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Strategies to improve speak-up

Education and training could be used to enhance speaking-up behaviour. If it includes the whole team that would provide an opportunity to build shared understanding about everyone’s perspectives and to improve the communication and ultimately, the confidence to speak-up. 1

Two-Challenge Rule
Two-Challenge Rule has roots in aviation industry. One team member assumes the responsibility of the duties of another team member when it fails to respond to two consecutive challenges. In aviation case, both pilots have the same skills and can perform the same duties. 

Healthcare settings are different because of hierarchic gradients and differences in skills between team members – e.g., a nurse won’t be able to substitute a surgeon during a procedure. Still, two-challenge rule can be applied by calling for external assistance.

Pian-Smith et. al 2 suggested to pair advocacy and inquiry when applying this rule in healthcare settings. It starts to a statement describing an opinion followed by a question aiming to request que other person thoughts. Example: “I see that you plan to administer a spinal anaesthetic to this patient. She has a platelet count of 80,000. I learned that we shouldn’t do a spinal unless the count was at least 100,000. Can you clarify your view?” 

If no answer or a nonsensical answer, another advocacy-inquiry pair should be applied, and if no answer or nonsensical answer again, additional help should be sought. 

Diagram

Description automatically generated
Two-Challenge Rule. From Pian-Smith MCM, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, et al. Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simul Healthc. 2009;4(2):84–91. 

Graded Assertiveness
Graded assertiveness is a technique to improve communication when facing unsafe practice. It empowers the worker to use a structured, diplomatic, and respectful communication, preventing initial confrontation, when trying to redirect the management of the situation. It gives space to the other professional to correct any mistake/misunderstanding. When the achieved outcome is reached, the communication returns to the normal, but if necessary, it can progress to the next level with gradual increase in confidence.3

It is particularly valuable for junior workers/interns to express their concerns in an appropriate and non-confrontational manner. 3

Frameworks to support graded assertiveness:

  • CUSS (Concern, Uncertain/Uncomfortable, Safety and Stop) – a sequency that support communication when experiencing uncertainty or discomfort about a situation.
CUSS framework. Adapted from Speaking Up • LITFL Medical blog • MIME [Internet]. [cited 2022 Apr 29]. Available from: https://litfl.com/speaking-up/
  • PACE (Probe, Alert, Challenge and Emergency) – the sequency starts with a question that intends to raise awareness to the problem in a subtle way (e.g. “Are you going to try to intubate again?”).
PACE framework Adapted from Speaking Up • LITFL Medical blog • MIME [Internet]. [cited 2022 Apr 29]. Available from: https://litfl.com/speaking-up/
  • 5-step advocacy – An alternative approach:
5-step advocacy Adapted from Speaking Up • LITFL Medical blog • MIME [Internet]. [cited 2022 Apr 29]. Available from: https://litfl.com/speaking-up/

  1. Weller JM, Long JA. Creating a climate for speaking up. Br J Anaesth [Internet]. 2019;122(6):710–3. Available from: https://doi.org/10.1016/j.bja.2019.03.003
  2. Pian-Smith MCM, Simon R, Minehart RD, Podraza M, Rudolph J, Walzer T, et al. Teaching residents the two-challenge rule: A simulation-based approach to improve education and patient safety. Simul Healthc. 2009;4(2):84–91. 
  3. Hanson J, Walsh S, Mason M, Wadsworth D, Framp A, Watson K. ‘Speaking up for safety’: A graded assertiveness intervention for first year nursing students in preparation for clinical placement: Thematic analysis. Nurse Educ Today [Internet]. 2020;84(September 2019):104252. Available from: https://doi.org/10.1016/j.nedt.2019.104252

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