NURSES' NEAR-MISS REPORTING BEHAVIOR IN A BLAME-ORIENTED CULTURE: BARRIERS AND FACILITATORS IN PAKISTANI HOSPITAL SETTINGS

Abstract

Background: Near-miss reporting lets hospitals find and fix weaknesses before patients are harmed, but it depends on nurses being willing to report. In blame-oriented workplaces, near misses often go unreported. Evidence from Pakistan on why nurses report or stay silent is limited. To explore the barriers and facilitators of near-miss reporting among nurses in a tertiary care hospital in Multan, Pakistan. Methods: A qualitative descriptive design was used. Nineteen registered nurses from different wards were purposively sampled and interviewed individually using a semi-structured guide. Interviews were audio-recorded, transcribed, translated where necessary, and analysed using reflexive thematic analysis. Trustworthiness was supported using the criteria of Lincoln and Guba, and the study was reported following COREQ. Results: Four themes described barriers: fear of blame and punishment; a hierarchical and unsupportive climate; no feedback and no visible action; and practical and conceptual obstacles, including workload and uncertainty about what counts as a near miss. Four themes described facilitators: supportive leadership and psychological safety; visible feedback and learning; simple and confidential reporting systems; and professional values, peer support and training. Nurses linked silence to the expectation that management would look for someone to blame, and described the head nurse's first response as a key influence on whether they would speak up.

Conclusion: Nurses' reluctance to report near misses reflected a weighing of cost against benefit shaped by the surrounding culture, not indifference to patient safety. Hospitals should adopt a just-culture approach, train nurse managers to respond without blame, give feedback on every report, and offer a short, confidential reporting process.