Patient Safety 101: Teaching Students How to Deal with Silencing and Lack of Psychological Safety

Today I had an interesting conversation with a physician who teaches in a medical school and is doing interprofessional work with medical and nursing students.  We were discussing using the play Lisa Hayes and I wrote on physician/nurse/team relationships, and patient safety Bedside Manners.  We talked about taking scenes from the play in which teamwork and communication go wrong and redoing them to make it go right.  The play also looks at how medical errors occur because of poor communication.  Echoing comments that have been made to me by many nursing school faculty, the physician worried that confronting medical and nursing students with problematic situations –“with all the bad stuff,” as the MD put it — will discourage and dishearten them.

I can’t tell you how many times I have heard this kind of comment.  I sympathize with the predicament and the desire to protect students from being discouraged.  I think, however, that this approach is misguided, particularly when it comes to patient safety and prevention of medical errors and injuries.  Why?  Because nothing can protect students from the realities they will confront whether in medicine, nursing, or any other profession or occupation.  If they encounter problematic situations, not discussing these issues in professional schools won’t fool them.  They will believe what they see and hear. Without preparation and guidance in understanding what they are seeing and hearing, however, they may conclude that the problem of toxic hierarchies and the behaviors that result are not system problems but rather individual ones.  Or they may believe all doctors, nurses,  aides (fill in the blank) are jerks and unworthy of collaborative effort and action.

If, on the other hand, the problems of teamwork and poor communication are realistically and constructively discussed, analyzed in terms of their long history, (see Nelson and Gordon in Complexities of Care as well as many other essays on this issue) and their failures of Team Intelligence, then  students will be  armed with understanding.  If students are also given the skills to constructively deal with these situations, they may not be pleased, but will not experience the kind of discouragement and ethical angst that often results when one is blind-sided by reality, disarmed by rank and position, silenced by peers or superiors, when you lack the skills to deal with all or any of this.  One of the most important lessons of the aviation safety movement lies in how students and new hires (whether pilots of flight attendants or others) are confronted with uncomfortable behaviors and taught how to deal with them.  Listen to this story from new pilot Robin Cook, which we recounted in our book 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 who thinks he knows it all. You want to get along. So I was concerned about where to draw 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.”

Imagine how empowered students would be if they received these kinds of lessons in their professional training and if those lessons were reinforced throughout their careers!  I would argue that patients’ lives, patient safety, and decreasing medical errors and injuries depends on this kind of educational preparation.