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Nurses Too Scared to Speak Up

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   March 29, 2011

How many quality improvement projects are going on in your organization right now? How many committees are devoted to improving safety? If you're like most facilities, there are probably dozens. Across the country, countless hours are devoted to preventing errors that harm patients through creating checklists, protocols, automated systems, and the like.

Are they worthless?

That's what I started wondering when I came across a new study that examines why poor communication is still the biggest patient safety danger of all.

The report is a combined effort from the American Association of Critical-Care Nurses (AACN) and the Association of periOperative Registered Nurses (AORN) in partnership with VitalSmarts, a training and organizational performance company. AACN and VitalSmarts produced the seminal "Silence Kills" data five years ago that found:

  • 84% of physicians have seen coworkers taking shortcuts that could be dangerous to patients
  • 88% of physicians say they work with people who show poor clinical judgment
  • Fewer than 10% of physicians, nurses, and other clinical staff directly confront their colleagues about their concerns

The 2006 data greatly enhanced our conversations about how to improve safety and led to efforts such as AACN's healthy work environment initiative that has been adopted by many organizations.

Wanting to see what's changed in the last five years, the organizations, joined by AORN, conducted another study that surveyed 6,500 nurses and nurse managers. The data revealed some alarming statistics, released in a report "The Silent Treatment." Eighty-five percent of respondents said a safety tool had alerted them of a problem that might have been missed and potentially harmed a patient and yet 58% percent revealed they didn't say anything about it.

Among the study's key findings:

  • More than four out of five nurses have concerns about dangerous shortcuts, incompetence, and disrespect demonstrated by their colleagues
  • More than half say shortcuts led to near misses or harm, and only 17% of those nurses shared their concerns with colleagues
  • More than a third say incompetence led to near misses or harm, and only 11% spoke to the colleague considered incompetent
  • More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16% confronted their disrespectful colleague

"Safety tools such as protocols and checklists guard against honest mistakes," says AORN Executive Director/CEO Linda Groah, RN, MSN, CNOR, CNAA, FAAN. "However, this study tells us there is more work needed in the OR to support the surgical team's ability to establish a culture of safety where all members can openly discuss errors, process improvements, or system issues without fear of reprisal."

AACN President Kristine Peterson, RN, MS, CCRN, CCNS, says there has been progress made. "Compared with what we learned in 2005, nurses now speak up at much better rates and are now nearly three times more likely to have spoken directly to the person and shared their full concerns," Peterson says. "This increased focus on creating cultures of safety needs to continue until every health professional feels empowered to speak up to reduce errors and improve quality of care."

Despite the improvements, the "report confirms that tools don't create safety; people do," says David Maxfield, vice president of research at VitalSmarts and lead researcher of "The Silent Treatment." "Safety tools will never compensate for communication failures in the hospital."

This makes sense. What's the point in spending hours training staff to use a checklist or follow certain steps if nurses are too scared to speak up and say something when an error is revealed? This study was a wake-up call for me when thinking about patient safety, despite the fact I hear stories about belligerent surgeons, condescending physicians, and bullying nurses every day.

Just recently I heard a story from Gary Sculli when I spoke to him about implementing techniques from aviation crew resource management in nursing.

"While conducting a CRM session for nurses I asked the question, 'What would you do if you saw a physician about to do something that was going to cause harm to a patient?'" says Sculli. "A nurse confidently said, 'I would tell him to stop'. Then I said, 'What if he or she ignored you and continued?' What the nurse said next astounded me. 'Hey, I told him. It's on them at that point, but I would document what occurred.'"

This is a perfect example of what the study shows. We have a culture where nurses have been ignored, condescended, abused, or generally disrespected for so long that many have checked out and don't want to rock the boat or get into trouble. Or risk being shouted at.

How can any of us be happy about the fact we have a culture where people are so scared to speak up that they willingly let an error happen rather than risk saying something? What will it take to force us to confront the basics? Perhaps we need to stop developing new programs until we figure out a way to communicate?

Physicians and nurses must check their egos at the door and commit to improving the culture and communicating with respect. Without the concerted effort of the complete caregiving team, nothing will ever change. For the sake of our patients, we must empower everyone on the healthcare team so that all are valued and engaged in keeping our patients safe.

Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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