Abstract

The expression "shame and blame" has often been used to describe the culture within healthcare when a mistake is made. There has been little exploration, however, on the shame healthcare professionals experience after a mistake. Based on an original grounded theory study on the psychological impact of mistakes on health professionals, this article explores why the healthcare environment is a perfect ecosystem for growing shame, how individuals are coping or not coping with the negative effects of this powerful emotion and what might be done at the system, organizational and team level to mitigate these negative effects.

Introduction

Since the early 1990s, there has been a significant amount of discourse exploring how healthcare organizations might create a more open, transparent and safe environment where employees are able to report errors without fear of reprimand or punishment. Yet errors continue to be severely underreported as studies show that the healthcare environment still appears to be cloaked in silence, and mired in shame (Conway et al. 2011; May and Plews-Ogan 2012; Dekker 2013).

More importantly, health professionals have stated consistently that they are emotionally distressed after a mistake (de Feijter et al. 2012; Conway et al. 2011), and literature on the "second victim" (Hall and Scott 2012; Smetzer 2012; Clancey 2012; Dekker 2013) sheds light on the seriousness of these experiences. There has been an impetus within healthcare organizations to find ways to support these individuals, including peer support programs (Scott 2015; Hirschinger et al. 2015). However, if programs such as these are to succeed, there needs to be a thorough understanding about why health professionals react the way they do and how they might best manage and overcome these emotions.

Our study explored the psychological impact of errors on health professionals, so that we might understand better why they still do not feel safe to talk about errors, and continue to keep silent when things go wrong. The results provide insight into why and how health professionals experience shame after an error, and how its negative effects might be mitigated by the individuals, the team and the organization.

The Emotion of Shame

Shame involves a complex array of cognitive activities that include our perceptions of what others think about our actions or behaviours; this emotion comes not only from a person's belief that the actual self fell short of the ideal self, but also the belief that others perceive this same deviation (Van Vliet 2009). Definitions of shame emphasize its destructive nature and describe it as an "assault on the self" (Van Vliet 2008: 237), and "one of the most powerful, painful and potentially destructive experiences known to humans" (Gilbert 1997: 113). Brown (2012) explains that shame is a fear of disconnection where people are constantly asking themselves: "is there something about me that, if other people know it or see it, I won't be worthy of connection?"

Shame is the result of comparing oneself to an internal standard or ideal; it follows that the higher the standards one has, the more likely a person will encounter the feeling of shame.

Shame in Healthcare: Unachievable Standards

It is well-known that health professionals set an incredibly high standard for themselves and their work. The Hippocratic Oath "first do no harm" is reflected in the ethics of health professionals, which results in the expectation that a health professional will never harm a patient, whether deliberately or by mistake. This "yoke of perfection" (Hilfiker 1984) has been recognized for many years, and continues to be pervasive. Reason (2011: ix) states that health professionals "are raised in a culture of trained perfectibility" where the expectation is that, once trained, they will be perfect in all the work they do. Dekker (2013) maintains that fallibility continues to be a foreign concept in health professional training and culture. There is also a prevailing expectation in society that medical mistakes are unacceptable (Peters and King 2012). Patients demand error-free care, and expect those who provide healthcare to achieve the unachievable.

There are five main reasons why the nature of health professionals' work makes it impossible to meet this standard of perfection. First, they are constantly making decisions of extreme gravity where there are many opportunities daily to miscalculate, misdiagnose, misinterpret or misstep – often with extremely serious consequences. Second, health professionals must deal with escalating changes in medical knowledge along with growing specialization and interdependency of health professionals. Third, healthcare represents a place where situations are complex and uncertain, where unexpected events require a person to quickly change course many times throughout the day. Fourth, there is often no conclusive answer or decision in healthcare. Finally, the unpredictability of healthcare causes health professionals to make continuous and multiple unplanned decisions. Dekker (2009: 183) refers to the "discretionary space" where workers have room to maneuver when making decisions, but is, however, "a final kind of space filled with ambiguity, uncertainty and moral choices."

In an environment of unpredictability, efficiency and urgency, human errors are not only possible, they are inevitable. Unfortunately, there is no acknowledgement of the inevitability of mistakes and errors are considered anomalies in healthcare (Dekker 2013). Thus, the healthcare environment is a perfect ecosystem for growing shame when an error is introduced. Health professionals are constantly under pressure to do better, faster and with fewer resources, all the while threatened with blame and potential lawsuits if things go wrong (Peters and King 2012; Dekker 2013). Their expectations for themselves are extremely high, and any error is a failure, a blight on their standard of perfection. It is no wonder that shame plays a big part in healthcare culture, and spreads like a noxious weed throughout the healthcare environment.

Methods

This study was conducted using constructivist grounded theory (Charmaz 2014), and aimed to develop a theory, grounded in the data of the participants' experience, that generated new insights about the psychosocial process of how health professionals mitigate the negative effects of shame because of mistakes. The 21 participants were health professionals working in two Canadian academic paediatric hospitals in medicine (four physicians and five residents), nursing (seven) and pharmacy (five). Data collection was semi-structured one-on-one interviews using open-ended questions that aimed to draw stories about participants' own experiences of shame related to errors, and their ideas on how individual health professionals might better manage or cope with shame. Data were analyzed and explored after each interview with line-by-line coding then sorted and synthesized to develop the theoretical framework.

Results

The results of this grounded theory research are extracted from the data of stories and insights of the participants. The theoretical framework (Figure 1) developed from this data, identifies four categories or steps in the process of shame from mistakes: (1) weighing the risks and making a decision that sometimes leads to a mistake; (2) causing harm or potential harm; (3) unmasking the self as a fallible professional, where the key dynamics of the shame process occur and (4) recovery from shame, or rebuilding of the self as a fallible professional.


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Unmasking of the self as a fallible professional

What became clear during the interviews was that health professionals felt they must constantly portray themselves as trustworthy, competent and infallible towards their patients and colleagues. This mask of infallibility – a concept coined by Jay Katz (1984) – allows them to appear perfect to the outside world and, in the process, convince themselves of the truth of the mask. When a health professional makes an error, this mask can begin to erode, from both outside (external exposure) and in (internal erosion). One participant described this feeling as being "stripped naked" (nurse).

External exposure

As soon as an error is revealed, the health professional is suddenly vulnerable to external exposure. This takes many forms, including negative reactions such as judging, bullying, blaming and isolating, as well as organizational processes that are meant to be positive but can be traumatic for an individual who feels responsible for an error.

Participants describe their fear of being judged for their error, and assume others will think less of them because of the error, will use this error to assess their abilities in the future, explaining it with words such as "people are going to look at me like I'm stupid" (pharmacist).

Participants also maintain that silence is still the norm around errors, that there continues to be an understood code of silence when someone makes an error. To the person making an error, the silence can be just as powerful as words, implying blame and disapproval. One participant tried to sort out her feelings about this paradox:

It's so funny because you want silence, you want it because you don't want to be exposed, but you don't want it because you don't want to be lonely and isolated in how you feel (nurse).

There are several organizational processes that constitute standard quality improvement initiatives – such as reporting, incident management, debriefing, mortality and morbidity (M&M) rounds and disclosure – that were clearly a form of traumatic exposure and shame-inducing encounters from our participants' perspective. One nurse described her experience with incident management activities as "exposing me for the sham that I am in front of everybody." Disclosure to the families or patients was often described as one of the most distressful of the processes; one of the participants described the harrowing "walk down the hall" to tell the parents of the patient about the harm, which he said was "the longest walk you ever do" (physician).

Internal erosion

To whatever extent the health professional is exposed, he or she must also deal with the internal or self-inflicted impact of the error. The participants describe how they are suddenly confronted with a number of thoughts that begin to erode their self-identity:

It's almost like you've failed as a person (pharmacist).

This erosion, amplified by this shame, takes a number of forms, including self-doubting or second guessing oneself, counterfactual thinking, self-criticism and remorse.

One participant noted that even filling out a form to report an error starts a "whirlwind" of self-doubt and another noted that "it makes you beat yourself up" (nurse). Other participants describe how they begin to question their abilities. Participants also describe counterfactual thinking, using words such as "what if" to think back to the decision and wonder about what would have happened if they had made a different one:

And always thinking if I had done that, would it have made a difference. In my case, the baby I sent home died. So … you always wonder (physician).

Participants sometimes went beyond self-doubt to self-criticism, which can be defined as contempt and disgust for the self (Whelton and Greenberg 2005). This reaction was described repeatedly by many participants, who often used physical motions to demonstrate their frustrations with themselves (such as hitting the table, hitting their heads with their hands or clenching their fists). The participants also used derisive words, such as "stupid," "incompetent," "idiot" and "dumb" to describe themselves.

Rebuilding the self as a professional after an error

In the face of this external exposure and internal erosion, health professionals must find a way to reinforce their self-identity as a health professional to overcome the shame from their error.

Most participants recognized that the error they made had damaged their professional self-identity, and were compelled to rebuild themselves. Having acknowledged their role in the error, grappled with emotions of shame, rebuilt their confidence and allowed time to heal the wounds of external exposure, they slowly tackle the job of reinventing themselves as less than perfect – but still worthy of being a health professional, or as one physician put it: "one way or the other you have to start living with it, that this happened."

Two participants were, at least outwardly, not affected by errors they had made. They declared that they felt no emotional upheaval, no shame and no lasting effects from errors they had made. Their tough exterior deflected any insinuation of incompetence; they simply refused to allow the error to reshape their self as a perfect professional:

Ruminating on what happened isn't going to help anyone … You need to be convinced yourself that what you're doing is right otherwise you shouldn't do it (resident).

At the other end of the spectrum were two individuals who could not return to who they were before the error. These participants had made life-changing decisions as a result of an error, one by transferring to another department where he thought he would be less likely to make an error that would harm a patient, and the other by removing herself from clinical to administrative work. Both remained in their original profession, but continue to carry their burden of shame.

Containing

When they make an error, health professionals attempt to contain it in several ways. First, many do their best to keep the error from becoming public knowledge. Another way of containing the error is by minimizing it. It was often the case that the participant will note that the error was "only a little error" or "not a big deal" – even though later in the interview they sometimes revealed that the patient was harmed – thus deflecting the shame they felt about it. Another way of containing was for participants to remind themselves that errors are random, that they "just happen" or are "bad luck"; participants seem to have an easier time dismissing an error, if they can reassure themselves that they are "only human" and not perfect.

Rationalizing

This response to an error includes behaviours where an individual thinks about the error in an analytical manner to explain how they made the error:

Yeah, just thinking about why did I do that at the time, why was that the decision that I made. Because we generally make decisions for reasons, we don't just randomly decide to do something (pharmacist).

Avoiding responsibility

Some participants diminished their responsibility for harm done to the patient by questioning – and even dismissing the possibility of – a causal relationship between the error they made and the eventual consequences to the patient, as does the following participant:

I never felt it was what I had done that made him die. I was doing what I should've been doing but how this happened and it got to a cardiac arrest stage (nurse).

Talking to someone

Some participants noted that talking to a colleague helped reassure them, especially if they acknowledged that they made mistakes too:

I think I would just discuss what happened with them and talk about the emotions that I'm experiencing, because I feel like it's not uncommon for this to happen, so hopefully they would have relatable situations that I could talk to them about (resident).

A few participants felt that disclosing their error and apologizing to the patient was one way of moving on from the shame they felt, perhaps seeking forgiveness, or reassurance that they did everything they could.

Discussion

You remember their face, you remember their parents, you remember the hospital. It's that salient … it's forever ingrained in your mind (physician).

The psychosocial process that health professionals undergo when they make an error is overwhelming and complex. It can have a significantly negative effect on their well-being and on their ability to care effectively for their patients. The process is mired in shame, confounded by social interactions with other team members and patients and cluttered with the internal struggles with their identity as health professionals. Yet, somehow, health professionals generally endure. Despite the constant pressures of being perfect, the complexity of care, the inevitability of errors, the ongoing pressures of time and resources, they persevere.

Depending on how successful the individual is in reinforcing the mask of infallibility, the negative impact of the shame will vary from very little to very high (Figure 1). At the low end of the spectrum, where the mask remains intact, are those who do not allow themselves to feel much emotion about an error, and are seemingly nonplussed about the error. They exude confidence and avoid responsibility for the error wherever possible. This may or may not be a healthy response to an error; Cassell (1987) postulated that the more certitude a health professional exhibits, the more troubling their inevitable feelings of uncertainty will be.

At the other end of the spectrum are those individuals whose masks have been emaciated. These are individuals who are not able to cope with the external exposure and internal erosion they experienced as a result of the error. They condemn themselves to remaining unforgiven and unmasked.

With most health professionals, however, their infallibility masks are eroded to some extent, but they are able to reinforce them and overcome the shame. Successful reinforcement can be described as resilience, or that ability to adapt and change for the better in response to challenges that are a threat to their integrity or survival (Dekker 2013: 94). These resilient individuals remold their masks with rational thinking, taking responsibility for the error without catastrophizing, seeking to understand why they made the error through analysis and acknowledging that they are "only human" or fallible. The remolded mask is one of a fallible, perhaps a little less but still confident individual who has gained wisdom and humility from the experience of the error. This great majority of health professionals recognize themselves as competent despite their fallibility.

Conclusion

Shame is the acid of the erosion of the mask of infallibility and the harsh sunlight of exposure. But shame is also the force that enables a health professional to reassess who they are, what they have done and what they need to do in the future to avoid feeling this shame again. Shame reminds a health professional that they are only human, that they can make mistakes and that they can learn from and move on from mistakes.

To help health professionals through the shame of errors, what is needed is not the open and transparent culture so often described in a "just culture of safety," (Khatri. Brown and Hicks 2009) but an empathetic culture of safety. As individuals, we can show empathy to a health professional who makes a mistake by admitting our own fallibility, and sharing the emotional experiences we have had with mistakes. As noted by Brown (2010), "the two most powerful words when we're in this struggle are 'me too.'" Empathy helps reshape and remold the mask of infallibility, and helps health professionals who have made a mistake recognize they are not alone in their struggle with being an imperfect and fallible human being in a highly complex, unpredictable and demanding profession.

An organization can nurture this empathic culture of safety by focussing not only on what went wrong in the system – or on internal processes and investigations that are often perceived as inquisitions rather than analyses – but also on the individual's emotional journey throughout the process. By supporting our healthcare workforce through the emotional trauma of an error with compassion and with formal support programs designed to care for the traumatized health professional, we will nurture a safer psychological environment that will ultimately foster a safer environment for the patients.

About the Author

Diane Aubin, PhD, is a senior program manager, in Career Development, Strategies for Patient-Oriented Research, University of Alberta. She worked for 10 years in the field of patient safety and medico-legal issues in adverse events, at both the Canadian Patient Safety Institute and the Canadian Medical Protective Association.

Sharla King, PhD, is director of Health Sciences Education and Research Commons; associate professor, Faculty of Education; and area coordinator for the Master of Education in Health Sciences Education program in the Faculty of Education at the University of Alberta. She is currently principal investigator or co-principal investigator on projects related to integrating interprofessional competencies into health science programs and developing, implementing and assessing team-based simulation modules.

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