5 Ways to Create a Speak Up Culture in Healthcare

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5 Ways to Create a Speak Up Culture in HealthcareIt’s important to create a “speak up” culture where staff members feel comfortable going to management when delicate problems arise. This is especially true in healthcare, where one persons decisions have the potential to affect hundreds of others. The following story is a perfect example.

Danida would voluntarily offer to administer pain medication for YOUR patient because “she had the time” and wanted to help you out. She would frequently ask physicians to increase the opioid doses for patients because she claimed she was advocating for them. She even made sure she medicated patients before shift change so that the oncoming nurse didn’t have to deal with pain medication requests as soon as they finished report. Outwardly, Danida seemed like a dedicated, compassionate nurse who was always willing to help her coworkers. But everyone knew Danida was diverting.

Everyone except the boss.

Employees know things that you don’t. Far too often, they won’t tell you even if it impacts patients in a negative way. Because organizations know this, they try to encourage their employees to bring forth any concerns they have involving patient care.  They talk a lot about creating a “speak up” culture where employees feel safe to verbalize concerns, mistakes, or near misses without fear of retaliation or punishment.

But is it all just lip service?

You can say you have an “open door policy” or transparent organization but let’s face it. those are just hollow words. Seriously, have you ever heard someone say, “I have a closed-door policy”? It’s similar to when someone says, “I’m going to be honest…” When I hear that, I think, well, does that mean you’re usually dishonest?

I’ve talked with many employees and groups of leaders who share that although their organization SAYS they don’t want YES people and that they want their employees to speak up, it’s really just words coming out of someone’s mouth.

One group of leaders I interviewed during a focus group were so fearful about speaking up to their executive leadership team, that they didn’t let me take any notes, made sure I wasn’t recording anything (I had to put my phone on the table so that they could verify I wasn’t recording), and hid their name badges so I couldn’t see their names! They offered numerous examples of initiatives that they KNEW would fail but were too afraid to speak up knowing that anyone who did usually got fired.

The minute employees get yelled at or blamed for speaking up; patient care gets compromised.

In the seminal article by the Institute Of Medicine (IOM), Silence Kills, a study of 1700 nurses shows that 90% of us won’t speak up in the face of bad practice (behavior), even in life and death situations.

According to the Joint Commission, 70% of medical errors can be linked to poor communication in one way or another.

[easy-tweet tweet=”Did you know that 70% of medical errors can be linked back to poor communication?! #speakup”]

During multidisciplinary rounds, a nurse offers his opinion about the patient. A physician interrupts and says, “When you have MD next to your name, then you can speak.” What is the likelihood that the nurse in such a situation will speak up again? What is the impact to patients? Did anyone take action against this physician? Sadly, no. “Well, that’s just the way he his. Just ignore him.”

Stop saying you have an open door policy and that you encourage employees to speak up when they witness bad behavior, bad practice or disagree with the leader’s decisions – unless you truly mean it. Instead, create an environment where your employees feel safe voicing their concerns without fear of retaliation, that you will break their confidence, or that you will blow them off.


1. Make giving and receiving feedback a habit

Please stop relying on the annual performance reviews as your mandatory opportunity to provide your employees with feedback. Giving ongoing feedback is an essential part of everyone’s growth and development. Feedback should be delivered at minimum, monthly during a one-on-one conversation with your employees. Make sure you include these key pieces:

“This is what you are doing well (and be specific).”

“This is something you could work on (and be specific).”

Ask your employees to give YOU feedback about your role as their leader.  Ask these:

“Tell me one thing I’m doing really well as your leader.”

“Tell me one thing I could do better.”

2. Reduce anonymous options to voice concerns

I’m an advocate for having a mechanism to allow for the anonymous reporting of disruptive behaviors, especially if an employee is really being targeted and tortured. However, encouraging people to call the corporate hotline or submit an anonymous tip in the comment box just encourages passivity and reinforces the fear that speaking up honestly may lead to negative consequences.

You want people to get comfortable with being uncomfortable any time they witness or experience anything that may impact patient care. You accomplish this by requiring them to tell someone – not slip a piece of paper in a box that nobody reads or call a hotline that is usually managed by a third party vendor.

[easy-tweet tweet=”It’s crucial that #nurses speak up any time they witness something that could impact patient care.”]

3. Be visible

As a leader, you need to BE where your people are. If your office is in a different building or up three flights of stairs, your employees are less likely to seek you out. If you can’t move your office to be closer to your staff, at least spend time on the unit with them – not just a drive by – but hang out with them throughout the day.

One of the leaders in my online academy shared a great way to handle this situation! Her office was on another floor, so once or twice a day she would take her laptop and set up at the nurses’ station to answer emails, review reports, etc. Her staff knew she was working, but because she was so visible they became more comfortable letting her know about situations on the unit in real time. This allowed her to support and guide her staff appropriately and led to staff being more willing to speak up about situations that they may have kept silent about before.

4. Take action

The number one reason why employees DON’T speak up isn’t fear; it’s complacency.  They don’t believe you will do anything about it. I hear it all the time. An employee tells their manager about a concerning situation, but doesn’t SEE the results. Even if the manager takes action, if they don’t close the loop, the employee assumes they didn’t do anything about it.

Letting them know how you take action can be very helpful. For example:

“Thank you for bringing this to my attention. Here is my process for addressing concerns like the one you just brought to me. I investigate…then I…then I… I might not be able to share the details of that investigation with you due to confidentiality but I promise to at least let you know that the situation was handled.”

Then make sure you keep your employee informed. Not doing so will encourage complacency.

5. Be the role model

Ultimately, it’s what you DO that influences the behavior of your employees – not what you SAY. If your employees give you constructive feedback and you freak out on them, you’ve taught them to never give you feedback again.

[easy-tweet tweet=”Ultimately, it’s what you DO that influences the behavior of your employees – not what you SAY.”]

If your employee confides in you about a situation with a coworker or physician and asks that you not tell them the information came from them, and then you walk immediately out to the nurses’ station, grab that employee and force them to talk about it in your office – that employee will never come to you again.

If YOU complain about other people, the other leaders, and the organization in front of your staff and add phrases like, “Oh he’s untouchable…nobody is going to do anything about him” or “That’s just the way it is here. Better get used to it” or “It’s better just to keep quiet so you don’t lose your job”, then you are NOT role modeling a speak up culture.

How many patients didn’t get the pain relief they needed because Danida used it on herself?

How many healthcare dollars were spent feeding Danida’s addiction yet were charged to patient’s insurance?

How many of her coworkers lost trust in her, thereby impacting team cohesion?

What about Danida who needed help herself?

We all have an ethical responsibility to our patients and each other as human beings to cultivate a culture where EVERYONE speaks up no matter what. It’s okay to be uncomfortable – speak up anyway.Be kind. Take care. Stay connected.

Helping you cultivate a healthy happy workforce,

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