Medical errors occur on a regular basis in the hospital setting and are currently estimated as the third leading cause of death in the US (Makery & Daniel, 2016). Medical error is not unique to the US and has significant implications for healthcare on a global scale. For example, in Australia, medical errors have contributed to18,000 deaths and even more disabilities (Weingart, Wilson, Gibberd & Harrison, 1999). Because medical errors have devastating effects that can lead to patient harm and death, initiatives to further understand this phenomenon are necessary (Leapfrog, 2016). Beyond patients and their families, it is well documented that medical errors negatively affect healthcare workers. Medical errors also result in unnecessary financial burdens totaling millions in the US, costs of which are then borne by healthcare systems (Andel, Davidow, Hollander, & Moreno, 2012).
Much of the healthcare industry’s attention to safety over the last decade or so can be credited to the 1999 Institute of Medicine (IOM) report entitled, To Err is Human. This pivotal IOM report stressed the occurrence of human error in the medical field.
It is well known that communication problems can increase the occurrence of medical errors. The Joint Commission, a healthcare accrediting body, determined that up to 80 percent of serious medical errors are due to issues with communication (2012). Other research studies have also shown that mistakes in interpersonal communication are associated with more than 60% of medication errors (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005).
Speaking up, a subset of communication, is recognized as a means of improving patient safety. As Kolbe et al. (2012) stated, “Speaking up is increasingly considered essential for error prevention and quality of care” (p. 3). Although it is recognized that a nurse’s willingness to speak up in the healthcare setting is paramount to properly functioning in the fundamental role as patient advocate to improve safety, studies consistently show that nurses are hesitant to speak up (Maxfield et al., 2010). Lyndon et al. (2012) found that 12 percent of nurses said they would not speak up even if they perceived a high probability of patient harm. Kaissi, Johnson and Kirschbaum (2003) found that while an overwhelming majority of nurses responded that members should speak up, 15 percent reported hesitancy in verbalizing safety concerns. Studies have identified a number of barriers that deter nurses from speaking up including fear of negative consequences, feelings of futility, and an individual’s lack of assertiveness (Kaissi, Johnson, & Kirschbaum, 2003; Schwappach & Gehring, 2014; Okuyama, 2014)
Methods: This research study used a mixed methods design and was conducted at one mid-sized community hospital. The explanatory sequential research design, a type of mixed methods study, requires quantitative analysis be concluded first, followed by qualitative to elaborate on the findings. Secondary data from the hospital’s 2015 employee engagement (EE) survey were used and included hospital staff (n=321) from seven inpatient nursing units. Of these staff, 65% (n=208) were registered nurses (RNs), 30% (n=94) were nursing assistants and patient care techs, and the remaining 5% (n=19) were undefined. Spearman’s correlations were used to determine the strength of relationships between 63 survey questions and the outcome variable which focused on nurse willingness to speak up when there was a care concern.
Following the quantitative phase five interviewees (n=5) were selected using purposive sampling. All interviewees were RNs; two leaders and three bedside nurses. Interviews occurred over a four-day period in March 2017 and were conducted with one interviewee at a time. Using a semi-structured approach, each interview lasted about one hour. Coding was performed by the researcher with both unstructured and structured readings of the interview manuscript. A modified validity strategy was used and confirmed accuracy of coding.
Results: The Spearman’s correlation tests identified 42 of the questions on the EE survey as being moderately related and 21 questions as having strong relationships with speaking up. Results showed that the major factors influencing nurse willingness to speak up were perceptions regarding leadership, process improvement, quality, safety, and culture. Physician and staff relationships were found to have the lowest correlation with willingness to speak up.
Six major themes emerged from coding; they were professional integrity, charge and teaching, non-punitive, novice/young, positive recognition, and relationship. Analysis of theme emergence was conducted based on role, and may have signaled different priorities held by leaders versus bedside nurses. Theme frequency based on interview was also analyzed. These results showed evidence that specific influential experiences impacted the factors identified by individuals as being most important.
It is necessary that both leaders and organizations recognize their role in facilitating a nurse’s willingness to speak up because it has the potential to prevent medical error and improve patient safety. Knowledge of themes on the part of hospital leadership may help them be more receptive to and supportive of nurses when they speak up.
Conclusion: Speaking up is a means to improve patient safety yet it is not an established practice. While the decision to speak up is complex, organizational leadership at every level can encourage staff nurses to do so.