Enhancing Nursing Assistant Curriculum: Incorporating Strategies to Speak Up for Safety

Submitted by Christina R. Miller, MSN-Ed, RN

Tags: advocacy assertiveness communication nursing assistant patient safety

Enhancing Nursing Assistant Curriculum: Incorporating Strategies to Speak Up for Safety

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Christina Miller is a faculty member at Meridian Medical Arts Charter High School in Meridian, Idaho. She recently completed her graduate degree at Excelsior College.


Nursing Assistants are non-licensed clinical staff who, despite being directly involved in patient care, may be reluctant to call out safety concerns because of their position within the clinical hierarchal structure. The current nursing assistant training curriculum provides basic instruction on communication and teamwork skills, however, does little to reinforce the importance of the nursing assistant’s role, or empower these staff to bring safety concerns forward. This reluctance to speak up may result in unaddressed safety issues and patient harm.

Enhancing Nursing Assistant Curriculum

Contributions from all members of the healthcare team are necessary to ensure the delivery of safe, quality patient care. This teaching-learning project was focused on nursing assistants; these individuals are essential members of the nursing team but are often left out and underrepresented in initiatives to promote patient safety. The goal of this project was to teach structured communication techniques to nursing assistant students as a method of improving their comfort in using speaking-up behaviors, and therefore, improving patient safety.


Since the publication of To Err is Human (Institute of Medicine (IOM),1999), patient safety has become a priority focus of the healthcare industry; unfortunately, despite the attention on the improvement of safety culture, communication failure continues to be one of the largest contributing factors in the occurrence of adverse events. This includes barriers to effective communication caused by healthcare workers’ reluctance to speak up and call out safety concerns. This issue has been related to the influence of the hierarchal structure of healthcare in which staff on lower levels may believe their input is less valuable and therefore are hesitant to speak up or question those in authority, even when something seems wrong or is potentially dangerous (Clapper, 2018; Kim et al., 2020).

Structured communication techniques, such as those found in TeamSTEPPS®, have proven to be an effective solution to promote a healthy safety culture and level the hierarchy of healthcare environments. The Agency for Healthcare Research and Quality program TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety), a nationally recognized patient safety initiative, is an evidence-based strategy designed to enhance team performance and communication in health care (Maneval et al., 2020). When properly implemented, TeamSTEPPS® can minimize negative aspects of hierarchies in clinical settings by empowering all members of the healthcare team to speak up for safety (Clapper, 2018) and create environments in which open communication is encouraged.

TeamSTEPPS® methods are recognized by the Joint Commission as a best practice solution to deliver safe, quality patient care. Training on these methods, or similar structured communication techniques, has been recommended for all clinical staff by the National Academy of Medicine and the Quality and Safety Education for Nurses initiative (Reeves et al., 2017); hence, these strategies have been proposed as additions to undergraduate nursing and physician education curricula (Maneval et al., 2020; Reeves et al., 2017) to enhance patient safety, readiness for practice, and ability to function on interdisciplinary teams.

Although there is an abundance of literature demonstrating the benefits of structured communication technique training, it appears this is offered most frequently to licensed professional healthcare staff and there is a dearth of evidence on the inclusion of nursing assistants in these initiatives. This gap in team member development perpetuates rigid hierarchies of “authority and power…and downward communication” (Howe, 2014, p. 133), thus creating a continuous cycle of reluctance to speak up. This is unfortunate, considering the role of the nursing assistant; these individuals spend more time directly interacting with patients than other clinicians in most care settings (Howe, 2014).

Based on this fact alone, nursing assistants are in a key position to prevent errors that result in patient harm because they may observe or otherwise come to know information before other members of the healthcare team. As their title implies, nursing assistants work closely with licensed nurses to provide care for patients using a team approach; collaboration and effective communication is critical to the effectiveness of this partnership (Campbell et al., 2021).Training nursing assistants to recognize the crucial importance of their role on the care delivery team, as well as empowering them to communicate concerns assertively and respectfully, better prepares these individuals to be advocates for patient safety upon their entry into the workforce.

In nursing education, the broad topic of patient safety is not explicitly taught, although components are included across a variety of subjects – for example, practices to reduce medication administration errors and strategies to prevent patient falls. Although it is not appropriate to provide this group with safety instruction related to topics outside the nursing assistant scope of practice, general safety culture education, including communication skills and “timely expression of patient care concerns” are appropriate for inclusion (Kim et al., 2020, p. 250).

Learner Population

A group of 17 students enrolled in a high school nursing assistant course was surveyed to explore their experiences with communication. Survey questions of particular interest were related to their comfort level in speaking up if a concern arises, and the perception of their ability to communicate with authority figures. Results of the survey demonstrated a high level of uncertainty among the students in these aspects of communication.

Reeves et al. (2017) note students may perceive themselves as unimportant outsiders, prone to self-doubt, and reluctant to speak up out of fear of being wrong, ignored or even humiliated. However, these same perceptions and feelings of insecurity may extend to novice clinical staff, especially those in entry-level positions (Clapper, 2018). Nursing assistants are often left out of team communication (Howe, 2014); therefore, it was hypothesized this issue would likely persist in the students’ role as new nursing assistants.


The established nursing assistant curriculum provided a framework to build upon and principles of the TeamSTEPPS® program were easily incorporated by scaffolding onto concepts students had previously learned. Interactive teaching strategies were used to promote student engagement during the lesson on TeamSTEPPS® methods. In the lesson, students were taught two different TeamSTEPPS® techniques:

  • the CUS tool, which focuses on the use of keywords (I am concerned, I am uncomfortable, this is a safety issue) to assert a safety concern.
  • the two-challenge rule, which involves verbalizing a safety concern twice - the first time, by raising concern in a firm and supportive manner and expressing the concern a second time if needed once it is realized the message may not have been received properly (Clapper, 2018).

Students were taught to use these tools assertively and respectfully, as well as how to escalate their concerns if the use of the tool was not effective. Instructional strategies were designed to encourage student engagement and included the use of a game, a discussion based on a critical-thinking question prompt, and an interactive quiz.

Additionally, students watched pre-recorded simulated patient care scenarios to identify which TeamSTEPPS® method was being used or could have been used to enhance communication. To further evaluate learning and assess higher-order understanding, students were asked to create scenarios that involved formulating speaking-up phrases using TeamSTEPPS ® tools and role play those scenarios for the class.

After the lesson, students were again surveyed to determine if their comfort level in speaking up with concerns or communicating with those in authority had improved. Before learning the TeamSTEPPS® methods, students reported they felt uncertain of their abilities with these skills; post-learning results demonstrated students felt much more comfortable and prepared to share concerns and speak up.


Adverse patient outcomes have been attributed to communication failures and the influence of hierarchal structure. To overcome these challenges, strategies such as TeamSTEPPS® have been successfully implemented in healthcare environments, as well as in licensed clinical staff training programs; unfortunately, the nursing assistant population is under-represented in these safety initiatives.

Despite being entry-level personnel, these staff members are valuable members of the interdisciplinary team, with knowledge and input that is critical to the safe delivery of patient care. Learning techniques to enhance their ability to communicate promotes the development of nursing assistants who are well-prepared to function in clinical environments as assertive advocates for patient safety.


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