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  • Writer's pictureStephen Harden

Over 50% of Your Staff Will Not Speak Up for Patient Safety: Six ThingsYou Must Do To Fix This

Updated: Aug 7, 2020

To help improve their patient safety and create alignment with the National Patient Safety Goals, I conducted a site assessment for a large, very well-run hospital in the mid-west. I watched as a physician, dressed in his street clothes, flew into a patient’s OR holding room to discuss that morning’s surgical procedure.

He was completely oblivious to, or totally disregarded, the large and easily seen warning signs indicating the patient was under isolation procedures for infection precautions.

All of the other staff in the room were completely gowned and gloved as per policy. During the surgeon’s entire visit, not one staff member said anything to the surgeon about his violation of the policy (and there were several that came and went during his time in the room). When asked about the event later by my colleague, none of the staff could give any reason for their failure to speak up.

When the event was later brought to the attention of the surgeon, he was dumbfounded no one said something to him. He said he would have welcomed the input and been thankful for it.

When the story was told to the unit administrators, they said that if there was ever a surgeon at their hospital who would have been open to a stop-the-line assertive statement from the staff, it would have been that surgeon.

What is especially troubling about this incident is that it is so common across the country. Unless it is fixed, it will be almost impossible for hospitals to achieve the National Patient Safety Goals.

AHRQ just released the summary of the data from all of the Safety Climate Surveys conducted last year. The national data about the willingness to speak up in our nation’s hospitals paints a dismal picture.

At first glance, the data doesn’t look so bad, but if you look at average responses in the communications domain, you will see that staff are saying, “Sure, I will speak up or ask questions--as long as the person I am talking to is not senior to me.” The data tells us that if any hierarchy is present in the interaction, over 50% of staff will not speak up.

This is a serious patient safety issue.


Six things you must do to fix this now:

1. Provide interdisciplinary training on how to speak up. Telling is not training. Training means you tell the learner why assertiveness is important, demonstrate through video or role modeling how to speak up, provide an opportunity for the learner to practice speaking up, and provide feedback to the learner on how they did in the guided practice session.

2. Ensure your teams train as teams. You must have a variety of staff positions in the training sessions so that learners can practice making an assertive statement to someone senior to them. In our training, we insist physicians participate so nurses and other staff can hear the physician tell them, “It is okay for you to talk to me like that. That’s how I want you to do it.” In my experience, there is no substitute for this type of senior-to-junior feedback. You cannot change the data above without this type of learning environment.

3. Adopt and publish a ‘Zero Tolerance’ policy for “payback.” The number one reason staff tell me they don’t speak up is that if they do, physicians can make their lives miserable; and when that payback happens, “Administration won’t support me.” Leadership action on retribution for speaking up must be as swift and as public as HR and privacy concerns will allow.

4. Embed assertiveness training in your new-hire training and mentoring/precepting programs.

5. Revise your P&P Manuals with clear and unambiguous directives requiring the use of stop-the-line language.

6. Celebrate loudly and often those nurses who speak up and stop the line to protect a patient’s safety or quality of care. Send them handwritten “thank you” notes. Put a laudatory written report into their personnel file. Let them know you care.


Behavior that gets rewarded gets repeated. Seriously folks, 5 out of 10 staff not willing to use stop-the-line language with someone more senior to them is unacceptable for patient safety. We can't reach National Patient Safety Goals like this. Let’s fix it.

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