Just Culture
Ernstmeyer & Christman- Nursing Management & Professional Concepts 2e- OpenRN
Just Culture
The American Nurses Association (ANA) officially endorses the Just Culture model. In 2019 the ANA published a position statement on Just Culture, stating, “Traditionally, healthcare’s culture has held individuals accountable for all errors or mishaps that befall clients under their care. By contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A Just Culture also recognizes many individual or ‘active’ errors represent predictable interactions between human operators and the systems in which they work. However, in contrast to a culture that touts ‘no blame’ as its governing principle, a Just Culture does not tolerate conscious disregard of clear risks to clients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated).”
The Just Culture model categorizes human behavior into three causes of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior.
- Simple human error: A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a client. In this example, a root cause analysis reveals a system issue that must be modified to prevent future client errors (e.g., change the labelling and storage of look alike-sound alike medication).
- At-risk behavior: An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a client’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the client. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.
- Reckless behavior: Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk.[1] For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong client. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.
These examples show three different causes of medication errors that would result in different consequences to the employee based on the Just Culture model. Under the Just Culture model, after root cause analysis is completed, system-wide changes are made to decrease factors that contributed to the error. Managers appropriately hold individuals accountable for errors if they were due to simple human error, at-risk behavior, or reckless behaviors.
If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes. In the “simple human error” above, system-wide changes would be made to change the label and location of the medication to prevent future errors from occurring with the same medication.
Individuals committing at-risk behavior are held accountable for their behavioral choice and often require coaching with incentives for less risky behaviors and situational awareness. In the “at-risk behavior” example above where the nurse ignored an error message on the barcode scanner, mandatory training on using a barcode scanner and responding to errors would be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[2] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the state’s Board of Nursing with mandatory substance abuse counseling to maintain their nursing license. Employment may be terminated with consideration of patterns of behavior.
A Just Culture in which employees aren’t afraid to report errors is a highly successful way to enhance client safety, increase staff and client satisfaction, and improve outcomes. Success is achieved through good communication, effective management of resources, and an openness to changing processes to ensure the safety of clients and employees. The infographic in Figure 4.4[3] illustrates the components of a culture of safety and Just Culture.
The principles of culture of safety, including Just Culture, Reporting Culture, and Learning Culture are also being adopted in nursing education. It’s understood that mistakes are part of learning and that a shared accountability model promotes individual- and system-level learning for improved client safety. Under a shared accountability model, students are responsible for the following[4]:
- Being fully prepared for clinical experiences, including laboratory and simulation assignments
- Being rested and mentally ready for a challenging learning environment
- Accepting accountability for their part in contributing to a safe learning environment
- Behaving professionally
- Reporting their own errors and near mistakes
- Keeping up-to-date with current evidence-based practice
- Adhering to ethical and legal standards
Students know they will be held accountable for their actions but will not be blamed for system faults that lie beyond their control. They can trust that a fair process will be used to determine what went wrong if a client care error or near miss occurs. Student errors and near misses are addressed based on an investigation determining if it was simple human error, an at-risk behavior, or reckless behavior. For example, a simple human error by a student can be addressed with coaching and additional learning opportunities to remedy the knowledge deficit. However, if a student acts with recklessness (for example, repeatedly arrives to clinical unprepared despite previous faculty feedback or falsely documents an assessment or procedure), they are appropriately and fairly disciplined, which may include dismissal from the program.[5]
See Table 4.2c describing classifications of errors using the Just Culture model.
Table 4.2c. Classification of Errors Using the Just Culture Model
| Human Error | At-Risk Behavior | Reckless Behavior |
|---|---|---|
| The caregiver made an error while working appropriately and focusing on the client’s best interests. | The caregiver made a potentially unsafe choice resulting from faulty or self-serving decision-making. | The caregiver knowingly violated a rule and/or made a dangerous or unsafe choice. |
| Investigation reveals system factors contributing to similar errors by others with similar knowledge and skills. | Investigation reveals the system supports risky action and the caregiver requires coaching. | Investigation reveals the caregiver is accountable and needs retraining. |
| Manage by fixing system errors in processes, procedures, training, design, or environment. | Manage by coaching the caregiver and fixing any system issues:
|
Manage by disciplining the caregiver. If the system supports reckless behavior, it requires fixing. |
| CONSOLE | COACH | PUNISH |
Systems leadership refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements:[6]
- The Individual: The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
- The Community: The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
- The System: An understanding of the complex systems shaping the challenge to be addressed
Just Culture Cases
Review the following case descriptions. Identify the classification of error that has occurred and the recommended actions that should occur.
A chief nursing officer receives a daily report of organization incident reports and reviews the following incident:
Incident Description
Client Mr. Joe Doden, Room 13067, Medical-Surgical floor
On the afternoon of May 15, 2024, Nurse Sarah was responsible for administering Mr. Joe Doden’s insulin dose. The insulin vials used by the hospital had recently been redesigned by the manufacturer, which led to changes in the labeling. The client was scheduled to receive ten units of regular insulin at 14:30. However, at 1450 the client turns on his call light, reports feeling unwell. He is shaky, confused, and sweating profusely. The client’s glucose is checked, and he is found to be hypoglycemic. He is treated based upon the hypoglycemia protocol and recovers without further complication.
Case Investigation A
Action: Sarah RN who administered the insulin was following the protocol but mistakenly read the dosage due to a poorly designed label on the insulin vial. The nurse was focused on the clients best interests and followed all required steps.
Findings: The investigation revealed that the labeling on the insulin vials was confusing and had led to similar errors by other nurses in the past. The system’s design flaw contributed significantly to the error.
Question A: How would you classify this error? What actions should be taken?
Case Investigation B
Action: Sarah RN, due to time pressure and a high client load, decided to skip the double-check protocol for administering the same insulin dose, believing it would save time without causing harm.
Findings: The investigation revealed that the hospital’s workload and time pressures often led to shortcuts in following safety protocols.
Question B: How would you classify this error? What actions should be taken?
Case Investigation C
Action: Sarah RN, is familiar with the protocol and knowingly bypassed the double check system, dismissing its importance and administering a medication dose on her own.
Findings: The investigation found that the nurse had a history of disregarding safety protocols, showing a pattern of reckless behavior. This behavior was not supported by the hospital’s policies or environment.
Question C: How would you classify this error? What actions should be taken?
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
- “Just Culture Infographic.png” by Valeria Palarski 2020. Used with permission. ↵
- Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11), 42-48. https;//doi.org/10.1097/01.NAJ.0000526747.84173.97. ↵
- Barnsteiner, J., & Disch, J. (2017). Creating a fair and just culture in schools of nursing. American Journal of Nursing, 117(11), 42-48. https://doi.org/ 10.1097/01.NAJ.0000526747.84173.97. ↵
- Dreier, L., Nabarro, D., & Nelson, J. (2019). Systems leadership for sustainable development: Strategies for achieving system change. CR Initiative at Harvard Kennedy School. https://www.hks.harvard.edu/sites/default/files/centers/mrcbg/files/Systems%20Leadership.pdf ↵
Health care professionals must recognize emerging signs of stress that may result from job demands and the nature of health care work. There are a variety of ways that stress can manifest itself. Taking action early can help to prevent workplace burnout. Burnout can be manifested physically and psychologically with a loss of motivation for one’s work. Nurses and other health care professionals must mitigate stress and burnout to sustain engagement with their profession. Failure to acknowledge the implications of professional burnout only exacerbates the cycle as stressors are transferred to remaining team members and colleagues, resulting in the potential for attrition and turnover.
Although the term “stress” often has negative connotations, it is important to remember that not all stress is considered harmful. Normal stress, also referred to as "eustress," does not have lasting consequences and is successfully managed by the individual who is experiencing it.[1] Normal stress, when successfully managed, can increase awareness and focus, resulting in feelings of motivation and competence in the individual who is experiencing it. For example, normal stress may be experienced by a nursing student as they organize their weekly planner specifying time for class, study time, work shifts, or meeting with friends. Although the calendar looks busy, the student can use the stress resulting from a “time-constrained schedule” to motivate oneself to be efficient in completing tasks. This student may feel great satisfaction as they cross off tasks on the “to-do” list. Hopefully, as task achievement occurs, the student transitions from feelings of stress to feelings of empowerment.
Conversely, harmful stress, also referred to as "distress," occurs when stress is not adequately self-managed. Harmful stress is reflected by physical, mental, and behavioral manifestations.[2] See Figure 12.2[3] for an illustration of an individual experiencing harmful stress. Harmful stress can lead to burnout and exhaustion, and if left unaddressed, it can have significant health implications for the individual experiencing it. Let’s return to the example of the nursing student reviewing their busy schedule. Harmful stress can be experienced by a student looking at their busy weekly schedule and feeling overwhelmed and exhausted. Rather than focusing on manageable tasks and crossing items off the list, this student is reluctant to take action and feels distress regarding where to begin. The student demonstrating harmful stress may struggle with overwhelming fatigue, irritability, and may feel overwhelmed with feelings of inadequacy at one’s ability to meet the task requirements.
Harmful stress can impact the employment setting as well. It can damage staff engagement, cause significant physical manifestations, and impede the ability of the employee to safely perform work. Harmful stress can quickly result in the breakdown of collegial relationships and also influence the overall practice environment. Potential signs of harmful stress are described in Table 12.3.
Table 12.3. Harmful Stress: Physical, Mental, & Behavioral Manifestations[4]
| Physical | Headache
Joint discomfort Sleep disturbance Cardiac abnormality (e.g., heart rate, rhythm changes) Increased blood pressure Dry mouth Indigestion Constipation or diarrhea Excessive sweating Dizziness Tremors |
|---|---|
| Mental | Anger
Irritability Mood changes Depression Conflict with friends, family members, coworkers Isolation of self from others Reduced self-confidence |
| Behavioral | Increased alcohol consumption
Smoking or drug use Overeating or loss of appetite Increased arguments with coworkers Increased errors in the workplace |
Nurses and health care professionals should be mindful of the physical, mental, and behavioral manifestations of harmful stress so prompt action can be taken when signs begin to occur. Harmful stress must be addressed early so it does not continue to evolve and lead to career burnout. Additionally, stress can have significant implications beyond one’s career. An individual's physical and emotional health and well-being are strongly aligned with positive stress management. Harmful stress that goes unaddressed can lead to unresolved physical ailments, deterioration in mental and physical well-being, and the breakdown of familial relationships. The negative impact of harmful stress can be difficult to overcome after it has taken hold of an individual.
It can be helpful to mindfully gauge how one is handling stress on a routine basis. See the link to the Perceived Stress Scale in the following box.
Gauge your current level of stress using the State of New Hampshire's Perceived Stress Scale.
Stressors Resulting From the COVID-19 Pandemic
In addition to the inherent stressors that can occur in health care settings as a result of normal job-related tasks and demands, unique challenges and stressors have occurred for nurses as a result of the COVID-19 pandemic. See Figure 12.3[5] for an image of a COVID care provider. The Future of Nursing 2020-2030 highlights the impact of the COVID-19 pandemic on the profession. The COVID pandemic has placed extraordinary demands on nurses as they try to meet ever-expanding health care challenges placed on them. Hospitals are continuously overcrowded and needed medical equipment can be sparse.[6] Nurses are asked to provide frontline care to infectious clients with transmission-based precautions in isolation rooms.[7] These nurses then return to their home environments, hoping that they do not spread infection to their families while supporting the needs of the family unit. These continuous job and life stressors compound the physical and psychological demands on nurses. With little respite care for themselves, nurses are at risk for the impact of compounding stressors on their own health.
Read a meta-analysis about interventions to support the resilience and mental health of frontline professionals during a pandemic.
