The By-Stander Phenomenon and Patient Safety

indexOver the past few months, I’ve spent a lot of time working with nursing students, medical students, and nurses, physicians, pharmacists and many others talking about interprofessional practice and patient safety.  One of the reasons why IPE programs have been developed is to enhance patient safety.  If clinicians and others who work in healthcare do so in isolated silos, they will have trouble communicating with each other, will not share critical patient care information and will not feel comfortable speaking up when they notice that a mistake is about to be made or otherwise act to prevent patient harm.

As I have talked with students, and nurses and doctors already in practice, one thing keeps coming up.  I call it the by-stander phenomenon.  Many, many people who are either in practice or learning to be healthcare professionals work in systems that socialize them to be by-standers when it comes to patient safety.  They tell me that they see things that are worrisome, dangerous, or downright horrifying and yet they do not feel comfortable bringing them to the attention of someone who could do something about patient safety for fear of reperecussions.  I have written about this in my blog before, but I am writing about it more now because I have been struck by so many people relating stories about their unwillingness to speak up to protect patients because of this fear of some sort of retaliation.

Consider the following.  I was in a classroom talking with medical students recently at a session discussing interprofessional care and practice.  The issue of patient safety came up and with it the problem of hand-washing or cleaning.  We discussed how many of those who work in healthcare don’t clean their hands when touching patients.  We talked further about the risks of such problematic behavior.  And then I asked whether the folks in the room would remind an attending physician to wash/clean his or her hands if they noted that had forgotten to do so.  The students agreed that it would depend.  On what, I asked?  On whether they felt the attending physician would welcome the reminder or would react negatively to that.  I thought about the comment, and said,” So what you are saying is that patient safety depends?  If I am  patient, I am thus essentially dependent on serendipity.  If you notice something that is threatening to me you will only act to protect me if the attending or authority figure in question seems to be a good guy?  But what happens to me if you notice that the attending has not washed his hands and you think he will get angry if you tell him — or her?  They sheepishly agreed.  While not surprising, this fact is nonetheless chilling.  And what is even worse is that the role modeling going on in healthcare teaching institutions all over the country is not only telling people they should be bystanders, it’s socializing them to become the attending who does not want to be reminded that he/she has not washed their hands or is about to make some other mistake.

I’ve also  heard a lot about the by-stander problem when I visit nursing schools.  Hospitals all over the country are trying to get nurses and doctors and other healthcare professionals to work more effectively together.  One way they are doing this is to teach a method of communication called SBAR (Situation, Background, Assessment, Recommendation).  This is something that is now being emphasized in nurse to physician communication.  Instead of the nurse calling and saying, “This is Four South, I need an order for … for Mrs. Jones,  the nurse is supposed to call the physician or NP or PA, and introduce himself with his first and last name, explain the situation, convey the assessment, and then make a recommendation about what, concretely, should be done.

And herein lies the problem.  Nurses have been taught not to make recommendations to physicians.  They have often been told that to even use medical language, as in the patient has a UTI, is to make a medical diagnosis.  So they hint and hope, and try to make the physician think that what the nurse knows needs to have happen is not her/his idea but rather than the physician’s.  Indirect language, and communication has thus been the norm, one that has been rigorously enforced.  So now nurses are supposed to make recommendations.  And many are worried about doing that.

Similarly, I have written about many nurses who notice a patient safety problem, perhaps even raise it, and seeing that their concerns go nowhere do not push, or prod, or persistently advocate because what, they feel, is the point?  They are the eyes, ears, and yes brains of the system, but they are effectively rendered blind, deaf, and dumb by system higher –ups.

Is it any wonder, given these constraints that patient harm is such a problem and that there seems to have been so little movement to make patients safer.

What is needed here is action and it is action that must come from the top.  When it comes to speaking up –students, nurses, housekeepers, anyone on a lower rung of the totem pole – needs to be told by higher ups that this is something that is wanted, expected and that it will be supported.  In teaching institutions, if we really want patients to be safe, physicians, if they truly want to lead, need to do so not only by example but by explicit instruction.  They need to tell every medical student, resident, nurse etc to please tell them if they see them making a mistake, forgetting to wash their hands, or otherwise have a patient safety concern that needs to be addressed, or a safety related question or issue that needs clarification.   Nurses need to do the same with those working under them.  And middle level and high level administrators, no matter what the discipline, need to make the same commitment and also commit to support any staff member who is concerned about patient safety.

TeamSTEPPS has a method called CUS that it teaches its trainers and trainees.  It’s called CUS . And it stands for Concerned, Uncomfortable, It’s a Safety issue.  We need to teach everyone who works in healthcare about CUS, to use CUS and to recognize that CUSing is not something people do to pass the time but rather something they do when something very troubling is happening.

A lot of people worry about commenting when there is ambiguity in a situation when it is grey rather than black and white.  While, that may be understandable, it is critical for people to know that their comments will be welcome and appreciated if they are uncertain about a particular patient safety concern.

The issues I referred to above are not grey areas.  There is nothing ambiguous about a person who hasn’t washed their hands touching a patient.  Nor is there anything ambiguous about making a recommendation about patient care and quality when you know what you are talking about – which nurses do, which is why they went to school in the first place.

Nurses, residents, housekeepers, etc need to know that their critical concerns are addressed by management when they are articulated.We have to address the by-stander phenomenon now!!  My life and the lives of millions of people like me can no longer depend….on how someone thinks someone in authority will behave.  We need more CUSing in healthcare which, because it will bring safer care, and will thus result in a whole lot less of the kind of cussing that occurs when patients have been harmed.

  • Ann Gallagher

    Dear Suzanne (if I may),

    I have been reading your work with interest for some time.

    I particularly like your piece re ‘Just a nurse’.

    I would like to refer to this in a forthcoming lecture and write to ask which is the preferred reference – the one I have is: Just a Nurse by Suzanne Gordon (Excerpted from a presentation made by Suzanne at ONS Fall Institute of Learning 11/05)

    Is it ok if I cite this or do you prefer another source for this work?

    I will look forward to hearing from you


    Ann, UK

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