. In our study, participants frequently described scenarios where questionable practices were tolerated or unreported, suggesting that normalization of deviance may be a contributing factor to the code of silence.
Breaking the code of silence is both a personal and organizational responsibility. Overcoming personal and systemic barriers to reporting inappropriate practices is essential.30,31 For healthcare providers, reporting inappropriate practices poses a multi-faceted ethical dilemma (Figure 1). On the one hand, they must consider societal ethical values, which prioritize human life and health and which would therefore proscribe keeping silent about inappropriate behaviors. These values are reflected in the codes of ethics governing the medical profession. American Medical Association’s second principle of medical ethics states: “A physician shall [. . .] strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities”.32,33 Similarly, Provisions 3, 4, 5, 6, and 8 of the American Nursing Association’s Code of Ethics emphasize a nurse’s responsibility to report unsafe practices. For instance, the interpretive guidance for Provision 3.4 states: “Nurses must [. . .] establish and sustain a culture of safety. When errors or near misses occur, nurses must follow institutional guidelines in reporting such events to the appropriate authority and must ensure responsible disclosure of errors to patients”. 34 Further, the guidance for Provision 4.3. states: “Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review”. 34 Given that nurses represent 55% of hospital employees nationally, 34 their role in identifying and reporting inappropriate practices is critical.
Ethical Reporting Dilemma in Healthcare
On the other hand, however, healthcare professionals who witness inappropriate behavior—or learn of it secondhand—must weigh not only societal ethical values but also the more nuanced goals and values of their healthcare organization. While healthcare organizations generally endorse societal values about life and health, specific goals and values can vary organization type: whether it is secular non-profit, religious non-profit, or for-profit. Nevertheless, a goal for any organization is minimizing risks to ensure its long-term viability. To avoid potential legal challenges and protect the organization’s reputation, both management and care team peers (licensed professionals) often (1) look the other way, (2) “circle the wagons” to protect themselves and their colleagues, and/or (3) resist calls for transparency when errors or other inappropriate behaviors occur. These dynamics are at the heart of the code of silence both among peers (who may fear making mistakes themselves and wanting future support) and management (seeking to prevent lawsuits and negative publicity). Several senior healthcare executives have openly expressed to the authors that their goal is to “deal with the situation while keeping it as quiet as possible,” reflecting a desire to manage issues internally while minimizing negative perceptions among employee, patient, and the broader community.
It is important to acknowledge that not all instances of silence are necessarily unethical. In some situations, silence may reflect legitimate concerns—such as protecting patient privacy, avoiding legal complications from unverified claims, or preserving team cohesion. While our findings emphasize the risks of silence in shielding inappropriate practices, we acknowledge that the ethical implications of silence are context-dependent and not uniformly negative. *
Reducing errors and improving care quality hinges on dismantling the culture of silence and fostering supportive environments. The quality control literature emphasizes that service system improvements, including in healthcare, are best achieved through team-oriented processes that focus on collaboration rather than blame. 35 Unfortunately, the punitive, win-lose culture that pervades many American institutions stands in opposition to Deming’s cooperative “no blame” approach, which fosters innovation, trust, and continuous improvement. In terms of game theory, the current defensive posture in American healthcare contrasts sharply with the cooperative spirit that Deming advocates for quality improvement. This contrast is even more pronounced in today’s understaffed, overworked, overstressed, and litigious healthcare environment. Despite these challenges, we believe that steps from the well-established quality improvement processes can be leveraged to break the code of silence. Below are our key recommendations to address this issue:
a) Allow healthcare professionals to report unsafe practices or ethical lapses without fear of retaliation; b) Use AI-driven analytics to identify patterns of non-reporting and the underlying reasons behind these results; c) Generate actionable insights to support continuous learning and policy improvements.
As documented in the organizational change literature, sustained transformation in organizations depends on clear structures, visible support from top leaders, and a culture that rewards continuous improvement.38,39
By implementing these strategies, healthcare organizations can begin to dismantle the code of silence, enhance trust and transparency, and strengthen safety and quality of care.
Limitations
While this study demonstrates that the code of silence is prevalent in the healthcare profession and is not limited to isolated incidents, it has certain limitations.
First, this is an exploratory qualitative study that relied on a relatively small, non-random sample. As a result, the findings may not be fully generalizable to the entire healthcare industry. While the sample includes different occupations within healthcare, it may underrepresent perspectives from non-acute care settings or less frequently sampled healthcare roles. Furthermore, the open-ended questionnaire used in this study was not formally validated using established psychometric methods. While the questions were reviewed for clarity and appropriateness after the initial eleven interviews, this informal review does not provide the same level of assurance regarding the instrument’s reliability and validity as a formal pilot test on a separate sample. The lack of formal validation may have influenced the comprehensiveness and depth of the data collected, potentially limiting the generalizability of the findings. Future research using a randomized and geographically diverse sample, with rigorously validated research instruments, would help validate and extend these findings.
Second, the study depends on self-reported data, which inherently carries the risk of recall bias and social desirability bias. Given the sensitive nature of the topic, some respondents may have been reluctant to fully disclose instances of unethical or inappropriate behavior, either to protect colleagues, to avoid workplace repercussions, or distance themselves from complicity in a culture of silence. As a result, it is likely that our findings underrepresent the true prevalence and scope of the code of silence. In this sense, any bias introduced by self-reporting likely contributes to conservative, rather than inflated, estimates of the problem. Future research could strengthen validity by triangulating qualitative findings with archival data (e.g., incident reports) or by employing a mixed-methods approach.
Third, while efforts were made to ensure confidentiality and encourage honest disclosure, the sensitive nature of the topic may have influenced participants’ willingness to fully disclose their experiences and perceptions. Some respondents may have underreported or framed their responses cautiously due to fear of repercussions in their workplace.
Finally, as with most qualitative research, data interpretation is inherently subjective, relying on thematic analysis. Although steps were taken to maintain rigor, researcher bias in identifying and categorizing themes cannot be entirely eliminated. Future research could incorporate mixed-methods approaches, combining qualitative insights with quantitative survey data, to strengthen the robustness of the findings.
Conclusion
Addressing the code of silence extends beyond healthcare and is, in fact, a societal issue impacting various industries. Recent high-profile cases involving organizations like Boeing, Facebook, Norfolk Southern Railroad, and the Memphis Police Force illustrate that this challenge is widespread. Therefore, the authors recommend leveraging the vast body of organizational change literature and the wealth of knowledge and experience as a foundation for addressing the code of silence in healthcare.
Implementing the recommendations outlined in this paper requires a concerted and strategic effort by healthcare organizations. Shifting toward a culture that values transparency, accountability, and patient-centered care is key. By enhancing reporting systems, improving data collection, and creating supportive environments where leadership is actively engaged, healthcare organizations can foster change. Additionally, providing continuous training, encouraging collaboration, and emphasizing ethical codes will ensure that inappropriate practices are addressed rather than ignored. Ultimately, these efforts will not only combat the code of silence, but also lead to improved patient safety, enhanced quality of care, and a healthier work environment for healthcare professionals. Embracing this transformative approach is essential for creating lasting improvements in healthcare delivery.
Footnotes
Appendix
Acknowledgements
We acknowledge with gratitude the participation of the graduate students in a Health Care Ethics class, who provided the inspiration for this study and collected the data.
Author contribution
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.