To err is human. To speak up? It depends, study says

Brendan Murphy , Senior News Writer

A resident sees a fellow clinician breach sterile field while placing a central catheter. Another clinician is paying little heed while rounding on new patients, distracted by a stream of text messages. Will the resident say something about these actions that could adversely affect patients? The distressing answer, says a recent study, is that it depends, in part, on who the clinician is.

Residents are much less likely to speak up about unprofessional behavior when it involves an attending physician than they are when the actor is a nurse or peer, says the study, published in BMJ Quality & Safety.

The study determined that even in instances where a patient safety threat was observed, respondents were much less likely to speak up if the offender was an attending physician rather than a fellow resident. They were much likelier to point out the mistake if made by an intern.

“Power differential is one of the many drivers of whether or not people feel comfortable speaking up around a variety of concerns,” said William Martinez, MD, who co-wrote the study. “One of the other main drivers is psychological safety—what you anticipate the response to be and whether or not you anticipate there to be a confrontational response or some sort of consequence. Whether it is actual or perceived, it doesn’t so much matter. What we’re seeing is that, at least the residents in our study perceived there to be a lesser degree of psychological safety and a power differential that drove the difference” in response rates.

The data were gathered through a survey of about 900 medical and surgical interns and residents from medical centers across the country. They were presented two vignettes that assessed the likelihood of their speaking up. One vignette was a traditional safety threat (a breach of sterile field during placement of a central catheter), while a second vignette presented a professionalism-related safety threat (an inattentive colleague who is looking at a smartphone and texting while rounding on patients). Respondents were then asked how likely they would be to vocalize their concern if the clinician was a nurse, intern, resident or attending.

In the traditional safety threat vignette, about nine in 10 respondents said they would speak up to a nurse, intern or resident—contrasted with about six in 10 if the offender were an attending. In the breach of professionalism vignette, just 9 percent of survey respondents said they would be willing to speak up to an attending.

“In the professionalism vignette, the residents were even less likely to speak up across the board,” said Dr. Martinez, an assistant professor of medicine at Vanderbilt University School of Medicine. “That difference points to the unique nature of professionalism threats, where the anticipated response to speaking up may be felt to be more confrontational. For professionalism-related threats, the action may be perceived as deliberate and may more likely be attributed to the character traits of the person involved. That sets up the anticipated response to feel a little more confrontational.”

Dr. Martinez believes that creating an environment where all clinicians feel comfortable speaking up is vital. After all, when health professionals speak up they do so with patient safety in mind.

Fostering an open dialogue among physicians of all experience levels starts from the top, Dr. Martinez said.

“One very simple thing—and something that I do when I’m an attending, largely based out of my own research—is that when I start with my team I always make sure to let them know that I expect them to speak up and we all are susceptible to lapses in our decision-making or execution of a medical procedure,” he said. “We may have a blind spot or we may not have heard something correctly. If they see something that they don’t think is right, it’s up to everybody on the team. We have a collective responsibility to the patient to always raise our concern.”

The study indicates that residents are more likely to speak up about a patient safety threat and unprofessional behavior if they believe that their concerns will lead to meaningful change. In many ways, this can be addressed at the institutional level, Dr. Martinez said. At Vanderbilt, for instance, there is a system in place that allows clinicians to report a professionalism-related issue about someone or something they have observed.

“About 75 percent of folks who are made aware of some kind of concern, they start to manifest fewer concerns in the future,” Dr. Martinez said. “Sometimes simply making people aware can be an effective tool.”

“It really starts with leadership,” he said. “You have to have leadership in place that is willing to support people in speaking up and in speaking up to or about anyone regardless of their status within an institution. If you don’t have that your progress is going to be limited.”