When medical errors go unreported and undiscussed at academic health centers (AHCs), the quality and safety of patient care is at risk. A 2005 study showed that less than 1 in 10 health care professionals speak up when they see colleagues provide care that is potentially harmful to patients.1 Evidence that “silence kills”1 has provided momentum for the efforts of health care organizations to promote quality and safety through creating a culture that empowers more members of the health care team to speak up in the best interest of patient care.2 In addition to the significant toll on patient care, however, silence also inhibits organizational vitality. Although the movement to “speak up” is championed as a lifesaving endeavor in the clinical context, it has not gained the same kind of traction across other critical mission areas of AHCs. Dialogue is essential to transform institutions into learning organizations. Silence, on the other hand, impedes organizational vitality by limiting the flow of information necessary for positive organizational performance.3,4 An organization without a culture of dialogue fails to learn from mistakes, suppresses differences of opinion, does not address problems holistically, and ignores sources of innovation and system improvements. In this Perspective, we invite the AHC community to explore the organizational structures that inhibit conversation and provide recommendations for addressing these barriers.
What Causes Silence at AHCs?
Many characteristics of AHCs interfere with open discussion. With departmental silos, competition for resources, rigidly defined ranks and hierarchies, and chronic time pressures, there are few unifying forces in AHCs.5 Further, systems of promotion and tenure, sponsorships for professional development and leadership positions, award nominations, institutional grant reviews, and other processes of academic recognition rely largely on internal and external peer review and the support of those in power—the chair and the dean. Faculty find it hard enough to have difficult conversations with peers and mentees,6 hesitating to voice concerns that could jeopardize existing professional relationships. Standing up to existing authority gradients presents hurdles, and few professionals have witnessed this behavior effectively modeled. Although the phrase “speaking truth to power” has been in the vernacular for decades and continues to resonate strongly, the challenges inherent in “upward dissent” remain.7
Research on organizational silence and employee voice shows that this is not an uncommon phenomenon. Milliken et al8 found that 85% of employees in their sample had, at least once, felt unable to raise an important issue to their supervisor. Although this study was done in the corporate sector, the issues participants struggled to raise are relevant for any type of organization: (1) concerns about a colleague’s or supervisor’s performance or competence, (2) problems with organizational processes, (3) concerns about pay equity, and (4) disagreement with policies or decisions.8 Studies show that the primary reasons employees do not voice their concerns are fear of being labeled (i.e., as a troublemaker or complainer), fear of damaging relationships, a sense of futility, and fear of retribution.8,9 The social aspect of silence is particularly powerful. Among people who work together, shared beliefs about whether speaking up is safe and effective is highly predictive of whether an employee does so.10 Further, being labeled a troublemaker or complainer can lead to a loss in social capital.8 Fear regarding isolation may be particularly salient for members of underrepresented minority groups.11
Both organizational silence and dialogue have social elements, and dialogue is an exchange that requires skills not only in talking but also in listening.12–15 Many leaders of AHCs may suffer from “the dean’s disease,” which Bedeian16 characterizes as a series of subtle changes in how deans and others interact, resulting in the dean’s increasing intolerance for dissenting views and the creation of an inner circle of “carbon copies” who only tell the dean what he or she wants to hear. Over time, this “loyalty” shields the person in authority from the day-to-day realities of the institution and distorts information he or she needs for critical decisions. The more homogeneous and unified the top management team is, the more it may be threatened by dissent.
Clearly, this disease may “infect” other senior administrators as well. Souba and colleagues17 defined institutional elephants as “important problems within departments, the medical school, or the teaching hospitals that need to be confronted but for various reasons are ignored, often for long periods of time.” In Souba and colleagues’ survey of chairs of departments of medicine and surgery, 69% of respondents reported that elephants were widespread or common at their organization, and that issues were more commonly ignored by deans and hospital leaders than by other department chairs or themselves. Like the institutional leaders referred to by the chairs, it is quite possible that the chairs who responded to the survey were unaware of the elephants in their own units.
What Can AHCs Do?
AHCs must commit to being learning organizations, which use open discussion to learn from mistakes, share knowledge, and develop new ideas.4 Organizations in which “holistic thinking” occurs incorporate explicit learning processes, such as seeking out dissenting views during discussions, identifying assumptions that may affect decision making, and revisiting well-established beliefs, making way for new ideas.18 The leaders of learning organizations are attentive listeners who appreciate differences of opinion and reinforce learning by creating a supportive environment in which it is safe to speak up, share one’s perspective, and talk openly about problems.
Organizations can be thought of as conversations with dialogue and relational processes as primary vehicles for organizational development.19 In the organization-as-conversation model, change efforts focus on patterns of meaning (what people say and think about institutional values, strategy, information, etc.) and patterns of relating (how people treat each other, who makes decisions, what is openly discussed, etc.). Because such patterns are constructed and reconstructed through daily interactions with others, there are countless moments to change the way one participates.20–22 Helping faculty and institutional leaders learn to attend to “here-and-now interactions”21 and engage respectfully with each other across all kinds of differences are central to an effective organizational culture.23 Furthermore, the following practices can help insulate AHCs against creating a culture of silence.
Develop institutional leaders to counteract organizational silence
Leaders play a critical role in shifting the patterns that hold elephants in place. The best AHCs invest in training leaders so that they embrace change and promote innovation.24 Thus, leadership development programs must illuminate the impact of organizational silence, help leaders understand the value of empowered teams, and train leaders in relational communication so that they become comfortable with conflict and differing perspectives. As Souba et al17 assert, people cannot solve the problems they do not talk about. Studies imply that when leaders are directly involved in process or quality improvement initiatives, more people feel comfortable raising issues and offering solutions.25 Such involvement sends the message that the leader is invested in change, which decreases concerns about power and status differences26 and increases the perception of the leader’s openness, which is highly related to the willingness of employees to voice concerns.27 It behooves leaders to display openness and engage in ongoing improvement cycles, framing speaking up as an integral part of the process.
It is thus incumbent on administrative leaders to mine proactively for dissenting views and to create a culture in which differences are identified and discussed. A key step is to help leaders understand the fear that some faculty may have about the social consequences of being labeled, and reframe speaking up as being “courageous” rather than “complaining.”8 To further reinforce the importance of creating an environment in which relational communication flourishes and speaking up is supported, leadership should be evaluated on these communication skills and offered coaching if necessary.
Develop faculty members’ skills in raising difficult issues with those in positions of power
Even when a leader works to create safe space for conversation to occur, members of the organization need experiences to enhance their confidence in raising difficult issues and to rehearse approaches to framing issues with individuals who have more positional power. Thus, it is critical to invest in professional development activities to help all faculty become skilled at broaching differences.
As an example of an easily replicable intervention to provide faculty with opportunities to practice skills, we conducted a national workshop designed to illustrate how to convert an “undiscussable” problem into a “talkable” one with someone in power. Through a series of exercises, participants shared perceptions about the risks involved in initiating such conversations, the criteria they use when deciding to raise risky issues, and strategies they have tried to engage in difficult conversations (see List 1). We next presented core practices of self-monitoring and the tenets of relational communication practices, such as eliciting the other’s perspectives with open questions, listening with curiosity rather than automatically sorting into agree/disagree or right/wrong, establishing a mutual purpose, revealing one’s reasoning and testing assumptions, and asking for help in understanding one’s own thinking.4,12–15 In triads, participants practiced their skills through either a provided case or a situation from their own experience. The strategies for becoming more fluent in the face of conflict were brought forth with a recognition that many faculty members will, at some point, encounter values conflicts with supervisors or with organizational expectations. Appealing to shared values can be the “higher purpose” used to encourage partnership with someone in power in identifying a solution.28
List 1 Participant-Generated Ideas Regarding Barriers, Decision-Making Criteria, and Strategies for Transforming “Undiscussable” Topics Into “Talkable” Topicsa Cited Here
Barriers against open discussion
- Desire to be liked
- Concern about the impact of raising a difficult issue on the relationship
- Leadership culture
- Resistance to input
- Tendency to “shoot the messenger”
- Tolerance of retaliation
- Time pressures
- Assumptions about the motivation of the “other” party
- Lack of knowledge of the whole organizational picture
Decision-making criteria for raising an issue
- Asking, “What is the evidence for the issue and of the need to raise it?”
- Exploring “gut level” feelings and values conflicts related to the issue
- Maintaining one’s personal integrity in role
- Determining whether it is necessary to an initiative/project/program
- Conducting a risk–benefit analysis (e.g., What is at stake if I don’t speak up?)
Strategies for transforming undiscussable topics into talkable topics
- Carefully prepare how you will set the stage and be clear about your goals
- Present evidence, not emotions
- Put yourself in the other’s shoes to gain broader perspective
- Present yourself as wanting to help the other be more effective
- Ask a well-framed question to help the other think in a new way
- Help decision makers see the wider impact of choices
- Reference alternative “authorities” (e.g., core mission, code of conduct)
- Build allies; speak to someone better positioned than you
- Bring together those involved and emphasize interdependence
- Make a follow-up appointment
aGenerated by workshop participants at the Association of American Medical Colleges Group on Faculty Affairs and Group on Diversity and Inclusion Joint Professional Development Conference, Indianapolis, Indiana, August 2012.
Train mentors to coach others in raising difficult conversations
Employing a model analogous to “training the trainer,” not only can mentors learn to improve relational communication skills6 but they also can be taught to coach others in raising difficult issues. As a coach, the mentor works to increase a colleague’s self-awareness and self-trust, enabling the colleague to use his or her own strengths and to generate a personalized approach to a difficult conversation.29 Coaching conversations prompt the reflection necessary to uncover attitudes and assumptions that may be holding someone back from addressing a “sacred cow.”30 A coach can help a colleague see that he or she has a responsibility to act and that there is value in taking action—that addressing the issue will make a difference. Coaches can also be invaluable in helping a colleague see hidden risks and potential challenges in raising the issue. Although a coach should not give the answer, he or she can provide alternate ways to see a situation and illuminate a colleague’s blind spots and potential pitfalls.31 A coach assists others to uncover their sense of purpose in raising issues and to keep a focus on their core values.28 In coaching conversations, the coach should model skills of active listening and the use of inquiry.15 A coach can provide resources in addition to expertise, but most important, by allowing someone to practice a difficult conversation, a coach can help a colleague clarify his or her thought processes and find his or her voice.
Applying Theory to Practice
Given the complex challenges facing AHCs, clashes among competing perspectives are to be expected. One key to organizational learning and institutional vitality is the effectiveness of those “leading from the middle” in addressing difficult issues. A powerful example comes from Maine General Health, which launched a compre hensive initiative to address conflict resolution after a system-wide employee satisfaction survey showed that the number one concern was “handling conflict.”32 This hospital system’s senior executive team worked collaboratively with human resources and professional development staff on the intervention, which included training more than 1,000 employees in a structured communication skills program, collecting employee stories about failures and successes in speaking up, and using a strategic communication plan to disseminate information about the overall project. Through this process, “speaking up” was added to their values statement and became an expectation for all employees.
Training in communication skills is imperative to counteract the costs of organizational silence. Indeed, effective communication and the ability to manage difficult conversations are core competencies for all faculty members,33 and relational communication skills development is essential for all leaders, faculty, staff, and trainees.34 We invite the AHC community to embrace the responsibility to create opportunities that enable faculty and leaders to refine this essential competency and collectively build our capacity to address current and future challenges.
1. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A Silence Kills: Seven Crucial Conversations for Healthcare. 2005 Provo, Utah Vital Smarts, L.C. http://www.silenttreatmentstudy.com/silencekills
. Accessed May 8, 2014
2. Suchman AL, Sluyter D, Williamson P Leading Change in Healthcare: Transforming Organizations With Complexity, Positive Psychology and Relationship-Centered Care. 2011 London, UK Radcliffe Pub Ltd
3. Morrison EW, Milliken F. Organizational silence: A barrier to change and development in a pluralistic world. Acad Manage Rev. 2000;25:706–725
4. Senge PM The 5th Discipline: The Art and Practice of the Learning Organization. 2006 New York, NY Currency Publishing
5. Gilmore TN, Hirschhorn L, Kelly M Challenges of Leading and Planning in Academic Medical Centers. 1999 Philadelphia, Pa Center for Applied Research http://themomentyoucantignore.com/sites/default/files/resources/Leading_Planning_AMC.pdf
. Accessed May 8, 2014
6. Bickel J, Rosenthal SL. Difficult issues in mentoring: Recommendations on making the “undiscussable” discussable. Acad Med. 2011;86:1229–1234
7. Kassing JW. Speaking up: Identifying employees’ upward dissent strategies. Manag Commun Q. 2002;16:187–209
8. Milliken FJ, Morrison EW, Hewlin PF. An exploratory study of employee silence: Issues that employees don’t communicate upward and why. J Manag Stud. 2003;40:1453–1476
9. Detert JR, Burris ER, Harrison DA. Debunking four myths about employee silence. Harv Bus Rev. 2010;88:26 June
10. Morrison EW, Wheeler-Smith SL, Kamdar D. Speaking up in groups: A cross-level study of group voice climate and voice. J Appl Psychol. 2011;96:183–191
11. Bowen F, Blackmon K. Spirals of silence: The dynamic effects of diversity on organizational voice. J Manag Stud. 2003;40:1393–1417
12. Isaacs W Dialogue: The Art of Thinking Together. 1999 New York, NY Doubleday
13. Scott SC Fierce Conversations: Achieving Success at Work and in Life One Conversation at a Time. 2002 New York, NY Berkley Publishing Group
14. Stone D, Patton B, Heen S Difficult Conversations: How to Discuss What Matters Most. 1999 New York, NY Penguin Books
15. Patterson K, Grenny J, McMillan R, Switzler A Crucial Conversations: Tools for Talking When the Stakes Are High. 2012 New York, NY McGraw-Hill
16. Bedeian AG. The dean’s disease: How the dark side of power manifests itself in the office of the dean. Acad Manag Learn Educ. 2002;1:164–173
17. Souba W, Way D, Lucey C, Sedmak D, Notestine M. Elephants in academic medicine. Acad Med. 2011;86:1492–1499
18. Garvin DA, Edmondson AC, Gino F. Is yours a learning organization? Harv Bus Rev. 2006;;86::109–116
19. Broekstra GGrant D, Keenoy T, Swick C. An organization is a conversation. In: Discourse and Organization. 1998 London, UK Sage
20. Suchman ALSuchman AL, Botelho RJ, Hinton-Walker P. Control and relation: Two foundational values and their consequences. In: Partnerships in Healthcare: Transforming Relational Process. 1998 Rochester, NY University of Rochester Press
21. Suchman AL. Organizations as machines, organizations as conversations: Two core metaphors and their consequences. Med Care. 2011;49(suppl):S43–S48
22. Suchman AL. A new theoretical foundation for relationship-centered care. J Gen Intern Med. 2006;21(1 suppl):S40–S44
23. Brater DC. Viewpoint: Infusing professionalism into a school of medicine: Perspectives from the dean. Acad Med. 2007;82:1094–1097
24. Straus SE, Soobiah C, Levinson W. The impact of leadership training programs on physicians in academic medical centers: A systematic review. Acad Med. 2013;88:710–723
25. Adler-Milstein J, Singer SJ, Toffel MW. Speaking up constructively: Managerial practices that elicit solutions from front-line employees. Working Papers–Harvard Business School Division of Research:1-A6 2010 http://www.mpm.med.uni-erlangen.de/e3102/e3186/inhalt3188/HBS_Speaking-up-constructively_100824.pdf
. Accessed May 8, 2014
26. Edmondson AC. Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. J Manag Stud. 2003;40:1419–1452
27. Detert JR, Burris ER. Leadership behavior and employee voice: Is the door really open? Acad Manag J. 2007;50:869–884
28. Gentile M The Giving Voice to Values Curriculum. http://www.babson.edu/faculty/teaching-learning/gvv/Pages/home.aspx
. Accessed May 8, 2014
29. Thorn PM, Raj JM. A culture of coaching: Achieving peak performance of individuals and teams in academic health centers. Acad Med. 2012;87:1482–1483
30. Cheliotes LG, Reilly MF Coaching Conversations: Transforming Your School One Conversation at a Time. 2010 Thousand Oaks, Calif Corwin
31. Key Consulting Group Inc. Constructive Coaching Conversations. Paths to Leadership 2003. http://www.keyinc.com/keyinc/Articles/CoachConversations.pdf
. Accessed May 8, 2014
32. Bullock S. Empowering staff with communication Healthc Exec. 2011:80–82 July/August
33. Milner RJ, Gusic ME, Thorndyke LE. Toward a competency framework for faculty. Acad Med. 2011;86:1204–1210
34. Bickel J. Focus on improving relational communication skills and discussing what matters most. Acad Med. 2012;87:1471–1472