Lack of Communication Pervasive in Hospitals, Patients Affected

The 2005 “Silence Kills” health care workforce study unearthed a number of troubling realities about the pervasive lack of communication between health care providers:

• 84 percent of doctors have seen co-workers taking shortcuts that could be dangerous to patients;
• 88 percent of doctors work with people who show poor clinical judgment;
• fewer than 10 percent of physicians, nurses, and other clinical staff directly confront colleagues about their concerns.

Still, despite the volume of safety tools and checklists (eg, handoff protocols, computerized order entry systems, automated medication-dispensing systems) developed to prevent communication errors and breakdowns, the problem is remains pervasive.

A follow-up study (“The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives”) conducted by the American Association of Critical-Care Nurses and VitalSmarts, a company that specializes in corporate training and organizational performance, finds that 85 percent of nurses confirm “that safety tools work,” but that their effectiveness is “undercut by “risks that are widely known, but not discussed." The authors termed these “undiscussables.”

58 percent of respondents (the study polled 6,500 nurses and nurse managers from health systems around the United States in 2010) indicate that these undiscussables made them feel “unsafe to speak up about the problems or where they were unable to get others to listen.”

Undiscussables are a severe detriment to patient health. More than 80 percent of nurses feel that “10 percent or more of their colleagues take dangerous shortcuts…are missing basic skills…[and] are disrespectful.” 26 and 19 percent of respondents, respectively, have seen patients come to harm as a result of these dangerous shortcuts and incompetence.

The disrespect, they say, “undermines their ability to share concerns or speak up about problems,” which would explain why in each instance, only 17, 11, and 16 percent of respondents “shared their concerns with the colleague in question.”

The data is disappointing and “suggest[s] that without support from physicians, nurses, and administrators, these system improvements cannot guarantee patient safety.” The hope is that by studying “successful outliers,” the small percentage of vocal nurses serving as agents for change, health care systems and providers can incorporate “high-leverage behaviors” that will “change the trajectory of harmful patient care.

There is evidence that such behaviors are taking root.

“Compared with what we learned in 2005, nurses now speak up at much better rates and are now nearly three times more likely to have spoken directly to the person and shared their full concerns,” says AACN President Kristine Peterson, RN, MS, CCRN, CCNS. “This increased focus on creating cultures of safety needs to continue until every health professional feels empowered to speak up to reduce errors and improve quality of care.”

The study described nurses who chose to speak up as “positive deviants or exceptional nurses,” and each related a story in which speaking up “made a positive difference.” They cited seven “skills and actions [that] lead to their success”:

1. When the issue wasn’t urgent, they collected facts, ran pilot tests, and worked behind the scenes.
2. They assumed the best, and spoke up. Sometimes it just takes one person to pave the way.
3. They explained their positive intent—how they wanted to help the caregiver as well as the patient.
4. They took special efforts to make it safe for the caregiver—to avoid creating defensiveness.
5. They used facts and data as much as possible, often taking the other person into the actual situation.
6. They avoided telling negative stories or making accusations.
7. They diffused or deflected the person’s anger and emotion.

But even the exceptional nurses were driven to speak up by strong motivating factors. The “elements that helped these exceptional nurses overcome their concerns about speaking up” include:

1. They had spoken up sometime in the past, and a patient had been protected.
2. A patient had already been harmed, and the incident was being reviewed.
3. They had a strong trusting relationship with the person they needed to confront.
4. One or more physicians had made it clear that they appreciate it when nurses speak up.

“Safety tools such as protocols and checklists guard against honest mistakes,” says Linda Groah, RN, MSN, CNOR, CNAA, FAAN, Executive Director and CEO of the American Association of periOperative Registered Nurses. “However, this study tells us there is more work needed in the OR to support the surgical team’s ability to establish a culture of safety where all members can openly discuss errors, process improvements or system issues without fear of reprisal.”

One can only hope that the incremental steps taken on this front since “Silence Kills” will turn into lengthy strides.