VitalSmarts, Aorn, & AAcn present:
The Silent Treatment
Why Safety Tools and Checklists Aren't Enough to Save Lives
David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah
was conducted immediately before AACN's national standards for healthy work environments were released10. It identified seven concerns that often go undiscussed and contribute to avoidable medical errors. It linked the ability of health professionals to discuss emotionally and politically risky topics in a healthcare setting to key results like patient safety, quality of care, and nursing turnover, among others.
The Silent Treatment
shows how nurses' failure to speak up when risks are known undermines the effectiveness of current safety tools. It then focuses on three specific concerns that often result in a decision to not speak up: dangerous shortcuts, incompetence, and disrespect. The Silent Treatment
tracks the frequency and impact of these communication breakdowns, then uses a blend
Imagine you are a nurse
of quantitative and qualitative data to determine actions
who has been given a set of new
that individuals and organizations can take to resolve
safety tools that warns you whenever your patients are in danger. That would
be powerful, life-saving information, right? But what if nobody listened to you or heeded your warnings? This kind of breakdown is happening in hospitals every day. The quote below is one of 681 collected in the course of this research.
"I think nearly every day we are faced with the hand-off allergy list.
When communication breaks down, it breaks down
Frequently, the surgeons will order an antibiotic the patient is allergic
in two very different ways. Business theorist, Chris
to according to the safety checklist. When the patient is out of surgery,
Argyris ,groups these breakdowns into two categories:
nurses have to call the surgeon, the anesthesiologist, and sometimes
honest mistakes and undiscussables11. Each category
even the pharmacist before someone listens. Sometimes, we go ahead
has a different cause, produces a different range of
and give the drugs anyway, but when you really listen to the patient's
outcomes, and requires different solutions. Honest
story, sometimes that is not the right thing to do."
mistakes include accidental or unintentional slips and errors—for example: poor handwriting, confusing labels,
Poor communication is deadly, especially in critical care settings1,2. When
difficult accents, competing tasks, language barriers,
communication breaks down in intensive care units (ICU) and operating
distractions, etc. Somehow, the baton is dropped during
rooms, the result is catastrophic harm3,4,5,6 and even death7,8. The study
handoffs between shifts, departments, specialties, or
examines an especially dangerous kind of communication breakdown: risks
caregivers. Psychologist, James Reason, describes these
that are known but not discussed, or "undiscussables."
honest mistakes as the human equivalent of gravity12—they are inevitable. So they must be guarded against.
It builds on findings from research conducted in 2005 by the American Association of Critical-Care Nurses (AACN) and VitalSmarts9 as documented
When healthcare organizations invest in improving
in the research Silence Kills: The Seven Crucial Conversations for Healthcare
communication, they usually focus on reducing these
honest mistakes. They implement handoff protocols, checklists,
to three concerns: dangerous shortcuts, incompetence, and
computerized order entry systems, automated medication
disrespect. Respondents were asked how often they face these
dispensing systems, and other similar solutions all aimed at doing
concerns within their immediate work group, how they handle these
away with these unintentional slips and errors. These improvements
concerns, and how these concerns have impacted patients on their
are absolutely essential but they fail to address the second category
units. In addition, the instrument included questions that explored
of breakdowns, the undiscussables.
personal, social, and structural sources that could influence how dangerous shortcuts, incompetence, and disrespect are handled.
When people know of risks and do not speak up, the breakdown feels more intentional. Someone knows, or strongly suspects, that something is wrong, but chooses to ignore or avoid it. He or she may
Safety Tools and organizational Silence—
attempt to speak up but quits when faced with resistance. It's not a
Story collector Findings
slip or error; it's a calculated decision to avoid or back down from the conversation. Information-based solutions like protocols, checklists,
The Story Collector listed four survey safety tools that are intended
and systems don't do much to solve the breakdowns in this second
to prevent unintentional slips and errors (Universal protocol
category. The literature on organizational silence13,14 suggests that
checklist15, WHO checklist16, SBAR handoff protocol17, and drug-
solving undiscussables will require deeper changes to cultural
interaction warning systems). The respondents (nurses) were then
practices, social norms, and personal skills.
asked how often they had been in situations where one of these tools worked—where it warned them of a problem that otherwise
The Silent Treatment
examines these calculated decisions to not
might have been missed and harmed a patient.
speak up. It tracks how risks that are known but not discussed undermine many current safety tools. It documents the frequency
As noted in the chart below, 85 percent (2,020) of the nurses
and impacts of these discussions, and shows how individuals and
said they had been in this situation at least once, and 29 percent
organizations can make undiscussables discussable.
(693) said they were in this situation at least a few times a month. These results strongly confirm that safety tools work. Operating rooms and ICUs are fast paced, complex, and full of disruptions.
Study Design and Sample
Checklists, protocols, and warning systems are an essential guard against unintentional slips and errors.
Two survey instruments were employed: a Story Collector and a Traditional Survey. The Story Collector generated rich, qualitative
However, the Story Collector data documented that the effectiveness
data; the Traditional Survey produced purely quantitative data.
of these safety tools is being undercut by undiscussables: 58 percent (1,403) of the nurses said they had been in situations
Convenience sampling was used for both instruments. Members of
where it was either unsafe to speak up or they were unable to
the AACN and the Association of periOperative Registered Nurses
get others to listen. And 17 percent (409) said they were in this
(AORN) were invited via e-mail to participate in the study. The
situation at least a few times a month.
e-mail invitation included an online link that assigned respondents to one of the two instruments. The Story Collector was completed by 2,383 registered nurses, of whom 169 were managers; The Traditional Survey was completed by 4,235 nurses, of whom 832 were managers.
Story Collector: This survey instrument asked respondents to share actual incidents—stories that described times when they were personally unable to speak up or get others to listen. The data obtained through the Story Collector is similar to what researchers otherwise might gather from interviews, but with several differences. First, the Story Collector methodology can reach more people than interviews allow. Second, Story Collector questions are standardized and presented in writing, so interviewer bias is eliminated. Third, respondents write their own responses, so transcription errors are eliminated. Fourth, people generally do not share more than a couple stories in writing—fewer than what a researcher might generate from an interview, so less data is collected from each respondent.
Traditional Survey: This survey instrument was a more traditional Likert-scale questionnaire. It collected quantitative data related
control, or do you feel able to solve them or prevent them
from happening again in the future?
A Few Times a Month
Using this tool, the study documented 608 incidents, averaging
128 words each. Of these self-described incidents, 8 percent
A Few Times a Month
represented patterns that were described by the respondent as
permanent, pervasive, and beyond his or her control—what the current study refers to as "triple negatives." Triple negatives
represent the kinds of communication breakdowns that systematically prevent safety tools from protecting patients.
All of the triple negatives were high-stakes incidents because they involved a risk to patient safety. Three quarters of the incidents
involved confronting physicians, two thirds involved standing up to a group, and half involved disrespect, threats, and anger.
Below are three examples of the triple negative incidents:
• "A special graft was ordered and due to arrive at 10:00. The
surgeon insisted the day before he had to have this particular graft. The day of surgery the graft was not yet physically in the
building but the surgeon insisted we put the patient to sleep. My stand was that unless you were prepared to use something
else we should wait until it arrived. All of our checklists and
Safety Tool Warned Me of
Safety Tool Warned Me. But
a Problem the Team Might I was Unable to Speak Up
protocols require that all implants and necessary items are
Otherwise have Missed
and Get Anyone to Listen
available before the case begins. The surgeon said he would [get the graft] if necessary. I felt we were jeopardizing patient
The nurses who indicated they experienced these undiscussables
care, setting a poor example to the staff and why do we go
were asked to describe the incident in some detail, and were given
through all these things in the first place?"
the following prompt:
• "As a cost saving measure, the institution I worked for looked
for the lowest priced generic item, so the same medication
Please describe a specific incident when a tool warned you
ordered looked different every time you dispensed it. The bin
about a possible problem, but it was either hard to speak up
on the shelf might have four different shaped and colored vials
or hard to get others to listen and act. We want to understand
all labeled as the same item. I took one of the administrative
what happened. Please relate this incident as if you were
safety people through our medication room to show them how
telling us the whole story from beginning to end. What kind
easy it was to make an error when no two vials of the same
of tool/checklist/warning system were you using? What was
medication looked the same. After that we saw much less
the possible problem you discovered? Who did you need to
substitution and greater consistency."
convince and collaborate with to solve it? What did you do? How did they react? What made it difficult? What happened
• "Inserting central line at bedside in ICU. Used checklist but
in the end? What conclusions did you draw as a result?
surgeon refused maximal sterile barrier and in fact, ridiculed me and hospital staff for instituting (this precaution) when
Each nurse then rated the incident he or she had described using
there is no ‘proof' it works. Hospital does not allow RN to stop
procedure so it was inserted without maximal sterile barrier."
• Permanence: Was this experience a one-time event, or is it
The incidents above capture the kinds of high-stakes and emotional
part of a continuing pattern in how people treat each other in
differences of opinion that occur within operating rooms and ICUs. These
your work environment?
differences become dangerous when they become undiscussable.
• Pervasiveness: Was this experience isolated to only one part
of your work life (for example, experienced with just one
physician, one caregiver, one manager, one patient, or one kind
Traditional Survey Findings
of problem) or is it widespread across all areas of your work?
As noted earlier, the 2005 Silence Kills
study examined seven
• Lack of Control: When incidents like the one you just
concerns that often go undiscussed, and linked the ability to
described happen, does it feel as if they are out of your
discuss these emotional, risky topics to key results such as patient safety, quality of care, and nursing turnover.
The 2010 study examines three of the seven concerns found in the
• 41% have spoken to their manager about the person
2005 study, using the same Likert-scale survey items. These three
whose shortcuts create the most danger to patients.
concerns—dangerous shortcuts, incompetence, and disrespect—
• 17% have spoken to the person taking the dangerous
are not necessarily prompted by any of the safety tools examined
shortcuts, but haven't shared their full concerns.
with the Story Collector. Instead, they tend to emerge over time, as people observe each other on the job. Findings from non-
• 31% have spoken to the person taking the
supervisory nurses who completed the current study's Traditional
dangerous shortcuts, and shared their full concerns.
Survey are summarized below:
2 Concerns about incompetence.
1Concerns about dangerous shortcuts.
a. Incompetence is common.
a. Shortcuts are common.
• 82% work with people who "are not as skilled as
they should be (for example, they aren't up-to-date
• 84% work with people who "take shortcuts that could
on a procedure, policy, protocol, medication, or
be dangerous for patients (for example, not washing
practice or are lacking basic skills)."
hands long enough, not changing gloves when appropriate, failing to check armbands, forgetting to
b. Incompetence is dangerous.
perform a safety check)."
• 31% say that incompetence has led to near misses.
b. Shortcuts are dangerous.
• 26% say incompetence has affected patients, but
• 34% say that these dangerous shortcuts have led to
• 19% say incompetence has harmed patients.
• 27% say shortcuts have affected patients, but
c. Incompetence is often left undiscussed.
• 48% have spoken to their manager about the person
• 26% say shortcuts have harmed patients.
whose missing competencies create the greatest
c. Shortcuts are often left undiscussed.
danger to patients.
• 11% have spoken to the person, but haven't shared
their full concerns.
• 21% have spoken to the person, and have shared
their full concerns.
Silence Kills: The Seven Crucial Conversations For Healthcare
3 Concerns about disrespect.
a. Disrespect is common.
that seven categories of conversations
• 85% work with people who "demonstrate disrespect
are especially difficult and, at the same
(for example, are condescending, insulting, or rude—or yell, shout, swear, or name call)."
time, especially essential for people
b. Disrespect causes problems.
in healthcare to master. These seven
• 46% say that disrespect undercuts respect for their
conversations include: broken rules (including
dangerous shortcuts), mistakes, lack of support,
• 19% say that disrespect makes them unable to get
incompetence, poor teamwork, disrespect, and
others to listen.
micromanagement. The study showed that a
• 20% say that disrespect is making them seriously
consider leaving their job or profession.
majority of healthcare workers regularly see
c. Disrespect is often left undiscussed.
colleagues take dangerous shortcuts, make
• 49% have spoken to their manager about the person
mistakes, fail to offer support, or appear critically
whose disrespect has the greatest negative impact.
incompetent. Yet the research reveals
• 16% have spoken to the person who is demonstrating
disrespect, but haven't shared their full concerns.
fewer than one in ten speak up and
• 24% have spoken to the person who is demonstrating
share their full concerns.
disrespect, and shared their full concerns.
The data presents a convincing case. Organizational silence leads
• "A cardiovascular surgeon was putting in an arterial line at
to communication breakdowns that harm patients.
the bedside. We have a checklist that must be completed for line placement that includes full barrier, washing hands, etc.
1. More than four out of five nurses have concerns about
The M.D. refused the sterile gown, mask, hat, and drape,
dangerous shortcuts, incompetence, or disrespect.
and used only sterile gloves. The nurse offered the full barrier
2. More than half say shortcuts have led to near misses or harm.
again telling him that all lines were put in with full barrier in
3. More than a third say incompetence has led to near misses
our unit. He continued with the procedure. The bedside nurse
did not feel empowered to stop the procedure. She later took the problem to the unit manager. No action was taken."
4. More than half say disrespect has prevented them from getting
others to listen to or respect their professional opinion.
This study shows that taking problems to a manager, and assuming he or she will handle them, doesn't produce the kind of immediate and
5. Fewer than half have spoken to their managers about the
reliable results needed in healthcare.
person who concerns them the most.
6. And fewer than a third have spoken up and shared their full
concerns with the person who concerns them the most.
The data also shows that nurses are more likely to take their concerns to their managers than they are to speak directly to the person they are concerned about. Since working through the hierarchy is often assumed to be the appropriate way to address a problem, it is important to examine how well this strategy works.
results from nurse ManagersThe responses from the 832 nurse managers who completed the Traditional Survey were reviewed separately from the non-supervisory nurses. A surprising finding was that managers do not appear to be a reliable path for resolving concerns about dangerous shortcuts, incompetence, or disrespect.
Only 41 percent of the nurse managers reported that they had spoken up to the person whose dangerous shortcuts create the most danger for patients. Equally troubling is that only 28 percent had spoken up to the person whose missing competencies create the most danger for patients, and only 35 percent had spoken up to the person whose disrespect has the greatest negative impact.
The data above comes from the nurse managers, themselves. They
admit their failure to address these important patient safety issues.
2005 and 2010 Studies
The Story Collector data provides dramatic confirmation from the
In general, the results from The Silent Treatment
2010 study are in
line with the Silence Kills
2005 data. But there are a few differences
• "During the surgical safety checklist, we realized the permit
that need to be explained. More of the nurses in the 2010 study have
and the scheduled surgery did not match (wrong side). We
concerns about dangerous shortcuts, incompetence, and disrespect;
tried to stop the doctor (plastic surgeon) and he said the
more have seen patients harmed; and more speak up about their
permit was wrong. The patient was already asleep and he
concerns. The authors of the 2010 study believe these differences
proceeded to do the wrong side against what the patient had
likely stem primarily from the differences in the two samples.
verified, which had matched the permit. We could not get any
The nurses in the 2010 study were more likely to come from
support from the supervisor or anesthesiologist. The surgeon
settings where the job demands and patient acuity are higher: 87
completed the case. Nothing was ever done. "We felt awful
percent work in an operating room, recovery room, ICU, cardiology
because there was no support from management to stop this
unit, emergency department, or progressive care unit. The nurses
doctor. What is the point of having a checklist when it is not
in the 2005 study were randomly selected from 13 participating
consistently followed? We felt absolutely powerless to being
hospitals, and were more likely to work in medical-surgical units.
an advocate for the patient."
When the nurses in the 2010 study were compared to the 2005
Using this methodology, the exceptional nurses described 284
nurses who worked in critical care and surgical settings, their
incidents in detail, averaging 123 words per incident. Twenty-eight
levels of concern and patient harm were similar. But there is a
percent of the incidents represented patterns that were described by
hopeful difference in one area.
the respondent as permanent, pervasive, and empowering—what the current study refers to as triple positives. These triple positives
A much higher proportion of critical care and perioperative nurses
are the kinds of communication skills that make undiscussables
speak up in 2010. In 2005, only 10 to 12 percent of nurses spoke
discussable and protect patients from harm.
up. In 2010, these percentages have improved to between 21 and 31 percent. While these percentages are still unacceptably low, the authors of the 2010 study believe these increases represent real progress and may be due to the increased focus that healthcare organizations have placed on creating cultures of safety.
from Exceptional nursesSilence Kills
found that caregivers who are able to speak up and resolve undiscussables report better patient outcomes, are more satisfied with their workplace, exhibit more discretionary effort, and are more committed to staying in their unit and their hospital.
The findings reported in The Silent Treatment
show that only a small minority of non-supervisory nurses spoke up when they had a concern related to dangerous shortcuts, incompetence, or disrespect. Only 9 percent spoke up in all three of these situations, and only 14 percent spoke up in two of the three. Given the benefits that come from speaking up, the authors of the current study turned back to the Story Collector data to learn more about how nurses can successfully approach undiscussables.
The literature on positive deviance18,19,20 provides helpful insight
Like the triple negatives, these conversations were high stakes
into this group of nurses. Positive deviants are similar to their peers
differences of opinion where emotions ran high. As the exceptional
in most ways: they have similar backgrounds, work in the same
nurses described how they handled these conversations, several
environment, and have access to the same resources. Yet they have
patterns emerged. Below are some of the skills and actions
found a way to succeed in the very circumstances where most of
exceptional nurses cited as leading to their success:
their peers are failing.
The nurses who spoke up—the positive deviants or exceptional
1When the issue wasn't urgent, they collected facts, ran
nurses—were asked to share a second story, this time a positive
pilot tests, and worked behind the scenes.
one. They were given the following instructions.
• "I took the hospital protocol, came up with a
Please share one other story with us. Think of a time when you
worksheet…and included little cheat sheet notes. I had
made a positive difference by speaking up. This could be a time
one other nurse use it to start, then I saw what else
when others would have let the situation slide, not recognized
could improve the worksheet… The form was presented
its importance, or felt unable to speak up—but you did, and it
to the staff, and I had many other nurses thanking me."
was important that you did. Describe this incident so we can understand the skills you used. Please relate this incident as
2 They assumed the best, and spoke up. Sometimes it
if you were telling us the whole story from beginning to end.
just takes one person to pave the way.
What was the possible problem you discovered? Who did you
• "They were opening sterile supplies in one room,
need to convince or collaborate with? What did you do? What
covering them, and moving them across the hall to
was it that made you effective? What happened in the end?
another room. The OR manager knew this was wrong,
What conclusions did you draw as a result?
and stopped the practice after I complained."
Each exceptional nurse then rated the incident he or she had
• "Staff ratio not safe for acuity of patients. Spoke
described using the same three dimensions as before: permanence,
with charge nurse. She was receptive to talking to
pervasiveness, and control.
administrator. Changes were made to assignment. It
is worth the risk to speak up when patient and nurse
6 They avoided telling negative stories or making
safety [are] at risk."
• "A mistake does not mean a bad practitioner . . not
They explained their positive intent—how they wanted
correcting a mistake does."
to help the caregiver as well as the patient.
• "I asked the surgeon if he had made the patient aware
7 They diffused or deflected the person's anger
that he was in critical condition and that he would
struggle to survive the surgery. He said he had not. I
• "He looked at me and said, ‘You've been drinking the
then asked if I could make the patient aware for him.
corporate Kool-Aid . . and lost your common sense.' I
The surgeon agreed by saying, ‘If you think you can,
tried very hard to avoid taking his statement personally,
and laughed it off . . I saw the surgeon in the hallway
• "A nurse was teaching a patient about a medication,
about an hour later and expanded the joke to include
misread the name of the medication and had not
more than Kool-Aid…We both had a laugh."
noted the past medical history thoroughly. She was
Two behaviors were notable by their absence in the Story Collector
teaching about a condition the patient did not have, and
data: none of the exceptional nurses tried to use threats to
describing a sound-alike medication the patient was not
influence the physicians and other caregivers, and none showed
taking. I called [the nurse] to come out of the room and
their frustration or anger. These nurses kept their feelings and
helped her see the error. She returned to the patient and
emotions in check.
cleared up the mistaken information. By acting quickly and discreetly, I was able to help her and her patient."
The stories the exceptional nurses tell make it clear that skills alone
are not enough. Many of the stories show the extraordinary courage
They took special efforts to make it safe for the
it takes to step up to these conversations. When caregivers fail to
caregiver—to avoid creating defensiveness.
voice their concerns, it's easy to accuse them of bystander apathy.
• "The surgeon was marking the wrong foot, while talking
But apathy is the wrong word. It's more like bystander agony.
to the patient about something social . . I opened the
These exceptional nurses were desperate to speak up, but often
chart to the permit and lightly reminded him we were
believed that voicing their concerns would violate norms, accepted
doing the other foot today . . Presenting the issue to
practices, and even rules.
the surgeon in a nonthreatening manner saved face in
Below are themes that reveal elements that helped these exceptional
front of the patient and made him grateful that I spoke
nurses overcome their concerns about speaking up:
• "[I] described [to a colleague] the potential interaction
between an antihypertensive drug and an over-the-
1They had spoken up sometime in the past, and a
patient had been protected.
counter drug the patient was taking. The colleague had not taken a full history of drug exposures, and was
• "[During] pre-op screening before taking a patient to
grateful for the reminder, agreed the interaction was
surgery, I have discovered discrepancies between the
important to note, and warned the patient not to take
consent form and what the patient says. The surgeons
this class of over-the-counter medication."
never want to go back after their initial visit. I feel very good advocating for the patient. All they have is me and
5 They used facts and data as much as possible, often
I will not let them down. There is nothing more important
taking the other person into the actual situation.
than the patient being safe and confident that they understand their procedure."
• "I brought up the labs on the computer, and had
them available to show the doctors . . I was effective
• "The surgeon . . was at a dinner party and was very
because I had the facts at hand."
vocal about how much trouble I would be in if he had to come back for no reason. He came back and took the
• "I asked the surgeon if this contrast medium would
patient into surgery. The leg had occluded. I was never
be a problem. He brushed it off. I approached the rep
so nervous about the outcome, and was so relieved to
who brought in some of the kypho materials needed
have been correct."
for the procedure. He thought there may be a problem. The surgeon was approached again. There was no literature available. The surgeon called the radiologist . .
2 A patient had already been harmed, and the incident
was being reviewed.
Anesthesia was also consulted. The pharmacy was called. The result was that the contrast was not the same, but
• "The patient died five days later. We did an RCA (Root
that Benadryl was given as a precaution."
Cause Analysis) on this case, and it revealed that the
multiple surgeons attending this patient had not had
policies and practices, and sometimes even formal evaluation and
any direct communication with one another—just paper
consults . . The VP of Medical Staff . . was very helpful . . I also received support from the Chief of Surgery. I felt
The next section of The Silent Treatment
study focuses on what
very supported by the Chief Nurse Executive in helping
organizations can do to create a culture that encourages and
me go up the chain of the medical staff."
enables people to speak up.
• "Both surgeons and anesthesiologists give Toradol intra-
op or post-op . . but don't always communicate . . This
has resulted in patients receiving double doses. I took this
What organizations can Do
concern to the OR Management meeting, Dept of Surgery meeting, and Dept of Anesthesiology meeting. A new
Undiscussables represent an entrenched organizational problem.
protocol was developed and increased communication in
As such, they will require a multifaceted solution21,22. A helpful way
to think about this multifaceted solution is to use six sources of behavioral influence23 as summarized below:
3 They had a strong trusting relationship with the person
Source 1—Personal Motivation. If it were up to them,
they needed to confront.
would the nurses want to speak up? Does it feel like a moral
• "I was a nurse the surgeon worked with most of the
obligation or an unpleasant annoyance to them?
time. Even though he wasn't happy, he trusted my judgment. He is aware that I know the AORN standards
Source 2—Personal Ability. Do the nurses have the
as well as the evidence behind practice issues."
knowledge and skills they need to handle the toughest challenges of speaking up?
• "I think what made me effective was my relationship
with the surgeon. I trusted my clinical judgment and
Source 3—Social Motivation. Are the people around them
experience, and refused to be intimidated by the
(physicians, managers, and co-workers) encouraging them
residents and hierarchy."
to speak up when they have concerns? Are the people they
• "I have made efforts to introduce myself to staff I do not
respect modeling speaking up?
know. My getting to know others has helped . . us work
Source 4—Social Ability. Do others step in to help them
when they try to speak up? Do others support them afterward
so the risk doesn't turn against them? Do those around them
One or more physicians had made it clear that they
offer coaching and advice for handling the conversation in an
appreciate it when nurses speak up.
• "I spoke up and stated, ‘This patient is fully anticoagulated
right now. Do you think it is wise to start a central line
Source 5—Structural Motivation. Does the organization
when we are okay with PIV [peripheral intravenous] for
reward people who speak up or does it punish them? Is
now?' All the surgeons turned to me and stated, ‘Wow,
speaking up included in performance reviews? Are managers
we forgot. Thanks for making a good point.'"
held accountable for influencing these behaviors?
• "[I] asked M.D. to wash his hands before central line
Source 6—Structural Ability. Does the organization
insertion. He did it and thanked me in front of the patient
establish times, places, and tools that make it easy to
for reminding him."
speak up—for example, surgical pauses, SBAR handoffs,
• "I looked closely at the specimen, and informed the surgeon
etc.? Are there times and places when caregivers are
that I did not see an appendix. He came over, looked at the
encouraged to speak up? Does the organization measure
specimen, and confirmed what I saw. He told everyone in
the frequency with which people are holding or not holding
the room that's why anyone in this room can speak at any
these conversations—and use these measures to keep
time. Then went back in and took the appendix."
management focused on this aspect of patient safety?
If the goal is to eliminate the communication breakdowns that are
Organizations must overwhelm the problem of organizational silence.
fueled by organizational silence, then caregivers need the skills and
This requires deploying multiple sources of influence—all aimed
motivation exhibited by these exceptional nurses. However, individual
at motivating and enabling people to speak up. Research shows that
skills and personal motivation won't be enough unless speaking up
combining four or more of sources of influence can increase success by
is also supported by the social and structural elements within the
as much as ten times24.
healthcare organization. The current lack of speaking up is not just a matter of individual initiative; it reflects social norms, organizational
The Traditional Survey that was used for The Silent Treatment
study included a series of questions that measured how many of these six
sources were combined to make undiscussables discussable. For example, the following questions were used to measure Personal Ability:
• People here have the skills they need to intervene without
The Magnet Recognition
• When people here have a concern, they know how to politely
Program®, a program of the
get others to stop what they are doing and listen.
American Nurses Credentialing Center,
The number of sources of influence an organization used predicted
recognizes healthcare organizations
the concerns nurses had, the harm they saw, and their intent to leave the organization or profession. The negative correlations in table
that provide nursing excellence. It is
1 below are all highly significant. They show that when hospitals
based on more than a dozen quality
employed more sources of influence nurses saw fewer dangerous shortcuts, less incompetence, and less disrespect. These nurses also
indicators and standards of nursing
saw less harm being done to patients and were less likely to consider
practice as defined in the 3rd edition of
leaving their organization or profession.
the ANA Nursing Administration: Scope
The Magnet Recognition programs25 and the AACN Beacon Award
& Standards of Practice (2009).
for Excellence26 are two national programs that encourage a multifaceted approach to improving patient care.
The Beacon Award for
Although neither program specifically targets all six sources
Excellencetm, a program of the
of influence, each requires that a broad range of strategies be employed in combination. The positive correlations in the table
American Association of Critical-Care
below show that hospitals that achieve Magnet Recognition or
Nurses, recognizes excellence at the
AACN's Beacon Award use significantly greater numbers of the six sources of influence. See table 2 below.
unit level where patients receive their principal nursing care after hospital
admission. It is based on criteria in six
categories: leadership structures and
Number of Sources of
systems; appropriate staffing and staff engagement; effective communication;
The negative correlations in table 3 below show that these multifaceted approaches are associated with fewer concerns, less
knowledge management and best
patient harm, and lower intent to leave the organization or profession.
practices; evidence-based practices
While many of the correlations are significant, the associations aren't as consistent or as strong as those found with the number of sources
and processes; and patient outcomes.
of influence. See table 3 below.
Incompetency Incompetency Disrespect
Incompetency Incompetency Disrespect
Source 1—Personal Motivation. The goal is to connect to people's existing values to stimulate their passion for keeping
The results presented in The Silent Treatment
point the way toward
patients safe. The most effective way to make this connection is
positive change. When healthcare organizations tackle the silence
through sharing personal experiences. The least effective way is
using a combination of sources of influence, they achieve substantial
to resort to verbal persuasion: data dumps, lectures, sermons, and
improvements. Below are recommendations for how healthcare
rants. Examples of sharing personal experiences include:
organizations can use this multifaceted approach to create a safety culture where people speak up effectively when they have concerns.
• Physicians, nurses, and other caregivers tell stories of near
misses—times when patients would have been harmed if the
1Establish a Design Team. Enlist a small team that includes
safety practices hadn't been followed.
senior leaders, managers in the targeted areas, and opinion
• Physicians, nurses, and other caregivers share examples of
leaders among physicians, nurses, and other caregivers. This
times when speaking up saved a patient from harm.
design team works with all caregivers to identify crucial moments,
• Physicians, nurses, and other caregivers tell stories of
vital behaviors, and strategies within each of the six sources of
injuries—times when a shortcut might have been taken and
influence described below. The design team then provides a few
no one spoke up, and a patient was harmed.
initial strategies within each of the six sources and helps teams in patient care areas select, modify, and create additional strategies.
• Physicians, nurses, and other caregivers meet with patients
who have been injured when receiving healthcare to learn
2 Identify Crucial Moments. There is a handful of perfect-
about the harm and how it affected the patients.
storm moments when circumstances, people, and activities
Source 2—Personal Ability. The goal is to make sure everyone
combine to put safety protocols at risk. The design team needs
has the skills they need to be 200 percent accountable for safe
to identify and spotlight these crucial moments so that people
practices. Design teams make the mistake of assuming people can
will recognize when they are in them. An example of one of these
"just do it." Effective organizations use training, have patient care
crucial moments is when the surgery schedule is pushed into the
areas develop their own scripts, and use role-plays that include
evening, and people are in a rush.
physicians, nurses, and other caregivers. Examples include:
3 Define Vital Behaviors. People need to know what to
• Supervisors, managers, and team champions participate
say and do when they find themselves in these crucial
in formal training in how to handle high-stakes, emotional
moments. These are the vital behaviors that keep patients safe.
differences of opinion27.
Examples of vital behaviors used at Spectrum Health include:
• Patient care areas develop their own scripts. For example,
• 200 percent Accountability. Each staff member is 100 percent
"Doctor, I have a safety concern."
accountable for following safe practices and 100 percent
• Patient care areas practice these scripts with the physicians,
accountable for making sure others follow safe practices.
nurses, and other caregivers they will be holding accountable.
• Thank You. Staff members make it safe for others to hold
Sources 3 and 4—Social Motivation & Social Ability. The
them accountable. When they are reminded of a safety
goal is make sure people have the support they need to be 200
practice, they thank the other person and redouble their
percent accountable for safe practices. The mistake made here is to
efforts to keep the patient safe.
assume that verbal support from management is enough. Effective
organizations use both managers and physician champions for each
Develop a Playbook. Safety requires that the vital
patient care area. Examples include:
behaviors be acted on in a highly reliable way—especially
during the crucial moments when they are the toughest. The
• Patient care areas identify the physicians who would make
most powerful way to make sure these behaviors are consistently
the best champions, and then invite them to join in. Rarely
followed is to create a multifaceted influence plan that uses all six
are these invitations rejected.
sources of influence. This plan is captured in a playbook that can
• Patient care areas discuss and define the champion role.
be disseminated throughout the organization.
They identify the forms of participation and support a patient
Departments and individaul patient care areas can use this playbook
care area requires from its champions.
as the starting point. They may adopt some of the strategies
• Champions meet with individuals who challenge the initiative
wholesale, modify others, and invent new strategies on their own.
and win them over. For example, they work with people who
But they need to make sure they have a few strategies within each of
object to safety practices, to being held accountable, or to
the six sources of influence.
holding others accountable, and gain their support.
Below are examples of strategies that fit within each of the six sources.
Source 5—Structural Motivation. The goal is to make sure incentives support safe practices and reward people for 200
percent accountability. The mistake organizations make is to forget
four out of five nurses in this study have these concerns, more
that rewards and punishments matter. Effective organizations build
than one in four have seen either shortcuts or incompetence lead
incentives into performance reviews, promotions, pay, and perks—
to patient harm, and more than half say disrespect from others has
and they don't shy away from using punishments when necessary.
undermined their ability to take action. Yet less than a third of these
nurses spoke up in an effective way about their concerns.
• Organizations create gift certificates, badges, and other
The stories nurses tell about trying to speak up reveal the variety
small tokens to recognize and reward people for consistently
of challenges they face. Three quarters involved confronting
following safe practices and for demonstrating 200 percent
physicians, two thirds involved standing up to a group, and half
involved disrespect, threats, and anger.
• Organizations build safe practices into physician contracts
and performance reviews.
• Organizations create a quarterly measure of the frequency with
which people practice the vital behaviors area by area. They build a specific improvement goal for this measure into the accountability system of all directors and above.
Source 6—Structural Ability. The goal is to make sure there are places, times, and systems that support safe practices and 200 percent accountability. Effective safety cultures use the principles of organizational improvement to make safe practices and accountability easy and convenient. Examples include:
• Physicians, nurses, and other caregivers review safe
practices to make them less cumbersome and more effective.
• Compliance is measured and tracked. These measures
include quality as well as consistency, so that safe practices never degrade into box-checking exercises.
Focusing on the exceptional nurses who do speak up highlights
• Design teams and patient care areas create cues, reminders,
some key skills they employ. They begin by explaining their positive
and protocols to make 200 percent accountability safe and
intent; use facts and data as much as possible; make it safe for the
other person; avoid negative stories and accusations; and deflect
• The organization publishes quarterly data by department to
anger and emotion. If every caregiver has these skills, it will go a
keep attention focused on the vital behaviors.
long way toward resolving the problem of organizational silence.
The recommendations above are a starting point. The goal is to
There is cause for optimism at the organization level. Nurses today
create a playbook that includes crucial moments, vital behaviors, and
are voicing their concerns nearly three times more often than they did
strategies within each of the six sources of influence. Organizations
just five years ago. This improvement suggests that speaking up is
and teams can then use the ideas within the playbook to create a
becoming easier and more accepted within healthcare organizations.
multifaceted plan that is tailored to their individual situation.
Key programs such as the Magnet Recognition Program and AACN's Beacon Award for Excellence have contributed to this progress, most
likely because they demand that organizations take a multifaceted
The Silent Treatment
details the success and limitations of current
approach to improving care. AORN also provides powerful tools—
safety tools. Most of these tools work by warning caregivers of
one focused on Just Cultures and another on Human Factors—that
potential problems. But warnings only create safety when the
can help organizations create a culture of safety. This research shows
caregiver who is warned is able to speak up and get others to
that explicitly multifaceted approaches, such as the six sources of
act. The data in this study reveals that caregivers, including nurse
influence, are the most predictive of success.
managers, are often unable to accomplish this level of candor.
There were strong negative correlations between how many of the
As a result, they either clam up or blow up. They fail to have an
six sources of influence were employed and the incidence and harm
influence; and patients are harmed.
of the three concerns. This means that combining multiple sources
This inability to influence extends beyond safety tools. Caregivers
of influence all aimed at improving people's ability to speak up
are often unable to speak up and resolve their concerns about
is associated with fewer dangerous shortcuts, incompetence, and
dangerous shortcuts, incompetence, and disrespect. More than
disrespect, as well as with lower levels of the harm they produce.
Healthcare organizations need to learn from both successful
The American Association of Critical-
individuals and successful organizations. The communication skills
Care Nurses is the largest specialty nursing
that exceptional nurses already have should become the norm
organization in the world, joining together the interests of more
among all caregivers. Healthcare organizations should establish a
than 500,000 acute and critical care nurses. AACN strives to
design team, identify crucial moments, define vital behaviors, and
create a healthcare system driven by the needs of patients and
develop a playbook that combines change strategies within each of
their families, one that optimizes the contributions of acute and
the six sources of influence.
critical care nurses. www.aacn.org
Together, these approaches will create a safety culture where
The Association of periOperative Registered
people who know of or strongly suspect risks do speak up, even
Nurses, representing the interests of more than 160,000
when they encounter resistance. Patients can no longer afford to
perioperative nurses, provides nursing education, standards, and
have issues related to their health and safety remain undiscussable.
services that enable optimal outcomes for patients undergoing operative and other invasive procedures. AORN's 40,000 registered
About the Authors
nurse members facilitate the management, teaching, and practice of perioperative nursing, are enrolled in nursing education or
David Maxfield is the Vice President of Research at VitalSmarts,
engaged in perioperative research. www.aorn.org
a global training and consulting firm headquartered in Provo, Utah.
An innovator in corporate training and
Joseph Grenny is cofounder of VitalSmarts.
leadership development, VitalSmarts is home to the award-
Ramón Lavandero is Director, Communications and Strategic
winning Crucial Conversationsw®, Crucial Accountability™, Change
Alliances of AACN, the American Association of Critical-Care Nurses,
Anything™, and Influencer Training® and New York Times
and Clinical Associate Professor at Yale University School of Nursing.
books of the same titles. When used in combination, these courses enable organizations to achieve new levels of performance by
Linda Groah is Executive Director and CEO of AORN, the Association
changing employee behavior. VitalSmarts has trained more than one
of periOperative Registered Nurses.
million people worldwide. www.vitalsmarts.com
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Registration of Medicines PI standardised texts MEDICINES CONTROL COUNCIL PACKAGE INSERTS FOR HUMAN MEDICINES STANDARDISED TEXTS This guideline is intended to provide recommendations to applicants wishing to submit applications for the registration of medicines. It represents the Medicines Control Council's current thinking on the safety, quality and efficacy of medicines. It is
Li et al. / J Zhejiang Univ-Sci B (Biomed & Biotechnol) 2011 12(12):983-989 Journal of Zhejiang University-SCIENCE B (Biomedicine & Biotechnology) ISSN 1673-1581 (Print); ISSN 1862-1783 (Online) www.zju.edu.cn/jzus; www.springerlink.com E-mail: firstname.lastname@example.org Gastric motility functional study based on electrical bioimpedance measurements and simultaneous electrogastrography*