CONTINUING EDUCATION Back to Basics: Speak Up
1.2
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14507 Session: #0001 Fee: Members $9.60, Nonmembers $19.20
Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire March 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to speaking up in the OR to prevent mistakes and patient harm.
Conflict of Interest Disclosures
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.10.020
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 407
Back to Basics: Speak Up LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
1.2 www.aorn.org/CE
ABSTRACT Being able to identify problems and bring them to the attention of OR team colleagues is crucial for the safety of both patients and perioperative team members; however, being able to do this means being comfortable with speaking up under circumstances that may be difficult. Disruptive or intimidating coworker behavior also makes speaking up difficult, but it is important to address in the interest of providing safe, effective care to patients. To remedy this, health care workers should create awareness of the problem and motivate others to take action; establish a culture of respect; set expectations to help eliminate disrespectful behavior; and create a learning environment that eliminates hierarchical structures, fosters professionalism, demonstrates respect, and enforces a zero tolerance policy. AORN J 99 (March 2014) 408-412. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.020 Key words: speak up, disruptive behavior, culture of respect, culture of safety, hierarchical structures, zero tolerance.
A
s a new nurse in the OR, Jill found it to be an exciting and rewarding place to work. She had a fantastic orientation and a great preceptor. She was given plenty of time to learn and feel confident in her new role. Then she met Dr Cook. Dr Cook was a gynecologic surgeon with a reputation for being hard on the staff and impatient with anyone new. She treated Jill with indifference when she was in orientation, and Jill’s preceptor told her to avoid Dr Cook at all costs. She was able to do that for a while, but eventually she had to circulate a case for Dr Cook. Jill was a great perioperative nurse and had no difficulty with the technical aspects of the job, but as she was entering information into the electronic medical record during the procedure, she noticed that as Dr Cook reached up to adjust the light she contaminated her glove (Figure 1). Jill was paralyzed with fear, afraid to speak up and tell Dr Cook that she had made a
mistake. No matter what Jill said to herself, she could not find the courage to speak. Jill was so upset that she did not speak up that it made her seriously question her ability to be a perioperative nurse. SPEAK UP The type of scenario between Jill and Dr Cook is not uncommon, but it is important to address in the interest of providing safe, effective care to patients. “Intimidating and disruptive behaviors” in the health care setting that prevent nurses and others from speaking up can lead to medical errors and adverse effects for patients, as well as increase the cost of care and lead to low patient satisfaction scores.1 Another effect of allowing this type of behavior to continue is that personnel will look for jobs in other facilities. “To assure quality and to promote a culture of safety, health care
http://dx.doi.org/10.1016/j.aorn.2013.10.020
408 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
BACK TO BASICS: SPEAK UP
www.aornjournal.org
Figure 1. Students are often the brunt of (A) disrespectful and intimidating behavior, which can (B) cause personnel to be too scared to speak up or (C) cause personnel to look for jobs in other facilities. What’s Wrong With This Picture? reprinted with permission from AORN, Inc, Denver, CO. All rights reserved.
organizations must address the problem of behaviors that threaten the performance of the health care team.”1(p1) Addressing this behavior can be difficult, and health care personnel often avoid taking action. Research has shown that only a small percentage of health care workers speak up when they see mistakes, incompetence, disrespect, or poor teamwork.2 Sometimes, as in Jill’s case, nurses and other personnel are afraid to speak up when they experience intimidation or disrespectful and abusive behavior. One study showed that although 77% of health care workers experienced disrespect and abuse, only 7% spoke to the person and discussed their concerns.2 This statistic becomes even more disturbing when health care personnel avoid confrontation despite the fact that this avoidance may have a negative effect on the patient. Many health care providers have not reported important health
care information regarding their patient so they do not have to talk to the offending person.3 Disrespectful and disruptive behavior (Figure 2; view Supplementary Video 1 at http://www.aorn journal.org.) cannot be tolerated in the perioperative environment. Perioperative personnel must work as a team to provide not only safe patient care but also a pleasant environment for each other. Without mutual respect and trust among all members, safe patient care can suffer.1,2 HOW-TO GUIDE Health care workers report that they find it difficult to have a confrontation or to speak up because they do not have the confidence to do so.2 Most have never been taught to address these types of situations, and many will leave a facility rather than endure the abusive treatment or attempt to remedy it.3 Disruptive or aggressive behavior might be AORN Journal j 409
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March 2014 Vol 99 No 3
Figure 2. Intimidating and disruptive behaviors in the perioperative stetting can lower morale and potentially lead to patient safety issues. Reprinted with permission from Effective Communication in the -Med, Inc; Perioperative Setting. Woodbury, CT: Cine 2012.
tolerated within a facility because of production pressures and increasingly demanding documentation and other requirements.3 However, it is important to address these behaviors and create a culture of respect and safety (Figure 3; view Supplementary Video 2 at http://www.aornjournal.org). Culture of Respect and Safety To create a culture of respect and safety, implementation must begin at the leadership level, and transformation of the very core values of the organization must occur. One way to facilitate this is for leaders to be role models.4 Leaders should demonstrate to employees and others that the needs of every individual staff member are important and reinforce that all personnel should share this same vision and way of thinking. Leape et al4 recommend the following steps as major tasks that every leader should take to encourage a culture of respect: n
Motivate and inspiredCreate awareness of the problem and motivate others to take action.
410 j AORN Journal
Figure 3. Disruptive and aggressive behaviors cannot be tolerated in the perioperative environment because they can undermine a culture of safety. Reprinted with permission from Effective Communication in the Perioperative Setting. Woodbury, CT: -Med, Inc; 2012. Cine n
Establish preconditions for a culture of respectd Treat staff members with respect by showing concern for their well-being. n Lead policy formation initiatives regarding disrespectful behaviordSet expectations for acceptable behavior. n Engage frontline staff membersdEliminate the causes of disrespectful behavior by listening to and engaging with staff members. n Create a learning environmentdStudents are often the brunt of demeaning and disrespectful behavior. Work to eliminate hierarchical structures, foster professionalism, and demonstrate respect. Enforce a zero tolerance policy for disrespectful behavior. What Nurses Can Do There are ways that nurses can change their behavior and become empowered to speak up as well. The following are tactics from The Silent Treatment,5 which is the follow-up study to a 2005 Vital Smarts Study. n
Personal motivationdShare and listen to personal stories. When nurses share near misses and examples of how speaking up helped save a patient from harm, this sharing is a much better tool for learning than a lecture.
BACK TO BASICS: SPEAK UP n
Personal abilitydPractice handling different scenarios, such as role playing and scripting. Developing scripts on how to begin to speak up and how to handle emotions are crucial for empowering nurses to speak up. Not all nurses have the same ability and confidence to speak up, so practicing and working with scripts, as well as learning from others, will give them the support they need. n Social motivation and social abilitydIt is crucial for managers and physicians who champion respectful behavior to give nurses the support they need to be successful at speaking up. These champions can support nurses when they have to confront someone and give them the courage they need to challenge others for patient safety issues. n Structural motivationdIncentives matter. Managers should reward nurses for speaking up and following all patient safety practices. Recognition and rewards, such as gift cards and other small tokens, go a long way toward honoring patient safety efforts. n Structural abilitydMeasure success. By focusing their attention on the consistency and quality of safety behaviors and being aware that everyone is accountable, nurses can help change behavior.
www.aornjournal.org
the personal satisfaction of making a difference by learning to speak up and by addressing difficult situations. Additionally, by doing so, they are demonstrating their commitment to their profession and to the unit in which they work.5
TIPS AND TRICKS Leaders, physicians, and nurses can be instrumental in changing negative, disruptive behavior and making it safer for nurses and others to speak up. The following tips can help. n
Leader and physician involvement are key to success. Commitment to nurses at the frontline of perioperative care has to be communicated.6 n Managers can provide scenarios for role playing to help nurses deal with difficult situations. n All perioperative team members need to be on board with a speak-up plan and support one another.6 n All personnel should remember to n use the phrase “it is a patient safety issue” when speaking up, n create pocket cards with safety protocols listed to show when a process is not being followed, n use facts and data instead of opinion when calling a mistake to someone’s attention,5 n not show frustration or anger when speaking up and stay calm during these moments,5 n not threaten or try to influence the other person,5
BENEFITS The obvious benefit to speaking up is protecting patients from harm. Communication issues, lack of effective communication, and the other issues identified here are significant contributors to patient Video Resources harm and medical error.1 Costs to individual hospitals n Crucial Conversations. Vital Smarts. http://www.vitalsmarts.com. and the nation’s health care n Marshall D. Assertiveness in health care: speaking up for patient system could be signifisafety. Safer Healthcare. http://www.youtube.com/watch?v¼ cantly affected by the preZUV-OhxXVeA. vention of medical errors.6 n Want to create a healthier work environment? Vital Smarts. Nurses and other members of http://www.vitalsmarts.com/hwe. the perioperative team can Web access verified November 4, 2013. feel empowered and have
AORN Journal j 411
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n
n
let colleagues know that they are helping them by preventing them from making a mistake,5 and be forgiving of self and others and remember that everyone makes mistakes.
WRAP-UP Speaking up is a huge issue in the perioperative setting as well as other settings within the health care system. There are safety processes in place that protect patients, but when they are bypassed, speaking up is the only way to address them. Sometimes, it takes courage and strength to confront surgeons and other colleagues, but by doing so, the nurse can save a patient from preventable harm or death. Speaking up for patients in the perioperative setting means providing the patient with a voice and empowers nurses and others to make a difference. SUPPLEMENTARY DATA The supplementary videos associated with this article can be found in the online version at http:// dx.doi.org/10.1016/j.aorn.2013.10.020. References 1. Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008;40:1-3. http://www.joint
412 j AORN Journal
2.
3.
4.
5.
6.
commission.org/assets/1/18/SEA_40.PDF. Accessed November 5, 2013. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills: The Seven Crucial Conversations in Healthcare. Aliso Viejo, CA: American Association of Critical-Care Nurses (AACN) and Vital Smarts; 2005. http://www.aacn.org/WD/Practice/Docs/PublicPolicy/ SilenceKills.pdf. Accessed November 5, 2013. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7): 845-852. Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-858. Maxfield D, Grenny J, Lavandero R, Groah L; Vital Smarts, AORN, American Association of Critical-Care Nurses. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. Aliso Viejo, CA: AACN; 2010. http://www.aacn.org/WD/hwe/docs/ the-silent-treatment.pdf. Accessed November 5, 2013. Sayre M, McNeese-Smith D, Leach L, Phillips L. An educational intervention to increase “speaking-up” behaviors in nurses and improve patient safety. J Nurs Care Qual. 2012;27(2):154-160.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
EXAMINATION
1.2
CONTINUING EDUCATION
Back to Basics: Speak Up
www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge of best practices related to speaking up in the OR to prevent mistakes and patient harm.
OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
“Intimidating and disruptive behaviors” in the health care setting that prevent nurses and others from speaking up can lead to medical errors and adverse effects for patients, as well as increase the cost of care and lead to low patient satisfaction scores. a. true b. false
2.
Leaders should demonstrate to employees and others that the needs of certain individual staff members are more important than others and should reinforce that all personnel should share this same vision and way of thinking. a. true b. false
3.
According to Leape et al, major steps that every leader should take to encourage a culture of respect include 1. creating awareness of the problem and motivating others to take action.
Ó AORN, Inc, 2014
2. establishing preconditions for a culture of respect. 3. setting expectations for acceptable behavior. 4. eliminating the causes of disrespectful behavior by listening to and engaging with staff members. 5. working to eliminate hierarchical structures, fostering professionalism, and demonstrating respect. 6. enforcing a zero tolerance policy for disrespectful behavior. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 4.
Ways that nurses can change their behavior and become empowered to speak up include 1. sharing and listening to personal stories. 2. practicing how to handle different scenarios through role playing and scripting. 3. being socially confident and assertive at all times.
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4. focusing attention on the consistency and quality of safety behaviors. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 5.
Actions that can help to change behavior include a. using the phrase “it is a patient safety issue” when speaking up.
414 j AORN Journal
CE EXAMINATION b. showing frustration or anger to demonstrate the seriousness of the behavior. c. using clearly stated opinions during a confrontation. d. using threats and influence to implement changes.
LEARNER EVALUATION
1.2
CONTINUING EDUCATION PROGRAM
Back to Basics: Speak Up
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2. Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
Ó AORN, Inc, 2014
www.aorn.org/CE
7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _________________________________
March 2014
Vol 99 No 3
AORN Journal j 415
1.2
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
www.aorn.org/CE Continuing Education Contact Hours
Approvals
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Event: #14507 Session: #0001 Fee: Members $9.60, Nonmembers $19.20
Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
The CE contact hours for this article expire March 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge of best practices related to speaking up in the OR to prevent mistakes and patient harm.
Conflict of Interest Disclosures
Objectives 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.10.020
Ó AORN, Inc, 2014
March 2014
Vol 99 No 3
AORN Journal j 407
Back to Basics: Speak Up LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR
1.2 www.aorn.org/CE
ABSTRACT Being able to identify problems and bring them to the attention of OR team colleagues is crucial for the safety of both patients and perioperative team members; however, being able to do this means being comfortable with speaking up under circumstances that may be difficult. Disruptive or intimidating coworker behavior also makes speaking up difficult, but it is important to address in the interest of providing safe, effective care to patients. To remedy this, health care workers should create awareness of the problem and motivate others to take action; establish a culture of respect; set expectations to help eliminate disrespectful behavior; and create a learning environment that eliminates hierarchical structures, fosters professionalism, demonstrates respect, and enforces a zero tolerance policy. AORN J 99 (March 2014) 408-412. Ó AORN, Inc, 2014. http://dx.doi.org/10.1016/j.aorn.2013.10.020 Key words: speak up, disruptive behavior, culture of respect, culture of safety, hierarchical structures, zero tolerance.
A
s a new nurse in the OR, Jill found it to be an exciting and rewarding place to work. She had a fantastic orientation and a great preceptor. She was given plenty of time to learn and feel confident in her new role. Then she met Dr Cook. Dr Cook was a gynecologic surgeon with a reputation for being hard on the staff and impatient with anyone new. She treated Jill with indifference when she was in orientation, and Jill’s preceptor told her to avoid Dr Cook at all costs. She was able to do that for a while, but eventually she had to circulate a case for Dr Cook. Jill was a great perioperative nurse and had no difficulty with the technical aspects of the job, but as she was entering information into the electronic medical record during the procedure, she noticed that as Dr Cook reached up to adjust the light she contaminated her glove (Figure 1). Jill was paralyzed with fear, afraid to speak up and tell Dr Cook that she had made a
mistake. No matter what Jill said to herself, she could not find the courage to speak. Jill was so upset that she did not speak up that it made her seriously question her ability to be a perioperative nurse. SPEAK UP The type of scenario between Jill and Dr Cook is not uncommon, but it is important to address in the interest of providing safe, effective care to patients. “Intimidating and disruptive behaviors” in the health care setting that prevent nurses and others from speaking up can lead to medical errors and adverse effects for patients, as well as increase the cost of care and lead to low patient satisfaction scores.1 Another effect of allowing this type of behavior to continue is that personnel will look for jobs in other facilities. “To assure quality and to promote a culture of safety, health care
http://dx.doi.org/10.1016/j.aorn.2013.10.020
408 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
BACK TO BASICS: SPEAK UP
www.aornjournal.org
Figure 1. Students are often the brunt of (A) disrespectful and intimidating behavior, which can (B) cause personnel to be too scared to speak up or (C) cause personnel to look for jobs in other facilities. What’s Wrong With This Picture? reprinted with permission from AORN, Inc, Denver, CO. All rights reserved.
organizations must address the problem of behaviors that threaten the performance of the health care team.”1(p1) Addressing this behavior can be difficult, and health care personnel often avoid taking action. Research has shown that only a small percentage of health care workers speak up when they see mistakes, incompetence, disrespect, or poor teamwork.2 Sometimes, as in Jill’s case, nurses and other personnel are afraid to speak up when they experience intimidation or disrespectful and abusive behavior. One study showed that although 77% of health care workers experienced disrespect and abuse, only 7% spoke to the person and discussed their concerns.2 This statistic becomes even more disturbing when health care personnel avoid confrontation despite the fact that this avoidance may have a negative effect on the patient. Many health care providers have not reported important health
care information regarding their patient so they do not have to talk to the offending person.3 Disrespectful and disruptive behavior (Figure 2; view Supplementary Video 1 at http://www.aorn journal.org.) cannot be tolerated in the perioperative environment. Perioperative personnel must work as a team to provide not only safe patient care but also a pleasant environment for each other. Without mutual respect and trust among all members, safe patient care can suffer.1,2 HOW-TO GUIDE Health care workers report that they find it difficult to have a confrontation or to speak up because they do not have the confidence to do so.2 Most have never been taught to address these types of situations, and many will leave a facility rather than endure the abusive treatment or attempt to remedy it.3 Disruptive or aggressive behavior might be AORN Journal j 409
SPRUCE
March 2014 Vol 99 No 3
Figure 2. Intimidating and disruptive behaviors in the perioperative stetting can lower morale and potentially lead to patient safety issues. Reprinted with permission from Effective Communication in the -Med, Inc; Perioperative Setting. Woodbury, CT: Cine 2012.
tolerated within a facility because of production pressures and increasingly demanding documentation and other requirements.3 However, it is important to address these behaviors and create a culture of respect and safety (Figure 3; view Supplementary Video 2 at http://www.aornjournal.org). Culture of Respect and Safety To create a culture of respect and safety, implementation must begin at the leadership level, and transformation of the very core values of the organization must occur. One way to facilitate this is for leaders to be role models.4 Leaders should demonstrate to employees and others that the needs of every individual staff member are important and reinforce that all personnel should share this same vision and way of thinking. Leape et al4 recommend the following steps as major tasks that every leader should take to encourage a culture of respect: n
Motivate and inspiredCreate awareness of the problem and motivate others to take action.
410 j AORN Journal
Figure 3. Disruptive and aggressive behaviors cannot be tolerated in the perioperative environment because they can undermine a culture of safety. Reprinted with permission from Effective Communication in the Perioperative Setting. Woodbury, CT: -Med, Inc; 2012. Cine n
Establish preconditions for a culture of respectd Treat staff members with respect by showing concern for their well-being. n Lead policy formation initiatives regarding disrespectful behaviordSet expectations for acceptable behavior. n Engage frontline staff membersdEliminate the causes of disrespectful behavior by listening to and engaging with staff members. n Create a learning environmentdStudents are often the brunt of demeaning and disrespectful behavior. Work to eliminate hierarchical structures, foster professionalism, and demonstrate respect. Enforce a zero tolerance policy for disrespectful behavior. What Nurses Can Do There are ways that nurses can change their behavior and become empowered to speak up as well. The following are tactics from The Silent Treatment,5 which is the follow-up study to a 2005 Vital Smarts Study. n
Personal motivationdShare and listen to personal stories. When nurses share near misses and examples of how speaking up helped save a patient from harm, this sharing is a much better tool for learning than a lecture.
BACK TO BASICS: SPEAK UP n
Personal abilitydPractice handling different scenarios, such as role playing and scripting. Developing scripts on how to begin to speak up and how to handle emotions are crucial for empowering nurses to speak up. Not all nurses have the same ability and confidence to speak up, so practicing and working with scripts, as well as learning from others, will give them the support they need. n Social motivation and social abilitydIt is crucial for managers and physicians who champion respectful behavior to give nurses the support they need to be successful at speaking up. These champions can support nurses when they have to confront someone and give them the courage they need to challenge others for patient safety issues. n Structural motivationdIncentives matter. Managers should reward nurses for speaking up and following all patient safety practices. Recognition and rewards, such as gift cards and other small tokens, go a long way toward honoring patient safety efforts. n Structural abilitydMeasure success. By focusing their attention on the consistency and quality of safety behaviors and being aware that everyone is accountable, nurses can help change behavior.
www.aornjournal.org
the personal satisfaction of making a difference by learning to speak up and by addressing difficult situations. Additionally, by doing so, they are demonstrating their commitment to their profession and to the unit in which they work.5
TIPS AND TRICKS Leaders, physicians, and nurses can be instrumental in changing negative, disruptive behavior and making it safer for nurses and others to speak up. The following tips can help. n
Leader and physician involvement are key to success. Commitment to nurses at the frontline of perioperative care has to be communicated.6 n Managers can provide scenarios for role playing to help nurses deal with difficult situations. n All perioperative team members need to be on board with a speak-up plan and support one another.6 n All personnel should remember to n use the phrase “it is a patient safety issue” when speaking up, n create pocket cards with safety protocols listed to show when a process is not being followed, n use facts and data instead of opinion when calling a mistake to someone’s attention,5 n not show frustration or anger when speaking up and stay calm during these moments,5 n not threaten or try to influence the other person,5
BENEFITS The obvious benefit to speaking up is protecting patients from harm. Communication issues, lack of effective communication, and the other issues identified here are significant contributors to patient Video Resources harm and medical error.1 Costs to individual hospitals n Crucial Conversations. Vital Smarts. http://www.vitalsmarts.com. and the nation’s health care n Marshall D. Assertiveness in health care: speaking up for patient system could be signifisafety. Safer Healthcare. http://www.youtube.com/watch?v¼ cantly affected by the preZUV-OhxXVeA. vention of medical errors.6 n Want to create a healthier work environment? Vital Smarts. Nurses and other members of http://www.vitalsmarts.com/hwe. the perioperative team can Web access verified November 4, 2013. feel empowered and have
AORN Journal j 411
SPRUCE
March 2014 Vol 99 No 3
n
n
let colleagues know that they are helping them by preventing them from making a mistake,5 and be forgiving of self and others and remember that everyone makes mistakes.
WRAP-UP Speaking up is a huge issue in the perioperative setting as well as other settings within the health care system. There are safety processes in place that protect patients, but when they are bypassed, speaking up is the only way to address them. Sometimes, it takes courage and strength to confront surgeons and other colleagues, but by doing so, the nurse can save a patient from preventable harm or death. Speaking up for patients in the perioperative setting means providing the patient with a voice and empowers nurses and others to make a difference. SUPPLEMENTARY DATA The supplementary videos associated with this article can be found in the online version at http:// dx.doi.org/10.1016/j.aorn.2013.10.020. References 1. Behaviors that undermine a culture of safety. Sentinel Event Alert. July 9, 2008;40:1-3. http://www.joint
412 j AORN Journal
2.
3.
4.
5.
6.
commission.org/assets/1/18/SEA_40.PDF. Accessed November 5, 2013. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills: The Seven Crucial Conversations in Healthcare. Aliso Viejo, CA: American Association of Critical-Care Nurses (AACN) and Vital Smarts; 2005. http://www.aacn.org/WD/Practice/Docs/PublicPolicy/ SilenceKills.pdf. Accessed November 5, 2013. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7): 845-852. Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, part 2: creating a culture of respect. Acad Med. 2012;87(7):853-858. Maxfield D, Grenny J, Lavandero R, Groah L; Vital Smarts, AORN, American Association of Critical-Care Nurses. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. Aliso Viejo, CA: AACN; 2010. http://www.aacn.org/WD/hwe/docs/ the-silent-treatment.pdf. Accessed November 5, 2013. Sayre M, McNeese-Smith D, Leach L, Phillips L. An educational intervention to increase “speaking-up” behaviors in nurses and improve patient safety. J Nurs Care Qual. 2012;27(2):154-160.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR, is the director, evidence-based perioperative practice, AORN, Inc, Denver, CO. Dr Spruce has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
EXAMINATION
1.2
CONTINUING EDUCATION
Back to Basics: Speak Up
www.aorn.org/CE
PURPOSE/GOAL To provide the learner with knowledge of best practices related to speaking up in the OR to prevent mistakes and patient harm.
OBJECTIVES 1. Discuss common areas of concern that relate to perioperative best practices. 2. Discuss best practices that could enhance safety in the perioperative area. 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
“Intimidating and disruptive behaviors” in the health care setting that prevent nurses and others from speaking up can lead to medical errors and adverse effects for patients, as well as increase the cost of care and lead to low patient satisfaction scores. a. true b. false
2.
Leaders should demonstrate to employees and others that the needs of certain individual staff members are more important than others and should reinforce that all personnel should share this same vision and way of thinking. a. true b. false
3.
According to Leape et al, major steps that every leader should take to encourage a culture of respect include 1. creating awareness of the problem and motivating others to take action.
Ó AORN, Inc, 2014
2. establishing preconditions for a culture of respect. 3. setting expectations for acceptable behavior. 4. eliminating the causes of disrespectful behavior by listening to and engaging with staff members. 5. working to eliminate hierarchical structures, fostering professionalism, and demonstrating respect. 6. enforcing a zero tolerance policy for disrespectful behavior. a. 1, 3, and 5 b. 2, 4, and 6 c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6 4.
Ways that nurses can change their behavior and become empowered to speak up include 1. sharing and listening to personal stories. 2. practicing how to handle different scenarios through role playing and scripting. 3. being socially confident and assertive at all times.
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4. focusing attention on the consistency and quality of safety behaviors. a. 1 and 3 b. 2 and 4 c. 1, 2, and 4 d. 1, 2, 3, and 4 5.
Actions that can help to change behavior include a. using the phrase “it is a patient safety issue” when speaking up.
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CE EXAMINATION b. showing frustration or anger to demonstrate the seriousness of the behavior. c. using clearly stated opinions during a confrontation. d. using threats and influence to implement changes.
LEARNER EVALUATION
1.2
CONTINUING EDUCATION PROGRAM
Back to Basics: Speak Up
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss common areas of concern that relate to perioperative best practices. Low 1. 2. 3. 4. 5. High 2. Discuss best practices that could enhance safety in the perioperative area. Low 1. 2. 3. 4. 5. High 3. Describe implementation of evidence-based practice in relation to perioperative nursing care. Low 1. 2. 3. 4. 5. High CONTENT 4. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 5. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High 6. Will you be able to use the information from this article in your work setting? 1. Yes 2. No
Ó AORN, Inc, 2014
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7. Will you change your practice as a result of reading this article? (If yes, answer question #7A. If no, answer question #7B.) 7A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: ________________________________ 7B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 8. Our accrediting body requires that we verify the time you needed to complete the 1.2 continuing education contact hour (72-minute) program: _________________________________
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