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Adopting a Mental Framework to Speak Up for Patient Safety

Have you experienced a hesitancy to speak up when encountering a patient safety issue? If so, you are not alone. Most healthcare workers can relate to the unsettling feeling of knowing something is not quite right and being unsure if they should intervene. When the reason for hesitancy is associated with a fear of a personal loss, such as the lack of leadership support, risk of retaliation, or isolation from peers, it’s all too easy to remain silent rather than draw unwanted negative attention. How do we reconcile the knowledge that every year hundreds of thousands of patients die from preventable medical errors, and that many instances could be intercepted with better communication?1 Regardless of organizational limitations, how can a frontline healthcare worker push past barriers to bring patient safety issues forward? To address these questions, we will evaluate the interplay of authenticity, character, and moral courage as relationships within a mental framework that influence our ability to speak up for patient safety.

Speaking Up for Patient Safety – A  Mental Framework

Authenticity is the act of living in alignment with our values. If our choices don’t represent who we are, then there is a contradiction in either behaviors or ideas, which creates a disturbing experience called cognitive dissonance. Much like a repulsive response to soundwaves clashing in discord, one cannot tolerate this lack of harmony in the mind for very long without being pulled in one direction or the other. Therefore, we are drawn to either repress or alter one in order to resolve the internal conflict. Our choices must be consistent with our character for us to have harmony with ourselves. Being in tune with our intuition can assist in noticing cues that alert us to a problem and, more importantly, help us make choices to act on issues as they arise in a way that honors who we are.

To be authentic, we must first develop a conscious understanding of who we are as an individual (self-awareness), which involves “the examination or observation of one’s own mental and emotional processes.”2 Tying self-awareness to what we believe we can achieve (self-efficacy) and to our personal choice to act on that belief of capability (self-agency) leads to personal empowerment, which is “the process of becoming stronger and more confident, especially in controlling one’s life and claiming one’s rights.”3 Therefore, self-awareness, self-efficacy, self-agency, and empowerment work together to form a consciousness of our individual, authentic self.

We all come from different walks of life, with unique backgrounds, experiences, and hereditary influences. Each of these factors impacts our personality and shapes how we respond to life. A person’s character is defined as the mental and moral qualities distinctive to an individual.”4  Our character is developed throughout our lifespan as we come to terms with both the individual and collective human experience, in which to convey our values. The accumulation of one’s values, “a person’s principles or standards of behavior; one’s judgment of what is important in life”5 construct what becomes their personal ethics, “moral principles that govern a person’s behavior or the conducting of an activity.”6 The development of one’s character, values, and ethics orchestrate the philosophy that translates into one’s worldview:

A worldview is a collection of attitudes, values, stories, and expectations about the world around us, which inform our every thought and action. Worldview is expressed in ethics, religion, philosophy, scientific beliefs, and so on.7 A worldview is how a culture works out in individual practice.8

 Actions, the behaviors and things we do that carry out a purpose, are how we apply the “individual practice” of our world view in the decisions of our daily life.8

Moral courage
Reviewing Lawrence Kohlberg’s stages of moral development illustrates how we justify the reasoning for moral thought processing, as depicted below. Stages 1–3 between preconventional and conventional are expressed as self-centric and are transactional in nature; whereas stages 4–6 move from conventional to postconventional and begin the evolution into moral courage, and eventually to altruism. Elevating an attitude of morality that focuses on others moves us away from drivers of self-interest to feasibly perform acts of service that align with our personal ethical code.

Kohlberg’s stages of moral development9

In healthcare, putting the patient first is stated as our highest priority; however, having a patient-centric focus is an individual mindset each healthcare worker must decide to commit to on their own in order for patient safety to truly become a reality in practice. A patient-centric focus helps to develop one’s skills of observation by heightening awareness of the moral duty to someone else’s wellbeing. It is through fostering this mindset that we begin “actively scanning and assessing elements of the situation to gain information” so we can enter a “state of knowing the conditions that affect one’s work,” called situation awareness.10 Moral courage provides both the moral reasoning and the inclination necessary to act in the best interest of the patient.

Moral courage can happen spontaneously when triggered by an injustice. It is typically invoked when we make the conscious choice to draw a line in the sand to protect the rights of another:

Moral courage is the willingness to take a potentially costly moral action simply because it is your duty to do so, or “the right thing to do.” It is acting in spite of the personal consequences because of the harm that can be prevented or good provided to others. Moral courage is what turns moral judgment into moral action.11

Moral courage promotes the role of advocacy by “using one’s position to support, protect, or speak out for the rights and interests of another.”12 The higher our sense of moral courage, the more likely we are to advocate when situations call for action. Altruism is the highest form of universal moral development in that it is not merely a spontaneous event. Altruism is a world view that frames a state of mind without being prompted by conscious thought; instead, it is a natural response. According to Kendra Cherry, “Altruism is the unselfish concern for other people—doing things simply out of a desire to help, not because you feel obligated to out of duty, loyalty, or religious reasons. It involves acting out of concern for the well-being of other people.”13

All of these components work together in the moment-to-moment decisions that we make as healthcare workers. Depending on how far each one of us has personally developed in each of these areas will impact the way we perceive situations, how we choose to respond, and the consequences of how they play out. We are accountable for our own individual responsibility and our role in patient safety, but we also must seek to continuously build and maintain trusting relationships with others. Teams are made up of individuals who each have their own personal journey of self-discovery. We can be the kind of people that inspires others to grow by remaining open to the potential that we all share to elevate one another. Knowing that we live and work in less-than-ideal circumstances and that we will undoubtedly encounter opportunities to prevent harm, we will face moral dilemmas which challenge what we say we believe and what we actually do. Each day we can set a mental intention to make choices that influence the safety of those who can’t intervene for themselves, knowing we can make a significant difference right where we are.


  1. Okuyama, Ayako; Wagner, Cordula; and Bijnen, Bart. “Speaking up for patient safety by hospital-based health care professionals: a literature review.” BMC Health Services Research, 2014. https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-61
  2. Lexico, s.v. “values,” accessed April 29, 2021, https://www.lexico.com/en/definition/introspection
  3. Lexico, s.v. “empowerment,” accessed April 29, 2021, https://www.lexico.com/en/definition/empowerment
  4. Lexico, s.v. “character,” accessed April 29, 2021, https://www.lexico.com/en/definition/character
  5. Lexico, s.v. “value,” accessed April 29, 2021, https://www.lexico.com/en/definition/value
  6. Lexico, s.v. “ethics,” accessed April 29, 2021, https://www.lexico.com/en/definition/ethics
  7. Sire, James W. 2015. Naming the Elephant: Worldview as a Concept. Intervarsity Press.
  8. Gray, Alison J. “Worldviews,” in International Psychiatry: Bulletin of the Board of International Affairs of the Royal College of Psychiatrists, Volume 8, Issue 3. Cambridge University Press, 2011, pp. 58–60.
  9. org. “Development: Personality,” accessed April 29, 2021. https://www.cbsd.org/cms/lib/PA01916442/Centricity/Domain/1829/Unit%203-Development-Personality.pdf
  10. gov. “TeamSTEPPS Situation Monitoring Facilitator Guide,” accessed April 29, 2021. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.pdf 
  11. Shaub, Michael K. “Why is the world so lacking in moral courage?” Texas A&M University Mays Business School, February 6, 2018. https://mays.tamu.edu/ethics/2018/02/06/why-is-the-world-so-lacking-in-moral-courage/
  12. American Nurse Journal. “Speak to be heard: effective nurse advocacy,” accessed April 29, 2021. https://www.myamericannurse.com/speak-to-be-heard-effective-nurse-advocacy/
  13. Cherry, Kendra (2021). “What Is Altruism?” Verywell Mind, accessed April 29, 2021. https://www.verywellmind.com/what-is-altruism-2794828

Lisa M. McKown (Wakeman), MBA, CRCST, CIS, CHL, MBTI, is a manager of research and development for Beyond Clean. She graduated with a Bachelor of Science degree in Integrative Leadership and an MBA from Anderson University. Lisa is a doctoral student in the Richard Fairbanks School of Public Health: Global Health Leadership program through IUPUI in Indianapolis, IN. She also holds a certification as a Meyers-Briggs Practitioner, specializing in interpersonal communication. Lisa contributes as an SME volunteer for standards development and other industry-related projects that promote the sterile processing profession, including writing workshops focused on creating and revising questions for the IAHCSMM certification exams. As a healthcare professional driven to influence positive change for patient safety initiatives, Lisa is a catalyst for the advancement of infection prevention within sterile processing. Her passion is education and she is energized when she can use her experience to develop people.

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