Creating a Just Culture: Nursing Management Guide

In healthcare, mistakes happen despite the best intentions and efforts of healthcare workers (HCWs) to avoid them. Your organization can minimize patient harm by supporting a just culture. Nursing, the largest segment of the healthcare workforce, requires a systems-based approach to addressing errors that prioritizes patient safety and staff well-being.

If you’re looking to build a just culture policy and process for your facility, we’re here to help. This guide will explore just culture and discuss ways that you can create and manage this system within your organization.

Understanding What Just Culture Means

While there is a broader just culture definition in healthcare, it does have a specific application to nursing. Just culture is a management principle that shares and balances the nurse’s accountability for their actions with the organization’s responsibility for their system flaws. Nurse leaders uphold this culture by ensuring that when errors occur, they treat staff in a fair and safe manner, free of retaliation.

Healthcare organizations are complex, and it’s common for their processes to have design flaws that contribute to errors. This is why the individual and the organization share accountability in just culture. So what is just culture in nursing? It exists when nurses become empowered to report mistakes and system safety concerns because the culture they operate in focuses on correcting and preventing problems, instead of simply blaming and punishing individuals.

Building Upon Existing Culture

Build upon the foundation of your workplace culture when implementing a just culture. Nursing leaders must nurture an environment of trust and communication where nurses feel safe to report errors, discuss close calls, and learn from adverse events without fear of retaliation. Investing in the aspects of your organization’s existing culture that align with just culture will not only help your nurses feel respected and supported, but will also help the concepts of just culture take root in your organization and ultimately improve patient safety and staff well-being.

For instance, if one of your organizational values is teamwork, consider hosting a nursing hackathon for your facility to address key aspects of just culture. Hackathons are events where subject matter experts come together to tackle very specific issues during a short period of time. It’s like focusing a laser of expertise on specific problems to quickly generate workable solutions.

In the healthcare environment, nurse hackathons can offer a secure environment promoting open communication, collaboration, and innovation among management, nurses, and other healthcare professionals. This event will actively engage your staff, strengthen one of your existing organizational values, and facilitate the development of solutions tailored to your organization.

Reporting Errors

Open and honest reporting of errors is essential in a just culture. Your organization will require an efficient event reporting system to collect the information needed for a root cause analysis (RCA). A thorough RCA will reveal the individual’s and the system’s contributing factors that led to a mistake. This allows you to develop an action plan to correct and prevent recurring incidents.

Responding to Errors

When implementing a just culture, leaders should be aware that this isn’t a blame-free culture. You’ll still evaluate the actions of HCWs to identify behaviors that lead to mistakes and patient harm. The following are explanations of these types of behaviors and recommended management responses provided by the Agency for Healthcare Research & Quality (AHRQ):

Human Errors

Human errors occur when an individual unintentionally performs an incorrect action, i.e., a slip, lapse, or mistake. The management response is to console the nurse or HCW who made the human error and make any needed changes to the system or procedures to safeguard to prevent a recurrence.

Behavior Example: A nurse forgets to administer a patient’s medication because the pharmacy hadn’t delivered it before the initial medication pass.

At-Risk Behaviors

At-risk behaviors refer to actions an individual takes when they underestimate or don’t recognize the potential consequences of their choices — increasing the likelihood of an adverse event. The manager coaches the individual to help them identify the risk and remove incentives to continue the behavior as it isn’t conducive to a just culture. Nursing management will assess the systems in place to confirm that their processes only promote safe behaviors.

Behavior Example: A nurse takes the shortcut of reconstituting their patients’ IV medication bags because they can make them up faster than the pharmacy.

Reckless Behaviors

Reckless behaviors are the third and most egregious of behaviors. The individual intentionally performs actions with a deliberate disregard for the well-known risks that are substantial and unreasonable. Since these actions are blameworthy, the management response is to punish the HCW by taking remedial or disciplinary action to prevent the error from occurring again.

When reckless behavior involves malicious intent or possible criminal conduct, take prompt and decisive action to safeguard your patients. The American Organization for Nursing Leadership, has published guiding principles to assist your team in establishing a process for addressing these rare occurrences.

Behavior Example: A nurse reports to their shift and assumes patient care while under the influence of alcohol after attending a family event before work.

Collaborating With Stakeholders

Every healthcare discipline that interacts with patients and senior management must be involved in creating a just culture. Nursing managers are influential leaders who are instrumental in fostering multidisciplinary collaboration and teamwork across the organization.

While this article focuses on how nurse management can create a culture of safety, the responsibility belongs to all employees within your organization. Leaders’ actions and behaviors set the example in implementing and championing a just culture.

Creating Policies and Procedures

In collaboration with the team, nurse managers develop and implement standardized processes to ensure the success of a just culture. Clear, intentional, and well-drafted policies and procedures are critical to helping your organization and staff make decisions, take appropriate action, and serve as the guideline for daily operations. They define expected behaviors and expectations and what process to follow when the unexpected occurs, such as medical errors.

Also, policies and procedures — and their consistent application — have the added benefit of providing reliable (and repeatable) results. The standardization of practices helps to develop behavioral norms and a level of self-enforcement that will deepen the just culture impact on your facility.

Training and Education

To ensure a strong just culture, educate and train your staff well. If you don’t have a nurse educator, work with human resources to assist in the content development and training rollout.

Set the foundation for a just culture by educating staff on its principles and why it’s vital. Include training sessions to explain policies and procedures and incident reporting. The better prepared your team is, the smoother the implementation will be. Here is an example of a rollout plan to help you get your just culture training program implemented:

1. Plan

• Identify the goals and objectives of the education and training program.
• Obtain leadership support and approval.

2. Design

• Develop learning objectives, curriculum, and content.
• Choose the format and delivery methods (online modules, in-services, etc.).
• Create a content development timeline.

3. Deliver

• Train leadership and department champions.
• Schedule and deliver education and training sessions.
• Provide resources to support learning.

4. Review

• Offer refresher sessions for reinforcement.
• Monitor and evaluate the effectiveness of the program.
• Collect feedback and provide a process to incorporate viable suggestions.
• Regularly update training materials.
• Incorporate training into new-hire orientation programs.

Need More Resources on Just Culture, Nursing Management, or Healthcare Compliance?

Now that you have a better understanding of just culture in nursing, you may be interested in taking your healthcare management skills to the next level. Don’t miss out on our latest management guides and resources that will help to expand your knowledge and stay ahead of the curve.