'When blame is lopsided, it can lead to tragedy'

  | July 18, 2017

If we accept the premise that doctors and nurses are among the most well-intentioned people in society — devoting their lives to alleviating human suffering caused by disease — we must also acknowledge that there is often a deep divide between these two communities of caregivers. The hierarchy that exists in many healthcare environments leads to a diminution in the respect shown by doctors towards nurses, and a corresponding resentment on the part of nurses when they are made to feel that their role is subservient.

So we probably shouldn't be surprised that doctor-driven healthcare systems would find a way to blame nurses for many of the errors that occur. Add to the power imbalance the fact that nurses spend much more time than doctors caring for patients, and so the probability that harm will occur to patients during their watch is statistically higher. Those dynamics often lead nurses to be blamed even when the cause of the harm is systemic, rather than personal.

There are institutions in which the roles of nurses and doctors are seamless, where collaboration and mutual respect rule the day. In these settings, the clinical team retains a hierarchy of authority, but the manner in which work is organized reflects a more egalitarian and collaborative approach. Doctors and nurses are able learn together, enhance care delivery, and minimize the harm that arises from systemic causes.

I keep hoping for the day when more hospitals and health systems will display the latter characteristics, but I see slow progress.

Some recent examples

In the United Kingdom, a nurse named Jane Frances Kendall recently received a 24-month disciplinary period for a 2014 incident in which she failed to attempt CPR on a nursing home resident whom she found to be “waxy, yellow and almost cold," with no pulse or vital signs. Britain's Nursing and Midwife Council ruled that Kendall was acting outside of her competence and was not qualified to certify death.

But one commenter on the report, a former executive nurse in Britain's National Health Service, noted that the review panel didn't appear to understand the difference between diagnosing death (a clinical job) and certifying death (a legal responsibility). “Nurses can't and don't need to certify death," she wrote, “but they can diagnose death and act in accordance with best practice guidance."

A disciplinary action can have a huge effect on a nurse's career.

At MedStar Health in 2011, a nurse named Annie administered insulin to a patient whose glucometer read “high," and who reported that her blood sugar felt high. In fact, the patient's blood sugar was critically low, and she was admitted to the ICU. Annie was suspended, but an internal review later determined that the equipment was at fault, and her suspension was reversed.

In a 2014 MedStar training video about the incident, promoting a systems approach to safety culture, Annie talked about how the experience affected her psyche: “I felt like I was talked to like a five-year-old. I wasn't talked to like I was an adult. I mean, I'm a nurse because I come to take care of people. For a long time, it really shook me. When I came to work, I was apprehensive about everything I was doing."

We could understand why a person who is unjustly blamed for a medical error might be more likely to commit another one than his or her colleagues. But it's just as likely that, because there is a spotlight on their performance, there's a greater tendency to misinterpret their actions as individual weakness than as a function of the environment in which they work.

Indeed, the root cause of many medical errors is a lack of proper systems and protections in the workplace. In 2012, NBC News reported on a nurse who accidentally disposed of a living donor's kidney during a transplant, not realizing that it was in a chilled, protective slush that she removed from an operating room. The hospital eventually blamed poor oversight and communication and insufficient policies, and disciplined both nurses and physicians. But the punishment doled out to the nurses was more severe than to the doctors.

When the blame is lopsided, it can lead to tragedy.

In 2010, Kimberly Hiatt, a NICU nurse at Seattle Children's Hospital, was fired after a medication error that led to an infant's death, and later committed suicide. But a few months earlier, a dentist at the same hospital hadn't been fired for prescribing an incorrect dose of a Fentanyl patch to an autistic 15-year-old boy after routine dental surgery, leading to his death. And an ER doctor wasn't disciplined for wrongly administering a drug to a critically ill patient through an IV instead of an injection in the muscle, leading to complications.

In a letter to the editor to The Seattle Times after Hiatt's suicide, retired anesthesiologist F. Norman Hamilton, M.D., noted the injustice: “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error … If we fire every person in medicine who makes an error, we will soon have no providers."

The power to reverse this phenomenon lies with hospital leadership. Absent affirmative actions to protect nurses from premature and inappropriate blame, they will remain at professional and personal risk from a doctor-dominated setting when patients are harmed.

Human factors expert Terry Fairbanks, M.D., has explained to me that this is one of the biggest barriers to moving organizations to an overall safer and more resilient level: “We stop with individual blame, which makes leaders blind to the work-flow and process set-ups, which are really what need to be managed."

At the personal level, we owe it to the nurses and their profession to address this problem. At the health system level, we owe the same to our patients if we are to create a safe and high quality patient care environment.

But the leadership imperative goes beyond the response to medical errors. Indeed, the blame mentality when errors occur is just one symptom of out-of-whack power structures. At the clinical departmental level, there can be a tendency to diminish the role of nurses in morbidity and mortality case reviews or root cause analyses. Why? Because nurses often observe things that are viewed as undermining doctors' authority or judgment. The arrogance that can accompany doctors' higher degree of training acts to exclude what are often astute observations.

The hospitals and nursing homes that offer the highest levels of care are the ones in which concepts of shared governance, crew resource management, joint training and like are built into the everyday lives of doctors and nurses. But the unbalance often starts at the highest level of governance, where boards of trustees have staff doctor representation but less or no staff nurse representation.

I have seen proposals to add the nursing view to boards dismissed with the contention that nurse board members will only advocate for higher salaries and different staffing ratios. In contrast, no one seems to believe doctor board members will behave in a parallel selfish manner. No, they are viewed as paragons of virtue, without whose judgment a board cannot possibly understand the complexities of care delivery.

In short, unless governing bodies and leaders accept the premise that doctors and nurses are both among the most well-intentioned people in society and grant them equal status in the overall and clinical governance of health care institutions, we inevitably build in a skewed power structure that undermines our ability to provide the best care.

Paul F. Levy is the former CEO of Beth Israel Deaconess Medical Center and the author of “Goal Play! Leadership Lessons from the Soccer Field." Artwork by John Holcroft | Getty Images​

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A completely vital commentary that will require leadership to actualize. Nurses are the most trusted occupation in the United States (Gallup 2016) Nurses (84%) Pharmacists (67%) Medical doctors (65%) Dentists (59%) and the environment for them universally is made so difficult as you state here. This needs to be top of mind for Hospital Boards or there is no end in sight.
Name: 
Linda Galindo
Email: 
linda@lindagalindo.com
Nurses do not spend more time taking care of patients than doctors. Nurses spend more time on hospital floors at the bedside!!!!! As a surgeon I stand in surgery all day long and sometimes night, so the statement that nurses spend more time taking care of patients is incaccurate and offensive! Please correct. The rest of the article is correct!!! I would add that adminstration many times has more of a blame culture from managers and directors more than the doctors. The culture of blame must be solved, and not putting all the blame on doctors would be a start!
Name: 
Jeff Angel
Email: 
jangel@mpoc.cc
I don't believe I've put all the blame on the doctors. What I've said is that in these organizations, the power is centered in the doctors. Thus, as you note, very often the blame that is directed at nurses actually comes from managers and directors, many of whom are reluctant to raise issues of performance or work-flow with the MDs. Thanks for your suggestion about clarifying the time spent. Indeed, surgeons spend more time on their feet doing cases. (Of course, they are accompanied there by anaesthesiologists, nurses and surgery technicians.) Once the patients leave the ORs, though, the preponderance of their care is by nurses, whether in the PACU or on the floors. Ditto for their care before the surgeries, in the pre-op areas.
Name: 
Paul Levy
Email: 
plevy0808@gmail.com
And doctors' call duties stretching as long as 180 hours at a go where days just dovetail into one another and theatre nurses change shifts on mere 8- hour intervals? And yet the doctor has not a single minute of rest after all this stress! And as doctors suffer employment-derived depression, fatigue, sleeplessness, social isolation and absolute burnout culminating in suicides, may I ask you how many nurses committed suicide in the US in the past year...compared to 500 physician suicides per annum in the US alone! Must you lose a close physician relation to such horrible deaths before you moderate your outlook and views on these matters?
Name: 
Dr Tosin Akindele
Email: 
tosinmajewa@gmail.com
The lives of many doctors, especially trainees, are adversely affected cruelly inhumane conditions. I've known many people who suffer mentally and physically from this environment. That is a serious problem in itself, and the profession seems incapable of modifying the work rules that make it so. But that doesn't take away from the problem I raise. Both problems exist.
Name: 
Paul Levy
Email: 
plevy0808@gmail.com
I don't think this article was directed towards you or just your field. Nurses work more areas than just a hospital floor just as doctors work in more areas than an operating room. You and your field may be the exception. There is ALWAYS an exception to the rule. This was an overall generalization across all fields, locations and nations pointing out a different perspective. In my field and the nurses are the ones spending more time with patients. The doctors here even agree that the nurses spend more personal time with patients than the physicians.
Name: 
Jessica
Email: 
jessica.mccully@shawneemission.org
My concern is that this article could stir up hostility based on a provocative title but not based on evidence. When physicians actually lead healthcare systems (as the CEOs) quality outcomes are better and the nursing professionals and other staff are more satisfied. I'm afraid that (based on actual statistics and outcomes) it's when nonclinicians lead that harmful silos are erected and nonhealthcare-related distractions are more likely to harm the culture.
Name: 
Patty Fahy MD
Email: 
Pattyfahy@mac.com
I'd be very interested in seeing that evidence, Patty. I've seen no indication in my travels around the world that such a correlation exists. I've seen hospitals led by both MDs and non-MDs that do an excellent job on quality and safety; and likewise both types that have done awful jobs on that front. Ditto with regard to job satisfaction for nurses and other staff. The results don't seem to relate to the profession of the leader at all, but to the quality of leadership.
Name: 
Paul Levy
Email: 
plevy0808@gmail.com

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'When blame is lopsided, it can lead to tragedy'