The Code of Silence in Healthcare: Exploratory Cross-National Evidence and a Framework for Reporting and Responsibility

Abstract

Background

The “code of silence” in healthcare refers to reluctance among professionals to report misconduct or unsafe practice. Prior research in the United States identified tensions between personal ethics, professional standards, and organizational pressures in shaping speaking-up behavior. It remains unclear whether these dynamics extend across institutional and cultural contexts.

Purpose

This study examines whether patterns of awareness and response to inappropriate practice previously identified in a U.S. sample replicate in Romania, and how institutional context may shape interpretations of responsibility and reporting behavior.

Design and Method

Using a structured replication design, we administered the same core survey instrument used in the prior U.S. study to all licensed clinical staff at a large Romanian public hospital (N=458 invited; 201 complete responses). Comparative analysis examined descriptive patterns of indirect and direct awareness, actions taken, reasons for inaction, and perceived outcomes.

Results

Reluctance to act following awareness of inappropriate practice was observed in both contexts, suggesting cross-system robustness of silence-related dynamics and raises the possibility of important differences. Exploratory evidence suggests that U.S. respondents appear to report higher awareness levels and greater reliance on formal supervisory reporting channels, whereas Romanian respondents seem to more frequently report direct interpersonal intervention and greater uncertainty about outcomes. Differences appear consistent with variation in regulatory structures, reporting mandates, and hierarchical norms.

Conclusion

The code of silence appears across healthcare systems but may operate through context-specific mechanisms. In more formalized regulatory environments, responsibility may be more often enacted through institutional escalation, whereas in other settings it may be framed as interpersonal correction. The findings also suggest that effective interventions must distinguish between episodic and recurring problems, as well as between clinical error and inappropriate conduct. To clarify these distinctions, we propose a Deming-inspired governance framework indicating that different types of problems require different institutional responses, ranging from learning-oriented process improvement to formal accountability mechanisms.

Introduction

Hans Christian Andersen’s classical tale The Emperor’s New Clothes famously illustrates how individuals may collectively avoid stating an obvious truth. ¹ Morrison & Milliken draw on this metaphor to describe organizational silence: the “apparent paradox in which most employees know the truth about certain issues and problems within the organization yet dare not speak that truth to their superior.” ² The present study extends organizational silence research into the healthcare context, where silence may have direct implications for patient safety, professional accountability, and organizational learning. Healthcare professionals operate at the intersection of personal moral commitments, professional ethical standards, organizational imperatives, and legal requirements. Decisions about whether to speak up therefore involve not only perceptions of risk and safety but also judgments about personal responsibility for patient outcomes and organizational responsibility for enabling—or discouraging—employee voice. In this respect, silence in healthcare represents a particularly consequential form of organizational silence, as failures to speak up about unsafe practices may directly affect patient safety and quality of care. Yet existing research has rarely examined how these forms of responsibility are perceived, negotiated, and prioritized by healthcare professionals, particularly across different institutional and cultural contexts. ³

A recent exploratory study documented the prevalence of the code of silence in healthcare and highlighted the tension that healthcare professionals experience between personal values and professional ethics, on the one hand, and fear of retribution and institutional priorities, on the other. ⁴ That study was conducted in the United States, within a distinct national culture and institutional healthcare environment. While these findings provide important insight into silence dynamics in U.S. healthcare, it remains unclear whether similar patterns emerge in healthcare systems operating under different regulatory structures, professional norms, and cultural expectations. To examine whether these dynamics extend beyond the U.S. context, the present study replicates and extends this line of inquiry in Romania. In doing so, the study moves beyond documenting prevalence to examining whether the mechanisms underlying silence—and the interpretation of responsibility for addressing it—remain consistent across institutional contexts.

Cross-cultural examination is particularly relevant for understanding the code of silence, as national culture, professional norms, and institutional arrangements may influence both the perceptions of responsibility and willingness to speak up. Accordingly, we conducted a study in a Romanian acute care hospital, administering an anonymous questionnaire to all 458 members of its medical staff (physicians, nurses, and pharmacists). The survey yielded 239 responses (52%), of which 201 were complete and valid for analysis (44%).

The remainder of the paper proceeds as follows. We review the theoretical foundations relevant to understanding the code of silence in healthcare and then describe the key institutional features of the Romanian healthcare system. We then present the results of the study and compare them with the findings from the prior U.S. research. Finally, we discuss the implications of these findings for understanding personal and organizational responsibility in overcoming the code of silence across cultural and institutional contexts.

The present study contributes to the literature in three ways. First, it extends prior research on the code of silence in healthcare by examining whether patterns observed in a U.S. sample are replicated in a different national and institutional context. This structured cross-national replication helps clarify which aspects of silence-related behavior appear robust across healthcare systems and which may be contingent on institutional design and the regulatory environment. Second, it advances theory by focusing explicitly on personal and organizational responsibility as key lenses through which healthcare professionals interpret silence-related decisions. In particular, the study examines whether responsibility is enacted primarily through interpersonal correction of problematic behavior or through formal escalation to organizational authority. Third, by situating these dynamics within the Romanian healthcare system, the study offers insight into which aspects of the code of silence appear robust across contexts and which may be shaped by institutional arrangements and cultural norms. Building on these insights, the study further proposes a heuristic framework distinguishing between episodic and recurring problems and between clinical error and inappropriate conduct, suggesting that different types of problems require different governance responses.

Silence, Reporting, and Patient Safety in Healthcare Organizations

The hazards of silence in healthcare have been increasingly recognized since the modern patient safety movement reframed adverse events as predominantly systemic rather than purely individual failures. From Deming’s systems perspective, ⁵ the code of silence in healthcare is influenced not only by individual ethics and competence, but also by the systems within which healthcare professionals operate. The Institute of Medicine’s landmark report To Err Is Human further argued that punitive reactions to reported mistakes may themselves become barriers to patient safety, because they discourage disclosure and drive concerns underground rather than allowing organizational learning to occur. ⁶

Building on these systems-oriented perspectives, the concept of just culture has emerged as a prominent framework for balancing organizational learning and individual accountability in healthcare.^7,8 Just culture approaches reject both punitive blame and complete exoneration, instead distinguishing between human error, at-risk behavior, and reckless conduct, with each requiring a different organizational response. By emphasizing fairness, transparency, and proportional accountability, just culture seeks to encourage reporting and open discussion of mistakes while preserving professional responsibility for unsafe behavior. Research suggests that healthcare professionals are more likely to report concerns when they perceive organizational responses as fair, consistent, and oriented toward learning rather than punishment. Consequently, just culture has become a central component of contemporary patient safety governance and efforts to reduce organizational silence in healthcare.

Underreporting is a significant concern: a substantial proportion of adverse events and near misses witnessed by clinicians are never formally documented, while reporting systems tend to capture minor events more often than serious or recurring problems,^3,9 weakening institutional learning and obscuring persistent structural vulnerabilities.

A substantial body of healthcare-specific literature has sought to explain why clinicians who recognize unsafe or inappropriate practices nonetheless remain silent. Edmondson’s influential work on psychological safety demonstrated that healthcare teams with stronger climates of interpersonal trust and openness often report more errors, not fewer, because staff feel able to discuss mistakes without fear of humiliation or retaliation. ¹⁰ Systematic reviews of speaking-up behavior in healthcare have identified several recurring determinants of silence, including steep professional hierarchies, the anticipated ineffectiveness of reporting systems, fear of damaging workplace relationships, blame-oriented cultures, understaffing, and burnout.^3,11 Clinicians thus weigh the potential patient-safety benefit of raising concerns against the interpersonal and career-related risks of doing so, and many prefer informal correction to institutional escalation, especially in highly hierarchical systems, where silence may emerge as an adaptive organizational response rather than merely an individual ethical failure. ⁹

An important insight from this literature is that silence is not simply a reaction to isolated incidents, but a process capable of reshaping organizational norms over time. Banja’s discussion of the “normalization of deviance” in healthcare, adapting Vaughan’s analysis of the Challenger disaster, describes how behaviors that initially provoke concern may gradually become accepted when they are repeatedly tolerated without immediate adverse consequences. ¹² Under such conditions, shortcuts and procedural violations may cease to be recognized internally as problematic even while increasing organizational risk. The distinction between isolated lapses and recurring patterns of tolerated deviance is highly consequential for healthcare governance, because superficially similar unreported events may reflect fundamentally different organizational dynamics.

These distinctions parallel the systems-based quality improvement tradition introduced into healthcare through Deming’s work on organizational variation and process management. Continuous improvement challenges the “bad apple” assumption that adverse outcomes arise primarily from deficient individuals, emphasizing instead that many failures emerge from the processes within which competent professionals operate. ¹³ Central to Deming’s framework is the distinction between common-cause variation, embedded within stable processes, and special-cause variation, which signals exceptional disturbances requiring targeted intervention. Applied to the code of silence, this suggests that not all unreported events should be managed identically: isolated clinical mistakes, recurring system deficiencies, and chronic professional misconduct may call for fundamentally different responses, ranging from learning-oriented process improvement to formal accountability. Understanding organizational silence in healthcare therefore requires examining, across contexts, how professionals interpret responsibility, assess institutional credibility, perceive psychological safety, and determine whether problematic situations should be addressed through interpersonal correction, organizational learning, formal escalation, or disciplinary accountability.

Publicly Documented Instances of Silence in Romanian Healthcare

Prior research in the United States indicates that a persistent code of silence exists in healthcare, sustained by informal norms that discourage reporting observed errors, rule violations, or unsafe practices. ⁴ Although healthcare professionals frequently witness such behaviors, only a small proportion speak up, contributing to risks for patient safety as well as negative organizational outcomes such as reduced morale and increased turnover. This silence is often reinforced by institutional practices that favor internal, confidential handling of concerns, potentially weakening accountability and transparency within healthcare organizations.

Public reporting suggests that similar dynamics are present in Romania. Media coverage of several high-profile malpractice cases points to initial efforts to avoid scrutiny or minimize responsibility, consistent with patterns associated with a code of silence. The cases discussed below are illustrative rather than exhaustive and are presented as contextual examples rather than representative evidence regarding the prevalence of misconduct or silence-related behaviors within Romanian healthcare.

Surgical Error

In 2022, a physician in a Bucharest clinic left a surgical sponge inside a patient during abdominal surgery, which led to septicemia and the patient’s death.^14,15 Subsequent investigations revealed that members of the Advisory and Control Commission of the National Institute of Forensic Medicine (NIML) attempted to obstruct scrutiny by delaying or withholding scientific approval of the official cause of death report. ¹⁶ Both the doctor and several forensic specialists were later prosecuted. ¹⁷

Death of a Newborn

In 2025, a newborn died shortly after birth at the Reşița County Emergency Hospital, despite an apparently uncomplicated pregnancy, prompting the family to request further investigation. ¹⁸ Investigators identified multiple irregularities, including delayed intervention and the alteration of official scheduling records to conceal prohibited consecutive shifts by the attending physician. ¹⁶ Hospital administrators cited chronic understaffing, while the physician denied any error. ¹⁹ At the time of writing, the case remains under investigation.

Death of a Young Physician

In 2025, a 37-year-old physician and medical director at the County Emergency Hospital in Buzău was found dead in the hospital’s emergency room. ²⁰ Colleagues reported that she was chronically exhausted, frequently worked overtime, and allegedly used medical substances to cope with fatigue, yet these conditions were widely known and unchallenged within the organization. The hospital manager publicly described her as “a dedicated doctor,” noting that she routinely worked at least seven additional shifts per month beyond her regular duties. ²¹ Despite clear signs of overwork, no formal interventions were reported prior to her death. Police have opened an investigation and are treating the case as a suspicious death.

These publicly documented cases provide contextual background for the present study and illustrate the types of organizational and professional dynamics that may shape healthcare professionals’ willingness to speak up in Romania. To better understand these dynamics, it is important to consider the broader institutional and cultural context in which Romanian healthcare professionals operate.

Institutional and Cultural Context of Healthcare in Romania

Legal Compliance, Professional Responsibility, and Institutional Accountability

Trust between physicians and patients is closely tied to legal compliance, particularly regarding informed consent, confidentiality, and patient autonomy. Physicians in Romania show limited awareness of key legal provisions regarding informed consent and confidentiality. ²¹ The first national assessment of Romanian physicians’ legal compliance found that only 46.67% of physicians’ practices adhered to legal standards. ²² Although 94.02% of physicians reported anxiety about malpractice, only 17.67% had been formally accused. This discrepancy suggests a climate in which legal risk is perceived as high, while formal accountability mechanisms may be inconsistently applied—conditions that can shape decisions about whether to report concerns or remain silent.

Scholars have also identified gaps in legal education and have called for clearer malpractice legislation, stronger institutional oversight, and greater integration of medical law into medical training. ²³ The absence of well-defined procedures and support structures may contribute to uncertainty regarding responsibility and appropriate reporting channels, thereby reinforcing tendencies toward silence.

Concerns regarding malpractice procedures further complicate perceptions of responsibility. Prior research suggests that responsibility for adverse outcomes is often experienced as individualized rather than shared across institutions and systems. ²⁴ Workplace conditions such as staffing shortages and excessive workload are frequently perceived as underexamined in malpractice determinations. Such dynamics may encourage defensive practices and reluctance to report errors, particularly when organizational support is perceived as weak.

Workload, Stress, and Organizational Pressures

Orkload and stress among the Romanian medical staff represent additional contextual factors fueling the code of silence. Media reports document cases of severe physician burnout in Romanian hospitals. ²⁴ However, a study conducted during the Covid-19 pandemic found self-reported stress levels to be low to moderate, ²⁵ a pattern that the authors interpreted as possible under recognition or dissociation from stress symptoms. When combined with chronic understaffing and high workload, such conditions may normalize compromise and reduce the likelihood that unsafe practices are challenged openly.

Cultural Norms and Ethical Orientation

Broader cultural factors may also play a role. Romania’s historically patriarchal and authority-oriented traditions have been associated with strong respect for hierarchy and family structures, potentially influencing attitudes toward autonomy and dissent.^25,26 Although physicians generally report a positive professional self-image, studies have identified areas of ethical vulnerability, particularly regarding autonomy and justice as bioethical principles. Autonomy and justice were rated lowest among bio-ethical principles, while truth was relatively respected but ambivalently so.

In hierarchical cultural contexts, deference to authority and institutional loyalty may further discourage upward voice, thereby intersecting with organizational dynamics to sustain patterns of silence.

Methodology

Research Design

The present study examines whether the dynamics underlying the code of silence in healthcare—previously documented in the United States—generalize to a distinct institutional and cultural context. Specifically, we investigate whether the willingness to report medical errors or misconduct, as well as patterns of perceived personal and organizational responsibility, observed in the United States ⁴ replicate in Romania.

By conducting a structured replication using the same core instrument and analytic framework, we assess the cross-national robustness of the original findings and identify context-specific similarities and differences. Rather than assuming universality, this design allows us to evaluate whether the code of silence reflects broader professional dynamics in healthcare or is contingent upon particular legal, cultural, and institutional environments. The research design was to replicate, to the extent possible, the survey instrument used in the U.S. study, ⁴ with minimal contextual adaptations limited to response categories necessary to reflect local organizational structure. The use of the same core instrument supported structured descriptive comparison despite differences in sampling and administration.

The central research question guiding this extension is:

To what extent do perceptions of personal and organizational responsibility and willingness to report misconduct in Romanian healthcare mirror those observed in the United States?

A secondary objective is to identify systematic differences that may be attributable to institutional or cultural contexts.

Sample and Procedure

We collected data in an acute care hospital in a large Romanian city. This was a large public hospital specializing in rheumatology, physical and rehabilitation medicine, internal medicine, pulmonology, orthopedics and traumatology, neurology, ENT, and sports medicine. After obtaining approval from the hospital director and the hospital commission on ethics (Approval #27 of November 17, 2025), all of the hospital’s 212 physicians, 244 nurses, and three pharmacists were invited to respond to an online survey. Participation was voluntary and anonymous, and no personal identifier data were collected. Informed consent was obtained electronically through the online survey. Participants were presented with an information and consent page and indicated their consent by choosing to continue with the survey. The questionnaire and the informed consent statement are included in the Appendix.

To maximize comparability with the original U.S. study, the survey was administered in English. All medical staff were required to demonstrate sufficient English proficiency as part of professional credentialing, reducing risks associated with translation and back-translation procedures.

The survey was conducted in December 2025 over a period of about a month, and two reminder emails were sent.

Response Rate and Analytical Sample

The survey yielded an overall response rate of 52% (N=239). Of these respondents, 201 (44% of the total invited sample) identified their professional affiliation (physician, nurse, or pharmacist) and constitute the analytical subsample used for cross-national comparison. This subsample approach ensures comparability with the U.S. dataset, which also focused on licensed clinical professionals. Further, because participants responded using predefined categories replicated from the original U.S. study instrument, responses were not retrospectively coded by the researchers.

Nonresponse bias cannot be fully ruled out; however, the response rate is considerably above that reported in much survey-based research in healthcare settings and provides a sufficiently large analytical sample for descriptive cross-national comparison.

The cross-national analysis focuses on descriptive comparison of response patterns between the Romanian and U.S. samples: examination of frequencies and response patterns within and across the two study contexts. Because the study is exploratory and the samples are not equivalent in design or administration, inferential statistical testing is not conducted; rather, the objective is to assess pattern replication. This approach allows for meaningful evaluation of cross-context robustness while avoiding unwarranted claims of statistical equivalence.

Comparative Findings: Patterns of Awareness and Response to Inappropriate Practice

The comparative analysis revealed systematic differences not only in levels of awareness of inappropriate practice, but also in response patterns and reported outcomes, suggesting structurally distinct reporting environments and different cultural expectations.

The U.S. personal interview study used a judgment sample of 88 healthcare professionals, in contrast to the 201 online responses from the Romanian hospital medical staff who self-selected after being invited to participate. Table 1 shows considerable similarities in the composition of the two samples in terms of professional composition and distribution of years of work experience. The samples differed in practice setting: 100% of the respondents in the Romanian sample worked at the hospital that served as a site for this research, compared to 69.3% of the U.S. sample, where the next most frequent practice was nursing homes/long term care centers.

Table 1.

Samples Description

​	US Sample	%	Romanian Sample	%
	N		N
Sample Size	88	​	201	​
Profession
Nurses	53	60.2%	105	52.2%
Physicians	14	15.9%	93	46.3%
NPs, PAs	6	6.8%	​	​
Pharmacists	10	11.4%	3	1.5%
Other – CNAs,Admin, etc.	5	5.7%	​	​
	88	100.0%	201	100.0%
Years in healthcare	​	​	​	​
10 years +	51	58.0%	135	67.2%
6 to 9 years	15	17.0%	28	13.9%
5 years or less	22	25.0%	41	20.4%
	​	​	201	​
Practice setting	​	​	​	​
Hospitals	61	69.3%	201	100.0%
Nursing homes, LTC, etc.	12	13.6%	​
Clinics, med practices, etc.	15	17.0%

Indirect Awareness of Inappropriate Practice

Respondents in both studies were 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?” Table 2 highlights several substantively meaningful differences.

Table 2.

Indirect Awareness of Inappropriate Practices: A Comparison

​	US sample	%	Romanian Sample	%
	N		N
Indirect awareness of inappropriate practice, incl.:	61	69.3%	61	30.3%
Drugs/narcotics – patient related	13	14.8%	1	0.5%
Stealing/fraud	13	14.8%	2	1.0%
Patient abuse – verbal, emotional	9	10.2%	2	1.0%
Provider Impairment	9	10.2%	1	0.5%
Lacking credentials – bad, poor decisions	8	9.1%	15	7.5%
Medical/provider errors	7	8.0%	13	6.5%
Subordinate abuse	​	​	18	9.0%
Other	2	2.3%	10	5.0%
(Q3,4)	​	​	​	​
What did they do about it? – “Took action”	34	55.7%	27	44.3% *
Reported to administration	22	36.1%	4	6.6%
Reported to licensing board	2	3.3%	0	0.0%
Discussed with individual	3	4.9%	19	31.1%
Other	7	11.5%	4	6.6%
What was the outcome?
Individual was fired	15	45.5%	1	3.7%
other disciplinary action	​	​	4	14.8%
No known outcome	4	12.1%	8	29.6%
Inappropriate behavior stopped	1	3.0%	8	29.6%
Other	​	​	4	14.8%
What did they do about it? – “Nothing.” Reasons:	27	44.3%	27	44.3%
Reasons:
Intimidation by employer	8	29.6%	6	22.2%
Wasn’t their business (avoidance)	8	29.6%	4	14.8%
No patient harm	6	22.2%	4	14.8%
Not wanting to get involved with the law	3	11.1%	1	3.7%
Patient wasn’t suffering	1	3.7%	2	7.4%
It was easier to fix it than report it.	1	3.7%	8	29.6%
Avoid Legal Issues - Keep Quiet	​	​	1	3.7%
Other	​	​	2	7.4%
(Q5,6,7)	​	​	​	​

*For consistency with the U.S. study, percentages further down in this table are based on the number of respondents aware of inappropriate action.

When asked, “What did they do about it?”, 44.3% of both the U.S. and the Romanian samples reported not taking any action. When action was taken, a meaningful contrast emerged between the two studies. In the Romanian study, 31.1% of the responding medical staff reported discussing the issue directly with the individual involved, consistent with the possibility of greater reliance on interpersonal communication. In contrast, in the U.S. institutional environment where mandated reporting and institutional compliance structures may shape behavioral responses, nearly 40% of U.S. respondents reported the issue to a supervisor or a licensing board.

As a follow-up question, respondents in both studies were asked “What were the reasons nothing was said or done?” The findings suggest a strong parallel in the ranking of responses in both surveys. The most frequent reasons for not taking action included:

• 1) employer intimidation (U.S. 29.6%, Romanian 22.2%),

• 2) avoidance – wasn’t their business (U.S. 29.6%, Romanian 14.8%),

• 3) no patient harm (U.S. 22.2%, Romanian 14.8%).

The response with the most marked contrast was “Easier to fix it than report it”, indicated by only 3.7% of the US sample, but 29.6% of the Romanian sample, again suggesting greater reliance on direct resolution rather than formal reporting in the Romanian context.

There was a clear difference in the reported outcomes of actions taken in response to inappropriate situations, with substantially higher termination rates in the US sample (45.5% of those who reported taking action) but only 3.7% of the Romanian sample. At the same time, there was greater outcome uncertainty in the Romanian sample: 29.6% reported that they did not know the outcome, and just as many reported that the inappropriate behavior stopped even if they did not take action, compared with only one such report in the US sample. These differences may reflect variation in regulatory enforcement intensity, organizational due process procedures, or transparency of disciplinary mechanisms.

Direct Awareness of Inappropriate Practice

In both studies, respondents were next asked: “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?” Table 3 presents a comparison.

Table 3.

Direct Awareness of Inappropriate Practices: A Comparison

​	US sample	%	Romanian Sample	%
	N		N
Direct Awareness of Inappropriate Practice, incl.:	60	68.2%	44	21.9%
Drugs/narcotics – patient related	8	13.1%	1	2.3%
Stealing/fraud	9	14.8%	2	4.5%
Patient abuse – verbal, emotional	11	18.0%	2	4.5%
Provider impairment	10	16.4%	3	6.8%
Lacking credentials – bad, poor decisions	6	9.8%	9	20.5%
Medical/provider errors	11	18.0%	7	15.9%
Subordinate abuse	​	​	11	25.0%
Other	3	4.9%	5	11.4%
What They Do About it? – “Took Action”	42	68.0%	24	54.5% †
Reported to administration	32	53.3%	7	15.9%
Reported to Licensing Board	6	10.0%	1	2.3%
Discussed with Individual	3	5.0%	14	31.8%
Took direct admin action	1	1.7%	​	​
Other	​	​	2	4.5%
What was the outcome?	​	​	​	​
Individual was fired	12	23.5%	3	12.5%
Investigation/pending legal action	6	10.7%	​	​
Remedial training	4	7.8%	​	​
Individual faces jail time	2	3.8%	​	​
Other disciplinary consequences	3	5.8%	​	​
No discernible outcome, incl.:	16	30.8%	​	​
Inappropriate behavior stopped	9	17.6%	10	41.7%
Inappropriate behavior continued	4	7.8%	​	​
nothing	​	​	5	20.8%
outcome unknown	​	​	3	12.5%
Complaint wasn’t taken seriously	2	3.9%	​	​
Individual quit	1	1.9%	​	​
other	​	​	2	8.3%
What they did about it? – “Nothing.” Reasons:	11	18.0%	17	38.6%
Intimidation by Employer	​	​	3	6.8%
Wasn’t their business	​	​	2	4.5%
Their behavior wasn’t inappropriate	5	31.3%	​	​
no harm to patient	​	​	2	4.5%
Patient wasn’t suffering	1	6.3%	2	4.5%
It was easier to fix it than report it.	​	​	5	11.4%
Avoid legal issues	​	​	1	2.3%
Other	4	25.0%	3	6.8%

^†For consistency with the U.S. study, percentages further down in this table are based on the number of respondents aware of inappropriate action.

Our first observation is that the nature, level, and structure of the responses regarding direct awareness of inappropriate practice are very similar to those reported for indirect awareness. More than two-thirds (68.2%) of the U.S. respondents and 21.9% of the Romanian respondents were directly aware of inappropriate medical practice. These findings closely mirror the overall indirect awareness rates of 69.3% and 30.3%, respectively, demonstrating internal consistency across indirect and direct awareness measures within each national sample.

The most striking difference concerns the reported subordinate abuse: 25% in the Romanian subsample vs. none in the U.S. subsample. There were also more reported cases involving lack of credentials leading to poor decisions: 20.5% in the Romanian study vs. 9.8% in the U.S.

The follow-up question asked about the action taken: “What did they do about it?” Nearly forty percent (38.6%) of the Romanian respondents reported doing nothing, contrasted with only 18% in the U.S. study. Among those who reported taking action, 31.8% in the Romanian study reported discussing the incident directly with the individual involved, while over half (53.3%) of the US respondents reported the inappropriate practice to a supervisor. This again suggests greater reliance on direct interpersonal communication in the Romanian context, whereas respondents in the United States appear more likely to use formal organizational reporting channels.

Discussion

This study examined whether patterns associated with the code of silence in U.S. healthcare replicate within a distinct institutional and cultural context. The findings suggest both cross-context robustness and meaningful contextual variation in how inappropriate practice is perceived, interpreted, and acted upon. Although the research design does not permit formal statistical equivalence testing, several response distributions were strikingly similar across samples. For example, the incidence of inaction following awareness of inappropriate practice (43% vs. 51%) and reports of no discernible outcome (21% vs. 23%) suggest that silence-related dynamics are not confined to a single national setting. Reluctance to report inappropriate practice—an operational indicator of the code of silence—appears in both healthcare environments, despite substantial differences in regulatory architecture and institutional design.

These findings align with the theory on organizational silence ² which conceptualizes it as a climate-level phenomenon emerging when organizational structures and managerial signals make voice appear risky or futile. Viewed through this lens, the code of silence in healthcare reflects not merely individual hesitation but a structurally embedded pattern shaped by hierarchy, ambiguity of consequences, and perceived leadership receptivity. Reluctance to report inappropriate or unsafe behavior may reflect not only formal reporting structures but also perceptions regarding psychological safety, including whether individuals believe they can raise concerns without fear of retaliation or interpersonal consequences. The recurrence of inaction across two national systems suggests that silence may be reproduced through common features of professionalized, hierarchical institutions rather than idiosyncratic national characteristics.

At the same time, response patterns also differed. A substantially higher proportion of U.S. respondents reported awareness of inappropriate practice (69.3%) compared to Romanian respondents (30.3%). Methodological factors likely contributed: U.S. data were collected via peer interviews potentially facilitating disclosure, whereas Romanian data were collected through an institutionally administered online survey, possibly heightening perceived proximity to authority. Differences may also reflect variation in institutional transparency norms and expectations regarding what constitutes “reportable” misconduct. In more formalized regulatory environments, professionals may be more likely to identify and label behaviors as inappropriate practice.

Cultural communication norms may also play a role. Research on employee voice indicates that speaking up depends not only on ethical judgment but on anticipated managerial openness and procedural justice.^27,28 In higher power-distance or relationally oriented contexts, voice may be channeled through interpersonal correction rather than formal escalation. Prior scholarship characterizes Romanian professional culture as relatively high-context, with strong emphasis on relational trust and sensitivity to hierarchical positioning. ²⁶ In such environments, disclosure of misconduct—particularly in formalized formats—may carry heightened perceived interpersonal risk.

Another difference concerns the reported prevalence of subordinate abuse in the Romanian sample and its absence in the U.S. sample, which warrants careful interpretation. This disparity may reflect hierarchical dynamics, reporting thresholds, or category interpretation rather than objective prevalence alone. In more vertically structured organizational environments, behaviors experienced as coercive or abusive may be more salient to subordinates yet less likely to be formally challenged. Conversely, U.S. respondents may classify similar behaviors under different reporting categories (e.g., professionalism concerns, hostile work environment), thereby diffusing this category statistically. Future research should disentangle definitional and structural explanations for this disparity.

Overall, the cross-national comparison suggests that the code of silence is likely not monolithic but may be system-dependent. While inaction recurs across contexts, the mechanisms sustaining silence appear to differ—ranging from fear of retaliation to normalization of informal containment. By providing replication and exploratory evidence for contextual divergence, this study extends organizational silence theory into a high-stakes professional domain and underscores that silence in healthcare is best understood as a structurally embedded feature of governance systems rather than solely an individual ethical failure.

Future Research Directions

Future research would benefit from directly measuring organizational and contextual variables that may influence silence-related behaviors in healthcare settings. For example, studies could incorporate validated measures of organizational culture, psychological safety, hierarchy, trust in reporting systems, perceptions of retaliation risk, and confidence in institutional accountability processes. Such approaches would allow researchers to examine more directly whether differences in reporting behaviors are associated with specific cultural, regulatory, or institutional characteristics rather than inferring these mechanisms indirectly from response patterns alone. Comparative multi-site or cross-national studies using more standardized sampling and data collection procedures could also help clarify the extent to which observed differences reflect broader systemic influences versus methodological variation. In this way, the present findings may serve as a useful foundation for more targeted investigation of the mechanisms underlying silence and reporting behavior in healthcare organizations.

Implications for Practice

The comparative findings suggest that addressing the code of silence in healthcare requires differentiating among types of problems rather than applying a uniform reporting solution. Drawing conceptually on Deming’s distinction between common-cause and special-cause variation, ⁵ we propose a heuristic framework that distinguishes between (1) episodic versus recurring problems and (2) medical error versus inappropriate conduct (Table 4). This framework clarifies how silence operates differently across contexts and why governance responses must vary accordingly. Unlike many just culture frameworks, which primarily distinguish among types of human error and accountability responses, the present framework focuses on distinguishing among types of problematic situations and the corresponding governance implications for speaking up.

Table 4.

Deming-Inspired Framework of Improving Reporting, Responsibility in Healthcare

​	Random, Non-recurring	Non-random, Recurring
Medical Errors	Quadrant I: Medication errors, mistakes, poor documentation, etc.	Quadrant II: Lack of credentials or appropriate knowledge, recurring poor judgement, lack of training, etc.
Inappropriate Practice	Quadrant III. Mistakes, stress, stealing, impairment, harassment, etc.	Quadrant IV. Chronic mistakes, stress, burnout, stealing / fraud, impairment, harassment, in need of training / credentialing, etc.

Quadrant I: Random, Non-Recurring Medical Errors

Episodic medication mistakes, documentation lapses, or isolated clinical errors typically reflect system-level vulnerabilities rather than intentional misconduct. In this quadrant, silence is often rooted in fear of punitive consequences. Traditional process improvement approaches grounded in psychological safety and just-culture principles remain appropriate. Institutions should emphasize learning, error transparency, and rapid feedback loops.

When reporting channels are perceived as punitive, even isolated errors may be concealed. Strengthening confidential reporting systems and visibly separating learning reviews from disciplinary processes can reduce this risk.

Quadrant II: Recurring Medical Errors

Recurring clinical errors—persistently poor judgment, inadequate training, or repeated lapses—signal structural or supervisory failures rather than isolated variance. In this quadrant, silence reflects normalization of deviance rather than momentary fear.

Leadership accountability becomes critical. Senior medical staff and hospital administration must distinguish between system redesign and performance management. Transparent review processes and documented corrective pathways increase the credibility of enforcement and reduce reliance on informal peer correction.

Quadrant III: Random, Non-Recurring Inappropriate Practice

Isolated incidents of harassment, impairment, theft, or stress-induced misconduct require a different response from clinical error. Even if episodic, such behaviors implicate professional ethics and legal standards. Silence in this quadrant often reflects ambiguity regarding reporting obligations or fear of interpersonal retaliation.

Enhanced ethics and legal education can reduce uncertainty surrounding whistleblower protections and procedural fairness. Organizations should provide clear guidance regarding reporting obligations, whistleblower protections, and circumstances requiring formal escalation rather than informal resolution.

Quadrant IV: Recurring Inappropriate Practice

Chronic harassment, repeated impairment, ongoing fraud, or sustained ethical violations represent structural governance failures. In this quadrant, silence may be sustained not only by fear but by tacit acceptance or reputational shielding.

Formal accountability mechanisms are indispensable. Leadership signaling is especially consequential: when senior administrators are perceived as protective of high-status professionals or inconsistent in enforcement, silence is likely to persist. Conversely, consistent enforcement and transparency about outcomes signal that reporting will trigger a credible institutional response.

Cross-nationally, this quadrant may be particularly sensitive to differences in enforcement credibility. In environments where formal systems are mistrusted or inconsistently applied, staff may default to interpersonal containment, thereby allowing recurring misconduct to persist.

Integrative Implications Across Quadrants

Across all quadrants, the effectiveness of reform depends on aligning institutional design with a shared understanding of responsibility. When responsibility is construed solely as individual moral courage, silence remains likely. When institutions visibly assume accountability—through protected reporting channels, fair review procedures, and consistent leadership engagement—voice becomes less discretionary and more normative.

The comparative findings from the United States and Romania suggest that interventions must be calibrated to institutional and cultural context. Formal reporting mechanisms may be most effective where enforcement systems are trusted, whereas relational approaches may play a larger role in settings characterized by strong hierarchy or reliance on interpersonal networks. Reform efforts that ignore these contextual dynamics risk strengthening procedural form without altering behavioral reality.

Limitations

There are several limitations which should be considered when generalizing the findings of this study. First, the two samples were not matched probability samples and differed in data collection modality (interview vs. online survey), limiting causal attribution of observed differences. Second, because cultural, institutional, and regulatory variables were not directly measured, interpretations relating to these factors should be viewed as exploratory and hypothesis-generating rather than causal conclusions. Third, because the study relied on self-reported experiences regarding sensitive organizational issues, the findings may be affected by measurement-related biases such as recall bias and reluctance to disclose potentially consequential experiences. Fourth, the Romanian sample was drawn from a single hospital, which may limit generalizability within the national system. Fifth, the Romanian survey was administered in English to preserve consistency with the original U.S. instrument and support exploratory comparison across studies. Although English proficiency was common among professional staff at the participating hospital, use of a non-native language may still have affected question interpretation or willingness to disclose sensitive experiences.

Conclusion

By demonstrating both replication and contextual divergence, this study advances understanding of the code of silence as a structurally embedded phenomenon rather than merely an individual ethical failure. Extending organizational silence theory into a high-stakes professional domain, the findings suggest that inaction persists across institutional contexts, even though the factors sustaining silence may differ.

The Deming-informed governance framework proposed here suggests that episodic medical error, recurring clinical failure, isolated misconduct, and chronic inappropriate practice require distinct accountability responses. Addressing silence in healthcare therefore requires system-level reforms that align reporting architecture, leadership signaling, and enforcement credibility with professionals’ commitments to patient safety. Without such alignment, formal policy may expand while silence endures.

ORCID iD

Ivan M. Manev https://orcid.org/0000-0002-7068-5434