It is now well recognized that the majority of avoidable patient deaths and injuries could be prevented by better teamwork and communication. What does this mean in practice? It means that in many instances, someone knew that patient harm was imminent but that someone didn’t speak up – or didn’t speak up with enough urgency – to stop harm from happening. In many instances that someone – as I have written elsewhere in this blog – was lower down on the healthcare ladder and was afraid or unable to alert someone higher up on the ladder that an error was about to occur. Sometimes, harm happens because someone lower down the power gradient knew something bad was about to happen and did, in fact, try to alert higher ups but no one listened. Harm occurred not only because no one acted on warnings in a particular case. Even greater harm was done because lower level staff now feel so frustrated and demoralized that they are convinced there is no point in taking future action to prevent patient harm. People who may have taken huge risks to alert higher ups to problems are now absolutely certain there is no point in taking any risk in the future.
A recent article in Quality and Safety BMJ entitled “Deafening Silence? Time To Reconsider Whether Organisations Are Silent or Deaf When Things Go Wrong,” explores how silence begins and becomes a cultural habit because organizational higher-ups do not heed the warnings of so-called “whistle-blowers” who bring attention to critical problems within an institution. Authors Aled Jones and Daniel Kelly argue that when it comes to preventing harm, the focus is generally on why people don’t speak up or blow the whistle on harmful practices. The prevailing notion is that people are too often silent and so our energy must be spent on getting them to raise their voices to protect patients from harm.
Looking at several recent scandals in the National Health Service in Great Britain – problems at the Mid Staffordshire National Health Service for example – the authors report that the conventional wisdom was that people did not speak up to prevent harm. In fact, numerous reports document that the contrary was the case: many people tried to bring attention to poor quality and practice but that no one listened. A nurse tried to raise her concerns. Rather than be supported by her nursing colleagues, she was told to “watch her back.” A junior doctor raised concerns to management and a post-graduate Dean and no one took action. “Inquiry counsel Tom Baker described the repeated raising and subsequent disregard of concerns in Mid Staffordshire as ‘a cry from staff who appear to be being ignored’.
The authors go on to consider the notion of “organisational silence ” or “cultures of silence.” They argue that a more accurate definition of what goes on in many healthcare institutions that ignore employees or staff attempts to raise critical concerns is not silence but rather organizational deafness or what they call “the deaf effect.” As they put it, “The term ‘Deaf Effect’ has its roots in management and information studies literature, being defined as occurring ‘When a decision maker doesn’t hear, ignores or overrules a report of bad news to continue a failing course of action’ When organizational deafness is the prevailing mode of response to concerns, then the authors go on to argue, silence does become the dominant mode of response because voice is viewed as futile and silence viewed as the only option. Deafness leads to silence and silence becomes, as they put it, contagious. “If employees are ignored when one concern is raised, this can lead to silence about a range of other concerns.”
The question thus becomes how does one fight deafness and the deaf effect and encourage voice. In order to do this, organizations must encourage voice and thank people, reward people, and encourage people who deliver not only good news but bad. In the UK, the government is beginning to do this by recognizing whistleblowers on the Prime Minister’s New Year’s Honours List. In the US, managers need to do the same. I would suggest getting rid of any and all signs in managers office alerting staff that this is a “whining free zone.” I would also hand out cards like this one that I made up (I stole the idea from a natural food store in Portland, Oregon.) It’s the Don’t Shoot the Messenger Card.
In another post, I will consider the issue of organizational silence because I think it is one that must also be considered. But for now, everyone in the patient safety movement should be reading this new article and putting into practice what we should all be preaching.
For the past fifteen years, since the Institute of Medicine published its report To Err Is Human, patient safety has become the watchword of the day. Money has been spent. Initiatives have been launched. Champions have been recruited. Whether it is the hospital CEO, the Chief of Medicine, the Vice President of Nursing, everyone is on board when it comes to patient safety. And yet, the numbers of patient deaths and injuries are barely budging. In fact, the only progress we seem to be making is in adjusting the statistics on patient deaths upward. When the Institute of Medicine report came out in 1999, the public was informed that 98,000 patients were dying of preventable medical mistakes every year – the equivalent of a jumbo jet crashing every three days. In 2013, we learned that that figure was probably a radical underestimation. The correct figure is over 400,000 a year – making deaths due to preventable medical errors the third leading cause of death in the US. Read more >>
On Monday, my husband and I flew back to San Francisco from Boston after a two week visit. As we were sitting in the airport waiting for our 4:13PM flight with United Airlines, we were told that the flight was delayed two hours. The reason? Unspecified “maintenance.” Needless to say, we weren’t ecstatic about the delay. As an anxious traveler, I also worried about which particular maintenance issue had caused the tardy departure. Was it a serious engine problem? If so, would whatever repair was performed actually maintain us in the air for six hours at 36,000 feet? I know I have written about the wonders of the airline safety model, but I’m only human and worry is something at which I excel. Read more >>
In response to my latest newsletter posting, I got this wonderful email from an MD, OB/GYN Rob Olson. Rob wrote the following and told me I could post it on my blog. It is a perfect example of mature, reflective leadership, how to form a team, support a team member, and create psychological safety. So here it is:
I had a 42-year-old patient having her first baby who was transferred into me after being stuck at 7cm for over six hours in an outside birthing center. She was post dates and clinically had a large baby with the head not engaged at a -2 station. She did not want pain medication nor an epidural. I felt she had adequate uterine contractions but was planning to check with an internal pressure transducer until I examined her and found she was at 8cm. An hour later she was at 9, then she did not make any further progress and I ordered a primary cesarean section 3 hours later.
The young charge nurse questioned me and wanted to discuss both the possibility of Pitocin as well as an epidural. This irritated me but after I explained myself, she accepted my clinical judgment. The surgery went well for both the mother and the 9 lbs. 5 oz. infant.
However, the next day, upon reflection, I realized I should not of been irritated but instead I should have welcomed the inquiry from the charge nurse as she was just demonstrating patient advocacy and safety. So I wrote an email to her supervisors praising her behavior as a demonstration of a “culture of safety”. We should all welcome discussion of our patients so we can encourage teamwork.
Rob Olson, MD, FACOG
Society of OB/GYN Hospitalists
Rob’s website is http://www.obgynhospitalist.com/
If more physicians, nurse managers, professors etc reacted in this way and thought about their actions we’d be out of the woods when it comes to people speaking up to protect patients.
Hippocrates may have said “first do no harm” centuries before Florence Nightingale reiterated the injunction, but nurses really believe that they are morally superior to physicians or many others in healthcare when it comes to protecting patients from danger. As the American Nurses Association Code of Ethics assert in its Provision 3, “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”
Nurses may disagree on many issues, but on the definition of the nurse as THE patient advocate, they actually do speak with one voice. I have seen – and written about –many nurses who, in fact, tirelessly advocate for their patients. What these nurses do is embody true advocacy. Advocacy, as I have written in When Chicken Soup Isn’t Enough: Stories of Nurses Who Stand Up for Themselves, Their Patients, and their Profession, is not simply hoping things go well for the patient. An advocate, as the dictionary defines it, is “a person who argues for or supports a cause or policy: a person who works for a cause or group: a person who argues for the cause of another person in a court of law.” Being an advocate, by definition, thus means speaking up to defend or argue for another person. Thus to be a patient advocate, by definition, involves speaking up to protect a patient from harm. It involves, again, by definition, the willingness to take risks to protect a patient from harm.
It has been with increasingly greater distress that I have heard nurses, over the years, simultaneously assert that they are patient advocates, while also insisting that they cannot possibly risk their jobs if they see a patient about to be harmed by a physician or by some hospital policy, or by some action by someone who has the power to discipline or punish the nurse who is observing potential harm. In July the online publication Nurse Together posted an article entitled “Medical Errors: Why Don’t Nurses Speak Up?” It discussed the fact that, in nine out of ten cases when there is a medical error someone knows something or sees something that could prevent the error. Rather than speaking up, they remain silent. They do this because they believe physicians are “untouchable,” or because they receive no management support – but only discipline, when they speak out.
The simple fact is that the majority of nurses I have met believe that speaking up will get them into trouble. The problem starts in nursing schools. While the visible, explicit curriculum in nursing schools teaches nurses that they should advocate for their patients, it does not teach them how to advocate in real life situations where the odds are stacked against advocacy. They are also not taught how to confront and overcome the hidden curriculum of nursing, which they encounter the minute they hit the wards. In too many instances, nursing students who enter hospitals or other healthcare institutions for their clinical rotations are instructed by preceptors who have no training in conflict resolution and negotiation and who teach them to shut up rather than speak up. These nurses are, in turn, supervised by managers who similarly have no conflict resolution skills and whose default position is discipline and punish rather than coach, teach, and support.
The other day, for example, I was giving a lecture at a four year university nursing program. I asked students – who ranged I age from 20 to 50 – whether they would speak up, if they saw a patient about to be harmed. With no exceptions, they all said they were afraid to speak up. Ditto the working nurses in the room. The students also told me that their preceptors all advised them to shut up, when they told their preceptors of problems in patient care. “That’s just the way it is, what can we do about it? “ they said. “You don’t want to be thought of as a know-it-all do you?” was the response of another.
So I have a modest proposal. Instead of teaching nursing students that they are patient advocates, why don’t nursing professors teach students how to advocate for patients in the face of what might seem to be insurmountable odds? Why don’t they choose preceptors more carefully so that students are always paired with nurses who actually know how to speak up in the face of such odds and could thus help nurses learn a skill which they will have to master and refine throughout their careers? And why doesn’t hospital nursing management create an environment in which patient advocacy and protecting patients from harm can actually occur so that we finally move from aspiration to reality when it comes to patient care?