Organisational paradoxes in speaking up for safety: Implications for the interprofessional field

Patient safety continues to be a pressing concern within health service organisations. Links between patient harm and problems in team-based care have served as the rationale for many interprofessional interventions (Reeves, Clark, Lawton, Ream, & Ross, 2017). Of particular salience is the perceived problem of silence, whereby individual practitioners experience themselves as unable to speak about their various safety concerns. The stakes are high, as noted in the various references to the fatal effects of such silences (e.g. BRI Inquiry, 2001; Ceci, 2004; Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005). These problems of silence have been anchored in concerns about communicative competencies, as well as power differentials, fears of reprisal, and lack of mutual respect (Maxfield et al., 2005). The response from concerned organisations has been to launch education programmes, communication skills training, and intentional culture change initiatives to empower all members of the organisation—irrespective of profession, occupation, or location—to “speak up for safety. ” The ideals of such programmes rest on at least two common principles: (1) anyone in the organisation should be able to articulate their safety concerns and (2) these safety concerns will be heard in a meaningful way. While the role of power differentials, psychological safety, and the deleterious effects of silences is well established, what I seek to explore is a potential dilemma in the way organisations have taken up these ideas and translated them into wide reaching educational programmes of “speaking up. ” This is not a critique of the act of “speaking up,” nor of the intentions of the various programmes. Instead, my aim is to reconfigure the problem space of speaking up, attending to the particularities of the various professions and how those nuances potentially complicate organisational change efforts. In doing so, I hope to bring attention to the challenges experienced by programme leaders and clinicians as they work to improve patient safety as part of an organisation-wide mandate. There is a paradox to be managed here. In one sense, it is good leadership practice to abstract the notion of safety to such general terms that all professions can relate to the concern and experience themselves as enrolled in a common cause. However, the translation from an organisational wide mandate to local practices is enormously complex. In the abstraction of safety to a general ethos that is relatable across professions, it is difficult to maintain relevance for the variety of professionals who are working in different parts of vast organisations, connected with a range of patients at different stages of illness and/or recovery. There is risk that a high-level approach—while well grounded in shared concerns and priorities—might inadvertently contribute to some of the interprofessional tensions that perpetuate organisational silences about safety. To develop this argument, I first highlight the ways in which safety, risk, and professional identity are entangled within health service organisations. Given these entanglements, I highlight one of the potential dangers of “speaking up. ” I do not mean to imply that such programmes are insincere nor that there is a veiled professional intent embedded in these programmes. Instead, I aim to highlight the danger of not being heard. This gap in not necessarily an act of wilful organisational inattention, but may be a natural consequence of a complex organisation with many competing priorities operating simultaneously. This may also be a further consequence of differences between the professions: Different professions are implicated in different kinds of risk. As a consequence, various interpretations of these organisationwide mandates to “speak up” might inadvertently contribute to ongoing frustration, disengagement, and thereby continue to reinforce the very silences they seek to redress. I end by highlighting some of the limitations of adopting metaphors from other industries and offer suggestions for increased reflexivity about the various interconnected networks that must articulate together to create ongoing patient safety.