Speaking out with courage

Do your nurses feel secure about speaking out when they spot errors or malpractice? HRMR asks what can be done to create a culture of moral courage.

One of the biggest barriers to patient safety is nurses’ fear of retribution if they speak up, according to hospital C-suite executives and risk managers surveyed this year by American International Group (AIG). For an extreme example of the repercussions of such a situation, read our feature on The Good Nurse, the true story of how a serial killer managed to go undetected in hospitals for 16 years, despite many nurses having concerns about his behavior.

The AIG survey supports research by the National Association for Healthcare Quality (NAHQ) which found that despite 20 years of quality and safety improvements, healthcare providers still hold back from speaking up, fearing retaliation and intimidation.

Physicians agree, even though they are often the reason nurses are fearful of speaking up. Dr Peter Angood, CEO of the American College of Physician Executives says the fear of retaliation is so “distinct and quite palpable” that some hospital staff are afraid to mention a threat to patient safety exists.
Steve Harden, CEO of patient safety training company LifeWings, believes the fear of speaking up urgently needs to be tackled in order to reduce patient harm.

“As a result of my own work with 140 healthcare organizations over the last 13 years, I have come to the conclusion that if we could get staff to speak up without fail when they perceive a problem with patient care, we could fix 85 percent of patient harm,” he says.

TRAINED TO INTERVENE
LifeWings recommends three steps that can change the fear of speaking up: first, train staff to speak up. “Telling is not training,” said Harden. “Training means you have told them how, shown them how (with a demonstration), given them an opportunity to practice through role play and/or simulation, and given them expert feedback on their practice. If you haven’t done this you haven’t trained.”

Secondly, you should put an escalation policy in place. Staff must know who to call to escalate an issue to get a satisfactory resolution. The number one reason trained nurses fail to speak up is that there is no mechanism in place to give them immediate support at the bedside.

Finally, you should put a ‘no retribution policy’ in place. The second most often cited reason for not speaking up is summed up in this anonymous quote from a nurse: “Sure, administration will support me when I speak up. They’ll even come to the bedside if I need them to. But later, for the next three months, that physician will make my life a living hell. And no one will do anything about it.”

Harden believes these three items go hand in hand: train; escalate; stop retribution, and that by using them you can overcome one of biggest barriers to patient safety today.

Susan Paparella, vice president of the Institute for Safe Medication Practices (ISMP), agrees. She says that organizations that are successful in reducing medication errors typically pay a lot of attention to the culture they have established.

“It’s a culture of safety, a learning culture,” she says. “They understand how to coach their employees and how to establish expectations. There’s a culture of accountability where you understand that there are times when human error is going to happen but there are other times when people engage in risky behavior, and we have to coach people to understand how that could contribute to errors.”

Paparella recommends promoting a culture of openness internally so that errors are owned and discussed and the necessary lessons are learned. As a patient safety organization (PSO) that produces regular safety alerts, ISMP makes it possible to learn not just from errors within your organization but from errors at other organizations too.

“Sometimes we’re not that good as leaders at taking that on. We say ‘if that didn’t happen here we don’t have a problem’ and we don’t recognise it until it has created an error. Establishing that culture of shared learning is important. Look to external sources of information and error, such as the ISMP medication safety alert, because very serious events may be rare but they’re so bad when they happen that there is so much learning to be had even from outside your organization.”

Dr Vicki Lachman, president of healthcare consultation, training and coaching specialist VL Associates, believes nurses need a helping hand to speak out. She has written books and articles on the subject of moral courage, a trait that she says healthcare organizations should cultivate in their nurses.

“It’s less of an issue for seasoned nurses—it’s the young ones that I find have the hardest time because they’re still getting their sea legs and trying to figure out the power structure,” she says. “They are still trying to figure out how much they can actually speak up. They have to know that leadership will back them up—if they see high profile doctors getting away with things it can make them wonder if it would be safe to speak up. The chief medical officer is the person who should be preventing that kind of disruption in the organization.”
Besides the danger to patient safety, not speaking up can haunt a doctor or nurse and negatively affect their morale.

“I’ve taught ethics to masters and doctor level nurses for the last nine and a half years and in their discussion boards they all remember and share a time when they didn’t speak out and how it still stays with them—they can feel bad for years afterwards,” Lachman says.

FOLLOW THE CODE
In order to nurture moral courage she has developed an acronym—CODE—which hospitals can use to help nurses speak out.
C: Courage—the nurse requires the moral courage to speak out.
O: Obligation—the nurse has an ethical obligation to speak out, outlined in the Code of Ethics for Nurses from the American Nurses Association (ANA).
D: Danger management—the nurse needs the ability to get past their fight or flight danger response and cognitively re-frame the situation so that they feel able to cope with speaking out.
E: Expression—speaking out through the use of assertiveness and negotiation skills.

Lachman was inspired to create these guidelines because she frequently heard about nurses being in ‘moral distress’. By choosing the acronym CODE she also implied a nod to the nurses’ code of ethics which gives them a moral obligation to speak out.

“I wanted to develop the CODE to help them, so that when they’re confronted with an ethical or moral situation that they would have an idea as to what’s necessary, because it’s hard to think when you’re under that kind of stress,” she says. “CODE lays out what I’ve determined as the basic skills you’re going to need to have the courage to be the best patient advocate that you can.”

Whatever methods you use to help your staff speak out with courage, the effects on your organization can be profound. Lachman has found that many hospitals with Magnet recognition from the American Nurses Credentialing Center have good systems in place for promoting moral courage. Get it right, and the effects can certainly be long-lasting and wide-reaching.

“What I always say to nurses is that moral courage is a habit and
a skill,” says Lachman. “The good news is the more you do it, the
easier it gets. After a while it can become just as much of a habit as not speaking up—but it’s so important not to have retaliation because that sends people spinning.” 