Do staff speak up about dangers, or give them `the silent treatment'?

Prevent shortcuts, address missing skills, or risk patient harm

(Editor's note: This issue includes the first part of a two-part series looking at the problem of staffing keeping silent when danger looms. This month we discuss the recently released report The Silent Treatment. We examine why staff don't speak up and how to address that problem. In next month's issue, we offer four recommendations to create a culture in which people speak up effectively about concerns.)

A new nurse was called into the OR for a lengthy case. At the end of the case, the nurse turned to break down the back table and noticed the indicator strip in the instrument pan had not changed.

"We had done the whole case with unsterile instruments, and it was entirely my responsibility for not noticing it when I was first setting up my case," says Jan Davidson, MSN, RN, perioperative education specialist at the Association of periOperative Registered Nurses (AORN). Davidson turned to the vascular surgeon and said, "I need to tell you what I did." "He never once became angry with me," she says. "He knew how devastated I was."

The following day, they went to meet with the patient and the family. "He presented it to them in a way that made it sound as if 'we, the team' have let you down; never 'she, the scrub nurse,'" Davidson says. "I worried about that patient for several years, always afraid he would get an infected graft that would be detrimental to him. As far as I know, with the administration of strong postoperative antibiotics, he never did."

Davidson scrubbed for many years with that surgeon, and he never mentioned the incident again. "Without his support, without the support of my manager, without the support of the anesthesiologist, and without the support of my fellow nurse who was circulating the case, I don't know that I would have continued to work in the OR and perhaps would have left nursing altogether," she says. "Instead, I felt supported for speaking up and empowered in knowing I could speak up again if I felt we were not practicing safe patient care. That was over 30 years ago, and we are still working on fostering that culture!"

Her views are seconded by a recently released report titled The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives, conducted by the Association of periOperative Registered Nurses (AORN), the American Association of Critical-Care Nurses (AACN), and VitalSmarts, which is a corporate training company in Provo, UT. The study collected data from more than 6,500 nurses and nurse managers who were members of AACN and/or AORN. (For the full study results, go to http://silenttreatmentstudy.com and select "Download the study.")

The Silent Treatment found that 85% of respondents have been in a situation in which a safety tool warned them of a problem. Of the nurses who had been in situations where safety tools worked, 58% percent had been in situations in which they felt unsafe to speak up about the problems or in which they were unable to get others to listen. The implications are serious: Upward of 195,000 people die each year in U.S. healthcare facilities because of medical mistakes.

Is your staff taking shortcuts?

The Silent Treatment concludes providers fail to raise concerns about shortcuts when risks are known, which undermines the effectiveness of current safety tools.

Eight-four percent of respondents say that 10% or more of their colleagues take dangerous shortcuts. Of those respondents, 26% say these shortcuts have harmed patients. Despite these risks, only 17% have shared their concerns with the colleague in question.

"Dangerous shortcuts are absolutely a problem in outpatient surgery," Davidson says. Volume equals money, she points out. "Staff may take shortcuts in an effort to get their rooms turned over quickly," Davidson says.

For example, staff might inadequately wipe down the surfaces of the OR table and equipment between cases. "In the pre-op area, you may see the nurses, in an effort to be efficient and prepared, spike all their IV bags and prime the tubing at the beginning of the day so they are all ready when the patient comes in to be admitted," Davidson says. "This is a prime source of infection." The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that spiked IV solutions be used within one hour of being prepared.

Members of the staff need to feel empowered to speak up about potential harm to a patient when they are pressured to quickly turn over rooms or admit patients, Davidson says. "In their haste to be efficient and fit in that 'one more case for the day,' they risk putting their patient in harm's way, which could result in an event far more costly than the revenue they generated from that one more case," she says.

Another potential problem area is postop care, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI. "One of the concerns is, do they have adequate monitoring, and is the patient kept there an adequate time, or is he/she sent home sooner than they should be," Trosty says. If employees have not been adequately trained, and they aren't monitoring patients closely enough, "you can have a potential negative result," he says.

The Silent Treatment signals a need for zero tolerance regarding workplace behavior that threatens patient safety, says Linda Groah, RN, MSN, CNOR, CNAA, FAAN, executive director/chief executive officer of AORN and a co-researcher on the study. "Shortcuts are not acceptable. Incompetence will be reported, and those without adequate judgment and skills will be held accountable," she says. "Disrespect will not be tolerated, and managers have the responsibility to respond and to react to the information they receive from their staff. It is their responsibility to support their staff and be respectful in their communications." (For more information on incompetence and disrespect, see stories below.)

The study also underscores the need for teamwork, Groah says. "It is a call to action for members of the surgical team to sit down together and map out clear strategies that will result in a culture of safety," she says. "That means a culture of trust in which all members of the perioperative team are encouraged to provide safety-related data and are acutely aware of the distinction between acceptable and unacceptable behaviors."

Managers: Don't fail to train staff

'Incompetency' might be lack of education

While "incompentence" showed up as a primary patient safety issue in the recent study The Silent Treatment, this problem is not specific to any one surgery setting, says Jan Davidson, MSN, RN, perioperative education specialist at the Association of periOperative Registered Nurses (AORN). AORN sponsored the study, along with the American Association of Critical-Care Nurses (AACN) and VitalSmarts, a corporate training company in Provo, UT.

"It should never be assumed by anyone that working in an outpatient setting is somehow an easier job and that the nurses that work in such a setting are somehow not as skilled as the nurse that works in another perioperative setting," Davidson says. "That is far from the truth."

However, outpatient surgery staff often work with very limited resources, she adds. "Managers need to hear them when they say, 'help us to be better by allowing us time for regular and ongoing education.'"

Nurses and other clinicians in outpatient surgery wear many hats. "We fail them when we don't provide them with the necessary tools and/or training they need to also assume the role and responsibility for something they have never had to do before, such as the facility radiation safety officer or the infection prevention specialist," Davidson says. "We also fail them when we don't provide them regular and consistent time allotted for continuing education and in-services."

Managers need to provide tools and/or training to refine staff members' critical thinking skills and/or their critical care skills such as with advanced cardiac life support (ACLS) and pediatric advanced life support (PALS), she says. In The Silent Treatment study, 82% of respondents said that 10% or more of their colleagues are missing basic skills and, as a result, 19% say they have seen harm come to patients. Only 11% have spoken to the incompetent colleague.

Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI, says, "The question is, are you making sure your personnel have adequate training in CPR, if patients have heart-related problem, and that you not only know how to respond, but you have adequate equipment to respond and stabilize them before 911 or emergency personnel can get there?"

Have an emergency plan, Trosty advises. "There should be an early indication of basic skills and understanding, to help prevent potential harm to a patient, should one of these potentially negative events occur," he says.


A primary safety issue: R-E-S-P-E-C-T

Is a respectful attitude missing among your staff? It has to come from the top down, says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI.

For example, while surgeons traditionally are seen as captains of the ship, "that doesn't mean [they] need to be discourteous, rude, curt, or insulting toward [their] employees," Trosty says.

The same advice goes for nurses toward each other, and clinicians toward clerical staff, he says. Any time you're a negative team, you're putting patients at a greater risk, Trosty says.

Disrespect showed up as a primary concern in the recent study The Silent Treatment, sponsored by the Association of periOperative Registered Nurses (AORN), the American Association of Critical-Care Nurses (AACN), and VitalSmarts, a corporate training company in Provo, UT. Eighty-five percent of respondents said that 10% or more of the people they work with are disrespectful and therefore undermine their ability to share concerns or speak up about problems. Only 16% have confronted their disrespectful colleagues.

One solution is a code of conduct, as required by The Joint Commission. The code of conduct, which includes information on how to handle disrespectful behavior, should be reviewed with new employees, says Jan Davidson, MSN, RN, perioperative education specialist at the Association of periOperative Registered Nurses (AORN).

"Disrespectful behavior amongst peers or physicians should never be allowed, and there should be language in the medical staff bylaws and the employee handbook that emphasizes a zero tolerance for disrespectful behavior," Davidson says. (For more information on this topic, see The Joint Commission's brochure on having a code of conduct can be accessed at http://www.jointcommission.org/Code_of_Conduct.)