Providence St.Vincent Medical Center is Empowering Nurses to Speak up for Safety

Added on Jun 16, 2016

Providence St.Vincent Medical Center is Empowering Nurses to Speak up for Safety
By Erin Graham
From Industry Edge June 2016

It is well-established that nurses play a critical role in providing vigilant health care, and the actions nurses take—or don’t take—have a direct impact on patient outcomes. Less known, however, are the contextual and individual barriers nurses face in consistently and reliably speaking up in the face of potential threats to patient or caregiver safety.

Speaking up for safety is a key component of an organization’s ability to function as a High Reliability institution. In a High Reliability environment, all staff members are empowered to share their concerns about potential safety problems with others, both within their disciplines and across them. Staff are supported and encouraged to have questioning attitudes and to ask clarifying questions, and the organizational climate allows them to voice safety concerns without hesitation.

Caregivers’ ability to speak up for safety is an emerging area of research. Studies have shown that caregivers often choose to remain silent, even when they would rather share their observations. This can be due to fear of reprisal or retaliation, or to the social pressures that naturally exist in groups. Other times, caregivers have found that when they do speak up, their concerns are ignored or they face repercussions.

This complex topic inspired Helen Anderson, MSN, RN, NEA-BC, director of Nursing & Patient Care Services at Providence St. Vincent Medical Center, to investigate why professionals speak up or remain silent when patient (or staff ) safety is at stake. “The silver bullet in speaking up for safety is identifying why people actually do it or don’t do it,” she said. “Understanding this can help us overcome what could be preventing us from optimizing patient outcomes.”

Anderson is writing her Doctor of Nursing Practice research thesis on the factors that influence the decisions of nurses—in particular, whether to speak up or not to. Having been a nurse for 30 years, she is familiar with nurses’ role as gatekeeper to patient safety; as front-line staff uniquely positioned to catch early signs of unsafe conditions.

High Reliability in Action

Providence St. Vincent is part of Providence Health & Services in Oregon. The organization committed its efforts to becoming a High Reliability health care system with a goal of zero patient harm. Staff training included using the error prevention tool of speaking up for safety: telling staff how to speak up, demonstrating how to do it, giving them opportunities to practice and providing feedback. It also included putting mechanisms in place that would give staff support at the bedside to reach a satisfactory resolution.

As hospital staff learned how to use these tools, Anderson became interested in the factors that influence clinical nurses’ decisions around whether or not to use them.\

10 Factors to Speaking Up for Safety

In her examination of current literature, Anderson has identified 10 key factors—mostly contextual, as opposed to individual—that greatly influence the decision to speak up for safety.

1. Leadership and Expectations: Leadership behavior—on the part of a charge nurse, manager, CNO or informal leader— including role modeling, directly influences the performance of a team. When leaders act with integrity and accountability, it inspires courageous actions in others. Setting clear expectations for a safe environment creates the space for staff to develop their own moral courage.

2. Culture of Support: Caregivers must be confident that their unit and the wider organization will support them. This means leaders must foster a workplace culture that rewards ethical behavior.

3. Commitment to a Culture of Safety: Organizations need to make it clear that speaking up for safety is a long-term expectation that will be sustained over time, and not simply an “initiative of the month.” Improvements don’t occur until the team believes that “this is who we are,” at both the unit and hospital levels.

4. Teamwork on a Unit and Organizational Level: A healthy, supportive relationship among team members acts as a motivation to voice concerns, as does the desire to help the organization or work unit perform more effectively and make a positive difference for the collective group.

5. Moral Obligation: Nurses who feel a moral obligation to speak up for safety, because of the nature of the work they do, use a questioning attitude when making clinical decisions. Those who feel it is their right and responsibility to promote safety actively work to improve their practice in order to make the best clinical decisions for patients.

6. Negative Experiences: A history of working in an unsupportive, unstimulating environment impacts staff members’ practice in future work environments. It takes time to adjust to a culture of collaboration, teamwork, safety and engagement—and to feel that their voice matters.

7. Normative Behavior: Cultural norms—such as inclusive decision making, peer checking, peer coaching and “ask a question/ question an answer”—influence organizational members’ thinking, behavior, motivation and performance.

8. New Graduate Nurses: New nurses tend to speak up for safety when they feel their voices will be heard. This directly relates to the kinds of behavior they see role-modeled, and to whether or not they are encouraged to act in a morally courageous way and whether that behavior is positively reinforced.

9. Power Gradients: Inordinately large authority gradients and excessive professional courtesy increase the risk of adverse events. Closing gaps in power gradients (leader-to-subordinate relationships) encourages collaboration across ranks and disciplines.

10. Reception and Perception: A highly influential factor in speaking up is the anticipated reaction. For example, is the person being questioned encouraging or dismissive? The way someone receives a question—as a thoughtful inquiry or as a “challenge”—will effectively promote or dissuade that behavior and will influence others who see their reaction.

The Moral Courage Lens

As the science of patient safety deepens, nurse-researchers like Anderson are adding to the body of research driving High Reliability by exploring drivers of quality care. In addition to examining existing research on how factors such as power gradients and work culture influence a nurse’s decision to speak up, Anderson is also exploring the reverse: What personal attributes, attitudes and beliefs are factors in a nurse’s decision to act on behalf of someone’s safety?

As part of her thesis, Anderson is conducting a survey on this topic, drawing on a potential pool of 1,200 nurses at her hospital. She will examine speaking-up behavior through the lens of moral courage.

Moral courage, Anderson said, is the character trait that is applied when someone will take a risk and speak up, despite their worries about how it will be received. “It means asking a question and saying your peace in a respectful, compassionate way because you made a well-intentioned decision to do so based on ethical values,” she said.

Anderson’s study will look at individual factors in the display of moral courage and speaking up, such as nurses’ feelings of responsibility toward patients and their sense of obligation as professionals, as well as their job satisfaction, confidence, levels of experience, communication skills and educational backgrounds. “What gives someone the ability to overcome their fears and stand up for their core values and ethical obligations?” she asked.

Anderson is working closely with the hospital’s ethics committee in her work. “Moral courage is needed to confront all kinds of situations, including unethical practices,” she said. “It helps individuals address ethical issues by taking action when doing the right thing is not easy.”

In exploring the intersection of contextual factors (such as workplace culture and leadership influence) with personal characteristics (fortitude, moral courage), Anderson hopes to take the hospital’s High Reliability capabilities to the next level. She also hopes the work will ensure that they can sustain the progress they have made in creating a culture of speaking up for safety—because it’s the right thing to do.