Loud and Clear: How and When to Speak Up for Patient Safety

Podcast Transcript

Carol Pehotsky:

As nurses, our patients are counting on us to advocate for them, to speak up when something doesn't seem quite right, but that's certainly easier said than done. How do I make sure I speak up in a way that's heard? We'll talk about all of that and more on today's episode of Nurse Essentials.

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing, from patient care to advancing your career to navigating tough, on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, Associate Chief Nursing Officer of Surgical Services Nursing. The topic of speaking up is one that's certainly near and dear to my heart, and one that can take all forms.

It can be as simple as I need more information. I need another order. I need a clarification on an order. It can go to, I don't think we're headed on the right path, or I have a question. And it can go all the way to, I think we need to stop the line; there's a problem here. And I can still remember from many a year ago as a new nurse, that fear or that concern about how am I going to speak up? I know I need to say something, but I'm not sure what to do, and benefit from preceptors and experienced nurses all around me that would take me under their wing and say, here, say it like this. Or let's think about what you need to say and let me help you sort of practice how to say it before you have to make that phone call. And sometimes we have that time and sometimes we don't, and that's why speaking up in a way that gets heard is so important to our specialty and to our careers.

So, our special guest today is Craig Tobias. He's a Director of Nursing at Cleveland Clinic Marymount Hospital, and during his nearly 16-year career, he's led nursing teams across multiple specialties. And those interactions have taught him a lot about when and how to raise concerns about patient care and safety. Craig, welcome. Thank you for joining us.

Craig Tobias:

Hi, Carol. Thanks for having me. Excited to do my first podcast!

Carol Pehotsky:

Right?

Craig Tobias:

I got to brag to my kids I was doing a podcast this week and I don't know if they think I'm crazy or I'm old already because, you know, for a 13-year-old, I should be doing TikTok, not podcasts.

Carol Pehotsky:

It's a good thing 13-year-olds aren't our target demographic yet, right?

Craig Tobias:

That's a, not yet, not yet.

Carol Pehotsky:

That's right. So, nurses are in a privileged position. We observe; we address safety issues. If you have a story from your career throughout, something that resonates with you, clearly, you've been passionate about speaking up as well, so what sort of comes to your mind first about a story in your career around speaking up?

Craig Tobias:

At Cleveland Clinic, patients come first; we're always gonna stand up and do the right thing for patients. And I think throughout my career, going from a staff nurse to a charge nurse to an ANM to a manager to a director, there’s always been that opportunity, where it just feels natural for a nurse to say, hey, that's not the best thing for a patient today. Well then, that one's the easy one for us. I think where nurses have to really grow more is when we do that with each other sometimes, and finding that same type of, you know, my coworker's just as important, or, you know, the entire hospital patient view is as important as well. So, I have 100 of them when I worked in the PACU. We're not moving on until we all do this universal timeout. And I've had many on the floor as a staff nurse on med-surg or it's like, this is one of those patients that we're not gonna leave alone today.

This is one of those situations where this order from a provider is not the right order, and we're gonna question it. There are a lot of examples of that, but I think the important part is that it's always easy to say what's best for the person involved, right? And that's where we really find our north star in all of that, you know? Patients first, caregivers always. And at Cleveland Clinic, that's what we try to do best.

Carol Pehotsky:

Absolutely. And true for nurses everywhere, but yes, lots to be proud of here. So, thinking about that, you know, obviously no one likes to be wrong. No one likes sticking their neck out, right? That's not necessarily easy to do. So, I know I've heard nurses say, but what if I'm wrong? So, you're approached by a nurse who says that same thing, what do you tell them about speaking up and that concern about maybe not being right and speaking up?

Craig Tobias:

Yeah, great question. Uh, and I think, you know, that's a culture and a shift that we actually do well at Cleveland Clinic. But I think there's always gonna be that, you know, I don't want to be wrong, like you said. But you'd rather second-guess than not question it and then be wrong in the other direction, right?

Carol Pehotsky:

Sure.

Craig Tobias:

And so, I think that for me, the more important piece of that is, it's always okay to ask twice, right? It's always okay to say, eh, somebody explain that to me. And I think I've learned a lot in my director role about sitting back and asking questions versus just seeking out answers, and that's something that I think we have to teach all of our caregivers, anybody in the system in any type of role, it's okay to ask a question. We tell small children this, no question's a dumb question, right?

Carol Pehotsky:

That's right.

Craig Tobias:

Yeah, and in reality, that is true because we'd all rather know and do it the right way. And if it takes five seconds to ask a question, it’s well worth that five seconds. For 10 minutes, if we're all on the same page.

Carol Pehotsky:

So, let's say I'm a brand-new nurse, and I think you've raised already a great point about forming it in a question. That it's seeking more information, it's not quite so interrogative, if you will. It diffuses a situation. What are some other strategies you've shared with newer nurses or maybe nurses new to our specialty? You know, we both have spent time in periop and PACU services, and it's different speaking up in a different specialty. So, what would you share with nurses who are new to our specialty or to nursing in general?

Craig Tobias:

Yeah, I think it's part of the job that we have to actually really make sure we take the time to train and orient it. Right? And so, definitely don't avoid it. Don't wait 'til that situation occurs to say, hey, here's the day. You should stop the line. We have enough examples, being a large healthcare system, and having a lot of experience in stopping the line, we can share those experiences before we even get to that scenario. And this way, we're setting that groundwork of, okay, here's a really good one for you. So-and-so didn't sign the consent form and wants to take the patient to surgery. No, we're gonna stop the line. That's an automatic one, right? And then we give caregivers, new caregivers, some support and knowledge base of what stop the line really means. Versus, it's 2:00 in the morning and I have to call a doctor for something, but they don't want to wake up, and then, you know, we do that whole thing around, round and round and round. Or it's the weekend, and I don't want to bother my nurse manager because they're home and it's the weekend. I think if we educate people at the front end about what's important and why, and then give them real-time examples of what we're dealing with, it helps cement that, too.

Carol Pehotsky:

Yeah, absolutely. It's content to be delivered, and so for any of our listeners, no matter which organization you're from really, talking back, if you're a leader, considering that, and if you're not in a leadership position, talking to your leadership, really talking about how we integrate this into residencies and into nurse fellowships, into any training to really make sure that the first time I've spoken up isn't the first time in clinical practice. How do I create simulations or case studies or other opportunities that make it safe for nurses to practice those phrases? So, when it happens for the first time clinically, there's those canned phrases they can pull out of their back pockets. When I think of our OR nurses in training, you know, some of our most experienced OR nurses turn to those new periop residents and say, here are my words, just use them until you come up with your own. And it's really arming our nurses, any of our healthcare professionals, with those key phrases. It doesn't have to be creative writing; it can be, here's what I need to say to get your attention.

Craig Tobias:

Yeah, absolutely. And, you know, we have to be careful that we don't apologize for asking to speak up.

Carol Pehotsky:

Yeah.

Craig Tobias:

Right?

Carol Pehotsky:

Yeah.

Craig Tobias:

And I think that's something that we struggle with sometimes. Hello Dr. so-and-so, I'm sorry to bother you about this patient safety list, right? No! That's what we're doing, and then we're doing it all for the right reasons, right? And no one should ever apologize for saying, I have a safety concern. So, I think that's one that we really need to encourage, too. It's the right thing to do always, and no one should ever feel sorry for it, right?

Carol Pehotsky:

Absolutely. And I think that's a good point: How do we teach people to listen up when someone's spoken up? Any thoughts about that?

Craig Tobias:

Yeah, well obviously listening is a lot harder than talking. I think we do well when we, as a system and as Cleveland Clinic, do safety rounds, right? And now we have a talk on safety points that I think we get every week about last year's safety event. And there's some transparency in that, but if we just run out and say, "Hey, everybody, this is what happened at Marymount last week! Don't let it happen at your hospital," then we're not actually gonna get anywhere. We really got to be able to ask probing questions, which then prompt you to listen back. So, hey, this happened at one of our sister hospitals. Do you think it could happen here? And somebody says, absolutely, that could have happened here yesterday because this happened and that happened. And that's where you really start to gather the information that's gonna help us be safer. And I think that's where we have to empower our teams to tell us what those issues are or what those gaps might be so that we can have better communication and better outcomes for everybody.

Carol Pehotsky:

And at the moment, any suggestions for, I'm a senior nurse perhaps working with a junior nurse, and that junior says, excuse me, I'm not sure we're on the right path. And maybe as a senior nurse, I'm not used to hearing that. So, what would you tell me in terms of how to hone my listening skills at the moment?

Craig Tobias:

Yeah, again, I think part of it is education and teaching; part of it is making sure we have the right culture in place. Nursing has been talking about eating the young since Florence Nightingale, I think. And so here we are in 2023, and that's one of the last concerns I wish we would ever have been not being willing to listen to each other and have that open dialogue no matter who it is. I'm living in the medical-surgical world right now. We obviously have huge gaps in staffing, and I have all kinds of age differences [between] my nurses. I have nurses who’ve got a couple years to go and they're retiring. You know, mid-60s. And I have 21-year-old new grades. For them to work together, sometimes the subject's forced because staffing can be so poor. But at the same time, they all know when they do it together, it makes the day go better. The patients are safer. We have less hiccups. And so, I think speaking to those things as well. Take your knowledge as an experienced nurse and give that to someone else. It's lessons, its life lessons, it's professional lessons. I would like to say everybody gets it right every time, too, but we also, look, that's not a reality. And that's part of it, too. Let's do our best. We all know it's gonna be tough with whatever the scenario might be, but let's do the best we can today, you know? And then debrief, right?

Carol Pehotsky:

Yes.

Craig Tobias:

Hey, how do you think it went with your coaching session with your new grad yesterday? Do you think you could've done it differently? Maybe give some feedback, things like that. You know, coaching and learning, we talk about it in nursing all the time. It's a lifelong learning experience, nursing is, healthcare in general. And so, I think that's part of it, too, making sure we're all willing to improve on ourselves no matter the scenario.

Carol Pehotsky:

Well, and back to your point about education, you know, being in receipt of someone speaking up to you, there should be intentionality around that as well, as talking to nurses of all sorts of tenure. Or physicians or providers is, is really that intentionality that says, if somebody says to you, I have a question. The right answer is, what's your question? Not, I don't have time for your question, right? So really being intentional about talking to people so that if somebody's speaking up, I need to listen up. That's a phrase we've used in this organization, but no matter where you're listening from, really thinking about how can you, as a nurse in your organization, advocate for two-ended education, right? That's, how do I say, I have a concern, and how should I receive that concern when it's voiced to me? So, we've talked a little bit about junior nurses and senior nurses and really bridging that gap. I, certainly as, as nurses, we interact with providers as well. Any strategies that you'd like to share with nurses around ways to really communicate with our providers, whether it's an urgent speaking-up opportunity or something that is slightly less time-bound and really how to make sure to get our message across?

Craig Tobias:

Yeah, so we were talking about, this is a hot topic right now, plan of care visits, right? And so, when we do plan-of-care visits, sometimes we see our nurse's kind of sitting in the backseat. You know, and the physician's driving the plan-of-care visit, and at the end of it, it's like, hey, is that okay? And the nurse says, yes, and then they walk out of the room. Being an active participant in that dialogue is something that we really need to encourage more of. But I think that's where we get it at, right? And that's gonna build that relationship between the provider and the nurse. They're gonna see, oh, look, there's my nurse, Craig, and he's talking to Dr. so-and-so about my care; he really understands what's going on just as much as my doctor does; I feel safe. I feel comfortable. Right?

And then I think that'll help encourage the patient to say, I actually don't understand what the two of you are talking about.

Carol Pehotsky:

That's right.

Craig Tobias:

Right? And so, like I want to be on the inside of that, too. So, I think there's opportunity still, and I think it's mainly because of the pace of time. No one has ill intentions of not wanting their patient or their nurse or their doctor to understand what's happening today; it's whether or not we know how to stop ourselves in the moment and say, okay, let's all stop and actually have this conversation, versus let's fly through it because we got to get to the next hundred things. And that's high reliability when you talk about it, too, right? This is how we really get into, like, what we're gonna do and what matters most and what's gonna be the most important thing today. And the plan-of -care visit, that's the patient's understanding, right? Does my patient, our patient, understand what's happening today?

Carol Pehotsky:

Absolutely. You know, you mentioned high reliability, and there's no shortage of curriculum out there and approaches that really look into how to create this culture in any organization, not just ours, that says we dialogue with each other and really we know that whether it's near-miss events where we caught it just in time or not, that there are lots of precursor events, there's the Swiss cheese holes aligning, if you will, etc. So, we know it's not people; it's processes, really. But that's much easier to say and to talk about when you're not one of the Swiss cheese holes, when you're not somewhere in that process as a healthcare provider. What would you tell nurses who say, but if I speak up, it's gonna come out that I made a mistake or was distracted, or somehow feeling like this is the pointy end of the stick for them?

Craig Tobias:

Yeah, and that's hard. And it goes back to what we were talking about earlier: Nobody wants to be, quote, unquote, in the wrong or do something wrong. And certainly, nobody wants to cause patient harm, right? And it's probably one of the worst feelings when you come to work every day to take care of somebody, but in the end, you may not have done your best or may have actually gone in the other direction and caused harm. Or you missed something that caused harm or, you know, one of the scenarios that we have, and one of the great tools that we have here are, is the just culture tree, right?

Are we doing everything we're supposed to do the best way we can so that if it is a process, then we know, right? This is a process failure, and the process failed the caregiver, versus, you know, someone didn't file the process and then we have to deal with it. And I think that's important that we discuss those tools, it's like anything else, I think in my personal humble opinion if you tell me there's a curveball in the pitcher's repertoire, I'm gonna know when I strike out by missing a curveball. Eh, I should've seen the curveball coming, right?

And so same thing with caregivers; they want to be educated, they want to know the process of things that happened. It's not meant to scare people; it's not meant to cause fear about not doing right or wrong. It's just that, you know what, when something does go wrong, we're gonna look at it a certain way to make sure we do everything we can to make sure it never happens again.

Carol Pehotsky:

Certainly. And it isn't always that something bad has happened; oftentimes, we missed a step in the process. And that's why it really isn't just about the outcome; it's really looking at, this process didn't go how it was supposed to, so really creating those mechanisms that say, we need you to speak up any time, right? If the process failed me, or I got to a step in the process and I didn't know what to do, it wasn't crystal clear, so how do we make those processes as clear as possible for caregivers to take that uncertainty and that ambiguity out of it for them?

Craig Tobias:

Yeah, absolutely. Any time you say, whoops” at work, there a there's an opportunity to do something different.

Carol Pehotsky:

Yes.

Craig Tobias:

Or in the same breath, a-ha.

Carol Pehotsky:

Yes.

Craig Tobias:

You know, like, whoa, that was a great thing, right?

Carol Pehotsky:

Yes.

Craig Tobias:

I mean, we can do that in the other direction as well.

Carol Pehotsky:

And really making sure that the people who are providing that care are at the table to help create those processes because they're the ones who are gonna know. It's all well and good to create a policy, but if the caregiver holding that policy says, what you have given me here is not something I can execute. It's really, how do we make sure that we've refined that so that they say, got it, yes, I have everything I need. Fulfill this order, deliver this care, I know what's expected of me and I know what the best evidence-based practice is around this. So certainly, we know that not speaking up could have patient-harm consequences, but certainly it takes a toll on the nurse as well, the healthcare professional. Can you explain some of those risks or what you've seen in your career in terms of people that have struggled with that?

Craig Tobias:

Yeah, so I've done some work in the second-victims space in my career. The work was borne out of an adverse event that happened once. I've seen the process as a leader, and I've seen the process as a nurse, and so when you think about the emotional harm that can be caused to someone who's trying to do good, it's kind of what I was reaching too early. Professionally as a nurse, we're the number one trusted profession in the world, right? And we hear that all the time. But that's also because we hold ourselves in high regard.

Carol Pehotsky:

Sure.

Craig Tobias:

And so, when we don't do our best, we can really be down ourselves. And it's not just nursing, I think, you know, healthcare in general really wants to be there, right?

We want to be the people you come to when you are the most vulnerable and need to trust people the most, it's healthcare. And so, when we have these events or things that really can cause us to struggle emotionally, we really have to have mechanisms in place, you know? At Cleveland Clinic, we have Emerge Stronger, which is specifically for our second victims of adverse events. You know, when we say adverse events, you said it earlier, it's not always because we made a mistake, right? It's just because the outcome of the patient or a caregiver may have not been what we wanted; it was just a bad event. But how do we support people in that exact moment? And a lot of that's the same thing, training, teaching, being aware of the pulse of your team and the people around you. And knowing that, like I said earlier, with the just-culture tree and all the things we do here, we're gonna do what's best for everybody involved, no matter what the outcome of the event was and no matter what the almost outcome of the event was. And so, I think that's where we really want to go to provide that psychological safety, right? It's okay to say, no, we're not gonna do this today. It's also okay to say, I shouldn't have done this today and I did, and now here's what happened.

Carol Pehotsky:

Right.

Craig Tobias:

And that's really the big picture piece of that, is it's okay to say both ends of it.

Carol Pehotsky:

So, Craig, we have the benefit of lots of great tools in our organization around, like you mentioned, the just-culture decision tree, where it gives leaders an opportunity to go through each step of the process to really think about an event that has happened or almost happened, and how do we want to address this to make sure we're really keeping at heart the just culture that asks, did the processes fail us? You know, how can we learn from this? And so on, we have other ways that as an organization, we share near-miss events or lessons learned so we can really reflect on each location and each practice, and say, what can I learn from a situation as a leader and as a caregiver? Knowing that hopefully with people in the audience who are from all over, what would you say to nurses or nurse leaders? What things should they be taking back to their teams and their organization to say, here's some things we need in place to really encourage speaking up and listening up?

Craig Tobias:

Yeah, I think one of the best parts is the fact that we're ever evolving. We all know that healthcare changes, and so the speed of the pace changes. It's funny when I go to nursing conventions and these other things and see some of these poster presentations or podium presentations, and they're like, oh, look at this great tool that we started here, you know, at this hospital system. And I think, oh, we had that like 10 years ago at Cleveland Clinic, right? Sometimes we have a wealth of tools in our toolkit that we don't always use, right? And some of those are just-culture decision trees, caring for caregivers, having leadership present on all these units.

Look at our tiered huddles, right? Every day, someone has an opportunity at 7:00 AM at every bedside on the med-surg unit to say, hey, I think this was a risk last night. Or hey, I think we could do this better. Or hey, this is something I really think we need to talk about. So, we put a lot of things in place so we can gather that information. The key is to get the information back, right?

Carol Pehotsky:

Yes.

Craig Tobias:

And so that, that's where we get the wins. So, the more we provide feedback in the end, whether that's, hey, you know what? That was a great idea, and now it's gonna do this, and now we're gonna have this new tool, or you really helped catalyst a new way of calling, you know, an event what it is. And then being able to bring all those resources back to them too. Caring for Caregivers is a great resource, and we've had it here for a long time. And it will take care of our caregivers in all kinds of situations. You know, we have leadership training; we just talked about high-reliability training that's coming for all our caregivers soon. That's another great tool that we have. Do we arm our leaders with how to prepare for high reliability of an organization? As I talked about earlier, we provide Emerge Stronger for our caregivers that are involved in adverse events that really feel distressed about what they do at work, or what happened at work one day. So, I think the real key, and the win in all of that, is making sure that we use the tools when we need them, but also ensuring that everyone knows what tools we have.

Carol Pehotsky:

Yeah, so if you think about things that someone could take from what we've experienced here, things like making sure that speaking up is trained and listening up is trained, and so it becomes part of your curriculum wherever you're a nurse. Creating those mechanisms, whether it's a daily huddle, whatever that looks like in your organization to say, how do we, outside of the moment, share with our leaders, hey this didn't go as intended, or, we're struggling with this protocol to really have natural mechanisms to elevate those concerns. And like you said, to really loop back with teams to say, we heard your concern, and we're addressing it. Or we need your ideas on how to address it, and then how to really make sure that we're, you know, our version is caring for caregivers, but to our listeners: Think and look around your organization. What structures do you have in place, whether it's an employee assistance program? What other things are in place when somebody's saying, I'm struggling with the ethics of this, or I need to let some things out. What mechanisms are there? And if there aren't programs second victims, that can be a great opportunity for an organization to really take care of their caregivers.

So, Craig, thank you so much for sharing your expertise with our audience. We're gonna switch gears a little bit and spend the last few minutes together. Our listeners have heard so much about you as an expert, now we want the opportunity to learn a little bit more about you as a nurse and a person of the world. So, it's our speed-round questions, so I'm looking forward to your gut reaction. You mentioned earlier, that, you know, you bragged to your kids that you were gonna get to be on a podcast. So, if you had the opportunity to be a podcast host, what would your podcast topic be, and who would your first guest be?

Craig Tobias:

Well, I think the only podcast that I ever really, like, got hooked on was Ron Burgundy podcast, so I don't know if that's, you know. But I think comedy would be fun. I think it's the levity that I don't always get in my day-to-day job, but I think something like that, you know, I don't know.

Carol Pehotsky:

A little bit.

Craig Tobias:

Definitely not gonna say I'm as funny as Will Ferrell, but you know.

Carol Pehotsky:

You know. It's a place to start.

Craig Tobias:

And I got a whole sleeve full of dad jokes, you know.

Carol Pehotsky:

Ah, it's the dad joke podcast with Craig Tobias. You heard it here first, folks!

Craig Tobias:

My kids are cringing already.

Carol Pehotsky:

I'm sure. That's all right. That's good for them. So, it's time to unwind at the end of your day, what's your go-to media? Do you prefer TV or books or music? What's your go-to?

Craig Tobias:

We are movie people, Netflix, put everything down and watch a movie together. So, that's our go-to move. And it's still family time. We don't always agree on what movie to watch, but there's enough media out there now; we can find something.

Carol Pehotsky:

That's right. Well, Craig, thank you so much for joining us and take care.

Craig Tobias:

Thank you, thank you.

Carol Pehotsky:

As always, thanks so much for joining us for today's discussion. Don't miss out! Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing. Until next time, take care of yourselves, and take care of each other.

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice questions.