Just Culture in Nursing

JUST CULTURE: An Approach that is Right and Just for the Philippine Nursing System

• Bernardo Oliber Alconis Arde Jr., RN, MAN

Nursing has always been regarded as a “humanistic science” since it has evolved from experience to science. Anchored by altruistic motives, nurses perform nursing care to patients with tact and prudence; otherwise patients’ safety is jeopardized. Hence, it is safe to say that nursing should be a ‘perfect discipline’ – an arena where mistake is never an option.

While there are great efforts by the nursing community to pursue perfection by its evidence-based approach, the fact still stand that humans are fallible. And by human nature, even if nurses make the best choices of care for their patients, other factors aside from these choices may still make them vulnerable to committing errors. If nurses’ infallibility can never be attained, how then can it be managed?

Traditionally, healthcare’s culture has held individuals accountable for all errors or mishaps that befall patients under their care. When errors occur, the immediate solution is to blame an individual for the error. Blaming individuals creates a culture of fear, discourages open reporting and discussion of errors, and does little to prevent future errors or improve the safety of the health care system (NCBON, 2011). According to Leape (2000), as cited by American Nurses Association (2010) these approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes. Many observers attribute underreporting to the punitive (‘‘name and blame’’) approach that many healthcare organizations have taken with regard to safety incidents. By inculcating a sense of fear, the punitive approach discourages reporting and, in doing so, prevents organizational learning and improvement (Barach & Small, 2000; Blegen et al., 2004; Kadzielski & Martin, 2002; Kingston, Evans, Smith, & Berry, 2004; Manasse, Eturnbull, & Diamond, 2002; Wakefield et al., 2001, 1999).

As an alternative to this traditional system, application of a model which is widely used in aviation industry known as the Just Culture Model seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues (ANA, 2010). Just Culture, as defined in aviation industry, is a culture in which front line operators are not punished for actions, omissions or decisions taken by them that are commensurate with the experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated (Eurocontrol, 2014). Reason (n.d), as quoted by Skybrary (n.d) claimed that it is an atmosphere of trust in which people are encouraged, even rewarded for proving essential safety-related information but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.

In 1997, as mentioned by ANA (2010), John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information. A Just Culture is also explicit about what constitutes acceptable and unacceptable behavior. Therefore a Just Culture is the middle component between patient safety and a safety culture (Reason, 1997). However, the term “Just Culture” was first used in a 2001 report by David Marx (Marx, 2001), a report which popularized the term in the patient safety lexicon (Agency for Healthcare Research and Quality, n.d.). Further he argues that discipline needs to be tied to the behavior of individuals and the potential risks their behavior presents more than the actual outcome of their actions (Marx, 2001).

In the health care arena, Medscape (n.d) emphasized that Just Culture recognizes that human error and faulty systems can cause a mistake and encourages an investigation of what led to the error instead of an immediate rush to blame a person. A just culture, expert say, is a ‘‘non-punitive’’ environment in which individuals can report errors or close calls without fear of reprimand, rebuke, or reprisal (Blegen et al., 2004; Karadeniz & Cakmakci, 2002; Kingston et al., 2004; Pizzi, Goldfarb, & Nash, 2001; Wakefield et al., 1999; Wild & Bradley, 2005). The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, “hazardous” human behavior such as staff errors, near-misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems — not to identify and punish the individual (Pepe & Cataldo, 2011).

In the Philippines, where nurses face a lot of workplace-related issues such as understaffing, undue remuneration, and hostile employers to name a few, they become more vulnerable to making mistakes. With so much pressure at hand due to how these errors are addressed currently plus the fact that nurses are more often unappreciated, they may burnout putting the delivery of care at stake. This existing practice is opposed by the concept of Just Culture, where according to Pepe and Cataldo (2011), is a model that distinguishes among human error, at-risk behavior, reckless behavior, malicious willful violations and the corresponding levels of accountability.

Moreover, just culture is not a “blame-free” approach. It is a strategy that gets into the root of the problem, whether it is a worker wilfully contributing to the error or the system providing inadequate support to the worker’s need. Furthermore, it is a system of justice that involves both investigatory action and disciplinary action. Hence, a “just culture” stands between a ‘‘blaming’’ or punitive culture, on the one hand, and a ‘‘no-blame’’ or ‘‘anything-goes’’ culture, on the other. This view reflects the connotation of balance typically associated with the terms ‘‘just’’ or ‘‘fair.’ (Weiner, Hobgood & Lewis, 2007). It balances the need to learn from mistakes and the need to take disciplinary action where appropriate.

In a setting where just culture is implemented, encouragement of error disclosure is emphasized through open communication. As stated in Skybrary (2014) the personnel is clear, that in the interest of safety, the organisation wants to know, at all times, about unsafe events, unsafe situations that have presented themselves or could arise. They are keen to step forward and speak up when they perceive a situation as dangerous, think of a procedure as risky, or any other issue in their daily tasks that they judge as potentially harmful and are yet without good remedy. This system makes sure the staffs are motivated to report and the trend must be maintained. Moreover, whenever there are reports, the organization assures that they are acknowledged, discussed properly and provided with appropriate feedbacks.

When errors occur, the person who committed the error is not blamed instantly. He or she is not punished outright but rather a safety investigation is initiated to determine the proper disciplinary action. The organisation investigates why this error was made and what can be done to avoid them or to mitigate the effects for future operations. The workforce is protected as best as possible from negative consequences resulting from human error or subsequent investigations and in principle the organisation will defend and support people should external prosecutions or litigations target them. The organisation attempts to repair the situation as best as possible and restore the operations to normal. The organisation provides compensation for those that have experienced personal loss or damage. The organisation tries hard to prevent that same event from happening again. A case is not closed by condemning or finding the guilty one, but by discovering the underlying problems in the system, by rectifying this and by repairing the damages done (Skybrary, 2014).

When the problem is discovered, rectified and repaired, the organisation then communicates the situation with confidentiality to all the members of the group. This dissemination intends not to humiliate somebody but rather provides a learning platform for everyone. In just culture, the error that has happened was seen not as something to be fixed but rather an opportunity of learning and ironing the system. It creates an environment of introspection while errors are discussed and collectively outlines improved policies, protocols and/or guidelines. It also shapes a venue for the enrichment of managerial competencies.

Hence, it is an implicit claim of just culture that it is inevitable for practitioners to commit mistakes that even the most experienced individual is capable of making mistakes. It is also implied in just culture that punishment is not an assurance that workers will not be making mistakes and that perfecting a performance is impossible and can never be sustained.

ANA (2010), in their position paper about this concept officially endorse the Just Culture concept as a strategy to reduce errors and promote patient safety in health care. In their efforts to endorse this “non-punitive” approach, they promote and disseminate information about the Just Culture concept in ANA publications, through constituent member associations, and ANA affiliated organizations. Hence, the feasibility of incorporating this approach in the present system in the Philippines must also be taken into consideration.

However, the adopting organization must develop its own strategies in implementing just culture. It is because no single method fits all in applying the just culture. This concept, when used as an approach in improving the quality of care, must be contextualized depending on the acceptance and capability of the institution to implement this model. Once this approach is incorporated in the system, ANA (2010) encourages continued research into the effectiveness of the Just Culture concept in improving patient safety and employee performance outcomes. To this end, Just Culture might just be the absolute answer to the faulty system not only of nursing but might as well the entire Philippine Healthcare system.

References

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Weiner, B. J., Hobgood, C., & Lewis, M. A. (2008). The meaning of justice in safety incident reporting. Social Science & Medicine, 66(2), 403-413.