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1 WORKPLACE BLAME AND RELATED CONCEPTS: AN ANALYSIS OF THREE CASE STUDIES. Running Head: Blame-related distress Authors: Judy E. Davidson, DNP, RN, FCCM, Donna L. Agan, EdD, Shannon Chakedis RN, MSN, OCN, Yoanna Skrobik MD FRCP(c) MSc. Author Affiliations: EBP/Research Liaison (Dr. Davidson), University of California San Diego Health System; Director, Operations Integration (Dr. Agan), Scripps Mercy Hospital; Clinical nurse (Ms. Chakedis), Moore’s Cancer Center, University of California San Diego Health Systems; McGill University Department of Medicine; Critical Care Division, Kingston General Hospital, Queen’s University (Dr. Skrobik). CorrespondingAuthor: Judy E. Davidson DNP RN FCCM, EBP/Research Nurse Liaison, UCSD Health System, 200W Arbor Drive, San Diego CA 92103 Mail Code 8929, [email protected] Conflicts: None to declare Funding: None Presentations: Oncology Nursing Society January 2014 Los Angeles, Sigma Theta Tau Odyssey Research Conference November 2014 Ontario Ca, National Teaching Institute May 2015 San Diego CA Keywords: Blame, Staff Retention, Moral Distress, Research, Tool Development, Workplace health

Abbreviations list (In order of appearance): B-RD= Blame-related distress ICU= Intensive care unit PTSD= Post-traumatic stress disorder

Abstract Blame has been thought to affect quality by decreasing error reporting. Very little is known about the incidence, characteristics or consequences of the distress caused by being blamed. Blame-related distress (B-RD) may be related to moral distress, but may also be a factor in


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2 burnout, compassion fatigue, lateral violence and second victim syndrome. The purpose of this manuscript is to explore these related concepts through a literature review applied to three index critical care clinician cases.

Workplace blame is believed to worsen care delivery and patient safety, since clinician behavior, such fear of blame1 or perceived dishonor2, can lead to decreased error reporting3. However, the incidence, characteristics or consequences of the distress caused by blame have not been described in the literature to date. It is possible that blame-related distress (B-RD) may be triggered by, and contribute to, other environmental or individual patient safety determinants such as moral distress, burnout, compassion fatigue, lateral violence and second victim syndrome. The purpose of this manuscript is to explore these related concepts through a literature review applied to case studies. The index case analyses served as the impetus to explore the concept of Blame-Related Distress in preparation for a research program (reported separately). Composite Cases According to a study by the Office of the Inspector General, U.S. Department of Health and Human Services, approximately one in seven hospitalized patients experience a serious adverse event4. Another one in seven are affected by a less serious adverse event. While this statistic is shocking, the impact blame associated with the healthcare provider in this context appears to have been overlooked. The following anonymized, real-scenario based cases aim to gain a better understanding of how blame impacts clinicians in the workplace. Case 1: Consider a physician who has practiced for many years without significant negative events. One day a critically ill patient dies following an elective procedure carried out by the


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3 physician. Intensive care unit (ICU) staff nurses associate the procedure with the patient’s death; however, no debriefing occurs. He looks back and feels badly for the patient but cannot find anything that he had done differently in previous cases that could have caused the outcome. The nursing staff’s distress escalates, and hospital management blames the physician for the death without due process. He sees this as unjustified because he did nothing intentionally to cause the death; an autopsy confirms an unexpected complication that explains the patient’s demise. He feels shunned by those once considered colleagues, and spends years addressing complaints sent to various governing and academic bodies by the hospital’s administration. The recruit hired to replace him publicly describes having to replace him because of a death he caused. He takes on shift work at a geographical location remote from his home and children. In this less stressful environment, he is able to de-escalate questioning his abilities and fear of shaming by others. He slowly rebuilds his confidence. Years later he can remember the blame as if it had occurred moments ago, every detail emblazoned in his memory. The distress subsides but never truly goes away.

Case 2: As is customary in hospitals where physicians are not staff members, a nurse leader writes policies at their request. One policy allows a medication, known to cause respiratory depression, to be administered to patients who are not intubated. The nurse’s literature review reveals evidence that others have successfully implemented a similar policy for the off-label use of this medication. He contacts the organizations that have published this evidence and uses their policy as a basis for the practice change. He implements the practice change with the precautions that the receiving patient must have a dedicated nurse, and that audible alarms be monitored at all times while the patient is in the emergency department or intensive care unit. He was proud of


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4 the evidence-based analysis and of the measures put into place to ensure patient safety. A patient receiving this medication receives a free-flow of the medication due to a pump malfunction and has a respiratory arrest. The supervisor subsequently blames the nurse who wrote the policy for the negative patient outcome. The nurse loses faith in the organization because the policy had been reviewed at many committee meetings and approved by physicians and the organizational leadership. He questions himself and his leadership abilities and ruminates about the experience. He is despondent, suffers sleeplessness and recurrent averse memories of the moment when his supervisor blamed him for the outcome. He leaves the organization, but even years later, avoids policy-writing responsibilities. He has difficulty driving past the hospital where this event occurred. Others misinterpret his aversion to situations at work that could have a similar outcome as apathy. It takes years and a change in position, for his confidence and pride in his work to return in his chosen profession. Case 3: A new nurse experiences her first patient with a cardiac arrest. She is the nurse administering medication during the resuscitation event. The patient expires. She is called into the supervisor’s office the next day and told that she administered an undiluted vasopressor (which should have been admixed into a piggyback solution and administered slowly on a pump) and that this was the likely cause of the patient’s death. She cannot live with the fact that she could have ‘killed’ another human. She goes into the medication room and self-administers a lethal injection of a toxic substance. Her peers find her dead. Moral distress Of all of the concepts related to blame, most is known about moral distress. Ethical beliefs emerge from professional codes of ethics, political views, family values, religion, and


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5 work and life experience5. Because of the differences between each individual’s personal history, any given situation may have more than one right course of action. Moral distress occurs when the individual’s perception of personal and professional values or ethical obligations are violated, resulting in psychological distress6. If those involved in provision of care or decision-making feel that their personal values, principles, or beliefs have been compromised, moral distress may result12. Moral distress may lead to feelings of sadness, powerlessness, avoidance behaviors, anger, and frustration that may adversely affect patient care6,11. This distress may continue long after the event has occurred 7-10. The lingering distress following the initial moral distress has been termed moral residue11,12. Organizational culture also influences moral distress. Organizational processes, structures, and policies may lead to moral distress when the right action is clear to the individual, who is prevented from taking this action due to these organizational issues13, as was the case in the debriefing requested in Case 1. Societal or political issues within or beyond the organization may also frame a culture that prevents people from doing what they feel is right and result in moral distress14. An example might be the need to find a clinician who will take responsibility for an event when fear of litigation is present. Burnout is predominately associated with the organizational root causes of moral distress10. There is an inverse relationship between moral distress and physician/nurse collaboration, as well as with professional autonomy15. Nurses are required by the American Nurses’ Association Code of Ethics to take action as a moral agent16-18. This document also declares that nurses may remove themselves from situations where negotiations do not result in the preservation of integrity, thus encouraging nurses to leave organizations where they are exposed to repeated breaches in ethical standards17-19. The public policy statement from the American


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6 Association of Critical Care Nurses mandates that hospitals be obliged to assess, identify, and address moral distress. Nurses are instructed to be knowledgeable about moral distress and to use available resources to act upon it 20. It is not clear how many critical care nurses integrate this knowledge into their practice. The roles played by education, or inclusiveness-fostering leadership that leads to a sense of psychological safety21 in this domain remain uncertain. Although nurses spend more time with patients than any other clinicians, they are the least comfortable disclosing their distress22. It is therefore important to seek these nurses out and proactively offer support in a non-threatening manner, encouraging open discussion and the right to be heard22. The risk for moral distress is higher among those who care for the dying patient 7 , underscoring the importance of debriefings after unanticipated or complex deaths11,22,23. Ethics or palliative care consults may assist in debriefings; however, staff may not naturally engage in these activities and may need training to participate in these difficult discussions to find meaning or reassurance22. Health care providers working in adult ICU settings suffer from higher levels of moral distress than non-ICU clinicians (p < .001)24. In one study, all members of an ICU team reported experiencing moral distress25. ICU physicians manifest significant work-related distress26, are reported to experience burnout rates of 50%27 and a quarter to a third suffer depressive symptoms28. Despite this high-risk profile, physicians become detached as morally distressing cases unfold and are less likely to engage in constructive behaviours (venting, mentoring networks, and building team cohesion) than are nurses or ancillary staff25. To our knowledge no study has specifically addressed critical care physician moral distress. How employees learn of assistance programs to cope with, or manage, distress29 is unclear, and appears variable because


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7 of differences in organizational and resource infrastructures30. Most publications have focused on critical or palliative nursing practice’s association with moral distress31. In summary, moral distress arises when ethical beliefs or values have been compromised, resulting in psychological or physical distress. Action can change and improve local culture. Some models such as ethics education and empowerment for critical care nurses32 decrease the incidence of moral distress and improved nursing staff retention. Whether these measures are effective, particularly those in high-risk areas such as critical care24,30,is unclear. Models of care delivery that enhance iterative interprofessional communication using shared decision-making and debriefing after negative incidents, such as the educational model cited above, appear to minimize the prevalence of moral distress and moral residue. In the presented case studies, the distress experienced by the clinicians stemmed from blame. In all three index cases the person took action and was then accused of contributing to the negative outcome. Institutional priorities- particularly when error is perceived or suspectedmay clash with the values required to maintain a healthy and collaborative workplace culture and ongoing patient safety3. Blame, and its concomitant shaming, may lead to moral distress, avoidance and sleeplessness. All recipients of blame went on, as is described in moral distress trajectories, to leave the organization (albeit by suicide in the third case). Burnout and Compassion Fatigue Burnout results from prolonged work-related emotional and interpersonal stressors and results in exhaustion, depersonalization, and a sense of inefficacy33. Repeated exposure to distressful situations heightens the probability of burnout or compassion fatigue and it corollary intent to leave the position, stress disorders, exhaustion, cynicism, a sense of inefficacy34, staff turnover and negative patient care8,34. Both burnout and compassion fatigue are forms of work-


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8 related stress34 most commonly seen in occupations involving the care of others35. When comparing the index cases, emotion, inefficacy, exhaustion and withdrawal appear to have been triggered by blame. The individuals in the case studies each worked in the high-risk critical care environment, where staff shortages, workplace dissatisfaction rates, and clinician suffering could potentially be worsened by local or institutional blame. Compassion fatigue was first describe in critical care clinicians36, and can occur suddenly and unexpectedly from exposure to a traumatic event (e.g., caring for a suffering patient)37. Compassion fatigue is treatable, preventable, and typically faster to resolve than burnout38. Signs of compassion fatigue include sadness, grief, nightmares, avoidance, addiction, somatic complaints, increased psychological arousal, changes in beliefs and expectations, detachment, and decreased intimacy34. Whether blame-related distress, with avoidance, nightmares and somatic symptoms, and compassion fatigue related to the trauma of blame, are a continuum is not clear. However, since blame is associated with shaming and isolation, two determinants of clinician wellness (and perhaps performance) are taken away: meaningful recognition and empathy31. Hospital staff and physicians may have unrealistic expectations for themselves and this can lead to burnout and eventual compassion fatigue. Expectations that following standard operating procedures will lead to a positive outcome for the patient can be disappointing 34. Encounters with the negative patient outcomes inherent to the critical care environment may thus lead to burnout or compassion fatigue. The variability in its preponderance suggest that coping strategies such as changes in the nature of work involvement, debriefing, taking action to change the situation, life outside of work, spiritual or religious introspection, and attitude modification,39 may play a determining role in its frequency. Nurses working in areas such as ICUs40 and


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9 oncology are most vulnerable to the compassion fatigue and burnout 39 related to the empathy and engagement instrumental to therapeutic relationships 34. Figley suggested that individuals with high levels of empathy to patient experience (e.g. pain, suffering, trauma) are more likely to experience compassion fatigue41. On an organizational level, integrating data describing the slightly higher burnout risk in ICU nurses, or the propensity for compassion fatigue in oncology nurses, may allow for pre-emptive measures and preventative- and perhaps healing- professional social awareness38. The professional insult of knowing that a patient was harmed under their care could have triggered burnout or compassion fatigue following the events described in all three presented case studies. The questioning of one’s abilities described with both the physician and the nurse leader can result in classic burnout symptoms. These individuals (cases 1 and 2) did benefit from changing their work environments, as described in burnout and compassion fatigue recovery trajectories, albeit at significant personal and financial cost. All three individuals worked in the ICU, a high-risk environment24. Lateral Violence and Incivility Lateral violence constitutes a constellation of acts of incivility by colleagues in the workplace. These acts can take the form of infighting, unprofessional behavior, sabotage, rudeness, ignoring those seeking help, bullying, yelling, throwing objects, non-verbal disapproval such as eyerolling or walking away from an unfinished conversation. Incivility and lateral violence result in burnout, compromise teamwork, erode morale in the workplace, and increase staff turnover 42-44, and appear related to institutional ethical conduct factors that contribute to moral distress45. In contrast, safe and just working environments are associated with improved patient outcomes46 better communication47 and learning48; psychological safety predicts engagement in quality


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10 improvement 21. When adverse events are unintended or driven by missing or broken organizational processes, being blamed for the outcome can be an act of lateral violence. Institutional leadership and a culture of respectful communication can break the incivility and the silence (‘that kills’49) surrounding difficult events, heighten social influence and awareness, and improve outcomes50. Pre-emptive individual and team-communication skills taught in ‘Crucial Conversations’ type initiatives50 counter the emotional reactivity inherent to blaming in highly charged situations- such as those that disrupt patient care goal cohesion51 in critical care. In all three cases the recipients of blame had not willfully caused harm, and external bodies did not corroborate the administration of blame. The blame, therefore, might have constituted lateral violence. Second Victim Second victims have been defined as clinicians who are traumatized by an unanticipated adverse event, and thus themselves become victims of the event52. Frequently, these clinicians feel personally responsible for the patient outcome, and self-attribute blame. Many feel as though they have failed the patient, second-guessing their clinical skills and knowledge base, similar to the feelings associated with moral distress. The physical and psychological consequences of medical errors described in secondary victim studies include depression, anxiety, post-traumatic stress disorder (PTSD), guilt, inadequacy, inability to perform on the job, and thoughts of leaving the profession52-54. Many received support from colleagues, peers, or supervisory personnel52,55. A hallmark study on second victim syndrome outlined the six stages of recovery after an adverse patient event: (1) chaos and accident response, (2) intrusive reflections, (3) restoring personal integrity, (4) enduring the inquisition, (5) obtaining emotional first aid, and (6) moving on55,56. Blame may result in similar stages; this has never been


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11 explicitly described. Effective second victim response teams or support programs have been developed to diminish the negative psychological impact on the provider52, and perhaps anticipate and avert ‘blaming the victim’57. We believe blame-related distress can cause secondary victim syndrome. Not all blame, of course, is associated with a true error. Healthcare institutions aim and are mandated to protect the vulnerable public, in this case the patients. Wrongfully blamed clinicians are very likely to suffer the additional burden of natural injustice in addition to the stigma of a ‘shame and blame’ process. Current literature does not differentiate between blamerelated distress, where true errors occurred, and blame-related distress in the context of unjustified blame. In all the case studies presented here all three recipients of blame were psychologically compromised as a result of this blame. As in second victim syndrome, the blame resulted in intrusive thoughts. Blame The literature on blame is largely published at an ‘opinion’ level of evidence. It is generally understood that blaming employees or physicians for negative patient outcomes is illadvised and that all efforts should be made to investigate whether negative outcomes were caused by missing or broken processes instead of human error3,58. Many organizations have implemented reporting systems intended to support teams29,52 and learning from mistakes rather than being punitive59. Blame-free work environments are supported; nonetheless, blame still exists59. Even in cases where human error occurs, organizations are encouraged to discipline judiciously and limit punishment only when conscious violation of a policy or a standard can be determined, striking a balance between blame and accountability 3,58,60. Even though this guiding principle has been widely promoted, there has been little research on the subject.


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12 Encouraging a blame-free culture is intended to promote safety and a positive work environment in which it is safe to report errors46. A multinational study of patient safety officers from 16 countries found that a culture including blame was reported as the one of the top barriers to reporting patient safety events61. One Swedish survey of patient safety officers found that the top rated action (83% of 167 responses) to promote patient safety was perceived as ‘Improving organizational culture to promote reporting and avoid blame’62. The Gap To date, the personal impact of being blamed for a negative patient outcome has been studied only in the context of second victim research (i.e., medical errors) and not specifically focused on blame. Further, moral distress has been described as distress that occurs when healthcare providers know the right thing to do but are prevented from doing it. Through these case studies we know that symptoms and consequences of moral distress may occur when a healthcare worker believes they have provided appropriate care according to practice standards and in keeping with their personal and professional values, morals, and ethical beliefs, but are blamed by peers, colleagues, physicians, family members, or administrators when patients experience adverse outcomes. The distress caused by blame could result in a loss of moral integrity or the feeling that core values and duties have been violated. It is possible that actions known to minimize or reduce moral distress given the current definition could extend not only to situations where distress occurs from in-action, but also when blame occurs following action and results in a negative patient outcome. There is no literature regarding these hypotheses at this time. Critical care environments are particularly challenged when it comes to maintaining a culture of compassion and kindness50.


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13 Conclusions Healthcare leaders are often in the position of reviewing perceived medical errors with negative patient outcomes with hospital staff. In most cases negative outcomes are not caused by willful acts of harm, but instead by human error, slip or lapse, organizational process failures, or insufficient resources. Looking back on these index cases, it is important to frame case reviews in the workplace in a way that will not result in perceived blame. Leaders can teach staff how to investigate and debrief following a negative patient outcome in a way that does not incur blame, cultivating an environment of performance improvement instead of punishment to prevent blame-related distress. The distress caused by blame should foster proactive reaching out to provide support to those who may be affected by a negative patient outcome. The definitive distinctions between moral distress, lateral violence, burnout, compassion fatigue, second victim syndrome, and blame-related distress are unclear. Further research is needed to explore the incidence, antecedents and consequences of blame.


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