A culture of fear worsens the nursing shortage and medical errors

There has been a lot talk about changing how we reimburse providers for healthcare from one that pays for services performed, to another that reimburses providers depending on what happens to the patient.

I think we must take a couple of steps back and first tackle the public health crises we are facing that is putting our healthcare in danger, namely, medical errors and the growing nursing shortage. Despite identifying work place conflict as the root cause, the number of medical errors and shortages of nurses has continued to rise over the past decade.

Until the role of organizational culture in conflict is fully addressed, we will continue to have nurses abandon the profession and unacceptable levels of medical errors. The culture of fear that permeates the healthcare system effectively blocks open communication and collaboration that is necessary to resolve conflict and provide the safe working environment necessary for quality healthcare. Rather than learning from medical mistakes and resolving conflict, healthcare managers and leaders place blame for errors squarely on doctors’ and nurses’ shoulders. Fear of litigation, blame, accusations of incompetence, and retaliation creates unresolved conflict throughout the organization. With unresolved conflict, mistrust persists, anxiety grows, conflict escalates and mistakes escalate, creating an unsafe, hostile environment.

Although errors and hostility are the proximate cause of conflict, the root cause is in the system: failure in the design of processes, tasks, training, and working conditions that make errors more likely. However, if we want to significantly reduce the number of medical errors and retain our best nurses, working conditions must change; the culture of fear that permeates healthcare must be replaced with one of trust.

Change must start at the top. Healthcare managers and leaders must be willing to change their behavior and work collaboratively with all healthcare workers to minimize the effect conflict has in the workplace. In this new environment of trust, employees will be empowered to openly communicate and collaborate and to learn from mistakes, which will result in a spiral of trust and, as a consequence, better patient care. Without change from the top of the organization, mistrust will persist no matter how many systems designs are implemented.

Jeffrey I. Kreisberg served on the faculty the University of Texas Health Science Center at San Antonio where he was a Professor of Pathology, Medicine, Surgery, Urology, and Molecular Medicine.  He is the author of Taking Control of Your Healthcare.


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  • http://twitter.com/Lyall Lyall

    Exactly. Systems systems systems.

    It only takes one incident of management/supervisors using the error reporting tool (AIMS, Riskman, probably called something else in America) in a punitive manner for a nurse to loose confidence in the patient safety/quality improvement process.

  • Franki

    I have three observations in response to the article: 1. I, too, have seen the finger of blame point down to the person below so often that it seems all errors are the fault of the nurses aide, never the people with any authority. 2. Still, this does not mean we can wait for human nature to change before we try to fix the perverse incentives in the reimbursement system. Those who really do have the authority to decide the systems are influenced by both intended and unintended financial impact on their institutions. 3. I have heard those in regulatory decision-making positions aver that the reimbursement formulas have no bearing on quality of care. Baloney! Why are we surprised to get poor quality when that pays more than high quality?

  • LynnB

    The awful thing about the “never events” is that chronically ill patients who are likley to get UTI’s, etc etc –may get denied care , may get worse care . .

    If I KNOW that my patient has a neurogenic bladder from diabetes and can’t empty and gets narcotics and now REALLY can’t empty the right thing is is checking bladder volume and if it gets too full , intermittent or indwelling cath .But if I do the right thing and they still get a UTI Medicare punishes my hospital. If I hope for the best they are more likely to get a UTI but this time its not my fault per Medicare

    The most direct way of keeping your hospital solvent has always been to avoid the chronically ill if at all possible . I don;t do it, my hospital doesn’t do it, but the few hospitals that appear to do so look really great on hospital compare. God help the university hospitals.

  • http://patientprivacyreview.blogspot.com/ Doug Capra

    Would someone convince me that there is actually
    a nursing shortage? My take is that there are plenty
    of LPN’s and RN’s looking for work. The truth seems
    to be that these well-trained, well-educated nurses
    are being replaced by cna’s, patient techs, etc.
    who only get a few months of training and are
    paid much less, and know much less. Also, these
    nurse assistants are being given more and more
    latitude as far as their scope of practice goes.
    They’re being allowed to do more and more
    kinds of procedures, some invasive, that only
    nurses could do in the past.
    Now, if I’m wrong correct me. But supply
    me with some facts.

  • Darlene

    I have been a nurse for 19 years and my observation related to poor nursing care and nursing errors that do or do not result in patient harm is that they seem to stem from poor nursing education in addition to the “culture of fear.” Nursing programs are becoming shorter, which results in less clinical experience for students, which is invaluable to a nursing education.
    Moreover, schools are lowering their acceptance standards to the point where some are turning out task oriented nurses who have no understanding of physiology and the reasons behind why and the way these tasks are done. In such an environment, increased errors are inevitable.

  • http://www.facebook.com/profile.php?id=1418631459 Lynne G Siegel

    The reality is: The healthcare system will not fund the experienced, trained, and educated older R.Ns. to work for them. It’s too costly to pay for their  health insurance and risk management of a “possible injury” and a long term retirement of someone with a family, and someone who can’t return the favor of lifting patients and delivering many more years of cheap labor, which is, of course,  profit driven.  If you all think this isn’t so, take a look at the numbers of R.N’s who have actually retired from institutions with full retirement benefits, who have completed an entire Nursing career, with excellent health and NO physical complaints related to their workplace. Good luck. If you DO find any, you probably can count them on 2 hands, if that.

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