Speaking Up for Safety and Civility 2011

Aims To think about what makes it hard to speak up To think about what we can do to make it easier to speak up

We teach our kids to do it, so why can’t we?

Why does speaking up matter? Maxfield et al 2011, The Silent Treatment. Why safety tools and checklists aren’t enough to save lives. ( silenttreatment study.com) >80% nurses (n=4235) had concerns about dangerous shortcuts, incompetence or disrespect. >50% said shortcuts have led to near misses or harm >50% said disrespect has prevented them from getting others to listen or respect their professional opinion <50% had spoken to their managers about the person who concerns them most <30% had spoken to the person directly Worse where pt acuity and job demands are higher

What are the hurdles to speaking up? Professor Dan Raemer – Harvard Medical School/Massachusetts General Hospital “Responding to (very) challenging cases”

Hurdles Relational Content Self Climate

Relational hurdles Perceived hierarchy Respect for territory Respect for experience Value of the relationship Familiarity with the individual

Content hurdles Uncertainty about the issue Uncertainty about the consequences Confidence about being able to deal with the consequences

Self Perception of limited responsibility Avoidance of potentially embarrassing situations Fear of being wrong Personal reputation Protection of physician autonomy Natural obedience

Climate Not an environmental norm Waste of time Fear of repercussions Absence of a rubric/tool

The 2-challenge rule 1.Question with curiosity 2.Question with concern 3.Bring in a third party CHALLENGE TWICE THEN CALL FOR ASSISTANCE

Lessons Learnt The world’s worst air disaster happened in 1977 when two Boeing 747 jumbo jets collided on a runway at Tenerife, killing 583 people. After reviewing the cockpit voice recordings investigators realised that the steep authority and experience gradient in the cockpit between the captain, the first officer and the flight engineer “probably made his crew reluctant to question his decisions”. In other words, the junior staff were so intimidated by their senior that they felt they could not stop him from causing an accident they knew was about to happen, even though they had the ability to”.

The 2-challenge rule 1.Question with curiosity…… 2.Question with concern…….

1. Question with Curiosity CIVILITY “I’m curious to know why you felt it necessary to yell at me in that way?” “I’m curious to understand why you were not interested in listening to Mrs Smith’s concerns about her sister”

2. Question with Concern CIVILITY “When you yell and shout in that way I am concerned that you do not respect my views” “I am really concerned that that Mrs Smith does not feel as though her questions have been answered appropriately and that she is feeling anxious”

SAFETY “I am interested to know why we are using this particular antibiotic….”

Question with Concern SAFETY “I noticed that the patient file clearly says that the patient is allergic to this medication, I am really concerned that he may have an anaphylactic reaction as a result of having this specific antibiotic? Why are we giving it in this case?”

Bring in a third Party Ask another opinion Discuss with someone else Or take control………