Over the past month, I have been doing a lot of traveling and lecturing about patient safety. What keeps coming up in my encounters with doctors, nurses, and others who work in healthcare is the subject of fear, silencing, self-silencing, institutional silencing and pedagogical silencing. As I wrote in one of my last posts, an attending uses a nursing student to intimidate a resident. Nurses intimidate nursing assistants, newly graduated nurses, and each other. Doctors, a surgeon ten years out of training, informs me, “eat their young.” So do nurses, according to what I thought was almost exclusively nursing territory. Fact is, in health care, toxic hierarchy and the silence it generates is a gift that keeps on giving.
After one of my last lectures, I received this from a nursing student at a major North American nursing school. The student is in a direct entry Masters program to become an NP. Yet, as you will see from this post, the student is being resocialized to conform to the current status quo in healthcare. The student writes:
“Coming from a background in outdoor adventure and guiding, I’ve generally been someone who speaks up and out when an issue has to be discussed. To not do so can lead to serious consequences when in the wilderness. One can’t afford to not speak up when you’re an hour away from the summit (which you spent all day getting to), but a storm is a half hour away and it’s about to crash down around you. People depend on you to get them through safely, and the team has to work together to make it through safely, whether it be on a river or a mountain. But entering nursing completely warped my sense of advocacy and speaking out. Being silent when seeing a group of physicians enter a room with not a one of them washing their hands left me feeling crippled with shame, and when I brought it up to my preceptors, it was suggested that I “not be that person” who tells others what to do.”
The student said that my talk about teamwork was emboldening and hoped to speak up more readily in the future. But this comment reminded me of one I wrote about in my JAMA article last year when a veteran healthcare teacher did not speak up when she saw a physician failing to wash his hands. My article in JAMA on hand-washing began with this story:
“A friend, who is a medical educator in a residency program at a medical school told me she was accompanying an intern as they trailed alongside an attending physician who was seeing patients in an outpatient clinic. The attending examined three patients in a row and did not clean his hands before or after examining any of them. One of those patients had MRSA. Both my friend and the intern noted the problem. Neither said a word. My friend told me she was stunned that she did not intervene. Unlike the intern, who could be easily intimidated by the veteran physician’s status, she had nothing to lose, she said, by reminding the physician of his Hippocratic oath. He had no power over her. Why, she wondered, had she not spoken up?”
In this regard, the culture in the aviation industry is totally different. Compare, for example, the experience of pilot Robin Scott, when he began his career as a pilot at age 24. As we wrote in the chapter on Teamwork in Beyond the Checklist, “Robin Scott began his career as a pilot in 2002, when at age twenty-four he landed his dream job with a commuter airline. During his initial flight training and then in his orientation at the commuter, Scott says he learned a great deal about teamwork in a variety of CRM courses. “In our three month new-hire course, we read and heard a great deal about how CRM and collaboration had helped avert disaster. We did simulated scenarios with a captain who would ignore us, shut us down, or try to intimidate us,” Scott recalls. “We learned how to deal with that. When I got out and started “flying the line,” I definitely felt this helped me, empowered me. You’re on probation for almost a year and you don’t want to ruffle any feathers. You don’t want any captain to blacklist you or start spreading the rumor that you’re one of those big mouths whothinks he knows it all. You want to get along. So I was concerned about where todraw the line with safety. What to do if it was a gray area. But CRM taught us, “No, you have to speak up, this isn’t a one man show.”
This problem of self-silencing in patient safety is critical. When will it end? How can we get to the point that has been reached in aviation, the conviction that Robin Scott describes, that when it comes to safety there can be no self-silencing?