​​​​​​​​​​Melanie Vicente at TWH
Melanie Vicente, pictured here in the Day Surgery Recovery Room at Toronto Western Hospital, found she wasn’t alone in finding it difficult to talk to colleagues about mistakes. But her research has led to a conversation that is giving staff the tools to do so. (Photo: UHN)​​

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Melanie Vicente knew right away proper procedures hadn't been followed.

The patient was to have been up and out of bed following heart surgery to guard against the possibility of experiencing post-operative complications such as delirium, but when Melanie arrived for her evening nursing shift it was obvious the patient had never left the bed.

Whether due to workload, disregard for best practices or another factor, her colleague didn't get the patient mobile.

"How did he do getting out of bed today?" Melanie asked nervously, tiptoeing around the subject with her colleague because she was nervous about the possible negative reaction. The answer confirmed Melanie's suspicions – the patient hadn't been walked or had his feet dangled out of the bed.

Overnight, the patient became delirious and tried to hit Melanie, who had to call for help.

"I was afraid to speak up, even though I knew the patient should have been mobile," Melanie, who now works in the Post-Anesthetic Care Unit and the Day Surgery Department at Toronto Western Hospital, says of the incident five years ago at Toronto General. 

Caring Safely Logo​"I didn't feel I was able to say something when I saw something wrong."

Melanie's experience is far from unique. Every day at UHN – and in hospitals across Canada – healthcare workers stay silent when confronted by their colleagues making errors or taking shortcuts, or mistakes of their own. The reasons revolve around workplace culture – from fear of an angry confrontation, being "put in your place" by fellow staff or being branded as a "know-it-all" who's not a team-player.

Courageous conversations

​"It takes a lot of courage to have that conversation because they often don't go well," says Joy Richards, UHN's Vice-President Patient Experience & Chief Health Professions. "It's the rare person who says, 'at all costs it's the right thing to do, even though I'm worried about my job or being ostracized.'"

Caring Safely, UHN's Patient and Workplace Safety Transformation, aims to change that. Along with embracing safety as a core value, anticipating failure and having reliable processes to minimize risk, mutual respect is a key to working together to create a culture of safety.

In a workplace with mutual respect, all members of a team feel empowered to voice concerns about the way things are being done. They know that learning from failure, being open to change and using data and communication to drive reliability, resilience and safety across the system will make everyone better and safer.

It's the concept of Crew Resource Management (CRM), which was introduced to the aviation industry following a spate of deadly airline crashes in the 1970s. Analysis showed the primary cause of those accidents was human error, with breakdowns in interpersonal communications, leadership and decision-making a chief concern in a number of those scenarios.

CRM has been adopted by healthcare providers, including UHN, as they strive to become high reliability organizations (HROs). At its core is the idea that if you don't speak up, bad things can happen.

Image of Joy Richards
Joy Richards, UHN’s Vice-President Patient Experience & Chief Health Professions, says it takes a lot of courage to have conversations with colleagues about mistakes “because they often don’t go well.” (Photo: UHN Visual Services) ​​​

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CAP Fellowship research

"You want everyone to have the confidence and ability to speak up and the key is giving them the tools to do that," Joy says.

Upset by the situation involving the delirious patient, Melanie approached her manager, Linda Flockhart, who challenged her to do something about it, rather than just be frustrated about what had happened. Together, they decided Melanie should pursue a fellowship through UHN's Collaborative Academic Practice (CAP), delving deeper into the key topic of nurses "speaking up" in the workplace.

"It's a very important topic because it's about patient and workplace safety," says Linda, Clinical Director, Peter Munk Cardiac Centre and Toronto General Hospital Critical Care.

"Managers are not available 24/7 to support discussions between staff members. Staff need to have the communication skills and confidence to raise concerns with colleagues.

"We are all accountable for the care provided to patients."

Three questions; four key findings

As part of Melanie's CAP research project, Registered Nurses in TGH's Cardiovascular Intensive Care Unit – with a range of between two and 25 years of experience – were interviewed.   

Each was asked three questions:

  • Tell me about experience of speaking up when you saw another practitioner doing something they knew was wrong.
  • Tell me about an experience of not speaking up (remaining silent) when you saw another practitioner doing something you knew was wrong.
  • Tell me what you think supports nurses to speak up or what keeps them from speaking up when witnessing something you know is wrong.

Melanie found that four key findings emerged from her research:

  • Nurses were confident speaking up to a colleague they felt was at the same level or below them.
  • When nurses stayed silent or spoke up and it resulted in a negative interaction, it stayed with them and impacted future interactions with them and their colleagues.
  • Healthcare staff are accountable for the care they provide and must be able to take issues to their managers if they are unable to resolve, or if patients or staff are at risk. Dealing with issues openly is highly important.
  • The choice to speak up was dependent on the severity of the situation, with nurses picking and choosing when to speak based on how severe they thought the error or short-cut they witnessed was.

"I realized it's not just me, it's a lot of my colleagues," Melanie, who has a Master of Science in Nursing from York University, said of the research findings. "And, even a nurse with 25 years experience still didn't feel the ability to speak up all of the time."

Image of Linda Flockhart
Linda Flockhart, Clinical Director, Peter Munk Cardiac Centre and Toronto General Hospital Critical Care, encouraged Melanie to pursue a fellowship through UHN’s Collaborative Academic Practice (CAP), delving deeper into the key topic of nurses “speaking up” in the workplace. (Photo: UHN)​​​​

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'Creating a culture of safety'

In April of this year, Melanie addressed the Operating Room Nurses Association of Ontario 14th Biennial Conference with a presentation entitled "Silence Kills: What Breaks Down at the Critical Point in Communication that Leads Nurses to be Silenced?" In addition to reviewing her findings, she offered a series of recommendations for what nurses on all levels "can do to make a difference for patient safety."

At the top of Melanie's suggested remedies is "creating a culture of safety," which includes such key things as reporting unsafe conditions for patients and staff, communicating clearly and respectfully and recognizing your own limits. She also discusses how to speak up about issues a nurse may be having with another healthcare professional, stressing the importance of avoiding "seven habits that affect your credibility" – gossiping, judging, negativity, complaining, excuses, exaggeration and whining.

"When you speak up, you will be taken seriously because your attitude is sincere," Melanie says.

While Melanie's focus has been on nurses, it's clear that a number of other healthcare professions share these same issues when it comes to making patients and the workplace safer.

Melanie, Joy and Linda are among a number of nurses and senior managers at UHN looking to take the findings of this research and other empirical as well as anecdotal evidence and develop tools to speak up more effectively. It's seen as a key part of Caring Safely.

"We need to have a scenario of mutual respect because we're all here for one goal – patients," says Melanie, who hopes to expand her research. "They're why we're here, they're why we come to work."​

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