Leadership dynamics and hierarchies inherently exist in organizations. While these dynamics can be beneficial to an organization, some leadership dynamics can be harmful. Leadership dynamics in the health care setting can be especially dangerous as these dynamics can contribute to medical errors. Medical errors are the third leading cause of death in the United States following heart disease and cancer (DeAngelis, 2016). Furthermore, research from Johns Hopkins reveals that nearly 250,000 Americans lose their lives each year due to a medical error. This number is a rough estimate due to the broad range of medical errors that can occur. A variety of factors may cause a medical error, such as a breakdown in communication among a treating team to issues with technology design (Deangelis, 2016).
While it is difficult to count the number of deaths that have been caused by a medical error, factors that lead to medical errors can be explored in order to determine the best practice in prevention. Tucker and Edmonson point out that the reported number of hospital errors tend to focus on errors that result in the death of a patient, but there are also more subtle errors that occur on a daily basis in the health care setting that deserve attention as well. (Tucker & Edmonson, 2003). Medical errors are of public health concern because any patient in a health care setting is vulnerable to having a medical error. Evidence suggests that medical errors also impose a high economic burden on our society; it is estimated that nearly 15% of hospital expenditures are attributed to medical errors. Among the most burdensome adverse events that occur in the United States are healthcare-associated infections (HAI), venous thromboembolism (VTE), pressure ulcers, and medication errors (Slawomirski, 2017). Leadership dynamics and hierarchies that exist in the health care setting are contributing factors to these medical errors.
This chapter explores psychological safety along with how leadership, hierarchy, and teamwork may create less or more safe environments. A systems science perspective is introduced along with examining the nurse-physician relationship and personal experiences with psychological safety.
Leadership in the health care setting serves an essential role in ensuring that quality care is being delivered. Cross-disciplinary teams work together to share responsibility of caring for a patient, which can create challenges. A recent study by Nembhard shows 70-80% of medical errors are related to interactions among healthcare team members (Nembhard, 2009). These interactions within cross-disciplinary teams are essential in delivering the most efficient and quality care. Due to the increase in specializations of the health care field, patients are typically treated by several individuals rather than just one primary care physician. These individuals are referred to as cross-disciplinary teams and are comprised of individuals who have various specializations such as nutrition, respiratory therapy, and physical therapy (Nembhard, 2009).
As cited in Northouse’s book on Leadership: Theory and Practice, organizational team-based structures are essential for having the ability to respond quickly and adapt to constant, rapid change which is inevitable in the health care field (Northouse, 2016). Looking at how these teams share leadership can determine whether or not a team is performing its best. The complexities of the health care setting can cause frustration, misunderstandings, and miscommunications which ultimately results in tension among a treating team. This tension creates a risky environment that is more susceptible to error (Clough 2008). The various perceptions among a team can also cause miscommunication which may cause medical errors. Surveys and interview studies on healthcare providers perceptions of teamwork in dynamic medical environments reveal how healthcare providers tend to perceive the quality of teamwork differently.
Clinicians are more likely to perceive the quality of the leadership and the communication of the team more positively than the nurses. Similarly, doctors who were still training reported more negative perceptions of teamwork than their senior counterparts. One study specifically analyzed how the various members of a treating team of an operating room perceived the same situation. The operating team was comprised of surgeons, nurses, and anesthesiologists and each rated tension levels differently (Manser, 2008). The study conducted on this operating team revealed how each member of this team perceived responsibility; the surgeons, nurses, and anesthesiologists would rate their respective profession as having less responsibility than the other profession (Manser, 2008). These findings indicate that team members from different health care professions do not fully understand the importance of one another’s role. And ultimately, pointing fingers at which profession should have more responsibility does not help eliminate a medical error. Team members should instead be knowledgeable in the importance of each team member’s role in treating the patient and they should also understand how each role fits together cohesively to provide the best quality care for that patient. A retrospective analysis of adverse event reports revealed that communication and issues with teamwork were among 22-32 percent of contributory factors (Tucker, 2003).
Human Error vs. Systems Error
When analyzing medical errors in the health care setting, two approaches can be used: the individual approach and the systems approach. The individual approach examines individual characteristics that may contribute to an error such as forgetfulness, carelessness, or moral weakness. The system approach is more concerned with the conditions and the environment in which the individual is subjected. The systems approach also recognizes that humans are prone to error, and this should be expected even in the most successful organizations. While many medical errors in a health care setting are caused by an individual error, the complex environment of health care creates a risky environment for many systems errors.
Edmonson and Tucker point out that historically, hospitals have relied on highly skilled health care professionals to compensate for operational failures. The issue with relying on the most dedicated or knowledgeable nurses or physicians to help reduce medical errors is that this approach fails to recognize the role that management and leadership can have in ensuring quality care (Tucker, 2003).
In an extensive study performed on work system failures on the front lines of delivery in hospitals, Tucker and Edmonson analyzed 239 hours of observation and 26 nurses at 9 different hospitals in order to understand the importance of the relationship between organizational learning and process failures. The hospitals that were selected were referred by nursing governing boards for being hospitals that processed reputations for nursing excellence. By including hospitals that were all deemed as ‘excellent organizations,’ this allowed for Edmonson and Tucker to obtain results on how excellent nursing hospitals handle service failures (Tucker, 2003). The result revealed that nurses experienced five broad based problems including:
1. Missing or incorrect information
2. Missing or broken equipment
3. Waiting for a human or equipment resource
4. Missing or incorrect supplies
5. Simultaneous demands of their time
An interview with an oncology nurse points the blame at down-stream internal support departments as the main source of disruptions; “The daily problems we face are from the outside of our own unit—central supply and housekeeping, for example. It is not the people on the unit. It is not what we do or don’t order for our supplies. It is a system problem (Tucker, 2003).” While it is important to look at the entire system, it is also necessary that the nursing staff own up to their own errors as well rather than pointing the blame elsewhere.
Nurse vs. Physician Collaboration and Challenges
Collaboration among different specializations of health care workers can create a break-down in communication which can ultimately lead to medical errors. The dynamic between nurses and physicians, specifically, has been the most studied in the health care field and studies reveal how this dynamic in the hospital setting has historically been problematic. Nurses are often viewed as the “non-physician caregiver” and are depicted as being inferior to the treating physicians; this dynamic can have unintended consequences when treating the patient. Tucker and Edmonson analyzed this nurse versus doctor relationship and identified that, “….although nurses witness and experience a variety of problems and employ a number of creative solutions to resolve emergent issues, they generally do not communicate these to other members in the hierarchy” (Nembhard, 2009).
The U.S. Department of Health and Human Services’ (DHHS) Agency for Healthcare Research and Quality (AHRQ) asked the Institute of Medicine to conduct a study to identify aspects of work environment and working conditions that may have an impact on patient safety. When an individual is hospitalized, living in a nursing home or rehabilitation facility, or delivering a baby, that individual spends the most time interacting with the nurse than any other health care provider, including the treating physician (Institute of Medicine, 2003).
Although nurses play such a critical role in minimizing medical errors, the field of medicine has long been entrenched with a status hierarchy which has made it difficult to speak across professional boundaries (Nembhard, 2009). This professional hierarchy in medicine has been well studied and reveals that surgeons are ranked with the highest level of prestige followed by specialty physicians, then primary care physicians, followed by nurses, physical therapists and subsequent allied health workers (Nembhard, 2009). The status between physicians such as primary care physicians compared to specialty physicians is smaller than compared with physician versus non-physicians such as physician and a nurse. (Nembhard, 2009).
The role of nursing and physicians themselves also differ in their communication styles. Nurses are typically taught to communicate in broad terms with regard to clinical situations, and they tend to have a broader view. Physicians, on the other hand, are very concise and detail oriented. In a typical hospital setting, the nurse is usually responsible for relaying a medical situation to the physician. Because nurses often do not make the diagnosis for a patient, they may communicate a very long and detailed narrative to the physician which can ultimately lead to an error as the physician is impatiently waiting for the nurse to get to the point.
The Institute for Safe Medication Practices (ISMP) revealed in a study of 2,000 health care professionals that intimidation was a main contributor to medication error. Health care professionals reported that they have administered a medication to a patient even when they felt uncertain due to pressure and intimidation (Institute of Medicine, 2013). Furthermore, a content analysis on medical malpractice cases across the United States revealed that care teams were comprised of low status and high-status members with physicians being the high-status member and the nurses being the low status members. The analysis revealed that physicians have completely disregarded vital information that was communicated to them by a nurse. On the other hand, nurses admitted that they have refrained from sharing relevant information for diagnosis and treatment from physicians (Nembhard, 2009). This status-consciousness and hierarchical environment is very problematic in the health care field as human life is at risk.
The health care field is known to be very hierarchical, and this type of environment is at risk for medical errors. When workplaces lack psychological safety, employees are less likely to feel comfortable speaking up about an issue even if they believe they know they are correct. In health care settings that lack psychological safety, nurses tend to feel hesitant to speak up to a physician (Castel, 2015). The nurse withholding information from the physician is an example of the impact of psychological safety. When an individual remains silent and does not feel that they can speak freely, this is not a safe environment. In this content analysis of the interaction between nurses and physicians, it is evident that a lack of psychological safety exists; this inefficient communication can lead to medical errors. In an in-depth study on system failures in hospitals, 70% of the nurses that were interviewed reported that they believe that in the event that an issue occurs during their shift, their manager would want them to work through the issue on their own. The nurses also noted that speaking up or asking for help was a sign of incompetence (Tucker, 2003).
Amy Edmonson points out that when an environment is psychologically safe, four main things occur: learning, risk management, innovation, job satisfaction/job meaning. If an individual is in a psychologically safe environment, that individual is more likely to ask more questions, listen, ask for help, and gain more data. Edmonson points out that personal learning is not only important for that individual, but it is crucial for the entire organization or team in which the individual is working. For example, if an individual works in an intensive care unit, psychological safety allows one to feel more comfortable speaking up about what they observe and allows one to point out a discrepancy or a process failure. This ability for a team to speak openly with one another is crucial in creating a safe environment for the patient. Risk management in the health care setting is essential among a care team. The care a patient receives is highly interdependent which means that the patient outcomes depend on discussions, coordination, and decision making from multiple caregivers. Psychological safety links a care team with the patient outcomes, as it is a tool that helps teams make decisions more thoughtfully and skillfully without a team member feeling afraid to speak up. Innovation is the third important outcome that occurs when an environment is psychologically safe; innovation allows team members to brain storm and collaborate more effectively. Innovation also allows individuals to engage in learning processes, such as rapid cycle learning processes that allow teams to determine what works and what does not work which is essential in providing quality care. The fourth important outcome is job satisfaction. Edmonson points out that when an individual works in an environment that is psychologically safe, they report a higher sense of worth to the company and respect by their colleagues. When people feel more confident about their job, they are more motivated to perform to the best of their abilities (Edmonson, 2018).
As a clinical research coordinator for The James Cancer Hospital, I have experienced first-hand issues with psychological safety. I work with different clinics at the hospital, and it is evident that some clinics have a more welcoming environment than others. Part of my job responsibility is to assess patients on clinical trials for any toxicities they may have experienced. The patient typically sees me (the research coordinator), a nurse, a patient care assistance, a nurse practitioner, and their treating physician. As the research coordinator, I typically feel inferior to the other health care professionals that interact with the patient. Many times, the patient may not provide the same information to me, the nurse, and the treating physicians, and in cases where I do not feel comfortable approaching a physician, this can create a break down communication which can ultimately harm the patient. Creating a psychologically safe environment is not just about creating harmony among team members, but it can also drastically improve a patient’s quality of care.
Case Studies/ Research Examples
Founded in 1945, Kaiser Permanente is the largest, non-profit health system in America. Known for its integrated care model, it provides care to nearly 8.3 million patients. This health care system is often analyzed due to its high level of quality care and patient safety. As part of Kaiser Permanente’s model, standardization is essential. An example of the effectiveness of their standardization for medical responses is how the staff handles fetal distress. In the event that fetal distress has been identified by an individual, simple rules are to be implemented. If an individual sees a problem, they have one minute to analyze the situation by themselves, two minutes to observe the problem with another person, and by the third minute, that individual is taking action to correct the problem. The rationale behind this simple three-minute rule is to remove the uncertainty that nurses may have in regards to communicating with the doctor. Some nurses may have a moment of judgement where they are wondering if this is urgent or if the doctor is busy and if they should call the doctor or not. Rather than dwelling on these questions that may contribute to long delays, the three-minute rule provides a clearer response that can help avoid a serious medical error: fetal asphyxia. (Leonard, 2004).
Transformational versus Transactional Leadership as a tool to reduce medical errors in hospitals
Identifying how these medical errors occur in various health care setting is essential in determining what can be done to reduce these errors. Leadership style in health care settings has a significant impact on the quality of care that will be produced. Furthermore, research has shown that certain leadership styles can be effective in improving patient safety. Transformational leadership is viewed as the most effective management style that helps to establish a culture of safety. Transformational leadership is defined as “The process whereby a person engages with others and creates a connection that raises the level of motivation and morality in both the leader and the follower” (Northouse, 2016). With this type of leadership style, leaders work in collaboration with their followers in pursuit of common goals. This relationship of mutual stimulation helps to raise the level of aspirations of both the leader and the follower which ultimately has a transforming effect on both. The leader also must maintain the relationship with their followers by promoting two-way communication and the exchange of knowledge and ideas. When implemented properly, this leadership style creates organization change that is necessary to achieve increased patient safety (Institute of Medicine, 2003).
The transformational leadership style is viewed as more efficient than the traditional transactional leadership style with respect to increasing patient safety. A transactional leadership style would be more concerned with individual interests rather than a group of people with common interests working towards a common goal. Transformational leadership seeks to encourage individuals to collaborate with one another for the common goal of patient safety. One can compare both transactional and transformational leadership in the nursing role and how this can impact patient safety. For example, a nurse who enjoys the flexible hours of nursing may request to work a 24-hour shift on a weekly basis in order to have more days off throughout the week.
A transactional leader would try to accommodate this type of request for all of the nurses, despite evidence that shows extended work hours may be detrimental to patient safety (Institute of Medicine, 2003). Contrary to transactional leadership, the transformational leader would educate the nursing staff on patient safety and worker fatigue and would collaborate with the nursing staff to develop work hour policies and scheduling that would help encourage and prioritize the patients’ needs (Institute of Medicine, 2003). The leader characteristics and behaviors that have shown to have a positive impact on safety culture include an empowering leadership style, delegation of important duties to junior members of a team, and enhancing employee engagement (Singer, 2013).
The Institute of Medicine has reviewed behavioral and organizational research on effective workforce environments and high-reliability organizations. They identified five management practices that have proven to show successful achievement in keeping patients safe within the context of health care organizations (HCOs). These five management practices include: “(1) balancing the tension between production efficiency and reliability (safety), (2) creating and sustaining trust throughout the organization, (3), actively managing the process of change, (4) involving workers in decision making pertaining to work design and work flow, and (5) using knowledge management practices to establish the organization as a learning organization” (Institute of Medicine, 2003). In order for these five management practices to be carried out efficiently, each organization’s board of directors, midlevel management, and senior level management must participate.
Medical errors in the health care setting cannot be completely eliminated, but further analysis on health care systems can help reduce medical errors and improve patient safety and quality of care. Due to the high complexity of health care systems and care across various specializations, the environment is at risk for medical errors. The etiology of medical errors can be multi-factorial in a health care setting and these can occur at the individual, team, agency, community, and professional level. Research has shown that leadership and management styles of health care organizations can help reduce these errors from occurring. The historical hierarchy of health care professionals has created status conflicts that reduce psychological safety. Health care environments that lack psychological safety further facilitate miscommunication across care teams. By instilling transformational leadership styles in healthcare delivery along with further reducing medical errors by flattening out the existing hierarchy and working in interdisciplinary teams (Leonard, 2004).