So whose responsibility is it to act in an emergency? Everyone? No one?
In healthcare, nurses, doctors and other professionals are taught to act together; hence the term “healthcare team.”
Assigning general responsibility to a team may be a two-edged sword, however.
An article in the New England Journal of Medicine earlier this year illustrated this dilemma very well:. A male patient in the ICU developed multisystem failure and a mysterious rash. Over 11 days the patient reportedly was seen by a total of 40 doctors representing nine specialties.
Remarkably, no diagnosis was made.
The authors of the study wrote that because of the complexity and chaos, no one assumed primary responsibility for the patient assuming “someone else” would bear the burden of authority and responsibility.
In the News
;Recent very tragic events in the news have stimulated public discussion on the interesting psychological behavior called bystander effect.
A few months ago a young honor student in Chicago was viciously beaten to death by a mob while others stood by and watched. Days after the incident had caused a media buzz and elicited national outrage; no one had come forward to offer information. Local kids explained that cooperating with the police is a cultural taboo and would be viewed as “snitching.”
A 15-year-old in California was savagely sexually assaulted for hours outside her school dance while more than a dozen bystanders did nothing to help. Even in the context of such brutality: a struggling girl, with police and school officials close by, despite the ubiquity of cell phones and the current proclivity for texting, not one person raised the alarm.
Bombarded with sensory data, individuals sift through a sea of alternatives and come up with a decision or judgment based on many factors, ranging from habit to cultural norms to a psychological need for self preservation or conformity.
The bystander effect, i.e., the tendency of individuals not to offer help in emergency situations if others are present, was popularized by the Kitty Genovese incident. In 1964 Genovese, a young woman in New York was raped and stabbed to death while as many as 38 people, all of whom had the opportunity to intervene or call the police, did neither.
Psychologists have repeatedly duplicated that phenomenon experimentally; showing that subjects faced with an emergency are much more likely to respond if they are alone, than if they are in a group.
Two separate but related decision making factors result in the seemingly illogical reaction called the bystander effect.
The first is a diffusion of responsibility whereby observers all assume that someone else is going to intervene and so each individual feels less responsible and refrains from doing anything. The expected sense of individual accountability is lessened as it is transferred to someone else.
In healthcare, a similar line of reasoning results in the common manifestation where “someone” or “everyone” is responsible, so no one actually executes the action; no matter how vital it is.
In the NEJM article, two physicians involved in the man’s care weighed in after the fact and admitted because neither knew what was wrong with the patient they’d ordered a series of unnecessary tests while hoping the other would diagnose him.
Just as strangers who witness a crime may do nothing, willing to dismiss the incident as someone else’s problem, doctors without ownership in a patient’s care may not act, Drs. Robert Stavert and Jason Lott, residents in dermatology at Yale School of Medicine, explained in the Jan. 13 article.
Another reason for bystander effect is a lesser known phenomenon called pluralistic ignorance.
This is a phenomenon first described by social psychologists Daniel Katz and Floyd Allport and is defined as a situation where a majority of group members privately reject a norm, but assume (incorrectly) that most others accept it.
Plural ignorance is based a lot on peer pressure and is found in situations, for example, when students force themselves to engage in risky behavior to appear “cool” to their peers.
Research shows that interviewed individually, many conformists admit that they wish they did not have to conform. They also falsely assume that they are the only ones who would rather go against the grain if there were no perceived adverse consequences.
Decision-making skills are learned and become more reinforced with use. The same logic heightened in emergencies is often symptomatic of the skills used in everyday life. For instance, it is very likely that the way some deals with workplace conflict is predictive of how that person would respond as a bystander in a crisis.
One area of constant discussion is how healthcare professionals can gain more recognition. One does not want to trivialize the horrendous tragic incidents currently in the news or to suggest direct equivalency with our professional plight, but there are parallels regarding how we react.
Most people are willing to simply be bystanders assuming that someone else will act. This is actually very similar to diffusion of responsibility.
Pluralistic ignorance comes into play whenever an individual assumes she is unique in having a strong opinion. Alternatively, they convince themselves that daring to stand out or draw attention to oneself would be viewed unfavorably by the peer group.
Again, that often results in a group of unhappy people standing around looking at each other and assuming everyone else is satisfied with the status quo.
Act on Your Core Values
Going along with the perceived norm or the organizational/unit culture can directly dictate work ethic and quality of care delivered to patients.
Leaving the difficult tasks to others, not being a patient advocate, not going the extra mile and using shortcuts “because everyone else does it” are all examples of making patients suffer from workplace application of the bystander effect.
The more rewarding and mutually effective decision is to act on one’s beliefs and core values. Each person acting individually, and exactly where they are right now, can also be remarkably powerful.
Decision making is not an automatic mindless process. It can be learned and can be more logical than automatic, given enough commitment and practice.
No matter what situation one finds themselves in from the trivial to the significant, the simple to the complex, the decision – and the power – resides in the individual.
Glen McDaniel is a healthcare consultant, clinical lab scientist, speaker and freelance writer. His interests include mediation, leadership, change and ethics. He can be reached at [email protected].