Silence

A short story about turning an unexpected corner in communication research

Silence is more eloquent than words.

~ Thomas Carlyle

Silence is a text easy to misread. 

~A.A. Attanasio

Better silent than stupid.

~ German proverb

Silence is one of the hardest arguments to refute. 

~ Josh Billings

Silence at the proper season is wisdom, and better than any speech.

~Plutarch

Silence is the most perfect expression of scorn.

~ George Bernard Shaw

Silence is the ultimate weapon of power.

~ Charles De Gaulle

In field research, there are moments when you can literally hear a pin drop. In fact, an observation session may contain as much silence as sound.

Are you listening for that? What meaning do you make of it?

I study how healthcare teams communicate.

My work has tended to focus on communication that is visible & audible. Recently, however, my data have revealed something I hadn’t paid any attention to before:

Team communication existsin a spectrum of speech and silence.

Sounds obvious, doesn’t it? In fact, you might wonder why I hadn’t noticed it before.

Now that it’s smacked me in the head, the role of silence seems absolutely critical to my work. Let me show you what I mean, and why I think it matters.

The circulating nurse, who is new to the operating room, relieving someone on break, says to the scrub nurse: “How many sets of

sponges did you have?” (The circulating nurse speaks loudly; the scrub nurse is soft spoken.) The staff surgeon picks up on this

exchange and asks: "What are you missing?” Neither nurse responds to his question. The circulating nurse leaves the rooom

and checks something with the earlier circulating nurse, then returns to the room. The staff surgeon says, "you're not answering

the question. Are you missing something?” The circulating nurse says there is no issue.

(Operating room fieldnote 672)

The staff surgeon noted loudly, without looking at anyone in particular: "So we'll maybe give this guy a couple of doses

of postoperative antibiotics". There is no immediate response from anyone present, although the staff

anaesthetist looks up, seems to register what the staff surgeon has said, pauses in her work, but does not respond. A couple minutes later, the junior surgical

resident asks, "What did you say about postoperative antibiotics?" There is no response from the staff surgeon.

The question remains unresolved.

(Operating room fieldnote 1103)

Methods point

Silence is not the absence of communication.

Methods point

Silences communicate:

agreement, passivity, resistance, distractedness, disregard, biding time…

Silence can influence the quality of the care that teams provide

in both positive and negative ways.

The circulating nurse and scrub nurse are doing their count near the end of the case. Surgical resident

requests “4-0 Vicryl please” [a type of suture] from the scrub nurse. The scrub nurse’s back is to him;

she doesn’t immediately respond. Resident requests again with a slightly louder voice: “Can I get a 4-0

Vicryl please?” Nurse still doesn’t respond. The surgical resident raises his eyebrow at the junior

resident across the table. A few moments later, the count is done. The nurse repeats “4-0 Vicryl”,

handing the suture. The resident takes it, appears irritated, sighing loudly and shaking his head.

(Operating room fieldnote 1171)

What does this silence mean?

Nurse didn’t hear the request; silence is not a communicative act.

Nurse did hear the request, but she’s busy. Silence is a

communicative act that delays response.

Nurse did hear the request. She seeks to delay wound closure until the counting protocol is complete.

Silence acts as a conflict-avoidance mechanism in a

situation of potential conflict.

Silence is not the absence of meaning: it can be purposeful and meaningful,

functional or dysfunctional.

(Glenn 2004)

Silence may reveal power relations and communicative constraints.

(Manias & Street 2001; Riley & Manias 2005; Gillespie et al 2007; Bradbury-Jones et al 2007)

For team communication research, silence is a key piece of the puzzle.

But most empirical work in this domain focuses on communicative presence –

what can be seen and heard.

Furthermore, observational and assessment tools in this domain

emphasize concrete, audible bits of data:

“information gathered and exchanged”

Silences, neither gathered nor exchanged, are elided by these tools.

We’ve only begun to grapple with

the problem of silence.

One interesting place to start…

Her hearing was keener than his, and she heard silences he was unaware of.

~D.M. Thomas

How do we educate novices to hear – and correctly interpret –

silences in healthcare team practices?

Staff surgeon says loudly without taking his eyes from the surgical field: "Almost certainly we’re

going to need a flexible sigmoidoscope and Dr. Black [urologist]." The circulating nurse

responds, using the surgeon’s first name, “When, Larry?” There is no response from the

surgeon, who continues working. The nurse goes to call central processing to get the

equipment sent up, after which she pages the urologist.

(Operating room fieldnote 893)

What does this nurse hear in the silence that prompts her to act rather than wait?

Situation too emergent for surgeon to respond?

Surgeon doesn’t have ‘when’ answer yet and will respond when s/he does?

Question not worthy of response?

“I asked for it now, so I need it now”

The use and the interpretation of silence are sophisticated communication skills

on a healthcare team.

We don’t know much about these skills; there’s a lot of research to be done here.

Ideas to pursue

Silence and powerSilence and decision-making

Silence and persuasionSilence and socialization

lorelei.lingard@schulich.uwo.ca