- Email: [email protected]
Why is it so hard for doctors to speak up when they see an error occurring?
CSIRO PUBLISHING
Healthcare Infection, 2013, 18, 72–75 http://dx.doi.org/10.1071/HI12044
Why is it so hard for doctors to speak up when they see an error occurring? Claire Dendle1,2 MBBS, FRACP, GCHPE Andrea Paul1 GradDipEd, MA(AppLing) Carmel Scott3 RN, CICP Elizabeth Gillespie3 BN, RN, CICP, MPubHlth (Melb) Despina Kotsanas2 BSc(Hons), MClinEpi Rhonda L. Stuart1,2,3,4 MBBS, FRACP, PhD 1
Department of Medicine, Monash University, Wellington Road, Clayton, Vic. 3168, Australia. Department Infectious Diseases, Monash Medical Centre, 246 Clayton Road, Vic. 3168, Australia. 3 Department Infection Control and Epidemiology, Monash Medical Centre, 246 Clayton Road, Vic. 3168, Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. Background: The ability of doctors to ‘speak up’ when a medical error occurs is a cornerstone of patient safety. Hand hygiene (HH) is one of the simplest methods of reducing patient harm and represents a behavioural model in which to observe medical staff interaction. Our hypothesis is that the hierarchical structure amongst doctors prevents them from speaking up, which in turn contributes to poor HH compliance. Methods: An anonymous survey was administered to doctors employed in a health service in Melbourne, Australia. Questions included: willingness to prompt doctors to perform HH, reasons for not speaking up, perceived reactions of a doctor being prompted to perform HH and perceived reaction if they were asked to perform HH. Results: One hundred and sixty-three doctors completed the questionnaire. Willingness to prompt a doctor to perform HH decreased as the questioned doctor’s seniority increased, with 88.5% willing to ask an intern but only 40.4% willing to ask a consultant. The main reason for not asking a senior doctor was not wanting to speak up to a superior. Conclusions: Our study highlights a steep medical hierarchy, with less than half of the doctors willing to question seniors, even when they noticed an error occurring. We suggest that if acquired, the skills needed to respectfully prompt HH are transferrable to many other patient safety initiatives. Received 11 October 2012, accepted 11 December 2012, published online 10 April 2013
Introduction ‘As we must account for every idle word, so we must account for every idle silence.’ Benjamin Franklin ‘I have observed my senior colleagues fail to clean their hands at the bedside and despite being an infectious diseases physician, whose job it is to promote hand hygiene (HH), I remained silent. I was uncomfortable and unable to question my boss and as Benjamin Franklin said, I ‘must account for the idle silence’.’ Hand hygiene (HH) is one of the simplest yet most effective methods of reducing patient harm through reduction of hospital-associated infections.1 In 1840, Ignaz Semmelweis provided evidence that cleaning the hands of healthcare workers (HCW) reduced maternal mortality.2 It is notable
that Semmelweis failed to convince his medical colleagues of the benefits of HH or to adopt the practice. Today, remarkably, HH programs around the world consistently report that doctors have the lowest compliance of all professional groups.3 Hand hygiene compliance presents an opportunity to observe and understand the behaviour of doctors around medical error and ‘speaking up’. Our hypothesis was that the strong hierarchical structure amongst doctors contributes to the reluctance among them to speak up in the face of medical mistakes, and that this in turn may contribute to their poor compliance in HH programs. We thus sought to determine if doctors would challenge each other if they noticed a failure to perform HH and to explore the reasons for the chosen behaviour, in order to inform future quality programs.
Journal compilation Ó Australasian College for Infection Prevention and Control 2013
www.publish.csiro.au/journals/hi
Speaking up about medical errors
Healthcare Infection
73
100
Implications
*
The strong hierarchical structure in medicine impedes junior doctors ‘speaking up’ when errors occur, and this should be considered in the design of patient safety programs. Hand hygiene represents a good model in which to teach doctors how to ‘speak up’ at the bedside.
90
% willing to speak up
*
80 70 60 50
No
40
Yes
30 20 10 0
Methods An anonymous survey was sent to the hospital email addresses of all doctors within our health service during February 2012. Southern Health is the largest health service in Melbourne, Australia with 2100 acute, subacute, mental health and aged care beds. Doctors were classified as interns (first year postgraduation), residents (second and third year postgraduation), registrars (at least 3 years post-graduation and undertaking specialist training) and consultants (at least five years post-graduation and fully qualified specialists). Survey questions included demographic information, willingness to remind medical staff to perform HH, reasons for not speaking up, perceived reaction of other medical staff to being reminded to perform HH, the doctors’ own perceived reaction to being asked to perform HH, and doctors’ beliefs of the importance of HH and their role in preventing hospitalassociated infections. All data was de-identified. The Southern Health Human Research Ethics Committee (A) approved this study as quality research. Results One hundred and sixty-three doctors completed the questionnaire; 82 (51%) were males and 118 (73%) were aged less than 45 years. Responding doctors included 12 (7.4%) interns, 34 (20.9%) residents, 37 (22.7%) registrars and 80 (49.0%) consultants. Specialities included 65 (40%) medicine, 32 (20%) surgery, 24 (15%) obstetrics and gynaecology, 11 (7%) paediatrics and 31(18%) other. One hundred and thirty-six (83.4%) doctors regarded HH as very important and 23 (14.1%) as important while only 3 (1.8%) regarded it as mildly important. No doctor thought HH was unimportant, although one (0.6%) admitted to having no knowledge of its importance. When questioned about their own role in preventing hospital-associated infections, 73 (44.8%) believed they had a very large role, 56 (34.4%) a large role, 24 (14.7%) a small role and 4 (2.5%) a very small role. Six (3.6%) doctors admitted to having no idea about their role in preventing HAIs. Willingness to ask a doctor to perform HH decreased as the seniority of the doctor being asked increased. 139 (88.5%) were willing to ask an intern but only 63 (40.4%) were willing to ask a consultant (Fig. 1).
Intern
Resident
Registrar
Consultant
Seniority of doctor being questioned Fig. 1. Willingness of medical staff to ‘speak up’ if a doctor does not perform HH.
The reason for not asking colleagues to perform HH differed according to the seniority of the doctor being asked. The main reason for not challenging interns and residents was the desire not to interrupt them (8 (47.1%) and 8 (34.7%) respectively), but the main reason for not challenging registrars and consultants was an unwillingness to question a senior figure (25 (55.6%) and 56 (64.4%) respectively) (Fig. 2). The main anticipated reaction of the doctor being asked to perform HH also differed according to the seniority of the doctor being asked. Fifty per cent (n = 69) of medical staff believed that interns would be embarrassed to be asked to perform HH whilst 40.9% (n = 63) of medical staff believed consultants would be irritated to be asked to perform HH (Fig. 3a). When doctors were asked to comment on what their own reaction to being asked to clean their hands would be, the majority stated they would be thankful (28.5 to 40.5%) or embarrassed (28.1 to 42.9%) with a minority believing they would be irritated by such a confrontation (3.3 to 17.9%) (Fig. 3b). Discussion Our study highlights the steep medical hierarchy that exists among medical staff and an underlying reluctance to challenge behaviour, even when that behaviour could potentially threaten patient lives. Fewer than half of the doctors in our study were willing to challenge senior doctors and the main reason doctors did not speak up was because ‘they did not feel it was their place’ to reprimand a superior. Patients rely on recognition and correction of medical errors to keep them safe. In the case of HH, patient harm may be caused by any member of the treating team, regardless of seniority. Therefore prevention is dependent upon doctors recognising, not only their own errors, but also those of team members. HH represents a behavioural model to assist in understanding how doctors think and to demonstrate the barriers in communication between members of a treating medical team. Lessons learnt can be applied across many other patient safety initiatives.
74
Healthcare Infection
C. Dendle et al.
HH is not important
Embarassed
Don't want to interrupt
Not my place to question a superior
Concerned about assessment
Thankful
Surprised
Embarassed
Irritated
100 90
100
80
90
70
Percentage (%)
80 60
70 60
50
50
40
40
30
30 20
10 0 t
n i es
In
R
t
r
n de
r te
n lta
ra st
R
i eg
u ns
o
C
Seniority of doctor being questioned Fig. 2. Reasons for not ‘speaking up’ when doctors do not perform HH.
Not speaking up when error occurs is a well-recognised phenomenon in medicine.4 In the UK National Health Service, half the healthcare professionals who detected a colleague’s error or incompetence remained inhibited about reporting it.4 High-profile ‘whistleblowing cases’ have highlighted that even when gross negligence is occurring, there remains stigma and unwillingness for doctors to speak up.5 For HH in particular, role modelling is well documented and the influence of senior staff to impede or improve a HH program has been noted.6,7 The aviation industry has identified communication breakdown as a key factor in error. Analysis of black-box recordings demonstrated that most plane crashes were not the result of a single pilot error but rather a series of miscommunications and misunderstandings.8,9 As a consequence, Crew Resource Management (CRM) training is mandatory, at all levels of seniority, and has resulted in widespread culture change within aviation. The principle behind CRM is that any member of the team, regardless of seniority, can speak up if they notice an irregularity occurring. CRM training has been adopted by other industries with a strong hierarchical structure, such as fire fighters and the defence forces but is not widely applied in medicine.8,9 ‘Teamwork initiatives’ within medicine have demonstrated improvements in patient safety.10 Berenholtz and colleagues demonstrated remarkable improvements in central-line infection rates in intensive care when one of the key initiatives was that any healthcare worker could halt proceedings if they noticed a breach in infection-control practices.10 Over 15 years ago, Yap and colleagues demonstrated improved compliance with HH when medical teams specifically decided that all members of the team (medical or nursing) could remind any doctor who failed to perform HH.11 However this has not been a core initiative of many HH programs.
Percentage (%)
20
10 0 Intern
Resident
Registrar
Consultant
Seniority of doctor being questioned 100 90 80 70 60 50 40 30 20 10 0 Intern
Resident
Registrar
Consultant
Rank of doctor Fig. 3. Comparison of participant’s opinion of the reaction of the doctors they would ask to perform HH compared with their own reaction if asked to perform HH. (a) Anticipated reaction of a doctor who is asked to perform HH. (b) Participant’s own reaction if a doctor asked them to perform HH.
The key finding from our study, that doctors will not challenge their superiors, primarily because they are embarrassed and afraid of causing embarrassment, has implications for the design of future hand hygiene programs. Increasingly, doctors are expected to make decisions that are objective and evidence-based. What is seldom recognised, however, is that how doctors ‘feel’ also affects clinical decision-making. These ‘feelings’ are relevant in the complex social networks that exist within hospitals and if not taken into account with promotion of patient-safety initiatives will impact on their effectiveness. Doctors in our study possessed adequate knowledge of the importance of HH but were unable and unwilling to communicate the importance of its application which suggests the absence of clear pathways at the bedside through which to challenge unprofessional behaviours. Hence for future programs, in order to transform behaviour, resources need to be directed to improving communication skills and strategies to minimise social risk to staff. Empowerment to challenge may involve teaching
Speaking up about medical errors
Healthcare Infection
explicit strategies for delivering potentially sensitive or threatening information and dealing with strategies that prevent, minimise or negate the message. This involves providing ‘moves’ (staged communication steps) and specific wording. The embedded cultural norm of ‘not speaking up’ was evident from internship, suggesting this issue needs to be addressed right from medical school, and throughout vocational training. Our findings support the increasinglyheld view that it is insufficient to teach quality and safety topics in isolation; rather, instructions need to be integrated into the clinical environment.12 Specific skills, such as the ability to speak up need to be systemised and revisited repeatedly, in different contexts, so they become consolidated and instinctive. HH represents such an integrated skill, a skill that is performed by all healthcare workers, regardless of seniority, multiple times per day within different settings. The main limitations of our study include the small numbers, the fact that the study was done in a single health service and the self-reported data; however, it exposes what doctors practising clinical medicine may suspect to be true, that the medical hierarchy affects the behaviours of doctors. The findings are likely to be widely relevant as most doctors have acquired their clinical skills thorough observations and role modelling from superiors, and almost universally, medicine is a hierarchical culture. Conclusion The greatest opportunity to improve patient outcomes over the next few decades will not come from discovering new treatments, but from learning how to deliver existing therapies more effectively and safely.13 Doctors are expected to systematically monitor and improve their practice and the practice of those they supervise5 but this system is inherently flawed if a trainee will not prompt supervisors to change lifethreatening behaviours such as omitting HH. The central role of communication on delivering safe and effective healthcare is increasingly recognised and being investigated by observational and discourse approaches14 In medicine, like other hierarchical professions, we must devise mechanisms of devolving and questioning authority, whist maintaining a system of command. HH represents a platform on which to conduct future research that examines the use of techniques to empowering junior staff to speak up and to encourage senior staff to facilitate open communication. Conflict of interest
75
Funding No external funding was used. References 1.
2.
3.
4.
5.
6.
7.
8.
9. 10.
11. 12.
13.
14.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Suavan V, Touvenau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307–12. doi:10.1016/S0140-6736(00)02814-2 Nuland S. The Doctors’ Plague: Germs, Childbed Fever and the Strange Story of Ignac Semmelweis. New York: WW Norton and Company, Inc.; 2003. Grayson ML, Russo PL, Cruickshank M, Bear JL, Gee CA, Hughes CF, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. Med J Aust 2011; 195(10): 615–9. doi:10.5694/mja11.10747 Firth-Cozens JR, Firth A, Booth S. Attitudes to and experiences of reporting poor care. Clin Gov 2003; 8: 331–6. doi:10.1108/ 14777270310499423 Faunce TA, Bolson SN. Three Australian whistleblowing sagas: lessons for internal and external regulation. Med J Aust 2004; 181: 44–7. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141: 1–8. Jenner EA, Watson PWB, Miller L, Jones F, Scott GM. Explaining hand hygiene practice: an extended application of the Theory of Planned Behaviour. Psychol Health Med 2002; 7: 311–72. doi:10.1080/13548500220139412 Pizzi L, Goldfarb NI, Nash DB. Chapter 44. Crew resource management and its applications in medicine. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2001. Available from: https://www. premierinc.com/safety/topics/patient_safety/downloads/23_AHRQ_ evidence_report_43.pdf [verified 26 March 2013]. Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320: 781–5. doi:10.1136/bmj.320.7237.781 Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32(10): 2014–20. doi:10.1097/01.CCM.0000142399.70913.2F Yap LB, Bowler ICJW, Maxwell PH. Guiding hands of our teachers. Lancet 2001; 357(9254): 480. doi:10.1016/S0140-6736(05)71289-7 Paul A, Sherif M. A medico-linguistic approach to clinical skills teaching. In: Teaching, Learning and Assessing Clinical Skills: Does One Size Fit All? 2nd International Clinical Skills Conference Abstract Book; 2007 July 1–4; Prato, Italy. p. 99. Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet 2004; 363: 1061–7. doi:10.1016/S0140-6736(04)15843-1 McGregor J, Lee M, Slade D, Dunston R. Effective clinical handover communication: improving patient safety, experiences and outcomes. Pilot Report. Sydney: University of Technology; 2011.
There are no conflicts of interest to declare.
www.publish.csiro.au/journals/hi
Healthcare Infection, 2013, 18, 72–75 http://dx.doi.org/10.1071/HI12044
Why is it so hard for doctors to speak up when they see an error occurring? Claire Dendle1,2 MBBS, FRACP, GCHPE Andrea Paul1 GradDipEd, MA(AppLing) Carmel Scott3 RN, CICP Elizabeth Gillespie3 BN, RN, CICP, MPubHlth (Melb) Despina Kotsanas2 BSc(Hons), MClinEpi Rhonda L. Stuart1,2,3,4 MBBS, FRACP, PhD 1
Department of Medicine, Monash University, Wellington Road, Clayton, Vic. 3168, Australia. Department Infectious Diseases, Monash Medical Centre, 246 Clayton Road, Vic. 3168, Australia. 3 Department Infection Control and Epidemiology, Monash Medical Centre, 246 Clayton Road, Vic. 3168, Australia. 4 Corresponding author. Email: [email protected] 2
Abstract. Background: The ability of doctors to ‘speak up’ when a medical error occurs is a cornerstone of patient safety. Hand hygiene (HH) is one of the simplest methods of reducing patient harm and represents a behavioural model in which to observe medical staff interaction. Our hypothesis is that the hierarchical structure amongst doctors prevents them from speaking up, which in turn contributes to poor HH compliance. Methods: An anonymous survey was administered to doctors employed in a health service in Melbourne, Australia. Questions included: willingness to prompt doctors to perform HH, reasons for not speaking up, perceived reactions of a doctor being prompted to perform HH and perceived reaction if they were asked to perform HH. Results: One hundred and sixty-three doctors completed the questionnaire. Willingness to prompt a doctor to perform HH decreased as the questioned doctor’s seniority increased, with 88.5% willing to ask an intern but only 40.4% willing to ask a consultant. The main reason for not asking a senior doctor was not wanting to speak up to a superior. Conclusions: Our study highlights a steep medical hierarchy, with less than half of the doctors willing to question seniors, even when they noticed an error occurring. We suggest that if acquired, the skills needed to respectfully prompt HH are transferrable to many other patient safety initiatives. Received 11 October 2012, accepted 11 December 2012, published online 10 April 2013
Introduction ‘As we must account for every idle word, so we must account for every idle silence.’ Benjamin Franklin ‘I have observed my senior colleagues fail to clean their hands at the bedside and despite being an infectious diseases physician, whose job it is to promote hand hygiene (HH), I remained silent. I was uncomfortable and unable to question my boss and as Benjamin Franklin said, I ‘must account for the idle silence’.’ Hand hygiene (HH) is one of the simplest yet most effective methods of reducing patient harm through reduction of hospital-associated infections.1 In 1840, Ignaz Semmelweis provided evidence that cleaning the hands of healthcare workers (HCW) reduced maternal mortality.2 It is notable
that Semmelweis failed to convince his medical colleagues of the benefits of HH or to adopt the practice. Today, remarkably, HH programs around the world consistently report that doctors have the lowest compliance of all professional groups.3 Hand hygiene compliance presents an opportunity to observe and understand the behaviour of doctors around medical error and ‘speaking up’. Our hypothesis was that the strong hierarchical structure amongst doctors contributes to the reluctance among them to speak up in the face of medical mistakes, and that this in turn may contribute to their poor compliance in HH programs. We thus sought to determine if doctors would challenge each other if they noticed a failure to perform HH and to explore the reasons for the chosen behaviour, in order to inform future quality programs.
Journal compilation Ó Australasian College for Infection Prevention and Control 2013
www.publish.csiro.au/journals/hi
Speaking up about medical errors
Healthcare Infection
73
100
Implications
*
The strong hierarchical structure in medicine impedes junior doctors ‘speaking up’ when errors occur, and this should be considered in the design of patient safety programs. Hand hygiene represents a good model in which to teach doctors how to ‘speak up’ at the bedside.
90
% willing to speak up
*
80 70 60 50
No
40
Yes
30 20 10 0
Methods An anonymous survey was sent to the hospital email addresses of all doctors within our health service during February 2012. Southern Health is the largest health service in Melbourne, Australia with 2100 acute, subacute, mental health and aged care beds. Doctors were classified as interns (first year postgraduation), residents (second and third year postgraduation), registrars (at least 3 years post-graduation and undertaking specialist training) and consultants (at least five years post-graduation and fully qualified specialists). Survey questions included demographic information, willingness to remind medical staff to perform HH, reasons for not speaking up, perceived reaction of other medical staff to being reminded to perform HH, the doctors’ own perceived reaction to being asked to perform HH, and doctors’ beliefs of the importance of HH and their role in preventing hospitalassociated infections. All data was de-identified. The Southern Health Human Research Ethics Committee (A) approved this study as quality research. Results One hundred and sixty-three doctors completed the questionnaire; 82 (51%) were males and 118 (73%) were aged less than 45 years. Responding doctors included 12 (7.4%) interns, 34 (20.9%) residents, 37 (22.7%) registrars and 80 (49.0%) consultants. Specialities included 65 (40%) medicine, 32 (20%) surgery, 24 (15%) obstetrics and gynaecology, 11 (7%) paediatrics and 31(18%) other. One hundred and thirty-six (83.4%) doctors regarded HH as very important and 23 (14.1%) as important while only 3 (1.8%) regarded it as mildly important. No doctor thought HH was unimportant, although one (0.6%) admitted to having no knowledge of its importance. When questioned about their own role in preventing hospital-associated infections, 73 (44.8%) believed they had a very large role, 56 (34.4%) a large role, 24 (14.7%) a small role and 4 (2.5%) a very small role. Six (3.6%) doctors admitted to having no idea about their role in preventing HAIs. Willingness to ask a doctor to perform HH decreased as the seniority of the doctor being asked increased. 139 (88.5%) were willing to ask an intern but only 63 (40.4%) were willing to ask a consultant (Fig. 1).
Intern
Resident
Registrar
Consultant
Seniority of doctor being questioned Fig. 1. Willingness of medical staff to ‘speak up’ if a doctor does not perform HH.
The reason for not asking colleagues to perform HH differed according to the seniority of the doctor being asked. The main reason for not challenging interns and residents was the desire not to interrupt them (8 (47.1%) and 8 (34.7%) respectively), but the main reason for not challenging registrars and consultants was an unwillingness to question a senior figure (25 (55.6%) and 56 (64.4%) respectively) (Fig. 2). The main anticipated reaction of the doctor being asked to perform HH also differed according to the seniority of the doctor being asked. Fifty per cent (n = 69) of medical staff believed that interns would be embarrassed to be asked to perform HH whilst 40.9% (n = 63) of medical staff believed consultants would be irritated to be asked to perform HH (Fig. 3a). When doctors were asked to comment on what their own reaction to being asked to clean their hands would be, the majority stated they would be thankful (28.5 to 40.5%) or embarrassed (28.1 to 42.9%) with a minority believing they would be irritated by such a confrontation (3.3 to 17.9%) (Fig. 3b). Discussion Our study highlights the steep medical hierarchy that exists among medical staff and an underlying reluctance to challenge behaviour, even when that behaviour could potentially threaten patient lives. Fewer than half of the doctors in our study were willing to challenge senior doctors and the main reason doctors did not speak up was because ‘they did not feel it was their place’ to reprimand a superior. Patients rely on recognition and correction of medical errors to keep them safe. In the case of HH, patient harm may be caused by any member of the treating team, regardless of seniority. Therefore prevention is dependent upon doctors recognising, not only their own errors, but also those of team members. HH represents a behavioural model to assist in understanding how doctors think and to demonstrate the barriers in communication between members of a treating medical team. Lessons learnt can be applied across many other patient safety initiatives.
74
Healthcare Infection
C. Dendle et al.
HH is not important
Embarassed
Don't want to interrupt
Not my place to question a superior
Concerned about assessment
Thankful
Surprised
Embarassed
Irritated
100 90
100
80
90
70
Percentage (%)
80 60
70 60
50
50
40
40
30
30 20
10 0 t
n i es
In
R
t
r
n de
r te
n lta
ra st
R
i eg
u ns
o
C
Seniority of doctor being questioned Fig. 2. Reasons for not ‘speaking up’ when doctors do not perform HH.
Not speaking up when error occurs is a well-recognised phenomenon in medicine.4 In the UK National Health Service, half the healthcare professionals who detected a colleague’s error or incompetence remained inhibited about reporting it.4 High-profile ‘whistleblowing cases’ have highlighted that even when gross negligence is occurring, there remains stigma and unwillingness for doctors to speak up.5 For HH in particular, role modelling is well documented and the influence of senior staff to impede or improve a HH program has been noted.6,7 The aviation industry has identified communication breakdown as a key factor in error. Analysis of black-box recordings demonstrated that most plane crashes were not the result of a single pilot error but rather a series of miscommunications and misunderstandings.8,9 As a consequence, Crew Resource Management (CRM) training is mandatory, at all levels of seniority, and has resulted in widespread culture change within aviation. The principle behind CRM is that any member of the team, regardless of seniority, can speak up if they notice an irregularity occurring. CRM training has been adopted by other industries with a strong hierarchical structure, such as fire fighters and the defence forces but is not widely applied in medicine.8,9 ‘Teamwork initiatives’ within medicine have demonstrated improvements in patient safety.10 Berenholtz and colleagues demonstrated remarkable improvements in central-line infection rates in intensive care when one of the key initiatives was that any healthcare worker could halt proceedings if they noticed a breach in infection-control practices.10 Over 15 years ago, Yap and colleagues demonstrated improved compliance with HH when medical teams specifically decided that all members of the team (medical or nursing) could remind any doctor who failed to perform HH.11 However this has not been a core initiative of many HH programs.
Percentage (%)
20
10 0 Intern
Resident
Registrar
Consultant
Seniority of doctor being questioned 100 90 80 70 60 50 40 30 20 10 0 Intern
Resident
Registrar
Consultant
Rank of doctor Fig. 3. Comparison of participant’s opinion of the reaction of the doctors they would ask to perform HH compared with their own reaction if asked to perform HH. (a) Anticipated reaction of a doctor who is asked to perform HH. (b) Participant’s own reaction if a doctor asked them to perform HH.
The key finding from our study, that doctors will not challenge their superiors, primarily because they are embarrassed and afraid of causing embarrassment, has implications for the design of future hand hygiene programs. Increasingly, doctors are expected to make decisions that are objective and evidence-based. What is seldom recognised, however, is that how doctors ‘feel’ also affects clinical decision-making. These ‘feelings’ are relevant in the complex social networks that exist within hospitals and if not taken into account with promotion of patient-safety initiatives will impact on their effectiveness. Doctors in our study possessed adequate knowledge of the importance of HH but were unable and unwilling to communicate the importance of its application which suggests the absence of clear pathways at the bedside through which to challenge unprofessional behaviours. Hence for future programs, in order to transform behaviour, resources need to be directed to improving communication skills and strategies to minimise social risk to staff. Empowerment to challenge may involve teaching
Speaking up about medical errors
Healthcare Infection
explicit strategies for delivering potentially sensitive or threatening information and dealing with strategies that prevent, minimise or negate the message. This involves providing ‘moves’ (staged communication steps) and specific wording. The embedded cultural norm of ‘not speaking up’ was evident from internship, suggesting this issue needs to be addressed right from medical school, and throughout vocational training. Our findings support the increasinglyheld view that it is insufficient to teach quality and safety topics in isolation; rather, instructions need to be integrated into the clinical environment.12 Specific skills, such as the ability to speak up need to be systemised and revisited repeatedly, in different contexts, so they become consolidated and instinctive. HH represents such an integrated skill, a skill that is performed by all healthcare workers, regardless of seniority, multiple times per day within different settings. The main limitations of our study include the small numbers, the fact that the study was done in a single health service and the self-reported data; however, it exposes what doctors practising clinical medicine may suspect to be true, that the medical hierarchy affects the behaviours of doctors. The findings are likely to be widely relevant as most doctors have acquired their clinical skills thorough observations and role modelling from superiors, and almost universally, medicine is a hierarchical culture. Conclusion The greatest opportunity to improve patient outcomes over the next few decades will not come from discovering new treatments, but from learning how to deliver existing therapies more effectively and safely.13 Doctors are expected to systematically monitor and improve their practice and the practice of those they supervise5 but this system is inherently flawed if a trainee will not prompt supervisors to change lifethreatening behaviours such as omitting HH. The central role of communication on delivering safe and effective healthcare is increasingly recognised and being investigated by observational and discourse approaches14 In medicine, like other hierarchical professions, we must devise mechanisms of devolving and questioning authority, whist maintaining a system of command. HH represents a platform on which to conduct future research that examines the use of techniques to empowering junior staff to speak up and to encourage senior staff to facilitate open communication. Conflict of interest
75
Funding No external funding was used. References 1.
2.
3.
4.
5.
6.
7.
8.
9. 10.
11. 12.
13.
14.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Suavan V, Touvenau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307–12. doi:10.1016/S0140-6736(00)02814-2 Nuland S. The Doctors’ Plague: Germs, Childbed Fever and the Strange Story of Ignac Semmelweis. New York: WW Norton and Company, Inc.; 2003. Grayson ML, Russo PL, Cruickshank M, Bear JL, Gee CA, Hughes CF, et al. Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative. Med J Aust 2011; 195(10): 615–9. doi:10.5694/mja11.10747 Firth-Cozens JR, Firth A, Booth S. Attitudes to and experiences of reporting poor care. Clin Gov 2003; 8: 331–6. doi:10.1108/ 14777270310499423 Faunce TA, Bolson SN. Three Australian whistleblowing sagas: lessons for internal and external regulation. Med J Aust 2004; 181: 44–7. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004; 141: 1–8. Jenner EA, Watson PWB, Miller L, Jones F, Scott GM. Explaining hand hygiene practice: an extended application of the Theory of Planned Behaviour. Psychol Health Med 2002; 7: 311–72. doi:10.1080/13548500220139412 Pizzi L, Goldfarb NI, Nash DB. Chapter 44. Crew resource management and its applications in medicine. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2001. Available from: https://www. premierinc.com/safety/topics/patient_safety/downloads/23_AHRQ_ evidence_report_43.pdf [verified 26 March 2013]. Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320: 781–5. doi:10.1136/bmj.320.7237.781 Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32(10): 2014–20. doi:10.1097/01.CCM.0000142399.70913.2F Yap LB, Bowler ICJW, Maxwell PH. Guiding hands of our teachers. Lancet 2001; 357(9254): 480. doi:10.1016/S0140-6736(05)71289-7 Paul A, Sherif M. A medico-linguistic approach to clinical skills teaching. In: Teaching, Learning and Assessing Clinical Skills: Does One Size Fit All? 2nd International Clinical Skills Conference Abstract Book; 2007 July 1–4; Prato, Italy. p. 99. Pronovost PJ, Nolan T, Zeger S, Miller M, Rubin H. How can clinicians measure safety and quality in acute care? Lancet 2004; 363: 1061–7. doi:10.1016/S0140-6736(04)15843-1 McGregor J, Lee M, Slade D, Dunston R. Effective clinical handover communication: improving patient safety, experiences and outcomes. Pilot Report. Sydney: University of Technology; 2011.
There are no conflicts of interest to declare.
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