Äußern Assistenzärzte und Pflegekräfte sicherheitsrelevante Bedenken?

Zusammenfassung

Hintergrund

Zu steile Hierarchiegefälle („Autoritätsgradient“) können dazu führen, dass sich Assistenzärzte und Pflegekräfte dem Oberarzt gegenüber nicht mit sicherheitsrelevanten Informationen zu Wort melden und gelten daher als Risikofaktor für die Patientensicherheit.

Methode

Im Rahmen eines Zwischenfallkurses am Simulator wurden 59 Ärzte und 18 Pflegekräfte mit 7 Problemsituationen konfrontiert, die vom Oberarzt verursacht wurden. Häufigkeit und Form der verbalen Intervention von Mitarbeitern wurden erfasst. Im Debriefing wurden die Teilnehmer zu den Motiven befragt, die zur Unterlassung oder zu der Art der gewählten Kommunikationsform geführt hatten.

Ergebnisse

Probleme, die nur durch verbale Intervention gelöst werden konnten, wurden in 66% der Fälle identifiziert und in 28% angesprochen. Zu 35% erfolgte dies als Andeutungen, zu 25% unter allgemeiner Benennung des Problems, und nur in 40% der Fälle wurde der Oberarzt deutlich auf das Problem angesprochen. Dadurch kam es in weniger als 10% zur erfolgreichen Intervention. Den Grund für ihr Schweigen konnten 37% der Teilnehmer nicht benennen, 35% wollten den Konflikt nicht ansprechen und 12% begründeten ihr Schweigen mit der Autorität des Oberarztes.

Schlussfolgerung

Assistenzärzte und Pflegekräfte sind selten in der Lage, sicherheitsrelevante Bedenken dem Oberarzt gegenüber adäquat zu verbalisieren. Auch Oberärzte, die im Alltag Unterstützung in Anspruch nehmen würden, werden vom Team allein gelassen.

Abstract

Background

Due to the negative impact on decision-making too steep authority gradients in teams represent a risk factor for patient safety. As residents and nursing staff may fear sanctions they may be reluctant to forward critical information to or challenge planned actions of attending physicians. In the setting of a simulation course it was investigated whether and to what extent team members would challenge decisions of familiar attending physicians. In each case where participants did not voice an opinion the underlying motives for the behavior were investigated.

Methods

A total of 59 physicians and 18 nursing staff participated in the scenario. During a rapid sequence induction they were confronted with 7 critical situations created by the attending physician who had been instructed by the simulation team. Recommendations of the German Society of Anaesthesiology were ignored as well as clinical standard operating procedures (SOPs) and two potentially fatal drug administrations were ordered. An attempt was made to determine whether team members were aware of the safety threat at all and if so how they would solve the resulting conflicts. The level of verbal challenge was scored. During debriefing participants were asked to verbalize the motives which they thought might account for their silence or level of challenge.

Results

In situations where non-verbal conflict resolution was possible 65% of the participants pursued that strategy whereas 35% voiced an opinion. Situations necessitating verbal intervention were identified in 66% but 72% of the participants chose to remain silent. Team members decided to challenge the attending physician in only 28% of the situations. In 35% their statement was oblique, in 25% the problem was addressed but not further pursued and only in 40% did participants show crisp advocacy and assertiveness and initiated discussion. Asked why they had refrained from challenging the attending physician 37% had no answer, in 35% of situations participants observed a discrepancy between their own knowledge and the intended course of action yet they decided not to address the problem, 12% explained their behavior with the perceived authority of the attending physician and 8% stated that in their opinion attending physicians violated SOPs on a daily basis. None of the participants had the feeling that the simulation setting had provoked a response different to what they might have done in everyday life.

Conclusions

The authority gradient can have a major negative impact on perioperative patient care. Residents and nursing staff are seldom able to challenge the attending physicians when patient safety is at risk. However, even attending physicians who normally accept feedback and criticism from team members can fail to receive support.