Silence kills--challenging unsafe practice: one in eight patients in New Zealand is estimated to suffer an adverse event during their time in hospital. Good communication and team work are the keys to overcoming these errors.

Over the past 33 years, I have worked in 14 intensive care units (ICUs) in New Zealand and overseas. During this time, I have observed that when collaboration is poor, nurses resort to covert actions to achieve "good" patient outcomes. Error-hiding frequently occurs when staff believe they will be blamed for their "failures" ICU nurses seldom report the abusive behaviour of staff, even if this harms patient safety or nursing morale. For years "I wondered why somebody didn't do something. Then I realised, I am somebody" (anon).

Hospitals may save lives, but hospitals also kill patients. The publication To err is human: building a safer health system (1) galvanised the world's attention by stating the numbers of patients dying from health care errors in America was equal to two jumbo jets crashing every three days. This was based on an American study with an adverse event rate of 3.7 percent of admissions to hospital. (2) Even more alarming results were found in other countries. It was reported that Australia had an adverse event rate of 16.6 percent; (3) the United Kingdom a 10.8 percent rate; (4) and New Zealand a 12.9 percent rate of hospitalised patients. (5) (It is important to note the American study excluded adverse events if they did not result in patient harm. The British, Australian and New Zealand studies included all documented adverse events.)

The New Zealand study was a retrospective chart review of 13 randomly selected hospitals. The charts of approximately one in a 100 of all publicly funded hospitalisations were sampled, giving a finding of one in every eight patients suffering an adverse event. The study estimated 1500 deaths per year were caused by preventable adverse events. These 1500 deaths are equivalent to four Boeing 747s crashing in New Zealand every year; are three times the road traffic injury death rate; and double the deaths from both homicide and suicide. (6) As documentation of the errors was a pre-requisite, the actual incidence of adverse events is undoubtedly much higher.

Over six percent of the total adverse events were identified as being both preventable and occurring inside the hospitals If the statistics are extrapolated, Christchurch Hospital, with its 35,600 inpatient admissions, (7) has an estimated 2245 patients (using 20,000 bed-days) each year experiencing preventable adverse events while they are in hospital.

In the New Zealand study, 40 percent of the 6.3 percent of patients were admitted solely as a result of a preventable adverse event that occurred while they were receiving treatment in the emergency department or hospital clinics. (5) In this article, I will put aside this 40 percent and focus on errors occurring to the remaining 3.8 percent of patients. This is a much less "scary" number; however it still means documented and preventable adverse events are estimated to occur to one in every 26 patients. New Zealand is a diverse population with varying beliefs and practices and a "one size fits all" health care response is not appropriate. Maori cultural concepts of health interlink environmental, mental, spiritual and social/whanau dimensions to the physical dimensions of wellbeing. (8) The Treaty of Waitangi is described as New Zealand's founding document, applying to all situations, including health care. (9) If nursing silence negatively affects patient care or protection, it may contravene the Treaty's cultural safety requirements.

A survey of more than 2000 American health care workers revealed 88 percent of respondents had experienced intimidation from a doctor in the past year. (10) This included the use of condescending language or intonation, impatience with questions and reluctance to answer questions or phone calls. Within the past year, 57 percent of nurses said their questioning of an order was squelched with "lust give what I prescribed"; 4g percent had felt pressured into giving a drug when they had serious doubts about its safety; and seven percent had been involved in a medication error as a result. Intimidation is a safety issue. A nurse who is intimidated will be reluctant to question an order or action. Yet, by doing this, an adverse event could potentially be avoided.

The myth of infallibility 

Of 17,000 staff in 13 American hospitals, two thirds found it difficult or impossible to confront a person causing them concern. (11) The reasons given were: a perceived tack of ability; a belief that "it's not my job"; fear of retaliation; tack of time or opportunity; and a lack of confidence that it would do any good. Nonetheless, health professionals also find it difficult to confront their own errors, as only six percent of adverse drug events identified in another American study had a corresponding incident report. (12) A litigious society and a myth of infallibility (nurses and doctors seeing themselves as "fixing" problems, not causing them) may be an additional obstruction to admitting errors. Medical training culture has a hidden curriculum that discourages both admitting fault and challenging authority. A hierarchical group structure and a "code of silence" keep problems within the group. (1) The Bristol Royal Infirmary Report described these as "obstructions to patient safety" and were implicated in causing the unnecessary deaths of possibly 100 babies. (13) This report noted safe care was much more than the competence of health professionals; safe care also required teamwork and good communication.

Non-ethnic cultural issues are implicit in the "nurse-doctor game", expressed as "nurses use subtle non-verbal and cryptic verbal cues to communicate recommendations which, in retrospect, appear to have been initiated by the doctor". (14) Open disagreement is avoided through the appearance of deference to the doctor's authority. Nonetheless, a distorted delivery of information will further exacerbate poor communication.

New Zealand's Health and Disability Commissioner's Code of Patient's Rights states: "Every consumer has the right to an environment that enables both consumer and provider to communicate openly, honestly, and effectively ... in a manner that minimises the potential harm to, and optimises the quality of life of that consumer." (15)

The Ministry of Health's Reportable Events: Guidelines states the health sector has failed to learn from adverse events, as it has an outmoded approach compared to other industries, and "traditional boundaries and a culture of blame must be broken down". (16)

Research has shown wide gaps between the number of errors documented in retrospective studies and those reported by observers. When errors have been specifically looked for, their rates were found to be distressingly high. (17,18) In everyday hospital practice, the socialised expectation is that mistakes are unacceptable, with doctors and nurses viewing "an error as a failure of character--you weren't careful enough, you didn't try hard enough". (19) This may result in a gap between reported and actual errors, due to the difficulty doctors and nurses have in dealing with their own "infallibility".

Humans are fallible and errors may occur even in the best units. In addition, the adverse event may have arisen white trying to save or prolong life, and the patient may have been very ill at the time. More importantly, it is often the best health professionals who make the worst mistakes. (20) Errors may occur when a skilled professional is distracted (such as interpreting multiple stimuli or alarms) while carrying out an automatic action. These errors are entirely involuntary, are more typical of experts than novices, and can happen to the most careful practitioner. (21) If there is no skill or knowledge deficit, the mistake must be forgiven by the unit administration, the person concerned and by his/her peers. When an error occurs, the issue should not be who transgressed, but how and why the defences failed, with the emphasis on building "up-stream" defences to prevent recurrence and mitigation of the effects when errors do happen.

To encourage reporting of errors, those who report must be immune from disciplinary action. The purpose of the Protected Disclosures Act is to promote safety by facilitating disclosures of wrongdoing, through protecting employees who make them. (22) The Health Practitioners' Competency Assurance Act protects confidentiality when information collected is part of quality assurance activities. (23) In her report on the then Canterbury Health, former Health and Disability Commissioner Robyn Stent goes further, stating " ... staff who fail to complete incident reporting farms act in an unprofessional and unethical way". (24)

The high cost of poor communication has been described like this: "People see others make mistakes, violate rules or demonstrate dangerous levels of incompetence, repeatedly, over long periods of time, in ways that hurt patient safety and employee morale, but they don't speak up and the critical variable that determines whether they break this chain by speaking up is their confidence in their ability to confront." (11)

Patient safety should always be paramount. The nurse has legal, professional, moral and ethical obligations that mandate a refusal to carry out unsafe orders, as well as acting when others hurt patient safety.

Doctors are often blamed for making inappropriate decisions, or being "short" or rude, whereas nurses are often blamed for not knowing what is going on. However, in both cases the real problem may be ineffective communication, not unprofessional behaviour or lack of knowledge. (25) If a change in the patient's condition requires a change in treatment plan, the nurse needs to present this information clearly and logically. If the doctor is giving orders that are unsafe, the nurse is obligated to clarify them.

A standard, assertive communication process needs to be encouraged, such as a statement of the problem, followed by the rationale and potential solution. If conflict arises, it must be addressed (not avoided), with support from colleagues. When a nurse queries a doctor's order and is rebuffed, it is crucial to activate the "two challenge rule" This rule dictates that "any question that is not answered must be posed again, and, if still not answered, must automatically be referred to a third party for resolution". (26) If issues cannot be resolved, the nurse must activate the chain of command. Nurses are responsible for their own professional acts and omissions, and may be held responsible for poor communication.

The American Association of Critical Care Nurses notes: "A significant gap often exists between what nurses are accountable for and their ability to participate in decisions that affect those accountabilities. Evidence suggests that physicians, pharmacists, administrators and nurses assign primary responsibility for patient safety to nurses. However, only eight percent of physicians recognise nurses as part of the decision making team. (27)

Some nurses are more able to be assertive due to factors like age, gender, education, and economic or social class. Despite this, the use of medical dominance to "win" conflicts may silence nurses, preventing the integration of multiple perspectives in the solving of complex patient problems. One nurse may consider a "good" nurse-doctor relationship as "he does not yell at me", whereas another may define a "good" relationship as "he seeks and values my opinions."

Whenever possible, nurses should frame their communication with doctors in "medical" terms, which means using brief, fact-based, action-oriented information that is associated with a request for a specific action. (28) The patient is the vulnerable recipient of care and the situation may not allow time for playing the "doctornurse" game, or for the interpretation of vague verbal or non-verbal communications.

Communication breakdowns also occur when nurses do things that conflict with their professional judgement, due to their tack of confidence in their ability to do so (such as failing to confront a doctor who has written an unsafe or unclear order). Nurses are particularly at risk for role conflict, as their patient advocate responsibilities may compete with their rote of an employee expected to follow hospital policy and doctors' "orders" Although these potentially competing rotes may challenge nurses' moral and ethical belief systems, nurses have their own professional standards. No doctor's order or intimidation should be given sufficient weight to override a nurse's professional standards.

Addressing conflict may save lives

Conflict may be inevitable and possibly even beneficial Doctors emphasise the curing of patients, white nurses emphasise caring. Nurses say they often manage their professional rote to minimise conflict, yet conflict may both facilitate, as well as hinder patient safety. Moreover, collaboration that increases nurses' control over their environment will provide a safety net against errors, as fewer errors occur when collaboration and communication are strong. (29) An American study in 1995 corroborated this, finding nurses were responsible for intercepting 86 percent of medication errors made by doctors, before the error reached the patient. (30) Nurses reported disruptive behaviour by doctors after the nurse had questioned or sought clarification of orders and after sudden changes in the patient's status. (31) The primary cause of this disruptive behaviour was doctors believing orders were not being carried out correctly or in a timely manner, often precipitated by doctors "not getting their own way" To achieve what is right for patients, nurses may resort to communicating through the "nurse-doctor" game or the use of covert actions. (13)

One study noted the interaction between professionals caused 16 percent of adverse events. (17) A descriptive survey of more than 2000 hospital workers found communication breakdowns may be responsible for up to 20 percent of art medical errors, noting: "Forty percent [of nurses] who had concerns about a medication order assumed it was correct or asked another professional to talk to the prescriber, rather than interacting with the intimidating prescriber. Seventy-three percent asked colleagues to help them interpret an order or validate its safety so they did not have to interact with the prescriber. Forty-nine percent felt pressure to... administer a medication despite their concerns." (32)

A study of 1500 respondents found disruptive behaviour was both horizontal and vertical. (33) Forty-nine percent of doctors had witnessed other doctors acting badly, and 72 percent of nurses had seen other nurses acting badly. Vertically, 47 percent of doctors had witnessed nurses acting badly, and 86 percent of nurses had seen doctors acting badly. In this study, the majority of respondents believed only around two percent of doctors and nurses exhibited disruptive behaviour. Of concern was that 17 percent of respondents knew of an adverse event that occurred as a result of the disruptive behaviour of this two percent. (33)

A definition for disruptive behaviour includes intimidation, humiliation, undermining, domination and bullying. Zero tolerance of these disruptive behaviours must be enforced, regardless of the offender's status in the organisation. Nurses need to support colleagues in conflict. Rather than abandoning a colleague to manage conflict alone, nurses should go to the area and demonstrate their support through their presence. (28) From a legal point of view, documenting disruptive behaviour is essential to establish an institutional record. (34) The Health and Disability Commissioner recommends staff complete incident reporting forms, as professional and ethical standards expect this. (24)

One writer has put safety into an everyday perspective: "When I drive over a bridge, I want to know the builders worked in close collaboration. Not that they argued their way through the design and construction and somebody won because they talked louder or simply had more authority, and somebody else went away full of resentment to put in the rivets, or whatever. The same goes for health care--or any interdependent system. The people who do the work have to find collaborative ways to negotiate their differences." (35)

Promoting a no-blame culture

Everyone working in health has a responsibility to create a workplace culture oriented toward preventing errors, as well as intercepting the errors that will inevitably occur. Nurses should refuse to play the "nurse-doctor" game. They should communicate patient care needs in "medical" terms, with an associated request for a specific action. It is imperative a no-blame culture is promoted, as the shame of making an error may create pressure to hide or cover-up the error.

Conflict must be addressed; it is inevitable and is not inherently good or bad. Procedures are needed for dealing with conflict, such as peer support and the "two challenge rule". Although the 2005 study showed only about two percent of staff were disruptive, their "bad" behaviour was repeated again and again. This two percent of staff were associated with 17 percent of adverse events. (33) An employee who is intimidated may be too scared to question an order or action, when this questioning might have prevented an error. If nurses do not intervene to stop disruptive behaviour they are abetting the disruptive team member and are possibly allowing a patient to be harmed. To protect patient safety and staff morale, disruptive behaviour must be documented in incident reports.

The patient is really in danger if no one feels able to disagree with a care plan. Healthy nurse-doctor relationships are not just a nice thing to have; they are essential for patient safety and are mandated by ethical, moral, cultural and legislative requirements. Nurses must be able to critically influence practice and protect patients. "I wondered why somebody didn't do something. Then I realised, I am somebody"--This somebody is you!

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in October 2006.

References

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Sandi Evans, RN, DipMid, PGCert, MN, is a staff nurse in Christchurch Hospital's child acute assessment unit. This article was developed from her MN dissertation last year.