Professor Mary Dixon-Woods Director, The Healthcare Improvement Studies Institut (THIS Institute) University of Cambridge

Healthcare Employees Can Work in a ‘Culture of Fear’, Where Speaking Up is Discouraged Interview with:

Professor Mary Dixon-Woods Director, The Healthcare Improvement Studies Institut (THIS Institute) University of Cambridge

Prof. Dixon-Woods

Professor Mary Dixon-Woods
Director, The Healthcare Improvement Studies Institute
(THIS Institute)
University of Cambridge What is the background for this study? What are the main findings?

Response: The challenges around employee voice are well documented. For various reasons, employees in all industries are often reluctant to raise concerns when they witness disruptive or unsafe behaviour from their colleagues. But it’s crucial that they speak up – especially in healthcare. Patient safety may depend on it.

Our study focused on a large academic medical centre in the US that wanted to improve employee voice. Despite having reporting mechanisms in place, the organisation still had issues with disruptive behaviour from group of powerful senior individuals that went unchallenged and contributed to a culture of fear.

Through confidential interviews with 67 frontline staff and leaders and the organizational actions that followed, we learned it’s important for employees to feel that their concerns will be dealt with authentically. It also helps when healthcare organisations have clear definitions of acceptable and unacceptable behaviour and well-coordinated response mechanisms. Once someone does raise a concern, organizations need good, fair and transparent systems of investigations and be prepared to implement consequences for disruptive behaviour consistently. What should readers take away from your report?

Response: Simply put, it’s not enough just to say you’re committed to employee voice. The organisation we studied had multiple mechanisms to report incidents. But the systems were slow and complicated, and employees didn’t believe their reports would lead to action.

If organisations want to provide safe and high-quality healthcare, staff need to genuinely feel comfortable speaking up when they witness disruptive behaviour and know that the response will be appropriate. Healthcare leaders needs to be trained on how to encourage voice and to have difficult conversations. If not, employees may remain silent and disruptive behaviour may go unchecked. This can contribute to negative organisational culture and put patients at risk. What recommendations do you have for future research as a result of this work?

Response: After our work diagnosing these challenges, we analysed and shared our findings with the organisation’s leaders, who implemented interventions to formalise how they dealt with transgressive behaviours. Two years later, this systematic approach of diagnosis and intervention appears to have had some positive effects within the organisation. Going forward, this approach could be formally evaluated in other contexts, and may be able to address similar problems elsewhere.

 Disclosures: This study was funded by Mary Dixon-Woods’ Wellcome Trust Investigator award (WT097899) and by Johns Hopkins Medicine. The Healthcare Improvement Studies Institute (THIS Institute) is supported by the Health Foundation – an independent charity committed to bringing about better health and healthcare for people in the United Kingdom. Mary Dixon-Woods is a National Institute for Health Research (NIHR) Senior Investigator. She holds an adjunct post at Johns Hopkins University. 


Acad Med. 2018 Sep 11. doi: 10.1097/ACM.0000000000002447. [Epub ahead of print]

Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study.

Dixon-Woods M1, Campbell A, Martin G, Willars J, Tarrant C, Aveling EL, Sutcliffe K, Clements J, Carlstrom M, Pronovost P.

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Last Updated on October 4, 2018 by Marie Benz MD FAAD