A culture of fear permeates the healthcare system

The culture of fear that led to dozens of fatal plane crashes in Korea, the molestation of young boys at Penn State University, and the tens of thousands of deaths of patients in our health care system are all a consequence of unresolved organizational conflict arising from a culture a fear. Unless, we replace fear with trust, conflict won’t be resolved.

In Korean culture, questioning authority is unacceptable and led to a culture of fear in the airline industry. We’re talking about fear of humiliation and retaliation. This culture of fear led to tragic airline mishaps due to pilot error; the co-pilot could never question the pilot. Finally, early this century the system has changed to one of trust and there has not been any further incidents. Building team work and collaboration instead of retaliation.

We all know what happened last week at Penn State. A culture of fear over upsetting Joe Paterno and his football kingdom ruined the lives of who knows how many children and may financially ruin the university.

The same culture of fear infects our healthcare system. The CEO could do no wrong at Parkland Hospital in Dallas until an investigation published by the Dallas Morning News exposed the hospitals’ callous disregard for patient safety. However, attitudes didn’t change until Medicare took over the daily operations at the hospital and threatened to relieve Parkland from its Medicare privileges. The arrogance displayed by Parkland leadership nearly took down this major hospital. It is still not certain how this will turn out.

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, like those at Parkland, 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.

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 a 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. He blogs at Taking Control of Your Healthcare and can be reached on Twitter @kreisberg.

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  • Anonymous

    From the article, it appears that to change the culture, the initiator of the fear had to change.  In medicine, that would be the attorneys and the feds.  So, how about some suggestions to remove the sources of the fear so we can build bridges of trust?  Until then, nothing will change.

    • http://makethislookawesome.blogspot.com/ PamC

      The sources of fear, as the article points out, comes from the top. It comes from fear of reprisal, consequence, career limiting moves… the fear of being wrong *at all*. Until we can all say “oops!” and own our own mistakes, until the daily authorities and hierarchies that health professionals deal with allow “oops” moments… yeah, the change will be difficult. 

      But it is oh so very necessary…

      Brilliant article! Well done!

  • http://www.patrickkeady.org/ Patrick Keady

    Mission/Vision seems to be key here.  While Parkland Hospital has a mission it looks like the hospital needs to regularly influence behaviours by reminding itself of its Mission, and these reminders need to be challenged by insurers, patients and the public.  Penn State has a Mission too.  Although its just too wordy and therefore unlikely to impact on the behaviours of its employtees. The Missions are as follows:

    Parkland Hospital : ‘dedicated to the health and well-being of individuals and communities entrusted to our care’. 

    Penn State University : ‘Penn State is a multicampus public research university that educates
    students from Pennsylvania, the nation and the world, and improves the
    well being and health of individuals and communities through integrated
    programs of teaching, research, and service.
    Our instructional mission includes undergraduate, graduate,
    professional, and continuing education offered through both resident
    instruction and online delivery. Our educational programs are enriched
    by the cutting edge knowledge, diversity, and creativity of our faculty,
    students, and staff.

    Our research, scholarship, and creative activity promote
    human and economic development, global understanding, and progress in
    professional practice through the expansion of knowledge and its
    applications in the natural and applied sciences, social sciences, arts,
    humanities, and the professions.

    As Pennsylvania’s land-grant university, we provide
    unparalleled access and public service to support the citizens of the
    Commonwealth. We engage in collaborative activities with industrial,
    educational, and agricultural partners here and abroad to generate,
    disseminate, integrate, and apply knowledge that is valuable to society’

  • Bin King

    In Korean culture, questioning authority is unacceptable .. This is absurd…

  • http://pulse.yahoo.com/_SIV73MVD22SX7DLY2R2EYB4NBQ Bethany

    The key word here was all heathcare workers. I had a ” damn I can not believe that just happened moment” August 16,2010. It changed my life went it happened to be more careful. I immediately reported it because I thought after 271/2 yrs in radiology going to the floor to inject a patient for a bone scan and this is the first time it happened to me ,It could happen to someone else.   I had checked the order on the chart outside the door,all the patient’s information name ,DOB,etc. I went in introducted myself to the patient in my usual upbeat  manner ” Good Morning, Mr,John Doe!______pt I am my name From the Nuclear Medicine department your onocologist, Dr.Jane Doe has ordered a bone scan to see why your back is hurting. He asked questions including would diarhea affect his scan. He was wrapped up and the IV site was available. He did not want to show me his ID bracelet . I simply forgot to ask his DOB  I injected and  to my horror the chart outside his door belonged to the patient one doorway over. Ever since our hospital had placed the charts outside the patients’ doors everything had always matched up but on this one floor one chart was not lined up that way. Yes,I made a mistake in which caused me my job and might as well be my career because the CNO from another campus and VP of Imaging fired me, The hospital that I worked at is part of a growing heathcare system {5 hospital and 100s of Dr. Offices} , I can not work, do clinicals if I was to return to school ,or volunteer with the organization. What makes this worst is that others have done the same thing and I have withness this first hand or hung IV fluids with the wrong patient name on it and they were not fired. In my case Just Culture did not prevail,and doing the Right Thing was not for my family and I, and has not done anything to help patient safety.
          I did appeal, and was told who is going to believe you over the Cheif Nursing Officier and the VP of Imaging. I believed my past eval, letters from patients,relationship with other staff, and the fact I was having problems with my Parathyroid and was seeing a physician for memory problems  would help. I was always there and change my appointments  when staffing was a problem.

  • Doug Capra

    And where does communication with the patient and his/her family come in with all this? Nurses and all their assistants, who are the frontline of patient care, are often afraid to report all kinds of violations they see every day because they know the top doesn’t want to hear the truth. They fear reprisal. These are the caregivers who are in the trenches minute to minute and really see what’s goingon. Thus, the role of patient advocate becomes a joke. Who advocates for the patient? That’s why many people feel they need a family member or a hired patient advocate with them every minute they’re in the hospital. Yes, this problem needs to be fixed. But in the meantime, who’s really looking out for the patient. Who is really putting the patient at the top of the list? 

  • Chris OhMD

    I agree with Bin King that comments such as “In Korean culture, questioning authority is unacceptable “. this kind of comment is clearly from someone who has no understanding of foreign culture but simply likes to write about them. Yes the traditionally confusius based cultures have this bias but let us remember that the same South Korean culture is the one that saw the fastest economic transformation in one generation in modern history. If such “culture of fear” is responsible for plane crashes how does it lead to such outstanding performance in economic innovation? You should do more research before you write.

  • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

    Government and bureaucracy mandated managerial-ism destroys good healthcare

  • Smythe DuVal

    Good article.