For nursing educators, clinical skills leads, and healthcare faculty responsible for communication training
Picture this: a nurse on a busy surgical ward notices something is off with a post-operative patient. Vital signs are slightly abnormal. Nothing dramatic — not yet. She is worried, but the attending physician has a reputation for impatience, and she is not sure how to frame the concern quickly without being dismissed. She says something vague. The doctor moves on. Three hours later, the patient is in intensive care.
This scenario is not exceptional. It is, according to a decade of malpractice data, distressingly common.
In healthcare, the stakes of poor communication are not a delayed project or a frustrated client — they are measured in patient harm, preventable deaths, and nine-figure legal costs. And yet communication skills training in healthcare education has historically been treated as a soft add-on: something learners pick up through osmosis on the ward, rather than a clinical competency that requires deliberate, structured practice.
The evidence says that is not working.
In 2015, CRICO Strategies — the patient safety and malpractice research arm of the Risk Management Foundation of Harvard Medical Institutions — published one of the most comprehensive analyses of communication failures in US healthcare ever conducted. Analysing over 23,000 malpractice cases filed between 2009 and 2013, they found that communication failures contributed to 30% of all claims. The human and financial toll was significant.
"Communication failures contributed to 1,744 patient deaths and more than $1.7 billion in malpractice costs over a five-year period." — CRICO Strategies, Malpractice Risks in Communication Failures, 2015
These were not fringe cases. Communication breakdowns appeared across every clinical setting the researchers examined — from obstetrics and emergency medicine to general medical wards and outpatient care. In obstetrics, communication was a contributing factor in 41% of cases. In surgery, 35%. And critically for nurse educators: inpatient and nursing settings were not immune.
What makes the 2025 follow-up from Harvard's Risk Management Foundation even more sobering is the trajectory. Their 10-year lookback, published in November 2025, found that despite decades of awareness, investment in patient safety infrastructure, and regulatory pressure, communication-related harm has not meaningfully declined. The pattern has held: approximately 30% of malpractice claims still involve communication as a contributing factor. The problem, in other words, is structural — not accidental.
Percentage of malpractice cases in which a communication failure was a contributing factor, by clinical setting. Across all cases, communication was involved in 30% of claims — a finding consistent across a decade of data.
The CRICO data does not treat "communication failure" as a monolith. When researchers looked at what type of communication broke down, two patterns dominated.
The most common was provider-to-provider communication — the handoffs, escalations, and referral conversations that happen dozens of times per shift on any ward. These include the moment a nurse calls a physician with a concern, the shift change handover, or the handoff between an ED team and a receiving ward. When these conversations go wrong — when critical information is omitted, buried, or never conveyed — patients pay the price.
The second most common was provider-to-patient communication: the conversations around consent, treatment plans, discharge instructions, and risk explanation. When patients do not understand what is being done to them or why, the consequences range from missed follow-up appointments to fatal misunderstandings about post-discharge medication.
Proportion of communication-related malpractice cases attributed to each breakdown category. Provider-to-provider failures account for the largest share, followed by provider-to-patient gaps.
Most clinical communication training addresses knowledge. Learners are taught what good communication looks like — they read the SBAR framework, attend a lecture on active listening, role-play a difficult conversation in pairs. Some of this is useful. But knowledge of communication principles and the ability to communicate under pressure are different things.
The research on skill development is clear on this point. The Agency for Healthcare Research and Quality (AHRQ) — whose TeamSTEPPS programme is among the most extensively evaluated communication training initiatives in US healthcare — found that training which includes observed practice with structured feedback produces significantly better outcomes than didactic instruction alone. Learners need to experience the difficulty of speaking up to a sceptical senior clinician, to feel the discomfort of that hierarchical moment, and to have space to practise it in a context where failure carries no patient risk.
This is precisely why simulation-based approaches have grown in clinical education. Simulation allows learners to encounter the pressure and unpredictability of real clinical communication — escalating a concern to a physician who pushes back, managing a distressed patient who refuses to engage, navigating a handover when information is incomplete — without those encounters having real-world consequences.
Knowledge of communication principles and the ability to communicate under pressure are different things. Learners need to practise the hard moments, not just read about them.
In nursing education specifically, the evidence for simulation-based communication training is strong. A 2022 systematic review in Nurse Education Today (Merriman et al.) found that simulation-based communication training for nursing students consistently improved self-efficacy, communication competency scores, and clinical performance when compared with traditional instruction alone. Crucially, programmes that combined scenario-based practice with structured debriefing showed the largest effects — reinforcing that it is not simulation per se, but the quality of the feedback and reflection built around it, that drives learning.
For nursing faculty and clinical education leads, the evidence points to some clear principles.
Good communication is teachable and assessable. It can be broken down into observable behaviours — eye contact, active listening, structured information transfer, appropriate assertiveness — and practised in the same way that clinical procedures are practised. Framing it as a "soft skill" that students either have or do not have is both empirically wrong and educationally limiting.
The research on skill acquisition consistently supports the value of deliberate practice with feedback. For communication skills, this means giving learners multiple opportunities to practise difficult interactions — escalation, breaking bad news, managing conflict — in environments where they can fail safely and receive specific feedback. A single role-play exercise in year one of a nursing programme is not sufficient.
The data on communication failures in healthcare shows that provider-to-provider communication — and particularly nurse-to-physician escalation — is the highest-risk category. Training programmes that do not specifically address the psychological and situational barriers to speaking up are missing the most important part of the problem.
Tools like SBAR (Situation, Background, Assessment, Recommendation) are valuable for providing structure. But research suggests learners need to practise applying these frameworks in variable, unpredictable conditions — not just memorise the acronym. The goal is fluency under pressure, not recitation in a calm setting.
Communication training outcomes are often poorly tracked. Institutions that are serious about reducing communication-related harm need to be able to demonstrate that training is working — through measurable behavioural change, not just completion rates or satisfaction scores. Assessment tools that capture observed communication competency, rather than self-report alone, provide more useful data for curriculum development and quality assurance.
The 2015 CRICO data and the Harvard RMF's 2025 follow-up together tell a consistent story: communication failure is not a marginal risk in healthcare. It is one of the most common, costly, and preventable sources of patient harm. And it is one that healthcare educators are uniquely positioned to address — by treating communication as the clinical skill it is, and giving learners the structured, repeated, feedback-rich practice they need to develop it.
The question is not whether to prioritise communication training. It is whether the approaches currently in use are equal to the scale of the problem.
How Bodyswaps supports communication skills training in healthcare — Healthcare and nursing use cases
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How many deaths are caused by communication failures in healthcare?
According to a major study by CRICO Strategies (the research arm of the Harvard Risk Management Foundation), communication failures in US healthcare contributed to 1,744 patient deaths over a five-year period from 2009 to 2013. Communication was a contributing factor in 30% of all malpractice cases analysed. A 2025 follow-up by Harvard RMF confirmed this rate has not meaningfully improved over the following decade.
What percentage of malpractice cases involve communication failures?
Approximately 30% of all medical malpractice cases involve a communication failure as a contributing factor. This figure comes from CRICO Strategies' 2015 analysis of over 23,000 malpractice cases and has been broadly confirmed by subsequent research. In some specialties, the rate is higher: obstetrics (41%) and surgery (35%) see the highest proportions.
Why do communication failures happen in nursing?
Communication failures in nursing most often stem from hierarchical pressure (nurses feeling unable to speak up to physicians), inadequate handover processes, time pressure on busy wards, and gaps in training around structured communication tools like SBAR. Research consistently identifies fear of conflict and concerns about professional relationships as key barriers to effective escalation — the single highest-risk communication failure in clinical settings.
How can hospitals and nursing schools reduce communication errors?
The evidence points to three key approaches: (1) treating communication as a clinical skill that requires deliberate practice, not just theoretical instruction; (2) using simulation-based training to create safe environments for practising high-stakes interactions like escalation and handover; and (3) providing structured, individualised feedback so learners can identify and correct specific communication gaps. Programmes that combine knowledge, practice, and feedback produce significantly better outcomes than lecture-based training alone.
1. CRICO Strategies (2015). Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Risk Management Foundation of Harvard Medical Institutions. https://cdn2.hubspot.net/hubfs/217557/Documents%20-%20CBS%20Report%20PDFs/Malpractice%20Risks%20in%20Communication%20Failures%202015.pdf
2. Harvard Risk Management Foundation (2025). Benchmarking Report: 10-Year Lookback on Communication. Press release, November 2025. https://www.rmf.harvard.edu/News-and-Blog/Press-Releases-Home/Press-Releases/2025/November/2025BenchmarkingReport10yearlookbackComm
3. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. AHRQ Publication. https://www.ahrq.gov/teamstepps/index.html
4. Sibley, A., Latter, S., & Perkins, P. (2019). Barriers to escalation of care in nursing: a systematic review. Journal of Nursing Management, 27(5), 884–894.
5. Merriman, C., et al. (2022). Simulation-based communication training for nursing students: a systematic review. Nurse Education Today, 109, 105217.
6. The Joint Commission (2023). Sentinel Event Data: Root Causes by Event Type. Oakbrook Terrace, IL: The Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/
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