Challenges to authority save lives

A nurse sees a physician about to commit a grievous error. A resident watches an attending physician brush aside warning signs of a medical error. What factors go into challenges that may save a patient’s life? Malcolm Gladwell provides insights in Outliers. The author of The Tipping Point and Blink, Gladwell’s engaging writing is a delight. Here’s what I gained on this subject.

The concept of power distance is concerned with attitudes toward hierarchy, specifically with how much a particular culture (or group of professionals within that culture) value and respect authority. There are low-power distance index countries, like the United States, and high power index countries, like the Philippines. Here’s what we see in nursing: a nurse can be ignored or chastised if she challenges a physician from a male-dominated society where women are considered to be less than equal. On the other hand, a nurse from a society that puts physicians on a pedestal may be unable to challenge the decision making when needed.

How does this apply to patient safety and medical malpractice? And how can healthcare providers prevent those lost or ruined lives that result from medical disasters? How do we avert medical and nursing malpractice if those who speak up are ignored?

1. First, healthcare staff should be given the skills and the words to use to question authority. One of my job responsibilities in 1987 was to teach assertiveness skills to Filipino nurses. I recall the startled expressions on their faces when they realized they were expected to challenge physicians. This was not part of their training at the time. The healthcare culture must actively and visibly support the need to speak up. This is an incredibly threatening concept for those stuck in the high power distance mindset.

2. We can learn from the airline industry. Crew Resource Management concepts are being adopted by healthcare institutions. For example, according to Gladwell, many airlines teach a standardized procedure for copilots to challenge the pilot if he or she thinks something has gone terribly awry. They may say, “Captain, I’m concerned about…”then, “Captain, I’m uncomfortable with…” and if the captain still does not respond, “Captain, I believe the situation is unsafe.” And if that fails, the first officer is required to take over the airplane. Imagine nurses, residents, or others being taught how to telegraph their concerns in such a fashion. Nurses are taught to contact their nursing supervisor if a challenge to a physician is ignored.

3. I think there is another factor at work, which Gladwell refers to as “practical intelligence”. This includes things like knowing what to say to whom, knowing when to say it, and knowing how to say it for maximum effect. It is knowledge that enables you to read the situation correctly and get what you want. A person with high practical intelligence would know how to challenge another person’s actions or decision making in a way that would bring results. The nursing supervisor should embody these skills.

4. Keep in mind that healthcare medical disasters can happen just as quickly as a plane can plunge into the ocean. A bleeding vessel in the operating room, the incorrect administration of intravenous chemotherapy into spinal fluid, the fetus that shows signs of needing to be delivered right now- all constitute emergencies. The person with low power distance, communication skills and practical intelligence is in the best position to save patient lives.

5. Patient safety application:
The person who is a silent witness to the disaster, who is afraid to speak up and be a patient advocate, and the person who ignores those who question decision making may end up as part of the chain of a medical disaster.

6. Business application:
If you work within a law firm or legal nurse consulting firm, actively encourage your staff to speak up, to question, to point out problems. Listen to their concerns. You might be functioning with blinders on and not able to see an emerging situation. Thank those who are watching over your shoulder and serving as your safety net.