The blame culture in nursing: how to make a change in your workplace
A punitive response to errors affects patient safety and staff morale. There is another way
A punitive response to errors is bad for patient safety and staff morale. There is another way
- Evidence from other industries shows using phrases such as ‘what’s happened?’ rather than ‘who’s to blame?’ is more productive
- New guidance from NHS Resolution explains practical steps staff and organisations can take to embed a ‘just and learning culture’
- Taking a learning approach when staff make mistakes is better for patients too, as care ultimately improves
When something goes wrong, a simple shift in language can make all the difference.
Instead of asking ‘who’s to blame?’ or ‘what did you do?’, try asking ‘what happened?’ and ‘what were the circumstances?’. This can be the key to improving patient care as well as the lives of healthcare staff.
That’s the message in new guidance from NHS Resolution, the body that manages claims for compensation against the NHS in England. Published in July, Being Fair: supporting a just and learning culture for staff and patients following incidents in the NHS makes a powerful case for shifting away from the blame culture that still too often pervades health services.
Learning from mistakes and supporting those who make them
Organisations that have a culture of learning from mistakes – and supporting those who make them – are already seeing the benefits both in improving patient safety, and in staff productivity as well as happiness.
It sounds compelling, but nurses working in the stretched health service might find it hard to swallow. There have been successive attempts to induce the NHS to shift from a blame culture to one of learning, yet there are still organisations where staff feel unable to confess to their own errors or to flag up areas of poor practice. Why should it should be any different now?
The difference, say two of the authors of Being Fair, is that the idea of a just and learning culture is gaining momentum, winning support from national organisations and regulators.
‘Yes, the blame culture is still there, says Suzette Woodward, senior adviser to NHS Resolution and one of the report’s authors. ‘And yes we have been talking about it for 20 years, but what is different, or feels different now, is that there’s a much greater focus from a greater group of people. It used to be isolated people saying “we’ve got a blame culture, what should we do about it?”.’
‘This isn’t a charter for staff, it’s a charter for everybody. It’s about learning from what’s gone wrong rather than being blamed’
Denise Chaffer, co-author of Being Fair, and NHS Resolution director of safety and learning
Dr Woodward says organisations including NHS Improvement and the Care Quality Commission are now putting more emphasis on the importance of a just and learning culture. ‘It feels like all of this coming together is such an amazing opportunity to do something different this time round.’
Co-author Denise Chaffer, director of safety and learning at NHS Resolution, shares this view. ‘We have support from a lot of national organisations and regulators that this is the right thing to do, and I think that’s a very powerful message,’ she says.
‘This guidance has pulled together ideas about what good looks like, and it’s not about just staff, or just patients, it’s about both.
'What’s important to know is that staff being valued is good for patients. We need patients to be supported and looked after by staff who feel valued. This isn’t a charter for staff, it’s a charter for everybody. It’s about learning from what’s gone wrong rather than being blamed.’
What can organisations do to make the shift, and what does it mean for nurses?
The guidance includes several case studies showing what a just and learning culture looks like in practice. One showcases a triage system implemented at Barts Health NHS Trust in London to determine whether disciplinary action is necessary or appropriate.
Another outlines the approach adopted by Mersey Care NHS Foundation Trust. This is based on the work of Sidney Dekker, a professor known for his work on human factors and safety, who says that three questions should be asked when something goes wrong: who is hurt?, what do they need?, and whose obligation is it to meet this need? (see box below).
The guidance also includes a suggested ‘Just and Learning Culture Charter’ to help organisations develop their own policies, while a further case study outlines NHS Improvement’s ‘just culture guide’, which also acts as an aide memoir for people determining the appropriate response when something goes wrong.
‘When an excellent nurse makes a mistake, they are a victim too’
When Amanda Cooney got a phone call from one of the district nurses in her team confessing to a potentially catastrophic medication error, she didn’t hesitate in her response.
The nurse, who was visiting a care home to give insulin to two patients, had given the wrong insulin to one.
‘This was a nurse with an exemplary record, an excellent, compassionate nurse, and she made a mistake,’ says Ms Cooney, district nurse team leader with Mersey Care NHS Foundation Trust. ‘No one was with her and the patient had dementia, so she actually didn’t have to say anything – nobody would have known – but she rang me straightaway. She was very distressed when she spoke to me – it was her worst nightmare. I just said to her to go and sit in the office and I’d be there in five minutes.’
Patient safety first, followed by staff support
The priority was obviously making sure the patient was safe and all the correct steps were taken, including informing the care home staff, the patient’s GP, the diabetes team, and the patient’s daughter, and planning additional visits to the patient that day.
But the elderly woman wasn’t the only person who needed care. ‘The patient was the first victim, if you like, but the nurse was the second victim. She was so upset – she hadn’t come to work that day meaning to harm that patient. She is an absolutely fabulous nurse. My next step was talking it through with her and seeing what she needed from me.’
Ms Cooney is one of around 50 ‘just and learning ambassadors’ at Mersey Care, where she leads a team of around 20 district nurses in Sefton, an area just north of Liverpool City. The team was formerly part of Liverpool Community Health NHS Trust, which was taken over by Mersey Care last year following serious concerns about patient care, safety and culture.
She firmly believes that rather than blaming people for making mistakes, it is essential to learn from them.
‘I had come from a team where there was low morale, a really poor culture. Staff were feeling blamed, and not being honest when things went wrong’
Amanda Cooney, district nurse team leader
‘When our team came over to Mersey Care I had seen the just and learning ambassador role and it was something I was really passionate about. It fitted with my values. I’d been thinking for a long time that if we worked in this way that the outcomes would be better for patients.
‘I had come from a team where there was low morale, a really poor culture, a lot of patient harm. Staff were feeling blamed, and not being honest when things went wrong.
‘They were frightened because in the organisation that we’d come from, there was a lot of blame: you were "sent to Coventry" for speaking up, so if you reported patient harm, you weren’t spoken to and other team members turned against you. I have experience of that myself.
‘So it was about promoting a culture where people felt psychological safety to speak up.’
Responding to the medication error
This was demonstrated by the aftermath of the nurse's insulin error. When Ms Cooney talked it over with the district nurse once they left the care home, the nurse ‘identified the learning herself’, she says. ‘She saw what we needed to do so that we didn’t make that mistake again.’
The district nursing team also discussed the issue and came up with ideas to reduce risk in the future. ‘It came from them,’ Ms Cooney says.
Practical changes included keeping the insulin in a locked cupboard and adding a picture of each patient to their nursing file.
Ms Cooney has every praise for the trust’s senior management team, particularly Mersey Care director of workforce Amanda Oates, who has blogged about the journey to a just and learning culture.
‘Our chief executive is 120% behind this as well,’ says Ms Cooney. ‘It’s uplifting and inspirational and it’s great to be able to be really proud of where you work.’
‘Meet hurt with healing’
For Ms Cooney, as a nurse who freely admits to having made mistakes, a compassionate approach is vital whether you’re working with colleagues or patients. And that includes when things go wrong.
‘Don’t meet hurt with more hurt – meet it with healing and learning. We’re on a continuous journey and we’ve still got a lot of work to do. But I think we should absolutely feel proud of the progress we’ve made so far.’
Understanding what promotes patient safety
For Dr Woodward, it’s about changing the way we look at patient safety, and she believes that nurses are well placed to do that.
She worked as a clinical nurse for 15 years before moving into the field of patient safety and has had many high profile roles, including national clinical director for the Sign up to Safety Campaign, a national initiative to reduce incidents of avoidable harm in the NHS, and senior adviser for the Department of Health and Social Care in England. But she believes her time in clinical nursing really helped to sharpen her patient safety focus.
‘You can say there’s a business case for being kind’
Suzette Woodward, co-author of Being Fair, and senior adviser to NHS Resolution
‘When you talk about patient safety, most people think it’s about failure and when things go wrong. Every single person that works in healthcare makes mistakes. It’s inevitable, because they are human beings. And as a nurse you can understand what that truly feels like because you will have committed some yourself.
‘But also you understand the circumstances and situations that they will have faced. You understand what it’s like to look after complex patients in complex circumstances. You understand because you’ve been there.’
Reframing patient safety in a positive way is a good start, she adds. ‘This isn’t looking at things from the perspective of failure. This is looking at what we do really well and then building on that with cultures of kindness and compassion.’
There is a growing body of evidence showing the benefits of this approach, she adds. ‘Now some statistics are coming out that say, for example, that staff are 43% more productive if you show gratitude and recognition. That’s an amazing statistic that means you can therefore say there’s a business case for being kind.’
Creating a just and learning culture: 6 practical things you can do now
Advice from Suzette Woodward, co-author of the Being Fair guidance and senior adviser to NHS Resolution:
- Don’t ask ‘what did you do?’ when something doesn’t go as planned, instead ask ‘what happened and what were the circumstances that led to the actions and decisions made?’. This seeks to learn rather than blame and to understand without judging
- Assign someone to support those involved for as long as they need that support, to help with the emotional harm and psychological impact
- When something doesn’t go as planned it is almost always the case that it has gone as planned many times before, so instead of focusing purely on when it went wrong, seek to work out why it normally works okay and therefore the difference on this occasion. This helps to provide a positive culture of safety which leads to learning
- Measure progress Organisations with a culture that is fair and focused on learning have lower disciplinary rates. You can therefore measure progress towards a just culture by charting these rates for all to see
- Really listen and create the opportunity for people to come together not only professionally, for example at briefings, debriefings and huddles, but also socially, so that they can develop positive relationships. This has been proven to help people speak out without fear of repercussions
- Say thank you to the people you work with. It is a powerful way to show you value their contribution, and builds trust and confidence
Disproportionate disciplinary action against BME staff
Of course, if everything were perfect in the health service, then there would be no need for the guidance. The document itself paints a mixed picture, and includes several challenges.
These include ensuring that organisations embed the principles of equity and fairness in their policies, practices and culture – the report highlights, for example, the disproportionate disciplinary action experienced by black, Asian and minority ethnic (BAME) staff – and tackling bullying and harassment.
‘It’s so simple, but it’s a shift in emphasis from “Who did this, who’s responsible?” to “Who has been hurt and how are we going to prevent it happening to someone else”’
‘We see some excellent practice, and areas where staff feel very supported and there’s a more open and valuing way of working,’ says Dr Chaffer. ‘The problem is that there’s variation. But it’s not up for debate; we have to do it. To make it safer, we have to have a culture where we learn.
‘There’s lots of evidence from other industries that the most important thing when something goes wrong is using simple phrases like “what’s happened?” and not “who’s to blame?”. It’s so simple, but it’s a shift in emphasis from “Who did this, who’s responsible and tell me the timeline?” to "Who has been hurt, how are we going to understand what’s happened and how are we going to prevent it happening to someone else".’
Being open about mistakes
So how can nurses be persuaded that it's okay - even desirable - to be open? NMC director of fitness to practise Matthew McClelland has no doubt that nurses should feel this way – and accepts that the regulator has a role in spreading and encouraging a just and learning culture.
‘The first thing is to be really clear that we care about a just culture – that it’s something that we value,’ he says, pointing to last year’s announcement of the NMC’s new person-centred fitness to practise approach, and the current consultation on its strategy (closes on 16 October). A just and learning culture is embedded in the NMC’s work, he adds, from ensuring it is reflected in educational standards to working with employers.
The shift from a blame culture also has immediate relevance for fitness to practise processes – for example, regulators will give weight to the context in which an incident takes place, and also an individual’s recognition of the need to take remediation action (such as extra training or mentoring) if required.
‘We want to reassure nurses that they should be open about mistakes,' Mr McClelland says. 'This isn’t about punishing people for the past; it’s about ensuring someone is safe for the future.’
‘Support nurses through the process’
The RCN's head of nursing (quality & regulation), Christine Callender, agrees that when things do go wrong it is important that nurses are able to speak openly about the errors so that they can learn from them and act to prevent recurrence.
‘No nurse goes to work with the deliberate intention to cause harm, so when something goes wrong it can be devastating,’ she adds.
‘It is important that nurses are supported through the process of what went wrong and a more systems-based approach is established to learn from and continuously improve patient safety and prevent an ongoing culture of blame.’
Jennifer Trueland is a health journalist