When Everyone is Responsible, No One Is: Is your team making your job harder?
"Hey, I noticed all of the oral care kits I put in the room yesterday are still sealed. It looks like this patient hasn't been receiving oral care."
"That can't be," the director of nursing answered.
"Why not?"
"Well, because everyone is responsible for oral care. Everyone does it."
A bright, waving red flag enters the conversation…
A lesson I learned throughout the process of promoting an oral care initiative in my hospital is that when everyone is responsible, no one is. It doesn't matter how important it is, how easy it is, or how cheap it is (and yes, oral care is ALL of these things); we still often neglect it. Similar to answering call bells, some facilities have decided that asking everyone to be responsible is the best approach to making sure someone actually does it. But boy oh boy, how wrong they are…
The Bystander Effect
Intuition tells us that the more people we involve, the better equipped we are to handle a given situation. But is this accurate? The bystander effect says no. See, when many people are involved in a task, the chance of something being missed does decrease, but actually increases. And not just by a little bit.
It's been found that the likelihood of providing a necessary intervention is cut in half when at least five people are involved. And this lack of intervention can have a real-life impact.
For example, an experiment was conducted in which a room was slowly filled with smoke. Smoke. Ya know, that thing that often means FIRE. So, you would think most people would alert the researchers that smoke was coming into the room, right? Turns out they were much less likely to do so when in a room with others than when alone. When we are alone, we are the only ones who can be held responsible. When we are in a room filled with other people, anyone might be responsible. “Hey, if nobody else is saying anything, why should I?”
It's kind of like a whole bunch of medical professionals pointing their fingers at each other when asked, “Who did the oral care today?” When everyone’s responsible, no one is.
Why does this happen?
Researchers have identified several psychological factors that contribute to the bystander effect, including the following concepts:
Diffusion of responsibility: When others are present, people feel less personal responsibility to help. They may assume that someone else will take action. So, they sit back, relax, and faultlessly watch everything around them unravel.
Social influence: People look to others for cues on how to behave. If no one else is helping, they may conclude that the situation is not urgent (even when it absolutely is!)
Evaluation apprehension: People may be afraid of being judged or embarrassed if they help. Nobody wants to be that person if it’s not actually an emergency. It’s like calling a code blue and later finding out it was a false alarm. Everyone looks at you side-eyed, even though you were just trying to help.
How does the bystander effect affect SLPs?
It's not hard to imagine how this effect might impact other areas of care as well. Should you discuss the discharge goals? Nah, the other SLP probably handled that. Should you discuss the risks of vocal injury after intubation? Well, the ENT should be any day. Should you mention the possible adverse effects of feeding tubes? No, the doctor will definitely handle that.
If we are unsure, check to ensure it's been done. If not, do it. Remember, the most impactful things are usually quick, easy, and cheap. But missing them can add time, increase difficulty, and make things very expensive very fast.
How can we help minimize its effects?
Here are some ways we can combat the Bystander Effect:
Identify a specific individual: Research suggests that directly asking a specific person for help increases the likelihood of receiving assistance. Instead of calling out to a group, single someone out. For example, say, "You in the red shirt, please call 911!" For oral care, this could mean writing a rotating schedule in which ONE person is responsible for oral care that day. That’s their job and nobody else’s.
Clearly label the situation as urgent: Ambiguity can lead to inaction. Bystanders might be unsure whether a situation truly requires intervention. Clearly stating that it's urgent can prompt them to act. In oral care, this could be making an announcement at shift huddle to clarify the importance of doing oral care and how it should be seen as a form of infection control. “Brushing teeth saves lives, people!”
Delegate specific tasks: Giving people clear instructions on what to do can overcome the diffusion of responsibility. For example, we could provide regular training on proper oral care so they know what is actually expected. Once they do it a few times, it becomes clockwork.
Educate people about the bystander effect: Simply being aware of it can make them more likely to help. Encourage discussions with your team about this phenomenon, and find unique ways to overcome it tailored to your facility. Why? Because every facility is different.
The bystander effect is a powerful force that can hinder even the most basic care in healthcare settings. It's easy to assume someone else is taking care of things, especially when everyone is "responsible." As we've seen, this often leads to critical tasks falling through the cracks. But we can fill in those cracks.
Whether it's oral care, answering call bells, or communicating vital patient information, we need to be vigilant in combating this phenomenon. By implementing strategies like assigning clear roles, emphasizing the urgency of tasks, and fostering open communication, we can create a culture of accountability and ensure that every patient receives the attention they deserve.
Ultimately, overcoming the bystander effect is about shifting our mindset from "someone else will do it" to "I need to make sure it gets done." Let's all commit to being active participants in patient care, taking initiative, and advocating for those who cannot advocate for themselves.
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