Download The Silent Treatment and more Exams Surgical Pathology in PDF only on Docsity!
Imagine you are a nurse who has been given a set of new
safety tools that warns you whenever your patients are in danger. That would be powerful, life-saving information, right? But what if nobody listened to you or heeded your warnings? This kind of breakdown is happening in hospitals every day. The quote below is one of 681 collected in the course of this research. “I think nearly every day we are faced with the hand-off allergy list. Frequently, the surgeons will order an antibiotic the patient is allergic to according to the safety checklist. When the patient is out of surgery, nurses have to call the surgeon, the anesthesiologist, and sometimes even the pharmacist before someone listens. Sometimes, we go ahead and give the drugs anyway, but when you really listen to the patient’s story, sometimes that is not the right thing to do.” Poor communication is deadly, especially in critical care settings^1 ,^2. When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm^3 ,^4 ,^5 ,^6 and even death^7 ,^8. The study examines an especially dangerous kind of communication breakdown: risks that are known but not discussed, or “undiscussables.” It builds on findings from research conducted in 2005 by the American Association of Critical-Care Nurses (AACN) and VitalSmarts^9 as documented in the research Silence Kills: The Seven Crucial Conversations for Healthcare. Silence Kills was conducted immediately before AACN’s national standards for healthy work environments were released^10. It identified seven concerns that often go undiscussed and contribute to avoidable medical errors. It linked the ability of health professionals to discuss emotionally and politically risky topics in a healthcare setting to key results like patient safety, quality of care, and nursing turnover, among others. The Silent Treatment shows how nurses’ failure to speak up when risks are known undermines the effectiveness of current safety tools. It then focuses on three specific concerns that often result in a decision to not speak up: dangerous shortcuts, incompetence, and disrespect. The Silent Treatment tracks the frequency and impact of these communication breakdowns, then uses a blend of quantitative and qualitative data to determine actions that individuals and organizations can take to resolve avoidable breakdowns.
Background
When communication breaks down, it breaks down in two very different ways. Business theorist, Chris Argyris ,groups these breakdowns into two categories: honest mistakes and undisscussables^11. Each category has a different cause, produces a different range of outcomes, and requires different solutions. Honest mistakes include accidental or unintentional slips and errors—for example: poor handwriting, confusing labels, difficult accents, competing tasks, language barriers, distractions, etc. Somehow, the baton is dropped during handoffs between shifts, departments, specialties, or caregivers. Psychologist, James Reason, describes these honest mistakes as the human equivalent of gravity^12 — they are inevitable. So they must be guarded against. When healthcare organizations invest in improving communication, they usually focus on reducing these
VitalSmarts, AORN, & AACN present:
The Silent Treatment
Why Safety Tools and Checklists Aren’t Enough to Save Lives
David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah
honest mistakes. They implement handoff protocols, checklists, computerized order entry systems, automated medication dispensing systems, and other similar solutions all aimed at doing away with these unintentional slips and errors. These improvements are absolutely essential but they fail to address the second category of breakdowns, the undiscussables. When people know of risks and do not speak up, the breakdown feels more intentional. Someone knows, or strongly suspects, that something is wrong, but chooses to ignore or avoid it. He or she may attempt to speak up but quits when faced with resistance. It’s not a slip or error; it’s a calculated decision to avoid or back down from the conversation. Information-based solutions like protocols, checklists, and systems don’t do much to solve the breakdowns in this second category. The literature on organizational silence^13 ,^14 suggests that solving undiscussables will require deeper changes to cultural practices, social norms, and personal skills. The Silent Treatment examines these calculated decisions to not speak up. It tracks how risks that are known but not discussed undermine many current safety tools. It documents the frequency and impacts of these discussions, and shows how individuals and organizations can make undiscussables discussable.
Study Design and Sample
Two survey instruments were employed: a Story Collector and a Traditional Survey. The Story Collector generated rich, qualitative data; the Traditional Survey produced purely quantitative data. Convenience sampling was used for both instruments. Members of the AACN and the Association of periOperative Registered Nurses (AORN) were invited via e-mail to participate in the study. The e-mail invitation included an online link that assigned respondents to one of the two instruments. The Story Collector was completed by 2,383 registered nurses, of whom 169 were managers; The Traditional Survey was completed by 4,235 nurses, of whom 832 were managers. Story Collector: This survey instrument asked respondents to share actual incidents—stories that described times when they were personally unable to speak up or get others to listen. The data obtained through the Story Collector is similar to what researchers otherwise might gather from interviews, but with several differences. First, the Story Collector methodology can reach more people than interviews allow. Second, Story Collector questions are standardized and presented in writing, so interviewer bias is eliminated. Third, respondents write their own responses, so transcription errors are eliminated. Fourth, people generally do not share more than a couple stories in writing—fewer than what a researcher might generate from an interview, so less data is collected from each respondent. Traditional Survey: This survey instrument was a more traditional Likert-scale questionnaire. It collected quantitative data related to three concerns: dangerous shortcuts, incompetence, and disrespect. Respondents were asked how often they face these concerns within their immediate work group, how they handle these concerns, and how these concerns have impacted patients on their units. In addition, the instrument included questions that explored personal, social, and structural sources that could influence how dangerous shortcuts, incompetence, and disrespect are handled.
Safety Tools and Organizational Silence—
Story Collector Findings
The Story Collector listed four survey safety tools that are intended to prevent unintentional slips and errors (Universal protocol checklist^15 , WHO checklist^16 , SBAR handoff protocol^17 , and drug- interaction warning systems). The respondents (nurses) were then asked how often they had been in situations where one of these tools worked—where it warned them of a problem that otherwise might have been missed and harmed a patient. As noted in the chart below, 85 percent (2,020) of the nurses said they had been in this situation at least once, and 29 percent (693) said they were in this situation at least a few times a month. These results strongly confirm that safety tools work. Operating rooms and ICUs are fast paced, complex, and full of disruptions. Checklists, protocols, and warning systems are an essential guard against unintentional slips and errors. However, the Story Collector data documented that the effectiveness of these safety tools is being undercut by undiscussables: 58 percent (1,403) of the nurses said they had been in situations where it was either unsafe to speak up or they were unable to get others to listen. And 17 percent (409) said they were in this situation at least a few times a month.
The 2010 study examines three of the seven concerns found in the 2005 study, using the same Likert-scale survey items. These three concerns—dangerous shortcuts, incompetence, and disrespect— are not necessarily prompted by any of the safety tools examined with the Story Collector. Instead, they tend to emerge over time, as people observe each other on the job. Findings from non- supervisory nurses who completed the current study’s Traditional Survey are summarized below: 1 Concerns about dangerous shortcuts. a. Shortcuts are common.
- 84% work with people who “take shortcuts that could be dangerous for patients (for example, not washing hands long enough, not changing gloves when appropriate, failing to check armbands, forgetting to perform a safety check).” b. Shortcuts are dangerous.
- 34% say that these dangerous shortcuts have led to near misses.
- 27% say shortcuts have affected patients, but without harm.
- 26% say shortcuts have harmed patients. c. Shortcuts are often left undiscussed.
- 41% have spoken to their manager about the person whose shortcuts create the most danger to patients.
- 17% have spoken to the person taking the dangerous shortcuts, but haven’t shared their full concerns.
- 31% have spoken to the person taking the dangerous shortcuts, and shared their full concerns. 2 Concerns about incompetence. a. Incompetence is common.
- 82% work with people who “are not as skilled as they should be (for example, they aren’t up-to-date on a procedure, policy, protocol, medication, or practice or are lacking basic skills).” b. Incompetence is dangerous.
- 31% say that incompetence has led to near misses.
- 26% say incompetence has affected patients, but without harm.
- 19% say incompetence has harmed patients. c. Incompetence is often left undiscussed.
- 48% have spoken to their manager about the person whose missing competencies create the greatest danger to patients.
- 11% have spoken to the person, but haven’t shared their full concerns.
- 21% have spoken to the person, and have shared their full concerns. 3 Concerns about disrespect. a. Disrespect is common.
- 85% work with people who “demonstrate disrespect (for example, are condescending, insulting, or rude— or yell, shout, swear, or name call).” b. Disrespect causes problems.
- 46% say that disrespect undercuts respect for their professional opinion.
- 19% say that disrespect makes them unable to get others to listen.
- 20% say that disrespect is making them seriously consider leaving their job or profession. c. Disrespect is often left undiscussed.
- 49% have spoken to their manager about the person whose disrespect has the greatest negative impact.
- 16% have spoken to the person who is demonstrating disrespect, but haven’t shared their full concerns.
- 24% have spoken to the person who is demonstrating disrespect, and shared their full concerns.
Silence Kills: The Seven Crucial
Conversations For Healthcare found
that seven categories of conversations
are especially difficult and, at the same
time, especially essential for people
in healthcare to master. These seven
conversations include: broken rules (including dangerous shortcuts), mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. The study showed that a majority of healthcare workers regularly see colleagues take dangerous shortcuts, make mistakes, fail to offer support, or appear critically
incompetent. Yet the research reveals
fewer than one in ten speak up and
share their full concerns.
The data presents a convincing case. Organizational silence leads to communication breakdowns that harm patients.
- More than four out of five nurses have concerns about dangerous shortcuts, incompetence, or disrespect.
- More than half say shortcuts have led to near misses or harm.
- More than a third say incompetence has led to near misses or harm.
- More than half say disrespect has prevented them from getting others to listen to or respect their professional opinion.
- Fewer than half have spoken to their managers about the person who concerns them the most.
- And fewer than a third have spoken up and shared their full concerns with the person who concerns them the most. The data also shows that nurses are more likely to take their concerns to their managers than they are to speak directly to the person they are concerned about. Since working through the hierarchy is often assumed to be the appropriate way to address a problem, it is important to examine how well this strategy works.
Results from Nurse Managers
The responses from the 832 nurse managers who completed the Traditional Survey were reviewed separately from the non- supervisory nurses. A surprising finding was that managers do not appear to be a reliable path for resolving concerns about dangerous shortcuts, incompetence, or disrespect. Only 41 percent of the nurse managers reported that they had spoken up to the person whose dangerous shortcuts create the most danger for patients. Equally troubling is that only 28 percent had spoken up to the person whose missing competencies create the most danger for patients, and only 35 percent had spoken up to the person whose disrespect has the greatest negative impact. The data above comes from the nurse managers, themselves. They admit their failure to address these important patient safety issues. The Story Collector data provides dramatic confirmation from the subordinate’s perspective.
- “During the surgical safety checklist, we realized the permit and the scheduled surgery did not match (wrong side). We tried to stop the doctor (plastic surgeon) and he said the permit was wrong. The patient was already asleep and he proceeded to do the wrong side against what the patient had verified, which had matched the permit. We could not get any support from the supervisor or anesthesiologist. The surgeon completed the case. Nothing was ever done. “We felt awful because there was no support from management to stop this doctor. What is the point of having a checklist when it is not consistently followed? We felt absolutely powerless to being an advocate for the patient.” - “A cardiovascular surgeon was putting in an arterial line at the bedside. We have a checklist that must be completed for line placement that includes full barrier, washing hands, etc. The M.D. refused the sterile gown, mask, hat, and drape, and used only sterile gloves. The nurse offered the full barrier again telling him that all lines were put in with full barrier in our unit. He continued with the procedure. The bedside nurse did not feel empowered to stop the procedure. She later took the problem to the unit manager. No action was taken.” This study shows that taking problems to a manager, and assuming he or she will handle them, doesn’t produce the kind of immediate and reliable results needed in healthcare.
Differences Between
2005 and 2010 Studies
In general, the results from The Silent Treatment 2010 study are in line with the Silence Kills 2005 data. But there are a few differences that need to be explained. More of the nurses in the 2010 study have concerns about dangerous shortcuts, incompetence, and disrespect; more have seen patients harmed; and more speak up about their concerns. The authors of the 2010 study believe these differences likely stem primarily from the differences in the two samples. The nurses in the 2010 study were more likely to come from settings where the job demands and patient acuity are higher: 87 percent work in an operating room, recovery room, ICU, cardiology unit, emergency department, or progressive care unit. The nurses in the 2005 study were randomly selected from 13 participating hospitals, and were more likely to work in medical-surgical units.
is worth the risk to speak up when patient and nurse safety [are] at risk.” 3 They explained their positive intent—how they wanted to help the caregiver as well as the patient.
- “I asked the surgeon if he had made the patient aware that he was in critical condition and that he would struggle to survive the surgery. He said he had not. I then asked if I could make the patient aware for him. The surgeon agreed by saying, ‘If you think you can, then go ahead.’”
- “A nurse was teaching a patient about a medication, misread the name of the medication and had not noted the past medical history thoroughly. She was teaching about a condition the patient did not have, and describing a sound-alike medication the patient was not taking. I called [the nurse] to come out of the room and helped her see the error. She returned to the patient and cleared up the mistaken information. By acting quickly and discreetly, I was able to help her and her patient.” 4 They took special efforts to make it safe for the caregiver—to avoid creating defensiveness.
- “The surgeon was marking the wrong foot, while talking to the patient about something social... I opened the chart to the permit and lightly reminded him we were doing the other foot today... Presenting the issue to the surgeon in a nonthreatening manner saved face in front of the patient and made him grateful that I spoke up when I did.”
- “[I] described [to a colleague] the potential interaction between an antihypertensive drug and an over-the- counter drug the patient was taking. The colleague had not taken a full history of drug exposures, and was grateful for the reminder, agreed the interaction was important to note, and warned the patient not to take this class of over-the-counter medication.” 5 They used facts and data as much as possible, often taking the other person into the actual situation.
- “I brought up the labs on the computer, and had them available to show the doctors... I was effective because I had the facts at hand.”
- “I asked the surgeon if this contrast medium would be a problem. He brushed it off. I approached the rep who brought in some of the kypho materials needed for the procedure. He thought there may be a problem. The surgeon was approached again. There was no literature available. The surgeon called the radiologist... Anesthesia was also consulted. The pharmacy was called. The result was that the contrast was not the same, but that Benadryl was given as a precaution.” 6 They avoided telling negative stories or making accusations.
- “A mistake does not mean a bad practitioner... not correcting a mistake does.” 7 They diffused or deflected the person’s anger and emotion.
- “He looked at me and said, ‘You’ve been drinking the corporate Kool-Aid... and lost your common sense.’ I tried very hard to avoid taking his statement personally, and laughed it off... I saw the surgeon in the hallway about an hour later and expanded the joke to include more than Kool-Aid…We both had a laugh.” Two behaviors were notable by their absence in the Story Collector data: none of the exceptional nurses tried to use threats to influence the physicians and other caregivers, and none showed their frustration or anger. These nurses kept their feelings and emotions in check. The stories the exceptional nurses tell make it clear that skills alone are not enough. Many of the stories show the extraordinary courage it takes to step up to these conversations. When caregivers fail to voice their concerns, it’s easy to accuse them of bystander apathy. But apathy is the wrong word. It’s more like bystander agony. These exceptional nurses were desperate to speak up, but often believed that voicing their concerns would violate norms, accepted practices, and even rules. Below are themes that reveal elements that helped these exceptional nurses overcome their concerns about speaking up: 1 They had spoken up sometime in the past, and a patient had been protected.
- “[During] pre-op screening before taking a patient to surgery, I have discovered discrepancies between the consent form and what the patient says. The surgeons never want to go back after their initial visit. I feel very good advocating for the patient. All they have is me and I will not let them down. There is nothing more important than the patient being safe and confident that they understand their procedure.”
- “The surgeon... was at a dinner party and was very vocal about how much trouble I would be in if he had to come back for no reason. He came back and took the patient into surgery. The leg had occluded. I was never so nervous about the outcome, and was so relieved to have been correct.” 2 A patient had already been harmed, and the incident was being reviewed.
- “The patient died five days later. We did an RCA (Root Cause Analysis) on this case, and it revealed that the
multiple surgeons attending this patient had not had any direct communication with one another—just paper consults... The VP of Medical Staff... was very helpful
... I also received support from the Chief of Surgery. I felt very supported by the Chief Nurse Executive in helping me go up the chain of the medical staff.”
- “Both surgeons and anesthesiologists give Toradol intra- op or post-op... but don’t always communicate... This has resulted in patients receiving double doses. I took this concern to the OR Management meeting, Dept of Surgery meeting, and Dept of Anesthesiology meeting. A new protocol was developed and increased communication in hand off.” 3 They had a strong trusting relationship with the person they needed to confront.
- “I was a nurse the surgeon worked with most of the time. Even though he wasn’t happy, he trusted my judgment. He is aware that I know the AORN standards as well as the evidence behind practice issues.”
- “I think what made me effective was my relationship with the surgeon. I trusted my clinical judgment and experience, and refused to be intimidated by the residents and hierarchy.”
- “I have made efforts to introduce myself to staff I do not know. My getting to know others has helped... us work as a team.” 4 One or more physicians had made it clear that they appreciate it when nurses speak up.
- “I spoke up and stated, ‘This patient is fully anticoagulated right now. Do you think it is wise to start a central line when we are okay with PIV [peripheral intravenous] for now?’ All the surgeons turned to me and stated, ‘Wow, we forgot. Thanks for making a good point.’”
- “[I] asked M.D. to wash his hands before central line insertion. He did it and thanked me in front of the patient for reminding him.”
- “I looked closely at the specimen, and informed the surgeon that I did not see an appendix. He came over, looked at the specimen, and confirmed what I saw. He told everyone in the room that’s why anyone in this room can speak at any time. Then went back in and took the appendix.” If the goal is to eliminate the communication breakdowns that are fueled by organizational silence, then caregivers need the skills and motivation exhibited by these exceptional nurses. However, individual skills and personal motivation won’t be enough unless speaking up is also supported by the social and structural elements within the healthcare organization. The current lack of speaking up is not just a matter of individual initiative; it reflects social norms, organizational policies and practices, and sometimes even formal evaluation and reward systems. The next section of The Silent Treatment study focuses on what organizations can do to create a culture that encourages and enables people to speak up.
Resolving Undiscussables—
What Organizations Can Do
Undiscussables represent an entrenched organizational problem. As such, they will require a multifaceted solution^21 ,^22. A helpful way to think about this multifaceted solution is to use six sources of behavioral influence^23 as summarized below: Source 1—Personal Motivation. If it were up to them, would the nurses want to speak up? Does it feel like a moral obligation or an unpleasant annoyance to them? Source 2—Personal Ability. Do the nurses have the knowledge and skills they need to handle the toughest challenges of speaking up? Source 3—Social Motivation. Are the people around them (physicians, managers, and co-workers) encouraging them to speak up when they have concerns? Are the people they respect modeling speaking up? Source 4—Social Ability. Do others step in to help them when they try to speak up? Do others support them afterward so the risk doesn’t turn against them? Do those around them offer coaching and advice for handling the conversation in an effective way? Source 5—Structural Motivation. Does the organization reward people who speak up or does it punish them? Is speaking up included in performance reviews? Are managers held accountable for influencing these behaviors? Source 6—Structural Ability. Does the organization establish times, places, and tools that make it easy to speak up—for example, surgical pauses, SBAR handoffs, etc.? Are there times and places when caregivers are encouraged to speak up? Does the organization measure the frequency with which people are holding or not holding these conversations—and use these measures to keep management focused on this aspect of patient safety? Organizations must overwhelm the problem of organizational silence. This requires deploying multiple sources of influence—all aimed at motivating and enabling people to speak up. Research shows that combining four or more of sources of influence can increase success by as much as ten times^24. The Traditional Survey that was used for The Silent Treatment study included a series of questions that measured how many of these six
Recommendations
The results presented in The Silent Treatment point the way toward positive change. When healthcare organizations tackle the silence using a combination of sources of influence, they achieve substantial improvements. Below are recommendations for how healthcare organizations can use this multifaceted approach to create a safety culture where people speak up effectively when they have concerns. 1 Establish a Design Team. Enlist a small team that includes senior leaders, managers in the targeted areas, and opinion leaders among physicians, nurses, and other caregivers. This design team works with all caregivers to identify crucial moments, vital behaviors, and strategies within each of the six sources of influence described below. The design team then provides a few initial strategies within each of the six sources and helps teams in patient care areas select, modify, and create additional strategies. 2 Identify Crucial Moments. There is a handful of perfect- storm moments when circumstances, people, and activities combine to put safety protocols at risk. The design team needs to identify and spotlight these crucial moments so that people will recognize when they are in them. An example of one of these crucial moments is when the surgery schedule is pushed into the evening, and people are in a rush. 3 Define Vital Behaviors. People need to know what to say and do when they find themselves in these crucial moments. These are the vital behaviors that keep patients safe. Examples of vital behaviors used at Spectrum Health include:
- 200 percent Accountability. Each staff member is 100 percent accountable for following safe practices and 100 percent accountable for making sure others follow safe practices.
- Thank You. Staff members make it safe for others to hold them accountable. When they are reminded of a safety practice, they thank the other person and redouble their efforts to keep the patient safe. 4 Develop a Playbook. Safety requires that the vital behaviors be acted on in a highly reliable way—especially during the crucial moments when they are the toughest. The most powerful way to make sure these behaviors are consistently followed is to create a multifaceted influence plan that uses all six sources of influence. This plan is captured in a playbook that can be disseminated throughout the organization. Departments and individaul patient care areas can use this playbook as the starting point. They may adopt some of the strategies wholesale, modify others, and invent new strategies on their own. But they need to make sure they have a few strategies within each of the six sources of influence. Below are examples of strategies that fit within each of the six sources. Source 1—Personal Motivation. The goal is to connect to people’s existing values to stimulate their passion for keeping patients safe. The most effective way to make this connection is through sharing personal experiences. The least effective way is to resort to verbal persuasion: data dumps, lectures, sermons, and rants. Examples of sharing personal experiences include:
- Physicians, nurses, and other caregivers tell stories of near misses—times when patients would have been harmed if the safety practices hadn’t been followed.
- Physicians, nurses, and other caregivers share examples of times when speaking up saved a patient from harm.
- Physicians, nurses, and other caregivers tell stories of injuries—times when a shortcut might have been taken and no one spoke up, and a patient was harmed.
- Physicians, nurses, and other caregivers meet with patients who have been injured when receiving healthcare to learn about the harm and how it affected the patients. Source 2—Personal Ability. The goal is to make sure everyone has the skills they need to be 200 percent accountable for safe practices. Design teams make the mistake of assuming people can “just do it.” Effective organizations use training, have patient care areas develop their own scripts, and use role-plays that include physicians, nurses, and other caregivers. Examples include:
- Supervisors, managers, and team champions participate in formal training in how to handle high-stakes, emotional differences of opinion^27.
- Patient care areas develop their own scripts. For example, “Doctor, I have a safety concern.”
- Patient care areas practice these scripts with the physicians, nurses, and other caregivers they will be holding accountable. Sources 3 and 4—Social Motivation & Social Ability. The goal is make sure people have the support they need to be 200 percent accountable for safe practices. The mistake made here is to assume that verbal support from management is enough. Effective organizations use both managers and physician champions for each patient care area. Examples include:
- Patient care areas identify the physicians who would make the best champions, and then invite them to join in. Rarely are these invitations rejected.
- Patient care areas discuss and define the champion role. They identify the forms of participation and support a patient care area requires from its champions.
- Champions meet with individuals who challenge the initiative and win them over. For example, they work with people who object to safety practices, to being held accountable, or to holding others accountable, and gain their support. Source 5—Structural Motivation. The goal is to make sure incentives support safe practices and reward people for 200
percent accountability. The mistake organizations make is to forget that rewards and punishments matter. Effective organizations build incentives into performance reviews, promotions, pay, and perks— and they don’t shy away from using punishments when necessary. Examples include:
- Organizations create gift certificates, badges, and other small tokens to recognize and reward people for consistently following safe practices and for demonstrating 200 percent accountability.
- Organizations build safe practices into physician contracts and performance reviews.
- Organizations create a quarterly measure of the frequency with which people practice the vital behaviors area by area. They build a specific improvement goal for this measure into the accountability system of all directors and above. Source 6—Structural Ability. The goal is to make sure there are places, times, and systems that support safe practices and 200 percent accountability. Effective safety cultures use the principles of organizational improvement to make safe practices and accountability easy and convenient. Examples include:
- Physicians, nurses, and other caregivers review safe practices to make them less cumbersome and more effective.
- Compliance is measured and tracked. These measures include quality as well as consistency, so that safe practices never degrade into box-checking exercises.
- Design teams and patient care areas create cues, reminders, and protocols to make 200 percent accountability safe and simple.
- The organization publishes quarterly data by department to keep attention focused on the vital behaviors. The recommendations above are a starting point. The goal is to create a playbook that includes crucial moments, vital behaviors, and strategies within each of the six sources of influence. Organizations and teams can then use the ideas within the playbook to create a multifaceted plan that is tailored to their individual situation.
Conclusions
The Silent Treatment details the success and limitations of current safety tools. Most of these tools work by warning caregivers of potential problems. But warnings only create safety when the caregiver who is warned is able to speak up and get others to act. The data in this study reveals that caregivers, including nurse managers, are often unable to accomplish this level of candor. As a result, they either clam up or blow up. They fail to have an influence; and patients are harmed. This inability to influence extends beyond safety tools. Caregivers are often unable to speak up and resolve their concerns about dangerous shortcuts, incompetence, and disrespect. More than four out of five nurses in this study have these concerns, more than one in four have seen either shortcuts or incompetence lead to patient harm, and more than half say disrespect from others has undermined their ability to take action. Yet less than a third of these nurses spoke up in an effective way about their concerns. The stories nurses tell about trying to speak up reveal the variety of challenges they face. Three quarters involved confronting physicians, two thirds involved standing up to a group, and half involved disrespect, threats, and anger. Focusing on the exceptional nurses who do speak up highlights some key skills they employ. They begin by explaining their positive intent; use facts and data as much as possible; make it safe for the other person; avoid negative stories and accusations; and deflect anger and emotion. If every caregiver has these skills, it will go a long way toward resolving the problem of organizational silence. There is cause for optimism at the organization level. Nurses today are voicing their concerns nearly three times more often than they did just five years ago. This improvement suggests that speaking up is becoming easier and more accepted within healthcare organizations. Key programs such as the Magnet Recognition Program and AACN’s Beacon Award for Excellence have contributed to this progress, most likely because they demand that organizations take a multifaceted approach to improving care. AORN also provides powerful tools— one focused on Just Cultures and another on Human Factors—that can help organizations create a culture of safety. This research shows that explicitly multifaceted approaches, such as the six sources of influence, are the most predictive of success. There were strong negative correlations between how many of the six sources of influence were employed and the incidence and harm of the three concerns. This means that combining multiple sources of influence all aimed at improving people’s ability to speak up is associated with fewer dangerous shortcuts, incompetence, and disrespect, as well as with lower levels of the harm they produce.
