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What makes clinicians fearful to speak up? The 'undiscussables'
New study: Many stay silent even when safety tools signal danger
For years, risk managers and other healthcare leaders have been pushing physicians and staff to speak up when they see a dangerous situation, but new data suggests the effort has been only moderately successful at best. The focus on providing tools to improve patient safety might have overshadowed what really matters most: behavioral changes.
Research and regulatory bodies have long confirmed that poor communication in health care is harmful at best and deadly at worst. A 2005 study called Silence Kills, conducted by VitalSmarts. a corporate training company in Provo, UT, and the American Association of Critical-Care Nurses (AACN), found that among 1,700 nurses, physicians, clinical-care staff, and administrators, more than half witnessed their coworkers break rules, make mistakes, fail to support others, demonstrate incompetence, show poor teamwork, act disrespectfully, or micromanage.
Specifically, 84% of doctors observed colleagues who took dangerous shortcuts when caring for patients and 88% worked with people who showed poor clinical judgment. Despite the risks to patients, less than 10% percent of physicians, nurses, and other clinical staff directly confronted their colleagues about their concerns.
With upward of 195,000 people dying each year in U.S. hospitals because of medical mistakes, the Silence Kills study suggested that creating a culture where healthcare workers speak up before problems occur was a vital part of the solution. Aware of the risks communication breakdowns have on patient safety and employee morale, the healthcare community has made substantial investments in the past five years to operating systems designed to reduce unintentional slips and errors such as handoff protocols, checklists, and computerized physician order entry systems.
While these safety tools are an essential part of the formula for solving avoidable medical errors caused by poor communication, a new study called The Silent Treatment, conducted by VitalSmarts, AACN, and the Association of periOperative Registered Nurses (AORN) in Denver, has found the tools aren't enough and that silence still kills.
Problems known but not discussed
Lead researcher David Maxfield, vice president of research with VitalSmarts, tells Healthcare Risk Management that the study of more than 6,500 nurses and nurse managers conducted in 2010 builds on the findings from the Silence Kills study.
The new research reveals that safety tools fail to address a second category of communication breakdowns, he says. These are the "undiscussables," which are risks that are widely known, but not discussed. The results suggest that without support from physicians, nurses, and administrators, these system improvements cannot guarantee patient safety, Maxfield says.
"Tools don't create safety; people do," he says. "If you take a perfectly good safety tool and drop it into a culture that is not supportive, you're going to have problems. Safety tools work and they are important, but they rely on the person receiving the warning or using the checklist being able to speak up to the others in the room and having them listen."
The Silent Treatment examines the calculated decisions healthcare professionals make daily to not speak up, even when safety tools alert them to potential harm. Specifically, the study shows that health care professionals' failure to raise the following three concerns when risks are known undermines the effectiveness of current safety tools: dangerous shortcuts, incompetence, and disrespect.
Tools aren't acted on
The Silent Treatment found that 85% of respondents have been in a situation where a safety tool warned them of a problem. Thirty-two percent said this happened at least a few times a month, which confirmed that safety tools work. Checklists, protocols, and warning systems are an essential guard against unintentional slips and errors.
However, the research also documented that the effectiveness of safety tools is undercut by undiscussables. Of the nurses who had been in situations where safety tools worked, 58% percent had also been in situations where they felt unsafe to speak up about the problems or where they were unable to get others to listen.
The Silent Treatment study collected data from more than 6,500 nurses and nurse managers from health systems around the United States during 2010. All research participants were members of AACN and/or AORN. (For the full study results, go to http://silenttreatmentstudy.com and select "Download the study" at the bottom left.)
The Silent Treatment concludes that there are three primary problem areas:
Dangerous shortcuts: 84% of respondents say that 10% or more of their colleagues take dangerous shortcuts. Of those respondents, 26% say these shortcuts have harmed patients. Despite these risks, only 17% have shared their concerns with the colleague in question.
Incompetence: 82% say that 10% or more of their colleagues are missing basic skills and, as a result, 19% say they have seen harm come to patients. Only 11% have spoken to the incompetent colleague.
Disrespect: 85% of respondents say that 10% or more of the people they work with are disrespectful and therefore undermine their ability to share concerns or speak up about problems. And yet, only 16% have confronted their disrespectful colleague.
Some improvement seen
Not all survey respondents remained silent. The study identified a small minority of nurses who spoke up when they observed dangerous shortcuts, incompetence, or disrespect. By studying these successful outliers, the research uncovered the high-leverage behaviors all healthcare practitioners should master to change the trajectory of harmful patient care, Maxfield says.
"Despite the concerns here, this data doesn't mean all our efforts have not worked. Things have gotten better since our 2005 study," he says. "In 2005, nurses spokes up at about a 12% rate when they had concerns. Today they are speaking up at about a 25 to 30% rate. So we've seen dramatic improvement, but there's still a long way to go."
The authors suggest that when it comes to creating healthy work environments that ensure optimal quality of care, individual skills and personal motivation won't be enough to reduce harm and save lives unless speaking up is also supported by the social and structural elements within the organization. Changing entrenched behavior in health care organizations will require a multifaceted approach. To this end, the authors provide recommendations leaders can follow to improve people's ability to hold crucial conversations.
Put maximum focus on a few issues
To have the most impact on changing the social norms within your organization, Maxfield suggests that risk managers focus on only two or three key behaviors. One example of a key behavior would be the rule "every tool, every time," meaning patient safety tools are to be used without exception. Another is "everybody speaks, everybody listens."
"You throw everything you can think of at those behaviors," Maxfield explains. "Address the multiple sources of influence: personal, social, and structural. Some deal with motivation, making it a higher priority or a moral passion for people, while other influences have to do with ability, giving them a script or supportive people to call upon."
Research has shown that if you put four or more of these influences together, it is 10 times more effective than if you use just one of them, Maxfield says. "A lot of these influences are strategies or approaches that a risk manager uses all the time, but they use them in isolation," he says. "They might focus on a training program, which is important but only one part. Or they might focus on having people share stories about when speaking up made a difference. Again, that is important, but by itself, it is not enough."
No tolerance for disrespect
The Silent Treatment also signals a need for zero tolerance regarding some workplace behavior that threatens patient safety, says Linda Groah, RN, MSN, CNOR, CNAA, FAAN, executive director/chief executive officer of AORN and a co-researcher on the study.
"Shortcuts are not acceptable. Incompetence will be reported, and those without adequate judgment and skills will be held accountable," she says. "Disrespect will not be tolerated, and managers have the responsibility to respond and to react to the information they receive from their staff. It is their responsibility to support their staff and be respectful in their communications."
The study also underscores the need for teamwork in surgery, Groah says. "It is a call to action for members of the surgical team to sit down together and map out clear strategies that will result in a culture of safety," she says. "That means a culture of trust in which all members of the perioperative team are encouraged to provide safety-related data and are acutely aware of the distinction between acceptable and unacceptable behaviors."
With more focus on patient safety from accrediting bodies and government regulators, having a culture of safety might soon be more than just the right thing to do, says Dorrie Fontaine, RN, PhD, FAAN, dean and professor at the University of Virginia School of Nursing in Charlottesville and past president of AACN. "We would like to see hospitals and schools do the right thing without the threat of legal action, but this is now rising to the point that we could see this becoming a regulatory and compliance issue with serious legal consequences," she says. "We are seeing that policies must have teeth, that there must be consequences for bad behavior. People get demoralized when they see that there are no consequences for bad behavior. I would like to see us do it because it's right for families and patients, but the option of legal consequences should be out there."
The problem of "undiscussables" and people not speaking up can be found in even the best healthcare organizations, Fontaine says. Her school and the University of Virginia Medical System are highly regarded and considered among the country's best, but they recently had a situation in which patient safety was threatened when a caregiver's concerns were not heard and acted on, she says. "The former dean of nursing decided to bring everyone together the OR nurses, physicians, the anesthesiologists and we had several dinner meetings with all hands on deck to talk about listening," she says. "Now, they didn't call it listening. Nobody would come for that because they all think they know how to listen. She called it 'advanced listening,' and everyone showed up."
Dorrie Fontaine, RN, PhD, FAAN, Dean and Professor, University of Virginia School of Nursing, Charlottesville, VA. Telephone: (434) 924-0141. E-mail: email@example.com.
Linda Groah, RN, MSN, CNOR, CNAA, FAAN, Executive Director/Chief Executive Officer, Association of periOperative Registered Nurses, Denver. Telephone: (303) 755-6304. E-mail: firstname.lastname@example.org.
David Maxfield, Vice President of Research, VitalSmarts. Provo, UT. Telephone: (801) 765-9600.