Ninety-three percent of nurses and other clinicians responding to a recent survey say that 10 percent or more of their co-workers have taken dangerous shortcuts in providing care—with one in four saying this resulted in patient harm. More than 80 percent say that one in 10 or more of their co-workers are missing basic skills. But what equally concerns the study's sponsors—including the Association of periOperative Registered Nurses and the American Association of Critical-Care Nurses—is that only 31 percent of the respondents spoke up about these situations. That's roughly a threefold increase from what the researchers found in a 2005 study titled "Silence Kills." David Maxfield, vice president of research for VitalSmarts, a research-based training firm with a health care emphasis and the other survey sponsor, says hospitals need to create a "safety culture," one in which speaking up is encouraged. Maxfield talked with Bob Kehoe, H&HN contributing editor, about the survey's findings.

How did this study differ from the 2005 study?

New safety tools that were just coming out in 2005—universal protocols, perioperative briefings, crew checklists and SBAR (situation, background, assessment, recommendation) handoffs were just being implemented as a solution to communication breakdowns. This study looked at whether these tools were sufficient.

What was the key finding from the current study?

Eighty-five percent of the people we studied said they had been in a situation in which one of these safety tools—such as a checklist or a handoff protocol or a drug interaction warning system—worked. It prevented harm to a patient.

At the same time, more than half of those we studied said they were unable to speak up or get others to listen because a safety culture did not exist.

Why were they reluctant to speak up?

Three reasons were most often cited. One was, "It's not my job." The second reason was that they were busy. The third and most common reason was that they were afraid of some kind of retaliation—something as simple as not wanting to make someone angry.

Which areas of improvement were most significant?

Nurses, in particular, are speaking up at much better rates. In the 2005 study, they were speaking up 10 to 12 percent of the time. Now they're speaking up 20 to 30 percent of the time. That's far from the 100 percent we need, but it's two to three times better than in 2005.

When are these communication challenges occurring?

The most common is when there is a disagreement, where there are high stakes and one or more of the parties becomes emotional. That's the time when the vast majority of the people in our study start to back off and fail to speak up to protect the patient at the level they should.

How do you get clinicians more comfortable about speaking up?

One of the things we did in the study was have them share examples of how they spoke up and clone that so that everyone has those skills. The second is to change the culture itself and make it safer for people across the organization to speak up and be heard.

The data indicated that nurses see colleagues taking shortcuts. What are they seeing?

Primarily, they see people not washing their hands or not washing them appropriately, people not changing gloves when it's appropriate, not gowning up appropriately, not checking arm bands or skipping surgical pause.

Why aren't nurses calling timeouts or taking other actions?

They're saying loud and clear that those are good ideas, they work and that those safety tools are critical to improving patient safety. They're also saying that it's harder than you might imagine to speak up and ask for a timeout when a more powerful person starts to get angry. You need to have confidence in your skills and support from the organization.

Is it realistic to think that we'll get 100 percent or have a large majority of clinicians speak up in these types of situations?

Absolutely. We've been working on this and we usually start with something very simple like perfect hand hygiene. When we worked with Spectrum Health, Grand Rapids, Mich., they were a little above the national average—about 60 or 70 percent compliance with wash in and wash out; within six weeks they were at 90 percent and they've been at 95 percent for two years now. They did that by focusing on three behaviors. The first is wash in and wash out. Every time you enter a patient area you wash and every time you leave a patient area you wash.

The second behavior is whenever you see someone enter or leave a patient area without washing up, you have to talk to him or her. And third, when someone does remind you to wash up, show appreciation and wash up again.

Disrespect seems to be a common concern among respondents. How can this be addressed?

We're working with a number of hospitals in which disrespect is an issue. The typical approach is to establish a code of conduct first that defines disruptive behavior. That's essential, but at the same time it creates a backlash in that some physicians feel as though every time they turn around, someone is drawing a line in the sand.

When implementing a code of conduct, you should also identify the stressors that cause disruptions. We've done this in cooperation with Maimonides Medical Center in New York City.

What Maimonides has done so well is combine a code of mutual respect with process improvement to try to reduce those stressors that cause disruptive behavior and train the physicians and staff how to have these conversations in a more productive way. We consider it a three-pronged approach: 1) A code of mutual respect; 2) Process improvements that reduce those stressors that cause disruptive behavior; and 3) Training in communications skills so that people can talk constructively about emotional differences.

What recommendations came out of the study That should be passed onto hospital executives?

Identify the moment when safety protocols are put at risk. Most people use most of the safety protocols most of the time, so look for the exceptions and focus your efforts there. Second, identify the vital behaviors that will fix the problem during those crucial moments. One of the most important vital behaviors is that everyone holds everyone accountable for using the safety tools. Next, train people how to do that. Finally, develop a playbook of strategies. Don't rely on training alone. Look at how you can reduce the crucial moments, make these crucial moments less emotional and intense and give people coping skills.