Attribution theory and healthcare culture: Translational management science contributes a framework to identify the etiology of punitive clinical environments

The Institute of Medicine's seminal report, To err is human: Building a safer health system, established the national patient safety framework and initiated interest in changing the traditionally punitive healthcare culture. This paper reviews a multidisciplinary literature and offers an attribution framework to explicate the organizational processes that contribute to an industry-wide culture where clinicians are routinely blamed for adverse patient events. Attribution theory is concerned with the manner in which people explain the behaviors of others or themselves by assigning causality for events. To date, attribution theory, though well established in the management literature, has yet to be translated to healthcare. In this paper, we first describe the historical evolution of attribution theory in relation to human behavior in clinical practice and healthcare management and then discuss the work environments in contemporary healthcare organizations. Next, we demonstrate the applicability of attribution theory to healthcare by providing two adverse event exemplar cases. Then, the Healthcare Attribution Error Model is offered to demonstrate how concepts from attribution theory serve as antecedents to the employee cynicism, learned helplessness, organizational inertia, and the emerging Just Culture perspective. We conclude by suggesting attribution theory offers an important theoretical framework that warrants further conceptual development and empirical research. In the quest to produce exceptional healthcare environments where safety and quality are fundamental employee concerns, healthcare managers and clinical professionals need theoretically supported knowledge and evidence-based insights.