An essential element of professional practice, nurse advocacy for patient safety is embedded in the American Nurses Association’s Code of Ethics. Yet evidence suggests nurses and other healthcare professionals don’t always speak up with their patient-safety concerns. In 2005, the Silent Treatment Study involving 1,700 nurses, physicians, and other healthcare professionals found that 84% observed fellow clinicians take dangerous shortcuts but fewer than 10% confronted these individuals about their actions.

Why are so few of us willing to speak up on our patients’ behalf? Amy C. Edmonson, a social psychologist and professor of leadership and management at Harvard, studied the fears of people working in groups. From her observations in health care and other industries, she found employees believe others in the workplace are constantly evaluating them. For workers in all settings, protecting one’s image is important. The added stress of maintaining one’s image while under a perceived microscope of scrutiny at work is the main reason clinicians don’t speak up; they feel it’s not safe to do so.

Edmonson uses the term psychological safety to describe an individual’s perception that the practice environment is conducive to taking a potentially image-threatening risk. In psychologically safe environments, healthcare professionals believe they won’t suffer adverse consequences if they report a mistake or ask for help, education, or feedback. In environments that lack psychological safety, on the other hand, workers tend to keep their concerns to themselves.

Fears that promote silence

Edmonson identified four distinct fears that promote silence—fear of being perceived as ignorant, incompetent, negative, or disruptive. Let’s examine how each of these fears can affect patient safety.

Fear of being perceived as ignorant

Fear of being perceived as ignorant makes a person less inclined to ask questions. For instance, a nurse who floats to a different unit may lack recent experience accessing central venous catheters. She’s afraid to ask for assistance because she thinks nurses on the unit will look down on her for not understanding this seemingly basic skill. So she accesses a patient’s catheter on her own and unknowingly violates sterile technique. As a result, the patient develops a bloodstream infection.

Fear of being viewed as incompetent

Fear of being viewed as incompetent makes a person less likely to report a mistake or near-miss. Suppose a nurse narrowly avoids giving a medication to the wrong patient because she is distracted by a phone call from the lab. She fails to report this near-miss because she fears her manager and peers will think she’s incompetent.

Failing to report events and near-misses is particularly harmful because it prevents organizational learning. Learning from this event could have led to systematic changes to limit nurse distractions during medication administration, which might prevent future medication errors from harming patients.

Fear of being seen as negative

Fear of being seen as negative can stop someone from giving accurate individual and team performance appraisals. Say, for example, a nurse manager conducts a meeting with her staff. She reports that two patient falls occurred in the past week, and she seeks feedback from the team on how these falls could have been prevented. One of the unit’s newer nurses witnessed significant delays in answering patient call bells but was afraid to speak up because she feared the team would think she’s negative. If she had spoken up, strategies to improve call-bell responsiveness could have been addressed, helping to prevent future falls.

Fear of being seen as disruptive

During a time-out in the operating room, a nurse isn’t sure if the patient’s correct hip was marked for surgery. She considers speaking up, but the orthopedic surgeon is running behind and has encouraged everyone to be as efficient as possible so he can finish all of his cases before his son’s soccer game starts. The nurse keeps her concern to herself, fearing she’ll be seen as disruptive if she speaks up. If she had spoken up, the patient could have avoided wrong-site surgery.

Communication failure: A leading cause of patient harm

Overwhelming evidence points to communication failure as a leading cause of patient harm. To address the communication problem, a foundation of psychological safety must be achieved. Laying this foundation requires a deliberate process on the part of team members at all levels of the organization.

Transforming power-based relationships

Presence of someone with higher status in the organization intensifies the perceived risks of speaking up. Team leaders are responsible for transforming these power-based relationships and flattening the hierarchy.

To influence psychological safety in a positive way, leaders must make sure they’re directly accessible to the team. Traditional access barriers, including the need to go through assistants or residents, should be removed. This increases the likelihood of team members approaching the leader with questions or concerns and speaking up immediately as patient-care issues arise.

When confronted with questions or disclosure of mistakes or errors, the leader must make a conscious effort to treat team members with respect to reinforce their willingness to share information. She must clearly convey she’s receptive to hearing bad news. Also, she can acknowledge her own “humanness” by telling her team she needs them to speak up because she knows she may overlook certain things. She can seek feedback directly from team members at all levels to show she wants their input.

When encouraging participation, the leader must especially encourage junior or lower-status team members to speak up, as by asking junior team members for their input and calling on them before calling on senior team members. In addition, she must manage overpowering behaviors of higher-status team members. Leaders must not tolerate inappropriate, demeaning, bullying, or disruptive behaviors by any team member.

Structured processes for learning and communication

To succeed in creating a psychologically safe practice environment, healthcare leaders must develop structured processes for team learning and communication. The healthcare industry has taken particular notice of airline safety improvements over the last few decades. The Commercial Aviation Safety Team was founded in the late 1990s in response to multiple serious events; 10 years later, the rate of commercial air travel fatalities had dropped 83%. Like the healthcare industry, airlines have highly skilled employees who must function effectively as team members to ensure safe performance. Structured, open communication is a key driver of this safety improvement.

In health care, the main purpose of promoting open communication and feedback is to generate learning to improve the safety and quality of patient care. The leader must create a structure to support this process. One such structure involves briefings and debriefings. Briefings have been used successfully in many high-risk industries, including aviation, to unite the team in a shared framework or “mental model” for performance. The group’s task defines the nature of the briefings and debriefings. (See Structured processes used in healthcare settings by clicking the PDF icon above.)

Providing a common structure for communication

For teams to communicate safely and effectively within structured processes, a common communication style and common assertion techniques must be established. Nurses and physicians are taught to communicate in markedly different ways, which can cause or contribute to reluctance to speak up about safety concerns. Physicians are taught to be concise and get to the point quickly. Nurses, on the other hand, are reminded during their educational process that they can’t make diagnoses; this message can make them insecure about presenting their assessment results, causing them to paint a broad picture of the patient’s condition when communicating with physicians. The physician on the receiving end of this lengthy message becomes impatient, waiting for the nurse to “just ask for what she wants.”

The SBAR (Situation, Background, Assessment, Recommendation) tool can provide a common structure for communication. When SBAR is used as intended, the nurse is asked to suggest a diagnosis and ask for a specific treatment or action from the physician. But many nurses are uncomfortable doing this and haven’t been taught to think and communicate within this structure. Role-playing and practice with case studies can make them more comfortable. Faculty at some nursing schools already are working to embed this communication style in the new generation of nurses.

Because of the entrenched healthcare hierarchy, nurses tend to communicate deferentially and indirectly when they speak up about patient-safety concerns. How can leaders pave the way for team members to assert their concerns effectively? One organization has empowered nurses to bypass SBAR in critical obstetric situations simply by stating, “I need you to come now and evaluate this patient.” Physicians understand they’re accountable for responding promptly every time. Another example of mutually agreed-upon critical language derives from United Airlines’ safety program, called CUS—an acronym for I’m Concerned, I’m Uncomfortable, This is unSafe.

For critical language to be effective, leaders must ensure all team members understand it, grasp its intent, and adopt a culture that enables immediate actions to address patient-safety concerns when this language is used. (See How staff nurses can promote psychological safety by clicking the PDF icon above.)

Implementing new communication models

Implementing these new communication models can be challenging. Formalized education addressing effective communication has been lacking. Many clinicians lack the skills they need to engage in crucial conversations in their personal lives—yet we expect them to draw on such skills when patient safety is at stake.

Other factors—gender, age, race, religion, culture, tenure, education, and cliques—also can threaten team communication. Leaders must have robust administrative support to ensure the success of this new communication framework. Organizational development teams can be crucial in creating classes and promoting role-play and other creative interactive learning strategies to help launch new communication models.

Emerging from the cloak of silence

In a broad sense, all healthcare professionals report to the patient. If we were all players on a basketball team and our communication and teamwork were poor, we’d lose games and our coach would be fired. When we exhibit similar shortcomings in our healthcare teams, the patient suffers harm. Embracing this shared mental model of accountability to the patient is the first step in laying the foundation for psychological safety. This model empowers nurses to emerge from the cloak of silence and take an active, professional role in keeping patients safe.

Selected references

CAST: The Commercial Aviation Safety Team. http://www.cast-safety.org/apex/f?p=180:1. Accessed March 14, 2014.

Edmonson A. Managing the risk of learning: Psychological safety in work teams. In: West MA, Tjosvold D, Smith KG, eds. International Handbook of Organizational Teamwork and Cooperative Working. London: Blackwell; 2003.

Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-i90.

Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.

Maxfield D, Grenny J, Lavandero R, Groah L. The silent treatment: Why safety tools and checklists aren’t enough to save lives; 2011. www.silenttreatmentstudy.com/. Accessed March 11, 2014.

World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. 2008. http://www.who.int/patientsafety/safesurgery/ss_checklist/en/. Accessed March 11, 2014.

Susan Tocco is the director of operational effectiveness at Orlando Health in Florida. James DeFontes is the assistant executive medical director at Kaiser-Permanente in Pasadena, California.