Speaking Up for Safety and Civility

2011

Aims

• To think about what makes it hard to speak up

• To think about what we can do to make it easier to speak up

We teach our kids to do it, so why can’t we?

Why does speaking up matter?

Maxfield et al 2011, The Silent Treatment. Why safety tools and checklists aren’t enough to save lives. (www.the silenttreatment study.com)

• >80% nurses (n=4235) had concerns about dangerous shortcuts, incompetence or disrespect.

• >50% said shortcuts have led to near misses or harm• >50% said disrespect has prevented them from getting others to

listen or respect their professional opinion• <50% had spoken to their managers about the person who

concerns them most• <30% had spoken to the person directly• Worse where pt acuity and job demands are higher

What are the hurdles to speaking up?

• Professor Dan Raemer – Harvard Medical School/Massachusetts General Hospital

“Responding to (very) challenging cases”http://www.hnehealth.nsw.gov.au/HNESSC

Hurdles

• Relational• Content• Self• Climate

Relational hurdles

• Perceived hierarchy• Respect for territory• Respect for experience• Value of the relationship• Familiarity with the individual

Content hurdles

• Uncertainty about the issue• Uncertainty about the consequences• Confidence about being able to deal with the

consequences

Self

• Perception of limited responsibility• Avoidance of potentially embarrassing

situations• Fear of being wrong• Personal reputation• Protection of physician autonomy• Natural obedience

Climate

• Not an environmental norm• Waste of time• Fear of repercussions• Absence of a rubric/tool

The 2-challenge rule

1. Question with curiosity2. Question with concern3. Bring in a third party

CHALLENGE TWICE THEN CALL FOR ASSISTANCE

Lessons Learnt

The world’s worst air disaster happened in 1977 when two Boeing 747 jumbo jets collided on a runway at Tenerife, killing

583 people. After reviewing the cockpit voice recordings investigators realised that the steep authority and experience

gradient in the cockpit between the captain, the first officer and the flight engineer

“probably made his crew reluctant to question his decisions”. In other words, the junior staff were so intimidated by their senior

that they felt they could not stop him from causing an accident they knew was about to happen, even though they

had the ability to”.

The 2-challenge rule

1. Question with curiosity……2. Question with concern…….

1. Question with Curiosity

CIVILITY

•“I’m curious to know why you felt it necessary to yell at me in that way?”

•“I’m curious to understand why you were not interested in listening to Mrs Smith’s concerns about her sister”

2. Question with Concern

CIVILITY

“When you yell and shout in that way I am concerned that you do not respect my views”

“I am really concerned that that Mrs Smith does not feel as though her questions have been answered appropriately and that she is feeling anxious”

SAFETY

“I am interested to know why we are using this particular antibiotic….”

Question with Concern

SAFETY

“I noticed that the patient file clearly says that the patient is allergic to this

medication, I am really concerned that he may have an anaphylactic reaction as a result of having this specific antibiotic?

Why are we giving it in this case?”

Bring in a third Party

• Ask another opinion• Discuss with someone else• Or take control………