A new perspective on blame culture : an experimental study

OBJECTIVES: Recently, a range of different institutions worldwide has identified the 'culture of blame' and the fear of being punished as the principal reasons for the lack of medical error reporting and, consequently, of their reiteration and of the poor quality of patient care. Despite much theoretical debate, there currently exist no experimental studies that directly investigate the presence and pervasiveness of the blame and punishment culture in health care contexts. In order to document empirical evidence for this culture in medicine and nursing, we conducted an experimental study asking physicians and nurses to express their fear of blame or punishment in the context of having made an error that would cause: (i) no; (ii) mild; (iii) severe consequences; or (iv) the death of the patient. METHODS: Two hundred and forty-nine health care providers (38 physicians, 11 medical students, 127 nurses and 73 nursing students) were included in the study. Two main data emerged: first, in general, the fear of being blamed is higher than the fear of being punished. Second, while the fear of being blamed is equally distributed among all participants, the fear of being punished varies according to the experience of subjects (it is higher in nursing students than in seniors nurses) and to their professional role (student and senior nurses are more susceptible to it than medical students and senior physicians). CONCLUSION: Given the relevance of these factors in medical error reporting and the evidence that they are so deep-seated not only in senior professionals, but also in students, we argue that an educational approach, together with an organization-based intervention, is desirable to shape cultural attitudes of health care providers in the direction of a 'safety culture'.