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

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.