A 2026 national survey of over 3,500 clinicians and healthcare administrators reports that only 32% consistently speak up about safety concerns—indicating that nearly 68% do not address these issues, underscoring persistent communication failures in healthcare.
The findings, published ahead of print in the May 2026 issue of the American Journal of Critical Care, come from Silence Kills 2.0: How Communication Failures Stifle Innovation and Harm Patients. The study shows that while willingness to speak up has improved over the past two decades, hesitation in high-stakes situations continues to affect patient outcomes and limit the adoption of innovations such as AI.
Building on a seminal 2005 study co-sponsored by Crucial Learning and the American Association of Critical-Care Nurses (AACN), the updated research offers a 20-year view of how communication culture shapes both patient safety and healthcare performance.
Progress Has Improved, But Risk Persists
The data show measurable improvement in clinicians’ willingness to speak up. Today, 32% of respondents report addressing potentially harmful behaviors when they see them, compared with just 10% in 2005.
However, risk remains embedded in everyday practice: 40% of healthcare workers report witnessing rules being broken at least weekly, and 22% report observing mistakes in patient care just as often.
Only about half confront the issue directly and fully express their concerns
These gaps between observation and action continue to create patient safety vulnerabilities.
The “Crucial Moments” That Shape Safety Culture
The study revisits seven high-risk scenarios first identified in 2005, including when clinicians observe colleagues breaking rules, making mistakes, or demonstrating incompetence. It also introduces an eighth factor: how perceived workplace bias influences a clinician’s willingness to speak up.
Although more respondents report confidence in addressing concerns directly, hesitation remains common across these situations.
Speaking Up Is Directly Linked to Outcomes
The findings show a clear connection between communication and outcomes.
Clinicians who consistently speak up report better patient safety outcomes, improved patient experiences, and stronger clinical results. They are also less likely to consider leaving their organization within the next six months, suggesting that communication culture is a workforce factor.
Vicki Good, chief clinical officer at AACN and co-lead researcher, emphasized the role of communication in shaping care 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 Also Limits Innovation, Including AI
The study also examined how communication culture affects the adoption of new technologies and practices, including artificial intelligence and machine learning.
Teams with high levels of candid communication were significantly more likely to implement new approaches and improve care.
Among high-candor teams (those in the top decile):
- 89% actively seek ways to improve patient outcomes and quality of care
- Team members report feeling empowered to propose more effective practices
By comparison, only 32% of lower-decile teams report being proactive in improving patient outcomes and quality of care.
These findings suggest that communication culture is not only a safety issue but also a key factor in innovation readiness.
Joseph Grenny, cofounder of Crucial Learning and co-lead researcher, said the study offers clear direction for healthcare leaders.
“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.”
What This Means for Nurses
For nurses, who are often the first to recognize changes in patient condition or workflow breakdowns, the findings reinforce a familiar reality.
Speaking up is not just a professional expectation. It is a critical component of patient safety.
Two decades after the original “Silence Kills” report, the need for action is clear. Now is the time for every clinician and healthcare leader to commit to consistent, candid communication. Take the next step: speak up, support your colleagues, and help transform patient safety and outcomes.
