Will staff really speak up if needed?

The health care community has been urging staff and patients to "speak up" when necessary to protect patient safety, but how do you know if your staff truly will make a stand in a difficult situation? After all, it's easy to say you will do the right thing, but in the heat of the moment, a staff member can be intimidated by superiors and fearful of rocking the boat.

So how can a risk manager know if nurses and other staff really will speak up? Finding the answer will require some work, says Grena Porto, RN, MS, ARM, CPHRM, senior vice president with Marsh, a health care management company in Philadelphia, PA, and past president of the American Society for Healthcare Risk Management (ASHRM). The work is necessary because it is foolhardy to just assume that staff will speak up because you tell them to, Porto says. Employees will quickly get the idea that the correct response is, "Yes, I will speak up to protect patient safety." But that doesn't mean they really feel empowered to do so, Porto says.

"A lot of people want to just say, 'We'll train the nurses, tell them what to do, and they will do it.' In fact, they don't," Porto says. "The culture really needs to support what you're telling them to do. Organizations that want to put all their focus on training the staff are missing the boat, because you have to create a systemwide culture."

Nurses and other staff are astute observers of the employer's culture and will respond accordingly, she says. They are quick to recognize that leaders are preaching about the virtues of speaking up for safety but at the same time dismissing staff concerns or even punishing those who speak. "It only takes one or two instances to undermine your whole effort. The staff say they're not going to speak up because they saw what happened to someone else who opened their mouth," Porto says. "Of course, they'll still tell you that they will do the right thing and speak up, because that's what you want to hear. I see that a lot."

Data can help reveal truth

If you want a "stop-the-line" culture, in which even the lowest-ranking employee can intervene when patient safety is threatened, that attitude must be modeled across the board, up to the highest levels of management, Porto says. That culture can be reinforced, for instance, by having top management personally and publicly praise employees who do speak up. An item in the employee newsletter, with the hospital president praising a housekeeper who spoke up to protect a patient, for example, can go a long way toward showing that the organization really supports this effort, Porto explains.

How do you know if you have that culture in place? Porto says you may have to collect data. Never just rely on what people tell you or the "feel" you get in the workplace, she says. Porto recommends using the "Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report" from the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD. This report discusses data from 108,621 hospital staff respondents across 382 participating hospitals, and it provides insight into how staff members see patient safety efforts. The report includes detailed guidelines for how risk managers can compile similar data in their own organizations and compare it to the data in the AHRQ report, which can give you some idea of how successful your effort is.

"So many of the respondents say it's not safe to speak up, and I don't think those organizations are unusual," Porto says. "And those are in organizations that cared enough to ask the question. In those that weren't willing to actually ask, I'd have to guess that the responses would be even worse. From this report, it's astonishing how little progress we've made."

Local culture can be important

The effort to encourage nurses to speak up is worthwhile because each instance of an error, near miss, or policy violation is an opportunity to improve patient safety, says Lori A. Paine, RN, MS, patient safety manager at Johns Hopkins Medicine in Baltimore.

"If we merely see nurses as the executors of provider orders, we miss the opportunity for the nurses to be that final check," she says. "That's how we see nurses, as a vital part of the system, sometimes the last gatekeeper for safety. If they are not empowered to speak up and if we don't listen to them, the organization misses a huge opportunity to improve safety."

Nurses have a long history of speaking up

Risk managers should remember that there is nothing new about urging nurses and other staff to speak up, says nursing historian Martha M. Libster, PhD, RN, CNS, associate professor of nursing at East Carolina University in Greenville, NC.

"You're not blazing a new trail here, and that's a good thing," she says. "There is a long history of nurses standing up to physicians and others, speaking up when necessary to protect their patients. So if you keep that in mind, the prospect of encouraging nurses to speak up isn't such a formidable challenge."

Libster advises risk managers to keep that in mind when approaching nurses about the necessity of speaking up and to remind them that this responsibility has long been a part of the nurse's role in health care. This strategy will be more effective, and more historically accurate, than addressing the nurses as if you are now going to ask them to do something new and different, she says. "I would suggest that you remind them that this has always been an important part of their job, that it is their professional and ethical responsibility to speak up," she says. "What you can offer now is some help in terms of advising them about how to speak up. Emphasize the practical, how they can do this, rather than implying that this concept is something new and different." [Editor's note: Contact Libster at (252) 744-6448 or libsterm@ecu.edu.]

Paine points out that, while organizational culture is important, the "local" culture of a staff member's unit or work area can be the driving factor in whether someone speaks up. Even if the overall culture of an organization is on the right track, there may be considerable variability from one unit to another, she says. "We see this sometimes in our event reporting, which we watch carefully and mine for any signs of problems that we need to address," Paine says. "Sometimes we will see reports that a nurse or supervisor is resistant to reporting from others, or we may also see a sharp discrepancy in the number of event reports coming from one unit. That can suggest that the staff in that particular unit are feeling discouraged from reporting these events to us."

Paine also notes that there are continuing concerns among some staff about the risk manager's role and what will happen if a concern is reported to the risk manager. Some staff may fear the intervention of a risk manager more than punishment from their supervisors, she says. "Risk managers can help by tearing down some of those walls and showing what you can do to help in those situations," she says.

Staff must be assured that you will support them when they act on behalf of a patient, says Christy Dempsey, BSN, MBA, CNOR, previously vice president and director of perioperative services at St. John's Regional Health Center in Springfield, MO, and now senior vice president of clinical operations for PatientFlow Technology, a health care consulting firm in Boston.

"From a management perspective, that's what I did to encourage people to speak up and act," she says. "I told them that as long as they followed the proper procedures and acted in the best interests of the patient, I would stand by them completely and support their actions. I wanted them to feel that they weren't going to be out there by themselves if they stuck their necks out."


For more information on encouraging nurses and other staff to speak up, contact:

  • Christy Dempsey, BSN, MBA, CNOR, Senior Vice President of Clinical Operations, PatientFlow Technology, Boston. Telephone: (617) 358-5060. E-mail: cdempsey@patientflowtech.com.
  • Lori A. Paine, RN, MS, Patient Safety Manager, Johns Hopkins Medicine, Baltimore. Telephone: (410) 955-2919. E-mail: lapaine@jhmi.edu.
  • Grena Porto, RN, MS, ARM, CPHRM, Senior Vice President, Marsh, Philadelphia. Phone: (215) 246-1144. E-mail: grena.porto@marsh.com.