Seventy-two seconds into liftoff, a defective mechanical part set off a string of events that caused the Challenger space shuttle to tear apart as millions watched it vanish in the air. An investigation of this 1986 catastrophe found that before liftoff, engineers had voiced concerns about a potential mechanical defect and its possible impact—but upper management at the National Aeronautics and Space Administration (NASA) discounted their opinions.

History repeated itself 17 years later with the Columbia space shuttle disaster. During liftoff, engineers noticed a piece of foam had broken off the fuel tank and inadvertently punctured a small hole in the shuttle’s left wing. Some expressed concerns about this. But again, their opinions were discounted and further investigation was halted. As the Columbia returned from its mission, the shuttle disintegrated over Texas.

Had the opinions of the engineers and frontline staff who’d dared to “rock the boat” and disrupt the status quo been taken seriously, the Columbia and Challenger outcomes might have been drastically different. Even though different types of equipment failure caused these tragedies, Congressional investigations identified communication failures as the common denominator responsible for both. The failures involved a series of barriers that discouraged workers from speaking up, along with a NASA culture that didn’t support exploring “what-if” scenarios or value challenges to the status quo.
Flash forward to August 2005 and the unfolding of Hurricane Katrina. This natural disaster shared some similarities with the Challenger and Columbia catastrophes. At various stages of Katrina’s emergence and aftermath, technology and expertise clearly identified potentially serious consequences. But numerous communication barriers squelched those who spoke up and made it hard for others to challenge the status quo.

These three tragedies showed that although technological advances allow us to monitor intricate space missions, predict weather patterns, and assess a multitude of physiologic functions in hospital patients, our ability to communicate and act on these findings is what saves lives and avoids errors.

The importance of speaking up

Nurses often encounter opportunities to challenge conventional practice and intercept errors that could lead to poor patient outcomes. Speaking up seems like a simple act—especially when, for instance, a colleague performs the wrong procedure or gives the wrong drug. Root cause analyses of sentinel events has shown that in most of these situations, errors resulted not from equipment failure but from communication failures among healthcare team members.

Over the past two decades, multiple papers, articles, and scholarly discussions have addressed the links among communication, collaboration, and medical errors. We’ve known for some time that skilled communication affects patient safety and the health of the work environment. To help ensure safety and sustain healthier environments, we must design and implement strategies to promote a culture that supports openness to new ideas and candid feedback, while encouraging staff to challenge the status quo.

When a healthy work environment is combined with just culture, skilled communication becomes a tool to solve problems, generate effective solutions, and promote individual growth. Healthy work environments and just culture principles replace finger-pointing with the collective efforts of workers who speak up to identify inefficiencies and solutions. All persons involved share the goal of improving the process, team dynamic, or both. In other words, team members attack issues, not individuals.

When information is incomplete, assumptions or attributions about another person or situation can lead to stereotyping—which impedes the ability to keep an open mind. Without an open mind, it’s difficult for someone to give or receive candid feedback. In organizational cultures that lack candor and openness, challenges to the status quo may be based on inaccurate information, or people may avoid speaking up even when inappropriate actions or practices occur. Unfortunately, in health care, too many situations arise where workers fail to speak up and disrupt the status quo—with serious repercussions.

How to disrupt the workplace in a positive way

Disruption has a negative connotation, but it can be positive. Disrupting the status quo can even save lives. Healthcare workers can use several strategies to disrupt a situation in a positive way, helping to create an environment where workers keep an open mind, deliver and receive candid feedback, and help colleagues avoid attribution errors. In these errors, a person makes assumptions about another’s actions. (See Attribution error: Filling in the blanks by clicking the PDF icon above.)

So how can you positively disrupt the workplace and improve your work environment? First, become more aware of your own behavior. Remember—it’s human nature to fill in the blanks when you see someone performing a procedure incorrectly. Think how you’ve responded after seeing such a situation: What actions did you take? What behaviors did you demonstrate?

During this self-awareness technique, keep in mind that actions and behaviors are what we actually do, whereas our intentions are what we mean to do. We tend to judge others by their actions and to judge ourselves by our intentions. To avoid this bias, focus on your actual—not intended—behaviors and actions. Going forward, observe your own behavior when you challenge and disrupt the status quo or address someone involved in a near-miss situation. If you’re so passionate about your ideas that you cut that person off in mid-sentence, interrupt his or her attempts to explain, or bulldoze him or her with facts and opinions, your “disruption” may be perceived as pushy and overbearing.

At the other end of the spectrum, silence isn’t always golden. In some situations, you may want to speak up…but you hesitate. Know that avoiding speaking up may be a negative disruption that prevents you from diverting a near-miss or preventing improper care. Avoidance also can disguise itself as a desire for team harmony. In a difficult situation, the desire to maintain harmony may lead some people to go along with the crowd; as a result, the team may neglect to see the reality unfolding in front of them.

Why should nurses create positive disruption?

Nurses should challenge the status quo and create positive disruption because our patients deserve the best from us. Every day, we have the opportunity to think outside the box to create new ways of delivering safe health care. We shouldn’t wait for another medical error or Challenger-like disaster to create change. Instead, let’s push ourselves to challenge and positively disrupt the status quo when confronting those who defend ineffective or dangerous practices simply because “that’s the way we’ve always done it.” Congressional investigations of the Challenger and Columbia shuttle missions and the Katrina aftermath produced hundreds of pages detailing myriad situations where people had key information or insights but failed to challenge the status quo, or whose opinions weren’t heard or valued.

These catastrophes remind us of what happens when we let resistance to new ideas prevent us from hearing new perspectives. Don’t accept “But we’ve always done it this way” as an excuse to continue the status quo, if that status quo could be harming patients. Expand your own knowledge and your peers’ knowledge. Be spontaneous and let new ideas bubble up and out. Our opinions and nursing knowledge can and will continue to play a critical role in the future of health care.

Self-awareness promotes positive disruption

When you become more self-aware, you’re more likely to create a disruption that’s positive, not negative. When you listen to your thoughts at a gut level, you can catch yourself when you start to make assumptions and attributions. Greater self-awareness helps you keep an open mind, listen at a visceral level, give candid feedback, and receive constructive feedback from others. These behaviors allow you to positively disrupt the status quo by engaging and involving others to identify problems and generate effective solutions.

When creating positive disruptions, remember to:

• focus on your actions, not intentions, when explaining your ideas to others
• make a conscious effort to increase your self-awareness and thus avoid incorrect assumptions
• amplify your self-awareness to maintain an open mind
• set yourself up to give and receive candid feedback
• challenge and engage your peers to create solutions and improve the health of your work environment.

Implementing these strategies will help you tap into the expertise that exists within, uncover the
solutions and collective wisdom you and your team members possess, and create positive disruptions that help safeguard patients and sustain a healthy work environment.

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Cindy Lefton is vice president of Organizational Consulting at Psychological Associates and a clinical nurse educator for trauma and acute care surgery at Barnes-Jewish Hospital in St. Louis, Missouri.