EXECUTIVE SUMMARY
New research suggests that physicians’ and nurses’ fears of repercussions from error reporting are quite different. This difference means that “speak up” campaigns might need to be tailored to each group.
- Discipline-specific “speaking-up” training should be balanced with learning in inter-professional teams.
- Tailored patient safety strategies might be needed for different care settings.
- the Study Confirms That Leadership Support For Safety Has A Powerful Influence On Positive Nurses’ And Physicians’ Perceptions.
Efforts to encourage error reporting and voicing concerns about patient safety always have faced the hurdle of staff and physicians fearing there will be repercussions. Risk managers and patient safety officers have tried to address that fear in various ways, but new research suggests a “one-size-fits-all” approach won’t work because doctors and nurses have significantly different fears.
The disparity in how physicians and nurses fear repercussions from speaking up about errors or safety concerns is so significant that it should dictate major changes in how risk managers address the issue, says Evan Castel, a PhD candidate in the Department of Geography’s Collaborative Program in Public Health Policy at the University of Toronto. He and his colleagues studied 2,319 nurse and 386 physician responders from three Canadian provinces. They concluded that age, gender, tenure, teaching status, and province were not significantly associated with the perception of fear from repercussions. They also found that strong organization and unit leadership support for safety explained the most variance in fear for both groups. (The full report is available online at http://tinyurl.com/zwvxvnu.)
Some of the results were surprising and troubling, Castel says. Many organizational behaviors change with age and time on the job, he notes. Staff members can become more secure and confident, so they might speak out more. Another option is that they can become more invested in organizational policies, and become more protective of workplace reputation and the status quo.
“To our surprise, neither age nor time in the organization was associated with fear of reporting errors, nor was working in a teaching hospital, where staff are in contact with new curricula and emerging best practices,” Castel says. “Instead, the role of supportive safety leadership stood out as pivotal. Whether this leadership came from the unit or organization mattered too, with organization-level leadership having over twice the effect on fear for nurses than physicians, while the role of unit leadership was similar for both groups and far smaller.”
The researchers also saw a surprising variation in fear of repercussions across care settings, with mental health nurses and community care physicians being particularly afraid of reporting.
“At the same time, we expected areas with both high risk and specialist staff like ED, OR, and CCU units to score particularly well, but this wasn’t observed. So we hope our work spurs further inquiry into how different care settings can work to encourage open communication.”
NO CHANGE WORKS FOR ALL
The authors concluded that the differences between nurses’ and physicians’ perceptions of fear of error reporting mean no single change is likely to produce universal improvements in patient safety in both groups.
They suggest that it might be advantageous to tailor some “speaking up” improvement strategies for each discipline. Additionally, they note that physicians don’t seem to benefit from some of the same supportive processes that help nurses avoid fear of repercussions.
“Accordingly, any discipline-specific ‘speaking up’ training should be balanced with learning in inter-professional teams to ensure that beneficial practices developing in one discipline are shared across the care team and to ensure ‘speaking up’ strategies address any barriers that stem from cross-disciplinary authority gradients,” they wrote.
TAILORED STRATEGIES
They also suggest that tailored patient safety strategies might be needed for different care settings such as mental health and community care. Castel says a key lesson for risk managers is that good safety leadership really does matter.
“It had the largest influence on whether clinicians felt unafraid to report medical errors — far outweighing the role of individual characteristics — and it matters to nurses and physicians regardless of age, tenure, and gender,” Castel says. “But nurses and physicians also behaved differently with regard to fear of speaking up, as did different care settings, so organizations shouldn’t rely on a one-size-fits-all approach to building a positive reporting climate.”
The research can be useful for risk managers trying to prioritize safety initiatives, and it demonstrates what efforts will have the highest return on investment, Castel suggests. He and his colleagues observed that leadership factors are pivotal: The large effect of organization-level leadership on fear, especially for nurses, will emphasize to risk managers how much strong safety signals from higher leadership matter. After all, staff perceptions of organization priorities are core to safety climate, Castel notes, so when leaders demonstrate that safety is a key priority through their own actions, real change can happen.
“And leadership style can really matter here,” he says. “Helping educate these leaders to move from bureaucratic to more participative leadership styles may allow them to better hear about frontline staff safety concerns and bring back solutions to integrate into decision-making processes.”
SECRECY AND SILENCE
Castel also thinks the study adds momentum to the movement away from the “blame the individual” punitive approach to errors, which can have the effect of encouraging secrecy and silence.
Factors such as clinician age, gender, and tenure had little or no association with their fear of repercussions, so he says individual-level factors might be the wrong levers to consider in isolation to change safety perceptions and behaviors. A better strategy is to consider how the individual works within the unit and organization, he says.
“We also identified several lower-scoring care settings where targeted risk management interventions may prove very effective, and we noted differences between nurses’ and physicians’ fear behaviors,” Castel notes. “This latter finding suggests that any discipline-specific ‘speaking up’ training should be balanced with learning in inter-professional teams. This encourages beneficial practices developing in one discipline being shared across the larger care team and also across any potential cross-disciplinary authority gradients.”
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