Speaking Up

OVERVIEW

• ‘Speaking up’ refers to a person in a non-dominant or non-leader role expressing a concern or suggested course of action to another person in a dominant or leader role
• Speaking up here refers to raising a concern before an act of commission or omission, rather than after it has occurred, which is distinct from reporting sentinel events or ‘whistleblowing’; it is sometimes referred to as ‘speaking out’ or ‘assertiveness’
• Health care professionals are expected to speak up about their concerns before a critical event reaches a patient to provide a chance to correct the plan or intervention
• Speaking up is vital to maintaining patient safety in critical care settings, yet often does not occur
• We must always advocate for our patients and never leave a situation thinking ‘I should have said something!’
• Patients should also be encouraged to speak up
• Speaking up requires courage and skill, but is essential!

“Primum non tacere – first do not be silent”

IMPORTANCE OF SPEAKING UP

• Speaking up can help avoid patient care errors or assist in recovering from them
• The safety and transparency of an organisation can in part be gauged by the freedom of their staff to ‘speak up’ when the time is right
• speaking up is a predictor of technical team performance
• Failure to speak up is common
  • The 2010 Silence Treatment study of 6,500 nurses and nurse managers in the USA found that 84% reported >10% of their colleagues taking dangerous shortcuts, and 26% said these shortcuts have actually harmed patients. Despite these risks, only 17% shared their concerns with the colleague in question.

BARRIERS TO SPEAKING UP

Individual factors

• the follower may be uncertain that they are correct
• uncertainty about how to ‘speak up’ effectively
• perceived effectiveness of speaking up (“won’t change anything anyway”)
• lack of a feeling of responsibility or not feeling like it is his/ her ‘job’ (e.g. emergency nurse who observes that an anaesthetist keeps repeating attempts at a difficult intubation instead of performing a cricothyroidotomy)
• fear of being wrong, getting ridiculed or looking incompetent
• fear of creating inter-personal conflict or being seen as a trouble maker
• lack of job satisfaction (people with higher levels of job satisfaction are more likely to speak up)
• lack of sense of personal control and autonomy (a sense of making an impact at work)
• previous experience

Situational factors

• unclear or ambiguous situations
• not wanting to interrupt other activities
• perceived low risk of harm from concerning behaviour/ action
• excessive cognitive load
• lack of inter-disciplinary hospital policies dealing with the situation

Interpersonal and cultural factors

• lack of a ‘speaking up’ culture in the workplace and administrative support
• intimidation
• steep power gradient
• cultural and linguistic differences
• team/ leader attitudes

HOW TO SPEAK UP

• The common approach of speaking indirectly in a ‘hint and hope’ fashion is ineffective
• The person speaking up must be assertive
• Graded assertiveness approaches are effective; an alternative is the ‘Two challenge approach’
• Focus on the problem, avoid the issue of who is right and who is wrong
• Always be respectful
• If there is time, start off curious rather than adversarial, use appropriate body language and tone of voice
• In emergencies you may not have time for niceties!

GRADED ASSERTIVENESS

Overview

• graded assertiveness allows the junior person to avoid conflict or triggering defensiveness initially, but allows them to escalate if required
• It gives the senior person a chance to correct any mistakes or misunderstandings and to save face
• Different approaches include CUSS, PACE, and 5-step advocacy

CUSS approach

• Concern – “I’m concerned that…”
• Unsure – “I’m unsure that…”
• Safety – “It is not safe…”
• Stop – “Stop what you are doing…”

PACE approach

• Probe – e.g. “Do you know that…?”, “I don’t understand why you want to do…”
• Alert – e.g. “I think that will cause…””
• Challenge – “Your approach will harm…”
• Emergency action – e.g. “STOP what you are doing!” “For the safety of the patient we need to…”

5-step advocacy

• Attention getter – “Excuse me, Doctor”
• State your concern – “The patient is hypotensive”
• State the problem as you see it – “I think we need to get help now”
• State a solution – “I’ll phone ICU to arrange transfer”
• Obtain an agreement – “does that sound good to you?”

TWO CHALLENGE APPROACH

Approach described by Pian-Smith et al, 2009:

• First challenge using advocacy-inquiry e.g. “I see that you plan to administer a spinal anesthetic to this patient. She has a platelet count of 80,000. I learned that we shouldn’t do a spinal unless the count was at least 100,000. Can you clarify your view?”
• If no sensible response then provide second challenge with advocacy-inquiry; e.g. “I see that you plan to administer a spinal anaesthetic, but I worry her platelets are too low. I think it’s unsafe and we should do a general anaesthetic. What do you think?”
• If no sensible response then get additional help to protect the patient and resolve the disagreement

HOW TO FACILITATE SPEAKING UP

• Raise awareness
• Establish a culture of ‘speaking up’ through leadership and actionable, sustainable policies and practices (some studies show nurses are unlikely to speak up unless supported by specific policies)
• Provide training in open, non-defensive team-working principles and communication skills (e.g. team-based simulation)
• Role modelling of best practice (including thanking/ praising those who speak up appropriately)

References and Links

Journal articles

• Bolsin S, Pal R, Wilmshurst P, Pena M. Whistleblowing and patient safety: the patient’s or the profession’s interests at stake? J R Soc Med. 2011 Jul;104(7):278-82. PMC3128871.
• Dwyer J. Primum non tacere. An ethics of speaking up. Hastings Cent Rep. 1994 Jan-Feb;24(1):13-8 PMID: 8045760.
• Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. PMC1765783.
• Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014 Feb 8;14:61. PMC4016383.
• Pian-Smith MC, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, Raemer D. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc. 2009 Summer;4(2):84-91.PMID: 19444045.
• Srivastava R. Speaking up–when doctors navigate medical hierarchy. N Engl J Med. 2013 Jan 24;368(4):302-5.PMID: 23343060. [Free Full Text]

FOAM and web resources

• American Association of Critical-Care Nurses. The silent treatment: why safety tools and checklists aren’t enough to save lives. Aliso Viejo (CA): The Association. Available from: Silent Treatment Study