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Actively caring for safety: Overcoming bystander apathy

From the November 20, 2008 issue

ISMP has often been invited to assist organizations in their analysis of sentinel events. During our discussions, practitioners have sometimes shared an uncomfortable truth with us regarding these tragic events: they were not surprised that it happened. Many practitioners have told us that it was only a matter of time before a tragic event happened in their organization. So we asked these practitioners what they—knowing that a particular hazard existed in their organization—tried to do to prevent the events. We were often told that they had not personally reported the problem to their supervisor, completed an event or near miss report, or intervened in any way to prevent such events. But they felt sure others knew about the problem.

When we have visited organizations to conduct prospective risk assessments, we’ve asked staff what medication-related accidents are “waiting to happen” in their organization. Many practitioners have given us thoughtful answers, but few have personally reported the safety concern to their supervisors, or intervened in some way to correct the problem. Again, they stressed that others knew about the problem. 

Before you judge these practitioners too harshly, the truth is, they are no less concerned about patient safety than you are. They are devastated by the harmful events that have happened in their organizations, and/or sincerely concerned that such an event could happen. They can provide example after example of going the extra mile for their patients. So why do otherwise caring practitioners fail to report safety hazards until after an error has happened? Why do they fail to personally intervene to correct the hazards they see every day or notify others regarding the problem? According to psychologists, bystander apathy plays a significant role in these failures.(1)

The rape and murder of Catherine (Kitty) Genovese in 1964 brought public attention to bystander apathy. Kitty was raped and stabbed right outside her New York City apartment building. As she screamed for help, lights went on and windows opened in the neighborhood. Kitty’s attacker fled, but when he saw that no one was coming to help Kitty, he returned and continued the attack for another 30 minutes until she was dead. The first and second attacks were witnessed by 38 neighbors, but no one intervened to help or called the police until long after Kitty’s murderer left the scene. When questioned, the 38 observers could not explain why they did not call police earlier. Their apathy was first attributed to big city life, where indifference to others seemed rampant.(2) But hundreds of studies have since concluded that bystander apathy is not caused by indifference but by a belief that others in a group who see the same risks will intervene.(1)    

Studies have shown that people are less likely to intervene when other people are present and able to help.(1) When groups of people are involved, the responsibility to act is diffuse rather than personal. We can easily convince ourselves that our help is not needed. Someone else will report and take care of the problem. This applies not only to emergency situations, like in Kitty Genovese’s case, but to what we may consider nonurgent situations that someone else will address. Although more an environmental issue than a safety issue, one study found that only one in 598 people picked up a small paper bag littering the ground that had been purposely placed near a 50-gallon trash barrel in a city park.(3) Almost everyone either walked around or stepped over the bag without stooping to pick it up, assuming someone else would take care of it.

The finding that people often do not act when they can share responsibility with others is analogous to most work settings, including healthcare. It plays a particularly detrimental role in patient safety, as noted with the failure to report risks that eventually led to a sentinel event. A culture of safety can only be achieved if every person intervenes regularly to protect and promote patient safety. Everyone must assume responsibility and never wait for someone else to act. Everyone must be actively caring about patient safety. 

An individual typically makes five sequential decisions before acting on a safety issue.(1,4) The decisions are influenced by the nature of the problem, the presence of others and their reaction to the problem, and relevant social norms. These decision points suggest certain methods for decreasing bystander apathy.

Step 1. Is something wrong?(1,4) The first step to actively caring about safety is to notice that something is wrong. Most healthcare practitioners are well aware that medical errors are a significant threat to patient safety. But in the context of a hectic healthcare environment, busy practitioners can quickly learn to tune out irrelevant stimuli and, thus, may overlook, fail to report, or fail to correct safety hazards they encounter every day. To ensure engagement in actively caring behavior, staff need to enhance their skills at identifying safety hazards and maintain a healthy preoccupation with the risk of errors. These skills can be honed in simulation exercises.  

Step 2. Is my help needed?(1,4) If the need to intervene is not blatantly obvious, people tend to seek an answer to this question by observing their colleagues. Unfortunately, with everyone watching for action from others before they intervene, appropriate steps may never be taken. Social context also can have a dramatic effect on whether a person decides that his or her help is needed, or even if there is a problem that needs to be addressed. In one of the first important studies to define this problem, students were left in a room into which pungent smoke was pumped.(4) When each student was left by himself or herself in the room, 75% quickly left to report the smoke. But only 10% of the individual students that were in a room with two passive strangers left to report the smoke. Many students concluded that nothing was wrong since the two strangers didn’t get up to leave. Each student tried to “stay cool,” looking around for social cues to determine if a problem existed. The students who failed to leave the room developed a shared illusion of safety with the passive strangers.

There are several ways to counteract our tendency for inertia in groups. First, it is important for staff to feel they belong to the groups in which they work. Bystander apathy is lessened when people know one another and have developed a sense of belonging or mutual respect from prior interactions.(1) The second way is to promote a sincere belief and commitment to interdependence among staff. A social norm of helping each other, rather than working independently, should be fostered.

The third way is to build synergy among workgroups. Synergy is the term used to describe a situation where the final outcome of a system is greater than the sum of its parts. However, psychologists have described a group phenomenon called social loafing in which the whole (group) is NOT greater than the sum of the parts (individuals).(1) Researchers, for example, measured the effort exerted by eight people, first independently and then together, when pulling a rope in a simulated tug-of-war.(5) But the group effort only measured half of the sum of the eight individual efforts. The eight subjects worked harder alone than as a team, so group synergy was not achieved. Group synergy can only be experienced when group members know each other, agree on common goals, and function well as an interdependent team. Individuals also need to feel a sense of personal responsibility for the team’s efforts. They need feedback regarding their contributions to safety and rewards for a job well done in order to build a sense of personal responsibility for the team’s safety record.(1)
Finally, you should lead by example. If you want to promote actively caring for safety you need to demonstrate these behaviors consistently, sending the message that “patient safety begins with me.”

Step 3. Is it my responsibility to intervene?(1,4) It is easy to assume that safety is someone else’s responsibility in a group setting. But people will take action if their responsibilities are clear and if they voluntarily pledge to meet them.(1) Theft on a public beach was the subject of one early study that clearly demonstrates this concept. Researchers posing as vacationers randomly asked individual sunbathers to watch their possessions while they swam in the ocean.(1) A short time later, a second researcher approached the man’s belongings and snatched his radio. Ninety-four percent of the sunbathers who promised to watch the man’s belongings intervened, often dramatically. But only 20% of the bystanders who were not specifically asked to be “watchdogs” reacted to the obvious theft. A social norm must be established that everyone shares equally in the responsibility to keep patients safe.

Steps 4 and 5. What should I do? When should I do it?(1,4) These steps point to the importance of education and training so staff feel capable of reporting and managing safety risks. When people know what to do, they do not fear making a fool of themselves and are less likely to wait for another person to take action. Education gives staff the rationale and principles behind particular safety interventions and empowers them to take action, leading to a sense of ownership.(1) When people receive tools to improve safety and believe the tools will be effective, the risk of bystander apathy decreases. The bottom line is that people who have learned how to take action through relevant education and training are likely to be most successful in actively caring for safety.

References: 1) Geller ES. The Psychology of Safety Handbook. Boca Raton, FL: CRC Press LLC; 2001. 2) Rosenthal AM. Thirty-Eight Witnesses. New York: McGraw Hill; 1964. 3) Jenkins E, Cuddiky K, Hearn K, Geller ES. When will people pick up and pitch in? paper presented at the Virginia Academy of Science meeting, Blacksburg, VA; April 1978. 4) Latane B, Darley JM. Group inhibition of bystander intervention. J Personal, Soc, Psychol 1968;10:215. 5) Dashiell JF. Experimental studies of the influence of social situations on the behavior of individual human adults. In A Handbook of Social Psychology, Murcheson E. Ed. Worchester, MA: Clark University Press; 1935.

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