Voluntary incident reporting systems are one approach to improve patient safety,1 as evidenced by their inclusion in many hospital accreditation programs. For example, the Joint Commission (United States) has Sentinel Events as part of its Comprehensive Accreditation Manual for Hospitals,2 Accreditation Canada now has voluntary incident reporting as one of its Required Organizational Practices,3 and the Australian Commission on Safety and Quality in Healthcare has a standard titled “Governance for Safety and Quality in Health Service Organisations,” whereby incident reporting is a core requirement.4 When properly used, incident reporting systems allow data to be collected and aggregated for the determination of patterns that may lead to corrective action.5 Reported incidents can also be used as learning tools.6
However, voluntary incident reporting systems have also been described as a source of frustration, falling short of generating intended benefits. Their effectiveness is diminished by barriers to voluntary incident reporting, some of which are related to concerns about repercussions to the reporting health care professional.7–9 This has been the case despite a continual de-emphasis on blame and responsibility of the frontline worker10,11 and an increased emphasis on the systems' properties of patient safety.12–16 A better understanding of factors influencing the decision to report incidents will facilitate efforts to improve systematic collection of patient safety threats.
Voluntary incident reporting systems are complex sociotechnical systems, which can benefit from evaluations using a social science lens.17,18 Using these approaches, researchers have identified factors that enable and hinder incident reporting.19–21 Research has shown variability in beliefs about, and the practice of, reporting.5 Variations are observed across and within professional disciplines.22 There are also variations in practices of self-reporting and peer reporting. Because incident reporting systems are intended to detect trends and patterns,1 any source of variation will undermine the credibility of results. Thus, understanding factors contributing to varying practices is important.
We undertook this qualitative study to better determine the views of those who do and do not self-report and peer report. To perform this work, we considered one source of variation to be the “frames” that practitioners apply to the practice of reporting. Frames are templates that individuals hold cognitively and that guide interpretation of events.23,24 They are derived from individuals’ past experiences and social milieu and are used to guide an individual’s actions in particular scenarios.25 It is not uncommon for practitioners working in the same site to hold different frames.5,26 We wanted to better understand the frames that enable and hinder self-reporting and peer reporting, as well as the differences between these frames. Furthermore, we wanted to understand what frames were used within and across professional disciplines. Understanding underlying frames would allow organizations and workgroups to communicate with and train professionals in ways that would promote both self-reporting and peer reporting and that would reduce variability in reporting practices.
Several works have contributed to positioning of errors within a systemic framework. Reason’s27 work has been highly influential in this context. Reason proposed multifactorial causes for any accident.28 Some of these causes are at the frontline (physician, nurse) and are proximal to the patient—what Reason called the sharp end. However, other causal factors are not as visible but contribute possibly to even more incidents at the frontline, given the scope of their coverage (procedures, management, regulations). These are distal from the patient—what Reason called the blunt end. His earlier work29 describing active errors as those at the sharp end differing from, and often resulting from, latent errors—errors at the blunt end—is still important to a holistic understanding of accident causation. Reason’s ideas were used in the seminal patient safety publication To Err Is Human by the Institute of Medicine30 and the National Academy’s Crossing the Quality Chasm,31 which have set the stage for patient safety discussions to go beyond the focus at the frontline.
Other works in safety more broadly have continually de-emphasized the sole responsibility of the frontline worker, trying to promote a more holistic understanding of how systems are generally safe yet vulnerable to accidents.32–38 Notwithstanding these system views, there is still a strong perception among frontline health care practitioners that individuals play a critical role in preventing an incident or indeed causing an incident. Research on reporting behavior by health care professionals shows that enablers and obstacles to reporting are rooted in beliefs that the individual at the frontline holds responsibility for incidents and/or that reporting incidents has consequences at the individual level. This focus on the individual permeates practices related to self-reporting and peer reporting.
A primary inhibitor for self-reporting is fear to report. Burkoski39 speaks of leadership in health care blaming individuals for error as being a significant impediment to frontline reporting; a fishbone diagram in Noble and Pronovost8 (p. 248) illustrates classes of fear (professional and public) as two of many barriers to incident reporting. In a systematic review of reporting, Pfeiffer and colleagues’40 evidence-informed psychological framework on factors influencing willingness to report includes fear as an influence on a frontline worker’s willingness to voluntarily report an incident. They also present a decision-making framework to report, including factors such as individual and organizational, the perception of the incident reporting system and the incident characteristics as being factors practitioners use in their willingness to report. Other inhibitors to self-reporting include the perception that errors are inevitable,20 that reporting is overly bureaucratic,20,41 and that incident reports are used as a gauge of incompetence.42 Facilitators for self-reporting are less commonly addressed but include duty of the profession43 and feeling as though one is making a difference.42
Peer reporting—reporting an incident believed to be caused by or not prevented by a peer—has its own set of barriers and enablers. Peer-reporting practice encounters “powerful group norms against tattling” and work groups that “make peer reporting a proscribed and risky behavior”44 (p. 39). Kingston et al45 showed that physicians prefer to keep incidents “in house,” prioritizing loyalty to colleagues, but that nurses peer report out of a sense of duty to their profession. A systematic review of nurses’ reporting practices by Whitehead and Barker43 revealed that confidentiality enabled peer reporting, along with incident severity, the experience of the nurse, as well as personal feelings and beliefs. King and Hermodson46 and King47 constructed a decision-making framework that encompasses individual, situational, and organizational variables in concert with the severity of the incident and the intentionality of the peer’s action that govern a nurse’s choice to report a fellow nurse. Other barriers to peer reporting include unknown consequences for the reported peer48 and for the reporter.49,50
Despite the studies that have looked at reporting practices, gaps exist in terms of comparing self-reporting and peer reporting, as well as in terms of exploring the frames underlying self-reporting and peer-reporting facilitators and barriers. Frames are schemata that individuals hold and that guide interpretation of events.25 Frames are rooted in individual and sociocultural experiences, and the two are closely intertwined.25,51,52 Individuals and groups working in an organization might perceive their environment in different ways because they hold different frames, and this results “in differential strategies for action across the organization”26 (p. 348). In this study, we focused on the frames that enable and inhibit self-reporting and peer (including interprofessional) reporting among physicians and nurses. Thus, we ask 2 research questions: What enabling and inhibiting frames underlie self-reporting and peer-reporting practices? How do these frames held by physicians and nurses differ from each other?
This study was part of a larger research project on voluntary incident reporting and safety in a teaching hospital in Ontario, Canada. The reporting system at the hospital is ostensibly available to all employees through any networked device (e.g., computer). The incidents are entered using the patient’s medical record number, and the identity of the reporter is known. The reporter enters a narrative describing an incident using the passive voice and facts but does not record his/her judgment concerning why an incident occurred. The incidents are sent to clinical managers, who investigate them locally and log them in the electronic system. The incidents are then reviewed by physician clinical reviewers to assess whether harm was caused to the patient and are sent to core reviewers, who assess larger hospital issues.
We focused our study on General Internal Medicine—one of the largest departments in the hospital. The study began in spring 2012, with a quality review meeting whereby the researchers were introduced to key personnel who would later become interviewees. For 5 months, 2 researchers (both independently and together) confidentially interviewed hospital personnel. The chief physician and the clinical director were key informants, each of whom recommended other personnel to interview based on our request to sample individuals with a variety of views and practices related to incident reporting. This process yielded 23 additional interviews purposefully sampled. To increase the number of physicians in the study and to reach residents, an e-mail was sent out, to which 2 physicians and 3 residents responded. Thus, overall, 30 in-depth interviews with physicians and nurses were undertaken as follows: 7 attending physicians (including the chief physician and the clinical reviewers), 3 residents, the clinical director of nursing, 4 nursing leaders (clinical managers and nurse educators, referred to as educators), as well as 15 registered and practical nurses with a range of experience and reporting practices.
The interview included questions about the physicians’ and the nurses’ reporting and safety practices, as well as the reasons underlying their practices. Interviews averaged 45 minutes and were digitally recorded and transcribed. Data analysis was undertaken by 2 researchers (TH, SC), who met to discuss the themes in the interviews and the derivation of codes based on the data gathered. Atlas.ti (GmbH, Berlin, Germany) software was used to code the interviews and retrieve quotations. A third researcher (AF)—not involved in data gathering—also participated in reviewing quotes and the emerging analysis. Through our collective work, we identified the enablers and the inhibitors to self-reporting and peer reporting as well as analyzed the frames used by the physicians and the nurses to explain their decisions to report or not to report. We organize our findings under 2 overarching headings: enabling frames and inhibiting frames of self-reporting and peer reporting.
In this article, we focus specifically on frames that enable/hinder self-reporting and peer reporting as well as on the differences in the frames of physicians and nurses. This is not to say that the interviewees did not speak of other foci of reporting. For example, the participants indicated that insufficient time is an element in any type of reporting, which we consider under a “reporting logistics” framework that is not discussed here. Similarly, a “first, do no harm” theme that shows a patient-centric view was evident in the interviews and was discussed extensively in relation to more general safety concerns. However, these themes are not the focus of this study; comparing self-reporting and peer reporting and their underlying frames is the present objective. In the sections that follow, we elaborate and provide illustrative quotations on each of the frames that enable and inhibit self-reporting and peer reporting, and we compare the frames held by the physicians and the nurses.
Enabling Frames of Self-reporting and Peer Reporting
We found that there are 3 main frames used by frontline health care practitioners that enable self-reporting: professional accountability, trust in the system, and learning from error, and 3 main frames that promote peer reporting: severity of incident or repeated errors by a health care professional, learning from errors, and anonymity. However, these were not found equally across the professions. Table 1 displays the frames as found through the interviews with the physicians and the nurses.
The physician reports were infrequent when it came to reporting on incidents in which the physician himself/herself was involved. This was expressed by a physician and clinical reviewer, who reviews a large number of incidents reported into the incident reporting system. When asked whether events entered in the system by physicians were events in which others were involved, the physician and clinical reviewer stated the following.
Physician and clinical reviewer 1: Oh versus what they [themselves] did? Yeah I think it's definitely related to something else that’s happened somewhere.
Interviewer: Do they enter their own issues? So if they miss something would they enter that?
Physician and clinical reviewer 1: I’ve never seen one.
Some physicians attempt to influence colleagues and residents to engage in self-reporting but indicated that this is seldom practiced.
Physician and clinical reviewer 3: I’ve told the residents we should probably write up ourselves … we should write up our own events that have been caused by our care … But I haven't seen many people writing that up … So I would say, just knowing how things work, people probably don't write up their own errors in there.
In contrast to physicians, nurses engage more readily in self-reporting. This was well illustrated in a quote from a registered nurse: “I've probably done more on myself than on other nurses” (registered nurse 11). Nursing has a long history with reporting in this hospital, as does the profession. The frame of professional accountability in nursing, which derives from training and from expectations set by the nursing regulatory college, was evident in many of the nurse interviews. Nurses may hold the belief that reporting is a professional obligation, mandated by the regulatory college.
Registered nurse 10: If you make a mistake, it’s self-reporting, it’s from College of Nurses. We need to do that, like it's mandatory for every nurse.
Registered practical nurse 2: …as a part of staying competent and avoiding … either personal or a professional misconduct or abuse situations … you would want to—as a part of your duties—to fill in this kind of thing.
In fact, nurses readily engage in encouraging other nurses to self-report, extending their frame of professional accountability to encompass other nurses who might not self-report, as registered nurse 9 stated: “Hopefully if a nurse has made an error you can encourage them to do self-assessment, self-reporting.” In addition, there is a belief held by some nurses that the voluntary incident reporting system is nonpunitive. This reveals a frame consistent with the organizational message that reporting is nonpunitive. These nurses felt secure in self-reporting and, when directly questioned, expressed certainty that self-reporting does not result in blame or reprimand.
Registered nurse 2: I don’t feel like if I did something bad and I wrote myself up that I’d be punished or anything for it.
Registered practical nurse 4: It’s not really just about the nurses making errors … it’s not to blame me … it’s not to kind of punish me in a way.
These nurses trusted the organizational messaging of no-blame reporting and seemingly did not feel threatened in reporting incidents. This frame is highly enabling and aligns with larger organizational goals. Furthermore, many nurses believed that self-reporting aided learning from the reported incident.
Registered nurse 11: If I report a fall or I report medication being wrong we can look at that as more of a learning experience.
Registered nurse 3: [My manager says] it’s totally a learning thing, we’re all human, we’re all gonna make mistakes as long as we learn from it, that’s the major thing.
This learning frame is also highly enabling. This removes the stigma of reporting because learning from one’s incidents tends to frame reporting those incidents as part of a larger goal, of continuous improvement. If the learning experience frame could be held generally by frontline workers, many of the barriers associated with self-reporting and peer reporting could diminish significantly.
Some of the frames enabling peer-reporting behavior differed from the frames underlying self-reporting. The interviewees indicated that physicians might report peers more than they report themselves. A repeated errors/severity frame underpinned some peer-reporting practices. Reporting a fellow physician is facilitated if the reporter believes the physician is a “bad apple.”
Physician and clinical reviewer 1: I mean clearly if you know there’s a doc who’s a bad apple for example who always botches something, then I think I would have a lower threshold to bring it up or document it.
The nurses also used this frame of repeated error of a fellow nurse as serving as an incentive to report that fellow nurse.
Registered nurse 9: You come in and you find out the same nurse is doing a near miss in a repetitive [fashion], then of course in my mind it’s clear that you have to [report] it because they’re missing something.
Registered nurse 3: Now I feel that if you don’t report it then these errors that are being made the other nurse will never be aware of it. So she's not gonna learn from it. So I always make sure I report the situation.
In addition, practitioners will engage in peer reporting if the reporter determines the incident to be severe enough, indicating a severity threshold below which one would not report a peer.
Interviewer: Okay so you wouldn't write an incident report on another nurse?
Registered nurse 6: [Only if] there was something really bad … if there was a threat to the patient … it depends on the severity of the mistake.
The frames enabling peer reporting diverge from here—no other frames enabling peer reporting among physicians were found. Nurses, however, have more complex frames that are used enabling peer reporting.
In peer reporting, as in self-reporting, some nurses spoke of the act of reporting as a way to learn about incidents and their causes as well as a way to help find solutions. The desire to learn from the error was the main attribute of this frame, which is effective at diverting attention from the individual reporting and reported on and focusing instead on how to prevent recurrence of the incident encountered.
Registered practical nurse 2: Any error that your colleague makes if we’re doing a very similar role … caring for the same patient, often if it happened to them, in my mind, it could very easily happen with me … I want to know what it was that happened and how we can all learn from this kind of thing.
Registered nurse 9: If there’s an error that happens [to your colleague] you can look at that and if there’s a pattern then … make solutions [to] prevent that from happening again.
The abovementioned frame facilitates not only peer reporting but also self-reporting for nurses. We noted that some of the nursing participants who spoke about trusting the incident reporting system not to be punitive also spoke about the importance of reporting incidents for learning.
The anonymity frame that nurses hold also enables peer reporting. This refers to the ability to report a fellow nurse but not name him/her in the incident report.
Registered practical nurse 1: You can say you found patient on floor beside bed. Patient reported that he fell. So that’s what I mean it’s very objective but … you don’t try to place blame.
Registered nurse 11: Well I guess it’s more or less anonymity, just anonymously. So it's not really going back to the person that’s doing it.
The inspiration behind this may come from the training that the nurses receive, “If it’s happening to you, it’s happening to other people” (educator 1), which does not require the identity of the nurse involved in the incident to be revealed. In addition, the message of not blaming one’s colleagues has been communicated.
Clinical manager 2: We keep saying that it's not punitive. We don’t want to feel like the nurses are pointing fingers and that it’s a learning process.
In this way, nurses can report incidents without “pointing fingers” and consequently laying blame on a colleague. It is worth noting that all peer-reporting enablers were restricted to one’s workgroup—that is to say that physicians (rarely) peer report fellow physicians and nurses peer report fellow nurses. No frames that enable interprofessional peer reporting (physician reporting nurses and vice versa) were found.
Inhibiting Frames of Self-reporting and Peer Reporting
The 3 main frames used by frontline health care practitioners that serve as barriers to self-reporting include fear of blame, incompetence, and career progression, and the 3 main frames that inhibit peer reporting include tattletale, locus of responsibility, and professional boundaries. These are depicted in Table 2.
Fear of blame and being found at fault was pervasive among both physicians and nurses.
Resident 1: There’s a huge fear of blame and a huge culture of fear of being perceived as being incompetent.
Physician 2: There’s a big culture among residents and med students and even staff I think there’s still a stigma of reporting things because people are worried about being reprimanded and punished.
Registered nurse 6: I’m sure the manager would say like “oh this is nonpunitive” … I made an [error in a previous position]. She raised her voice and was pretty much angry and it made me very nervous. I’m like, “Oh wow, can't make mistakes here.”
Registered practical nurse 2: There would be a feeling of fault or backlash … like a punishment associated with it if it's something that they feel could have been avoided.
The blame frame has been existent in medicine and health care generally for a long time, and this is what much of the work in patient safety has tried to address. Encouraging frontline staff to report incidents without fear of punishment has been a significant challenge. As mentioned, this hospital had gone to some effort to dispel the idea that incident reports would be used to blame a practitioner, and yet these quotes demonstrate that the frame of being blamed for reporting an incident is held very strongly by both physicians and nurses.
Personalizing an incident and framing it as a matter of incompetence are a major deterrent to self-reporting. Resident 1 stated, “I think the perception is that when you report errors it’s not just the error that gets reported it’s the person who made the error.” Physicians’ fear for one’s reputation as a professional is prominent. Referring to such notions as “look(ing) like an idiot” and “personal screwup” is indicative of the tendency to personalize an incident. These notions also point to the stigma that physicians associate with being involved in incidents.
Resident 3: You don’t want to disappoint your superiors, you don’t want to disappoint the patient, you don’t want to disappoint their family and you don't want to look like an idiot.
Physician and clinical reviewer 2: If you’re reporting something that actually [indicated a] personal screwup … I would say that probably people would think twice.
Nurses, like physicians, hold pride in their competence and skills as well as fear for their reputation. They refer to the incompetence frame as an inhibitor to self-reporting.
Registered practical nurse 2: I think it’s a bit of a kind of knowing your colleagues might feel a certain way about you afterward if they figure out you did something or have an opinion about it and your reputation may be at stake.
Overall, framing incidents as a mark of personal failure is a barrier to self-reporting and one that patient safety has tried to combat. A powerful detractor is not only what the reporter thinks of himself/herself but also how he/she believes others will perceive the self.
Further, self-reporting serving as an impediment to career progression is a frame shared by younger physicians, residents, and nurses. The need to impress those who make decisions about job placements can act as a deterrent to self-reporting.
Physician 2: In order to get into that area [the residents] need to be on their best behavior and … need to impress a certain staff physician in order to gain access to that area. And they feel as though if they were to do something by reporting an error that that would be looked upon as negative.
Registered nurse 8: (Some think) “oh my God you made a medication error there’s one x on your evaluation or on your file … The next x you're gonna lose your job….” There's still a lot of thinking about that.
It is important to note that the fear of blame and incompetence frames that are held by physicians and nurses run counter to the formal views held at the institution. This is illustrated in the chief of internal medicine’s quote below, which acknowledges the frames generally held by physicians while indicating that the incident reporting system is not intended as punitive but as a learning system.
Chief physician: I think docs in the hospital would just need to be constantly reminded … that it’s … not a punitive system that someone's going to use to identify you as a problem person … that it’s really to learn and decide how we can make changes. But docs should know that—I mean we've been told that time and time again.
Similarly, the local nursing senior personnel (clinical manager, educator) spoke about the nonpunitive aspects of incident reporting.
Clinical manager 1: It’s not like I keep a running total of who has filled it out and who’s made the error. So it’s very nonpunitive and it’s really trying to just get everybody to understand that it really is to look at the systems. Because if you make a mistake most likely it’s human error or there’s some system in place that is just not working … I do believe it’s just a culture that, when you made a mistake in the past that you felt that you were going to get in trouble. And now it’s you make a mistake and what do we learn from that. But I think there still are people that are afraid to tell somebody they've made a mistake.
Educator 2: So they don’t always see it as something to look at the whole system, they look at it as a punitive thing, where part of my education to them is that it is to look at the whole system. Just because you gave the wrong med there could have been other factors involved that included other parts of the system causing that to happen.
The fear of blame, incompetence, and career progression frames are inhibitors to self-reporting shared by both physicians and nurses, notwithstanding the organizational messaging aimed at alleviating these concerns.
In peer reporting, avoiding tattletale is a pervasive frame that is held by physicians and nurses. A resident described this perspective by saying, “This is something that happened to other people … you’re sort of overseeing and watching what everybody else is doing … I feel like it’s a tattletale system” (resident 2). Other quotes refer to the act of reporting as “squawking” on a colleague, which has a negative connotation and is something physicians would like to avoid.
Physician and clinical reviewer 3: Because even the other day when we were talking about … how the patient didn’t receive any emergency care and the team [said] “well we really don't want to report it because we don't want to … report the emerg doc.”
Physician 3: I wouldn’t want to squawk on a colleague right that did a procedure wrong or prescribed the wrong treatment—you know what I mean.
The nurses had similar views regarding peer reporting, such as “They may think that they’re like snitching” (registered nurse 11), which echo the physician-held frame that reporting colleagues involves tattletale and going behind someone's back.
Interviewer: Why would you hesitate about filling a report on somebody else?
Registered practical nurse 4: I just keep on thinking that I am kind of going behind someone’s back. That’s why I don't like the idea.
Registered nurse 6: If it was a medication error, some nurses get really offended if you [peer report]. They go “oh she wrote me up….”
Framing the act of reporting a colleague as tattletale carries an underlying implication that reporting violates social conventions and therefore should be avoided.
Another inhibitor to peer reporting is the view that reporting on peers' incidents is outside an individual's locus of responsibility. This frame was held by some of the nurses who indicated that nurse peer reporting is associated with disciplining, a role that is reserved for management.
Registered nurse 7: It’s not really up to me to discipline another nurse. It’s not my job.
Educator 1: I know that in certain cases … writing an incident report … was seen more or less as a system of retribution from nurse to nurse.
Another inhibiting frame relates to reporting on incidents in which a practitioner from a different profession is involved. This is the interprofessional boundary frame. In terms of physicians reporting nurses, there seemed to be an understanding among physicians of what nurses are responsible to report, and physicians will generally not report what they believe to be nursing-related incidents.
Physician and clinical reviewer 2: It’s kind of required, you know, like for them, because the nurses will administer the medications.
Physician and clinical reviewer 3: We don’t usually put a lot of things that are kind of nursing related.
For the nurses, physician status plays an influential role and has major implications for interprofessional reporting, as evidenced by the chief of internal medicine.
Chief physician: [Nurses] should [report physicians] but I don’t know if they do … but I can see there being a culture of feeling like they’re tattletaling on doctors or maybe one of reprisal even though they’re reassured that it’s not working that way … I think doctors are seen as the … moral and clinical leaders … It's part of that sort of hierarchy that they might be worried about doing that.
Furthermore, the nurses stated not wanting to “go above” a staff physician and focusing on correcting the problem as opposed to reporting physicians. They would call the physician or speak with other individuals (their managers or the pharmacist) to seek clarification. This frame of observance of social structures in a hospital is a deterrent to reporting these incidents.
Interviewer: If you had come across a short form in an order would you think of recording, putting that into the system?
Registered nurse 1: No not likely. I’d call the doc and just get a verbal order … or we'll ask the pharmacist.
Interprofessional reporting is seen as an unfamiliar practice. A physician would not report nursing events, and nurse educators were challenged to think that the incident reporting system would apply to professions outside nursing. This alludes to the long history of nurse reporting and fairly limited history of general internal medicine physician reporting, to the extent that reporting is seen by senior nurses to be restricted to the nursing domain.
Educator 2: I think that a lot of people don’t even think of those as errors. So for instance if the physician wrote in the wrong chart they’ll just call the physician.
Educator 1: Maybe it’s just not part of our culture … We’re just so used to thinking of ourselves as a unit in terms of nursing practices and nursing processes and we’re so used to dealing with issues within our own scope of practice that I don't think many people think of [incident reporting] as being a tool for physician improvement as well.
Thus, there is a strong tendency to stay within one’s professional boundaries when it comes to peer reporting.
This study focused on specific aspects of reporting that have not received sufficient attention in the literature, namely, the frames that are held by physicians and nurses with respect to self-reporting and peer reporting. The results show that some frames enable self-reporting and peer reporting, whereas other frames inhibit self-reporting and peer reporting. Self- and peer-reporting behaviors are underpinned by these frames, which are derived from individual and sociocultural experiences of frontline workers. The results show variability in the views regarding self-reporting and peer-reporting practices among physicians, among nurses, and across the 2 groups. In this section, we elaborate further on the origin and influence of frames, delve into the differences between enabling and inhibiting frames, and compare the findings for the 2 professional groups.
Individuals use frames to understand their workplace settings,23–25 and these can be informed by several factors that include past work experiences, training, socialization, profession, interactions, and group norms. Researchers have pointed to the prevalence of a variety of frames in organizations. For example, following Goffman,52 Leonardi26 indicates the following:
Frames demarcate a set of cultural resources that one will use to create schemata of interpretation that guide (one’s) actions…. The concept of frames helps to explain why groups of people who share access to the same toolkit of cultural resources might act and perceive the world in different ways (p. 348).
Similarly, in her empirical study, Chreim24 found that individuals in the same organization hold or “appropriate” different frames, based in part on their own experiences, such as how they interface with a new technology. As one of the quotes we reported before illustrates, a nurse learned in an earlier experience that mistakes are not tolerated, and this underlies her holding a fear of blame frame. Our analysis also points to organizational messages related to learning, which found resonance among a number of the participants in the study. Thus, there are several individual and sociocultural factors that help shape the frames that frontline workers hold, and these frames influence their decision to report.5,20
The findings also show that there are similarities and differences in the frames held by the 2 professional groups. A look at Tables 1 and 2 indicates that the frames that are shared by physicians and nurses tend to be those that inhibit reporting, namely, the fear of blame, incompetence, and concern for career frames when it comes to self-reporting and the tattletale frame when it comes to peer reporting. The nurses resolved the tattletale obstacle by reporting their colleagues anonymously.
It is important to note that a frame held by some of the practitioners—the learning frame—trumps the inhibitors to self-reporting and peer reporting. Viewing the objective of voluntary incident reporting as learning from errors allows practitioners to depersonalize incident reporting. The focus becomes how to prevent recurrence of incidents and not the individual reporting or reported on. In fact, it is the focus on the individual that underpins the fear of blame, the fear for one’s career and reputation, as well as the view that peer reporting is equivalent to tattletale. The prevalence of these views in health care settings has been well documented in the literature.40,43,53–55 They seem to be culturally ingrained beliefs that persist despite organizational and policy attempts to dispel fears. In a summary of various reports of a significant lapse in the National Health Service (NHS) health care system in Mid Staffordshire, England, the National Advisory Group on the Safety of Patients in England (colloquially known as the “Berwick report”) states that achieving safety depends “on major cultural change” and that essential to this change is the need to “abandon blame as a tool”54 (pp. 10-11). In trying to address this well-known blame culture,55,56 organizations espouse a just culture, although Weiner et al57 found that just culture58 has been loosely defined for health care. In the case we studied, the general message accompanying the implementation of the voluntary incident reporting system was that it was intended as a learning system and not as a punitive system. The quotes we provided from physician and nurse leaders attest to this focus in the messaging. Thus, what are the implications of these findings? We consider the implications in the next section.
We would like to address the limitations of the study as well as implications for research and practice. In terms of limitations, it is worth repeating here that this study focused specifically on self- and peer-reporting and excluded other aspects of patient safety views and practices. Another limitation is that this is a qualitative study that does not allow us to provide frequencies of views and frame occurrence in the site we studied. However, the strength of qualitative research lies in its ability to delve into and achieve an in-depth understanding of local contexts.59,60 What is lost in terms of frequencies is gained in depth in understanding of the views that underlie decisions to self-report and peer report. The themes we elaborated on here can be tested in survey studies that would provide information on the prevalence of frames underlying the decision to self-report and peer report. In addition, this study was undertaken in 1 hospital department, which limits the generalizability of the study. However, as numerous methodologists have pointed out, the strength of case study research lies not in its generalizability to a population but in the thick, rich descriptions of the dynamics present at the site studied.59–62 Thus, qualitative researchers provide information on the site studied and extensive quotations that allow the reader to determine transferability of the findings to different contexts.
What are the implications of our findings that reporting practices are underpinned by deep-seated views and beliefs deriving from individual experiences as well as group interactions and norms? It can be said that ingraining the practice of incident reporting as well as making it a prevalent and relatively invariable practice within and across professions require intensive investment in education and training, as well as demonstrating the systemic benefits of reporting while exercising vigilance to avoid the punitive side. These are lengthy processes. Persistent communication about systems benefits and nonpunitive aspects of incident reporting is needed but is not sufficient. This communication should be consistent with practices at the local levels—where group culture and norms have a major influence on individual views and practices. As Hor et al5 point out, incident reporting mechanisms and accountabilities must be woven into the local cultural context to be effective. Approaches used for ingraining new beliefs and practices have followed the principles laid out by Lewin,63 who proposed the importance of considering the individual and the group in efforts aimed at change. Schein,64 whose work builds on Lewin's, points out that, for lasting change to occur, it is best to provide training to the whole group in such a way as to allow the group members to reveal their views and then to introduce “collectively a new set of standards for judging” (p. 34) what is acceptable belief and behavior. It is important that the collective understands the value of peer reporting and self-reporting and that it appropriates the frames that enable these behaviors.
In conclusion, health systems and hospitals should consider the various frames that enable and inhibit self-reporting and peer reporting among different professional groups when trying to improve the quality of information derived from incident reporting systems. Increased attention to group norms and local contexts would enhance patient safety initiatives such as incident reporting systems.
The authors thank all participants of this study for their willingness to contribute and their frank discussions.
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