Commitment from senior leadership will help nurses understand just culture

CLICK to Email
CLICK for Print Version

Quality improvement

Commitment from senior leadership will help nurses understand just culture

After reading this article, you will be able to:

  • Define just culture terms 
  • Identify ways to engage staff in creating a just culture 

Prevention of adverse events is a part of working in a hospital environment, and when an event does occur, how it is dealt with can have an effect on patient safety. Ensuring that your hospital’s leadership team and upper management are committed to the just culture philosophy will help the nursing staff understand their role in error prevention.

Medical City Dallas Hospital (MCDH) addressed the need to involve managers by forming an executive council to review all potential near misses and sentinel events, says Laura Weber, RN, MBA, CPHQ, assistant vice president for quality and organizational development. This process change is one of a few that MCDH rolled out in relation to sustaining a just culture over the past two and a half years. 

“We reinvigorated our just culture process … and went back and talked about what a just culture is,” says Weber. 

The executive council that reviews all potential near misses and sentinel events goes over the definition of just culture (see p. 5) with the meeting invitees: the staff member or members involved in the event and the manager of the unit where the event occurred, who has usually conducted an initial investigation.

“This can be intimidating because the group is made up of our chief nurse executive, risk manager, vice president of quality, and myself,” says Weber. “When we first started [this process], we knew what our intention was—to learn more about what happened and do the right kind of analysis—but [the staff involved] didn’t know. So we had to do a lot of training on what the purpose of this council is.”

Using the principles of just culture, the executive council decides the next steps to be taken. This often involves performing a root cause analysis, dealing with the issue on an individual basis, or both.  

Making ‘believers’ out of staff

At MCDH, there’s an emphasis on balancing a nonpunitive culture with one that’s completely blame free. Nevertheless, staff still need to be held accountable for their actions if high-risk behavior is discovered or policies are knowingly ignored.

Recognizing that human error will happen is essential to understanding why a just culture is imperative, Weber says. When reevaluating the hospital’s just culture program, MCDH focused on three behaviors:

  • Human error (e.g., mistakes)
  • At-risk behavior (e.g., shortcuts, not following policies exactly in low-risk settings)
  • Reckless behavior (e.g., conscious disregard for following policies and procedures in high-risk areas)

These definitions help the executive council frame its decisions on next steps, says Weber. If a safety event was the result of human error as opposed to reckless behavior, the course of action will reflect that.

Although meeting with the executive council can be a daunting experience after an error or near miss has occurred, Weber says it’s at that point that staff members truly understand what it means to work in a just culture.

“Once they’ve been involved in that process, and certainly if they’ve been involved in a root cause analysis, that’s when you make believers out of people,” she says. “Because then they see that this was not punitive at all—it was really trying to figure out what went wrong and how we can prevent something from happening in the future.”

Additionally, attending a meeting with the executive council shows staff members that the hospital cares about who it employs by going through the process of determining whether reckless behavior was exhibited—which is usually not the case, says Weber. 

Seeing results from hard work

MCDH has found that a broad focus on reducing errors and supporting a just culture has helped the facility maintain a low fall rate and a low medication error rate. 

Weber says that since the hospital took a second look at its culture two and a half years ago, staff have rated the two questions on the annual employee engagement survey—concerning the reduction of medical errors and support for the reporting of patient safety issues—as two of the most favorably scored areas.

Advice for hospitals building a just culture

Continuous communication is a must if your hospital is serious about building and maintaining a culture of safety, says Weber. One of the areas in which MCDH has had to focus is making staff aware that they work in a nonpunitive environment. 

Presenting real-life examples to the staff to show how easily adverse events can occur helps them understand the culture. It also shows that the organization wants those events to be reported so a proper analysis can be done; however, this takes time and effort.

Involving staff members in the analysis of an event when something goes wrong has bolstered MCDH’s efforts in sustaining a just culture. Through the executive council’s guidance and process, the hospital has incorporated staff in this important process. But prior to the improvement project, Weber’s team found that it wasn’t involving frontline caregivers as much as it should have. It took a recommitment from senior leadership to communicate the expectation that staff involved in the event should participate in the analysis of that event.

“That occurred on two levels. One, it was making the managers accountable for getting their staff to the team meetings and working with them on whatever they needed to do,” says Weber. The second included working around night staff’s schedules. 

Clearly defined just culture terms

The following definitions are reviewed in a meeting between Medical City Dallas Hospital’s executive council and staff involved in a near miss or adverse event:

  • Close call: An unplanned occurrence that does not cause injury or harm to people or property but, under different circumstances, could have. 
  • Just culture: Marx’s four concepts of behavior create the link between discipline process and patient safety:
  • Human error: Inadvertent action that caused or could have caused an undesirable outcome.
  • Negligent conduct: System failure or failure to act as a reasonably prudent person (e.g., nurse, respiratory therapist) would in the same or similar circumstance.It is directly related to harm.
  • Reckless conduct: Conscious disregard for a substantial risk
  • Intentional rule violation: Intentional, knowing violation of a rule, procedure, or duty in the course of performing a task
  • Sentinel event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Major permanent loss of function means sensory, motor, physiologic, or intellectual impairment not present on admission requiring continued treatment or lifestyle change.
  • Serious preventable adverse event: Any event (including CMS reportable events, CMS hospital-acquired conditions including those specified as serious preventable events, and National Quality Forum and Leapfrog serious reportable events) within the control of a provider that results in harm and requires a new or modified physician order for management of the patient’s medical care.


Patient Safety Monitor (Briefings on Patient Safety), October 2010, HCPro, Inc.