21. Working in a blame culture? (matter for discussion)

Essex Branch

That this meeting of RCN Congress discusses the difficulties that nursing staff encounter from the increasing blame culture in our society.

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Progress report

Action on this item is combined with item 8 - Too scared to care.

Committee decision: Covered by existing work
Council member/other member/stakerholder involvement: Susan Fern,
Anne Wells, Maura Buchanan
Staff contact: steve.jamieson@rcn.org.uk , howard.catton@rcn.org.uk

The RCN has carried out a significant amount of work around the issue of litigation and indemnity schemes since the debate.

In England, the College was represented on, and contributed to, the Department of Health’s independent review of the requirement to have insurance or indemnity as a condition of registration as a health care professional. The review made its report in June 2010. Particular emphasis was put on improving the education of health care professionals around personal accountability and indemnity.

The RCN lodged a request for a judicial review of the Independent Safeguarding Authority, in which the College challenged the nature and scope of the scheme. The RCN is also looking at the implications regarding indemnity of the recent White Paper on the NHS, as well as Lord Jackson's review of legal costs in clinical negligence claims.

The RCN is also reviewing its response to the proposal to introduce a statutory duty of candour on health care organisations/professionals when errors arise in health care delivery.

The RCN in Scotland is involved in the government’s review of no-fault compensation schemes for clinical negligence claims. In Wales, the RCN is evaluating the introduction of the NHS redress measure for handling complaints/claims.

Ongoing work includes regular user group meetings with the NMC on improving processes for handling allegations of professional misconduct/unfitness to practice, which are growing in numbers each year. The RCN’s own indemnity scheme is to be reviewed in 2011, including a tender in the autumn for clinical negligence solicitors to defend members.

The RCN is holding a series of workshops, which started in autumn 2010, on the legal aspects of nursing care, including accountability, standards of care and litigation, as well as contributing to workshops, seminars and conferences across UK throughout the year.  

Debate report

Samantha Neville of the Essex Branch opened the debate with the suggestion that nurses are fearful to make decisions because of the repercussions they may face. She pointed out that nurses are anecdotally blamed for incidents outside of their responsibility and the reluctance to admit to mistakes robs them of the opportunity to learn from them.

Jeremy Fowler of the Tees Valley Branch spoke in support of the resolution saying, “It is essential to have a culture of openness to encourage a culture of safety.” He believed that only a non-judgemental approach could foster the environment for safe patient care.

Citing an example of good practice in his own trust, John Hill of the Scunthorpe Branch said a trial of a no-blame culture led to non-judgemental investigations of drug errors that increased learning and significantly decreased disciplinaries.

Nigel Pike implored delegates to use their safety representatives if they were frightened by anything. “Use your safety reps, they have the knowledge and expertise to take your concerns forward,” he said.

Background

There are a range of factors which can inhibit or enable a no blame culture in health care delivery settings, and there is a need for a joined-up approach across all players - staff, management, and wider agencies including the health care system regulator.

Regulators in the four UK countries are all charged with ensuring safe and high quality care in the NHS and play a role in checking that service providers adhere to legislation, which includes incident reporting and quality improvement. There may also be a role for the regulators to check that providers have appropriate reporting structures in place to allow no blame reporting and learning from incidents. In England the Care Quality Commission, along with others, can also monitor foundation trusts and plays a key role in deciding whether or not to remove the management of failing organisations - thus playing a wider part in the blame culture environment.

Recent public concern at hospital or service-wide failures in patient care has created intense scrutiny of the steps regulators and employers take to ensure concerns are promptly reported and fairly dealt with. Such public scrutiny has provided a good opportunity to remind employers and employees of their moral and legal duties in respect of reporting concerns. However, the intense media spotlight and public calls for justice and reparation may discourage staff from reporting concerns, particularly where they may have a stake in the service concerned.

The case of registered nurse Margaret Haywood, who helped in the undercover filming of a Panorama documentary to expose poor standards of care and was subsequently struck off by the NMC in 2008 for breaching patient confidentiality, added to concerns of both members and the public. It seemed as if the structures put in place to protect the public may potentially discourage the very disclosure necessary to drive change.

The RCN launched its Raising concerns raising standards hotline initiative for members who have concerns over clinical and staff safety in the workplace and who have registered issues through their normal internal procedures. The initiative – which is not a substitute to raising issues with employers or regulators – is designed to uncover what impinges on patient safety and the steps taken in response.

Patient safety is viewed by many as the number one priority for health departments in all four countries and for all NHS organisations at every level. Patient safety and quality is enhanced in organisations where staffing levels and skill mix are appropriate to the needs of patients, continuing professional development is encouraged and where nursing is supported and adequately invested in by the executive and non executive boards. However, competing priorities at all levels could result in unsatisfactory compromises and unsafe care being delivered; if health care staff feel that their concerns are not being taken seriously within their own organisation, this should be seen as an organisational failure and executive teams should be held accountable.

While the RCN recognises that the regulatory bodies have a significant part to play in promoting patient safety, it is the culture of the organisation in which nurses work which makes the greatest contribution.

References and further reading
1000 Lives Campaign (2009) Introducing the 1000 Lives Campaign, 1000 Lives Campaign: Cardiff.
www.wales.nhs.uk/sites3/home.cfm?orgid=781

Aiken L, Clarke S, Sloane D, Sochalski J, Silber J, (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction, JAMA: Journal of the Medical Association, 288 (16), pp.1987-1993

Needlemann J, Buerhaus P,  Mattke S, Steward M,  Zelevinsky K,  (2002) Nurse-staffing levels and the quality of care in hospitals, New England Journal of Medicine, 346 (22), pp. 1715 – 1722