How Punitive Is Nursing Culture and How Does that Impact Patient Safety
I’ve been thinking a lot lately about punitive cultures in healthcare. It seems that the mantra of both nursing and medicine is that “nurses eat their young,” and that “doctors eat their young.” Don’t know about pharmacy, PT, OT and others, but it seems that no one is eating lunch but they everyone is nonetheless stuffed because of this professional canabalism. Well, we know that hungry people are also irritable and unpleasant and we also know that feasting on one’s professional young is neither a recipe for professional satisfaction nor for high quality performance.
I am less familiar with the ways in which medicine eats its young, but I know for a fact that continued professional feasting on the younger generation is alive and well in nursing. One of the things that most impressed — or rather depressed — me when I first began writing about nursing was how punitive the culture was. I was surprised to see how nurses — particularly nursing leaders and academics — treated not only the younger members of the profession but anyone who had the temerity to critique an institutional or individual position or to disagree with institutional policies and procedures. As I began to write more and more about nursing and attend more and more nursing meetings, I almost felt that people began to treat me like a member of the profession and I soon became part of the daily meal.
I remember speaking at a nursing conference when President Clinton and his wife introduced their health plan. This particular state nursing association had announced that it was giving its unconditional support to the plan. I had been asked to give a lecture and when I respectfully — and very gently believe me — questioned the organization'”unconditional” support for the President’s plan (it is a very poor negotiating position, particularly for RNs, to unconditionally support any plan of almost any politician) I was shocked to find that the group’s President would literally not say hello to me as she passed me in the hotel hallway. In other words, an invited guest was shunned because she questioned the wisdom of a particular organizational position.
I learned the hard way that in nursing, as in the Amish community, shunning is all too common. I was once asked to write a review of a book written by a nurse historian for a major American newspaper. I didn’t much like the book and debated whether to be kinder to the author because she was a nurse than I would have been if the writer had been, say a doctor, or journalist. No, I thought, to do that would be a kind of reverse nursism — not taking someone seriously intellectually because she was a nurse. So I critiqued the book — strongly but by no means viciously. At another conference I attended, the Dean of the historian’s school of nursing, a woman who had been friendly to me in the past, quite literally, refused to acknowledge my presence. Wow, I thought, this is pretty amazing, something I had never experienced in any other occupational or academic discipline. I seemed into the convent, and discovered that people were summarily excommunicated if they disagreed with the dogma. At that conference, I talked with a friend of mine, another dean at another university, and suggested she talk to the dean who shunned me, asking if it was really worth it to her to “burn” the only journalist in the country who, at that time at least, routinely covered nursing. My friend talked to her and the shunning dean reluctantly acknowledged my existence.
I keep thinking of these incidents when I ponder the complicated relationship nurses have to patient safety and patient advocacy. On the one hand nurses are definitely a critical part of the patient safety net. On the other hand, nurses at all levels constantly describe the fact that their socialization into a punitive culture makes them fear speaking out. Many RNs in critical safety positions relate that they feel unsupported by their nursing hierarchy when it comes to challenging a physician or institutional policies that relate to patient safety. Nursing students report that they feel fearful and uncomfortable challenging their professors and that their clinical instructors often respond defensibly to being questioned. “Who are you, you young whipper snapper,”seems to be a common response.
At a recent patient safety conference, I attended a seminar on Just Culture given by a group of physicians and nurses at Montefiore Medical Center. The clinical team described their efforts to transform their hospital environment so that people would not be punished if they admitted or reported an honest mistake. The team had developed a tool to help judge if a mistake was an honest one or due to reckless behavior that did indeed warrant disciplinary action. The team presented two cases of mistakes made by RNs and asked those attending to discuss them with those seated at their tables. It was clear that the two examples were honest mistakes that anyone in a similar situation would have made. Clear at least, to me and another woman — an RN — sitting at our table. It was fascinating to watch the six other women — all patient safety officers in their institutions, and all nurses — discuss the cases. You could almost palpably feel their desire to get out the baseball bats and let the nurses who made the mistakes take their blows. There was no excuse that they would accept to let the nurses presented in the case studies off the hook. “How could they be so stupid?”one RN asked. “How could she not know the proper dose of that drug,” another chimed in. “Sure she just got out of nursing school, but still, that’s no excuse.” I marveled, as did the other RN at the table, at the angry, judgmental tone with which these people who were responsible for patient safety approached the issue of error. They simply could not overcome their animus at anyone who made a mistake.
This punitive culture needs to be addressed and soon. Nurses will never be able to play a leading role in patient safety if they do not support each other, do not help each other to admit to and learn from mistakes, and do not create a culture in which everyone nourishes the next generation as well as each other.
I attended a meeting a few years back where a CNO described a hospital safety program called “Good Catch.” It was about incentivizing staff to call out near misses – incidents that should be seen as the Holy Grail of patient safety because they teach such valuable lessons. The hospital actually gave prizes to the units that called out the most near misses. Far from punitive (and maybe a little extreme), they sure got the word out that honest information sharing is a good thing. It was a nice example of administrators with their heads in the right place when it came to scrutinizing mistakes.
programs like this are very good news indeed and need to be publicized
Great post, Suzanne. I have been on the receiving end of the “shunning” culture that is often allowed to permiate the nursing profession. We do have the tendency to group students and novice nurses into catagories while ignoring their individual qualities and contributions to the team. I have also noticed the reverse happening to the senior generation of nurses by the junior. It is particularly apparent in critical care and emergency environments. Younger nurses can have an over-confidence, or one might say cockiness about their level of clinical skills and knowledge while disregarding the wisdom and experience of their senior colleagues. Either way, when nurses “eat their young” or commit “elder abuse” it perpetuates a culture of patient care that is neither safe for the patient nor favorable for our profession.
You make such a good point. It’s not just a problem of eating the young, everybody seems to be very quick to attack or be disrespectful to one another. So really the take home message here seems to be that if we’re going to be more civil and respectful to patients people can’t continue to be uncivil — at every professional, educational, and age level — to each other either inter or intra-professionally. Love you comment.
This has been a subject close to me for years. This, lateral or horizontal violence, and shunning, is the seed bed of any form of oppression. Whether reading about the Holocaust, the Gulag State, Apartheid, or nursing homes the principles are the same. When (job) security is found in obedience to, or compliance with an arbitrary, ever changing, hierarchical social order rather than individual excellence we will find oppression and all its ugly manifestations, of active or passive violence. It boils down to “you can’t serve two masters.” In the Report on Truth and Reconciliation this is most concisely described; a nurse’s responsibility is to her patient, in the case of government employment, if it is in the government’s interest to return a patient to stable health in order to inflict further torture, fear of losing her job will make the nurse compliant to the government rather than an advocate for her patient. The same will occur with her co-workers.
As the focus of health care has become more and more on regulatory compliance, as it is evidenced in the medical record, it has been pulled away from the bedside. Actual care takes a back seat to following the rules. “If it wasn’t documented it wasn’t done” has been inverted to, “If it was documented it was done,” even if it wasn’t. If I went to the in service and signed the compliance form I’m being compliant.
In my state the surveyors make new rules before each round of surveys and cite facilities for not following these new rules. The new rules are always a standardized means of achieving the ends identified in the regulation. The regulations are about preventing infections, falls or other injuries, they do not dictate the means. But the surveyors have decided that they are the font of all means. Facilities must follow the means identified by the surveyors or suffer the consequences, even when these means make no clinical, scientific, or logical sense, e.g. wearing gloves while providing feeding assistance, is based on a lack of understanding of infection control. Staff wear clean gloves to protect ourselves. When gloved, our hands are always contaminated. Hand washing protects residents, not gloves, with the exception of sterile gloves. DONs and administrators know that questioning a surveyor only results in punitive action and so they direct their staff to comply. They become so anxious about cites that they doubt their own knowledge and go along. This abuse trickles downward onto the nurses, aides, auxiliary staff, and patients or residents.
When I was a new nurse I was on the receiving end of the “shunning” over what I now see as an honest mistake over a drug dosage that had to do with a physician’s handwriting. The nursing supervisor had to go to the pharmacy to get the drug, so she saw the order and did not question it or me. I gave the drug in the amount that I read the order as calling for……and boy did the sky fall on me! Fortunately the patient was not harmed, but I felt awful……and also betrayed. I was removed from that unit and placed on probation at that hospital. It turned out not to be a bad thing in the end, but I have never forgotten it.