Organizational silence is a collective-level phenomena wherein little is said or done in response to important issues that an organization is facing. The report focuses on some of the less evident elements that can endanger patient safety by contributing to organizational silence.
The study of sociotechnical systems and convergent research fields from the cognitive, social, and organizational sciences might assist pinpoint some of the underlying causes that influence and sustain organizational silence. Three levels of analysis have been used to group these factors: individual, social, and organizational. Individual factors include the availability heuristic, self-serving bias, and status quo trap. Social factors include conformity, responsibility diffusion, and microclimates of distrust. Organizational factors include unchallenged beliefs, the good provider fallacy, and neglect of the interdependencies.
INDIVIDUAL FACTORS
Although many of the active mistakes that people make appear to be random, they often happen in predictable and regular ways. The uncritical use of heuristics (i.e., rules of thumb) and self-evaluations that result in biased decision-making in the conduct of daily activities is the root cause of many of these foreseeable blunders. The availability heuristic, the self-serving bias, and the status quo trap are particularly important in this regard.
Although there are many other potential areas of individual vulnerability that might be covered, these three were chosen for this article because of their potential impact on the quality and safety of care received in a variety of health care delivery contexts.
Availability Heuristic
The To Err Is Human (Institute of Medicine 1999) report was essential in bringing medical error’s pervasiveness in U.S. healthcare delivery to light. However, a 2002 survey indicated that only 5% of doctors and 6% of the general population considered medical error to be one of the most severe healthcare issues (Blendon et al. 2002). Many providers do not consider the national patient safety issue to be relevant to their institutions due to the relatively low number of preventable deaths and significant adverse events at any given institution as well as a widespread underreporting of such events.
The availability heuristic contributes to the explanation of why the issue is disregarded. According to research by Tversky and Kahneman from 1973, people evaluate an event’s frequency based on how readily they can recall it. Depending on how quickly they can think of particular examples of an occurrence, providers, like other people, determine whether an event is common or infrequent. It is not unexpected when clinicians state that they do not think that X, Y, or Z is an issue at their institutions if relatively occasional instances that cause harm to patients go unreported and are not widely discussed. As a result, they remain unavailable.
Self-Serving Bias
When people experience good fortune, they often believe that they deserve it and that it is justified. When others have poor luck, a sneaking notion that they may have earned it may be harbored. A number of “above average” studies provide additional proof of a self-serving bias. In these studies, large majorities of people have claimed to be above average in terms of intelligence (Wylie 1979), driving prowess (Guerin 1994), and work ethics and performance (Brenner and Molander 1977; Heady and Wearing 1987), all the while being unaware of the 50% of the population that lies on the other side of the bell curve.
Drivers who evaluate themselves as “above average” even after an accident show how few individuals celebrate or even admit being “below average.” There is no incentive to discuss problems and work toward improvement when everyone thinks their performance is “above average.” Studies have demonstrated that people are more prone to self-bias when they are deeply involved in an activity, when they feel accountable for the result, and when they are visible in their activity (Weary 1978, 1980; Weary et al. 1982). These factors are present in the majority of clinical settings.
The Status Quo Trap
Regardless of the specific industry, organization members show a significant propensity to maintain the status quo. It is extremely challenging to resist the seemingly irresistible pull of the status quo, whether it be when implementing a new healthcare procedure, creating a new product, or maintaining one’s mutual fund portfolio. The status quo is convenient and does not call for further action. Making a break and choosing a fresh path calls for decision-making, ambiguity, doubt, and increased accountability.
As a result, it is simple to come up with excuses for staying silent, which reduces the psychological risk to people (Hammond, Keeney, and Raiffa 1998). Maintaining the status quo is preferable to changing course because, similar to many other businesses, health care crimes of commission incur a greater punishment than sins of omission. It is interesting to notice that people recall their acts more vividly than those they forgot to take or decided not to take (Ross and Sicoly 1979; Ross, McFarland, and Fletcher 1981).
SOCIAL FACTORS
Group behavior studies shed more light on the underlying causes of organizational silence. Conformity is a well-known social phenomena that has the negative effect of limiting differing viewpoints and evaluations among peers. Group members may also experience a diffusion of responsibility, in which roles and obligations are muddled and personal accountability is diminished. In addition, social environment variances at the hospital unit level have caused some units to be labeled as “microclimates of distrust.” These societal phenomena all deserve closer examination.
Conformity
Convincing research dates back to the 1950s and demonstrates how people will change their opinions and views to match those of those around them (Asch 1951, 1955, 1956). With and without the presence of other people’s judgments, respondents’ assessments of a task were compared in the traditional research design. On tasks that are easily understood, like determining the relative lengths of unequal vertical lines, individuals conform to the incorrect assessments of the experimenter’s confederates but provide accurate assessments in the absence of these confederates.
Gaining acceptability in a group or community is one obvious reason people adopt the actions and ideas of others—especially if the community is made up of experts and there is a knowledge gap between the target person and other members of the group. Additionally, when the group is significant to the target person and when the target person perceives themselves as similar to group members (and hence more readily identifies with them), conformity is encouraged (Aronson 1999).
Diffusion of Responsibility
Organizational quiet may be affected by a group trait called diffusion of responsibility. The propensity for people to take on less responsibility when their efforts are combined in pursuit of a shared objective as opposed to accountability on individually given tasks is known as social loafing in the social psychology literature (Sweeney 1973; Ingham et al. 1974; Latane, Williams, and Harkins 1979). The more neutral phrase, diffusion of responsibility, is employed here because loafing could imply deliberate abdication of responsibility (which may or may not be the case), whereas diffusion of roles and responsibility (along with some associated misunderstanding) is more of an intrinsic trait of organizations.
CONCLUSIONS
Leaders and managers in the healthcare industry are envisioned in a new role. It is one that values system complexity understanding highly and does not find solace in organizational silence or in straightforward answers. It emphasizes interdependencies rather than just the parts. It recognizes disagreement and a diversity of viewpoints as indicators of an effective organization and challenges unity, consensus, and agreement when these goals are attained too quickly. It is a position that is sensitive to the status quo, self-serving bias, and the availability heuristic’s hidden traps. It comprehends how social elements affect how people behave in groups and the potentially negative effects of conformity, responsibility-distribution, and distrust-fostering microclimates.
Health care administrators and leaders will play a new role. It is one that places great importance on comprehending system complexity and does not find solace in either organizational quiet or straightforward answers. Instead than only focusing on the parts, it emphasizes the interdependencies. When agreement, consensus, and unity are attained too easily, it examines them and emphasizes diversity of opinion and disagreement as indicators of organizational health. The job is subject to the status quo, self-serving bias, and hidden traps of the availability heuristic. It is aware of how social elements affect group dynamics and the negative effects that conformity, responsibility-distribution, and distrust-fostering microclimates may have.
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