Although there are many quotable passages in James Reason’s 2008 book The Human Contribution, this is one of my favorites:
For any organization, the only attainable safety goal is not zero accidents, but to strive to reach the zone of maximum practicable resistance and then remain there for as long as possible. For this, each organization requires both reliable navigational aids and some internal means of propulsion (1, p. 285).
Obviously, attaining zero accidents is unrealistic or as Reason might say, “Impracticable.” But it seems entirely possible, not to mention tremendously worthwhile, to work hard on ramping up our safety practices and environments to their highest levels of resilience and then “remain there for as long as possible.” Achieving those goals at least requires good information systems that collect and analyze data on accidents and near misses. But those systems will be ineffective without leaders who have the know-how and the will to implement strategies that improve patient safety (1).
I think it safe to say that anyone involved in patient safety would admit to the importance of personnel speaking up in achieving maximum system resilience. After all, staff witness hazards, threats, error pitfalls, etc., on a daily basis. But we all know how difficult it is to develop an organizational culture where employees feel comfortable speaking up about these safety issues (2). The literature offers at least four reasons why:
- Fear of retaliation likely tops the list (3). Staff feels unsafe in speaking up because virtually every system fault or concern has a person who will be (unfavorably) implicated in that speaking up allegation—a person who might not only become very defensive over the charge but who might want to “hurt the messenger.”
- A lack of the skills in speaking up is another challenge (4). Although I might approach Nurse Smith and voice my concern about some practice behavior of hers that seems problematic, if she becomes angry and threatening, words can fail me. Combined with my fear of retaliation, not knowing how to proceed with a constructive conversation inhibits my speaking up even more.
- “It’s not my job!” is another cause for the reluctance to speak up (5). Professionals tell me that production pressures at their hospitals and clinics can cause personnel to telescope their energies to their patients only. So, I might make a mental note of some practice or situation on my floor that imperils safety and then take measures to protect my patients from it. But elevating that issue to an organizational level by speaking up may require too much time. And besides, the thought that “Things usually work out OK despite problems” is enormously comforting and will encourage silence, even in the face of numerous safety threats (4).
- Professional collegiality is another factor that discourages speaking up. Patients come and go but staff work side-by-side for months, years and sometimes decades. Inter-professional relationships can easily be strained if staff feels humiliated by someone’s speaking up, such that patient safety might be diminished so that staff can all remain friends (6).
There’s an old saying that “Culture eats strategy for breakfast every day,” and the problems surrounding speaking up—indeed, as they exist in any organizational culture, not just healthcare—underline that saying’s truth. So, we need culture change, which largely issues from leadership. And the literature does indeed describe strategies for realizing speaking up such as:
- Leaders must encourage speaking up and stoutly protect employees who do (2,5). All the promises in the world will be for naught if employees are convinced that a “speaking up” campaign will primarily result in certain persons being targeted and penalized or dismissed from their positions (6).
- Leadership will have to teach employees that when one individual speaks up about another, the former will need compelling evidence to support his or her claims, as some may suspect those claims of being mean-spirited or vindictive (6,7).
- Very importantly, leadership must take speaking-up allegations seriously by not only investigating them but by providing feedback to the originator and informing him or her about what was done. A recent essay found that employees who are confident that nothing will be done about their report, allegation, or complaint will probably not speak up (2). Why bother?
- Leadership should figure out ways to model and reward speaking up. For example, some hospitals periodically feature and applaud an employee who called attention to system faults and flaws. Also, leadership should constantly walk the talk by describing its own quality improvement efforts to mitigate variables that lead to errors or unsafe conditions (7).
- Leaders will have to commit resources to employee education, such as teaching the best words and phrases to use in speaking up. They especially need to include training on conducting emotionally difficult conversations, which are inevitable in speaking up situations (8).
But it is as easy for me to write these words as it is hard to realize them in action, which is why we need good leaders. In the decades since hospitals and clinics have merged into massive systems of service delivery, strong leadership has become quintessential in achieving organizational goals, especially bearing on efficiency and navigating the competitive pressures of the marketplace. The organization that implements a healthy and productive speaking up culture should go a considerable distance towards reaching those objectives. But I want to end with a few words on what might be the greatest obstacle in achieving a speaking up culture, even though it’s one that is rarely on any institution’s quality improvement radar screen. It is the need for humility.
One of the hardest things for human beings to deeply absorb and truthfully admit is their imperfection. Human imperfections are wide-ranging and include our relational skills; the quality of our knowledge; our ability to learn, process, and retain information; our managing our emotions so they don’t interfere with our judgments; and the list goes on and on (9).
We all admit this in the abstract, but when we are confronted with any pointed suggestion for improving our professional work or relational behaviors, we often and, for some people, typically, react with defensiveness, suspicion, and hostility. One reason, as Abraham Maslow knew so well (10), is that it’s very important for humans to retain their self-esteem. Consequently, when they are implicated in or unfavorably targeted by an instance of speaking-up, they can feel dishonored, de-valued, marginalized or rejected (11). And those are hard feelings to bear.
I can very much relate to this despite how seemingly innocuous was the incident I’m going to tell. Many years ago, a colleague said to me, “Now, John, please don’t take this the wrong way, but your breath is bad.” I was absolutely stunned and could barely speak. And I’m sure I got mad. But in the years since, I have marveled at the courage it took for that person to confront me and how beneficial knowing that was for me. (And I’ve been carrying breath mints ever since.) Indeed, not a week goes by when I don’t come across someone with bad breath but I say nothing. But am I alone? How about you? Sound familiar?
Regrettably, I never thanked my colleague who is now long retired. But reflecting on that incident so long ago brings the challenge of speaking up into clear relief: The courage it takes to do it; the unpleasant reaction it might provoke; but the enormous value it can have for a person’s career, self-knowledge, and even quality of work. It’s an exercise in humility to accept something like that, but learning to is a very, very good thing.
So, there it is: Speaking up can be a marvelous tool in achieving system resilience if we can commit our knowledge, will power, and humility to it. But we do not teach humility in our health professional training programs despite that being an excellent place to start: that we are all fallible; that even the best of us makes mistakes (and fairly frequently, too); that mistakes are inevitable in hyper-complex environments like health care; that it is not a mark of incompetence to be confronted with our shortcomings; that we can always improve not matter how advanced or experienced we are; but that it is a mark of maturity, other-regard, and patient-centeredness to better ourselves by learning from mistakes (4). Consequently, if we are really committed to patient safety, we will tirelessly pursue learning about and remediating our individual and system flaws so as to continue advancing the nation’s safety agenda and ramping up our systems to their maximum levels of resilience.
- Reason J. (2008). The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Burlington, VT: AShgate Publishing Company.
- Etchegaray JM, Ottosen MJ, Dancsak T, and Thomas EJ. (Nov. 4, 2017). Barriers to speaking up about patient safety concerns. Journal of Patient Safety, PMID: 29112033.
- Dwyer J. (1994). Primum non tacere: An ethics of speaking up. Hastings Center Report, 24(1):13-18.
- Banja J. (2005). Medical Errors and Medical Narcissism. Sudbury, MA: Jones and Bartlett Publishers.
- Maxfield D, Grenny J, Patterson K, McMillan R, and Switzler A. (2005). Silence kills: The seven crucial conversations for healthcare. Retrieved from http://www.aacn.org/WD/Practice/Docs/PublicPolicy/SilenceKills.pdf.
- Banja J, Craig KD. Speaking up in case management, part II: Implementing speaking up behaviors. PCM Journal. 15(5):237-242.
- Gerstein M. (2008) Flirting With Disaster. New York, NY: Union Square Press.
- Sotile WM and Sotile MO. (1996) Managing yourself while managing others. Physician Executive, 22(9):39.
- Croskerry P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8):775-780.
- Maslow AH. (1962). Toward a Psychology of Being. Princeton: Van Nostrand Company.
- Pyszezynski T, Greenberg J, Solomon S, Arndt J, and Shimel J. (2004). Why do people need self-esteem? A theoretical and empirical review. Psychological Bulletin, 130(3):435-468.
John D. Banja, Ph.D. is a professor in the Department of Rehabilitation Medicine and medical ethicist at the Center for Ethics at Emory University in Atlanta. His area of specialization is patient safety ethics, and he consults frequently on medical malpractice cases.