Jeong et al.¹ categorized tens of clinical areas in a large Korean hospital into four classes according to its area’s safety culture profile according to the Korean version of Safety Attitude Questionnaire (SAQ-K).¹ There were noticeable variances in SAQ-K scores among the classes for the most domains: teamwork climate, safety climate, perception of management, working conditions and even job satisfaction.¹ Though such variance definitely stuck out, what really caught our eyes was the extreme invariance in stress recognition (SR) domain scores: indeed, all classes of clinical areas reported remarkably consistent SR score across the hospital ranging from 66.87 to 69.09.1Where did this ‘unexpected consistency’ come from, and how can we interpret it?

According to Jeong’s series of articles on SAQ-K, SR domain of SAQ-K asks each healthcare worker (HCW) to explain stress affected his or her performance. Instead of asking about clinical area where an HCW is working, the SR domain asks each HCW to assess his or her own susceptibility to stress.^1-4 Therefore, it might be possible that each HCW gave themselves higher scores than they should have. It is also possible that the HCWs had been well trained to handle stress, so their SR scores might reflect a kind of ceiling effect. Lastly, this ‘unexpected consistency’ might have been purely accidental because HCWs in all classes gave the same responses.

There are many plausible scenarios for the invariance in SR scores. Jeong et al.¹ did not investigate it, but recommended further study.¹ As safety experts, however, we cannot afford to wash our hands of such matters; we must consider the worst-case scenario so that we can prepare for it.

For seasoned patient safety experts, the most fearful situation is when the system itself has already been designed to be prone to errors; macro-level problems are the most difficult to solve. Therefore, the gloomiest situation is that there are hospital- or even country-wide system problems that override the differences across clinical areas or even hospitals, leveling the SR scores and possibly reducing each HCW’s level of stress perception. Unfortunately, this systematic desensitization to stress seems to be supported by statistical data of healthcare industry of Korea.

Let us take a look at some macro-level indicators of the workload on HCWs in Korea: the number of doctors per 1,000 populations is 2.0, one of the lowest among members of the Organization for Economic Co-operation and Development (OECD). There are only 4.7 nurses per 1,000 population, around half the average of OECD countries in 2013.⁵ However, the number of beds per 1,000 population was 10.3, second only to Japan.⁵ In sum, in Korea, fewer HCWs are taking care of more patients, especially in hospitals. This nation-wide understaffing has imposed an excessively heavy workload upon HCWs in Korea, who are more exhausted than ever.

Korea’s culture might have made this situation worse. In Asian culture, speaking up when people feel something is wrong is discouraged, and might even be considered a challenge to a superior.^6,7 By the same token, a person who reports feeling stressed or overworked is criticized for being weak.⁷ These physical and cultural conditions might have forced HCWs to suffer in silence. Unfortunately, however, by remaining quite, health care workers might have lost the ability to know when they are being overworked to point that their job performance and the safety of their patients are being compromised.

Some safety experts might argue that limiting the work hours of HCWs could keep HCWs at optimal performance by decreasing their workload and the possibility of medical errors.⁸ This apparent quick fix could do more harm than good, because, restricting HCWs’ working hours may keep many patients from seeing their physicians; this is the creation of “unmet needs.”

Trapped in their stressful jobs for years, HCWs might have learned to make the best of the resources at their disposal without complaint; psychologists term this behavior “learned helplessness”.⁹ Learned helplessness arises when a person keeps failing to escape from a situation or solve a problem; HCWs might have given up hope that their working situation would improve in order to resolve their cognitive dissonance between their working conditions and their concerns about their performance.¹⁰ Learned helplessness becomes a cultural trait if the difficult situation persists,^11,12 and Korean healthcare seems to be a culture in which HCWs are trained to be impervious to stress.

Why are we so concerned about HCWs’ imperviousness to stress? The answer is quite simple: without the ability to identify the sources of their stress, HCWs cannot counteract them. A safety expert, James Reason, described an HCW’s intuitive real-time evaluation of his or her level of fatigue in preventing adverse events.¹³ In order to make this determination, an HCW needs to be able to identify the stressors and their potential impact on his or her performance. This is precisely what the SR domain of SAQ-K is intended to measure.

In addition, HCWs’ inability to admit the possibility that stressors can impair their performance might lead HCWs to blame themselves, not the systems in which they work, for adverse events.  This is exceptionally poisonous in improving safety; with this way of thinking, systems approach, an axiom of safety, to change the working environments to prevent future events is always off limit. Furthermore, we cannot expect an HCW to consider systems or environmental factors when other HCWs, especially less experienced ones, made an error under pressure. Indeed, SR is the bedrock of patient safety and we need maximum firmness of it.    

None.

Authors declare that there are no conflicts of interests.

Fortunately, in December 2014 the Korean National Assembly passed the Patient Safety Law.  The law will lead the entire healthcare field to review the state of patient safety across the country and provide resources to improve safety. Au fond, it is by far the most dramatic opportunity to improve the current situation in the healthcare field. We should be prepared for this upcoming change. Healthcare workers should be trained not to suffer in silence and to emerge from their learned helplessness. We should show HCWs how to identify sources and signs of stress; this is not only their right but also part of their ability to protect their patients.

In presenting the worst-case scenario, we might have been overly sensitive to the SAQ results of the hospital. However, if this brings attention to HCWs’ ability to admit that they are overworked and in so doing to improve patient safety, we are proud to have followed the first principle of safety: to prepare for the worst. That is how we can make the world safer.

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2. Jeong HJ, Jung SM, An EA, et al. Development of the Safety Attitudes Questionnaire - Korean Version (SAQ-K) and Its Novel Analysis Methods for Safety Managers. Biom Biostat Int J. 2015;2(1):00020.
3. Jeong HJ, An EA, Kim SY, et al. Combinational Effects of Clinical Area and Healthcare Workers' Job Type on the Safety Culture in Hospitals. Biom Biostat Int J. 2015;2(2):00024.
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