The ease by which healthcare practitioners speak up when they witness unsafe behaviours and practices is one of the most important safeguards against patient safety incidents. According to Ayako Okuyama and colleagues, speaking up is ‘the raising of concerns by health care professionals for the benefit of patient safety and care quality. Writing in a paper titled Speaking up for patient safety by hospital-based health care professionals: a literature review, Okuyama and colleagues pointed out that the time to speak up is ‘upon recognising or becoming aware of the risky or deficient actions of others within health care teams’. The examples of concerns which the authors highlighted as reasons to speak up included ‘missed diagnoses, poor clinical judgement, lapses, rule breaking, and failure to follow standardised protocols‘.

Whilst speaking up is recognised as fundamental to patient safety, Okuyama and colleagues noted that, unfortunately, healthcare practitioners rarely speak up when they become aware of patient safety hazards. To support their assertion, they cited research which identified the factors which inhibit healthcare practitioners from speaking up, and one of these is the perception that speaking up will be ineffective, and may even carry ‘the risk of potential negative outcomes‘. They referred to this perception as a low ‘perceived efficacy of voice‘, and they attributed it to such factors as the discouraging attitude of healthcare leaders, and the tendency for health institutions to ignore those who speak up. They however also acknowledged that speaking up often requires the practitioner to carry out a fine ‘balancing act of trying to be pro-social and constructive while at the same time being mindful of personal costs‘. Other factors which Okuyama and colleagues identified as obstacles to healthcare practitioners speaking up are:

• • The fear of ‘the responses of others’ to their action
  • The fear of conflict
  • The desire to avoid conveying bad news
  • Excessive professional courtesy
  • The ambiguity and lack of clarity of the clinical situation

The willingness of clinicians to speak up was also discussed by David Schwappach and Katrin Gehring in their paper titled Silence that can be dangerous: a vignette study to assess healthcare professionals’ likelihood of speaking up about safety concerns. Pointing out that the likelihood of speaking up about patient safety is influenced by ‘contextual factors‘, the authors explained that those holding management roles were more likely to speak up than those who hold lower positions, and that concerns about medication safety were more likely to trigger speaking up than violations of hospital hygiene rules. Other factors Schwappach and Gehring identified as reducing the likelihood of speaking up included:

• • The practitioner’s personality traits
  • The practitioner’s previous unsuccessful attempts at speaking up
  • The fear of damaging their relationships with the involved health care professionals

Beyond individual factors, organisational culture also plays a major role in determining the likelihood of practitioners speaking up. Exploring this theme in a paper titled Speak up-related climate and its association with healthcare workers’ speaking up and withholding voice behaviours: a cross-sectional survey in Switzerland, David Schwappach and Aline Richard explained that the psychological safety of the organisation may either enable a favourable speak up-related climate, or foster a sense of resignation about speaking up. In this regard, the authors urged organisations to establish a supportive climate which encourages ‘voicing behaviours‘, and discourages ‘withholding voice‘.

In their own survey of the factors that impede healthcare practitioners from speaking up, Jason Etchegaray and colleagues found that more than half of their healthcare respondents cited organisational reasons for why they never speak up about patient safety concerns. Publishing their findings in a paper titled Barriers to speaking up about patient safety concerns, the authors identified the following as the leading organisational factors inhibiting practitioners from speaking up:

• • The fear of repercussions from their leaders
  • The fear of negative feedback
  • The expectation that speaking up will make no difference to the situation
  • The negative perception of the organisations safety and teamwork culture

Another intriguing factor which inhibits speaking up is what Margaret Heffernen referred to as wilful blindness. Writing in her book appropriately titled Wilful Blindness, Heffernen referred to this as the human tendency to ignore evidence that is inconvenient, and as the purposeful avoidance of the opportunity and responsibility to be informed. Remarking that ‘we become blind because we are so afraid of what we might see and what we might feel’, she attributed this to the human need for reassurance, security and certainty.

In contrast to wilful blindness, Heffernan referred to the Cassandra syndrome to describe people who cannot help but see the inconvenient, and who are compelled to speak up even if their warnings are ignored. It is in the context of the Cassandra syndrome that she discussed whistleblowing, a type of speaking up in which concerns are raised outside the confines of the organisation. Heffernen acknowledged that whistleblowing is often carried out at great personal and professional cost to the whistleblower, and she illustrated this with the examples of Alice Stewart, an epidemiologist who warned of the risks of childhood leukaemia from ante-natal X-rays, and Stephen Bolsin, an anaesthetist who warned about the dangerous practices in a paediatric cardiac surgery unit.

In the next post, we will look at the morbidity and mortality conference in preventing human error