Speaking Up for Patient Safety: Techniques to Support Assertiveness
Laura M. Cascella, MA, CPHRM
Speaking up about risks, concerns, and errors in patient care is crucial for patient safety. Although voicing concerns may seem like a reflexive response for healthcare providers and staff, barriers can prevent it from happening. Fear, intimidation, lack of confidence, power differentials, and other factors can thwart individuals’ efforts to assert concerns. These issues can permeate healthcare organizations that permit or do not constructively address disruptive behavior, bullying, workplace incivility, retaliation, and blame.
To combat an environment in which healthcare providers and staff do not feel empowered to raise concerns, healthcare organizations must establish a culture of safety that includes psychological safety. Supporting a culture of safety is particularly important as healthcare delivery models expand to include more types of providers and providers who are working more closely together.
An effective culture of safety fosters an environment in which advocating for patients is not only accepted, but also encouraged and expected. In theory, supporting “speaking up” behavior seems fairly straightforward; however, the barriers mentioned above can create a complex dynamic that makes the actual practice of speaking up difficult. Although progress has been made, the Agency for Healthcare Research and Quality’s (AHRQ’s) 2021 Surveys on Patient Safety Culture: Hospital Survey 2.0: 2021 User Database Report notes that almost 30 percent of respondents (a) did not speak up when they saw someone with more authority doing something unsafe for patients, and (b) were afraid to ask questions when something did not seem right.1
To address these issues, AHRQ has developed several techniques that healthcare organizations can incorporate into their safety strategies to help providers and staff advocate on behalf of their patients, assert safety concerns, and resolve conflicts of interest in a professional manner. These strategies, described below, include the assertive statement, CUS, the two-challenge rule, and DESC script.
The Assertive Statement
Members of the care team who are not in leadership or decision-making positions can use the assertive statement to raise safety concerns. This technique is respectful of authority, but allows individuals to assert concerns and suggestions.
The technique is a five-step process that involves (1) opening the discussion, (2) stating the concern, (3) stating the real or perceived problem, (4) offering a solution, and (5) obtaining agreement. Healthcare providers and staff members also can teach patients and their families how to use this technique to voice concerns and play an active role in their care.2
CUS
The CUS technique is designed to use when a conflict of information is identified that warrants one or more team members voicing their Concerns, stating that they are Uncomfortable, and articulating that a Safety issue exists. AHRQ notes that the CUS method is helpful when a team member is trying to raise a concern, but it seems like no one is paying attention. CUS should be used sparingly and reserved for urgent situations.3
Two-challenge rule
The two-challenge rule can be used when a conflict of information is identified that warrants a team member speaking up, alerting, and/or questioning other team members before proceeding any further with a task or intervention. This technique provides a framework for asserting concern if a clarification has been requested, but a response is not forthcoming or does not address the concern. The two-challenge rule also triggers next steps for elevating safety concerns if they are not resolved.4
DESC Script
DESC script is designed to help resolve various types of conflict, including interpersonal conflict and situations involving hostile behavior. The person initiating the discussion should Describe the specific situation (using concrete data when possible), Express concerns about the action or situation, Suggest other alternatives and seek agreement, and state Consequences (in terms of team goals, while striving for consensus).5
In Summary
Implementing the communication techniques described in this article can help empower healthcare providers and support staff — regardless of their positions in the team hierarchy — to raise concerns that might ultimately impact patient safety and quality of care.
The assertive statement, CUS, the two-challenge rule, and DESC script offer valuable frameworks for decisive and self-assured communication; however, to realize their full potential, these techniques must be part of an overall culture of safety that emphasizes teamwork, sets forth standards for professionalism and conduct, effectively addresses disruptive and hostile behavior, and takes a nonpunitive approach to managing errors and near-misses.
Learn More
To learn more about the techniques in this article and building a culture of safety, see AHRQ’s TeamSTEPPS® website and MedPro’s Risk Resources: Culture of Safety. Additionally, MedPro’s booklet Simulation Training: Sample Scenarios describes how to incorporate these techniques, as well as other TeamSTEPPS® methods, into patient safety training.
Endnotes
1 Famolaro, T., Hare, R., Yount, N. D., Fan, L., Liu, H., & Sorra, J. (2021, March). Surveys on patient safety cultureTM (SOPS®) Hospital survey 2.0: 2021 user database report (AHRQ Publication No. 21-0017). Retrieved from www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2021-HSOPS2-Database-Report-Part-I-508.pdf
2 Agency for Healthcare Research and Quality. (2019, March). TeamSTEPPS fundamentals course: Module 6. mutual support. Retrieved from www.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html
3 Ibid.
4 Ibid.
5 Agency for Healthcare Research and Quality. (2020, January). Pocket Guide: TeamSTEPPS. Retrieved from www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
