Assessment of nurse's perceived just culture: a cross-sectional study.

BACKGROUND: The non-punitive approach to error investigation in most safety culture surveys have been relatively low. Most of the current patient safety culture measurement tools also lack the ability to directly gauge concepts important to a just culture (i.e. perceptions of fairness and trust). The purpose of this study is to assess nurses' perceptions of the six just culture dimensions using the validated Just Culture Assessment Tool (JCAT). METHODS: This descriptive, cross-sectional study was conducted between November and December 2020. Data from 212 staff nurses in a large referral hospital in Qatar were collected. A validated, self-reported survey called the JCAT was used to assess the perception of the just culture dimensions including feedback and communication, openness of communication, balance, quality of event reporting process, continuous improvement, and trust. RESULTS: The study revealed that the overall positive perception score of just culture was (75.44%). The strength areas of the just culture were "continuous improvement" dimension (88.44%), "quality of events reporting process" (86.04%), followed by "feedback and communication" (80.19%), and "openness of communication" (77.55%) The dimensions such as "trust" (68.30%) and "balance" (52.55%) had a lower positive perception rates. CONCLUSION: A strong and effective just culture is a cornerstone of any organization, particularly when it comes to ensuring safety. It places paramount importance on encouraging voluntary error reporting and establishing a robust feedback system to address safety-related events promptly. It also recognizes that errors present valuable opportunities for continuous improvement. Just culture is more than just a no-blame practice. By prioritizing accountability and responsibility among front-line workers, a just culture fosters a sense of ownership and a commitment to improve safety, rather than assigning blame.

Fostering a just culture in healthcare organizations: experiences in practice.

BACKGROUND: A just culture is regarded as vital for learning from errors and fostering patient safety. Key to a just culture after incidents is a focus on learning rather than blaming. Existing research on just culture is mostly theoretical in nature. AIM: This study aims to explore requirements and challenges for fostering a just culture within healthcare organizations. METHODS: We examined initiatives to foster the development of a just culture in five healthcare organizations in the Netherlands. Data were collected through interviews with stakeholders and observations of project group meetings in the organizations. RESULTS: According to healthcare professionals, open communication is particularly important, paying attention to different perspectives on an incident. A challenge related to open communication is how to address individual responsibility and accountability. Next, room for emotions is regarded as crucial. Emotions are related to the direct consequences of incidents, but also to the response of the outside world, including the media and the health inspectorate. CONCLUSIONS: A challenge in relation to emotions is how to combine attention for emotions with focusing on facts, both within and outside the organization. Finally, healthcare professionals attach importance to commitment and exemplary behavior of management. A challenge as a manager here is how to keep distance while also showing commitment. Another challenge is how to combine openness with privacy of the parties involved, and how to deal with less nuanced views in other layers of the organization and in the outside world. Organizing reflection on the experienced tensions may help to find the right balance.

Barriers and enablers in implementing an electronic incident reporting system in a teaching hospital: A case study from Saudi Arabia.

BACKGROUND: Widespread recognition of the impact of healthcare adverse events has triggered incident reporting system implementation to promote patient safety. The aim was to assess the effectiveness, usability, enablers, and barriers of the Electronic Occurrence Variance Reporting System (eOVR) in addition to end user satisfaction. METHODS: This study comprised a cross-sectional survey two years after implementation of the eOVR. Secondary data analysis evaluated the volume of incident reporting before and after implementing the eOVR. OUTCOME MEASURES: Primary outcome measures: satisfaction and system usability, system security, workplace safety culture, training, and reporting trends. An overall satisfaction was collected. SECONDARY OUTCOME: rate of reported OVRs per 1000 admissions. Furthermore, barriers and enablers to the reporting process were explored. RESULTS: Study findings indicate that the eOVR has been successful in terms of high satisfaction according to respondents. Most of the respondents found the system easy to access, maintained patient confidentiality and reporting anonymity. Around half the respondents indicated having a non-punitive culture of reporting in their hospital. Physicians had significantly lower scores in all primary outcomes Incident reporting increased by 33.6% (p < 0.0001) after implementing the eOVR. CONCLUSION: Successful incident reporting systems should be easy and simple to use, accessible and include features that guarantee anonymity and confidentiality. End-users should be trained prior to launching such a system. The implementation of such systems needs to be combined with promoting a just culture in the organization, timely feedback, more involvement and focus on physicians and junior staff which will improve user satisfaction and reporting rates.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework.

OBJECTIVE: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. METHOD: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. RESULTS: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. CONCLUSIONS: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

How We Do It: Operationalizing Just Culture in a Radiology Department.

OBJECTIVE. The purpose of this article is to describe how establishing routine practice sessions facilitates adoption by modality operations managers of the just culture model of error management in a radiology department. CONCLUSION. Implementation of ongoing just culture training among radiology operations managers can help them approach uniformity, equity, and transparency in managing errors. Managers see the just culture method as an effective tool that helps improve the safety of patient care.

Ethics in Publishing: Complexity Science and Human Factors Offer Insights to Develop a Just Culture.

While ethics in publishing has been increasingly debated, there seems to be a lack of a theoretical framework for making sense of existing rules of behavior as well as for designing, managing and enforcing such rules. This letter argues that systems-oriented disciplines, such as complexity science and human factors, offer insights into new ways of dealing with ethics in publishing. Some examples of insights are presented. Also, a call is made for empirical studies that unveil the context and details of both retracted papers and the process of writing and publishing academic papers. This is expected to shed light on the complexity of the publication system as well as to support the development of a just culture, in which all participants are accountable.

Creating a Just Culture in the Perioperative Setting.

There has been an increased perioperative focus on avoiding adverse events and providing safe patient care since To Err Is Human: Building a Safer Health System published in 2000. Adverse events continue to occur in perioperative areas and are likely underreported. The interdisciplinary nature and high cost of perioperative care may discourage personnel from speaking up for fear of retribution and punishment when reporting. Organization leaders can implement a just culture that focuses on improving patient care processes and safety rather than placing blame after an adverse event. A tenet of just culture is achieving balanced accountability between systems and individuals. Strategies for just culture implementation include leader support, policies and procedures for reporting, accessibility of reporting systems, provision of information for staff members, identification of support champions, and creation of a good catch program. Leaders also should measure and track progress associated with the just culture in their facility.

The moderating role of just culture between nursing practice environment and oncology nurses' silent behaviors toward patient safety: A multicentered study.

BACKGROUND: Patient safety is a critical part of healthcare delivery that must be prioritized to guarantee optimal patient outcomes. Oncology nursing is a specialized area of nursing that demands great focus on patient safety because of the high-risk nature of this patient group. Nurses play an important role in ensuring that patients receive safe and effective care. However, the nursing practice environment can have a substantial impact on how nurses respond to patient safety problems. A just culture can promote open communication and identify potential safety issues, whereas a culture of silence can have a negative impact on patient outcomes. OBJECTIVE: Firstly, assess the relationship between the nursing practice environment and oncology nurses' silent behavior towards patient safety. Secondly, the interaction effect of just culture as a moderator in this relationship. METHOD: A cross-sectional, correctional research design was employed. Data was collected from 303 nurses working at the oncology departments of five hospitals in Egypt using three questionnaires. Data was analyzed using SPSS-PROCESS Macro (v4.2). RESULTS: There was a moderate, negative, and significant correlation between the nurse practice environment and silent behavior of nurses towards patient safety. The interaction effect of just culture with nurse practice environment strengthens this relationship, thus enhancing errors reporting. CONCLUSIONS: This study emphasized on the importance of creating a just culture that facilitates open communication and eliminating the potential hazards result from nurses' silence. Thus, oncology nurses must be encouraged to report issues related to patient safety.

Insights on just culture from seafarers and shipping companies in Indonesia: An exploratory study.

BACKGROUND: Just culture aspires to prompt organizational learning from enhanced feedback by frontline operators. Just culture requires mechanisms to eliminate fear and sanction but not accountability when reporting safety-related issues. Adopted in sectors such as aviation, just culture remains an underdeveloped field in the maritime sector. OBJECTIVE: This study explores how some pre-requisites for a just culture (i.e., ease of reporting, motivation to report, and trust) are perceived and potentially implemented by seafarers' and shipping company safety representatives in Indonesia. METHODS: Semi-structured interviews were used to collect qualitative data in an exploratory study involving eleven active seafarers and four safety managers from shipping companies in Indonesia. RESULTS: The conditions for ease of reporting seem present, at least on paper. Shipping companies receive one to two near-miss reports per month. However, incidents seem to be underreported. It appears that companies are unsuccessful in establishing the motivation and trust necessary to enhance safety event reporting. CONCLUSION: The study suggests that the concept of a just culture is not well understood among certain Indonesian shipping companies. The main barriers to implementing a just culture relate to hierarchical structures in the industry, frequent crew changes, blame culture, and lack of anonymous reporting for safety concerns.

Second Victims in Industries beyond Healthcare: A Scoping Review.

The second victim phenomenon (SVP) refers to workers negatively impacted by involvement in unanticipated adverse events or errors. While this phenomenon has been extensively studied in healthcare since its acknowledgment over 20 years ago, its presence and management in other high-risk industries have remained unclear. We conducted a scoping review aiming to map the SVP in non-healthcare industries, as well as to explore the available interventions or support programs addressed to help second victims (SVs). A total of 5818 unique records were identified and, after the screening process, 18 studies from eight sectors were included. All industries acknowledged the existence of the SVP, though many did not use a specific term for defining the SV. Similarities in psychological and emotional consequences were found across sectors. Support strategies varied, with the aviation sector implementing the most comprehensive programs. Self-care and peer support were the most reported interventions, while structured clinical support was not mentioned in any industry. Our review highlighted a lack of standardized terminology and industry-specific, evidence-based support interventions for the SVP outside of healthcare. Healthcare appears to be at the forefront of formally recognizing and addressing the SVP, despite traditionally learning from other high-reliability industries in safety practices. This presents opportunities for reciprocal learning and knowledge transfer between healthcare and other high-risk sectors.

Exploring Safety Culture in the ICU of a Large Acute Teaching Hospital through Triangulating Different Data Sources.

Safety Culture (SC) has become a key priority for safety improvement in healthcare. Studies have identified links between positive SC and improved patient outcomes. Mixed-method measurements of SC are needed to account for diverse social, cultural, and subcultural contexts within different healthcare settings. The aim of the study was to triangulate data on SC from three sources in an Intensive Care Unit (ICU) in a large acute teaching hospital. A mixed-methods approach was used, including analysing the Hospital Survey for Patient Safety Culture results, retrospective chart reviews using the Global Trigger Tool (GTT) for the ICU, and staff reporting of adverse events (AE). There was a 47% (101/216) response rate for the survey. Further, 98% of respondents stated a positive patient safety rating. The GTT identified 16 AEs and 11 AEs that were reported in the same timeframe. The triangulation of the data demonstrates the complexity of understanding components of SC in particular: learning, reporting, and just culture.

Just Culture: How Do We Address Risky and Unprofessional Behaviors that Lead to Errors?

Unprofessional behavior in the procedural arena is associated with worse patient outcomes. This is thought to be due to breakdowns in communication structures and team dynamics. Behavioral issues are often uncovered during the investigation of serious event reports. Understanding differences in behavior deviations enables leadership to best address each type with an appropriate response. This allows institutions to address reckless behavior and unprofessionalism, while concomitantly creating a culture that fosters trust to promote self-reporting and sharing of information. These are characteristics of high-reliability organizations that produce sustained excellence in patient outcomes.

Review of Complaints to the Rhode Island Board of Medical Licensure and Discipline 2018-2020.

OBJECTIVE: This study aimed to examine the patterns of complaints filed against physicians in Rhode Island, investigate the factors associated with complaint rates and outcomes, and assess the impact of the implementation of a new Framework for Just Culture. METHODS: Complaint data from the Rhode Island Department of Health's complaint tracker and physician licensing database were analyzed for the period of 2018 to 2020. Descriptive and statistical process control analyses were conducted to assess complaint rates, investigation rates, and adverse outcomes. RESULTS: Over the three-year period, 1672 complaints were filed against Rhode Island physicians, with approximately 40% of complaints being opened for investigation. The implementation of the Framework for Just Culture coincided with a sustained decrease in the rate of complaints opened. Failure to meet the minimum standard of care was the most common allegation, and male physicians and those aged 40-50 were more likely to have complaints filed against them. CONCLUSIONS: The study highlights the importance of complaint investigations in upholding standards for medical licensure and clinical competence. The Framework for Just Culture may have influenced the investigation process, resulting in fewer investigations opened without compromising the identification of cases requiring disciplinary action. These findings provide insights into physician accountability and the need for ongoing monitoring and improvement in complaint handling systems.

Perceptions of Radiation Safety Culture in Medical Imaging by Role.

PURPOSE: To determine whether radiologic technologists' perceptions of determinants of radiation safety culture differ significantly based on their primary role. METHODS: A secondary analysis of deidentified data from 425 radiologic technologists who participated in the Radiation Actions and Dimensions of Radiation Safety questionnaire, a 35-item survey with valid and reliable psychometric properties, was performed. Nine determinants (dependent variables) of radiation safety culture were analyzed in this study. The radiologic technologists worked primarily as staff technologists; shift, team, or modality leads; and managers or directors. Descriptive statistics were used to analyze differences in favorability for the determinants of radiation safety culture by primary role. Games-Howell post hoc tests were conducted to analyze the hypothesis for each determinant. RESULTS: Four determinants demonstrated significant differences with appropriate observed power between staff technologists, leads, and managers and directors: questioning attitude (P < .001), feedback loops (P < .001), leadership actions (P < .001), and nonpunitive response (P < .001). DISCUSSION: The findings indicate that dialogue is needed between all stakeholders to improve the radiation safety culture and that power imbalances caused by the hierarchical system should be considered when seeking to improve the safety culture. CONCLUSION: Positional hierarchies in the medical imaging profession affect the perception of radiation safety, with managers and directors having different perceptions of leadership actions, questioning attitudes, feedback loops, and nonpunitive responses than staff technologists. Therefore, radiologic technologist subgroups must be included purposefully in the process of establishing a radiation safety culture in the imaging department.

Patient Safety and Clinician Well-Being.

Clinician well-being and patient safety are intricately linked. We propose that organizational factors (ie, elements of the perioperative work environment and culture) affect both, as opposed to a bidirectional causal relationship. Threats to patient safety and clinician well-being include clinician mental health issues, negative work environments, poor teamwork and communication, and staffing shortages. Opportunities to mitigate these threats include the normalization of mental health care, peer support, psychological safety, just culture, teamwork and communication training, and creative staffing approaches.

Preventing Wrong Tooth Extraction in Primary Care Oral Surgery: LocSSIPs - Key Aspects of Implementation for Achieving and Sustaining Compliance.

The success of Local Safety Standards for Invasive Procedures (LocSSIPs) in preventing wrong tooth extraction and other patient safety incidents is based on sustained staff compliance from the outset, ahead of implementation. This paper (the second of two on the topic of LocSSIPs) aims to equip primary care dental practitioners with key practical solutions to implement LocSSIPs successfully and sustainably, and the leadership knowledge to create a long-term, safe, patient-centred and just service.

Peer review and its ethical implications.

Peer review is an essential tool for institutions and providers to meet the modern goals of safety and quality in health care. It is a mechanism that leads to a just culture within a health care institution whereby errors and complications are considered products of the system rather than isolated actions by an individual. The benefits and potential drawbacks of peer review are outlined in this review with a special emphasis on the interface between peer review and principles of medical ethics. It is argued that peer review, in the ideal setting, is founded upon the principles of beneficence and justice, and to varying levels on non-maleficence and autonomy.

Perspective: in pursuit of a learning culture.

Transitioning from peer review to peer learning is an important step forward in developing a learning culture. Additional measures are going to be required to meet this goal. Ideas toward establishing a learning culture are detailed in this perspective.

Perception of just culture and its association with work-related psychosocial factors in an Iranian industrial setting: Implications for prevention of errors.

BACKGROUND: A just culture is one in which the reporting of errors and near misses is supported without fear of retribution. The relationship of just culture and psychosocial factors at work has not been explored sufficiently in the literature. OBJECTIVE: To investigate the perception of just culture and its association with socio-demographic and work-related psychosocial factors among 302 employees in an industrial setting in Iran. METHODS: Just culture was assessed using the Just Culture Assessment Tool, and the Copenhagen Psychosocial Questionnaire was used for evaluation of psychosocial work factors (including influence at work, meaning of work, commitment to the workplace, predictability, rewards, quality of leadership, social support from supervisors, trust, and justice and respect). Data were analysed using t test, analysis of variance (ANOVA), and general linear regression analysis. RESULTS: The results indicated that the employees had a fairly positive view on their organisation's just culture, though there were some areas such as trust and balance that needed further attention. The psychosocial issues (particularly commitment to the workplace, meaning of work, social support from supervisors, and rewards) were not adequate from the employees' perspective. Predictability, rewards, and quality of leadership, were the significant psychosocial predictors of just culture in a multivariate regression model. CONCLUSIONS: The findings highlight the areas that need to be considered to improve the experience of organisational just culture, which is important from the point of view of prevention of safety errors and incidents.

Just culture in healthcare: An integrative review.

BACKGROUND: In spite of two decades of the patient safety movement in the United States, healthcare safety remains a significant problem. The paucity of empirical literature related to Just Culture in healthcare indicates a need for this concept to be examined and operationalized. PURPOSE: The purpose was to appraise the literature regarding the use and application of Just Culture in healthcare. METHODS: Using Whittemore and Knafl's framework for integrative reviews, a review of the literature was conducted using Cumulative Index to Nursing and Allied Health Literature, PubMed, PsychInfo, and Cochrane Review to identify peer-reviewed literature published between 2010 and 2020. The following search terms were used: "Just Culture" AND "healthcare system" OR "health care" OR "healthcare." RESULTS: After screening for inclusion and exclusion criteria, a set of 10 articles were included in the review. Four main themes were identified: Error Management, Balance, Leadership and Staff, and Systems Leadership for Change. CONCLUSION: There is a paucity of empirical research and quality improvement projects focusing on Just Culture. The themes identified in this integrative review provide the direction and focus for additional research and quality improvement efforts that will promote the adoption of Just Culture and improvement in patient safety.