Just Culture

Write an introduction and conclusion.

“Just Culture”

For one to move forward and avoid making similar mistakes in future, they need to learn
from the past mistakes. However, for a person or a system to learn from a mistake, they need to
analyze the error and understand the changes they have to adapt to avoid making them in future.
In every system, errors are bound to occur for example in a healthcare system (Pedroja, 2013).
There is a good number of patients who die in hospitals because of issues arising from
preventable medical errors for example individual and group recklessness of medical
practitioners, and so there is the need for health companies to improve their functionality to make
the system safer for them and the patients (Duffy, 2017).
According to Pedroja, (2013), though the errors caused may result into minor to severe
consequences, it is essential that people understand that even in a just culture, errors occur and it
is better to look at the positive impact of the mistakes, that is, it helps in making them avoid
making the same mistake in future hence making the system better. In a “just culture” system,
the organization uses information on the errors to build and safeguards routines that prevent
future occurrences of the same mistakes, hence increasing the safety for both the patients and the
medics (Duffy, 2017). In general, a “Just Culture” can be described as a culture that gives people
a learning environment that is open, fair and safe especially in managing behavioral choices
(Duffy, 2017).




Significance of a Just Culture
Unfortunately, a just culture is not one that is common in the healthcare setting today
(Pattison & Kline, 2015). Healthcare cultures today are ones that are filled with blame and fear
(Pattison & Kline, 2015). Instead of blaming others or fear of being reprimanded, a just culture is
one that promotes a balance of accountability and reporting (Pattison & Kline, 2015). People
make mistakes and errors do occur in healthcare but punishing people does not solve the problem
(Boysen, 2013). Nurses do not report mistakes because of fear of the consequences and doubt
that anything will happen to improve the processes (Kennedy, 2016). An organization can shift
towards a just culture by staying true to the mission, values, and vision of the company. Also, it
moves by providing systems that will decrease the chance of errors, allowing staff to learn and
grow from mistakes that occur, reporting errors and providing changes that will improve
processes, and finally understand the difference between honest mistakes and those that arise due
to lack of standards (Kennedy, 2016).
Accountability of Errors in a Just Culture
Although a just culture is one that promotes reporting of errors, it does not allow staff not
to be accountable for their actions (Kennedy, 2016). Mistakes are going to occur in healthcare no
matter what changes or safety measures are taken. In a just culture, leaders must be aware of the
different types of errors that can occur (Ulrich, 2017). There is human error that happens when
an adverse outcome arises when someone makes a poor decision or choice (Kennedy, 2016).
There is at-risk behavior which is when nurses or staff member choose to perform duties without
following the standards or protocols of the organization (Ulrich, 2017). An example of an at-risk
behavior is when a nurse performs a task that did not cause any harm to the patient, and they


believe it will continue not to cause damage when played that way (Kennedy, 2016). Finally,
there is reckless behavior which is when a nurse or staff member deliberately choose to ignore all
protocol, standards, and practices when performing tasks (Kennedy, 2016). In a just culture,
when understanding the error, the action that occurs following the failure will depend on what
affected the adverse outcome whether it is from human error, at-risk behavior, or reckless
behavior (Kennedy, 2016).
Transformational Leadership in a Just Culture
When shifting into a just culture, the organization must establish and maintain standards,
accountability, and reporting of errors that does not place blame but rather provide ways to
improve processes so that the errors do not reoccur (Marquis & Huston, 2015). Unfortunately,
implementing a just culture is a slow process but one that will provide organizations with ethical
and fair nurses who report errors and provide safe, adequate care (Kennedy, 2016). A just culture
also provides leadership that is effective, empowers staff, and ultimately improves the
satisfaction of the team (Kennedy, 2017). Leadership is essential to make sure that a just culture
is present within an organization (Marquis & Huston, 2015).
Nurse leaders in healthcare today struggle with trying to find ways to promote learning
when errors occur (Warner, 2016). Transformational leaders see a mistake as a way to encourage
learning and develop effective quality care (Warner, 2016). Leadership in a just culture should
provide a positive attitude towards the organization’s goals and help the staff to be empowered
(Warner, 2016). Effective leaders ultimately can have a positive influence on the culture of an
organization (Warner, 2016). Leaders who provide coaching that is understanding and not
blaming towards staff when an error occurs will be likely to reduce the mistake from happening
again as well as helping the nurse to understand the mistake (Warner, 2016). In a just culture,


leaders empowered the nurses to take ownership of their practice as well as promote
opportunities for growth for all staff (Warner, 2016). The leadership of an organization that
understands errors, unfortunately, do occur but are willing to review the processes and search the
facts; this promotes an environment that allows nurses to not fear but grow. Nothing is more
powerful when a mistake occurs, and the staff learns from the error, and a process is changed so
that safety and quality care is improved. A culture that holds true to promoting safe care to all
patients cannot happen without a just culture (Marquis & Huston, 2015).
Reviewing Positive Impact of Just Culture through Current Literature
According to Boysen (2013), mistakes in healthcare settings can lead to injury, poor
patient outcomes, and occasionally, death. It is crucial for healthcare organizations and facilities
to recognize and evaluate errors while identifying why, where, when, and how mistakes and
unintended incidences occur so that agencies can work toward preventing future errors and
dangerous occurrences from happening. Boysen (2013) states that while some organizations
problem solve after mistakes have occurred by ascertaining the person accountable and
regulating appropriate punishment for the individual at fault, this approach is not sufficient
enough to resolve issues or prevent future errors in care from occurring.
Just culture is defined by carefully corresponding the necessity for an atmosphere in
which open and candid risk reporting is obligatory and encouraged with the end of a high-
standard learning environment and ethos (Boysen, 2013). Critical components of just culture
include appropriate management of employee behaviors and decision-making tactics, persistent
vigilance about the prospect of failure, acknowledging and transferring to expertise irrespective
of employee station or status and capacity to acclimatize when unanticipated errors or problems
occur. Other components include aptitude to focus on a task while also acknowledging care


holistically, and the ability to modify the hierarchy within an organization as unique situations
present themselves (Weick and Sutcliffe, 2001; as cited in Boysen, 2013).
To understand the positive impact implementation of just culture has to healthcare
organizations and risk reduction, it is imperative to examine the failure of healthcare providers to
expertly investigate and take appropriate action after receiving reported data related to errors in
care (Institute for Safe Medication Practices, 2017). Failure to report, evaluate, and initiate
positive and future preventative change after an error occurs may offer explanation for the fact
that, 38% of employees participating in a recent survey by the Agency for Healthcare Research
and Quality felt it is often pure coincidence that grave errors do not happen in their organization
(Institute for Safe Medication Practices, 2017).
Furthermore, this survey regarding risk reporting and improving patient safety after an
error in care occurs cites that only 64% of respondents felt mistakes in care have provoked
positive changes within their organization (Institute for Safe Medication Practices, 2017). When
correctly and devotedly executed by all individuals within a healthcare organization, just culture
is a dependable systematic approach to cultivating patient safety and reducing poor outcomes
and empowers organizations to efficiently achieve safety and better quality of care (Institute for
Safe Medication Practices, 2017).
Application to Nursing
Implications or Consequences for Nursing Leaders
The nursing profession is especially relevant to the just culture and succession planning
models. Nursing leaders must support a culture that promotes transparency and moral courage
within their circles of influence. Just culture must be upheld from every position of nursing; from
the classroom setting to the hospital managerial position, to the legislative level. It is the code


that enables nurses to be emboldened to transform their work environments to improve the care
of an ever-changing population. Patient safety is empowered by a fair and just culture as the
system enables the employees to monitor the workplace proactively and participate in safety
efforts in the work environment (Boysen, 2013). This ability to act for the good of patients must
be modeled by leadership, educators, and legislators for it to ultimately reach the bedside.
Consequences of not promoting and encouraging just culture are many. Nurses need to be
emboldened to report near misses and errors. When nurse leaders do not support clear
communication and the moral courage of staff nurses to take action when there is a problem in
the system or about an aspect of care; the unwanted behavior may be reinforced. It may continue
to the devastation of the organization staff and patients. (Penn, 2014). A problem as simple as
malfunctioning thermometers that are essential measurement and diagnostic tools is reliant on
the established trust and free communication between the nurses using the thermometers and
their managers. If this message is poorly relayed or ignored, the diagnosis of sepsis may be
delayed and care provided may be inefficient or ineffective for the served population until the
problem is resolved.
The concept of a just culture is based on a non-punitive attitude toward human error
(West, 2013). When nursing leaders encourage a just culture, patients ultimately receive better
care. This is because nurses are empowered to think critically about the system and processes
they are working with and can openly voice how to improve to provide better care. Implications
for nursing leaders to promote just culture within their organizations include creating a system or
process in which nurses find it easy to discuss and relate their needs to their supervisors.


Practical examples include having an Action Required Box that is routinely reviewed by
managers in which staff nurses can whistle-blow situations that need improvement anonymously.
Another example is to have regular meetings and open staff forums that allow free
communication and problem solving about the planning of facility changes. Stigma regarding
the filing of Midas reports and other sentinel event reporting must be diminished through
interdisciplinary discussion and education. The ingredient that constitutes a just culture is open
and transparent pathways of communication from working staff to those change agents or leaders
in the facility so that the organization can quickly adjust itself to meet the needs of its
community. As leaders, we must support the just culture through organizational protocols and
intentional modeling to improve the safety and care of our patient populations.


In general, it is essential to understand that having a “Just Culture” in a healthcare system
is very important especially in solving problems in the institution. A “Just Culture” positively
influences the performance and productivity of a system, which in turn dictates the strategies to
be used by the company for its development in future. Health practitioners need to understand
that them making an error is normal and hence need to embrace such errors, as the mistakes are
learning platforms that allow them to avoid making the same mistakes in the future. One way for
a health company to display an actively working environment that protects its patient from harm
and at the same time working towards the overall improvement of medical care is by adopting a
“Just Culture.” It is the role of every individual in the health organization to support the “Just
Culture” because only then will it be positively influential to the organization and the people it
serves, that is, the patients (Duffy, 2017).




Boysen, P. G. (2013). Just Culture: A Foundation for Balanced Accountability and Patient
Safety. The Ochsner Journal, 13(3), 400–40
Duffy, W. (2017). Improving Patient Safety by Practicing in a Just Culture. AORN Journal,
106(1), 66-68.
Institute for Safe Medication Practices. (2012). Just Culture and Its Critical Link to Patient
Safety (Part II). Institute for Safe Medication Practices.
Kennedy, B. (2016). Team concepts toward a just culture. Nursing Management, 47(6), 13-15.
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing:
Theory and application (8th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Pattison, J., & Kline, T. (2015). Facilitating a just and trusting culture. International Journal of
Health Care Quality Assurance, 28(1), 11-26.
Penn, C. E. (2014). Integrating just culture into nursing student error policy. Journal Of Nursing
Education, 53(9), 107-109. d
Ulrich, B. (2017). Just Culture and Its Impact on a Culture of Safety. Nephrology Nursing
Journal, 44(3), 207-259.


Warner, S. L. (2016). Productive errors. Nursing, 46(4), 57-59.
West, E., Zidek, C., Holmes, J., & Edwards, T. (2013). Intraprofessional collaboration through
an unfolding case and the just culture model. Journal Of Nursing Education, 52(8), 470-

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